{"1": {"fulltext": "", "height": "4658", "width": "3194", "jp2-path": "practicaltreatis00muss_0_0001.jp2"}, "2": {"fulltext": "LIBRARY OF CONGRESS.\\nChap... J- Copyright No.\\nShellJ\\n_ I 5\\nUNITED STATES OF AMERICA.", "height": "4344", "width": "2664", "jp2-path": "practicaltreatis00muss_0_0002.jp2"}, "3": {"fulltext": "", "height": "4388", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0003.jp2"}, "4": {"fulltext": "", "height": "4364", "width": "2652", "jp2-path": "practicaltreatis00muss_0_0004.jp2"}, "5": {"fulltext": "", "height": "4400", "width": "2660", "jp2-path": "practicaltreatis00muss_0_0005.jp2"}, "6": {"fulltext": "", "height": "4380", "width": "2652", "jp2-path": "practicaltreatis00muss_0_0006.jp2"}, "7": {"fulltext": "PRACTICAL TREATISE\\nON\\nMEDICAL DIAGNOSIS\\nFOR STUDENTS AND PHYSICIANS.\\nBY\\nJOHN H. MUSSEE, M.D.,\\nPKOFESSOR OF CLINICAL MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA PHYSICIAN TO THE\\nPHILADELPHIA AND THE PRESBYTERIAN HOSPITALS; CONSULTING PHYSICIAN TO THE WOMAN S\\nHOSPITAL OF PHILADELPHIA AND TO THE WEST PHILADELPHIA HOSPITAL FOR WOMEN\\nFELLOW OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA; MEMBER\\nOF THE ASSOCIATION OF AMERICAN PHYSICIANS, ETC.\\nTHIRD EDITION, REVISED AND ENLARGED.\\nILLUSTRATED WITH 253 WOODCUTS AND AS COLORED PLATES\\nLEA BROTHERS CO.,\\nPHILADELPHIA AND NEW YORK.", "height": "4412", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0007.jp2"}, "8": {"fulltext": "TWO COPIES RECEIVED.\\nLibrary of Congrftt*\\nOffice of the\\nN0V2818PQ\\nBegitUr of C\u00c2\u00abpyr!ffcf*\\n^V\\n48625\\nEntered according to the Act of Congress, in the year 1899, by\\nLEA BROTHERS CO.,\\nIn the Office of the Librarian of Congress, at Washington. AH rights reserved.\\nSECOND COPY.\\nDOENAN, PRINTER,\\nPHILADELPHIA.", "height": "4384", "width": "2652", "jp2-path": "practicaltreatis00muss_0_0008.jp2"}, "9": {"fulltext": "to\\nTO THE\\nMEMOEI OF MY FATHER\\nBENJAMIN MUSSER, M.D\\nMY GRANDFATHER\\nMARTIN MUSSEE, M.D.", "height": "4396", "width": "2648", "jp2-path": "practicaltreatis00muss_0_0009.jp2"}, "10": {"fulltext": "", "height": "4396", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0010.jp2"}, "11": {"fulltext": "PREFACE TO THIRD EDITION.\\nThe appearance of a third edition seems to justify the author s\\nconvictions expressed in the preface to previous editions concerning\\nmethods of diagnosis.\\nThe present issue has been largely rewritten and rearranged. The\\nrecent advances in methods of diagnosis which have proved to be\\nreliable have been added.\\nI am indebted to many kind friends for valuable assistance. Dr.\\nJoseph Sailer rewrote the chapter on Nervous Diseases, arranging it\\nto conform with the body of the book. Dr. William C. Posey wrote\\nthe section on Diseases of the Eye. Dr. Thomas S. Kirkbride, Jr.,\\nwrote the pages on the Pictoric Records of Physical Signs, and spared\\nneither time nor labor in the preparation of the new plates. Dr.\\nW. S. Smith, of Boston, most kindly revised the section on Sputum,\\nmaking valuable additions. Dr. Fred. H. Howard rendered valuable\\nassistance and prepared the index. Finally, I am indebted to my\\nsecretary, Miss Fannie V. Coe, for valuable assistance rendered while\\nthe work was passing through the press.\\n1927 Chestnut Street, Philadelphia.", "height": "4408", "width": "2684", "jp2-path": "practicaltreatis00muss_0_0011.jp2"}, "12": {"fulltext": "", "height": "4388", "width": "2664", "jp2-path": "practicaltreatis00muss_0_0012.jp2"}, "13": {"fulltext": "PREFACE TO SECOND EDITION\\nSuccess in treatment requires both accuracy and completeness\\nin diagnosis. Partial knowledge of the nature of the case differs\\nmerely in degree from ignorance, and treatment based on either\\ninvites chances unjust alike to the patient and to the interests of the\\nphysician.\\nDiagnosis, being a practical art, should be held to include not\\nmerely the recognition of a disease or a complication of diseases,\\nbut also a determination of the health-value of the patient. Thus\\nin a case of pneumonia not only should the presence of the malady\\nbe established, but the functional condition of all the organs should\\nalso be investigated, in order that rational treatment may be pre-\\nscribed and a rational prognosis given. In other words, the physi-\\ncian should never forget that a patient is a unit, comprising closely\\ninteracting organs, and that the response to treatment will be satis-\\nfactory in proportion to its adaptation to the condition of the entire\\norganism. After twenty years of experience as a general practi-\\ntioner, a hospital physician, and later as a consultant, the writer\\nis confirmed in the conviction that success in treatment follows only\\nupon diagnosis of the most comprehensive character, and, further-\\nmore, that the status prcesens should be clear to the physician, not\\nonly at the outset, but also at every stage of the disease.\\nThe first edition of this work was prepared with these ideas of\\ncompleteness in view, and its early exhaustion is gratifying as an\\nevidence that practitioners and teachers recognize the vital impor-\\ntance of complete diagnosis, and have given their approval to an\\nearnest effort to present a knowledge of it in available form.\\nThis opportunity for revision has been conscientiously utilized,\\nand the new edition will be found to embody the latest approved\\nadvances and the newly established facts and methods in this most", "height": "4416", "width": "2656", "jp2-path": "practicaltreatis00muss_0_0013.jp2"}, "14": {"fulltext": "Vlll\\nPREFACE TO SECOND EDITION.\\nactive and ^practical branch of medicine. The series of illustrations,\\nwhich was already unusually large for a work of this character, has\\nbeen enriched with many new engravings and colored plates. The\\nauthor can claim to have been a most critical student of his own\\nbook, and likewise to have profited by the criticisms of other teachers\\nand practitioners.\\nAlthough there is no royal road to diagnosis, either through\\ncompends or more or less elaborate catalogues of diseases which aid\\nthe memory at the expense of comprehension and judgment, a\\nserious study of the subject is repaid in the acquisition of a most\\nvaluable power. Modern research has placed this fundamental\\nbranch upon the plane of an exact science, and has correspondingly\\nelevated the whole superstructure of medicine. Instruments and\\nmethods of precision, physical, chemical, microscopical, and bio-\\nlogical, are now so readily at the command of every practitioner\\nthat he is legally as well as morally bound to exhibit in his diag-\\nnosis and treatment a degree of certainty far greater than could\\nformerly have been exacted.\\nIn conclusion, it has been the primary purpose of this book to\\ndeal with the whole subject of diagnosis in its present state of\\ndevelopment in clear language and with abundant illustration, to\\nafford the practitioner a consultant upon which he might rely, and\\nto present the facts and principles in such a manner as to give\\nthe undergraduate and postgraduate student a rational grasp and\\npractical working knowledge of this fundamental science and art.\\nThe author takes this opportunity of acknowledging his renewed\\nindebtedness to his friend, Dr. H. B. Allyn, for valuable assistance\\nwhile the work was going through the press; to Dr. J. Allison\\nScott for the care and patience he took in supervising the production\\nof most of the drawings and for suggestions in the chapter on Dis-\\nof the Kidney; to Dr. Joseph Sailer, Dr. J. Dutton Steele,\\nand Dr. James Ely Talley for timely suggestions and great aid in\\nverifying references. To Mrs. Philip Putnam Chase the author is\\nunder obligations for the skill and patience required in the execu-\\nti .11 of many of the drawings.\\nStreet, Philadelphia,\\nOctober, 1896.", "height": "4396", "width": "2672", "jp2-path": "practicaltreatis00muss_0_0014.jp2"}, "15": {"fulltext": "PREFACE TO FIRST EDITION.\\nModern methods of medical education demand that the student\\nshould be taught the expressions of morbid action, or, in other words,\\nthe phenomena of disease. He must be brought into contact with\\nthem in the hospital-ward and the outpatient-room, which are the\\nmedical laboratories where all the data are collected, analyzed, and\\nused in discriminating the various disorders.\\nThe object of this volume is to aid the student in the pursuit\\nof such laboratory-studies, and at the same time to furnish the prac-\\ntitioner with a reliable practical guide to diagnosis for use in his\\ndaily work. It has been thought best to combine in these pages\\nthe study of the objective phenomena or .signs of disease, the subjec-\\ntive phenomena or symptoms, and the methods employed for their\\ndetermination. Special attention has been paid to research for objec-\\ntive phenomena appearing in physical, chemical, and biological changes\\nin the tissues and secretions. The necessity for elaborate descriptions\\nor extended lists of minutiae as guides to differentiation is being rap-\\nidly displaced by the use of instruments of precision. Formerly,\\nfor instance, extensive tables were displayed to indicate the differen-\\ntial diagnostic features of anaemia and chlorosis now a few moments\\nexamination of the blood decides the nature of the affection, and\\nwhether iron or arsenic is to be given for its cure.\\nThe following pages bear evidence that the author does not under-\\nvalue the direct and collateral data obtained by inquiry. Without\\nthem an examination carefully conducted according to all other\\nmethods may go for naught in the distinction of disease.\\nThe association of morbid processes with their phenomena is a prac-\\ntice of the utmost importance to students, and a chapter has there-\\nfore been inserted upon the Symptomatology of Morbid Processes.\\nBacteriological Diagnosis has become an established method by which", "height": "4416", "width": "2648", "jp2-path": "practicaltreatis00muss_0_0015.jp2"}, "16": {"fulltext": "x PREFACE TO FIRST EDITION.\\nvarious disorders are recognized, and it is essential that the procedures\\nin this new means of research should be fully outlined. The chapter\\non this subject is included not merely as a guide and reference for\\nthe trained student, but it is hoped that it will also emphasize the\\npossibilities of bacteriological studies, and inspire those who are them-\\nselves without facilities for prosecuting laboratory-work to have exam-\\ninations made for diagnostic purposes by experts with laboratories at\\ntheir command.\\nMy best thanks are due to my associate in private and hospital\\nwork and teaching, Dr. H. B. Allyn, for assistance without which\\nthis book could not have been written to Dr. H. Toulmin for aid in\\nthe collaboration of the sections devoted to the examination of Sputum\\nand Feces to Dr. Charles Burr, of the Infirmary for Nervous Dis-\\neases, for the articles on Cerebral and Spinal Localization and on\\nElectrical Diagnosis and to Drs. Joseph Sailer, W. H. Fenn, and\\nJ. E. Talley, for valuable assistance.\\nFortieth and Locust Streets, Philadelphia,\\nFebruary, 1894.", "height": "4396", "width": "2672", "jp2-path": "practicaltreatis00muss_0_0016.jp2"}, "17": {"fulltext": "CONTENTS\\nPART I.\\nGENERAL DIAGNOSIS.\\nCHAPTER I.\\nGeneral Observations.\\nPAGES\\nThe data upon which a diagnosis is based The data obtained by inquiry.\\nThe data obtained by observation. Object of diagnosis Requirements on\\nthe part of the student Methods of diagnosis Direct. Indirect (by exclu-\\nsion). Differential Diagnosis sometimes impossible. Avoid haste\\nDiagnosis should not be limited Modern diagnosis Case-record Scope\\nof the present volume 17-23\\nCHAPTER II.\\nThe Data Obtained by Inquiry.\\nThe Social History: Age, sex, occupation, habits, residence (past and\\npresent family relations, exposure to contagion. The Family History:\\nParents, grandparents, brothers and sisters of each brothers and sisters of\\npatient wife and children. The History of Previous Diseases. The History\\nof the Present Disease Duration. Mode of onset. Evolution of the disease 24-31\\nCHAPTER III.\\nThe Data Obtained by Inquiry {Continued).\\nThe Present Condition The subjective symptoms Mode of determina-\\ntion Their fallacy \u00e2\u0080\u0094Their value. Feigned disease. Local Subjective Symp-\\ntoms General Subjective Symptoms 32-35\\nCHAPTER IV.\\nThe Data Obtained by Inquiry and by Observation (Continued).\\nPain 36-58\\nCHAPTER V.\\nThe Data Obtained by Observation.\\nThe objective symptoms correspond to phenomena in nature. Method of\\nprocedure; method of the observer. Inspection, palpation, percussion. The\\ninstruments required 59-63", "height": "4416", "width": "2660", "jp2-path": "practicaltreatis00muss_0_0017.jp2"}, "18": {"fulltext": "xii CONTENTS.\\nCHAPTER VI.\\nThe Data Obtained by Observation {Continued).\\nPAGES\\nThe first sight impressions. General abnormal vital conditions. Fits or\\nSeizures. Coma. Collapse. Shock. 1. The personal appearance. 2. The\\napparent age. 3. The temperament and constitution. 4. The attitude and\\ngait. 5. The general for m and nutrition. The size enlargement, diminution.\\nThe weight 64-79\\nCHAPTER VII.\\nThe Data Obtained by Observation (Continued).\\nThe face the facial expression. The head. Mumps\u00e2\u0080\u0094 facial hemiatrophy.\\nHydrocephalus. The hair. The lips. The neck\u00e2\u0080\u0094 the thyroid gland exoph-\\nthalmic goitre the bloodvessels of the neck 80-90\\nCHAPTER VIII.\\nThe Data Obtained by Observation (Continued).\\nThe Eye and Ear 91-109\\nCHAPTER IX.\\nThe Data Obtained by Observation (Continued).\\nThe extremities hands. The shape temperament occupation claw-\\nhands u seal-fin hands rheumatoid arthritis nervous affections\\nspade hands\u00e2\u0080\u0094 large bones of acromegalia osteo-arthropathy wrist-drop.\\nThe movements spasm tremor. The skin color moisture. Fingers.\\nHeberden s nodosities contraction of fascia Dupuytren s contraction de-\\nviation in shape The nails. Trophoneuroses cold hands and feet. Ray-\\nnaud s disease -erythromelalgia 110-118\\nCHAPTER X.\\nThe Data Obtained by Observation (Continued).\\nThe skin. The color redness pallor jaundice cyanosis the bronzed\\nskin Addison s disease hemochromatosis chloasma tinea versicolor\\nvagabond s disease argyria freckles. The nutrition. Moisture and dry-\\nness\u00e2\u0080\u0094 hyperidrosis anhidrosis. Scars. Hemorrhages mode of recogni-\\nnition cause significance. Eruptions their clinical significance nature\\nof the lesion distribution associate morbid phenomena general symp-\\ntoms. Table of skin diseases erythema nodosum urticaria medicinal\\nrashes erythema of infectious diseases roseola milaria or sudamina.\\nGeneral diagnosis 119-147\\nCHAPTER XI.\\nThe Data Obtained by Observation\u00e2\u0080\u0094 (Continued).\\nThe subcutaneous connective tissue. (Edema causes mode of recognition\\nsituation\u00e2\u0080\u0094 feet, face, arms, and head oedema of trichinosis\u00e2\u0080\u0094 angioneurotic\\noedema. Myxoedema. Connective-tissue dystrophies. Scleroderma. Sar-\\ncomata cysticercus cellulosae brawny induration. Subcutaneous nodules.\\nThe lymphatic glands. Enlargements local general. Adenitis. Hodgkin s\\ndisease. Tuberculosis and leukaemia 148-162", "height": "4416", "width": "2688", "jp2-path": "practicaltreatis00muss_0_0018.jp2"}, "19": {"fulltext": "CONTENTS. xiii\\nCHAPTER XII.\\nThe Data Obtained by Observation\u00e2\u0080\u0094 {Continued).\\nPAGES\\nThe muscles idiopathic muscular atrophy pseudo-hypertrophy\u00e2\u0080\u0094 Thorn-\\nsen s disease paramyoclonus multiplex. Myositis myalgia muscular\\nrheumatism 163-168\\nCHAPTER XIII.\\nThe Data Obtained by Observation [Continued).\\nThe bones general examination. Enlargement acromegaly\u00e2\u0080\u0094 osteitis de-\\nformans pulmonary osteo- arthropathy diminution rhachitis osteomalacia.\\nLocal examination position and shape nodes inflammation osteomye-\\nlitis 169-190\\nCHAPTER XIV.\\nThe Data Obtained by Observation (Continued).\\nChills fever subnormal temperature 190-208\\nCHAPTER XV.\\nThe Data Obtained by Observation (Continued\\nFever. The Intoxications 209-216\\nCHAPTER XVI.\\nThe Data Obtained by Observation (Continued).\\nFever. The Infections. Causal relation of bacteria to disease, Koch s\\nlaws, value in diagnosis. Bacteria Saprophytes, parasites, pathogenic, non-\\npathogenic, aerobic, anaerobic, facultative anaerobic. Morphology: Micro-\\ncocci, bacilli, spirilla Micrococci. Morphology Form and size. Repro-\\nduction, fission grouping. Biological characters Non-motile. Pigment\\nproduction. Liquefaction of gelatin. Production of acids. Toxic ptomaines\\nand toxalbumins Bacilli. Morphology Form and size. Reproduction,\\nfission, spores grouping. Biological characters: Motility. Pigment pro-\\nduction. Liquefaction of gelatin. Production of acids. Putrefaction, fer-\\nmentation. Spirilla. Morphology Form and size. Reproduction, fission\\ngrouping. Biological characters. Motility. Pigment-production. Lique-\\nfaction of gelatin. Production of acids and fermentation wanting 217-222\\nCHAPTER XVII.\\nThe Data Obtained by Observation (Continued).\\nFever. The Infections. Data obtained by inquiry By observation.\\nLocal infection General infection. Pyaemia septicemia. Terminal infec-\\ntions. Fever in carcinoma. Afebrile infections. Infections of certain bac-\\nteriology of uncertain bacteriology. Bacteriological diagnosis. Method of\\nresearch Microscopical examination, cultivation, inoculation. Essentials\\nin technique\u00e2\u0080\u0094 Method of research: Blood, discharges, exudations; mode of\\ncollection. Apparatus. Preparation of apparatus. Sterilization. Micro-", "height": "4416", "width": "2656", "jp2-path": "practicaltreatis00muss_0_0019.jp2"}, "20": {"fulltext": "XIV\\nCONTENTS.\\nscopical examination Technique, cover-glass preparations. Methods of\\nstaining spores. Hanging drop cultivation of micro-organisms. Cul-\\nture-media. Tube- and plate-cultures. Smear- and stab-cultures Inocu-\\nlation of animals Special bacteriological diagnosis\\n223-245\\nCHAPTER XVIII.\\nThe Data Obtained by Observation (Continued).\\nFever. The infectious diseases. Infections not recognized by bacterio-\\nlogical or blood examination 246-273\\nCHAPTER XIX.\\nThe Data Obtained by Observation (Continued).\\nFever. The infectious diseases. Infections recognized by examination\\nof the blood\\n274-308\\nCHAPTER XX.\\nThe Data Obtained by Observation (Continued).\\nFever. The infectious diseases. Infections recognized by the examina-\\ntion of excretions and secretions or by the products of the infectious inflam-\\nmations\\n309-356\\nCHAPTER XXI.\\nThe Data Obtained by Observation (Continued).\\nExploratory puncture or aspiration for diagnosis: Instruments. Preparation\\nof instruments. Preparation of skin. Point of puncture. Exudations (Pus-\\nSero-pus. Gangrenous debris. Blood. Serum. Chyle) Pus. Blood-\\ncorpuscles. Bacteria. Protozoa. Vermes. Crystals Chemical examina-\\ntion: Sero-purulent exudations. Putrid exudations. Hemorrhagic exu-\\ndations. Serous exudations. Chylous exudations. Pleural effusions. Trans-\\nudations. The contents of cysts Hydatid, ovarian, renal, pancreatic\\n357-368\\nCHAPTER XXII.\\nThe Blood\\n369-399\\nCHAPTER XXIII.\\nThe Morbid Processes and their Symptomatology.\\nKnowledge of symptoms of morbid processes essential they control con-\\nclusions drawn from data. Morbid processes are few. I. Alterations in\\nblood and circulation. Anaemia and plethora Hyperemia, active and\\npassive (Edema and dropsy Thrombosis and embolism Hemorrhage\\nBlood-pressure. II. Disturbances of nutrition: Inflammation Gangrene\\nand necrosis Fever\u00e2\u0080\u0094 Atrophy and hypertrophy. Degenerations: Albu-\\nminous Fatty Colloid\u00e2\u0080\u0094 Mucous Pigmentary Calcareous Amyloid\\nFibroid. III. Anomalies of growth Tumors\u00e2\u0080\u0094 Cysts Cancer\\n400-416", "height": "4416", "width": "2648", "jp2-path": "practicaltreatis00muss_0_0020.jp2"}, "21": {"fulltext": "CONTENTS. xv\\nPART II.\\nSPECIAL DIAGNOSIS.\\nCHAPTER I.\\nPAGES\\nThe Nose and Larynx 417-449\\nCHAPTER II.\\nDiseases of the Lungs and Pleurae 450-579\\nCHAPTER III.\\nDiseases of the Heart, the Bloodvessels, and the Mediastinum 580-685\\nCHAPTER IV.\\nDiseases of the Mouth, Fauces, Pharynx, and (Esophagus 686-724\\nCHAPTER V.\\nDiseases of the Stomach, Intestines, and Peritoneum 725-853\\nCHAPTER VI.\\nDiseases of the Liver, Spleen, and Pancreas 854-899\\nCHAPTER VII.\\nDiseases of the Kidneys 900-968\\nCHAPTER VIII.\\nDiseases of the Nervous System 969-1062", "height": "4416", "width": "2660", "jp2-path": "practicaltreatis00muss_0_0021.jp2"}, "22": {"fulltext": "ERRATA\\nPage 203, third line from top, omit disease after malingering.\\nPage 230, twelfth line from bottom, for moist, read most.\\nPage 268, seventh line from bottom, for in a week, read in about three weeks.\\nPage 272, fourth line from bottom, insert actinomycosis after glanders.\\nPage 277, fifth line, omit the comma after malignant.\\nPage 282, fourth paragraph, second line, for four hours, read forty-eight hours.\\nPage 284, third line from top, for roseate read rosette.\\nPage 289, third paragraph, fifth line, insert combined after ulceration.\\nPage 299, third line from bottom, for forms are decreased, read forms are rela-\\ntively increased.\\nPage 305, fourth paragraph, fifth line, for 1 to 5, read 1 to 50.\\nPage 359, thirteenth line from bottom, for intercellularis, read intracellulars.\\nPage 369, sixth line from bottom, for identity, read entity.\\nPage 373, fifteenth line from bottom, for value, read volume.\\nPage 386, third paragraph, first line, for acidity of blood, read alkalinity of\\nblood in both places.\\nPage 489, fifth line from top, insert tissue after pulmonary.\\nPage 491, thirteenth line from top, for implies, read applies.\\nPage 496, fifth line from top, for tympanite read tympanitic.\\nPage 611, second paragraph, third line, for distended read distending.\\nPage 821, fourth line from top, for tubules read intestines.", "height": "4412", "width": "2672", "jp2-path": "practicaltreatis00muss_0_0022.jp2"}, "23": {"fulltext": "MEDICAL DIAGNOSIS.\\nPART I.\\nGENERAL DIAGNOSIS.\\nCHAPTER I.\\nGENERAL OBSERVATIONS.\\nThe data upon which a diagnosis is based The data obtained by inquiry. The data\\nobtained by observation. Object of diagnosis Requisites on the part of the\\nstudent Methods of diagnosis Direct. Indirect (by exclusion). Differential\\nDiagnosis sometimes impossible. Avoid haste Diagnosis should not be lim-\\nited Modern diagnosis Case records Scope of the present volume.\\nThe sufferings of one avIio comes under the care of a physician are\\nindicated by symptoms of which the patient himself is cognizant, and\\nfor which usually he applies for relief or by alterations of the physical\\nor chemical structure of the whole or a part of the body, or of the\\nfunctional activity of organs alterations which, although not apparent\\nto him, are evident to the observer, the physician. The symptoms of\\nwhich the patient complains, and of which he alone has knowledge,\\nare known as the subjective symptoms of disease. The symptoms which\\nthe physician observes, some of which, as the changes of the exterior,\\nmay be apparent to the patient, are known as the objective symjrfoms of\\ndisease.\\nThe subjective symptoms of disease, as well as such objective symp-\\ntoms as the patient is aware of, have a history. It may be the brief\\none of sudden onset, or a long one of rise and fall, of ebb and flow, of\\nthe mingling of complex phenomena from time to time. The story of\\nthe evolution of the disease is written as the history of the present\\nThe present disease may be due to previous attacks of disease, or be\\nmodified by the occurrence of previous disease. We may be consulted\\nfor the effects of one link in a chain of morbid disorders which began\\nin infancy or early adult life. We should learn, therefore, of the occur-\\nrence of previous disease. Certain types of constitution and some few\\ndiseases are transmitted by parents to offspring we should, therefore,\\ninquire into the family history. A further insight into the nature of\\nthe suffering may be obtained by a knowledge of the age, sex, habits,\\n2", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0023.jp2"}, "24": {"fulltext": "18 GENERAL DIAGNOSIS.\\noccupation, environment, etc. in short, by a knowledge of the social\\nhistory for, if the cause of the disease under consideration is deter-\\nmined, a distinction from other affections with allied phenomena can\\nfrequently be made.\\nThe subjective symptoms, the history of the present disease, the previous\\nhistory, the family history, and the social history are learned by inquiry\\nof the patient or the friends of the patient by methods and within\\nlimitations hereafter to be described. It is proper that they should be\\nascertained, if practicable, before the objective symptoms are studied.\\nAfter the story of the patient is ascertained in full, the objective symp-\\ntoms are sought for. Examination of the patient by the use of the\\nsenses of sight, of touch, of hearing, with the instruments of precision\\nto aid them the physical examination and by chemical and bacteri-\\nological methods, reveals the presence or absence of the latter class of\\nsymptoms.\\nThe phenomena of disease are ascertained, therefore, by inquiry\\nand by observation. The facts or data thus collected and the dis-\\ncriminate interpretation of them constitute diagnosis.\\nObject of Diagnosis. The object of diagnosis is to determine the\\ncondition of the living patient who may be suffering from disease. It\\nimplies not only that the phenomena of disease are detected, but also\\nthat the effects of the disease on the organism are determined, and\\nthat the morbid process which is the cause of the phenomena is ascer-\\ntained. Even this is too restricted an idea of diagnosis. It should\\ninclude also the recognition of the cause of the morbid process. The\\nlatter is known as the etiological diagnosis. In addition to naming the\\ndisease and its cause we should include in the diagnosis a determina-\\ntion of the stage of the disease and the recognition of its complications.\\nMoreover, diagnosis implies such knowledge of the patient s condition\\nas to enable an estimation of the dangers liable to arise and of the\\noutcome of the disease the prognosis.\\nDiagnosis is not made in order to give the disease a name alone but\\nto treat it, and as it is not disease that we treat but a patient with an\\nailment, full knowledge of the patient and of his environment, his\\nmode of life, habits, occupation, etc., must be obtained by inquiry.\\nThe practical result of diagnosis is the ability to remove or prevent\\nthe occurrence of the morbid processes, or to mitigate their effects by\\nrational therapeutics.\\nRequisites on the Part of the Student. As data are to be col-\\nlected by inquiry and by observation, it is obvious that he who would\\ninquire and observe intelligently and successfully must be possessed of\\nknowledge and qualifications of a high order. The phenomena of\\nhealth must be familiar to him. He must have a full knowledge of\\nphysiology, to recognize the aberrations of function, and of pathology, to\\nunderstand the production of symptoms by disease. He must know\\nthe organic results of pathological processes morbid anatomy. He\\nmust have learned, by reading and experience, the significance of symp-\\ntoms, or of groups of symptoms, and their relation to morbid processes.", "height": "4400", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0024.jp2"}, "25": {"fulltext": "GENERAL OBSERVATIONS. 19\\nHe must have a knowledge of the evolution of disease and the phe-\\nnomena of each period in its development, to secure an accurate account\\nof the disease under consideration. He must know the influence of\\nmorbid processes on the body and their effect in the production of sub-\\nsequent disease, in order to ascertain correctly the various diseases of\\nthe patient and infer rightly their relation to the phenomena under\\nconsideration. The significance of the family history can be appreciated\\nand correctly applied only by a knowledge of the diseases which are\\ninherited or which arise in certain physical types of individuals, which\\ntype is inherited. The social history is not worth securing unless the\\ninquirer knows the influence of age and sex, of race, of occupation, of\\nhabits, of residence, of degree of labor, in the development of disease,\\nor the influence of the environment on the individual the action and\\nreaction of external forces on forces within.\\nTo ascertain the objective symptoms, he who would observe properly\\nmust knoAV anatomy, to recognize the seat of the disease, and physiology,\\nto discern the departures from health. He must be trained at the bed-\\nside in the use of the senses, and know how to discriminate and inter-\\npret phenomena observed by them. He must know how to use instru-\\nments of precision, as the microscope, and must learn its revelations.\\nThe laws of chemistry and the methods of chemical examination must\\nbe familiar to him. Bacteriology and the data obtained from its\\nmethods must be appreciated fully.\\nIt is thus seen that the inquirer must have knowledge gained by\\nreading and knowledge gained by observation at the bedside and in the\\npost-mortem room. He acquires thus, on the one hand, the recorded\\nexperience of others, and learns that certain symptoms under certain\\ncircumstances indicate a definite malady. On the other hand, he learns\\nthat certain symptoms are associated with definite lesions.\\nMethods of Diagnosis. But we must not only secure facts, we\\nmust also be able to utilize them for analysis and induction the result\\nof which is the formation of the diagnosis. The diagnosis is obtained\\nby three methods the direct, the indirect, and the differential. By the\\ndirect method the data collected are sufficient to warrant a positive con-\\nclusion. An indirect diagnosis is made by exclusion. A symptom\\ngroup may represent several diseases. Each affection is passed in\\nreview and excluded until one is found to correspond more closely to\\nthe data of the case under consideration. It is not one, because of the\\nabsence of certain symptoms it is not another, because of the presence\\nof certain essentially different symptoms. A negative is thereby\\nproven. By the differential method the diagnosis of one of a few pos-\\nsible diseases must be made, the data for and against which are passed\\nin review. The direct method is scientific, rational, and the most prac-\\ntical. It is a process of pure inductive reasoning.\\nDiagnosis Sometimes Impossible. Notwithstanding our efforts\\nto collect data by inquiry and by observation, we are often unable to\\nmake a diagnosis. This arises when premises are wanting for the pro-\\ncess of induction. The subjective symptoms may not tally with the", "height": "4408", "width": "2676", "jp2-path": "practicaltreatis00muss_0_0025.jp2"}, "26": {"fulltext": "20 GENERAL DIAGNOSIS.\\nknown processes of disease, or the narrator of the history of the present\\ndisease may omit important evidence from lack of memory or knowl-\\nedge, from design, or for other reasons. The objective phenomena may\\nbe developed in an ill-defined way, or they may be obscure, as the state\\nof the abdominal contents in a person who is obese or they may point\\nto one or more processes the subjective symptoms of which are not\\npresent. At the time of observation the disease may not have devel-\\noped fully, may not have spelled itself out. Under these circum-\\nstances a provisional diagnosis must be made or conclusions held in\\nabeyance. If we are considering a contagious disease, for sanitary\\nreasons, the infectious disease should be given the benefit of the doubt.\\nIf, on the other hand, the disease requires prompt remedial action, the\\nsymptoms must be taken as the indication for therapy.\\nAvoid Haste. If prompt action is not required, too great haste\\nshould be avoided. It is not necessary to make a diagnosis at once,\\nand it is not a confession of ignorance if time is asked before an opinion\\nis given. Repeated observation and reflection should be employed\\nbefore a conclusion is arrived at. This particularly applies to the class\\nof cases which represent a condition the resultant of improper environ-\\nment, for the proper detection of which social data, knowledge of tem-\\nperament, etc., must be acquired. Then, again, it may be necessary to\\nobserve the patient under changed circumstances, or study the effects\\nof diet on renal secretion, or on the function of other organs. Haste\\nleads to faulty diagnosis, and therefore to misdirected therapeusis.\\nDiagnosis Should Not be Limited. It is not sufficient to give a\\nname to a group of symptoms and be satisfied that the diagnosis is\\nmade. Every method must be used to collect data. The exact physi-\\ncal condition of the patient must be ascertained and the functional\\npowers of all the organs correctly determined. We thus learn if the\\nmore evident disease is the single expression of a morbid process, or if\\nit is the surface storm, the currents of which are underneath. A pleu-\\nrisy or pneumonia may be the outcome of or complicate a latent\\nnephritis. A peritonitis may be the sequela of an appendicitis or pyo-\\nsalpinx. Or diseases in two or more organs, due to the same process,\\nmay exist at the same time, as suppurative pleuritis and pericarditis.\\nIt would not be sufficient to recognize one of the affections alone.\\nFor purposes of treatment it is not sufficient to recognize a neuralgia\\nor a spasm. The state of the patient on account of which the neuralgia\\ndeveloped must be ascertained. Attention must be called to the im-\\nportance of not being lulled into a false security by the belief that the\\ndiagnosis of the first day is sufficient. Complications may arise or the\\nmorbid process invade new territory. Thus, in the course of pneu-\\nmonia, in a few days a meningitis may arise or an ulcerative endocar-\\nditis ensue.\\nModern Diagnosis.. Anyone who takes the trouble to recall the\\nmethods of diagnosis that were in use twenty years ago will be struck\\nby the wonderful expansion of the means now at hand to unravel the\\nmysteries of disease. Then a few instruments of precision and a few", "height": "4400", "width": "2664", "jp2-path": "practicaltreatis00muss_0_0026.jp2"}, "27": {"fulltext": "GENERAL OBSERVATIONS. 21\\nchemical reagents were required. The microscope was employed to\\nexamine only a few of the excretions and the blood. Now the instru-\\nments of precision are multiplied and the scope of their explorations is\\nincreased. 1 Chemistry, among other things, helps to fathom the mys-\\nteries of gastric disease. The microscope has extended its domain,\\nand, with the new methods of staining fluids and tissues, has become\\nthe key that unlocks many of Nature s secrets. The new science of\\nbacteriology has come to our aid, and now instead of waiting to estab-\\nlish a diagnosis until an epidemic counts its victims by hundreds it is\\nobtained at once.\\nCertainty in diagnosis, for these reasons, has made a decided advance.\\nThe number of diseases which can be positively diagnosticated has in-\\ncreased. Methods of investigation and new instruments of precision\\nare increasing daily. May we not hope that in the future the horizon\\nof absolute knowledge will be extended far beyond its present limits\\nNew instruments and new methods will surely avail.\\nThe use of the large number of instruments that are essential, and\\nthe chemical and bacteriological examinations that are made, require\\na great deal of time. Often the diagnosis is a question of hours or\\neven of days. The patient profits thereby. The tax on the physician\\nis far greater than it was a few years ago. The bedside labor is great,\\nand, in addition, he must haye a laboratory at his command for micro-\\nscopical, chemical, and bacteriological work. The outcome is that the\\nscientific physician must have a clientele limited in number, or else have\\none or more assistants to aid him in his investigations. Without doubt\\nthe latter will soon occur. Not as in days of old will we find in the\\npractitioner s office the apprentice, compounding drugs and rolling\\nbandages, assisting in the operations of bleeding and dressing ulcers,\\nbut the highly trained, scientific assistant, who by labors in the labora-\\ntory and at the bedside is competent to collect data suitable for scien-\\ntific methods of reasoning.\\nCase Records. Records of cases should be kept for obvious reasons.\\nThe habit compels a general survey of the case, and tends to prevent\\noversight in the examination. It naturally aids in the training of the\\npowers of observation. It teaches precision in the narration of cases.\\nThe memory is aided by repetition and by lack of haste in ascertaining\\nphenomena. The data are on record for more mature reflection, and to\\naid in the study of the literature of similar cases. The record is of\\nvalue in case the patient returns for advice after a lapse of time. It\\nmay be of medico-legal value. The mental effect on the patient is\\ngood, for the taking of notes requires time and accurate studied obser-\\nvation. In case it is desired to study a large number of cases, records\\nare scientific data. The records may be kept on loose sheets and filed\\nfor future use. When a sufficient number are secured they may be\\nclassified and bound in volumes devoted to the various diseases, or\\nthey may be noted in a blank-book. At the end of the year the book\\n1 As a most simple illustration, witness the knee-jerk and reflexes, learned by per-\\ncussion, an old method, in extended use.", "height": "4416", "width": "2648", "jp2-path": "practicaltreatis00muss_0_0027.jp2"}, "28": {"fulltext": "22 GENERAL DIAGNOSIS.\\nis indexed according to the diseases and the names of the patients. A\\nbetter method is by a system of cards. The cardboard should be six\\nby eight inches. One card is devoted to each case, although more can\\nbe used. They are arranged and catalogued according to the library\\nsystem of card catalogues.\\nMethod of Record. A systematic plan must be pursued in noting\\nthe cases. It need not correspond to the lines of inquiry in the exami-\\nnation of the patient, which are modified by the circumstances of the case.\\nThe following outline explains itself. The various data should be\\nrecorded in sequence, and in such manner that the facts of each line of\\ninvestigation can be readilv culled for review and analvsis. (See Chap-\\nters II. and III.).\\nKECOKD OF CASE NO.\\nDiagnosis. Result.\\nName and residence, place of birth, and former residence.\\nI. Social history Age, sex, race, married or single, children, the number and\\nhealth miscarriages.\\nOccupation Present and previous home surroundings, sanitary conditions, etc.\\nHabits: Tobacco, alcohol, tea, narcotics; sexual habits; regularity of meals,\\ncharacter of food, and method of eating; number of hours of sleep, degree of\\nfatigue brain-use, exercise.\\nII. Family history Hereditary tendency health of parents, brothers, sisters,\\netc. Cause of death and age at which it occurred.\\nIII. Htstory of previous diseases Character of convalescence from syphilis\\nand gonorrhoea injuries.\\nIV. History of the present disease Date, mode of onset, and probable exciting\\ncause of present trouble evolution of the disease to date of examination.\\nV. The present condition\\nA. Inquiry The subjective symptoms.\\nB. Observation The objective symptoms.\\nExternal appearance, development, color, figure, height and weight, attitude,\\nexpression of face.\\nTemperature, perspiration, eruption, swelling. Condition of limbs and joints.\\nExamination of the digestive apparatus Mouth, tongue, gums, and pharynx\\nabdominal organs contents of stomach, faeces.\\nExamination of respiratory apparatus: Nose, mouth, and larynx. The lungs inspec-\\ntion, palpation, percussion, auscultation, mensuration. Cough and expectoration.\\nExamination of circulatory apparatus: Inspection and palpation of cardiac area\\npercussion, auscultation of heart; similar examination of arteries and veins;\\nthe pulse examination of the blood.\\nExamination of the urinary apparatus Kidneys, ureters, and bladder examina-\\ntion of urine.\\nExamination of the nervous system Intelligence, subjective nervous phenomena,\\nsleep, gait, station, reflexes, paralysis, tremor, pain, convulsions, headaches,\\ndisturbances of sensation, disturbance of speech. The organs of special sense.\\nExamination of fluids obtained by puncture.\\nBacteriological examination of blood, sputum, secretions, exudations, etc.\\nDiagnosis.\\nPrognosis.\\nTreatment.", "height": "4408", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0028.jp2"}, "29": {"fulltext": "GENERAL OBSERVATIONS. 23\\nHow to Use the Book for Diagnosis. We must anticipate a\\nlittle. The student can by ready reference make practical use of the\\nwork as the hand-book is used in the laboratory. It is supposed that\\nthe case has been thoroughly investigated, according to the directions\\nindicated in the book, and the data arranged in accordance with the\\ncase record. An analysis of the data is then made. The value of\\nthat obtained by inquiry and that obtained by observation is carefully\\nconsidered. The diagnostic significance of the respective data may be\\nfound by consulting the index or by a review of the chapters devoted\\nto the special subject. An estimate of the value of the data obtained\\nby inquiry, including the subjective symptoms of disease, will be found\\nin the sections devoted to general diagnosis if the data are general\\n(Chapters II. to XXII. inclusive). If the data obtained by inquiry\\nrefer to special organs they will be estimated in the sections on special\\ndiagnosis that treat of the manifestations of disease in the respective\\norgans. In the same manner data obtained by observation that are of\\na general character are considered in the sections on general diagnosis.\\nData pointing to disease of special organs are considered in the chapters\\ntreating of the respective organs.\\nIt must be understood by the student that by general data we mean\\nsuch as may be expressive of the disease of various internal organs.\\nThus, the student of internal medicine examines the eye not with the\\nview of finding any special disease of that organ, but to note any\\nchanges, physiological or anatomical, which may have resulted from\\nprimary disease elsewhere. Diseases of the nervous system, of the\\nblood, of the heart, or of the kidneys may be expressed in eye altera-\\ntion of some kind. Similarly, the skin, the bones, and joints, as well\\nas other structures, are studied. Many internal diseases will have their\\noutward or physical expression in general anatomic change or in the\\nchange of one set of tissues. When this is the case the disease will\\nbe discussed when considering its most manifest external expression, as\\nmyxoedema under enlargements of the body and acromegaly under\\nbones and joints. The book is arranged, therefore, for diagnostic\\nconvenience and not for pathological classification.", "height": "4412", "width": "2660", "jp2-path": "practicaltreatis00muss_0_0029.jp2"}, "30": {"fulltext": "CHAPTER II.\\nTHE DATA OBTAINED BY INQUIEY.\\nThe Social History Age, sex, occupation, habits, residence (past and present), family\\nrelations, exposure to contagion. The Family History Parents, grandparents,\\nbrothers and sisters of each brothers and sisters of patient wife and children.\\nThe History of Previous Diseases. The History of the Present Disease Duration.\\nMode of onset. Evolution of the disease.\\nMode of Procedure. First the subjective symptoms of the disease\\nare elicited, so that, if necessary, measures may be directed for the\\npatient s relief at once, and that we may have the advantage of obser-\\nvation of the patient s intelligence, expression, etc., and at the same\\ntime ascertain the direction further inquiry should take, in order\\nthat embarrassment may pass oft and composure ensue before an\\nobjective examination is made. It seems preferable, however, to begin\\nthe record with the social history of the case, for a scientific and orderly\\nprocession in the data acquired, and then proceed to record the facts of\\nfamily history, previous history, and history of present disease. Cer-\\ntainly it is immaterial how they are considered in the following discus-\\nsion, and for convenience, therefore, the above order will be followed.\\nIt is to be remembered that the patient s complaints and the objective\\nphenomena or, if the patient is unconscious or otherwise unable to\\nspeak intelligently, the latter alone are the central threads around\\nwhich the diagnosis is woven.\\nThe Social History.\\nThe aid to diagnosis obtained from inquiry into the social history\\ncannot be considered exhaustively. Works on hygiene must be con-\\nsulted. General ideas will be given reference to the influence of\\nvarious factors will be found under the individual diseases. That\\nsuch data are of value is illustrated in various forms of colic. For\\ninstance, knowledge that the patient labored in lead ivill often simplify\\nthe diagnosis of the nature of this symptom.\\nThe Age. The age is learned, for each period in the evolution and\\ninvolution of life has its peculiar physiological processes susceptible to\\nvariations by external influences.\\nA large group of affections arise in the first period of infancy, from\\ninheritance or congenital malformations, from accidents incident to\\nparturition, and from improper management of the cord. In a later\\nperiod, in acquiring adaptability to environment, by the feebly resist-\\ning organism, disturbances of digestion from poorly prepared or improper\\nfood arise pulmonary disorders from improper clothing, ventilation,\\netc., occur. The developing nervous system has more acute suscepti-", "height": "4412", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0030.jp2"}, "31": {"fulltext": "THE DATA OBTAINED BY INQUIRY. 25\\nbilities, and hence a long array of reflex symptoms or diseases is ob-\\nserved at this period. Another group of diseases, the exanthemata, and\\nalmost all contagious diseases, are more prevalent in childhood, because\\nthey arise out of exposure to a specific cause which usually occurs\\nbefore the child attains many years. The anatomical arrangement of\\nthe larynx, disproportionately small, makes the diseases of that organ\\nmost frequent in childhood, and a serious factor in mortality.\\nAt puberty we see the perversions (from earlier years) liable to arise\\nas adolescence advances. Ansemia and chlorosis are prone to develop\\nat this period. In the middle period the diseases that arise from occu-\\npation, from exposure to external agencies, from habits, are seen.\\nMoreover, processes beginning in adolescence are reaching their acme,\\nand find expression in later life, as the cysts of hydatid disease, or renal\\ncalculi, or manifestations of gout. In later life degenerations of the\\nvascular and cerebro-spinal systems occur affections due to fibrosis,\\na resultant of wear and tear, as atheroma cancer calculous disease,\\nand other diseases prevail.\\nThe Sex. The prevalence of various diseases in the sexes in undue\\nproportion arises because of difference in the anatomical structure and\\nphysiological offices of the two, and because of the difference in expo-\\nsure to varying causal agencies. Diseases more common to the male\\nsex occur on account of occupation, from exposure, from over-activity\\nof mind and body, and, finally, from the formation of bad habits.\\nThe diseases of the female sex that are more prevalent, apart from their\\nown peculiar affections arising out of menstruation and childbearing,\\ntake place because of the more or less sedentary nature of their lives,\\nand hence, among other things, the opportunities for introspection.\\nHysteria, neurasthenia, and nerve disorders abound with them. Males\\nare more subject to epilepsy, gout, diabetes, locomotor ataxy, and vesi-\\ncal disease. Females are more subject to exophthalmic goitre, rheu-\\nmatoid arthritis, chorea, and the above-mentioned nervous disorders.\\nOccupation. This must be ascertained in the inquiry, for each\\noccupation demands effort in one particular direction, or compels expo-\\nsure to deleterious influences. Writer s cramp, eye-strain, and a series\\nof disorders thus arise. Knowledge of exposure to particular irritants,\\ncoal or fine particles of metal or stone, gases, chemicals, effluvia of all\\nkinds, and to diseases contracted from animals, is valuable in diagnosis.\\nThe manner and degree of employment of the mind must be inquired\\ninto.\\nIt is not to be forgotten that the occupation at different periods of\\nlife must be found out, the age at which life s battle began, and the\\ncircumstances that surrounded the early career. The deleterious influ-\\nence of a former occupation may be observed after the patient is in an\\nentirely different sphere of labor.\\nHabits. Habits as to clothing (catarrhal affections and rheumatism),\\nas to hours of rest and sleep (neurasthenia), as to character of food,\\ntime, regularity, and manner of eating (the indigestions, gout), as to", "height": "4416", "width": "2648", "jp2-path": "practicaltreatis00muss_0_0031.jp2"}, "32": {"fulltext": "26 GENERAL DIAGNOSIS.\\nexercise, and as to the use of alcoholic stimulants (cirrhosis of the liver,\\nneuritis, brain affections), of tobacco (amblyopia, cardiac palpitation),\\nof tea or coffee, of narcotics, must be inquired into. Methods of work,\\nmethods of recreation, domestic joys or sorrows, must be ascertained.\\nA knowledge of the habits, of the life (of the inner life, indeed) of\\nthe individual, is essential to a rational diagnosis, and hence a true\\ntherapeusis.\\nPlace of Residence and Dwelling. A knowledge of the place of\\nresidence is of service. Town residence and country residence, a resi-\\ndence in a damp locality, by the sea and in the mountains, in particular\\nvalleys, in different water-sheds, in tropical or frigid clime, each makes\\nan impress on the constitution, even if actual disease is not created.\\nHence malarial regions, goitre districts, localities in which individuals\\nhave to an unusual degree vesical calculi, or in which special epidemic\\ndiseases abound, as yellow fever, cholera, or dysentery, must be inquired\\nfor. Knowledge of the places of residence at different periods of life\\nand the duration of such is often important information.\\nThe situation and degree of comfort for habitation of the dwelling\\nmust be learned. The sanitary arrangements drainage, ventilation,\\nwater-supply, heating are to be scrutinized.\\nFamily Relations. Marriage and the number of children, with\\ntheir degree of health, must be recorded. If a woman, the number of\\nchildren born, the character of the labors, the number of miscarriages.\\nIs there trouble in the marital relation Has there been sorrow, or\\nsudden shock, or long nursing, or great care Are the financial cir-\\ncumstances easy Has there been recent malfeasance How many\\ninvalid women arise out of such ashes\\nQuestions so personal can only be put after long acquaintance, or\\ninformation obtained through judicious inquiry of friends.\\nFrequently more delicate questions must be put, as to masturbation\\nor excessive venery, but with great caution, and only when conditions\\ndemand it. In epileptiform convulsions, profound hysteria, neuras-\\nthenia, the development of locomotor ataxy, or spinal paralysis, prompt,\\nclear, manly questions as to these habits are to be put, not reference\\nmade to them in prudish or mawkish suggestion.\\nExposure to Contagion. If the suspected ailment partakes of the\\nnature of a contagious disease, the probability of exposure to the disease\\nmust be looked into and the presence of epidemics ascertained. The\\nperiod of incubation must be known in such cases. The prodromal\\nsymptoms must also be known.\\nThe Family History.\\nThis inquiry is instituted in order to determine the affections which\\nmay or may not be hereditary. We learn also the average duration\\nof life in the family and the relation of the mortality to the physio-\\nlogical epochs in life. Data of the latter character are of value in esti-", "height": "4412", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0032.jp2"}, "33": {"fulltext": "THE DATA OBTAINED BY INQUIRY. 27\\nmating the possible duration of life for purposes of life insurance, and\\nthey also throw light on abnormal conditions thus to learn that most\\nof the members of the family died of apoplexy at a comparatively early\\nage, or of aneurism or of arterial degenerations, is to learn that vascular\\nchanges developed earlier than usual. To secure accurate data, the\\nage and state of health of parents, brothers, and sisters, if living, are\\nascertained or, if dead, the cause of death and age at which it took\\nplace. Similar questions may be applied to several generations of the\\nfamily and to collateral branches.\\nInherited Diseases. Concerning the question of direct inheritance\\nof disease, but few are strictly so. Of these, nervous diseases are the\\nmost common, as progressive muscular atrophy, hereditary chorea,\\nThomsen s disease, Friedreich s ataxia, migraine, epilepsy, and forms\\nof insanity. The writer has seen chronic Bright s disease, or a state of\\nthe constitution that predisposes to it, occur in several generations\\nwithout the usual exciting causes of that affection. Syphilis may be\\ninherited. Haemophilia is the most striking affection that is trans-\\nmitted by inheritance. Generally it is not the diseases themselves that\\nare hereditary but types of tissue that predispose to disease, as in\\ntuberculosis or cancer or conditions of the organism that favor imper-\\nfect metabolism, as is seen in gout or rheumatism.\\nThe family physician, who comes in contact with one or more gener-\\nations, profits most by the knowledge of the family history. He learns\\nthe predisposition to various minor ailments to headaches and attacks\\nof indigestion, bilious attacks, for instance he learns the power of\\nresistance to disease in the family, or their capability to undertake\\nlarge duties in life he learns their susceptibility to drugs and their\\ntendency to take stimulants. Nerve force is the capital with which\\nthe battle of life is kept up. If it is at a minimum in groups of\\nfamilies, diseases or conditions of poor health due to its use a use not\\nexcessive in others arise.\\nContagious Diseases. In the inquiry it may be well to ascertain\\nthe probability of disease being transmitted from husband to wife, or\\nthe opposite. Syphilis and gonorrhoea and tuberculosis are examples.\\nNot only may this probability apply to the transmission of disease from\\nhusband to wife, but to its transmission along lines of families. Then,\\ntoo, we must inquire of mothers for the manifestations of syphilis in\\nthe children.\\nCaution must be exercised in the pursuit of knowledge of this kind,\\nas strained, or even ruptured, marital relations may result from injudi-\\ncious intimations.\\nMalignant Disease. Caution must be employed in order not to\\narouse family pride if evidence of scrofula is sought for, or to pro-\\nvoke undue alarm when inquiry into the family history of cancer is\\nmade. Disarm suspicion by inquiring for the symptoms of the disease\\nin various organs in which it may occur, as jaundice, uterine hemor-\\nrhage, etc., or ask about growths or tumors. Do not use the specific\\nterms, consumption and cancer.", "height": "4416", "width": "2652", "jp2-path": "practicaltreatis00muss_0_0033.jp2"}, "34": {"fulltext": "28 GENERAL DIAGNOSIS.\\nObscure Terms. Moreover, care must be exercised to secure defi-\\nnite data, not to over-estimate statements as to the cause of death being\\ndropsy, or jaundice, or cold, or teething, or change of\\nlife. Control questions must be put by inquiry into the character of\\nthe symptoms that attended the fatal illness, and by giving the affections\\nthe various popular names that are given them in different countries.\\nCommon Morbid Processes. The data of the family history are\\nof no avail unless it is remembered that many fundamental affections\\nhave various modes of expression. Various diseases may be allied to\\nthe one suspected to exist in the patient, and be overlooked because of\\nthis difference of expression. One member of the family may die of\\nheart disease, another of rheumatism, or some have had chorea, or\\ncutaneous affections, or renal calculi such ailments are expressions of\\nthe same morbid process. Finlayson well puts them into groups and\\nfittingly portrays them as follows In regard to scrofulous [tuber-\\nculous] diseases, we ask for swollen glands or waxy kernels/ or running\\nin the neck, diseases of the spine and other bones, bad joints, white\\nswellings, or c incomes/ as they are termed in Scotland disease of the\\nglands, of the bowels, water in the head, consumption of the lungs, or\\ndecline, or weakness of the chest, with spitting of blood, and so on.\\nHeart disease, rheumatism, chorea, psoriasis, and some other cuta-\\nneous affections, and perhaps renal concretions and emphysematous\\nbronchitis, appear to replace each other in different members of the\\nsame family.\\nThe neurotic group includes the various forms of neuralgia, epi-\\nlepsy, hypochondriasis, hysteria, and insanity apoplexy and hemiplegia\\nmay (perhaps doubtfully) be included in this group their hereditary\\ncharacter seems rather to be associated with vascular disorders. Gout,\\ndisease of the liver, contracted kidney, renal calculus and gravel, and\\nangina pectoris form another allied group and these have also some\\naffinity with the disorders connected with arterial degenerations. Syph-\\nilis, which, of course, has marked hereditary characters, assumes such\\na multitude of forms as to preclude enumeration but the tendency is\\nfor such syphilitic diseases to fail in the course of time from early death\\nor sterility. Abortions, stillbirths, early deaths in infancy, associated\\nwith cutaneous eruptions on the buttocks and with snuffles, are im-\\nportant in many family histories nervous deafness, opacities of the\\ncornea, notched teeth, epilepsy, and imbecility are occasional manifes-\\ntations of the same disorder in those children who survive.\\nConclusions. It is thus seen that in securing the family history\\ndata are acquired which may be (1) complete and of value in estimat-\\ning family tendencies or (2) vague and of doubtful value. The latter\\nis due to lack of memory on the patient s part or to his ignorance of\\ntechnical terms. The difficulties must be overcome by control ques-\\ntions prompted by our knowledge of the nature of the disease and its\\nfrequency at different ages, by an inquiry for symptoms, and by inves-\\ntigation into collateral and remote branches of the family.", "height": "4412", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0034.jp2"}, "35": {"fulltext": "THE DA TA OB TAINED B Y INQ UIR Y. 29\\nThe fact that diseases skip a generation (atavism) must be remem-\\nbered. A generation may be small or decimated by accidental disease,\\nand hence the force of the family history be weakened. At times in a\\nfamily sufficient time has not elapsed for predisposition to arise, as\\nwhen we inquire into the illness of a child whose parents are in early\\nadult life. Finally, all negative facts must be recorded. Such knowl-\\nedge must act as a control element in estimating the value of the family\\nhistory.\\nThe History of Previous Diseases.\\nThe remote effects of disease, and of its sequelae, as impressed on the\\norganism, make it essential to inquire into the nature of the previous\\ndiseases of the patient whom we are studying. The date and character\\nof the disease, the duration, the degree of severity, and the completeness\\nof convalescence must be determined.\\nMany diseases, as the exanthemata, usually occur but once in the\\nsame person, and, therefore, in the diagnosis of obscure cases, if a his-\\ntory of their occurrence has been ascertained, they can be excluded in\\nthe count. Others recur from time to time, as croupous pneumonia,\\nchorea, acute rheumatism, and tonsillitis. The history of a previous\\nattack of a certain disease may point to the nature of a second attack\\nwhich otherwise may be obscure. Some diseases, as rheumatism,\\nsyphilis, and gonorrhoea, have pronounced sequelae. Knowledge of\\nthe occurrence of the primary disease may solve doubts as to the nature\\nof the sequela?.\\nInfectious diseases lead to forms of neuritis and to brain affections,\\nor to inflammations of organs. The seat of the specific inflammatory\\nprocess varies in different diseases. After measles we find the mucous\\nmembranes impressionable and after scarlet fever, the serous mem-\\nbranes, the ears, the kidneys liable to inflammation. The history of an\\nattack of hepatic or renal colic may point to the diagnosis of an\\notherwise obscure process in the liver or kidney.\\nThe history of injury must be sought for in brain and spinal affec-\\ntions. The occurrence of a surgical operation in the past may point to\\nlesions for which it was resorted to, which again may be the source of\\ndisease.\\nThe History of the Present Disease.\\nScope of Inquiry. The history of the present disease includes an\\naccount of the sufferings of the patient, which I have said are the sub-\\njective symptoms, of the duration of the disease, of its mode of onset,\\nand of the evolution of its symptoms up to the time it was seen by the\\nphysician. The patient also gives an account of such objective symp-\\ntoms as could be noted by him, as swelling of the legs, the date of its\\ncommencement, mode of onset, and progress. In the case record the\\nhistory to the date of examination is first recorded, and then the sub-\\njective symptoms are noted. The same order will be followed in the\\ntext. Practically, it is better to learn the symptoms on account of\\nwhich the patient applied for treatment, and, with them as a guide, to\\ninquire into the date of origin and mode of development of the disease.", "height": "4416", "width": "2652", "jp2-path": "practicaltreatis00muss_0_0035.jp2"}, "36": {"fulltext": "30 GENERAL DIAGNOSIS.\\nMethod of Inquiry. The history and subjective symptoms are best\\nlearned in the language of the patient. If the memory fails or the\\nsymptoms are not clearly narrated, judicious questions will suffice to\\ncomplete the story. Leading questions must not be put until the\\npatient s own account is fully given.\\nOften the patient will be too voluble and introduce irrelevant matter,\\nor too taciturn from modesty or a desire to conceal facts, as when illegit-\\nimately pregnant. While much time is lost in listening to a prolix\\naccount of sufferings, the student will do well at first to bear with the\\npatient, for it gives him the opportunity to study character, observe\\nthe mental and emotional characteristics of the patient and the expres-\\nsion of the countenance. To suppress the loquacious, free the tongue\\nof the silent, gather scintillations of intelligence out of the dense clouds\\nof ignorance, requires knowledge of human nature of a high degree,\\nacquired only by long practice. (Allied difficulties have been discussed\\nin the paragraphs devoted to the family history.) Indeed, the wonder-\\nful faculty of seeking information in this manner has been the capital\\nof many physicians of large practice. It is by this means and by\\ntricks that the charlatan plies his vocation. A favorite method of the\\nquack, after a few words from the patient, is to tell him how he the\\npatient feels. They have some knowledge of the march of the\\ndisease, and portray its full development to the surprised and credulous\\nvictim. Elsewhere (see Subjective Symptoms) the reliability of such-\\ndata is discussed, and the student must not for one moment consider\\nthe data obtained by inquiry as of equal value with those obtained by\\nobservation the former is the mere skeleton of the diagnosis.\\nIt is particularly important to secure a chronological order of events\\nin the disease. They are essential and logical and throw much light\\non the progress of the affection. The diagnosis is much easier if such\\nsequence is followed. Of course, there are circumstances when only\\nthe minimum amount of information of this character can be secured.\\nThe patient may be unconscious, or in a convulsion, or unable to speak\\nfrom dyspnoea. It then becomes necessary to rely on the testimony of\\nfriends or to gather the information from the circumstances that\\nsurround the patient.\\nMode of Onset and Duration of the Disease. It is well to learn\\nif the onset of the disease was sudden or gradual. If the former, the\\nmost striking phenomena are to be ascertained a chill, convulsion,\\nsudden pain, sudden vomiting, a profuse diarrhoea each points to lines\\nof further inquiry. If the latter, did it follow upon an acute illness,\\nor did each symptom gradually increase in intensity, and as each week\\nor each month passed by new phenomena creep into the symptom com-\\nplex. We thus learn if the affection under consideration is acute or\\nchronic its duration. It must not be forgotten that certain affections\\nmay be two or three days or, on the other hand, as many weeks in\\ndeveloping, as typhoid fever, which, nevertheless, is acute. It must\\nbe remembered, also, that diseases may have sudden acute expressions,\\nand that a chronic disease may be in existence a long time without the\\npatient s knowledge. An acute colliquative diarrhoea or a convulsion", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0036.jp2"}, "37": {"fulltext": "THE DATA OBTAINED BY INQUIRY. 31\\nis often the first intimation of a chronic nephritis, and an attack of angina\\npectoris the first symptom of organic heart disease of long standing.\\nTo appreciate the relationship of acute to chronic disease, or of acute\\nphenomena to chronic morbid processes, requires a full knowledge of\\nthe processes of disease.\\nEvolution of the Disease. In making inquiry concerning the evo-\\nlution of the subjective symptoms, the frequency, duration, character,\\nand degree of severity of each symptom, and its relationship to the func-\\ntion of the organ apparently affected, must be inquired into. Thus in\\nthe case of pain in the abdomen, we must learn its character, its fre-\\nquency, its duration, its intensity, and its location, and whether asso-\\nciated with functional disturbance of any of the viscera in which the\\npain presumably has its origin. Or, if there is frequency of micturi-\\ntion, the length of time the symptom has been present, the degree of\\nfrequency, the time in the twenty-four hours when the micturition is\\nmost frequent its relation to food, exercise, or emotions the charac-\\nter of the act of micturition, and its association with other evidences of\\nfunctional disorder or organic disease of the genito-urinary tract.\\nHaving ascertained the full story of the patient, including all data\\nobtained by inquiry, special attention must be paid to the sufferings or\\ncomplaints of the moment. They must be further inquired into in the\\nmanner above indicated. They may have been detailed in the begin-\\nning but information obtained from an account of the evolution of the\\ndisease or the previous history will require a repetition, with the put-\\nting of fresh questions or control questions. Having obtained the\\nchronological account of the factors of life and of disease, we are prepared\\nto examine into the significance of subjective symptoms.\\nThe steps thus far taken in the diagnosis are four in number. While\\nconsiderable that is not essential may be gathered, the very gleaning\\nof the facts enables the student to acquire objective information from\\nthe speech, the gesture, the expression, etc., of the highest value.\\nMoreover, the facts ascertained are of value in determining a line of\\ntreatment to be pursued which will be scientific and rational, for in\\naddition to the diagnosis the causal factors of the disease are often\\nfound.\\nTo repeat, preceding the fifth and final step in the diagnosis, the data\\nsecured by inquiry (1) the social history, (2) the family history, (3)\\nthe history of previous diseases, (4) the history of the present disease\\nmust be fixed in the mind. Marshalling the facts thus obtained in\\norderly procession, we are enabled to systematically add the facts of the\\npresent condition. Consideration of the data thus secured leads, by\\ninductive reasoning, to the desired conclusion a diagnosis.", "height": "4416", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0037.jp2"}, "38": {"fulltext": "CHAPTER III.\\nTHE DATA OBTAINED BY INQUIRY\u00e2\u0080\u0094 {Continued).\\nThe Present Condition The subjective symptoms Mode of determination Their\\nfallacy Their value. Feigned disease. Local subjective symptoms General\\nsubjective symptoms.\\nWe now come to the final step in the investigation the determi-\\nnation of the present condition, the status prcesens. To determine the\\npresent condition inquiry and observation are necessary. This chapter\\nand the succeeding one will discuss only the data obtained by inquiry.\\nThey, therefore, include the subjective symptoms other than those that\\npertain to special organs or systems. Caution, circumspection, adroit-\\nness, combined with tact and good judgment, are more essential to\\nsecure a true account of the patient s sufferings even than to obtain a\\ncorrect history of the disease.\\nThe subjective symptoms are expressive of the sensations of the patient,\\nand vary in accordance with the sensibilities of the individual affected.\\nThus acute pain may apparently represent a severe process in one,\\nwhile in au other the same severity of process may be represented by\\nthe minimum amount of pain. It is well known that individuals of\\none nationality bear pain with greater fortitude than individuals of\\nanother.\\nCaution. The patient. Individuals vary not only as to pain\\nsense but as to other subjective symptoms. The morale is shattered\\nin some more readily than in others thus, for instance, oppression of\\nthe pr*cordia may strike terror to some, while to others it would be\\nsimply a sense of discomfort. Moreover, subjective symptoms are con-\\nstantly before the patient while in distress, if only in the mind s eye.\\nBecause of this perturbed state they grow in magnitude rather than\\ndiminish. We must study them from many points of view. The mode\\nof onset, frequency, degree, and character of the symptoms must be\\ninquired into. The competency of the witness under the circumstances,\\nfrom lack of accurate noting of symptoms, failure of memory, varying\\ndegree of susceptibility to impressions, etc., may well be doubted.\\nThe physician. But not only does the varying l personal equation\\nof the patient render subjective symptoms fallacious, the same factor\\nin the physician contributes to the fallacy. The latter may have unfor-\\ntunately formed, by hearsay regarding the patient, a preconceived notion\\nof the nature of the disease or from personal bias in favor of particular\\ndiseases, on account of narrow lines of study or lack of breadth of view\\nof pathological processes, he may set out to prove a theory rather than\\nto establish a fact. In either case, by leading questions, by placing\\nemphasis on certain parts of the testimony, the subjective symptoms\\ncan be juggled with and made to tell any but the truthful story.", "height": "4412", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0038.jp2"}, "39": {"fulltext": "THE DA TA OB TAIN ED B Y INQ UIR Y. 33\\nIt is to be remembered that it is our province not only to ascertain\\nthe cause of suffering in the sick, but also to detect the flaws in the\\ntestimony of him who would feign sickness. The malingerer utilizes\\nsubjective symptoms to hide his deception because they cannot be seen,\\nfelt, weighed, measured, or ascertained by hearing.\\nFeigned Disease. To detect feigned sickness demands much acu-\\nmen on the part of the physician. He must not only be able to make\\nan accurate and exhaustive objective examination of the patient, but be\\nalert to appreciate surroundings and conditions. Feigning may be\\nsuspected if there is a motive, as in the case of prisoners, pension\\napplicants, students at school or college, and persons who hold policies\\nof insurance indemnifying in case of sickness. The hospital beat\\nthus plays upon charity.\\nIf sickness recurs frequently without definite cause, while the sub-\\njective symptoms are mild and quickly relieved and the objective symp-\\ntoms negative, the use of instruments of precision will detect the\\nmalingerer. With their aid we can usually find out if the subjective\\nand objective phenomena tally. The failure of such tally proves the\\ndeception. The thermometer frequently exposes the deception, as fever\\ncan rarely be simulated, although tricks Avith the thermometer may be\\ncarried on. A favorite method is to rub it, and thus cause the mercury\\nto rise. Frequently the suspected person must be placed under close\\nsurveillance, unknown to him, and tricks of all sorts, suggested by the\\nsurroundings and circumstances, played upon him to make him unwit-\\ntingly testify to his deception.\\nThe student will learn later that there is a mimicry of disease, and\\nthat in certain nervous affections the simulation of subjective symp-\\ntoms is its chief role. In hysteria, subjective and objective symptoms\\nare masked. Long experience and acumen are required by the physi-\\ncian to unmask the deceptions. The age of the patient, the sex, the\\nstate of the emotions, the varying expressions of the symptoms (under\\nvarying circumstances) with attention fixed or removed the mobility\\nof the symptoms under excitement or emotional disturbance, the lack\\nof harmony between functional disorder and organic change, are the\\nelements to be considered in order to fathom the mysteries. Often\\nanaesthesia must be induced in order to dissipate simulated tumors,\\nrelax rigid joints or contracted limbs. Magnetism, electricity, and\\nother tests are likewise employed. In the chapter on Hysteria its\\nmanifold expressions will be adverted to, and it will be seen that func-\\ntional disorder of almost every organ or special sense is simulated in\\nthis affection. Organic processes even are imitated, as joint inflamma-\\ntions, peritonitis, and other grave conditions.\\nValue of Subjective Symptoms. Notwithstanding the fallacy of\\nsubjective symptoms in that they may be feigned or mimicked, they are\\nvaluable evidences in the hands of the scientific inquirer. If the\\npatient is a good witness their value is much enhanced. He must be\\nintelligent and truthful. His testimony is of value if he can array in\\nlogical order the sequence of symptomatic events which culminated in\\n3", "height": "4412", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0039.jp2"}, "40": {"fulltext": "34 GENERAL DIAGNOSIS.\\nthe condition for which he seeks relief. If he can clearly narrate the\\nevents in his past life, or in the lives of his ancestors, which appertain\\nto physiological aberrations, his story is an aid to the searcher for truth.\\nIf, with this, the doctor is possessed with a scientific turn of mind,\\nconsidering evidence without allowing previous conceptions to influence\\nhim, capable of discerning the truth and discarding the false, of an-\\nalyzing and weighing statements, and of appreciating their relationship\\nto what is known of morbid processes, the patient s statements of sub-\\njective symptoms are of value in the discernment of disease.\\nLocal Subjective Symptoms. The symptoms of which the patient\\ncomplains may be general or local. The former will be briefly consid-\\nered in this section the latter will be discussed in the respective sec-\\ntions devoted to disease of the various organs to which the subjective\\nsymptoms refer. They are symptoms due to functional disturbances\\nof the respective system that is the seat of disease, as dyspnoea or cough\\nin diseases of the respiratory system, anorexia or nausea in diseases\\nof the digestive system. An exception will be made in the case of pain.\\nWhile there may be such general suffering as to constitute pain (gen-\\neral soreness, aching, rhachialgia), yet the symptom has its point of\\norigin most frequently in some local disorder. Notwithstanding this\\nfact, however, as it is a symptom common to so many affections, and as\\ngeneral rules apply to the recognition of its multitudinous forms, a brief\\nsection will be devoted to its study.\\nGeneral Subjective Symptoms. The general subjective symptoms\\nthat is, the abnormal and disagreeable sensations which extend more\\nor less over the whole body, or are referable to more than one organ\\nor apparatus are few in number and are not diagnostic of any partic-\\nular affection. They are at times the only symptoms complained of by\\nthe patient, and require investigation. They include abnormal sensa-\\ntions of strength or weakness, general numbness or tingling, and general\\nparesthesia of all kinds general vasomotor disturbance, causing sen-\\nsations of heat, such as occur in flashes, or sensations of cold, from mild\\nchilliness or creeps to the pronounced chill or rigor, sudden perspi-\\nrations, general throbbings or pulsations, and general discomfort, to\\nwhich the term nervousness is applied. Irritability, disorders of sleep,\\nand the more distinct nervous manifestations above mentioned, will be\\nreferred to in sections on nervous diseases, and particularly discussed\\nunder Hysteria and Neurasthenia.\\nA feeling of strength, or the idea of an ability to perform great feats\\nof strength or endurance, or a great mental feat, is a subjective symp-\\ntom that is dwelt upon by the patient who is developing or passing\\nthrough certain stages of paretic dementia. It is accompanied by other\\nevidences of exhilaration. Exhilaration attends chlorosis and forms of\\nhysteria and neurasthenia, the physical or mental exhibition of strength\\ntaking place in the after part of the day and evening or upon undue\\nexcitement. Corresponding depression usually follows.\\nA sense of weakness, or exhaustion, or of fatigue is often complained\\nof. If an absolute demand is made upon the bodily strength it can", "height": "4396", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0040.jp2"}, "41": {"fulltext": "THE DATA OBTAINED BY INQUIRY. 35\\nrespond, but otherwise it is not exerted. The patient complains of\\nbeing more tired in the morning than upon retiring, or of a sense of\\ninability to perform accustomed or special duties. Mental depression\\nusually attends the phenomena. It is due to neurasthenia generally,\\nbut is a frequent accompaniment of and dependent upon the forms of\\ntoxaemia to which malaria, gout, and rheumatism belong of the\\ntoxaemia of certain varieties of indigestion, of tobacco, alcohol, and\\nother narcotic poisons (tea or coffee), and of mineral poisons. The\\nsame sense of fatigue attends the prodromal stage of the specific fevers.\\nIt has been a symptom observed frequently of late in the sequential\\nperiod of influenza.\\nThe sensation of weakness must not be confounded with true weak-\\nness or muscular prostration. While the patient is aware of its pres-\\nence, it is well to consider it under the objective phenomena of disease,\\nfor it is a readily recognized sign of disease.\\nNumbness, or tingling, or burnings may be general or local. It is a\\ncommon form of paresthesia, to be discussed in the section on nervous\\ndiseases. It must be remembered that, while a disorder of sensation,\\nit is due to morbid conditions outside the pale of the nervous system.\\nIt may be of reflex origin, from irritation at a distant point, or it may\\nbe and usually is due to toxaemia, as lithaemia. Other subjective vaso-\\nmotor disturbances that are of frequent occurrence are likewise mani-\\nfestations of nerve disorder from reflex or toxic causes. Flushings,\\nand a constant sensation of heat, with or without perspiration, which\\nattend the perturbation of the menopause, are common in uterine dis-\\norders and in chronic gastritis.\\nThe student will learn that the curious manifestations to which refer-\\nence has been made are all evidences of ill health, of a depressed\\nvitality, of a condition in which there is malnutrition, poverty of\\nnerve-force, and lack of blood-richness (anaemia). There may be\\nperipheral irritation or a toxaemia, but the under-current of ill health\\nis the fundamental derangement.\\nChill and fever. Both are subjective as well as objective phenomena,\\nbut as one can be accurately estimated by an instrument of precision\\n(thermometer), and as both are generally associated, the discussion of\\nthem will be postponed. (See Objective Signs.)\\nThe abnormal sensation of cold or of heat will be discussed in the\\nchapter on Nervous Diseases.", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0041.jp2"}, "42": {"fulltext": "CHAPTER IV.\\nTHE DATA OBTAINED BY INQUIRY\u00e2\u0080\u0094 (Continued).\\nPAIN. 1\\nDefinition. Pain is a general term used in medicine to describe a\\nnumber of subjective symptoms connected with morbid processes. It\\nmay be defined as a sensation which produces on the part of the organ-\\nism, as a whole, the desire to abolish or escape from it. It is the\\nexpression in consciousness of injury to the peripheral or central ner-\\nvous system by irritation or lesion at times the central end of the\\nperipheral nerves may be the seat of irritation, causing so-called referred\\npains. This definition, however, fails to include the hyperesthesias,\\nthe hyperalgesias, and all simulated pains. But the latter are to be\\nincluded in this section, on the ground of clinical convenience, whilst\\nthe two former are only of significance as conducing to the production\\nof pain.\\nPathology. The pathology of pain is generally believed to be a\\nstate of impaired nutrition, and hence of injury, gross or microscopic,\\neither at the periphery or in the afferent nerve tract. The cause may\\nbe purely functional, as, for example, when pain is due to the over-\\nstimulation of the tract by its normal stimulus and its consequent ex-\\nhaustion or to strictly local conditions, as pressure, injury, or inflam-\\nmation or to systemic conditions acting locally, as the neuralgias of\\nanaemia. There is also the so-called sympathetic or reflex pain, due to\\nirritation in a part removed from the locality to which the sensation is\\nreferred.\\nPains in reference to the general nervous system may be classified\\naccording to the localization of the lesion into (1) peripheral, (2) cen-\\ntral, and 3) general. Peripheral pains are those due to some alteration\\neither in the structure or nutrition of the peripheral nerves, and the\\ndisturbance may be situated at the sensory terminations, or anywhere\\nin the course of the nerve or in the nerve-roots. Pains due to causes\\nsituated in the latter place are usually perceived at the peripheral dis-\\ntribution of the nerve, and are, therefore, spoken of as referred pains.\\n1 Pain is treated in a suggestive manner, and so much space is given to it because\\nit is too frequently improperly managed. Its cause is never thoroughly investigated.\\nAnodynes are given for its relief, thus too frequently creating victims of the morphine-\\nchloral-, or other habit The following articles are suggestive Head On Disturb-\\nances of Sensation, with Especial Reference to the Pain of Visceral Disease, Brain,\\nvol. xvi., Part I., 1893; Ross: Brain, 1888: Mackenzie: Medical Chronicle, 1888;\\nMackenzie: Points Bearing on the Association of Sensory Disorders and Visceral\\nDisease, Brain, vol. xvi., Part III., 1893. Also, papers by Starr. See Section on\\nNervous Disorders.", "height": "4400", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0042.jp2"}, "43": {"fulltext": "THE DATA OBTAINED BY INQUIRY. 37\\nThe nature of central pain is not at present clearly understood. Cer-\\ntain cases have been reported in which pain has been perceived in one\\npart of the body, usually an extremity, and at post-mortem no lesion\\nwhatever could be found in any portion of the afferent nervous system\\ncoming from this region. Lesions, however, have been found in these\\ncases in the brain itself, and it is supposed that these are responsible\\nfor the painful impression. General pains are those due to some toxic\\ncondition of the blood, or impairment of the nutrition of the nervous\\nsystem as a whole, and manifested as pain in the regions of least resistance.\\nCause. Conditions acting upon the peripheries of the sensory nerves\\nare injuries or disease of the surfaces or of the viscera. Conditions\\nacting upon the nerve in its course may be either internal or external.\\nAmong the internal causes are the chronic and acute forms of neuritis.\\nAmong the external causes are tumors, perineural inflammatory pro-\\ncesses, or anything causing mechanical injury to the nerve itself.\\nNerve roots are usually involved in intraspinal growths, in spinal men-\\ningitis, and, occasionally, as a result of disease of the vertebral column.\\nThe lesions causing the central pain are embolism, hemorrhage, soften-\\ning, inflammatory processes, tumors, and injuries. General causes are\\nthe anaemias, the intoxications, the infectious fevers, and perhaps certain\\ndrug habits, as morphia although it is usual to include the pains com-\\nplained of by opium eaters among those due to simulation.\\nVariations in Disease. Pain is, perhaps, the most variable symp-\\ntom in disease. It ranges from a sensation of mere discomfort, as the\\ndull ache of chronic lumbago, to the stabbing pain of pleurisy, or the\\nintolerable anguish of heart-pang. It is at times compatible with the\\nhighest mental endeavor or the severest physical exertion, or the whole\\nenergy of the organism is absorbed in resisting it. It may be definitely\\nlocalized in any part of the body, in any of the tissues, or distributed\\nover an ill-defined area.\\nThe Recognition of Pain.\\nThe Mode of Expression. As a rule, the physician learns of its ex-\\nistence by the complaint of the patient. Thus he learns more or less\\naccurately its location, character, degree, and duration, and usually\\nsomething concerning its causation. But the value of this source of\\ninformation is variable. The patient may be voluble, and describe too\\nmuch or taciturn, and shrink from admitting his suffering or ignorant,\\nand unable to give a clear account. Fortunately, there are other ways\\nby which suffering is expressed which may be grouped among the\\nobjective symptoms. They are (a) Facial expression, the most common\\ninterpreter of the emotion, is far more reliable. The tense and drawn\\nlineaments, the clinched jaws, the dilated pupils, the livid countenance,\\nmake a picture of agony which, with the labored respiration, the general\\nshrinkage of the body, are unmistakable. (See Chapter VII., The Face.)\\nOr, in a less intense form, the shrieks and struggles or the groans of\\nmore prolonged suffering are no less impressive in their suggestiveness.\\n(6) Not less characteristic are the various postures assumed the sudden\\nfixity of heart-pang the retracted head of meningitis the immobile side", "height": "4416", "width": "2644", "jp2-path": "practicaltreatis00muss_0_0043.jp2"}, "44": {"fulltext": "38 GENERAL DIAGNOSIS.\\nof pleurisy the crouching attitude or restlessness of colic the flexed\\nthighs and immobile trunk of peritonitis the shoulder drooping to the\\naffected side in renal colic or the bent knee of arthritis, (c) Further,\\nthere are certain reflex actions that are associated with local irritations\\nthus the closing of the eyelid on irritation of the conjunctiva the sneeze\\nor cough on irritation of the nasal or laryngeal mucous membrane the\\nerection following irritation of the urethra or even the limp character-\\nistic of pain on moving or resting the weight of the body on an affected\\nlimb. Then there is the sudden shrinking of the whole body, the\\nattempt to defend, or the sudden movement of the hand to the affected\\npart, or the sudden jerking away of the part itself if the act be possi-\\nble these are true reflexes, and sufficiently diagnostic of local suffering.\\nIt scarcely need be mentioned that in children, in the insane, in persons\\nunable for many reasons to communicate their thoughts, the expression\\nof pain is of the greatest diagnostic value in determining its seat, (d) The\\nphenomena of the associate morbid processes may serve to indicate the\\noccurrence of pain and its seat. Thus pain is one of the cardinal symp-\\ntoms of inflammation it is commonly associated with nerve-injury it\\nis frequently accompanied by local flushing or herpetic eruptions in\\nneuralgia.\\nSources of Error. In estimating the presence or absence of pain,\\nor its degree, certain control conditions must be borne in mind. Un-\\nfortunately pain is one of the most unreliable of symptoms. It is neces-\\nsarily a subjective symptom, with, in all probability, qualitative as well\\nas quantitative variations. The particular degree in either respect is\\nof importance in diagnosis, and as only the roughest means, if any, are\\navailable to estimate it objectively, the physician is compelled to rely\\nalmost wholly upon the statements and appearance of the patient. His\\nstatement can err in two directions the patient can exaggerate his\\nsufferings or depreciate them. The tendency to exaggeration is most\\nmarked in the nervous temperament in those suffering from chronic\\ndisease of long standing in those accustomed to in-door and mental\\nlabor in women and in the young. The tendency to depreciation is\\nmost marked in the phlegmatic temperament in those accustomed to\\nhardship, especially if of small intellectual development in men and\\nin the aged. Both tendencies are to be corrected as nearly as possible\\nby observing the associated symptoms and the character of the patient,\\nand by skilful questioning. The appearance can deceive because of\\nundue susceptibility to suffering on the part of the patient, or unusual\\ninhibitory power. There can be no question that painful stimuli,\\nusually easily borne, in some produce almost unbearable misery. Such\\nexaggerated sensibility occurs in the emotional, in the weak and debili-\\ntated, and in the delicately nurtured. Mental association is a powerful\\nfactor it is well known that soldiers, who in the heat of battle disre-\\ngard serious and necessarily painful wounds, will suffer intensely under\\nthe probably less painful offices of the surgeon and it is unfortunately\\na common experience that the surroundings of the operating-room make\\nthe most trifling and briefest operations full of serious suffering.\\nHabitual use of opium seems to increase this susceptibility in a remark-\\nable manner. Patients will even submit to operations for the relief of", "height": "4404", "width": "2568", "jp2-path": "practicaltreatis00muss_0_0044.jp2"}, "45": {"fulltext": "THE DATA OBTAINED BY INQUIRY. 39\\na supposed ailment that is found to have no physical basis and this\\noccurs in cases in which there is no reason to believe that the pain\\nis simulated as an excuse for the indulgence. Moreover, a pseudo-\\nneuralgia is wont to occur in victims of the morphine habit. It may\\nsimulate a gastralgia or an intestinal colic. The writer has seen an\\ninnocent victim of morphine suffer from pseudo-hepatic colic, with-\\ndrawal of the drug causing subsidence of the periodical attacks of pain\\nand vomiting. Inhibition is a much more serious source of error, for\\nwhile undue attention to one part is only reprehensible when practised\\nto the neglect of others, a patient who disregards pain may fail to direct\\nattention to the real seat of disease. It is sometimes exercised to a\\nmost remarkable degree. The stoicism of the American Indian under\\ntorture is attested by many observers certain religious sects among\\nthe Hindus habitually afflict themselves in the most ingenious ways\\nthe early Christian martyrs rejoiced in misery. It is common to find\\nthis disregard of pain among those exposed by occupation to discom-\\nforts and injuries, and the Teutonic and Slavic races appear to possess\\nit in a higher degree than the Celtic or Semitic. Shock either, inhibits\\npain or diminishes the normal response to it. Lastly, and by no means\\nto be neglected, a most common source of error is undue credulity or\\nskepticism on the part of the physician, for he may be deceived by an\\neloquent and persuasive complaint, or discredit true suffering.\\nSimulated Pain (see Feigned Disease) is to be recognized by the\\nexistence of a motive for deception. The simulation is common enough\\nin those who seek damages for injuries, or in those who have a morbid\\ncraving for sympathy and attention. Its detection depends upon the\\nskill of the physician, who, by distracting the attention from the part\\ncomplained of, observes that the pain disappears, or, on the other hand,\\nthat pain is admitted in a part to which attention is directed more-\\nover, the physician observes an absence of adequate physical alteration,\\nand usually inconsistency in the symptoms, for the malingerer is seldom\\nable to simulate a correct clinical representation for any length of time.\\nEspecially in the latter case is the observation of the invalid s sur-\\nroundings of considerable importance. The so-called hysterical mask\\nis of much value, for the bitter complaints and the placid or even smiling\\nfeatures cannot fail to strike the observer by their incongruity. True\\nhysteria is apt to be deceptive, and more than one humiliating failure\\nis recorded of even the most skilful of our craft. The difficulty is in-\\ncreased because actual physical changes occur, as amaurosis with dila-\\ntation of the pupil, contracture and induration about the joints, unques-\\ntionable anaesthesias, and palsies. True hysteria is often to be detected\\nonly after prolonged and painstaking study of the case the careful\\nexclusion of organic visceral disease by the absence of the character-\\nistic symptoms of the nervous degenerations, such as ankle-clonus, or\\naltered electrical reactions, or changes of the fundus oculi and often\\nby the impossibility of associating the sensory lesions with the known\\nanatomical distribution of the nerves.\\nObjective Investigation of Pain. In order to estimate accurately\\nthe diagnostic value of pain, the statement of the patient must be cor-", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0045.jp2"}, "46": {"fulltext": "40 GENERAL DIAGNOSIS.\\nrected by his expression, posture and manner, and the apparent nature\\nof the disease. Pain is one of the cardinal symptoms of inflammation\\nvasomotor and muscular disturbances are often associated with neural-\\ngia any morbid condition exerting pressure on a nerve-trunk, as a\\nneoplasm, callus, etc., commonly causes pain. Hence if the objective\\nphenomena of these disorders are present, they lend color to the com-\\nplaint of pain, and, if not, they should be inquired for. Attempts have\\nbeen made to estimate the acuteness of the pain-sense with scientific\\naccuracy, or at least to secure a practical method for measuring its\\nvarying intensity in different localities in the same case. Bjornstrom,\\nof Upsala, has contrived a pair of forceps that compress a fold of skin\\nthe amount of pressure required to produce pain, which can be read\\nfrom a scale, indicates the degree of sensibility or rather resistance to\\npainful impression. Another instrument, Buch s, accomplishes the\\nsame thing by direct pressure, and hence can be used over the super-\\nficial nerve-trunks. Another method more generally available is the\\napplication of an induced faradic current of variable strength single,\\nnaked-wire electrodes being best for this purpose. The common clinical\\nmethod, by far the most inaccurate and only applicable in cases of\\nmarked analgesia, is a pin or needle forced through a fold of skin. No\\nmethod has yet been suggested for even the approximate estimation of\\nthe acuteness of sensibility to internal pain, and it must still be left to\\nthe judgment of the patient.\\nThe Clinical Value of Pain. The presence of pain is recognized\\nby the above-mentioned circumstances. Its degree, with the limita-\\ntions indicated, has been estimated. Its clinical value is then to be\\nconsidered. From what has been said above, the converse of many of\\nthe propositions is true. By pain and the mode of its expression we\\ncan judge of the character, temperament, and nervous susceptibility and\\nperturbability of the patient. It aids us in the recognition of hysteria\\nand helps to detect the malingerer. We learn the patient s capability\\nof resistance, and hence, in a measure, his strength. We learn the\\nquickness of receptivity in consciousness of the peripheral irritation, or\\nthe degree of intelligence, or the amount of stupor or, if conditions\\nare present which usually cause pain, its absence may show disease of\\nthe conducting paths to the brain. Further, the absence of pain under\\nthe above circumstances points to the occurrence in the local process of\\nsuch change as has destroyed peripheral nerve-endings. Thus, when\\npain ceases in dysentery gangrene has ensued. In intestinal obstruc-\\ntion its cessation indicates the same process. In profound shock pain\\nis not complained of the amount of pain, therefore, indicates the\\ndegree of shock. Hence, in peritonitis, in which shock frequently\\noccurs, pain may be wanting entirely. The abdominal surgeons welcome\\nits occurrence after an operation, as it indicates the absence of shock.\\nWhile the above lessons, from the presence or absence of pain, are\\nnot to be under-estimated, the value of pain to the physician is from\\nthe stand-point of diagnosis. By this symptom we may be enabled to\\ndetermine the location of disease and the nature of the causal morbid\\nprocess.", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0046.jp2"}, "47": {"fulltext": "THE DATA OBTAINED BY INQUIRY. 41\\n(A) The location of the disease is determined (a) by the seat of the\\npain and (6) in part by the mode of expression. The mode of expression\\nalso indicates its point of origin in a general way and its probable cause.\\nThey are (1) the facial expression, (2) the posture, (3) the reflex actions,\\n(4) the associate phenomena. They need not be referred to again.\\n(See page 37.) (B) The nature of the causal morbid process is judged\\nby the study of pain from various stand-points. Thus in the consider-\\nation of the symptoms of pain we must learn (1) the mode of onset,\\n(2) the duration, (3) the time of occurrence, (4) the character or variety,\\n(5) the location, (6) the modifications produced by pressure, tempera-\\nture, rest, motion, posture, electricity, drugs, and climate.\\n1. Mode of Oxset The mode of onset of pain is in the majority of\\ncases an indication of the acuteness of the morbid process. (A) The\\nonset may be sudden, as (1) in gout or acute inflammations of serous\\nmembranes, as pleurisy or peritonitis (2) in certain headaches, particu-\\nlarly in those of congestive or emotional origin (3) in acute obstruction\\nof canals (4) in contraction of muscular structures in their effort to\\nremove a foreign body, as in the intestines, the gall-ducts, the vermi-\\nform appendix, the ureters, bladder, or uterus (5) in rupture of the\\nstructure in which it is developed. Here we have the most typical\\nsudden pain. Thus, in rupture of an aneurism or of the heart there\\nis sudden, sharp pain. In rupture or perforation of the stomach or\\nintestines, or any of the hollow viscera, this character of pain arises.\\n(6) Sudden pain also occurs in certain neuralgias or neurosal affections.\\nIt is seen in its most striking form in angina pectoris, locomotor ataxia,\\nand in acute brow-ague, or trigeminal neuralgia. (B) The onset\\nmay be gradual, and may be associated with continuous increase in\\nintensity or variation. Such onset indicates that the process is one of\\nslow development and not attended by a solution of continuity, as\\nfrom rupture or tear. It usually occurs in various forms of rheuma-\\ntism, in inflammations of muscles and of mucous membranes, in chronic\\ninflammations of serous structures, in chronic bone disease, and in\\nslowly developing mechanical pressure, as tumors.\\n2. Duration The duration of the pain indicates the acuteness or\\nchronicity of the causal morbid process, (a) Pain of short duration\\nis seen in the affections in which it develops suddenly (see Mode of\\nOnset), in acute serous inflammations, and in neuralgias, (b) Pain of\\nlong duration, if constant, is usually due to organic lesions if inter-\\nmittent, it may be due to neuralgia. Pain that is continued over a\\nlong period of time excludes the sudden accidents that were previously\\nmentioned, unless change in the character of the pain takes place.\\nPain is also divided, as to duration, into temporary and constant\\npain. Temporary pain indicates an abeyance or relief of the morbid\\nprocess, while the constant pain points to its continuance. Constant\\npains are seen in bone affection, in inflammation of muscles, in reflex\\npains due to chronic disease elsewhere, as the backache of uterine\\ndisease, or the inframammary neuralgias from the same cause. Pain\\nmay also be intermittent or remittent, paroxysmal and periodic, [a) In-\\ntermittent and remittent pains are characteristic of neuralgias, or\\npoint to a functional origin they are recurring because the cause", "height": "4416", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0047.jp2"}, "48": {"fulltext": "42 GENERAL DIAGNOSIS.\\nwhich superinduces them is again operative. Thus recurring head-\\naches due to eye-strain may be intermittent or remittent in the sense\\nthat they occur only when the eye is used. Attacks of such pain recur\\nover a long period, (b) Paroxysmal pain is the form which occurs\\nwhen there is obstruction of channels, as the gall-ducts in biliary colic,\\nthe intestines, the uterus, and the ureters in the various forms of colic\\nto which they are liable. The paroxysms of pain recur in the course\\nof the attacks, (c) The term periodic is applied to pains that occur at\\ndistinct intervals. Pain that is periodic has frequently for its cause\\nmalaria in some form. The toxic headaches and nerve headaches, as\\nmigraine, are often periodic. (Consult Headaches.)\\n3. The Time of Occurrence. The time of the occurrence of\\npain is important. Pains may occur in the daytime, or during the night\\nexclusively. Nocturnal pains are common in syphilis. They are usually\\ndue to periosteal inflammation. Diurnal pains are usually reflex from\\nfunctional disorders. Some pains, as headache due to cardiac weakness\\nand to forms of anaemia, are present during the day, because the patient\\nis in the upright position. They disappear in the recumbent position,\\nand hence are absent at night.\\nThe time-relation of pain to functional acts is of importance. Thus\\nin gastric pain its relation to the taking of food is to be ascertained.\\nPain coming on before meals is gastralgic occurring after meals, it is\\ndue to ulcer or cancer, sometimes to indigestion. Chest pains, in-\\ncreased by the act of breathing, are muscular or pleuritic.\\n4. Character. Pain may be sharp, lancinating, or stabbing it\\nmay be throbbing, or it may be dull. Sharp, lancinating, or stabbing\\npain is usually due to inflammation of serous membranes, to colic in\\nvarious forms, and to forms of neuralgia. Cutting pain is a sharp form\\nthat occurs in flatulent colic. Throbbing pain is usually associated\\nwith acute inflammation, whether superficial or deep. It may be\\nrhythmical with the pulsations of the heart. Dull pain is due to slow\\nchronic inflammation in the bones and in the viscera it is the pain of\\nmyalgia and of fatigue in the muscles. It may be of an aching charac-\\nter. But aching pains may also be general they are found among the\\nprodromata of the acute diseases, attend and follow a chill, and occur\\nin most characteristic form in influenza and dengue. Pressing pain is\\ncomplained of when it attends an attempt to remove material from the\\nviscera, as the passage of water when the bladder is inflamed the\\npassage of faeces in dysentery. The term tenesmus is applied to it,\\nso that we have vesical tenesmus and rectal tenesmus. The passage\\nof clots or other material from the uterus is attended by pain with\\npressure or bearing-down/ as it is termed.\\nNature of the Disease. Finally, the character of pain is often an\\nindication of the nature of the disease as well as of the tissue affected\\n1. Thus boring and constant pain is seen in bone and periosteal disease.\\n2. Soreness or aching in muscular affections. 3. The pain is sharp and\\nstabbing when serous membranes are affected. 4. Smarting and burn-\\ning, or, perhaps, dull and sore when mucous membranes are inflamed.\\n5. Burning or itching in affections of the skin. 6. Dull and usually\\nconstant in visceral affections, although in malignant disease of various", "height": "4412", "width": "2584", "jp2-path": "practicaltreatis00muss_0_0048.jp2"}, "49": {"fulltext": "THE DATA OBTAINED BY INQUIRY. 43\\norgans it may be sharp and paroxysmal. 7. Aching, burning, and\\nthrobbing in the nerve-trunk and its distribution, with tenderness,\\ncommonly indicate neuritis. 8. A sense of swelling, distention, or\\nbursting attends the pain of obstructions of hollow viscera, as in renal\\nor hepatic colic. 9. Rending or tearing pain may be complained of\\nwhen a hollow viscus or sac is ruptured, as notably in the rupture of\\nthe sac of extra-uterine pregnancy. (See pain crises/ 7 page 44.)\\n5. Location and Distribution. It may be of questionable advan-\\ntage in some cases that the localization of pain generally indicates the\\nsituation of the morbid process. Too often an apparently adequate\\nexplanation of the symptoms may thus be found, whilst other pathologi-\\ncal changes may be overlooked. But, on the other hand, the condi-\\ntion to which attention has been called by the pain might, on account\\nof its obscurity or unusual location, altogether escape observation.\\nThe location is, in general, an indication of the seat of the disease.\\nIt may be accepted as an almost universal rule that pain due to a local\\nprocess is limited to the immediate or associated nerve-supply of the\\ndiseased region. This holds true even when the referred pains that\\nis, those felt in the associated nerve-supply are as far distant from the\\nsite of the morbid process as the knee pain of coxitis, the shoulder pain\\nof hepatic disease, pain in the neck from pericarditis or diaphragmatic\\npleurisy, the ear and temporal pain of lingual carcinoma, the pain in\\nthe legs from cancer or ulcer of the rectum, the testicular and thigh\\npain of renal colic, or the umbilical pain of vertebral disease.\\nOn the other hand, Hilton lays down the rule that pain in any part,\\nin the absence of a local process, is due to exalted sensitiveness of the\\nnerves of that part, and depends upon a cause remote from the painful\\narea. The term sympathetic is applied to this group of pains. Further,\\nHilton remarks that pain on the surface of the body must be expressed\\nby the nerve which resides there, and, hence, the cause of the pain\\nmust be situated between the peripheral termination and its central\\norigin. This applies particularly to the pains which arise from disease\\nof the vertebrae and the referred pains described above. As a corol-\\nlary to this, in the investigation of the cause of pain, the nerve, its\\nanastomoses, and the organs supplied by it should be investigated.\\nBut the pains may be general as well as local.\\n1. General pains are due either to central or to peripheral dis-\\nturbance of the nervous system by a poison circulating in the blood.\\nThis may be the poison of fevers, or it may be a rheumatic or gouty\\npoison. It is seen in the common affection known as cold, when\\nthe pains are probably myalgic. In syphilis, malaria, lead-poisoning,\\nand toxaemias generally there is general pain, soreness, and fatigue.\\nGeneral pains are not confined to the muscles, but are also seated in\\nthe fibrous structures and bones. In their more severe forms such\\npains occur in dengue, and are known as u break-bone.\\n2. Local pains may be (a) superficial or deep-seated (b) circum-\\nscribed or diffused.\\n(a) Superficial pains are due to involvement of the superficial nerves\\ndistributed to the skin or to the muscles directly underneath, or to the\\nstructures in close relation to the skin, as the peritoneum, the pleura,", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0049.jp2"}, "50": {"fulltext": "44 GENERAL DIAGNOSIS.\\nor the pericardium. Deep-seated pains, when in the extremities, are\\ndue to bone disease when in the abdomen, to disease of the viscera,\\nparticularly inflammatory affections, to aneurism, or bone disease when\\nin the chest, to disease of the aorta and mediastinum.\\n(b) Circumscribed pain is always due to a small area of disease, or is\\nreflex. Thus, in ulcer of the stomach the pain is usually circumscribed\\nto a small area in the epigastrium in inflammation of the appendix, to\\nthe region of that structure. Diffused pain indicates involvement of a\\nlarge area with less intensity of process than when circumscribed.\\nWhen the pain is diffused, or, as it is sometimes called, radiating, over\\nan area of nerve distribution, its point of origin may be found somewhere\\nin the course of the nerve, either in the trunk or in one of its branches.\\nCorollary: Given pain in a locality, study the nerve-supply of that\\nregion and the nerve anastomoses connected therewith. We learn much\\nfrom the study of this distribution. The referred pains have been indi-\\ncated (page 43). Among others, the pain of angina radiates down the\\narms. The pain of diaphragmatic pleurisy is referred to the front of\\nthe abdomen above the umbilicus. Radiating pains, however, are chiefly\\ndue to disease in the course of the nerve, the pain being referred to\\nits trunk and terminal distributions, as pain in the foot in sciatica.\\nPain from pressure upon the nerves at their exit from the spinal\\ncanal is at the periphery of the nerves, as in the centre of the ab-\\ndomen, and not at the point of exit. Pain in this locality is frequently\\nan indication of disease of the vertebrae, propagated by the sixth or\\nseventh dorsal nerve. Pain between the shoulders is often due to\\naneurism which presses upon the vertebra?. (See Pain in the Heart.)\\nBilateral, symmetrical, and superficial pains indicate a central or bilat-\\neral cause while, on the other hand, unilateral pain implies a seat of\\norigin which is one-sided.\\nPeripheral Pain of Central Origin. We have referred to\\npains of the extremities or trunk due to central disease. In meningitis\\nand other general organic affections of the brain and cord peripheral\\npains are frequent, and may be the earliest and most striking symp-\\ntoms. Indeed, it is very common to find patients with spinal-cord\\ndisease who have been treated for a long time for what was supposed\\nto be rheumatism. The pains in the joints of central origin may be\\nconstant, or paroxysmal and lancinating when the disease is chronic.\\n(See Character.) The cardinal rule, that all peripheral pains, without\\nobvious local cause, should lead to an examination of the nervous\\nsystem, must never be forgotten. The paroxysms of pain may be most\\nexcruciating, and sometimes cause collapse. They are known as painful\\ncrises. Pain may be complained of in various viscera, as well as in the\\njoints. Sudden, intense pain, with functional disturbances of the affected\\nviscera, occurs independently of any lesion of the part or of any apparent\\nexciting cause. One class of the attacks is known as gastric crises.\\nThe pain is in the epigastrium, and is associated with vomiting. In\\nanother class laryngeal crises occur, with pain in the larynx and violent\\nspasmodic cough, with dyspnoea. The pain extends over the shoulders.\\nOr we may have rectal crises, with sensation of burning in that situation\\nurinary crises, simulating renal colic, and genital crises. Pains, in", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0050.jp2"}, "51": {"fulltext": "THE DA TA OB TAINED B Y 1NQ UIR Y. 45\\ncrises, also occur in the muscles. Crises occur chiefly, if not entirely,\\nin locomotor ataxia. They are distinguished from pain due to other\\ncauses by their sudden onset, their extreme severity, the absence of\\norganic disease or local cause in the affected viscera, the sudden termi-\\nnation, the normal condition between the attacks.\\n6. Pain Modified by Pressure, Movement, Rest, or Mental\\nDiversion. We also study pain under the influence of pressure,\\nmovement, temperature, rest, etc. Pain that is modified by pressure is\\ngenerally superficial. It is usually of an inflammatory origin. The\\nvariety of the pressure gives some clue to the nature of the pain. If\\nthe pain is increased by pressure of the finger-tips, it is due to ulcer or\\ninflammation when internal and to inflammation if external. Although\\nof visceral origin, gastralgia and colicky pains in the intestine, which may\\nbe a neurosis, are relieved by pressure, particularly if the whole hand\\nis applied. Pain from the dislocation of an organ, as a movable kidney\\nor displaced uterus, or from dependent viscera, may be relieved by\\njudicious pressure in the proper direction, so as to relieve the displace-\\nment.\\nPain from affections of the nerve-trunks can be distinctly localized\\nby pressure in the course of the nerve-trunk, and particularly at the\\npoints where the cutaneous filaments of the nerves come through the\\nfascia. These points in the thorax are along the vertebral column, in\\nthe axillary region, and anteriorly about the parasternal line the points\\nof Valleix. We distinguish neuralgias from myalgias by the presence\\nof these tender points. Pain due to bone disease can frequently be\\ndistinguished in this way. By pressure or weight upon the head or\\nshoulders we may ascertain if pain is due to vertebral disease. The\\npresence of renal calculus or of gall-stones may be determined by the\\nexcitation of pain by pressure.\\nPain increased by movement points to an affection of the bone,\\nmuscle, joint, or nerve in the part moved groups of muscles may be\\nisolated for the tests. Some few pains are relieved by movement of\\nthe body, only because the mind is diverted in this act. Pain, when\\nsuperficial and increased by movement, is due to neuritis, myalgia, or\\nrheumatism.\\nAlmost all pains are modified by rest. Its influence has but little\\ndiagnostic significance. In some cases of doubt as to the nature of a\\nvisceral pain, functional rest of the organ, by which relief is obtained,\\nmay aid in determining its locality. Thus, rest to the eye may relieve\\na headache, the nature of which was obscure until this respite was\\nsecured. Pain modified by temperature (cold or heat applied to the\\nspine, ice or hot water in a sponge) and by electricity usually gives\\ninformation as to the seat of the disease in the spinal column, of which\\nthe pain is the external expression. Pain modified by climate is rheu-\\nmatic or neuralgic if modified by weather or season, it is due to neu-\\nralgia or neuritis, whether of gouty or traumatic origin.\\nThe patient may describe an excruciating pain in an area, but not\\nexhibit outward evidence or physiological change which should accom-\\npany such suffering. Thus the pain may simulate that of peritonitis.\\nSuch pain is often modified and mollified by fixing the attention of the", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0051.jp2"}, "52": {"fulltext": "46 GENERAL DIAGNOSIS.\\npatient on some other part or on some extraneous subject, when the\\npreviously alleged tender area may be pressed upon without causing\\nany evidence of suffering. Similarly, attention may be called, by a\\nleading question, to pain in some other region. The admission of the\\noccurrence of such pain, and other evidences of hysteria, point to the\\nunderlying causal factor in the production of pain. A most important\\ncharacteristic of pain, and one that serves to distinguish the pain of\\norganic disease from that of hysterical origin, is its variability with\\nexcitement, or on fixation of the attention of the sufferer on other\\nparts. Moreover, the subject will fall into the trap of describing it as\\nhaving characters contrary to the usual attributes of pain or being asso-\\nciated with phenomena not compatible with the pain if judicious\\nleading questions are put.\\nResume. Notwithstanding clinical investigation we may not be able\\nfrom the character and locality to determine the real cause of the pain.\\nIn general it may be borne in mind that pains are due (1) to disease of\\nthe central nervous system or the nerve-trunks (2) to inflammations\\n(3) to intoxications, as from malaria, lead, and other forms of toxaemia\\n(4) to pressure on the nerve-trunks (5) to reflex influences. If in\\ndoubt, therefore, the general symptoms and condition of the patient\\nmust be ascertained in order to determine the causal origin, and hence\\nthe true nature of the pain. In all cases of pain the controlling motive\\nin diagnosis should be to determine the general condition of the patient\\nand find the cause of the pain.\\nReference must be made to the curious change that takes place in\\npersons with chronic morphine intoxication. Such persons are very\\napt to have functional pain. This form of pain is usually paroxysmal\\nand severe, and may simulate organic pains. The most common clini-\\ncal form seen is gastralgia. The subjects of locomotor ataxia suffer\\nfrom pain, on account of which they have to take enormous doses of\\nmorphine. This habit is soon acquired, but notwithstanding the large\\ndose of the drug paroxysmal pain continues in its severity it simulates\\nthe crises of the primary disease. It becomes a very difficult matter,\\nand is often impossible, to decide whether the pain is due to the mor-\\nphine-habit or to the primary affection. (See Source of Error, p. 38.)\\nPain in the Head.\\nPains in the head may be classified, according to location, into those\\ndue to affections of the scalp, those due to affections of the cranium, and\\nthose due to intracranial conditions.\\n1. Affections of the scalp are to be further classified as those of\\nthe shin, those of the occipito-frontalis muscle, and those of the nerves.\\nThe occurrence of itching and burning commonly indicates some local\\ncondition of the skin if the itching is slight, seborrhoea should be\\nlooked for if more severe, eczema burning and itching of a severe\\ntype commonly indicate dermatitis venenata the pediculus capitis\\nshould not be forgotten. A feeling of tension, with soreness, accom-\\npanies the eruption of erysipelas. Intense local irritations are caused\\nby burns and scalds the latter, however, are alone likely to give rise to", "height": "4412", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0052.jp2"}, "53": {"fulltext": "THE DATA OBTAINED BY INQUIRY. 47\\nerror, because the hair is not immediately destroyed. A sore feeling,\\nwith local tenderness, limited to a sharply denned swelling, with a sen-\\nsation of less resistance in the centre and some darkening of the skin, is\\ndiagnostic of a bruise. Hyperesthesias of the scalp frequently accom-\\npany meningeal and cranial affections, and there are even local changes,\\nsuch as the so-called puffy tumor of necrosis of the inner table of the\\nskull.\\nSharp pains in the occipital or frontal region, increased by wrinkling\\nthe scalp, or brief pressure, but generally relieved by firm and constant\\npressure, occurring with irregular periodicity, and associated with\\nmeteorological changes, are suggestive of occipital myalgia. The diag-\\nnosis is confirmed by the presence of other symptoms of lithsemia.\\nNeuralgia occurs in paroxysms, accurately located in the course\\nof one or more of the nerve-trunks, and presenting points of special\\nsensitiveness where the nerve emerges from the skull and where it\\ndivides for its cutaneous distribution. The pain is usually relieved\\nby firm pressure, but it is to be remembered that sharply local-\\nized pressure on the nerve-trunks against the hard skull will cause a\\ntraumatic tenderness. The character of the pain is variable it may\\nbe of the most acute or rending form, or, but more rarely, a persistent\\ndull ache it may be throbbing, or occur in successive paroxysms at\\nbrief intervals, or it may be regularly periodic. There are often asso-\\nciated vasomotor, secretory, and motor disturbances local blushing or\\nsweating may be observed along the course of the nerve, and spasms may\\noccur in the muscles of the eyelids, for instance, or more general spasms,\\nas in the terrible tic douloureux, distinguished by pain from tic convulsif\\nThe commonest seat is the supraorbital, the dental, the auricular, and\\nthe occipital nerves. In the great majority of cases it is unilateral.\\nThe sensory nerves of the scalp and face are the trigeminus and the\\nbranches of the cervical plexus. The distribution is as follows the\\nophthalmic division of the trigeminus is distributed to the eyeball,\\nlachrymal gland, the mucous membrane of the nose and eyelids, the\\nintegument of the nose and upper eyelid, the forehead, and the anterior\\nhalf of the hairy scalp. The superior maxillary division supplies the\\nskin over the malar bone, and that of the lower eyelid, side of the nose,\\nand upper lip the upper teeth, the upper part of the pharynx, the\\nantrum of Highmore, and the posterior ethmoidal cells the soft palate,\\ntonsil, and uvula, and the glandular structures of the roof of the mouth.\\nThe inferior maxillary division is distributed to the side of the head,\\nthe upper anterior portion of the external ear, the external auditory\\ncanal, the lower lip, and lower part of the face the tongue, the mouth,\\nthe lower teeth and gums, the salivary glands, and the articulation of\\nthe jaw. The great occipital is distributed to the back of the head, the\\nsmall occipital to a narrow region just in front of it, and the greater\\nauricular to the skin of the posterior portion of the pinna and the skin\\nover the mastoid and parotid gland.\\nPain simulating neuralgia is frequently due to some local irritation\\nforeign bodies have been known to cause paroxysmal attacks for a\\nnumber of years, until removed diseases of the bones are a prolific\\nsource, especially in the case of the jaws and the cervical vertebrae.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0053.jp2"}, "54": {"fulltext": "48 GENERAL DIAGNOSIS.\\nEnlarged cervical glands occasionally irritate the great auricular or\\nsmall occipital nerve. Bilateral occipital pain is very characteristic of\\ncancer of the cervical vertebrse. In these cases there is usually\\npain on movement of the head or pressure upon it, and some stiffness\\nof the neck. Intracranial growths occasionally cause pains, usually\\nparoxysmal, limited to one of the branches of the trigeminus.\\nReflex Neuralgia. Certain of the cephalic nerve-pains are symptom-\\natic of disturbance in the associated but distant nervous distribution.\\nPain in the region supplied by the ophthalmic division is very common\\nin influenza. It is usually dull, aching, and continuous, increased by\\npressure and anything tending to increase congestion. A severe, acute\\nattack of indigestion will produce ocular and supraorbital pain. Re-\\nfractive lesions of the eye cause the same kind of pains, which are,\\nhowever, increased by using the eye and relieved by rest and atropine.\\nThe use of the latter is an important diagnostic procedure. Pain in the\\ntemporal region and the external auditory meatus is often due to intense\\nirritation of some of the branches of the inferior dental the usual cause\\nis cancer of the tongue, but irritable lingual ulcer may also produce it,\\nand even severe inflammatory conditions of the lower jaw. The pain is\\ndescribed as sharp, lancinating, and paroxysmal, liable to exacerbations,\\nespecially when the primary lesion is irritated, and relieved when it is\\nalleviated. Pain may be caused in the ear alone when there is irrita-\\ntion of the teeth.\\nSystemic Neuralgia. Perhaps in the majority of cases of cephalic\\nneuralgias the cause is to be found in some systemic disturbance. If\\nthe attack is preceded by a desire to sleep, occurs when the dew-point is\\nhigh, and is associated with increase of urates in the urine, it is prob-\\nably lithcemic the pure gouty forms are most apt to succeed indulgence\\nin rich food or red meat, and there is ordinarily irritability of temper.\\nDiabetic neuralgias are invariably worse as the amount of sugar excreted\\nis increased, and there are usually similar affections of the nerves in\\nother parts of the body. Regularly periodic pains, worse in the spring\\nand fall, occasionally preceded by a slight chill or malaise, suggest\\nchronic malaria. The diagnosis can readily be confirmed by exam-\\nination of the blood and by the detection of enlargement of the spleen.\\nSyphilitic neuralgias are usually worse at night the pain is described\\nas boring, and may be periodical. There is likely to be some thicken-\\ning of the bones, and perhaps a diminution of elasticity of the tissues,\\nand almost always local tenderness. The pain is almost immediately\\nrelieved by iodide of potassium. In anwmic neuralgias the pain is not\\ncharacteristic, but it is temporarily improved by the recumbent posture\\nand stimulants, and is worse during menstruation. The general appear-\\nance of the patient and an examination of the blood readily suggest the\\ncause. In locomotor ataxia there are occasionally cephalic crises of a\\nneuralgic nature these come on suddenly and are exceedingly severe,\\nbut usually occur only at long intervals the pain is shooting or stab-\\nbing, and does not remain located in one nerve-trunk. Chronic lead-\\nand alcohol-poisoning also cause neuralgias, but they are not of them-\\nselves characteristic, and never occur as isolated symptoms, being\\nfrequently associated with peripheral neuritis.", "height": "4412", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0054.jp2"}, "55": {"fulltext": "THE DATA OBTAINED BY INQUIRY. 49\\nSecondary Neuralgia. Dull, burning pains, commencing perhaps\\nwith a chill, and accompanied by febrile symptoms, indicate inflamma-\\ntions of the mucous membranes of the head. A dull, persistent head-\\nache located just beneath the eyebrows often accompanies coryza, and\\nindicates extension to the frontal sinuses if the nose alone is involved,\\nthere is a feeling of fulness and occasional sharp pains or tickling sen-\\nsations. A feeling of dryness and some discomfort on swallowing\\naccompanies the various forms of stomatitis and pharyngitis in the\\nlatter there is also a sensation of tickling and fulness in the ear, due to\\nextension along the Eustachian tube. Pain at the angle of the jaw,\\nwith tenderness, and increased on swallowing, almost invariably unilat-\\neral and associated with swelling of the parotid, is unmistakably due to\\nparotitis. The neuralgias and inflammations of the middle ear are\\nexceedingly painful they may consist of a sharp continuous pain, or a\\nseries of regular exacerbations and remissions, or a throbbing sensation\\npain often radiates to the jaws and side of the face. As suppuration\\noccurs, the feeling becomes one of extreme tension until the membrane\\nis perforated, when there is immediate relief. Tinnitus throughout the\\nwhole course of the case is very common. The inflammations of the\\neye produce local pain, usually causing the sensation of a rough foreign\\nbody. Usually there is a slight supraorbital tenderness, and, in iritis,\\nsharp pains radiate over the whole area of distribution of the two upper\\nbranches of the fifth. Certain ulcers of the mouth are comparatively\\npainless, noma often developing insidiously. Syphilitic ulcers are to\\nbe distinguished by their painlessness from simple and tubercular ulcers,\\nwhich are very irritable, and carcinomata, which are liable to paroxysms\\nof pain even when not irritated.\\nIt may not be out of place to mention the value of certain anaesthesias\\nas diagnostic signs thus in neuritis of branches of the fifth there may\\nbe cutaneous anaesthesia while there is tenderness over the nerve-trunk.\\n2. Affections of the Cranium. A dull, constant headache, limited\\nto a small area, later increasing in severity, and the pain assuming,\\nperhaps, a boring character tenderness, often very severe, over the\\naffected area, and probably slight oedema of the scalp, with some\\nrigidity of the muscles of the neck, and the ordinary signs of the in-\\nflammatory process, indicate inflammation of the cranial hones. In the\\nsimple cases there will usually be some history of injury, the pains will\\nnot be especially periodic, and the fever will be irregular. In the\\nsyphilitic cases there Avill be the history and symptoms of infection,\\nthe pain will become worse at night, and usually there will be concom-\\nitant rise of temperature. The pains will also be controlled by iodide\\nof potassium, but as it often requires enormous doses to accomplish\\nthis result, the failure of a moderate dose should not be considered as\\nexcluding syphilis.\\n3. Intracranial Headaches. Intracranial headaches are functional\\nor organic. Both forms may be acute or chronic. The typical acute\\nfunctional headache is seen in the more or less common type known as\\nmigraine or hemicrania.\\nMigraine is a periodical neurosis characterized by pain in the tri-\\ngeminus and other cranial nerves. The headache is usually unilateral,\\n4", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0055.jp2"}, "56": {"fulltext": "50 GENERAL DIAGNOSIS.\\nand, as it is probably clue to vasomotor disturbances, is always associated\\nwith vasomotor symptoms. It occurs more particularly in women,\\nfrequently begins in early childhood, and continues throughout adoles-\\ncence. It is often hereditary. It occurs most frequently in women\\nwho suffer from anaemia or from menstrual difficulties. It sometimes\\noccurs in the early stages of secondary syphilis. The habit which pre-\\ndisposes to the headache may develop after long physical or mental\\nover-exertion. The attacks, however, are excited by over-exertion,\\nmental excitement, or disturbances of digestion. Pain of migraine is\\npossibly situated in the pia and dura mater.\\nSymptoms. The attack develops with or without premonitions.\\nIn each individual different prodromal symptoms are recognized as in-\\ndicating the approach of an attack. Undue nervousness, a general sense\\nof discomfort, pressure or heat in the head, vertigo, tinnitus, spots before\\nthe eyes, excessive yawning, and repeated chilliness are the most common.\\nPremonitory Symptoms. The pain is most frequently felt on the\\nleft side of the head first. It is seated in the anterior frontal, the\\ntemporal, or parietal region. The pain is continuous, and increases in\\nintensity to the height of a paroxysm. Painful points are not usually\\ndetected, although the whole skin may be hypersesthetic. The patient\\nis sensitive to light and sound, intolerable nausea intervenes, and vomit-\\ning may occur at the height of an attack. The eye-symptoms are very\\npronounced. Flashes before the eyes, scintillating scotoma, or hemian-\\nopia may occur.\\nThe vasomotor .symptoms that attend the attack are of two varieties,\\ndividing the disease into the spastic and angioparalytic forms. In\\nspastic migraine the skin on the affected side is cool, the forehead and\\near pale, the temporal artery is contracted, the pupil is dilated, and the\\nflaw of saliva increased. In the paralytic form there is redness of the\\nface on the affected side. The temporal arteries are dilated and pulsate\\nstrongly. The face is hot, the pupils contracted, and there is often\\nunilateral sweating.\\nChronic Headaches. Chronic functional headaches are usually\\nhabitual in the sense that the attacks are constant, but there may be\\nlonger or shorter intervals of freedom from pain. The nerves affected\\nare the trigeminus, and the four upper cervical and sensory branches\\nof the vagus to the posterior fossa of the skull. Three types of such\\nhead-pains are seen ordinary headache, migraine, and neuralgia.\\nHeadaches are caused, as a rule, by diffuse irritations located in or\\nreferred to the peripheral ends of the nerve-tracts above referred to.\\nNeuralgias, on the other hand, are caused by irritations of the trunks of\\nthese nerves.\\nCauses. 1. Hsemic. (a) Anaemia; (b) diathetic states (gout, rheu-\\nmatism, diabetes) (c) infections (malaria, syphilis, specific fevers). 2.\\nToxic (lead, and other mineral poisons, alcohol, the poison of uraemia,\\ntobacco). 3. Neuropathic states (epilepsy, neurasthenia, chorea, hyste-\\nria, neuritis). 4. Keflex causes (ocular, nasopharyngeal, auditory,\\ngastric, sexual, uterine). 5. Organic disease.\\nHeadaches are divided according to their situation into frontal, occip-\\nital, parietal, vertical, diffuse, and combinations of both. The most", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0056.jp2"}, "57": {"fulltext": "THE DATA OBTAINED BY INQUIRY.\\n51\\ncommon forms are the frontal, the frontal-occipital, and the diffuse.\\nOcular headaches are usually frontal when due to errors of refraction.\\nWhen due to muscular insufficiencies they are occipital and cervical.\\nNasopharyngeal headaches are dull, frontal, or diffuse. When the\\npharyngeal tonsil is enlarged the headache may be dull, frequently\\nrecurring, and seated in the occipital region. In follicular tonsillitis\\nand in obstruction of the Eustachian tubes the headaches are diffuse.\\nIn disease of the middle ear they are temporal and occipital. Gastric\\nor dyspeptic headaches without constipation are often occipital, some-\\ntimes frontal. With constipation and intestinal irritation they are diffuse\\nand frontal. Uterine and ovarian headaches are occipital and vertical.\\nNeuropathic headaches are seated on the top of the head, as in clavus,\\nor they are associated with spinal irritation. Neurasthenic headaches\\nare usually associated with a sense of pressure or weight, and are seated\\nin the frontal and vertical regions. In spinal irritation the pain is of\\na boring character in the occipital region. The earliest symptom of the\\nneurasthenic headache is neck-weariness and pain in the neck. The\\nFig. l.\\nAnaemia.\\nEndometritis.\\nBladder.\\nConstipation caries of incisor v\\nError of eye-refraction^\\nGastric dyspepsia ---w\\nEye.\\n./\u00e2\u0080\u0094-y Decayed teeth.\\n7*-^* Pharyngitis otitis media.\\nUterine.\\nSpinal irritation.\\nShowing the location of pain in various headaches. (After Dana.\\nneurasthenic headaches occur in brain-workers when the brain and eyes\\nare overtaxed. Headaches in epliepsy are severe, and are confined to\\nthe vertical or occipital region.\\nOrganic headaches are usually violent, associated with fulness and\\nthrobbing. They may be remittent, becoming more intense with each\\nexacerbation. The organic headaches may be due to inflammation, to\\nabscess and softening, to tumor, to congestion of the brain, and to\\ninflammations in the meninges. Anything which increases the blood\\nwill increase the pain in organic headaches. In acute inflammation\\nof the brain the pain is agonizing, continuous, associated with vomit-\\ning and fever, and sometimes delirium. In abscess of the brain the\\npain is less violent. It is occasionally paroxysmal and attended by\\nparalysis and disturbed intellection. In tumor of the brain the head-\\nache is severe and paroxysmal. In congestion the pain is dull, increased\\nby stooping, by sleep, and by bodily or mental fatigue. Some conges-\\ntive headaches are due to violent exercise, and are relieved by bleed-\\ning at the nose. In all congestive headaches the face is flushed, the\\nbloodvessels are turgid, and the vessels in the eye-ground will be", "height": "4408", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0057.jp2"}, "58": {"fulltext": "52 GENERAL DIAGNOSIS.\\nfound to be overfilled. In meningitis the pain is constant, is more or\\nless fixed, and sometimes very sharp. Syphilitic headaches are frontal\\nor temporal, worse at night, and often periodic.\\nHeadaches are divided according to the character of the pain 1.\\nPulsating and throbbing. 2. Dull and heavy. 3. With constriction,\\nsqueezing, or pressing. 4. Hot and burning. 5. Sharp and boring.\\nThe headaches of the first class are usually associated with vasomotor\\ndisturbances, as in migraine. To the second class belong the toxic and\\ndyspeptic headaches to the third, the neurotic and neurasthenic to\\nthe fourth, rheumatic and ansemic to the fifth, hysterical, neurotic,\\nand epileptic. Vertigo is a common accompaniment of the dyspeptic\\ntype of headache situated in the frontal regions. /Somnolence is more\\nmarked in the syphilitic, ansemic, and malarial headaches. Nausea is\\nmore common in occipital forms of headache.\\nDuration. Eye-strain causes occipital pain, which is rarely per-\\nsistent, but comes on after prolonged use of the eyes. It may be asso-\\nciated with headache in other parts, due to other causes. In chronic\\nmeningitis the headache is persistent and located in the vertex or the\\nparietal regions. When thickening of the meninges, with adhesions,\\ntakes place from trauma, there is constant pain with frequent exacer-\\nbations, sensitiveness of the head, incapacity for study. Uremic head-\\nache is not constant. Persistent headache may be present in the latter\\nstages of Bright s disease and in diabetes. In atheroma pain in a part\\nor the whole of the head is common. It may be persistent, though\\nsubject to exacerbations in case of excitement or violent exercise.\\nHeadache following study, in children, is due to brain-strain, to eye-\\nstrain, or to indigestion. Persistent headache is sometimes due to\\nasthma. In rare instances headache is said to be idiopathic. Neu-\\nralgic headaches are usually periodic, and may be associated with\\nthrobbings or pulsations. They are associated with vasomotor signs.\\nHysterical headaches are irregular and shifting they persist after all\\ncauses are removed they are replaced by pain in other parts of the\\nbody. They are usually associated with other manifestations of hysteria.\\nNeuralgia.\\nNeuralgia is characterized by pain in the course of distribution of the\\naffected nerve. The pain is of pronounced severity, and occurs in re-\\nmissions and intermissions. The symptoms of a neuralgic paroxysm\\nmay be preceded by hyperesthesia over the part subsequently affected.\\nThe pain is of a burning or shooting character. It is usually limited\\nto the distribution of the affected nerve, but may extend into other\\nregions. It may be excited by external irritants, by mental excite-\\nment, and often by movement of the part. On examination the area\\nof distribution of the affected nerve may be found to be anaesthetic,\\nbut usually there is a hyperesthesia of the skin. Wherever the\\naffected nerve is accessible to pressure pain can be elicited. The nerve-\\ntrunk may be tender during the attack, as well as during the intervals.\\nIn neuralgia there is often some spasm of the muscles supplied by the\\nnerve.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0058.jp2"}, "59": {"fulltext": "THE DA TA OB TAIN ED B Y INQ UIR Y. 53\\nVasomotor symptoms are common. The skin may be pale or red-\\ndened. When the trigeminal nerve is affected the skin and conjunc-\\ntivae are both reddened. The secretions, as the tears, may be modified.\\nEruptions like urticaria or herpes may develop along the course of the\\nnerves. Prolonged neuralgia may cause marked nutritive disturb-\\nances.\\nGeneral Conditions. A patient who is subject to neuralgia may\\nbe in apparent good health. The neuralgia may be due to constitu-\\ntional causes, as rheumatism or gout to some form of toxaemia, as\\nmalaria to some condition of the blood, as anaemia and may be due\\nto trauma or to cold.\\nThe following individual forms of neuralgia are seen 1. Neuralgia\\nof the trigeminus, or tic douloureux. The entire fifth nerve or some\\nof its branches are affected. The pain is often severe and may be asso-\\nciated with twitchings, with vasomotor disturbances, with eruptions,\\nand with changes in the secretions. Trophic changes, as the hair turn-\\ning gray, or ulceration of the cornea may follow. Usually a single\\nbranch is affected, either the first branch (ophthalmic), the second\\nbranch (supramaxillary), or the third branch (inframaxillary). Points\\nof pressure are, as a rule, readily detected at the foramina for the exit\\nof the nerves. 2. Occipital neuralgia. 3. Neuralgia of the brachial\\nplexus. 4. Intercostal neuralgia. 5. Neuralgia of the lumbar plexus,\\nof which we have lumbo-abdominal, crural, and obturator neuralgia.\\nThis form of neuralgia (lumbar plexus) must not be confounded with\\nbone and joint disease, with lumbago, renal colic, appendicitis, and uterine\\naffections. 6. Sciatica. 7. Genital and rectal neuralgia.\\nTrigeminal neuralgia must be distinguished from headache due to\\nother causes, affections of the bones and periosteum, and affections of\\nthe teeth. The distribution and paroxysmal character of the pain and\\nthe points of tenderness assist in the diagnosis.\\nPain in the Legs and Feet.\\nParoxysmal Pain. Pain in one leg may be due (1) to sciatic\\nneuralgia or (2) to neuritis. The former does not exhibit localized\\ntenderness and is not aggravated by movement. The latter, also\\ncalled sciatica, is recognized by tenderness in the course of the sciatic\\nnerve or at its exit from the pelvis, and by increase in the pain when\\nthe limb is extended by forced movement. The pain is constant, worse\\nat night, and characterized by agonizing paroxysms. It follows ex-\\nposure to cold or may be caused by rheumatism. One of the many\\nbranches of the sciatic may be affected, exhibiting tenderness in its\\ncourse. If the sciatica persists, wasting of the muscles, herpetic erup-\\ntions, and areas of anaesthesia over the affected leg may be found.\\nSuch neuritis is usually traumatic (cold), alcoholic, rheumatic, gouty,\\nor syphilitic the exact cause in each case must be ascertained by the\\nassociate phenomena and by the exclusion of other causes. Pain in\\nthe leg may also be due to (3) pressure on the sciatic nerve by a pelvic\\ngrowth, (4) neuroma, (5) rheumatism, (6) syphilis of bone or a syphilitic\\ngumma of muscle or connective tissue.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0059.jp2"}, "60": {"fulltext": "54 GENERAL DIAGNOSIS.\\nFixed pain in the leg, in contradistinction to the mobile pains of\\nneuritis, is usually situated in the fascice or muscles or in the bones.\\nIt may be due to rheumatism, when the pain is diffused and the\\nnerve points of tenderness are wanting. It may be the result of\\nstrain or injury, a history of which must be carefully inquired for.\\nThe latter may be the exciting cause only, in a person of rheumatic\\ndiathesis, the fixed pain at the situation of the injury being due to\\nrheumatism. Fixed traumatic pains are usually accompanied by ten-\\nderness on pressure, and aggravated by movement both active and\\npassive, the tenderness on pressure not necessarily being in the nerve-\\ntrunk. In malignant disease of the long bones, mobile neuralgic-like\\npains may precede for some time the fixed pain of the permanent pro-\\ncess. (See A Case of Carcinoma of the Bones, J. H. M.)\\nBilateeal pains in the extremities are often of central origin, and\\nmay be due to spinal sclerosis to malignant disease of the vertebra\\npressing on the cord to pelvic growth, or lumbar abscess, causing\\npressure on both nerve-trunks in the pelvis.\\nPains of the feet not due to affections of the large nerve-trunks are\\n1. Pain in the Articulations due to Flat-eoot. This may\\nbe in the tarsus or at the metatarsal articulations. It is a common\\ncause of pain in the extremities, and may be unilateral or bilateral.\\nFlat-foot from breaking of the arch can readily be recognized pressure\\non the sole of the foot may increase the pain.\\n2. Pain in the Heel. This is often of gouty origin, and is a per-\\nsistent source of complaint in many instances.\\n3. Pain in the Interosseous Spaces Between Distal Ends\\nof the Third and Fourth Metatarsal Bones (Morton s painful\\naffection of the foot). It occurs in people who are on their feet a great\\ndeal, is relieved by a night s rest, increases as the day goes on, and is\\nincreased by pressure or by wearing a tight shoe. It is worse in wet\\nand cold weather. Localized pressure at the point on the sole indicated\\nabove causes extreme pain.\\nWe cannot leave the extremities without a word regarding pains in\\nthe extremities of distinctly central origin the forerunners of hemor-\\nrhage into the brain. Mitchell has called attention to these pains.\\nThey occur suddenly without evidence of local disease they are\\nlocated in one of the extremities, usually the leg, are excruciating,\\nand not influenced by position, local applications, or pressure. In\\na patient with hard arteries and high pulse-tension they should be\\nlooked upon with suspicion.\\nPain in the Arms.\\nUnilateral Pain. It may be due (1) to neuritis associated with\\ntenderness of the nerve-trunk (2) to neuroma, as, indeed, any peripheral\\nnerve may be affected (3) to simple neuralgia or neuralgia from the\\npressure of enlarged axillary lymphatic glands of a morbid growth\\nof an aneurism on the nerves (4) to rheumatism or myalgia (5) to\\nbone disease.\\nBilateral pain in the arms is of central origin, due to diseases of the", "height": "4416", "width": "2648", "jp2-path": "practicaltreatis00muss_0_0060.jp2"}, "61": {"fulltext": "THE DA TA OB TAIN ED B Y INQ UIB Y. 55\\nvertebra or of the spinal cord, or neuralgic, due to anaemia or toxaemia\\nof some form.\\nPains of the Thorax.\\nPainful diseases of the muscles and of the viscera will be considered\\nin the chapters on Diseases of the Heart and Lungs. Pains of reflex\\norigin will be referred to. They are usually seated in the shoulder or\\nthe back, and are due to liver or gastric disease. The pain of liver\\ndisease is referred to the right shoulder of ulcer of the stomach, to\\nthe interscapular region and the lumbar region, or to the top of the\\nshoulder, as in a case observed by Wood.\\nPain behind the sternum is often a reflex neurosis from gastric dis-\\norder. It may occur in bronchitis. It may also be due to cancer of\\nthe mediastinum, to aneurism, or angina. Pain in the sternum or ribs\\nis syphilitic or due to periostitis or necrosis following typhoid fever,\\nrarely to cancer. Chronic fibrous inflammation of one or more of the\\nattachments of the muscles is of common occurrence. The pain lasts\\nfor years. It is persistent, sometimes associated with stiffness it is\\nincreased by movement, and there may be extreme aching pains in the\\nparts. The pain of vertebral caries transmitted along the course of\\nthe nerve has been referred to.\\nGirdle-pain. This is a peculiar pain or sensation in the trunk, due\\nto disease of the spinal cord. It is described as the sensation of a band\\ndrawn tightly around the body. It varies from a simple drawing\\nsensation to extreme pain which encircles the trunk. It is situated\\nabove the level of the umbilicus. In milder forms it is due to chronic\\nmyelitis or spinal sclerosis in severe forms to inflammation of the\\nnerve-roots, or to cancerous, syphilitic, or tubercular disease of the\\nmeninges.\\nPain in the Spine.\\nPain in the spine is due less frequently to organic disease of the cord\\nthan to acute or chronic inflammation of the meninges, to disease of the\\nbones of the vertebral column, or to curvature of various forms from\\nmuscle- weakness. Rhachialgia and tenderness in the course of the\\nspine occur after concussion.\\nI. Disease of the Spinal Cord. In organic disease of the\\ncord pain may be referred to the loins, the sacrum, or to the parts about\\nthe spine, but not to the spinal column itself. In the same disease of\\nthe cord we may have also the eccentric or radiating pains, of which\\nmention has been previously made, due to irritation of posterior nerve-\\nroots. They may be dull, resembling those of rheumatism. In acute\\ncases the pains are accompanied by febrile symptoms, which may simu-\\nlate rheumatism, especially when the other spinal symptoms are in\\nabeyance. In chronic cases these peripheral spinal pains are influenced\\nby the weather, and this likewise makes it difficult to distinguish them\\nfrom rheumatism. Rheumatic pains in the limbs occurring after middle\\nlife, with or without joint-changes, should suggest locomotor ataxia.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0061.jp2"}, "62": {"fulltext": "56 GENERAL DIAGNOSIS.\\nIn this affection sharp and darting pains, pain crises/ and girdle\\nsensations occur.\\nII. Disease of Vertebrae. Fixed localized pain at some point\\nin the vertebrae points to traumatic, syphilitic, or tubercular caries, or\\nto pressure necrosis, as by an aneurism. Pain due to vertebral dis-\\nease is both local and radiating. It is increased by pressure directly\\non the spinal column (on the head), by heat or by cold, or by electricity,\\napplied over the part. It is relieved by removing the pressure of the\\nweight above, as by raising the head or shoulders. It is relieved by\\nthe absolutely recumbent posture. With this pain the movements\\n(flexibility) of the spine are interfered with, because of spasm of the\\nmuscles or anchylosis there may be deformity. When the patient is\\nplaced upon a flat surface the normal lumbar arch is changed.\\nIII. Disease of Meninges. Pain due to meningeal disease is local\\nand radiating. It is associated with muscular spasm and stiffness of\\nthe spinal column.\\nIV. Spinal Curvature. The pain of curvature from muscular\\nweakness extends along the nerves. The patient is afebrile. The signs\\nof organic disease above mentioned are absent, but muscle-weakness and\\ngeneral signs of debility are present. Pain in the spine frequently attends\\nscurvy and rhachitis. It may be accompanied by paresis of the muscles\\nand closely simulate an organic brain or cord disease.\\nPain in the Side.\\nPain in the left side the so-called inframammary pain is one of\\nthe most frequent complaints heard by the practitioner. By discussion\\nof it we can show how the symptom pain, wherever situated, must be\\ninvestigated in order to determine the tissue affected and the nature of\\nthe disease. The tests used in the study of nerve affections (q. v.) are\\nnot given. It may be due to many causes, to exclude any one of which\\ninquiry as to the mode of onset, duration, and character of the pain\\nmust be made. Then the structures underneath and about the seat of\\npain must be examined. 1. The skin to exclude any swelling or\\ntumor or herpes zoster, and to determine the tender nerve-points. 2.\\nThe muscle to exclude myalgia or pleurodynia. Examine for tender-\\nness note the effect of movement does full breathing increase the\\npain Palpate Avith the fingers and with the whole hand. Negative\\nresults exclude any muscular affection. 3. The nerves, (a) Tender\\npoints (b) herpes (c) the vasomotor appearance. The presence of\\nanaemia, other neuroses and neurasthenic phenomena, or toxic condi-\\ntions, as malaria, lead, or gout, lend color to the view that the pain is\\nneuralgic. 4. The pleura. Auscultate for friction if pleuritis. In-\\nquire for cough. Note the character and effect of breathing. 5. The\\npericardium. Note friction of pericarditis or thrill by palpation. Is\\nthe heart disturbed in function 6. The heart. It is rare that disease\\nof this organ causes pain, although it maybe present in dilatation. Is it\\naffected in a reflex manner, causing palpitation or irregularity Look\\nfor distant disease. Angina or pseudo-angina pectoris may be present", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0062.jp2"}, "63": {"fulltext": "THE DA TA OB TAIN ED B Y INQ UIR Y. 57\\n7. 1 The stomach and colon. A dilated stomach or loaded colon may\\ncause pain by pressure upward. Gastralgia may also be the cause. 8.\\nThe spine. Determine if it is diseased or if there is pressure by an\\naneurism or a mediastinal growth. If a local cause is not ascertained,\\nlook for a central or reflex disorder.\\nAlthough any one of the above conditions may cause pain in the\\nside, it is usually (1) a reflex pain from gastric disorder; (2) pain from\\nneuritis (3) a true neuralgia from anaemia (4) a neuralgia from heart-\\nfatigue. (Hilton.)\\nIt is to be observed that every local tissue must be examined, and\\nquestions asked as to the various attributes of the pain.\\nPain in the Loins.\\nWhen acute, without fever, pain in the loins may be due to lum-\\nbago, to a sudden uterine retroversion, to a suddenly moved kidney, or\\nto calculus of the kidney with fever, acute Bright s disease, smallpox,\\nmuscular rheumatism, tonsillitis, influenza, dengue, or spinal meningitis\\nmust be looked for.\\nChronic Pain in the Back Backache. Backache may be due to\\nmany causes. When in the region of the kidneys, they may be at\\nfault. Organic disease (Bright s) may be associated with backache\\nmore frequently, pain, if in one kidney, is due to a calculus or to accu-\\nmulation of uric-acid gravel. Pressure over the kidney or a sudden\\njar from a false step will usually excite the pain. It may be constant\\nin moved or movable kidney. When low down, just above or over\\nthe sacrum, it is due to disturbance of the pelvic viscera. The uterus,\\nthe colon, and rectum (impacted, cancerous) must be examined\\nOtherwise we may have (a) Pain due to affections of the muscles.\\n1. Myalgia of rheumatic origin. Increased by movement, by damp-\\nness, by pressure. Often relieved by warmth, by the recumbent\\nposture, or rest. It is associated with symptoms of lithsemia and with\\nthe passage of red sand in the urine. When the fascia or the ligaments\\nof the vertebrae are affected, the upright position and pressure in small\\nareas increase the pain other muscles may be affected alternately. 2.\\nMyalgia from sprain. A history of injury is obtained. Usually one side\\nis larger than the other. Tenderness is present and movement in-\\ncreases the pain. There may be increased swelling, vasomotor disturb-\\nance, or ecchymoses. A neurosis of the so-called spinal or traumatic\\n1 Shoulder-tip pain, due to anastomosis of phrenic nerve with 3d and 4th cervical\\nand to parts of liver and round ligament i Hilton) or of phrenic nerve and subclavius\\n(Rolleston) or of vagus with spinal accessory, which communicates with 3d and 4th\\ncervical. The v. and s. a. are sensitive to pressure. (Embleton.\\nInframammary pain (6th, 7th, and 8th intercostal spaces). The aorta at left side,\\n3d dorsal vertebra, is in relation with the 4th, 5th, and 6th intercostal nerves through\\nthe sympathetic ganglia, through which also the heart sympathetics are in anasto-\\nmosis The 4th, 5th, and 6th intercostal nerves supply cutaneous branches to the\\n6th, 7th, and 8th intercostal spaces. The inframammary pain is a reflex neuralgia\\nexpressive of some heart-distress. The latter is brought about by exhaustion of the\\nmedullary and vasomotor centres, from worry or overwork, or from long-continued\\nirritation of the uterine nerves. In leucorrhoea this pain is most common. (Jacob-\\nson Hilton on Eest and Pain.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0063.jp2"}, "64": {"fulltext": "58 GENERAL DIAGNOSIS.\\ntype (hysteria) attends the pain. 3. Myalgia from fatigue. Not only\\nacute fatigue after exertion, but chronic muscle-tire (and nerve-tire).\\nThe pain is increased on exertion, after mental, physical, or emotional\\neffort. Neurasthenia, anwmia, or local exhaustive disease (uterine,\\ngastro-intestinal, etc.) are present. The muscles are usually flabby,\\nand the vertebral column is not supported. The patient lounges or\\nsupports the back. Spinal curvatures are observed.\\n(6) Pain due to affections of the nerves. Nerve-pain is recognized\\nby the tender points by vasomotor phenomena.\\n(c) Pain due to disease of the spine, the membranes, or the cord.\\n(See above.)", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0064.jp2"}, "65": {"fulltext": "CHAPTER Y.\\nTHE DATA OBTAINED BY OBSEEVATION.\\nThe objective symptoms correspond to phenomena in nature. Method of procedure;\\nmethod of the observer. Inspection, palpation, percussion. The instruments\\nrequired.\\nThe Objective Symptoms.\\nThe objective symptoms of disease are the most important to ascer-\\ntain. They are the handwriting on the wall. The impress of\\nforces for good or evil is observed. In determining them we deter-\\nmine the physical, chemical, and vital condition of the organism its\\nstate after the action of the forces of its environment. The physical\\nand mental status of the patient is measured. He is individualized.\\nThe objective symptoms are data by which a complete diagnosis is\\nmade. Without such data the diagnosis is mere guesswork one of\\nprobability. With such data alone, if accurately and precisely col-\\nlected, a positive diagnosis can very frequently be made. A correct\\ndiagnosis depends upon the skill and thoroughness of the physician and\\nhis ability to interpret the data secured, always provided that clear,\\nsuccinct data can be obtained\\nThe data obtained by inquiry are carefully recorded, after which the\\nfollowing procedure is conducted. A physical examination of the\\npatient is made, followed by an immediate study, or, if time permits, a\\nstudy at leisure of the fluids of the body microscopically, chemically,\\nand bacteriologically. In the physical examination we make a general\\nsurvey of the individual, and form an estimate of his height and weight.\\nThe various organs and tissues are interrogated by the senses appli-\\ncable to the investigation of each, aided by special instruments. The\\nnatural secretions and discharges, abnormal discharges, all exudations\\nor transudations, and cystic fluids are passed upon.\\nThe student will soon learn that the process of ascertaining the ob-\\njective signs of disease is in no respect different from that which obtains\\nin the study of any object in nature or any like phenomena. The\\nchemist notices the form, the color, the density, etc., of the object\\nunder examination the effects of heat and cold, of various reagents\\nupon its structure he determines its component parts and ascertains\\nits relation to other objects in nature. From data thus obtained by\\nthe use of all his senses he classifies the object. The biologist notes\\nnot only the physical appearance of a given form of life, but also the\\nphenomena of the living, sentient matter under all conditions in a\\nvaried environment. By comparison and analysis the living being is\\nclassified.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0065.jp2"}, "66": {"fulltext": "60 GENERAL DIAGNOSIS.\\nBy the same powers of observation and the same analytical process,\\nthe departures from health are recognized and classified. Is it not,\\ntherefore, a wonderful aid to the diagnostician to possess faculties\\nwhich have been trained to minute observation by previous studies in\\nsciences allied to medicine\\nWhat has been thus imperfectly said is intended to emphasize the\\nfact that no mystery attends the recognition of the objective signs of\\ndisease. Abundant opportunities of observing disease at the bedside,\\npatient training, skill in technique, and a systematic procedure are\\nessential.\\nMethod of Procedure.\\nThe method by which the data ascertained by observation are secured\\nis modified by the circumstances under which the patient is seen. It\\nis obvious that the patient who comes to the office, or is not sufficiently\\nill to be in bed, has sufficient strength to stand, and should be given\\nan exhaustive examination. Moreover, we can inquire into certain\\nabnormalities, as the gait, not visible in bed. On the other hand, in\\nthe case of a bed patient, we learn the position he assumes when lying\\ndown, and have better opportunities for thorough examination of the\\nvarious organs. Often the objective examination must be very brief,\\non account of the patient s extreme illness. It may be advisable,\\nalthough unfortunate, to exclude one or more methods, as percussion,\\nif there is pain, or auscultation, if there is great restlessness or orthopnoea.\\nIf a complete examination is made, it is well to begin with the\\nexterior. After the external examination is made, the internal exami-\\nnation is conducted, by grouping together and examining organs func-\\ntionally related, as the heart and bloodvessels, in diseases of the heart\\nthe nose, larynx, and lungs, in diseases of the latter. The student will\\ndo well to begin at the head and take up the organs in their continuity.\\nComparison. The results obtained by observation are based upon\\ncomparison the student must bear this constantly in mind. We\\ncompare the body as a whole with our conception of the normal indi-\\nvidual, formed by a study of a large number of persons. We compare\\nsymmetrical parts the right side of the chest with the left, the arm\\nsuspected to be the seat of the disease with the healthy arm, etc. The\\ncardinal rule in an examination is to base the significance of ascertained\\nfacts upon comparison with known normal conditions.\\nMethods of Observation.\\nSecuring the Data. To accomplish these ends, examination is\\nmade by the sense of sight (inspection) by the sense of touch (palpa-\\ntion) by the sense of hearing (auscultation) and by the sense of hear-\\ning applied to the discrimination of sounds developed by percussion.\\nBy percussion or tapping the part we also elicit the peculiar phenom-\\nena known as reflexes.\\nThe sense of taste is not used to determine the objective phenomena\\nof disease. Some data, such as the odor of the exhalations and dis-\\ncharges, are obtained by the sense of smell.", "height": "4416", "width": "2564", "jp2-path": "practicaltreatis00muss_0_0066.jp2"}, "67": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 61\\nInspection. By inspection we judge of the physical condition of\\nthe whole or a part of the body, as seen in the shape and size and in\\nthe color of the vital condition, by the expression of countenance, by\\nthe character of the movements of the body as a whole or in part, by\\nthe position in bed, and by the gait. The appearance of fluids (blood)\\nand of discharges is also observed. The results of inspection as to size\\nare confirmed by actual weighing.\\nIn order that the data obtained by inspection may be complete and\\naccurate, every portion of the body, and of its internal cavities which\\ncan be seen by the unaided or aided eye, should be inspected. The\\nclothing should be removed, and, bearing in mind the proprieties, the\\nwhole body should be examined. For this purpose the patient should\\nbe under a good light. The light should always fall directly on the\\nsurface. The entire surface, of course, need not be exposed at once,\\nand circumstances may be such that only one portion need be exam-\\nined. Nevertheless, the fact must be insisted upon that patients who\\nhave been ill for a considerable time, as well as all grave cases, should\\nbe examined all over. It is even more important to do this if the\\npatient is comatose. A node on the tibia, undue prominence of the\\nvertebrae, a special rash about the anus, may afford information which\\ncould not be obtained in any other way. It is assumed that the patient\\nhas been examined lying down. In nervous diseases and diseases\\naffecting the muscles and bones, the patient s gait, his ability to stand,\\nthe method of rising or assuming a sitting posture, and the performance\\nof other customary physiological acts should be observed. For this\\npurpose, as above mentioned, portions of the body can be covered, or a\\nlight gown thrown over the patient from head to foot.\\nMethod of the Observer. In order to secure the data in full,\\nthe student should teach himself a method of observation by which all\\nthe facts are collated in regular systematic order. Whether the exam-\\nination is general or local, whether the whole of the body is referred to\\nor only a part, as, for instance, the nose, the student should accustom\\nhimself to make observations in the following order First, the shape\\nor contour (expression) second, the size third, the color fourth, the\\nmovability and the physiological condition of the part on movement.\\nIf this plan is pursued, little, if anything, will be overlooked. A simi-\\nlar order should be followed in the investigation of the character of the\\nsecretions and excretions of the body.\\nInspection of Special Regions. In the inspection of special\\nregions artificial light and special instruments are also required. The\\nartificial light should be secured from an Argancl or Welsbach burner,\\nor from a gas-jet with a reflector, or from electricity. To facilitate the\\nexamination the room should be darkened and head-mirrors used as\\nreflectors. A number of these have been devised, any one of which is\\nsuitable if it fits the head well and can be adjusted with comfort, so that\\nthe observer can throw the light on the part he wishes to examine, and,\\nat the same time, peer through the centre of the mirror. A special\\narrangement of the patient and the light is required. The patient\\nshould sit in an easy, comfortable, erect position, with the light on a\\nlevel with the part to be examined, a little behind, and to his right or", "height": "4416", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0067.jp2"}, "68": {"fulltext": "62 GENERAL DIAGNOSIS.\\nleft, according to the convenience of the examiner. Special apparatus\\nis required for the examination of each cavity mirror, tongue-\\ndepressor, and specula for the throat, an ophthalmoscope for the eye,\\netc. (See respective sections.)\\nPalpation. The results of inspection are confirmed, when possible,\\nby palpation, and the sense of touch supplies additional data. The\\nnutrition of the parts is ascertained. The density, the resistance, the\\nspecial character of the part, whether solid or liquid, are determined by\\nthis method of examination. On examination of the skin, the degree\\nof dryness or moisture, the character of the skin, whether smooth or\\nrough, the density of the part as to degree of thickness and resist-\\nance are all ascertained by means of the sense of touch. The pres-\\nence or absence of pitting is observed, and the nature of swellings\\nascertained. In a similar manner local areas are examined. The\\nsame routine method should become habitual with the student. First,\\nthe shape and contour second, the size third, the color, its change\\non pressure, etc. fourth, the movability of the part, and the character\\nof the normal movements, as when a joint is under observation fifth,\\nthe resistance and density of the part examined, or special characteris-\\ntics revealed by touch the elasticity of the skin, firmness of muscles,\\nand, in swellings, the presence or absence of fluctuation. Other phe-\\nnomena are detected, which are vital, in contrast to the above, which\\nare physical. By palpation, alone or with instruments, we determine\\nthe sensibility of the part, the presence or absence of tenderness, the\\ntemperature, and the degree of moisture. In the examination of special\\nregions by means of palpation some phenomena are determined pecu-\\nliar to the system under examination, and dependent upon its physio-\\nlogical or functional action. Thus, in palpation of the chest, in addi-\\ntion to its movement, we note the vibrations transmitted to the hand\\nwhen the patient is asked to speak, or detect abnormal vibrations from\\nthe friction of two rough surfaces together (pleura), or from the throw-\\ning of fluids into agitation fremitus, friction, and rales are thus trans-\\nmitted.\\nKnowledge of the action of the heart and of its position is obtained\\nby palpation thrills are detected, abnormal impulses felt. (For\\nmethod of procedure, see respective organs.)\\nAuscultation. By auscultation we hear and analyze the sounds\\nthat attend respiration, the movements of the heart and of the blood in\\nthe bloodvessels. Abnormal sounds may be created in the pleura and\\npericardium and in hollow viscera, as the oesophagus, stomach, and\\nintestines and their presence is likewise ascertained by auscultation.\\n(See Diseases of the Lungs and Heart.) The character of the voice as\\nto the quality and degree of loudness is studied to determine abnormal-\\nities in the respiratory tract or any speech defects of central or periph-\\neral origin.\\nPercussion. By percussion, sounds are elicited which indicate the\\nphysical condition of the part percussed. In health the lungs and the", "height": "4412", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0068.jp2"}, "69": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 63\\ngastrointestinal tract contain air in certain proportions, and therefore\\nthe sounds yielded by percussion are always of a known character.\\nAny change from the normal sound is indicative of disease, of abnor-\\nmal structure, or of alterations in the normal relations of the parts.\\nPercussion determines these changes, and, in addition, enables us to\\nestimate the size of organs. It is possible to determine the size of the\\nliver, the heart, or the spleen, because of the relationship of these\\nairless, non-resonant bodies to the air-containing structures around\\nthem. As this method of securing data is of the greatest use in pul-\\nmonary and abdominal diseases, the mode of procedure will be described\\nin the chapters on Diseases of the Lungs and Abdomen.\\nOther Methods to Secure Data. In addition to the data obtained\\nby the above methods, valuable and essential data are obtained by\\nchemical, microscopical, and bacteriological examinations of the fluids,\\ndischarges, exudations, and transudations, and by aspiration and special\\nexamination of the fluids obtained from the natural cavities, or from\\ncysts of the body. Bacteriological diagnosis and exploratory puncture\\nwill be considered in a special chapter.", "height": "4412", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0069.jp2"}, "70": {"fulltext": "CHAPTER VI.\\nTHE DATA OBTAINED BY OBSERVATION\u00e2\u0080\u0094 {Continued).\\nThe first sight impressions. General abnormal vital conditions. Fits or seizures.\\nComa. Collapse. Shock. 1. The personal appearance. 2. The apparent age.\\n3. The temperament and constitution. 4. The attitude and gait. 5. The general\\nform and nutrition. The size\u00e2\u0080\u0094 enlargement, diminution. The weight.\\nGENERAL EXAMINATION OF THE EXTERIOR.\\nThe general appearance of the patient affords an idea of the ability\\nhe has to cope with the antagonistic forces of his environment, or to\\novercome the deleterious effects of his occupation. It indicates the\\neffect of present or past disease or of inherited disease. The first sight,\\nstriking impression, is always to be noted. Very sick, coma-\\ntose, collapsed, etc., or robust, cyanosed, etc., are speaking\\nmemoranda. To the experienced practitioner, the opinion formed at\\nfirst glance is often of great diagnostic significance. It may happen\\nthat the patient is suffering from some unusually abnormal vital con-\\ndition, a study of which must be made before the exhaustive survey of\\nthe case Ave are about to enter upon is conducted.\\nGeneral Abnormal Vital Conditions. Impairment of conscious-\\nness and fits are readily recognized. The two often go hand-in-hand,\\nbut in some instances, as in fainting-fits, consciousness is not lost.\\nThe following list includes the various forms with their associate phe-\\nnomena. Only those are mentioned which occur instantaneously. For\\ntheir symptomatology and diagnosis the appropriate sections on special\\ndiagnosis must be consulted.\\n1. Unconsciousness, a. Syncope. The face is pale but calm, the\\npulse feeble or imperceptible, the extremities cool nausea or hurried\\nbreathing may precede. The breathing is quiet in the attack. The\\npupils respond to light. No pain. (See Heart Disease.)\\nb. Cerebral Disease. (Spasm is sometimes associated.) Head-\\npain, congested face, hemiplegia, facial palsies, pupils irregular and\\nirresponsive, cornea not sensitive; incontinence of urine.\\nc. Intoxications. Alcohol, opium, and other narcotics ursemia,\\ndiabetes, toxaemia from infections, sunstroke.\\n2. Fits. a. Epilepsy. (1) Hautmal: aura, convulsions (a)\\ntonic, respiratory muscles affected, face livid, stupor afterward (6)\\nclonic, tongue bitten, stupor follows. (2) Petit mal pallor sudden,\\nno convulsions.\\n6. Infantile Convulsions. Usually reflex from indigestion\\nmay be the onset of a specific fever or due to high temperature.", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0070.jp2"}, "71": {"fulltext": "THE DA TA OB TA IN ED B Y OBSER VA TION. 6 5\\nc. Puerperal Convulsions. Headache, amaurosis, oedema, sup-\\npressed and albuminous urine clonic convulsions, tongue bitten, com-\\nplete coma. (See Uraemia.)\\nd. Uraemia. Unilateral or bilateral clonic convulsions. (See Renal\\nDisease.)\\ne. Alcoholism and Sunstroke.\\nOrganic Brain Diseases (syphilis, tumor, softening, etc.).\\ng. Fits with Partial or no Loss of Consciousness. Hystero-\\nepilepsy, focal or Jacksonian epilepsy, hysteria, cerebral embolism,\\nthrombosis, or hemorrhage, spasms of various kinds.\\nh. Fits with Vertiginous Movement. The forms of vertigo are\\ngastric, aural, and labyrinthine (Meniere s, also paroxysmal), ocular,\\ncerebellar, from congestion of the brain (reflex), epileptic.\\n3. Collapse. Collapse may occur in a person in apparent health\\nand be the first indication of disease, as in rupture of a large blood-\\nvessel causing internal hemorrhage. Or it may occur in the course of\\ndisease, as typhoid fever, when intestinal hemorrhage takes place.\\nThe symptoms are those of prostration, with partial loss of con-\\nsciousness, or the mind is perfectly clear. The face is pale, pinched,\\nand bathed with perspiration. (See Hippocratic Facies.) The skin is\\ncool and clammy. The hands are cold. The skin is wrinkled. The\\neyes are sunken and encircled by dark rings. The voice is weak or sup-\\npressed. The pulse is rapid and thready, or may be absent at the\\nwrists. The heart-sounds are indistinct. The temperature falls. The\\nrespiration may be hurried or shallow, sighing and gasping. The\\nurine is scanty or may be absent. Collapse is due to hemorrhage, ex-\\nternal or internal to perforation of abdominal viscera to peritonitis\\nto excessive watery discharge, as in cholera or serous purging. It may\\nbe due to pernicious malarial fever. Coma attends this form.\\n4. Shock is a condition in which the vital powers are blunted or\\nstunned, with or without mental terror or anxiety. It is likely to be\\nseen in injury, surgical operation, hemorrhage, angina pectoris, severe\\npain from any cause, any sudden cerebral or spinal lesion, undue\\nmental and emotional strain. Its presence points to a grave ante-\\ncedent condition, near or remote. The symptoms are those of collapse.\\nLocation of Disease. A general view of the exterior will often\\nindicate which system is the probable seat of the disease. For instance,\\nviolent respiratory action points to the lungs paralysis, to the nervous\\nsystem the enlarged abdomen, to disease of the viscera in that region.\\nThe apparently hasty view has already given the practitioner much\\ninformation.\\nWe then note with more deliberation (1) the personal appearance\\n(2) the apparent age (3) the temperament and constitution of the\\npatient or the evidence of any diathesis or cachexia (4) the position\\nassumed in standing, walking, or in bed (5) the general form and\\nnutrition.\\n1. The Personal Appearance.\\nFrom the general appearance, the patient s habits as to industry,\\nneatness, or care of dress may be observed these habits are of diag-\\n5", "height": "4408", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0071.jp2"}, "72": {"fulltext": "QQ GENERAL DIAGNOSIS.\\nnostic importance, particularly in brain affections. The appearance\\nalso shows frequently whether the patient is addicted to alcohol or to\\nthe use of narcotics. Moreover, the slit-boot, to relieve the swelling of\\ngout, the loosely fastened boots from swollen ankles, the unduly worn\\nsole as in spastic paralysis, the unbuttoned waist-band because of dropsy\\nor increased weight, the stained trousers from drops of urine, are seem-\\ning trifles, but of diagnostic value.\\nThe occupation of the patient is often important in throwing light\\nupon his disease the brown, weather-beaten face of the farm laborer,\\nsailor, or driver contrasts strongly with that of the merchant, clergy-\\nman, or clerk. A machinist can often be recognized by his grimy, oily\\nhands. All this information can be obtained at a glance, and many\\ndetails can be added before the patient has taken his seat in the con-\\nsulting-room.\\n2. The Apparent Age.\\nThe apparent age of the patient should be estimated from his appear-\\nance, and compared with the exact age when this is learned later. In\\nthis way the physician will be able to judge whether the patient is\\naging too rapidly or bearing his age well. An obvious advantage of\\nnoting the patient s age is that it enables us at once to exclude a large\\nnumber of diseases which are not found in the period of life to which\\nthe patient belongs. For example, if the patient is a child, we need\\nnot consider the chronic degenerations and the visceral cirrhoses which\\nappear in middle and later life. Conversely, in an old person we do\\nnot expect to meet with the exanthemata which affect children almost\\nexclusively. So, too, typhoid fever and pulmonary tuberculosis are\\nmore common in adolescence and early manhood than in childhood and\\nold age. Again, in very young girls, the question of menstruation and\\nits difficulties never have to be considered. Gray hair in a person\\nunder thirty-five generally indicates a feeble constitution and prema-\\nture age. Loss of hair is not significant, for, apart from a tendency to\\nbaldness which is very marked in some families, professional men who\\ndo much brain-work, especially in hot, close rooms, are apt to become\\nbald much sooner than other men. The presence of wrinkles at the\\ncorners of the eyes and of crow s feet/ and of dull, dry, lustreless\\neyebrows, should be noted as indicating aging, whether the person has\\nlived long or not. In women approaching forty, who do not gain in\\nflesh, there is often a suggestive prominence of the angles of the jaw\\nand sternomastoid muscles, with a certain loss of roundness and elas-\\nticity of the cheeks. The latter appearance, however, may be due to\\nloss of molar teeth.\\n3. The Temperament and Constitution of the Patient.\\nIn former times emphasis was laid upon appearances which pointed\\nto a particular diathesis or type of inherited constitution. Five varie-\\nties of diathesis were described to which general appearances pointed.\\nThey were the gouty or sanguine-arthritic, the strumous, the nervous,\\nthe bilious, and the lymphatic. While certain appearances point to the", "height": "4408", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0072.jp2"}, "73": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 67\\noccurrence of groups of individuals who may be classified under one of\\nthese diatheses, it is well not to lay too much stress upon them for\\ndiagnostic purposes. As pointed out by Gairdner, it is not proper to\\ndesignate the diathesis off-hand. Individual appearances should be\\ncarefully noted, so that only after the completed examination a final\\nconclusion as to the diathesis can be drawn.\\nIn the gouty or sanguine diathesis the osseous system and muscles\\nare well developed, the nutrition active, and the patient usually robust\\nin appearance. The digestion is good, respirations deep, the circula-\\ntion is well carried on (as shown by the florid skin and the large heart),\\nthe pulse is firm and steady, and the pressure in the arteries is high.\\nThe head is large and the jaw prominent, the teeth good. The hair is\\nof strong growth. The individual with such diathesis is predisposed\\nto the arterial changes of advancing age. Apoplexy, aneurism, and\\nangina pectoris, or complications resulting from the senile changes in\\nthe heart and arteries, develop.\\nIn the strumous diathesis the bones and the glandular system are\\nchanged and the appearance of the face is expressive the bones of\\nthe chest are small the long bones are slender, while their epiphyses\\nare large the forehead is broad and prominent, the lips full, the alee\\nnasi thick, the teeth are carious, the lower jaw light and thin, the hair\\nis fine and often of a light hue, the eyelashes long, the eyebrows arched,\\noften heavy. In this diathesis the nutritive changes are poor, inflam-\\nmations are usually sluggish disease of the bones, of the glands, and\\nforms of tuberculosis are apt to be more severe.\\nIn the nervous diathesis we see small, active, restless beings, with\\nsmall bones and large muscles. They are full of energy, and carry on\\nlarge business or mental operations. The features are well formed, the\\neyes active. Such types readily become the victims of overwork and of\\nearly breaking-down of the nervous system and of dyspepsia. They\\npossess idiosyncrasies toward drugs, particularly opiates.\\nIn persons of the bilious diathesis we find a dark skin, dark hair,\\nmuddy conjunctivae. They are usually not well nourished. Their\\ndigestion is poor, and they are subject to attacks of so-called bilious-\\nness. Sick headaches are common. Fatigue is not borne well.\\nIn the lymphatic diathesis there is lack of energy and sluggishness of\\nnutritive processes such persons are unable to keep up in the wear\\nand tear of life. They are usually pallid and have soft muscles.\\nIn addition to diathesis, cachexice are also noted. Cachexias arise\\nfrom the ravages of disease, especially when the number of the red\\ncells of the blood is reduced and the haemoglobin diminished. Cachexia?\\nare caused especially by syphilis, gout, and chronic malarial poisoning.\\nIn cancer of some part of the digestive apparatus and, indeed, in all\\nforms of chronic disease of the digestive tract a cachexia is seen.\\nThe anaemia from poisoning with lead, arsenic, and other metallic\\npoisons produces an appearance to which the term cachexia has been\\napplied, although in truth it only resembles one. Each form of\\ncachexia takes its name from its cause, as the syphilitic or the cancer-\\nous cachexia.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0073.jp2"}, "74": {"fulltext": "GENERAL DIAGNOSIS.\\n4. The Attitude and Gait of the Patient.\\nThe attitude of the patient gives information as to his physical vigor,\\nand, to a certain extent, of his alertness of mind. A man vigorous of\\nmind and body will stand firmly upon both feet, with back straight,\\nshoulders square, and head erect. When one is depressed by care or\\ndisease the shoulders have a tendency to droop and the head to fall\\nforward. Indecision and a vacillating disposition are sometimes indi-\\ncated by the patient standing first on one foot and then upon the other\\nwhile talking, or by an unsteady look from the eye.\\nWhen one shoulder is lower than the other and the patient is of\\nphthisical build, pale, and emaciated, the attitude is strongly suggestive\\nof phthisis or chronic pleurisy on the side on which the shoulder is\\ndepressed. Sometimes, in acute pleurisy, the patient will walk with\\nthe shoulder depressed and the arm firmly pressed against the affected\\nside, so as to restrict its movements as much as possible.\\nDecubitus. The attitude of the patient in bed is often significant.\\nHe may assume the active dorsal, or the side position, with the body\\narranged so that it is comfortable and unconstrained. Then slight in-\\ndisposition only is present. On the other hand, the side position, the\\ndorsal position, or the upright or semi-upright position may be assumed.\\nTo the close observer the attitude of a patient in bed is sometimes\\nreassuring. He lies easily upon his back, or turned slightly to one\\nside with the arms uncovered, and may even turn or sit up to meet\\nthe physician as he enters the room all these signs point to moderate\\nillness or to the approach of convalescence.\\nSide Position. A patient with acute pleurisy or pneumonia will\\nlie on the affected side so as to limit its motion as much as possible.\\nThe breathing will be shallow and frequent, the expression of the face\\nanxious, and occasionally a spasm of pain contracts it as the patient\\ncoughs or is obliged to take a full breath. He usually lies on the\\naffected side because fixation is thus secured and pain on inspiration is\\ndiminished, and also because there is a greater liberty for expansion of\\nthe free, healthy side. If effusions are present, by lying on the side of\\nthe effusion pressure is removed from the heart and the unaffected\\nlung, an obvious advantage.\\nAt times, in case of thoracic aneurism, if situated on one side, or of\\nmovable thoracic tumors, the patient will lie on the side which is the\\nseat of the disease.\\nThe dorsal position, as assumed in health or slight disease, has\\nbeen referred to. When the position is assumed in grave disease it is\\ncalled passive dorsal, because it is often assumed without volition of\\nthe patient.\\nIn grave cases of typhoid or other low fevers the patient lies upon\\nthe back and shows a marked tendency to slip down in the bed. The\\nexpression of the face is heavy or vacant. The lips and teeth require\\nconstant cleansing to keep them from sordes the tongue is dry and\\nglazed or covered with sordes the tendons of the wrists twitch convul-\\nsively, and the patient lies with open or half -open eyes (coma vigil), pick-\\ning at the bedclothes or at imaginary objects which float before his eyes.", "height": "4408", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0074.jp2"}, "75": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 69\\nA healthy baby a few months old finds motion an almost ceaseless\\ndelight. It will lie on its back, kick up its feet, play with its toes or\\nsome object that attracts it, crowing, wriggling, squirming. In rickets,\\non the contrary, the little patient lies as quiet as possible, even refrain-\\ning from crying, because all motion is painful. In cerebrospinal men-\\ningitis the head is drawn backward and downward and the muscles at\\nthe back of the neck are rigidly contracted.\\nIn acute disease involving the peritoneum or neighboring organs, such\\nas acute peritonitis, appendicitis, or endometritis, the patient lies on the\\nback with the legs flexed upon the thighs and the thighs upon the\\nabdomen. Motion is avoided as much as possible, and so is any press-\\nure upon the abdomen.\\nThe lateral or dorsal position, with legs drawn up and trunk\\nand head drawn down to meet them, occurs with groans of pain and\\npossibly involuntary bearing-down in hepatic and intestinal colic and\\nduring the throes of labor.\\nThe Semi-upright or Upright Sitting Position. In an acute\\nattack of asthma the patient is found sitting up in bed, or in a chair,\\npossibly by an open window. The expression of the face is anxious,\\nthe skin dusky or pale, and moist. The breathing is loud, noisy, and\\nscraping. The demand for oxygen is imperative, difficulty is experi-\\nenced in inspiration and expiration, not enough air for physiological pur-\\nposes being able to enter the alveoli expiration is prolonged and labored\\n(expiratory dyspnoea). The patient sits with the chin raised and head\\nerect, the hands grasping the arms of a chair or the bedclothing, so\\nthat, by fixing the chest, the accessory muscles of respiration can be\\nof the greatest assistance in supplementing the diaphragm. In emphy-\\nsema, in its late stages, or when complipated with bronchitis and asthma,\\nthe same position is assumed almost constantly.\\nIn pericarditis with effusion, in large pleural effusions, and in advanced\\nheart disease with anasarca, the patient is unable to lie down on account\\nof the smothering feeling which the recumbent position induces. In\\npericarditis the expression of the face is extremely anxious, the patient\\nhaving a dread of impending death.\\nIn large pleural effusion the expression is not usually so anxious,\\nbut the dyspnoea may be intense. The patient is propped up in bed,\\nleaning slightly to the affected side, and devotes all his energies to\\nbreathing, avoiding every exertion, such as moving, answering ques-\\ntions, or coughing, which taxes his breathing-muscles still more. One\\nside of his chest may be observed to move violently while the other is\\nmotionless.\\nIn heart disease and anasarca dyspnoea frequently amounts to orthop-\\nnea. The patient may be found propped up in bed or seated in a large\\nrocking-chair, some patients finding greater comfort in the latter. The\\nface is pale, livid, or jaundiced, and may be swollen, while the cellular\\ntissue throughout the body is oedematous, and the cavities, especially\\nthe peritoneum, are more or less filled with fluid. In diaphragmatic\\npleurisy the position assumed is very characteristic the erect sitting\\nposture, with the body leaning forward and laterally, to relieve the\\npain.", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0075.jp2"}, "76": {"fulltext": "70 GENERAL DIAGNOSIS.\\nThe Prone Position. Rarely the patient is found lying upon the\\nabdomen. He assumes this position because it gives relief to abdominal\\npain or to colic of any form. Owing to the change in the relative posi-\\ntions of the organs brought about by this posture, the pain of an ulcer of\\nthe stomach, of aneurism, or of caries of the vertebrae may be mitigated.\\nIn tetanus opisthotonos occurs. The body rests on the head and heels\\nand the trunk is arched upward, because of tonic contraction of the\\nspinal muscles. In strychnine-poisoning with tonic convulsions the\\nsame position may be assumed.\\nMnprosthotonos, vaulted side position, is occasionally assumed in\\ntetanus and also in strychnine-poisoning.\\nUnclassified Positions. Irregular or bizarre positions are usually\\nassumed in affections of the nervous system, particularly in hysteria.\\nRestlessness. Often the patient is unable to assume a position, or,\\nat least, to remain fixed in any position. This may occur on account\\nof pain, or because of irritation or anaemia of the nerve-centres. In\\ncases of moderate cerebral hemorrhage, and of shock, there is great\\nrestlessness. The patient is restless without the appearance of agita-\\ntion. In profuse hemorrhage, whether uterine, intestinal, or pulmo-\\nnary, on account of cerebral anaemia, there is also restlessness with\\nsighing and gasping. The pallor, the quickened pulse, the great thirst,\\nwith the history of bleeding, are sufficient to explain the restless state.\\nIn chorea there is more than restlessness there is constant twitching\\nof muscles with jerking from one side of the body to the other. The\\npatient does not keep the covers on when in bed, and by her jerky\\nmovements often does herself considerable injury.\\nIn cerebral meningitis the patient tosses from side to side or lies with\\nthe head retracted and pressed deeply into the pillow. The eyes are\\ninjected, the pupils contracted, and frequent sharp cries are uttered,\\nespecially if the patient be a child.\\nIn hysterical convulsions the patient, usually a young woman, tosses\\nwildly to and fro, screaming, laughing, or crying or coma may be\\nmimicked. The moods often change with great suddenness. The\\nappearance is very alarming at first sight but the pulse and breathing\\nare not much accelerated, there is no fever, and the patient is conscious\\nenough not to injure herself even to the extent of biting the tongue.\\nGait. The gait is sometimes characteristic. (See Nervous Diseases.)\\nThe hemiplegia patient advances the sound limb, and then brings the\\nother up to it by lifting the pelvis and swinging the paralyzed limb\\naround by a movement of circumduction. The shoe is worn down at\\nthe toe in an irregular way. Sometimes the shoulder on the sound\\nside is thrown outward and forward, so as to facilitate the raising of\\nthe pelvis on the paralyzed side in order that the limb may be circum-\\nducted. The arm may be rigid or bent at the elbow, the fingers being\\nflexed upon the palm and the thumb turned in.\\nIn locomotor ataxia there is uncertainty in the gait, which may only\\nbe felt by the patient or be apparent to the observer also. There is\\nirregularity in the line of progression, or the movements become very\\njerky and erratic. As there is very little motion at the knee, because\\nit is spasmodically braced, the pelvis is slightly tilted until the foot is", "height": "4416", "width": "2552", "jp2-path": "practicaltreatis00muss_0_0076.jp2"}, "77": {"fulltext": "THE DATA OBTAINED BY OBSERVATION.\\n71\\nreleased the foot is then raised unnecessarily high, jerked rapidly\\nforward and outward and brought down with a sudden stamp, or flail-\\nlike action, on the heel. The patient s centre of gravity undergoes\\nseveral changes at each step, so that he swings from side to side. He\\ncannot walk in the dark, and, at a later stage, requires the aid of canes\\nto prevent him from falling forward.\\nFig. 2\\nGait in a case of locomotor ataxia instantaneous serial photographs. (Muybridge and Dercum.)\\nIn paralysis agitans the attitude and gait of the patient are peculiar-\\nThe head and body are thrown forward and fixed in that position the\\narms are slightly abducted and partly flexed, the hands being in the\\nposition in which a pen is held or a pill rolled. The legs are also bent\\nat the knees. Rhythmical tremors affect the hands first and then the\\nrest of the body, the head and neck usually escaping. On attempting\\nto walk the gait is festinating that is to say, each step becomes more\\nrapid than the preceding, until the patient is prevented from falling\\nonly by catching hold of something. The tremors cease during sleep,\\nand are independent of voluntary motion. (See Fig. 3.)\\nIn spastic paraplegia the patient walks with two sticks. He leans\\non the left one, arches the back, and then lifts the pelvis and the right\\nlimb as far from the ground as possible, but cannot quite clear it. The\\nleg is rigid and the foot dragged around in a semi-circle. The toe has\\na marked tendency to stick to the ground, and is brought forward with\\na scraping sound. The knees have a tendency to interlock, and the\\nfoot which is brought forward is apt to cross in front of the other.\\nIn disseminated insular sclerosis the gait is somewhat jerky and resem-\\nbles the gait of ataxia or of tumor of the cerebellum. Of course, the", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0077.jp2"}, "78": {"fulltext": "72 GENERAL DIAGNOSIS.\\ndisease that causes such peculiarity in gait cannot be established with-\\nout first observing the mental and nervous phenomena that attend such\\naffections.\\nFig. 3. Fig. 4.\\nSide view of a case ot paralysis agitans, show- Spastic paraplegia, cross-legged progression,\\ning forward inclination of trunk. Tendency to (Deecom.)\\npropulsion. (Dercdm.)\\nIn hysterical paraplegia there is sometimes complete loss of power of\\nstanding or of walking. The patient falls if an attempt is made to\\ncompel her to stand. Or she walks with the knees and the hips semi-\\nflexed or in awkward attitudes, implying greater muscular exertion\\nthan necessary for the normal gait. It is recognized by the fact of its\\noccurrence in young subjects in whom other striking phenomena of\\nhysteria are observed. (See page 73.)\\nCross-legged Progression. This form of gait is seen in children with\\nspastic paraplegia, and occurs because of contracture in the calf muscles.\\nWhen the child begins to walk, one foot gets over in front of the other.\\nSometimes a swinging oscillation of the body occurs, which may persist\\nthroughout adult life. (See Fig. 4.)\\nThe gait of pseudo-hypertrophie muscular paralysis is known as the\\nwaddling gait. This oscillating character is assumed in order that the\\nto bring the centre of gravity over each foot", "height": "4412", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0078.jp2"}, "79": {"fulltext": "THE DATA OBTAINED BY OBSERVATION.\\n73-\\n011 which the patient successively throws his weight, because the weak\\ngluteus medius cannot counteract the inclination toward the leg that is\\noff the ground, unless the balance is exact (Gowers). The position\\nassumed in getting up from the floor, as described by Gowers, is pathog-\\nnomonic. The patient turns over in the all-fours position, raises the\\nFig. 5.\\nFig.\\nfW\\nV\\nHysterical astasia-abasia. (Lloyd.)\\ntrunk with his arms, rests the trunk\\nupon the extended hands, then extends\\nthe knees, pushes back with the hands\\nuntil he can grasp one knee with the\\ncorresponding hand, then grasps the\\nother knee, and pushes up the trunk by\\ngradually raising the point of support\\nfor the hand upon the thigh. (Fig. 5).\\nThe swaying gait, like that of a\\ndrunken man (cerebellar titubation), is\\nsignificant of cerebellar disease. (See\\nStation.)\\nFeebleness of the gait attends gen-\\neral paresis and the early stage of\\nchronic myelitis, but, of course, is of\\nno significance unless it is attended by other symptoms of these affec-\\ntions.\\nTypical pseudo-muscular hypertrophy.\\n(Derctjm.)", "height": "4416", "width": "2556", "jp2-path": "practicaltreatis00muss_0_0079.jp2"}, "80": {"fulltext": "74 GENERAL DIAGNOSIS.\\nThe gait of paramyoclonus multiplex and of Thomsen s disease is also\\npeculiar. (See Muscles.)\\nStation. Astasia and abasia are terms employed to define the\\nloss of power of standing and of walking, respectively, without paraly-\\nsis. Both may occur. (See Fig. 6.) They are usually due to hysteria.\\nAtaxic Astasia in Locomotor Ataxia. The inability to stand\\nis observed under many circumstances. Either with (1) the eyes closed,\\nor (2) the eyes open and the toes and heels in contact, or (3) with the\\neyes open and feet apart. The latter occurs in the highest degree of\\nataxia, and may be followed later by complete loss of power of standing.\\nSwaying. If a healthy person stands with the eyes shut the body\\nwill sway slightly. In a patient with locomotor ataxia swaying is\\nseen in increased degree.\\nIn pseudo-hypertrophic paralysis, if the patient stands, there is that\\nextreme curvature of the spine known as lordosis. It disappears entirely\\nwhen the pelvis is supported, as in the sitting posture. In the latter\\nstages of this affection there is posterior or lateral convexity of the\\nspine with astasia.\\nIn the paroxysms of Meniere s disease the loss of power of standing\\nmay be absolute. The patient may be hurled to the ground and be\\nquite unable to rise or sit up. The nature of the paroxysm is sus-\\npected on account of the sudden onset and the complaint of vertigo,\\ntogether with the ear symptoms that attend this affection.\\nIn disease of the middle lobe of the cerebellum, sAvaying from side to\\nside, or in large waves, is observed. The appearance is like that of a\\ndrunken person. While the walk is peculiar the patient can usually\\nsit up.\\n5. General Form and Nutrition.\\nThe general form and nutrition of the body are estimated by the\\ncolor of the skin, the amount of subcutaneous fat, the degree of muscu-\\nlarity, the size and shape of the osseous system. Hence we estimate\\nthe degree of physical development of the individual by the size, the\\nweight, and the condition of the muscles, as well as by the state of\\nother tissues. To recognize lack of development is often to be able to\\nexplain phenomena of a functional nature which otherwise could not\\nbe accounted for. The color will be considered under the head of the\\ncondition of the skin.\\nImportance of such Observation. It is extremely important\\nthat these observations should be made, particularly in childhood and\\nadolescence. Not only are marked departures from the normal signifi-\\ncant, but slight deviations point to the occurrence of processes which\\nmodify nutrition. Unless lack of development is detected, it is fre-\\nquently impossible to explain the occurrence of some functional disor-\\nder, as neuralgia, or of derangement of the viscera, or of indefinable ill\\nhealth, as the result of which the patient shows inaptitude for exertion\\nor inability to conduct the usual affairs of life. The recognition of\\nmalnutrition, as shown in lack of tone of muscles, or diminution of\\nweight, is often sufficient to point the way to successful treatment by\\nhygienic methods.", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0080.jp2"}, "81": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 75\\nSize. Change in size may be general or local. General increase or\\ndiminution in size, not necessarily abnormal, is due to enlargement or\\ndiminution of the muscles and fat, singly or combined. When large\\naccumulations of fat take place the word obesity is applied to the con-\\ndition. The estimation of the patient s size as compared with his weight\\nis usually based upon the amount of subcutaneous fat. The general\\naccumulation can readily be recognized by rotundity of the exterior.\\nSize affords some information as to the degree of development of our\\npatients and as to the kind of diseases to which they are most liable.\\nWhile there is no absolute standard by which to compare the relative\\nproportion of height to girth in individual cases, yet there is a type\\ngenerally recognized as being usual, and variations from it give rise to\\nsuch expressions as stout, spare, slender, thin, tall, and short. Stout\\nusually expresses an increase in girth and a moderate excess of flesh\\nover the normal. When used in this sense it becomes synonymous\\nwith lusty, and indicates an increase of flesh which is well distributed\\nand due to healthy, active nutrition without impairment of physical\\nactivity. In some cases, especially in women, stoutness is used as a\\neuphemism for corpulency, but not often for that excess of fat properly\\ncalled obesity. Stoutness, in the sense of lustiness, up to middle life is\\nan indication of physical and often of mental vigor. It is often found\\nin gouty and rheumatic subjects. A tendency to take on flesh after\\nthe age of forty-five, especially if the person s occupation is sedentary\\nand his habit of body inactive, is not to be regarded as favorable. It\\nmay be compared to a warrior s persisting in wearing an increasingly\\nheavy weight of armor after the campaign is over. Increased weight\\nunder such circumstances is not increased strength, but increased\\nburden, and the burden becomes greater with advancing years. Those\\navIio are under forty and stout, in the sense of having too much fat in\\nproportion to bone and muscle, bear fevers and exhausting diseases\\nbadly. Women at the menopause are very prone to take on flesh\\nrapidly. Fat subjects after middle life, and to an increasing degree\\nafter that period, are liable to fatty degeneration of the heart, blood-\\nvessels, and important viscera.\\nPersons who are tall and thin, especially if they have become tall\\nrapidly after puberty, are commonly looked upon as delicate, and as\\nespecially liable to consumption. There is reason for this view. But\\nif they live to be twenty-five or more, without disease of the lungs or\\npleura, they may then live to a great age.\\nSome patients have an appearance which is well described and under-\\nstood by the word spare. The form is compactly put together, but\\nwith small bones and a scanty allowance of fat. There is a tendency\\nto leanness rather than to roundness of form.\\nIn still others muscle and bone predominate, and the form is apt to\\nbe angular, as in those described as wiry. They are often possessed of\\ngreat muscular power and resistance to strain. Those of spare and\\nwiry habit bear disease very well. Inspection alone may leave one in\\ndoubt whether to regard an individual as thin and delicate or spare.\\nLight will be obtained from the patient s occupation and the amount\\nof physical exertion of which he is capable, and also from the tonicity", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0081.jp2"}, "82": {"fulltext": "76 GENERAL DIAGNOSIS.\\nand hardness of his muscles. If one stops to think a moment, he will\\nsee that, for the same amount of heart and lung capacity, a man will\\nbe better off if spare than if corpulent because in the latter case he\\nhas an additional load to carry, and he has to nourish and keep up a\\nthick blanket of fat from which he derives no adequate advantage.\\nHence a person of spare build, who survives childhood and adolescence\\nwithout disease, probably has, on the whole, a better prospect for long\\nlife than a stout person.\\nNormal Habit. In estimating the patient s size or weight it is\\nimportant to ascertain if he has a regular habit of taking on flesh at\\ncertain periods of the year, for instance, or if it has developed suddenly\\nor followed acute disease.\\nWeight. Xothing has yet been said of the weight, but, as it affords\\na precise estimation of the size, particularly if considered in relation\\nto the height and age, the following discussion will include the two-\\npoints, size and weight.\\nWhile the eye can estimate approximately the weight of the body\\nand the degree of emaciation, the physician should make it a rule to\\nascertain the weight accurately by means of scales. Machines are\\nnow made which can be used for weighing the patient and at the same\\ntime noting the exact height. It is particularly important to note the\\nweight from time to time. In the course of wasting disease we learn\\nthe effects of treatment, or, on the other hand, the march of disease in\\nspite of treatment. In obscure cases, as in tuberculosis, persistent loss\\nof flesh is a serious diagnostic and prognostic symptom. After acute\\ndisease, if the patient is weighed every week, the onset of insidious\\nsequelae, as tuberculosis, may be detected.\\nThe relation of body- weight to height is of importance. It is also\\nimportant to know the average weight of the individual in different\\nperiods of life. The progressive increase in weight which should take\\nplace after birth should be remembered, as the opposite is positive\\nevidence of malnutrition.\\nMr. Hutchinson s table enables us to judge the average weight of a\\nhealthy man of a given height\\nA man of 4 ft. 6 in. to 5 ft. in. ought to weigh about 92.26 lbs.\\n5 5 1 115.52\\nit 5 u 2 5 3 127.86\\n5 4 5 5 139.17\\n5 6 5 7 144.29\\n5 8 5 9 157.76\\n5 10 5 11 170.86\\n5 11 6 177.25\\nIn some life insurance tables in this country the average weight for\\nthe height is lower, especially in persons over five feet ten inches.\\nWeight ix Disease. The question of weight is an important one\\nin disease. As has been stated, persons with an excess of fat do not\\nbear fevers and exhausting processes so well as those who have a\\nrelatively larger proportion of firm muscles. Remember, if emaciation\\nis present, to ascertain its amount and degree, its possible relation to\\nunusual mental care or to acute disease. Slow progressive emaciation", "height": "4408", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0082.jp2"}, "83": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 77\\nis of serious moment, as evidence of tuberculosis or disorder of assimi-\\nlation. Remember the wasting that is associated with great hunger,\\nexcessive thirst, and polyuria in diabetes mellitus. On the other hand,\\nsuch symptoms as occasional cough, slight evening fever, and impair-\\nment of resonance at one apex of the lung become much more signifi-\\ncant of incipient phthisis if accompanied by loss of weight. At any\\nstage of phthisis a maintenance of the body-weight is one of the most\\nfavorable elements in prognosis.\\nAgain, while loss of weight attends all the diseases of the digestive\\ntract which interfere seriously with nutrition, it progresses more rapidly\\nand steadily, and attains a greater degree, in malignant disease than in\\nthe mechanical or functional diseases. Hence the question of loss of\\nAveight is important in deciding between chronic catarrhal gastritis and\\ngastric carcinoma. But still more important is the question of the time\\nduring which loss of flesh has been taking place, and whether it has\\nbeen progressive or interrupted by periods of gain in weight. If during\\ntwo or three years the patient has been vomiting occasionally, and\\nlosing flesh, but gaining again from time to time, it is much more\\nsignificant of gastric catarrh than of gastric cancer.\\nFalse Increase of Weight. In certain cases of great anasarca,\\nand in malignant disease of the abdomen, especially huge cysts of the\\novary in women, and sarcoma of the kidney in children, there may be\\nactual increase of weight due to the accumulation of water or to the\\nnew growth, though the rest of the body is manifestly emaciated.\\nWeight in Children. In babies and children fat is more likely\\nto be a sign of good health than in adults. Nevertheless the quality\\nof the flesh is to be taken into consideration. There are fat and flabby\\nbabies and children, and there are others who are fat but whose flesh\\nhas a firm, solid feel. The former often gain and lose flesh rapidly,\\nand, when ill, do not appear to have much resisting power. The size\\nof a child gives a good idea of its nutrition. A child may have its\\ngrowth stunted by bad food and unfavorable hygienic conditions, or\\nthe stunting may be the result of exhausting disease, such as whooping-\\ncough.\\nIncrease in size and weight then may be due to changes in (1) the\\nskeleton (see Chapter XIII.) (2) the muscles (3) the adipose tissue\\n(4) the subcutaneous connective tissue, giving rise to accumulations of\\nserum, mucin, or connective tissue dystrophies (see Chapter X.).\\nDiminution in size is due to changes in (1) the skeleton (2) the\\nmuscles, and (3) the adipose tissue. The word emaciation is applied\\nto excessive atrophy of fat and muscles. If it is accompanied by\\ngreat exhaustion and apparent loss of fluid, the word marasmus is\\nemployed.\\nDegree of Loss. The whole body may exhibit considerable loss\\nof flesh, the cheek bones and temporal fossae being distinctly visible,\\nthe muscles soft, the limbs wasted, and the subcutaneous fat dimin-\\nished. It is important to notice whether flesh has been lost or not,\\nand how much, and how long a time the loss has been going on. Such\\nfacts furnish the clue not only to diagnosis but to treatment also.\\nFlesh is lost in almost all diseases, acute or chronic, but it becomes of", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0083.jp2"}, "84": {"fulltext": "78 GENERAL DIAGNOSIS.\\nspecial moment in diagnosis in the latter. It is most noticeable in\\ntuberculosis, cancer, marasmus, cirrhosis of liver and kidneys, diabetes,\\nin anaemias, and in cachectic conditions due to prolonged suppuration\\nor chronic diarrhoea, in gastric neurasthenia and anorexia nervosa.\\nLocal Change in Size. There may be local increase or diminu-\\ntion in size, alone or combined. It is not to be forgotten that accumu-\\nlations of fat may take place in special portions of the body the abdo-\\nmen is the favorite seat for excessive accumulation, particularly in\\nwomen and in men of sedentary life, with habits of excessive indul-\\ngence in food and drink. When one part is increased in size and\\nanother growing progressively small the disparity indicates disease (see\\nbelow). The face is swollen, especially under the eyes and above the\\njaws, in the dropsy of large white kidney and in parotitis. The neck\\nmay be enlarged in the sterno-clavicular notch or laterally above the\\nclavicles in aneurism. The thyroid, as a whole, or either lobe, is\\nenlarged in goitrous affections and in Graves s disease.\\nThe face may be thin and even much emaciated, while the abdomen\\nis greatly distended from dropsy or from tumors of the various abdom-\\ninal viscera or glands. The chest is enlarged or contracted. Local\\ndecrease in size in thorax or abdomen is significant of tumors.\\nThe head is much increased in size in chronic hydrocephalus, while\\nthe face remains small. The bones of the cranium are enlarged in\\nleontiasis ossea. The head, face, and neck enlarge in the affection\\ndescribed by Allen Starr as megalocephalie. (See Chapter VII.)\\nThe loss in flesh in the extremities or special muscles may be local\\nand atrophic in character, as in some diseases of the nervous system,\\nsuch as neuritis, infantile palsy, hemiplegia, and monoplegia. Loss of\\nflesh of the arms is said to be a symptom in cystic ovarian tumor.\\nThe increase in size may also be local, as in hydrocephalus, elephan-\\ntiasis, dystrophies, myxoedema, oedema, and various tumors.\\nThe General Musculature. The state of the muscles must\\nalways be learned. It has been referred to in the discussion on emacia-\\ntion. A few words more seem necessary. It must be remembered that\\na person can be obese and yet have poor muscular development, or have\\nlittle fat and fair muscle. General lack of muscular development or\\nmuscular weakness is an important sign of malnutrition, and may ex-\\nplain the nature of many symptoms. The muscular weakness can be\\napproximated by the degree of firmness of the muscle. Weakness of\\nthe muscles of the spine, with resulting curvature, or inability to keep\\nthe erect posture, is sufficient cause for the occurrence of neuralgic\\npains in the course of related nerve-trunks, and for the displacement of\\norgans within the thorax or abdomen, often causing functional dis-\\nturbance. Various uterine displacements and functional disorders may\\nbe mitigated by toning up the nutrition of the muscles of the trunk.\\nForms of indigestion, sluggishness of secretions, particularly of the\\nbowels, follow in the wake of debilitated muscles and pass away as such\\nmuscles gain tone. It may be that the indigestion has not taken place\\nbecause the muscles are weak, although in a measure there is relation\\nbetween them but the weak, flabby muscles are pronounced indica-\\ntions of a state of the system which may develop indigestion. More-", "height": "4416", "width": "2568", "jp2-path": "practicaltreatis00muss_0_0084.jp2"}, "85": {"fulltext": "THE DA TA OB TA IN ED B Y OBSER VA TION. 7 9\\nover, weakened abdominal walls, separated recti muscles, and diastasis\\nfavor dropping of the liver, stomach, and other organs, causing gastro-\\nenteroptosis with its train of symptoms. The detection of muscular\\ndeficiency leads to correct lines of treatment. Atrophy of muscles\\noccurs because of disuse, because of sedentary occupation or of a life\\nof ease and luxury, with improper nutrition. It is sure to follow im-\\nproper assimilation, as seen in extreme degree in anorexia nervosa.", "height": "4416", "width": "2580", "jp2-path": "practicaltreatis00muss_0_0085.jp2"}, "86": {"fulltext": "CHAPTER VII.\\nTHE DATA OBTAINED BY OBSERVATION\u00e2\u0080\u0094 {Contin ued).\\nThe face the facial expression. The head. Mumps facial hemiatrophy. Hydro-\\ncephalus. The hair. The lips. The neck the thyroid gland exophthalmic\\ngoitre the bloodvessels of the neck.\\nThe Face and its Expression.\\nThe face is a mirror in which are reflected all degrees of ill health,\\nfrom that which amounts only to temporary indisposition and depres-\\nsion up to the gravest cachexia. The face reflects also the degree\\nof intelligence of the patient and his mental condition at the time, as\\nwell as his emotions, and, in a large measure, his character. The face\\nis usually a fairly good index of the temper of the individual benev-\\nolence, amiability, and purity are written as plainly on some faces as\\nanger, lust, dishonesty on others. (See Nose and Mouth in respective\\nchapters on special diagnosis.)\\nThe face frequently affords us valuable information concerning the\\nhealth, habits, and temperament of the individual. Everyone is\\nfamiliar with the bright eye and animated countenance of a friend\\nwhich lead us to say, You are looking very well to-day, and with\\nthat slight pallor, diminished clearness of the conjunctiva, with per-\\nhaps a dark circle under each eye, which lead us to infer that he is\\ndepressed or has passed a sleepless night. The face also gives unmis-\\ntakable evidence of alcoholism by its bloated appearance, injected or\\nglassy eye, dull expression, and nervousness when the patient is\\naddressed suddenly.\\nFull-blooded persons, disposed to endarterial changes, frequently as\\nthe result of gout, often have, at a little distance, the ruddy appearance\\nof blooming health. Closer inspection, however, shows that the ruddy\\ncolor is due to a dilated or congested condition of the minute blood-\\nvessels. This condition, when associated with high tension in the arte-\\nries and accentuation of the aortic second sound, is highly suggestive\\nof chronic nephritis. (For color and complexion, see the Skin, Chapter\\nX.)\\nMoreover, the face tells of the presence or absence of pain, and, to a\\ncertain extent, of its character. Everyone has witnessed the sudden\\ncontraction of the brow and eyelids and the involuntary sucking in of\\nthe breath when some one has bitten upon a tender tooth. Other faces\\nbear the imprint of long-continued more or less constant suffering.\\nAccording to Eustace Smith, pain in the head in children is indicated\\nby contraction of the brows pain in the chest, by sharpness of the\\nnostrils and in the belly, by a drawing of the upper lip. (See the\\nFace in Children and Pain, Chapter IV.)", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0086.jp2"}, "87": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 81\\nIt will be seen that the expression, the color, and the outline of the\\nface are valuable indications of disease.\\nThe master mind in clinical medicine, the late Austin Flint, Sr.,\\ntersely described the various appearances of the face in disease, with\\ntheir clinical significance, as follows\\nThe Facie s of Renal Disease. In some cases of acute albuminuria\\nand of chronic parenchymatous nephritis the large white kidney of\\nBright puffiness of the face from oedema, with notable pallor, renders\\nthe aspect highly diagnostic.\\nThe Malarial Facies. Pallor of the face, sallowness, and slight\\npuiimess, if renal disease be excluded, point to malarial disease.\\nThe Facies of Carcinoma. Notable anaemia, a waxy or straw-\\ncolored complexion, and more or less emaciation, in combination, render\\nthe aspect marked in some cases of malignant disease. In a patient\\nover forty years of age this aspect has considerable diagnostic import,\\nalthough it is by no means always present when malignant disease exists.\\nThe Typhoid Facies. In the middle and later periods of typhoid\\nfever the countenance is often dull, besotted, expressionless. This\\nfacies may be present in the typhoid state, which is incident to diseases\\nother than typhoid fever e. g. y pneumonia. Coexisting with a dusky\\nhue of the skin and congestive redness of the conjunctiva, it distin-\\nguishes typhus as contrasted with typhoid fever.\\nThe Facies of Acute Peritonitis. The upper lip raised so as to\\nexpose the front teeth gives an aspect which characterizes, in a certain\\nproportion of cases, acute peritonitis. It is often wanting, but when\\npresent it is strongly diagnostic.\\nThe Facies of Acute Pneumonia and Hectic Fever. Circum-\\nscribed redness of one or both of the cheeks, with abruptly defined\\nborders, is diagnostic of acute pneumonia. If it be observed in a case\\nof chronic pulmonary disease it denotes the so-called hectic fever, and\\nis a sign of phthisis. The wan, emaciated appearance with the bright\\neye and hurriedly expanding nostrils excites our fears that the progress\\nof the latter affection is most rapid.\\nThe Facies of Exophthalmic Goitre. Projection of the eyeballs,\\ngiving to the face a remarkably staring and sometimes ferocious ex-\\npression, conjoined with enlargement of the thyroid body and frequency\\nof the pnlse, is distinctive of the affection known as exophthalmic\\ngoitre Graves s or Basedow s disease.\\nThe Choleraic Facies. In the collapse stage of cholera the face is\\ncontracted, sometimes wrinkled the cheeks are hollow, the eyes sunken,\\nthe skin is livid, and the expression denotes indifference. This com-\\nbination of traits is quite distinctive. They are, however, to a certain\\nextent combined in the state of collapse which occurs in some cases of\\npernicious intermittent fever and in other pathological connections.\\nThe Hippocratic Facies. This facies denotes the moribund state.\\nThe skin is pale, with a leaden or livid hue the eyes are sunken, the\\neyelids separated, and the cornea loses its transparency the nose is\\npinched and the eyes are contracted the temples are hollow and the\\nlower jaw drops. Hippocrates described this facies in graphic terms,\\nand the name Hippocratic has ever since been used to designate it.", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0087.jp2"}, "88": {"fulltext": "82 GENERAL DIAGNOSIS.\\nThe Face in Children. Inspection is even more important in the\\ncase of children than in adults. The pale, pinched, weazened face of\\nsome babies who have snuffles, ulcers, or striated lines at the corners\\nof the mouth, and look prematurely aged, with prominent forehead and\\na depressed nasal bridge and retrousse tip, characterizes inherited syph-\\nilis. In older subjects the undeveloped face and skull are striking.\\nIn rickets the head is unusually large with flattened vertex, projecting\\nforehead, and open fontanelle. In hydrocephalus the head becomes\\nvery much enlarged, the eyes prominent, the bones of the face remain-\\ning small, the expression vacant. In adenoid disease of the pharynx,\\nwith tonsillar hypertrophy, the dull apathetic expression, with the\\nthickened lips, the small nasal orifices, and the gaping mouth are char-\\nacteristic. In cretins the thickened lips, the protruded tongue with\\nsaliva dribbling from the open mouth, the flattened nose, with the\\nidiotic expression and pallid, waxy skin, are easily recognized. To a\\nlessened degree such appearances are seen in backward children,\\nwho, it may be said, are undeveloped cretins. In measles the red,\\nswollen face, the reddened, weeping eyes, and running nose make a\\nvery striking picture. An irritating, excoriating discharge from the\\nnose in a child may indicate the existence of a nasal diphtheria.\\nThe Face in Nervous Disease. All varieties of mental aberration\\nare reflected in the face the suspicious, at times revengeful, look of\\nthe delusional monomaniac the wild look and excited manner of the\\nmaniac the plaintive, depressed, injured look of melancholia the\\nvacant, listless, peaceable, animal-like look of dementia a look which\\nchanges to animation only at the sight of food or some coveted luxury.\\nAll these expressions come to be recognized very readily by those who\\nsee much of the insane. In addition, in hysteria expressions of varied\\nemotions are seen in neurasthenia a worn and wearied aspect of coun-\\ntenance is noticeable.\\nThe face often tells of the existence of some organic nervous dis-\\norder. The peculiar heavy expression, drooping eyelids, though they\\nclose improperly, and sluggishly moving lips, betoken the early stage\\nof the facio-humero-scapular type of muscular atrophy, and is some-\\ntimes seen in Friedreich s ataxia.\\nChange in the expression and appearance of the face more frequently\\noccurs because of change in the function and nutrition of the muscles,\\non account of central or peripheral disease of the nervous system. On\\nthis account we have facial spasm or tremor, and unilateral, bilateral,\\nor local facial paralysis. Further consideration of these conditions will\\nbe found in the local examination of the muscles (Chapter XII.) and\\nin Diseases of the Nervous System.\\nIn peripheral facial palsy the paralyzed side of the face has a staring,\\nvacant expression, owing to the fact that the eyelid is motionless.\\nThe angle of the mouth on the affected side is depressed. The whole\\nparalyzed side is devoid of wrinkles, has a smoothed-out, glazed appear-\\nance tears flow over the cheeks and saliva dribbles from the corner\\nof the mouth. The contrast with the normal side is most marked when\\nthe patient smiles or frowns. (See Fig. 7.)\\nIn glosso-labial pxdsy there is progressive palsy, with tremulousness", "height": "4416", "width": "2560", "jp2-path": "practicaltreatis00muss_0_0088.jp2"}, "89": {"fulltext": "THE DA TA OB TAIN ED B Y OBSEB VA TION. 83\\nof tongue and lips progressive failure of articulation and dribbling\\nof saliva. Sometimes the patient is able to open the lips but unable to\\nclose them without the aid of the hand. In paralysis agitans the mask-\\nlike expression of immobility has been described as Parkinson s mask.\\nA slow, hesitating, thick manner of speaking, with a tendency to\\nslur the labial and lingual consonants, when associated with irregu-\\nlarity of the pupils, slight tremulousness of the lips, and the loss of the\\nfine adjustment of other muscular movements, such as writing, is very\\nsuggestive of general paralysis of the insane, especially when the condi-\\ntion develops in a middle-aged man.\\nFacial hemiatrophy is a peculiar affection, characterized by pro-\\ngressive wasting of the bones and soft tissues of one side of the face.\\nThe disease is rare it begins, as a rule, in childhood, but may develop\\nin later life. The local change is diffuse in some instances, however, it\\nslowly spreads from a spot in the skin, involving, in succession, the\\ntissues underneath. The skin changes in color and the hair falls out.\\nThe eye is sunken on the affected side, on account of wasting of the\\ntissues of the orbit. The bone of the upper jaw atrophies to a more\\nFig. 7. Fig. 8.\\nComplete facial palsy. Patient unable to close eye\\nof the affected side. (Dercum.) Facial hemiatrophy. (Lyman.)\\nadvanced degree than the other bones which undergo wasting. Because\\nof the wasting of the alveolar processes the teeth become loose and fall\\nout. The wasting is sharply limited by the middle line. (See Fig. 8.)\\nThe disorder is easily recognized. The patient looks as if the face were\\nmade up of two halves from different persons. It must not be mistaken\\nfor facial asymmetry that is associated with congenital wry-neck. The\\ncontraction of the sterno-mastoid muscle from birth distinguishes the\\naffection.\\nThe outline of the face and any change in the shape of the head\\nshould next be observed. Both changes, as seen in myxwdema and\\nscleroderma (see Skin, Chapter X.), are described. The striking changes\\nin acromegalia, rickets, and osteitis deformans are described in Chapter", "height": "4416", "width": "2560", "jp2-path": "practicaltreatis00muss_0_0089.jp2"}, "90": {"fulltext": "84 GENERAL DIAGNOSIS.\\nXIII. on Bones and Joints. In leprosy the face is characteristic\\nthe leonine countenance -faeies-leontina is the result of the tuberous\\noutgrowths about the eyes and forehead.\\nEnlargement of the Face. Swelling. Other changes in the out-\\nline of the face and skull are significant. The face is swollen and\\ndeformed in erysipelas and smallpox, and, to a moderate degree, in\\nmeasles. The specific eruption serves to distinguish each one. The\\npumness of the eyelids and general swelling of the face in the course of\\nBright s disease will be referred to. (See OEdema.)\\nCEdema of the face occurs in trichinosis. It occurs at two periods in\\nthe course of the disease. It is seen in the eyelids in the beginning of\\nthe disease and disappears after a few days. Later it returns with\\npain, tension, and restriction of the movement of the eye-muscles.\\nMumps. In mumps the swelling is characteristic. It usually begins\\non one side. The swelling of the parotid gland is observed in front of\\nthe ear, then it extends below and around it and behind the ramus of\\nthe jaw. Unless there is much collateral oedema the outline of the\\ngland is preserved. The gland is tender and boggy, not indurated.\\nViewing the face from the front, the midlateral aspects are seen to\\nbulge. The ears stand out from the head. The jaws are fixed. The\\nsubmaxillary glands are usually enlarged.\\nThe data to be considered in the study of an infectious disease are\\npointed out in the chapter devoted to those affections. In addition\\nto such data the diagnostic features of mumps are the symptoms of\\nthe invasion of the general symptoms and the local signs.\\nThe symptoms of the invasion are sudden, with chilliness, a rise in\\ntemperature, which is generally moderate (101\u00c2\u00b0 to 103\u00c2\u00b0), and pain at\\nthe angle of the jaw. The corresponding parotid rapidly begins to\\nswell, as well as the adjacent cellular tissue. Along with pain on\\nmovement of the jaws, any acid liquid, as vinegar, which stimulates\\nsalivary secretion, increases the pain. At times the submaxillary\\nglands are involved instead of the parotids, or they may be enlarged\\nand painful several days before the parotid is affected. The disease\\nmay be limited to one side or involve the opposite side, as the process\\nin the one first attacked subsides. Rarely it is bilateral from the start.\\nWhen the swelling has lasted from three to five days the fever sub-\\nsides and the swelling begins to disappear rapidly. At this time, how-\\never, the opposite side may be attacked or the testicles become inflamed.\\nUsually it is the right testicle. In girls and women the ovary or\\nmamma is rarely inflamed. Resolution is extremely rapid, and usually\\nthe disease is not followed by sequelae. Sometimes, however, deafness\\nis left. In fact, sudden deafness sometimes announces the commence-\\nment of an attack.\\nIf to these facts we add the data obtained in the social history, the age\\nof the patient under fifteen, and the history of exposure or the presence\\nof an epidemic, the diagnosis is easily made.\\nIt must be borne in mind that parotid swelling, inflammation, with\\nor without suppuration, may occur in the course of various infections,\\nnotably typhoid fever and septicaemia. It may also be traumatic.\\nChronic enlargement of the parotid occurs in syphilis. In some cases", "height": "4416", "width": "2536", "jp2-path": "practicaltreatis00muss_0_0090.jp2"}, "91": {"fulltext": "THE DA TA OB TAINED B Y OBSER VA TION. 85\\n(Osier and Kiimmel) the submaxillary and lachrymal glands are con-\\njointly enlarged with the parotid.\\nThe Lips. Color. The lips are pale in anaemia, and livid in\\ncyanosis from chronic lung or heart disease with feeble circulation.\\nVesicles (herpes) are apt to appear upon them in common colds, in cer-\\ntain febrile diseases, particularly pneumonia, and with many women\\nduring or immediately following menstruation. A child with heredi-\\ntary syphilis may show ugly fissures, or the scars which result from\\nthem, at the angles of the mouth. In facial palsy the angle of the\\nmouth on the paralyzed side is depressed and free from wrinkles. In\\nglosso-labial-laryngeal palsy the lips tremble, twitch, and may have to\\nbe closed with the fingers after they have been opened. In general\\nparalysis of the insane the lips tremble, and speech is thick, 7 hesi-\\ntating, and uncertain, with a tendency to elide syllables and slur the\\nlabial consonants.\\nHair. The hair often indicates the state of the nutrition of the indi-\\nvidual. Changes in it may be significant of syphilis or other internal\\nmorbid processes. The abnormal growths and changes in the texture\\ndue to local parasitic disease will not be referred to. Undue and rapid\\nfalling out of the hair in patches, known as alopecia, is indicative of\\nsyphilis and of profound intoxication by the virus of this disease. The\\nhair can be pulled out in large masses without difficulty or pain. This\\nfalling of the hair must not be confounded with the excessive falling\\nout which takes place in the convalescence of acute disease, particularly\\nof typhoid fever, nor with that following an attack of gout or erysipelas.\\nColor op the Hair. Obscure paralysis or anaemia may be ex-\\nplained by noting if the hair is artificially colored. Lead and other\\npoisonings have repeatedly arisen from the use of hair-dyes. Other\\nchanges in the color are often significant. Early gray hair may go\\nhand-in-hand with premature endarteritis. The term canities is\\napplied to the diminished development of pigment. Premature gray\\ncolor in defined patches occurs in nerve-lesions, as paralysis of one of\\nthe branches of the fifth pair, and is a trophic change. Sudden change\\nin the color of the hair, usually to gray, takes place at times under the\\ninfluence of fright, mental anxiety, or deep emotion.\\nGreen hair is seen in brass-founders and workers in copper-mines\\nblue hair in laborers in cobalt-mines and persons employed in the\\nmanufacture of indigo. Chemicals applied to the hair change its color\\nperoxide of hydrogen bleaches the hair, pyrogallic acid turns it\\nblack. Drugs administered internally, as jaborandi and its alkaloid,\\nchange the color to dark hues.\\nThe Head.\\nThe posture of the head and abnormal movements are due to affec-\\ntions of the muscles of the neck, and will be considered in a study of\\nlocal affections of muscles. (See Chapter XII.)\\nEnlargement. Change in the size and shape of the head is seen\\nin rickets, acromegalia, and otitis deformans, along with other skeletal\\nchanges, and are discussed in the chapter on the Bones and Joints.", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0091.jp2"}, "92": {"fulltext": "86\\nGENERAL DIAGNOSIS.\\nEnlargement is due, however, to local hypertrophy of the bones, to\\nhypertrophy of the soft tissues (myxoedema and leprosy), and to\\nenlargement of the contents of the cranium. Enlargement of the bones\\nis seen in leontiasis ossea. In osseous hypertrophy the bones are thick-\\nened. Gowers states such thickenings may simulate hydrocephalus at\\nany age. He thinks it doubtful whether the nature of osseous hyper-\\ntrophy can be ascertained during life.\\nEnlargement due to increase of cranial contents is seen in hydro-\\ncephalus.\\nHydrocephalus. The enlargement of the skull is very conspicuous,\\nand the disproportion of the cranium to the face is striking. The\\ncranium is rounded or globular in shape, and the fontanelles are seen\\nCongenital hydrocephalus. Female, aged seventeen,\\nof the hair could not be represented.\\n(The thinness\\nto be very large, tense, and bulging, and the sutures widely separated.\\nThe disproportion in size between the face and head is increased by the\\nprojection of the anterior portion of the skull. The axis of the eyes is\\ndirected downward, and they are partly covered by the eyelids, because\\nof the oblique direction of the orbital plates. The head is supported\\nwith difficulty. The eyeballs roll from side to side. There is frequently\\nstrabismus. The skin is stretched tightly over the cranium, and the\\nhair is scanty. (See Fig. 9.)", "height": "4416", "width": "2568", "jp2-path": "practicaltreatis00muss_0_0092.jp2"}, "93": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 87\\nDiminution in the size of the head is seen in microcephalia (circum-\\nference less than seventeen inches). It is usually abnormal in shape.\\nFontanelles. After a consideration of the size and shape of the head\\nwe turn our attention to an examination of the fontanelles and the\\nbones of the head. The fontanelles in a healthy child, with the excep-\\ntion of the anterior, close in the early weeks of life. The anterior\\nclose from the sixteenth to the twentieth month. We note whether\\nthey are open or closed, prominent or depressed. New openings or fon-\\ntanelles and loose bone plates, the normal fonanelles remaining open, are\\nseen in so-called craniotabes a condition found in congenital syphilis\\nand rarely in rhachitis.\\nProminence or fulness may be temporary or permanent. When the\\nformer, a passing fever with cerebral congestion may be the cause\\nwhen the latter, hydrocephalus and other brain affections in which\\nthere is increase of internal pressure. Depression of the fontanelles\\noccurs in general atrophy, marasmus, and in wasting diseases generally.\\nIt is present in collapse, and is of grave prognostic omen. In pneu-\\nmonia and other respiratory affections with dyspnoea, retraction is\\nobserved. The former affection, with cerebral symptoms, is thus dis-\\ntinguished from cerebral meningitis in which the fontanelles bulge.\\nThe fontanelles are neither prominent nor depressed in rickets, a point\\nof distinction between this affection and hydrocephalus or enlargement\\nfrom other internal causes. They may remain open, moreover, long after\\nthe usual period of closure in rhachitis, even to the third or fourth year.\\nThe Bones. The bones of the cranium may be thickened they\\nmay be the seat of periostitis, of necrosis, and caries. Xecrosis and\\ncaries of the frontal bone are almost pathognomonic of syphilis. Necro-\\nsis of the jaw bone belongs to phosphorus-poisoning. The mastoid and\\npetrous portions of the temporal bone should be examined in many\\naffections. The symptoms that should call our attention to these bones\\nare pain and tenderness over the mastoid, rigors, and fever, with the\\nsymptoms of thrombosis of the cerebral sinuses, pain in the head, con-\\nvulsions, and strabismus. Examination in this region should extend\\nto the occipito-atlantal articulation. Disease of this articulation, and\\nparticularly tubercular disease, causes stiffness of the neck or falling\\nforward of the head. On account of the stiffness, associated with diffi-\\nculty of deglutition and pain, the writer has seen it mistaken for retro-\\npharyngeal abscess.\\nAuscultation and percussion. We have thus far limited our examina-\\ntion of the head to inspection and palpation. Auscultation has been\\npractised, and at one time it was thought the continuous murmur heard\\nover the vertex in children was due to intracranial disease. Osier,\\nhowever, pointed out its occurrence in healthy children, hence, unless\\nheard in adults, its presence is not of diagnostic significance. McEwen,\\nof Glasgow, has found that in cerebral abscess and tumor and also in\\nmeningitis, secondary to ear disease, a difference in the percussion-note\\nwas found over the affected area, and at the same time the percussion\\nresistance was increased. The site of disease was indicated by a note\\nhigher in pitch than the usual osteal note. Comparison of the two\\nsides must be made.", "height": "4416", "width": "2580", "jp2-path": "practicaltreatis00muss_0_0093.jp2"}, "94": {"fulltext": "88 GENERAL DIAGNOSIS.\\nThe Neck.\\nThe position and movements of the larynx and trachea, the thyroid\\ngland, the lymphatic glands, and the vessels of the neck should be\\nobserved.\\nThe larynx and trachea occupy the median line in health, but may be\\ndeflected to the right or left. The deflection is more readily noticed at\\nthe lower part of the neck, and can be ascertained by comparing its\\nposition with the normal relation to the adjacent muscles. The change\\nin position is due to disease within the thorax. An aneurism or a\\nmediastinal tumor may cause this alteration. In cases of chronic\\nfibroid phthisis the trachea is pulled to the side of the affected lung.\\nWhen the respiratory movement of the larynx and trachea is excessive\\nand associated with dyspnoea the source of the dyspnoea is of laryngeal\\norigin. When, on the other hand, the movements are lessened, or the\\norgans remain fixed, notwithstanding violent efforts at respiration, the\\ndyspnoea is due to disease in the mediastinum, as enlargement of the\\nmediastinal glands, or aneurism pressing upon a bronchus. Tracheal\\ntugging may be seen, but is usually determined by palpation. It is\\nparticularly characteristic of aneurism of the descending portion of the\\naorta. The aneurismal sac presses upon the bronchus, and, with each\\npulsation of the vessel, tugs or pulls downward upon the trachea, which\\ntugging is transmitted to the hand. (See Diseases of the Vessels.)\\nThyroid Gland. It may be enlarged or atrophied. Atrophy is\\nshown by absence of fulness, which would otherwise be present. (See\\nMyxoedema and Acromegalia.)\\nEnlargement of the thyroid can be detected without much\\ndifficulty. It may be limited to one lobe, or both lobes may be affected.\\nIt may vary in size from a small localized swelling to large masses\\nwhich fill the median and lateral sides of the neck, pressing upon the\\ntrachea and extending into the thorax. On palpation the swelling may\\nbe soft or hard. In the fibrous forms the swelling is not very large\\nand is very much indurated. In the cystic forms of the thyroid en-\\nlargement fluctuation may often be detected it may be localized to a\\nsmall area of the lobe, or may be detected over the entire affected lobe.\\nIn some cases, on palpation, a purring or thrill is transmitted to the\\nfingers. The thrill is synchronous with the heart s action and due to\\nincreased vascularity of the gland. Auscultation under these circum-\\nstances reveals a systolic murmur.\\nCauses. Enlargement of the thyroid gland may be due to simple\\nhypertrophy, to fibro-cystic enlargement, or to enlargement in which\\nthe vascularity is more prominent, as in exophthalmic goitre. 1. In\\nsimple hypertrophy the enlargement is often intermittent, increasing\\nin size at each menstrual period, or coming on in pregnancy, to disap-\\npear after labor. It may then disappear entirely or return at the\\nmenopause. 2. The fibro-cystic enlargement which occurs in countries\\nin endemic form is persistent. 3. The enlargement of exophthalmia\\ngenerally continues throughout the course of the disease. (See below.)\\nExophthalmic Goitre. Exophthalmic goitre, Graves s or Basedow s\\ndisease, is far more frequent in women than in men. It may develop", "height": "4416", "width": "2584", "jp2-path": "practicaltreatis00muss_0_0094.jp2"}, "95": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 89\\nat anv age, but is most common in early adult life. A neurotic hered-\\nity, exhausting disease, general debility, and anaemia are predisposing\\ncauses, while sudden fright or shock is the most common exciting\\ncause. Graves s disease begins slowly.\\nThe data just recorded are those of the social and family history, and\\nwith the objective symptoms to be described complete the picture of\\nthis affection.\\nOf the three classic symptoms, rapidity of the heart s action, with\\npalpitation, enlargement of the thyroid, and prominence of the eyes (exoph-\\nthalmos), the first is the essential symptom. It is also usually the\\nearliest. Either enlargement of the thyroid or exophthalmos may be\\nabsent for months or years, and in some instances throughout the disease.\\n1. Tachycardia. Attacks of palpitation may recur at intervals for\\na long time before their true nature is suspected. In these attacks the\\nbehavior of the heart is much like that which occurs under the influence\\nof fright or great excitement. The frequency may not be over 100 or\\n120 in the early attacks, the rate being normal in the intervals. In the\\nlater and severe attacks, however, the pulse beats 160 or 180 or even\\n200. It is small and regular. The heart beats with increased force\\nthe sounds are loud, sharp, and clear, occasionally being heard several\\nfeet from the patient. In time the heart becomes hypertrophied and\\ndilated, and there is often a loud, basic, systolic murmur.\\nThe larger arteries and even sometimes the smaller ones show the\\nvascular disturbance by increased pulsation, sometimes with thrill.\\n2. The Thyroid Glaxd. The thyroid is usually the next to be-\\ncome affected. It enlarges slowly from vascular dilatation, the swell-\\ning at first subsiding in the intervals between attacks, but subsequently\\npersisting. The right lobe may be larger than the left. The enlarge-\\nment is painless, soft, and compressible. It may pulsate with or with-\\nout thrill, and over it can be heard hamiic murmurs.\\n3. The Eyes. Prominence of the eyes is the most conspicuous\\nfeature of well-marked cases. Like enlargement of the thyroid, it\\nvaries in degree, and rarely is wholly absent. The protrusion allows\\nthe white sclerotic to show above and below the cornea, giving the eyes\\nan unnatural, startled, staring appearance. The protrusion may be so\\ngreat that the eyelids cannot close more commonly they close, but\\nwhen the eyeball is simply directed downward the upper eyelids do\\nnot follow but remain spasmodically elevated or lag behind the move-\\nment of the eyeball (Yon Graefe s sign). The eyeball may become\\ninflamed and even slough from undue exposure. In rare instances one\\neyeball alone is affected, and in these cases the lobe of the thyroid of\\nthe opposite side is enlarged. Stelwag s sign (widening of the palpe-\\nbral fissures) is the third ocular sign of significance in exophthalmic\\ngoitre. Finally, Mobius calls attention to the frequency of insufficiency\\nof the internal recti muscles.\\nIn addition to these characteristic symptoms loss of flesh and strength,\\nmoderate pyrexia of irregular type, impaired appetite, diarrhoea, and\\ndespondency are observed. The diarrhoea is of the nervous type\\nincreased peristalsis without local catarrh. Menstruation is apt to be\\nirregular or to cease. Tinnitus aurium, headache, and vertigo are not", "height": "4416", "width": "2564", "jp2-path": "practicaltreatis00muss_0_0095.jp2"}, "96": {"fulltext": "90 GENERAL DIAGNOSIS.\\nuncommon, and sometimes there is profuse sweating. A restless, nervous\\nexcitement (Charcot) is very common. Muscular tremor (Marie), occur-\\nring on voluntary movement, is frequently observed, and, with diar-\\nrhoea, is almost as common as the three primary symptoms. OEdema\\nof the feet is often seen if there is coexisting mitral disease. Transitory\\nvasomotor oedema of the eyelids, the face, hands, and the supraclav-\\nicular and infraclavicular regions occurs. It is usually circumscribed,\\nand may not pit on pressure.\\nFig\\nExophthalmic goitre.\\nGraves s disease, as a rule, runs a chronic course, lasting for years.\\nA few cases that have run an acute course of a few weeks, some ending\\nin recovery and some in death, have, however, been reported. More-\\nover, there may be recurring attacks with apparent recovery in the\\ninter yals.\\nDeath results from gradual weakening of the heart and its direct and\\nindirect effects. It may be hastened also by uncontrollable diarrhoea,\\nacute mania, and epilepsy. The disease may also be complicated with\\nhemorrhages, and these may be the immediate cause of death.\\nEnlargement of the thyroid gland from the above-mentioned causes\\nmust be distinguished from enlargement due to abscess, cancer, sarcoma,\\nor adenoma. Abscess usually follows infectious diseases in the writer s\\ncase it followed typhoid fever. With carcinoma and sarcoma there is\\namemia and gradual loss of flesh. It must also be distinguished from\\nother tumors in this region. It particularly must not be confounded\\nwith enlargement on the right side due to an innominate aneurism.\\n(See Aneurism.)\\nThe Vessels of the Neck. Changes take place in the arteries and\\nveins, observed by inspection, palpation, and auscultation. (For a de-\\nscription of these changes, see Arteries and Veins.)\\nThe Lymphatic Glands. (See Chapter XI.)", "height": "4416", "width": "2552", "jp2-path": "practicaltreatis00muss_0_0096.jp2"}, "97": {"fulltext": "CHAPTER VIII.\\nTHE DATA OBTAINED BY OBSERVATION\u00e2\u0080\u0094 {Continued).\\nTHE EYE AND EAR.\\nThe Eye. Indirectly the eye and the skin are the external struc-\\ntures that present the most evidence of disease in other organs. This\\nis true of the eye, because of the comparative ease of its examina-\\ntion, and because it is a highly specialized organ, bearing close relation-\\nship to the vascular and nervous system. Its special functions are\\nsubservient to the highest physiological cerebral action hence any per-\\nturbation of or organic change in the cerebrum is expressed in altered\\neye function, either of movement or of vision. Its nerve and vascular\\nconnection with the brain render it sensitive to internal change. In\\ndiseases of the nervous system the eye is the one organ the examina-\\ntion of which is essential to make a diagnosis. Constant reference in\\nthe chapter on Nervous Disease will be made to this section, and the\\nconverse holds that in the study of this section reference must be made\\nto the nervous system. But diseases of the heart, the kidneys and sys-\\ntemic conditions, such as gout, rheumatism, diabetes, etc., find expres-\\nsion often in some eye change.\\nMuch may be gained from an inspection of the eye and its adnexa\\nregarding the state of the general system. This is at once evident\\nwhen we reflect that of the twelve pairs of cranial nerves four pairs are\\ndevoted solely to this important organ, while in the eye itself we have\\nunfolded to our gaze a living nerve-head, the optic papilla, and the\\nretinal vessels, which offer to our view the perfect cycle of the supply\\nof an organ with arterial and the escape of its venous blood. More-\\nover, the eye presents in compact form representation of nearly all the\\ntissues of the body.\\nIn order to insure that nothing shall escape scrutiny in the inspec-\\ntion of the eye, it is necessary to follow some settled plan of investi-\\ngation, and for this purpose it is well to pursue an anatomical order,\\nproceeding from the superficial to the deeper structures.\\nThe Lids. (Edema is not an infrequent symptom of renal disease\\n(see (Edema of the Face), and may occur in cases of profound anaemia\\nand chlorosis it may indicate the prolonged use of arsenic, or it may\\nbe originated by disease of the orbit or some of the periorbital sinuses\\nof the same side. The dropsy may accumulate during the night and\\nbe seen in the morning on rising. Morning puffiness is natural to\\nsome individuals. Both it and the swollen face following a debauch\\nare not to be confounded with oedema.\\nPtosis, or drooping of the eyelid, may be congenital, more usually it\\nis a symptom of disease within the brain. (See Paralysis of the Third\\nNerve.)", "height": "4416", "width": "2556", "jp2-path": "practicaltreatis00muss_0_0097.jp2"}, "98": {"fulltext": "92 GENERAL DIAGNOSIS.\\nLagophthalmus is that condition in which the lids can be closed\\nbut imperfectly, and follows paralysis of the orbicularis muscle, due to\\nlesions of the portio dura. According to Bull and Hansen, paralysis\\nof the orbicularis muscle is of common occurrence in leprosy.\\nBlepharospasm, or active closure of the lids from spasm, is of a\\nreflex nature, originated by excitation of a filament of the fifth nerve.\\nIt is always present to a greater or less degree in photophobia or intol-\\nerance of light this latter symptom is a frequent associate of ocular\\ndisorders, and is also found in certain stages of meningitis, cerebral\\ntumors, typhus, measles, etc. It accompanies many forms of head-\\nache, especially migraine, and it may be the expression of a hyper-\\nesthesia of the retina in nervous subjects, apart from any actual in-\\nflammation of the retina. Cramp of the orbicularis muscle has been\\nnoted quite often as a symptom of hysteria. Nictitation, or undue\\nwinking of the eyelids, occurs not infrequently in children as part of a\\nhabit of chorea.\\nStyes or small boils which form on the tarsal margin, and blepharitis\\nor inflammation of the. margin of the lids, while often due to an error\\nof refraction, may denote some defect in the general health, such as\\nanaemia or scrofula.\\nVaccinal eruption may appear on the eyelids, occurring as a\\nsmall ulcer with an indurated border and yellow floor at the commis-\\nsures, and is usually attended by some swelling of the lids and face\\nand by enlargement of the preauricular glands.\\nChancre may appear either as a primary or secondary sore, and is\\ngenerally situated in the conjunctiva lining the lids.\\nMalignant pustule, or specific anthrax, is seen at times, though\\nrarely, on the lids of those who are exposed to infection from diseased\\nanimals or decayed animal matter.\\nXanthelasma consists in the formation of small, irregular, opaque,\\nyellowish patches, slightly elevated above the surrounding skin. These\\nareas may either remain localized or the disease may involve the palms\\nof the hands, the flexures of the fingers, and the inside of the mouth.\\n(See Tongue.)\\nThe Orbit. Exophthalmus, or proptosis, abnormal prominence or\\nprotrusion of the eyeball, is usually occasioned by some disease of the\\norbit or of the neighboring sinuses which encroaches upon the cavity\\nof the orbit. It is one of the diagnostic features of exophthalmic goitre\\n(see Exophthalmic Goitre), and may also be caused by paralysis of the\\nocular muscles. It has been seen, though rarely, after spontaneous\\nhemorrhages into the orbit in cases of haemophilia and scurvy.\\nEnophthalmus, or retraction of the eyeball, may be the result of ex-\\nhausting diseases, such as peritonitis, or secondary to some orbital\\nlesion. It is very pronounced in the sudden atrophy that occurs in\\ncholera from loss of water.\\nExtraocular Muscles. Before detailing briefly the measures em-\\nployed for the detection of paralysis of the extraocular muscles, and\\nthat the subject may be grasped more readily, a few Avords of expla-\\nnation will be given regarding the anatomy and physiology of the\\nmuscles engaged in the ocular movements.", "height": "4412", "width": "2568", "jp2-path": "practicaltreatis00muss_0_0098.jp2"}, "99": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 93\\nThe eyeball is suspended in the orbital cavity by means of six mus-\\ncles the four recti, superior, inferior, internal, and external, and the\\nsuperior and inferior oblique. Of these the four recti and the superior\\noblique have their origin at the apex of the orbit, while the inferior\\noblique rises from its lower inner wall. These muscles exercise their\\naction upon the movements of the globes in three pairs, each pair being\\ncomposed of two antagonistic muscles the rectus internus and exter-\\nnus the rectus superior and inferior, and the superior and inferior\\nobliques. The sixth nerve supplies the external rectus, the fourth the\\nsuperior oblique, the remaining four muscles receiving their impulses\\nfrom the third nerve.\\nWhen all of the muscles are in a state of equal tension and the visual\\naxes are directed straightforward in the horizontal plane, the eyes are\\nthen said to be in the primary position. Any deviation from this is\\nknown as a secondary positio7i, the simplest of these being direct lateral\\nor vertical movements. Thus, the rotation of the eye directly inward\\nis accomplished by the rectus internus, outward by the rectus externus,\\nupward by the superior rectus and the inferior oblique, and downward\\nby the inferior rectus and the superior oblique. Oblique movements\\nof the eyeball, however, are more complicated and necessitate the action\\nof a third muscle to regulate the torsion which the eye undergoes Avhen\\nit is moved from the perpendicular. This is occasioned by the fact\\nthat while the plane of the points of origin and insertion of the rectus\\nexternus and internus corresponds with the horizontal plane of the\\neyeball, that of the rectus superior and inferior and of the oblique mus-\\ncles do not correspond with the vertical and horizontal planes respect-\\nively. Therefore, so soon as the globe is moved into the oblique posi-\\ntion, it rotates or undergoes a certaion amount of torsion. Thus, the\\nsuperior rectus, in addition to elevating the eye, rotates the upper part of\\nthe cornea toward the nose, while the inferior rectus, in direct antagonism\\nto it, depresses the eye and rotates the upper half of the cornea exter-\\nnally these muscles exercising their greatest degree of torsion when\\nthe eyeball is turned inward and either upward or downward. The\\nsuperior oblique depresses the eye and rotates the upper part of the cornea\\ninternally, while the inferior oblique elevates the eye and rotates the\\nupper half of the cornea externally. The obliques, in antagonism to\\nthe superior and inferior recti muscles, exercise their maximum amount\\n\u00e2\u0080\u00a2of torsion, therefore, when the eye is rotated externally and either\\nupward or downward.\\nIt appears from the foregoing that in inward and downward\\nmotion the rectus internus and inferior and the superior oblique will\\nbe brought into play in outward and upward, the rectus externus\\nand superior and the inferior oblique and in outward and down-\\nward movements the rectus externus and inferior and the superior\\noblique.\\nManner of Detecting Palsies of the Extraocular Muscles.\\nNormally, the movements of both eyeballs are in perfect association\\nand harmony, so that the images of objects fall upon corresponding\\npoints of both retinae, and single vision obtains. If this harmonious\\n.action be interrupted by paralysis of one or more of the extraocular", "height": "4416", "width": "2564", "jp2-path": "practicaltreatis00muss_0_0099.jp2"}, "100": {"fulltext": "94 GENERAL DIAGNOSIS.\\nmuscles, however, then this no longer happens, and limitation in the\\nmovement and deviation of the affected eye is the result, coupled with\\ndouble vision or diplopia.\\nLimitation in the Movements and Deviation of the Af-\\nfected Eye. In studying limitations of motion in the eyes, the ex-\\naminer seats himself before the patient and requests the latter to follow\\nwith his eyes the movements of a candle which is carried through all\\nthe different meridians of the visual fields, any muscular deviation\\nbeing made evident by a failure in correspondence of the images from\\nthe candle reflected from the cornea, as well as by the lagging in the\\nmovements of the eye in the deviation of the action of the affected\\nmuscle. There are three general laws which have been formulated\\nwhich should be borne in mind in this connection. 1. The limitation\\nin motion as well as the diplopia increases toward the side of the\\naffected muscle. 2. The secondary deviation (the deviation which the\\nsound eye makes while the affected eye is fixing the candle) is greater\\nthan the primary deviation (the deviation of the affected eye while\\nthe sound eye fixes). 3. The image formed on the retina of the affected\\neye is projected in the direction of the paralyzed muscle.\\nDiplopia. The character of the diplopia varies according to the\\nmuscle or muscles whose function has been disturbed. Generally\\nspeaking, diplopia is either simple or homonymous, or crossed or heter-\\nonymous. In the former the image of the affected eye lies on the cor-\\nresponding side and betokens convergence of the visual axes, while in\\nthe latter the image of the affected eye is projected to the opposite side\\nand indicates divergence of the visual axes. In order to ascertain the\\nrelation of the two images to the respective eyes, it is essential that the\\ndiplopia should be carefully tested.\\nTest for Diplopia. For this purpose the patient is seated in a dark-\\nened room with a red glass placed before one of the eyes, in order to\\nfacilitate the identification of each image by its color, and a lighted\\ncandle is held on a level with the head about five metres off. Having\\nnoticed any deviation which the eyes make in the primary position,\\nupon a chart especially constructed for this purpose, the candle is moved\\nthrough the different meridians of the visual field, the patient being\\nrequested to regard the flame with both eyes while the head remains\\nquiet, each deviation being carefully noted on the chart.\\nAfter the deviations have been recorded the diagnosis of the affected\\nmuscle or group of muscles will be much facilitated by the following\\nrules If the diplopia be lateral, then the paralysis is either of the\\nrectus internus or externus. If, in addition, the images are crossed,\\nthen the internus is at fault, but if they are homonymous the ex-\\nternus is paralyzed. If the diplopia be vertical, and in the upper\\nfield, then the paralysis is either of the rectus superior or the oblique\\ninferior. If the images be crossed, paralysis of the superior rectus is\\nindicated, but if they be homonymous, implication of the inferior\\noblique is designated. If the diplopia be vertical and in the lower\\nfield, then the paralysis is either of the rectus inferior or obliquus supe-\\nrior crossed images indicating paralysis of the rectus and homony-\\nmous that of the oblique muscle.", "height": "4416", "width": "2572", "jp2-path": "practicaltreatis00muss_0_0100.jp2"}, "101": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 95\\nAdditional Symptoms. In addition to the study of the anomalies\\nin motion and of the diplopia, considerable information may also often\\nbe gained by noting the position of the head in ocular paralyses.\\nThus, in paralysis of the sixth nerve, the face is turned toward the\\nparalyzed side in paralysis of the fourth nerve, it is turned downward\\nand toward the shoulder of the paralyzed side and in paralysis of the\\nthird nerve, the face looks toward the shoulder of the same side. Not\\nrarely dizziness is complained of and false projection of the field of\\nvision, causing patients to make faulty estimation of distance.\\nThe Clinical Significance of Disturbances in the Motility\\nof the Extraocular Muscles. In addition to the significance\\nwhich paralysis of the eye muscles bears io lesions of the brain and of\\nthe cranial nerves, and which will be dwelt upon at length later, dip-\\nlopia may proceed from some much less serious disturbance, as, for\\nexample, derangements of the digestive organs or alcoholic intoxicants.\\nTransient attacks of diplopia may be among the earliest symptoms of\\ntabes dorsalis, and may occur at the very beginning of cerebral men-\\ningitis.\\nMonocular diplopia is a rare symptom, and when it can be dis-\\nassociated from some local disturbance in the media of the eye, may\\nbe attributed to hysteria.\\nOcular deviations or paralytic squint, as has just been described, must\\nbe differentiated from concomitant squint or strabismus. In this latter\\nvariety there is no great restriction in movements of the eyes in any\\ndirection, the faulty position of the visual axis remaining constant\\nwhile the eyes are moved from side to side, and the secondary devia-\\ntion being equal to the primary. This is the condition which is com-\\nmonly known as cast or cross-eye, and usually makes its appearance\\nin children with high degrees of far-sightedness.\\nNystagmus is a spasmodic condition of the muscles of the eye, pro-\\nducing rapid oscillations of the ball, usually horizontal, sometimes\\nrotary and rarely vertical. It is of great value as a symptom, being\\nfound in many brain lesions, usually those of the restiform bodies, the\\nvermiform process, and of the cerebellum. It is also seen in Fried-\\nreich s ataxia, in miners, and often as the result of visual defects.\\nMuscular Insufficiencies. Of late years much attention has\\nbeen given by ophthalmologists and neurologists to the study of errors\\nin the extraocular muscle balance in different reflex psychoses. While\\nthe assertion which has been made by some, that chorea and even epi-\\nlepsy may be originated by such deviations, is extreme, it is neverthe-\\nless quite true that many forms of headache, of vertigo, of nausea, and\\nof vague neuralgic pain of a cephalgic type can be traced to this source.\\nIt is important, therefore, that the clinician should be acquainted with\\nsuch errors, and should be familiar with the methods employed for their\\ndetection.\\nThe device of Maddox is usually employed for this purpose. This\\nconsists of a glass cylinder which is fitted into a linear opening, which\\nis made in a metallic disk. The patient is seated before a candle flame\\nfive metres off and requested to regard the name with both eyes. The\\nrod is then placed before one of the eyes perpendicularly and an image", "height": "4416", "width": "2540", "jp2-path": "practicaltreatis00muss_0_0101.jp2"}, "102": {"fulltext": "96 GENERAL DIAGNOSIS.\\nof a perpendicular streak of light obtained from that eye. If the streak\\nof light be deviated toward the same side as the eye before which it is\\nheld, a condition of excessive convergence or esophoria is present but\\nif the streak deviates toward the opposite side, then a divergence of the\\nvisual axes or exophoria exists. If the streak be on a higher or lower\\nlevel than the flame, vertical imbalance or hyperphoria is present.\\nBalance of the muscles is known as orthophoria.\\nThe Conjunctiva. The conjunctiva being a transparent though\\nvascular membrane, any changes in the amount or the constitution of\\nthe blood will at once evidence itself in its folds. Thus, in anaemia\\nthere is always a pallor of the conjunctival vessels, while in plethora\\nthere is usually a passive dilatation of the vessels which gives the eye\\nan injected appearance, and occasions the bloated eye of the drunk-\\nard. In jaundice the conjunctiva is yellow. Spontaneous hemorrhages\\ninto the membrane are seen in whooping-cough, asthma, epilepsy, and\\nin calcareous degeneration of the bloodvessels, and it may be the seat\\nof hemorrhagic infarcts in ulcerative endocarditis.\\nInflammation of the conjunctiva is an early symptom in measles, and\\nin typhus fever it is a constant sign, and serves to distinguish this affec-\\ntion from typhoid. It is also present in yellow fever, and may likewise\\nconstitute one of the earliest signs of meningeal and cerebral diseases.\\nA passive hyperemia follows disease of the cervical sympathetic.\\nThe Cornea. The cornea being an avascular membrane, deriving\\nits nourishment from the surrounding structures, it is very prone to\\nundergo inflammation whenever the vitality of the system becomes\\nmuch lowered, and as a result of this inflammation opacities remain\\nwhich have a very deleterious action upon vision. These opacities may\\nbe either superficial or interstitial. When superficial they are not infre-\\nquently the result of burns, traumatisms, and extension of the inflam-\\nmation from the surrounding conjunctiva in many cases they denote,\\nhowever, that the eye has been the seat of a phlyctenular inflammation,\\na form of ocular disease which is quite common in scrofulous children\\nand in individuals below par.\\nSuperficial ulceration of the cornea is observed also in all fevers of a\\ntyphoid type, when the patient lies in a semi-conscious state with the\\nlids but partly closed. Dust and bacteria gather between the lids,\\nand as the patient winks but seldom a crust forms on the cornea, which\\nis followed by extensive ulceration. Abscesses of the cornea form in\\nthe stage of desquamation of variola, and must be differentiated from\\nthose which arise in the pustular variety of the disease at an earlier\\nperiod. Ulcers also form in the seventh week of typhoid, being usually\\ncoincident with abscesses in the scalp and skin of the back.\\nThe type of interstitial opacities of the cornea is seen in inherited\\nsyphilis. Indeed, to the trained eye, the appearance of the haze in\\nthis class of cases is so characteristic that the diagnosis of the systemic\\naffection might be made for the eye alone. Malaria and scrofula may\\nalso produce similar types of corneal inflammation. The small areas\\nof opacity which form in the upper and lower parts of the cornea near\\nthe limbus, and which at times encircle the cornea, are known as arcus\\nsenilis. This is commonly supposed to be indicative of arterial sclero-", "height": "4416", "width": "2564", "jp2-path": "practicaltreatis00muss_0_0102.jp2"}, "103": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 97\\nsis, although the author has never found ground to warrant this asser-\\ntion. It may always be diagnosed from a somewhat similar opacity of\\ninflammatory origin by the fact that in the latter variety, the opacity\\nbeing due to an inflammation usually beginning at the corneo-scleral\\nmargin, the haze is continuous with the conjunction of the two mem-\\nbranes whilst in arcus senilis there is a zone of clear corneal tissue\\nbetween the margin of the cornea and the rim of the opacity.\\nAfter lesions of the fifth nerve the cornea may ulcerate from trau-\\nmatic and trophic causes, and after paralysis of the seventh nerve it\\nmay suffer from exposure due to inability to close the lids.\\nIris. Inflammation of the iris is a common symptom of secondary\\nsyphilis it occurs under the form of a gummatous infiltration of the\\nmembrane in the tertiary variety, and is seen, though rarely, in inher-\\nited syphilis. It is not an infrequent symptom of chronic rheumatism\\nand gout, and may be caused by tuberculosis and rheumatoid arthritis.\\nThe Pupil. The pupil may react either directly or indirectly to\\nlight stimulus. In order to observe this, the patient is seated before a\\nwindow and requested to gaze at the sky. The examiner, stationed in\\nfront of the patient with his back to the window, excludes one eye by\\nplacing his hand over it, and notes the size of the pupil under diffuse\\ndaylight. The eye is then covered with the other hand, and the dila-\\ntation which should follow is also approximated. The hand is then\\nwithdrawn, and, if nothing prevents, the iris will contract to the same\\nsize as that which existed at the commencement of the test. The\\nfellow eye is then to be tried in a similar manner. This is known as\\nthe direct reflex action of the pupil indirect or consensual reflex action\\nbeing the contraction or dilatation which occurs in the shaded eye when\\nthe exposed eye is being examined, and should correspond precisely\\nwith the movements of the pupil of that eye.\\nHaving noted the reaction of the iricles to light stimulus, the patient\\nis now directed to transfer his gaze to the examiner s finger, which\\nshould be made to slowly approach the eye, whilst its fellow is screened\\noff as in the former test. The amount of the contraction induced by\\nthis accommodative effort is carefully noted, and the same procedure\\nrepeated in the fellow eye. The obstructing hand is finally removed,\\nand the patient being requested to look fixedly at the tip of the sur-\\ngeon s finger with both eyes, observation is made of the contraction of\\nthe pupil, which should be induced by the effort at convergence which\\nis occasioned by approximating the finger to the eyes in the median\\nline.\\nHippus is a spasmodic alternating contraction and dilatation of the\\npupil, which is seen at times in mania, hysteria, and other allied disor-\\nders. Rhythmical alterations in the size of the pupils occur frequently\\nin the so-called Cheyne-Stokes respiration the pupil contracting\\nduring the period of apnoea and dilating with the first few breaths.\\nModification in the Size and Behavior of the Pupils as\\nthe Result of Disease. Pupillary reaction to light is a reflex phe-\\nnomenon, the optic nerve being the afferent nerve, and the third nerve\\nthe efferent nerve, supplying the sphincter of the iris communicating\\nfibres between the corpora quadrigemina and the centre from the third", "height": "4416", "width": "2564", "jp2-path": "practicaltreatis00muss_0_0103.jp2"}, "104": {"fulltext": "98 GENERAL DIAGNOSIS.\\nnerve making such a reflex possible. The mechanism of pupillary\\nreaction being of an extremely complicated nature, and necessitating\\nthe activity of a number of nerves and nuclei, it is not strange that\\nanomalies in its behavior should be frequently met with in disorders\\nof the central nervous system.\\nDilatation of the pupil (mydriasis), apart from local diseases, of\\nwhich glaucoma is the type, may be produced by certain psychical\\nemotions, such as fright and emotion, or it may be caused by diseased\\nprocesses giving rise to irritation of the pupil dilating centre or fibres\\n(irritative or spasmodic mydriasis), or by paralysis of the pupil con-\\ntracting centre or fibres (paralytic mydriasis or iridoplegia).\\nIrritation mydriasis occurs (a) in hyperemia of the cervical portion\\nof the spinal cord and in spinal meningitis (b) in the early stages of\\nnew growths in the cervical portion of the cord (c) in cases of intra-\\ncranial tumor and other diseases causing high intracranial pressure,\\naccording to Raehlmann, although Leeser points out that these may\\nalso give rise to paralytic mydriasis (d) in the spinal irritation of\\nchlorotic or anaemic people, after severe illness, etc. (e) as a premoni-\\ntory sign of tabes dorsalis in cases of intestinal worms, owing to\\nthe stimulation of the sensitive nerves of the bowel, and sometimes in\\nother forms of intestinal irritation (g) in psychical excitement e. g.,\\nacute mania, melancholia, progressive paralysis of the insane (often,\\nthen, unilateral, with myosis in the other eye). (After Swanzy.)\\nParalytic mydriasis (iridoplegia) may be due either to a paralysis of\\nthe pupil contracting centre or as a result of the stimulus not being\\nconducted from the retina to that centre. It may be found under the\\nformer circumstances (a) Sometimes in progressive paralysis where\\nat first there was myosis (b) in various diseased processes at the base\\nof the brain affecting the centre of the third nerve (c) in a late stage\\nof thrombosis of the cavernous sinus (d) in orbital processes which\\ncause pressure on the ciliary nerves. (After Swanzy.)\\nIt is said to be present in acute dementia, when there is oedema of\\nthe cortex, and is found in cerebral softening. It occurs in irritation\\nof the cervical sympathetic and occasionally in aortic insufficiency.\\nContraction of the Pupil (Myosis). Having excluded myosis\\nfrom local causes, especially from the sequelse of iritis, it will be found\\nthat contraction of the pupil may be caused by a disease process irri-\\ntating the pupil-contracting centre or nerve-fibres (the irritative myosis\\nof Leeser), or by one causing paralysis of the pupil-dilating centre\\nor nerve-fibres (the paralytic myosis of Leeser), or by a combination\\nof both.\\nIrritation myosis is found in (a) the early stages at least of all in-\\nflammatory affection of the brain and its meninges, in simple, tuber-\\ncular, and cerebro-spinal meningitis. When, in these diseases, the\\nmedium myosis gives place to mydriasis, the change is a serious prog-\\nnostic sign, indicating the stage of depression with paralysis of the\\nthird nerve (b) in cerebral apoplexy the pupil is at first contracted,\\naccording to Berthold, who points out that this contraction is a diag-\\nnostic sign between apoplexy and embolism, in which latter the pupil\\nis unaltered (c) in the early stages of intracranial tumors situated at", "height": "4416", "width": "2552", "jp2-path": "practicaltreatis00muss_0_0104.jp2"}, "105": {"fulltext": "THE DA TA OB TA INED B Y OB SEE VA TION. 9 9\\nthe origin of the third nerve or in its course (d) at the beginning of\\na hysterical or of an epileptic attack (e) in tobacco amblyopia, prob-\\nably from stimulation of the pupil-contracting centre by the nicotine\\nin persons following certain trades, as the result of long main-\\ntained effort of accommodation (watchmakers, jewelers, etc.), the pupil-\\ncontracting centre being subject to an almost constant stimulus (g) as\\na reflex action in ciliary neurosis consequently, in many diseased con-\\nditions of those parts of the eye supplied by the fifth nerve. (After\\nSwanzy.)\\nParalytic myosis occurs in spinal lesions above the dorsal vertebra\\ne. g., injuries and inflammations, especially of the chronic form. The\\ncontracted pupil occurring in gray degeneration of the posterior columns\\nof the spinal cord has been long known as spinal myosis. In the\\nsimple form of this myosis the pupil has but a medium contraction,\\nand reacts both to light and on convergence. This condition is found\\nin the early stages alone, when the disease has attacked merely the\\ncilio-spinal centre, or higher up, as far as the medulla oblongata later\\non, when Meynert s fibres become engaged, we have the Argyll-Rob-\\nertson pupil. The very minute pupil often seen in tabes dorsalis is\\nprobably due to secondary contraction of the sphincter pupillse.\\nParalytic myosis is also found in general paralysis of the insane. In\\nacute mania the pupil is usually much dilated, and when this mydriasis\\nis changed for myosis approaching general paralysis may be prognosti-\\ncated. Myosis, following on irritation mydriasis, is also found in mye-\\nlitis of the cervical portion of the cord. In bulbar paralysis, if paralytic\\nmyosis occurs, the disease is probably complicated with progressive\\nmuscular atrophy, or with sclerosis of the brain and spinal cord.\\nMyosis may also be due to paralysis of the cervical sympathetic, result-\\ning from injury, from pressure of an aneurism of the carotid, innomi-\\nnate, or aorta, or from pressure of enlarged lymphatic glands. In\\napoplexy of the pons varolii myosis is present, but it is not yet certain\\nwhether it is an irritation myosis or a paralytic myosis.\\nInequality of the pupils may denote lesion of the third nerve, affection\\nof the cervical sympathetic in the cervical region of the spinal cord,\\ngeneral paralysis of the insane, or some unilateral lesion of the brain.\\nThe Lens. Cataract. An opacity in the crystalline lens should\\nalways awaken the suspicion of its being due to diabetes, as cataract is\\nof not infrequent occurrence in this disease. Although renal disease\\nalso has been held accountable by some for the occurrence of cataract,\\nno satisfactory evidence has been given to prove this assertion.\\nThe Eye Ground. In order to study the remaining structures of\\nthe eye, it is necessary to have recourse to the ophthalmoscope. The\\nessential part of this instrument consists in a concave mirror, whereby\\nthe light from a lamp which is placed back and slightly to the side of\\nthe patient s head may be projected into the interior of the eye about\\nto be examined. This mirror is provided with a small central aper-\\nture, through which the examiner looks and studies the details of the\\nback of the eye or fundus oculi, as it is technically called. When the\\ninstrument is held close to the eye, and the eye-ground studied without\\nthe intermediation of other means, the procedure is known as the direct", "height": "4416", "width": "2540", "jp2-path": "practicaltreatis00muss_0_0105.jp2"}, "106": {"fulltext": "100 GENERAL DIAGNOSIS.\\nmethod of ophthalraoscopical examination. In the indirect method, on\\nthe other hand, the ophthalmoscope is held about sixteen inches from\\nthe eye and an inverted image of the fundus obtained by means of a\\nconvex lens, which is interposed between the ophthalmoscope and the\\neye, and serves to collect the rays of light into a focus between the lens\\nand the eye of the examiner. The former method possesses the advan-\\ntage of magnifying the interior of the eye about fourteen times, while\\nthe indirect, although of less magnifying power, permits of the exami-\\nnation of a greater part of the fundus at a glance.\\nThe ophthalmoscope, in addition to giving us information in regard\\nto the condition of the media of the eye, as, for example, of the exist-\\nence of commencing cataracts, or of opacities within the vitreous humor,\\nunfolds to our gaze the head of the optic nerve as well as the retina\\nand the choroid, and renders patent to our view the different diseases to\\nwhich they are liable. 1\\nRetinitis. The systemic affection which is accompanied by a lesion\\nof the retina more often than any other is disease of the kidneys, espe-\\ncially chronic interstitial nephritis. Indeed, about 30 per cent, of all\\ncases of this variety of renal lesion have an ocular manifestation. Ret-\\ninitis may also be seen as an early symptom in the nephritis of scarlet\\nfever and pregnancy. Its occurrence in the cirrhotic kidney is of\\ngloomy import, for patients with a retinal complication in this disease\\nusually die within two years of its first appearance. Retinitis may also\\nbe occasioned by pernicious anaemia, leukaemia, diabetes, syphilis, and\\nheart disease.\\nChoroiditis is usually the result of syphilis, but may in rare in-\\nstances be the seat of tubercles. Gout may also originate a subacute\\ninflammation of the membrane.\\nOptic Neuritis. The optic nerve being really a prolongation of\\nthe brain, and being, of a consequence, so often liable to be affected in\\ncerebral disorders, it is of the utmost importance that the clinician\\nshould be able to recognize changes in its appearance. Indeed, it is\\nsafe to say that the study of a nervous case/ so called, is never com-\\nplete without the report of the ophthalmoscopic findings.\\nPapillitis, or choked disk, an inflammation of the head of the optic\\nnerve, is rarely idiopathic, but is occasioned by cerebral growths and\\nby meningitis, especially of the base of the brain, and by the same con-\\nstitutional diseases which originate retinitis. It also occurs in acute\\nfevers, and it may be the result of suppression of the menstruation.\\nUsually, however, choked disk is the result of an intracranial tumor,\\noccurring in 90 per cent, of all such cases, and as it is an early sign, its\\ndetection has frequently been the means of the discovery of many in-\\ntracranial neoplasms. As a rule, tumors of the cerebellum and those\\nof the cerebrum which interfere with the circulation in the lymph pas-\\nsages of the brain originate it, the size and the character of the tumor\\nnot seemingly influencing its production.\\nThe variety of optic neuritis which has just been discussed is an\\n1 It has not been thought proper in a work of this kind to give further details re-\\ngarding ophthalmoscopy, the student being referred to special text-books upon ophthal-\\nmology for a perusal of that important subject.", "height": "4416", "width": "2564", "jp2-path": "practicaltreatis00muss_0_0106.jp2"}, "107": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 101\\nascending neuritis, the inflammation beginning at the intraocular termi-\\nnation of the nerve and spreading upward from this to the brain.\\nThere is also an interstitial or descending neuritis which is commonly\\ncaused by meningitis. Retrobulbar or toxic neuritis is a variety of\\nInflammation of the optic nerve where the disease confines itself to the\\nbundle of nerve-fibres which go to supply the macular regions. This\\ndisease is commonly caused by alcohol and tobacco, although it may be\\noriginated by quinine, the salicylates, lead, and iodoform. It may also\\nbe caused by rheumatism and catching cold, and there is a rare form\\nwhere the disease is transmitted through certain families from genera-\\ntion to generation.\\nOptic Atrophy. This may be secondary to some inflammation of the\\noptic nerve or retina, or it may be a primary disease.\\nSecondary or consecutive atrophy is usually the result of optic neu-\\nritis it may, however, be originated by local causes either within the\\neye or the orbit. Primary atrophy, on the other hand, though occa-\\nsionally idiopathic, is generally found associated with some disease of\\nthe spinal cord, especially with locomotor ataxia. In this affection it\\nis frequently an early sign, and it has been noted by Benedikt, of\\nVienna, that when this occurs it is rare for a tabetic patient to become\\nataxic. It has also been remarked that cases in which blindness is\\nwell advanced suffer but little from the pains which are characteristic\\nof this disease. Simple atrophy occurs also in lateral and insular\\nsclerosis, and is frequently seen in general paralysis of the insane.\\nBefore proceeding further with the consideration of the cerebral\\nexpansion of the optic nerve, it becomes necessary to study the methods\\nwhich are used in the determination of the visual acuity, both central\\nand peripheral, as these are valuable and often necessary adjuncts in\\nestablishing the diagnosis of many obscure, cases of cerebral disease.\\nCentral vision is tested by means of black letters printed on a\\nwhite test card, those devised by Snellen being usually employed on\\naccount of the admirable system upon which they are founded. The\\npatient is seated five metres away from the card, and one eye being blind-\\nfolded he is requested to read the lowest line of letters which he can\\ndistinguish. If the vision fails to correspond to the standard, it is\\nnecessary to exclude hypermetropia, myopia, and astigmatism by means\\nof convex, concave, and cylindrical lenses before it can be definitely\\nasserted that the vision is lowered as the result of disease.\\nPeripheral vision, or the extent of space of which the eye is con-\\nscious when it is fixed on any given point, may be estimated in several\\nways it is accomplished, however, most accurately by means of the\\nperimeter. This is an instrument which consists of an upright rest\\nfor the chin and a semi-circular arc or bar, graded in degrees, which re-\\nvolves upon a middle point, and is capable of describing a hemisphere\\nin space. The eye under examination being directed straight ahead at\\nthe fixation point, the fellow eye being blindfolded, the test object, a\\nsmall square of white paper, is brought from the periphery toward\\nfixation. The patient is then asked to indicate the instant the object\\nis perceived, and the examiner marks the degree upon a chart pro-\\nvided for the purpose. If the perimeter be not at hand, the field", "height": "4416", "width": "2556", "jp2-path": "practicaltreatis00muss_0_0107.jp2"}, "108": {"fulltext": "102\\nGENERAL DIAGNOSIS.\\nmay be obtained fairly accurately as follows The patient is seated\\nopposite the surgeon with one eye bandaged. He is then directed to\\nlook at the corresponding eye of the examiner whilst the observer s\\nfinger is slowly brought in from the periphery toward the eye through\\nthe different meridians. In this way the surgeon can ascertain whether\\nFig. 11.\\nThe McHardy perimeter.\\nthe patient permits his eye to wander from the fixation point, and at\\nthe same time he can compare the extent of the patient s field with\\nthat of his own. The field for form or white extends over 150\u00c2\u00b0\\nhorizontally and 110\u00c2\u00b0 vertically, that of the different colors falling\\nwithin this in the following order yelloAV, blue, red, and green.\\nScotoma. As the patient s macula corresponds to the fixation point\\nin the visual field, the physiological blind spot which is occasioned by\\nthe entrance of the optic nerve into the eye will be found in the tem-\\nporal portion of the field. Pathological blind spots are knoAvn as\\nscotoma, and these may be either central, paracentral, or disseminated.\\nWhen central, they indicate either a disease of the macula or of the\\nfibres of the optic nerves supplying the macula, so that a central\\nscotoma is one of the diagnostic features of retrobulbar neuritis.\\nHemianopsia. This term is used to imply a defect in one-half\\nthe field of vision, the defect being named according to the blind area.\\nThus, temporal hemianopsia means that the eye cannot perceive objects\\nwhen situated in the outer half of the field. The most common form", "height": "4416", "width": "2544", "jp2-path": "practicaltreatis00muss_0_0108.jp2"}, "109": {"fulltext": "", "height": "4412", "width": "2564", "jp2-path": "practicaltreatis00muss_0_0109.jp2"}, "110": {"fulltext": "PLATE I.\\nLEFT VISUAL FIELD. RIGHT VISUAL FIELD.\\nFixation Point. Fixation Point.\\nI. Genicu/ate Body\\nLint Capsule\\nrc ffr/ Cortex\\nR. OmpiW", "height": "4416", "width": "2552", "jp2-path": "practicaltreatis00muss_0_0110.jp2"}, "111": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 103\\nof hemianopsia is the loss of the temporal field in one eye and of the\\nnasal field in the other, this condition being known as lateral homony-\\nmous hemianopsia. If the temporal portions of both fields are lost,\\nthe defect is known as bitemporal hemianopsia binasal hemianopsia,\\nindicating a loss in the nasal fields of both eyes. Superior and inferior\\nhemianopsia are very rare.\\nIt is often possible bi/ studying the changes in the visual fields to locate\\nquite definitely the seed of the cerebral lesion. By a reference to the\\ndiagram (Fig. 12) it will be at once evident that a lesion of the\\nl f R\\nDiagram showing the course of the optic fibres in the chiasm. (Hirt.)\\nchiasm would necessarily comprise the crossed fibres of the optic nerve,\\nand would occasion bitemporal hemianopsia. Such a lesion may be due\\nto basilar meningitis, periostitis, liyperostitis, fracture of the body of\\nthe sphenoid, distentions of the infundibulum, and of the third ven-\\ntricle, or to tumors, especially those of the pituitary body, and finally\\nsyphilitic gumma. If due to the latter cause, there may be transient\\nrecurrent attacks of the hemianopsia. Bitemporal hemianopsia is also\\nan early symptom of acromegalia. The lesion in superior and inferior\\nhemianopsia is usually in the chiasm also, affecting its superior or in-\\nferior portions these defects in the fields may, however, be caused by\\nsymmetrical cortical lesions and by optic neuritis. (See Plate I.)\\nIf the lesion affects the outer angle of the chiasm, then monocular\\nnasal hemianopsia is the result.\\nLesioxs of the Teact and Cextres. As shown in Plate I.,\\nthe optic tract after crossing the eras to the hinder part of the optic\\nthalamus divides into two branches, one going to the thalamus and the\\nexternal geniculate bodies and to the anterior quadrigeminal bodies\\nfrom which fibres pass into the hinder part of the internal capsule, and\\nentering the occipital lobe, form the fibres of the optic radiations termi-\\nnating in the cuneus, the perceptive visual centres while the fibres of\\nthe other branch pass to the internal geniculate bodies and the posterior\\nquadrigeminal bodies.\\nA lesion affecting the optic fibres anywhere posterior to the optic\\nchiasm will produce lateral hemianopsia, so that this symptom of itself\\nis of little value in localizations. There are, however, certain accessory\\nsymptoms which, when taken in conjunction with it, will often serve to\\nestablish the seat of the lesion in most instances. Thus, in hemian-\\nopsia from lesions of the optic tract there is an absence of the symptoms\\nwhich occur when the cortex is affected as mind-blindness, word-", "height": "4416", "width": "2580", "jp2-path": "practicaltreatis00muss_0_0111.jp2"}, "112": {"fulltext": "104 GENERAL DIAGNOSIS.\\nblindness, etc. while other symptoms indicating a basal lesion are apt\\nto be present, as, for example, implication of the cranial nerves, espe-\\ncially those supplying the ocular muscles. Lesions of the optic tract\\nare also frequently associated with a disease of the eras cerebri, so that\\nhemianesthesia or hemiplegia of the opposite side of the body would\\nbe associated with the hemianopsia. There is, however, a sign which\\nenables us at once to say definitely whether the lesion be in the optic\\ntract or not, and this is known as the Wernicke or pupillary inaction\\nsign. This is elicited as follows The patient is seated in a darkened\\nroom with one eye blindfolded, and is directed to look straight ahead\\ninto the darkness. The eye being slightly illuminated by an assistant\\nby means of the diffuse light from a plane mirror, which is reflected\\ninto the eye from a light placed behind the patient s head, the examiner\\nslowly throws a small beam of concentrated light from a concave mirror\\nupon the blind half of the retina. If the pupil fails to react, the lesion\\nis then in the geniculate bodies or in the tract, inasmuch as the failure\\nin the pupillary activity indicates that the lesion must have involved\\nthe sensory motor arc of the pupil as well as the visual fibres.\\nAlthough when present the Wernicke sign is of great value, recent\\nobservations have shown that its absence is not conclusive. Lesions\\nof the optic tract may be due either to neoplasms or to tubercular or\\ngummatous meningitis, or more rarely they may be the result of cere-\\nbral softening and hemorrhage. As yet clinical evidence is too meagre\\nto permit of a diagnosis of lesions of the primary optic ganglia (pulvi-\\nnar anterior corpora quadrigemina and external geniculate bodies),\\nalthough in lesions of the pulvinar two typical symptoms occur viz.,\\nhemianopsia and athetosis and sometimes hemianesthesia may be\\npresent. In like manner, also, while it is generally believed that\\nlesions of the optic radiations cause homonymous hemianopsia, it has\\nnot been definitely proven that these fibres have solely to do with\\nvision.\\nThe hemianopsia is usually thought to depend upon cortical lesions\\nin the occipital lobe, when it is unaccompanied by any of the accessory\\nsymptoms which have just been detailed. The chief diagnostic symp-\\ntom of a central lesion, however, is what is designated as negative\\nvision, vision nulle, for in these cases the patient has no subjective\\nsensations of the defect in his visual field. Cortical hemianopsia may\\nalso be incomplete, but a quadrant of the field being lost.\\nTransitory hemianopsia, or scintillating scotoma, is the occurrence of\\nsymmetrical defects in the field of vision which usually conform to the\\nhemianopic type, and in which a play of lights frequently appears as a\\nprecursor of an attack of migraine. (See Migraine.)\\nVisual hallucinations may also be hemianopic in character, and are\\ndue to irritation of the visual memory centre.\\nHysterical amblyopia may manifest itself either in complete blindness\\nor central scotoma, but more commonly as defective central vision with\\nconcentric contraction and reversal of the visual fields.\\nParalysis of the Motor Nerves of the Eyeball. Although in the\\nsection which dealt with the diseases of the ocular muscles the vari-\\nous forms of ocular deviation and the different varieties of diplopia", "height": "4416", "width": "2552", "jp2-path": "practicaltreatis00muss_0_0112.jp2"}, "113": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 105\\nwhich resulted therefrom were mentioned at length, it is necessary to\\nrefer still further to their causes and to point out their connection with\\ncerebral diseases.\\nParalysis of the orbital muscles may be due to orbital lesions or to\\nthose at the base of the brain they may indicate pontine lesions, or\\nthey may be originated by causes operating higher up in the cerebrum\\nabove the nuclei. In making the differential diagnosis between central\\nand peripheral palsies, it must be remembered that those of central\\norigin are frequently associated with other symptoms which denote\\nintracranial involvement, while peripheral palsies are generally isolated\\nand often complete.\\nPeripheral paralyses of the orbital muscles are generally the\\nresult of either rheumatism or syphilis. When due to the latter\\ndisease they are usually tertiary manifestations, and especially is this\\napt to be the case if the third nerve is involved, which seems to be\\nsingularly prone to be attacked by gumma of the base. Paralysis of\\nthe sixth nerve is frequently of rheumatic origin.\\nSyphilis causes fully one-half the cases of central paralysis, affecting\\neither the nuclei of the nerves or the neighboring brain structure, the\\nthird and fourth ventricles, or the aqueduct of Sylvius.\\nDiphtheria usually causes a paralysis of the ciliary muscle it may,\\nhowever, affect one or more of the external muscles. Diabetes is com-\\nplicated at times by paralysis of the external rectus. Influenza, herpes\\nzoster, and whooping-cough are also rare causes of ocular palsies.\\nParalysis of the eye muscles is seen in paretic dementia, bulbar paraly-\\nsis, and in multiple and posterior sclerosis. In locomotor ataxia they\\nmay be transient and appear at an early stage of the disease. Ocular\\npalsies have also been caused by poisoning by lead, nicotine, sulphuric\\nacid, carbonic oxide, and tainted meat.\\nComplete paralysis of the third nerve causes the following\\nsymptoms The upper lid droops, the pupil is partially dilated and\\nimmovable, and the power of accommodation is lost. The globe is\\nslightly protruded and strongly diverged externally by the two unaf-\\nfected muscles (the external rectus and the superior oblique). In in-\\ncomplete paralysis of the third nerve, as well as in paralysis of the fourth\\nand sixth nerves, the diagnosis is made by a study of the deviations and\\nby the character of the diplopia, which has been already referred to.\\nThere is a peculiar form of intermitting paralysis of the third nerve,\\nknown as ophthalmoplegic migraine, which occurs in the young and is\\nassociated with headache and at times with vomiting.\\nParalysis of the ciliary muscle, or cycloplegia, follows a lesion of the\\ntrunk of the oculomotor nerve or of the anterior part of its nucleus.\\nIt is quite common as a sequel of diphtheria, and occurs, though rarely,\\nin connection with spinal disease.\\nOphthalmoplegia externa and interna refer to paralyses of all or nearly\\nall of the external and internal muscles. As the lesion in this affec-\\ntion is central, it is frequently known also as nuclear paralysis. In its\\nacute form it is due either to an acute inflammatory process in the\\nnuclei or to hemorrhage, while the chronic depends upon a degenerate\\natrophy of the nerve nuclei, similar to that which is seen in progressive", "height": "4416", "width": "2560", "jp2-path": "practicaltreatis00muss_0_0113.jp2"}, "114": {"fulltext": "106 GENERAL DIAGNOSIS.\\nmuscular atrophy and in chronic bulbar paralysis, with which they\\nmay become associated.\\nIn conjugate lateral deviations of the eyes, although the axes of vision\\nof both eyes are deviated from the middle line, yet they remain parallel\\nwith one another. This condition is generally the result of a cortical\\nlesion which involves the movements of the eyes to the right or to the\\nleft, and is usually the result of apoplexy. A spasm deviation of the\\neyes in the same direction occurs as the result of irritative lesions of the\\nbrain, involving the association centres or tracts, and also in hysteria.\\nThe Localizing Value of Paralysis of the Orbital Muscles.\\nParalysis of the Third Nerve. Ptosis, the most frequent symptom\\nof diseases of this nerve, may be present as a focal symptom in cortical\\nlesions without paralysis of any other branch of the third nerve. This\\nwould seem to indicate a special centre for the elevator of the lids, and\\nthough not definitely ascertained, such a centre is believed to exist in\\nfront of the upper extremity of the ascending frontal convolution close\\nto the centre. Ptosis on the side of the lesion, without paralysis of the\\nother branches of the third nerve, has been seen in disease of the pons,\\nand again by forming a factor of a crossed paralysis may seem to\\nlocalize a lesion in the crus cerebri, although Avhen the third nerve is\\nparalyzed by a lesion in this situation it is usually involved as a whole.\\nGrossed hemiplegia is a term used to express a disease of the crus\\ncerebri when there is paralysis of the third nerve on the side of the\\nlesion, with hemiplegia, hemianesthesia, and often facial and sometimes\\nhypoglossal paralysis of the opposite side of the body.\\nComplete paralysis of every branch of the third nerve without any\\nother paralysis is almost always basal so, also, are those cases in\\nwhich when there is hemiplegia it is slight as compared with the degree\\nof the third-nerve paralysis. Lesion of the interpeduncular space and\\nthrombosis of the cavernous sinus also indicate third-nerve palsies but\\nin the latter the other orbital nerves, as well as the fifth and the optic\\nnerve, may be involved as well Third-nerve symptoms may also be\\ndistant symptoms of tumors of the cerebral hemispheres, more particu-\\nlarly if accompanied by violent general head symptoms.\\nAs a symptom of cerebral lesion solitary paralysis of the fourth nerve\\nis rare. When present it is apt to be produced by a basal lesion. In\\ncombination with paralysis of the third nerve it speaks for a lesion in\\nthe cerebral peduncle extending back to the valve of Vieussens.\\nWhen j^ctralysis of the sixth nerve occurs as the only focal sign it is\\nprobably due to disease of the base as a distinct symptom. On account\\nof the lengthened course these nerves take over the most prominent\\npart of the pons, which renders them readily affected by distant press-\\nure they are more liable to provide a distant symptom than any other\\ncranial nerve. Thus paralysis of this nerve is not infrequently a dis-\\ntant symptom of tumor of the cerebellum, whereas paralysis of the\\n1 This section has been epitomized from the excellent article on the subject in\\nSwanzy s Hand Book of Diseases of the Eye.", "height": "4416", "width": "2568", "jp2-path": "practicaltreatis00muss_0_0114.jp2"}, "115": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 107\\nthird nerve is more apt to be a distant symptom in a lesion of the cere-\\nbral hemisphere.\\nParalysis of the sixth nerve, simultaneous in its onset with hemi-\\nplegia of the opposite side of the body, indicates a lesion in the pons,\\nusually a hemorrhage, on the side corresponding to the paralyzed nerve.\\nBasal paralysis of the nerve is frequently double, especially in syphilis.\\nIn combination with paralysis of the facial, paralysis of the sixth\\nnerve is referable to a pontine lesion.\\nThe Ear.\\nSubjective Symptoms. Buzzing, roaring, hissing, singing, and\\nother sounds in the ear tinnitus aurium are symptoms which may\\nor may not be due to disease of the ear. If associated with vertigo, it\\nmay be due to Meniere s disease. They may be the aura preceding an\\nepileptic attack or the subjective phenomena attending syncope. Many\\ndrugs when pushed to physiological effects cause tinnitus.\\nThe External Ear. The external ear should always be examined.\\nThe thin ear may show the ansemic or chlorotic hue more strikingly\\nthan other portions of the body, or the opposite condition may be\\nmore vividly shown. Hmmatoma auris is seen in general paralysis of\\nthe insane and in other forms of insanity. It is a trophoneurosis.\\nThe ear is thickened and deformed, on account of effusion of blood\\nbetween the cartilages and the perichondrium. It is discolored, and\\nsimulates the subcutaneous effusion due to injury. Tophi are observed\\nin the external ears of patients with a gouty diathesis. They are\\nsmall, hard, gritty accretions, seen in the external ear along the margin\\nor in the depressions. They consist of urate of soda.\\nThe Discharge. When cerebral symptoms or symptoms of infec-\\ntion (pyaemia) are present the presence or absence of ear discharge must\\nbe ascertained. Middle-ear disease very frequently results in inflam-\\nmation of the mastoid, and from thence the sinuses and adjacent mem-\\nbranes of the brain become inflamed or the ear suppuration may be\\nthe primary focus from which general infection has taken place. It\\nmay not be possible in all cases to observe a discharge. It may have\\ndiminished or disappeared on account of the fever. Tenderness and\\noedema over the mastoid, perforation or bulging of the ear-drum, as\\nwell as other inflammatory signs, point to the occurrence of suppura-\\ntion of the middle ear and mastoid cells. It must not be forgotten\\nthat a bloody discharge from the ear may take place in fractures of the\\nskull. The ears must also be examined in cases of coma from injury,\\nor if the origin of coma is obscure.\\nThe Auditory Nerve. The Hearing. The power and acuteness of\\nhearing must be tested. This may be done with the voice, a watch, or\\na tuning-fork. Normally, the instrument should be heard at an equal\\ndistance from either ear. If both sides are equally affected the hear-\\ning of a patient must be compared with that of a healthy person. The\\nticking of a watch should be heard at a distance of about three feet.\\nThe tuning-fork is used by placing it on the skull. In some cases the\\nvoice may be easily heard, while the ticking of a watch can be distin-", "height": "4416", "width": "2552", "jp2-path": "practicaltreatis00muss_0_0115.jp2"}, "116": {"fulltext": "108 GENERAL DIAGNOSIS.\\nguished only with great difficulty. The tuning-fork is used to deter-\\nmine by bone conduction whether deafness is due to obstruction or\\ndisease of the auditory nerve. If it is due to obstruction the vibrating\\ntuning fork placed on the vortex is heard better on the deaf side on\\ncontact with the skull than when held close to the ear (Rhine s test).\\nObstructive deafness, is always due to disease of (1) the external meatus,\\n(2) the tympanic membrane and middle ear, or (3) the Eustachian tube.\\nDeafness from internal ear disease may be due to affections of the\\nlabyrinth as inflammation, caries, and necrosis\u00e2\u0080\u0094 or of the auditory\\nnerve. The tuning-fork is not heard on contact with the skull. The\\nauditory nerve may be diseased in its course, or the auditory centre\\nmay be affected. (See Nervous Diseases, Part II., Chapter VIII.)\\nIt must not be forgotten that certain drugs, as quinine and the sali-\\ncylates, may cause deafness. It may be an early and premonitory\\nsymptom of typhoid fever, or cerebro-spinal meningitis, and may occur\\nearly or late in the course of mumps. Deafness due to occupation is\\nworthy of mention. It is not uncommon in blacksmiths, boiler-makers,\\nlocomotive engineers, and firemen. In some instances the patients can\\nhear better in the noise incident to their work than when the surround-\\nings are absolutely quiet.\\nHyperesthesia of the Auditory Nerve. Very rarely in cer-\\ntain cases of facial paralysis, and not seldom in hysteria, there is abnor-\\nmal acuteness of hearing (oxyacoia). In some individuals suffering\\nfrom hemicrania or tic douloureux, and in meningitis, the hearing of\\ncertain sounds for example, high musical notes and whistling is\\naccompanied by pain. Nervous patients often complain of subjective\\nnoises, buzzing, roaring, hissing, and singing the so-called tinnitus\\naurium.\\nParalysis of the Auditory Nerve. No case of absolute uni-\\nlateral deafness, due to a focal lesion in a hemisphere, has as yet been\\nobserved. Deafness from disease of the auditory nucleus is very rare.\\nThat due to disease of the peripheral nerve is much more common.\\nWe may have a rheumatic auditory paralysis similar to that of the\\nfacial nerve, or the deafness may be due to pressure from a tumor or\\ninflammatory exudate at the base of the brain, or disease of the mas-\\ntoid process of the temporal bone. The localization of the lesion is\\noften extremely difficult. The only positive point is, that labyrinthine\\ndisease is apt to be accompanied by vertigo while in disease of the\\nnerve-trunk vertigo is absent.\\nMeniere s Disease. Aural Vertigo. We may define vertigo as a\\nsubjective feeling of motion referred by the patient either to his own\\nbody or to surrounding objects, with loss of equilibrium and without\\nunconsciousness.\\nIn this disease, first described by P. Meniere in 1861, there is\\nparoxysmal vertigo (sometimes so sudden and intense as to throw the\\npatient to the ground), tinnitus aurium, nausea, pallor, clammy sweat,\\nand vomiting. The severity of the attacks varies greatly. There may\\nbe momentary unconsciousness. There is sometimes jerking of the\\neyeballs, nystagmus, or diplopia. The disease is paroxysmal in char-\\nacter, but slight vertigo and tinnitus are apt to persist between the", "height": "4416", "width": "2560", "jp2-path": "practicaltreatis00muss_0_0116.jp2"}, "117": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 109\\nattacks. Some deafness is present. The attacks may vary in frequency\\nfrom several in a day to only one in several months.\\nParalyzing Vertigo. Gerlier describes a remarkable form of parox-\\nysmal vertigo accompanied by weakness, paresis in the extremities,\\ndrooping of the eyelids, marked lassitude, and depression without un-\\nconsciousness. It occurs only in men, and is epidemic in the Canton\\nof Geneva.\\nHysterical or functional deafness is recognized by (1) its association\\nwith undoubted symptoms of hysteria (2) its sudden occurrence\\nafter shock, emotional disturbance, or trauma (3) the absence of a\\ncause in the auditory apparatus for the deafness (4) impairment of\\nbone-conduction and aerial conduction to the same degree (5) the\\nfrequent coexistence of anaesthesia of the pinna and external meatus\\n(6) frequently recovery takes place suddenly.\\nHysterical deaf-mutism is a rare condition, characterized by (1) sudden\\norigin (2) absolute aphasia and aphonia (3) absence of signs of paralysis\\nof the lips and tongue and of any paralytic phenomena except hysterical\\nhemiplegia (4) preservation of intellectual faculties and power of\\nwriting (5) frequent coexistence of hysterical stigmata (6) usually\\nrapid recovery.", "height": "4416", "width": "2564", "jp2-path": "practicaltreatis00muss_0_0117.jp2"}, "118": {"fulltext": "CHAPTER IX.\\nTHE DATA OBTAINED BY OBSEBVATION\u00e2\u0080\u0094 Continued).\\nThe extremities hands- The shape temperament occupation claw-hands\\nseal-fin hands rheumatoid arthritis nervous affections spade hands\\nlarge bones of acromegalia osteo- arthropathy wrist-drop. The movements\\nspasm tremor. The skin\u00e2\u0080\u0094 color moisture. Fingers. Heberden s nodosities\\ncontraction of fascia Dupuytren s contraction deviations in shape. The\\nnails. Trophoneuroses cold hands and feet. Raynaud s disease erythro\\nmelalgia.\\nTHE EXTREMITIES.\\nThe Hands.\\nThe Shape. We bear in mind the variation in the form of the\\nhand in different types of individuals the broad and heavy hand of\\nthe sanguine, the slender, dexterous hand of an individual of the nervous\\ntemperament (see Chapter VI.), the large joints of the hand of so-\\ncalled strumous persons, and the effeminate hand of the one who is\\ninclined to tuberculosis, present sharp contrasts. Then, too, the l occu-\\npation hand indicates in a general sense the disease the patient is\\nliable to none more striking than the hand of the miner, the blue-\\nblack dottings of which sharply indicate the possibility of anthracosis.\\nFinally, we note the broad hand and clubbed fingers that are seen in\\ncongenital heart disease. The withered hand of age and wasting of the\\nhands, as in phthisis or malignant disease, need not be referred to, as\\nthey are part of the general process.\\nFig. 13.\\nPseudo-muscular atrophy. Claw-hand\\nPresenting more striking changes in shape are the peculiarly de-\\nformed hands seen in affections of the muscles and joints. These\\ndeformities will be described in the respective sections (Chapters XII..", "height": "4416", "width": "2564", "jp2-path": "practicaltreatis00muss_0_0118.jp2"}, "119": {"fulltext": "THE DATA OBTAINED BY OBSERVATION.\\nIll\\nand XIII.), although in pas\\nm\u00c2\u00a3\\nthey may be grouped together. First\\nwe have the claw-hand of progressive muscular atrophy of innam-\\nFjg. 14.\\nRheumatoid arthritis. The tapering fingers are seen. The phalangeal joints are swollen many\\nare anchylosed. The wrist is stiff. The muscles are atrophied the forearm-muscles much\\nwasted.\\nFig. 15.\\nPhotograph of a case of lead-paralysis affecting the extensor muscles. (Gray.\\nmation of the ulnar and median nerve, and of chronic poliomyelitis\\nthe seal-fin hand of chronic gout and rheumatoid arthritis, spasm\\nof the extensor muscles causing deflection to the ulnar side. The", "height": "4416", "width": "2460", "jp2-path": "practicaltreatis00muss_0_0119.jp2"}, "120": {"fulltext": "112\\nGENERAL DIAGNOSIS.\\ngnarled hand of rheumatoid arthritis and the knotted hand of gout are\\ncharacteristic. In the former the tapering, shining fingers, the bulbous\\nphalangeal joints, the pallid, clammy surface, dotted with freckles, the\\nlocked joints, the atrophied muscles, combined with exquisite tender-\\nness of the involved parts, make a picture never to be forgotten. The\\nFig. 16.\\nExamples of the positions of the fingers in the movements of athetosis. (StrUmpell.)\\npeculiar deformity occurring in scleroderma is described in the chapter\\ndevoted to the skin. Then we have the deformity resulting from\\nflexion of the hand on the forearm, the forearm on the arm as seen in\\ncerebral palsies of children and in the hemiplegias.", "height": "4416", "width": "2544", "jp2-path": "practicaltreatis00muss_0_0120.jp2"}, "121": {"fulltext": "THE DA TA OB TAINED B Y OB SEE VA TION. 1 1 3\\nThe spade-like hands of myxoedema and the enlarged bones of\\nthe hands of acromegalia and pulmonary osteo-arthropathy are described\\nin other sections.\\nDeformities of the hand from other causes than the ones just men-\\ntioned are often observed. Temporary contractures occur in tetany,\\nin temporary hemiplegia or monoplegia, and in paralysis of the exten-\\nsors. Dropping of the hand from the radius toward the ulna occurs in\\nacute poliomyelitis from paralysis of the extensors. Then we have\\nparalysis of the median, ulnar, and other nerves, with their character-\\nistic deformity. (See Nervous Diseases.) So-called wristdrop is seen\\nin peripheral neuritis (musculo-spiral nerve), and may be unilateral or\\nbilateral. The hand hangs from the wrist on account of paralysis of the\\nextensor muscles. Both hands may drop, although it sometimes happens\\nthat one is affected from a few days to a few weeks before the other.\\nJlovements. One can infer the limitation of movements of the hands\\nin the affections described above. The stiffened and immobile hand\\nof chronic rheumatism, in which enlarged joints are prominent, contrast\\nwith the painfully locked hand of rheumatoid arthritis. Involuntary\\nmovements, as tremors and spasms, are also observed. The tremor of\\nage, of hysteria, of paralysis agitans, of exophthalmic goitre, of mer-\\ncurial and other intoxications, and of disseminated sclerosis, is most\\nmarked in the hands. It is in the hands and arms we see that most\\nsignificant tremor or twitching with aimless picking at the bedclothes,\\ndescribed in an account of the typhoid state (Chapter XIV.), known\\nas subsultus tendinum. Twitching and spasm of the hand or arm are\\nseen in convulsive disorders, and may be unilateral or bilateral, as in\\nhysteria, chorea, epilepsy, true and Jacksonian, tetanus, and tetany.\\nWhen permanent, it is seen as an expression of a chronic cerebral\\nprocess, as hydrocephalus. Alternating spasm and relaxation of the\\nfingers, hand, and arm are seen in athetosis.\\nHaving noted the shape and movement of the hand, we direct atten-\\ntion to the skin, the nails, and the fingers.\\nThe Skin.\\nThe skin of the hand need not be considered apart from the skin of\\nthe rest of the body. It is smooth or rough, dry and harsh, moist and\\nwarm, under the same circumstances that affect the skin generally. In\\nrheumatoid arthritis it has been described as peculiar. Both the dorsal\\nsurface and the palm are moist and very soft, and the former is dotted\\nwith freckles. In progressive muscular atrophy and exophthalmic goitre\\nthe skin is moist. The cold, clammy skin of one laboring under excite-\\nment, as may be caused by the first visit to the physician, is well known.\\nColor. The color of the hands is significant of the state of the cir-\\nculation and the condition of the blood. The blue finger-tips and the\\npallid hand accompany similar color changes in the lips, and are early\\nsigns of cyanosis and of anemia.\\nThe swellings of the hand, inflammatory or cedematous, do not differ\\nfrom swellings of the joints or the subcutaneous connective tissues in\\nother portions of the body. Several exceptions are to be noted. First,\\n8", "height": "4416", "width": "2556", "jp2-path": "practicaltreatis00muss_0_0121.jp2"}, "122": {"fulltext": "114\\nGENERAL DIAGNOSIS.\\nFig. 17.\\nthe swelling that attends articular rheumatism with involvement of\\nthe wrist-joint extends over the dorsum of the hand frequently, while\\nthe fingers are free from the process. Second, a localized swelling on\\nthe dorsum of the hand is often due to a ganglion from a local affection\\nof the tendons. Third, Gnbler s tumor is a swelling that is seen in\\nwrist-drop from displacement backward of the carpal bones. Fourth,\\nlong-continued inflammatory swelling, with subsequent rupture of the\\nskin, is seen in mycetoma. Finally, traumatic injuries produce tendo-\\nsynovitis, bone affections, and palmar abscess. Syphilis and gonorrhoea\\nmay be causal factors in the production of such processes, it is impor-\\ntant to remember. (See Chapters X. and XIII.)\\nThe Fingers.\\nIn gout and rheumatism the joints of the fingers are enlarged and\\npainful. The swellings of the joints of each condition cannot well be\\ndistinguished. In gout, tophi, hard, Avhite, sometimes glistening\\nmasses are likely to be present in the joints or along the tendons, on\\naccount of great accumulation of\\nurate of soda. They are more promi-\\nnent on the dorsal surface of the\\n|^L X joints, and sometimes break through\\nmj ^vS ^k. e s m so that the chalk-like\\nconcretion exudes. It was said by\\nSir Thomas Watson that a gouty sub-\\nject under his care used his joints to\\nkeep tally while playing cards.\\nHeberden s Nodes. Haygarth s\\nnodosities. The term end -joint\\narthritis is also applied to this con-\\ndition. This node belongs to the\\nfirst of the three divisions Charcot\\nmakes of rheumatoid arthritis. The\\nnodules develop gradually at the\\nsides of the distal phalanges. The\\nsubject may be in good health, or\\nmay have had attacks of gout, or\\nhave suffered from acid dyspepsia.\\nAt first the joints may be a little\\nswollen and tender. The swelling\\nand tenderness may be periodical,\\nand the size may be increased with\\neach fresh paroxysm. The tubercles\\nare seen at the side of the dorsal\\nsurface of the second phalanx, the\\ncorresponding cartilage becomes soft,\\nthe ends of the bone may be ebur-\\nnatcd. A moderate anchylosis takes place. The nodules are often\\nconsidered of good prognostic omen it is even said that they are a sign\\nof longevity. It is certain that the large joints are rarely involved\\nwhen these nodules are present.\\nHeberden s nodes.", "height": "4416", "width": "2640", "jp2-path": "practicaltreatis00muss_0_0122.jp2"}, "123": {"fulltext": "THE DA TA OB TA I NED B Y OBSER VA TION. 115\\nThe tips of the fingers may be bulbous, or club-shaped, in some cases\\nof phthisis and of other forms of chronic lung disease, and also of\\nchronic heart disease. It is most common, however, in bronchitis and\\nphthisis. The clubbing is associated with changes in the nails (see\\nbelow and illustration of pulmonary osteo-arthropathy).\\nDeviations in Position and Shape. Eversion is characteristic of\\nrheumatoid arthritis, but deviations due to abnormal flexion or exten-\\nsion are the most characteristic. Flexion of the first phalanx of the\\nlittle finger is due to contraction of the palmar fascia or to paralysis of\\nthe common extensor from disease of the musculo-spiral nerve. Con-\\ntraction of the fascia of the hand, causing more or less flexion of the\\nlittle and ring fingers, is frequently seen, and may be an indication of\\ngouty diathesis. It is certain that these contractions are seen in several\\nmembers or generations of a family in which gout is prevalent. It is\\ncalled Dupuytren s contraction.\\nAbnormal extension is usually very marked. Hyper-extension of\\nthe middle phalanx is due to paralysis of the flexor sublimis from\\ndisease of the median nerve hyper-extension of the distal phalanges\\nto paralysis of the flexor profundus muscle from disease of the median\\nand ulnar nerves. Extension of the proximal phalanx, with extreme\\nflexion of the two distal phalanges, contributes to form the claw-\\nhand/ (See Muscles.) Contractions due to chorea or to central\\nlesions, as post-hemiplegic contractions, will be considered under\\nspecial diagnosis. It is thus seen that the peculiar combined exten-\\nsion and flexion, causing abnormal shape of hands and fingers, is due\\nto (1) local joint inflammation (subluxations) (2) local neuritis and\\nparalysis (3) progressive (spinal) muscular atrophy (4) idiopathic\\nmuscular atrophy, rarely.\\nThe Circulation. Raynaud s Disease. Local Asphyxia. The\\nhands or fingers become pale and intensely cold they are the seat of\\nnumbness, and are without sensation. The term i dead fingers\\ngraphically describes the appearance. The pallor usually comes on\\nsuddenly, and continues for a variable period. As the pallor disap-\\npears there is a gradual return of warmth, and the color changes to\\na livid red, dark blue, or even blackish hue. The paroxysms of\\nalternating pallid and livid hue may occur several times in twenty-four\\nhours. In some cases the lividity becomes so intense that gangrene\\nensues in small superficial spots, or even involves the whole finger.\\nPain may or may not be present, and does not increase when the hand\\nhangs down. In my experience it is more frequently present and ex-\\ncruciating at the time the fingers are dead. The tip of the nose\\nand the lobe of the ear may be affected, and occasionally other parts of\\nthe surface. The sensitiveness to touch is markedly lessened. Ray-\\nnaud s disease occurs usually in ill-nourished subjects, or after an acute\\ndisease, as typhoid fever. It may be associated with vascular spasm\\nin internal organs, giving rise to epilepsy, hemoglobinuria, temporary\\naphasia, or hemiplegia. It is usually worse in cold weather.\\nErythromelalgia. Local changes in color are often due to neuritis\\neither of the trunk or of the terminal endings of the nerves. When\\nsuch changes are associated with pain we use the term erythromelalgia.", "height": "4412", "width": "2580", "jp2-path": "practicaltreatis00muss_0_0123.jp2"}, "124": {"fulltext": "116\\nGENERAL DIAGNOSIS.\\nIt is characterized by redness of the surface with increased tempera-\\nture it is usually seen in the extremities and is limited to the distri-\\nbution of the affected nerve. It is worse in summer, increased by\\nartificial heat, and aggravated when the extremity is dependent or\\npressed upon. The redness is attended by burning and extreme local\\ndiscomfort, in which all sorts of sensations are described tearing of\\nthe finger-nails, pulling or pricking of the skin, twistings of thousands\\nof needles, and other forms of torture. I know of no peripheral pain\\nwhich is the source of greater agony.\\nGlossy skin is seen after nerve-injuries and neuritis, and in central\\naffections in which the trophic nerves are involved. The skin is shiny,\\nsmooth, drawn very tightly over the surface, and sometimes atrophied.\\nRed and pale mottling may be seen. The surface is free from hair.\\nBurning pain precedes and accompanies the change. (See Nails.)\\nThe Nails.\\nThe Shape. The appearance of the nails enables us to estimate the\\nduration of certain diseases, or the time when convalescence began it\\nalso indicates local interference with the nutrition of the parts. Thus,\\ncurving of the nails, with the club-shape of the finger-ends, occurs only\\nFig. 18.\\nClubbed fingers with curved nails (middle finger slightly flexed).\\nin chronic diseases, as phthisis or emphysema, or in chronic cardiac\\ndisease and aneurism. In the latter it is sometimes found on one hand\\nonly. It is sometimes seen in other chronic wasting diseases. The\\nnails may curve transversely or longitudinally. When transversely\\nthe appearance is like that of a filbert, and when longitudinally they\\nare said to be incurvated. This change in shape may occur without\\nclubbing of the fingers. The shape is altered in acromegalia and\\npulmonary osteo-arthropathy. (See Chapter XIII.)", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0124.jp2"}, "125": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 117\\nColor. White marks on the surface are usually seen after an illness,\\nand may indicate the date of recovery. The marks develop at the\\nroot of the nail, and as the nail grows the marks approach the tips of\\nthe lingers, and thus their position denotes the time that has elapsed\\nsince convalescence set in. If they are seen half-way up the nails, con-\\nvalescence is probably of three months standing. We get a good idea\\nof the condition of the blood in the capillaries from the appearance of\\nthe tissue under the nails. If there is anaemia, pressure on the finger-\\ntips will drive the blood from the capillaries. Stephen Mackenzie s\\nrule, that if such pressure completely empties the vessels so that they\\nbecome pale, it indicates that the globular richness of the blood is re-\\nduced one-half, is a fair and rapid test of the degree of the anaemia.\\nThe purplish and bluish-black discoloration of cyanosis previously\\nreferred to is first seen under the nails. Sometimes the capillaries\\npulsate, and this pulsation is more visible under the nails than in any\\nother part of the body except the retina. It may occur in aortic\\nregurgitation.\\nNutritive Changes. The nails undergo chronic inflammation with\\ndestruction in various skin affections, and the matrix is the seat of acute\\ninflammation in onychia. Onychia may be simple or syphilitic. Its\\npresence may indicate the organic origin of otherwise obscure nervous\\nsymptoms. It may be only a simple inflammation, or it may result in\\nthe loss of the nail and necrosis of the bone.\\nDeformity of the nails (toe) occurs in acute and chronic myelitis. In\\nlocomotor ataxia the nails fall out.\\nIn neuritis the trophic change is marked the growth is arrested,\\nand the nail becomes dark and brittle and curved in its long axis, while\\nlateral arching takes place. The cutis underneath thickens and the\\nskin at the base retracts. The fingers may be clubbed. When growth\\nis resumed a distinct roughened line of demarcation is seen. In leprous\\nneuritis there is destruction of nails and phalanges. Atrophy and ulcer-\\nation at the base of the nails, followed by necrosis of the phalanges, is\\nseen in so-called Morvan s disease, which is not really a disease but a\\nsymptom of neuritis or syringomyelia. Enlargement with thickening\\nand sometimes twisting occurs after fevers, as typhoid, or in the course\\nof syphilis and in sclerodactyle. The nutrition is changed in Ray-\\nnaud s disease. In some cases the nails become dry, scaly, and cracked,\\nor hypertrophied entirely. In the hemiplegia from cerebral apoplexy\\nthe growth is arrested on the paralyzed side. This is tested by stain-\\ning the nails of the two hands at the same level with nitric acid the\\nrelative position of the stain upon corresponding nails of the two hands\\nwill show whether there has been growth or not. The return of func-\\ntional power is indicated by renewed growth.\\nThe Feet.\\nEnlargement or deformities of the feet and legs may be due to\\nchanges in the joints, the bones, and the subcutaneous connective\\ntissue. Hence we would have swelling due to oedema and myxoedema,\\nand enlargements due to acromegalia and pulmonary osteo-arthropathy.", "height": "4416", "width": "2556", "jp2-path": "practicaltreatis00muss_0_0125.jp2"}, "126": {"fulltext": "118 GENERAL DIAGNOSIS.\\nThe chapters so frequently referred to will contain a discussion of these\\nsubjects, and to the Chapter on Joints must be referred all articular\\nchanges. It must be recalled that pain may be due to flat-foot and to\\nneuralgia of the third interosseous nerve. (See Pain.) Flat-foot must\\nalways be looked for when inability to walk is complained of. Changes\\nin the shape of the foot from muscular affections will be described,\\nbearing in mind that claw-foot is a prototype of claw-hand/ y\\nfound in progressive muscular atrophy and in Friedreich s ataxia.\\nThree nutritional changes take place in the feet that are of diagnos-\\ntic significance perforating ulcer of the foot, a trophic change occur-\\nring in locomotor ataxia gangrene, the result of endarteritis (usually\\nsenile), or occurring in the course of diabetes mellitus mycetoma, or\\nMadura foot. Perforating ulcer usually begins as a blister, then an\\nabscess, and finally an ulcer.\\nThe nails of the feet are subject to the same changes that take place\\nin the nails of the fingers.\\nCold Hands and Feet. Patients frequently complain of coldness\\nof the extremities. It is a common and often serious complaint. It\\nis natural to expect a peripheral coldness when the central organ of\\ncirculation is weakened. Coldness takes place in the final hours pre-\\nceding death. It occurs in collapse, in hemorrhage, and in shock.\\nBut we also see it in organic disease of the heart, with impairment of\\nthe circulation. It is a common vasomotor condition in nervousness,\\nindependent of hysteria. It is a marked feature in NothnageFs angina\\npectoris vaso motoria, as well as in true and false angina pectoris.\\nA visit to a physician, or excitement from any cause, is likely to be\\nattended by coldness of the hands and feet. Under these circum-\\nstances the extremities are often bathed in a cold and clammy perspi-\\nration. In senile endarteritis cold hands and feet frequently occur.\\nThey are an index to the state of the peripheral circulation in other\\nparts of the body, as the brain.\\nThe poisons of gout, of rheumatism, and of other diseases, which irri-\\ntate peripheral and vasomotor nerves, may cause cold hands and feet.\\nIn gastric and intestinal dyspepsia, with the absorption of toxic prin-\\nciples, as leucomaines, this symptom may be present.\\nChanges of sensation in the skin of the extremities will not be con-\\nsidered in this section. They will be taken up in the chapters devoted\\nto the diseases of the nerves. It is sufficient to state that anaesthesia\\nin local areas, and due to causes limited to the skin, is seen in morphoea,\\nin the anaesthetic form of leprosy, and in certain ischsemic states (urti-\\ncaria). It is accompanied by loss of tactile sensibility. Hyperesthesia\\nand parcesthesia occur with various local affections, but they are with-\\nout diagnostic significance except in nervous diseases.", "height": "4416", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0126.jp2"}, "127": {"fulltext": "CHAPTEK X,\\nTHE DATA OBTAINED BY OBSEEVATION\u00e2\u0080\u0094 {Continued).\\nThe skin. The color redness pallor jaundice cyanosis the bronzed skin Addi-\\nson s disease hemochromatosis chloasma tinea versicolor vagabond s dis-\\nease argyria freckles. The nutrition. Moisture and dryness hyperidrosis\\nanhidrosis. Scars Hemorrhages mode of recognition cause significance.\\nEruptions their clinical significance nature of the lesion distribution asso-\\nciate morbid phenomena general symptoms. Table of skin diseases erythema\\nherpes \u00e2\u0080\u0094erythema nodosum urticaria medicinal rashes erythema of infec-\\ntious diseases roseola miliaria or sudamina. General diagnosis.\\nTHE SKIN.\\nColor. The portions exposed to the air exhibit more varied and\\npronounced changes of color than parts that are covered. The changes\\nin color herein described refer more particularly to the face and hands.\\nThe color of other parts partakes of the same tint as that of the face,\\nother things being equal, except that the intensity is less. Comparison\\nof the two should always be made, and the mucous membranes examined,\\nas control observations. For the latter the conjunctiva?, lips, and mouth\\nare sufficient, always remembering the possibility of hyperemia of the\\nconjunctiva from other causes.\\nLocal color changes of the face will be particularized in this section.\\nIt is not to be forgotten that the color varies with the type whether\\nblonde or brunette and that variations in the latter at times easily\\nescape recognition.\\nThe skin in a healthy child is of a faint pink color as age advances\\nit loses its fresh appearance and becomes paler, except in those whose\\noccupation exposes them to atmospheric influences. In the latter, the\\nskin becomes weather-stained, and may assume a mahogany or reddish-\\nbrown hue. In old age, the color is apt to deepen and become duller,\\nwhile the loss of subcutaneous fat allows the skin to lie in folds, espe-\\ncially about the jaws and neck, and wrinkles are marked, especially\\nbetween the eyebrows, over the nose, and at the angles of the eyes and\\nmouth.\\nApart from these changes, which are physiological or necessarily the\\nresult of occupation, the skin exhibits changes which are the result of\\nthe habits or health of the individual. Some persons, especially if\\nblondes, retain to old age the fresh, pink skin of childhood. In others\\nis seen early a dull, muddy complexion. This is common in those\\nwho use coffee to excess and are habitually constipated. In others\\ndigestive derangements, particularly constipation, uterine disorders, or\\ngouty derangements produce, in addition to a muddy complexion, crops\\nof acne and comedones, or black-heads. It must be admitted, however,", "height": "4416", "width": "2564", "jp2-path": "practicaltreatis00muss_0_0127.jp2"}, "128": {"fulltext": "120 GENERAL DIAGNOSIS.\\nthat some persons preserve a fresh complexion in spite of marked\\ndigestive disturbance. Considerable congestion of the superficial blood-\\nvessels, giving a person a florid appearance, may be due, especially in\\na young person, to alcoholic excesses and there is a popular belief\\nwhich connects such an appearance, when coupled with a tuberous nose\\nand a crop of angry-looking pustules, with a prolonged use of spirits.\\nThe sebaceous glands of the skin of the face merit but a passing\\nnotice. Deficiencies or excesses of secretion, or alteration of it, are\\nusually due to local causes. Excessive secretion of sebaceous matter,\\nknown as seborrhoea, or steatorrhea, is seen in two forms. First, with\\noily exudation second, with drying of the secretion and the formation\\nof crusts. It may be more pronounced in strumous subjects. The\\nopposite condition, or asteatodes, is seen in wasting diseases, particularly\\ndiabetes, and in xeroderma and ichthyosis.\\nColor Increased. The Abnormally Red Skin. Physiological\\nhyperemia has been spoken of. The color is intensified when the\\ncapillaries are overfilled or the blood-current is unusually rapid. The\\nhyperemia may be general or local, and is due to dilatation of the capil-\\nlaries, possibly from nerve-influences. General hyperemia is seen in\\nfever, in poisoning from atropine, and from organic poisons derived\\nfrom food or the result of intestinal putrefaction.\\nLocal hyperemia attends the phenomena of blushing, and comes and\\ngoes in nervous persons with every psychical impression. Rarely in\\nneurasthenics the hyperemias may be extreme, amounting almost to an\\nerythromelalgia. Abnormal redness may be diffused over the whole\\nface or may present the circumscribed flush of phthisis the local deep-\\nred area, on one cheek, of pneumonia the evanescent flush of anemia,\\nwith cardiac palpitation and the creeping flush, with raised border, of\\nerysipelas, appearing on the bridge of the nose or at the nostril. In\\nphthisis, moderate excitement or exertion, the taking of food, or the\\nonset of fever, tinges the cheek with the blush of hectic. In migraine,\\nthe burning flesh may be limited to one side. Capillary congestion on\\nthe cheeks or on the tip of the nose occurs with the endarteritis of the\\naged, but is seen also in early life in cases of hepatic cirrhosis or of\\nobstruction of the hepatic circulation from other causes.\\nColor Lessened. It is caused by diminution of the amount of\\nblood in the capillaries, or because its richness in haemoglobin has been\\nreduced.\\nPallor. Diminished amount of blood in the capillaries occurs\\nfrom active contraction or spasm of the arterioles, from hemorrhage,\\nor from weak heart. The pallor, therefore, is usually acute or tem-\\nporary, and may be recurrent. It attends fright, syncope, or nausea\\nand vomiting. It occurs also in acute poisoning, in acute disease, such\\nas diphtheria, and in hemorrhage. The pallor due to loss of blood\\nmay be instantaneous if the hemorrhage is sudden and large, or develop\\ngradually if it is small and continued over a long period. The onset\\nof sudden pallor is of diagnostic significance in diseases in which hem-\\norrhage may occur, as in aneurism, gastric or intestinal ulcer, and\\ntyphoid fever. Symptoms of collapse are seen with this form of\\npallor.", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0128.jp2"}, "129": {"fulltext": "THE DA TA OB TA IN ED B Y OB SEE VA TION. 1 2 1\\nPallor of long duration, or chronic pallor, if we may so term it, is\\nseen in a number of diseases. In all of them there are diminution in\\nthe amount of red corpuscles and destruction of the haemoglobin. It\\nis characteristic of blood affections, as the various forms of anaemia. It\\ndoes not necessarily occur in leucaemia indeed, the cheeks and lips\\nmay be red. It is seen, in a striking form, in chronic Bright s disease,\\nin cancer, in chronic poisoning, as from lead or arsenic, in chronic\\ncatarrh of the stomach or of the bowels, and in chronic infectious pro-\\ncesses, as tuberculosis and syphilis.\\nWhile paleness is recognized as the fundamental or prevailing color\\nof the skin in many of the above-noted affections, a further tinge gives a\\ncharacteristic hue to the skin thus, in chlorosis there is a greenish\\nappearance of the face, which is in striking contrast to the pearly col-\\nored conjunctivas. In carcinoma the yelloimsh tinge of the pallor often\\ncauses it to be mistaken for jaundice. In pernicious anmnia a straic-\\ncolored appearance of the skin has been frequently described, which\\nmay cause it to be mistaken for carcinoma. It is worthy of remark\\nthat the cachectic pallor in carcinoma is not likely to occur unless\\nthere are primary or secondary deposits in the gastro-intestinal tract or\\nthe liver, and it is well known that pernicious anaemia is usually sec-\\nondary to gastric or hepatic disorder. The peculiar hue of the pallor,\\ntherefore, may be due to a common cause in these affections. The\\npallor that attends Bright* s disease is usually associated with slight\\npuffiness under the eyelids, or local dropsical accumulations elsewhere.\\nIn chronic poisoning with lead pallor is associated with a blue line\\nupon the gums and drop-wrist while in arsenical poisoning there are\\nfrequently associated a puffiness of the eyelids and looseness of the\\nbowels.\\nIt is not well to lay much stress upon the variations in hue of the\\npallor. They are not of diagnostic importance in themselves, but only\\nwhen associated with the characteristic symptoms and signs of the\\nrespective affections in which this hue occurs.\\nIt must not be forgotten that there are a large number of individuals\\nin whom pallor is the normal condition. This is particularly the case\\nwith those who lead a sedentary life and are confined within doors.\\nThere are a number of occupations which predispose to pallor.\\nAbnormal Color. I. The Yellow Skin. Jaundice. The yel-\\nlow coloration is seen not only in the skin but in the sclerae (see the\\nEye) and the mucous membranes. The discoloration of the skin is not\\ndifficult of recognition. It varies in shades from a slight yellow hue to\\nyellow-green or olive-green, and in many forms of jaundice to brownish-\\nyellow. The yellow hue of the skin in jaundice may be preceded and\\nis always accompanied by tingeing of the conjunctivae its presence in\\nthis situation confirms the observation. The mucous membrane under\\nthe tongue early gives evidence of jaundice or, if the lips are everted\\nand a glass slide pressed evenly on the surface, the yellow discoloration\\nof the mucous membrane will shine through.\\nThe yellow tint of the conjunctivae must not be confounded with the\\nsame color due to subconjunctival fat. The latter is not uniform in the\\nconjunctivae, but may occupy cone-shaped areas.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0129.jp2"}, "130": {"fulltext": "122 GENERAL DIAGNOSIS.\\nThe physiological yellow color of the skin that is seen in infants\\nshortly after birth is not a true jaundice, but in all probability arises\\nfrom excessive destruction of red corpuscles in the over-congested\\nskin. On light pressure with the finger the color changes. It\\nfades from shades of yellow into the genuine flesh-color. The con-\\njunctivae are natural, and the urine is free from bile-pigment.\\nThe faeces are normal. By these symptoms a distinction can be\\nmade.\\nJaundice is a symptom due to a number of diseases. In the first\\nplace, it is most frequently due to disease of the liver this form is\\nknown as hepatogenous jaundice. It may possibly be due to destruc-\\ntion of the corpuscles of the blood and liberation of the haemoglobin,\\nthe so-called hcematogenous jaundice. The various causes of the former\\nwill be considered under diseases of the liver. The latter is said, not\\nwithout objection, to be due to destructive agencies in the blood, such\\nas ptomaines, which are absorbed in gastro-mtestinal disease, or to\\npoisons that develop in the course of pyaemia, yellow fever, malarial\\nand relapsing fevers it may also be due to snake-bite or to poisons that\\nare imported, as in mineral poisonings, or chloroform, ether, or chloral.\\nIn both instances the yellow coloration of the skin is due to coloring-\\nmatter of the bile or of the blood, or bilirubin, which is deposited in\\nthe cells of the rete mucosum.\\nOther symptoms due to the same cause are associated with hepato-\\ngenous jaundice. Their presence may be of diagnostic value in deter-\\nmining the nature of the yellow color of the skin in cases of doubt.\\nThese symptoms are (1) Itching. This symptom is intolerable the\\nsurface of the body is often seen to be covered with scratch-marks on\\naccount of the irritation of the peripheral ends of the nerves in the skin\\nby bile-pigment. (2) Slow pulse. Slowness of the pulse also fre-\\nquently attends jaundice. (3) Secretions and excretions. The saliva,\\nor expectoration, if present, is bile-tinged, and the urine is dark col-\\nored, due to the presence of the pigment. (See Urine.) While the\\nexcretions are all tinged with bile in the hepatogenous form, the faeces\\nare free from bile, hence they are pale or of an ashy color. On account\\nof the absence of bile in the intestines its physiological effects are lost,\\nand therefore flatulency from fermentation becomes an important\\nsymptom.\\nII. The Blue Skin. Cyanosis. This peculiar hue is recognized\\nwithout difficulty. The bluish or bluish-red appearance of the skin is\\nfirst seen at points furthest from the central organ of circulation, as in\\nthe extremities. The mucous membranes, in which the capillary cir-\\nculation is readily seen, also exhibit the change early. It is early seen\\nalso in the finger-tips, particularly underneath the nails, about the\\nphalangeal joints, and in the lips. Subsequently the entire surface of\\nthe skin may become dusky or cyanosed, as its cause increases in\\ndegree. Its onset, it is said, can be anticipated by the state of the\\nveins on the under part of the tongue overfilling or extreme disten-\\ntion of these vessels always occurs in cyanosis. At first the color,\\nwherever situated, usually disappears on pressure, but as the hue\\ndeepens it remains in spite of pressure.", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0130.jp2"}, "131": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 123\\nCauses. Cyanosis is (1) respiratory, due to overfilling of the veins\\nand capillaries with blood not sufficiently oxygenated, or (2) vascular,\\nto an excess of venous blood, oxygenation not being interfered with.\\n1. Respieatoey. All conditions which interfere with the aeration\\nof the blood cause more or less cyanosis. Practically sufficient air\\ncannot get to the blood, or sufficient blood to the air. Obstruction of\\nthe air-passages, diminution of respiratory area, and diminished or in-\\nefficient respiratory movements prevent oxygen getting into the blood\\ninterference with the circulation in the lungs prevents the blood getting\\nair. Both causes are often combined.\\na. Obsteuction of the Aib-passages. This may occur in the\\nupper respiratory tract, or in the capillary bronchi. (1) Fauckd ob-\\nstruction, by pharyngeal abscess or tonsillitis, or, in rare cases, by\\ndiphtheria, causes moderate cyanosis. (2) Obstructive laryngeal dis-\\neases produce cyanosis varying in degree with the amount of obstruc-\\ntion and its persistence. The cyanosis is of short duration in spasmodic\\ncroup and in laryngismus stridulus it is prolonged in the more per-\\nsistent inflammatory affections. Its gradual onset, in moderate degree,\\nas seen by the purple lips or dusky finger-tips, is of serious prognostic\\nimport in the course of tuberculous laryngitis even if symptoms of\\ngrave obstruction have not arisen. (3) Tumors, pressing on the trachea\\nor bronchi, narrowing the air-channel, cause cyanosis. The tumors\\nmay be situated in the neck, as the thyroid gland, or within the medi-\\nastinum. (4) Spasm of the bronchi, as in asthma, occlusion of the\\nbronchioles, as in bronchitis, both acute and chronic, and particularly\\nthe grave forms of capillary bronchitis in childhood, cause cyanosis.\\n(5) Foreign bodies anywhere in the upper regions of the respiratory\\ntract are fruitful sources of cyanosis.\\nb. Diminution of the Respieatoey Aeea. Cyanosis from this\\ncause occurs in pneumonia, in cedema of the lungs, in tuberculosis, and\\nin all forms of pleural effusion and of intrathoracic tumors compressing\\nthe lung. It is an important diagnostic feature of acute tuberculosis.\\nc. Diminished oe Insufficient Respieatoey Movements. De-\\nficient chest-expansion, because the action of the respiratory muscles is\\ninterfered with, lessens the respiratory area. This interference may\\nbe either on account of muscular or pleuritic pain, on account of paraly-\\nsis, or, in the case of the diaphragm, on account of upward pressure by\\naccumulations in the abdominal cavity, as large peritoneal effusions, an\\nenlarged liver or spleen, or an abdominal tumor. In bulbar paralysis\\nand peripheral neuritis, in paralysis of the diaphragm, and in spasm of\\nthe muscles of respiration (as in tetanus) there is diminished respira-\\ntory movement. In forms of progressive muscular atrophy and in other\\nrare affections of the muscles, as trichinosis, cyanosis is also observed\\nfor the same reasons.\\nd. Obsteuction of the Pulmonary Vessels. Interference with\\nthe circulation within the lungs, from pressure on the pulmonary artery\\nor vein by aneurism or mediastinal tumor, or from disease of the heart\\nitself, is a most frequent cause of cyanosis. In affections of the heart it is\\nnot seen until in the case of valvular disease, for instance compensa-\\ntion is lost and the right heart is dilated, causing an accumulation of", "height": "4416", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0131.jp2"}, "132": {"fulltext": "124 GENERAL DIAGNOSIS.\\nblood in the lungs. In the latter condition the bronchitis of passive con-\\ngestion of the mucous membrane is an additional cause for the cyanosis.\\n2. Cardiovascular. Obstruction to the flow of venous blood\\nanywhere in the circulation will lead to the development of cyanosis.\\nThis is the cyanosis of passive congestion. Cyanosis due to causes\\nmentioned above is always general. Cyanosis arising from the causes\\nindicated in this section may be general or local, depending upon the\\nseat of obstruction. General cyanosis may occur in (1) congenital\\nheart disease (2) in valvulitis, when compensation is lost and dila-\\ntation has taken place (3) in incompetency of the valves from\\ndilatation (4) in weak heart or enfeebled action from pericardial\\neffusion. In congenital heart disease the cyanosis is so great and so\\npersistent that the affection has been termed blue disease or morbus\\nCQ3ruleus.\\nLocal cyanosis is seen when there is obstruction of the venous trunks\\nfrom external pressure, or from disease of the venous wall, causing\\nthrombosis. It may be limited to the head and upper extremities, in\\nobstruction of the descending cava by tumor or aneurism, or to the\\nlower portion of the trunk and the lower extremities in obstruction of\\nthe ascending cava by pressure from tumors within the abdomen and\\nthorax. One extremity may be the seat of local venous stasis from\\npressure upon the veins, or its occlusion by thrombosis the arm in\\ncases of cancer of the breast and axillary glands, the leg in cases of\\nfemoral phlebitis, represent typical forms of venous stasis. A striking\\nform is due to causes affecting the vasomotor nerves, giving rise to\\nperipheral capillary spasm. (See under Fingers, Kaynaud s Disease.)\\nIII. The Bronzed Skin. Pigmentation. Addison s Disease. The\\nmost marked form of bronzing is seen in Addison s disease an affec-\\ntion characterized by a gradual loss of strength without much loss of\\nflesh by gastric uneasiness and occasional vomiting feeble circula-\\ntion, and a bronze hue of the skin.\\nSocial History. The disease occurs most frequently during the active\\nperiod of life, from the age of twenty to forty years, and nearly twice\\nas often in males as in females.\\nAsthenia. The disease begins insidiously with gradual and progres-\\nsive loss of strength. It becomes evident from the patient s languor,\\nweariness on slight exertion, and inaptitude for mental effort that he\\nis suffering with some exhausting disease. The most characteristic\\nsymptom is the extreme prostration without any obvious cause. Any\\nexertion requires great effort and may induce fainting.\\nGastric Symptoms. The appetite is impaired or lost, there is more\\nor less discomfort at the epigastrium, and occasional vomiting.\\nPerhaps at this time a close inspection may show some discoloration\\nof the skin, but usually this appears later. By degrees the gastric\\nsymptoms become more prominent, and vomiting may be so frequent\\nas to shorten life materially. Finally, the patient is unable to leave\\nthe bed. Dull pains in the head, back, and abdomen are not uncom-\\nmon neuralgic pains in the limbs may be complained of and Osier\\nstates that there is tenderness on pressure in the lumbar region in a\\nconsiderable proportion of cases.", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0132.jp2"}, "133": {"fulltext": "", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0133.jp2"}, "134": {"fulltext": "PLATE II\\nAddison s Disease, Showing Bronzing of Skin, and White\\nAreas of Atrophy. (Coleman.)", "height": "4416", "width": "2704", "jp2-path": "practicaltreatis00muss_0_0134.jp2"}, "135": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 125\\nThe pulse is extremely small and feeble in the later stages it may\\nbe absent at the wrist.\\nBronzing. The discoloration of the skin is the most striking symp-\\ntom of the disease when it is well marked. The external surfaces are\\nchanged in hue, and delicate portions of the skin underneath the cloth-\\ning are also bronzed. The discoloration is not removed by pressure.\\nThe areas are irregular in shape. The skin is soft and pliable. The\\npigment which causes the discoloration is deposited in the rete Mal-\\npighia.\\nThe pigmentation is never seen in the cornea or in the nails. The\\naxilla, the flexure of joints, the median line, the areola about the nipple\\nand other normal areas of pigment deposit are the common sites.\\nBronzed areas in sharply circumscribed patches are also seen in the\\nmucous membrane of the lips and cheeks.\\nSometimes the whole body becomes of a walnut-juice color, a bronz-\\ning which is deeper in exposed surfaces. At times only portions of\\nthe body are discolored, in which case the dark hue shades off grad-\\nually into the normal hue of the skin. Wilks 1 states that in all the\\ncases which he has seen the scalp, finger-nails, soles of the feet, and\\npalms of the hands escaped pigmentation.\\nNevertheless, discoloration of the skin is not an essential symptom\\nof the disease in some cases it is entirely absent. These cases, espe-\\ncially if associated with much vomiting, run a more acute course than\\nthe others, lasting only a few weeks. Such cases have been mistaken\\nfor typhus fever.\\nOn the other hand, diseases of the suprarenal capsules not usually\\nassociated with the Addison symptom-complex, as carcinoma, are\\nattended by pigmentation. In about an equal proportion of cases it\\nis absent, however.\\nThe discoloration of the skin in Addison s disease must not be con-\\nfounded with that of sunburn. The latter discoloration is limited to\\nparts that are exposed to the sun, is more uniform, and the mucous\\nmembranes are free. Moreover, the ansemia and debility of Addison s\\ndisease do not attend it. The pigmented areas in the mucous mem-\\nbrane of the mouth, seen in a certain class of negroes, must not be\\nmistaken for the pigmentation of Addison s disease. (See Plate II.)\\nIn persons living in filth general discoloration of the skin takes place,\\nknown as vagabond s disease but because it is so general and the\\nskin is rough and thickened, and other evidences of filth are seen, it\\ncan easily be recognized. In the latter stages of jaundice the dark-\\ngreen, olive, or black hue of the skin might be taken for the general\\nbronzing of Addison s disease. The appearance of the conjunctiva is\\nsufficient to indicate the cause of the bronzing. In certain cases of\\ntuberculous peritonitis, even if the adrenals are not involved, the pecu-\\nliar brown discoloration which simulates Addison s disease is present.\\nIn scleroderma pigmentation occurs, although rarely.\\nThe pigmentation that occurs in uterine disease or in pregnancy (uterine\\nchloasma) resembles the bronzing of Addison s disease. It is usually\\n1 Keynolds System of Medicine, Philadelphia, 1880, iii. 561.", "height": "4412", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0135.jp2"}, "136": {"fulltext": "126 GENERAL DIAGNOSIS.\\nconfined to the forehead and cheeks and the normal pigmentary areas of*\\nthe skin. The mucous membranes are not affected, although in pregnancy\\nthere may be the characteristic change of the vaginal mucous membrane.\\nThe vomiting and weakness that attend pregnancy may sometimes lead\\nto confusion vomiting is early, pigmentation late in pregnancy.\\nThe affections just described must not be confounded with the dis-\\ncoloration yellowish-brown in hue of tinea versicolor, a parasitic skin\\ndisease. The latter is recognized by its color and irregular dissemina-\\ntion. It especially occupies the chest and spreads to the abdomen. It\\nrarely ascends above the neck. It does not usually, therefore, occur\\nin parts exposed to the air, or in parts that are the seat of normal pig-\\nmentation. Then, again, the surface desquamates in brownish scales.\\nExamination of the scales in a drop of dilute liquor potassse, under the\\nmicroscope, shows both spores and mycelium. The spores are of the\\nfungus micro-sporon furfur. Another skin affection is attended by\\nbronzing leukoderma. In diabetes bronzing is often seen independently\\nof any parasitic invasion of the skin, and apparently the result of the\\ncachexia. It is possible that it is due to the cirrhosis of the liver\\nwhich causes the glycosuria. But if the pancreas is primarily at\\nfault the skin change is more likely to occur. In certain forms of\\nhepatic cirrhosis, as so-called Hanot s, or the hypertrophic form,\\nbronzing, undoubtedly the result of blood destruction, hcemochroma-\\ntosis, is seen in rare instances.\\nAt times the bronzing and other characteristic symptoms of Addi-\\nson s disease are associated with tuberculosis in other organs. Con-\\nversely, in cases of phthisis in which there is bronzing, tuberculous\\ndisease of the suprarenal capsules may be suspected, and it adds to the\\ngravity of the prognosis.\\nArgyria. If nitrate of silver is administered over a long period of\\ntime, fine black particles of the metal or of the albuminate are deposited\\nin the kidneys, the intestines, and the skin. The corium is the principal\\nseat of the deposition. The discoloration of the skin is gray or gray-\\nish-black. It is not changed by pressure, and is usually limited to the\\nface and hands. Small specks may also be noted in the mucous mem-\\nbrane of the mouth. The cornea and nails are not affected. Persons\\nare usually in good health, although the presence of the skin-change, if\\nseen in a patient with coma, would point to the possible presence of\\nepilepsy, on account of which the drug had been taken.\\nFreckles. Freckles are not usually of special diagnostic significance.\\nTheir occurrence in an unusual degree on the back of the hand and\\nforearm has been observed, however, in cases of rheumatoid arthritis.\\nHemorrhages.\\nHemorrhages in the skin are called, according to their size, petechia^\\necchymoses, vibices, and hcematomata. The petechia? and ecchymoses are\\napt to appear in the hair follicles, and vary in size from a pin-point to\\na split pea.\\nMode of Recognition. They must be distinguished from erythe-\\nmatous and other eruptions. They may be raised above the surface of", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0136.jp2"}, "137": {"fulltext": "THE DA TA OB TAIN ED B Y OBSER VA TION. 127\\nthe skin they do not disappear upon pressure, and vary in hue from\\ndeep red to yellow-brown, according to their depth beneath the surface\\nand to the degree of absorption that has taken place since the hemor-\\nrhage occurred.\\nVierordt advises the following test to distinguish them from erythe-\\nmas Press a piece of glass (a microscope slide) upon the suspected\\nspot. A hemorrhage is rendered more distinct, while the surrounding\\npart becomes more anaemic. An inflammatory hyperemia, on the\\nother hand, disappears.\\nCause. Hemorrhages may be due to affections of the blood or dis-\\nease of the bloodvessels. They occur in the course of blood diseases,\\nbecause such change in the quality of the blood takes place that permits\\ndiapedesis more readily. They are more particularly, but not exclu-\\nsively, seen in dependent parts, especially in the lower extremities.\\nSignificance. While subcutaneous hemorrhages are easily recog-\\nnized, their diagnostic significance is more difficult to determine, and\\nmust depend upon the phenomena with which they are associated.\\nMoreover, the situation of the hemorrhage is in a measure an index of\\nits causal origin thus hemorrhages about joints are usually purpuric\\nor hemophilic.\\n1. Hemorrhage with Fever. Subcutaneous hemorrhages in the\\ninfections are due to changes in the quality of the blood, and indicate\\nthe severity of the infection, or to obstruction of the bloodvessels with\\nemboli. To the former class belong cerebrospinal fever and measles,\\nvariola, and scarlatina. In the exanthemata they precede, develop with,\\nor even replace the characteristic eruption, the latter being darker in\\ncolor than normal. Hemorrhages will probably take place at the same\\ntime from the mucous membranes perhaps the nares will be occluded,\\nand the mouth and fauces filled with clotted blood. In milder infections\\nsordes collect in the mouth only. They indicate the degree of malignancy\\nof these affections. To the same class of affections belong epidemic\\nhemoglobinuria and morbus maculosus neonatorum, diseases of newborn\\ninfants but little understood, although no doubt of an infectious nature.\\nTo these may be added the severe forms of purpura hemorrhagica,\\nattended by fever, marked visceral disturbances, skin eruptions, and\\ngreat oedema.\\nHemorrhages due to obstruction of the vessels are known as hemor-\\nrhagic infarcts, and are seen in pyaemia, and ulcerative endocarditis. The\\nhemorrhages are small, sometimes elevated, more abundant on the\\nextremities, but distributed over the trunk they are seen as small\\nareas in the mucous membranes, observed in the conjunctivae, and, on\\nophthalmoscopic examination, in the retina. The association of chill,\\nfever, and sweat, the presence of pus in some structures of the body,\\nand the characteristic joint affections point to pyaemia. On the other\\nhand, if due to ulcerative endocarditis, the physical signs of this affec-\\ntion render the recognition of the cause of the hemorrhage clear.\\nFinally, in rheumatic fever with involvement of the joints we have the\\noccurrence of purpura. (See Erythema, same chapter.)\\n2. Hemorrhage with Anaemia. Hemorrhages occur in all forms\\nof anaemia attended by debility. In idiopathic or pernicious ansemia", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0137.jp2"}, "138": {"fulltext": "128 GENERAL DIAGNOSIS.\\nthey are usually small, but may become extensive. They occur on the\\nextremities, and, usually, on the dorsum of the feet or hands. There\\nmay also be retinal hemorrhages. They are also seen in the secondary\\nanaemias that arise in the later stages of tuberculosis and of carcinoma,\\nparticularly of the stomach in the later stages of Bright s disease, and\\nof cirrhosis of the liver.\\nScurvy is an affection characterized by anaemia, debility, and wasting,\\nin which there are hemorrhages under the skin as well as from the\\nmucous surfaces. The gums are particularly affected. They bleed\\neasily. Hemorrhages also occur in the deep lymphatic spaces, in the\\nmuscles, underneath the periosteum, and in the joints. In scurvy-\\nrickets similar hemorrhages are seen. (See Chapter XIII.)\\n3. Purpura. Primary purpura occurs without any known cause.\\nIt has been divided, for convenience, into simple and hemorrhagic\\npurpura, though the two probably differ only in intensity.\\nSecondary purpura occurs in connection with a variety of febrile and\\nconstitutional diseases 1. Scurvy. 2. Haemophilia. 3. Hodgkin s\\ndisease. 4. Splenic leucocythaemia. 5. Pernicious anaemia. 6. Chronic\\nlesions of the kidney and liver, with or without jaundice. 7. Ulcera-\\ntive endocarditis. 8. Malignant sarcomata. 9. Infectious diseases.\\nA. In simple purpura the hemorrhages are limited to the skin.\\nThey consist of 1. Bright-red spots, varying in size from a pin-\\nhead to a silver three-cent piece. These spots are under the skin\\nand are unaffected by pressure. They fade gradually from red to\\nyellow and disappear. 2. Larger spots or streaks called vibices. 3.\\nEcchymoses.\\nThe disease is said to be most common about the age of puberty.\\nIt may come on in the midst of apparent health, or it may follow an\\nillness, as typhoid fever.\\nPurpura occurs especially upon the legs, the standing position seem-\\ning to favor its occurrence. It comes on in successive crops. Some-\\ntimes large blebs, filled with thin blood, form under the skin, and\\ngangrene at times occurs.\\nB. In the hemorrhagic form 1 hemorrhages occur from the nose,\\nstomach, bowels, vagina, and bronchi, or into the kidney or other\\nviscus. Cutaneous and submucous hemorrhages also occur.\\nThe onset of these cases is sudden, though there may be a day or\\ntwo of depression, lassitude, headache, and nausea. The first symptom\\nnoticed is generally fever, which is apt to be moderate, then eruption\\nupon the skin is detected, and for a day or two the patient may seem\\nto be only slightly ailing. Copious epistaxis may now occur, or a\\nhaematemesis or haematuria, or all of these and other hemorrhages, may\\noccur the same day. The temperature may be only moderately raised,\\nor it may reach 104\u00c2\u00b0 to 105\u00c2\u00b0, or even a higher point. The pulse at\\nfirst is frequent (120 to 140), but of good volume and tension. Subse-\\nquently, in unfavorable cases, it becomes thready and very frequent.\\nRespiration is not affected, and the mind is clear the face is pale and\\n1 See Grave Forms of Purpura Hemorrhagica. Musser: Trans. Association of\\nAmerican Physicians, vol. vi.", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0138.jp2"}, "139": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 129\\nanxious. Hemorrhage may also occur into the choroid and brain-\\nsubstance, with blindness and paralysis as sequels. It may also occur\\ninto the uvula or tonsil.\\nThe subjective symptoms are pains in the loins, limbs, epigastrium, or\\nchest. Often these pains announce a fresh hemorrhage, as into the\\nkidney, or a fresh crop of purpuric spots. The degree of ansemia\\ndepends upon the copiousness of the hemorrhage and the length of time\\nthe disease lasts. Sometimes the hemorrhages cause great exhaustion,\\nwith a tendency to collapse.\\nThe urine, in the case of hemorrhage into the kidney, of course\\ncontains blood sometimes casts are also found.\\nC. Another variety of purpura is known as peliosis rheumatica, the\\npeculiar features of which are tender and swollen joints, oedema of the\\nsubcutaneous cellular tissue, and purpura associated with urticarial\\nwheals and intense itching (purpura urticans). The subcutaneous\\nhemorrhages consist of petechia?, vibices, and ecchymoses. There may\\nbe such large hemorrhages into the penis, scrotum, and uvula as to\\nresult in gangrene and slow separation of the dead tissue by ulceration.\\nEpistaxis may occur, but copious hemorrhages from the stomach, the\\nbowel, or into the kidney or other organs are rare. Endocarditis and\\npericarditis occur as complications in some cases. The duration is\\napt to be long, convalescence being delayed by repeated outbreaks of\\npurpura with multiple arthritic symptoms and oedema.\\nDiagnosis. It is distinguished from scurvy by the absence of ante-\\ncedent debility and ansemia, of spongy gums, of brawny induration in\\nthe limbs, and by the fact that the hemorrhages do not usually occur\\naround a hair follicle. In scurvy there is a history of deprivation of\\nvegetable food, whereas purpura may occur in the midst of robust\\nhealth. As a rule, the cutaneous hemorrhages are larger in scurvy\\nthan in purpura.\\nIt is distinguished from acute infectious diseases, particularly typhus,\\ncerebro-spinal fever, and smallpox, by the absence of severe constitu-\\ntional symptoms which characterize the graver forms of these diseases\\nin which alone a purpuric eruption is likely to be severe enough to\\ncause doubt. Hemorrhages from mucous surfaces are rare in the\\nlatter.\\nHaemophilia is distinguished by the history the patient gives of being\\na bleeder by heredity, and the fact that the bleeding has been started\\nby some injury, wound, or operation.\\nIt is distinguished from the hemorrhages of leukwmia by the absence\\nof enlarged spleen and liver, and by the fact that there is no excess of\\nleucocytes in the blood.\\nMalignant sarcoma causing hemorrhages is recognized by the pre-\\nvious history of anaemia and cachexia, anol by the detection of primary\\nor secondary growths.\\nIt must not be confoundeol with Raynaud s disease, a vasomotor\\naffection characterized by local syncope, local asphyxia, and gangrene.\\n4. Haemophilia. The diagnostic significance of subcutaneous hemor-\\nrhage is clearer when associated with profuse hemorrhages in other\\nportions of the body, and when there is also a history of the occur-\\n9", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0139.jp2"}, "140": {"fulltext": "130 GENERAL DIAGNOSIS.\\nrence of such hemorrhages in the family. Haemophilia is a constitu-\\ntional affection characterized by bleeding, which is spontaneous or\\noccurs upon slight injury. It is nearly always hereditary, but may\\narise de novo.\\nMales are very much more liable to it than females, the ratio being\\nabout 11 to 1. This curious disposition to bleeding maybe transmitted\\nfor generations, and almost always to the males through the female\\nmembers of the family that is to say, the daughter of a bleeder is not\\nusually affected, but she transmits the tendency to her sons, who\\nbecome bleeders so, too, the granddaughters are not bleeders, but they\\nin turn transmit the disposition to their male offspring. It generally\\nshows itself early in life, usually before the end of the second year, and\\nalmost invariably by puberty.\\nThe affection usually first declares itself by the occurrence of a hem-\\norrhage, either spontaneous or the result of slight injury, the bleeding\\nbeing far more profuse than would be natural, and in some cases abso-\\nlutely uncontrollable.\\nLegg 1 has divided haemophilia into three degrees, according to the\\nseverity of the symptoms. The first is characterized by external and\\ninternal bleedings of every kind, and by joint-affections the second,\\nby spontaneous hemorrhages from mucous membranes, but no trau-\\nmatic bleeding or ecchymoses, and no joint-affections the third, by a\\ntendency simply to ecchymoses. The first form is seen most fre-\\nquently in men the second most frequently in women and the third\\nin either sex.\\nThe most frequent seat of hemorrhage is the nose, and the next the\\ngastro-intestinal tract. The bleeding is from the capillaries it may\\nprove fatal in a few hours, or last for days and weeks with final recov-\\nery. Intense ansemia follows the prolonged hemorrhage, but the blood\\nis replaced with remarkable rapidity. All operations, even the most\\ntrivial, are extremely dangerous in bleeders. Circumcision, extraction\\nof teeth, and leeching are credited with the most deaths by Grandidier.\\nJoint-symptoms are very common. The knees, elbows, ankles, and\\nshoulders are the ones most frequently involved. The attack may be\\nmarked by pain, redness, swelling, inflammation, and fever or fever\\nmay be absent or pain alone may be complained of. The attacks are\\nliable to recur, especially in cold, damp weather, and may result in\\nstiffened, deformed joints.\\nThe diagnosis is easy when the history of a hereditary tendency to\\nbleed can be obtained. Osier 2 properly remarks that slight joint-trouble\\nand petechia? are as much a manifestation of the disease as the more\\nsevere hemorrhages. In cases in which no history can be secured\\nthe diagnosis is made by noting a persistent liability to hemorrhage,\\nwithout adequate cause, and associated with joint-affections.\\nOsier gives the following excellent summary of the affections with\\nwhich haemophilia can be confounded\\n1. The umbilical hemorrhages of infants, due to jaundice or to syph-\\nilis, hemorrhagica neonatorum, etc.\\n1 Haemophilia. London, 1892.\\n2 Quoted by Osier, Pepper s System of Medicine, 1885, iii. 932.", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0140.jp2"}, "141": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 131\\n2. Purpura simplex, often seen in debilitated, rarely in healthy chil-\\ndren, usually confined to the legs, and in some cases associated with\\nrheumatic pains or swellings in the knees and ankles.\\n3. Peliosis rheumatica.\\n4. Purpura hemorrhagica, morbus maculosus Werlhofii, a grave\\ndisease, characterized by extensive cutaneous ecchymoses, mucous hem-\\norrhages, but not dependent on any local disease, or, as far as known,\\non any specific poison.\\n5. Infective purpura due to the action of some specific poison\\nsmallpox, measles, scarlet fever, cerebro-spinal fever, etc. The hem-\\norrhages may be cutaneous and trivial, or may be in the most aggra-\\nvated form of interstitial and mucous bleedings, as seen, for example,\\nin black smallpox.\\n6. Toxic purpura, as in snake-bites and many poisons, such as phos-\\nphorus.\\n7. Simple hemorrhagic diathesis, under which may be included those\\ncases in which, without any hereditary disposition or previous hemor-\\nrhagic history, there is a tendency to uncontrollable hemorrhage from a\\nslight wound.\\n8. Hsematidrosis, bloody sweats, which occur usually in hysterical\\nor epileptic females, and are in rare instances accompanied by mucous\\nhemorrhages.\\n5. Hemorrhage in Central Nervous Disease. Neuritis. Pur-\\npura in some instances is believed by Mitchell to be due to primary\\ndisease of the nervous system certainly we do see it in neuritis, in\\nRaynaud s disease, in myelitis, and in locomotor ataxia. It may occur\\nin hysteria, when drops of blood ooze through the skin at the time of\\nthe attack (hsematidrosis).\\n6. Hemorrhage of Toxic Origin. The virus of snakes causes hem-\\norrhages under the skin. In jaundice the blood is disintegrated and\\nhemorrhages take place. In malignant types the mucous membrane\\nbleeds and sordes collect on the tongue, lips, and gums. To the same\\nclass belong the subcutaneous hemorrhages that follow the adminis-\\ntration of certain drugs, as copaiba, iodide of potassium, quinine, and\\nbelladonna. (See Medicinal Rashes.)\\nEruptions.\\nDiseases of the skin are usually characterized by eruptions. Now,\\nsuch eruptions may be primary and local (from causes operating directly\\non the skin) in the sense that they occur independently of any internal\\naffection or secondary, the resultant of an internal morbid process.\\nThe morbid processes are the same, and morbid processes in the skin\\ndo not differ from such processes in other epithelial structures. The\\nanatomical and physiological peculiarity of the part causes the difference\\nin the phenomena. Hence ansemias and hyperemias, inflammations,\\nacute or chronic, with or without exudation hemorrhages, atrophies, and\\nhypertrophies, new growths, and parasitic affections are found in both.\\nBut instead of a painless inflammation with transudation of mucus, as in\\nmucous membrane inflammation, we have a more or less painful inflam-", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0141.jp2"}, "142": {"fulltext": "132 GENERAL DIAGNOSIS.\\nmation, with itching (nerve-supply), and with sebaceous and sudorifer-,\\nous gland exudation. Otherwise the same symptoms attend each but\\nocular examination of the inner mucous membranes is not possible.\\nWhile the reader is referred to special works on skin diseases for a\\ndescription of the primary or local skin affections, the secondary affec-\\ntions will be briefly noted. It must not be forgotten that the local\\naffections eczemas, parasitic disease, etc. are modified by the general\\nconditions or state of health of the patient.\\nClinical Significance. This depends, first, upon the special\\ncharacter of the eruption, the nature of the lesion second, its distribu-\\ntion (a) in the layers of the skin, (6) over the surface of the body\\nthird, its association with other morbid phenomena or various circum-\\nstances.\\nI. The Nature of the Lesion. Observation concerning the\\nnature of the lesion includes (1) its anatomical character, (2) the order\\nof appearance, (3) its uniformity, and (4) the mode of invasion.\\nA knowledge of anatomical lesions is essential in order to be able to\\ndefine exactly the morbid process and determine the primary cause of\\nthe lesion. For a long period of time the lesions were divided into\\nprimary and secondary. The lesions known as scabs, scale, raw sur-\\nfaces, scratch-marks, and ulcers are always secondary. Scars and\\nmacular appear latest. The other lesions herein described are primary.\\nThe writer follows Dr. Pye-Smith in the description of them, as well\\nas in most of the matter appertaining to cutaneous affections.\\n1. Hypercemia, or congestion.\\na. Mere overfulness of the vessels from paralysis of the vasomotor\\nnerves, with redness and heat, but without the exudation and tissue\\nchanges which accompany inflammation. This hypersemic blush, readily\\nproduced in the physiological laboratory, is rarely seen as an uncompli-\\ncated morbid condition (e. g., Trousseau s tache cerebrate).\\nb. Active, arterial, or inflammatory hypercemia, varying in color from\\nbrilliant scarlet to rose-pink, and combined with heat, tingling, or other\\nsensations.\\nc. Passive, venous, or congestive hypercemia, dependent upon retarded\\ncirculation and distended venules. The color is purple, bluish, or livid,\\nthe surface is cold, and there are no painful sensations.\\n2. Pimple, or papule. A small, solid elevation of the skin.\\na. The acute inflammatory papule.\\nb. The chronic large inflammatory papule, discrete or confluent.\\nc. A solid non-inflammatory papule.\\nd. Solid elevations of the skin, which may be called false papules.\\n3. Vesicle. A visible cavity in the skin filled with transparent\\nliquid.\\n4. Pustule. A cutaneous abscess.\\n5. Bulla, or bleb. A very large vesicle.\\n6. Scab, or crust. A dried-up concretion of the contents of a vesi-\\ncle, pustule, or bleb.\\n7. 8eaU (squama). A dry flake of epidermic cells.\\n8. Wheal (pomphos). A flat, solid elevation of the skin, much larger\\nthan a papule, and of ephemeral duration.", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0142.jp2"}, "143": {"fulltext": "THE DA TA OB TAINED B Y OBSER VA TIOK 33\\n9. Scratch-mark. An injury to the skin, of linear form and curved\\noutline.\\n10. Raw. A surface which has lost its horny layer of epidermis.\\n11. Chap (rima). A crack or fissure which goes through the epi-\\ndermis.\\n12. Sore (ulcus). The result of destruction by inflammation, which\\nhas reached below the Malpighian layer and has destroyed the papilla?.\\n13. Scar (cicatrix). The result of the healing process after an injury\\nor disease deep enough to destroy the papillae of the part.\\n14. Nodule. A solid elevation of the skin larger than a papule and\\nseated in its deep layer.\\n15. Stain (macula). A patch of increased pigmentation of the skin.\\n16. Hemorrhage (ecchymosis). When a bloodvessel of the cutis vera\\ngives way a dark-red or purple mark is produced, which (like the\\nmacula) does not disappear on pressure.\\nThe recognition of the exact anatomical lesion is not sufficient for\\ndiagnosis unless the mode of invasion is observed at the same time.\\nThe rash often spreads from a single focus, or numerous foci appear\\nand coalesce. The lesion is best studied in the most recent part. Not\\nonly is the mode of local invasion to be noted, but also the uniformity of\\nthe anatomical lesion. Often, instead of a simple lesion, various kinds are\\npresent at the same time, or they develop in successive order thus, in\\nsmallpox, we have first the papule, then the vesicle, and finally the pustule.\\nII. Distribution. The location of the lesion in the various layers of\\nthe skin, and the distribution over the surface of the body, must be\\nobserved. The layers of shin (1) The horny layer of the epidermis\\nmanifests the pathological changes of hypertrophy, atrophy, dryness,\\nor desquamation of the cuticle. Dead scales result, in addition to the\\nhypertrophies and atrophies indicated in the outline. (2) The eruption\\nin a large number of cases is limited to the living Malpighian layer of\\nthe epidermis and to the papillary layer of the cutis. The hyperemias\\n(erythemata), and inflammations of all kinds, are confined to these\\nlayers. In this situation they never leave scars. (3) The deep layer\\nof the cutis is so intimately connected with the subcutaneous tissue that\\nmorbid changes in it involve the latter, and even extend more deeply.\\nThe affections are more severe, but less numerous than affections of the\\nsuperficial layers, and are always followed by cicatrices. The changes\\nin the sweat glands, sebaceous glands, hair, and nails, so far as they\\nrefer to internal medicine, have been treated in another section.\\nArea of distribution The distribution of the eruption over different\\nareas of the body is of great importance in the diagnosis of the various\\nerythemata due to exanthems and to morbid conditions of the gastro-\\nintestinal tract. It will be noted more in detail when the specific erup-\\ntions are considered. The student should also bear in mind the rela-\\ntionship of eruptions or cutaneous changes of nutrition (trophic disor-\\nders) to the affected nerve-supplies.\\nIII. Associate Morbid Phenomena. The student of internal\\nmedicine should particularly observe the associated morbid phenomena,\\nor concomitant circumstances, in order to determine the nature of the\\nskin affection, which may be the expression of internal disorder. The", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0143.jp2"}, "144": {"fulltext": "134 GENERAL DIAGNOSIS.\\nassociated morbid phenomena of diagnostic significance are fever, jaun-\\ndice, albuminuria, and the phenomena of past or present syphilitic dis-\\nease, tuberculosis, rheumatism, or the rheumatic habit. The presence of\\none of these processes or diseases points to particular affections. Thus,\\na large number of eruptions is attended with fever another group is\\nof frequent occurrence in the course of rheumatism another class\\nbelongs to syphilis, while a fourth class is associated with anaemia, jaun-\\ndice, or albuminuria. This subdivision is not based on the nature of\\nthe eruption but on its association with other phenomena. It will be\\nlearned later that all the groups belong to the hemorrhages or the ery-\\nthemata. The true relationship of the two classes of phenomena can be\\nfully ascertained only by inquiry into the history and course of the erup-\\ntion and, in addition, into the concomitant phenomena. Thus, if the\\neruption is thought to be due to the exanthemata, the period of incuba-\\ntion, mode of infection, symptoms of the invasion, and the progress of\\nthe attack must be inquired into.\\nGeneral Symptoms. In order to determine accurately the cause of\\nan eruption and appreciate its diagnostic significance, the general health\\nmust be inquired into, the condition of the stomach and bowels and\\nthe character of the urine must be ascertained. It must be remembered\\nthat local skin disorders are influenced, for good or ill, by the general\\nhealth. Functional disorders of the stomach and bowels are a fre-\\nquent source of many of the erythemas, while in diabetes pruritus and\\nforms of dermatitis are of common occurrence. The latter are also ob-\\nserved in Bright s disease. The cause for the eruption is the same in\\nboth, in all probability that is, a perverted secretion of the skin, or,\\nif oedema is present, impaired nutrition of the surface.\\nThe subjective symptoms are of great importance in the attempt\\nto ascertain the true nature of an eruption. Pain, itching, burning,\\nsmarting, and tenderness are significant of the inflammations. Pain\\ndue to inflammation is constant and smarting, burning or throbbing in\\ncharacter. Sometimes, however, pains of a neuralgic character, inter-\\nmittent and distributed in the course of nerve- trunks, precede the\\ndevelopment of eruption. This is seen in herpes zoster. Itching is an\\nimportant symptom in disease of the skin. It is not present in the\\neruption due to the exanthemata generally, except in smallpox, chicken-\\npox, and rubella. Its absence is a striking peculiarity of the erup-\\ntions of syphilis but in erythema, especially if associated with oedema,\\nit is a most annoying symptom. In other skin diseases, as eczema,\\npsoriasis, and the parasitic affections, it is much more common and of\\nextreme annoyance.\\nItching may be present without any anatomical evidence of skin\\ndisease. It is seen in the troublesome pruritus that occurs in the aged,\\nparticularly about the intestinal and genito-urinary orifices, symptom-\\natic of affections of the organs related thereto. It is a symptom which\\nshould lead to an examination of the urine, as diabetes is sometimes\\nfound to be the fundamental source of the complaint. It has been pre-\\nviously noted that itching occurs to a high degree in jaundice. It is\\nalso due to the internal administration of drugs, as opium and mor-\\nphine, and sometimes quinine.", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0144.jp2"}, "145": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 135\\nIn addition to the associate pathological phenomena which should be\\nascertained in the study of skin eruptions, in order to determine their\\nrelationship to internal affections, other circumstances should be inquired\\ninto, such as the occupation, the character of the clothing, degree of\\ncleanliness of the patient the effects of climate, the season, tempera-\\nture, and the state of the air.\\nThe following very concise outline, taken from the Avork of the above-\\nnamed author, to whom the writer is indebted for much of the data\\nof this section, is here given to enable the student to appreciate more\\nthoroughly the pathological relations of the various skin diseases. The\\ntable also shows at once the relation of the eruptions to the internal\\ndisorders which concern us more particularly in this work\\nDiseases or the Skin Kegarded as Physiological Processes.\\nPathological Arrangement.\\nAcute Inflammations. Diffuse, e. g., scarlatina, morbilli, syphilis, roseola (eruptive\\nfevers, erythema).\\nWith venous congestion Erythema nodosum (rheumatism).\\nWith oedema Urticaria, erythema nodosum (gastro-intestinal disorder and rheu-\\nmatism).\\nWith necrosis Furunculus, anthrax (diabetes).\\nLocalized in papules Enterica (erythemata), syphilis, eczema, prurigo.\\nLocalized in vesicles Eczema, zona, variola, scabies, herpes, varicella (eruptive\\nfevers, infectious diseases).\\nLocalized in pustules\u00e2\u0080\u0094 Impetigo, variola, scabies, syphilis, sycosis, acne.\\nLocalized in blebs Pemphigus, scabies, rupia.\\nDesquamating during involution Scarlatina, etc.\\nChronic Inflammations. With venous congestion Acne rosacea, pernio.\\nWith over-production of epidermis\u00e2\u0080\u0094 Psoriasis, pityriasis rubra.\\nWith oedema Elephantiasis.\\nWith fatty degeneration Xanthelasma.\\nWith hypertrophy Elephantiasis.\\nWith cicatrization Cheloid.\\nWith ulceration Lupus, syphilis, lepra.\\nNew growths Xanthelasma, lupus, lepra, syphilis, cancer.\\nAtrophy\u00e2\u0080\u0094 The senile skin, linae gravidarum.\\nHypertrophy Ichthyosis, cornu cutaneum, clavis, verruca.\\nHemorrhage Traumatic (e. g., flea bites), typhus, scurvy.\\nPigmentation Syphilitic maculae, melasma, chloasma, icterus, ephelis.\\nCongenital malformations Ichthyosis, cutaneous nsevus.\\nNeurosis\u00e2\u0080\u0094 Pruritus (diabetes, jaundice).\\nAnomalies of Secretion. Increased, diminished, or perverted Seborrhcea, xeroderma,\\nhyperidrosis, anidrosis, chromidrosis, etc. Obstructed Comedo, milium, acne,\\nsudamina.\\nA glance at the above outline will show that the eruptions which\\nparticularly concern us belong to the class of diseases to which the term\\nerythema is applied.\\nErythema. Classification. Erythemata may be divided, in\\naccordance with the classification of Kaposi, into acute, contagious,\\nexudative dermatoses, represented by measles, scarlatina, rubella, and", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0145.jp2"}, "146": {"fulltext": "136 GENERAL DIAGNOSIS.\\nsmallpox and the acute, non-contagious, inflammatory dermatoses,\\nwhich may be further subdivided into (1) typical forms, idiopathic and\\ntoxic, including urticaria, or nettle-rash (2) varieties of herpes (3)\\nerythemas due to boils, colds, or erysipelas. The first group of the\\n?io?i-contagious form includes the class which should always be consid-\\nered in connection with the diagnosis of fevers. The skin inflamma-\\ntions closely simulate in their symptoms the eruptive fevers, even to\\nthe affections of the mucous membranes. Besnier has named them the\\njjseudo-exanthems, and divides them into rubeloids and scarlatinoids.\\nBoth simulate eruptive fevers throughout their course, and hence both\\nare acute and febrile. The scarlatiniform erythemas are febrile at the\\nbeginning, subacute m course, but of longer duration than the fever\\nthey simulate. They are the most common forms, and arise from in-\\nfectious diseases, such as puerperal fever, septicaemia, and gonorrhoea,\\nor from toxaemia due to drugs or articles of food.\\nCharacter of eruption in the non-contagious forms. The ery-\\nthemata are characterized by (a) rose rash with injection of the surface,\\neither (b) with general oedema, or with circumscribed local oedema,\\nforming wheals or with papules. In rare cases bullae are also formed.\\n(c) The rash is followed by a branny desquamation, (d) The exuda-\\ntion that attends the lesion is always watery, in contradistinction to the\\nsero-purulent or purulent exudation of eczema and scabies. Sometimes\\nslight hemorrhages attend the lesion, as in cases of purpura or of urti-\\ncaria, (e) The course of the erythema is of diagnostic significance. It\\nbegins quickly, and is usually attended with febrile symptoms, some-\\ntimes mild, again very intense. The duration is short at least it\\nis not indefinite. The erythemas that are recurrent must not be con-\\nsidered to be one process of long duration, (g) The locality of the\\nerythema is not of precise diagnostic significance. The eruption is\\nusually symmetrical, and the favorite localities may be defined as the\\nextensor surfaces of the forearms and leg, the face, cheeks, neck, and\\nthe chest and abdomen. True erythema does not attack the scalp, the\\nflexures of the joints, the palms (except erythema multiforme), nor the\\nsoles. (A) The local symptoms that attend erythemata are mild. Local\\ntenderness is more marked than in eczema. Smarting and tingling\\nare complained of, but severe pain and excessive itching are rare. Only\\nwhen wheals are present do we find pruritus. The rash of erythema\\ndoes not spread. Patches occasionally unite, but an affected area never\\nenlarges its borders.\\nThe etiology of erythema is involved in obscurity. Although\\nthe frequent associate phenomena are not of etiological, they are cer-\\ntainly of diagnostic significance. We may have them occur under the\\nfollowing circumstances 1. In one class the eruption is symptom-\\natic, depending upon dyspepsia or upon rheumatic fever. 2. In the\\neruptive fevers, especially scarlatina and measles, in enteric fever and\\ncholera, and in syphilis, there is an early erythema preceding the later\\ntrue eruption. 3. The most striking instance of the relationship to\\ninternal disorder is seen in the rash that arises after the administration\\nof medicine, as copaiba, or after the taking of certain foods. 4. The\\nerythemata occur most commonly in children and young people.", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0146.jp2"}, "147": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. J 37\\nThey are very frequent in men. The age at which they occur coincides\\nwith that of rheumatism.\\nVarieties of non-contagious erythemata First, erythema multi-\\nforme in simple form, with papules or with exudation it may disap-\\npear in a few hours, or persist for a day or two and form rings {ery-\\nthema fug ax or erythema annulatum). With the fading of the redness\\nfaint desquamation ensues, and there may be a few pigment marks.\\nThe annular form is observed in rheumatic fever. In addition to\\nrheumatism erythema multiforme may be found associated with the\\nfollowing affections Typhoid fever, puerperal fever, gonorrhoea,\\ncholera, infectious endocarditis and osteomyelitis, syphilis, leprosy,\\nvaccination, and surgical septicaemia. Osier has called attention to the\\nvisceral complications of erythema exudativa multiforme associated with\\nthe skin lesions viz., gastro-intestinal crises, endocarditis, pericarditis,\\nacute nephritis, and hemorrhage from the mucous surfaces. Arthritis\\nis also seen in some instances. The skin lesions range from simple\\npurpura to local oedema, and from urticaria to large infiltrating hemor-\\nrhages of the skin and subcutaneous tissues. The gastro-intestinal\\ncrises are attended by colic, with vomiting and diarrhoea.\\nErythema l^ve often appears upon the tense skin of dropsical\\nparts. It may be the result of acupuncture.\\nVesicular and Bullous Erythema. To this class belong the\\naffections known as herpes and erythema bullosum.\\nHerpes zoster is seen in the cutaneous distribution of one or more\\nnerves. It consists of vesicles of flattened form, ranged in clusters of\\ntwenty or thirty, lying on a reddened, slightly swollen bed of skin.\\nThe number of clusters varies from one to ten. The vesicles develop\\nin quick succession, beginning usually near the roots of the nerve whose\\nbranches they follow. A short papular stage precedes the vesicles, and\\nsome of the vesicles abort. The eruption tends to dry up in five or six\\ndays. The crusts form in yellowish or brownish clusters, which fall\\noff in the third week, leaving purple stains.\\nWhen the disease attacks the face it follows the course of the fifth\\nnerve. The several twigs of the trifacial are traced out from their\\npoints of emergence from the bony canals. Great swelling of the eye-\\nlids sometimes takes place on account of the loose tissue, so that the\\nlesion may be mistaken for erysipelas. Ulceration of the cornea and\\niris sometimes occurs, and, when lower divisions of the trifacial are\\naffected, vesicles may appear in the mucous membrane of the mouth\\nand palate. The cervical nerves and those of the upper extremity are\\nalso affected in their distribution. The eruption on the arm rarely\\ngoes below the elbow. When the second and third intercostal nerves\\nare affected the intercostohumeral branch produces an eruption down\\nthe inner side of the arm. The eruption occurs frequently on the\\ntrunk. Following the course of the dorsal nerves it slants downward\\nas it approaches the pubes.\\nIn the distribution of the disease in the lower limbs the eruption\\nrarely extends below the knee or buttocks. It follows the course of\\nthe external cutaneous or anterior crural nerves, or that of the small\\nsciatic. Some of the branches of the sacral nerves are also affected.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0147.jp2"}, "148": {"fulltext": "138 GENERAL DIAGNOSIS.\\nThe disease is unilateral, and its precise limitation to one-half of the\\nbody is of the greatest diagnostic significance.\\nWhile fever or general symptoms do not usually attend its course\\nin any marked degree, insomnia and depression are likely to occur,\\nprobably on account of the severe neuralgic pain. Pain is the most\\nimportant subjective symptom. It is localized in the nerves, in the\\ndistribution of which the eruption takes place. It is not so likely to\\nbe present in the young. The pain may precede the eruption by\\nseveral days, and persist long after the eruption subsides. This is\\nparticularly the case in old people.\\nHerpes labialis, or facialis, consists of vesicles arranged in\\ngroups or clusters upon an inflamed surface. They appear very sud-\\ndenly upon the upper lid or the alse of the nose, sometimes on the\\ncheek or chin, and they may appear inside the mouth. They undergo\\nsome changes, as in herpes zoster, but are not attended by severe\\nneuralgic pain. They are also symptomatic of an internal disorder,\\nan acute catarrh (cold), or follow a rigor, as in intermittent fever or\\npneumonia. They may be present in epidemic cerebro-spinal menin-\\ngitis, but are never present in tuberculous meningitis. Diagnosis of\\nthe former disease is confirmed by their presence (Klemperer). Herpes\\niris and herpes preputialis have no diagnostic significance of internal\\ndisease.\\nErythema Nodosum. With the erythema there is great oedema.\\nThe spots are somewhat painful and tender, but do not itch. The\\nredness of the erythema is modified by the hue of venous congestion.\\nSmall hemorrhages may be seen. The patches develop on the legs,\\ntheir long diameter being parallel to the tibia. They rise slowly into\\nhard masses. They may be seen on the ankles or the calf, and some-\\ntimes on the ulna. They occur frequently in those who have suffered\\nfrom rheumatic fever.\\nUrticaria is a form of erythema in which wheals, sometimes sur-\\nrounded by an erythematous blush, are seen. It is an acute inflamma-\\ntory oedema of the cutis. The serous exudation fills the lymph-spaces\\nand expels blood from the venules. It takes place suddenly, and may\\nbe excited by chemical irritation or a mechanical irritant, as the finger\\ndrawn across the skin. Small patches, or large white areas, are seen,\\ndue to the coalescence of smaller ones (giant urticaria). All parts of\\nthe body may be affected, except the scalp, face, and soles of the feet.\\nThe eruption is not symmetrical. Its course may be acute, or it may\\nbe chronic and transitory, characterized by successive attacks. It is\\nthe form of erythema in which intense itching is the most pronounced\\nsymptom. There are no other subjective symptoms. The itGhing\\ncauses restlessness and loss of sleep. Urticaria is symptomatic of gas-\\ntric or intestinal disturbance, or the ingestion of drugs or poisons.\\nAnother form follows the tapping of a hydatid cyst. It occurs some-\\ntimes in women at each menstrual period, and may be traced to ovarian\\ndisorder. It may occur after severe shock to the nervous system, with\\nhigh fever. It is not an infrequent complication of rheumatic fever.\\nIt occurs in men and women equally, but is most frequent in children\\nand adolescents.", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0148.jp2"}, "149": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 139\\nMedicinal Rashes. To the erythemata belong most of the so-called\\nmedicinal rashes.\\nThe following drugs are known to cause erythema potassium bro-\\nmide and iodide, copaiba, cubebs, the essential oils, capsicum, santonin,\\nchloral, opium, morphine, antipyrin, salicylic acid and its compounds,\\niodoform, belladonna and atropine, tar, carbolic acid, arsenic, cannabis\\nindica, digitalis, mercury, silver, copper, and antitoxin.\\nBelladonna produces in susceptible persons, or when administered\\nin poisonous doses, a diffuse, bright-red erythema, closely resembling\\nthat of scarlet fever, but without the darker red points which interrupt\\nthe latter. Atropine also produces in some persons, especially on the\\nshoulders, arms, chest, and face, an eruption of disseminated, small,\\nhard vesico-papules, showing no tendency to pustulation. They are\\nseated on an inflammatory base, but are more superficial than acne.\\nThe bromides produce a characteristic pustular eruption which is\\nmost intense upon the shoulders, face, chest, and arms. Large doses,\\nor long-continued administration, are generally required to bring it\\nout. It is conspicuous upon the face of some epileptics.\\nThe iodides produce an eruption which is not often pustular, but\\nan erythematous or papular rash is not uncommon. It appears chiefly\\nabout the forearms, face, and neck. Vesicles, bulla?, and purpuric\\nspots are also occasionally seen.\\nThe eruption produced by quinine is generally erythematous, and is\\nattended with itching and burning the face and neck are attacked\\nfirst.\\nOpium and its alkaloid also produce, in susceptible persons, an\\nerythematous scarlatinoid eruption which is accompanied by intense\\nitching. Itching, especially about the nose, is much more common\\nwithout eruption.\\nCopaiba produces a vesico-papular or papular eruption which resem-\\nbles urticaria and erythema multiforme. It is itchy. It is more apt\\nto be seen on the extremities. It may be purpuric.\\nThe eruption of cubebs is a diffused erythema, with millet-sized\\npapules, coalescent here and there. Unlike the eruption of copaiba,\\nit is more copious over the face and trunk than over the extremities.\\nAntipyrin causes a measles-like or urticaria-like eruption.\\nErythemata of Infectious Diseases.\\nThe inflammations of the skin which are symptomatic of a specific\\ninfection are also of an erythematous variety. The term exanthemata\\nhas been applied to the latter, but the eruptions of typhus and typhoid\\n(enterica) belong to the same class. The characteristics and distinc-\\ntions of the various forms will be described in sections devoted to the\\nrespective diseases. The student should remember the associate general\\nphenomena, particularly fever, the onset and the course of which should\\nbe carefully observed.\\nRoseola. Roseola is of a deep rose-color, not arranged hi crescentic\\npatches, as in measles, nor scarlet and capable of being resolved into\\ninnumerable red points, as in scarlatina. It is not so diffuse as the", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0149.jp2"}, "150": {"fulltext": "140 GENERAL DIAGNOSIS.\\nlatter. It precedes smallpox, scarlatina, measles, cholera, typhoid fever r\\nsyphilis, diphtheria, and malaria. In smallpox, in cases of cholera, and\\nafter parturition and surgical operations, the rash is copious, but is\\ncharacterized by being seated over the lower half of the abdomen and\\nthe anterior and inner aspects of the thighs. It may appear elsewhere,\\nbut is usually confined to that portion of the body.\\nThe erythema of roseola may be mistaken for rubella, measles, or\\nscarlatina. The following are points of distinction First, it is neither\\ncontagious nor epidemic second, there are no prodromal symptoms\\nthird, the rash does not come out after a definite period of fever fourth,\\nit is not confined to any special locality fifth, the fever is of short\\nduration and moderate degree, rarely above 101\u00c2\u00b0; sixth, there is no\\ncatarrhal discharge from the eyes or nose or in the pharynx the fauces\\nand palate are reddened without swelling seventh, it is not seen in\\nthe mouth, like the eruptions of measles or scarlatina eighth, if pres-\\nent, the fever which precedes the eruption is of only a few hours 7 dura-\\ntion (in scarlatina it lasts twenty-four hours, in measles seventy-two\\nhours) ninth, the rash is not crescentic as in measles, nor punctiform\\nas in scarlatina, though it must be admitted that severe cases of the\\naffection cannot be easily diagnosticated, the development of the sequelae\\nalone concluding the diagnosis.\\nTo add to the confusion, an erythema called roseola often precedes\\nthe eruption of a particular fever. The association with this class of\\nfevers has been indicated before.\\nSufficient reference has been made to the erythemata that attend rheu-\\nmatism. A few other internal (infectious) disorders are associated with\\nthe development of an eruption. In cholera y during the period of reac-\\ntion, a rose rash which may resemble erythema, urticaria, or scarlatina\\nappears coincidently with a rise of temperature. It is most frequently\\nseen on the forearms and backs of the hands, but may cover the back\\nand limbs. It may be slightly hemorrhagic and last two or three days.\\nA slight desquamation usually follows. In influenza a roseolous erup-\\ntion, covering the trunks and limbs and becoming papular, is seen in\\nrare cases.\\nIn addition, erythematous eruptions are sometimes seen in the course\\nof Bright s disease. Two forms, quite distinct from the previously\\nmentioned erythema lseve, are observed the roseola on the feet, legs,\\nand hands rarely on the chest and abdomen and the papular form\\non the thighs, arms, and shoulders. Itching and other subjective\\nsymptoms do not attend the eruption. A form with desquamation\\nmay begin on the limbs. These erythemata are common in the later\\nstages of Bright s disease, but are not of ill omen. In acute Bright s\\ndisease a transient roseola is observed very rarely so also is purpura.\\nIf there is much anasarca in tubal nephritis, erythema is more common.\\nThe eruptions usually appear independently of ursemic symptoms, and\\ndisappear during their continuance. They are in all probability allied\\nwith the inflammation which attacks the lungs and serous membranes\\nin Bright s disease.\\nSudamina. Here may be mentioned another eruption, or condition\\nof skin, common in the course of internal diseases. Sudamina, or", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0150.jp2"}, "151": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 141\\nmiliaria, are small, clear vesicles seen in large numbers, usually on the\\nabdomen, but also on any other part which reflects the light strongly.\\nThey are seen during and after the subsidence of profuse sweats.\\nWhile actual perspiration is seen on the forehead, the trunk may\\nappear free from moisture. When the hand is placed over it, as on\\nthe abdomen, the dryness is noted, but at the same time a roughened,\\nnutmeg-grater-like sensation is felt. On close inspection this is ob-\\nserved to be due to the eruption just mentioned. The vesicles are\\nusually of good prognostic omen in the course of febrile diseases, par-\\nticularly typhoid fever. They are due to the accumulation of perspi-\\nration under the epidermis.\\nGeneral Diagnosis of Skin Affections.\\n(Condensed from Pye-Smith.)\\nI. Factitious Eruptions. We must never forget the possibility of\\nthe affection before us being artificial. All kinds of dermatites, eczema,\\nerysipelas, pemphigus, impetigo, may be simulated by the application\\nof various irritants. Pigmentation also has often been imitated with\\nsuccess. Such artificial lesions will generally be found upon the arms,\\nrarely on the face, and scarcely ever beyond reach of the patient s\\nhands. Mustard, cantharides, and some other irritants can be distin-\\nguished with the aid of the microscope.\\nII. Traumatic Eruptions. In all cases of dermatitis we should\\nseek for the irritant, and sometimes it is so directly the cause of the\\ndisease that the eczema or impetigo in question may be considered\\npurely traumatic, and efficient treatment immediately follows accurate\\ndiagnosis sublata causa tollitur effectus.\\nPediculi in the hair should be carefully looked for in all cases of\\nimpetigo in children pediculi vestimentorum in prurigo of old people.\\nThe acarus of scabies, fleas, bugs, and gnats may be found. In adults,\\npediculi pubis may sometimes be found in the axillae as well as in their\\nproper region, and when they have been destroyed by mercurial oint-\\nment the patient is at once relieved from pruritus.\\nFrequently the irritant must be sought for in the objects which the\\npatient habitually handles. The coarser kinds of brown sugar are a\\nfrequent cause of eczema of the hands (grocer s itch). So with many\\nof the chemicals used in a variety of modern handicrafts. Constant\\nwashing of the hands in washerwomen, in scrubbers, in potmen, and\\nmany others produces eczema rimosum. The heat of the sun is the\\ncause of eczema solare and ephelides the heat of the fire, of the pig-\\nment spots on the shins of elderly people. Sweat, again, is a very\\ncommon irritant, producing the erythema which usually accompanies\\nsudamina and also intertrigo of opposed surfaces. Scratching, as a\\ncause of traumatic dermatitis, has been repeatedly referred to.\\nIII. Febrile Rashes. We must never forget that a cutaneous\\neruption may possibly be part of an acute exanthem. The use of a\\nclinical thermometer is a great help in this respect. Variola is fre-\\nquently mistaken for syphilis and other affections.", "height": "4412", "width": "2580", "jp2-path": "practicaltreatis00muss_0_0151.jp2"}, "152": {"fulltext": "142 GENERAL DIAGNOSIS.\\nIV. Medicinal Rashes. Other cases are due to certain kinds of\\nfood or to drugs. They have been described above.\\nV. Syphilodermata. When we have satisfied ourselves that the\\neruption before us is not factitious, nor directly traumatic, nor a symp-\\ntomatic eruption, we may next consider whether or not it is due to\\nsyphilis. In this inquiry it is undesirable to ask questions the answers\\nto which are as apt to mislead as to guide aright.\\n1. We should first consider the color of the affected skin, remember-\\ning, however, that the pigmentation which gives the so-called coppery\\nor raw-ham tint to a syphilitic eruption is the same which is sooner or\\nlater produced by all forms of dermatitis. Psoriasis, chronic eczema,\\nlichen planus, and prurigo may all produce shades which bear the\\nclosest resemblance to syphiloderma.\\n2. The lesions of syphilis are multiform. It is rare in any but\\nsyphilitic affections to find mere hyperemia in one part and associated\\npustules, papules, scales, or ulcers in others; and it is not often that a\\nsyphilitic eruption exhibits only a single elementary lesion.\\nA pustular eruption in an adult should always suggest the question\\nof syphilis when that of scabies has been answered in the negative.\\n3. Syphilitic eruptions, for some unknown reason, do not itch the\\nexceptions to this rule are remarkably few; they usually occur during\\nthe stage of scabbing of pustular rashes or during the healing of\\ntertiary ulcers. An ordinary secondary syphilide may, however, as a\\nrare exception, be so irritating that wheals and scratch-marks are\\npresent. On the other hand, psoriasis is often free from irritation,\\nwhile the degree of itching of eczema, and even of scabies and prurigo,\\nvaries greatly.\\n4. The local distribution of syphilitic disease is a great aid in diag-\\nnosis. Specific eruptions are certainly not, as a rule, symmetrical; the\\nearly roseolous rash is only so because it is general, and therefore, upon\\na surface like the human body, more or less symmetrical. Moreover, as\\nit chiefly affects the face, chest, and trunk generally, it is near the\\nmiddle line. But we do not see symmetrical patches of syphilide in\\ncorresponding parts of both sides of the face, both sides of the trunk,\\nor the right and left limbs. In all but the earliest syphilides the\\naffected patches are very decidedly and constantly un symmetrical,\\nirregularly scattered over head, trunk, and limbs, and chiefly remark-\\nable for having no well-marked seats of predilection.\\nThe forehead, especially about the roots of the hair, is, however,\\nvery frequently the seat both of the early and middle erythematous,\\nscaly, and pustular syphilides, and the palms of the hands and soles of\\nthe feet are frequently symmetrically affected with the later scaly eruption.\\nPractically, when we find a disease of the skin occupying some un-\\nusual position, we should at least consider the question of syphilitic\\norigin.\\n5. These signs, alone or in combination, serve to distinguish early\\nspecific roseola from erythema, eczema, scarlatina, and measles, and the\\nlater eruptions from eczema, lichen, impetigo, and psoriasis.\\nThe eruptions of congenital syphilis which are most liable to be mis-\\ntaken are The so-called pemphigus of infants, which is known by its", "height": "4416", "width": "2568", "jp2-path": "practicaltreatis00muss_0_0152.jp2"}, "153": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 143\\naffecting the palms and soles rupia, which, by the form of the crusts\\nand the ulcerated surface beneath, may always be distinguished from\\nimpetigo an erythematous rash of the nates and genitals of infants,\\nwhich is distinguished from eczema of the same parts, also common at\\nthat age, by its coppery color, its blotchy distribution, and more clearly\\ndenned margin.\\nThe tertiary ulcers of syphilis are distinguished by their presence in\\nunusual places, by their punched-out edges, circular or so-called horseshoe\\nshape, and by the fact that they usually give little pain or discomfort.\\nTertiary ulcers have no predilection for the outer side of the leg, but,\\ninasmuch as the part above the inner malleolus is, from anatomical\\ncauses, the chosen seat of varicose ulcers, most ulcers in the first posi-\\ntion will be syphilitic and in the latter not. Moreover, the age helps\\nin the diagnosis, as varicose ulcers rarely occur before the fortieth year.\\nMost ulcers on the arms are found to be tertiary syphilitic ulcers.\\nVI. Tineae. The next group of skin diseases includes those which\\nare due to vegetable parasites tinea versicolor of the trunk, eczema\\nmarginatum of the perineum and thighs, tinea circinata of the neck\\nand other parts, tinea sycosis of the chin, and tinea tonsurans of the\\nscalp. In all doubtful cases the microscope should be employed.\\nTinea of the scalp is rare in adults, and tinea circinata still more so\\ntinea marginata occurs only in adult males.\\nVII. Primary Superficial Inflammations. To distinguish the\\nsuperficial from the deeper kinds of dermatitis, we should notice\\nwhether the cutis alone is infiltrated and thickened, or whether it is\\nbound down by adhesions to the subcutaneous tissues. The presence\\nof scars, however slight, is a proof that the process has gone deeper\\nthan the papillae, and has more or less extensively destroyed the papil-\\nlary layer. Superficial inflammations, excluding those due to acarus,\\nto pediculi, and to other direct irritants, and excluding also those which\\nare the result of vegetable parasites and of syphilis, fall, with respect\\nto their treatment, into three large groups\\nThe first group, represented by impetigo and most forms of eczema,\\nconsists of inflammations which are subacute, and accompanied with\\nburning, itching, and pain, sometimes with a slight degree of fever.\\nThe second group of superficial inflammations of the skin is typically\\nrepresented by psoriasis, but includes lichen planus, the more chronic,\\ndry, and obstinate forms of eczema, and true prurigo. These affec-\\ntions are chronic, with little irritation, exudation, pain, or active signs.\\nThe third group is that of erythemata.\\nVIII. The Acne Group. Acne, both in its pathology and etiol-\\nogy, differs from other forms of dermatitis. The age of the patient\\nand its distribution are sufficient for diagnosis. It is at once a super-\\nficial and a deep dermatitis, and is often followed by scars. Its treat-\\nment consists entirely, or almost entirely, in local applications directed\\nto the correction of the sebaceous affection. With acne may be classed\\nsycosis and furunculus.\\nIX. Deep Affections. When we have ascertained that the affection\\nof the skin is deep, that is to say, that it goes below the papillary layer,\\nthe field of diagnosis is limited.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0153.jp2"}, "154": {"fulltext": "144 GENERAL DIAGNOSIS.\\nExcluding erysipelas, which is distinguished by its acute character\\nand febrile symptoms, excluding the pustular affections which affect\\nthe skin deeply and produce scars only at isolated points, such as acne,\\nvariola, and herpes zoster, and excluding, thirdly, leprosy and other\\nexotic diseases, we have to distinguish in the great majority of cases\\nwhich come before us in this country first, traumatic and varicose\\nulcers second, gummata and syphilitic ulcers third, lupus fourth,\\nrodent ulcer and fifth, carcinoma of the skin.\\nWith regard to the first of these, we must not assume, because a sore\\nupon the skin is said to be the result of a blow or a kick, that it is\\npurely traumatic, for syphilitic ulcers often arise in this way. Malig-\\nnant ulcers are rare, and are usually obvious from the age of the\\npatient, the pain they occasion, their tumid margins, and their blood-\\nstained secretions. Moreover, they are, with few exceptions, confined\\nto the neighborhood of the orifices of the body, especially the lower\\nlip, the urethra, the vulva, and the anus. Rodent ulcer, however, is\\nvery difficult to diagnose with certainty. Its locality, its slow and\\npainless progress, and its belonging to the latter half of life, usually\\nserve to distinguish it from lupus and its being single, excessively\\nchronic, and unaccompanied by nodes or other syphilitic lesions, are\\nthe best characteristics for diagnosis from a tertiary ulcer.\\nThe Nutrition of the Skin.\\nPalpation. The color, as determined by inspection, is a fair index\\nof the nutrition of the skin, but further information is obtained by pal-\\npation. In health the skin is smooth, firm, and elastic. When pinched\\nbetween the thumb and fingers and then allowed to escape, it slips\\nquickly back into its former position. When pressed or squeezed, it\\nbecomes pale from expression of blood, but resumes its natural hue\\nimmediately.\\nThe readiness with which the blood returns after pressure shows the\\ncharacter of the capillary circulation of the skin. This is active in\\nhealth and sluggish in serious disease of the lungs, heart, and blood-\\nvessels. In the eruptive fevers, especially in measles, scarlet fever,\\nand smallpox, sluggish capillary circulation with dusky eruption is a\\ngrave sign. In measles it is usually due to pulmonary complications,\\nand in other infectious diseases to the overwhelming effects of the poison.\\nAs age advances the skin becomes less elastic, and in old persons\\nmay lie in wrinkles. When pinched between the fingers the skin is\\nmore inclined to remain wrinkled. Fat persons whose skin is firm\\nand hard are in much better condition than those whose skin is loose\\nand flabby. The latter condition is frequently met with in babies,\\nparticularly those that are fed on artificial foods. When the skin is\\nthin and dry and loses its tone, so that, when pinched into folds, it\\nresumes its smoothness but slowly and sluggishly, it is usually evi-\\ndence, in a person under fifty, of some grave cachexia, as carcinoma.\\nMoisture and Dryness of the Skin. Moisture and dryness are in\\none sense correlated with the nutrition of the skin. It is quite certain\\nthat when the skin is abnormally dry its nutrition is impaired.", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0154.jp2"}, "155": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. H5\\nIn health the skin is not perceptibly moist, except as the result of\\nphysical exertion or under heat, or as the immediate result of imbibing\\na hot fluid or a sudorific drug. There is considerable individual differ-\\nence, however, within the limits of the normal. Rheumatic and stru-\\nmous persons may have a perceptibly moist and oily skin at all times,\\nwhile others have a skin which perspires very little, even under influ-\\nences which usually bring about perspiration.\\nPerspiration Increased. Hyper idrosis. It may be general or\\nlocal.\\nA. General increased perspiration is seen 1. With fever. It occurs\\nin the course of rheumatism, when the sweats are strong in odor and\\nacid in reaction. It is seen in tuberculosis, especially the miliary\\nvariety. It is sometimes marked throughout cases of typhoid fever.\\nGeneral perspiration also attends the violent muscular action of tetanus,\\nbut is not seen in epilepsy. An example of general sweating is seen in\\nthat curious affection to which the term sweating sickness has been\\napplied. It is a fever the nature of which is not well knowm, but in\\nwhich this symptom is most pronounced. Sweating is extreme in\\ntrichinosis.\\n2. With normal or subnormal temperature, a. Sudden, temporary\\nperspiration. Sweats occur from excitement or slight exertion hi\\npatients during convalescence. A general profuse perspiration may be\\nof short duration and occur suddenly after fright or shock in health.\\nIt is the characteristic perspiration of collapse. The forehead is cov-\\nered with sweat, large drops stand out on the face, the hands and feet\\nare moist or wet with perspiration, and the whole surface of the body\\nleaks. It is attended by a cold and clammy skin. In the collapse\\nof all forms of shock, or after hemorrhage or profuse discharge, as in\\ncholera, this form of perspiration is seen.\\nMore striking still are the perspirations that suddenly break out in\\nthe course of acute disease coincidently with a fall of temperature. We\\nhave (1) the critical sweats of pneumonia and relapsing fever (2) sweats\\nwhich terminate a paroxysm of intermitting fever, whether of malarial\\nor infectious origin (see Fever) (3) the profuse perspiration that\\nattends pyaemia, breaking out with each fall of temperature to disappear\\nas it rises (4) the night-sweats that attend tuberculosis and other ex-\\nhausting diseases. In tuberculosis and in pus-formation or accumula-\\ntion the oscillation of temperature, with or without chills, followed by\\nsweating, is knowm as hectic. Sudden breaking out of general per-\\nspiration, but more notably seen on the face, attends dyspnoea of pulmo-\\nnary origin and the attacks of dyspnoea in the course of organic heart\\ndisease. These perspirations are at times the result of an effort at\\nelimination, on the part of the skin, to relieve the kidneys or bowels,\\nsuch as the perspiration of urcemia, which is attended by a urinous\\nodor. At times it may also occur in jaundice. In the conditions just\\nmentioned there are coolness of the skin and cold extremities.\\nb. Prolonged Perspiration. In exhausting diseases, general and\\npersistent perspiration may occur, particularly in the later stages, as in\\ntuberculosis, and in any disease attended by persistent dyspnoea.\\n10", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0155.jp2"}, "156": {"fulltext": "146 GENERAL DIAGNOSIS.\\nB. Local increased perspiration (hyperidrosis localis) occurs when\\nthere is local vasomotor paresis. Thus, in organic diseases of the brain\\nand in affections of the peripheral nerves, in some forms of neuralgia,\\nin migraine and in hysteria, it has been observed. Sometimes one\\nside of the body alone is affected, even in a malarial paroxysm (hemi-\\ndrosis).\\nLocal sweats are sometimes significant. This is the case particularly\\nwith a sweat confined to the head, which occurs usually in children, and\\nis one of the striking characteristics of rickets. With the local sweat-\\ning the patient rolls his head at night from discomfort. The hair on\\nthe back of the head is rubbed off.\\nUnilateral sweating of the head may arise from destructive pressure\\non the sympathetic nerves, causing paralysis of the dilator fibres of the\\ncilio-spinal branches, in thoracic aneurism, and in caries of the lower\\ncervical vertebrae. There are usually contraction of the pupil and con-\\ngestion of the face on the same side.\\nDiminished Perspiration. Anidrosis. The skin is abnormally\\ndry in the early stages of acute disease attended by fever, particularly\\nif the febrile rise takes place suddenly, as in acute digestive disorders\\nof children. In adults, when the disease is accompanied by high fever,\\nas in thermic fever, the skin is dry. In the first day of the eruption\\nof the exanthemata the dryness is marked. Dryness of the skin is of\\nfrequent occurrence when there are copious discharges of water from\\nthe bowels or the kidneys. In choleraic diarrhoea the dryness occurs\\nsuddenly. In some affections, as diabetes and Bright s disease, the\\ndryness extends over a long period of time, and is frequently attended\\nby eruptions or desquamations and by the formation of boils. When\\nthere are accumulations of serum in the lymph-spaces of the subcu-\\ntaneous connective tissue, or changes in the connective tissue, as in\\ndystrophies or myxoedema, or scleroderma, the skin is dry because of\\nthe stretching and pressure on the bloodvessels.\\nScars. Scars are important proofs of the occurrence of previous\\ndisease, especially smallpox, chickenpox, and syphilis. Scars of the\\nfirst two occur in the form of circular pits, and almost always on the\\nface. Scars of syphilis are larger, circular, or oval in shape, and seen\\nusually to the best advantage on the extremities, but the single scar on\\nthe forehead is strikingly suggestive. Scars upon the legs in persons\\nunder thirty years of age, when not traumatic, are almost always\\nsyphilitic. Scars as the result of suppurating glands are seen most\\nfrequently in the neck, but may be found wherever there are glands,\\nespecially under the jaw and in the axilla and groin. They are most\\nliable to occur in tuberculous persons, either spontaneously or as the\\nresult of the exanthemata, erysipelas, or other infectious disease. When\\nsuch scars are met with in a person with incipient tuberculosis the\\nprognosis becomes more anxious.\\nThe appearance of the scar indicates its age in a general way, and\\nhence throws light upon the patient s previous history, and also serves\\nas a check upon the accuracy of his statements.\\nScars the result of wounds, injuries, or operations may be seen any-", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0156.jp2"}, "157": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 147\\nwhere they are of importance only so far as they may furnish a clue\\nto the cause of existing disease. Of such nature are the scars upon the\\nhead in cases of brain disease, particularly epilepsy.\\nThe scars of pregnancy, the striae seen upon the lower part of the\\nabdomen and the upper part of the thigh, must not be confounded\\nwith similar scars that occur in great oedema, and which are some-\\ntimes found in fat persons. They are also seen after typhoid fever.", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0157.jp2"}, "158": {"fulltext": "CHAPTER XI.\\nTHE DATA OBTAINED BY OBSEEVATION\u00e2\u0080\u0094 {Continued).\\nThe subcutaneous connective tissue. (Edema causes mode of recognition situation\\nfeet, face, arms, and head oedema of trichinosis angioneurotic oedema.\\nMyxoedema. Connective tissue dystrophies. Scleroderma. Sarcomata cysti-\\ncercus cellulosse brawny induration. Subcutaneous nodules. The lymphatic\\nglands. Enlargements local general. Adenitis. Hodgkin 1 s disease. Tuber-\\nculosis and leucaemia.\\nTHE SUBCUTANEOUS CONNECTIVE TISSUE AND\\nLYMPHATIC GLANDS.\\nEnlargements or swellings of the subcutaneous connective tissue,\\nother than the skin tumors and papular eruptions, on any portion of\\nthe surface of the body, are due to some change in the tissue or the\\nstructure or organs directly underneath the swollen part. CEdema,\\nmyxoedema, subcutaneous emphysema, dystrophies, scleroderma, brawny\\ninduration, and local subcutaneous swellings are the principal ones to\\nbe considered.\\n(Edema; Dropsy.\\nThe lymph-spaces of the subcutaneous connective tissue become over-\\ndistended with serum, causing an accumulation to which the general\\nterm dropsy is applied. If the accumulation is local and confined to\\nsmall areas it is known as oedema. If it is general, and if, in addi-\\ntion, the large lymph-cavities, the pleura, the peritoneum, and the\\npericardium contain fluid, it is known as anasarca. Accumulation\\noccurs because more fluid is poured out by the vessels than can be\\nremoved by the lymphatics and veins. This may depend either upon\\nobstruction of the veins and lymphatics, or excessive exudation from\\nthe bloodvessels, or both. The former condition, however, is rare,\\nand usually local, because, unless the obstruction is very great, the\\nveins and lymphatics are able to carry away more fluid than is effused\\nfrom the capillaries.\\n1. Excess of fluid transudes when there is local capillary change\\nfrom inflammation or the effects of poisons. The change must be in\\nthe capillaries. It was thought that this general process was of an\\ninflammatory nature, but at present it is believed to be due to the in-\\nfluence of poisons, probably absorbed from the intestinal canal, alter-\\ning the nutrition of the capillary vessels. Thus, the oedema and\\ngeneral dropsy of albuminuria, particularly in the early stage of that\\naffection, are thought to be due to a poison circulating in the blood\\nwhich also causes the nephritis. Mahomed found a pre-albuminuric", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0158.jp2"}, "159": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 149\\nstage of scarlet fever, in which he noted a peculiar reaction of the\\nurine, which gave a blue color with guaiac. A brisk purgative admin-\\nistered when this reaction was noticed would prevent the occurrence of\\nalbuminuria, whereas if the drug was withheld albuminuria always\\nfollowed. The purgative removed the poison which caused the\\nnephritis and oedema.\\nIt is well known that in urticaria there is marked local oedema.\\nBrunton thinks that some poisons circulating in the blood cause paral-\\nysis of the secreting power of the sweat-glands, on account of which\\nthere is not only effusion from the bloodvessels, but at the same time\\nsuch changes in the secreting-cells take place as to produce an acid,\\nthe local irritative action of which, upon the capillaries, causes a\\nfurther transudation of fluid. That acids circulating in the blood have\\nthe power of creating oedema, the experiments of Cash and Brunton\\nfully demonstrate. While, therefore, in the oedema of Bright s disease\\nin its earliest stage and in urticaria we have this explanation of the\\nphenomena, other factors are causal in other forms of oedema.\\n2. Increased transudation and obstruction to the flow of lymph are\\nthe causes of some forms of oedema. It may be of local origin, as in\\nthe oedema over the site of an inflammation or the oedema of an arm\\nor leg from venous occlusion, or it may be of general origin, as in car-\\ndiac disease. The obstruction may be in the lymphatics or in the\\nveins. In the former it may occur (a) from want of muscular action\\n(6) from want of inspiratory action of the thorax (c) diminution of\\nthe diastolic suction of the heart (d) positive pressure on the veins.\\nIn the latter, obstruction of the veins is caused by conditions similar to\\nthose affecting the lymphatics, and arises from (a) want of muscular\\naction (b) want of movement of the thorax and (c) feeble action of\\nthe heart and, in addition, it is likely to be caused by (d) complete\\narrest of blood-flow from external pressure upon the vein or from\\nplugging of the vein. It can readily be seen, with a little knowledge\\nof physiology, how the above factors favor the development of oedema\\ndue to disease of the heart and to venous obstruction. The baneful\\nfactors are those which retard the flow of blood, preventing its return\\nto the right heart. Hence it is called the oedema of passive congestion.\\n3. A third form of oedema, usually slight, is that which is seen in\\nanaemia. Several factors combine to produce it (a) the watery con-\\ndition of the blood (b) the condition of the capillaries and (c) vaso-\\nmotor paresis on account of imperfect nutrition of the vasomotor\\ncentres. It may be diffused, as in the anasarca that attends the\\nanaemia of malaria.\\n4. GEdema may be of nervous origin. Such is the oedema that\\noccurs in diseases or injuries of nerves. To it possibly belongs the\\noedema of beri-beri. It may be a trophoneurosis with secondary alter-\\nations in the permeability of the vascular walls, or it may be due to\\nvasomotor paralysis.\\nMode of Recognition. Whether the accumulation is in local areas\\nor distends the entire subcutaneous tissue, the oedema is not difficult of\\nrecognition. The part is swollen and puffy, the surface is pale, smooth,\\nand shiny, the temperature is usually low, and the affected area pits", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0159.jp2"}, "160": {"fulltext": "150 GENERAL DIAGNOSIS.\\non pressure. Pitting is more pronounced if the finger is pressed over\\na part which is seated upon a firm background, as bone. (Edema of\\nthe ankle or over the tibia is more readily recognized than oedema in\\nthe calves.\\nThe oedema obliterates normal depressions and increases the rotundity\\nof the affected part. It causes deformity, as of the face and neck\\nor of the penis, when the accumulation of serum is considerable. The\\nswelling appears in the most dependent parts if the oedema is diffuse\\nor the cause is general, as in cardiac disease or in parts made up of\\nloose connective tissue, as the eyelids or scrotum. The temporary dis-\\nappearance of the oedema, either entirely or from one part, to appear\\nin another, is a prominent feature of it. It will disappear between\\nmorning and evening, or its position will alter with change in the posi-\\ntion of the body. The presence of a previously existing oedema can\\noften be told by the scars or striae that resulted from overstretching of\\nthe skin, as of the abdomen and thighs.\\n(Edema is to be distinguished from (1) Inflammatory swellings,\\nby the absence of the classical signs of inflammation pain, heat, and\\nredness. (2) The enlargement of myxoedema differs from oedema by\\nthe absence of pitting on pressure, the occurrence of induration, which\\nresists the pressure of the finger, and by the occurrence of anaesthesia\\nor analgesia. (3) The swellings of connective-tissue dystrophies are\\nhard, localized areas that do not pit on pressure, and are not seated in\\ndependent parts of the body. They are found on the arm, for instance,\\nor on the thigh, or about the flanks and in the axillae. (4) The swell-\\ning of subcutaneous emphysema differs from oedema in that it arises\\nin the course of some disease of the air-passages, and, on palpation, the\\ncrackling sensation of air under the finger is distinctly felt, while there\\nis no pitting on pressure. In the cases that the writer has seen the\\nparts were particularly tender, although pain in subcutaneous emphy-\\nsema is said usually to be absent.\\nDiagnostic Significance. The value of oedema as a diagnostic sign\\ndepends upon its location, its mode of development, and its association\\nwith disease of other organs or structures of the body.\\nLocation. The oedema may be limited to small areas, as the eyelids,\\nthe face, or the feet, or to an arm or leg it may involve an arm and\\nleg of the same side or it may involve the extremities and trunk and\\neven include the face. We therefore have local and general oedema.\\nLocal (Edema. Local oedema occurs when there is pressure on a\\nvein or occlusion of it by a thrombus. (Edema of the arm from press-\\nure on the veins by enlarged lymphatic glands in the axilla, and oedema\\nof the leg from thrombosis of the femoral vein, are examples of this\\nform of local oedema. Dropsy of an arm often occurs when the patient\\nhas laid upon it. Local oedema also occurs over the seat of inflamma-\\ntion, and is a valuable diagnostic sign. It is an indication of suppura-\\ntion. It is known as inflammatory or collateral oedema. 7 It is\\ndue to obstruction of the lymph circulation. It is seen over the mas-\\ntoid when its cells are the seat of inflammation over the parotid\\ngland under the same circumstances over parts of the thorax in em-\\npyema over the praecordia in purulent pericarditis over the surface", "height": "4416", "width": "2612", "jp2-path": "practicaltreatis00muss_0_0160.jp2"}, "161": {"fulltext": "THE DATA OB TA IN ED B Y OBSEB VA TION. 151\\nof the liver in some cases of hepatic abscess in the abdominal parietes\\nin purulent peritonitis, but more marked over the primary focus of in-\\nflammation, as the gall-bladder region or the region of the appendix.\\nThe Arms and Thorax. Another form of local oedema occurs\\nwhen there is pressure upon the superior vena cava from aneurism or\\ndisease of the mediastinal glands. The oedema is then limited to the\\narms, head, neck, and thorax. Such oedema is usually associated with\\ncyanosis of the hands and arms. There is also marked distention of\\nthe veins of the upper parts of the body. The oedema has been found,\\nin a few instances, to be more marked on one side than on the other.\\nThis has occurred in cases of aneurism which communicated with the\\nvena cava. Either the collateral circulation on one side had been\\nestablished or pressure was greater on the left innominate vein. The\\noedema is sometimes limited to the head and arms. If the obstruction\\nof the superior cava is situated below the entrance of the azygos vein\\nthe chest shares in the venous congestion and resulting oedema. If,\\non the other hand, the obstruction is above the azygos vein there is\\nno oedema of the chest-wall. This form of oedema, as a rule, is easily\\nrecognized by the presence of the above-mentioned symptoms, with\\nother pressure-symptoms, due to disease of the mediastinum and by\\nthe results of physical examination, which reveals the presence of a\\ntumor in the thorax. It usually develops slowly, hand-in-hand with\\nthe other symptoms. At times, however, it occurs suddenly. Sudden\\noedema in this situation is always due to an aneurism which has rup-\\ntured into the vena cava (see above). The sudden onset is attended\\nby physical signs of aneurism, or, if they are not present, by a murmur\\ncharacteristic of the communication between an artery and a vein. It\\nmust be confessed that often the physical signs are not precise and the\\nmurmur is absent. The suddenness of the peculiar localized oedema is\\nthe chief point of diagnosis in favor of this rare form of aneurism.\\nThe (Edema of Trichinosis. (See Face.) (Edema of the skin over\\nthe affected muscles, as well as of the face, occurs in trichinosis. It\\nbegins early in the disease, disappears after a few days, to return again\\nlater. It is localized over the muscles, and is associated with the\\ngrowth of trichina? in them. It is distinguished from cardiac and\\nrenal dropsy by its course and situation as well as by the fact that the\\nscrotum and labia majora are never oedematous.\\nThe cause of the above forms of oedema is local and in close prox-\\nimity to or in intimate anatomical relation with the dropsical swelling.\\nBut the cause of local oedema may be central, or in a sense general.\\nIt then develops gradually and begins in special localities, as in the\\nfeet or face.\\nThe Feet. (Edema of the feet or ankles is usually due to disturb-\\nance of the circulation. It arises in heart disease, or in the course of\\nany exhausting and debilitating disease in which the heart has become\\nweakened. The organic change which takes place in the heart-muscle\\n(dilatation) in the course of obstructive valvular disease and in lung\\ndisease is often attended by oedema of the feet. Later a general dropsy\\nmay ensue. But oedema of the feet may occur from another cause\\ni. e., anaimia. In all forms of this affection puffin ess of the ankles may", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0161.jp2"}, "162": {"fulltext": "152 GENERAL DIAGNOSIS.\\nbe seen. An explanation of the canse has been given. Similar local-\\nized oedema in individuals of relaxed fibre occurs hi the evening after\\na day of considerable physical exertion. (Edema of the feet, subse-\\nquently becoming diffuse, occurs in beri-beri.\\n(Edema of the Face. (Edema may begin or remain localized in\\nthe face, and is very striking. (See Face and Eyelids.) It may be\\nlimited to the eyelids, as a simple puffiness, or may spread over the\\nentire face, causing complete obscuration of the normal outlines. It\\nis the oedema of renal disease, and differs from oedema of the feet in\\nFace of a patient with general anasarca due to chronic parenchymatous nephritis. (Hare.)\\nthat it is more marked in the morning on rising and disappears toward\\nnight. Of all forms of local oedema it is the most grave, and should\\nat once call attention to the condition of the urine, particularly if the\\npatient has just had an attack of scarlatina, or if it occurs in a woman\\nwho is pregnant.\\nThe diagnostic significance of primary local oedema may be summar-\\nized as follows (1) Eyelids or eyes Bright eye, tear that does not\\nfall in nephritis; (2) face, nephritis; (3) forehead, trichinosis; (4)\\nhead, pressure upon superior vena cava above the azygos vein (5) one\\nside of head, pressure upon innominate vein (6) head and arms, or\\nhead, arms, and thorax, pressure upon superior vena cava (7) one\\narm, pressure upon axillary veins (8) one leg, pressure upon femoral\\nvein (9) hothfeet or legs, pressure upon inferior vena cava by abdomi-\\nnal tumor, loss of vasomotor tone, heart disease, anaemia, late nephritis\\n(10) the loins, lumbar cushion, nephritis, cardiac disease if patient is\\nin recumbent posture (11) the scrotum, nephritis and cardiac disease", "height": "4416", "width": "2612", "jp2-path": "practicaltreatis00muss_0_0162.jp2"}, "163": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 153\\n(12) local oedemas over inflammations of structures underneath, as\\nbones, the gall-bladder, the appendix, the pleura, peritoneum, or peri-\\ncardium.\\nGeneral (Edema. Anasarca. General anasarca is due to heart or\\nto kidney disease in most of the cases. (Edema of the face and feet\\nmay become general. In cases in which the face is first (Edematous its\\nextension may be very rapid, so that twenty-four to forty-eight hours\\nafter the swelling is noticed the whole body is in a state of anasarca.\\nRenal disease. The extension of oedema, primarily seated in the feet\\nand legs (cardiac dropsy), throughout the rest of the body is more\\ngradual, and develops with other signs and symptoms of weakness of\\nthe heart. Hence cyanosis gradually appears. This may be seen first\\nin the extremities. Finally the face and lips take on the peculiar hue.\\nOn the other hand, in the general anasarca that follows the local\\noedema of the face in Bright s disease, pallor occurs, and as the oedema\\nincreases it becomes more and more of a waxy hue, while the extremi-\\nties beome glistening or shining in appearance. In the so-called wet\\nform of beri-beri general oedema comes on rapidly.\\nAngioneurotic (Edema. This curious affection is not of frequent\\noccurrence. It may be present in the individuals of several genera-\\ntions of a family. The attack conies on suddenly. The swelling is\\ncircumscribed. It may appear on the face, on the brow, the lips, or\\ncheek. The eyelid is a common situation. It may also occur on the\\nbacks of the hands, the legs, or in the throat. It remains but a short\\ntime and disappears as quickly as it came on. The outbreaks have\\nexhibited distinct periodicity. Local symptoms of itching, heat, or\\nredness, or general urticaria, may precede the swelling. The sudden\\nswelling causes great deformity. If the upper lip is affected, the\\nmouth cannot be opened if the hands, the fingers cannot be bent. In\\nthe hereditary cases the attack recurs every three or four weeks. The\\ndanger to life is from oedema of the larynx, which caused death in two\\nof Osier s cases. The general symptoms that attend the attack are\\ngastro-intestinal. Xausea and vomiting occur, followed by severe colic.\\nIt must not be confounded with simple urticaria, or the giant form of\\nthat affection, with which it may, however, have close affinities. It is\\nregarded by Quincke as a vasomotor neurosis, which leads to impair-\\nment of the permeability of the vessels.\\nRecapitulation. From what has been said the student will observe\\nthat oedema may be local or general that local oedema may be uni-\\nlateral or bilateral that oedema may be further subdivided, in accord-\\nance with the cause, into inflammatory dropsy, oedema or dropsy of\\npassive congestion, hydremic dropsy, and vasomotor dropsy. The\\nforms of passive dropsies just indicated may be subdivided into cardiac\\ndropsy, hepatic dropsy, and renal dropsy, according to anatomical\\ncauses.\\nAVhile the account of oedema just given refers more particularly to\\nthe subcutaneous accumulation of serum, the same pathology and\\netiology apply to accumulations in the large lymph-cavities, and hence,\\nin addition to general oedema, we may have ascites, hydropericardium,\\nhydrothorax, hydrocele, and effusion in the joints. The methods of", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0163.jp2"}, "164": {"fulltext": "1 54 GENERAL DIA GNOSIS.\\nrecognition of dropsy of the larger cavities will be deferred until dis-\\neases associated with these particular regions are discussed. It must\\nbe remembered that oedema or accumulations of serum in cavities may\\nbe of local or general origin.\\nIt must not be forgotten that two or more causes may combine to\\nproduce a dropsy, or that a dropsy of one cause may for a time be\\ndependent upon a second and even a more pronounced factor later on\\nin the development of the disease. Thus (a) the dropsy of hydremia\\nmay be aggravated by that of (6) weak heart which arises from\\nanaemia, to which may be added later the dropsy of vasomotor paresis.\\nThe dropsy in Bright s disease is due to (a) capillary changes pro-\\nduced by a poison circulating in the blood, and (6), later, to the con-\\ndition of the heart if, as is frequently the case, it undergoes dilatation.\\nMyxoedema.\\nEnlargement of the surface of the body, local or general, is also seen\\nin myxoedema, a condition which simulates dropsy, as already stated.\\nIn myxoedema the swelling is general. The face is involved. The\\nFio. 20.\\nA typical case of myxoedema. (Starr.)\\narms are more markedly swollen, however, than the fingers the legs\\nmore than the feet. Usually the swelling of the legs and arms is\\nirregular. In some cases supraclavicular paddings are marked. These", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0164.jp2"}, "165": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 155\\npaddings must not be confounded with the pseudo-lipomata, described by\\nVerneuil, occurring in these situations. The swelling is due to the\\ninfiltration of mucin into the connective tissue, and arises from some\\naffection of the thyroid gland. The gland is absent, functionally or\\nactually. The hard, indurating, non-pitting swelling is associated\\nwith striking change in the appearance of the face, particularly the\\nnose and forehead. The nose becomes thickened, the forehead more\\nprominent and overhanging. The outline of the face is rounded, so\\nthat the term full-moon is applied to it. The skin is thickened,\\ndry, and rough, somewhat translucent in appearance, pale or yellow in\\ncolor, and of a doughy consistence, but with a moderate degree of elas-\\nticity. The perspiration is diminished. The hands change in shape,\\nthey become square or spade-shaped, and the fingers clubbed. The\\nappendages of the skin change. The nails become brittle and dis-\\ntorted, the hair dry, harsh, and brittle, and it may fall out. With\\nthese remarkable changes in the exterior marked nervous and mental\\nsymptoms arise. Speech is thick and hesitating, the memory feeble.\\nThe intellect is dull and irresponsive, the temper irritable. Sensibility\\nis impaired, particularly the loss of sensation to pain. Patients have\\nbeen burned without their knowledge. This happened in one of the\\nwriter s cases. Abnormal sensations of heat and chilliness are com-\\nplained of, as well as other paresthesias. The patient is anaemic, the\\ntemperature is subnormal, the heart s action weak, the respiration slug-\\ngish. Breathlessness on slight exertion is pronounced, and exertion\\nitself is very difficult, while there is a greater sense of fatigue than the\\nexertion and the condition of the organs would warrant. The mus-\\ncularity is enfeebled. There are impairment of appetite, indigestion,\\nand flatulency. The urine may become albuminous, but for a long\\ntime is not characteristic save in amount and specific gravity. The\\nformer is increased, the latter lowered.\\nAs the case advances mental and physical failure become more pro-\\nnounced, the patient is subject to hallucination, and is extremely irrita-\\nble. Stupor sets in death may take place in coma or from uraemia.\\nIt is a disease of mature life, and occurs most frequently in women.\\nThe following varieties are seen (1) Spontaneous myxoedema of\\nthe adult (2) infantile myxoedema (3) operative myxoedema and\\n(4) endemic myxoedema or cretinism. In infantile myxoedema the\\nfunctions of the thyroid body are suppressed during the period of the\\ndevelopment of the individual. Typical cases justify the name of\\nmyxoedematous idiocy.\\nSubcutaneous Emphysema.\\nEnlargement or swelling of the surface, either local or general,\\nmay occur on account of air underneath the skin. The skin is pale\\nand quite distended, and hence depressions are filled up, as the axil-\\nlary, clavicular, and intercostal spaces. The primary seat of the swell-\\ning is in close proximity to the air-passages, and occurs because of\\ncommunication between them and the subcutaneous connective tissue.\\nIt may occur in ulcerations of the upper passages, as the larynx or", "height": "4412", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0165.jp2"}, "166": {"fulltext": "156\\nGENERAL DIAGNOSIS.\\nFig. 21.\\ntrachea in ulcerations of the oesophagus into the mediastinum in the\\nulceration and rupture of phthisical cavities into the chest-wall and\\nin rupture of the lungs from hard coughing, sharp crying, severe\\nexertions, such as blowing of wind instruments. The air may escape\\nunder the pleura to the mediastinum and thence to the neck, or, when\\nthe pleura is adherent, air will pass from the lung into the connective\\ntissue. The swelling gradually spreads over the entire body from the\\nseat of rupture or in close proximity to it. In a case of laryngeal\\nphthisis under the writer s care it encircled the neck and spread uni-\\nformly over the anterior and posterior portion of the thorax. Thence\\nit extended downward until it met a corresponding infiltration of the\\nlymph-spaces in the thighs, due to serum. The distinction between\\noedematous swelling and subcutaneous\\nemphysema could thus be made the\\nlatter offered no resistance, did not\\npit on pressure, crackled under the\\nfinger, and was quite tender on press-\\nure. Spontaneous pain was not pres-\\nent but any position was painful in\\nwhich the weight of the body pressed\\nupon the part affected.\\nConnective-tissue Dystrophies.\\nEnlargements of the surface are\\nseen in the so-called dystrophies.\\nThe dystrophy is usually due to a\\nlocalized anomalous overgrowth of\\nconnective tissue, probably of trophic\\norigin. It can easily be distinguished\\nfrom oedema by the absence of the\\nsigns of oedema, or from local inflam-\\nmatory swelling by the absence of\\npain, heat, and redness. The swell-\\ning occurs on the arms and legs,\\nusually on the outer aspects, and may\\noccur in various portions of the trunk.\\nIn one of t^ojirriter s cases the swell-\\ning were periodical or, rather, the\\npersistent swirlings increased in size\\nat irregular intervals.\\nDercum and Henry have described\\ncases of dystrophy in which the en-\\nlargements had been attributed to\\naccumulations of fat. The patients\\npresented marked subjective nervous\\nphenomena, paresthesias of all kinds,\\nsinking and depression. There were\\nNote accumulations on back and on ex-\\ntremities. See knees and elbows wrists and\\nankles unusually small, Patient aged 56.\\nSecond attack of insanity. (Original.)\\nwith flushings and sensations of\\nareas of anesthesia, pain, and tenderness in the nerve-trunks. Pain\\npreceded the advent of the swellings.", "height": "4408", "width": "2664", "jp2-path": "practicaltreatis00muss_0_0166.jp2"}, "167": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 157\\nHerpes zoster occurred in Dercum s case, and other symptoms of\\nneuritis were marked. The irregularity in the distribution of the\\nswellings, their character and mode of development, the occurrence of\\nneuritis, and the absence of perspiration, distinguished dystrophy from\\nlipomatosis or excess of fat. The patients were of a neurotic type, and\\nmental impairment usually resulted in the course of the disease. The\\ngeneral nutrition failed, particularly as gastro-intestinal disorders\\nensued.\\nScleroderma.\\nScleroderma is a hyperplasia of the subcutaneous connective tissue\\nwith swelling and induration. It is brawny. As the tissues are almost\\nimmovable, the term hide-bound is applied to this condition There\\nare marked stiffness and also pain.\\nIn localized scleroderma, or morphoea, the skin has a waxy or dead-\\nwhite appearance, is brawny and inelastic. There may be preliminary\\nhyperemia of the skin. Subsequently pigmentation of the hypersemic\\narea takes place, causing changes in color, or the pigment may atrophy,\\ncausing leucoderma. The secretion of sweat is diminished or entirely\\nabolished. In the diffused form the affection begins in the extremities\\nor face, and is accompanied by a sense of stiffness or tension the skin\\nis usually hard and firm, and gradually a diffuse, brawny induration\\ndevelops. The skin cannot be picked up in folds. It may appear\\nnormal, but is generally very smooth, glossy, and dryer than usual,\\nrarely pigmented. Scleroderma may be confined to a limb or may\\nbecome universal. The appearance of the face is characteristic. It is\\nexpressionless, and the lips cannot be moved, while mastication is im-\\npossible the eyes and the nose are deformed the hands become fixed\\nand the fingers immobile and contracted, on account of induration\\nabout the joints, the deformity being called sclerodactyle. It is thought\\nto be due to a trophoneurosis, or to fibrosis of the arteries of the skin,\\nwith connective-tissue overgrowth in the adjacent areas.\\nBrawny Induration.\\n(Edema must not be confounded with the brawny induration of the\\ncalves of the legs in scurvy, probably from deep-seated hemorrhage.\\nIt must be remembered, however, that oedema of the ankles is very\\ncommon in this affection. Brawny induration may also be found in\\nsyphilis. In a patient recently under the writer s care, in the Presby-\\nterian Hospital, a brawny induration of the thigh, with painless swell-\\ning and stiffness of the leg, appeared to be due to syphilis. It disap-\\npeared rapidly under treatment with potassium iodide.\\nLocalized Subcutaneous Nodules.\\nSarcomata. The subcutaneous nodules seen in these affections are\\nrarely, if ever, confounded with oedema or other swellings. In sar-\\ncoma the subcutaneous tumor becomes attached to the skin and may\\nchange its color. It is usually secondary to sarcoma in some other", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0167.jp2"}, "168": {"fulltext": "158 GENERAL DIAGNOSIS.\\norgan of the body. When primary, or secondary to organs in which\\nthere is normal pigmentation, as the eye, they become blue or bluish-\\nblack. On palpation the surface is found to be rough and uneven if\\nthe tumors are numerous.\\nPrimary melanotic sarcomata of the skin can always be distinguished\\nby their color. In both forms of sarcomata the general symptoms of\\nthis affection daily become more and more pronounced, and subcuta-\\nneous hemorrhages are commonly associated with the local phenomena.\\nThe first external evidence of lymphosarcoma may be subcutaneous\\nnodules in unusual situations. Thus, in a case under my observation,\\na lymphoid nodule was first observed in the third interspace on the\\nright side. Subsequently the glandular involvement followed.\\nCarcinomata. Subcutaneous lymphatic glands may be the seat of\\nsecondary carcinoma, and from their location may indicate the primary\\nsource of the disease. The glands above the left clavicle are some-\\ntimes secondarily affected in cancer of the stomach. In similar dis-\\neases of abdominal organs glands in the abdominal wall are enlarged.\\nThe subcutaneous nodules should be removed and examined microscop-\\nicall y. The structures of the umbilicus (skin and subcutaneous tissues)\\nenlarge, become nodulated, and sometimes the seat of fungoid ulcera-\\ntion in abdominal carcinoma, particularly of the stomach. It must\\nnot be forgotten that primary sarcoma or carcinoma of the skin, lim-\\nited to one area, and simulating an intra-abdominal growth, may occur,\\nas in a case under my care in the Philadelphia Hospital, operated on\\nby Horwitz.\\nOysticercus Cellulosse. The nature of the subcutaneous nodules\\nof cysticercus are recognized by microscopic examination. They are\\nusually associated with the larvae in other tissues, hence the patient\\ncomplains of great soreness and stiffness, and may become helpless.\\nRheumatic Nodules. Subcutaneous nodules are seen in rheumatic\\npatients in the course of the disease, or after the attacks. They are\\ncommon in the young. They are particularly frequent in cases of\\nrheumatic endocarditis. They may occur independently of the articu-\\nlar symptoms. They may occur in large numbers, and vary in size\\nfrom a small shot to a large pea. They are of fibrous structure.\\nThey are attached to the tendons and fasciae, particularly on the fingers,\\nhands, and wrists, but may be found over the elbows, knees, the\\nscapulae, and the spines of the vertebrae.\\nSyphilitic Nodes. Gummata are observed in the tertiary periods\\nof. syphilis. They must not be confounded with the enlarged glands.\\nThey are attached to the skin, and may from time to time ulcerate.\\nThey may be seen on the back or buttocks less frequently on other\\nparts.\\nThe Lymphatic Glands.\\nInformation of diagnostic value may be obtained from the condition\\nof the lymphatic glands. (See Chapter VII.) Enlargement may be\\ngeneral or local.\\nEnlargement of the cervical glands, and of the axillary and inguinal\\nglands attended by fever, occurs in that obscure infection described by", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0168.jp2"}, "169": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 159\\nDawson Williams and others called glandular fever. Similar glandu-\\nlar enlargement is quite characteristic of German measles or rotheln.\\n(See the Infections.)\\nEnlargement of the post-cervical glands, the epitrochlear glands, and\\nlymphatic glands in other portions of the body points to syphilis. In\\nthe two first-mentioned localities the enlargement is of great diagnostic\\nimportance, as it is less likely to be due to any other causes. Suppu-\\nrating glands do not here concern us.\\nInguinal and Axillary Enlargement. With or without suppuration,\\nenlargement always points to an irritation or lymphatic invasion in\\nthe area drained by the affected lymphatic gland. When in the groins\\nthe feet are affected, and when in the axillae the hands. Great enlarge-\\nment in either situation causes oedema of the corresponding extremity\\nif the veins are pressed upon. The axillary glands are early affected\\nand enlarged in mammary cancer. The breast should always be\\nexamined in oedema of the arm.\\nThe Supraclavicular Glands. These glands are often enlarged\\nand indurated, and may cause pressure-symptoms. The only local\\nenlargement that is of special diagnostic significance is that which is\\nseen above the clavicle on the left side. They often point to carci-\\nnoma of the stomach, as Troisier announced. 1 Indeed, there are cases\\nof this disease in which only the general symptoms of carcinoma are\\npresent. Local symptoms are wanting and the locality of the cancer\\ncannot be made out by the symptoms. The enlarged glands above the\\nclavicle are a fair indication that the stomach is the seat of the disease.\\nThe enlargement is probably due to transmission of the infection\\nalong the thoracic duct and its lodgement in the associated glands.\\nThe Cervical and Submaxillary Glands. Enlargement of the\\nsubmaxillary and cervical glands points to affections of the mouth\\nand throat or of the jaw and teeth. It is caused particularly by infec-\\ntious disorders in these localities. They are often the seat of nodular\\nenlargement in actinomycosis. (See collar in adenitis of leukaemia.)\\nScars at the site of former glands point to tuberculous destruction\\nor former bubo, and are suggestive.\\nThe glands are enlarged in simple adenitis, tuberculosis, Hodgkin s\\ndisease, leucocythcemia, sarcoma, and cancer. The moderate enlarge-\\nment of syphilis and the local enlargement from irritation in the area\\nof lymph-drainage have been mentioned. Adenitis is usually local.\\nThe gland is tender and the connective tissue around it is affected.\\nThere are local heat and pain. At first the gland is hard, later it\\nsoftens in the centre, and finally it exhibits fluctuation. In tuberculosis\\nmore than one gland is affected. Usually the glandular involvement\\nis bilateral (as in the neck). At first the glands are isolated. Later\\nthey become matted. The local symptoms are not marked and the\\nprocess is very indolent. Thick, cheesy pus is discharged which may\\ncontain tubercle bacilli. It causes tuberculosis when inoculated in\\nlower animals a method of diagnosis necessary to be resorted to fre-\\nquently. The tuberculin test must be used. Fever and decline\\n1 Bulletin et Memoires de la Societe Medicale des Hopitaux, January 13, 1888.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0169.jp2"}, "170": {"fulltext": "160\\nGENERAL DIAGNOSIS.\\noccur later, but often not until other structures, as the lungs, are in-\\nfected. (See Leucocythaemia.)\\nLympho Sarcoma is an infection of the glandular structures of ob-\\nscure origin. A local group of glands may be involved or the glands\\nthroughout the body may be the seat of the overgrowth. When the\\ninfection is general the deep-seated glands, as the mediastinal and\\nretroperitoneal, may be the first involved. Anaemia, fever, and signs\\nof intrathoracic and abdominal pressure may be present without decisive\\nindications of the nature of the disease. In a short time, however, a\\nsuperficial gland may enlarge, and from thence rapidly other glands be\\ninvolved. The occurrence of an enlarged gland in any part of the\\nbody may be suggestive of the nature of a deep-seated process. Posi-\\ntive diagnosis can be established, and the method should be resorted\\nto by removal of the gland and its examination microscopically. A\\ncase of this character seen with Hare showed the first evidence of\\nglandular infection in the enlargement of a small gland over the third\\ninterspace on the right side of the chest in front.\\nHodgkin s Disease.\\nHodgkin s disease (pseudoleukemia, lymphadenoma, or lymphatic\\nanaemia) is characterized by enlargement of the lymphatic glands and\\nother adenoid tissue by pro-\\ngressive oligocythemia with-\\nout, in most cases, much in-\\ncrease of leucocytes and by\\nthe development of lymphatic\\ntumors in unusual situations.\\nThe disease is most frequent\\nin the first half of life, three-\\nfourths of the cases bemg in\\nmales.\\nThe first symptom noted is\\nenlargement of the glands of\\nthe neck but sometimes the\\ninguinal, less frequently the\\naxillary glands, are first en-\\nlarged rarely the tonsils are\\nthe first to be affected. The\\nenlargement is painless and\\nprogressive, appearing first on\\none side of the neck and ex-\\ntending under the jaw to the\\nopposite side. The tumors at\\nfirst are distinct and movable\\nunder the skin. The swollen\\nglands may remain in this condition indefinitely for months or years\\nbut eventually they begin to enlarge very rapidly, lose their separate\\nidentity, and coalesce into large masses. Other glands in remote parts,\\nas the axilla and groin, retroperitoneum, and arm, are affected. They\\nIr\\nHodgkin s disease. Glands in right axilla and neck\\nmuch enlarged.", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0170.jp2"}, "171": {"fulltext": "THE DATA OB TA IN ED B Y OB SEE VA TION. 161\\nmay be soft and fluctuating, or very dense and hard, but heat, tender-\\nness, suppuration, and other evidences of inflammation are absent.\\nThe spleen becomes very much enlarged, but rarely attains the\\ndimensions common in leucocythaemia.\\nOther adenoid tissue in the intestine, tonsil, and posterior nares,\\nand even the thymus, may enlarge and give rise to pressure symptoms.\\nFever is a very constant symptom, but the type is not constant. The\\nonset of the disease may be marked by fever and constitutional symp-\\ntoms, and the glandular enlargement appears later. On the other\\nhand, in three cases reported by J. Dreschfeld, 1 all the patients enjoyed\\ngood health and were able to follow their work until a few weeks\\nbefore death. In all symptoms appeared suddenly, and consisted of\\npain, weakness, pallor, loss of appetite, and pyrexia.\\nCoincident with the rapid and extensive enlargement of the glands,\\nanaemia becomes pronounced and is accompanied by the usual symp-\\ntoms. Cough is often associated with anaemic dyspnoea, and in women\\nmenstruation may cease.\\nAlong with the general symptoms there are numerous local ones,\\ndue to the pressure or impairment of function cerebral anaemia from\\npressure on the carotids cerebral congestion from pressure on the\\nveins of the neck disturbance of the heart from pressure on the\\npneumogastric deafness difficulty in deglutition and mastication\\nand pleural, peritoneal, and pericardial effusions.\\nThe most frequent complications are nephritis, fatty degeneration of\\nthe heart, pleurisy, and, less frequently, pneumonia and pericarditis.\\nThe duration of the disease is from six to eighteen months. Two-\\nthirds of fifty fatal cases referred to by Gowers 2 ended in less than two\\nyears. It is difficult to determine accurately the beginning of the\\ndisease sometimes a long period of latency follows the early glandular\\nswelling sometimes a general anaemia precedes any noticeable swelling\\nof the glands and sometimes the disease runs an acute course, ending\\nfatally in two or three months.\\nDeath results most frequently from exhaustion but pressure upon\\nthe trachea producing asphyxia is not uncommon, and death has\\noccurred from starvation, the result of occlusion by pressure of the\\noesophagus. The complications already mentioned are the immediate\\ncauses of death in other cases.\\nThe diagnosis is not difficult with blood examination. By this means\\nleucocythaemia is excluded. It may be distinguished from tuberculosis\\nin the early stages when local by the site of the enlargement. In the\\nI former the submaxillary glands are involved in the latter the glands\\nin the anterior and posterior cervical triangles. The tuberculin test is\\nrequired, as insisted upon by Otis, to establish tuberculous adenitis.\\nLymphangitis or Angioleucitis. The streaked redness over the\\nsurface of the skin, with tenderness along the course of the lymphatics\\nand oedema, is characteristic of inflammation of the lymphatic vessels,\\nand need not be further mentioned. The glandular and dermal changes\\n1 British Medical Journal, April 30, 1892.\\n2 Reynolds System of Medicine, Philadelphia, 1880, vol. iii. 549.\\n11", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0171.jp2"}, "172": {"fulltext": "162 GENERAL DIAGNOSIS.\\nof elephantiasis, with chyluria, with or without lymph scrotum, are\\nunmistakable the disease is due to Xhefilaria sanguinis hominis.\\nLymphatism. Poor physical development has recently been ob-\\nserved with lymphatic overgrowth, or the constitutio lymphatieo. In\\nthis state sudden death is liable to occur. It is believed that one of\\nthe causes of death from anaesthesia and from antitoxin of diphtheria is\\na condition known as status lymphaticus. Hyperplasia of the lym-\\nphatic glands, the spleen, the thymus, and the bone marrow are rarely\\nfound in patients with rhachitis, and in hypoplasia of the heart and\\naorta. The internal lymphatic glands and the lymphatic structures of\\nthe alimentary tract are more frequently involved than the more\\nexternal glands. With this overgrowth of lymph-tissue the spleen\\nand the thymus gland are enlarged, and red marrow replaces the yellow\\nmarrow in young adults. The hypoplasia of the vascular system is\\nnot easily recognized. The left ventricle may be dilated and the\\nperipheral arteries diminished in size.", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0172.jp2"}, "173": {"fulltext": "CHAPTER XII.\\nTHE DATA OBTAINED BY OBSERVATION\u00e2\u0080\u0094 {Continued).\\nThe muscles idiopathic muscular atrophy pseudohypertrophy Thomsen s disease\\nparamyoclonus multiplex. Myositis myalgia muscular rheumatism.\\nTHE MUSCLES.\\nThe Nutrition. The nutrition of the muscles is observed by the\\nhand of the examiner while the muscles are made to relax and contract\\nalternately. We compare corresponding muscles of the two sides.\\nMeasurement of the limbs at corresponding situations makes the obser-\\nvation more accurate. The muscles may atrophy or hypertrophy.\\nEither condition may be local, unilateral, bilateral, or general.\\nMyoidema is a local contraction of the muscle which occurs upon\\nstriking it with a pleximeter or the finger, as in percussion. It is more\\nparticularly seen in thin subjects, usually tuberculous, and elicited by\\ntapping the pectoral muscles. The fasciculi raise in little humps, which\\npersist for a short time and gradually subside. At one time they were\\nthought to be diagnostic of tuberculosis. They are of no special\\nsignificance.\\nAtrophy.\\nThere are several varieties of atrophy 1. The atrophy of disuse.\\n2. Myopathic atrophy. 3. Myelopathic atrophy, or the atrophy of\\ndegeneration. It follows lesions of the motor path, of the cortex,\\nmedulla, or spmal cord and neuritis. (See Nervous Diseases.)\\nThe Atrophy of Disuse. It is also known as the atrophy of inac-\\ntivity. The muscles are slightly lessened in volume. The atrophy\\ntakes place very slowly it supervenes in cases of paralysis and in\\nthe joint-diseases which cause immobility. It occurs also in joint-\\ndisease from reflex influences. The electrical reactions of the muscles\\nare qualitative and unchanged. By this reaction atrophy from disuse\\nand atrophy from disease of the muscles can be distinguished from myelo-\\npathic atrophy, due to disease of the nerves (neuritis), or to degeneration\\nof motor nerves and ganglia.\\nMyopathic Atrophy. Muscular Dystrophy. In this form of\\natrophy the muscle is diseased. It diminishes in volume and finally\\nbecomes completely shrunken. Complete paralysis rarely ensues, but\\nthe reaction of degeneration cannot be determined.\\nIdiopathic Muscular Atrophy. Dystrophia muscularis pro-\\ngressiva (Erb). In this affection muscular wasting takes place with or\\nwithout initial hypertrophy. Three forms are seen\\n1. Atrophy with Pseudohypertrophy. It usually begins in\\nchildhood, and is often of congenital origin, being transmitted through", "height": "4412", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0173.jp2"}, "174": {"fulltext": "164 GENERAL DIAGNOSIS.\\nthe mother. It is first noticed just as the child is learning to walk.\\nThe extensors of the leg, the glutei, the lumbar muscles, the deltoids,\\nand the triceps and infraspinati muscles are involved, but the first\\nchange takes place in the muscles of the calves. The muscles of the\\nface, neck, and forearm are not usually affected in this form of the\\ndisease the muscles of the hand are not involved. While hypertrophy\\nprogresses in certain muscles others waste. The calves may hypertro-\\nphy, for instance, while the extensors of the leg waste away and become\\nweak. Attitude and gait are characteristic. (See page 7.3.) The patient\\nstands erect, with the legs apart, the shoulders thrown back, the spine\\ncurved, and the abdomen prominent. The waddling gait is character-\\nistic, and the method of getting up from the floor is pathognomonic.\\nThe course of the disease is slow, wasting follows the hypertrophy, but\\nthe weakness is greatest in the muscles first atrophied. Contractures\\nand distortions of the spine and of the bones of the leg take place.\\n2. Primary Atrophy. This is likewise congenital or manifests\\nitself in early life. It is divided into different types, according to the\\ngroups of muscles that are affected. The same process occurs as in\\nthe former, except that pseudohypertrophy is not primary. There\\nmay be several forms in different members of the same family. Of\\nthese we have the juvenile form of Erb. The upper arm and shoulder\\nand the thigh muscles are first involved. Later the muscles of the\\ngluteal region and calf may become enlarged and hard. The back\\nmuscles are gradually affected, inducing the attitude previously men-\\ntioned. The reaction of degeneration is not present. There is also an\\ninfantile type, first described by Duchenne, or the fascio-scapulo-humeral\\ntype. Erb s form begins about puberty. The other forms usually\\nbegin in childhood, but may be delayed. The face is involved it is\\nexpressionless, and in laughing the muscles move slowly the child\\ncannot whistle, as the lips are thick and everted. The eyes remain\\npartly open. The muscles of the group waste later the thighs become\\ninvolved. Erb has given a useful test to determine the strength of the\\nshoulder and girdle muscles. When the child is lifted by the armpits,\\nif the scapulohumeral groups are weak, the shoulders are forced up to\\nthe child s ears without resistance.\\n3. Peroneal Atrophy. A peroneal type of muscular atrophy has\\nbeen described by Charcot. The extensors of the great toe and after-\\nward the common extensors and peronei muscles are affected club-\\nfoot results. The muscles of the thigh may become involved later.\\nWhen the disease occurs in childhood it gradually spreads to the upper\\nextremities and affects the muscles of the hand, differing in this respect\\nfrom other forms of muscular atrophy. The thenar, hypothenar, and\\ninterossei muscles are symmetrically involved, producing the claw-hand.\\nUnlike the other forms of atrophy embraced under this heading, the\\nperoneal type is attended by disturbances of sensation, and by pain, fibril-\\nlary contractions, and vasomotor changes. The reactions of degeneration\\nmay be present. It is thought by competent observers to be simply a\\nform of neuritis and it is also called progressive neural muscular atrophy.\\nDiagnostic Features of Myopathic Atrophies. The disease\\nis characterized by gradual progression of the wasting and weakness in", "height": "4404", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0174.jp2"}, "175": {"fulltext": "THE DATA OBTAINED BY OBSERVATION.\\n165\\nvarious groups of muscles not specially related. We never see wasting\\nof the intrinsic muscles of the hands, as in the spinal forms of muscular\\natrophy, or of the tongue, pharynx, larynx, and eye. Electrical irri-\\ntability is lessened and reaction of degeneration is not present. Fibril-\\nlary twitching is not seen. Sensation is not affected. The reflexes are\\ndiminished and later may be lost. The sphincters are not involved\\ndeformities about the joints or in the spinal column may occur.\\nThe diagnosis of idiopathic muscular atrophy is not difficult if the\\nabove-mentioned facts are borne in mind. The fact that it occurs in\\nfamily groups is an important point in the diagnosis. In cerebral\\natrophy there is primary loss of power. In chronic anterior poliomy-\\nelitis (spinal atrophy) wasting begins in the muscles of the hands in\\nboth the simple and spastic form there are reactions of degeneration,\\nfibrillary twitching, and increase in the reflexes, and, in the latter,\\nspastic contraction of the legs. The myopathies occur early in life, and\\nare hereditary.\\nIn neuritis the paralysis is proportionately greater than the atrophy.\\nSensory symptoms are often present. The cause is distinct. There is\\nno family history.\\nGeneral Atrophy. In cachexias the muscles as well as the tissues\\nundergo atrophy. Even in nervous disease the atrophy of the muscles\\nmarkedly increases when general wasting takes place.\\nRaymond s Table of Atrophies.\\nCircumscribed atrophies\\nProgressive atrophies\\nProgressive myopathic\\nDiffuse atrophies\\nr Atrophy from compression.\\nAtrophy in inflammatory conditions (pleurisy, joint-disease, etc.).\\nAtrophy from injury or inflammation of individual nerves.\\nProgressive spinal muscular atrophy type Aran-Duchenne.\\nPseudohypertrophic muscular paralysis.\\nType Leyden-Mobius.\\nType Zimmerlin.\\natrophy Type Erb.\\nType Landouzy-Dejerine.\\nType Charcot-Marie.\\nInfantile form.\\nAcute of adults spinal paralysis, with\\nrapid course and curable (Landouzy-\\nDejerine) subacute and chronic form\\nchronic mixed form Erb diffuse\\nsubacute, general spinal paralysis\\n(Duchenne).\\nAnterior poliomyelitis\\nI Syringomyelia.\\nr Lead paralysis.\\nMultiple neuritis Lep rous neuritis,\\n(amyotrophic form)\\nMuscular atrophies of cere- With seC ondary degeneration involving the anterior cornua.\\n)ra origin wi^o^ secondary degeneration involviug the anterior cornua.\\nMuscular atrophy in hysteria\\nMuscular atrophy from sys- L Amyotrophic scleros.s.\\ntemic disease of the cord j ^osso-labio- laryngeal paralysis.\\n(Atrophy in myelitis.\\nAtrophy in compression of the cord.\\nAtrophy in multiple sclerosis.\\nAtrophy in tabes dorsalis.", "height": "4412", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0175.jp2"}, "176": {"fulltext": "166 GENERAL DIAGNOSIS.\\nHypertrophy.\\nHypertrophy of individual muscles occurs from overuse, as when an\\nextremity or a portion of the trunk is used in excess. General hyper-\\ntrophy of muscles occurs in Thomsen s disease. True hypertrophy is\\nrecognized by increased volume, great hardness, and increased vigor of\\nthe muscle.\\nPseudo-hypertrophy (see under Muscular Atrophy) is associated\\nwith increased volume of muscle but diminished power.\\nThomsen s Disease {Myotonia congenita). This is an hereditary\\ndisease and may occur in several generations of a family. Tonic\\ncramps take place in the muscles when voluntary movements are\\nattempted. The disease begins in childhood, rarely after puberty.\\nThe muscles become rigid and fixed when put in action. The lack of\\nvoluntary control of the muscles is shown by the slow contraction and\\nrelaxation when voluntary efforts are made. The rigidity may wear\\noff and the limb can then be used. It is particularly noticeable when\\nwalking is attempted. As the leg is advanced slowly it may remain\\nstiff for a second or two, but after it becomes limber the patient can\\nwalk for hours. If he stops walking the same difficulty is experi-\\nenced when he starts again. Both arms and legs are affected. Patients\\nare usually well nourished, however. There are no atrophies. The\\nmuscles are irritable, so that mechanical stimulus or pressure causes\\ntonic contraction. Movement and cold aggravate it. Sensation and\\nthe reflexes are not affected, and there is no evidence of disease of the\\ncerebro-spinal system, save the occurrence of hypochondriasis in some\\ncases. The myotonic reaction described by Erb is induced. (See\\nelectrical diagnosis Diseases of the Nerves.)\\nParamyoclonus Multiplex. In this affection there is clonic con-\\ntraction of the muscles. It is usually confined to the extremities and\\noccurs in paroxysms. It may have been caused by sudden twitching\\nor violent motion. The clonic spasms at first do not interfere with\\nthe patient s occupation, but gradually they increase. Both legs are\\naffected, and the number of contractions varies from 50 to 150 a minute.\\nThe contractions may be rhythmical. In severe cases the muscles of\\nthe back and abdomen contract violently. Tremor of the muscles\\nmay be present in the intervals. (For paralysis, spasm, tremor, contrac-\\ntion, etc., see Nervous System.)\\nMyositis. Inflammation of the muscles. (See also Trichinosis.) In\\ninflammation of the muscles there is pain, swelling, and loss of power.\\nIn universal myositis the inflammation begins in the lower extremities\\nand gradually involves other muscles of the body. They are swollen,\\nhard, and painful on pressure. Atrophy supervenes in groups of\\nmuscles. The muscles may become more or less rigid. Local oedema\\nof the skin over the muscles occurs. The progress is gradual, and\\ndeath ensues when the respiratory muscles are involved.\\nThe three cardinal symptoms that attend the disease as described by", "height": "4408", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0176.jp2"}, "177": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 167\\nLoenfeld are (1) Swelling of the extremities due to subcutaneous\\noedema and swelling of the muscle, causing functional disturbance (2)\\nextension to the muscles of respiration and deglutition (3) a more or\\nless extensive eruption. The latter is erythematous, its distribution is\\nusually general but irregular, and may be followed by pigmentation.\\nThe disease must not be confounded with trichinosis. In the latter\\nexamination of a small portion of muscle reveals the trichinae.\\nProgressive ossification of the muscles is rare. The muscle-tissues\\nundergo gradual ossification, either in localized spots or in wide-spread\\nareas. Inflammation of the muscle precedes the ossification. As the\\ninflammatory swelling subsides the muscles become hard and are grad-\\nually converted into bony tissue. The disease lasts many years.\\nMyalgia is an inflammation of the muscles produced by cold or\\ntrauma. There is pain on movement and spontaneous pain in the\\nmuscle it is tender on pressure. It may be the seat of spasm.\\nMuscular Rheumatism. In this variety of rheumatism there is pain\\nin the affected muscles, which often comes on suddenly in the night,\\nor is first noticed when the patient attempts to rise in the morning.\\nThe pain when the patient is at rest may be inconsiderable, rarely\\namounting to more than a dull, aching, sore feeling on attempting to\\nmove, to bend, or twist, or straighten himself, however, the patient\\ncatches himself suddenly on account of the agonizing, tearing, or burning\\npain. When the muscles are relaxed the patient is fairly comfortable.\\nSudden movement is the most painful. The affected muscles are\\ntender to the touch and to sharp blows. Muscular rheumatism may be\\nacute or chronic. In the latter the symptoms are very much like those\\nof chronic articular rheumatism, except that the muscles and not the\\njoints are affected. There is the same proneness to recur in unfavor-\\nable weather and in cold, damp seasons.\\nThe disease receives different names according to the muscle affected.\\nThe most common subvarieties are lumbago, in which the muscles\\nof the small of the back are affected pleurodynia, in which the inter-\\ncostal muscles suffer and torticollis, in which the sternomastoid and\\ntrapezius are painfully contracted.\\nIn lumbago the patient holds himself rigid and is unwilling to rotate\\nthe trunk upon the vertebrae. Often the most comfortable position is\\nthat in which he sits and bends slightly forward over another chair.\\nMotion is painful but pressure is not. Fever is absent. There is\\na history of repeated attacks, or of exposure, such as lying upon\\ndamp ground. Lumbago needs to be distinguished from disease of\\nthe spinal membranes, from disease of the vertebrae, aneurism, abdomi-\\nnal abscess, and diseases of the uterus and ovaries. The diagnosis of\\nrheumatism is arrived at by exclusion.\\nIn pleurodynia there is usually tenderness upon pressure as well as\\nupon motion and deep inspiration. The pain is of the same sore, burn-\\ning character, aggravated by coughing and sneezing. The patient\\nbreathes as little as possible, and often bends over toward the affected\\nside to lessen the motion. Pleurodynia is distinguished from pleurisy", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0177.jp2"}, "178": {"fulltext": "168 GENERAL DIAGNOSIS.\\nby the absence of fever, cough, and, above all, of friction-sounds. In\\nintercostal neuralgia there are painful points upon pressure, whereas in\\npleurodynia firm pressure is grateful, though tapping is painful.\\nIn torticollis the head is drawn to one side and fixed in that position.\\nThe sternomastoid especially is rigid and tender on pinching. In\\nspinal affections the head is retracted, and there are antecedent symp-\\ntoms, as headache and darting pains with fever.\\nFibrous Tissues. Intimately associated with rheumatic affections\\nof the muscles is that of the fibrous tissues or fascia. Pain, fixation,\\nand tenderness are noted, and if with them other rheumatic manifesta-\\ntions are found the diagnosis is established especially is the above true\\nof trauma.", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0178.jp2"}, "179": {"fulltext": "CHAPTEE XIII.\\nTHE DATA OBTAINED BY OBSERVATION\u00e2\u0080\u0094 {Continued).\\nThe bones general examination. Enlargement acromegaly osteitis deformans pul-\\nmonary osteo-arthropathy Diminution rhachitis osteomalacia. Local examination\\nposition and shape nodes inflammation osteomyelitis.\\nTHE BONES AND JOINTS.\\nMethod of Examination. When the bones and joints, especially\\nthe spinal column, are to be examined, the patient should be stripped,\\nand after the movements and position in the upright or semi-upright\\nposition have been noted, he should be made to lie down on a hard,\\nsmooth surface, and the trunk and joints examined in that position.\\nAnterior, posterior, and lateral movements of the spinal column must\\nbe made to determine its flexibility. In this manner deformities,\\nchanges in the length of the bones, and abnormal posture can be care-\\nfully observed. In addition we must note muscular wasting, the pres-\\nence of local tenderness and swelling, changes in the movements of the\\njoints, and loss of other functional activity causing lameness or joint-\\ndisability.\\nTo distinguish joint lesions from abnormal flexions or extensions,\\nthe result of spasm of muscles, anaesthesia must be employed.\\nThe Bones.\\nThe bones are fixed landmarks by which the location of organs is\\ndetermined. The student should familiarize himself with the shape of\\nthe bones and the location of normal tuberosities.\\nThe bones may be the seat of nutritive changes which involve the\\nskeleton in whole or in part, causing enlargement or diminution of the\\nosseous system, and hence of the body. Local changes are traumatic\\n(periostitis) or infectious, giving rise to nodes or to swellings.\\nGeneral Examination. Enlargements. Nutritive changes giving\\nrise to enlargement of the bones occur in acromegalia, osteitis defor-\\nmans, and pulmonary osteo-arthropathy.\\nAcromegalia.\\nMarie first described acromegaly, a skeletal change, characterized\\nby hypertrophy of the bones of the hands, feet, and face. The fibro-\\ncartilages of the ear and larynx are also enlarged. The enlargement\\nof the inferior maxillary and frontal bones causes the face to assume a\\npeculiar, elongated, elliptical outline. The nasal bones are enlarged,", "height": "4412", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0179.jp2"}, "180": {"fulltext": "170\\nGENERAL DIAGNOSIS.\\nFig. 23.\\nand the nose thickened the temporal fossae are deepened, on account of\\nenlargement of the malar bones. The forehead retreats because of the\\nenlargement of the frontal sinuses and projection of the superciliary\\nridges the chin is prominent and the lower teeth project beyond the\\nplane of the upper the lips and eyelids may be thickened the tongue\\nis enlarged and thickened. The hair is coarse and dry the face dry\\nand pigmented.\\nThe hands are peculiar they are much broader, the fingers are\\nsausage -shaped, and the hand spade-like in shape the nails are flat,\\nstriated, and too small. There is usually\\nspinal curvature the abdomen is prom-\\ninent, and, as before intimated, the\\nheight is increased. The muscles be-\\ncome weak and may atrophy the skin\\nC. mf is often pigmented varicose veins have\\nbeen observed, and the patient complains\\nof hemorrhoids. The thyroid gland may\\nbe atrophied or hypertrophied. It may\\nbe well to state, in passing, that with\\nthese appearances nervous phenomena\\nare observed and disorder of special\\nsenses complained of. Hemianopsia,\\nlimitation of the visual field, and blind-\\nness or deafness arise.\\nI Osteitis Deformans.\\nAnother remarkable change is seen\\nin the skeleton, and has been described\\nby Sir James Paget in this there is\\nmarked change in the contour of the\\npatient and a peculiarity in the mode\\nof locomotion. It is known as osteitis\\ndeformans. The head is advanced and\\nlowered, so that the neck is very short,\\nand the chin, when the head is at\\nease, is more than an inch below the\\ntop of the sternum. The chest becomes\\ncontracted, narrow, flattened laterally,\\ndeep from before backward, and the\\nmovements of the ribs and spine are\\nlessened the arms appear unnaturally long the shafts of each tibia\\nand femur are bent so that the patient becomes bow-legged. There is\\nsome stiffness, but no loss of power and not a great deal of pain. The\\nskull is increased considerably in thickness.\\nThese changes in the bones cause a dwarfed appearance of the trunk\\nin comparison with the legs and arms, and the posterior lateral curva-\\nture necessitates a characteristic attitude. The skeletal changes are\\nnoted particularly in the long bones. As a result of the enlargement\\nof the cranial bones, the face presents a triangular outline, with the base\\nCase of acromegaly. (Osborne.", "height": "4404", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0180.jp2"}, "181": {"fulltext": "THE DA TA OB TA IN ED B Y OB SEE VA TION. 171\\nabove and the apex below (see Fig. 24, outline 3), thus differing in\\nappearance from the outline in acromegaly (Fig. 24, outline 2).\\nFig. 24.\\nI\\n2\\no\\nOutline of face in\\nOutline in acro-\\nOutline in osteitis\\nmyxcedema.\\nmegaly.\\ndeformans.\\nPulmonary Osteo-arthropathy.\\nMarie distinguishes acromegaly from another skeletal change in\\nwhich there is hypertrophy of the bones of the extremities, including\\nenlargement of the shafts. In this form of arthropathy the bones of\\nthe head and face are not affected. The hands and feet are enlarged,\\nand the patellae and other bones of the knee-joints increased in size.\\nFig. 25.\\nPulmonary osteo-arthropathy. Female, aged eleven. Tuberculous vertebral caries and pulmonary\\ntuberculosis. Enlarged clubbed fingers and thickened ulna and radius. Private patient, 1885.\\nCurvature of the spine is present. The appearance of the fingers is\\ndifferent from that seen in acromegalia. The ends are enlarged and\\nbulbous, and the nails are too large and are curved in a transverse and", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0181.jp2"}, "182": {"fulltext": "172\\nGENERAL DIAGNOSIS.\\nlongitudinal direction, like the clubbed fingers of phthisis, although the\\nchief enlargement of the fingers is not terminal, and there is no cyanosis,\\nas in phthisical clubbing. The change seemed to be associated with pul-\\nmonary affections, and Marie called it osteo-arthropathk pneumonique.\\nDiminution.\\ncretins later\\nosteomalacia.\\nSmall development of the bones is seen in idiots and\\nlife diminution in size may occur from rhachitis and\\nRhachitis.\\nIn this affection the size of the body is lessened. For its recognition\\nit is important to know how rapidly the osseous deposits in childhood\\nhave formed. The fontanelles and the epiphyses must be examined.\\nIf the fontanelles are open beyond their period of closure in health, or\\nif the epiphyses are enlarged and lack firmness, the condition points\\neither to simple malnutrition or to rhachitis.\\nIn rhachitis late development of the teeth is observed. If the ribs are\\nexamined, nodules will be detected at the junction of the bone with\\nFig. 26.\\nFig. 27.\\n1 W\\n1 lilil 1\\n1$ m 1\\n1 1 1 I\\nWi f\\nM\\nyJv v~ mL\\n\u00c2\u00ae^^-*r-\\n.-.^tifc.\\nRhachitis; attitude in sitting; one hand raised\\nto exhibit swelling at the wrist. (Williams.)\\nRhachitis in moderate degree in a boy aged\\nfifteen months showing backward excurvation\\nof the spine. (Williams.)\\nthe cartilage. These may be seen, as well as felt, if the child is thin.\\nThey form the so-called rhachitic rosary. The thorax also is changed\\nin shape. At the junction of the cartilages and ribs a depression takes\\nplace which is continuous with a groove which passes out from the\\nensiform cartilage toward the axilla. This transverse curve is known\\nas Harrison s groove. It may deepen with inspiration. The sternum\\nprojects, forming the so-called pigeon-breast. (See Thorax.) Such", "height": "4416", "width": "2672", "jp2-path": "practicaltreatis00muss_0_0182.jp2"}, "183": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 173\\ndeformity must not be confounded with a similar one seen in adenoid\\ndisease. Changes at the lower end of the radius and ulna, and some-\\ntimes at the end of the humerus, are noticed. The parts are enlarged\\nat the junction of the shaft and epiphyses. There may be thickening\\nof the clayicles at the sternal ends. In the legs the lower end of the\\ntibia becomes enlarged, and at times the upper end, or even the shaft,\\nbecomes thickened. The child becomes bow-legged, or the tibiae and\\nfemora may arch forward. Knock-knee sometimes occurs. The\\nbones of the yertebral column and of the pelyis are also affected. The\\nspine is usually curved posteriorly, but the lateral curyature may also\\nbe produced with it. The contraction of the pelyis is such as to\\nnarroAV its outlet a matter of much importance for the future of\\nfemale children.\\nThe head of the child with rickets is quite characteristic. It has\\nbeen mentioned that the fontanelles remain open for a long time, and\\nareas of ossification are imperfect, so that the bone yields to the press-\\nure of the finger. This occurs particularly at the side, and the term\\neraniotabes is applied to it. The large head is square in shape, not\\nglobular, when seen from aboye downward. It giyes the face a pecu-\\nliar appearance. It is proportionately yery small, especially in the\\nlower two-thirds, while the forehead is broad and square.\\nRhachitis is usually developed in childhood, and is most common in\\nchildren with bad hygienic surroundings, who haye lived upon a\\nstarchy diet and haye taken cow s milk for too long a period of time.\\nA child that has been nursed during the mother s pregnancy is liable\\nto have the disease.\\nIn addition to changes in the bones a child presents other evidences\\nof defective nutrition. There is marked pallor the muscles are flabby\\nthe child is feeble and the weakness of the muscles results in an inac-\\ntion which resembles paralysis.\\nThe disease usually progresses slowly, and is eminently chronic. A\\nform is seen, however, in which the progress of the symptoms is more\\nacute. With some gastro-intestinal disturbances there are mild fever,\\nconsiderable weakness, and great restlessness. Sleep is disturbed, and\\npain is complained of if the child is of an age to make such com-\\nplaint. Soreness of the body is observed on handling the child and\\nof its own accord, on account of the pain and soreness, it avoids all\\ncustomary movements. The child lies on its back and shrinks from\\nany attempts to disturb it. The pain is not only caused by handling\\nof the muscles, but the bones also are sore and tender. Sometimes the\\nmost marked manifestations of the more acute forms are the gastro-\\nintestinal symptoms. It may often happen that vomiting and diar-\\nrhoea have as an underlying basis this rhachitic condition.\\nWith the above symptoms, and also in chronic cases, perspirations\\nabout the head are common. There is usually more heat of the head\\nthan is natural, hence in sleep the child rolls the head. This rolling\\ncauses the hair on the back of the head to be worn off. This sign is\\nmost characteristic of rhachitis when observed along with changes in\\nthe skeleton.\\nIn the acute and chronic forms enlargement of the liver and spleen is", "height": "4408", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0183.jp2"}, "184": {"fulltext": "174 GENERAL DIAGNOSIS.\\nobserved. The enlargement is not only actual, but also a false enlarge-\\nment may be seen from distortion of the organs, on account of changes in\\nthe vertebrae and ribs. The abdomen is prominent, usually on account\\nof flatulency, although the enlarged organs contribute to the swelling.\\nNervous phenomena are common in the course of rhachitis. Tetany,\\nlimited to the upper extremities, and laryngismus stridulus are the most\\nfrequent. Either of these complications may occur before the disease\\nis other wise suspected.\\nDiagnosis. The possible presence of rhachitis must not be over-\\nlooked in cases of chronic vomiting in childhood. The acute form of\\nthe disease must not be confounded with scurvy, as often happens in\\nthe case of children. It must not be forgotten that scurvy may set in\\nhi the course of rhachitis. In scurvy the pain, tenderness, and weak-\\nness are limited to the lower extremities. The immobility of the\\nextremities may go on to pseudoparalysis. The tenderness, however,\\nis great oedema is more pronounced, and local areas of periostitis are\\nmore common. In scurvy the gums are swollen and may be spongy,\\nor may be the seat of ecchymoses. The most decisive diagnostic crite-\\nrion is the therapeutic test, scurvy rapidly yielding to a proper regimen.\\nOsteomalacia.\\nAmong the general affections of the skeleton which may cause lessened\\nsize, osteomalacia must not be forgotten. As the lime salts are dis-\\nsolved the bones become preternaturally soft, break on the slightest\\nprovocation, or bend in various directions, depending upon the external\\npressure and the direction of the muscular force. The ribs are drawn\\nin by inspiratory force until the cavity of the thorax is lessened to a\\ndegree incompatible with life. The pelvis is deformed so that labor is\\nimpossible. (It occurs frequently in pregnancy.) All sorts of fixed\\ncontortions are assumed. If the patient is able to be up the body\\nshortens, the back becomes rounded, the neck flexed, so that the chin is\\nbrought close to the sternum. On palpation the bones can be indented\\nwith the finger, and crepitate like egg-shells.\\nOsteomalacia is easily distinguished from carcinoma or sarcoma of\\nthe bones. In the latter spontaneous fracture occurs in various parts\\nof the skeleton, but is generally preceded by pain and swelling at the\\nseat of fracture. Then, in sarcoma, subcutaneous hemorrhages are\\npresent. When a single joint is affected in osteosarcoma the same egg-\\nshell crackling is observed.\\nLocal Examination. The Position and Shape of Bones.\\nThe peculiar position (falling downward) of the scapula in paralysis of\\nthe serratus magnus is diagnostic of that affection, and indicates disease\\nof the posterior thoracic nerve. In examination of the clavicles frac-\\ntures must not be mistaken for disease of the bones, such as rickets.\\nThe examination of the spinal column is of the greatest importance.\\n(See Spinal Joints.) A study of the diseases of the spinal column due\\nto caries from tuberculosis is not within the province of this work\\nno physical examination, however, is complete without an investigation", "height": "4404", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0184.jp2"}, "185": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 175\\nof the movability of the spine and the presence or absence of curvature.\\nI refer to the curvature due to weakness of groups of spinal muscles.\\nFunctional disorders of the gastro-intestinal tract and of the uterus\\nare undoubtedly intensified by the presence of curvature, which leads\\nto deformity of the body, and hence to the assuming of abnormal posi-\\ntions when sitting or walking. The recognition of lateral or anterior\\ncurvature leads to the adoption of lines of treatment which otherwise\\nwould not be followed, but without which weak muscles, improper\\naeration of the blood, and sluggish circulation would persist. Pain in\\nthe distribution of nerves, or at their termination, is often due to spinal\\ncaries pressing on them as they pass through the foramina. The most\\nnoticeable is the pain about the umbilicus in children due to Pott s\\ndisease.\\nThe bones and cartilages connected with the thorax will be consid-\\nered under Diseases of the Lungs.\\nInflammation. The discovery of a slight change may lead to the\\nrecognition of a grave general process. Simple local inflammation or\\nperiostitis may be due to syphilis, and is recognized by local pain, swell-\\ning, and slight oedema. It may be diffuse. It is seen most frequently\\non the tibia, sternum, and clavicle. It not infrequently follows typhoid\\nfever.\\nNodules or nodes are usually due to syphilis. They form on vari-\\nous portions of the skeleton, but are most frequently seen on the skull,\\nespecially on the forehead they are also found on the shafts of the\\nlong bones, preferably the tibia, ulna, and clavicles. They are usually\\nmultiple or bilateral. They are painful and tender on pressure, and\\nmay be the seat of heat and redness. They are not so hard and dense\\nas exostoses. The latter are situated on the outer aspects of the bone\\nand in relation with the strongest tendons or muscles.\\nAs an illustration of the importance of recognizing nodes the writer\\nrecalls a case of persistent headache, the true nature of which was only\\nascertained by finding a small node on the skull. The headache had\\nbeen of long (five years) duration, and treatment for it had been\\nsought in many countries.\\nTenderness of the sternum upon pressure is often of diagnostic signifi-\\ncance and is usually indicative of syphilis. The pain and tenderness just\\nnoted, however, must not be confounded with local tenderness due to\\nnecrosis, which often arises in convalescence from fevers, notably those\\nof an infectious nature.\\nOsteomyelitis. The occurrence of high fever, with or without\\nchills, but usually with pysemic symptoms, without recognized cause,\\nshould lead to an examination of the bones. A spot of tenderness\\nfollowed by local redness and swelling on the tibia, for instance\\nwould indicate the seat of suppuration in osteomyelitis.\\nThe Joints.\\nThe Data Obtained by Inquiry. Careful observation of the bones\\nenables us largely to discern the nature of the diseased process, as has\\njust been indicated. It is true osteomyelitis is less likely of recognition", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0185.jp2"}, "186": {"fulltext": "176 GENERAL DIAGNOSIS.\\nthan any other process, but when the patient has been exposed to an\\ninfection, and fever is present, this condition must always be sought\\nfor in the absence of any other infectious area.\\nSuch is not true, however, of joint-disease. By observation we deter-\\nmine the joint affected and in part the nature of the morbid process.\\nOther data are needed. Hence we collect the usual data obtained by\\ninquiry. The social history is not productive of valuable data. Acute\\nrheumatism is more common in early life, rheumatoid arthritis in the\\nmiddle periods, and cnronic rheumatism in late life. Females are\\nmore commonly attacked than males in rheumatoid arthritis, and this\\naffection is more common in the poorer classes. Males and the well-\\nto-do are the victims of gout.\\nIn the family history one learns of the transmission of gout from\\ngeneration to generation and of the occurrence of rheumatism or of\\nits various allied processes in members of the same or previous genera-\\ntions. Previous diseases elicited are those of an infectious nature or an\\nintoxication, as of lead. Such diseases must be sought for if the true\\nnature of an arthritis is to be discovered. The history of the present\\ndisease is often that of recent infection or intoxication.\\nThe subjective symptoms of joint-affections are worthy of note. Pain\\nis the most prominent. This may be spontaneous, or may arise upon\\npressure, or follow attempts at movement. Spontaneous pain with ten-\\nderness is more pronounced in rheumatic and gouty inflammations of\\nthe joints. The pain is usually worse at night. This is particularly\\nthe case in tuberculous joints, and is due to removal of the apprehen-\\nsive spasm of the muscles whereby the joints had been protected.\\nPain in the joints must not be confounded with that of local or mul-\\ntiple neuritis. I have seen the pains of neuritis attributed to rheuma-\\ntism of the phalanges, tarsus, and ankle until paralysis of the exten-\\nsors took place. I have seen the pain of neuritis of the circumflex\\nmistaken for shoulder-joint disease. Multiple neuritis is attended by\\npains that may be located in the joints by the patient but neither in\\nlocal nor in general neuritis are the joints ever swollen, tender, or\\npainful on passive movement.\\nInspection. The size, shape, and color, the degree of movability and\\nthe position of the joints are observed.\\nThe Size and Shape. The joints may be enlarged. The enlarge-\\nment may be due to infiltration of the tissues about the joints, to effu-\\nsion within the joints, serous or purulent, or to inflammation of the\\nends of the bones.\\n1. When the enlargement is due to infiltration about the joint the\\ntissues are previously thickened, as shown by palpation, and the out-\\nline of the joint is changed. The normal contour is lost entirely, and,\\ninstead, there is a globular swelling beginning above and extending\\nbelow the joint, 2. When the enlargement is due to effusion it may\\nbe detected by palpation, as this secures fluctuation. This is particu-\\nlarly so in the large joints. If the joint involved is the knee the\\npatella will float. The effusion changes the normal contour, but,\\nin the earlier stages, may cause local swellings where the synovial\\nsacs are near the surface hence, at the articulation of the tibia and", "height": "4416", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0186.jp2"}, "187": {"fulltext": "THE DATA OB TA IN ED B Y OB SEE VA TION. 1 7 7\\nfibula with the tarsus, on the inner and outer side, a boggy swelling is\\nobserved. At the knee the swelling is on each side above and below\\nthe patella. When the effusion is great the joint becomes immobile,\\nand may be flexed from distention of the sac. 3. When enlargement\\nof the joints is due to hypertrophy of the bones the latter are thick-\\nened and very hard. There may or may not be, and usually is not,\\nfixation, and movement is but moderately interfered with.\\nChanges in the outline of the joint are also seen in rheumatoid arth-\\nritis. The loss of the cartilaginous substance of the joint, with the\\nsecondary osteophytic changes, causes deformity, so that in the case of\\nthe small joints of the finger subluxation is seen similar subluxations\\nare seen in larger joints. The ends of the phalangeal bones are thickened.\\nThe Color Change in the color is usually noticed in inflamma-\\ntions. The surface is either bright red or dusky.\\nThe Position. The position assumed is of diagnostic importance.\\nFlexion of the limb of the affected joint occurs in over-distention. It\\nmust be remembered that the hip-joint is flexed in appendicitis and in\\npsoas abscess or other affections in proximity to the psoas muscles.\\nIn rheumatoid arthritis there is subluxation. Immobility is observed.\\n(See Palpation.)\\nPalpation. By palpation we determine the degree of movability of\\nthe joints, the presence of fluctuation and of crepitation.\\n1. The movability of the joint is learned. Movement is inhibited in\\ninflammation on account of the pain. A reflex muscular spasm takes\\nplace if osteitis and cartilage-destruction are present. The spasm pre-\\nvents movement. In effusion there is less movability or even none at\\nall. In rheumatoid arthritis movement is prevented by the osteophytic\\ngrowths which surround the joint.\\n2. Fluctuation is revealed by palpation, pointing to liquid effusion\\nwithin the joint. (Edema of the surrounding tissues occurs in puru-\\nlent effusions.\\n3. A crepitus or grating sensation is observed in rheumatoid arth-\\nritis and other destructive diseases.\\nThe Morbid Process. The processes which give rise to change in\\nthe joints are inflammatory and degenerative, and, curiously, neurotic\\nor neuropathic. When a single joint is the seat of disease the process\\nmay be local, as in traumatic synovitis. But tuberculosis and other\\ninfections, gout and rheumatism or rheumatoid arthritis, may be local-\\nized to one joint the latter rarely, however. Multiple joint-disease,\\npolyarticular, is infectious or systemic (intoxication) usually.\\nMuch information, therefore, is learned by noting if the process is\\nlimited to one joint, monarticular or to many joints, polyarticular if\\nto large joints or to small joints if it is fixed, as in synovitis, or fugi-\\ntive, as in rheumatic fever. Monarticular inflammation of small joints\\npoints to gout of large joints, to gonorrheal rheumatism or pyremia.\\nPolyarticular inflammation of small joints, to rheumatoid arthritis of\\nlarge joints, to rheumatism. Lesions may be unilateral or bilateral,\\nsymmetrical or asymmetrical. Bilateral joint lesions are characteristic\\nof rheumatoid arthritis. Asymmetrical and fugacious lesions are seen\\nin rheumatic fever.\\n12", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0187.jp2"}, "188": {"fulltext": "178 GENERAL DIAGNOSIS.\\nIt must always be remembered that joint-lesions or processes may be\\nexpressions of general infections, as septicaemia, influenza, cerebro-spinal\\nmeningitis, scarlet fever, and dysentery or blood diseases, like purpura\\nor haemophilia or scurvy or of nervous diseases, like tabes dorsalis.\\nWe have to consider synovitis or arthritis single and multiple, trau-\\nmatic, toxic, or infectious, of which gonorrheal and tuberculous infec-\\ntions are the most common monarticular causes. We will then consider\\nrheumatism and gout, rheumatoid arthritis, and follow with the neuro-\\npathic joints.\\nSynovitis. The inflammation is recognized by pain, heat, redness,\\nand swelling. Effusion is present, and its physical signs are readily\\nelicited. It is both periarticular and intra-articular. It may be due\\nto traumatism, but we are chiefly concerned with inflammations due to\\ninternal morbid processes. When single joints are affected the most\\ncommon causes are tuberculosis, pyaemia, and gonorrhoeal infection.\\nA mild degree of inflammation may be limited to one joint in subacute\\nrheumatism. When many joints are affected the cause is an infectious\\none, as rheumatism, septicaemia, pyaemia, epidemic cerebro-spinal men-\\ningitis, scarlet fever, and dysentery, rarely gonorrhoea.\\nThe Tuberculous Joint. In tubercidosis the joint is swollen and\\nthe neighboring tissue oedematous. Effusion may be detected. There\\nis fever. The hip, the knee, the elbow, the wrist, and the ankle are\\nmost frequently affected. Cheesy material may be withdrawn by tap-\\nping. Destruction ultimately takes place, with subluxations and sub-\\nsequent fixation of the joint. With fever, wasting, and local signs of\\ntuberculosis in other portions of the body the true nature of the affec-\\ntion is indicated. The tuberculous process may be limited to the\\naffected joint, extend to the tendinous sheaths, or secondary tuberculosis\\nof internal organs may supervene.\\nThe Joint of Gonorrhoeal Rheumatism. The knee-joint is usually\\naffected. Signs of acute or subacute inflammation are present, with\\noedema and effusion. The patient is a male in whom an acute or\\nchronic urethral discharge is found. The pain is worse at night. The\\nprocess is of long duration. Metastasis does not take place. Destruc-\\ntion rarely occurs, but anchylosis may. General pyaemic symptoms\\nmay ensue, and^ gonorrhoeal endocarditis supervene. The micro-organ-\\nisms (gonococci) can be found in the blood and in the pus of the\\naffected joint. There is entire absence of heart-symptoms from simple\\nendocarditis. The general and local signs of rheumatism or of a rheu-\\nmatic diathesis, and changes in the urine, skin eruptions, cardiac\\nlesions, etc., are wanting. In certain cases many joints are affected,\\nbut the temperature is not so high or the sweats so profuse as in acute\\nrheumatism. Tendo-synovitis is not infrequent.\\nRheumatic Fever.\\nAn acute, general, febrile, non-contagious disease, characterized by\\nspecific inflammation of the joints and their contiguous structures, hence\\ncalled acute articular rheumatism. It is further characterized by a ten-\\ndency of the inflammation to involve the larger joints successively, to", "height": "4412", "width": "2560", "jp2-path": "practicaltreatis00muss_0_0188.jp2"}, "189": {"fulltext": "THE DATA OB TA IN ED B Y OB SEE VA TION. 179\\nskip from one joint to another, and to be associated with endocarditis\\nor pericarditis.\\nThe predisposing causes of rheumatic fever are heredity, which is\\noperative in 25 or 30 per cent, of the cases age 81 per cent, of first\\nattacks occur between the eleventh and thirtieth years (Pye-Smith)\\nsex in childhood girls are more frequently affected than boys, but after\\nthat period sex appears to have no influence. Polyarticular inflamma-\\ntions, sometimes rheumatic in nature, are met with during convales-\\ncence from scarlatina and dysentery. They also occur in association\\nwith the puerperal state and gonorrhoea, in which they are probably\\npysemic. The nature of the polyarthritis which occurs in connection\\nwith dengue and haemophilia is obscure.\\nSymptoms. The onset of the disease is not characterized by con-\\nstant symptoms. Sometimes the fever and joint-inflammations are\\npreceded a day or two by debility, wandering pains in the joints or\\nmuscles, and loss of appetite. In other cases there is a chill or repeated\\nattacks of chilliness, followed in a day or two by fever and inflamma-\\ntion of the joints. In rare cases the onset may be followed not by in-\\nflammation of the joints but by inflammation of the serous membranes,\\nparticularly those of the heart and its sac.\\nThe temperature may rise a day or two before there are any joint-\\nsymptoms, or fever and arthritis may begin almost simultaneously.\\nThe temperature rises rapidly to 102\u00c2\u00b0, 103\u00c2\u00b0, or 104\u00c2\u00b0 F., and one or\\nmore of the larger joints, generally the knee and ankle, become painful,\\ntender, swollen, and hot.\\nThe Joixt. There may be great pain on motion before there is\\nevident swelling or much local tenderness. The pain varies from mere\\ndiscomfort to the most excruciating suffering. It is always aggravated\\nby motion or pressure, and is at times so exquisite that the slightest\\ntouch, the weight of the bedclothing, or the jar of the bed from a heavy\\nstep in the room makes the patient cry out. It may extend beyond\\nthe joint to neighboring tendons and nerves. The swelling like-\\nwise varies greatly sometimes there is only slight pufnness with\\nincreased distinctness of the cutaneous veins, increased heat in the part,\\nbut no general redness in other cases there is considerable swelling\\nabout the joint, so that the bony prominences are obliterated, the sur-\\nface being tense, red, and very hot to the touch. There is often effu-\\nsion into the joint, Swelling is most marked in the wrist and ankle,\\nand less so in the shoulders, hips, elbows, and knees.\\nMultiplicity of Joints Affected. A characteristic peculiarity of rheu-\\nmatism is its tendency to involve one joint after another. One or\\nseveral joints may be affected at first it is very common for the\\nright ankle to be affected, and then in a short time the opposite ankle,\\nfollowed by the left knee and right- knee, and so on with the other\\njoints. The inflammation usually lasts in each joint from two to four\\ndays. The process may subside in one articulation and begin in\\nanother with startling rapidity. At one visit of the physician the\\npatient s right ankle may be swollen, hot, and unbearably painful, and\\non the next day the right ankle may be quite well again and the patient\\nbe found suffering acute pain in the right knee or left ankle.", "height": "4408", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0189.jp2"}, "190": {"fulltext": "180\\nGENERAL DIAGNOSIS.\\nThe puke in the early stages of rheumatism is moderately accelerated\\n(99 to 110) it is regular, of good volume, often bounding, and some-\\ntimes hard. The urine is scanty, high-colored, abnormally acid, and\\ndeposits on cooling a copious precipitate of urates, resembling red sand\\nin appearance. The skin does not feel so hot as one would expect from\\nthe temperature. It is continuously covered with a copious, acid, and\\nsomewhat pungent perspiration. Nervous symptoms are not marked.\\nThere may, however, be slight nocturnal delirium. Sleeplessness from\\npain is very common.\\nThe temperature in rheumatic fever is not usually very high it is\\nmuch oftener under than over 103\u00c2\u00b0. In rare cases, however, espe-\\ncially when the fever is complicated with pericarditis, pneumonia, or\\nFig. 28.\\n103\\n102 i\\n101\\n100\\n9U\\ni\\ntf\\nI\\nS\\nI\\ns\\n\u00c2\u00ab5\\nMay\\nRheumatic fever. Admitted fourth day of disease.\\nsome disturbance of the heat-regulating apparatus, the temperature\\nmay attain the extraordinary range of 106\u00c2\u00b0-112\u00c2\u00b0 F. Such high tem-\\nperatures may occur suddenly or gradually, and are sometimes attended\\nwith marked brain-symptoms (so-called cerebral rheumatism).\\nEndocarditis and pericarditis may occur at any period of rheumatic\\nfever they may even precede any joint-inflammations. They are most\\ncommon, however, in the first two weeks of the disease. The younger\\nthe patient and the more severe the attack the greater the liability to\\nheart-complications. They occur in about one-fourth of all cases.\\nEndocarditis is most common often it is the only lesion, but some-\\ntimes it is associated with pericarditis and more rarely with myocar-\\nditis. These complications usually give rise to no symptoms at first.\\nHence the heart should be examined daily. A sense of constriction\\nin the prsecordia or pit of the stomach, an anxious expression of the\\nface, Avith pallor, a change in the frequency, but especially in the\\nrhythm of the pulse, and the occurrence of cough or dyspnoea, should\\nattract attention to the heart. The physical signs of the respective\\nlesions have been described fully under Diseases of the Heart.\\nThe setting in of convalescence from rheumatic fever is marked by\\ncleaning of the tongue, which also becomes less red, and increase in\\nthe secretion of urine, which remains of high specific gravity. The\\nfever subsides gradually, the joints cease to be red, swollen, and tender,", "height": "4408", "width": "2556", "jp2-path": "practicaltreatis00muss_0_0190.jp2"}, "191": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 181\\nthe acid sweats lessen, and the appetite improves. In proportion to\\nthe duration of the case and its severity the patient is left with debility\\nand marked anaemia, both red cells and haemoglobin being diminished.\\nIn ansemic cases a haemic murmur may be heard over the base of the\\nheart. In some cases acute dilatation has been observed, with a tri-\\ncuspid murmur.\\nComplications and Sequelae. Apart from heart complications which\\nhave been mentioned, pleuritis, pneumonia, and bronchitis occur in from\\n10 to 15 per cent, of the cases. They are frequently bilateral, and are\\nvery much more common in rheumatic fever with pericarditis or endo-\\ncarditis than in simple rheumatic fever. Moreover, the pulmonary\\ncomplications are frequently latent, and would be overlooked but for\\nthe daily physical examination of the chest. On the other hand they may\\ndevelop with great suddenness, and what appeared to be a full-blown\\npneumonia may subside suddenly as a fresh joint is affected. They\\nbehave more like sudden active congestions than true pneumonias.\\nRheumatic pleurisies are characterized by the rapidity with which effu-\\nsion takes place, the persistence of pain in the side during effusion, the\\ntendency to involve both sides in succession, the readiness with which\\nthe effusion is absorbed, and their acute course.\\nNervous System. The most common complication of the nervous\\nsystem is delirium, which is generally associated with insomnia and\\nhyperpyrexia, but the latter is not constant. These brain-symptoms\\ngenerally appear in the second week of illness, and about the time of\\nconvalescence, or while the joints are still inflamed. The delirium\\nmay be low and muttering, accompanied by ataxic symptoms or even\\nby tremors and spasms of muscles or it maybe furious. In favorable\\ncases a deep sleep ushers in recovery or, in unfavorable cases, the\\ndelirium persists with adynamia, the patient dying in collapse or coma,\\npreceded or not by convulsions.\\nChorea sometimes occurs as a complication, but it is more common\\nas a sequel of mild cases in children. Cerebral meningitis occurs occa-\\nsionally, especially when there is ulcerative endocarditis. Cerebral\\nembolism is another rare complication.\\nVarious spinal symptoms occur in some cases, at times with, and at\\ntimes without, demonstrable lesion of the cord or its membranes.\\nTetanus, myelitis, and spinal meningitis may all be simulated. Per-\\nhaps these symptoms are due to high temperature but very high tem-\\nperatures are met with without the occurrence of any cerebral or spinal\\nsymptoms.\\nNephritis is rare, but sometimes hemorrhage into the kidney occurs\\nwith its usual symptoms. Peritonitis is extremely rare.\\nVarious erythematous skin-eruptions are seen from time to time,\\nand occasionally purpura. Subcutaneous nodosities have been described\\nby several writers. They are attached to the tendons, fascia, and peri-\\nosteum, and are most frequent on the back of the elbow, the ankles,\\nand patella. They are painless, and may occur in any form of rheu-\\nmatism.\\nDiagnosis. Rheumatic fever is distinguished from gout by the\\nprofuse acid and acrid sweating, the tendency to involve a number", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0191.jp2"}, "192": {"fulltext": "182 GENERAL DIAGNOSIS.\\nof joints, and particularly the larger ones, by the greater intensity of\\nconstitutional symptoms, by the great liability to heart-complications,\\nand by the absence of uric acid from the blood.\\nIt is distinguished from pyaemia by the wandering character of the\\ninflammation the acid sweats the absence of any antecedent condi-\\ntion which would develop purulent foci such as injuries, abscesses, or\\nspecific eruptive fever the absence of chills, and the fact that in rheu-\\nmatic fever the sweats are constant, whereas in pyaemia they follow a\\nfall in the temperature. Cutaneous abscesses do not occur in rheuma-\\ntism, and after its subsidence the joint s usefulness is not impaired.\\nAcute synovitis resembles rheumatic fever, because in both occur\\nsymptoms of pain, tenderness, and swelling in connection with a joint.\\nUsually, however, in synovitis but one joint is involved, and there is\\na history of exposure to cold or injury. The effusion is limited to the\\nsynovial sac of the joint, is frequently abundant, and fluctuation can\\neasily be detected. The constitutional symptoms are much less marked\\nthan in rheumatism.\\nMilk-leg, or phlegmasia alba dolens, differs from rheumatism in that\\nit usually occurs in women after confinement, or as a complication or\\nsequel of fever, as typhoid fever. Usually one leg is affected, or part\\nof the leg, especially the calf. This becomes tense, tender, uniformly\\nswollen, and the seat of great pain. The leg is moved with much diffi-\\nculty. The femoral vein may be found to be knotted and tender.\\nThere is almost always evidence of antecedent disease.\\nAcute periostitis when close to a joint simulates rheumatism. But\\nthe tenderness and heat are not in the joint itself they are superficial,\\nand are associated with less swelling. Pitting on pressure is common\\nand circumscribed fluctuation usually discloses the presence of suppu-\\nration. Pysemic symptoms are added to the local symptoms, particu-\\nlarly if osteitis or osteomyelitis is present.\\nThe articular symptoms of glanders are to be distinguished by the\\noccupation of the patient, the mode of onset, the associated symptoms,\\nespecially one or more pustules, and the fact that the painful joints are\\nnot so apt to be swollen and red as in rheumatic fever.\\nIn syphilis joint-pains frequently occur, but their character is made\\nout by the fact that the joints are not inflamed, and that the pain is\\nmuch worse, or occurs only at night, and by the history of the patient\\nand the therapeutic test.\\nIn some diseases of the brain and spinal cord joint-inflammations of\\ntrophic origin occur. They are distinguished by the coexistence of\\nsome lesion of brain or cord, with hemiplegia or other palsy, and of\\nother trophic changes, such as bed-sores, atrophied muscles, loss of\\nhair, shiny skin, and defective growth of nails.\\nSubacute Articular Rheumatism.\\nIn some instances the joint-inflammation is less severe, and is\\naccompanied by only slight fever. One or more joints may be affected.\\nIt differs from the ordinary form in being milder in degree and more\\npersistent, lasting sometimes for months. It is generally subacute from", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0192.jp2"}, "193": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 183\\nthe beginning, but may be the type present in those who have had\\nseveral attacks of rheumatic fever and have been left in a very sensi-\\ntive condition. Rheumatic fever is usually subacute in children, and\\noften only one joint is involved. Cardiac complications are more fre-\\nquent than in adults, and chorea may occur as a sequel. Erythema\\nnodosum and subcutaneous nodosities are more common in children.\\nChronic Articular Rheumatism.\\nIn this form the patient has pain and stiffness in one or more joints,\\nor in the contiguous tissues. The joints most frequently affected are\\nthe shoulder and knee. The pain is more or less constant, but worse\\nin damp weather or on the approach of a storm, and worse also at\\nnight in many cases. Conversely, it is better in warm, dry weather.\\nThere is not much if any tenderness, and rarely any swelling or ele-\\nvation of temperature. The joints very frequently crack and grate on\\nmotion. In the interval between the attacks there is no impairment\\nof the usefulness of the joints. In very chronic cases there may be\\nsome atrophy of muscles and permanent stiffness, even fibrous anchy-\\nlosis.\\nIn some cases there are repeated attacks of subacute articular rheu-\\nmatism, accompanied by the usual symptoms and joint-effusions.\\nChronic articular rheumatism is distinguished from ehronic gout by\\nthe fact that there is no special tendency to involve the great toe, by\\nthe absence of the deformities resulting from gout, and the absence of\\ndeposits of sodium urate in the ears, fingers, and around the joints.\\nGout.\\nA disease characterized by specific arthritis, associated with uric\\nacid in the blood and the deposit of sodium urate in the joints, or\\nmanifesting itself as a diathesis in which occur other inflammations of\\nnon-articular tissues and various disturbances of functions of organs,\\nthe blood also containing uric acid.\\nGout is common in Europe, particularly in England, but in its ar-\\nticular form is rare in this country. There is an hereditary predispo-\\nsition in from 50 to 60 per cent, of the cases. It results from over-\\neating of rich foods and the drinking of malt liquors, associated with\\ninsufficient exercise and excretion. Garrod has called attention to its\\nassociation with lead-poisoning. Paroxysms are induced by indiscre-\\ntions in eating or drinking, by nervous shock or great mental strain,\\nby exposure to cold or injury, or by overwork and sexual excesses.\\nThe characteristic phenomena of gout are preceded for a variable\\ntime by acid flatulent dyspepsia, colicky pains in the stomach and\\nbowel, constipation alternating with diarrhoea, and scanty, heavily\\nloaded urine. Accompanying these dyspeptic symptoms often are\\nimpairment of physical and mental vigor, irritability of temper, and\\nhypochondriasis.\\nIn other cases the premonitory symptoms are palpitation of the heart,\\nor dyspnoea resembling asthma, or various nervous symptoms, as drow-\\nsiness, insomnia, or headache.", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0193.jp2"}, "194": {"fulltext": "184 GENERAL DIAGNOSIS.\\nIn acute articular gout the onset is often sudden, especially in the\\nfirst attack. The patient may go to bed in apparent health, but wake\\nup early in the morning with a feeling of discomfort or uneasiness,\\nusually in the great toe. In some cases the pain is agonizing from the\\nfirst. The patient finds he is unable to step upon the foot without\\ntorturing pain. The ball of the great toe is hot, swollen, red, and\\nexquisitely resentful of the slightest touch or jar of the bed. The\\nveins are swollen and the joint stiff. There is slight fever, perhaps\\nchilliness, thirst, coated tongue, constipation scanty, high-colored urine,\\ndepositing urates on cooling the skin is warmer than normal, and\\nthere is slight perspiration. The pain usually abates during the day\\nand increases at night. It is aggravated by motion and attended by\\npainful muscular cramps. By the end of the first day or two the swell-\\ning increases and the pain lessens, owing to diminished tension of the\\npart. Pain on motion is still great, however, and without treatment\\nmay continue for a week or two under treatment the paroxysm sub-\\nsides in four or five days.\\nBoth great toes may be attacked in the first seizure, more often\\nalternately than simultaneously, and sometimes other joints than those\\nof the toes are affected.\\nAfter the subsidence of an attack the urine contains a larger quan-\\ntity of uric acid, and the patient feels better in health and spirits than\\nfor some time. A second attack may be postponed for several years,\\nbut usually after that the intervals between them steadily diminish,\\nuntil an attack recurs every few weeks or months, and the patient\\nmay be scarcely ever free from it. Other joints than the toes, particu-\\nlarly those of the fingers, become involved in subsequent attacks.\\nThe Blood. INeusser has attributed to gout and the uric-acid diath-\\nesis the presence of granules, observed after staining, in the white\\ncorpuscles, but they have been found in other affections, and are not\\ndiagnostic. The nature of many otherwise obscure gouty manifesta-\\ntions or arthritic changes may be determined by an examination of the\\nserum of the blood. Collect the serum which accumulates in a blister\\nand examine for uric acid. (See Blood.)\\nChronic gout results from repeated acute attacks. It is characterized\\nby deformity of the affected joints, around which are deposited chalk-\\nstones (tophi) of sodium urate. Similar deposits occur in the helix of\\nthe ear. The first appearance is that of a clear vesicle under the skin,\\nwhich subsequently becomes chalky- white and solid. The deposits of\\nsodium urate occur not only in the cartilages of the joints but in the\\nligaments and bursa? also, resulting in great impairment of motion and\\ndeformity. In extreme cases an appearance is presented by the\\nhand very closely resembling a bundle of French carrots with their\\nheads forward, the nails appearing to take the place of the stalks\\n(Gar rod).\\nGouty abscesses consist of collections of liquid and solid sodium urate,\\nwhich discharge, with or without pus, through the skin. A patient\\nmay have a number of them with but very little impairment of the\\ngeneral health. They may even act as a helpful vent to the system.\\nIn so-called retrocedent gout the external joint-manifestation is sup-", "height": "4416", "width": "2568", "jp2-path": "practicaltreatis00muss_0_0194.jp2"}, "195": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 185\\npressed or replaced by an internal inflammation, as one of the serous\\nmembranes.\\nGout attacks the nervous system, causing headache, delirium, and\\nsometimes apoplexy, apoplectiform seizures, epilepsy, mania, various\\nneuralgias, and spinal symptoms.\\nIt also affects the heart and bloodvessels, causing valvulitis and chronic\\narteritis.\\nThe symptoms presented by the digestive organs have been men-\\ntioned. They are often premonitory of an attack.\\nThe kidneys may be affected, causing typical contracted kidney, or\\nthere may be chronic cystitis and urethritis.\\nRheumatoid Arthritis.\\nRheumatoid arthritis, or rheumatic gout, is an affection characterized\\nby acute or chronic inflammation of the joints, of progressive charac-\\nter, and resulting in deformities. It is attended with very little fever,\\nand occurs apart from any known systemic disease.\\nIt may be acute or chronic. The acute form differs but little in its\\nmanifestations from acute rheumatic fever. Several joints are en-\\nlarged, tender, and painful. Constitutional symptoms, such as fever,\\nloss of appetite, frequent pulse, thirst, and furred tongue, occur as in\\nrheumatism. Profuse acid sweats, however, are absent, and so is the\\ntendency to serous inflammations. Moreover, while the larger joints, as\\nin rheumatism, may be affected, the smaller ones also, especially of the\\nfingers and toes, are inflamed and often the seat of serous effusions.\\nFurthermore, the inflammation persists in the affected joints and does\\nnot jump from one to another. Instead of disappearing in a few\\nweeks, it drags on for a much longer time. The pain subsides, but\\nthe swelling persists, and permanent deformity results in at least some\\nof the joints. The muscles of the arms and legs waste and are affected\\nwith painful spasms.\\nThe disease is most common in young women exhausted by repeated\\npregnancies or prolonged lactation, and is favored by poverty, priva-\\ntion, and cold.\\nThe chronic form is much more common. It also attacks most fre-\\nquently young women who are exhausted or are subjected to great\\nfatigue. There is pain, numbness, or formication in a joint, as the\\nknee. The joint becomes tender, painful, and may be slightly swollen.\\nThis subsides after a while, but sooner or later the same joint or\\nanother one becomes affected, the process is persistent, one joint after\\nanother is attacked, and gradually all the joints may become greatly\\ndistorted, enlarged, and the seat of contractions. There may be no\\nimpairment of general health, or, at most, only dyspeptic symptoms.\\nThe progress is interrupted by remissions from time to time. Pain\\nmay be severe and subject to nocturnal exacerbations. The shape of\\nthe joints is altered by the effusion into the joints and adjacent bursse,\\nby thickening of the tissues around the joints, growths of new bone on\\nthe joint-extremity of the bones, absorption of the articular cartilages,\\nand growths of new cartilage in the synovial sheaths, relaxation of", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0195.jp2"}, "196": {"fulltext": "186 GENERAL DIAGNOSIS.\\nligaments, muscular contractures, and luxation of the joints. The\\njoints crack and creak like rusty hinges, are sore and stiff, and the\\nattached muscles are affected with painful cramps. (See Fig. 29.)\\nFig. 29.\\nRheumatoid arthritis.\\nGreat enlargement of the joints at times occurs from the causes\\nalready mentioned and from infiltration of the overlying tissues. The\\nenlargement is rendered more conspicuous by the atrophy of adjacent\\nmuscles. (See Fig. 14.)\\nIn addition to the articular symptoms other phenomena attend the\\nprocess. One of the more common is increased frequency of the pulse.\\nAlthough the patient is afebrile, the average pulse-rate is 100 to 120,\\nor even more. Moreover, the pulse is soft and compressible, in con-\\ntradistinction to the pulse of gout and rheumatism. It is worth noting\\nthat a return to the normal frequency of pulse is a sign that the pro-\\ncess of the disease is arrested, although the joint-lesions remain.\\nThe shin is characteristic. It is soft and often much freckled, while\\nthe complexion is fair. C. T. Griffiths has observed the pigmentary\\ncutaneous changes, along with neural symptoms, prior to the joint-\\nmanifestations, and describes two forms a diffuse melasmic discolora-\\ntion, and dark-brown spots resembling moles, but not raised. Moist-\\nure of the skin with clamminess is common. It is limited to the palms\\nof the hands, or may occur in the distribution of certain nerves. The\\nsweats are not acid they are usually local, but may be profuse. Pain\\nindependent of the joint-lesion is due to neuritis, and may precede the\\njoint-trouble. It is not merely confined to the nerve-trunks, but affects\\nthe smaller branches which are distributed to muscles, as the base of\\nthe thumb. Numbness and tingling are often present.\\nThe progress of the disease is pretty steadily worse. In extreme\\ncases not only are the limbs crippled, deformed, and helpless, but there\\nis fixation of the cervical spine and of the articulations of the jaw, so\\nthat the patient cannot move the head or masticate food.", "height": "4412", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0196.jp2"}, "197": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 187\\nThe following describes the characteristic deformity of the hand\\nThe first phalanx of the fingers is either flexed npon the metacarpus or\\nextended, and the terminal phalanx in like manner is either markedly\\nflexed or extended upon the second, or these two phalanges are kept\\nat a straight line, while the first phalanx is, as usual, decidedly flexed\\nupon the metacarpus. The hand is pronated and the fingers turn\\ntoward the ulnar side (Palmer Howard and Charcot). (See Fig. 29.)\\nThe foot is abducted and flattened, and the great toe abducted across\\nand above the other toes. Rarely it may be beneath the other toes.\\nThe metatarso-phalangeal joint is enlarged.\\nA variety of the disease is sometimes met with, chiefly in old persons\\n(senile arthritis), in which the tendency is to involve one or two joints,\\nparticularly the hip, or hip and knee. It is of slow progress, and is\\notherwise attended with the same deformities as the usual polyarticular\\nform.\\nRheumatoid arthritis is distinguished from gout by the absence of\\nheredity and by its development under the exhausting influences of\\nrepeated pregnancies, lactation, poverty, and malnutrition. Rheuma-\\ntoid arthritis is progressive, with occasional remissions gout occurs\\nin successive attacks, with intermissions. Uric acid is absent from the\\nblood in the former and is present in gout. Rheumatoid arthritis in\\nthe vast majority of cases is subacute or chronic. The acute form is\\ndistinguished from acute gout by the duration of the paroxysm and the\\nabsence of intermissions by there being less heat, swelling, and red-\\nness of the joints, and less infiltration of the soft parts by the fact\\nthat large and small joints are involved, and that there is no special\\ntendency to inflammation of the great toe.\\nFrom chronic gout rheumatoid arthritis is distinguished by the\\nabsence of hereditary predisposition, of repeated acute attacks, and of\\nthe causes of gouty paroxysms indulgence in sugars, acids, malt\\nliquors, etc. Moreover, rheumatoid arthritis most frequently begins\\nin the hands, and is symmetrical and bilateral. Gout has a predilec-\\ntion for the great toe, and is unilateral. Again, gout attacks well-fed\\nmales most frequently after the age of thirty years, while rheumatoid\\narthritis tends to attack women under the depressing influences already\\nmentioned. It may, however, occur in both sexes, and even be asso-\\nciated with gout.\\nRheumatic fever is distinguished from acute rheumatoid arthritis by\\nits tendency to involve the larger joints, its erratic course, acid sweats,\\nand heavy deposits of urates from the urine, its shorter course, its ten-\\ndency to heart-complications, and its subsidence without impairment of\\nthe usefulness of the joints.\\nChronic articular rheumatism is distinguished by the preceding his-\\ntory, the tendency to seasonal exacerbations, by its involving fewer\\njoints, and not being so symmetrical in the joints affected. It does not\\nproduce so great deformity as is common in rheumatoid arthritis, nor is\\nit so likely to affect the vertebrae and jaws. The existence of valvular\\nheart disease or a history of antecedent chorea is in favor of rheumatism.\\nThe joint-affections of locomotor ataxia are distinguished by the asso-\\nciated symptoms of incoordination and absent knee-jerk, by their", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0197.jp2"}, "198": {"fulltext": "188 GENERAL DIAGNOSIS.\\nsudden onset without pain or fever, by the occurrence of large effusion\\ninto the joint, with subsequent disorganization, fractures, and dislo-\\ncations.\\nGonorrhoea! arthritis is distinguished by the history of gonorrhoea\\nor the existence of a discharge from the urethra, by the tendency of\\nthe disease to attack the larger joints, particularly the knee or shoul-\\nder, and to become fixed in one, not wandering from one to another.\\nThe affected joint suffers effusion, and the synovial membranes and\\nbursoe are inflamed. The process is very chronic but indolent, and\\nthe heart rarely becomes affected.\\nScurvy.\\nThe joints are swollen, painful, and tender in about one-third of all\\ncases of scurvy. When to these joint-symptoms the spongy gums, the\\nhemorrhages, the anaemia, and cachexia are added, scurvy may be\\nsuspected.\\nScorbutus, or scurvy, is a constitutional condition brought about\\nby a long-continued diet deficient in fresh vegetables. It is character-\\nized by pallor, great physical weakness and mental sluggishness,,\\ndyspnoea, subcutaneous and submucous hemorrhages, a swollen, spongy\\ncondition of the gums, and a brawny induration, especially of the calves\\nand hams.\\nThe onset of the disease is gradual, and is marked by a peculiar\\ndirty-yellow or greenish pallor of the face, associated soon with an\\napathetic expression of the face, physical weakness, and decided lack of\\ncustomary energy. The appearance is so characteristic that patients\\nare said to detect it readily in others, though unaware of it themselves.\\nSleep and digestion are good, but rheumatoid pains may be complained\\nof. Other prominent subjective symptoms are fatigue on slight exer-\\ntion, dyspnoea, faintness, and despondency. In the course of a week\\nor two petechia) appear upon the lower extremities, especially around\\na hair as the centre. (See page 128.) Depending upon the severity of\\nthe case there are also bullae, vibices, and ecchymoses. Brawny indu-\\nration, due to deep effusion of blood, occurs, especially in the calves\\nand hams, producing considerable pain on flexure of the knees.\\nThere is no fever apart from complications. The pulse is frequent,\\nweak, and small, and the first sound of the heart and the impulse may\\nbe very faint.\\nThe face is swollen and of a dirty, possibly greenish-yellow color,\\naccording to Bird, Buzzard, and others in some cases the eye and its\\nsurroundings are the only parts exhibiting signs of scurvy at this time.\\nThe integument around one or both orbits is puffed up into a bruise-\\ncolored swelling. The conjunctivae covering the sclerotic is tumid and\\nof a brilliant red color throughout, and about an eighth of an inch in\\nthickness or elevation above the cornea, leaving the cornea at the\\nbottom of a circular trench or well. 1 The condition is not inflam-\\nmatory. These cases often terminate fatally.\\n1 Buzzard: Keynolds System of Medicine, 1880, vol. i. p. 451.", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0198.jp2"}, "199": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 189\\nThe gums swell almost always, become spongy, and bleed upon the\\nslightest irritation. They are dark cherry-red in color and look not\\nunlike a split cherry. Sometimes they swell, so as almost to hide the\\nteeth completely and even to protrude the lips. The breath has a\\nheavy, sickening odor, and the teeth sometimes drop out of their sockets.\\nIn addition to the cutaneous and gingival hemorrhages, hemorrhages\\noccur from the nose and other mucous surfaces, and effusions take place\\ninto the lungs, intestines, pericardium, and pleura, associated with in-\\nflammatory products. There may be no physical signs on the part of\\nthe lungs to account for the dyspnoea, or some dulness and bronchial\\nbreathing, or a few rales, may be detected.\\nA very peculiar symptom, and sometimes the earliest, is hemeral-\\nopia, nyctalopia, or night-blindness, in which the patient can see during\\nthe day but not by moonlight, and apart from artificial light is totally\\nblind at night.\\nSo-called scurvy-rickets is more or less common in infants fed on arti-\\nficial food exclusively or on sterilized milk. It is therefore limited\\nto the first four or five years. The symptoms of scurvy are added to\\nthose of rhachitis. In the eight cases I have seen, the most pronounced\\nfeatures were those of weakness, anaemia, polyuria, restlessness, the\\nscorbutic gums, local periostitis, particularly of the tibia, sometimes\\nperiarticular inflammation, and always a general tenderness of the\\nbody, as in rhachitis.\\nThe Tabetic Joint. In forms of nervous diseases, particularly in\\nsclerosis of the posterior columns, secondary joint-involvement some-\\ntimes occurs. The change in the large joints is preceded by pain,\\nstiffness, and inability to use them. Gradually nutritive changes take\\nplace. At first there is boggy swelling. The cartilages become eroded,\\nthe heads of the bone waste, the ligaments ossify, and irregular bony\\ngrowths project. Wasting of the head of the femur is followed by\\ndislocation. Sometimes an effusion takes place in the joints, and there\\nmay be periarticular oedema. The large joints are most commonly\\naffected the knee, hip, ankle, and elbow. Injury excites the abnor-\\nmal atrophic process. When the tarsal bones and the articulations are\\naffected the foot becomes flat, and the tarsal and metatarsal articulation\\nand the tarsal bones project forward or backward. This is called the\\ntabetic foot.\\nThe Joint of Hysteria. Symptoms of joint-disease are seen in\\nhysteria. Pain and fixation of the joint are sometimes complained of.\\nThe joint rarely undergoes organic changes, but sometimes a plastic\\ninfiltration of the connective tissue outside of the capsule does occur.\\nThe hysterical nature of the pain and immobility are recognized by\\nthe absence of a cause for joint-lesion, the absence of fluctuation, or of\\nsigns due to erosion, by the association of the local symptoms with the\\nphenomena of hysteria, but, more particularly, by the fact that con-\\ntraction and even wasting precede the joint-symptoms. In true affec-\\ntions of the joint both occur after the joint has become diseased in\\nhysteria muscular contraction will take place first.\\nThe knee is the joint usually affected. Care must be taken not to be\\ndeceived by local vasomotor changes of hysterical origin which may", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0199.jp2"}, "200": {"fulltext": "190 GENERAL DIAGNOSIS.\\nbe observed under the surface of the joint. This local increased tem-\\nperature is not associated with general fever, however, while the vaso-\\nmotor changes indicated by the swelling of the skin, increased tension,\\nand the shining appearance, with increased sensibility, are not per-\\nsistent, but occur once or twice in the twenty-four hours. In a\\nremarkable case of Mitchell s the local vasomotor change took place\\nat night. The temperature of the knee which was affected increased\\nthree or four degrees, while the pulse remained at 80. The local symp-\\ntoms of heat, redness, swelling, tension, and increased pain passed\\naway by three o clock in the morning. The fact that the same symp-\\ntoms could be brought on by handling the knee, or by pressure upon\\nthe patella, pointed to its vasomotor origin.\\nIn joint-cases of hysterical origin the reflexes must be studied.\\nThey do not change, and the electrical reactions are normal, although\\nthere may be atrophy from disuse, but not to the degree that occurs\\nin organic disease. The muscles may be contracted, but, as previously\\nnoted, the contracture is primarily a relaxation, which takes place if\\nthe tension is removed. Concerning these vasomotor changes, Sir James\\nPaget s expression, A joint which is cold by day and hot by night\\nis not an inflamed joint, is a safe guide to the recognition of an hys-\\nterical joint. When the joint becomes hysterical after injury it is most\\ndifficult to ascertain its true nature.\\nSpecial Joints. The three joints that should concern the student\\nmore particularly are the shoulder, hip, and knee. When symptoms\\nare referred to either of these joints they should not be passed over\\nlightly. Grave consequences have followed the attributing of hip-\\njoint inflammation to rheumatism when it was of tuberculous origin.\\nNot only has hip-joint disease been mistaken for rheumatism, but the\\nmistake has even been made of considering the process to be going on\\nin the knee instead of in the hip. This is because there is often flexion\\nof the leg, and because pain is so often referred to the knee-joint.\\nOn the other hand, cases of hip-joint disease have been mistaken for\\nsuppuration in the pelvis or in the iliac fossa. Typhlitis or appendi-\\ncitis has frequently been mistaken for hip-joint disease.\\nIn the case of the shoulder- joint there is danger of confounding\\nneuritis of the circumflex nerve, and consequent paralysis of the del-\\ntoid, with affections of the joint. Although the patient is unable to\\nmove the joint, it is still readily moved by the physician, and the\\nphysical signs of joint-inflammation are wanting.", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0200.jp2"}, "201": {"fulltext": "CHAPTER XIV.\\nTHE DATA OBTAINED BY OBSERVATION\u00e2\u0080\u0094 {Continued).\\nChills fever subnormal temperature.\\nTHE TEMPERATURE.\\nBefore discussing the subject of fever, it is not illogical to consider\\nchills.\\nChills.\\nChills vary from a passing creep or cold sensation, extending\\nup and down the spine, to the shake or true rigor of one-half hour\\nor even longer. In infectious diseases the milder form is of as much\\nsignificance as the more severe. The rigor may be so violent and pro-\\nlonged as to terminate fatally. It must be distinguished from the\\nalgid stage of cholera and the coldness of collapse. The chill is\\nattended by general tremor or shaking, chattering teeth, cold extremi-\\nties, pallid face, often parched blue lips and finger-tips. Notwithstand-\\ning the peripheral coldness and the extreme sensation of cold, the in-\\nternal temperature rises, and may be 104\u00c2\u00b0 to 107\u00c2\u00b0.\\nClinically, a chill or rigor marks the onset of severe infection, as\\npneumonia. Chills are symptoms of some affections, as malaria.\\nThey are seen in the course of many diseases, as typhoid fever, tuber-\\nculosis, and septicaemia. In typhoid fever they disclose the occurrence\\nof a secondary infection or a mixed infection they may be due to\\nantipyretic treatment by coal-tar remedies (Osier) or result from con-\\nstipation. Endocarditis is attended by daily chills or they occur at\\nirregular intervals. Pyaemia and septicaemia, purulent inflammations\\n(infections), inflammations of the biliary or renal passages, stone in the\\nbiliary canal, or the pelvis of the kidney (see Intermitting Fever) are\\nfrequently attended by chills. The morphine habit gives rise to chills,\\nwith some fever.\\nFever.\\nIn conditions of health the body-temperature is maintained con-\\nstantly at about 98.6\u00c2\u00b0 F. (37\u00c2\u00b0 C). This stability of temperature is\\ndue to the central regulating apparatus called the thermotaxic mechan-\\nism, which controls the production and the dissipation of heat. Fever\\nis a condition characterized by an increase of temperature, with usually\\nincreased disintegration of nitrogenous tissue. The muscles and large\\nglands, as is well known, are the chief seat of heat-production. Both\\nheat-production and heat-dissipation are believed to be under the\\ncontrol of the nervous system, either through the motor nerves or", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0201.jp2"}, "202": {"fulltext": "192 GENERAL DIAGNOSIS.\\nspecial nerves which pass with them to and from definite centres in\\nthe brain, called heat-centres. In conditions of disease this thermo-\\ntaxic mechanism may be altered, so that the normal temperature is\\nincreased or lessened. (1) There may be elevation of temperature\\nfrom diminished dissipation of heat, though not necessarily increased\\nnitrogenous disintegration and disordered function. Or (2) there may\\nbe increased production of heat with diminished dissipation, hence the\\ntemperature will naturally be higher than if increased heat-production\\nwere accompanied by normal heat-dissipation. (3) There may be in-\\ncreased heat-production and at the same time increased heat-dissipation,\\nin which case there would be the increased waste of fever with or\\nwithout any elevation of temperature. (4) It is possible that heat-dis-\\nsipation may be greater than heat-production, or that the thermotaxic\\nmechanism may be disturbed, so as to promote loss, in which case\\nthere will be subnormal temperature.\\nMode of Determination of Fever. The temperature of the body\\ncan be roughly estimated by the hand of the physician, but this method\\nis open to many sources of error. The skin is at times hot, and gives\\na deceptive sensation of considerable elevation of temperature, whereas\\nwhen tested by the thermometer the temperature is found to be but\\nslightly or not at all above normal. So, too, when the skin feels cold\\nand clammy in phthisis and during a chill from any cause, the actual\\ntemperature of the body is decidedly above normal, and may be as\\nhigh as 103\u00c2\u00b0 or 104\u00c2\u00b0. To insure accuracy, therefore, it is iioav almost\\nthe universal custom to employ clinical thermometers. They are of a\\nconvenient size and shape for insertion under the arm or into the\\nmouth, rectum, or vagina. The better ones are provided with an inde-\\nstructible index, so that the mercury in the capillary tube remains\\nstationary at the highest level to which it rose when the thermometer\\nwas in the mouth or axilla. When not provided with such an index\\nthe reading must be made when the thermometer is still in position.\\nThermometers vary in the accuracy with which they register tem-\\nperature. The best ones are compared with an acknowledged standard,\\nand sold with a slip of paper which gives their fractional variations\\nfrom the standard. When the exact temperature is a matter of great\\nimportance, it should be taken in the rectum or vagina, as their tem-\\nperature is more nearly that of the body. It is of advantage to take\\nthe temperature in the rectum of children or in patients who are coma-\\ntose. This situation is also a good one to select when a bath is being\\nadministered. If possible, scybalous masses should be removed from\\nthe rectum. At least an incorrect reading may be obtained if the ther-\\nmometer should happen to be plunged into the faeces this must be\\nguarded against. From motives of delicacy, however, the axilla is to\\nbe preferred to the rectum and vagina on all ordinary occasions. The\\ntemperature it records is somewhat less than a degree below that of the\\nrectum. The temperature of the mouth is above that of the axilla and\\nbelow that of the rectum. It has some advantages over that of the\\naxilla, being more accessible and recording the temperature more\\nquickly and more accurately. Nevertheless, as the physician s ther-\\nmometer is carried from patient to patient, some place should be", "height": "4412", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0202.jp2"}, "203": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 193\\nselected which is less capable of absorbing disease-germs than the\\nmonth. The axilla is, therefore, by common consent the usual place\\nfor taking the temperature. Observe two precautions (1) Before\\nintroducing the thermometer see that there is no undue moisture if\\nthere is, the axilla should be wiped dry, otherwise a lower than a true\\nreading will be obtained. (2) See that the instrument is inserted into\\nthe armpit and does not project beyond the posterior fold, and that it\\nis not caught in a fold of the undershirt or night-dress. After the\\nthermometer is in position the arm should be brought gently across the\\nchest and kept in that position until the instrument is withdrawn.\\nThe arm should not be held rigidly, as such muscular action increases\\nthe hollow of the armpit and may keep the sides apart, instead of in\\ncontact, as they should be to make a correct reading. The length of\\ntime required to take the axillary temperature will depend upon the\\ninstrument used generally from five to eight minutes are required.\\nSome very delicate thermometers register in one minute, but they are\\ntoo fragile for ordinary use. If the index is in such a position that it\\ncan be seen, it is proper to withdraw the thermometer when the mer-\\ncury has ceased to rise for two minutes.\\nThe index, of course, must be shaken down to normal, or slightly\\nbelow normal, before the thermometer is again ready for use and the\\ninstrument must be carefully cleansed after use.\\nIn children who are restless the temperature may be taken in the\\ngroin, as the folds of fat readily admit of completely enveloping the\\nbulb of the thermometer. The height to which the mercury rises\\nwill correspond to the temperature of the axilla. The temperature of\\nthe urine corresponds exactly with that of the body, if taken when\\nfreshly passed and during the act, a method only applicable in the\\ncase of males. Sometimes this method of securing the temperature is\\nresorted to, particularly in patients who may act as malingerers, when\\nit is desirable to have the temperature taken in the physician s\\npresence.\\nIf the mouth is selected as the place in which the temperature is to\\nbe taken, care should be exercised that the thermometer is placed\\nunder the tongue, or along its side between it and the lower jaw, and\\nretained in position by the lips of the patient. If the teeth are set\\nfirmly on the thermometer, it may be broken, or, what is of still greater\\nimportance, it will be tilted out of position and a correct reading will\\nnot be obtained. The lips should be closed and breathing be carried\\non through the nostrils. Four to seven minutes is sufficient time to\\nallow it to remain in position. The patient should not have taken ice\\nor anything cold prior to the observation.\\nObservations of the temperature should be made at least twice a\\nday, in the morning and evening, and, as far as possible, at the same\\nhour on successive days. It is frequently desirable to have the tem-\\nperature taken every two or three hours, and sometimes at more fre-\\nquent intervals. This is particularly the case if observations of the\\nindications for, and the effect of, antipyretic treatment are to be made.\\nIn obscure cases the observations should be repeated at night as well\\nas during the day. In this manner the presence of unsuspected tuber-\\n13", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0203.jp2"}, "204": {"fulltext": "194\\nGENERAL DIAGNOSIS.\\nculosis may be revealed, or the occurrence of suppuration in some por-\\ntion of the body definitely determined. It should not be forgotten,\\nhowever, that the temperature may be taken too frequently for the\\npatient s good, the disturbance of his needed rest being distinctly\\nharmful.\\nAs the general range of temperature and its diurnal variations are of\\nmore importance than the absolute temperature at any one time, ther-\\nmometers not perfectly accurate in their reading are still good enough\\nfor clinical and therapeutic purposes.\\nPhysiological Variations of Temperature. The temperature is\\nsubject to physiological variations. 1. It rises from seven or eight in\\nthe morning until seven or eight in the evening, at which time it\\nreaches its maximum. It then begins slowly to fall, reaching its lowest\\npoint in the early hours of morning, between two and four. This\\ndiurnal fluctuation does not usually amount to more than a degree. 2.\\nExercise, etc. Violent exertion raises the temperature, and so does a\\nheated atmosphere, cold having a contrary effect. 3. Age. In infants\\nand young children, up to puberty, the temperature has a somewhat\\nhigher range, and is subject to greater variations than at a later period.\\nIn very old persons the temperature may be subnormal. The normal\\naxillary temperature of adults is 98.6\u00c2\u00b0 F. The period in the twenty-\\nfour hours in which the temperature is at its lowest ebb is from 12\\nP.M. to 4 a.m. It may then be subnormal. The writer has known\\nan over-cautious parent to make this physiological fall the subject of\\nmeddlesome observation and ill-judged treatment.\\nPathological Variations of Temperature. An elevation of tem-\\nperature above the normal, not to be accounted for by external heat or\\nsevere exhaustion, may be considered febrile, and is pathological.\\nThe range of febrile temperature varies from above normal to 105\u00c2\u00b0 or\\n106\u00c2\u00b0 in ordinary cases. A range above 106\u00c2\u00b0 may occur, but is not\\nusually compatible with life. Certain terms have been applied to\\nvarious degrees of temperature, to indicate in a general way the degree\\nof fever\\nVery low or collapse temperature.\\nBelow\\nAbout\\nNormal\\nAbout\\nAbout\\nAbout\\nAbove\\n35 c\\n36\\n36^\\n37\\n37*\\n38\\n38*\\n39\\n39.]\\n40\\n40]\\n41\\nCent.:\\n95.0\u00c2\u00b0\\n96.8\\n97.7\\n98.6\\n99.5\\n=100.4\\n=101.3\\n=102.2\\n=103.1\\n=104.0\\n=104.9\\n=105.8\\nFah.\\nSubnormal temperature.\\nNormal temperature.\\nSlightly above normal or sub-febrile temperatures.\\nModerately febrile temperature.\\nHighly febrile temperature.\\nHyperpyretic temperature.\\nFrom Finlayson.\\nThe Degree of Danger. In general the degree of danger to the\\npatient increases with the height of the fever, but the duration of the\\nhigh fever modifies this greatly. A temperature of 106\u00c2\u00b0 on the second\\nor third day of an acute lobar pneumonia is not rare, such cases fre-", "height": "4416", "width": "2568", "jp2-path": "practicaltreatis00muss_0_0204.jp2"}, "205": {"fulltext": "THE DATA OBTAINED BY OBSERVATION.\\n195\\nquently ending in recovery, while a temperature of 105\u00c2\u00b0 in the second\\nor third week of typhoid fever is of much graver significance. Da\\nCosta has reported a case of cerebral rheumatism in which the axillary\\ntemperature reached 110\u00c2\u00b0, yet the patient recovered. In the case of\\ninjury of the spine, reported by Teale, the extraordinary temperature\\nof 122\u00c2\u00b0 was recorded, and the temperature-range for days was between\\n112\u00c2\u00b0 and 114\u00c2\u00b0. The patient recovered.\\nFig. 30.\\nMalarial intermittent fever. Quotidian type.\\nThe Types of Fever. Fevers are divided, in accordance with the\\ncharacter of their range, into certain definite types. The types may\\nFig. 31.\\n102\u00c2\u00b0 -S--\\nrWllllllllllllllllI\\n99\u00c2\u00b0 q E EE\\nM 111 1 IliillMPfl\\nDATE 7 8 9 10 W 11 sV^tl2 13\\nMalarial intermittent fever. Tertian type.\\nbe indicative of special processes. It is certain that the recognition of\\na peculiar type forms a positive aid to diagnosis. The fever that con-", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0205.jp2"}, "206": {"fulltext": "196\\nGENERAL DIAGNOSIS.\\ntinues for more than two days, in which the difference between the\\ndaily maximum and minimum of temperature is less than 2\u00c2\u00b0, is known\\nas continued fever. (See Fig. 36.) The fever existing more than two\\ndays, in which the daily difference is greater than 2\u00c2\u00b0, is known as\\nremittent fever. Further, a fever in which there is a rise of temper-\\nature followed by a fall to or below the normal, occurring periodically,\\nFig. 32.\\nF.\\nj d\\n107\u00c2\u00b0\\n^T?\\n-2\\nf-\\n-i\\ni\\n\u00e2\u0096\u00a0s--^- 1\\ntt-\u00c2\u00b1\\n-2\u00e2\u0080\u0094\\nJ -5\\n\u00e2\u0096\u00a0g\\n5-.S.\\n-ii\\na..\\nCD^JJ\\np.\\n106\\n;-f *V\\n105\u00c2\u00b0\\n--Is J\\n104\u00c2\u00b0\\n103 u\\n103\\nr\\nt T\\n3 t\\n_\\nL.\\nior\\nIT\\nt:\\n1\\nn\\n100\u00c2\u00b0\\nd\\n99\u00c2\u00b0\\n1\\nt\\n98 u\\nr\\nf\\nT\\nf\\nV\\nt_,\\ni\\nJ\\n1\\nT _j\\nA\\n97\u00c2\u00b0\\nii\\nv\\ns\\n2\\n*N.\\nPULSE\\n,v\\nv\\n\u00e2\u0096\u00a0x*\\\\\\nx-T y cS\\na\\nRESP.\\ni4\\nH-\\n\u00e2\u0096\u00a0*v\\nf4\\n%f4\\nf^f-\\n5\\nv-,;\\nDATE\\n,t. N..v.\\n2\\n3\\nI\\nMalarial intermittent fever. Quartan type.\\nis known as intermittent fever. The paroxysms may occur daily, every\\nsecond or third day, or once a week. When the paroxysms occur\\ndaily, the intermittent fever is of quotidian type (see Figs. 30 and 33)\\nevery second day, tertian type, one day intervening without fever (see\\nFig- 37) every third day, quartan type, two apyretic days intervening\\nThe Course of the Fever. Fevers frequently have a definite\\ncourse, known as (1) the initial stage; (2) the fastigium (3) the\\nperiod of defervescence. During the initial stage the temperature rises\\nhigher each hour (or if extended over days, each day) than the pre-\\nceding hour or day in this latter instance interrupted by the daily\\nfluctuations. The stage may last from a few hours, as in a paroxysm\\nof intermittent fever, to four or five days, as in typhoid fever. In\\nthis stage we have a chill such as characterizes the onset of an inter-\\nmittent fever, or the recurrent chills or chilliness with headache and\\nbackache that attend the first four or five days of typhoid fever.\\nDuring this stage, also, the heat-dissipation from the cutaneous surface\\nis diminished and the total heat-dissipation is less. When the hand\\nis placed upon the patient the surface will be found to be cool, whereas", "height": "4400", "width": "2592", "jp2-path": "practicaltreatis00muss_0_0206.jp2"}, "207": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 197\\nthe temperature in the mouth or rectum will be found to be far above\\nthe normal. The patient complains of the coldness or chilliness, and\\nthe low temperature of the surface is indicated by the shrunken hand,\\nthe pallid, pinched face. The peripheral arteries are contracted, and\\nhence cause diminution in the amount of blood to warm the skin and\\nto compensate for the loss by radiation and conduction. This peripheral\\ncontraction is the cause of the chilliness and the fall in the tempera-\\nture of the skin.\\nDuring the second period of the course of pyrexia the fastigium\\nthe temperature of the body attains the highest point, and remains\\nalmost stationary, or may vary but a degree or two between maximum\\nand minimum. It may last a few hours or from two days to three or\\nmore weeks, during which time it may oscillate to the maximum point\\nof the first day. The temperature of the surface of the body is about\\nthe same as that of the deep parts, particularly in cases of pneumonia,\\nmeasles, and scarlet fever. In typhoid fever, acute rheumatism, and\\nphthisis, during this period, there may be a difference in the external\\ntemperature and the temperature taken in the cavities, as the mouth\\nor rectum. More or less antagonism between heat-production and\\nheat-loss exists under these circumstances. The latter may be greater\\nthan the former, if the skin perspires freely, as in rheumatism. The\\ntemperature then remaining high indicates that the production of heat\\nmust be proportionately increased, and hence far greater than in the\\ncases in which the external and internal temperature are nearly the\\nsame. (See Fig. 34 the fastigium here occurs in the first three days.\\nIn Fig. 37 the fastigium lasts until the crisis.)\\nIn the period of defervescence the temperature falls to the normal.\\nIn this period an attempt is made by the economy to return to a physi-\\nological state, in which heat-production and heat-loss are evenly\\nbalanced. The state of pathological pyrexia has come to an end.\\nThe termination may be by crisis. (See Figs. 31 and 37.) When this\\ntakes place the perturbation of the thermotaxic mechanism must be\\nvery great, but the normal state is at once resumed. In other cases\\nthe termination is by lysis the temperature falls a degree or two each\\nday until the normal is reached. (See chart of Typhoid Fever.) It\\nseems that the thermotaxic mechanism of health is restored with diffi-\\nculty. In some cases, in the period of defervescence, the aberrations\\nare very remarkable. It seems as if the thermotaxic mechanism which\\ncontrols heat-loss was in a convulsive state. The temperature rises\\nand falls irregularly, gradually resuming the normal only as the\\nstrength of the patient increases.\\nThe Mode of Onset Initial Stage. The onset may be sudden or\\ngradual. 1. The sudden onset occurs in acute diseases, as tonsillitis,\\npneumonia, and gastro-intestinal disorders of children, in erysipelas,\\nand in intermittent fever. Within a few hours the maximum of tem-\\nperature is reached. (See Fig. 37.) 2. The mode of onset may be\\ngradual. The initial stage is prolonged under these circumstances, as\\nin cases of typhoid fever. (See chart of Typhoid Fever.)\\nThe Mode of Decline the Defervescence. A sudden fall of\\ntemperature at the termination of a disease is known as crisis, which is", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0207.jp2"}, "208": {"fulltext": "198 GENERAL DIAGNOSIS.\\nalso attended by copious perspiration, a critical sweat/ or by the\\npassage of a large quantity of urine, and sometimes by several large\\nliquid stools. The pulse-rate and respirations fall correspondingly\\nwith the temperature. (See Fig. 37.)\\nThe defervescence may, however, occupy several days, in which case\\nit is called lysis. In this case the sweating is less marked, but may\\nrecur for several days. The slowing of the pulse and respiration like-\\nwise take place gradually. (See chart of Typhoid Fever.)\\nDiseases of sudden onset usually terminate with sudden decline, and\\nconversely in diseases with a prolonged onset the decline is also pro-\\nlonged. Many cases which naturally terminate by crisis may end by\\nlysis. This irregular termination is usually due to a complication.\\n(See Fig. 34.) For instance, in measles, pneumonia is usually the\\ncausal complication, while in pneumonia it is empyema or endocarditis.\\nThe Daily Range of the Prolonged Initial Stage and the Fas-\\ntigium. The daily range of the temperature in fever generally corre-\\nsponds to the normal variations. That is, the temperature is higher\\nin the evening than in the morning. The difference in the daily range\\nvaries in the different types of fever generally, as previously noted,\\nthe continued fevers show a smaller, the intermitting fevers a larger,\\ndifference between morning and evening temperature.\\nSometimes there is inversion of the normal range. The evening\\ntemperature is lower than the morning although a rare condition,\\nthis is of serious import. It is seen in the more severe cases of typhoid\\nfever and occasionally in tuberculosis.\\nRecrudescence. In many cases the fever returns after the temper-\\nature has fallen to the normal. This may occur from a number of\\ncauses. It may be from perturbation of the nervous system, on account\\nof excitement, over-exertion, loss of sleep, or from indigestion. Slight\\naberrations, which in health would not modify the temperature, cause\\npronounced oscillations in illness. Recrudescence, further, may be\\nproduced by a relapse. After the afebrile period following typhoid\\nfever, for instance, the temperature may rise and a full recurrence of\\nthe disease take place.\\nThe Symptoms of Fever. Pyrexia, or increased temperature, is\\nnot the only evidence of fever. The production of heat within the\\nbody is not due to increased tissue-change alone. It may be due, for\\ninstance, to increased oxidation of sugar, which is part of the substance\\nof the body. Physiologists have found that a high temperature may\\ntake place, and yet the quantity of urea and of carbonic acid discharged\\nmay not be as great as that of a healthy person who is taking active\\nexercise or who has eaten a large meal. It must be remembered,\\ntherefore, that it is not heat-production alone but alterations of heat-\\nregulation which cause pyrexia and its phenomena.\\nWasting. Wasting of the body is a striking symptom of fever.\\nThere is no doubt that even in fever of moderate duration great wasting\\nof the solid structures takes place. At the same time the blood wastes\\n(see observations of Thayer) and the various fluids of the body are\\nalso diminished, hence the disorders due to diminished secretion of\\nglands are prominent in the course of fever. Diminution of secretion", "height": "4416", "width": "2572", "jp2-path": "practicaltreatis00muss_0_0208.jp2"}, "209": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 19\u00c2\u00a3\\nin the gastrointestinal tract, causing thirst, loss of appetite, indigestion,\\nand constipation, indicates the wasting of the fluids. Scanty nrine of\\nhigh color and specific gravity is due to the same cause.\\nThe Pulse-eate. Acceleration of the pnlse is one of the phenom-\\nena that attend pyrexia. While increased pnlse-freqnency is the rule,\\nand is, in all probability, a result of the increase in temperature, other\\ncircumstances may cause a change in the pulse-rate in pyrexia. Thus,\\nin basilar meningitis, although there may be a high fever, the pulse is\\nnot more frequent. On the other hand, some diseases, usually accom-\\npanied by fever, as diphtheria and peritonitis, may be afebrile, and yet\\nthe pulse be very much accelerated.\\nAeteeial Texsiox. The rapidity with which the blood flows in\\nfever and the arterial tension do not bear a due proportion to the accel-\\neration of the pulse. The true febrile pulse is not dicrotic. In the\\nearly stages of fever the pulse is large and hard, the arterial tension is\\nhigh, and the vessels full. In the later stages arterial relaxation takes\\nplace, and the pulse becomes soft and feeble, and often small, with\\nlow pressure. The pulse is rapid, and dicrotism, or even hyperdicro-\\ntism, now becomes a prominent feature. The heart beating rapidly\\nempties itself incompletely and discharges less rather than more blood\\ninto the arteries. The impairment of the cardiac beat is no doubt due\\nto the degenerations on account of the high temperature, and is not\\ndependent upon any special febrile affection. Such changes also take\\nplace in the glands, particularly the liver and kidneys, and are known\\nas parenchymatous degenerations, or cloudy swelling. These changes\\nin the cardiac muscle may induce, in the later stages of fever, thrombi,\\nand cause death from heart-clot.\\nThe Respieatiox. The respirations are increased in fever, proba-\\nbly because of the close dependence of the regulating centre of respira-\\ntion on that of the heart. The heated blood acts as a stimulant to the\\nrespiratory centre. As proof of this, the hurried respiration of pneu-\\nmonia ceases as soon as the temperature falls, notwithstanding the fact\\nthat the affected part of the lung remains hepatized.\\nCeeebeal Symptoms. Delirium and other nervous symptoms may\\nattend fever. They are not dependent upon the increased temperature\\nof the blood alone. Xo relation appears to exist between the intensity\\nof the fever and the severity of the delirium. In relapsing fever a\\ntemperature of 106\u00c2\u00b0 occurs with the mind clear. In certain cases of\\ntyphoid fever a temperature of 103\u00c2\u00b0 is attended with marked delirium.\\nIf fever persists for a short time a low asthenic state, so-called adyna-\\nmia, may develop. Because the symptoms resemble those of typhus\\nfever, the term typhoid is also applied to them, and the condition\\nabout to be described is known as the typhoid state. The expression is\\ndull and heavy, the capillaries of the face are congested. There are\\nstupor and sluggishness of mental processes, so that the patient is slow\\nin answering questions. The stupor is attended with low muttering\\ndelirium, and may be followed by complete unconsciousness. The\\npupils are contracted, the eye heavy and dull. The patient is so pros-\\ntrated that he slips down into the bed from the pillow. There is\\nmarked subsultus tendinum. The tongue, if protruded, comes out", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0209.jp2"}, "210": {"fulltext": "200 GENERAL DIAGNOSIS.\\nslowly and is tremulous. It is dry and brown, and the mouth and\\nteeth are covered with sordes. The sensibilities are blunted, so that\\nfood and drink are not asked for, or particularly relished if given.\\nInvoluntary discharges take place from the rectum and bladder, and\\nthe incontinence of retention of the urine arises. The pulse is small,\\nfeeble, and dicrotic, the heart-sounds are weak and feeble. The first\\nsound becomes short and snappy like the second, or may be absent\\nentirely. Venous stases take place in the dependent portions, particu-\\nlarly in the back of the lungs.\\nAs oedema or hypostatic congestion advances the breathing becomes\\nshorter and labored. More or less cyanosis then creeps over the gen-\\neral surface. The urine becomes more and more scanty and high-\\ncolored, contains albumin, and sometimes blood.\\nThe typhoid state may continue for many days, or even last two or\\nthree weeks, although not in so advanced a degree as has been described.\\nIt is more likely to supervene when there is excessively high temper-\\nature, but it also occurs in the course of a prolonged illness with a\\ntemperature of moderate degree that is, 103\u00c2\u00b0 F. Although it is in\\nall probability due to the direct effects of heat upon the nerve-centres\\nand the organs of the body, yet there are cases in which the temper-\\nature is not high, and yet all the symptoms of the typhoid state super-\\nvene. While the typhoid state is common to typhoid fever it occurs\\nalso in pneumonia and septiewmia, and may even be seen in its most\\ntypical form in other conditions in which fever is not a pronounced\\nsymptom thus in urcemia, in the later stages of softening of the\\nbrain, in paresis, or in allied nervous diseases the symptoms of the\\ntyphoid state are most striking. In this class of cases it certainly\\ncannot be attributed to the fever, but is, in all probability, due to the\\ndepressing effect on the nervous system of material which should be\\nexcreted from the body, a view which has been advocated by Murchi-\\nson, Flint, and others.\\nAtaxia, or the ataxic state, in fever is a condition the opposite of\\nthe adynamic, or typhoid state. In the latter there is weakness, while\\nin the former there is exhibition of strength. In the latter the nerve-\\ncentres and the vital processes are depressed in the former they are\\nstimulated. Ataxia as an exhibition of strength is characterized by a\\nstrong pulse and by active, violent delirium, so that it is almost impossi-\\nble to keep the patient in bed by evidence of great muscular strength.\\nThe face is flushed, bright-red in color the eyes injected, bright, and\\nactive. The tongue is furred, but is not necessarily dry or brown.\\nThe delirium may be constant or paroxysmal, and is often maniacal in\\ncharacter. The temperature of the body is high, and a sensation of\\nintense heat is imparted to the hand when placed on the surface of the\\ntrunk. The patient may complain of a bursting, intense headache. If\\nthe ataxic state is not controlled after a few days, or at the most a\\nweek, the patient becomes exhausted and lapses into stupor, which\\nmay proceed to coma. In some forms, particularly in children, con-\\nvulsions may accompany the excessively high temperature and be fol-\\nlowed by coma. The so-called coma vigil may supervene. The same\\nexhibition of strength is shown. Ataxia is seen notably in scarlet", "height": "4412", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0210.jp2"}, "211": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 201\\nfever, cerebral pneumonia, and in forms of typhoid fever. The\\npeculiar behavior of the temperature and nervous systems in this affec-\\ntion and in apex pneumonia, or so-called pneumonia of the cerebral\\ntype, have led observers to mistake such cases for actual cerebral\\ndisease. Frequently they have been admitted into insane asylums for\\nsupposed mania. The true nature of such cases is often mistaken,\\nand, because of lack of attendants, the patients have jumped from the\\nwindow or done violence to themselves in other ways.\\nIt is as difficult to determine the exact cause of the extreme pertur-\\nbation of the nervous system in febrile ataxia as in adynamia. It may\\nbe due to a high temperature, acting on nerve-centres or to a poison,\\nas the special toxin of the infection which has caused the fever.\\nThe presence of fever may be suggested by flushing of the face.\\nThis may be general or local. The local flush of phthisis and of pneu-\\nmonia has previously been referred to. Dryness and pungency of the\\nskin occur in fever. In former times the sense of heat was given\\ndifferent attributes, said to be distinctive of various affections. Hence\\nthe terms calor mordex, etc. Thus the sensation to the hand of the\\nheat in typhus fever was said to be peculiar and characteristic. The\\ndegree of fever was determined by the sense of touch. The thermom-\\neter has displaced this method of reckoning temperature. Sweating is\\na condition habitual in some fevers. It may occur throughout the\\ncourse of the disease, or at certain stages only as instanced by the early\\nmorning or night-sweats of tuberculosis. In such cases it is cold and\\nclammy. The same sweatings are common in the fever of deep-seated\\nsuppuration and in disease of the bones. Sweating in defervescence\\nmarks the occurrence of crisis.\\nHeadache and pain in the back occur in the acute specific\\nfevers in the initial stage. One or both are nearly always present, but\\nin different affections they have diagnostic significance. Thus severe\\npain in the back is more pronounced in tonsillitis and smallpox, severe\\nheadache in cerebro-spinal meningitis, and protracted throbbing head-\\nache in typhoid fever.\\nSubnormal Temperature. A temperature below the normal may\\noccur independently of fever. It may follow as a sequelae of the dis-\\neases with more or less prolonged pyrexia. It occurs in the course of\\nwasting diseases, as in cancer, in starvation, at times in anaemia. It is\\nseen habitually in myxoedema, and occasionally in diabetes. In cer-\\ntain forms of tuberculosis it may extend over a long period of time,\\nas in tuberculous peritonitis. (See chart under Tuberculous Peritonitis.)\\nIn cases of cerebral abscess the temperature is often subnormal.\\nSometimes the drop to subnormal temperature may occur suddenly,\\nto be followed by a return to normal or even a rise above normal.\\nThe sudden fall may occur in shock, or in hemorrhage from any cause.\\nIt may take place from disturbance of the nerve-centres, as from\\napoplexy, thrombosis, or embolism of the brain, causing shock or other\\ndisturbance of the thermotaxic mechanism. It is characteristic of\\ncholera. In the course of organic heart disease pulmonary embolism\\nis also attended by subnormal temperature. In many of these in-", "height": "4412", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0211.jp2"}, "212": {"fulltext": "202\\nGENERAL DIAGNOSIS.\\nstances the temperature will rise (reaction) after the shock if the latter\\nis not too profound. This is notably the case in apoplexy and in\\nembolus or thrombus, because of local irritation or a secondary soften-\\ning. In apoplexy the rise in temperature will occur either from cen-\\ntral disturbance of the thermic mechanism or from secondary inflam-\\nmation about the clot. A subnormal temperature in the course of\\nFig. 33.\\n^EME MEMEM\\nE M E ME MEM\\nE M M E N\\nE M E M E\\nj\\nI.\\n.1\\n1\\n1\\n1\\n1\\nt T\\no\\nt t-\\n1\\nIOI\\nr\\n4\\n44\\nr h\\n4 1\\n1\\n4 4T\\n1\\n4 t 4\\ni\\n99--\\nt\\n-t\\ni c-\\n-r i\\na\\nIII\\nE\\n6 J\\n98\\nT t\\nM S\\n1 5\\n53\\nI\\n23\\n3\\n_\\n3-\\nA\\nh^\\n3\\nV-\\n96\\n4 _.\\nft\\nt-\\nL.\\n1 4\\n5\\nv-t-\\n_l\\nx 4\\nit\\ntt\\nzz\\nt\\nt\\n4\\n95--\\n3\\n5\\nT-\\nV \u00e2\u0080\u00944\\n1z\\nt\\nx\\nI\\ni.\\n-A t\\ni_\\n4\\n1\\n4\\nx\\n.4\\n^_\\ns:\\nSubnormal temperature. Oscillations in hepatic intermittent fever with jaundice. Catarrh of\\nducts, with diffused hepatitis. G. W., aged 60. Philadelphia Hospital, 1877.\\nfever may be due to an accident or complication, as hemorrhage in\\ndisease of the lungs, or in typhoid fever, or perforation of the intestine\\nin the latter condition. It may attend the crisis of acute disease. More\\nor less collapse usually attends the pathological fall of temperature\\nbelow the normal. While such fall is the result of accident in many\\nof the diseases mentioned, in others it is a part of the process.\\nThe chart (Fig. 33) represents the effect of a local process in the\\nlargest gland of the body upon the general temperature. It is possi-\\nbly a septic temperature, although the observation was made before\\nthe days of bacteriological research. The extreme low temperature is\\nremarkable.", "height": "4412", "width": "2584", "jp2-path": "practicaltreatis00muss_0_0212.jp2"}, "213": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 203\\nThe Diagnostic Significance of Fever. Its Clinical Causes.\\nThe presence of fever is itself of diagnostic importance.\\nA. It usually excludes hysteria and malingering disease.\\nB. It indicates that one of several morbid processes is present. The\\nmorbid processes which give rise to fever are\\nFirst, an infection, general or local, as seen in any one of the infec-\\ntious diseases and in the local inflammations induced by micro-organ-\\nisms, especially those known as pus-producing. When local, the\\ninflammation is known as purulent, suppurative, or septic. The micro-\\norganism, a product of its growth, or the poisons or ferments resulting\\nfrom the tissue change, disturbs the thermotaxic mechanism and causes\\nfever. Any tissue, membrane, or organ of the body may be the seat\\nof an infectious process.\\nSecond, an intoxication, or toxaemia, as caused by albumoses, ferments,\\ntoxins, or ptomaines, generated within the system, the result of im-\\npaired functional activity of organs or structures, or of cell metabolism,\\nas seen in tissue waste and by food products, medicines, or toxic\\nsubstances introduced from without. Catarrhal inflammations cause\\na toxic fever. The fever of gout, of ansemia, of starvation is toxic.\\nThird, fever may be of central origin, from disease of the brain in-\\nvolving the centres controlling heat, or from disease in proximity to the\\nheat-centres. It may arise in cases of brain-tumor, in cases of apoplexy,\\nand of thrombosis. The centres may also be irritated by direct ex-\\nposure to external heat alone, or possibly by poisons generated within\\nthe system on account of the heat (an intoxication), as in sunstroke.\\nFourth, a pronounced peripheral irritation or sensation of pain, reflexly\\naltering the thermotaxic mechanism, will produce fever. Hence, in iritis\\nor orchitis a fever arises out of all proportion to the local inflammation.\\nFinally, cases of continued fever exist that have not thus far been\\nclassified. One of the nurses of the Presbyterian Hospital with a\\ncontinued temperature from 100\u00c2\u00b0 to 103\u00c2\u00b0 was under my care for two\\nmonths. No general or local condition could account for it. The\\npatient was emaciated. She had had two years of very hard work.\\nAlthough fever kept up, the appetite was good. Careful and abundant\\nfeeding, with rest for many weeks, caused the temperature to fall to\\nnormal, with complete recovery. I looked upon it as a nervous fever\\nan expression of exhaustion. Fagge refers to such cases.\\nPractically, we must in all cases of fever decide between one of infec-\\ntious and one of toxic origin. Discussion of the mode of determining\\nthe occurrence of an infection will be considered shortly. In the mean-\\ntime we may observe that the poisons which are generated in the\\ngastro-intestinal tract are likely to disturb the cardiac and respiratory\\nas well as the thermotaxic mechanism. Hence we often see irregu-\\nlarity and intermittency of the heart so often as to look upon it as of\\ndiagnostic value in favor of toxic fever.\\nCertain clinical features of a febrile course belong, in the main, to\\nspecial affections, and thus far are diagnostic of them. Hence the\\nmode of onset or initial stage, the course or fastigium, the decline and\\nthe type should be carefully studied. They are a most important in-\\ndication of the nature of the disease.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0213.jp2"}, "214": {"fulltext": "204 GENERAL DIAGNOSIS.\\nThe Initial Stage. 1. In the initial stage of fever sudden, ex-\\ncessive rise of temperature from a condition of apparent health argues\\nagainst any of the acute specific fevers except scarlet fever. It is of\\nmore frequent occurrence in acute gastric or gastro-intestinal catarrh\\nin children than in any other ailment. It may be due to pneu-\\nmonia, and is significant of this infection in adults if attended by a\\nrigor. In children convulsions may replace the chill. The sudden\\nrise may be due to certain types of malaria, when it is also preceded\\nby a chill and followed by free sweating. It may also be due to affec-\\ntions of the throat, to follicular or phlegmonous inflammation of the\\ntonsils. The throat must always be examined in cases of sudden high\\ntemperature.\\nIn children, if pain attends any inflammatory affection, the tempera-\\nture will rise to a greater height than the local process alone would\\nwarrant. This is the case with suppurative inflammation of the\\nmiddle ear. This must always be borne in mind in sudden rise of\\ntemperature. The same active febrile reaction will take place in osteo-\\nmyelitis and in mastoid abscess. The associate signs point to the true\\nnature of the affection, although it must be confessed that in both the\\nsymptoms are often obscure in the beginning.\\n2. In typhoid fever the temperature rises in a characteristic way.\\nIt ascends by successive evening rises, followed by morning remis-\\nsions, until it reaches the maximum at about the end of the first week.\\nThe Fastigium. In typhoid fever the course of the fastigium is\\nof characteristic significance. From the end of the first, throughout\\nthe second week, and sometimes longer, the fever is of the continued\\ntype. Subsequently during the third week, or later, morning remis-\\nsions set in, the temperature for a time still rising to the former height\\nin the evening. Then the morning remissions become more decided,\\nthe temperature not rising as high in the evening, and so gradually\\nthe temperature sinks to and below normal. This course of the tem-\\nperature in typhoid fever is very far from being invariable it is modi-\\nfied by indiscretions on the part of the patient or his attendants, and\\nby the necessities of antipyretic or other treatment nevertheless, the\\ngradual onset of the fever and its long duration are sufficiently com-\\nmon to make them of great value in diagnosis, as, with the exception\\nof tuberculosis, there is hardly any other disease in which a continued\\nfever exists for two or three weeks apart from local inflammation or\\nsuppuration.\\nThe Decline. Defervescence. In the self-limited diseases there\\nis a period when defervescence should take place. A continuance of\\nthe fever, the persistence of the fastigium beyond the usual period,\\nindicates that the case is one of a greater degree of gravity than usual,\\nor that there is a complication. It is usually significant of a compli-\\ncation. In measles the complication is usually pneumonia. This\\nmay take place after the disease has developed, and may be the cause\\nof the unusual rise in temperature. In scarlatina it may indicate\\nacute nephritis, or inflammation of any of the serous membranes,\\nparticularly the pericardium or endocardium. Persistence of the\\nfastigium of typhoid fever after the period at which it should decline,", "height": "4404", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0214.jp2"}, "215": {"fulltext": "THE DATA OBTAINED BY OBSERVATION.\\n205\\nif the patient is well nursed and properly fed, usually indicates the\\noccurrence of a reinfection, a secondary infection, or the development\\nof tuberculosis. If the latter, the fever is more likely to develop dur-\\ning convalescence. Of the inflammatory complications, phlebitis and\\nglandular and bone infections are likely to cause persistence of fever.\\nFig. 34.\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nM\\nE\\nME\\nu\\\\*\\nM\\nE\\nM E\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\no-\\n104-\\n1\\n103\\n1\\n1\\nw\\n102-\\nI\\nv\\n-L\\nN\\nj\\ni\\nI\\n101-\\n1 1 1\\n1\\n1\\nIOO-\\n99-\\n1\\nt\\n1\\n1\\nw\\nN\\n1\\nI\\nV\\nv\\n1\\n1\\n1 1\\n1\\n\\\\l\\n1\\nJ\\n1\\n1\\n1\\nP.ilse\\ns _\\nf4\\nJjVc\\nc V\\n\u00e2\u0080\u00a2\\\\,o\\ni\\np^\\nP^-\\n*y\\n\u00e2\u0080\u00a2p/\\nDate\\nu\\n15\\n16\\n17\\nIS\\n19\\n20\\n21\\n22\\n23\\n24\\n25\\n2 i\\n27\\n28\\nI\\n3\\n4\\n5\\nScarlet fever. Modification of temperature by complications. Nephritis on the ninth day.\\nA Sudden Fall; Subnormal Temperature. A sudden fall of tempera-\\nture in a person who has previously had high fever signifies the crisis\\nif the time for that event has arrived, as in pneumonia or of a grave\\ncomplication, which induces shock. In typhoid fever this unusual\\ndrop in the temperature will take place if there has been hemorrhage\\nfrom the bowels, or perforation, or if peritonitis has developed. It\\nmust not be confounded with the sudden falls of temperature that\\noccur in the typhoid fever of children, corresponding to the onset of\\nconvalescence. They occur earlier in the period of the disease than\\nwith adults.\\nThe Type of the Fever. Intermittent Fever. The representative\\nof the type is seen in malaria, but it is simulated by a number of\\nconditions (1) In certain cases of typhoid fever and of relapsing fever\\nthe type is intermitting or paroxysmal. The same type of fever is\\nseen (2) in suppuration, particularly if the pus is confined, although in\\nbrain abscess the temperature may be normal or subnormal (3) in\\ninfectious endocarditis; (4) in tuberculosis. a. It may occur in the\\nearlier stages of tuberculosis. The primary seat of the lesion may be\\nin the lungs, in the bones, or in the glands, b. In pulmonary tuber-\\nculosis, after the formation of a cavity, intermitting fever is of common\\noccurrence. It is then of septic origin due to the septic influence of the\\nnecrosed tissue and products of putrefaction in the cavity. (See Fig. 35.)\\n(5) In lymphadenoma and anaemia the fever is at times paroxysmal.", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0215.jp2"}, "216": {"fulltext": "206\\nGENERAL DIAGNOSIS.\\n(6) In syphilis the same type is often seen. It may be noted (a) in the\\ninitial fever (6) in the tertiary periods of the disease where gummata\\nhave formed, or other forms of visceral syphilis have developed. (7)\\nFig. 35.\\nr\\nm|e|m\\nE M\\ne m\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nM E\\nM\\nM\\nE\\nM E\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nvl E\\nM\\nM\\nE\\nM\\nE\\nM\\nE\\nI\\nI\\nExec\\n1\\nA\\nn\\n-t 1\\nR\\n-t\\n1\\nII\\n-I\\nf\\\\\\ni\\n4\\n1\\n4\\nI\\n1\\nI\\nt\\ns\\n:r\\nI\\nf\\\\\\nt\\n|_\\nA\\nA\\nA\\nL\\nV\\nf\\nf\\nr\\ni\\n1\\nt\\nr~ _\\nA\\nI\\ni\\n1\\n1\\nr _\\ni\\n1\\n1\\nl\\nI\\n1\\nt\\n1\\nzt\\nIT\\n\u00c2\u00b17\\nI\\n\u00c2\u00b1f_\\ny\\nli-\\n4\\nIf\\n1\\ni\\ny\\nI\\nlt\\n4,\\nJL_\\nj\\nu\\nH\\njr\\nv\\n9\u00c2\u00ab-\\n1\\ni\\ni\\nV\\nJ\\ny\\n1\\n1\\nT\\no-\\nf\\ny\\nx\\nIntermitting fever of tuberculosis.\\nUrinary intermitting fever is the form Avhich usually occurs after the\\npassage of a catheter or sound, but it may also occur when there is\\nsuppuration in the genito-urinary tract. (8) Hepatic intermitting fever\\nis a form of frequent occurrence and of great diagnostic importance.\\nFig.\\nContinued fever of tuberculosis.\\nIt may be due to (a) gallstones somewhere in the biliary ducts, usually\\nwith obstruction (6) suppuration in the canal, with or without ob-\\nstruction (c) obstruction of the biliary passages by external pressure\\nwithout suppuration (d) inflammatory affections of the liver, as ab-\\nscess, and forms of cirrhosis. It occurs rarely in rapidly growing cancer.\\n(See Fig. 33.) (9) Intermittent fever may also attend the prolonged\\nuse of morphine.", "height": "4408", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0216.jp2"}, "217": {"fulltext": "THE DATA OBTAINED BY OBSERVATION.\\n207\\nOf the above-mentioned varieties of paroxysmal or intermitting\\nfever, those of the most common occurrence are due to suppuration,\\npyaemia, to infectious endocarditis, to tuberculosis, and to hepatic dis-\\norder. In addition to the paroxysmal temperature, rigors precede and\\nsweating follows the paroxysm, as in cases of malarial intermittent fever.\\nFig. 37.\\nU\\nE\\nW E\\nM\\nE\\nM\\nE\\nM\\nM\\nE\\nM E\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\n105\\n0-\\n104-\\nn\\nJ\\n1\\nft\\nv,\\n~L\\n_L\\n103\\n~~f\\nT_T\\n1\\nV\u00c2\u00b1-\\nA\\n\\\\t-\\n31\\nST\\n1\\n4 zz\\n1p\\n102-\\n1\\nIOI\\n1\\nIOO\\ntz\\n0-\\niz\\na:\\nA\\n99\\nT_\\ni~\\nzi\\n-i\\n1\\n~j\\nYz\\n/A\\nf\\nV\\nI\\nr_s\\nJZ\\nI\\nV\\nA\\n1_\\n98-\\nw\\nrz\\n47\\nv\\nV\\nl lllse\\n^S^So\\nZp\\nj\u00c2\u00a3--$\\n3000\\nI Is\\n3 SS\\n\u00c2\u00a3S\\nKS\\n.sss\\nS RR\\ns ss\\nj\\nDale\\ns\\\\-\\ni-S\\nCO\\nc\\ns\\n5tt\\nM\\n2\\noc\\nPneumonia. Sudden rise. Termination by crisis. Pseudocrisis also seen.\\nThe diagnosis from malarial intermittent fever can be established at\\nonce by an examination of the blood, which reveals in the latter the\\nplasmodia of Laveran.\\nRemittent Fever. Fever of a remittent type occurs in many of the\\nconditions in which intermittent fever is present. It is characteristic\\nof one of the forms of malaria. It is most frequently encountered in\\ntuberculosis of the lungs. The remissions usually occur in the morn-\\nings, but the order may be reversed. The same type of fever is met\\nwith in puerperal fever, pysemia, and septicaemia, and in local suppu-\\nrations, such as abscess of the liver and empyema. A continued fever\\nmay be made to resemble a remittent by antipyretic treatment, which\\nmay cause abnormal remissions. Remissions characterize the decline\\nof the continued fevers, particularly typhoid, during the period of lysis.\\nContinued Fever. Continued fever is met with in lobar pneumonia,\\ntyphoid fever, typhus fever, erysipelas, and tuberculosis. In acute\\nlobar pneumonia the temperature rises rapidly, and in a few hours\\nfrom the initial chill reaches 103\u00c2\u00b0 or 105\u00c2\u00b0. The morning and even-\\ning temperatures vary but little, usually not more than one or two\\ndegrees, until a crisis occurs in from four to eight days. The temper-\\nature then falls to or slightly below normal, and does not rise again.\\n(See Fig. 37.)", "height": "4416", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0217.jp2"}, "218": {"fulltext": "208 GENERAL DIAGNOSIS.\\nA marked remission in the fever sometimes occurs on the fourth\\nday, before the actual crisis the temperature falls to 100\u00c2\u00b0, and rises\\nagain to 103\u00c2\u00b0 or 104\u00c2\u00b0, remaining at that level for twenty-four or forty-\\neight hours, when the true crisis occurs. The first fall is known as the\\npseudocrisis. The fall of temperature of defervescence (crisis) may be\\ncompleted within a few hours.\\nThe Influence of Age and Sex. The significance of a high\\nfebrile change is not so great in children as in adults. That is, the\\nhigh temperature is not so important, inasmuch as children are liable\\nto have sudden, excessive increase of temperature and a higher tem-\\nperature may persist in children without deleterious effects upon the\\ntissues which are noticed in adults. In women of nervous tempera-\\nment the temperature is also likely to rise to a great height without\\nadequate cause or serious result.", "height": "4412", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0218.jp2"}, "219": {"fulltext": "CHAPTER XV.\\nTHE DATA OBTAINED BY OBSERVATION\u00e2\u0080\u0094 Continued).\\nFEVER. THE INTOXICATIONS.\\nPractically, it may be said that the symptom fever may be due to\\nan intoxication, an infection, or a central cerebral lesion. In this\\nchapter a word may be said of the fever of an intoxication. The sub-\\nstance which produces fever of this type may be a toxic material, the\\nproduct of local or general disturbance of tissue metabolism. Thus in\\na local catarrhal inflammation, as of the bronchi, the result of the\\ndirect action of an irritant vapor, toxic substances are generated which\\nFig.\\nFig. 39.\\nDATE AND\\nHOUR.\\nP.M. 8.\\nP\\n68\\nFt c\\nnt.u 1\\nI 99 100 101 102 103\\nOF\\nERA\\n4 P\\nHON\\nM.\\nIII.\\nM. 12.\\nK\\nA.M. 4.\\n8.\\n64\\nM. 12.\\n70\\nP.M. 4.\\n74\\n8.\\n70\\nV.\\nM. 12.\\n78\\nA.M. 4.\\n76\\n8.\\n78\\nM. 12.\\n71\\nP.M. 4.\\n78\\n8.\\n80\\nr\\nM. 12.\\n80\\nA.M. 4.\\n8.\\n76\\n1\\nM. 12.\\nP.M. 4.\\n74\\n7\\n80\\ni\\nM. 12.\\n78\\nTIME\\nA E\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nTEMP.\\nF.\\n1\\nA\\nS\\nM\\nI\\nv\\nJ\\nl\\nv\\ni\\nI\\nA\\nV\\nAseptic or fermentation fever.\\ndisturb the heat mechanism and\\nproduce fever. Now, an intoxica-\\ntion or simple inflammation, there-\\nfore, is attended by fever, which\\nmay be styled catarrhal fever.\\n(See Fig. 41.) In anaemia, on the\\nother hand, if all infections can be\\nexcluded, it may be said the gen-\\neral disturbance of tissue metab-\\nTemperature curve after amputation of the forearm, olism pOSSlbly gives rise to the\\nformation of a toxin which causes\\nthe fever well known to attend this process ancemic fever.\\nA better example of fever due to a poison is that which Collins\\nWarren terms aseptie fever. It is also known as absorption or fermen-\\n14", "height": "4412", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0219.jp2"}, "220": {"fulltext": "210\\nGENERAL DIAGNOSIS.\\ntation fever. The fever follows a perfectly aseptic operation, and no\\ncausal factor is present. It is due to the absorption of ferments, from\\nblood clot, or coagulated serum, or tissue debris. The temperature\\nrises to 102\u00c2\u00b0, and may remain above normal from three days to two\\nweeks. (See Figs. 38 and 39.) There is a striking absence of consti-\\ntutional symptoms, however. Another peculiarity is that the fever\\nbegins immediately after the operation. The urine is not lessened, the\\nbody- weight remains normal, and the pulse-rate corresponds to the\\ntemperature rise. In some instances an eruption like that of scarlet\\nfever surgical scarlet fever breaks out.\\nShould it happen that the retained fluids undergo decomposition and\\nare absorbed, a more intense type of fever is seen, attended by marked\\nconstitutional symptoms. We then have traumatic fever a fever which\\nsubsides as soon as the poison is liberated from the wound. In the\\nmeantime the temperature has been as high as 102\u00c2\u00b0 to 103\u00c2\u00b0 the pulse\\nvery rapid, delirium has been marked, and there has been furred\\ntongue, thirst, anorexia, restlessness, and malaise.\\nIt may happen that septic infection of a wound takes place. Thus,\\none of my patients, while dressing a suppurating vaccine wound, inoc-\\nulated or infected her finger. The ten-\\nder spot was followed by redness along\\nthe lymphatics, and enlargement of the\\nglands a lymphangitis. She had fever.\\nA deep cut in the infected spot released\\na serous discharge, the fever disap-\\npeared, and the lymphatic inflammation\\nsubsided at once. Such accidents hap-\\npen frequently to surgeons. Another\\npatient was infected by a surgeon who\\nhad just operated on an osteomyelitis.\\nThe temperature rose to 106.5\u00c2\u00b0 in twen-\\nty-four hours, and the constitutional\\nsymptoms were extreme. The wound\\nin the abdominal walls was opened and\\ncleansed, and the peritoneum was not\\nreopened no peritonitis resulted. The\\ntemperature fell four degrees at once.\\nThe muscles and other tissues of the\\nwound became grayish and almost pu-\\ntrid. Recovery was slow. Such cases are known as septic cases, the\\nailment septicaemia, and the intoxication saprazmia. (See Fig. 40.)\\nNo bacterial invasion of the body takes place, and there is no local\\nsuppuration. Xo doubt, in each instance micro-organisms infected the\\nwound, but the symptoms arose from the chemical product resulting\\nfrom their growth.\\nIn obstetric practice the retained putrefying placental fragment will\\ncause such symptoms. In medicine we see such intoxication tal e place\\nin infections. Thus in diphtheria, systemic intoxication with fever\\nresults from the absorption of a toxin from the local point of bacterial\\ngrowth. In tetanus the same toxic fever and symptoms occur. It is\\nFig.\\n40.\\nTIME\\nM\\nE\\nM\\nE M\\nE M\\nE M\\nE M\\nE\\nM\\nE\\n1n p\\nf\\nr-\\nj\\no\\nf\\n1\\n1\\nv\\non\\n3*\\n*N\\nV^\\nV\\n1\\nv\\n1\\nSeptic intoxication.", "height": "4408", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0220.jp2"}, "221": {"fulltext": "THE DA TA OB TAIN ED B Y OBSER VA TION. 2 1 1\\nimpossible to draw hard-and-fast lines between the toxic fever and the\\ninfective, pyogenic or suppurative fever, and, indeed, such cases prop-\\nerly belong and will be considered under the next prominent causes\\nof fever to be considered the infections.\\nBut fever may be due to other intoxications. It is well known\\nthat pepsin and other digestive ferments injected into the body cause\\nfever. It is supposed products of imperfect assimilation or digestion\\nabsorbed into the system from the gastro-intestinal tract give rise to\\nfever. Ptomaines or leucomaines, albumoses or peptones, absorbed\\nfrom the intestinal tract may thus cause fever. The retention of ex-\\ncretory products, as those of the renal organs, cause a systemic intoxi-\\ncation, with the frequent occurrence of fever. Gout, too, may be con-\\nsidered as an intoxication giving rise to fever.\\nThe fever of auto-intoxication (gastro-intestinal or glandular), so\\ncalled, therefore, is an entity. The clinician, at least, without proof\\nby the bacteriologist, sweeps the intestinal tract with his mercurials and\\nsalines, and thereby administers the causal antipyretic.\\nPoisoning by food products, as of cheese, meats, sausages, milk, etc.,\\nappear to cause fever, although it is possible intestinal bacteria may\\nplay some part in the process.\\nVarieties of Febrile Intoxications. It is assumed that the student is\\ninvestigating a case of fever. In keeping in mind an intoxication as\\na cause of fever, he must first consider all causes of intoxication from\\nwithin second, all causes from without the organism.\\nTo the first belong gout, uraemia, cholestersemia, and the auto-in-\\ntoxications from the intestinal tract, as well as those from modification\\nor suppression of internal secretions, as of the thyroid and other glands.\\nTo the second belong the following Sunstroke, morphinism, and\\nfood-poisoning. The fever due to an intoxication, as in the so-called/e6ri-\\ncula and in the simple continued or catarrhcd fever is of doubtful origin.\\nDiagnosis. The Action of the Heart. Increased frequency of car-\\ndiac action is a symptom common to all forms of fever. It is more\\ncommon to see irregularity and intermittency in the fever of intoxica-\\ntion, and especially of auto-intoxication, than in that of infections.\\nIndeed, I should call a fever which is attended by a cardiac neurosis,\\ncardiac mural disease and cerebral disease excluded, one of intoxication.\\nIncreased Respiration. The same may be said of the breathing.\\nWhen a respiratory neurosis prevails in the course of fever, it and the\\nfever attending are due to a common cause, an intoxication. Of\\ncourse, pulmonary and central brain and medulla disease are excluded.\\nIt seems both the above observations aid in the diagnosis of an in-\\ntoxication from an infection.\\nFebrile Intoxications.\\nSunstroke (siriasis, thermic fever, insolation, heatstroke). Whether\\nthe cause is the direct action of heat upon the brain centres, or whether\\na toxic substance is generated and becomes operative, in this affection\\nwe have the most pronounced expression of fever outside of the in-\\nfectious disorders. The flushed face, the pungent skin, the dyspnoea,", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0221.jp2"}, "222": {"fulltext": "212 GENERAL DIAGNOSIS.\\nand the rapid pulse forebode the high body temperature which in\\nthe axilla may reach 108\u00c2\u00b0 to 112\u00c2\u00b0. This is reached very rapidly,\\nand death takes place in coma hyperpyrexia. If recovery takes place,\\nthe temperature may be moderately continuous a few days. The pic-\\nture is added to by the nervous and cardiorespiratory phenomena.\\nIn some instances dyspnoea, heart-failure, and coma may follow on\\nrapidly, and death ensue in one or two hours. In other cases pain\\nin the head, dizziness, and languor precede the stupor. Nausea and\\nvomiting, perhaps diarrhoea, chest oppression, frequent micturition,\\nand convulsions may precede the insensibility. Unconsciousness is\\nlost quickly or gradually, and it may be transient or pass into deep\\ncoma. Relaxation of the muscles with twitching is seen, and the pupils,\\nat first dilated, become contracted. As the coma deepens, the heart s\\naction becomes more rapid and feeble, the respirations hurried, shallow,\\nand irregular, and death ensues, preceded or not by convulsions.\\nThe diagnosis is based on the history, the mode of onset, and the\\nhyperpyrexia. It must be distinguished from uraemia and apoplexy.\\nHeat exhaustion is readily recognized. The moist, pale, and\\ncool skin, the soft, feeble pulse, the quiet bat hurried breathing, are\\nunattended by fever. The collapse, for such it is, is not attended by\\ncoma, and it usually responds to treatment.\\nMorphinism. Lewin showed that morphinism is attended by fever.\\nThe fever may be continued or intermittent. When the latter, chills\\nare of frequent occurrence. The diagnosis is based on the history, on\\nthe evidence of poor nutrition without cause, on the general depression\\nand lassitude, and upon the temperament of the patient, to which is\\nadded poor sleep, restlessness, and itching of the skin. The peculiar\\nsallowness of the complexion and the prematurely aged appearance are\\nwell known. Pseudo-neuralgic pains are common, tabetic symptoms\\nmay be present, and notably gastro-intestinal symptoms, as gastralgia,\\nvomiting, diarrhoea, especially if the drug is withheld. Fever, it\\nmust be remembered, may be absent.\\nSimple Continued Fever. A non-contagious fever, lasting from\\none to twelve days, not dependent upon any known specific cause, and\\nnot attended with any definite local lesions. Its chief characteristic is\\nthe continued elevation of temperature.\\nIt occurs especially in children and in those prone to ready disturb-\\nance of the heat-regulating apparatus. Great mental and physical\\nexhaustion, prolonged bathing in the hot sun, and disturbances in\\ndigestion may cause it. Perhaps, as suggested by Guiteras, some of\\nthe cases occurring in the tropics and in very hot weather should be\\nregarded as very mild forms of thermic fever.\\nThe onset of the disease is abrupt. There may be a chill, or in ner-\\nvous children a convulsion but these are rare. The temperature rises\\nrapidly from 102\u00c2\u00b0 to 104\u00c2\u00b0, accompanied by headache, thirst, restlessness\\nor drowsiness, loss of appetite, a coated tongue, constipation, and occa-\\nsionally nausea. The urine is scanty, and sometimes there is a heavy\\ndeposit of urates. There may also be more or less muscular soreness.\\nSometimes within twenty-four or forty-eight hours free perspiration\\ntakes place, with rapid subsidence of the fever. This is ephemeral fever.", "height": "4416", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0222.jp2"}, "223": {"fulltext": "THE DATA OBTAINED BY OBSERVATION.\\n213\\nIn other cases the fever continues for a week or ten days longer.\\nDuring this time the symptoms already noted continue. Sleep is dis-\\nturbed and mild delirium is at times present. Respiration and pulse\\nare not much accelerated. Sudamina upon the abdomen and herpes\\non the lips are common. Pale-bluish maculae are sometimes seen.\\nFro. 41.\\nM\\nE\\nM\\nE\\nM\\nE 1\\nIt E\\nM\\nE M F.\\nMEM\\nE\\nM\\nE\\nM\\nE\\nX\\n1\\nit\\nI02-\\nit\\n\\\\X t-\\nu t\\nJ t-\\nA\\nn t-\\n_i\\n_J\\nj\\n1\\nrt\\nq\\nn\\n\\\\1\\nn\\n\\\\f\\nT\\n\\\\1\\n_j\\nit\\nIOO-\\ni_\\n3\\nit\\n1\\nrr\\nn\\nJ\\nIT\\nt\\nft\\nit\\nr\\n1\\nvr\\nIE\\n_\\nJt\\nit\\n1\\n1\\nI\\n1\\nn\\n1\\n1\\nt\\nA\\n1\\n_ t\\n,A\\n47\\n4 X\\n9 b\\ni\\n1\\n1\\n^T\\nI\\nit\\ny\\nit\\nX\\n97\\nv\\nDate\\n^10\\n12\\n13\\n14\\n15 10\\n17 18\\n19\\n20\\nSimple continued fever.\\nThe spleen is not enlarged except in very rare cases, and there are no\\nlocal evidences of disease. The fever subsides more gradually than in\\nephemeral fever, the defervescence being marked at times by perspira-\\ntion, a few loose stools, a copious deposit of urates in the urine, or by\\nhemorrhages from the nose, rectum, uterus, or urethra.\\nThe diagnosis from other fevers and febrile affections is made by the\\nabsence of any characteristic eruption, of enlargement of the spleen and\\nliver, and of any lesion, such as endocarditis, bronchitis, or pneumonia.\\nFood Intoxications. Among the intoxications which give rise to\\nfever are those due to food-poisoning. Meat, milk products, and shell-\\nfish cause an intoxication of the system which in the instance of the\\nfirst three forms often threatens life, and, from the suddenness of the\\nattack and the severity of the symptoms, points to an infection rather\\nthan an intoxication.\\nThe history of the case is often the first clue to its nature. The\\nsymptoms are those of acute gastro-intestinal irritation, to which are\\nadded, with or without afebrile periods, the symptoms of collapse.\\nMeat-poisoning. In the intoxication arising from poisoning by\\nmeat, the temperature rises from 101\u00c2\u00b0 to 104\u00c2\u00b0, preceded usually by a\\nbrief period of chilliness. The occurrence of fever may be preceded\\nby a period of incubation lasting from twelve to forty-eight hours.\\nDuring the period of incubation there is malaise, loss of appetite,\\nnausea, and colicky pains. As they increase chilliness ensues, and in\\nsome instances there is a marked rigor. Prostration occurs almost", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0223.jp2"}, "224": {"fulltext": "214 GENERAL DIAGNOSIS.\\nimmediately, with giddiness and faintness, and the occurrence of cold\\nperspiration. Headache and backache are liable to occur. Following\\nthe chilliness the symptoms of gastro- intestinal irritation arise, diar-\\nrhoea being more frequent than vomiting. The abdominal pain in-\\ncreases and the perspiration and clammy sweats become more pro-\\nnounced. As further evidence of the intoxication, there is an extreme\\ndegree of muscular weakness. The pulse becomes rapid, and later,\\nthready. In addition to muscular weakness, cramps in the legs and\\narms, followed by convulsive movements, occur, and the patient com-\\nplains of paresthesia of various forms. In milder cases the symptoms\\nof gastro-intestinal irritation and of muscular weakness attend the\\nfever. In the more severe cases fever is replaced by collapse.\\nPoisoning by Milk Products. Symptoms of gastro-intestinal irri-\\ntation and choleraic symptoms ensue. The diarrhoea of infants and\\ncholera infantum are types of this intoxication. The high degree of\\nfever that occurs is well known. In cheese-poisoning the fever is not\\ncontinuous as in the other forms, the temperature becoming subnormal\\nwith the onset of collapse.\\nPoisoning by Shell-fish. In mussel-poisoning the symptoms are\\nthose of an acute mineral poisoning with profound nervous symptoms.\\nFever does not attend this condition, but collapse follows quickly.\\nThere are no gastro-intestinal symptoms.\\nFish-poisoning is also unattended by fever, collapse occurring early.\\nAfebrile Intoxications.\\nFor convenience, and by contrast, the afebrile intoxications will be\\nconsidered. Herein will not be considered those important afebrile\\nintoxications due to disease of the ductless glands. They include some\\ndiseases of the suprarenal bodies (Addison s disease), the thyroid gland\\n(exophthalmic goitre and myxoedema), the lymphatic glands (status\\nlymphaticus), and the spleen.\\nAlcoholism. In acute alcoholism the reeling gait, the incoherent\\nspeech, followed by narcosis, are well known. The temperature is\\nafebrile. Often, indeed, it is subnormal, and when equal on both sides\\nof the body is very suggestive. The flushed face, possibly slightly\\ndusky, and the injected eye, would lead us to suspect the presence of\\nfever. The odor of the breath furnishes a clue. The heavy breath-\\ning, the full pulse, the dilated pupils, the stuporous rather than coma-\\ntose state, are accompaniments of this intoxication. The flaccid limb\\nof one side would point to hemiplegia from hemorrhage, especially if\\nthe coma is deeper than usual and the stupor more marked. But\\nurcemia and apoplexy, and either of the two in a drunken subject, must\\nbe borne in mind.\\nChronic Alcoholism. AVhen the poison is taken for a long time it\\nacts as a tissue poison and a check upon waste. Epithelial and nerve\\ndegeneration and fibrous overgrowth follow the first or poisonous irri-\\ntative action and fatty change the second. In the alcoholic, tremor\\nof the hands and tongue is seen. The action of the muscles is un-\\nsteady. The mind is dull, the temper irritable, forgetfnlness is most", "height": "4416", "width": "2664", "jp2-path": "practicaltreatis00muss_0_0224.jp2"}, "225": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 215\\ncommon, and later a dementia and epilepsy may ensue. Alcoholic\\nneuritis, to be described later, is of frequent occurrence.\\nGastro-intestinal catarrh with poor appetite and constipation is most\\nliable to ensue, and later cirrhosis of the liver and kidneys. Endar-\\nteritis and cardiac dilatation develop in some independently in others\\nwith the nervous affections, delirium tremens.\\nGrain-poisoning. Three forms are seen. When the grain is con-\\ntaminated by ergot, symptoms known as ergotism occur. Chronic\\nergotism may cause gangrene or a train of nervous symptoms in which\\nconvulsive movements are most prominent. In the gangrenous form\\nthe toes and fingers are the seat of mortification. The process is pre-\\nceded by anaesthesia, paresthesia, and pain. In the convulsive form\\nthere is slight fever with some weakness and tingling sensations in the\\nbody. Cramps and contractures occur in the extremities, continuing\\nfor hours or days, and relapsing frequently. A mild delirium or the\\ndevelopment of melancholia or dementia attends the convulsive form.\\nIn other intoxications fever is not so pronounced. In lathyrism the\\nsymptoms are those of spastic paralysis, which may proceed to para-\\nplegia. In pellagra, a disturbance due to maize, there are disorders\\nof digestion, loss of sleep, general pain, and debility. The digestive\\nsymptoms are those of salivation, dyspepsia, and diarrhoea. A pecu-\\nliar erythema arises. Subsequently, desiccation and desquamation of\\nthe epidermis occur, and often small boils develop. Headache, back-\\nache, spasms, and paralysis of the legs occur in the severe and chronic\\nforms. The nervous symptoms may give Avay to melancholia.\\nLead-poisoning. Intoxication due to lead or plumbism may be\\nacute or chronic. In the acute form we have symptoms of gastro-in-\\ntestinal irritation with constipation and extreme colicky pains. Anae-\\nmia may develop rapidly, and pronounced nervous symptoms arise.\\nAmong the latter we have neuritis, convulsions, epilepsy, and delirium.\\nHemorrhages from mucous membranes may be seen, and a form of\\nnephritis develops rapidly. The urine contains albumin and tube-casts.\\nFever is not a pronounced symptom.\\nThe characteristic symptoms of chronic poisoning are (a) saturnine\\ncachexia, in which anaemia is most pronounced (6) colic (c) paralysis,\\nwhich may be acute, subacute, or chronic, and which usually develops\\nwithout fever. The paralysis may be anti-brachial, causing character-\\nistic wrist-drop brachial, in which the scapulo-humoral form of paraly-\\nsis is seen, and an Aran-Duchenne class, resembling chronic anterior\\npoliomyelitis. Another is the peroneal type, in which the lateral\\nperoneal muscles, the extensor communis of the toes and the extensor\\nproprius of the big toe are paralyzed, causing the steppage gait. Fi-\\nnally, paralysis of the adductor muscles of the larynx occurs in lead-\\npoisoning. The paralysis often extends from a local group of muscles\\nthroughout the body, presenting symptoms like those of an ascending\\nparalysis with rapid wasting. In other instances the general paralysis\\noccurs primarily, the wasting and loss of power going hand in hand.\\nFever sometimes attends a general paralysis in lead-poisoning, (d) The\\ncerebral symptoms of the acute form have been mentioned. In the\\nchronic cases they may also occur. Optic neuritis, or neuro-retinitis, is", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0225.jp2"}, "226": {"fulltext": "216 GENERAL DIAGNOSIS.\\ncommon. Delirium, with hallucination, may occur. Tremor is a common\\nsymptom. It must not be forgotten that headache, convulsions, epi-\\nlepsy, and delirium may be manifestations of lead encephalopathy,\\neven in cases in which the history of exposure to lead is not direct (e)\\nchronic lead-poison leads to arterial sclerosis and contracted kidneys with\\nhypertrophy of the heart gout is very common, and may be seen in\\nboth acute and chronic forms, particularly in the big toe (g) as described\\nin the section in which the mouth and gums are discussed, the blue line\\nis the specific symptom of lead-poisoning. The reader is referred to\\nthat chapter for a description of the line. It must be remembered that\\nin all forms of obscure nervous disease, in gastro-intestinal irritation,\\nin arterio-sclerosis, and gouty arthritis, this line must be looked for.\\nArsenic-poisoning. Acute arsenical poisoning is attended by\\nsevere symptoms of gastro-intestinal irritation followed by the rapid\\ndevelopment of collapse. Fever is not a prominent symptom unless\\nrecovery is about to take place. The temperature is subnormal, but\\nas the collapse symptoms disappear fever due to gastro-intestinal ulcer-\\nation develops.\\nIn chronic arsenical poisoning the fever occurs only if there is great\\nirritation of the mucous membranes, as of the conjunctiva, mouth, or\\npharnyx. In this form, in addition to the irritation of these mucous\\nmembranes, there may be subacute gastro-intestinal catarrh, with diar-\\nrhoea. In other instances there is profound anaemia and debility, with\\nparesthesia and neuralgia. In others, again, paralysis like that of lead\\npalsy may occur. It must not be forgotten that puffiness under the\\neyelids may be due to this cause.", "height": "4412", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0226.jp2"}, "227": {"fulltext": "CHAPTER XVI.\\nTHE DATA OBTAINED BY OBSERVATION -(Continued).\\nCausal relation of bacteria to disease, Koch s laws, value in diagnosis. Bacteria:\\nSaprophytes, parasites, pathogenic, non-pathogenic, aerobic, anaerobic, facul-\\ntative anaerobic. Morphology Micrococci, bacilli, spirilla Micrococci. Mor-\\nphology Form and size. Reproduction, fission grouping. Biological char-\\nacters Non-motile. Pigment production. Liquefaction of gelatin. Production\\nof acids Toxic ptomaines and toxalbumins Bacilli. Morphology: Form and\\nsize. Reproduction, fission, spores grouping. Biological characters Motility.\\nPigment production. Liquefaction of gelatin. Production of acids. Putrefaction,\\nfermentation. Spirilla. Morphology Form and size. Reproduction, fission\\ngrouping. Biological characters. Motility. Pigment-production. Liquefaction\\nof gelatin. Production of acids and fermentation wanting.\\nFEVER. THE INFECTIONS.\\nWe have already indicated the diagnostic significance of the type of\\nthe fever (Chapter XIV.). Following the lead in part of the subjective\\nsymptoms, we next examine every organ and structure of the body\\nwhen the symptom -fever is present. By this examination we will\\nfind either (1 a functional disturbance of some organ of the body (2)\\nan inflammation (3) or we will find a general process, or infection, any\\nlocal inflammation being secondary, brain disease and intoxications\\nhaving been excluded.\\n1. Any functional disturbance of one or more organs glandular\\nattended by fever must be looked upon as an intoxication. Fevers due\\nto such causes have been discussed in the preceding chapter, so we\\npass on to inflammations, toxic and infectious, which cause fever.\\n2. Suppose we find local inflammation of some part, as an inflamma-\\ntion of the nares, a bronchitis, or an apparent gastritis or enteritis.\\nThe inflammation may be toxic or it may be infectious. As another\\nexample, let us take the kidneys. Blood, albumin, and renal casts\\nwould show that they are the seat of inflammation. This inflammation\\nmay be toxic, as from cantharides, or the toxin of an infection, or it\\nmay be infectious. In either instance the fever is caused by the local\\nprocess. To determine whether the inflammation is toxic (generally\\ncatarrhal) or infectious, we must rely upon the data obtained by in-\\nquiry, the clinical course, and the result of the examination described\\nin Chapter XYIL, which discloses the method of determining the\\npresence of an infection.\\n3. If the above are excluded we proceed with the bacteriological\\ndiagnosis. By this means we find if a general infection prevails. Such\\ndiagnosis may be necessary also to recognize pyaemia and septicaemia.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0227.jp2"}, "228": {"fulltext": "218 GENERAL DIAGNOSIS.\\nThe Infections.\\nIt had long been surmised that micro-organisms had much to do\\nwith morbid processes, and that the relationship was that of cause and\\neffect. It was known, for instance, that suppuration, surgical fever,\\nerysipelas, hospital gangrene, and puerperal fever were associated with\\nconditions which favored the multiplication of the lower forms of life.\\nWhat relationship the micro-organisms bore to the various affections\\nwas not known. Least of all were the specific micro-organisms which\\nwere the causes of particular specific morbid processes known. I have\\nsaid that it was surmised but there was groping about, a difference of\\nopinion, and a maximum of theory, a minimum of fact. It is true\\nthat in relapsing fever the spirillum had been found, and that none\\nhad been found in any other disease. Moreover, it is true that mon-\\nkeys had been inoculated and the disease reproduced in them. It is\\ntrue that the bacillus of anthrax had been seen in the blood in the\\nearly sixties. It is true that the great genius Pasteur had prosecuted\\nstudies of bacteria in animal and vegetable pathology to most brilliant\\nand practical conclusions. Nevertheless, there were confusion and\\ndoubt scientists were not satisfied with the demonstrations which\\nundertook to prove the causal relationship of micro-organisms to\\ndisease.\\nLaws to Establish Causal Relationship. By the genius of Robert\\nKoch theories and objections were set at naught. The scientific world\\nwas fully prepared by the labors of early investigators to accept Koch s\\nconclusions. They were based upon an array of well-authenticated\\nfacts, which anyone could prove for himself. The postulates formu-\\nlated by Koch, the fulfilment of which he considered as necessary in\\norder to identify an organism as the etiological factor in a given disease,\\nare as follows The constant presence of the organism in the affected\\ntissue of the diseased animal its isolation from the pathological lesions,\\nand its continuous cultivation in pure cultures under artificial condi-\\ntions through many generations the power of such pure cultures to\\nreproduce the disease when inoculated into susceptible animals and\\nthe detection of the organism in pure culture in the lesion found in the\\nanimal thus inoculated. The experimental circle was then repeated.\\nIn this manner the causal relationship of micro-organisms to special\\ndiseases had been proved by the distinguished investigator in the case\\nof anthrax, tuberculosis, and other affections. In a certain number of\\ncases particular species of bacteria and other micro-organisms have\\nbeen isolated from definite diseases and reasonably believed to stand in\\ncausal relation to them, but which have, nevertheless, not fulfilled all\\nthe requirements of the above-cited postulates. The difficulties often\\nencountered are The impossibility of reproduction in animals of the\\nclinical and pathological features that the diseases present in human\\nbeings, as is the case with typhoid fever, influenza, gonorrhoea, and\\nfibrinous or lobar pneumonia and the impossibility of satisfactorily\\ncultivating certain other organisms that are the constant accompani-\\nment of particular diseases of man, as, for instance, the plasmodium\\nmalaria?, the bacillus of syphilis, and the amoeba coli.", "height": "4416", "width": "2672", "jp2-path": "practicaltreatis00muss_0_0228.jp2"}, "229": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 219\\nThe infectious diseases, then, are those that are produced by a living\\ncontagion or micro-organism. The organism is introduced into the\\nbody through the skin, if the latter is the seat of some lesion, as in\\nsyphilis, tuberculosis, and anthrax through the air-passages, as in\\ndiphtheria, scarlet fever, and other specific fevers or through the\\ndigestive tract, as in typhoid fever, dysentery, and cholera. The\\nvirus, as the living cause is named, in many instances produces certain\\nchanges at the point of entrance the initial phenomena. It is then\\nconveyed by the lymphatics or bloodvessels to near-by organs in the\\nrelated lymph-stream or blood-stream, or transmitted to the whole\\nbody. When the whole body is affected an eruption is sometimes pro-\\nduced (eruptive fever), or the blood is changed in quality (diphtheria),\\nor many tissues are affected simultaneously, or the nervous system is\\nnotably disturbed. The above are the phenomena of general distribu-\\ntion of the virus, or of infectiveness. The virus or poison thus distributed\\nmay be the living organism, as in tuberculosis or anthrax, or it may be\\na poison generated by the organism, a toxin or ptomaine, as in diphtheria.\\nPhenomena of secondary local distribution are due to local changes\\nin organs affected secondarily. The poison has a special affinity for\\ncertain organs, as in whooping-cough, parotitis, pneumonia, or leprosy.\\nIn some instances the local phenomena are so marked as to give to\\nthe disease a corresponding distinctive feature. They are the granulo-\\nmata. Bearing in mind the above distinctions, specific infectious dis-\\neases are divided into six classes.\\nFirst Class. Acute Specific Fevers. The initial phenomena are\\nslight. The phenomena of infectiveness are marked an eruption is\\none of the most characteristic. The secondary local phenomena are\\nvariable. The following are included in this class Typhoid fever,\\ntyphus fever, variola, varicella, scarlet fever, measles, relapsing fever,\\nrubella, influenza, dengue, the plague, and cholera.\\nSecond Class. Specific Inflammation. Initial phenomena indefi-\\nnite. General phenomena (infectiveness) variable, but no eruption.\\nSpecific affinity of poison for one particular structure. Whooping-\\ncough, mumps, diphtheria, dysentery, erysipelas, tetanus, hydrophobia,\\ncerebro-spinal meningitis, rheumatic fever, and pneumonia belong to\\nthis class.\\nThird Class. Contagious or Infectious Suppuration. Initial phe-\\nnomena marked (suppuration) generalization not marked unless the\\nvirus enters the blood secondary local phenomena decisive. Gonor-\\nrhoea is one type, pysemia, or any infection from pus-producing micro-\\norganisms, as abscess, carbuncle, etc., a second, in which the blood is\\ninfected.\\nFourth Class. Infective Granulomata. Distinct initial phenom-\\nena. Phenomena of generalization not marked, or like specific fevers.\\nSecondary local phenomena prominent. Examples Tuberculosis,\\nsyphilis, leprosy, and glanders.\\nFifth Class. Iliasmatic Diseases. No initial phenomena.\\nSixth Class. Vegetable Parasitic Diseases.\\nIt is readily seen that when the definite cause of an infectious disease\\nis isolated, and the morphological and biological properties of the", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0229.jp2"}, "230": {"fulltext": "220 GENERAL DIAGNOSIS.\\ncausal micro-organism determined, the clinician has acquired a valu-\\nable aid to diagnosis. Indeed, in such affections the bacteriological\\ndiagnosis has become an absolute certainty.\\nBacteria.\\nTo determine the micro-organism which causes the infection the\\nstudent must be familiar with the morphology and biological properties\\nof the various forms of bacteria. (By means of this knowledge a bac-\\nteriological diagnosis is made.) The morphology The shape, the size,\\nthe mode of reproduction and grouping are to be studied. Bacteria or\\nfungi are divided morphologically into micrococci or spherical bacteria,\\nbacilli or rod-shaped bacteria, and spirilla or twisted forms. Bacteria\\nprocreate by simple fission, and are therefore known as fission-fungi or\\nschizomycetes. Some forms also produce spores. The biological proper-\\nties include motility, color, the growth on various culture-media and\\nunder various temperatures, and the product of vital activity.\\nMicrococci.\\nMorphology. To this group belong the spherical bacteria. Each\\ncoccus is of nearly equal diameter in all directions. They vary in size\\nfrom 0.1 /i to 1 or 2/i. A micromillimetre (/i) is one twenty-five thou-\\nsandths of an inch. The various micrococci resemble each other so\\nmuch in form and size that they cannot be distinguished by their micro-\\nscopic appearances. To distinguish them we depend on the color and\\ncharacter of their growth in various culture-media, on their pathogenic\\npower, and on other biological differences. The mode of grouping,\\nafter fission or reproduction, is an important characteristic by which\\nvarieties are differentiated. Just before dividing they are not perfectly\\nspherical, but short or long, oval. After division (for they divide in-\\ndefinitely when growing) the staphylococci are solitary or in pairs, or,\\noccasionally, in groups of four or in clusters, roughly likened to a\\nbunch of grapes, from which latter grouping they derive their name.\\nThe organism is called a diplococcus when associated in pairs. Some-\\ntimes two or four are included in a capsule. Zoogloea are groups of\\ncocci held together by a transparent glutinous substance. Streptococci\\nare characterized by a grouping in chains, known as chaplets or torula\\nchains, because division takes place in one direction only. When\\ndivision takes place in two directions, groups of fours, or tetrads, are\\nformed and when in three directions, groups or packets of eight are\\nformed, of which the sarcince are the most familiar examples. These\\nnames, significant of the grouping, refer to the predominating groups\\nas seen in microscopic preparations. In some of such groups, for in-\\nstance, are seen only diplococci or streptococci but in all, transitional,\\nirregular, and accidental groupings may be observed.\\nBiological Characteristics. Micrococci are not motile and do not\\nform spores. Products of vital activity The various forms of bacteria\\nare also distinguished by noting the difference in the products of vital\\nactivity. Of these, pigment-production is one of the most apparent.\\nThe staphylococcus pyogenes aureus and citreus are chromogenic or pig-", "height": "4412", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0230.jp2"}, "231": {"fulltext": "", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0231.jp2"}, "232": {"fulltext": "PLATE\\nFig 2.\\n.-1. Tubercle-bacilli.\\nft. Pneumococcus.\\nA. Anthrax. R. Streptococcus and Staphylococcus.\\nFiy. 4.\\n,4. Comma-bacillus. Gonococcus.\\nFi v\\nA. Recurrent Spirilla. Leprosy.\\nFig. 6.\\n/4. Normal Blood. B. Normal Blood.\\nA. I,euk:emia. Eberth s B", "height": "4408", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0232.jp2"}, "233": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 221\\nment-producing bacteria. The liquefaction of gelatin, when cultures\\nare made, is a biological characteristic which assists in the diagnosis of\\nthe various species. Some pathogenic as well as non-pathogenic germs\\nhave this effect on the nutrient medium others of both classes do not\\naffect it. A peptonizing ferment is formed during the growth of cells\\nwhich acts upon and dissolves the gelatin. The amount, degree, and\\ncharacter of the liquefaction serve to distinguish various species. The\\nstaphylococcus pyogenes aureus and albus (as well as some others) are\\nliquefying micrococci. Production of acids: Many bacteria produce\\nan acid lactic acid, acetic acid, butyric acid which gives an acid\\nreaction to the culture-media. This may be seen if a neutral litmus\\nsolution has been added to the gelatin. The pink color produced indi-\\ncates the presence of an acid. Culture-media, it must be remembered,\\nare alkaline or neutral. The pathogenic micrococci which produce an\\nacid are the staphylococci of pus lactic acid.\\nPutrefactive fermentation is set up by bacilli and not by micrococci.\\nOther products of vital activity need not concern us, as they are pro-\\nduced by non-pathogenic forms.\\nToxic ptomaines and toxalbumins are products of many forms of patho-\\ngenic bacteria, and cause the symptoms of infective diseases in many\\ninstances thus in diphtheria the local infective inflammation represents\\nthe seat of activity of the bacillus, the point at which its poisons are\\nbeing manufactured at the expense of the tissues in and on which it is\\ngrowing the general symptoms are due to the toxalbumin that has\\nbeen absorbed by the circulating fluids from this local seat of action.\\nThe isolation and detection of the toxalbumins are not sufficiently easy\\nto warrant such a mode of investigation for diagnostic purposes. Often\\nthe results of inoculation, by which the lethal effect is produced, aid in\\nthe diagnosis of the suspected ailment. (See Plate III., Fig. 2, b.)\\nThe Bacilli.\\nMorphology. The bacilli, or rod-shaped bacteria, differ widely in\\nform, in size, and in modes of grouping after fission. Form and size\\nThe longitudinal diameter is greater than the transverse, and the\\nforms vary from short oval or slender rods to long filaments some-\\ntimes short rods and long filaments are seen in pure cultures of the\\nsame bacillus, as in the typhoid bacillus. The transverse diameter of\\na given species does not vary, as a rule. The form of the extremities\\nof the rods must be observed. They may be square, slightly rounded,\\nround, oval, or lance-shaped or spindle-shaped. Reproduction and\\ngrouping: Fission or reproduction takes place by binary division,\\ntransverse to the longitudinal axis. They group in long chains, or are\\nsolitary or united in pairs. They may be surrounded by a capsule or\\ncollect in zoogloea masses.\\nSpores. When conditions unfavorable to continuous multiplication\\nby transverse division arise certain bacilli possess the property of\\nentering into a permanent or resting stage. In this case there de-\\nvelops within the body of the bacillus an oval, egg-shaped structure\\nan endogenous spore. The spore represents the inactive stage, and lies", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0233.jp2"}, "234": {"fulltext": "222 GENERAL DIAGNOSIS.\\ndormant until circumstances favorable to growth reappear, when it\\ndevelops into a bacillus identical with that from which it was formed.\\nSpores do not develop into spores but into bacilli. The spores retain\\ntheir vitality for months or years, and resist desiccation. They are\\nspherical or oval, and highly reproductive. They are formed by con-\\ndensation of protoplasm at the centre or at one end of the bacillus,\\nwhere they are retained in a linear position until set free. Some\\nbacilli grow into long filaments during spore-formation others change\\ntheir shape, swelling at the centre, becoming spindle-shaped or club-\\nshaped, according to the location of the spore within it. Many bacilli\\ndo not change their shape at this stage. The spores are free or col-\\nlected in masses with the bacilli as well as located in the parent bacillus.\\nMotility. The bacilli are often actively motile, because of the\\npresence of flagella. The movement is one of progression in different\\ndirections. It may be slow and deliberate, in a to-and-fro motion, or\\nserpentine, or a quick, darting forward motion.\\nBiological Characters. Products of vital activity. They may be\\nascertained in the same manner as in the study of micrococci. Pig-\\nment-production is seen in cultures of the bacillus pyocyaneus or bacil-\\nlus of green pus, of which there are several varieties producing various\\nshades of blue or fluorescent green. Liquefaction of gelatin This is\\nproduced by the bacillus anthracis and the bacillus pyocyaneus, the\\ncomma bacillus of cholera and many other species. Production of\\nacids The bacillus coli communis produces lactic acid. Fermentation\\nThe latter bacillus sets up fermentation of carbohydrates, as of glucose,\\nlactose, and saccharose. (See Plate III.)\\nThe Spirilla.\\nMorphology. They are seen in the form of curved rods or spiral\\nfilaments. The shorter ones are curved, the longer are spiral, like a\\ncorkscrew. The curved filaments may be short and rigid, or long and\\nflexible.\\nReproduction. They reproduce by binary division (fission).\\nBiological Characters. Motility. They are motile; the move-\\nment is rotary, as well as progressive in the direction of the long axis\\nof the filament. The presence of flagella is determined by Loffler s\\nmethod of staining. They are single at the ends of rods, or several\\nare seen at one extremity, or one or more may occur at both ends.\\nPigment-production: Pathogenic spirilla do not produce pigment.\\nLiquefaction of gelatin: The spirillum of cholera Asiatica (comma\\nbacillus) and the spirillum of cholera nostras (Finkler and Prior) both\\nliquefy gelatin in a peculiar manner. (See Plate III., Fig. 4, a.)", "height": "4416", "width": "2564", "jp2-path": "practicaltreatis00muss_0_0234.jp2"}, "235": {"fulltext": "CHAPTER XVII.\\nTHE DATA OBTAINED BY OBSERVATION\u00e2\u0080\u0094 {Continued).\\nData obtained by inquiry By observation. Local infection General infection.\\nPyaemia septicaemia. Terminal infections. Fever in carcinoma. Afebrile\\ninfections. Infections of certain bacteriology; of uncertain bacteriology. Bac-\\nteriological diagnosis. Method of research Microscopical examination, culti-\\nvation, inoculation. Essentials in technique. Method of research Blood, dis-\\ncharges, exudations mode of collection. Apparatus. Preparation of apparatus.\\nSterilization. Microscopical examination Technique, cover-glass preparations.\\nMethods of staining spores. Hanging drop Cultivation of micro-organ-\\nisms. Culture-media. Tube- and plate cultures. Smear- and stab-cultures\\nInoculation of animals Special bacteriological diagnosis.\\nFEVER. THE INFECTIONS.\\nUnfoktunately, the cause of many of the infectious diseases has\\nnot been definitely isolated. This group is largely the infectious\\ndisorders which are epidemic and contagious. In order to diagnosti-\\ncate them it is necessary to associate with the mode of onset and clini-\\ncal course of the disease the facts and laws pertaining to epidemics and\\nto contagion. Data, therefore, obtained by inquiry are quite necessary\\nto establish the diagnosis. Such data are useful in confirming the\\nresults of an objective or bacteriological examination of the patient,\\neven though the diagnosis be at once established by the latter method.\\nData Obtained by Inquiry. In the first place, we note the social\\nhistory, learning this while preparing for the objective examination.\\nIt should be personal and general. The age, the sex, the habits, the\\noccupation, are looked into. The nature of the prevailing diseases in\\nthe community are known or sought for, and all possible unusual cir-\\ncumstances in food, drink, clothing, are inquired for. In short, a his-\\ntory of exposure to influences which attend an intoxication or those\\nwhich permit infection are to be zealously sought for.\\nAn inquiry for previous diseases does not imply a history alone of a\\nprevious infectious disease, but a history of such diseases as are often\\nfollowed by infection. Thus, a history of a previous attack of gall-\\nstones or of renal calculus may be a clue to the localization of an infec-\\ntious process. Too much stress cannot be laid upon the diagnostic\\nvalue of the data obtained in this manner.\\nThe next data obtained by inquiry is the history of the present dis-\\nease. The mode of onset is of itself suggestive. Sudden onset points\\nmore closely to an intoxication, though not necessarily, although more\\nlikely in children. Otherwise sudden onset usually indicates one of\\nthe short infections, of which scarlatina and pneumonia are representa-", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0235.jp2"}, "236": {"fulltext": "224 GENERAL DIAGNOSIS.\\ntive types while gradual onset, a long infection, of which typhoid\\nfever is a type.\\nThe subjective symptoms are then inquired for and their site affords\\na clue as to the steps to be taken in the objective examination. Thus,\\npain in the throat with difficulty in swallowing calls for an examination\\nof the fauces pain in the chest, of the lungs in the prsecordia, of the\\nheart, etc. Any functional disturbance of an organ should also lead us\\nto a study of it.\\nData Obtained by Observation. The appearance of the inflam-\\nmatory process may be sufficient to decide its nature, however a boil,\\nan abscess, a carbuncle, which gives rise to more or less fever, because\\nthey are local infections, are readily recognized.\\nLocal Infection. When not preceded or accompanied by any pro-\\ncess elsewhere the infection is said to be local. An appendicitis, a\\ncholangitis, an inflammation of a serous membrane, as well as a boil or\\ncarbuncle, may be a local infection. In like manner the accidental\\nwound of a surgeon by which he is inoculated or infected by the micro-\\norganism of the pus may be an infection. The natural or acquired\\nwounds of the puerperium may also be infections. A local infection\\nhere arises. It must be borne in mind that any local inflammation may\\nbe infectious. It is not our purpose to consider here local infections.\\nSome, indeed nearly all, of the streptococcus and staphylococcus infec-\\ntions are local. The general symptoms are produced by a toxemia,\\nthe toxin alone passing into the blood.\\nGeneral or Systemic Infections. General infections alone, and\\nthose which may have more pronounced local expression, as pneu-\\nmonia or the pneumococcus infection, are discussed. It is of importance,\\nhowever, to remember that in determining whether a local inflamma-\\ntion is infectious or not, we use the same methods that are employed to\\ndetermine the nature of a general infection.\\nIt is also important to remember that a local infection may be circum-\\nscribed and cause a toxic fever. On the other hand, a small portion of\\nthe purulent exudate from the infection may get into the circulation\\nand be carried to distant parts, as the brain, the lungs, the kidney, the\\njoints, the spleen. Distant foci of inflammation are set up, giving rise\\nto multiple small abscesses in the organs affected. Pycemia is the name\\nof this form of systemic infection. Finally, such local infection may\\nbecome general and the case terminate in septicemia.\\nPyaemia is characterized by rigors, fever, usually intermittent, and\\nsweats. There is exhaustion the skin is slightly icterode. The odor\\nof the breath is sweet. There is anorexia, nausea, perhaps vomiting,\\nfrequently diarrhoea. Erythematous eruptions are seen. With these\\ngeneral symptoms there are present the physical signs of abscess in the\\nlungs or the spleen or other organs of the body, or we may have an\\nendocarditis. When the affection is limited to the portal area, and\\nmultiple abscesses of the liver succeed a purulent process in the area\\nof the portal vein, the general symptoms are combined with enlarge-\\nment of the liver, which is tender and painful, and perhaps with deeper\\njaundice. The micro-organisms which invade the system and cause\\nareas of suppuration are the streptococcus and staphylococcus pyo-", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0236.jp2"}, "237": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 225\\ngenes, the micrococcus lanceolatus, the gonococcus, the bacillus coli\\ncommunis, the bacillus typhi abdominalis, the bacillus proteus, the\\nbacillus pyocyaneus, the bacillus influenzae, and the bacillus aerogenes\\ncapsulatus.\\nDiagnosis. Pyaemia resembles in many respects tuberculosis of the\\nkidneys and calculous pyelitis, in both of which recurring rigors and\\nsweats are common. In gross aspects it resembles malaria. (See Inter-\\nmittent Fever.) In prolonged cases of pyaemia the symptoms may\\nresemble typhoid fever, but leukocytosis is present in the former con-\\ndition. Ulcerative endocarditis and acute miliary tuberculosis usually\\nresemble septicaemia, but may be confounded with pyaemia. Any febrile\\nprocess associated with chills may be taken for pyaemia. These phe-\\nnomena are seen in grave anaemias, in Hodgkin s disease, in hepatic\\nintermittent fever, and in the intermittent fever of carcinomatosis.\\n(See Chills, Chapter XIV.) Post-febrile arthritis, after scarlet fever\\nand gonorrhoea, is in all probability pyaemic. Of course, we rely in the\\ndiagnosis of pyaemia upon the data obtained by bacteriological methods\\nwhen their employment is practical.\\nSepticaemia. Again, we may find with the above-described wound, or\\nwithout any apparent local inflammation, fever, which is more or less\\ncontinuous. In addition there may be an occasional rigor. The pulse\\nis rapid, exhaustion, anaemia, and some emaciation are present. Sec-\\nondary infection of other structures may or may not be present.\\nMicrobic infection of the blood usually takes place. The process is a\\nsepticemia. If it originates from a local infection it is known as pro-\\ngressive septicemia. If independently of any apparent local infection\\nit is a cryptogenetic septicaemia. The former is easily recognized, par-\\nticularly if there is a history of a primary local infectious process.\\nThe micro-organisms which may give rise to the latter are the staphy-\\nlococcus pyogenes, the streptococcus pyogenes, the bacillus proteus, the\\nbacillus pyocyaneus, and the micrococcus lanceolatus. It is recognized\\nby a bacteriological diagnosis.\\nThe accompanying chart (Fig. 42) represents the course of an infec\\ntion and various areas of secondary infection in a general septicaemia.\\nThe illness extended over a period of thirty-five days. The first five\\ndays, as indicated by the chart, there was pneumonia at the base of the\\nleft lung. The crisis only is represented. From the tenth to the\\ntwenty-first day, to save space, the chart does not give the tempera-\\nture range. During this time the fever was continuous. On the\\ntwelfth the right pleura was infected on the nineteenth the fem-\\noral vein of the right leg, the temperature not rising above 101\u00c2\u00b0. On\\nthe twenty-first, as the chart indicates, a patch of pneumonia was found\\nin the right lung posteriorly. On the twenty-fourth pseudocrisis, and\\non the twenty-fifth and twenty-sixth the true crisis took place. On\\nthe twenty-ninth and thirtieth there was reinfection of the pleura of\\nthe left side. On April 3d phlebitis of the femoral vein of the left leg\\ndeveloped. During the course of the disease there was a low-pitched\\nendocardial murmur, which in all probability was anaemic. Sweats,\\nattacks of collapse, and irregular rigors took place. Life was imperiled\\nat the time of the collapse. The spleen was enlarged the sputa con-\\n15", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0237.jp2"}, "238": {"fulltext": "226\\nGENERAL DIAGNOSIS.\\nw\\no6 f4 l lM\\nr.:\\ni\\n2\\nIII I pUlUJI\\nI 7\\nmill npfffMt\\nz-\\n2\\nfR ofW 1\\n1;\\n7-\\niij+tr 1 1\\n2\\n81\\nUs 11:\\nHI.\\n-3H*\\n2\\nlliS VJ 1\\n8Z\\nrlinrfflf 1\\nWVLi MIL\\n8 MM\\n1-\\nb ei sW6 :i\\nIV l!.\\nrr. m-\\nE\\nS\\nz LLyJJLl 1 ^I ^-L-g^\\nFN v Wm\\n0E\\n2\\nI i fi n 1 1 1 fi i\u00c2\u00b0f\u00c2\u00b0 Prrr Titr -r\\n^\u00e2\u0080\u00a2JJIIIHIJlll\\nf5\\n1 )6 \u00c2\u00abr4+Uios-dt 1\\n_i?. p t\\nIg\\n2\\nrTTTTffnSiict-S\\n1 1 00 \u00c2\u00a7W !mll 1 1\\nor.\\n2 II\\nk v oA J |1|\\nII. \u00e2\u0080\u009ei\\nor. it.\\ni Tf II\\n58\\nu\\n5\\nIII 1\\nN\u00e2\u0080\u009e\\n_\\nj 1 1\\n^kifm 1 11\\n58\\n?z\\neiii-\u00c2\u00bb-444J wh+pi\\nns\\nHs*i (TBJJil ITsfr\\ni|jj iITTIIut=N-\\n\\\\z\\nI\\n\u00c2\u00abr w|05S|+Ht W\\niff wfl do-l 1 III\\n:t 7\\n2\\n1 1 1 1 1 1\\n12\\nP\\nin\\n1?.\\nE\\n4-Kn.f II 1 1 1 1 1 1\\nMS\\nrc\\nBmlfp? m m\\\\\\\\\\n18\\nzs\\n05\\n2\\nUJ\\n1 r, 1 ii\\n\u00c2\u00bbS\\n96\\nfj\\n15\\nill Mill\\n15\\nSI, Ml\\n08\\n2\\n-II]\\n85\\n2\\nIII II Pi\\n2\\n001\\n85\\n9K\\n95\\n2\\n55\\ni 1\\n11,\\n85\\n62\\n2\\nin\\n15\\n-i\\\\\\n15\\n2\\nmil\\n15\\nm;\\n2\\nZ6\\n15\\n2\\n86\\n55\\n88\\n15\\nSP\\ns _u\\n55\\nF8\\n88\\n05\\n2\\npp H* 1 1\\n18\\n05\\nn ;l\\\\\\n2\\n?8 0R\\n81 or.\\n3 -4 iH.J-\\nio\\n\u00e2\u0096\u00a0HT i7\\nrt- r-\\n15 15\\n0(1\\n15\\n2\\n1 ii i rn i 1 1 i\\nj\u00c2\u00a7-\\n1 -yitfeHllilill 1 1 1 1 1\\nJT I\\nM|\\n~W~\\n2\\nIII\\nI 1 Ml\\n1 I\\n18\\nM5\\nor-\\nUJ\\nlhoinpiwIo iigir\\nIII\\n55\\n2\\ni rrt\\nII si;8\\n_flg_\\n-J2-\\ni -1\\niilHIII\\n1 lllilii 1 1\\nus\\n2\\nIII l-w-bioiu;^-\\no Si 1- 1\\n1 INY ll T\\n1 1 1 1 1 1 1 1\\n2\\nII II II oU\\nT\\nIll 1 III\\n1 1 IIPP fRI\\n2\\nII 1 II 1 II 1\\n1 M rs\\nf l\\nUJ\\n-UUkH-=otu\\nmm Mi\\n05\\nuj\\n1 1 mlmfl\\nffiff*\\n1 1 1 I i 1\\nf. 1 101\\nM\\n2\\ni |-tfn-H-\\nII III\\n11II 1\\n^K\\n55\\n2\\nTP\\n353 1\\nUJ |_\\n\u00e2\u0096\u00a0Imis\\n9^1\\nt S 01 1\\n18\\n05\\ns\\n1 1| 1 1 1 1 1 II 1 1 1 II 1 1\\nWfc\\n\u00e2\u0080\u00a20.\\n6\\n2\\ng III\\njtPi |h|| 1 1 1| 1 1 1\\n55\\nn\\nin nn}+[+H\\n96(16 t\\n811\\nZZ\\nE\\nI o ff\\n-it i J i ~T\\niT^4 l 1 1 1\\n1 II 1 II 1 1 1\\nzz\\n2\\nOP\\n6l/l\\nnil\\n95\\n1 1 1 1 1 1 1 1 1 1 o.cjs\\n_J_!t\\n^0 119\\n2\\n1 fc\\n85\\nUJ\\n~r\\n2\\nIII 1 k\\ntt\\n95\\n66\\n2 1\\nH 1 L:|sj\u00c2\u00a5||^\\n1\\nill\\nH\\n\u00e2\u0096\u00a0h\\nMil\\ntmi\\n_w_\\n2\\nuiiuaxsoEn-jinriirfio\\n119 1|\\n(ml\\n2\\nii i iii\\nI 6\\nIff\\niff\\nIE I\\nLM j\\nTs^\\n2\\nllll Illllll illl Mil\\nff^M\\np|ffi g I j\\n_M_M|^\\n2\\nIII\\nkh TiTU\\nII\\nPPi\\n301 \\\\Z\\\\\\n2\\nan\\n--j- if 1 ill 1 |-U-,v\\n-H\\nT\\n_JJ L_\\n_5t\\n\u00c2\u00bbI\\nq\\n1 III\\nd jo -fi\\nf,\\n2 -j*-t i-t1ili1Piitt\\n^t\\nn\\ngkjj oto oTo o o 8 8 o ol S] S ^H\\nid o a", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0238.jp2"}, "239": {"fulltext": "THE DATA OBTAINED BY OBSERVATION.\\n227\\ntained pneumococci. The blood examination was negative. The\\npatient recovered.\\nFever, varying in type, sweats, emaciation, anaemia, and exhaustion\\nare the common general symptoms. The pulse is increased in f re-\\nqueue v, and is dicrotic and compressible. The heart sounds grow\\nweak,* the breathing hurried. There is slight delirium at times. The\\nurine contains albumin and casts. It is scanty, high colored, and of\\nhigh specific gravity. In some forms there is leucocytosis. There is\\nanorexia, nausea, and vomiting, often diarrhoea. As the case advances\\nthe symptoms of the typhoid state develop. (See Chapter XIV.)\\nObjective Sigxs of Septicaemia. In other instances there is\\nmarked evidence of a septic process in the structures which carried the\\npoisoned or infected blood from the primary point of entrance of the\\ninfecting material the infection atrium. Hence in this infectious pro-\\nFig. 43.\\nTIME\\nTEMP.\\n98\\nM\\nME\\nM E\\nM E\\niVl E\\nm|e\\nME\\nM E\\nm|e\\nI\\ni\\n1\\nA\\nL\\nA\\n1 y\\ni A\\nk/ x\\nI\\ni\\nV\\nl\\nl\\ni\\nI\\n1\\nTemperature record of septic infection.\\ncess in septicaemia we may see lymphangitis and adenitis. The\\nspleen is enlarged. There may be phlebitis, especially of the femoral,\\ninflammation of which is always infectious in character. Other veins\\nmay be affected. The endocardium is infected, and indeed endocarditis\\nmay be the chief symptom-complex of the septic process. The serous\\nmembranes may be involved, so that septic pleurisy or meningitis or\\npericarditis or jieritonitis or arthritis, singly or combined, may be local\\nexpressions of the sepsis. Hemorrhages from the mucous membranes,\\nor subcutaneously, either because the blood is destroyed (toxic) or be-\\ncause of multiple small infarcts, frequently attend septicaemia. Hemor-\\nrhages may be the most pronounced symptom of certain forms of in-\\nfection, as that due to capsulated bacilli. A slight jaundice of toxic\\norigin may prevail.\\nToxic Symptoms. In some instances there is a profound toxcemia in-\\ndicated by delirium, stupor, and later coma and convulsions. The", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0239.jp2"}, "240": {"fulltext": "228 GENERAL DIAGNOSIS.\\ntyphoid state may predominate. The intoxication may overwhelm\\nthe cardio- vascular centres. The pulse grows rapid and feeble, the\\nrespirations hurried and shallow. The urine is diminished in amount\\nand contains albumin.\\nThe clinical course varies with the infective agent. Streptococcus\\ninfections are characterized by chills, high fever, and an extreme septic\\nstate. Infection by the capsulated bacilli (Howard) gives rise to a\\nhemorrhagic septicaemia. In other infections the greater part of the\\nclinical course may be afebrile. Toxic symptoms, and especially in-\\ncreased frequency of pulse-rate with collapse phenomena, are present,\\nas in forms of infectious peritonitis.\\nA general infection, or this general expression of septicaemia, occurs\\nin the course of diseases in which the clinical course of the infectious\\nprocess is usually a definite one. Hence we speak of typhoid septi-\\ncaemia or a pneumococcus septicaemia when the intoxication or general\\ninfection is paramount to the local process. Then in tuberculosis and\\nother prolonged infections septicaemic symptoms arise, so that the ter-\\nminal phenomena of the disease are usually due to a mixed infection.\\nIt must then be understood that pyaemia or septicemia or septico-\\npyaemia are not due to special micro-organisms in the sense that\\ntyphoid fever is due to the bacillus typhosus, malaria to the Plasmo-\\ndium, or pneumonia to the pneumococcus.\\nTerminal Infections. At the termination of many chronic diseases,\\nas the various fibroid affections cirrhosis of the liver, the kidneys,\\nendarteritis, or spinal cord disease, and in carcinoma there is fever.\\nThis is generally due to an infection which the weakly resisting organ-\\nism invited.\\nFlexner has studied the terminal infections. In 255 cases of renal\\nand cardiac disease he found 213 infections, excluding tuberculosis.\\nThey were local and general. Infections of the serous membranes are\\nthe most common. The old clinical fact that serous inflammations\\nwere complications of Bright s disease has been proven by bacteriologi-\\ncal methods to be due to an infection, and not as formerly thought to a\\nchemical change in the blood. The following micro-organisms are met\\nwith the streptococcus pyogenes, the pneumococcus, the staphylococ-\\ncus aureus, the bacillus proteus, the gonococcus, the bacillus pyocy-\\naneus, and the gas bacillus.\\nTuberculous infection is also a terminal process in many diseases.\\nFrequently an acute tuberculosis of serous membranes is found in the\\ncourse of chronic heart or kidney disease.\\nFever in Carcinoma Fever occurs in the course of carcinoma\\nunder two circumstances. If it is proven that carcinoma is an infec-\\ntion this process is one cause of the fever. It is well known, however,\\nthat in rapidly growing cancer of the liver, fever, often intermitting in\\ntype, is present. It may also be present in general carcinoma, and in\\nall probability in carcinoma of the lungs and of the bones. But fever\\nin the course of cancer may be due to a secondary infection. It can be\\nreadily understood that the process is likely to take place if the malig-\\nnant disease occurs in the course of any of the tubes or channels. The\\ninfection atrium is the inflammation or ulceration found so often in", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0240.jp2"}, "241": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 229\\ncarcinoma, and in consequence local suppuration occurs. From this\\nlocal infection a general septicaemia may arise.\\nAfebrile Infection. Although most infections cause such reaction\\nof the system as to produce fever, some few are afebrile. Such is the\\ncase with tuberculosis when it is local and of syphilis in certain\\nstages. The writer is of the belief that when the syphilitic poison is\\nactive i. e., productive of lesions fever is present some time during the\\ntwenty-four hours. He is fully persuaded that mistakes are made\\nbecause fever is not considered a part of the syphilitic infection. He\\nhas seen it in all of the arbitrarily called stages of infection, and pre-\\nsenting all types of fever intermittent, remittent, and continuous.\\nThe rise may be moderate or very pronounced. For its detection the\\nthermometer should be employed every two hours.\\nTyphoid fever is an example of an infection which sometimes runs\\nits course without rise in temperature. This is very rare, but never-\\ntheless does at times occur.\\nInfections of Certain Bacteriology. In our investigation of the\\ncause of the fever in a suspected case we have found evidence of an\\ninfection as shown by (1) the phenomena of a local inflammation, (2)\\nby the presence of pyaemia or (3) of septicaemia. The clinical course\\nalone enables one to make a diagnosis generally. At times we may\\nhave to resort to more positive methods. The nature of the process,\\nhowever, is usually proven the nature of the infection must be decided\\nby bacteriological examination. We must, therefore, follow this mode\\nof recognition of an infection.\\nInfections of Uncertain Bacteriology. The presence of those\\ninfections, the bacterial cause of which is not known, must be deter-\\nmined somewhat differently. In one group we must be content with\\nthe data obtained by inquiry and by observation, comparing the symp-\\ntoms with the known course of a similar disease. Scarlet fever can\\nonly be recognized in this way. In subsequent chapters, therefore, the\\ninfections are divided into those recognized by inquiry and observation,\\nand those recognized by supplementary observation with bacteriological\\nmethods.\\nThe classification of the infectious diseases is based upon the fact\\nthat a specific micro-organism is known which gives rise to phenomena\\nsimilar in the respective infections. In other words, the infection of\\nmalaria or of tuberculosis or of diphtheria follows a recognized clinical\\ncourse. The period of invasion, the mode of onset, the symptoms\\nthroughout the course of the disease, are with notable exceptions prac-\\ntically the same.\\nBacteriological Diagnosis.\\nBacteriological examination includes (1) the finding of the specific\\nmicro-organism in the blood or tissues (of the subject) or in the patho-\\nlogical secretions or excretions (2) the isolation and cultivation of the\\nmicro-organism (3) the inoculation and the reproduction thereby of\\nthe disease in animals. In many infections the morphological pecu-\\nliarities of the micro-organism are so characteristic that a diagnosis may\\nbe established by finding it in the blood or the secretions. Thus an", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0241.jp2"}, "242": {"fulltext": "230 GENERAL DIAGNOSIS.\\nexamination of the blood, with or without staining, will disclose the\\npresence of the micro-organism of relapsing fever and of anthrax and\\nthe protozoa of malaria. The examination of inflammatory products\\nof an infection, as the sputa in pneumonia or tuberculosis, are sufficient\\nto determine the nature of the infectious inflammation of the lungs.\\nOn the other hand, in some infections, the absence, or rather failure of\\ndetection, of the micro-organism in the fluids or discharges is not proof\\nthat the disease is not present in the suspected individual. The infec-\\ntion tuberculosis well illustrates the propositions in the last two sen-\\ntences. If the bacillus is found in the sputum of a suspected case the\\ndiagnosis is established definitely, and no further procedures for diag-\\nnostic purposes are necessary. In other clinical forms, as tuberculous\\npleurisy, or empyema, or glandular or joint tuberculosis, the micro-\\norganisms are few and difficult to find. Cultures, or, more conclusive\\nstill, inoculations, must frequently be resorted to before a final conclu-\\nsion can be arrived at. It is possible that spores alone exist morpho-\\nlogical elements difficult to detect by staining and microscopical\\nmethods, but which may rapidly multiply under favorable culture\\nconditions or inoculation conditions. Again, micro-organisms have\\nbeen found in certain infections, and although thus far their causal\\nrelationship to them has not been fully proved, nevertheless their con-\\nstant occurrence in the special affection, and in it alone, renders their\\npresence of high diagnostic value. Thus the amoeba of dysentery and\\nthe plasmodium malaria? of Laveran are diagnostic of their respective\\naffections.\\nFor diagnostic purposes bacteriological investigations must be con-\\nducted in accordance with the methods of bacteriology. Such researches\\nare possible at this time, because of (1) the high degree of development\\nand mode of use of optical apparatus, including oil-immersion lenses,\\nAbbe s condenser and diaphragms (2) the discoveries by Weigert of\\nthe effects of aniline dyes on protoplasm, and the property of micro-\\norganisms of taking different stainings (3) of the principles of steril-\\nization by heat, by which foreign micro-organisms are excluded (4)\\nof the use of solid culture-media, and the plate-method of obtaining\\npure cultures suggested by Koch.\\nMethod of Procedure.\\nTo determine the presence of moist infections it is necessary to pro-\\nceed as follows\\nA. Examination of the blood.\\nB. Examination of the pathological secretions and excretions.\\nC. Examination of products of infectious inflammation secured by\\nexploratory puncture or evacuation of abscesses. (See Chapter XXI.)\\nD. Inoculations of animals with pure cultures of the organism or with\\nthe products of inflammation, as cheesy matter from a tuberculous abscess.\\nE. The use of products of bacterial growth to secure reaction, as\\ntuberculin in tuberculosis, and mallein in glanders. (See Tuberculosis.)\\nWhen there is no distinctive pathological fluid all the fluids of the\\nbody must be examined. In other cases the pathological discharge", "height": "4412", "width": "2580", "jp2-path": "practicaltreatis00muss_0_0242.jp2"}, "243": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 231\\n(pus), or perhaps the diseased tissue, must be studied. We get a\\nclue to the direction which the examination is to take from the nature\\nof the symptoms. In cases of pulmonary disease, the sputum of\\nfaucial disease, the membrane, pus, or other secretions from the fauces\\nin intestinal disease, the discharge from the bowels and in genito-\\nurinary disease, the urine. It must not be forgotten that in many,\\neven highly fatal diseases, the blood is not invaded by micro-organ-\\nisms. Death is due to the development of toxic substances. Hence,\\nas in cholera and diphtheria, the presence of the micro-organism is not\\nsought for in the blood, but in the specific excretion or exudation.\\n(See Tuberculosis.)\\nThe Apparatus. The apparatus necessary for the simplest bacte-\\nriological research comprises the following Sterilizers, incubators,\\nglass flasks, covered dishes, test-tubes and plates, platinum needles\\nfixed in glass handles, raw cotton, materials for culture-media, micro-\\nscope, with slides and cover-glasses, and, in addition to lenses of lower\\npowers, a one-twelfth oil-immersion lens, and finally the various stains\\nused.\\nPreparation of Apparatus. Boil all glassware for half an hour\\nin a solution of common soda (2 to 3 per cent.), then scrub thoroughly\\nrinse in warm solution of HC1 (1 per cent.) and then in pure water\\ndrain with tops down plug tubes and flasks with raw cotton, fitting\\nfirmly and evenly, so that the cotton can hold the weight of the test-\\ntube sterilize in dry oven. The test-tubes (plugged) are placed in a\\nrack for further use.\\nThe tubes and flasks are best filled with the culture-media through\\na spherical funnel that can be plugged with cotton. Then they are\\nto be sterilized in the steam sterilizer, as heretofore described.\\nThe cover-glasses must be thoroughly cleansed by immersion in\\nstrong nitric acid for a few hours, then rinsed in water, then in alcohol\\nand ether. They are then kept in alcohol.\\nSterilization. It should be understood that the first requisite for\\nthe prosecution of these studies is to secure absolute cleanliness and to\\nprevent the invasion of extraneous micro-organisms. The first step is\\nthorough sterilization of all appliances required for work and of all the\\nmedia, to destroy previously existing bacteria.\\nThe sterilization is best accomplished with steam, where the objects\\nto be sterilized admit of it. With dry heat a temperature of at least\\n150\u00c2\u00b0 C. must be applied for at least an hour, and, of course, can only\\nbe used for glassware and metal instruments. All media (see page\\n159), whether solid or fluid, are sterilized by steam. Media which\\ncannot withstand long exposure to the necessary heat are sterilized by\\nthe intermittent application of steam. The reason that this is effective\\nis that fully developed bacteria are destroyed at a much lower temper-\\nature and with shorter exposure than are the spores. One application\\nkills the developed bacteria, then the material is kept for a time in an\\nincubator spores develop into bacteria and are easily killed by a\\nsecond application. By repeating this process from three to five times\\nthe substance is effectually sterilized. If the exposure is made longer\\na much lower degree of heat may be used, so that in the case of blood", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0243.jp2"}, "244": {"fulltext": "232 GENERAL DIAGNOSIS.\\nserum it may be sterilized without coagulating the albumin. Usually\\nan exposure of fifteen minutes to steam on each of three successive\\ndays is used for stable media, and an exposure of an hour on six suc-\\ncessive days to a temperature of 70\u00c2\u00b0 C. for more delicate media, as\\nblood serum. In the intervals the material must be kept at a temper-\\nature of 25\u00c2\u00b0 to 30\u00c2\u00b0 C. A single application of steam under one to\\none and one-half atmosphere pressure is now often used.\\nThe ordinary Arnold steam sterilizer is as good as any. The\\ndry sterilizer is merely a metal box with copper bottom and ventilating\\nholes. It is well to have an asbestos casing.\\nMetallic articles, as forceps, platinum probes, etc., are best sterilized\\nin the flame of a Bunsen burner.\\nCollection of Material. A definite, careful method must be ob-\\nserved when the pathological product is removed from the patient or\\ncollected for investigation. (See Chapter V., Exploratory Puncture.)\\nPus and fluids should be placed in sterilized glass bottles or tubes, care\\nhaving been taken that instruments for the removal of the fluid were\\npreviously sterilized. Exposure to air should be as brief as possible.\\nThe fluid should not be contaminated with blood or antiseptic fluids\\nused for flushing or other surgical procedure. If an abscess is opened\\nor purulent peritonitis cut down upon, for instance, tube-inoculations\\ncan be made at the bedside. The previously sterilized platinum point\\nshould be kept before use in a test-tube closed with sterilized cotton.\\nIt is dipped into the pus before it flows over the skin, and the pus\\nshould be free from the blood of the incision. It is at once transferred\\nto the medium in the test-tube. Sputum should be collected in a pre-\\nviously sterilized bottle, or one thoroughly cleansed by boiling. The\\nbottle should have a wide mouth. Care must be taken to secure\\nsputum from the lungs, and not the secretion from the mouth and\\nfauces. Purulent portions, rather than mucoid, are to be sent for ex-\\namination. Intestinal discharges may be collected in sterilized glass\\njars and examined as soon as practicable. It may be necessary to keep\\nthe discharge at the temperature of the body. (See Faeces amoeba\\ndysenterica.)\\nExamination of Blood.\\nTo secure blood for microscopical study the finger must be thor-\\noughly cleansed with alcohol and puncture made with a sterilized\\nlancet or needle. After the blood flows a few seconds it is removed\\nand the cover-slip, previously cleansed in nitric acid solution, is gently\\npressed upon the second overflow. Another cover is placed over the\\nblood-stained surface of the first slip, the two rubbed together and\\nseparated by sliding them apart. (See Fig. 45.) Sternberg prefers to\\nspread the blood, which was collected at the edge of the cover-\\nslip, by drawing a polished glass slide, held at an acute angle, over the\\ncover-slip. In either case this thin film of blood is allowed to dry,\\nand can be examined later. Sternberg mounts the blood on a glass\\nslide at once.\\n1. Microscopical examination is made of the fresh blood. 2. Smear\\npreparations on cover-glass or slide are made for staining. 3. A drop", "height": "4416", "width": "2576", "jp2-path": "practicaltreatis00muss_0_0244.jp2"}, "245": {"fulltext": "THE DATA OBTAINED BY OBSERVATION.\\n233\\nof the blood is examined to observe the biological properties known\\nas agglutination, or the Widal reaction the serum diagnosis. 4. The\\nnumber of white corpuscles is counted, to show the presence or ab-\\nFiG. 44.\\nF:G. 45.\\nProper method of holding a cover-glass. (Cabot.)\\nIllustrating the position of cover-\\nglass during the spreading of hlood\\nfilms. (Cabot.)\\nsence of leucocytosis (see Blood), and a differential count of these cor-\\npuscles is also made. 5. The fresh blood is inoculated on media for\\ncultures.\\nI. Fresh blood is examined with the oil-immersion objective and\\nthe diaphragm of the sub-stage condensing apparatus (Abbe s) nearly\\nclosed. The protozoa? of malaria, the bacillus of anthrax, and the\\nspirillum of relapsing fever may be detected.\\nII. Cover-glass preparations are examined with the diaphragm open.\\nThe micro-organisms above mentioned and those of yellow fever and\\ntyphoid fever may be found in this manner. The method of staining\\nthe blood is described below. The following solutions are used 1.\\nBasic aniline dyes. 2. Loffler s alkaline methyl-blue. 3. Gram s.\\nIII. Sebum Diagnosis. The phenomena of agglutination consists\\nin the gradual approximation, clumping, and loss of motility in the\\nmicro-organisms of some infectious disease when the blood of a patient\\nsuffering from that disease is brought in contact with it. This is known\\nas the serum, or Widal reaction, and by means of it a number of infec-\\ntious diseases can now be recognized. If a drop of bouillon culture is\\nexamined with a high-power lens the organisms are seen darting about\\nand across the field with great rapidity in various directions. If to\\nten drops of a pure culture of certain varieties of infectious micro-\\norganisms one drop of the blood of a patient suffering from that infec-\\ntion be added the motility of the organisms is checked and clumps\\nappear in the field. The clumps enlarge rapidly, so as to be easily\\nvisible under a magnifying power of 500 diameters.\\nSerum from patients suffering from other diseases or from healthy\\npatients does not produce agglutination if the proportion of serum to\\nculture in the mixture is 1 to 10 or less. The reaction is specific.\\nThus typhoid bacilli are not clumped by any serum other than that of\\na typhoid patient or a patient immunized against typhoid fever by a\\nmore or less recent attack of the disease. Typhoid serum clumps no", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0245.jp2"}, "246": {"fulltext": "234\\nGENERAL DIAGNOSIS.\\norganism except the typhoid bacillus when used with a certain degree\\nof dilution and examined within a certain period of time.\\nFig. 46.\\nBouillon culture of typhoid bacilli before the addition of diluted typhoid serum.\\n(Magnified 500 diameters.) After Cabot\u00e2\u0080\u0094 serum diagnosis.\\nSerum diagnosis has become a valuable mode of recognition of\\ntyphoid fever, Malta fever, yellow fever, and glanders. It may be of\\nuse in other infections, as cholera and the pneumococcus infections.\\nThey are more accurately diagnosticated by other bacteriological meth-\\nods, however, and need not be considered here.\\nMethod. Three methods of securing the serum reaction are em-\\nployed microscopic, or quick test of the fluid serum or blood the\\nmicroscopic, or quick test of the dried blood and the macroscopic, or\\nslow test. Each of these methods is of value. The observer should\\nselect one and make it his object to become thoroughly familiar with\\nthat selected.\\nFirst, the quick test with fluid serum. The steps are first, to collect\\nthe blood second, to add it in certain proportion to the fluid culture\\nthird, to examine the slide and cover-slip.\\n1. Collecting the Blood. The blood is secured by puncture as\\nin the method described in diseases of the blood. If the ear is selected\\nit can be bled freely or blood squeezed out by the milking process until\\nabout fifteen drops are collected in a small test-tube. It is not neces-\\nsary to observe strict antiseptic precautions as in other instances. The", "height": "4416", "width": "2584", "jp2-path": "practicaltreatis00muss_0_0246.jp2"}, "247": {"fulltext": "THE DATA OBTAINED BY OBSERVATION.\\n235\\ninstruments and test-tube should be thoroughly cleansed. The blood\\nthus collected is allowed to coagulate in the tube, which may occupy\\nseveral hours. It is to be remembered that the clot collects on the\\nFig. 47.\\nThe same, five minutes after the addition of typhoid serum (dilution 1 10), showing\\ntypical clump reaction. (Magnified 400 diameters.) (Cabot.)\\nsides of the tube and over the surface of the blood. To secure the\\nserum this clot must be removed with a bit of wire.\\n2. Dilution. One drop of the serum is added to forty drops of a\\nbouillon culture. The same dropper must be used for each fluid, in\\norder that the size of the drops will be equal. The fluids are to be\\nmixed intimately in a small test-tube. A drop of this mixture of cul-\\nture and serum is placed upon a cover-glass, which is then inverted\\nover a hollow ground slide and examined under the microscope with\\nthe immersion lens. Within twenty minutes clumping should take\\nplace. If the reaction does not take place a new mixture should be\\nmade, in the proportion of 1 to 20 or 1 to 10. If there is no reaction\\nwith this dilution the test is negative. Instead of making successive\\nmixtures three tubes can be prepared at once, containing ten, twenty,\\nand forty drops each of the culture. A drop of serum can be added\\nand the test conducted as above.\\n3. Examination of Slide. A No. 7 Leitz dry lens or oil-immer-\\nsion lens can be used with a No. 3 or No. 4 eye-piece. Artificial light is\\npreferable to daylight if the latter is used a small aperture diaphragm\\nis the best. It is very necessary that the slide and cover-slip should\\nbe thoroughly cleansed.", "height": "4412", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0247.jp2"}, "248": {"fulltext": "236 GENERAL DIAGNOSIS.\\nThe Reaction. In a complete or typical reaction the field shows\\nthe presence of large clumps of bacilli isolated and motionless. (See\\nFig. 47.) No motile bacilli can be seen. The clumping may occur\\ninstantaneously or gradually. If the reaction is very marked, Greene\\nstates a mottling can be seen with the naked eye. Clumping and\\ncessation of motion are the essentials of the reaction, providing they\\ntake place within a certain time, and notwithstanding a certain degree\\nof dilution of the serum. When the reaction is feeble small clumps\\nappear, or, as Widal calls them, agglutination centres. As the field is\\nstudied bacilli are seen moving toward the centres and gradually rang-\\ning themselves in loose masses, sometimes like the spokes of a wheel.\\nDurham has called attention to a peculiar spinning motion of the\\nbacilli around one of its own ends, Avhich is seen in some of the fields\\nin which a few isolated bacilli remain. Such movements occur at the\\nmargin of the clump.\\nIt is very necessary to examine a drop of the pure culture before\\nthe addition of any serum, to make sure that clumping has not already\\ntaken place, particularly if the culture is old or has undergone sedi-\\nmentation. It is desirable that the bacilli should be isolated and\\nactively motile.\\nTime Limit and Dilution. As Cabot forcibly states, only when\\nclumping occurs within a certain time and in a certain degree of dilu-\\ntion is it of diagnostic importance. The test is quantitative and not\\nqualitative. The degree of dilution of 1 to 10 is quite sufficient if the\\ntime-limit for the reaction is at least fifteen minutes. Any clumping\\nof typhoid bacilli which takes place fifteen minutes after one part of\\nserum has been added to ten of the culture gives a probable typhoid\\nreaction. Various observers select different dilutions. Thus, Wilson\\nand Westbrooke make a dilution of 1 to 50 with a two-hour time-\\nlimit. Durham uses a dilution of 1 to 17 or 1 to 20.\\nInstead of the serum from the blood the serum of a blister may be\\nused, or the serum from blood which has been drawn directly from a\\nvein with antiseptic precautions.\\nThe whole blood can also be used in a fluid state. A drop of the blood\\ncan be drawn directly into ten drops of the culture previously meas-\\nured. This method is of great advantage for rapid work. The same\\ndropper should be used for measuring the culture and subsequently\\nthe blood. With the microscope at the bedside the test can be made\\nrapidly with but little risk of failure.\\nA still more convenient method consists in the employment of the\\npipette, used for diluting the blood in counting leucocytes. The blood\\nfrom the finger is drawn up to the 0.5 or 1.0 mark on the stem, and\\nthe bulb then filled with distilled water. The mixture is then blown\\ninto a small test-tube. As the dilution has already been made, a drop\\nof bouillon culture or a small portion of an agar culture may be added\\nto it directly and examined as above.\\nThe Reaction with Dried Blood. We owe to Wyatt Johnston, of\\nMontreal, the great credit of working out this simple but accurate\\nmethod of performing the reaction. It is of special value for sanitary\\nwork where blood has to be sent by mail for examination. The method", "height": "4412", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0248.jp2"}, "249": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 237\\nis simple. The blood is collected on glass or glazed paper. In this\\nmanner it can be preserved for an indefinite time and transported\\neasily. If the drop of blood is dried on a glass slide it can be dissolved\\nby the addition of a little water and then the culture added in the way\\npreviously described. If the drop is dried on paper it can be cut out\\nwith a pair of scissors and rubbed up in a watch-glass with one drop of\\nwater. When the blood is dissolved ten drops of culture are added,\\nand the examination is carried on as in the previous method.\\nSome operators collect the blood in the eye of a wire loop of a given\\nsize, and after placing it on a glass, dilute with water in the proportions\\ndesired, ten loopfuls of water being the amount usually selected to mix\\nwith the drop in the wire loop. Wilson and Westbrooke have modi-\\nfied Johnston s technique as follows They use a bit of platinum\\nwire, number 19 gauge, one end of which is bent into a loop, the\\ninside diameter of which is 2 mm. The loop is used to collect the\\nblood, several drops of which are deposited on a bit of aluminium foil,\\nnumber 40 gauge, 5 cm. square. After the blood is dried the foil is\\nrolled up. At the laboratory the bit of foil is then cleared of blood,\\nwhich flakes off easily. One mgm. of dried blood and 200 mgm. of\\ndistilled water are weighed out and mixed. This gives an exact dilu-\\ntion of 1 to 200 by weight 1 to 50 dilution by volume. A hanging\\ndrop of the dilution is inoculated with the bouillon culture and exam-\\nined. The time limit is two hours.\\nIt is essential for the success of the reaction that a pure culture of\\nthe typhoid bacillus should be employed. The most suitable culture\\nfor diagnostic work is that which is the most actively motile. It is\\ntrue, however, that many observers recommend the attenuated cultures.\\nThey hold that an actively motile culture is too sensitive, and may cause\\nclumping even with normal serum. If a fresh culture is kept at room\\ntemperature and transplanted every two or three days the culture main-\\ntains its motility and sensitiveness for a long period. The incubator\\nbouillon cultures of twelve hours growth are probably the most avail-\\nable. Johnston, whose experience is worth following, thinks the mo-\\ntility must not be excessive. He reduces the motility of the bacilli by\\ntransplanting his agar cultures once a month, growing them at room\\ntemperature. The bacilli from this culture, grown for twenty-four\\nhours on bouillon, show a slight gliding motion, which differs from\\nthe darting motion seen in an active culture. The bouillon, Johnston\\nholds, should be slightly acid, contrary to the general rule, which states\\nthat it should be neutral. It is quite necessary that the bouillon cul-\\nture should be young that is, twelve to twenty-four hours duration\\nin the incubator or two days at room temperature. When a culture\\nis made under these circumstances, before it is used it should be free\\nfrom sediment and only slightly turbid. It should also be free from\\nany spontaneous clumping and from non-motile or sluggish forms.\\nValue. The question may well be asked, What is the value of\\nthe serum reaction Let us answer by referring to typhoid fever\\nchiefly. When it is recalled that this reaction takes place in about 98\\nper cent, of all cases of typhoid fever, it can readily be seen what a con-\\nstant phenomenon it is in the course of continued fever. As a symp-", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0249.jp2"}, "250": {"fulltext": "238 GENERAL DIAGNOSIS.\\ntorn, therefore, it is one of the most constant. Its presence, however,\\ncannot be determined in a large number of cases before the eighth or\\ntenth day. It has been found as early as the third day, and, on the other\\nhand, may be absent until after convalescence has set in. In a large\\nmajority of cases the reaction appears, however, before the fourteenth\\nday. In a few instances, as Widal pointed out, the reaction disappears\\nas soon as the temperature remains normal. In other instances it may\\ncontinue several months, and in rare cases has been found as long as\\nten years after the disease.\\nIt is thus seen that the presence of the serum reaction is a valuable\\ndiagnostic symptom of some diseases, and notably of typhoid fever.\\nIts absence, however, does not disprove the presence of the disease.\\nSometimes the blood of a patient ill with some other disease, who has\\npreviously had typhoid fever, may give a positive reaction, and thus\\nlead to a false diagnosis. Absence of reaction in a supposed case of\\ntyphoid fever implies, in 98 per cent, of all cases, that this infection is\\nnot present, providing, of course, that the technique is correct and\\nthat repeated examinations have been made. In the following diseases\\nthe serum diagnosis is employed (1) Glanders (2) Malta fever; (3)\\nyellow fever (4) cholera (5) relapsing fever (6) typhoid fever.\\n4. Leucocytosis. The presence of leucocytosis is characteristic of\\nmany infections, and, on the other hand, is against not a few of the\\nmost common of the infectious disorders. Accurate study of the num-\\nber of white cells has led to fairly definite conclusions as to the diag-\\nnostic value of their increase or their diminution. The method of\\ndetermining the number is described in the chapter on Diseases of\\nthe Blood, which may be referred to in order that the student may\\nalso learn the circumstances under which leucocytosis occurs physio-\\nlogically. Pathologically we find inflammatory leucocytosis or the\\nleucocytosis of infectious disease occurring with such frequency as to\\nbe diagnostic. A classification of the degree can be roughly made only.\\n1. In Asiatic cholera, relapsing fever, scarlet fever, diphtheria, syphilis,\\nand erysipelas, leucocytosis occurs to a moderate degree. 2. In pneumonia,\\nsmallpox in the stage of suppuration, septicaemia, actinomycosis, trich-\\ninosis, glanders, beri-beri, acute rheumatism, cerebro-spinal meningitis,\\nand gonorrhoea it is also found, but more constant and more marked.\\n3. In all pyogenic infections, especially abscesses, in inflammations of\\nserous membranes and in gangrenous inflammation usually due to strep-\\ntococci or staphylococci infection, leucocytosis is great.\\nThe significance of leucocytosis depends not alone upon the number\\nof the white cells, but also upon their rise and fall in the course of the\\ndisease. The amount of local inflammation attending the infection is\\nnot a measure of the amount of leucocytosis. Moreover, the degree of\\nfever does not affect the leucocytosis. Fever may occur without in-\\ncrease in the white cells, and the opposite condition may also obtain.\\nWhen leucocytosis and fever are due to the same infection they may\\nrise and fall together, as we often see in cases of pneumonia.\\nAbsence of Leucocytosis. While the presence of leucocytosis is sig-\\nnificant of various infections, its absence is likewise of great significance.\\nHence if there is no leucocytosis it is possible either typhoid fever,.", "height": "4416", "width": "2572", "jp2-path": "practicaltreatis00muss_0_0250.jp2"}, "251": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 239\\nmalaria, influenza, measles, rotheln, or tuberculosis are present. The\\nblood-count can in this manner be employed to distinguish typhoid\\nfever, in which there is an absence of leucocytosis from a pyogenic\\ninfection, as appendicitis in which the other signs and symptoms\\nmay be quite similar. Pneumonia, on the other hand an infection\\ncharacterized by great leucocytosis may in this manner be distin-\\nguished from tuberculosis, in which there is an absence of leucocytosis.\\nWhen leucocytosis occurs in the course of any disease in which it is\\nnormally absent it is an indication of a complication. In typhoid\\nfever it is an indication of intestinal perforation and peritonitis, because\\nof a mixed infection. On the other hand, a fall of leucocytes in a\\ndisease in which they are increased is suggestive of localization of the\\ninfection, as the walling off of the abscess in appendicitis. Such\\nfall in pneumonia is of grave prognostic omen.\\n5. For direct bacteriological examination of the blood culture\\nmethods are resorted to. After the skin has been cleansed and made\\naseptic either a considerable portion of blood is withdrawn from a vein\\nwith a sterilized hypodermatic needle or blood is directly drawn with\\nthe instrument described by Ewing. After the blood is thus removed\\nit is transferred to the various media, and its further treatment is carried\\non in accordance with bacteriological methods. (See Cultivation of\\nMicro-organism s\\nExamination of Pathological Secretions and Excretions.\\nMicroscopical examination, with and without staining, and culture\\nmethods are employed, as detailed in the sections to follow\\nIn nasal discharges the bacillus of diphtheria, of glanders, of tuber-\\nculosis, and of the pneumococci, as well as pyogenic micro-organisms,\\nare found.\\nIn the mouth the micro-organisms peculiar to that cavity and the\\nmicro-organisms of actinomycosis may be found.\\nIn the fauces and pharynx the bacillus of diphtheria and pyogenic\\nmicro-organisms are discovered.\\nThe sputa (see Disease of Lungs) yield the tubercle bacilli, the pneu-\\nmococcus, the bacillus of influenza, and actinomycosis.\\nThe fceces (see Disease of Intestines) are examined for the bacillus\\ncoli communis, the spirillum of cholera Asiatica, bacillus typhosus, and\\ntubercle bacillus.\\nThe urine. Pyogenic micro-organisms, tubercle bacillus, typhoid\\nbacillus, the pneumococcus, and gonococcus are found in the urine.\\nThey are secured by cover-slip preparations of the pus, or by culture\\nmethods, as described in the section devoted to Diseases of the Kidneys.\\nExamination of the Products of Infectious Inflammation\\nMaterial Secured by Exploratory Puncture.\\nMaterial removed by exploratory operation or puncture may be\\nserous, bloody, or purulent (See Chapter XXI.) It must be examined\\nbacteriologically, microscopically, by culture methods, and by inocula-\\ntion. Serous fluids are not usually productive of bacteria when exam-", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0251.jp2"}, "252": {"fulltext": "240 GENERAL DIAGNOSIS.\\nined unless treated by sedimentation, and even then it is often neces-\\nsary to inoculate.\\nThe most important pathological product is pus. Fresh and stained\\npreparations are examined, and cultures are taken. We may find only\\none, sometimes two at the same time, of the folloAving micro-organisms\\n1. Staphylococcus pyogenes aureus. 2. Staphylococcus pyogenes albus.\\n3. Staphylococcus epidermidis albus (Welch). 4. Streptococcus pyo-\\ngenes. 5. The tubercle bacillus. 6. The bacillus of syphilis. 7. Ac-\\ntinomycosis. 8. The bacillus of glanders. 9. The bacillus of anthrax.\\n10. The bacillus of leprosy. 11. The bacillus of tetanus. 12. The\\nbacillus of influenza. (See Sputum.) 13. The micrococcus lanceolatus.\\n14. The bacillus coli communis. 15. The gonococcus.\\nFresh pus may be examined, but the stained is more satisfactory.\\nStaining by the method of Gram is the best, and is as follows After\\na cover-glass has been prepared and placed in Koch-Ehrlich s solution\\nof gentian-violet and aniline water, it is put into a solution of iodine\\nand iodide of potassium for two or three minutes. A dull red-brown\\ncolor is produced. It is then rinsed in absolute alcohol for some time.\\nThe micro-organisms are stained dark blue. The iodide of potassium\\nsolution is Iodine, 1 part iodide of potassium, 2 parts distilled\\nwater, 300 parts. By this method the various forms of micro-organ-\\nisms just indicated are readily brought out.\\nMethods of Staining Blood, Pus and Discharges. It is well to\\nconsider these collectively. Many have been devised, but those of\\nclinical value are the following\\n1. Aqueous solutions of basic anilines.\\n2. Loffler s alkaline methyl-blue.\\n3. Koch-Ehrlich s aniline water solutions.\\n4. ZiehPs carbol-fuchsin.\\n5. Loffler s method of staining flagella.\\n6. Gram s method.\\n7. Friedlander s method.\\n8. Giinther s method.\\n1 Basic anilines. Aqueous solutions of the basic aniline colors\\nfuchsin, gentian-violet, and methyl-blue are used of such strength\\nthat they can be seen clearly through an ordinary test-tube. They\\nmay be kept on hand in bottles with pipettes, or made from concen-\\ntrated alcoholic solutions as needed. They are used by simply drop-\\nping a few drops on the cover-glass preparation, which is held with\\nthe forceps, allowing it to remain about thirty seconds, and carefully\\nwashing off in water. It is placed on a slide, bacteria down, and the\\nexcess of water removed with blotting-paper.\\n2. Loffler s alkaline methyl-blue solution. Certain bacteria take a\\nstain more readily when an alkali has been added. The formula is as\\nfollows\\nConcentrated alcoholic solution methyl-blue 30 c.c.\\nCaustic potash, 1 10,000 100\\nIt is used in the same way as the simple solutions.\\n3. Koch-Ehrlich s aniline water solutions. Add to 100 c.c. of dis-\\ntilled water, aniline oil, drop by drop, thoroughly shaking after each", "height": "4412", "width": "2576", "jp2-path": "practicaltreatis00muss_0_0252.jp2"}, "253": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 241\\ndrop until it becomes opaque. Then filter. Add 10 c.c. absolute\\nalcohol and 11 c.c. of a concentrated alcoholic solution of either fuchsin,\\nmethyl-blue, or gentian-violet.\\n4. ZiehFs carbol-fuchsin solution.\\nDistilled water 100 c.c.\\nCarbolic acid 5 gra.\\nAlcohol 10 c.c.\\nFuchsin 1 gm.\\nThe use of these various stains will be described in the description\\nof the different bacteria.\\n5. Loffler s solution for flagella.\\nTannic acid, 20 per cent 10 c.c.\\nCold saturated solution ferric phosphate 5\\nSaturated solution fuchsin 1\\nA few drops of this solution are placed on the cover-glass contain-\\ning the bacteria and very gently heated until they begin to steam, and\\nthen the cover-glass is washed off in water. The preparation is then\\nstained with aniline water fuchsin. Different bacteria require differ-\\nent reactions, and so a few drops of an acid or alkaline solution are\\nrecommended to be added as the case requires. As a rule, however,\\nthe results obtained when neither acids nor alkalies are added are just\\nas satisfactory as those following such additions.\\n6. Gram s method consists in staining with a Koch-Ehrlich solution\\nof gentian-violet for twenty to thirty minutes, and then decolorizing in\\nIodine 1 gm.\\nPotassium iodide 2\\nDistilled water 300 c.c.\\nAfter remaining in this for five minutes the preparations are rinsed in\\nalcohol, and the process repeated until the violet color has disappeared.\\nFor Friedlander s and Grunther s methods, see Sputum.\\nTo detect spores of bacilli double staining may be employed. The\\npreparation is first stained in a hot Ziehl-Neelsen fuchsin solution,\\nthen decolorized with alcohol containing from 0.2 to 0.3 per cent,\\nhydrochloric acid. When stained again with methylene-blue the\\nspores appear red and the bacilli blue.\\nThe hanging drop. By the examination of colonies in the hang-\\ning drop we learn of the movement of the micro-organism. Place a\\ndrop of physiological salt solution on a cover-slip, and add a tiny por-\\ntion of colony on platinum wire place the slip, drop down, on a glass\\nslide, in the centre of which is a depression or hollow. Fix the slip\\nby applying a thin layer of vaseline around the margin of the depres-\\nsion. Care must be taken in focusing that the lens does not break the\\nglass, which may be readily done because of its transparency. The\\nbacteria are seen in motion on account of the motion their position is\\nconstantly altered. This motion must not be mistaken for the Brown-\\nian movement of suspended articles, which is vibratory from molecular\\ntremor.\\nCultivation of Micro-organisms. The object is to isolate the\\npathogenic organism from all other organisms and to exclude organ-\\n16", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0253.jp2"}, "254": {"fulltext": "242 GENERAL DIAGNOSIS.\\nisms that may be introduced from without by unclean instruments or\\nother means. Pure cultures are thus obtained,\\nCulture-media. Experience has taught us that various forms of\\nbacteria require different pabulum, and that various nutrient media are\\nrequired for the isolation of different micro-organisms. As to the bac-\\nteria hereafter noted, we are familiar with the proper soil for their\\ngrowth. The media used for bacteria of clinical importance are\\na freshly steamed potato, gelatin, bouillon, agar-agar, milk, and blood-\\nserum. They are prepared or mixed in various ways, and other things\\nmay be added, as a solution of litmus, to determine the reaction of the\\nbacterial products.\\nBouillon. Lean beef, 500 gin., soaked in one litre of water for\\ntwenty-four hours in an ice-chest strain through a coarse towel and\\npress until a litre of fluid is obtained. Add 10 gm. of dried peptone\\nand 5 gm. of salt. Then neutralize with a normal solution (4 per cent.)\\nof caustic soda. Boil till albumin is coagulated. Filter and sterilize.\\nNutrient Gelatin. Make bouillon as above (except neutral-\\nizing) and add 10 to 12 per cent, of gelatin, and neutralize after dis-\\nsolving it by heat. Filter.\\nIf not perfectly transparent, clarify by heating to 60\u00c2\u00b0 or 70\u00c2\u00b0 C, add\\nthe whites of two eggs beaten up with 50 c.c. of water mix thoroughly\\nand boil until albumin coagulates then filter. Sterilize and keep in\\nflasks or tubes.\\nNutrient Agar. Prepare bouillon complete add finely chopped\\nagar, 1 to 1.5 per cent. Place in a porcelain-lined iron vessel, mark\\nlevel of fluid, add 250 c.c. of water and boil slowly, with occasional\\nstirring, for three or four hours. Keep the fluid up to the mark by\\nadding Avater. Take the vessel from the fire and set in cold water.\\nStir until cooled at 68\u00c2\u00b0 to 70\u00c2\u00b0 C. add the whites of two eggs beaten\\nup in 50 c.c. of water. Mix carefully and boil for half an hour, keep-\\ning the fluid up to the level. Filter.\\nSometimes 5 to 7 per cent, of glycerin is added.\\nPotatoes. Select old potatoes scrub under water-faucet with\\nstiff brush cut out eyes and defects. Then place in 1 1000 HgCl 2\\nfor twenty minutes. Then place in steam sterilizer and steam forty-\\nfive minutes. Leave them in and steam fifteen or twenty minutes each\\nday for three days. Cut with knife sterilized in flame and lay with\\ncut surface upward in a sterilized covered dish.\\nAnother way of preparing potatoes is to cut cylinders with a cork\\nborer of such size as to fit loosely in a test-tube. A slanting surface\\nis then cut from the junction of the first and second thirds of the cyl-\\ninders diagonally to the opposite edge. These are left in running\\nwater over night, then placed in test-tubes with a cotton plug and\\nsteamed for forty-five minutes. On the second and third days they\\nare steamed fifteen to twenty minutes.\\nMilk. It should be sterilized in a steam sterilizer by the fractional\\nmethod. It is a good soil for the tubercle bacillus (Abbott).\\nBlood-serum. The original method of preparing blood-serum, as\\nrecommended by Koch (given in the text-books on Bacteriology), has,\\nin this country at least, almost entirely given place to the method of", "height": "4408", "width": "2584", "jp2-path": "practicaltreatis00muss_0_0254.jp2"}, "255": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 243\\nCouncilman and Mallory, the popularity of which is clue to the follow-\\ning advantages By it the serum is more quickly and easily prepared\\nrigid precautions against contamination during collection of serum are\\nnot necessary, and the resulting medium, while not transparent or even\\ntranslucent (points aimed at in the original method), fully meets all\\nthe requirements.\\nThe special points in the method are the serum is decanted into\\ntest-tubes as soon as obtained it is then firmly coagulated in a slant-\\ning position in the dry-air sterilizer at from 80\u00c2\u00b0 to 90\u00c2\u00b0 C. it is then\\nsterilized in the steam sterilizer at 100\u00c2\u00b0 C. on three successive clays,\\nas in the case of other culture-media. It may then be protected\\nagainst evaporation by sterilized rubber caps or sterilized corks, and\\nset aside until needed.\\nUnless the coagulation in the dry sterilizer be complete, the surface\\nof the serum will be found to be lacerated by bubbles and cavities after\\nit has been subjected to the steam sterilization. A similar formation\\nof cavities over the surface of the serum will occur if the temperature\\nof the hot-air sterilizer, in which it is solidified, is allowed to get above\\n90\u00c2\u00b0 C, or if it be elevated to this point too quickly.\\nIt is of no special advantage to have the serum clear, as the admix-\\nture of blood-coloring matter does not affect its nutritive properties.\\nLoffler s blood-serum mixture\\nNeutral meat infusion bouillon (see Bouillon) .1 part\\nGrape-sugar 1 per cent.\\nBlood-serum .3 parts.\\nTube-cultures and Plate-cultures. The plate method was intro-\\nduced by Koch for the purpose of isolating individual species of bac-\\nteria from mixtures. It may be practised either with gelatin or agar-\\nagar. Three tubes previously filled with the culture-media are liquefied\\nby warming in a water-bath, then cooled to the lowest point at which\\nthe medium remains fluid. One of the tubes is then held in the left\\nhand, A sterilized looped platinum wire inserted in a glass handle is\\ntaken in the other hand, passed through a flame, and cooled for a few\\nseconds. With this a bit of the material to be examined is taken up,\\nthe cotton plug is removed from the tube with the free fingers, and\\nthe wire inserted into the medium. Bv rolling the tube it is thor-\\noughly mixed. Then a second tube is inoculated with three loopfuls\\nfrom the first, and a third with three loopfuls from the second. Plates\\nhave been previously sterilized and placed in covered dishes also care-\\nfully sterilized. The plates are levelled and the contents of the tubes\\npoured upon their surface. Then they are cooled over ice- water until\\nthe medium becomes solid, when they are placed in a proper tempera-\\nture for development. In this way the bacteria are sufficiently diluted\\nto form distinct colonies from which pure cultures may be obtained.\\nA convenient modification of the method is the use of Petri s plates,\\nwhich are flat, round dishes with covers, the bottom of the dish serving\\nas the plate.\\nAnother modification (Esmarch s tubes) is the use of tubes with a\\nsmall quantity (5 c.c.) of the medium. By rolling the tube in the", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0255.jp2"}, "256": {"fulltext": "244 GENERAL DIAGNOSIS.\\nfingers the sides are coated with the media. They are then rolled on\\nice, so that the medium solidifies in a thin layer about its walls.\\nSmear- cultures and Stab-cultures. When the bacteria has been\\nisolated by one of these methods pure smear-cultures or stab-cultures\\nmust be made from them. A tube of the proper culture-medium is\\ntaken in the left hand, a bit of pure colony taken up on a sterilized\\nstraight platinum needle, the cotton plug removed as above, and the\\nneedle thrust straight into the medium for a stab-culture, or rubbed\\nover a slanting surface of media for a smear-culture. The plug is\\nimmediately inserted and the tubes transferred to the incubator.\\nWhen pure cultures have been obtained the species are recognized\\nby their mode of growth and behavior in different culture-media, the\\nreaction produced by their growth, and their appearance under the\\nmicroscope when stained and unstained.\\nWhen nutrient media are inoculated they must be kept at a favora-\\nble temperature. This will be detailed when each micro-organism is\\ndiscussed, as a number of pathogenic bacteria require a definite and\\ncontinuous temperature.\\nThe primary inoculation will often yield numerous colonies, the\\nnature of the bacteria comprising which must be determined by their\\nmorphology and biological characteristics. It is frequently necessary\\nto repeat the process of plating with several of the colonies obtained\\non the original plates, otherwise one cannot always be certain that the\\norganism for which he is seeking has been isolated in pure culture.\\nMicroscopical Examination of Colonies. Just here may be\\nstated the methods employed for the study of the morphology of the\\ncolonies secured by plate and other means of cultivation.\\nCover-glass preparations are made as follows Place on the cover-\\nglass a small drop of distilled water. With a platinum needle take\\nup the smallest possible quantity of the colony to be examined, mix\\nit with the drop and spread over the surface of glass. Dry under\\ncover or by holding with fingers over a flame, the layer of bacteria\\nbeing away from the flame. When dry pass it with forceps- three\\ntimes through the gas or alcohol flame to fix the albumin. It is\\nthen ready for staining.\\nInoculation of Animals.\\nAnother method of determining the pathogenic character of morbid\\nmaterial, as sputum, pus, or exudation, is by inoculating animals with\\na pure culture. This is done either by feeding or injection, as subcu-\\ntaneous or intravenous, into the peritoneal or pleural cavity, and, in\\nrare instances, into the anterior chamber of the eye or into the cranial\\ncavity.\\nAs animals are subject to only a few of the microbic diseases of\\nman, many experiments must often be made before a susceptible\\nanimal is found, and no conclusions can be reached as to the patho-\\nlogical power of a micro-organism until this point has been determined.\\nThe clinical course of the artificial disease must be observed to fulfil\\nthe diagnosis, and the difficulty of reproducing faithfully in animals", "height": "4412", "width": "2568", "jp2-path": "practicaltreatis00muss_0_0256.jp2"}, "257": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 245\\nthe clinical manifestations seen in man is often one of the gravest\\nobstacles to this method of diagnosis.\\nExamination of the animal is made as soon as possible after death.\\nThe autopsy is made with antiseptic precautions. After the skin is\\nremoved only sterilized instruments are to be used. The macroscopi-\\ncal appearances and the mode and progress of infection are noted for\\nthe purpose of aiding in the diagnosis. When the organs are exposed,\\nmaterial for culture is first obtained by inserting a platinum needle\\nthrough a small puncture in the capsule. Afterward cover-glasses\\nmay be prepared for immediate examination. Blood is taken from\\none of the cavities of the heart. After the autopsy all remains are to\\nbe burned and all instruments carefully sterilized.\\nSpecial Bacteriological Diagnosis. The following points must be\\ninvestigated in order to determine the specific nature of the micro-\\norganism which is supposed to be the productive agency of the disease\\nin question, viz. The form, micrococci, bacilli, spirilla, polymorphous\\nrelation to oxygen aerobic, facultative anaerobic, strict anaerobic\\ngrowth in nutrient gelatine liquefy, do not liquefy, do not grow at\\nroom temperature growth on potato growth on milk coagulate\\nmilk, do not coagulate, etc. color of growth chromogenic, non-chro-\\nmogenic spore-formation movement pathogenic power.\\nNote. For further information concerning technique the student must refer to the\\nwork of Abbott on the Principles of Bacteriology and to Sternberg s Manual of\\nBacteriology for an exhaustive account of the technique, and the morphological and\\nbacteriological characteristics of all bacteria, pathogenic and non-pathogenic.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0257.jp2"}, "258": {"fulltext": "CHAPTER XVIII.\\nTHE DATA OBTAINED BY OBSERVATION\u00e2\u0080\u0094 {Continued).\\nFEVER. THE INFECTIOUS DISEASES\\nInfections Not Recognized by Bacteriological or Blood\\nExaminations.\\nThis group includes most of the eruptive fevers which are conta-\\ngious and epidemic. Their recognition must be based on data of the\\nsocial history, the duration of the period of incubation, and upon\\nthe mode of onset and course of the respective infection. They are\\ntyphus fever, smallpox, varicella, scarlet fever, measles, rubella, mumps or\\nepidemic parotitis, glandular fever, whooping -cough, rheumatic fever,\\ndengue, beri-beri, syphilis, WeWs disease, milk-sickness, miliary fever, foot\\nand mouth disease, hydrophobia.\\nIt must be remembered that other infections are not always recog-\\nnized by bacteriological examinations, although if such examination\\ngives a positive result the diagnosis is final. The following data\\nshould be sought for in the diagnosis of any infection, but especially\\nin case of failure of the bacteriological methods or, if such methods\\nare successful, as a control in the diagnosis.\\nSocial History. In the diagnosis of the infectious diseases valuable\\ndata are obtained from the social history.\\nAge. Thus early age is the period of life in which the eruptive\\nfevers are more common adolescence, that of typhoid fever and tuber-\\nculosis. In the sex, however, we find but little of diagnostic value.\\nExposure. Bearing in mind the possible cause of the disease, we\\ninquire for all those circumstances which contribute to the origin of\\nthe infection. Hence we inquire into the food, the character of the\\nwater, and other material ingested. We inquire if an opportunity for\\ninhalation of infectious material could have occurred, as dried sputum\\nfrom a case of tuberculosis, or if exposure to the patient was possible.\\nWe learn the hygienic conditions and place of residence (malarial dis-\\ntricts, the tropics). The occupation wool-sorter, hostler, farrier\\npoints to the nature of the infection. In short, we inquire if the\\npatient has been exposed to any infection.\\nThe Presence of an Epidemic. We inquire if an epidemic of\\nthe suspected disease prevails, and if the patient has been exposed to\\nthe contagion. We consider etiological factors, as the season in which\\nthe infection prevails.\\nHistory of Previous Infection. In the history of previous diseases\\nwe inquire if the patient has had previous infections. Some contagious\\ndisorders rarely take place a second time, as scarlet fever, or measles.", "height": "4408", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0258.jp2"}, "259": {"fulltext": "THE DATA OBTAINED BY OBSERVATION.\\n247\\nHence, if the patient has never had them is not immune his sus-\\nceptibility is of diagnostic importance. Other infections predispose to\\nsubsequent attacks, as pneumonia or erysipelas, hence the occurrence\\nof a previous attack is important.\\nHaving secured the data above indicated, we proceed to an exami-\\nnation of the patient, noting the length of time since he had been\\nexposed to contagion, the mode of onset of the symptoms, and the\\nsubjective and objective symptoms at the time of the examination.\\nThese separate data will be discussed in the account of the various\\ninfections included in this chapter.\\nTHE ERUPTIVE FEVERS.\\nThe following infections are characterized by a specific eruption\\nwhich permit them to be given the above title. They are also mem-\\nbers of Class I., spoken of in Chapter XVII. The fever, in a measure,\\nruns a definite clinical course, and is of diagnostic significance. The\\ninfection bears such definite relation to the eruption, however, that the\\ndiagnosis is usually based upon the latter.\\nTyphus Fever.\\nIn this infection the temperature rises rapidly, reaching to 104\u00c2\u00b0 or\\n105\u00c2\u00b0 by the end of the second or third day. It is an acute contagious\\nfever, occasionally occurring sporadically, and often becoming epidemic\\nin the presence of destitution, filth, over-crowding, and bad ventilation.\\nFig. 48.\\n105\u00c2\u00b0\\n104\u00c2\u00b0\\n103\u00c2\u00b0\\n102\\n101\u00c2\u00b0\\n100 r\\n99\\n3 4 5\\nI\\n7 8 9 10 11 12 13 14 15 It! 17 18\\n7-\\nh\\nt\\n1\\nTyphus fever\u00e2\u0080\u0094 typical. (Doty.)\\nIt is characterized by abrupt onset with chill or with chilliness, a rapid\\nrise of temperature, lassitude, headache, and pains in the back and\\nlimbs. On the fourth or fifth day a peculiar spotted eruption appears,\\nwhich at first is macular and subsequently petechial. It is further\\ncharacterized by adynamia or ataxia, low muttering delirium, a suf-", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0259.jp2"}, "260": {"fulltext": "248 GENERAL DIAGNOSIS.\\nfused, heavy, drunken expression of countenance, by the absence of\\nlocal disease, and by a crisis which occurs on or about the fourteenth\\nday.\\nTyphus fever is variously known as ship fever, jail fever, camp fever.\\nThe period of incubation is usually about twelve days it may be\\nfive or eight days, or even a shorter time, depending upon the viru-\\nlence of the poison and the susceptibility of the patient. Malaise may\\nprecede by a day or two the onset of the disease.\\nInvasion is characterized by headache, faintness, vertigo, chilliness,\\nor a distinct rigor, pains in the back and thighs, loss of appetite,\\nnausea, constipation, and extreme weakness. The prostration is some-\\ntimes so great as to compel the patient to go to bed at once. The\\npuke is frequent, 100 or 140, and in grave cases shows a marked ten-\\ndency to become small, soft, and feeble. The patient is restless and\\nsleepless, and is annoyed by tinnitus. The expression of the flushed\\nface is listless and dull.\\nAbout the fourth or fifth day the typhus eruption begins to appear.\\nIt consists at first of dull red spots of irregular size and shape. They\\nare most numerous on the covered parts. Moore l says they are\\ndetected first near the axillae and on the wrists, then on the sides of\\nthe abdomen, afterward on the chest, back, shoulders, thighs, and\\narms. The skin is also mottled by another crop of maculae under the\\nskin mulberry rash\\nWhen the disease is fully developed the face is flushed, the conjunc-\\ntivae red, the pupils contracted, so as to resemble pin-holes ferrety\\neye the tongue dry and brown, the teeth covered with sordes, the\\nskin dry, hot, and stinging to the touch. The patient lies upon his\\nback oblivious to all his surroundings. Headache has given place to\\ndelirium, which may be wild and fierce, but is more commonly low\\nand muttering. There are marked ataxic symptoms subsultus ten-\\ndinum, tremors, picking at the bedclothes. Incontinence of urine and\\nfaeces sometimes occurs. The breathing is frequent, shallow, and noisy,\\nand the pulse frequent, soft, and feeble. The macular rash now\\nbecomes petechial. The patient is in a typical typhoid state. The\\nstupor may gradually clear up, or, on the other hand, deepen into\\ncoma or the patient may die from progressive weakening of the\\nheart, with or without pulmonary complications.\\nIn the majority of favorable cases, on or about the fourteenth day,\\nthe first sign of recovery is a sound sleep, from which the patient\\nawakes refreshed and rational. The temperature falls with great\\nrapidity, the pulse and temperature improve a typical crisis has\\noccurred.\\nCertain objective phenomena of the disease require special mention.\\nThe eruption is more copious in severe than in mild cases. A dull and\\nlivid color is a grave sign. Purpura and hemorrhages are sometimes\\nmet with in bad cases. The eruption does not occur in successive crops.\\nThe patient seems to be surrounded by a vapor of a pungent, musty\\nodor which is peculiar.\\n1 Eruptive and Continued Fevers, by J. W. Moore, Dublin, 1892.", "height": "4412", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0260.jp2"}, "261": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 249\\nThe heart early shows the effect of the poison. The impulse is\\ndiminished, and the first sound is less distinct. In grave cases, with\\nthreatening heart-failure, the sounds are feeble and distant, the impulse\\nimperceptible.\\nThe pulse is usually very much more frequent than normal, but may\\nbe abnormally slow (50 and even 30 per minute) this is sometimes a\\nbad sign.\\nThe weak heart and prostrate position of the patient favor conges-\\ntion, with oedema of the lungs. This condition is common.\\nDigestive symptoms have already been referred to. Vomiting, tym-\\npanites, and diarrhoea are rare, and still more so is intestinal hemor-\\nrhage.\\nThe urine is scanty and high-colored. Slight albuminuria is common,\\nand a few casts are found, but distinct nephritis is unusual. Convul-\\nsions, when they occur after the first week, are almost always uroemic\\nand almost invariably fatal. They may be due to retention of the\\nurine, as recorded by Stokes and Corrigan.\\nThe duration of the disease is from six to fifteen days the average\\nperiod is twelve to fourteen days. An abortive form is met Avith in\\nsome epidemics, the disease being of a mild type and subsiding at the\\nend of a week. In some cases so large a dose of the poison is absorbed\\nby the patient that he is stricken down in a few hours or a few days.\\nTo this form the name blasting typhus has been appropriately\\ngiven. The most important complications are hyperpyrexia, laryngitis,\\nbronchitis, and congestion of the lungs, extreme ataxia or profound\\nadynamia, nephritis, heart-failure, and parotitis, or other inflammatory\\nglandular swellings.\\nLaryngitis with oedema is a very rare but very dangerous complica-\\ntion.\\nDiagnosis. Cerebrospinal fever is distinguished from typhus fever\\nby greater intensity of the headache, by retraction of the head and\\nhyperesthesia, by greater liability to vomiting, and by the absence of\\nthe macular petechial eruption and the drunken, besotted aspect of\\ntyphus fever. In cerebro-spinal fever the patient suffers with photo-\\nphobia, and is liable to local palsies of the eye-muscles (strabismus) and\\nto general convulsions. Convulsions do not occur in typhus except\\nfrom a complicating nephritis or retention of urine.\\nUraemia is distinguished from typhus by the preceding history, by\\nthe absence of high temperature, and by the presence of oedema of the\\nface or extremities, a history of vomiting or diarrhoea preceding the\\nstupor. The condition of the urine and the absence of eruption are\\nthe final tests.\\nPneumonia is distinguished by the frequent respiration and rela-\\ntively slower pulse, and by the local physical signs and absence of\\neruption.\\nTyphoid fever is distinguished by its slow onset and marked\\nabdominal symptoms. The eruption of typhus is petechial and comes\\nout on the fourth or fifth day that of typhoid fever consists of rose-\\nspots and appears on the seventh or eighth day. In typhus fever\\nthe severe initial chill, the sudden onset, the greater prostration, and", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0261.jp2"}, "262": {"fulltext": "250\\nGENERAL DIAGNOSIS.\\nthe earlier appearance of cerebral symptoms are helpful in distinguish-\\ning it from tvphoid fever.\\nVariola.\\nThe temperature in variola, or smallpox, pursues a definite course,\\nwhich renders it of value in the diagnosis. Its sudden rise to an\\nunusual height without local inflammation but with severe backache is\\nsignificant. Its fall with the appearance of the eruption, followed in\\ntwo or three days by a secondary rise, is very characteristic.\\nFig. 49.\\nr.HE E M E 1 E w E :.l M E M E M E M E M E M E M E M E M E M E M E M t ME ME W i. M E MJE MIS M E\\n4 T T T\\n?EE\\nro3-- -|-P q -----------------_-----------------__\\n1 1 1\\n1 1 j. 1\\n\u00e2\u0096\u00a0^EEEEEEEEEEE? E\u00c2\u00b1 EEE,$EEEEE EiErEEEEEEEEEElEEEEEEEEEE\\n~EEEEEEEEfeiiEEEiEEEE^9EggiglE|EEE~EEE5EEEEEEEEEEEEE\\n,\u00e2\u0080\u009e,__ S __._._ S._ J -I------\\n;EE fe3EEEEEEEEE*E EEEnE^EE|=-=?EiE-E\u00c2\u00ab E8EEE EEEE\\n-EE*E|5^|EEEEEE\u00c2\u00b1EEEEllEEEEE|gpp|||EEEE\\n,_-- -K-- --z- i?;t:-|-S-g- gEEF--\\n99 EE J SiEE;,\\nt=\\n^^^^^W^^^W^^^^^^^%^\u00c2\u00a5\u00c2\u00a7$.\\nJ);it i 4 10 11 12 13 14 15 1G 1 IS 19 20 21 22 28 24 25 26 27 2S 29 30 31 2 3\\nTemperature in smallpox. Adult mild case.\\nVariola, or smallpox, is a specific infectious and contagious fever,\\nbeginning abruptly with chill, high temperature, headache, vomiting,\\nsweating, and intense pain in the back. On the second or third day\\nof the disease a characteristic shot-like, papular eruption appears, the\\npapules rapidly developing first into vesicles and then into pustules\\nwith the appearance of the rash the temperature falls, but rises again\\ntoward the end of the week in the pustular stage (fever of maturation\\nor suppuration). The contents of the pustules are discharged, crusts\\nform and are cast off about the eighteenth day. The disease may be\\naccompanied by a number of complications, particularly hemorrhages\\ninto the skin (purpuric smallpox) and from the mucous membranes\\n(hemorrhagic smallpox), both forms being popularly called black\\nsmallpox. For convenience of description the disease may be divided\\ninto four stages (1) Incubation, (2) invasion, (3) eruption, (4) des-\\nquamation.\\nIncubation. This stage lasts from ten to fourteen days, and is\\nusually unaccompanied by any symptoms except, toward its close, by\\nmalaise.\\nInvasion. The invasion is abrupt, and is marked by chilliness or\\na distinct rigor, headache, severe pain in the lumbar region, and some-\\ntimes delirium or convulsions, especially in children. The most promi-", "height": "4408", "width": "2608", "jp2-path": "practicaltreatis00muss_0_0262.jp2"}, "263": {"fulltext": "", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0263.jp2"}, "264": {"fulltext": "3\\nm\\nH\\nD\\nQ o\\no\\nA S\\nC\\nOS", "height": "4400", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0264.jp2"}, "265": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 251\\nneut symptoms are the excruciating headache and backache. The tem-\\nperature usually rises rapidly to 10-4\u00c2\u00b0 F. or higher in the first twenty-\\nfour or forty-eight hours. (See Fig. 49.) Headache and backache\\ncontinue there are pain in the epigastrium, a coated tongue, loss of\\nappetite, nausea or vomiting, constipation, and copious perspiration.\\nProstration is extreme. Erythematous eruptions are not uncommon,\\nespecially on the inner surfaces of the legs and thighs. Petechia are\\nfound in Simon s triangle, the base of which is at the umbilicus and\\napex at the knees.\\nThe stage of invasion lasts generally three days but it may be\\nshortened to two in very severe cases or lengthened to four in very\\nmild ones, and in complicated and hemorrhagic cases it merges into\\nthe stage of eruption. (See Plate IV.)\\nEruption. The characteristic eruption of smallpox appears first as\\nminute specks resembling flea bites. These in two or three days\\ndevelop into small papules which feel like shot under the skin. In a\\nday or two more the papules become vesicles, at first containing a\\nclear fluid, which, however, rapidly becomes turbid they are umbili-\\nFlG. 50.\\nDiscrete variola on the sixth day of eruption. (Welch.)\\ncated. In the course of another day or two the vesicles have become\\npustules and are globular in shape. The period of ripening or matu-\\nration, when pustulation is at its height, lasts about three days it is\\ncharacterized by a marked secondary fever, the temperature rising as\\nhigh as, or higher than, in the onset of the disease. The pustules now\\nbegin to dry up (desiccation) and form dry scales or scabs, which are\\ncast off toward the end of the third week of the disease (eighteenth", "height": "4412", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0265.jp2"}, "266": {"fulltext": "252 GENERAL DIAGNOSIS.\\nday) when the pustules have been deep enough to involve the true\\nskin, characteristic scars, called pits, are left.\\nThe eruption appears on the forehead, along the margin of the hair,\\nand in the scalp, then over the rest of the face, especially about the\\nnose and lips, subsequently progressing over the rest of the body from\\nabove downward. The eruption is most abundant upon the face and\\nhands, often being confluent here when discrete elsewhere. The face\\nmay appear horribly swollen, bloated, and disfigured, and both face\\nand hands are extremely painful from the great distention and the\\npustules, which are really small dermal abscesses.\\nVarieties. Three varieties of variola, depending upon the number\\nand disposition of the pocks and upon the presence of complications,\\nare recognized (1) Discrete (2) confluent (3) malignant.\\nIn discrete variola the pocks are not numerous, and are separated\\nfrom each other by intervening healthy skin.\\nIn confluent smallpox the pustules are close-set, occupy almost\\nthe whole body, and coalesce, so that the face looks as though covered\\nwith a black, rough mask the mucous membranes are also covered.\\nThe symptoms of the invasion are intensified, and the eruption may\\nappear before the third day. Patients are liable to suffer with profuse\\nsalivation, uncontrollable vomiting or diarrhoea (especially in children),\\nand with delirium, which is often violent and destructive. The face is\\ndreadfully swollen and the eyelids may slough the feet and limbs\\nalso may be swollen and painful. There may also be severe bronchitis\\nand pneumonia, abscesses, extensive sloughing, and a pysemic condition.\\nMalignant, or black, smallpox is a form in which the blood is\\nso altered that hemorrhages into the skin or from the mucous mem-\\nbranes occur. In the former case there are petechia? and ecchymoses\\nupon the skin in the latter more or less profuse hemorrhages occur\\nfrom the womb, kidney, bowels, lungs, and stomach. The mind of the\\npatient remains clear and he is conscious of his peril. The eruption is\\ndelayed or does not occur at all.\\nVarioloid is a mild form of smallpox occurring in a person protected,\\nbut not completely, by previous vaccination, or in a person who, from\\nother causes, does not possess the average susceptibility. It is charac-\\nterized, apart from its mildness, by great irregularity in the develop-\\nment of the symptoms. The initial symptoms, as a rule, are as severe\\nas in ordinary smallpox. Prodromal eruptions, especially the erythe-\\nmatous, are very common. The eruption may appear first on the face,\\nor on the chest and trunk first, and later upon the face. The fever\\nsubsides with its appearance. The eruption passes from the papular to\\nthe vesicular stage, as in ordinary smallpox but here the process, as a\\nrule, ceases, the vesicle drying up on the fifth or sixth day of the erup-\\ntion. If pustules form they do not reach their full development. The\\neruption is always discrete. There is usually no secondary fever.\\nDiagnosis. When fully developed, smallpox will not be mistaken\\nfor any other disorder. In the initial stage, however, there may be\\ndoubt whether the disease will prove to be pneumonia, cerebro-spinal\\nmeningitis, or typhus. If the patient has been exposed to smallpox\\nand is unprotected by vaccination, and he is suddenly seized with a", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0266.jp2"}, "267": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 253\\nchill, high temperature, and excruciating pain in the lumbar region,\\nthere is great probability in favor of smallpox. If the patient has\\ncomplained of headache, pains in the ankles and other joints, and is\\nseized with a severe rigor, explosive vomiting, and great weakness of\\nthe limbs, the chances favor meningitis in the absence of known expo-\\nsure to smallpox. In pneumonia, vomiting, chill, and high tempera-\\nture succeed each other, but excruciating backache is wanting, and, on\\nthe other hand, the respiration is increased out of proportion to the\\npulse, and even in this early stage there may be cough and roughening\\nof the respiratory murmur on one side.\\nTyphus fever begins abruptly with chill and high temperature but\\nthe eruption which comes out on the fourth or fifth day is first macular\\nand later petechial, the temperature does not fall with the appearance\\nof the eruption, the aspect of the patient is drunken and stuporous, the\\nconjunctivae are injected, the eye ferrety, the skin dry, hot, and biting\\nto the touch (calor mordex).\\nIn the papular stage of the eruption it may be mistaken for measles\\nbut the red, swollen, bleaiveyed, photophobic little patient with measles,\\nwith the characteristic coryza and obstinate cough, presents a very\\ndifferent appearance from that seen in variola. Moreover, the eruption\\nof measles is relatively flat, smooth, and velvety that of smallpox is\\nacuminate, hard, and shot-like. The temperature in smallpox falls as\\nthe eruption appears that of measles remains high and even increases.\\nThe papules of measles do not develop into vesicles.\\nIn the vesicular stage varioloid may be mistaken for ehickenpox. In\\nthe latter the eruption is practically vesicular from the start, occurs\\nwithout prodromata, appears first upon the chest and neck, later upon\\nthe face and scalp, is usually very scanty, and rarely becomes umbili-\\ncated or pustular. There are, however, severe forms of varicella, in\\nwhich fever, restlessness, and cough precede the appearance of the rash,\\nwhich is copious, some of the vesicles being inflamed at the base, some\\numbilicated, and some with purulent contents. These cases are most\\ncommon in scrofulous children whose hygienic surroundings are bad.\\nIn such cases the diagnosis cannot be made from the eruption. A con-\\nsideration of the following points must decide 1. History of exposure\\nto varicella on the one hand or smallpox on the other. 2. The pres-\\nence or absence of effective vaccination or of scars of antecedent vari-\\ncella. 3. The age of the patient smallpox occurs at all ages, varicella\\nonly in childhood. 4. The discovery among neighboring children of\\nvaricella or varioloid. 5. The rapid evolution of a varicella pock.\\nVaricella.\\nVaricella is one of the infections of childhood in which the febrile\\ncourse is very mild. It is an acute specific infectious fever, occurring\\nalmost exclusively in children, and characterized by the appearance, in\\nsuccessive crops, of colorless or pearly vesicles, which dry up and are\\nshed in from two to five days. It is attended with very little constitu-\\ntional disturbance. A second attack is extremely rare.\\nThe incubation is generally about two weeks, but may be one or", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0267.jp2"}, "268": {"fulltext": "254\\nGENERAL DIAGNOSIS.\\nthree weeks. In ordinary cases the first evidence of the invasion of\\nthe disease is the appearance of the eruption. In other cases, the\\nseverer ones, the child may be noticed for some hours or several days\\nto be indisposed, complaining of loss of appetite, nausea, headache, and\\nvague muscular pains. The fever is almost always moderate 100\u00c2\u00b0\\nto 101\u00c2\u00b0.\\nThe eruption consists first of hypersemic macules, compared by Trous-\\nseau to the rose-rash of typhoid fever. These macules rapidly become\\nfirst papules and then vesicles. The papules are not hard as in variola.\\nThey appear at first upon the chest, neck, face, and scalp, then upon the\\ntrunk and limbs. The development of the vesicles is so rapid that the\\neruption appears vesicular from the start. The vesicles vary in size\\nfrom a pinhead to a small pea. They are very superficial, and usually\\nFig. 51.\\nVaricella oil the fifth day of eruption.\\nrest upon a base that is slightly or not at all hypersemic. The contents\\nare at first watery, but subsequently become pearly. The reaction of\\nthe fluid is alkaline. Distinct mnbilication is rare, and pustulation\\nstill more rare, but both occur. The vesicles almost always dry up and\\nform scabs, yellowish or brownish, which drop off, leaving a slightly\\nreddened, sometimes depressed spot. Sometimes the vesicles are to be\\nseen upon the buccal mucous membrane and upon the throat. While\\nmost of the eruption appears on the first or second day, fresh vesicles\\ncontinue to appear for several days.\\nDesiccation usually occurs by the fourth or fifth day, and may be\\npresent in the first day or two. As the eruption appears in successive\\ncrops, often all stages, from the initial macule to the dried scales, can\\nbe seen in one case.\\nUsually the vesicles are widely scattered, a dozen or two over the\\nentire body. They are most numerous upon the back, and may be as\\nclose together as in discrete variola.\\nIn scrofulous and badly nourished children the lesions are more in-\\nflammatory and pustules are more common. If they are scratched,\\nulceration ensues. A gangrenous form has been described by Eustace\\nSmith and others the cases are apt to be fatal.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0268.jp2"}, "269": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 255\\nIn ordinary cases during the eruption the child is rarely more than\\nindisposed complications are rare, and the prognosis most excellent.\\nThe physician is not often consulted except to have his opinion as to\\nthe diagnosis. (For the differential diagnosis from smallpox, see\\nVariola.)\\nIt is distinguished from vesicular and pustular eczema by the fever,\\nthe symmetrical grouping and discrete character of the lesions, the\\ncomparative absence of itching and burning, and its shorter course.\\nImpetigo is distinguished by the absence of fever, the more local\\ncharacter of the eruption, and the fact that it is generally pustular. It\\nis more common upon the face and hands than is varicella.\\nScarlatina.\\nIn this eruptive fever the course of the temperature varies some-\\nwhat with the severity of the infection. In many instances fever\\nwould not be detected without the use of the thermometer. In others\\nit may rise to a great height, and even be hyperpyretic. Its onset is\\nsudden it reaches its greatest height when the eruption is complete.\\nThe temperature in scarlet fever usually conforms to a clearly defined\\ntype. The temperature increases gradually to the third or fourth day,\\nwhen the acme is reached. It declines by lysis in a period of four\\ndays. A seven days chart would be pyramidal in shape. In septic\\nforms (scarlatina anginosa), with ulceration of the fauces, the fever\\ncontinues and becomes remittent. In scarlatina maligna, hyperpyrexia\\nis likely to ensue rapidly.\\nScarlet fever is an acute, specific, contagious, and infectious fever,\\ncharacterized by a sudden onset, with vomiting, sore-throat, and high\\nfever, followed in twelve or twenty-four hours by a bright-red, puncti-\\nform eruption, by a very frequent pulse, by a desquamation which is\\noften in large flakes, by a very variable degree of severity, and by a\\nlarge number of complications and sequelae, especially nephritis and\\ninflammation of serous membranes.\\nScarlet fever preferably affects children from one to five years of\\nage. The liability to it diminishes after the tenth year but it is very\\nrare under the age of six months. Puerperal women are very suscep-\\ntible to the poison, and the existence of open wounds favors infection.\\nThe disease occurs in epidemics at longer intervals than is true of\\nmeasles. Cases are most numerous in the autumn and winter months.\\nThe peculiar poison is doubtless a living organism, but it has not been\\nisolated as yet. It is very tenacious of life, being capable of infecting,\\nthrough clothing in which it has been retained, months after the cloth-\\ning absorbed the poison.\\nFew diseases vary so greatly in severity in different cases and in dif-\\nferent epidemics. It may be the mildest or most malignant of diseases.\\nThe period of incubation is remarkably short, generally from three\\nto five days but it may be a few hours, and, in exceptional cases, six\\ndays.\\nThe invasion is abrupt. It is very common to be told that a child\\nwas apparently well on going to bed, but awoke in the middle of the", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0269.jp2"}, "270": {"fulltext": "256\\nGENERAL DIAGNOSIS.\\nnight, vomiting profusely and complaining of sore-throat. The child\\nis found in the morning with a temperature of 103\u00c2\u00b0 or 104\u00c2\u00b0, a pulse\\nof 120 to 140, and a scarlatinal eruption beginning to show upon the\\nneck and upper part of the chest. Close observation in such cases\\nmight have discovered that the child was feverish on going to bed, and\\nthat he had been somewhat chilly before that. Onset with decided\\nchill, vomiting, and nervous symptoms indicate a severe case.\\nFrc 52.\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\no-\\n104-\\nl\\\\\\nI\\n1\\n103-\\n0-\\n102\u00e2\u0080\u0094\\n0\u00e2\u0080\u0094\\nv\\nV\\n1\\nA,\\n0-\\nV\\nV\\nV,\\nA\\nN\\nH\\nPnlse\\n$tf\\n$4\\n/ft 6.\\n4\\nDate\\n\u00c2\u00a3n\u00c2\u00bb\\nN\\nScarlet fever. Mild attack intense eruption.\\nThe subjective symptoms of scarlatina are few they consist usually\\nof pain in swallowing, with stiffness of the neck-muscles, some head-\\nache, thirst, malaise, and a moderate amount of weakness. In the\\neruptive stage the skin itches, burns, and is frequently hypersesthetic.\\nThe objective symptoms and their order of succession are very charac-\\nteristic. Vomiting is the rule, except in mild cases, and hence is of\\nimportance in diagnosis, especially in otherwise doubtful cases. The\\ntemperature is high at the onset, frequently 103\u00c2\u00b0 or 104\u00c2\u00b0. It falls a\\ndegree or so in the morning but the following evening, when the\\neruption is usually at its height, it rises to 104\u00c2\u00b0 or 105\u00c2\u00b0, and then\\ngradually falls to normal in the course of a week in ordinary cases.\\n(Figs. 34 and 52.)\\nThe pulse-rate is characteristically frequent, being 120 to 160 oftener\\nthan slower. This frequency is not an indication of danger.\\nThe blood shows a leucocytosis, beginning on the first day and con-\\ntinuing through convalescence. A close relationship exists between\\nthe degree of leucocytosis and the rash. Suppurative complications\\ntend to increase the number of white cells. The finely granular eosino-\\nphiles are greatly increased during the first few days. The mononuclear\\ncells and lymphocytes are diminished at first, but after a short time\\ntheir percentage increases.\\nThe throat exhibits a uniform flush extending over pharynx, tonsils,\\nsoft palate, and sometimes forward on the hard palate, nearly to the", "height": "4408", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0270.jp2"}, "271": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 257\\nteeth. Sometimes dark-red points can be distinguished on the soft\\npalate. The tonsils are inflamed and projected toward the median line\\nfrom each side. Frequently the mouths of the follicles are blocked by\\na creamy-white exudate. It is not uncommon to find a severe follicu-\\nlar tonsillitis at the first visit.\\nThe tongue is at first covered with a thick, creamy fur, through which\\nenlarged red papilla? show. The enlarged papilla? look like small\\ngrains of red pepper sprinkled on the tongue. Sometimes the papilla?\\nare elevated and have a button-like appearance. The symptoms\\nappear very early in the disease, and may continue for three or four\\nweeks. The coating soon disappears from the tip, leaving it bright\\nred the strawberry tongue.\\nThe skin is hot and dry. The characteristic eruption usually appears\\nwithin twenty-four hours, often within six to eighteen hours, of the\\nchilliness or vomiting which marks the onset. Sometimes it comes\\nout very slowly, seeming to be just ready to appear, but not appearing\\nin its full development for four or five days.\\nThe intensity of the eruption varies from a scarcely perceptible ery-\\nthema to the color of a boiled lobster. Usually its intensity varies\\nwith the severity of the disease. In ordinary cases the patient appears\\nto be covered with a uniform red efflorescence but a closer inspection\\nshows that there are darker red spots between which the skin is more\\nor less erythematous. It is first seen about the ears and neck, and\\nspreads with great rapidity, covering the entire body in a day. It is\\nmost intense upon the trunk and flexor surfaces. Upon the extensor\\nsurfaces the punctate character is better seen. Pressure causes the\\nreduess to disappear, but it immediately reappears. Papular and vesic-\\nular forms of eruption are also seen. The physiognomy of the disease\\nis peculiar. The circle about the eyes, nose, and lips remains pale,\\nand in marked contrast with the rest of the fiery red face. Itching\\nand burning are annoying symptoms at times. The eruption fades\\ngradually, in ordinary cases disappearing, except when there is press-\\nure or irritation toward the end of the week.\\nThe eruption is succeeded by desquamation, which is extensive in\\nproportion to the intensity of the eruption. The flakes are larger than\\nin measles, and in severe cases the epidermis may come off in long\\nstrips. About the hands and feet this shedding is sometimes so great\\nas to be compared to a glove. This stage may be protracted for sev-\\neral weeks, danger of infection lasting as long as desquamation con-\\ntinues.\\nThe urine is at first scanty, high-colored, and febrile. Later, when\\ndesquamation is in progress, there is great liability to albuminuria as a\\ncomplication.\\nVarieties. In addition to the ordinary form already described scar-\\nlatina exhibits many irregular forms. There may be only a sore-throat\\nor follicular tonsillitis. If a rash is present, it is very faint, and hence\\neasily overlooked. The diagnosis in such cases must be made from\\nthe fact of exposure to infection and from the appearance of the throat.\\nThe occurrence of vomiting is very important in the diagnosis, as it is\\nrare in ordinary pharyngitis and tonsillitis. Often such cases escape\\n17", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0271.jp2"}, "272": {"fulltext": "258 GENERAL DIAGNOSIS.\\ndetection altogether, until possibly a dropsy from scarlatinal nephritis\\nindicates their nature.\\nSevere diarrhoea may prevent the eruption from developing upon the\\nskin. It appears upon the fauces, and the diagnosis is based upon this,\\nthe pulse and temperature, and the fact of exposure.\\nIn scarlatina anginosa the strength of the poison is spent upon the\\nthroat. Pain is great and deglutition difficult. The tonsils are greatly\\nswollen, so as almost to occlude the fauces, and their surfaces are cov-\\nered with creamy exudate. The cervical glands are swollen, and there\\nis a tense and brawny cellulitis. Sometimes the tonsils become gan-\\ngrenous, and the cervical or submaxillary glands suppurate or become\\ngangrenous, with resulting pyaemia and death. Suppuration may\\nextend to the ears and maxillary sinuses. In this form, also, a false\\nmembrane is sometimes found upon the fauces\u00e2\u0080\u0094 post-scarlatinal diph-\\ntheria. It is probably not due to the Klebs-Loffler bacillus, but to a\\nstreptococcus.\\nIn malignant forms the attack is ushered in with chill, followed by\\nhyperpyrexia, convulsions, marked ataxic symptoms, or stupor. The\\nprofound blood-disturbance is shown by the dusky hue of the eruption.\\nSome patients lie in coma-vigil, others are very restless and delirious.\\nVomiting and diarrhoea are sometimes superadded. Patients may\\nemerge from this condition and succumb later to a nephritis or to grave\\nanginose symptoms but death in a few days is the rule. In rare cases\\nthe dose of poison is so enormous that death takes place in a few hours,\\nwithout the appearance of any eruption.\\nComplications and Sequelae. The severe local symptoms men-\\ntioned under the anginose variety, together with convulsions, hyper-\\npyrexia, and ataxic symptoms, may properly be regarded as complica-\\ntions. Apart from these the most frequent are nephritis and endocar-\\nditis or pericarditis. Nephritis generally appears with the beginning of\\ndesquamation. It is nearly as frequent in mild as in severe cases,\\nprobably because the danger of exposure to cold is greater in the\\nformer, although the scarlatinal poison unquestionably has a selective\\naffinity for the epithelium of the kidney. The symptoms do not differ\\nfrom those of acute parenchymatous nephritis occurring under other\\ncircumstances. In some cases we have weakness, languor, slight fever,\\nand prolonged convalescence in others, oedema, anuria, convulsions or\\ncoma from uraemia. Endocarditis is often preceded by tenderness and\\nsoreness of the muscles and joints scarlatinal rheumatism.\\nEndocarditis and pericarditis develop in the coarse of the fever,\\ngiving rise to an increase or continuance of the fever, to local pain or\\ndyspnoea, and to the usual physical signs.\\nPleuritis and meningitis also may occur. Much more common com-\\nplications are otitis, peripheral neuritis, and affections of the joints,\\ngrouped as scarlatinal rheumatism. Paralyses, peripheral and central\\nin origin, are occasional sequels of the disease. Scarlatina is found\\nalso in association with other diseases.\\nDiagnosis. Sudden onset, rapid rise of temperature, persistent and\\ncauseless vomiting, and sore-throat lead one to suspect this affection.\\nThe characteristic eruption and its mode of evolution, the rapid pulse,", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0272.jp2"}, "273": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 259\\nthe peculiar tongue, the circle of pallor on the face, are characteristic\\nof the eruptive stage. The appearance of a punctate eruption in the\\naxilla and in the groins, together with the congestion of the tonsils and\\na punctate eruption in the roof of the mouth, no matter whether there\\nis any eruption anywhere else or not, are positive proofs of scarlet\\nfever (McCollom).\\nUnfortunately, all cases do not develop to the same degree, so that\\nfrequently we must wait for the period of desquamation more unfor-\\ntunately, for the occurrence of sequelae, as acute nephritis, otitis, or\\nadenitis.\\nScarlet fever is distinguished from measles by the mode of onset, which\\nis sudden, with chilliness, high temperature, vomiting, and sore-throat,\\nand great rapidity of the pulse whereas the onset in measles is gradual,\\nwith coryza, cough, moderate fever, perhaps looseness of the bowels,\\nbut no sore-throat. The eruption of scarlatina occurs on the first day,\\nthat of measles on the fourth the former consists of dark-red spots\\nwith intervening erythematous skin, the whole looking at a distance\\nlike a uniform bright-red flush the latter consists of raised, rounded,\\nor flattened spots or blotches, velvety to the touch, and, upon the body\\nand extremities, grouped in patches with crescentic outlines. The tem-\\nperature in scarlatina subsides gradually after the rash has reached its\\nheight that of measles increases until the eruption is complete, then\\nsubsides by crisis. The rash of scarlet fever persists for six or eight\\ndays that of measles fades as soon as it is complete, on the fourth\\nday. In the former, desquamation is in flakes or large strips in the\\nlatter it is branny and nearly invisible. Scarlatina involves by prefer-\\nence the serous membranes and kidneys measles the mucous mem-\\nbranes and lungs.\\nScarlatina has to be differentiated from pharyngitis, tonsillitis, and\\ndigestive disturbances, attended with vomiting, high temperature, and\\noccasionally erythematous eruptions.\\nIn ordinary pharyngitis and tonsillitis the redness is more apt to be\\nconfined to the pharynx, tonsils, and arches of the soft palate in scar-\\nlatina it extends as a flush over the soft and hard palate and buccal\\nsurfaces. In the former, high temperature, a very frequent pulse, and\\nvomiting are unusual in the latter they are the rule.\\nThe glands of the neck also are more apt to be involved in the latter.\\nIn acute gastritis there is usually a history pointing to indiscretion\\nin eating, with constipation. The pulse is not so frequent as to suggest\\nscarlatina, sore-throat is absent, and any erythema present lacks the\\n\u00e2\u0080\u00a2characteristic dark-red pomts, and is not followed by desquamation.\\nThe diagnosis from rubella is difficult at times. It differs from scar-\\nlatina in presenting mild catarrhal symptoms, sneezing, suffusion of\\nthe eyes, and cough, with a relatively fleeting eruption. The latter\\nperhaps appears most frequently upon the back and chest. Often the\\neruption is the first thing noticed amiss with the child. It more com-\\nmonly resembles the rash of measles than that of scarlatina, but when\\nit resembles the latter most it is apt to be discrete and of a darker red.\\nThere may be a very intense rash without much constitutional disturb-\\nance, the temperature being lower and the pulse much slower than", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0273.jp2"}, "274": {"fulltext": "260 GENERAL DIAGNOSIS.\\nwould be expected in a scarlatina presenting the same appearance.\\nNausea may be present, but vomiting is very rare. The post-cervical\\nand post-auricular glands are more commonly enlarged in rubella than\\nin mild scarlatina, though this symptom is not invariable.\\nDiphtheria is distinguished by its gradual onset, patches of false\\nmembrane developing upon the fauces early. In anginose scarlet fever,\\nwith severe follicular tonsillitis, the differential diagnosis is essentially\\nthe same as between simple follicular tonsillitis and diphtheria (q. v.).\\nIn addition, the pulse and temperature have a much higher range in\\nscarlatina. The erythema of diphtheria is distinguished from the erup-\\ntion of scarlatina by its fleeting character and the absence of desqua-\\nmation.\\nGrave cases which begin with repeated vomiting, convulsions, del-\\nirium, and insomnia simulate meningitis but a satisfactory cause for\\nthe latter is lacking, while the excessive heat of the skin, sore-throat,\\nvery frequent pulse, and early eruption clear up the diagnosis.\\nSo, also, the onset with vomiting, convulsion, and high temperature\\nresembles pneumonia; but in the latter the respiration is proportion-\\nately more frequent than the pulse, with altered breath-sounds and\\npercussion-sounds, while sore-throat and eruption are wanting.\\nMeasles.\\nThe course of the fever in this affection resembles that of smallpox\\nin that after the initial rise of the first twenty-four hours the tempera-\\nture remains normal until the appearance of the eruption on the third\\nday. It is an acute, specific, infectious, and highly contagious fever,\\ncharacterized by coryza and bronchitis, a red papular eruption, coming\\nout on the fourth day and followed by a branny desquamation about\\nthe ninth or tenth day. The mucous membranes are especially liable\\nto complications.\\nMeasles occurs in epidemics, especially in cold weather, but indi-\\nvidual cases are met with in large cities at all seasons of the year. It is\\nso contagious that when one case develops in a household or institution\\nalmost every person exposed to it and not protected by a previous\\nattack acquires it. Children from one to five years of age are most\\nsusceptible to the poison, but it may occur in utero and in old age\\nmoreover, the same person may have several attacks, showing that one\\nattack does not afford the same protection as an attack of scarlatina or\\nvariola.\\nMeasles is sometimes found in association with scarlatina and vari-\\ncella, but it is especially liable to occur after pertussis.\\nThe specific cause of the disease has not yet been isolated.\\nThe period of incubation lasts from eleven to fourteen days. During\\nthis time the patient may exhibit no symptoms, or may be irritable and\\nrestless, with disturbed sleep and occasional cough, and looseness of\\nthe bowels.\\nThe invasion is marked by cough and fever, and by redness of the\\neyes and lacrymation, sometimes with photophobia, sneezing, and an\\nirritating, watery discharge from the nose, which subsequently becomes", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0274.jp2"}, "275": {"fulltext": "", "height": "4408", "width": "2652", "jp2-path": "practicaltreatis00muss_0_0275.jp2"}, "276": {"fulltext": "PLATE V.\\nFig. I.\\nFig. II.\\nFig. IV.\\nThe Pathognomonic Sign of Measles (Koplik s Spots).\\nFig. i. The discrete measles spots on the buccal or labial mucous membrane, showing the isolated rose-\\nred spot, with the minute bluish-white centre, on the normally colored mucous membrane.\\nFig. 2.\u00e2\u0080\u0094 Shows the partially diffuse eruption on the mucous membrane of the cheeks and lips; patches of\\npale pink interspersed among rose-red patches, the latter showing numerous pale bluish-white spots.\\nFig. 3. The appearance of the buccal or labial mucous membrane when the measles spots completely\\ncoalesce and give a diffuse redness, with the myriads of bluish-white specks. The exanthema on the skin is at\\nthis time generally fully developed.\\nFig. 4. Aphthous stomatitis apt to be mistaken for measles spots. Mucous membrane normal in line.\\nMinute yellow points are surrounded by a red area. Always discrete.", "height": "4408", "width": "2576", "jp2-path": "practicaltreatis00muss_0_0276.jp2"}, "277": {"fulltext": "THE DATA OBTAINED BY OBSERVATION.\\n261\\nmucopurulent, and by cough and fever. In short, the early symp-\\ntoms are those of a severe coryza. These symptoms last from three to\\nfive days (generally four) before the eruption appears.\\nBut an eruption is commonly visible upon the base of the uvula and\\nsoft palate, as raised, discrete dark-red papules, several days before it\\nappears upon the body. The peculiar appearance of this eruption has\\nbeen accurately described by Koplik (1897). His observations have been\\ncorroborated, so that Koplik s sign is a well-established fact. Its\\nimportance can be understood when the necessity for early diagnosis for\\nquarantine purposes is realized. This sign appears twenty-four hours,\\nforty-eight hours, and even three to five days before the skin erup-\\ntion. It precedes the conjunctivitis and begins at the first rise of\\ntemperature. The eruption appears on the mucous membrane of the\\ncheeks and lips. It is not seen on the palate or the fauces. It is at\\nfirst discrete and then becomes confluent. It is at its height when\\nthe skin eruption appears and is spreading. In strong daylight this\\npathognomonic eruption is seen to consist of small irregular spots of a\\nFig. 53.\\nM\\nE\\nft\\nE\\nt\\nd\\ne\\nM\\nt\\nM\\ne\\nM\\nE\\nM\\nIC4-\\n103-\\n102-\\n0-\\n101-\\n100-\\n1\\nl\\\\\\nA\\n1\\n1\\nI\u00e2\u0080\u0094\\nV\\nI\\n1\\ni\\nMeasles. Temperature taken on the first day,\\nmade higher as the result of school and exertion.\\nFig.\\n54.\\nF.\\n1\\nT\\n1\\nM\\nw\\nit\\n4-i\\n103\u00c2\u00b0 3\\nf\\nr\\nA\\nn\\n1\\ni\\nu\\n1/\\n1US H\\n1\\ni-\\nv\\n1\\ny\\nI\\n_j\\nr\\nII\\nt\\nt^\\nVa\\ni-j\\nDAY OF D.S.\\n3\\ni\\n5\\n7\\n8\\n9\\nPULSE y\\nt*s\\nRESP.\\nA\\n/4\\ns4/\\nA\\n;x\\nDATE\\n10\\n11\\n12\\n13 1\\ni 15\\n1(\\n17\\nMeasles. Lower temperature second and\\nthird days. Hyperpyrexia sixth day. Abun-\\ndant eruption. Bronchitis severe.\\nbright-red color, in the centre of which is seen a minute bluish-white\\nspeck. The bluish-white speck is very small and delicately colored,\\nrequiring direct and strong daylight to see it. A combination of the\\nspeck on the rose-red background is a positive sign of the invasion of\\nmeasles. The spots must not be mistaken for sprue, which is opaque,\\nwhite, coarse, and plaque-like. When the rose-red spots coalesce,\\nKoplik describes the appearance of the mucous membrane to be made\\nup of large areas of rose-red, studded all over with minute raised bluish-\\nwhite specks, relieved here and there by the normal hue of the uriinvaded\\nmucous membrane. The accompanying figures from Koplik s latest\\npaper illustrate this important sign. (Plate V.) By this sign measles", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0277.jp2"}, "278": {"fulltext": "262\\nGENERAL DIAGNOSIS.\\ncan be differentiated from rotheln, scarlet fever, aphthous stomatitis,\\nforms of erythema and urticaria, drug eruptions, the antitoxin eruption,\\nand forms of syphilis. The temperature rises during the first day to\\n100\u00c2\u00b0 or 102\u00c2\u00b0, or higher, if the case is to be a severe one. The bowels\\nare frequently inclined to be loose and the passages somewhat greenish.\\nThe temperature falls on the second day to normal or nearly normal r\\nand then steadily rises until it reaches its acme with the full develop-\\nment of the eruption, when, in uncomplicated cases, it falls rapidly to\\nnormal. With the coming out of the eruption the coryza increases in\\nseverity, and cough is a prominent and annoying symptom. It con-\\nsists of a series of five or six explosive efforts without expectoration.\\nIn severe cases the cough is almost incessant, so that rest is much inter-\\nfered with. It depends upon a catarrhal inflammation of the entire\\nrespiratory tract, from the nose to the bronchioles.\\nFig. 55.\\n103\\n102\\n101\u00c2\u00b0\\n100\\no\\n99\\n98\\nDAY OF DIS.\\nPULSE\\nRESP.\\nDATE\\ny\\ni.\\ni\\nI\\nu\\naL\\n1\\n5l\\nLL\\ni\\nI\\nu\\nJ\\nr\\ns\\nf\\\\\\na/\\nA\\nf\\niiIL\\ns\\nu\\nV\\nV\\nr 1\\nK\\nQ\\nW-\\nOi\\nCO\\n*o\\nO\\nt-\\n00\\ni 4\\n3^\\nj^\\nf^\\n^4\\nS4\\nt4-\\nf4\\nCO\\nOS\\ni\u00e2\u0080\u0094 i\\nm\\nCO\\n3\\nMarch\\nMeasles. Characteristic chart. Female,\\niged twenty-seven.\\nObjective Symptoms. The eruption on the body appears first\\nabout the neck, face, and wrists, and spreads in two or three days over\\nthe entire body. It is usually most copious upon the face, which is\\nswollen, dark-red in color, and closely set with papules, which are\\nelevated, rounded at the summits, and feel like soft velvet to the touch.\\nWhen to this picture is added that of a severe coryza with mucoserous\\nexudate, which often glues the eyelids together and oozes out upon the\\nface, and a corresponding condition of the nasal orifices, the physiog-\\nnomy is at once seen to be very unusual. At this stage, moreover,", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0278.jp2"}, "279": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 263\\nphotophobia is often considerable, the child burrowing its head in the\\npillows to escape light.\\nThe eruption is not apt to be confluent upon the body here the\\ndark-red, elevated, smooth papules are very distinct. Sometimes they\\nare grouped so as to form crescentic outlines. The eruption fades in\\nthe order in which it appeared, and is followed by a fine branny\\ndesquamation. With the completion of the eruption the fever\\nfalls rapidly to or below normal, the coryza and bronchitis im-\\nprove correspondingly, and in forty-eight hours convalescence is fully\\nestablished.\\nComplications. The complications of measles affect for the most\\npart the mucous membranes of the respiratory and digestive tracts.\\nThe bronchitis, which is always present, may become capillary, or be\\nassociated with oedema or with areas of catarrhal pneumonia. These\\nare the most frequent and the most dangerous complications. Pneu-\\nmonia may develop while the eruption is coining out, in which case\\nthe eruption is delayed or the spots have a dusky or bluish hue (black\\nmeasles). More commonly, perhaps, pneumonia is discovered when,\\nthe eruption being complete, a crisis should occur.\\nEpistaxis is not usually dangerous. Profuse diarrhoea is very ex-\\nhausting and delays the evolution of the eruption. Severe conjuncti-\\nvitis, sometimes with ulceration of the cornea, is not uncommon.\\nOtitis media occurs oftener as a sequel than as a complication. Noma,\\nor cancrum oris, is a rare complication of measles occurring in ill-fed,\\nbadly nourished children. It is frequently fatal.\\nConvulsions may occur as a complication, especially when pneu-\\nmonia is developing.\\nSequelae. In cases in which there has been diarrhoea, measles is\\nsometimes followed by considerable weakening of the digestive power.\\nThe catarrh of the respiratory tract, which almost invariably accom-\\npanies it, predisposes to the development of whooping-cough and tuber-\\nculosis.\\nParalysis may follow measles. It may be central or peripheral in\\norigin, but generally is of the hemiplegic type cases of acute polio-\\nmyelitis, acute ascending paralysis, and disseminated myelitis have also\\nbeen reported.\\nVarieties. Measles without catarrh is rare. It cannot be recog-\\nnized from a measles-like rash, seen in rotheln, except by the occur-\\nrence in the neighborhood of other cases of undoubted measles.\\nMeasles without eruption is to be recognized by the coryza, possibly\\nwith eruption on the soft palate, the course of the temperature, and the\\nexposure to specific infection.\\nBlack measles is the name given to malignant forms in which, owing\\nto complications, particularly pneumonia, the skin is dusky and the\\neruption comes out poorly and has a bluish color. In rare instances\\nthe eruption shows a hemorrhagic tendency, the spots being livid or\\necchymotic. Actual hemorrhages from mucous surfaces may occur,\\nthe patient dying in coma or convulsions.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0279.jp2"}, "280": {"fulltext": "264 GENERAL DIAGNOSIS.\\nRubella.\\nIn a few instances this infection may run its course without fever.\\nIn the large majority of cases, however, a moderate degree of fever\\nprevails and in some it may reach a considerable height.\\nRubella is an acute, specific, contagious, and infectious fever, char-\\nacterized by a gradual onset, with moderate fever, sore-throat, and\\nslight coryza. The eruption, which appears without prodromata,\\nusually resembles measles more than scarlatina. The duration, how-\\never, is shorter than measles, the disease milder, and complications are\\nrare.\\nThe disease is amply proved not to be a hybrid of measles and\\nscarlet fever. The incubation-period varies from one to three weeks,\\nbut is generally about two. As a rule, this period is past without\\nsymptoms.\\nThe invasion is without prodromata, or none more definite than\\nlanguor and indisposition, the first thing noticed being the eruption.\\nThis in some cases consists of pale-red, smooth, slightly raised blotches,\\nclosely resembling measles, but more pronounced on the trunk, and\\ndiscrete. This is probably a very rare form. More commonly it\\nconsists of rose-red maculae or papules, occasionally confluent, but\\nusually discrete, and most marked upon the trunk. In still other\\ncases the eruption closely resembles that of scarlatina, differing chiefly\\nin being a paler red and accompanied by less heat of skin. Sometimes\\nthe eruption is circumscribed, as upon the face or limbs. It is usually\\nthe seat of considerable itching, and this may be the first symptom\\nthat attracts the patient s attention. It will be seen that the eruption\\nis multiform in character. Concurrently with the eruption, there is\\nusually slight rise in temperature (100\u00c2\u00b0-101\u00c2\u00b0), suffusion of the eyes,\\nwith slight lacrymation and photophobia, and slight pharyngitis\\nnausea is not uncommon, but vomiting is very rare. Higher tempera-\\ntures have been recorded in a few cases, and so have nervous symp-\\ntoms, such as delirium and convulsions, but they are chiefly interesting\\nas very exceptional possibilities. On the other hand, the disease may\\nrun its course without any fever.\\nThe eruption extends over the body in twenty-four to thirty-six\\nhours, less rapidly than in scarlatina, and pales much more quickly,\\nfading on the portions of the body first attacked before reaching its\\nheight on the last, and being completed in three or four days. Some-\\ntimes a branny desquamation succeeds.\\nIn addition to the mild coryza and eruption, the most important\\nobjective symptom is swelling of the cervical glands, all of them being\\nsometimes swollen, especially those behind the sterno-mastoid, the\\nauricle, and along the margin of the hair. This adenopathy, however,\\ncannot be relied upon exclusively in the differentiation from scarlatina\\nand measles.\\nRubella has few complications bronchitis, pneumonia, and otitis\\noccur rarely, and still more rarely false membrane on the throat, and\\nalbuminuria. The prognosis is excellent. It ends almost invariably\\nin recovery, except in very feeble children.", "height": "4412", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0280.jp2"}, "281": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 265\\nInfectious Diseases with Local Symptoms.\\nThe following infections are characterized by local manifestations\\nwhich are of greater diagnostic significance than the fever. These\\nlocal manifestations must, therefore, be carefully considered in the\\ndiagnosis, and, as intimated, must be relied upon for recognition of the\\nparticular infection. The infections belong to Class I. and Class II.\\nof the classification in Chapter XVII.\\nMumps.\\nThis infection presents marked local changes about the jaws coinci-\\ndent with the rise of temperature. The infection is recognized by the\\nswelling of the parotid and submaxillary glands or by the occurrence\\nof orchitis. It has been described in the chapter devoted to objective\\nchanges of the face.\\nGlandular Fever.\\nGlandular fever is an infectious disorder, the cause of which has not\\nbeen accurately determined. It is characterized by fever,, usually\\noccurring abruptly, with headache, pains in the limbs and in the lymph\\nglands of the neck. On examination of the fauces a slight pharyngitis\\nis observed and the tonsils are enlarged. With the rise of temperature\\nthere is frequent nausea and vomiting. The temperature rises abruptly\\nto about 102\u00c2\u00b0. In the second twenty-four hours the glands of the\\nneck, particularly those behind the sternocleidomastoid muscles, en-\\nlarge. They are tender. Although there may be some slight\\noedema there is no redness or swelling of the skin. The fever contin-\\nues for three or four days the enlarged glands, however, may remain\\nfor several weeks, and may end in suppuration.\\nThe infection usually occurs in children between the age of five and\\neight years. It may be epidemic and occur often earlier in life than\\njust mentioned. The other lymphatic glands about the neck and in\\nthe axilla and groin may be enlarged. In not a few instances there is\\nenlargement of the spleen, and cases of enlarged liver and mesenteric\\nglands are reported. The absence of an eruption serves to determine\\nthe infection from the eruptive fevers associated with adenitis, particu-\\nlarly measles and rotheln.\\nPertussis.\\nThe attention of the physician is called to this infection by the pecu-\\nliar character of the respiratory symptoms. Fever is more notable as\\nan expression of one of the complications broncho-pneumonia than\\nof the general infection. It may, however, be a serious symptom of\\nthe infection.\\nWhooping-cough is a specific catarrhal inflammation of the respira-\\ntory passages, involving especially the trachea and bronchi, and char-\\nacterized by paroxysms of cough, which are succeeded by spasmodic\\nclosure of the glottis and a peculiar inspiratory whoop. The disease\\noccurs especially in childhood, is contagious and infectious, and is some-", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0281.jp2"}, "282": {"fulltext": "266 GENERAL DIAGNOSIS.\\ntimes epidemic. Whooping-cough may be conveniently divided into\\nthree periods\\n1. The catarrhal stage.\\n2. The spasmodic stage.\\n3. The stage of gradual subsidence of the disease.\\nFirst Stage. The patient appears to have an ordinary cold. The\\namount of redness of the mucous membrane of the eyes, nose, and\\nthroat varies considerably, but there is not much discharge from the\\nmucous surfaces. The cough is dry, and sometimes a ringing quality\\ncan be detected. The patient is irritable, has slight fever, diminished\\nor capricious appetite, and restless sleep. A mild bronchitis of the\\nlarger tubes can be detected by physical exploration.\\nThe cough gradually becomes more frequent and paroxysmal, the\\neyes are red and suffused, and there is a mucopurulent discharge from\\nthe nose. The face often looks slightly swollen, especially about the\\nupper part and under the eyes. Lymphocytic leucocytosis is common.\\nThe Second Stage. Transition from the first to the second stage is\\nmarked by the appearance of the characteristic whoop. The parox-\\nysmal cough is made up of a series of rapid expiratory efforts, diminish-\\ning in force and duration when these cease there succeeds a prolonged\\ncrowing inspiration the whoop. There may be only one paroxysm\\nof coughing at a time, but more commonly, and always in severe cases,\\none paroxysm is succeeded by another. During the coughing the\\nchild s eyes become suffused, the tears overflow, and there is a discharge\\nof serum or mucopus from the nose, and of saliva and bronchial secre-\\ntion from the mouth. The face becomes swollen and dusky. If the\\nchild is walking about, it catches some object for support during the\\nparoxysm or, if old enough, rushes for the water-closet or a basin,\\nbecause the seizure usually terminates in vomiting. The matters\\nvomited consist of tenacious mucus and the contents of the stomach.\\nWith the mucus there may be streaks of blood, and occasionally there\\nis pure blood. During severe paroxysms, hemorrhages are apt to\\noccur these are generally small and most frequently submucous. In\\nwell-marked cases, when the disease has lasted some time, the face has\\na characteristic appearance it is swollen, sodden, and dusky, with\\ndull, heavy, red, and watery eyes. There is often ulceration of the\\nlingual fraenum.\\nThe number of paroxysms varies from two or three to twenty or\\nthirty or more in twenty-four hours, and they are worse at night.\\nThe whoop, while characteristic, is not present in every case, being\\nabsent especially in babies and very young children. Sometimes chil-\\ndren have choking spells without much coughing and without the\\nwhoop. Again, when pneumonia or measles occurs as a complication,\\nthe whoop usually ceases for the time, but may reappear later.\\nThird Stage. The third stage is less well denned than the first two.\\nIt may be said to begin when the nocturnal exacerbations become less\\nfrequent and severe. The number of paroxysms during the day dimin-\\nishes, and vomiting is a less frequent accompaniment. Appetite begins\\nto improve, and the child begins to gain in flesh and to pass more\\nrestful nights.", "height": "4412", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0282.jp2"}, "283": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 267\\nThe duration of the disease is variable. Ordinarily it lasts from six\\nto eight weeks, but it may be prolonged for several months. The\\npatient is liable, whenever he catches a fresh cold, to a temporary\\nreturn of the spasmodic cough, sometimes with the whoop.\\nThe great majority of the cases occur before the sixth year, and most\\nof these between the second and fourth years.\\nRheumatic Fever.\\nRheumatic fever is an infection associated with local symptoms of\\njoint-, endo-, and pericardial inflammation. The local symptoms are so\\nextreme as to call attention at once to the nature of the infection apart\\nfrom the course of the fever, as it is largely upon these symptoms that\\nthe diagnosis is made. The reader is referred to Chapter XIII. in\\nwhich the diagnosis of rheumatic fever is discussed.\\nDengue.\\nThe peculiarity of the fever in this infection is that it is attended by\\nsevere pains in the muscles and joints. It is an acute contagious dis-\\nease, occurring in epidemics and characterized by severe pains in the\\nhead, back, and joints, various skin eruptions, a prolonged convales-\\ncence, and a very low rate of mortality.\\nThe disease occurs in epidemics in tropical and subtropical countries,\\nand rarely in cooler climates. It derives its name, dengue (dandy),\\nfrom the stiff and unnatural gait assumed by convalescent patients.\\nIn the southern parts of the United States an expressive name given\\nto the disease is breakbone fever/\\nThe specific cause of the disease is believed by Dr. McLoughlin to\\nbe a micrococcus which is isolated. The period of incubation is short,\\nvarying, however, from a few minutes to several days, or even a week.\\nInvasion is very sudden and is rarely preceded by any prodromata.\\nIt is marked by chilliness or a chill, and very severe pains in the head,\\nback, and limbs. In children the onset may be by convulsions, which\\nare sometimes followed by stupor and vomiting. The pains are some-\\ntimes excruciating, and are accompanied by tenderness of the muscles\\nthere is extreme debility. The temperature rises to 102\u00c2\u00b0 or 103\u00c2\u00b0, but\\nrarely is much higher.\\nThe pulse is frequent 110, 120, or more. In from one to three\\nor five days the temperature falls to or below normal (the remission),\\naccompanied by sweating or diarrhoea, and fluctuates about this level\\nfor several days, when a second and moderate rise in temperature,\\nwhich is of short duration, occurs. During the first rise in tempera-\\nture there is a transient, generally scarlatiniform rash, which is not\\nfollowed by desquamation. The urine is febrile but not albuminous.\\nDuring the remission eruptions scarlatiniform, herpetic, urticarial, or\\nlike miliaria begin to appear, accompanied by the secondary rise in\\ntemperature. The eruptions may be in successive crops, and are fol-\\nlowed by desquamation. Convalescence is now established, but may be\\ninterrupted by relapses. Strength is regained very slowly. The most\\nfrequent complications are disorders of the nervous system, but bron-\\nchitis and diarrhoea occasionally occur.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0283.jp2"}, "284": {"fulltext": "268 GENERAL DIAGNOSIS.\\nBeri-beri.\\nBeri-beri is a febrile infectious disorder which prevails in epidemic\\nform, limited to tropical and subtropical countries. It is characterized\\nby multiple neuritis associated with anasarca. By most observers it is\\nbelieved to be an acute infection, although not a few think it is an\\nintoxication due to certain kinds of food. This is the view which pre-\\nvails in Japan. The circumstances predisposing to infections generally\\nprevail, however, such as overcrowding, the prevalence in hot and\\nmoist seasons, and the exposure of the patient to climatic influence.\\nIt is far more common in men, and usually attacks subjects whose ages\\nrange from sixteen to twenty-five.\\nSeveral clinical forms are seen. In the most complete form there is\\nrapid loss of power in the legs and arms, with atrophy of the muscles.\\nThe patients complain of pain, and later oedematous symptoms may\\nappear. With the loss of poAver in the legs there is paresthesia, with\\nfrequent palpitation of the heart and dyspnoea. The pain in the mus-\\ncles is associated with weakness and tenderness. In milder degrees of\\nthis form, pain, weakness in the legs, diminishing of the sensibility,\\nand paresthesia are the most common symptoms. Their onset will\\nbe gradual and be accompanied by catarrhal symptoms. The symp-\\ntoms may recur from time to time, and are much more aggravated\\nduring the warm season. Its recurrence and incomplete form may\\ncontinue ten or fifteen years.\\nFollowing the pain and weakness of the muscles, in some cases\\noedema becomes very pronounced, associated with effusions into the\\nserous cavities. General anasarca is attended by palpitation and rapid\\naction of the heart and dyspnoea. In this so-called wet or dropsical\\nform atrophy of the muscles is not observed until the oedema disap-\\npears. In some instances the infection is very intense, and is charac-\\nterized by more marked cardiac symptoms. In these instances acute\\ndilatation may be followed by cardiac paralysis and death in twenty-\\nfour or forty-eight hours.\\nThe diagnosis is based upon the occurrence epidemically or endemi-\\ncally in tropical regions of peripheral neuritis with oedema. Thus far\\nno bacteriological diagnosis obtains.\\nConstitutional Syphilis.\\nIntermittent, remittent, or continuous fever is attendant upon this\\ninfection sometime during its course. (See Afebrile Infections, Chap-\\nter XVI.) Want of recognition of the cause of this febrile phenomena\\nleads to many mistakes in diagnosis. (See Fig. 63.)\\nConstitutional syphilis may be acquired or congenital.\\nAcquired syphilis is characterized, first, by the initial lesion, or\\nchancre, which appears usually in a week after contagion second, by\\na period of incubation generally lasting six weeks, but varying from\\none to three months third, by so-called secondary symptoms, com-\\nprising febrile symptoms, polymorphous skin-eruptions, ulcers upon\\nthe tonsils, adenitis, less frequently mucous patches in the mouth, or\\ncondylomata about the anus, iritis and retinitis, and loss of hair. The\\nlesions of this period are symmetrical. Fourth, after an interval vary-", "height": "4412", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0284.jp2"}, "285": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 269\\ning from several months to twenty years, by so-called tertiary phenom-\\nena, which manifest themselves in some cases. These are clue to chronic\\ninflammatory indurations of the skin and subcutaneous tissue, resulting\\nin suppuration and ulceration or of the bones, producing periostitis\\nand necrosis or of organs, producing gummata and cirrhosis or of\\nthe nervous system, resulting in gummata or chronic degenerative\\nchanges. The lesions of this period are unsymmetrical. 1\\nThe course of syphilis in different persons varies as widely as any\\nof the eruptive fevers. In some the chancre is a mere papule which\\nheals almost unnoticed no secondary symptoms appear, and tertiary\\nsymptoms also are altogether wanting, or a chronic degeneration of\\nthe nervous system develops after the lapse of many years, the patient\\nin the meantime remaining in apparent health. All this may occur,\\ntoo, without the aid of specific treatment. In other cases the disease\\nis malignant tertiary symptoms appear very early or appear to take\\nthe place of secondary symptoms ulceration may rapidly melt down\\nand destroy the alse of the nose or the soft palate or rebellious perios-\\ntitis with necrosis may attack the tibia?, the nasal bones, or the cranium.\\nIn an ordinary case of acquired syphilis, in about six weeks after\\nthe appearance of the chancre, the patient complains of languor, weari-\\nness, slight fever, pains in the bones, impaired digestion, and a ten-\\ndency to anaemia. An eruption now appears. It is most marked on\\nthe trunk and upper extremities, especially the chest and forehead\\n(corona Veneris). The eruption may be roseolous, squamous, vesico-\\npapular, papular, pustular, bullous, or tubercular. The color has been\\naptly compared to that of a slice of raw ham. The enlargement of the\\ninguinal, epitrochlear, and postcervical glands, which precedes the\\neruption, persists. Shallow ulcers with a sharply defined grayish out-\\nline appear on both tonsils. They are painless and do not spread.\\nUlcers are also liable to appear upon the pharynx, buccal surfaces,\\ntongue, angles of the mouth, penis, vulva, vagina, and around the\\nanus. In the mouth these are apt to be very painful, and may persist\\nin spite of treatment for weeks or months. Relapses are not uncom-\\nmon. Sometimes there are raised white patches upon the pharynx.\\nSometimes the hair becomes very thin and falls out, leaving the patient\\nAvithout eyebrows and more or less bald. Iritis and retinitis are usually\\nlater symptoms. Other symptoms occasionally occurring at this stage\\nare periostitis, usually slight, and onychia.\\nThe most common of the symptoms enumerated are the eruption and\\nthe tonsillar ulceration.\\nThe eruption comes out gradually during two or three weeks, and\\npersists for about two months. Rarely, however, it is fleeting, or, on\\nthe other hand, is unduly prolonged.\\nThe secondary symptoms last from six to eighteen months. After\\ntheir disappearance the patient may remain entirely well for life. In\\nother cases after apparent health, lasting for months or years, the\\ntertiary phenomena already mentioned appear. In the interval the\\npatient may have suffered with various local skin eruptions or with\\nulcers upon the buccal mucous membrane.\\n1 Fever is a constant accompaniment of all forms of syphilis. (See Fever.", "height": "4416", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0285.jp2"}, "286": {"fulltext": "270 GENERAL DIAGNOSIS.\\nThe tertiary lesions of syphilis are the late syphilides (see Skin) and\\ngummata of the skin, subcutaneous connective tissue, muscles or inter-\\nnal organs. Visceral syphilis is seen at this stage. In the brain and.\\nspinal cord gummatous tumors, gummatous meningitis, gummatous\\narteritis, and localized scleroses are found. The symptoms are those\\nof brain tumor when the cerebrum is affected, and of tumor, menin-\\ngitis, or sclerosis when the cord is affected. In syphilis of the lung\\nwe may find gummata scattered through the lung or a fibrous inter-\\nstitial pneumonia beginning at the root of the lung. Diffuse syphilitic\\nhepatitis or gummata may be found when the liver is affected. The\\nrectum is the most common seat of syphilis of the digestive tract.\\nMyocarditis and localized gummata and endarteritis occur in cardiac\\nsyphilis, while in vascular syphilis obliterating endarteritis and gum-\\nmatous periarteritis are found. Syphilitic orchitis often occurs. Its\\npresence may aid in the diagnosis of obscure visceral syphilis.\\nHereditary syphilis differs in some respects from the acquired form.\\nAt birth the syphilitic infant usually exhibits no evidence of its inher-\\nited taint. In the course of from one to twelve Aveeks it develops a\\ncatarrhal inflammation of the nasal mucous membrane, which causes\\nsnuffling in breathing, and hence is called snuffles. An eruption\\nsoon appears, symmetrical in distribution. It is most frequently ery-\\nthematous or papular, but it may be squamous, vesicular, pustular, or\\nbullous. In hereditary syphilis it is more apt to be moist and to favor\\nthe genitalia and flexures of the thigh than in acquired syphilis. It is\\nof the same ham-color as in acquired syphilis. Coincident with the\\nsnuffles and eruption appear stomatitis and ulcers at the angles of\\nthe mouth, and sometimes condylomata around the anus. Meantime\\nthe child has begun to waste, to be peevish, to be ansemic, and gradu-\\nally to assume the appearance of a wizened, dried-up old man. As in\\nacquired syphilis, there may be iritis, though it is uncommon, and\\ninflammation of the other structures of the eye, but nodes and disease\\nof the liver are rare. The infant very frequently dies during this\\nperiod from exhaustion and inanition.\\nIf the child survives for a year the secondary symptoms usually\\ndisappear and the disease becomes latent. Relapses may occur, and\\nin them, according to Mr. Hutchinson, condylomata are likely to\\nappear. The same observer states that the tertiary period may begin\\nat any time after the fifth year, but it is commonly delayed till about\\nthe period of puberty. In the meantime the patient may appear fairly\\nwell, but usually his development is retarded, there is a tendency to\\namemia, and he has often nasopharyngeal catarrh, flattening of the\\nbridge of the nose, premature decay of the upper incisor teeth, and\\nr t i iberant forehead.\\nThe teeth may be perfectly normal, in other cases characteristically\\nsyphilitic. The malformation affects especially the upper central in-\\ncisors of the permanent set. It was first described by Mr. Hutchin-\\nson. It consists in a dwarfing of the tooth, which is usually both\\nnarrow and short, and in the atrophy of its middle lobe. This atro-\\nphy leaves a single broad notch (vertical) in the edge of the tooth, and\\nsometimes from this notch a shallow furrow passes upward in both\\nanterior and posterior surfaces nearly to the gum. This notching is", "height": "4416", "width": "2624", "jp2-path": "practicaltreatis00muss_0_0286.jp2"}, "287": {"fulltext": "THE DATA OBTAINED BY OBSERVATION.\\n271\\nusually symmetrical. It may vary much in degree in different cases\\nsometimes the teeth diverge, and at others they slant toward each\\nother. (See Part II., Chapter IV.)\\nFurther, the patient may have had or may now be attacked with\\nkeratitis, affecting both eyes, producing cloudy opacities and accom-\\npanied by great photophobia. Again, there may be nodes upon the\\nlong bones, with nocturnal exacerbations of pain. Cerebral deafness,\\naccording to Hutchinson, is not rare, but cerebral blindness is. There\\nmay be ulceration upon the legs, and periostitis and necrosis. The\\npatient usually recovers completely, but he is more liable to be carried\\noff by intercurrent disease than a healthy person, and in general has\\nless resisting power, especially to tuberculosis.\\nDiagnosis. The diagnosis of hereditary syphilis is based upon the\\noccurrence of snuffles and skin eruptions, and the existence of keratitis\\nor of cicatrices, especially about the angles of the mouth. A history\\nof repeated miscarriages is suggestive of maternal syphilis. The diag-\\nnosis of acquired syphilis is based upon the history of chancre, when that\\nhistory is obtainable upon the existence of polymorphous eruptions,\\nor of non-traumatic ulcers upon the legs of young adults, or of scars\\nin the groins or over the tibia, or of nodes, or of alopecia associated\\nwith sore-throat or mucous patches. The presence of obscure disease\\nof the bones, glands, or spinal cord should lead to the search for a\\npossible syphilitic infection. (See Malaria, Chapter XIX.)\\nFig.\\n92\\nZ 8(\\n5 81\\n3 82\\n\u00c2\u00a780\\n2 78\\n76\\n74\\n72\\n70\\n14\\n15\\n17\\n18\\n20\\n21\\n22\\n23\\n24\\n25\\nL li\\n\u00e2\u0096\u00a02 s\\n\u00e2\u0096\u00a0J .i\\n;su\\n1\\n2\\n1\\n7\\nJ\\n11\\n14\\n15\\nHi\\nis\\n20\\nX\\nX\\nA-\\nX\\nx\\n-\u00c2\u00bbs\\nr\\nS\\n1\\nr\\nJ\\n1\\ny\\nX MERCURIAL INUNCTION\\nReduction of heemoglobin after mercurial inunction in syphilis.\\nExamination of the blood during mercurial treatment may, in accord-\\nance with Justus observations, show the presence of syphilis. If this\\ndisease is present the percentage of haemoglobin falls suddenly and\\nrapidly during the hours immediately following the first administration\\nof the drug. Cabot has confirmed his observations. The accompany-\\ning chart shows the effect of mercury upon the blood. (See Fig. 56.)\\nWeil s Disease.\\nThe occurrence of jaundice without local hepatic symptoms during\\nthe course of fever suggests an infectious process. It is a well known\\nsymptom of pysemia and septicaemia. In the following infection\\nfever and jaundice are coordinate symptoms. Acute febrile jaun-\\ndice, which rapidly becomes malignant, occurring in butchers, laborers,", "height": "4416", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0287.jp2"}, "288": {"fulltext": "272 GENERAL DIAGNOSIS.\\nand brewers, has been described by Weil. After exposure to cold\\ngenerally, as in a beer-vault, the patient is seized with a chill, fol-\\nlowed by fever, with headache, vomiting, and epigastric pain. Jaun-\\ndice sets in rapidly. The temperature remains high, or may be inter-\\nmitting. Stupor, delirium, and coma, albuminuria, with suppression of\\nurine, subcutaneous hemorrhages, and hemorrhages from mucous mem-\\nbranes, rapidly ensue. Black vomit occurs early. In one of my cases\\nthere was enlargement of the liver, with subcutaneous oedema over the\\nhepatic area. The microscopical appearances were those of acute dif-\\nfused parenchymatous inflammation. In another, a brewery man, the\\nliver was enlarged, but without unusual change, save congestion.\\nThe delirium is sometimes violent. The appearance and symptoms\\nsuggest acute yellow atrophy of the liver. The etiological distinctions\\nare noteworthy the liver is not small leucin and ty rosin are not\\nfound in the urine the jaundice is more intense. The diagnostic cir-\\ncumstances of epidemic and contagious diseases serve to exclude yellow\\nfever. (See Yellow Fever.)\\nMiliary Fever.\\nThe occurrence of fever in association with profuse sweating is rarely\\nseen without attendant signs of pyogenic infection. When several cases\\nwith these symptoms occur at the same time, suggesting an epidemic,\\nthe infection we are about to consider must be thought of.\\nMiliary fever, or sweating-sickness, is an infectious disease, occur-\\nring in epidemics, and characterized by moderate fever, profuse sweat-\\ning, tenderness and a sense of oppression at the epigastrium, and a\\nvesicular eruption. The disease has occurred epidemically in Eng-\\nland, but is not met with now outside of France and Italy.\\nAfter mild prodromal symptoms the disease sets in suddenly with\\nmoderate fever, profuse sweating, and epigastric distress, sometimes\\namounting to anguish. The characteristic eruption appears on the third\\nor fourth day. It consists first of small reddish maculae, in the centre\\nof which a vesicle develops. The latter varies in size from a pinhead\\nto a pea. The contents are at first clear, but subsequently become\\npurulent. Desiccation and desquamation follow. The eruption is\\nmost profuse generally upon the neck and trunk. Sometimes there\\nare marked nervous symptoms, and even convulsions and fatal collapse.\\nIt is distinguished from rheumatism by the moderate fever and\\nabsence of joint-swellings, and from malarial fever by the absence of\\nchills, of periodicity in the febrile movement, and absence of malarial\\norganisms from the blood.\\nThe duration of the disease is from one to four weeks. The mor-\\ntality in some epidemics has been very high, in others very low.\\nInfections Transmitted from Animals to Man.\\nWhen fever occurs in persons in contact with animals or their prod-\\nucts the possible occurrence of the infections milk-sickness, foot-and-\\nmouth-disease, and rabies, as well as glanders and anthrax must be\\nthought of. The infections which follow are of uncertain bacteriology,\\nand are recognized not alone by the fever but also by the local symp-\\ntoms and a history of infection.", "height": "4412", "width": "2592", "jp2-path": "practicaltreatis00muss_0_0288.jp2"}, "289": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 273\\nMilk-sickness.\\nIt is an acute disease affecting cattle, and transmitted from them to\\nhuman beings in the milk or meat. The disease is limited to a few\\nsparsely settled localities west of the Allegheny Mountains. It is char-\\nacterized by great debility, with muscular tremor upon motion (hence\\nthe name trembles vomiting (hence called puking fever a\\npeculiar foetor of the breath, obstinate constipation, and moderate fever\\nor subnormal temperature. The vomited matters are said to be of a\\npeculiar soapy material of yellowish or greenish color. The duration\\nis usually less than a week. The patient may sink into a typhoid con-\\ndition and die in coma, or he may die in a few hours. Convalescence\\nis protracted.\\nFoot-and-mouth Disease.\\nA specific, infectious disease, communicated to man through cattle,\\nsheep, or pigs, and characterized by a stomatitis. It is communicable\\nby milk the period of incubation is from three to five days. Inva-\\nsion is characterized by slight fever, heat, and soreness of the mouth,\\nand the development of vesicles, which burst and leave shallow ulcers.\\nSaliva is freely poured out. The tongue swells greatly, and eating is\\npainful. Vesicles sometimes appear about the fingers, but not upon\\nthe feet. The disease lasts from one to two weeks, and ends almost\\ninvariably in recovery.\\nHydrophobia.\\nAn acute, specific disease communicated to human beings by the\\nbites of animals similarly affected. The animals most frequently\\naffected are the dog, fox, wolf, cat, and skunk 90 per cent, of the\\ncases in human beings are due to dog-bites.\\nThe period of incubation is uncommonly long and very variable from\\ntwo weeks to two months usually. It is said in some cases to be a\\nyear or more. The disease has been divided into three stages the\\nmelancholic, the spasmodic, and the paralytic.\\nIn the melancholic stage there is pain, hyperesthesia, or even reopen-\\ning of the healed wound. The patient is extremely depressed in spirits,\\nand may be irritable. He seems to be laboring under a constant ten-\\nsion of fear, and is keenly sensitive to light, sounds, or draughts. He\\nis affected with thirst, but attempts to swallow water cause intensely\\npainful spasm of the larynx.\\nThe second stage is reached usually on the second day. The laryn-\\ngeal spasms are increased and lead to intense dyspnoea and to pitiable\\nstruggling and gasping on the part of the patient. In addition to the\\nconvulsive seizures, the patient foams and froths at the mouth, and his\\nface expresses the extreme terror and mental anguish he feels. The\\nsecond stage lasts from one to three days, and is followed by the third\\nstage, exhaustion intermitting with paroxysms of less severity. The\\npatient may now be able to swallow easily, but there is great weakness\\nof the heart, and death may occur from failure of the heart, from\\nasphyxia, or in a convulsion. The duration, as indicated, is only a few\\ndays. The result is practically always fatal, but recovery may be\\npossible. Bites of the face are the most likely to be fatal.\\n18", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0289.jp2"}, "290": {"fulltext": "CHAPTER XIX.\\nTHE DATA OBTAINED BY OBSERVATION\u00e2\u0080\u0094 {Continued).\\nFEVER. THE INFECTIOUS DISEASES.\\nInfections Recognized by Examination of the Blood.\\nMicroscopical Examination. The following infections are recog-\\nnized by the examination of fresh blood Relapsing fever, malaria,\\nyellow fever, anthrax. Typhoid fever is also recognized, but is more\\nfrequently diagnosticated by means of serum diagnosis and by culture\\nmethods. By staining cover-slip preparations of the blood the diagnosis\\nby the direct method is confirmed.\\nSerum diagnosis enables us to determine the presence of typhoid\\nfever, yellow fever, and Malta fever.\\nBacteriological examination of the blood corroborates the diag-\\nnosis of typhoid fever made by the above methods. By it we are also\\nenabled to determine the presence of gonorrheal infection, of cerebro-\\nspinal meningitis, of the pneumococcus infection, and, in many in-\\nstances, of infection due to the staphylococcus, streptococcus, and bacil-\\nlus coli communis. The gonococcus infection alone will be considered.\\nIt must be remembered that the micro-organisms cannot be found in\\nthe blood mitil late in the course of the disease, and even then the\\ninfection must have a certain degree of intensity. Unfortunately, they\\ncannot be demonstrated in the majority of cases. Positive cultures\\nfor the above reasons are very valuable. ^Negative cultures do not\\nexclude septic infections.\\nRelapsing Fever.\\nRelapsing fever is the first infection which we will consider, because\\nhistorically it is the most important. It is the first infection in which\\na micro-organism was found to be causal, and is one to which Koch s\\nlaws can be applied. It is an acute, infectious, and contagious fever,\\noccurring in epidemics, and characterized by the sudden onset of a\\nfebrile period lasting five or seven days, which is followed by an inter-\\nmission lasting usually a week, and this in turn by a relapse lasting\\nthree days. Its development is favored by filth and famine, but the\\nspecific cause is believed to be the spirillum of Obermeier, which is\\nconstantly present in the blood during the febrile stage.\\nThe stage of incubation lasts from five to eight days (Pepper), during\\nwhich the patient may complain of malaise, lassitude, and flying pains.\\nThe invasion is sudden. It manifests itself by a chill or chills, frontal\\nheadache, pains in the back and limbs, vertigo, and great physical\\nweakness. The temperature rises very rapidly, reaching 105\u00c2\u00b0, 106\u00c2\u00b0,", "height": "4412", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0290.jp2"}, "291": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 275\\nor even higher, in the first day or two. The face is flushed, epistaxis\\nsometimes occurs, the headache and other pains persist, but delirium\\nis not common. The appetite is usually lost, thirst intense, the tongue\\ncoated white but moist, the bowels constipated. A mild catarrhal jaun-\\ndice is not infrequent. Pepper states that nausea and vomiting are\\nprominent symptoms, the matters vomited at times containing blood.\\nTenderness with pain in the epigastrium is frequently complained of.\\nThe urine is scanty, high-colored, and frequently contains albumin\\nand casts when jaundice exists the urine contains bile-pigment and\\nsometimes blood.\\nThere is no peculiar eruption in relapsing fever, but in this, as in\\nother fevers, erythemata, petechia?, and sudamina may be present.\\nThe pulse is often very frequent and soft, and haemic murmurs may\\nbe audible.\\nThe objective symptoms are few. They consist of the flushed face,\\nsometimes with slight jaundice and epistaxis, tenderness in the epigas-\\ntrium, with moderate enlargement of the spleen and liver, and consid-\\nerable cutaneous hyperesthesia, with tenderness along the nerve-trunks.\\nBronchitis and sometimes hypostatic congestion of the lungs, with\\ntheir usual physical signs, may be present.\\nThese symptoms continue without much change until the fifth or\\nseventh day, when a decided crisis occurs. Sometimes this is deferred\\nuntil the tenth day. The temperature within twelve hours falls from\\n106\u00c2\u00b0 or 108\u00c2\u00b0 to or below normal the pulse diminishes in frequency\\nfrom 120 or 130 to 60 or 70 vertigo, headache, and other pains dis-\\nappear as by magic. The crisis is marked most frequently by a pro-\\nfuse sweat, sometimes by diarrhoea, epistaxis, metrorrhagia, or intesti-\\nnal hemorrhage. The patient now enters upon convalescence without\\nfever, and apparently makes rapid strides toward complete recovery.\\nOn the seventh day from the crisis, however, a sudden relapse occurs,\\nwith a repetition of the symptoms of the first attack. The temperature\\nmay be higher and the febrile symptoms more severe, but the duration\\nis shorter only three or four days. The spirilla, which disappeared\\nin the apyretic interval, are again found in abundance. A second\\ncrisis, with its associated symptoms, now occurs. The spirilla again\\ndisappear, and in the majority of the cases there is no further bar to\\ncomplete recovery. A second, third, and even a seventh relapse may\\noccur, as in a case reported by Pepper. Organic lesions are not usually\\nleft behind, unless they have occurred as complications but even in\\nordinary cases the patient is left w r eak, anaemic, and with poor circulation.\\nExamination of the Blood. Microscopical Examination. In\\nthe blood at the height of the disease the spirillum of Obermeier is\\nfound.\\nThese are slender, Avavy, thread-like organisms of spiral shape, seven\\nor eight times the length of a red blood-cell, with a very lively forward\\nmovement in the direction of the long axis. They are from 16 to 40//\\nby 0.1/i. Under a low power the blood may appear to be in motion, as\\nthe result of their movement. They have so far been found only in the\\nheight of the febrile attacks but Von Jaksch states that as long as a\\nrelapse is to be feared the blood contains peculiar, highly refracting bodies", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0291.jp2"}, "292": {"fulltext": "276 GENERAL DIAGNOSIS.\\nresembling diplococci, which are especially numerous before the attack\\nin some cases it has seemed to him that these diplococci at the very\\nbeginning of an attack develop into short, thick rods, from which the\\nspirilla develop they may, therefore, prove to be spores. Staining is\\nunnecessary for the detection of spirilla, but cover-glass preparations of\\nthe blood can, if desired, be stained with fuchsin or gentian-violet or\\nLoftier s methylene-blue. (Plate III., Fig. 4, A.)\\nSerum Diagnosis. It sometimes happens that a diagnosis should\\nbe made during the afebrile period when the organisms have disap-\\npeared entirely from the peripheral circulation. LowenthaFs method\\nis as follows A drop of the suspected blood is mixed with one con-\\ntaining the living micro-organisms. The mixture is sealed up with\\nwax between slide and cover-glass and left in the thermostat at 37\u00c2\u00b0\\nfor half an hour. Blood from a patient who has just had a paroxysm\\nwill destroy the spirilla, so that they lose their motility and spiral curl\\nand accumulate in bunches. The reaction is like that of Pfeiffer s\\nphenomena rather than agglutinative. It is to be remembered that\\nthe bactericidal power of the blood dies out before the next paroxsym.\\nInoculation. As further aid to diagnosis typical relapsing fever\\ncan be produced by injecting the infected blood into monkeys.\\nThe most frequent complications are on the side of the lungs, kid-\\nneys, and heart. Lobar pneumonia is the most frequent. The heart\\nbecomes weakened by the very high fever and thrombosis, or sudden\\nfailure results. Embolism is very frequent. Suppurative parotitis,\\nabscess of the spleen, profuse epistaxis, abortion in pregnant women,\\nand neuritis deserve mention.\\nRelapsing fever occurs at all ages, but is most common in adults.\\nThe duration varies according to the number of paroxysms. If\\nthere is only one, it is about eighteen days. Under the name bilious\\ntyphoid a malignant form of relapsing fever has been described. It is\\ncharacterized by intensity of the symptoms of the ordinary form, and\\nby bilious or bloody vomiting, jaundice, and delirium, or by collapse,\\nwith purple nose, a small, frequent weak pulse, rigidity of the abdomi-\\nnal muscles, tenderness in the epigastrium, and cold, clammy skin. In\\nsome of the cases described by Graves, intussusception of the intestines\\nwas found after death. In other cases uraemia is an active factor.\\nDiagnosis. The earlier cases in an epidemic may not be recognized,\\nunless the blood be examined, until the occurrence of the characteristic\\nrelapse. The diagnosis is based upon the occurrence of an epidemic,\\nthe presence of the predisposing factors, the clinical course, and the\\nexamination of the blood. It is most likely to be mistaken for typhus\\nfever, which occurs under similar conditions. The aspect of the two\\ndiseases is very different. In typhus there is a heavy, stupid, some-\\ntimes besotted expression, with slight redness of the eyes and a con-\\ntracted pupil. The patient lies oblivious of his surroundings, with\\nlow muttering delirium and ataxic symptoms. In relapsing fever, on\\nthe other hand, the sensorium is rarely much disturbed, the spleen and\\nliver are enlarged, and there is hyperesthesia. Moreover, in typhus\\nthere is a spotted eruption, later becoming petechial. In relapsing\\nfever this is absent.", "height": "4412", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0292.jp2"}, "293": {"fulltext": "THE DA TA OB TA IN ED B Y OBSEB VA TION. 277\\nAnthrax.\\nThe next infectious disease, the cause of which can be determined by\\nan examination of the blood, is anthrax. This affection is also of his-\\ntorical importance, and is probably the best worked out of any of the\\ninfections common to man and the lower animals. It is also called\\nmalignant, pustule, charbon, wool-sorter s disease, splenic fever. It is\\nderived principally from herbivorous animals, and characterized by the\\ndevelopment of a pustule or boil, with extensive brawny oedema and\\nsubsequent toxaemia or toxaemia may appear first and metastatic\\nabscesses subsequently. The disease also attacks the gastro-intestinal\\nmucous membrane and the lungs.\\nAnthrax is caused by the anthrax-bacillus and its toxins. Outside\\nof the body it forms endogenous spores, which are extremely tenacious\\nof life, and to which infection is invariably due. They infect not only\\nthe carcasses of animals, but also the soil, all utensils used in the care\\nof the animals or the soil, and they persist with infective power in the\\nhides, hair, hoofs, and wool wool-sorter s disease It is possible\\nthat it may be transmitted to man by stings of insects, particularly\\nflies and mosquitoes.\\nThe period of incubation varies from a few hours to several days.\\nIn the form known as malignant pustule the patient has a pricking or\\nburning feeling, which may lead him to think he has been stung by\\nan insect at some exposed part of the body, particularly the hand, face,\\nor neck. At the seat of irritation, first a papule, then a vesicle, de-\\nvelops. The vesicle may attain considerable size. The contained\\nfluid quickly passes from clear to bloody, and then escapes, leaving a\\ndark-brown or black scab (anthrax).\\nThe original vesicle may be surrounded by a series of smaller ones.\\nInstead of disappearing, the base of the vesicle becomes inflamed and\\nindurated, the induration extending to surrounding tissue and causing\\na condition of brawny oedema. A whole arm or one side of the face\\nand neck may be swollen. There may or may not be an associated\\nlymphangitis and adenitis.\\nThe general health does not suffer at first, but in a day or two fever\\nsets in, accompanied by delirium, sweating, great weakness, enlarge-\\nment of the spleen, severe pains in the limbs, and diarrhoea. Death,\\npreceded by collapse, may occur in from five to eight days (Fagge),\\nor the tissue occupied by the pustule may slough out.\\nBollinger and others have called attention to anthrax oedema, in\\nwhich there is no pustule, but only a yellowish or greenish swelling of\\nthe tissues. Gangrene may ensue. It is seen most frequently in the\\neyelids, but may be on the head, hand, or arm.\\nIntestinal Form. Anthrax of the gastro-intestinal mucous mem-\\nbrane, as described by Bollinger, presents the following symptoms\\nthe patient first complains of malaise, loss of appetite, pains in the\\nlimbs, giddiness, and headache. Then vomiting may set in, and a\\nmore or less severe diarrhoea, the evacuations often containing blood.\\nThere may be pain in the abdomen, which becomes somewhat tumid\\nthe spleen is enlarged. Dyspnoea and lividity appear, with restlessness", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0293.jp2"}, "294": {"fulltext": "278 GENERAL DIAGNOSIS.\\nand with excitement or stupor. Epileptiform convulsions may occur,\\nthe upper limbs may be affected with tetanic spasms, there may be opis-\\nthotonos, and the pupils may be widely dilated. The pyrexia is slight,\\nand death is preceded by extreme collapse. The duration of the disease\\nis usually from two to seven days, but sometimes it is scarcely twenty-\\nfour hours.\\nWool-sorter s Disease. Still another form of anthrax occurs among\\nthe wool-sorters of Bradford, England it is characterized by intense\\ndyspnoea and a feeling of oppression or constriction. Breathing is\\nlabored, but not much accelerated. Only a few coarse rales are to be\\nheard on auscultation. The expectoration may be abundant and\\nbloody, or absent. There is a tendency to collapse, with cold, bluish\\nskin, and a subnormal axillary temperature. The rectal temperature,\\nhowever, is raised two or three degrees. Death may occur in coma\\nand convulsions, or suddenly, the mind being clear. The duration of\\nthe disease is from one to five days. Dr. Bell says that those who\\nsurvive for a week generally recover.\\nExamination of Blood. The bacillus anthracis is found in\\nthe blood of the patient or the pus of the lesions of anthrax or malig-\\nnant pustule.\\nMorphology. A bacillus, 2 to 3/* up to 20 to 25// in length and\\n1 to lj/z in breadth. The bacilli are often joined end to end in long\\nthreads, and these threads are massed together in bundles. As found\\nin animals they are short rods with square ends. They stain best with\\nLoftier s blue, but also with the basic anilines and by Gram s method.\\nWhen in the stage of spore-formation the threads look like strings of\\nbeads.\\nFig. 57.\\nf\\nBacillus anthraeis highly magnified, to show swellings and concavities at\\nextremities of the single cells. (Abbott.)\\nCultures. Biological Properties. It is aerobic, non-motile,\\nand liquefies gelatin. (See Plate III., Fig. 2, A Plate VI. Fig. 57.)\\nIt grows best in neutral or slightly alkaline media (gelatin, agar,\\nmilk, meat-infusion, etc.) at 20\u00c2\u00b0 to 38\u00c2\u00b0 C. The growth-limits are 12\u00c2\u00b0\\nand 45\u00c2\u00b0 C.\\nCultures on agar are quite characteristic, consisting of a dense cen-\\ntral mass with twisting and crossing bundles all around it. In gelatin\\nstab-cultures a fine branching threadwork grows out alongside the\\npuncture. The gelatin soon liquefies and the bacilli settle in white\\nmasses. The growth is abundant on potato, and is grayish, dry,\\nrough, and irregular. The virulence is attenuated by cultivation.\\nDrying does not kill the spores. Very toxic substances are found in\\nthe culture-medium.", "height": "4412", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0294.jp2"}, "295": {"fulltext": "PLATE VI\\nFIG. 1.\\nAnthrax-bacilli from Rabbit s Spleen.\\n(Oc. 4, ob. y 1 immersion.) Drawn by J. D. Z. Chase.\\nProtozoa of Malaria, Intracellular and Creseemic Forms.\\n(Oc. 4, ob. i 1 immersion. I Drawn by J. D. Z. Chase.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0295.jp2"}, "296": {"fulltext": "", "height": "4388", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0296.jp2"}, "297": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 279\\nInoculation. When inoculated, the organism produces the pus-\\ntule of anthrax. If inoculated into the abdominal wall of a guinea-\\npig or rabbit death follows in forty-eight hours. No reaction is seen\\nat the point of inoculation, but beyond this the tissues are oedematous.\\nEcchymoses are seen, and the underlying muscles are pale. The\\nspleen is enlarged, dark in color, and soft. Cover-slip preparations\\nconfirm the diagnosis.\\nAnthrax bacilli are not so numerous in human blood as in that of\\nthe lower animals. They are most likely to be found in the spleen,\\nwhich is apt to be much swollen.\\nBacillus anthracis in the blood of* a guinea-pig. X 1040. (Gibbes.)\\nDiagnosis. In doubtful cases a mouse or guinea-pig should be\\ninoculated with the blood. Carbuncle is distinguished by its tendency\\nto develop upon the back or shoulders and other covered portions\\nanthrax on uncovered portions. In carbuncle there is a series of open-\\nings resembling a sieve, filled with pus and plugs of necrotic tissue.\\nIn anthrax there is at first a central black crust. The boggy feeling\\nof carbuncle is different from that of the brawny oedema of anthrax.\\nFinally, in carbuncle, anthrax-bacilli are not found in the blood.\\nThe intestinal and thoracic forms are distinguished by the occupa-\\ntion of the patients, the absence of other adequate cause, and the result\\nof the blood-examination, cultures, and inoculation experiments.\\nMalarial Fevers.\\nThe next infection which we are about to consider is one of the most\\ncommon the world over. In its various forms it is recognized by direct\\nexamination of the blood. Its clinical features are such that often but\\nlittle difficulty surrounds its recognition, but no case should be unqual-\\nifiedly pronounced malaria without an examination of the blood. It\\ncomprises a group of fevers associated with the protozoan organism of\\nLaveran, and is characterized by periodic paroxysms of chill, fever, and\\nsweat. They are not contagious, but can be transmitted by inoculation.\\nMalarial fevers, while most prevalent in tropical and subtropical", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0297.jp2"}, "298": {"fulltext": "280 GENERAL DIAGNOSIS.\\nregions, are found also throughout the temperate zone, especially in\\nautumn and spring. In Europe their favorite habitat is Italy, and in\\nthe United States the Southern and Southwestern States. Conditions\\nthat especially favor their development are marshes and swamps, fed\\npartly by sea-water low ground along streams of slow current, and\\nfreshly upturned soil. The poison is carried in the air.\\nThe specific poison in malarial fevers is no doubt organic. The\\nprotozoan organism described by Laveran exhibits several different\\nforms, which he regards as stages in the development of one organism,\\nbut which may be different species. Golgi maintains that there are\\nseveral distinct varieties of parasites whose periodicity in development\\nand spor ulation corresponds with the different types of fevers.\\nIntermittent Fever. This is a type of malarial fever in which the\\ntemperature remains normal between the paroxysms.\\nA malarial paroxysm is characterized by (1) chill, (2) fever, and (3)\\nsweating, occurring in the order named and in immediate succession.\\nThe time between the beginning of one paroxysm and the beginning of\\nthe next is called the interval, that between the conclusion of a par-\\noxysm and the beginning of the next the u intermission. The interval\\nvaries in different forms of intermittent fever in the quotidian there\\nis a paroxysm every day, with an interval of twenty-four hours in the\\ntertian there is a paroxysm on alternate days, with an interval of forty-\\neight hours in the quartan there is a paroxysm every third day, with\\nan interval of seventy-two hours. In double quotidian there are two\\nparoxysms in the twenty-four hours, but not of the same intensity.\\nIn the double tertian there is a paroxysm every day, the first and\\nthird and second and fourth corresponding as to hour and intensity.\\nThat is to say, if there be a paroxysm at 10 a.m. Monday there will\\nbe another severe paroxysm at 10 a.m. Wednesday, while on Tuesday\\nand Thursday there will be milder paroxysms, but at another hour\\nthan 10 a.m.\\nIn the double quartan severe and mild paroxysms succeed each other\\nevery other day, but each third day is free from any paroxysm.\\nWhile the rule is for malarial fevers to occur periodically at the same\\nhour, the second paroxysm may occur an hour or two earlier (anticipa-\\ntion) if the disease is growing worse, or an hour or two later (postpone-\\nment) if it is growing better. (See Figs. 30, 31, 32.)\\nQuotidian intermittents are slightly more common than tertian, while\\nthe quartan variety is rare.\\nThe incubation-period probably varies widely, depending upon the\\nintensity of the poison. As a rule, repeated exposure is necessary to\\ndevelop the disease in temperate climates. During this period the\\npatient may suffer with headache, drowsiness, pains and aching in the\\nlimbs and back, constipation, a coated tongue, and thirst.\\nThe onset of a typical malarial paroxysm is marked by chilly sensa-\\ntions, especially along the spine, accompanied by yawning and the\\ndevelopment of goose-flesh. Then a decided chill sets in, the patient\\nshaking violently. The face is pale and pinched, the lips blue, the\\nnose pointed as the chill becomes worse the teeth chatter, the whole\\nbody feels cold, the skin feeling rough, dry, cold, and harsh. The", "height": "4408", "width": "2648", "jp2-path": "practicaltreatis00muss_0_0298.jp2"}, "299": {"fulltext": "THE DATA OBTAINED BY OBSERVATION.\\n281\\nfinger-nails and toe-nails are blue, the skin being wrinkled upon the\\npalmar and plantar surfaces. The superficial bloodvessels are so con-\\ntracted that a drop of blood is obtained with difficulty The voice is\\nthin and weak, almost inaudible.\\nThe volume of blood driven from the surface leads to congestion of\\nthe viscera, particularly the spleen, liver, and stomach. Nausea and\\nvomiting are not uncommon. The spleen is perceptibly enlarged, and\\nfrequently the liver also.\\nAlthough the surface temperature is depressed, the internal tempera-\\nture is rising, and may be two or three degrees above normal. By\\ndegrees the severity of the chill abates and the patient asks to have\\nthe extra bedclothing removed. Reaction has set in. The surface-\\nbloodvessels dilate and the skin becomes flushed. The temperature\\ncontinues to rise, often reaching 103\u00c2\u00b0 to 106\u00c2\u00b0, pulse and respiration\\nincreasing correspondingly in frequency. The patient complains of a\\nthrobbing, dizzy headache, and vomiting may recur. The bowels\\nremain constipated. The temperature now begins to fall, and the\\nsweating-stage succeeds. Perspiration appears first upon the forehead,\\nface, and neck, and gradually extends over the rest of the body. The\\nperspiration becomes more and more profuse, until the whole body is\\ndrenched with it. All the subjective symptoms vanish with wonder-\\nFiG. 59.\\no\\nM E\\nME ME ME\\nM E M E M E M\\nE\\nK\\nt\\nt t\\nt\\nio 3 c\\n1\\n4- 4\\n4 1\\nX t\\n-t I-\\nt\\nI\\nt\\nr\\nt-\\n1\\nr\\nq\\nIOO\u00c2\u00b0\\n1\\n14\\ni :3\\n1\\n.._,^j_.J\\nT\\nl\\n..IE k--\\n_. r_\\n9 s\\nt- i_\\nI\\ni 4 I\\nH _\\n4 4-15-\\n4-\\nT\\nJ.\\ni. i\\nX\\n\u00c2\u00b1_\\n4_\\n9\u00c2\u00b0\\nIntermittent fever. Temperature every six hours. Morning and evening temperature\\nand highest at chill.\\nful rapidity, and the patient, with the exception of exhaustion, seems\\nto be restored to complete health. The hot stage lasts from one to two", "height": "4412", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0299.jp2"}, "300": {"fulltext": "282\\nGENERAL DIAGNOSIS.\\nhours, the cold stage from three to eight hours, and the sweating-stage\\nfrom two to six hours.\\nIn the interval between paroxysms the patient is free from fever,\\nbut is anaemic, weak, and has impaired appetite and constipation.\\nDuring the entire paroxysm the mind remains clear.\\nThe chief objective symptom, apart from the phenomena of chill, fever,\\nand sweat alreadv described, is the occurrence of plasmodia in the\\nblood. (See Plate VI., Fig. 2 and Fig. 61.)\\nExamination of the Blood. The plasmodia of malaria were first\\npointed out b) r Laveran. They have been studied in Italy, especially\\nby Marchiafava and Golgi, and in this country by Councilman, Osier,\\nand Dock. Minute amoeboid bodies are found in the red corpuscles.\\nThese become pigmented with altered haemoglobin, and grow until\\nthey fill nearly the whole of the cell, the pigment being arranged\\nchiefly in a peripheral ring. Later, the amoeboid bodies become spheri-\\ncal and transparent, the pigment collecting in the centre. Sporulation\\nnow begins and a fresh crop of small, rounded parasites appears, to\\nbegin the same cycle over again in fresh corpuscles. (Plate VI.,\\nFig. 2.)\\nThree forms of parasites are described 1. The tertian, which sporu-\\nlate at the end of four hours, begin as small amoeboid intracorpuscular\\nbodies, gradually enlarge, produce fine brownish pigment-granules, and\\nfinally completely fill the corpuscle. In sporulation the segments\\nnumber fifteen to twenty.\\nMalarial plasmodia. (Reproduced from colored plate.) To the right two normal red blood-cells\\nwith central depression. In addition, several others with bluish contained bodies and pigment-\\nsprinkled cells, which show the endogenous development of the plasmodia. Besides, two of\\nLaveran s bodies, one exhibiting a delicate little basket appearance. Near the centre a poly-\\nnuclear white cell with bluish nuclei and red granulation. (H. Rieder.)\\n2. The quartan, which sporulate at intervals of seventy-two hours,\\nare smaller amoeboid movement is not so marked when full grown", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0300.jp2"}, "301": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 283\\nFig. 61.\\nR?\\nV\\nSL\\n3\\n8m\\nw\\nyr y\\n,C\\nj,\\nv.\\nJ\\nmm\\nM\\n\u00e2\u0096\u00a0V\\nV\\nId\\nThe first twelve figures show the malarial Plasmodium. It is a pale amoeboid body inside the\\nred corpuscle. It increases in size at the expense of the corpuscles. In the last four of the twelve\\nit is enlarged and contains pigment-granules derived from the haemoglobin. The figures of the\\nfourth row show progressive stages in the process of cleavage of the Plasmodium and shifting of\\nthe pigment-granules. In the fifth row the process of cleavage is seen to be completed, and final\\nisolation of the spores has taken place. The dark granules are pigment-granules. The last row\\nshows oval parasites\u00e2\u0080\u0094 La veran s corpuscles observed in h typical cases of malaria. (From Golgi,\\nStudien iiber Malaria, Forlschritte der Medicin, Bd. iv. Tafel., m.)", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0301.jp2"}, "302": {"fulltext": "284 GENERAL DIAGNOSIS.\\nthe parasites are smaller, and the corpuscles tend to shrink about them\\nand to become a deeper greenish color. They sporulate with five to\\nten segments in a very beautiful characteristic roseate appearance.\\n3. The sestivo-autumnal are smaller, and contain less pigment. The\\nperiod of sporulation is still in dispute. They usually form ovoid-\\ncrescentic or round bodies with coarse pigment-granules in the centre.\\nGolgi maintains that in tertian malarial fever the period between\\ninvasion of the corpuscles and the sporulation is two days in quartan,\\nthree days, the difference in cycle being due to a difference in the\\nparasites.\\nThe onset of the fever corresponds in time to the division of the\\nparasites.\\nThe crescentic form described by Laveran is said to be more common\\nin the irregular forms of malarial fever. Canalis says that it only\\nmakes its appearance several days after the first access of fever. It is\\nsomewhat longer than a red blood-cell, and the pigment tends to collect\\nin a focus about the middle of the parasite. Subsequently it becomes\\noval and divides into eight or more daughter-cells.\\nAnother form with flagella is occasionally found. Councilman says\\nit is most common in blood drawn directly from the spleen.\\nThe plasmodium of malaria may be stained as follows Cover-glass\\npreparations of the blood spread very thinly are dried in the air and\\nfixed by immersion for twenty minutes or half an hour in a mixture\\nof equal parts of alcohol and ether. They are then stained for twenty\\nto thirty minutes in concentrated aqueous solution methylene-blue, 60\\nparts per cent, solution eosin in 75 per cent, alcohol, 20 parts\\ndistilled Avater, 40 parts 20 per cent, solution potassium hydroxide,\\n12 drops. The cover-glasses are then washed in water, dried, and are\\nthen ready for mounting. The red blood-cells are stained rose, the\\nnuclei of leucocytes a deep dark-blue, and any plasmodia a delicate\\nsky-blue.\\nAronson and Phillips staining method is as follows Make concen-\\ntrated aqueous solutions of orange G., acid rubin, and crystallized\\nmethyl-green, leave them to settle, then mix in these proportions\\nOrange G., 55 acid rubin, 50 distilled water, 100 and alcohol, 50.\\nTo this add methyl-green, 65 distilled water, 50 and alcohol, 12.\\nLeave the mixture standing for a week. A well-diluted solution\\nshould be used for staining purposes one drop of the mixture should\\nbe added to 25 cubic centimetres of water the stain should be left on\\nfor twenty-four hours and the fixing of the preparations carried out at\\na temperature of 120\u00c2\u00b0 C. In the result the red corpuscles are stained\\norange, nuclei greenish blue, neutrophile corpuscles violet, and eosin-\\nophile red.\\nThe examination of the blood discloses the presence of a high degree\\nof anaemia. The haemoglobin is usually diminished in greater propor-\\ntion than the corpuscles. There is a marked reduction in the leuco-\\ncytes. Thus leucopenia is most marked after a paroxysm. There is\\na relative diminution of the polynuclear forms and a relative increase\\nin the mononuclear forms. In severe post-malarial anaemias, as Thayer\\npoints out, the blood is characteristic of pernicious anaemia.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0302.jp2"}, "303": {"fulltext": "THE DATA OBTAINED BY OBSERVATION.\\n285\\nIrregular Form. Irregular forms of intermittent fever are more\\ncommon in Philadelphia than the typical form just described.\\nIn the mild form the patient complains of great lassitude, irritability\\nof temper, and drowsiness during the day, but at night tosses upon his\\nbed and gets up in the morning more tired than when he went to bed.\\nThe back and limbs ache, and the latter feel as though they would\\ngive way under him. There is severe throbbing headache, with some\\ndizziness and faintness. The bowels are constipated the tongue\\nheavily coated with yellow fur. The temperature is moderately eleva-\\nted and the patient has great thirst. Nausea and vomiting are absent,\\nthough there is little desire for food. There may be a burning feeling\\nreferred to the splenic region. The patient is worse on alternate days,\\nand the attacks may be preceded by slight creeping chills. On inquiry\\nthe patient will be found to live in a low-lying district near one of the\\nrivers, or in a damp house over an unclean, moist cellar, or adjoining\\na place where fresh soil has been upturned.\\nIn the form known as dumb ague there is a periodically great\\ndepression, with aching in the head and limbs, a sensation of coldness\\nrather than chilliness, but no marked fever and sweating. Nausea\\nand vomiting may, however, be present. Da Costa says he has seen\\nit manifest itself by excruciating pain over the kidney, and almost\\nentire suppression of urine. There may also be severe paroxysms of\\ngastralgia. It is more common in old residents of malarious districts.\\nIn masked malarial fever the poison manifests itself in an attack of\\nneuralgia, especially of the supraorbital nerve and gastric nerves.\\nMalaria may also be latent until some impairment of the resisting\\npower brings it to light. Hence it appears as a complication of pneu-\\nmonia and dysentery and typhoid fever (Fig. 62), especially in the\\nFig. 62.\\n\u00e2\u0096\u00a04THvyEEH\\nm\\nK\\nlimi\\n\\\\/M\\\\r\\nCold tub-baths\\nAbundant malarial\\norganisms.\\nMalarial fever associated with enteric fever. (Thompson.)\\nsouthern and southwestern portions of the United States. Moreover,\\nwomen who have previously had intermittent fever may suffer a recur-\\nrence after confinement.\\nDiagnosis. The essential points in the diagnosis of intermittent\\nfever are the periodical recurrence of paroxysms of chill, fever, and\\nsweating, or of attacks of dumb ague, or of paroxysms of neuralgia,\\nwithout organic lesion, associated with the presence in the blood of\\npigment and plasmodia, and with enlargement of the spleen and possi-\\nbly of the liver. The so-called therapeutic diagnosis may be made", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0303.jp2"}, "304": {"fulltext": "286\\nGENERAL DIAGNOSIS.\\nan intermittent fever which does not yield to proper doses of quinine\\nin three days is not malarial. A typical malarial intermittent fever is\\nnot likely to be mistaken for anything else. (See Fever, pages 205,\\n206.) It needs, however, to be distinguished from septiccemic fever,\\ndue to absorption into the blood of pus and the toxins produced by\\nbacteriological growth. Such fever occurs in tuberculosis, especially\\nin the stage when cavities form and pus collects in the puerperal\\nstate, in empyema, subphrenic abscess, abscess of the liver, or, indeed,\\nin any form of suppuration. Here also, then, are recurring chills,\\nwith fever and sweating, but the attacks are not regularly periodical\\nand intermittent sometimes the fever is intermittent and sometimes\\nremittent, the chills recur at irregular intervals, and are not so violent\\nas in the malarial attack. The essential difference, however, lies in\\nthe fact that a local cause can be found to explain them, tuberculosis\\neither of the lung or of some other viscus, or a collection of pus in an\\norgan or cavity, or a foetid discharge from the womb, with local ten-\\nderness or peritonitis moreover, the patient loses flesh more or less\\nrapidly, his blood is free from malarial germs and pigment, and quinine\\ndoes not control the fever. (Plate VI., Fig. 2.)\\nFrom the intermittent fever of hepatic origin (described elsewhere\\nby the author) the diagnosis is more difficult, in that physical signs of\\nany local trouble may be wanting. But the fever is not regularly\\nintermittent, is not controlled by the quinine, but may be by measures\\ndirected to the origin of the trouble, and jaundice may be present.\\nFig. 63\\no memememememememememem emIeiv\\nememIemIemememememememem|em|e\\nTr ~ir\\n1\\nt u\\nin\\nI\\nt\\nI02 B V n\\nt 1- 1 1-\\nI p 1 t\\ntt 4 t 4\\nIt f-\\nt lit\\nft 1\\nt 4 t t\\n1 ILL\\nIOI H- r\\n1+ Tit\\n4 1 1\\nf 1t 4E\\n4 4 11\\nI\\noV l J 4 4 _j H 3 n\\n4 4 n it\\nIOO _ 4 J 4 4 4 4 t\\n4 ft -I 4 -I r-\\nioo- II I L\\nJ ft\\nII Js\\nt i\u00c2\u00ab tl nnl C4\\nI _\u00c2\u00a3 z\u00c2\u00a3_ I\\nt li3 j i n j ri 1\\nt~ 4l H t\\nJ 1 h y\\noc\u00c2\u00a3 t= ~t\u00c2\u00a3 u t\\ns j y j\\n99 i t: u\\n.1 L\\n/.s 1 J a 1 j\\nH T f j l^ s t J i? V\\nL. I- I\u00e2\u0080\u0094, r\\nfc i\\npi ii\\n4 4 4 -33\\no\u00c2\u00b0 ii/ y\\nT 1\\n9\u00c2\u00b0 -A, f A T ^7\\n4 -It\\n*e\\n1\\npuise y^y; s ?,4 yiyiyi yii i} i*\\nz? i r yk5 s M l^.i^y iyii4.i ii ii\\nl):ite -V e\u00c2\u00bb m si \u00c2\u00bb1 t\\\\ Si eS *s^\\n81 H o r-30O 2\\nA form of intermittent fever from syphilis. J. D., aged twenty-six years. Secondary period.\\nMercury and iodide of potassium relieved it. Observe that the pulse-frequency is not increased.\\nUrethral fever occurring as the result of operations upon the urethra,\\nor simply from the passage of a catheter or bougie, may be mistaken\\nfor malarial fever but the paroxysm is usually single, and the history", "height": "4416", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0304.jp2"}, "305": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 287\\nof the operation and the absence of plasmodia from the blood clear up\\nthe diagnosis.\\nSyphilitic fever is distinguished by a tendency for the chill, fever,\\nand sweating to be nocturnal in recurrence, and by evidence of a syph-\\nilitic infection coupled with absence of malarial germs from the blood.\\nRemittent Malarial Fever. ^Estiva-autumnal Types. A type\\nof malarial fever characterized by a remission instead of an intermis-\\nsion in the febrile paroxysms. It is due either to a greater intensity of\\nthe malarial poison or to a different species of organism. It is much\\nmore rare in temperate climates than either quotidian or tertian inter-\\nmittent, and is attended with more gastric disturbance and a much\\nlarger mortality (twelve times greater, according to the statistics of\\nthe civil war).\\nThe onset is more abrupt than in intermittent fever. Prodromata\\nare not so common, but when they occur they are of the same charac-\\nter. The chill is not usually so violent, nor the cold stage so long as\\nin intermittent fever on the other hand, nausea and vomiting are\\ncommon, and in some cases there are bilious vomiting and diarrhoea,\\ntenderness over the stomach and spleen, and sometimes jaundice. The\\ntemperature rises rapidly from 103\u00c2\u00b0 to 106\u00c2\u00b0, and remains high for a\\nlonger time than in intermittent fever, the hot stage lasting in severe\\ncases from six to eighteen or twenty hours.\\nDuring this time the patient suffers from headache, pains in the back\\nand limbs, great thirst, and gastric irritability. A remission now suc-\\nceeds. The temperature falls two or three degrees, but not to normal\\nfree sweating occurs, the nausea and vomiting cease, and the patient\\nbecomes much more comfortable. He may fall asleep from exhaus-\\ntion, but if awake is conscious of weakness, aching in the limbs, and\\nperhaps nausea. In the course of some hours the temperature again\\nrises, often to a higher point than before, but frequently without ante-\\ncedent chill. The same subjective symptoms are repeated, and another\\nremission follows. Daily paroxysms usually occur, those on alternate\\ndays being severe. The temperature often reaches its highest point at\\nthe third paroxysm. The disease generally runs its course in from\\nnine to twelve days, but it may last much longer. The type of fever\\nmay change to intermittent, which is a favorable sign, or become con-\\ntinued and again remittent, or remain remittent throughout finally, the\\nfever may subside gradually, or, less commonly, by crisis. The urine\\nis febrile but not albuminous. (See Examination of Blood, page 282.)\\nPernicious Malarial Fever. This, as the name implies, is a form\\nof malarial fever with destructive tendency. It is also called malig-\\nnant and congestive fever. It may be intermittent or remittent. Nearly\\n24 per cent, of the cases occurring in the U. S. Army from May 1, 1860,\\nto June 20, 1866, proved fatal.\\nBemiss l divides it into three classes the algid, or congestive, form\\n(2) the comatose form (3) the hemorrhagic form. To this another\\nclass, (4) the gastro-enteric form, may be added. It is important to\\nremark that the first paroxysm does not usually, in any of these forms,\\n1 Pepper s System of Medicine, 1885, vol. i. 666.", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0305.jp2"}, "306": {"fulltext": "288 GENERAL DIAGNOSIS.\\nindicate that the type of the disease is pernicious. The first seizure\\nmay, however, prove fatal.\\n1. The algid form, according to Bemiss, occurs more frequently\\nthan any other, its perniciousness being due to an aggravation of the\\ncold stage of an intermittent attack. The patient is extremely weak,\\nwith cold extremities, pinched features, blue lips, and faint voice.\\nRespiration is shallow, the pulse rather slow, feeble, and irregular he\\nis further exhausted by vomiting and liquid, offensive diarrhoea, the\\npassages sometimes being involuntary. There may be copious per-\\nspiration, but the internal temperature is very high. The mind may\\nbe clear, or there may be deep stupor. Unless speedy relief can be\\nafforded the attack ends fatally.\\n2. In the comatose form the patient is completely unconscious, the\\nskin hot and of a muddy, semi-jaundiced hue (Bemiss). Both\\npulse and temperature are increased. In other cases coma is preceded\\nby wild delirium, resembling acute meningitis.\\nThe comatose form is most apt to occur in those who continue to\\nreside in a malarious region without proper safeguards against its\\npoisonous influences.\\n3. In the hemorrhagic form there has been, as a rule, previous alter-\\nation of the blood, the bloodvessels, and other tissues, by long-con-\\ntinued malarial poisoning or cachexia. Then, when intense congestion\\nof these parts occurs as the result of the surface-chill, hemorrhage\\nfollows. In some districts, however, and at certain seasons, there has\\nbeen a special predilection of the poison for the kidney, with resulting\\nhsematuria. The prominent symptoms are a prolonged chill with high\\ntemperature nausea and vomiting, sometimes with the expulsion of a\\ngreenish-black fluid oedema of the lower extremities general anasarca\\nand occasionally oedema of the lungs, and hyclrothorax bloody and\\nalbuminous urine, with tube-casts and intense jaundice. Pain in the\\nright hypochondrium or over the kidneys is common.\\nBemiss asserts that uncomplicated malarial fever has not a hemor-\\nrhagic tendency.\\n4. The g astro-enteric form has for its prominent symptoms nausea,\\nvomiting, diarrhoea, intense thirst, extreme restlessness, a frequent,\\nfeeble pulse, and urgent dyspnoea. The breathing is deep-drawn\\nto each expiration succeed two respirations (Da Costa). The patient\\nis cold and partly collapsed. Reaction may or may not occur.\\nThe patient may have several paroxysms of pernicious malarial\\nfever and succumb in any one of them. Convalescence is slow. The\\nmost frequent sequelae of malarial fevers are anaemia, neuritis, and\\nparalyses, and malarial cachexia.\\nTyphoid fever is distinguished from pernicious malarial fever by its\\ngradual onset, the absence of chills and vomiting, as a rule, and, on the\\nother hand, the presence of epistaxis, delirium, and ataxic symptoms,\\ntympanites and diarrhoea, with pale-yellow watery stools, and rose-\\ncolored spots. The temperature in typhoid is more continuously high,\\nthe daily oscillations being of shorter range. A history of exposure to\\nmalarial infection and of previous attacks can often be obtained. The\\nurine of typhoid exhibits the diazo reaction malarial fever does not.", "height": "4412", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0306.jp2"}, "307": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 289\\nMalarial cachexia occurs especially in those who have lived for a\\nloner time in malarious regions. Thev may or may not have had\\ntypical malarial attacks. The patient suffers with dyspepsia and con-\\nstipation, with occasional bilious attacks the face is of a pale lemon-\\nyellow color, and may be slightly jaundiced there is marked anaemia,\\nwith pigment and crescentic and flagellate forms of plasmodia in the\\nblood, together with great enlargement of the spleen (ague-cake) and\\nsome enlargement of the liver. The patient is weak and languid, and\\nsometimes has considerable mental depression.\\nSerum Diagnosis.\\nThe infections just described are recognized by an examination of\\nfresh blood or cover-slip preparations. The next group of infections\\nmay be recognized by serum diagnosis. Too much stress must not be\\nplaced upon this method of diagnosis, yet its value is so great that\\none is fully justified in giving it a high place in the precise method of\\ndiagnosis of infections.\\nTyphoid Fever.\\nThe first of the infections to which such diagnosis has been applied\\nin extenso is typhoid infection or typhoid septicaemia. This infection\\nis caused by the bacillus typhosus. The most common expression of\\nit is seen in a symptom complex which attends a septic process and\\nlocal intestinal ulceration, which symptom complex we know as\\ntyphoid fever. This infection, it is stated by some, is unattended in\\nrare instances by fever. More frequently a febrile course, following\\na definite continued type of a duration of from twenty-one to twenty-\\ni eight days, prevails. In mild or abortive forms fever rarely reaches\\n103\u00c2\u00b0, and declines from the seventh to the fourteenth day. In the\\ngrave forms the fever is often very high and attended by cerebro-spinal,\\nrenal, pulmonic, or severe gastro-intestinal symptoms.\\nThe most important infection prevailing in the temperate zone is the\\none we are now about to consider. It is an acute, specific, infectious,\\nand mildly contagious fever, characterized by a gradual onset, a con-\\ntinued fever, an eruption of rose-colored spots, marked nervous and\\nabdominal symptoms, and an average duration of three or four weeks.\\nIt occurs sporadically and epidemically, and in large cities is apt to\\nbe epidemic. Its special habitat is in temperate climates, but it may\\noccur anywhere. It is relatively rare in the southern and southwestern\\nportions of the United States. It is more frequent in the latter part\\nof the summer and in the autumn and winter, and following hot and\\ndry summers. Young adults are especially prone to it, but cases have\\noccurred at all ages. Change of residence from the country to the city\\npredisposes to it. Those living in cities often acquire immunity, but\\nthey may lose it upon moving elsewhere. The state of previous health\\ndoes not seem to have any influence.\\nThe period of incubation in typhoid fever varies from four or five\\ndays to three weeks more commonly it is from one to two weeks.\\nDuring this time the patient usually is languid, becomes tired easily\\n19", "height": "4416", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0307.jp2"}, "308": {"fulltext": "290 GENERAL DIAGNOSIS.\\nupon exertion, has severe headache, sleeps poorly, and has bad dreams.\\nThere is often, even thus early, a dull and listless expression of the face.\\nToward the close of this period, and in severe cases, there may be\\ncolicky pain in the abdomen, a tendency to looseness of the bowels,\\ncough, epistaxis, mental sluggishness, and chilliness. Dr. Pepper says\\nhe has been led repeatedly to anticipate the approach of typhoid fever\\nby the unusual dulness of hearing and by the persistent occipital head-\\nache coming on after a few days of general malaise.\\nWhile the disease may begin abruptly, a gradual onset is so much\\nthe rule that it becomes important in the diagnosis from other disease-\\nconditions.\\nInvasion is not sharply marked. There may be chilliness, but a\\ndecided chill is unusual except when pneumonia is part of the initial\\nprocess. Muscular weakness, headache, and mental sluggishness are\\nmore pronounced, and the physician is consulted because these symp-\\ntoms persist, or because fever is discovered. The beginning of fever\\nis the most constant indication of the onset of the disease, and two\\nvery important early symptoms are cough from bronchitis and en-\\nlargement of the spleen.\\nThe most prominent and constant subjective symptom during the\\nfirst week is headache. Other very common symptoms are tenderness,\\nrarely pain, in the iliac region, more or less prostration, and impaired\\nappetite or loss of appetite.\\nThe objective symptoms are therefore the most important. The face\\nis pale rather than flushed, and has a dull, listless, apathetic expres-\\nsion. The tongue is heavily coated with a white fur which later\\nbecomes yellow. The abdomen is somewhat distended and tympanitic\\non percussion. There is usually tenderness in the right iliac region,\\nand gurgling upon palpation is pretty constant. Constipation may\\nbe present at first, and sometimes persists throughout the disease. A\\ntendency to diarrhoea is, however, characteristic of the disease. Even\\nif constipation exists at first, a laxative is apt to produce an excessive\\neffect. The number of stools varies from two or three to a dozen or\\nmore in twenty-four hours. They are light yellow in color (resem-\\nbling pea-soup), thin, watery, and offensive. The movements are not\\nusually attended with pain, and in severe cases may occur involuntarily.\\nEnlargement of the spleen is a very constant symptom. It may be\\ndetected at the onset, increases up to the height of the fever, subsides\\nduring convalescence, but recurs during a relapse. It covers a percus-\\nsion-area in the left hypochondrium of four to eight finger-breadths.\\nThe temjieratur e-curve, when not modified by treatment, shows a\\ngradual ascent during the first four or five days of the disease, with\\nmorning remissions. The temperature rises a degree or two in the\\nevening and falls half a degree or a degree in the morning. This\\nstep-ladder ascent is very characteristic. By the end of a week a\\ntemperature of 103\u00c2\u00b0, 104\u00c2\u00b0, or 105\u00c2\u00b0 has been reached, and it remains\\ncontinuously high, with slight morning remissions, during the second\\nand less frequently during the third week. In the third or fourth\\nweek the morning fall of temperature gradually becomes greater, and\\nby the end of the week sinks below the normal in the morning.", "height": "4412", "width": "2640", "jp2-path": "practicaltreatis00muss_0_0308.jp2"}, "309": {"fulltext": "THE DATA OBTAINED BY OBSERVATION.\\n291\\nThe temperature in mild cases may never rise above 103\u00c2\u00b0 at any\\ntime, and most of the time varies between 100\u00c2\u00b0 and 102\u00c2\u00b0. Or it may\\nFig. 64.\\no\\n104\\no\\n103\\n102\\n101\u00c2\u00b0\\no\\n100\\n99\\nDAY OF DIS.\\nDATE\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nM E\\nm\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\n1\\nA\\nA\\ns\\ns/\\n-y\\ni ,V,\\ni\\n1\\nu\\n1\\nr,\\nV\\nu\\n1\\n1\\nA\\n1,1 i\\nA\\nf\\ny\\ni\\nh\\nA\\n\\\\/i\\n1\\nV\\nV\\nu\\nV\\ni\u00e2\u0080\u0094 i\\nC3\\nCO\\nia\\nSO\\nt-\\nOO\\nC5\\no\\nN\\n8\\n8\\n7\u00e2\u0080\u00941\\nSeptember Oct.\\nTemperature ranges first week of typhoid fever. (Dock.)\\nbe 104\u00c2\u00b0 from the start more frequently during the second and third\\nweeks there are marked oscillations of the temperature a sudden fall\\nfrom 104\u00c2\u00b0 to 101\u00c2\u00b0, or a rise from 103\u00c2\u00b0 to 105\u00c2\u00b0 or 106\u00c2\u00b0. Hyperpy-\\nrexia is a temperature above 105\u00c2\u00b0.\\nFig. 65.\\nM E M E\\n1 E M E M E M\\nE M\\nE M\\nl M E MJE M\\nE M E M E\\nM E M E\\n1\\nQ_\\nIO4 1\\nh\\n=F T\\n5\\nr 1\\nA\\ni\\nx 6\\nIO3\\nV\\nf\\n^d A ai\\nt\\nT 5\\n~Z\\n:S d\\n2 i\\nA-P\\ni\u00c2\u00a3\\nX-\\nJ\\n5j\\nH t\\nI02 -7-\\ni\\n3\\n=Etf\\n~y\\n1\\nZ-\\nIOI J\\nx\\nDay ofDis. 2 3\\ni c\\n8\\n10 11 1\\n2 IS 11\\n15 16\\nPulse y^\\n6/ B6^ Ziy/ 82\\n^Os;\\np.o f s^ a\\ns/\\nMild typhoid fever. Gradual ascent.\\nThe pwfee is full, and in favorable cases slower than the pyrexia\\nwould lead one to expect. It is more frequently under 110 than over\\n120. In the second week it is markedly dicrotic.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0309.jp2"}, "310": {"fulltext": "292\\nGENERAL DIAGNOSIS.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0310.jp2"}, "311": {"fulltext": "THE DATA OBTAINED BY OBSERVATION.\\n293\\ns\\nE\\nS\\nI\\n-5\\n2\\ns\\ns\\n1\\n1\\nc\\ni-0\\n3\\nd\\n8\\n3N\\nc\\n3\\\\\\nC", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0311.jp2"}, "312": {"fulltext": "294 GENERAL DIAGNOSIS.\\nThe heart sounds are unchanged apart from complications, but in the\\nsecond and third weeks the first sounds often are feeble, indicating\\nheart weakness. A pulse of 120 or more is a graver sign in typhoid\\nfever than in other diseases. Therefore, when it becomes very frequent\\nand feeble, the extremities cool and the lips bluish, the outlook is\\ngloomy.\\nThe urine is at first scanty and high-colored. A slight degree of\\nfebrile albuminuria is not uncommon, and in rare cases the whole force\\nof the poison seems to be spent upon the kidneys, the urine containing,\\nbesides the usual blood and casts, biliary coloring-matter. In condi-\\ntions bordering on coma the patient may have retention of urine, or,\\non the other hand, he may pass it involuntarily. To obtain the diazo\\nreaction of Ehrlich two solutions are necessary. The first (a) consists\\nof 2 grams of sulphanilic acid, 50 c.c. hydrochloric acid, and distilled\\nwater 1000 c.c. The second (b) consists of a J per cent, solution of\\nsodium nitrite. These solutions are kept in separate bottles. Fifty\\nparts of solution a and one part of solution b are poured into a test-\\ntube and an equal volume of urine added. The test-solutions and\\nurine are now thoroughly shaken and then carefully overlaid with 1\\nc.c. of ammonia. At the junction of the two a pink or ruby ring\\ndevelops. Upon agitation the foam on the top of the mixture is also\\ncolored red. Normal urine gives a light brown ring. This reaction\\nis helpful in diagnosis, but may occur in acute phthisis, tubercular\\nmeningitis, and other diseases. According to Pepper, it is rarely\\nabsent in measles. The reaction is fairly constant in typhoid fever\\nafter the first week.\\nThe respiration in uncomplicated cases increases in frequency with\\nthe rise in temperature. It usually ranges between 24 and 36. The\\nslight bronchitis present in the beginning in most cases causes no\\ntrouble sometimes it lasts throughout and contributes to the tendency\\nto hypostatic congestion, which is always present. The physical signs\\nare those described elsewhere in these conditions.\\nThe nervous symptoms are often very prominent. In mild cases\\nthey consist of hebetude and nocturnal delirium, or they may be absent\\naltogether. Usually, however, by the beginning of the second week,\\nthere is some mental confusion, with nocturnal delirium. In more\\nsevere cases, and later in the disease, the delirium is of a low, mutter-\\ning character, with hallucinations of sight and sound more or less\\ncontinuous. The patient can be roused by a question, and makes an\\nintelligent answer, but speedily lapses into semi-consciousness. Pick-\\ning at the bedclothes or efforts to catch imaginary objects are very\\ncommon. Sometimes the delirium is wild and noisy, and the constant\\npresence of some one is needed to keep the patient from getting out of\\nbed. Patients have jumped out of windows, or run long distances\\nbefore being captured. Rarely the delirium has been so active as to\\nsimulate acute mania. Stupor may alternate with delirium. Rarely\\nthe patient lies with wide-open eyes, apparently staring fixedly at\\nsome object, but really unconscious (coma-vigil).\\nIn ataxic cases the patient has marked twitching of the tendons and\\njactitation. He is wakeful and restless, wearing himself out. The", "height": "4416", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0312.jp2"}, "313": {"fulltext": "THE DATA OBTAINED BY OBSERVATION.\\n295\\nhands and lips tremble, and lie keeps muttering to himself all the\\ntime.\\nConvulsions are rare, but may occur in children. Sometimes there\\nare considerable hyperesthesia and tenderness along the spine.\\nFig. 68.\\n106-\\n105\\n104-\\n103\\n102-\\nc-\\nior-\\nMJE\\nM\\nE\\nM\\nM\\nM E\\nM 6\\nM E\\nM t\\nm| e\\nM|E\\nM\\nE\\n1 E\\nM\\nE\\nM\\nE\\nT\\n[_\\n1\\nf\\n1\\nA\\n1\\nN\\n1\\nfl\\nA\\n1\\n7\\ni\\n1\\n1\\n1\\nV\\n1\\nV\\nl\\\\\\n1/\\nt\\n1\\n1\\n1\\nV\\nA\\nA\\n1\\n1\\nN\\nv\\n/l\\nJ\\n4\\n1\\n1/ _\\n1/\\nV\\nJ \u00c2\u00bby of Dis.\\nM\\nw\\n53\\nr-\\n5\\ns\\nn\\nU\\n2\\nDate\\nK\\nX.\\n5\\n\u00c2\u00a3j\\nS\\ns\\ns\\nX\\nH\\nGrave typhoid fever. Death. M., aged 22 years. Ataxic symptoms.\\nFig. 69.\\nt\\nE\\nM\\nM\\nM\\ns\\nM\\nE\\nM\\nE\\nM E MlE\\nM E M E M\\nE\\nM\\nE\\nM\\nE\\n105-\\n104-\\n103-\\n102\\nIOI-\\n100\\n99 _\\n9 s\\n97-\\n96-\\n1\\n1\\n1\\n1\\n1\\nn\\nl\\\\\\ni\\nT\\nA\\n\\\\l\\\\\\n1\\nv/\\nv\\nV\\n1\\nI\\nI L\\n1\\nt t\\nt- -t\\n:t\\nf\\n1\\n1\\nI\\n1\\nyi\\n1\\nV\\n1\\nj\\ni\\n_j\\n-t H\\nI\\n:fc\\nz\\nTyphoid fever in a child aged 12 years. Chart from twelfth to twenty-third day.\\nKepeated crises. (Frequent mode of termination in children.)\\nThe extent of the nervous symptoms depends upon the habit of the\\npatient as well as upon the height of the temperature and gravity of", "height": "4408", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0313.jp2"}, "314": {"fulltext": "296\\nGENERAL DIAGNOSIS.\\nthe disease. In children and neurotic individuals they may be pro-\\nnounced, with only moderate fever.\\nOn the seventh or eight day the eruption appears. It consists of\\nsmall, very slightly elevated, rose-colored papules, which disappear\\nupon pressure and come out in successive crops, each papule lasting\\nthree or four days. The spots are most common over the abdomen\\nand back, but are occasionally found elsewhere. They are usually few\\nin number, a half-dozen or dozen, but sometimes the eruption is very\\ncopious, especially in severe cases. Sometimes it is wholly absent.\\nDuring the latter part of the second week, and through the third\\nweek, the symptoms are apt to be intensified. The temperature keeps\\nup or even reaches a higher point. Delirium is more decided and con-\\nstant. The heart grows weak and the pulse increases in frequency.\\nSome degree of hypostatic congestion of the lungs is usual. Diarrhoea\\nmay be troublesome intestinal hemorrhages, announced by sudden\\nfall of temperature and symptoms of collapse, may occur. Tympanites\\nmay become so great as to interfere with respiration and circulation.\\nThis is the period when ulceration of Peyer s patches in the intestine is\\ndeepest, and when perforation is imminent. There is rarely any desire\\nfor food, though it is taken and assimilated. Nausea and vomiting are\\nrare. The tongue is dry, brown, sometimes glazed and fissured, and\\nsordes often collect on the teeth.\\nFig. 70.\\nk\\nE\\nM E\\nM\\nE\\nM 6\\nM E\\nM E\\nM\\nEMEMEMEME\\nL\\ni\\n1\\nr\\nx\\nt\\ni\\nr\\n-1-\\n-4-\\n-V\\nA\\nI02--\\nT-\\n-r\\ni-\\nr\\nf-\\ntt5\\ni\\n1\\nUA- 1\\n1\\n3Q 4\\nIOI\\nA t-\\nt\\nt-\\n1\\ntx\\n4^\\n_t\\n_\\nV\\nT\\nU 4f\\n1\\nW S\\n99\\nt\\n5 8\\n1\\nit t\\nx\\n9\u00c2\u00bb-\\nI\\n1\\n-t i-\\nI t\\n\u00e2\u0096\u00a0t t-*.\\n97\\n-t 4/\\n1/L\\nPulse y.\\n%f\\n2%i\\nS^ SK 2^\\nJ);.U\\ns\\na\\ncs\\na\\n55 ti ii H -i\\\\\\nCourse of temperature in a relapse beginning on the twenty-sixth day. First attack mild.\\nIn cases ending in recovery the temperature begins to fall in the\\nmornings delirium grows less sleep is more refreshing. Diarrhoea\\nceases, and constipation may even require treatment. The pulse does\\nnot usually improve as rapidly as the other symptoms. There is some-\\ntimes very marked anaemia without leukocytosis (Osier). When the", "height": "4416", "width": "2584", "jp2-path": "practicaltreatis00muss_0_0314.jp2"}, "315": {"fulltext": "THE DATA OBTAINED BY OBSERVATION.\\n297\\ntemperature sinks to normal or subnormal, convalescence has set in.\\nThis is very rapid as far as digestive symptoms are concerned, but\\nstrength returns very slowly. It may be interrupted by a relapse, in\\nwhich the original symptoms are reproduced, with high temperature,\\nbut the duration is shorter.\\nVarieties. It is now well known, as Osier forcibly states, that\\ntyphoid fever is no more primarily intestinal than is smallpox prima-\\nrily a cutaneous disease. Studies in bacteriology, promoted especially\\nby Chiari, Flexner, Kraus, Mcholls, and others, enables us to divide\\nthe infection into three varieties 1. Typhoid fever with intestinal\\nlesions, as described above. 2. Typhoid fever with general infection\\nor typhoid septicaemia. The symptoms are entirely those of an infec-\\ntion, and the diagnosis must rest upon the serum reaction and culture\\nmethods. 3. Typhoid fever with more intense infection of other organs\\nthan the intestines. The lungs, the spleen, the kidneys, and the cere-\\nbrospinal meninges are the structures invaded, so that we may have a\\npneumo-, nephro-, spleno-, or cerebro-spinal typhoid.\\nFig. 71.\\nM\\nE\\nm|e\\nM E\\nM\\nM E n\\n1 E M E\\nioo\\nT\\n1\\nt\\nI.\\n1\\nt\\n1\\np t\\nt F\\nA\\nI t\\nN\\nA\\nt\\nw\\n1\\n1\\n1\\n1/\\nIOI\\nP\\n1\\nf\\n1\\n99\\nP\\no-\\n_[_\\n98\\nj\\n0-\\nII\\n97-\\nf\\nt\\nGrave typhoid fever. Daily rigors. Death on nineteenth day. No complications.\\nVarieties are also based upon the severity of the disease, hence we\\nhave the abortive, grave, and ambulatory forms.\\nThe abortive form is so named because of the abbreviated course of", "height": "4416", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0315.jp2"}, "316": {"fulltext": "298 GENERAL DIAGNOSIS.\\nthe disease. The symptoms are sufficiently well marked to make the\\ndiagnosis clear, but the type is mild, and in a week or two convales-\\ncence is established. In rare instances an afebrile form with intestinal\\nsymptoms and eruption is seen.\\nIn the ambulatory form, commonly called walking typhoid/ the\\npatient, from ignorance of the gravity of his ailment or from apparent\\nnecessity, keeps at his work until weakness and incessant headache lead\\nhim to consult a physician in his office or at a dispensary. He may\\nthen be well into the second week of the disease. The majority of\\nsuch cases prove fatal.\\nGrave forms are due to especial severity of some symptoms or group\\nof symptoms, such as hyperpyrexia profound stupor, coma, or intense\\nataxia inability to take or retain sufficient nourishment profuse diar-\\nrhoea and intestinal hemorrhage great adynamia with weak heart and\\na tendency to cyanosis. In other cases the gravity results from the\\nexistence of complications.\\nIn the malignant form there has been a large dose of the poison or\\na very weak organism, or both, the result being an acute toxsemia; this\\nis not so common as in scarlatina and typhus fever.\\nIn the pulmonary form the onset may be so obscured by severe\\nbronchitis or lobar pneumonia that the primary disease is not suspected\\nat first. Severe bronchitis seems to be more common in children.\\nChill and initial high temperature are common in these cases.\\nTyphoid Fever without Intestinal Lesions. This rare form may\\npresent the clinical symptoms of typical typhoid, or may be of spleno-\\ntyphoid type, or of nervous type with extreme intoxication. The first\\ntype is rare. The second type, described by Eiselt, is characterized by\\nan excessively large spleen, with local inflammation and remitting\\nfever. In the third class the symptoms of the typhoid state with sub-\\ncutaneous and visceral hemorrhage occur. Jaundice is more or less\\ncommon.\\nComplications and Sequelae. Typhoid fever may be accompanied\\nby a number of complications, the most frequent and important being\\nsevere bronchitis, hypostatic congestion with oedema, and true lobar\\npneumonia bed-sores parotitis phlebitis, especially of the femoral\\nvein peritonitis from perforation of the bowel meningitis, acute\\nmania, or mental decay jaundice myocarditis periostitis and oste-\\nitis. Sequela? are not frequent. Sometimes, however, the foundation\\nis laid for permanent ill health. There may be impairment of the\\nsenses, mental weakness, and even insanity. Paralyses, neuritis, hyper-\\nesthesia, chorea, and epilepsy are occasional sequels.\\nExamination of the Blood. The infection is due to Eberth s\\nbacillus, the bacillus typhosus. The bacillus is found in colonies in\\nthe spleen, liver, mesenteric glands, kidneys, and intestines. It is also\\nfound in the feces and rarely in the urine. It may be seen in the\\nblood. It may be recognized by staining methods, although rarely.\\nIt has been isolated from the blood successfully, by culture methods, by\\nGwyn in a small number of cases.\\nMorphology. A bacillus 1 to 3/z long by 0.5 to 0.8//. broad, with\\nrounded ends. It is motile, facultative anaerobic, does not liquefy", "height": "4416", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0316.jp2"}, "317": {"fulltext": "THE DATA OBTAINED BY OBSERVATION.\\n299\\ngelatin. It has flagella 3 to 5 times as long as the bacilli. It stains\\nwith the anilines, best with Loffler s bine. The flagella are stained\\nby Loffler s special method. (See Plate III., Fig. 6, b.)\\nFig. 72.\\nE\\nM\\nE\\nM\\nE\\nM\\no-\\n1\\n1\\n1 _\\n1\\nJ\\n-T-\\ni\u00e2\u0080\u0094\\nt\\nt\\nr\\no-\\n1\\n\u00c2\u00b0J\\nJ\\nA\\n_J\\n1\\nZ\u00c2\u00b1\\n4\\niz\\nIZ\\nr^\\n1\\nT02-J\\nI\\n_1\\nvt\\n0-\\nV\\nz\\nz\\\\\\nn\\n1\\nr\\nX\\n1\\nX\\n1\\no-\\nv\\n1\\nDate\\nSi\\n?i\\nRenal typhoid.\\nNephritis on the twenty-fifth day. Course of temperature during\\nthree days preceding death.\\nSerum Diagnosis. This method of diagnosis has been more success-\\nfully employed in typhoid fever than in any other infection. The\\nmethods have been previously described. The agglutinative reaction\\ntakes place as early as the eighth day, rarely as early as the third day,\\nbut sometimes not until the fifteenth or twentieth day, and even may\\nnot occur until convalescence is established. By this means typhoid\\nfever can be distinguished from the infection due to the bacillus of\\nGartner (bacillus enteritidis). (See Lancet, January 15, 1898.)\\nThe paracolon bacillus infection, as shown by Gwyn (Bulletin of the\\nJohns Hopkins Hospital, 1898, vol. ix. No. 84), who studied a case\\nwhich resembled typhoid clinically, does not give this reaction. Influ-\\nenza and Malta fever and forms of tuberculosis can also be distin-\\nguished from typhoid fever by this method.\\nLeucocytosis. A determination of the number of leucocytes is of\\nvalue in the diagnosis of typhoid fever. It is one of the infections in\\nwhich leucocytosis does not occur. In a differential count some varia-\\ntion from the normal is seen. The large mononuclear and transitional\\nforms are decreased the poly nuclear neutrophils are decreased. The\\nabsence of leucocytosis aids in distinguishing typhoid fever from vari-\\nous septic fevers and acute inflammations. On the other hand, in a", "height": "4408", "width": "2652", "jp2-path": "practicaltreatis00muss_0_0317.jp2"}, "318": {"fulltext": "300 GENERAL DIAGNOSIS.\\nease of typhoid fever if leucocytosis occurs an inflammatory complica-\\ntion or mixed infection is possible. Perforation and peritonitis are\\nattended by leucocytosis.\\nIn addition to the absence of leucocytosis we find, after the second\\nor third week, gradual reduction of the red cells, and by the time con-\\nvalescence is established a marked anaemia develops. Both the red\\ncells and the haemoglobin are reduced.\\nCulture Methods. The bacillus can be isolated from the blood, the\\nstools, and the urine.\\nBiological Properties. The bacillus grows readily in acid\\nmedia as well as in the neutral or alkaline media, best at a tempera-\\nture of 38\u00c2\u00b0 C. Death-point, 60\u00c2\u00b0 C.\\nThe colonies develop in twenty-four to forty-eight hours. On gela-\\ntin plates they are small and white, nearly spherical irregular, granu-\\nlar, and yellowish-brown.\\nIn stab-cultures there is a whitish semi-transparent layer on the sur-\\nface, with sharply defined irregular edges, and along the puncture a\\ngrayish-white growth. (See Plate VII., Fig. 5.) It develops abund-\\nantly in milk. On potato it forms an invisible growth/ manifested\\nonly by increase in moisture, which is quite characteristic.\\nBacteriological Diagnosis. It would be most desirable if a\\nmeans of diagnosis, that would have no element of uncertainty about\\nit, could be found. Bacteriologists have sought for such means, and\\nat present seem to have found two methods, one of which at least has\\nbeen brought to such a degree of perfection as to be of value to the\\nclinician. They are Eisner s culture and Pfeiffer s bactericidal serum\\nmethods. Eisner s method l consists in the preparation of a culture-\\nmedium upon which no species of micro-organism can grow except the\\ntyphoid bacillus and the bacillus coli communis. For a description\\nof this complicated method the reader is referred to the recent works\\non bacteriology.\\nRecently bacteriologists have been successful in isolating the typhoid\\nbacillus from the stools and the urine. Unfortunately, the methods\\nare too complicated for clinical work. P. H. His, Jr., recovered the\\nbacillus typhosus and distinguished it from members of the colon group\\nby a combined plate and tube method. 2\\nFor differentiation of the typhoid from the colon bacillus the method\\nof Proskauer and Capaldi may be used. They employ two solutions.\\nIn solution No. 1 the typhoid bacillus does not grow at all. The colon\\nbacillus grows rapidly, produces a marked acid reaction, and the blue\\ncolor gives way to red. Solution No. 2 both bacilli grow, but the\\ntyphoid bacillus is the only one which gives an acid reaction. Note,\\nthe solutions are neutral in reaction and colored Avith litmus.\\nAnother method is that of Thoinot. He prepares a medium of\\nbouillon, to which he adds y^ per cent, of arsenious acid. On it the\\ntyphoid bacilli do not grow, while the colon bacilli multiply rapidly.\\n1 Zeit. Ilygien. und Infection ki\\\\, B. xxi. H. 1.\\n2 P. II. His, Jr., On a Method of Isolating and Identifying Bacillus Typhosus,\\netc. Journal of Experimental Medicine, vol. ii. No. 6, p. 677.", "height": "4416", "width": "2552", "jp2-path": "practicaltreatis00muss_0_0318.jp2"}, "319": {"fulltext": "Fig. 1.\\nPLATE VII.\\nFig. 2.\\nFig. 3.\\nStreptococcus\u00e2\u0080\u0094 Erysipelas. Streptoccocus Septicus. Staphylococcus.\\nFig. 4. Fig. S. Fig. 6.\\nIII! iii!\\nDlPHTHKRIA-KACILLI.\\nTyphoid-bacilli. Tuberculosis-bacilli.", "height": "4416", "width": "2652", "jp2-path": "practicaltreatis00muss_0_0319.jp2"}, "320": {"fulltext": "", "height": "4388", "width": "2648", "jp2-path": "practicaltreatis00muss_0_0320.jp2"}, "321": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 301\\nMark Richardson isolated bacilli in the urine of about 25 per cent,\\nof the cases of typhoid examined. They were present in large numbers\\nand in pure culture. They appeared late in the disease, and persisted\\ninto convalescence. The bacilli were always associated with albumin\\nand casts. After disinfection of the meatus the urine is passed in two\\nportions into sterilized test-tubes. The second portion is used. It is\\nimmediately plated upon plain agar. At the end of twenty-four hours\\nthe characteristic colonies appear. Richardson relies upon the active\\nmotility of the bacilli, which are set free in a typhoid colony by scar-\\nring with a platinum needle to distinguish them from the colon bacilli.\\nHe also used the dry serum reaction test. 1\\nPfeiffer s method, while of interest and full of suggestions as to its\\nfuture usefulness, cannot be applied with sufficient ease to render it\\npractical for clinical work.\\nInoculation. Thus far the results of inoculation have not proved\\nsatisfactory, and are certainly not of diagnostic value.\\nDiagnosis. A typical case of typhoid fever ought not to be mis-\\ntaken for any other affection, but atypical cases are numerous. The\\nmost common sources of error are a hurried diagnosis and a willing-\\nness to accept a demonstrable local affection as sufficient to account for\\nthe condition. In this way the significance of bronchitis, pneumonia,\\nand diarrhoea is overlooked. In the symptomatic form there will\\nalmost always be found a history of gradual onset and a degree of\\nfever and prostration greater than should attend the purely local affec-\\ntion. Moreover, in bronchitis and pneumonia, which are a part of\\ntyphoid fever, there may be found tenderness with gurgling in the\\nright iliac region, enlargement of the spleen, and epistaxis, to aid in\\nthe diagnosis while in cases in which the diarrhoea leads to uncer-\\ntainty, bronchitis, enlargement of the spleen, and epistaxis may coexist.\\nExamination of the blood, extended over a period of several days, is\\nnecessary to exclude the cestivo-autumnal type of malarial fever, which\\noften resembles typhoid fever.\\nNew Diagnostic Sign of Typhoid Fever. Dr. Simon Baruch\\nwrites as follows As soon as the patient shows a rectal temperature\\nabove 102.5\u00c2\u00b0 in the morning and 103\u00c2\u00b0 in the evening for three succes-\\nsive days, especially if this be accompanied by headache, dulness, or\\napathy, he is placed in a full bath at 90\u00c2\u00b0, which is reduced to 80\u00c2\u00b0,\\nwith constant friction over the body. In three hours, the temperature\\nstill being above 102.5\u00c2\u00b0, he receives another bath 5\u00c2\u00b0 cooler. This is\\nrepeated until the temperature of the bath is 75\u00c2\u00b0. If one or more of\\nthese baths fail to reduce the rectal temperature 2\u00c2\u00b0 in half an hour, the\\ndiagnosis of typhoid fever is almost certain, and the bath-treatment is\\ncontinued. The resistance of the rectal temperature to a bath of 75\u00c2\u00b0\\nfor fifteen minutes, with friction, is an almost certain test of typhoid\\nfever. 2 Dr. Baruch considers that the diagnosis of this disease should\\nno longer be obscure, even in the first days of its course.\\n1 Kichardson, M. W., On the Presence of the Typhoid Bacillus in the Urine.\\nJournal of Experimental Medicine, vol. iii. No. 3, p. 349.\\n2 New York Medical Journal, September 2, 1893.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0321.jp2"}, "322": {"fulltext": "302 GENERAL DIAGNOSIS.\\nAppendicitis is more likely to be mistaken for typhoid fever than\\nthe converse. There is usually a history of constipation, though the\\noccurrence of several inadequate movements a day may conceal the fact\\nthat there is a f aecal accumulation. In appendicitis the onset is more\\nabrupt and the local symptoms more pronounced than in typhoid.\\nPain and tenderness are prominent in appendicitis, and while they may\\nbe general over the abdomen at first, they are found to be more acute\\nin the iliac region and loin. Here, in place of gurgling, we find some\\nincrease of resistance on palpation, and a relatively dull note a\\nwooden sort of tympany or there may be a demonstrable tumor.\\nThe patient lies with the right leg drawn up, has moderate fever, and\\nvomiting. In fact, the attack is often introduced by chilliness and\\nvomiting. Headache is not a prominent symptom, while bronchitis\\nand enlargement of the spleen are absent.\\nAcute right-sided salpingitis simulates typhoid fever. It is distin-\\nguished by the history of a preceding vaginitis, endometritis, or abor-\\ntion, by the absence of diarrhoea, of enlargement of the spleen, and of\\nthe characteristic eruption. A digital examination through the vagina\\ndiscovers the womb pressed to one side and fixed, and a tender mass\\nblocking up the pelvis.\\nSimple continued fever is distinguished from typhoid fever of a mild\\ntype principally by the absence of bronchitis, of enlargement of the\\nspleen, of epistaxis, and of the characteristic eruption of typhoid fever.\\nIn simple continued fever constipation is more common than looseness\\nof the bowels, and gurgling is absent.\\nTyphus fever is distinguished by its sudden onset, the besotted ex-\\npression of the face, with reddened eyelids and small pupils, the\\nabsence of abdominal symptoms, and the occurrence on the fourth day\\nof maculae, which are subsequently converted into petechia?. It is of\\nshorter duration, and terminates very abruptly by crisis.\\nRelapsing fever differs from typhoid fever in its sudden onset with\\nchill, pain in the epigastrium, but absence of abdominal symptoms and\\neruption in the absence of marked nervous symptoms, in spite of the\\nhigh fever the short duration and termination by crisis, and the char-\\nacteristic relapse at the end of a week. The conclusive test is finding\\nspirilla in the blood.\\nAcute tuberculosis of the lungs, at times, closely resembles typhoid\\nfever. In both the onset is gradual, with cough and fever. In the\\nformer, however, the bronchial symptoms are more prominent, there\\nare apt to be recurring chills and sweats, the temperature is remittent\\nand irregular, emaciation is rapid, and constipation instead of diarrhoea\\nis the rule.\\nIn peritoneal tuberculosis there is persistent diffused pain in the\\nabdomen the belly is swollen. If effusion occurs, the physical signs\\ndisclose its presence. The temperature is irregular and may be below\\nnormal nervous symptoms comparable to those of typhoid are\\nwanting.\\nMeningitis before the stage of effusion exhibits exaggeration of the\\nreflexes and marked hyperesthesia. There may also be muscular\\nrigidity. The patient is restless, easily annoyed, and fussy about", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0322.jp2"}, "323": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 303\\nthings that would be unnoticed by a typhoid patient. Vomiting is\\noften present, whereas it is rare in typhoid fever. The temperature\\ndoes not maintain so high an average range as in typhoid fever, and is\\nsubject to greater oscillations. The pulse varies greatly, and may be\\nirregular.\\nIn septic meningitis the headache and vomiting are more persistent,\\nthe bowels are confined, and the abdominal walls are retracted. There\\nmay be double optic neuritis. In tubercular meningitis the knee-jerk\\nand other reflexes are variable, irregularly absent or present. In\\ntyphoid fever they are always present. In the former choroidal tuber-\\ncles may be seen with the ophthalmoscope. In tuberculosis in all\\nforms leucocytosis is present in typhoid it is absent. Typhoid fever\\nmust not be confounded with trichiniosis the peculiar muscular pain\\nand oedema do not occur in the former. Urcemia may simulate typhoid\\nfever when it becomes chronic but the age, the character of the urine,\\nthe cardio- vascular symptoms, are diagnostic, and, with the absence of\\nthe specific typhoid symptoms, render the diagnosis easy.\\nMountain Fevek is an infection which has been described as pecu-\\nliar to the mountains of our Western States, characterized by a con-\\ntinued fever with intestinal symptoms not unlike those of typhoid\\nfever. Irregularity of the temperature-range and the occurrence usually\\nof constipation rather than diarrhoea make it difficult to classify the\\ninfection from typhoid fever on the one hand and from forms of ma-\\nlaria on the other. Recent observations of Woodruff, who studied the\\nserum reaction in a large series of cases, show conclusively that the\\ninfection is typhoid fever, confirming the prior observations of Hoff,\\nSmart, and Raymond.\\nYellow Fever.\\nThe infection which we are about to consider is the latest of the\\nepidemic and contagious disorders for which a definite causal micro-\\norganism has been discovered. It is an acute, specific, contagious,\\nmiasmatic disease, endemic and epidemic on the tropical and subtropi-\\ncal shores of the Atlantic Ocean, characterized by a sudden onset, a\\nduration of a week or less, a characteristic facies, a fall in the pulse-\\nrate preceding a fall in temperature, and by albuminuria, jaundice, and\\nvomiting, with a tendency to hemorrhages. The specific micro-organ-\\nism is the bacillus icteroides describeol by Sanarelli.\\nYellow fever is endemic in Havana and other seaport cities of Cuba,\\nand in Rio Janeiro, Brazil. From these centres it is liable to become\\nepidemic, and to be carried in ships and by persons and clothing to\\nother places. In this way epidemics have developed in the seaports\\nof the United States, especially in the south around the Gulf of Mexico,\\nbut sometimes as far north as Philadelphia and New York. The\\ndisease becomes epidemic in the hot season and ceases upon the appear-\\nance of frost. The specific germ has not yet been isolated.\\nIn countries in which the disease is endemic it is the custom to\\nregard the native children as immune. Dr. John Guiteras, however,\\nis strongly of the opinion that the disease is kept alive between epi-\\ndemics by cases among these children. He has also shown that it", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0323.jp2"}, "324": {"fulltext": "304 GENERAL DIAGNOSIS.\\nprevails among white children before it becomes epidemic among\\nadults.\\nThe period of incubation varies from a few hours to two weeks.\\nGuiteras states that the cases in which it extends beyond the seventh\\nday are exceptional.\\nThe invasion is abrupt, and occurs usually in the night. It is marked\\nby chilliness oftener than by a decided chill. The temperature rises\\nrapidly to 102\u00c2\u00b0 to 103\u00c2\u00b0 or 104\u00c2\u00b0, not often higher in favorable cases.\\nThe pulse is correspondingly increased in frequency at first, but very\\ncommonly begins to fall before the temperature, so that later the pulse\\nis relatively slow. The face is peculiar and characteristic it is flushed\\nand somewhat swollen the eyelids are somewhat swollen, with red-\\ndened edges the eyes are watery, glistening, and slightly but dis-\\ntinctly tinged with yellow the pupil is small and brilliant. Guiteras\\nsays l The appearance of the face is often sufficiently characteristic\\non the first day of the disease to warrant a positive diagnosis/ The\\nearly manifestation of jaundice is undoubtedly the most characteristic\\nfeature of the facies of yellow fever. He also says that these phe-\\nnomena are often better observed at a slight distance than on close\\ninspection.\\nThe tongue is large, moist, and coated with white fur. The stomach\\nis irritable and the epigastrium tender. Nausea with repeated vomit-\\ning occurs. The fluid is at first of a light greenish-yellow, subse-\\nquently becoming decidedly bilious. The bowels are constipated.\\nThe urine almost invariably contains albumin at some time during\\nthe first three days. Its presence may be very transient. It may be\\nfound in the evening and not at other times. The amount of albumin\\nis sometimes very large, and abundant blood and tube-casts are found.\\nThe nephritis subsides rapidly, without leaving traces. The urine\\nis acid in reaction and scanty in amount. It is sometimes suppressed.\\nDuring this febrile period the patient complains of headache, pains\\nin the back and limbs, and intense thirst. The mind, however, is\\nusually perfectly clear. Contrary to expectation, Guiteras asserts that\\nthe nervous symptoms are, perhaps, more prominent in the adult than\\nin the child. The loquacity, the short-cut phrases and precipitate\\nspeech, the excitement, the show of indifference with unmistakable evi-\\ndences of fear all these, that are such prominent features of the dis-\\nease in the adult, are absent in the young. 2\\nIn from two to five days the temperature falls to or below normal,\\nheadache and pains in the limbs disappear, and the patient is cheerful\\nand thinks himself convalescent. This is the fact in mild cases, but\\nin more severe cases the period of remission or stage of calm is followed\\nby a return of symptoms in a few hours or at most a day or two. The\\njaundice deepens, vomiting becomes more urgent and in adults is accom-\\npanied by much retching. It is bilious, streaked with blood, or thick\\nand wholly black black vomit the temperature may rise again\\n1 .Report of the Surgeon-General of the Marine-Hospital Service, 1888; Keat-\\ning s Cyclopaedia of Diseases of Children, 1889, vol. i.\\n2 Keating s Cyclopaedia, loc. cit.", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0324.jp2"}, "325": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 305\\nas high as, or higher, than in the original paroxysm, or it may remain\\ndepressed. In any event the pulse is apt to be slow, often from 40 to\\n60. The urine contains albumin, blood, and casts, and may be sup-\\npressed, adding uraemia to the other toxaemia. Convulsions at this\\nstage are usually ursemic. Hemorrhages may occur from any mucous\\nsurface. The gums are tender, swollen, and bleed easily. There may\\nbe epistaxis, hemorrhage from the ear, bowel, uterus, or vagina. Preg-\\nnant women miscarry. Ecchymoses also may form. Death may take\\nplace in coma or convulsions. If the patient lingers beyond the fifth\\nor sixth day he sinks into a typical typhoid state, with diarrhoea and\\nmarked adynamia, from which he may or may not emerge.\\nAs in scarlet fever, the patient may be smitten down and die in a\\nfew hours from the time he was in apparent health. In other grave\\ncases the temperature remains high, and rises instead of falls on the\\nthird or fourth day. The duration of the disease is from two to five or\\nsix days if a typhoid state develops, it may last ten days or two weeks.\\nComplications are not common. Phlebitis and lymphangitis occur,\\nand Guiteras says he has noticed hepatitis, insanity, and paralysis\\n(probably from neuritis). Second attacks are extremely uncommon.\\nExamination of Blood. The bacillus icteriodes is a slender rod\\nfrom two to four micromes in length. It is ciliated and motile. By\\nstaining a drop of blood with Gram s method it is seen in more than\\nhalf the cases.\\nSerum Diagnosis. Woodson and the Archinards have found agglu-\\ntination to take place in a large proportion of cases of yellow fever.\\nThe blood, taken as early as the second day, gave a prompt reaction in\\nfrom 75 to 80 per cent, of all cases. Dilutions of 1 to 40 were used,\\nbut reaction took place in dilutions as low as 1 to 5. Pothier and\\nLerch report successfully upon this reaction. Cultures from the blood\\nproduce an organism which grows on ordinary media does not coagu-\\nlate milk, but ferments saccharine fluids.\\nInoculation. Inoculation of dogs and monkeys produces a clini-\\ncal picture similar to the original infection.\\nDiagnosis. Yellow fever is distinguished from pernicious malarial\\nfever by the slow pulse, the characteristic facies, the early transient\\nalbuminuria, the deep jaundice, the absence of diarrhoea, the occur-\\nrence of black vomit, the tendency to hemorrhage, and the clear mind.\\nIf it is not practical to make a diagnosis based upon an examination\\nof the blood, the three important characteristics which Guiteras laid\\nstress upon must be borne in mind in addition to the usual data secured\\nfor the purpose of determining the presence of an epidemic and conta-\\ngious disease. The three diagnostic points of Guiteras are the facies,\\nthe albuminuria, and the slowing of the pulse, with continuance or in-\\ncrease of the fever. By these means the affection must be distinguished\\nfrom dengue and from various forms of malarial fever, especially the\\naestivo-autumnal infections.\\nMalta Fever.\\nMalta fever is a remarkable infection which seems to prevail within\\nthe limits of the Mediterranean. It is an infection characterized by\\n20", "height": "4416", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0325.jp2"}, "326": {"fulltext": "306\\nGENERAL DIAGNOSIS.\\ngradual onset and by repeated remissions of the fever. The alternating\\nfebrile and afebrile periods which characterize the disease continue\\nfrom two months to two years. The most remarkable feature is the\\n1 s\\n8 8 t s r\\n,1 [l 1 i III llllllffif-\\nag.\\npi 1 |te^\\ni liii.T\\nttt-t ILLl\\n1\\nMIRIi\u00c2\u00a7\\ni||\u00c2\u00a7P\\n41\\nit\\nill II\\niiill\\nLi\\nll\\nww\\nrp-;-^!^\\n1\\ny\\nIf!\\nII \\\\\\\\yffr J\\nt lllllllllllllit UttS\\nj-\\nf\\nt 11 TmTitP\\nfiiii\\nft\\n1 1 j _i i r_LL\\n?^?#fl\\nT MTMr^ff\\n1 11111 IS\\nT m^-^\\niplil\\nSpE==Si\\n|l 1 11\\ntt\\niliiiiiiiiiilil\\n^t-b^ s\\nUlllHllllllPlt iUr T^\\nIWS\\nJlllllllllllllliiEf fntf\\n15:551\\nllllllll IIIIIHIffi Lr l iT4\\ni4| 1\\n-im ii ii iifum\\nup za^\\nIfllllllJMlMiiTllTl\\nggi\\n^H^UJjntf^m j\\n_ TH l ^fffi 1 Ji l4li 1 1 11 1 1 f\\n-j- 44- 4444 44\\n1 m+ffl LI 11 1 1 1\\nIm+wTff jtul\\n1\\nhT fttHHin i tpiTmi 1\\ntti IT\\nfnflff\\ntff-ffiff\\nffi-ffi#\\nIHtffl\\n-til] iiiiiii miiiii\\ntlfff Inn Iffffll ll\\nIII II lillllHI II lllliB", "height": "4412", "width": "2652", "jp2-path": "practicaltreatis00muss_0_0326.jp2"}, "327": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 307\\npeculiar character of the temperature-range, which consists of intermit-\\nting waves or undulations of fever of a distinctly remittent type.\\nThese periods of fever last from one to three weeks, followed by an\\napyretic period or a period of abatement lasting from two to ten days.\\nThe daily temperature-range may be intermittent or remittent. The\\nfebrile course may continue six months or more. During this time\\npatients grow more and more prostrated, become anaemic, and usually\\nsuffer from constipation. Profuse sweats attend the decline of the\\ndaily range, and in many instances we find enlargement of the spleen.\\nNeuralgias occur in various parts of the body the joints become en-\\nlarged, and fibrous tissues may be the seat of inflammation. Hughes\\nwho describes the disease most accurately describes a malignant\\ntype lasting a week or ten days, and an undulatory type continuing\\nfor weeks or months. Indeed, the relapses are known to occur over\\na period of two years. The third is known as the intermittent type,\\nin which there is a daily rise of temperature without other marked\\nsymptoms. The undulatory type is the most common variety. The\\ninfectious micro-organism is the micrococcus melitensis.\\nDiagnosis. The occurrence of fever described above in the coun-\\ntries bordering upon the Mediterranean, whether epidemic or endemic,\\nshould always suggest Malta fever. The possibility of its occurrence\\nin other tropical countries, as in the islands of the Caribbean Sea, must\\nnot be forgotten. A positive diagnosis is made by exclusion of all\\nforms of malaria by an examination of the blood, and of typhoid fever\\nby finding the bacillus typhosus in the urine or stools of the suspected\\npatient. The micro-organism has not been isolated from the blood,\\nbut the serum reaction is a valuable means of diagnosis. (See page 233.)\\nThis reaction is performed as in cases of typhoid fever. The culture\\nmust be carefully selected. With a 1 to 10 or 1 to 50 dilution aggluti-\\nnation takes place when the serum of a patient with Malta fever is\\nused. The serum of such a patient does not have any effect upon\\nthe typhoid bacillus nor upon other organisms. Aldrich states that\\nthe first reaction occurs about the fifth day.\\nGonorrhceal Infection.\\nAlthough the infection is usually limited to the genito-urinary tract,\\nit is well known that the gonococcus may enter the blood and infect\\ntissues elsewhere, causing a local inflammation. We therefore see\\nsymptoms due to the primary infection symptoms due to the infection\\nof the genito-urinary organs by direct continuity, and systemic infection.\\nThe primary infection involves the adnexae of the genital organs in the\\nmale and the female. Salpingitis, metritis, and ovaritis in females,\\nwith the occurrence occasionally of peritonitis, arise from spreading by\\ncontinuity. In both sexes cystitis, ureteritis, and pyelitis occur. The\\ninfection is usually mixed.\\nWhen the gonococcus invades the blood, symptoms of septicaemia or\\npyaemia arise. The infection may be rapid and fatal, and may termi-\\nnate ten days after the primary lesion. The occurrence of such general\\ninfection is suspected when the history of the primary infection can be", "height": "4416", "width": "2648", "jp2-path": "practicaltreatis00muss_0_0327.jp2"}, "328": {"fulltext": "308 GENERAL DIAGNOSIS.\\nsecured, and in addition the micro-organism can be recovered from the\\nblood, as was successfully done by Thayer.\\nIn other infections the joints become involved and we have the\\nphenomena of gonorrhoeal rheumatism (see Joints), the course and\\nsymptoms of which are discussed elsewhere. Endocarditis may result\\nfrom gonorrhoeal infection, and can only be distinguished from other\\nforms of endocarditis by the history and the finding of micro-organ-\\nisms in the blood. Myocarditis (Councilman) and pericarditis may\\nalso occur.\\nDiagnosis. Thayer and Blumer and Thayer and Lazear have suc-\\nceeded in recovering the gonococcus from the blood in this form of\\nsepticaemia. The blood is withdrawn from the median basilic vein by\\na sterilized syringe. A large quantity is secured. It is mixed with\\nmelted agar and immediately plated. The medium should contain\\nat least one-third blood. This is practically the medium which Wer-\\ntheim recommends. After forty-eight hours colonies appear half the\\nsize of a pin-head, granular, but with irregular borders. Cover-slip\\npreparations of the colonies, if the case is gonorrhoea, will show the tinc-\\ntorial and morphological characteristics of the gonococcus. (See Plate\\nIII., Fig. 3, B. The diagnosis is further established by finding the\\ngonococcus in any purulent discharge, as of the urethra or vagina. (See\\nChapter XXI. Exudations, etc.)", "height": "4412", "width": "2640", "jp2-path": "practicaltreatis00muss_0_0328.jp2"}, "329": {"fulltext": "CHAPTER XX.\\nTHE DATA OBTAINED BY OBSERVATION\u00e2\u0080\u0094 {Continued).\\nFEVER. THE INFECTIOUS DISEASES.\\nInfections Recognized by the Examination of Excretions and\\nSecretions or by the Products of the Infectious Inflammation.\\nThe following infections are disclosed by the examination of the\\nproducts of the infection found in the inflammatory areas (pus) in\\nthe excretions and secretions of the body in the sputa in the vom-\\nitus in the faeces or in the urine. The reader should refer to the\\nsections describing the method of the examination of pus, sputum,\\nand secretions bacteriologically. They are as follows Erysipelas,\\npneumonia, tuberculosis, influenza, cerebrospinal meningitis, diphtheria,\\nseptico-pycemia, glanders, cholera Asiatica, dysentery, bubonic plague,\\nleprosy, actinomycosis, tetanus, trichinosis.\\nErysipelas.\\nThe fever of this infection, particularly in a first attack, is very\\nmarked. It rises suddenly to a considerable height and may antedate\\nthe eruption. It resembles the course of a pneumococcus infection.\\nIt is an acute, specific, contagious, and infectious disease, character-\\nized by a sudden onset, with a bright-red eruption, which usually begins\\non the face near the nose or mouth and spreads over the entire face\\nand scalp. It is attended with burning heat of the skin and great dis-\\nfigurement from swelling.\\nThe specific cause of erysipelas is the streptococcus erysipelatosus.\\nIt is carried to a slight extent by the air, and still more in the dis-\\ncharges, especially those of the nose. Repeated attacks occur in per-\\nsons with chronic nasopharyngeal catarrh, carious teeth, or a sinus. It\\nis apt to attack persons with open wounds (surgical erysipelas), and\\npuerperal women, producing in these cases sloughing and septicseinia.\\nOne attack does not protect against another on the contrary, if there\\nis any focus in which the streptococci linger, one attack actually pre-\\ndisposes to another.\\nThe period of incubation is usually from three days to a week. On\\nclose inquiry a history of sore-throat and some enlargement of the\\ncervical lymphatics is usually found to precede an attack of facial\\nerysipelas. The invasion is sudden and is marked by chill. The tem-\\nperature rises to 104\u00c2\u00b0 or 105\u00c2\u00b0, and in the next two or three days may\\nrise still higher.\\nCoincidently with the rise in temperature the portion of the skin to\\nbe affected burns, tingles, is tender to the touch, and may be seen to be", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0329.jp2"}, "330": {"fulltext": "310 GENERAL DIAGNOSIS.\\nreddened. The redness increases in intensity and extent, while the\\nskin is swollen and slightly oedematous. The part of the face to be\\naffected is usually the cheek in close proximity to the nose, less fre-\\nquently near the month and ear. Vesicles and blebs often form when\\nthe inflammation is very intense. The redness disappears upon press-\\nure, but quickly returns sometimes it has a dusky, purplish hue.\\nA marked characteristic of the disease is its tendency to spread. In\\nordinary cases it involves one cheek, eyelid, and ear, and travels across\\nthe bridge of the nose to the other side. The inflammation is most\\nintense when it is spreading the advancing margin is raised, tense,\\nand brawny the line is thus sharply drawn between healthy and in-\\nflamed tissue. The loose tissue about the eyes swells enormously, both\\neyes are closed, the entire face swollen, red, and disfigured with vesi-\\ncles and blebs here and there. Curiously the chin escapes. The red-\\nness and swelling begin to subside in the part first attacked, before the\\nprocess has reached its height on the opposite side. As a rule, facial\\nerysipelas does not extend beyond the face, the scalp and neck being\\nspared. The scalp, however, is more frequently affected than the\\nneck occasionally erysipelas leads to extensive cellulitis of the scalp,\\nwith the production of a septic constitutional condition and much\\nlocal sloughing. The submaxillary glands are more or less enlarged,\\nsometimes so much so as to prevent the taking of solid food.\\nWhen on the body the eruption spreads over a greater extent than\\nwhen primary on the face, hence its name, the red runner. It may\\npass from the heel to the thigh, and over the trunk, lasting for weeks.\\nWhile the erysipelas is extending the fever continues, and is some-\\ntimes alarmingly high. The pulse is frequent and soft. Leucocytosis\\nis present. Nocturnal delirium is not uncommon in severe cases, and\\nsometimes nausea and vomiting are frequent. The bowels are usually\\nconstipated. The urine is high-colored, frequently contains a small\\namount of albumin, and actual nephritis sometimes occurs.\\nIn favorable cases of facial erysipelas the process is at an end in\\na week or less. It may be prolonged to two weeks, subsiding by crisis\\nor lysis, and convalescence is usually rapid. The vesicles or bullae dry\\nup into yellowish crusts and the epiderm is shed in large or small\\npieces according to the intensity of the process.\\nPneumonia and nephritis are the most frequent complications. Men-\\ningitis, pericarditis, and endocarditis also occur. Erysipelas may extend\\ninward and involve the fauces, pharynx, and larynx, producing oedema\\nand death from suffocation.\\nSequelae. If the scalp has been involved the hair falls out. The\\ncervical adenitis may result in abscess chronic nephritis may result.\\nOtitis media occurs occasionally, and so do keratitis and abscess of the\\neyelids.\\nOn the other hand, erysipelas is credited with causing the disappear-\\nance of lupus, chronic eczema, and sarcomata.\\nDiagnosis. Bacteriological Diagnosis. Examination of pus\\nor discharge from the nose or thorax will disclose the presence of the\\nstreptococcus. (See Plate VII., Fig. 1, and Chapter XXI.)\\nHerpes zoster of the face and forehead is distinguished from erysipelas", "height": "4416", "width": "2640", "jp2-path": "practicaltreatis00muss_0_0330.jp2"}, "331": {"fulltext": "THE DA TA OBTAINED B Y OB SEE VA TION. 31 1\\nby the fact that vesicles appear first, followed by erythematous redness,\\nand that they are limited by the median line, and are preceded and\\naccompanied by sharp neuralgic pain, whereas erysipelas affects both\\nsides of the face, and vesicles appear at the height of the disease the\\npain is much less in erysipelas. It is distinguished from dermatitis of\\nvarious kinds mainly by the sharper febrile reaction, the raised border\\nof the eruption, which begins on one side and spreads to the other.\\nErysipelas is rarely equally intense upon the two sides. Dermatitis\\nfrequently is. The latter often exhibits a rough surface, whereas, until\\nvesicles appear, erysipelas is smooth and shiny.\\nChronic erythematous eczema occurs in the middle-aged and old per-\\nsons, is afebrile, accompanied by little swelling but a great deal of\\nitching, and runs a slow course.\\nLobar Pneumonia.\\nThe Pneumococcus Infections. In typical cases of the infection we\\nare about to consider the course of the fever is of great diagnostic sig-\\nnificance. Its sudden rise to a great height, preceded by a rigor, is of\\nitself suggestive. During the succeeding days of the disease the morn-\\ning and evening temperature varies but little. When associated with\\nhurried respiration and the intoxication symptoms attending this infec-\\ntion, even though no physical signs are present in the lungs, pneumonia\\ncan reasonably be suspected. The termination of the febrile course is\\ncharacteristic of the infection. The sudden fall to normal or a subnor-\\nmal temperature known as the crisis brings to an abrupt end the\\nusually alarming symptoms.\\nAcute pneumonia, croupous or lobar pneumonia, is an infectious\\ninflammatory disease excited by the micrococcus lanceolatus (diplococ-\\ncus pneumoniae, pneumococcus) involving the vesicular structure of the\\nlungs, and followed by choking of the alveoli with the products of\\ninflammation it is attended by severe constitutional symptoms due to\\nthe toxines of the infecting organism.\\nSymptoms. Mode of Onset. The invasion of pneumonia is usually\\nsudden, and is marked by a chill. The temperature rises rapidly, and\\nmay reach 104\u00c2\u00b0 or 105\u00c2\u00b0 in the first twelve hours after the chill. With\\nthe fever, the patient complains of severe headache and pain in the\\nside, and has a short, quick cough and sometimes vomiting. The pulse\\nis moderately accelerated, and the respiration either is or soon becomes\\nvery frequent. The face is apt to be flushed, and there may be a circum-\\nscribed red spot on the cheek. The skin is hot and dry. On physical\\nexamination, within the first twenty-four hours, a small patch of con-\\nsolidation is detected, which may subsequently extend over a large\\narea.\\nWhile this is the picture of an ordinary pneumonia in its early stage,\\nall cases are by no means so clear. In some the course resembles that\\nof a general fever in which the pulmonary disease is a local manifesta-\\ntion. In such cases there may be prodromata, consisting of headache,\\ngeneral malaise, a slight bronchitis, and digestive disturbance. Then\\nfollows the chill. Central pneumonia. The fever may be high for", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0331.jp2"}, "332": {"fulltext": "312 GENERAL DIAGNOSIS.\\nseveral days before there is any discoverable consolidation of the lungs\\nand during this time cough may be wholly, or almost wholly, absent.\\nThe respirations increase gradually in frequency, and finally a Avell-\\nmarked pneumonia can be made out. It is customary to account for\\nthese cases by the supposition that pneumonia developed in the interior\\nof the lung and consolidation gradually extended to the surface. In\\nsome cases the patient presents no more definite symptoms for three\\nor four days than high fever, intense headache, and moderately accel-\\nerated respiration.\\nLater Stages. At the end of forty-eight hours, or, at the most,\\nof four days, the patient is found lying in bed in the dorsal position,\\nor on the affected side. The face is flushed, and countenance anxious,\\nthe respiration hurried, the alse nasi play vigorously. The tempera-\\nture varies little from the first day s rise the chest pain has subsided,\\nand the short, dry cough is now attended by viscid expectoration. The\\nrespiration continues hurried, the pulse full and bounding. During\\nthis time the physical signs of consolidation continue and increase.\\nAfter a period of five to ten days the termination takes place by\\ncrisis, the pain in the chest abates, the cough becomes looser, and the\\nexpectoration more free, but the other symptoms persist. In addition,\\nin some cases, delirium occurs, the pulse softens and becomes dicrotic,\\nthe urine becomes albuminous.\\nRespiratory Symptoms. Chest-pain, cough, hurried respiration\\nof a peculiar type, and expectoration are characteristic. The chest-\\npain is sharp and stabbing or lancinating. It is increased by breath-\\ning. It is seated about the nipple or in the axillary region, at the\\nangle of the scapula or below the diaphragm. Its seat always indicates\\nthe side affected. Cough is short and dry, smothered and painful\\nit soon becomes softer and painless as the expectoration becomes free.\\nIt may be absent in the feeble, in the aged, in alcoholic subjects, or in\\npersons with brain disease, including insanity.\\nCharacteristic symptoms of pneumonia are the increased frequency\\nand the type of the respiration. The rate in adults reaches 40, 50, or\\neven 60 per minute, and in children 80 and 100 are not very un-\\ncommon.\\nThe pulse, on the contrary, does not increase in frequency in the\\nsame proportion hence, the normal ratio of respiration to pulse of 1\\nto 4 ceases, and becomes 1 to 3 or 1 to 2.\\nInspiration is short, expiration quick and often attended by an expi-\\nratory noise or grunt. The long pause may take place after inspira-\\ntion instead of expiration. In children both are so short that unless\\nthe epigastrium is inspected it may be difficult to distinguish the two.\\nIn ordinary cases which run a normal course the cough is followed\\nby expectoration, which is at first viscid mucus, but gradually becomes\\nreddish-brown from admixture of blood the rusty sputum of pneu-\\nmonia. This sputum is characteristic, almost pathognomonic. It is\\nexpelled with difficulty from the mouth, clinging to the lips or to the\\nmustache. It cannot be removed from the spit-cup by turning it\\nupside down. It continues to be rusty, and as the crisis approaches\\nbecomes purulent and is discharged with ease. In typhoid pneumonia", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0332.jp2"}, "333": {"fulltext": "THE DATA OBTAINED BY OBSERVATION.\\n313\\nit looks like prune-juice (See Sputum.) It contains blood, alveolar\\nepithelium, the specific micrococcus, and later pus and small fibrinous\\ncasts.\\nFjg. 74.\\nM\\nE M\\nE M\\nE\\nM E\\nM\\nm\\nE\\nM E\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\n-f-\\n1\\n4=^\\nf\\nA\\nX\\nv\\nI\\nX\\no-\\n^4\\nX\\nH\\nrX\\nX\\n4\\n\\\\p\\nV\\n3\\nY\\n102-\\n1 x\\n1\\nM~\\nf\\nI\\n4\\no\u00e2\u0080\u0094\\n4\\nIOI-\\nF\\no-\\ni\\n-t-\\n_\\nIOO-\\nM\\n-A-\\ny\\n4\\n99\\nq=\\nV\\nrr\\n-n\\n\u00e2\u0096\u00a0tt\\nA\\n-4\\ni\\n-V-\\n1\\nr\\nt-\\n98-\\n^7\\ni\\nh\\nw\\n4\\nr\\nY-\\n-1\\nPnlse\\n^p\\n3\\nnS^-^\\nlis\\ns ss\\nS 2S\\nS S\\ns ss\\nS^\\nS \u00c2\u00a32\\nl);i e\\nbV\\n5\\nGO\\nR\\nB\\nN\\nN\\nB\\nUS\\nH\\nPneumonia. Sudden rise termination by crisis. Pseudo-crisis on eighth day.\\nFig. 75.\\n104\\n103\u00c2\u00b0\\n102\\n101\u00c2\u00b0\\n100\\n99\u00c2\u00b0\\nDAY OF DIS.\\nPULSE\\nRESP.\\nDATE\\nA\\n-ol\\n,_\\nL_\\ns\\n1\\nV\\n1\\ns\\nI\\ny\\n1\\n_)\\nT\\nO\\nt\\n1\\n1\\n1\\nM\\nCO\\n*l\\n10\\nt~\\nCO\\nf4\\n^x\\nX\\np4\\n^4\\nf4\\nA/\\n10\\nto\\nt-\\nCO\\n1\u00e2\u0080\u0094 i\\nBj\\nMay\\nPneumonia from first day. Pseudo-crisis on fourth day. Crisis began on fifth.", "height": "4416", "width": "2652", "jp2-path": "practicaltreatis00muss_0_0333.jp2"}, "334": {"fulltext": "314 GENERAL DIAGNOSIS.\\nThe Fever. The chill that precedes the fever is pronounced and\\nis always a warning to look for a pulmonic inflammation. In children\\na convulsion is rarely absent in frank pneumonias. During its occur-\\nrence the body-temperature rises. In twelve hours it reaches 104\u00c2\u00b0 to\\n105\u00c2\u00b0. (See Figs. 74 and 75.) It remains at this point, obeying the\\nlaws of diurnal variation. The hot, dry skin, the parched lips, the dry\\ntongue, the thirst, the anorexia, the hurried breathing, the occasional\\ndelirium, the loaded urine attest its presence. At the end of the third,\\nor more frequently the fifth, seventh, or ninth day, crisis takes place\\nthe fall is abrupt, and the normal or a subnormal temperature may\\nbe reached in from five to fifteen hours. Pseudo-crisis, as the accom-\\npanying chart indicates, may precede the true crisis by twenty-four or\\nforty-eight hours. The decline may take place by lysis, however. Pro-\\ntracted fever indicates delayed resolution or the occurrence of a compli-\\ncation.\\nCerebral Symptoms. In some cases, especially in children, the\\nonset of the disease may be marked by a convulsion. This is said to\\noccur more frequently in apical pneumonias than in pneumonias of the\\nbase. Headache and delirium are so pronounced in some cases as to\\nsimulate meningitis. This is most likely to be the case in severe apical\\npneumonia in children, and in double pneumonia either in children or\\nin adults.\\nDelirium may occur during the height of the fever, and occasionally\\nis maniacal. Nocturnal delirium may be a constant symptom in very\\ngrave cases. In drunkards it may simulate delirium tremens, and\\nmay be pronounced, without much fever. In the later stages of grave\\nor fatal cases a low form of delirium, with a tendency to coma, is\\ncommon.\\nThe Heart and Pulse. The pulse is small at the time of the chill,\\nbut becomes full and bounding during the fever later it may become\\ndicrotic. The pulse-respiration ratio has been referred to. The pulse\\nvaries in frequency and in character with the type of the disease. In\\nhealthy adults it is rarely over 110. In the debilitated it may be very\\nfrequent, small, and feeble in the aged, frequent and dicrotic. Exten-\\nsive consolidations reduce the amount of blood in the general circula-\\ntion, cause rapid action of the heart and a small pulse, and favor death\\nwith the heart in asystole.\\nThe heart-sounds are clear. A murmur low in pitch is often heard\\nin the mitral and pulmonary areas. The left ventricle acts forcibly.\\nThe pulmonary second sound is accentuated. If dilatation and failure\\nof the right heart takes place, the area of dulness may extend beyond\\nthe right edge of the sternum, an epigastric impulse be noted, tur-\\ngescence of the veins in the neck become marked, but, above all, the\\npreviously accentuated pulmonic second sound may become weak or\\ndisappear.\\nGastro-intestinal Symptoms. Vomiting frequently occurs in chil-\\ndren at the onset, and both in them and in adults may persist and mask\\npulmonary symptoms. The appetite is lost. The tongue is furred.\\nIt may become dry and brown. The bowels are constipated except\\nwhen complications occur. The spleen is enlarged. The vomiting and", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0334.jp2"}, "335": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 315\\nepigastric pain may be so pronounced as to mask the pulmonary symp-\\ntoms. The occasional presence of jaundice has caused it to be mistaken\\nfor hepatitis, congestion of the liver, and even for gallstones. I saw\\na case of pneumonia, said to be appendicitis and peritonitis because of\\nthe characteristic pain, colic, and vomiting, followed by great abdomi-\\nnal tenderness in the upper abdomen.\\nThe Blood. Leucocytosis is a marked accompaniment of pneumonia,\\nespecially in cases ending favorably. The white cells may be increased\\nfrom 12,000 to 40,000. They fall with the crisis, or probably a day\\nafter the termination of the fever. In malignant forms there may be\\nno leucocytosis. Increase in the fibrin network causing the buffy\\ncoat of older writers is commonly seen.\\nCutaneous Symptoms. Herpes on the lips, the nose, or the geni-\\ntals is of common occurrence. Sweating occurs with the crisis, or if\\nheart failure is imminent.\\nThe Urine. The urine is scanty and high-colored, and may contain\\na small amount of albumin. In some cases the chlorides are found to\\nbe absent. This is determined by acidulating the urine with a drop\\nor two of nitric acid, and then adding one or two drops of a 10 per\\ncent, solution of silver nitrate. If chlorides are present a heavy white\\ncloud of chloride of silver is thrown down. The chlorides are not\\ninvariably absent, or even diminished in pneumonia, hence their reap-\\npearance, which is said to indicate beginning convalescence, loses its\\nvalue as a prognostic sign.\\nPhysical Signs. (See Diseases of the Lungs, Plate XIX.) Con-\\nsolidation. Diminution in the amount of air, increase of solid con-\\ntents. On inspection, diminished movement. If extensive consolidation,\\nenlargement of the affected side. On palpation, inspection confirmed\\nand increased vocal fremitus discovered. Both are more marked at the\\nheight of consolidation. Percussion. In first stage, impaired resonance\\nor Skodaic resonance. In stage of hepatization, dulness or flatness, but\\nwithout any wooden quality or marked resistance.\\nAuscultation. In the early stage, that of congestion, the respira-\\ntory murmur is suppressed and crepitant rales are heard at the end of\\ninspiration. On full inspiration or after cough a broncho-vesicular\\nrespiration is brought out. When consolidation has taken place the\\nrespiratory murmur is bronchial. Rales, if present, are moist subcrep-\\nitant rales from associated bronchitis, or a few crepitant rales may still\\npersist, and a friction-sound be heard.\\nWhen resolution sets in the crepitant rale reappears, quickly followed\\nby moist subcrepitant rales, heard both on inspiration and expiration,\\nwhile dulness gradually yields to impaired resonance. The respiration\\nloses its bronchial character and again acquires a vesicular element\\nbefore becoming completely normal. It may be a week or two, or\\nmany months, even in uncomplicated cases, before the percussion-note\\nbecomes perfectly clear, and rales wholly disappear.\\nThe physical signs are modified by the intensity of the inflammation\\nin the lung structure and by the pleural complications. In massive\\npneumonia, for instance, the auscultatory signs are absent. On percus-\\nsion, the lung is absolutely flat. There is no fremitus or tubular breath-", "height": "4416", "width": "2668", "jp2-path": "practicaltreatis00muss_0_0335.jp2"}, "336": {"fulltext": "316 GENERAL DIAGNOSIS.\\ning. The physical signs resemble those of pleurisy with effusion. In\\nthe central pneumonia the physical signs may be delayed until the third\\nor fourth day. A few rales or febrile breathing over a small area may\\nbe the only indication of a possible lung process. In the aged the\\nphysical signs are obscure. In patients with laryngeal disease or marked\\nobstruction in the nasopharynx the physical signs may be indefinite.\\nBronchial breathing may not be heard unless the patient takes a full\\nbreath or coughs. In this class of cases, as well as those with feeble\\nrespiratory movement, as the aged, the Aveak, and those suffering from\\nsome other disease, as tuberculosis, the physical signs are not made out\\nbecause of the deficiency of respiratory movements. The indefiniteness\\nof the physical signs makes the diagnosis all the more difficult, because\\nit is this class of subjects in which the general symptoms of infection\\nare very slight. Increased respiration may be the most suggestive\\nsign. Slight elevation of the temperature and more or less stupor may\\nbe the only other clinical symptoms.\\nDuration and Course. The duration of the disease is from one to\\ntwo weeks. It may subside by crisis on the third, fifth, seventh, or\\nninth day, or gradually by lysis. Crisis is marked by a critical sweat,\\na copious discharge of limpid urine, or sometimes by a few loose move-\\nments of the bowels, accompanying a fall of temperature to or below\\nnormal.\\nInstead of clearing up, the pneumonia may progress to suppuration,\\nabscess, or gangrene. These conditions can be made out by the char-\\nacter and range of temperature, the general condition of the patient,\\nthe sputum, and the physical signs. Termination in abscess or gan-\\ngrene is rare.\\nIn cases proceeding to a fatal issue the strength fails, respiration\\nbecomes more labored, and expectoration increasingly difficult. The\\nnumber of respirations often diminishes, but the pulse continues fre-\\nquent and often becomes small and irregular. Physical examination\\nshows diffuse bronchitis with oedema. The heart s action is irregular\\nand rapid. The sounds are weak and feeble the first becomes short\\nand snappy like the second, and later both are weak or indistinct. Death\\nmay occur abruptly from convulsion, or more frequently from asphyxia,\\ndue to oedema of the lungs, which in turn sets in on account of weak-\\nness of the heart or the development of heart-clot from cardiac asystole.\\nVarieties. Migratory pneumonia. Sometimes, with the reappear-\\nance of abundant rales and increased expectoration, the fever continues\\nhigh, or, if the temperature has fallen to normal, again rises, the\\npatient is disinclined to take food, has a dry, brown tongue, and is often\\ndelirious. In such cases the pneumonia is probably extending in the\\nlung already involved, or has attacked the other lung.\\nTyphoid pneumonia is an unfortunate name for an adynamic form of\\nthe disease with typhoid symptoms. If it arises in the course of or\\ncomplicates low fevers, it is usually of the typhoid type but it occurs\\nalso in those much exhausted, in depraved health, or exposed to unhy-\\ngienic surroundings. It is found also in cases of septicaemia, in Bright s\\ndisease, in drunkards, and in the negroes in the southern part of the\\nUnited States.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0336.jp2"}, "337": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 317\\nThe characteristic features of this form of pneumonia are the great\\nphysical prostration and the weak heart-action. The fever is high, the\\nrespiration and pulse frequent, and delirium and vomiting are more\\nfrequent than in the ordinary form. The skin sometimes has a dusky\\nhue the tongue is heavily coated, or may be dry and brown, and\\nsordes collect on the teeth. The sputa may be rusty, and sometimes\\npure blood is expectorated. The disease may prove fatal rapidly, or\\nmay linger for a long time, the patient only gradually coming out of\\na low typhoid state. It is always dangerous.\\nBilious pneumonia is the name given to a type of pneumonia occur-\\nring in persons who are already suffering from malarial poisoning.\\nThe initial chill lasts longer, and the pain in the side, from coincident\\npleurisy, is more marked that in ordinary pneumonia. The fever is\\nmore remittent, and jaundice and vomiting are present.\\nPneumonia in infants is characterized by nervous symptoms. Re-\\npeated convulsions and active delirium may be most pronounced, fol-\\nlowed by torpor and coma. There is no sputa and but little cough.\\nThe apex of the lung is affected.\\nPneumonia in the aged is characterized by latency of symptoms.\\nThere is but little cough and expectoration. A tendency to the typhoid\\nstate, however, is pronounced. The physical signs are obscure.\\nPneumonia in alcoholic subjects also develops insidiously and may be\\nmasked by the symptoms of delirium tremens. The temperature may\\nbe the only indication of infection, as there is no pain, no cough, no\\nexpectoration, and no dyspnoea.\\nPneumonia with Other Infections. The staphylococcus and strepto-\\ncoccus pyogenes, the colon bacillus, and the bacillus pneumoniae (Fried-\\nlander) are often found with the pneumococcus, and may predominate,\\ninducing a mixed infection. The micro-organisms which cause diph-\\ntheria, typhoid fever, influenza, and the plague may cause a pneumonia\\nwhich resembles that of lobar pneumonia in the extent of the consoli-\\ndation. The micrococcus lanceolatus is found in increased numbers in\\nthe sputum of these cases. There is not the same intensity of pulmo-\\nnary symptoms, however. The respirations are not so hurried. The\\nphysical signs, while extensive, are obscure, and indicate rather a heavy\\nlung (congested) than one greatly consolidated. There is impaired reso-\\nnance, feeble breathing, and a few rales in a large number of cases.\\nIt is this form of lobar pneumonia which it is difficult to distinguish\\nfrom bronchopneumonia or catarrhal pneumonia an infection which\\nusually begins in the upper air passages. This form of local infection is\\nconsidered in the chapter on diseases of the lungs.\\nDiagnosis. The diagnosis is based upon the aggregation of special\\nsymptoms. The mode of onset, the chill, the course of the fever, the\\npain in the chest, the cough, the peculiar expectoration, the dyspnoea,\\nthe abnormal pulse-respiration ratio, the peculiar character of breath-\\ning, the physical signs, and leucocytosis are the phenomena of the symp-\\ntom-complex. It must be remembered that in children, in the aged, in\\ndrunkards, in cases of chronic disease, the type is different. In drunk-\\nards cerebral symptoms are more marked. In children the cerebral\\nsymptoms are more prominent, the expectoration often absent. In the", "height": "4416", "width": "2660", "jp2-path": "practicaltreatis00muss_0_0337.jp2"}, "338": {"fulltext": "318 GENERAL DIAGNOSIS.\\naged, the cough, the expectoration, and the fever are not pronounced\\nthe former may be absent the onset is insidious. The same onset and\\ncourse occur in wasting diseases, as cancer, phthisis, Bright s disease,\\ndiabetes, and organic heart disease. In this class of cases a small patch\\nof pneumonia, difficult to determine on physical examination, may be\\nattended by the gravest general symptoms. In all of the above cases,\\nif there is fever without cause, although no pulmonary symptoms are\\npresent, the lungs must be examined repeatedly. In many such cases\\nthe physical signs are obscured because respiratory action is enfeebled\\nby the primary condition.\\nPneumonia must be distinguished from other acute inflammatory\\naffections of the lung and pleura and from acute tuberculo-pneumonic\\nphthisis. The evidence for each is considered in the respective sections.\\nThe presence of leucocytosis serves to distinguish it from acute tubercu-\\nlosis and from typhoid fever, meningitis, and influenza. To distinguish\\npneumonia from pleurisy with effusion, the aspirator may be used.\\nBacteriological Diagnosis. Staining and microscopical exami-\\nnation of the sputum reveal the characteristic micro-organism. Care\\nmust be taken to secure the sputum from the lung. By inoculation of\\nrabbits with the sputum the disease is readily reproduced. The organ-\\nism is not readily found in the blood. (See the Sputum.)\\nPneumonia may be distinguished from cerebrospinal meningitis by\\nthe results of spinal puncture alone from acute tuberculous pneumonia\\nby the examination of the sputum. The diagnosis in the latter instance\\nmay be postponed, as tubercle bacilli are sometimes not found until the\\ntenth or twelfth day. (See Tuberculosis.) Typhoid fever sometimes\\nresembles pneumonia, and must be distinguished after the first week\\nby the results of serum diagnosis.\\nPneumococcus Septicaemia. The account we have just given of\\npneumonia represents but one phase of the pneumococcus infection.\\nThis infection may be attended, by very grave symptoms, especially\\nthose of a toxic nature, with but little if any involvement of the lung\\ntissue. It is well known that we may see the chill, fever, rapid pulse,\\nand hurried respiration with but little evidence of consolidation in the\\nlung, but with nervous symptoms paramount. Delirium, stupor, coma\\nwith the phenomena of the ataxic or the typhoid state may prevail. (See\\npages 199 and 200.) In the ataxic state the symptoms resemble those\\nof mania. In the typhoid form they are not unlike those of uraemia.\\nIn either instance death ensues in coma or from heart failure with its\\nattending symptoms. Preceding the cardiac failure the urine is dimin-\\nished in amount and the secretions generally suppressed.\\nIn other forms of this infection the localization of the process is in\\nthe pleura, as in empyema, in the pericardium, in the endocardium,\\nand in the cerebral meninges. Pneumococcus inflammation of these\\nstructures is very common. It may develop at the same time that the\\nlungs are affected, independently of the process in the lungs, or subse-\\nquent to it. These forms will be considered in a discussion of the\\nvarious local inflammations just referred to.\\nIt is important to remember that in pleural, pericardial, and cerebro-\\nspinal infections the nature of the infection can be determined by aspi-", "height": "4416", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0338.jp2"}, "339": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 319\\nration and bacteriological examination of the fluid removed from the\\nrespective serous cavity. The pneumococcus infection can be positively\\ndiagnosticated in this manner.\\nThese complications, which occur in the course of the disease, modify\\nthe clinical picture and obscure the diagnosis.\\nTuberculosis.\\nThe infection discussed in this section prevails to a greater degree\\nthan that of all the others combined. In some forms, as pointed out\\nin the clinical description, fever is one of the gravest symptoms. In\\nother forms the febrile process may not be pronounced. It must be\\nremembered that the fever may be due to the specific micro-organism\\nor its toxin, or it may be due to a mixed infection. Staphylococcus\\nand streptococcus infections are common attendants upon the tubercu-\\nlous infection. This secondary infection may disappear or may become\\nthe most prominent infection. In many instances a terminal infection\\nensues, causing mortal symptoms. Infection by the pneumococcus is\\nthe most common of these terminal infections. (See page 228.)\\nTuberculosis is an infectious disease, the course of which may be\\nacute or chronic. It is caused by the bacillus tuberculosis. This\\nmicro-organism sets up a specific inflammation characterized by the\\ndevelopment of nodules or tubercles, or by a diffuse growth of tuber-\\nculous tissue. Either anatomical product may undergo caseation or\\nsclerosis, and in either instance ulceration or calcareous degeneration.\\nInvasion of the body by the micro-organism may give rise to general\\ninfection, with an eruption of miliary tubercles in most of the organs\\nand structures of the body, or to a local infection. General tubercu-\\nlosis is acute local tuberculosis may be acute or chronic. In acute\\ntuberculosis the serous membranes, the lungs, liver, kidneys, lymphatic\\nglands and spleen, the bone-marrow, and choroid coat of the eye may\\nbe invaded in whole or in part. In chronic tuberculosis the lymph-\\nglands, the lungs, the serous membranes, the tissues and organs of the\\nalimentary canal, the liver, the organs of the genito-urinary system,\\nand the brain and cord are individually invaded.\\nDiagnosis. The diagnosis of any form of tuberculosis is aided by\\nthe determination of the chief factors in its etiology, where this is\\npossible.\\nBagtekiological Diagnosis. First. The discovery of the bacillus\\ntuberculosis in any inflammatory area, or any product of inflammation,\\nas serum, blood, pus, or the secretion from any gland or mucous mem-\\nbrane invaded by the disease, establishes at once the diagnosis of this\\ncondition. The method of determining the presence of this micro-\\norganism is fully detailed in the various descriptions of tuberculosis in\\nthe discussion of local diseases, and in the accounts of the examination\\nof the sputum and of exudations and transudations. Inoculation of\\ninflammatory products, as of a gland or of fluid which has been sedi-\\nmented, is a positive mode of diagnosis. Guinea-pigs are selected for\\nthis purpose.\\nSecond. As tuberculosis is an infectious disease, discovery of the\\ninfection is an aid in the diagnosis. Infection takes place by means of", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0339.jp2"}, "340": {"fulltext": "320 GENERAL DIAGNOSIS.\\nthe inhalation of the sputum or other secretions, which when dry float\\nabout in the air. It implies in a measure more or less contact with\\nindividuals previously infected. In rare cases such contact is produc-\\ntive of the disease by means of direct contagion. The second source of\\ninfection is the food-supply. This may occur from the consumption\\nof milk secured from a cow infected with tuberculosis. The eating of\\nmeat of tuberculous animals may possibly lead to infection. Direct\\ninoculation is another but rarer source of infection. This usually\\noccurs accidentally only.\\nThird. It is possible that tuberculosis may be inherited. A more\\nprominent etiological f actor which aids in the diagnosis of the disease,\\nis the presence of a certain type of structure which is a marked heredi-\\ntary characteristic in families, on account of which feeble resistance is\\noffered to the invasion of the tubercle-bacillus. The phthisical and\\nphthisinoid chest which belongs to this type has been described else-\\nwhere, and the tuberculous and scrofulous states have been outlined.\\n(See page 67 and Part II., Chapter II.) These anatomical conditions,\\nwhich are inherited, undoubtedly favor the development of tuber-\\nculosis.\\nIt is a mistake to lay much stress in the diagnosis of tuberculosis\\nupon the age or the occupation of the individual. Tuberculosis may\\noccur at any age. It is true, however, that at certain periods of life\\nthe tubercles are distributed more commonly in one group of organs,\\nwhile in other periods they affect another group. Lymphatic, joint,\\nand meningeal tuberculosis is most common in the first decade of life.\\nThe mesenteric glands are particularly open to invasion at this period.\\nThe diagnosis of tuberculosis, whether local or general, is further\\naided by a complete knowledge of the phenomena that attend the\\nentrance of the virus into the body and the mode of diffusion through-\\nout the body after infection has taken place. The phenomena at the\\npoint of entrance of the micro-organism are nearly always distinct.\\nThe general invasion is associated with symptoms like those of specific\\nfevers. The local secondary effects upon the tissues are always decided.\\nIt must be borne in mind that after the exposure, which may lead to\\ninfection, either an acute form of tuberculosis of a general character\\nmay be set up, with or without marked local symptoms, or acute local\\ntuberculosis alone may arise. In local tuberculosis the disease is con-\\nfined to one organ or to the lymphatic glands and the organs in the\\nlymphatic distribution, as the bronchial glands, which are primarily\\naffected, and to the lungs. In these structures the entire process of\\nnodular formation, caseation or sclerosis, ulceration or calcification,\\nmay take place. The disease remains primarily local. On the other\\nhand, it may be spread by continuity of structure through the lymph-\\natics throughout the remainder of the organ affected, leading to its\\nultimate destruction and the death of the patient or general infection\\nof the system may take place from the primary local area. The pri-\\nmary seat of infection may be the lungs, the larynx, the alimentary\\ntract, or the genito-urinary organs. Primary tuberculosis of the serous\\nmembranes, of the lymph -glands, of the bones and joints, may take\\nplace.", "height": "4416", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0340.jp2"}, "341": {"fulltext": "THE DATA OBTAINED BY OBSERVATION.\\n321\\nThe symptomatology and diagnosis of the various forms of tubercu-\\nlosis are detailed in the section devoted to the special diseases of the\\nvarious organs of the body.\\nThe Tuberculin Test. The physical signs and clinical symptoms\\nmay point to an inflammatory process in one of the many structures of\\nthe body which may be invaded by tubercle bacilli. On the other\\nhand, failure in health, loss of weight, anaemia, and moderate fever may\\nalone occur. The nature of the inflammatory process may be obscure.\\nTo determine more accurately whether the inflammation is tuberculous\\nor not, or the decline due to tuberculosis, we can resort to the use of\\ntuberculin. Since the researches of Koch, who introduced tuberculin\\nas a remedy in tuberculosis, he himself as well as a number of other\\nobservers, has employed this preparation to determine the presence of\\ntuberculosis in the body. In this country Trudeau has been the earliest\\nand most earnest exponent of this means of diagnosis. After the injection\\nof tuberculin a group of phenomena follows, known as the tuberculin\\nreaction, if tuberculosis existed anywhere in the body. It was thought\\nthe occurrence of this reaction was necessary to bring about a cure.\\nAs a therapeutic measure its value has not been upheld by experience.\\nThe invariable production of the reaction has led it to be used as a\\ndiagnostic medium.\\nPhenomena of Eeactiox. About twelve hours after the injec-\\ntion of tuberculin the temperature rises rapidly. In the course of a\\nfew hours it has risen two or three degrees. This elevation of tem-\\nFiG. 76.\\n103\\n102\\n101\\n100\\n98\\n97\\nV\\nA\\nll\\ns\\n1\\nX\\n1\\nA 1\\nu\\n-z;H\\ni\\nA\\nf\\nA\\nr\\nV\\nV\\ny\\nf\\n5J3\\n-V\\ns\\nr\\ns\\ny\\n1/\\nDAY OF DIS.\\nMai\\ni-jth\\nMai\\n\u00e2\u0080\u00a2h IS\\nth\\nlarc\\ni 141\\nh\\nMs\\nrcii\\n15th\\nPULSE\\noV\\ns\\n-,C,\\nf\\nf\\nJ 5\\n5$\\nEVENING\\n,-MC\\niBNir*\\nG\\nENI\\nG\\ni\\\\\\n3RNI\\nsG\\n,EV\\nE 1\\n3,\\n,-M\\nDRNI\\n:G\\nDATE\\nG-S [10-12\\n2-4\\n0-0\\n10-12\\n0-3\\n10-12\\n2-4\\n6-3\\n10-1S\\n2-4\\n6-8 |l0-12\\n2-4|,s| 1( ,2\\nTypical reaction with tuberculin.\\nperature is attended by malaise, pains in the head, back, and legs, and\\nsometimes nausea or vomiting. The maximum temperature is main-\\ntained for two or three hours, and then a gradual decline to the normal\\ntakes place. The normal temperature is reached in from twenty-four\\n21", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0341.jp2"}, "342": {"fulltext": "322 GENERAL DIAGNOSIS.\\nto thirty-six hours. The whole period of the reaction, from the time of\\nthe injection until the termination of the fever, is about forty-eight\\nhours. With the fall of temperature to normal the constitutional\\nsymptoms subside. The accompanying chart (Fig. 76) shows the\\ncourse of the fever in a typical reaction.\\nMethod. Twenty-four to forty-eight hours preceding the test the\\npatient s temperature should be taken every two hours to determine\\nthe range at this period of the disease. The injection should be made at\\na time when the reaction could be observed i. e., during the period\\nof normal or subnormal temperature. This, of course, can only be\\nselected if the temperature of the disease is intermittent. The hour of\\nday selected to inject the tuberculin should be such that the reaction\\nmay be conveniently observed during the waking hours of the patient.\\nBedtime or the early morning hours are the most convenient.\\nThe site of the injection is not material. Usually the interscapular\\nspace is selected. The amount of tuberculin employed is of the greatest\\nimportance. The initial dose should never exceed five milligrammes,\\nand it is better to use less than this, and an increasing quantity in-\\njected every second or third day. The maximum dose should not ex-\\nceed ten milligrammes. For children one-twentieth to one-tenth of a\\nmilligramme may be the initial dose. The crude tuberculin should be\\ndiluted at the time it is used with 1 to 2 per cent, solution of carbolic acid.\\nAt the point of injection a little redness and infiltration, with tender-\\nness to the touch, is observed. This local reaction may also be seen at\\nthe site of former negative injections when the larger dose produces\\nreaction. In pulmonary tuberculosis in which physical signs are\\nobscure some auscultatory phenomena which were previously absent\\nmay be found during the period of a reaction. This test also enables\\none to detect tuberculosis in the pleura, pericardium, peritoneum,\\ngenitourinary tract, and lymphatic glands, the meninges, bones, and\\nthe skin. The test is of special value in cervical adenitis.\\nIt must be remembered that a negative result with large doses of\\ntuberculin is of more value than a positive one. In the former instance\\none can affirm that tuberculosis is absent, as well as that there is no\\nold focus in any of these organs. It must also be remembered that\\nthe test should only be employed after all other means have failed to\\nmake a positive diagnosis.\\nAcute miliary tuberculosis has been spoken of elsewhere. (See Part II.,\\nChapter II.) Its course may resemble typhoid fever, septicaemia, or\\nmalignant endocarditis. It usually develops in the course of tubercu-\\nlosis in some other organ of the body. The typhoid form has been\\ndescribed in the section indicated. It must not be forgotten that the\\ndiagnosis is rendered positive by the demonstration of the presence of\\ntubercle-bacilli in the blood, or of the occurrence of choroidal tubercles\\nin the eye-ground. Another form is attended by marked pulmonary\\nsymptoms. This is the type seen in the bronchial pneumonia that occurs\\nin children following measles and whooping cough. (See Catarrhal Pneu-\\nmonia.) Of the pulmonary symptoms dyspnoea is the most prominent.\\nCyanosis is marked. The physical signs are not prominent, and may\\nbe those of bronchitis alone. Although there is impaired resonance", "height": "4412", "width": "2648", "jp2-path": "practicaltreatis00muss_0_0342.jp2"}, "343": {"fulltext": "THE DATA OBTAINED BY OBSERVATION.\\n323\\nat the base of the lungs, areas of hyper-resonance are observed above and\\nin front of the chest. Collapse of the lung may cause tubular breathing.\\nThe temperature rises to 102\u00c2\u00b0 or 103\u00c2\u00b0. An inverse type may be seen.\\nThe diagnosis of acute tuberculosis is determined by the history of\\ninfection from extraneous sources or from local tuberculosis in some\\nportion of the body, and by the presence of bacilli.\\nThe following conditions should point to the possibility of chronic\\ntuberculosis in some portion of the body (1) Emaciation, not otherwise\\nexplained (2) chlorosis or anaemia (3) weakness without cause (4)\\nfever the temperature should be taken every two hours during night\\nand day (5) causeless sweats (6) gastro-intestinal catarrh (7) morn-\\ning nausea (8) signs of local inflammation in some organ of the body.\\nInfluenza.\\nHigh temperature out of proportion to the local signs of inflamma-\\ntion in the lungs or other structures characterizes this infection. The\\nfever may be continuous, remittent, or intermittent.\\nFig. 77.\\nF\\n10(5\\n105\\n104\\n103\\n102\\n101\\n100\\n99\\n98\\n97\\nDAY OF\\nDISEASE\\nM\\nE\\nE\\nM\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nh\\nV\\n1\\nj\\n/I\\n1\\nv\\n1\\ny\\ny\\n1\\no\\n3\\n4\\n\u00e2\u0096\u00a0i\\n6\\n7\\nTemperature in influenza\u00e2\u0080\u0094 interrupted crisis. (Wilson.)", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0343.jp2"}, "344": {"fulltext": "324\\nGENERAL DIAGNOSIS.\\nFig. 78.\\nF.\\n105\u00c2\u00b0\\n104\\n103\\n102\\n101\\n100\u00c2\u00b0\\n99\\n98\\n97\u00c2\u00b0\\nDAY OF\\n[HSEASE\\nM\\nE\\nM\\nE\\nM\\nE\\nM E\\nM E\\nM\\nE\\nM\\nE\\nI\\n1\\nJ\\n1\\nA\\nf\\n1\\nA\\nJ\\n1\\nV\\ni\\n1\\nA\\nV\\nl|\\n1\\n2\\n3\\n4\\n5\\n6\\n7\\n-40\\nInfluenza\u00e2\u0080\u0094 intermittent type. (Wilson.)\\nFig. 79.\\nF\\n104\u00c2\u00b0\\n103\u00c2\u00b0\\n102\u00c2\u00b0\\n101\\n100\\n99 J\\n97\\nDAY OF\\nDISEASE\\nM\\nE IV\\n1 E\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nI\\n1\\nI\\ni\\n1\\nA\\nn\\nzf\\nzt\\n1\\n~t\\nr\\n1\\n1\\nj\\ny\\nA\\nA\\n1\\nv\\n1\\nI\\nA\\nx\\nv/\\nV\\nV\\nl\\ni\\n2\\n3\\n4\\n5\\no\\n7\\n-40\\n38\\nInfluenza\u00e2\u0080\u0094 remittent type. (Wilson.)", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0344.jp2"}, "345": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 325\\nInfluenza is a specific contagious febrile disease, occurring in wide-\\nspread epidemics, having a very short period of incubation, and charac-\\nterized by great prostration, marked nervous symptoms, and catarrhal\\ninflammation of the respiratory or gastro-intestinal tracts, or both.\\nThere is great liability to relapse, and to complications, which are gen-\\nerally pulmonary or nervous.\\nThe disease generally begins with the ordinary symptoms of coryza\\nbut the headache over the eyes and root of the nose is more severe, and\\nmay be so agonizing as to mask all other symptoms. The lacrymation,\\nrhinitis, and tormenting cough are all usually worse than in ordinary\\ncoryza. Physical weakness, weariness, and depression of spirits are\\nalmost invariably present, and they sometimes reach an extraordinary\\ndegree. Fever is usually moderate (100\u00c2\u00b0 to 102\u00c2\u00b0), but may be 104\u00c2\u00b0 to\\n105\u00c2\u00b0 for several days, and then gradually subside. It may terminate\\nby crisis (Fig. 77), or may assume an intermittent or remittent type\\n(Figs. 78 and 79). In ordinary cases the patient seeks relief first for\\nthe headache, severe aching pain in back and limbs, and extreme\\nweakness if these are relieved he is apt to complain most of incessant\\nracking cough, often due more to a tracheitis than to bronchitis.\\nNausea and vomiting are not uncommon, especially in the morning, at\\nwhich time also the patient frequently feels worse than he does later\\nin the day. Sleep is broken and restless, and may be accompanied by\\ndrenching perspirations. Severe neuralgic pains are common.\\nIn some cases the disease attacks the stomach and bowels especially,\\nand vomiting with diarrhoea are the prominent symptoms. In others\\nthe predominant symptoms are nervous, and great pain with prostra-\\ntion masks any catarrhal symptoms. Torpor and delirium may be\\npresent. Sometimes a prolonged and severe attack of asthma marks\\ninfection in susceptible persons.\\nThe duration of the disease is from a few days to a few weeks.\\nConvalescence is remarkably tedious, and is characterized by persistent\\nweakness. Sweats are often annoying during this time. The heart\\noften continues for some time to beat too frequently and to be easily\\nexcited by exertion. Relapses are common.\\nDiagnosis. Bacteriological Diagnosis. This is possible when\\nthe characteristic bacilli are detected by the means described in the\\nsection on sputum. Influenza in the great majority of cases is easily\\nrecognized. In certain cases, however, it is to be differentiated from\\npneumonia, typhoid fever, and cerebrospinal meningitis.\\nCases in which the disease sets in with high fever and marked\\nchest-symptoms are very apt to be mistaken for pneumonia but the\\nheadache and prostration are more intense, while the respiration is not\\nso frequent. Sweats are common, and albumin and casts in the urine\\nare by no means rare. Physical exploration shows that both lungs\\nare involved, though often not to the same degree. Resonance is im-\\npaired, and auscultation shows moist crepitant and subcrepitant rales,\\nwhich seem to be due to an oedematous condition of the lung-tissue,\\nassociated with a diffuse bronchitis. A true lobar pneumonia is rarely\\npresent even as a complication.\\nIf diarrhoea is one of the symptoms, typhoid fever has to be excluded.", "height": "4416", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0345.jp2"}, "346": {"fulltext": "326 GENERAL DIAGNOSIS.\\nThis is extremely difficult in the first two or three days. As a rule,\\nheadache, backache, nausea, and sleeplessness are at this time greater\\nin influenza, the spleen is not so much, if at all, enlarged, the diarrhoea\\ncan be checked, and tenderness and pain in the right iliac fossa are absent.\\nIt can be distinguished from cerebrospinal meningitis by noting the\\nfact that it begins with coryza, whereas cerebro-spinal meningitis\\noften sets in with chill, vomiting, and faintness the headache in the\\nformer is usually frontal, hi the latter occipital, and accompanied by\\nstiffness of the back of the neck. Further, in cerebro-spinal menin-\\ngitis there are often swellings of the joints, delirium alternating with\\ncoma, and in young subjects convulsions are common.\\nFinally, it may be said that the pronounced diagnostic feature is the\\npreponderance of general symptoms over local inflammations. The\\noccurrence of undue exhaustion, extreme general neuralgias and myal-\\ngias, high fever, and profuse sweats, without intense catarrh or inflam-\\nmation to account for or co-ordinating with them, is of the highest\\ndiagnostic significance. The presence of an epidemic, the contagious\\nnature of the affection, the sudden onset, and the bacteriological diag-\\nnosis, all point to influenza.\\nEpidemic Cerebro-spinal Meningitis.\\nIn this infection more than all others the course of the temperature\\nis without diagnostic significance unless it be that this want of a char-\\nacteristic course is significant. Its extraordinary irregularity is most\\nstriking when a large number of charts are examined. The fever may\\nhave the course and exacerbation of a typhoid temperature, but it is\\nmore similar to that of tuberculosis. It is often of very short dura-\\ntion, followed by a prolonged subnormal temperature. It may be high\\nfrom the immediate onset of the disease, or remain below 100\u00c2\u00b0 for\\nseveral days, and then suddenly rise to a great height. Remissions\\nand exacerbations may attend many of the cases. The most marked\\nfeature, apart from the irregularity of the temperature, is the inequality\\nbetween the pulse and the temperature. In some instances the pulse\\nis rapid, and the temperature is normal or subnormal, while later in\\nthe disease the pulse may be slow when the temperature rises to a con-\\nsiderable height.\\nConcerning the temperature, then, it may be said that it may be in-\\ntermittent, remittent, or continuous it may be intermittent at one\\nperiod, continuous at another it may be afebrile it may be afebrile\\nat one period and continuous at another.\\nCerebro-spinal meningitis, also known as spotted fever, is an acute,\\nspecific, infectious, and mildly contagious disease, endemic and epi-\\ndemic, characterized by evidences of systemic infection, and generally\\nalso by symptoms depending upon inflammation of the cerebral and\\nspinal meninges particularly intense pain in the back and head, hyper-\\nesthesia, retraction of head and neck, delirium, coma, convulsions, and\\nvomiting.\\nIt is most common in cold weather, and in children under fifteen\\nyears of age. None of the epidemics show a continuous extension. The", "height": "4416", "width": "2608", "jp2-path": "practicaltreatis00muss_0_0346.jp2"}, "347": {"fulltext": "THE DATA OBTAINED BY OBSERVATION.\\n327\\nperiod of incubation is unknown, but is probably short. It is free\\nfrom symptoms. The invasion of the disease is abrupt, although in\\nsome instances the patient may complain of rheumatoid pains in the\\nlimbs or a joint, and headache and weakness. Usually the first\\nFig. 80.\\nHhV Zl 23 21 25 20 27 28\\n29 30 1234567 8\\n10 U 12 13 14 15 10 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2\\n10\\nC MEMEMEMEMEMEME\\nMEMEMEMEMEMEMEM1MEMEM\\ntMEMEMEMEMEMEMEMEMEMEMEMEMEMEMEMEMEMEMEMEMEMEMEME\\ni\\nO 10(3\\nt J\\n10 -f\\nn\\ntt\\nI .zIrVL\\nA\\n4 K d-t -ft\\nlino\\nIiA-A-\\n7 A~l 7 T\\ng\u00c2\u00bb v Mi if vi\\n^VWL 7^1 Z\\n\u00e2\u0096\u00a0i- i u. i f vv J^-V\\nA_^\u00e2\u0080\u0094 ^ZA\\nv V s,j^l l^vv v i iA^V7\\n5 9S\\ns\\no\\nH\\n5\\nc 3U\\no-\\n,5\\n-/t -v 5 A,I\\n10Q 1 1\\na M Zfv\\n~\\\\A/ A Y\\\\ V W\\nMiK^i/\\n^3-J-\\nV- /\\\\y ^7 -^y\\\\ a\\ni 4Af\u00c2\u00a5 I\\nit\\n^Z T ^V^\\ni ^i\\n1\\n7i\\nCerebro-spinal meningitis, showing irregularity of pulse and temperature. (Councilman.)\\nsymptom is a severe chill, which may awaken the patient from sleep.\\nIn other cases the initial symptom is a convulsion. Then quickly\\nfollow repeated vomiting, intense headache, sometimes accompanied\\nby backache, retraction of the head, delirium, and extreme prostration.\\nThe rise in temperature is moderate, and the pulse is as often slow\\nas frequent. The face is pale and livid, expressing suffering, and the\\npatient may toss from one side of the bed to the other, begging some\\nrelief for his headache. Simple stiffness of the muscles of the neck\\nmay prevail. The pain in the head may be occipital or frontal. The\\npain in the back becomes more severe, and root-pains dart in all direc-\\ntions, but especially into the limbs or joints, which may be swollen and\\ntender to the touch in fact, the whole skin is hypersesthetic and the\\nreflexes are increased. The spinal muscles become rigid, and the head\\nis often retracted. Less frequently the back is arched and trismus\\noccurs. Delirium is common at night. It may develop very early or\\nappear at a late period of the disease. It is sometimes violent or low\\nand muttering. It is often of a sportive type, the patient making\\nabsurd remarks, cracking jokes, or singing snatches of a comic song.\\nDelirium may alternate with tonic or clonic convulsions and with\\nstupor. The appetite is poor, the bowels constipated. A remission\\nmay occur on the third day, with temporary improvement of the\\nsymptoms.\\nAs the attack progresses there may be strabismus, Avhich is usually\\ndivergent, inequality of the pupils, nystagmus, ptosis, and optic neu-\\nritis. Vertigo, tinnitus, anosmia, and photophobia are common.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0347.jp2"}, "348": {"fulltext": "328 GENERAL DIAGNOSIS.\\nHyperesthesia and delirium persist. Facial paralysis, a monoplegia,\\na hemiplegia, or a paraplegia may occur. The pulse becomes more\\nfrequent and the fever continues. In favorable cases improvement\\nnow begins, the headache and root-pains abating, and delirium and\\nspasms becoming less frequent. In unfavorable cases the convulsions\\nmay become more severe and end in fatal coma, or the patient may\\nsink into a typhoid condition, with nephritis as a complication. Coma\\nmay come on in the beginning and continue until death.\\nThe skin eruptions, which explain the name spotted fever, are\\nnot always present and exhibit no constant character. Herpes and\\npetechia are the most frequent in other cases the eruption is a pur-\\nplish mottling, or is macular, or the eruption resembles that of measles.\\nHerpes is most common on the nose and mouth, then on the cheek,\\nforehead, eyes, and ears. The blood shows a leucocytosis, the increase\\nbeing due to the polynuclear leucocytes.\\nIn the malignant (fulminating) form of the disease death occurs in\\na few hours, or two or three days. Such cases are apt to arise early in\\nan epidemic. The patient has a violent chill delirium occurs early\\nthe headache is less intense, or at any rate gives way rapidly to stupor\\nand coma. The pulse is frequent and feeble there may be no rise of\\ntemperature, the skin being cool, clammy, and cyanotic. Local or\\ngeneral convulsions may occur. The eruption may be purpuric, and\\necchymoses may even occur. The urine is scanty and contains albu-\\nmin and casts.\\nMild cases usually occur late in epidemics. They are characterized\\nby severe aching in the head, back, and limbs, nausea, vomiting,\\nvertigo, and prostration. They closely resemble the nervous type of\\ninfluenza, and would escape recognition except during an epidemic.\\nAn abortive form, ending in recovery in two or three days, and an\\nintermittent form, with exacerbations on alternate days, have been\\ndescribed.\\nThe duration of the disease is from a few hours to two or three\\nmonths. In ordinary favorable cases there is decided improvement\\ntoward the end of the first week, and convalescence is established in two\\nweeks. It may become chronic and last for weeks, and, as already stated,\\nmay be fatal in a few hours. Relapses are common in some epidemics.\\nThe most frequent complications are on the part of the lungs and\\nheart, particularly pneumonia and endocarditis or pericarditis. Pneu-\\nmonia often occurs so early that it is difficult to decide whether it is\\nprimary with marked nervous symptoms, or is only a complication of\\nthe cerebro-spinal fever. Nephritis also occurs.\\nThe most frequent sequels are deafness, blindness, headache, and local\\npalsies.\\nDiagnosis. The diagnosis in the presence of an epidemic is not diffi-\\ncult, although an absolute diagnosis can only be made by lumbar punc-\\nture. The fluid withdrawn is more or less cloudy if the patient has\\nmeningitis. If it is the epidemic form, microscopical examination of\\nstained cover-slips and cultures will expose the diplococcus. In some\\ncases fluid cannot be secured, either because the spinal canal is filled\\nwith membrane or the fluid is retained in the lateral ventricles.", "height": "4416", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0348.jp2"}, "349": {"fulltext": "THE DATA OBTAINED BY OBSERVATION.\\n329\\nThe fluid is turbid in the early part of the disease. In some cases\\na purulent sediment forms in the bottom of the test-tube at once. In\\nothers, the fluid is simply turbid, and after standing contains consider-\\nable fibrin and many cells. The fluid secured at the first puncture may\\nbe more turbid than that secured later, although the symptoms may be\\nmore severe than at first. If the acute symptoms subside the fluid may\\nbe clear, and no cells may be found. In the intermittent cases the\\nfluid may be clear during the interval that the patient is without\\nsymptoms. In chronic cases there may be no turbidity.\\nThe cells in the spinal fluid are chiefly polymorphonuclear leuco-\\ncytes pus corpuscles. Small lymphoid cells and large endothelial\\ncells may be present. The latter are phagocytic, and have large oval\\nor round nuclei. They may contain leucocytes and blood-corpuscles.\\nIn the pus corpuscles or leucocytes the diplococci are found they are\\nrarely found outside of the cells. Late in the disease the pus corpus-\\ncles do not stain sharply and are degenerated. In chronic cases the\\nfluid contains a few pus corpuscles which are smaller than usual, and\\nlike lymphoid cells.\\nBacteriological Diagnosis. This disease is due to the diplococeus\\nintracellular is. This micrococcus appears in diplococeus form as two\\nhemispheres the size of the ordinary micrococcus. It stains with the\\nordinary stains for bacteria. It is decolorized by the Gram method.\\nThe staining is sometimes irregular, some being brightly stained, others\\nfaintly. There is some variation in the size of the organisms. Both\\nvariation in size and staining are apparently due to degeneration. The\\ntwo organisms are sharply separated usually, though sometimes they\\nseem to be united. (Figs. 81 and 82.)\\nFig. 81.\\nFig.\\nFig. 81. Pas cells containing diplococci from the meninges. A few diplococci are in the exudate\\noutside of the pus cells. Between the pus cells there are delicate fibrillse of fibrin. The drawing\\nis an accurate representation of a group of cells in the field of the microscope. (Councilman.)\\nFig. 82. Pus cells from an alveolus of the lung in a case of diplococeus pneumonia. The cells\\nare swollen and contain immense numbers of diplococci. Both figures from stained cover-slips.\\nThe organisms do not grow profusely. The blood-serum mixture\\nof Loftier as prepared by Mallory is the best medium. It is often\\ndifficult to make cultures unless a large quantity of material is used.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0349.jp2"}, "350": {"fulltext": "330 GENERAL DIAGNOSIS.\\nTransfers must be made daily to keep cultures going. The growth\\non the serum mixture forms round, white, shiny viscid-like colonies\\nwith smooth outlines. They do not liquefy the blood-serum. In\\nthe tissues the diplococcus is found in the interior of the polynuclear\\nleucocytes.\\nCultures. Cultures should be made at the time of puncture. In the\\nmajority of cases a growth of the diplococcus is found, although even\\nin acute cases rarely they may not grow. In chronic cases a growth\\nis only rarely obtained. (Plate VIII.)\\nThis form of meningitis must be excluded from pneumococcus men-\\ningitis, tuberculous meningitis, and streptococcus meningitis. In the\\npneumococcus form the symptoms are comparatively slight and are\\nusually preceded by pneumonia. In the streptococcus form the clini-\\ncal history is like that of ordinary forms of meningitis. The evidence\\nof an infection elsewhere is usually present. Tuberculous meningitis is\\nrecognized by the methods employed to detect tuberculosis elsewhere\\nin a patient suffering from the usual symptoms of cerebro-spinal men-\\ningitis. The most positive method of distinction of the various forms\\nis by lumbar puncture. (See Chapter XXI.)\\nKernig s Sign (Kernig, 1884; better, 1898). This sign is of\\nvalue in the diagnosis of meningitis, but is present in any form. It is\\ndetermined by placing the patient in the dorsal decubitus, with the legs\\nrelaxed and fully extended at the knees. When the child is raised in\\na sitting posture the knees are flexed, and cannot be extended on\\naccount of contracture of the posterior muscles of the thigh. In adults,\\nif the patient is propped up, or seated on the side of the bed, and an\\nattempt made to extend the leg on the thigh, there is contraction of the\\nflexures. The test can be equally well performed by flexing the thigh\\non the abdomen until it makes a right angle. When an attempt is\\nmade to extend the leg it will be found that the limb cannot be fully\\nstretched out if meningitis is present.\\nDiphtheria.\\nIn this infection the temperature-range is variable. The infection\\nmay be intense, and yet the temperature remain subnormal, especially\\nif the fever is due to the toxin, and not, as is frequently the case, to a\\nmixed infection.\\nDiphtheria is an acute, specific, infectious, and contagious disease,\\nsporadic and epidemic, occurring especially in children from one to six\\nyears of age, and characterized by insidious or abrupt onset, with mod-\\nerate fever, and the development upon the fauces or upon any abraded\\nsurface of a grayish-white false membrane, which has a tendency to\\nextend, especially to the larynx. The subsequent phenomena are\\nthose of stenosis of the larynx, or toxaemia, with or without superadded\\nuraemia or marked cardiac Aveakness it is further characterized by the\\nliability to paralysis as a sequel.\\nDiphtheria is spread by inhaling the expired breath of a diphtheritic\\npatient, or breathing air which has been contaminated by the clothing\\nof the patient or the discharges from his nose and throat. It may also", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0350.jp2"}, "351": {"fulltext": "PLATE VIII\\nFig. 1.\\nFig. 2.\\nCerebro-Spinal Meningitis. (Councilman.\\nFig.\\nForty-eight-hour culture of diplococcus intracellularis on Loefner s blood-serum mixture.\\nFig. 2. Abundant growth in twenty-four-hour culture on fresh blood-serum. The colonies are\\nminute, very numerous, and somewhat resemble similar cultures of the pneumococcus.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0351.jp2"}, "352": {"fulltext": "", "height": "4388", "width": "2664", "jp2-path": "practicaltreatis00muss_0_0352.jp2"}, "353": {"fulltext": "THE DATA OBTAINED BY OBSERVATION.\\n331\\nbe transmitted directly, as when a fragment of membrane is ejected by\\ncoughing and infects the mouth or eye of physician or attendant.\\nMoreover, it is contained in the sewers of large cities where the dis-\\nease is endemic, and it persists in damp cellars if they have once been\\ninfected. Hence sewer-gas and cellar-air may carry the disease.\\nThere is reason also for believing that a similar disease affects birds,\\nfowls, and cats at times, and from them may be transmitted to man.\\nThese facts must be borne in mind in making the diagnosis.\\nThe specific poison is the Klebs-Loffler bacillus and its toxin.\\nWhile children from one to six years of age are especially liable to\\nit, no age is exempt neither the newborn babe nor the very aged.\\nOne attack does not protect a person completely against a subse-\\nquent attack.\\nThe period of incubation varies from a few days to two weeks, or\\nperhaps longer in exceptional cases. As a rule, it is less than a week.\\nIt is shorter when the poison is virulent, and when infection has been\\nupon abraded surfaces.\\nThe onset in mild cases is deceptively free from positive symptoms.\\nThe child is languid, perhaps slightly chilly, and has a little fever,\\nwith thirst, impaired appetite, and discomfort in swallowing. Unless\\nthe nature of the trouble is suspected the child is not thought ill enough\\nto be kept in-doors. The throat is slightly inflamed, especially about\\nthe tonsils. The child may protest that there is no pain on swallow-\\ning. In from twelve to twenty-four hours from the onset, sometimes\\nlater, a grayish pellicle will be found upon the tonsils, and the cervical\\nglands will be swollen.\\nFig. 83.\\n102\\n101\\n100\u00c2\u00b0\\n99\\no\\nDAY OF DIS.\\nPULSE\\nRESP.\\nDATE\\nr\\nM\\nA\\na\\nCO\\ni\\n1\\nJ\\n_\u00e2\u0096\u00a0\\nf\\n._:\\nu\\ns\\nV^-\\na\\n1\\ns\\nCM\\nV\\nI\\nn\\nA\\n(M\\nf\\\\\\na\\nY\\n,_\u00e2\u0080\u00a2\\nk\\nv\\n1\\n.J\\nA\\n1\\ni a\\na.\\no\\nA\\n\\\\j\\ns.\\nLL\\ns\\n_\u00e2\u0080\u00a2\\nV s0\\n-o-\\no\\n;_\\nK.\\nJK\\ni\\n7\\nV\\nr\\n10\\nO\\no\\nj-\\nt\\nV-\\nV\\nJ\\nz:\\n7\\nL,\\nj*\\nT\u00e2\u0080\u0094 1\\n01\\nM\\n53\\ns\\nCO\\nCO\\nCO\\nlO\\nlO\\nto\\nf4\\nf4\\n$6\\n*y*\\nf4\\n/4\\nf4\\nf4\\nf4\\n$4\\nS4\\nf\u00c2\u00ab4\\nf^f\\n$4\\nf4\\nf4\\nf4\\nf4\\nM\\nS3\\nCO\\n83\\ns\\nW\\nB.\\nB.\\nss\\nDiphtheria.\\nIn more severe cases the disease begins with chill or chilliness, fol-\\nlowed by a rise in the temperature to 102\u00c2\u00b0 or 104\u00c2\u00b0, sore-throat, and\\nsometimes vomiting, though this is not so common as in scarlatina.", "height": "4416", "width": "2652", "jp2-path": "practicaltreatis00muss_0_0353.jp2"}, "354": {"fulltext": "332 GENERAL DIAGNOSIS.\\nConvulsions and delirium may occur if the fever be high or the case\\nmalignant, but they are not common. Disgust for food makes it diffi-\\ncult to nourish the patient. Headache, thirst, and aching in the back\\nand limbs may be complained of. Prostration is often very pronounced\\nfrom the first.\\nObjective Symptoms. The characteristic false membrane appears\\nfirst as a grayish pellicle upon one or both tonsils, and spreads thence\\nto the soft palate and pharynx. The membrane soon becomes thicker\\nand whitish in color when fully developed it appears like white or\\ngrayish-white parchment, not lying loosely upon the surface, but em-\\nbedded in the mucous membrane, the inflamed swollen edges of which\\nrise above the false membrane, surrounding it as the crystal of a watch\\nis surrounded by the rim (J. Lewis Smith 1 As the membrane becomes\\nolder it may be brownish, or even blackish in color, if tincture of iron\\nhas been given. If it is forcibly torn from the underlying surface hem-\\norrhage is excited and the membrane is reformed. As the membrane\\nloosens spontaneously there is often marked inflammatory reaction at\\nthe edges of the surrounding mucous membrane, and in the tonsils\\nthere may be decided sloughing, with a dark, gangrenous appearance.\\nThe temperature usually falls on the second or third day, but this\\ndoes not indicate either a favorable or an unfavorable end. A temper-\\nature but little above normal is not uncommon in profound toxaemia.\\nAlbumin is usually present early, and often tube-casts and renal epi-\\nthelium also can be found. The submaxillary and cervical glands are\\nswollen, and it may be difficult to open the mouth sufficiently to inspect\\nthe throat.\\nAs pointed out by Buzzard and McDonnell, the patellar tendon\\nreflexes are often abolished as early as the first day.\\nIn favorable cases the membrane ceases to extend after three or four\\ndays there is no extension to the larynx the urine is free from albu-\\nmin, or only slightly albuminous and the pulse is not more than 100\\nto 120 and of good force.\\nIn unfavorable cases the membrane shows a tendency to extend,\\neither upward into the nasal fossae, producing a thin, irritating, excori-\\nating discharge from the nostrils, and rendering mouth-breathing neces-\\nsary or it may extend also to the ears through the Eustachian tube,\\nor into the maxillary sinus or the extension may be downward into\\nthe larynx, producing laryngeal stenosis. This is announced by hoarse-\\nness, with rapidly increasing difficulty in breathing. Inspiration is\\nhigh-pitched, noisy, and difficult the patient brings all the accessory\\nmuscles of respiration into play, the alae of the nose play, the ribs are\\nsucked in, and still he pants for breath. Every now and then a parox-\\nysm of coughing produces cyanosis.\\nIn other unfavorable cases the throat-symptoms are not dangerous,\\nbut uraemia develops. The urine is scanty, contains a large amount\\nof albumin, considerable blood, and numerous blood, epithelial, and\\ngranular casts. There are oedema of the feet and puffiness of the eye-\\nlids. There is apt to be repeated vomiting convulsions, followed by\\n1 KeatingVOvclopsedia of Diseases of Children, 1889, vol. i. 606.", "height": "4416", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0354.jp2"}, "355": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 333\\ncoma, and death may end the scene, or the patient may slowly emerge\\nfrom the dark valley.\\nIn still other cases the diphtheritic poison affects the heart. The\\npulse becomes feeble and very frequent, the first sound very faint\\nacute dilatation of the right heart may occur. There may be faintness\\nand a tendency to cyanosis on the slightest provocation, or attacks of\\nsinking and faintness may come without warning in still other cases\\nsudden exertion induces paralysis of the heart, and death.\\nIn some malignant cases the patient is overwhelmed by a large dose\\nof the poison, and dies in from one to three days in collapse from acute\\ntoxsemia, without any special local symptoms to account for it. In\\nothers the false membrane extends rapidly over the fauces, pharynx,\\nand nasal cavities to the larynx death occurs from early obstruction,\\nor, if it is postponed, there is extensive sloughing, with death from sec-\\nondary blood-poisoning or septic pneumonia.\\nIn exceptional cases the membrane is primary in the nares or larynx,\\nor develops upon some abraded surface, as a burn, or in the vagina of\\na puerperal woman. It may also attack the mucous membrane of the\\neye or the seat of a recent operation. Diphtheria also occurs as a com-\\nplication of other diseases, particularly scarlet fever.\\nThe most frequent sequelse are anaemia, albuminuria, and paralysis.\\nThe latter comes on in from one to two weeks after convalescence has\\nset in, but it may appear much earlier, and in exceptional cases later.\\nIt may be marked simply by loss of the knee-jerk, which has been\\nalluded to already in the symptomatology, or involve the palatal and\\npharyngeal muscles, causing nasal voice, difficulty in SAvallowing, and\\nregurgitation of food through the nose, or there may be multiple\\nperipheral neuritis.\\nLoffler s or the Klebs-Lbffler Bacillus. This is found in diph-\\ntheritic pseudomembranes, especially in the deeper portions. It is not\\nfound in the blood.\\nMorphology. A bacillus 2 to 3/* long by 0.5 to 0.8/z broad,\\nstraight or slightly curved, with very many irregular forms. (See Fig.\\n84.)\\nThe pseudo-diphtheritic bacillus resembles the genuine in all respects,\\nexcept that it is not pathogenic. It seems to be an attenuated form of\\nthe former.\\nBiological Properties. It is facultative anaerobic, non-motile,\\nand does not liquefy gelatin. It multiplies by fission. Stains with\\nLoffler s blue. Certain points are stained intensely, almost black. It\\ngrows in nutrient gelatin, nutrient agar, or bouillon, but best of all in\\nLoffler s blood-serum mixture (see page 243) at 35\u00c2\u00b0. (Death-point,\\n58\u00c2\u00b0, ten minutes exposure.) It forms large, round, elevated colonies,\\ngrayish-white in color and moist. There is no visible growth on\\npotato. Milk is a good soil. (See Plate VII., Fig. 4.)\\nOn inoculation it causes a diphtheritic pseudomembranous inflam-\\nmation. It generates a very poisonous toxin.\\nDiagnosis. Diphtheria is distinguished from ordinary pharyngitis\\nby the presence of membrane. From follicular tonsillitis by the pro-\\njecting mouths of the follicles containing a creamy-white exudate. Later", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0355.jp2"}, "356": {"fulltext": "334\\nGENERAL DIAGNOSIS.\\nthe exudate may cover the entire surface of each tonsil and be difficult\\nto distinguish from false membrane. The points of distinction are\\nthat in the former the exudate lies upon the surface and can be brushed\\nFig. 84.\\nColonies of pseudo-diphtheria bacilli\\nc. Colonies of diphtheria bacilli, X 249.\\n*II\\n\u00e2\u0080\u00a2It ^S\\nT\\nd. Diphtheria bacilli, X 1000.\\noff without force and without leaving a bleeding surface whereas in\\ndiphtheria the membrane is embedded in the mucous membrane and\\ncannot be torn from it without force. A raised, red inflammatory\\nborder of mucous membrane at the junction of the patch is strongly\\nsuggestive of diphtheria. In tonsillitis there is no appearance of mem-\\nbrane upon the soft palate or pharynx. Furthermore, in tonsillitis the\\nonset is attended with more fever and pain in swallowing than is true\\nin simple tonsillar diphtheria. The existence of albuminuria and swell-\\ning of the cervical glands indicates diphtheria, and the absence of knee-\\njerk is an important but not constant diagnostic sign of diphtheria.\\nThe presence of the Klebs-Loffler bacilli in a culture from a suspected\\nthroat is proof of the existence of diphtheria.\\nSeptico-pysemia.\\nThe clinical course of this infection and the bacterial causes have\\nbeen considered in Chapter XVI. (Class III. of infections). It will\\nbe recalled that the phenomena may attend a number of the infections\\ndescribed in this and in previous chapters. When occurring in the", "height": "4416", "width": "2680", "jp2-path": "practicaltreatis00muss_0_0356.jp2"}, "357": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 335\\ncourse of pneumonia, diphtheria, typhoid fever, etc., its causal origin is\\nrecognized by the methods discussed in the chapter referring to these\\ninfections. Septico-pysemia caused by pyogenic organisms, the so-called\\ncryptogenetic sepsis/ is recognized by bacteriological examination of\\nthe blood by an examination of the morbid secretions, or by an exam-\\nination of the products of inflammation. Bacteriological examination\\nof the blood has its limitations. Usually only late in the course of the\\ndisease and in the more intense infections can the bacteria be found.\\nExamination of the pus from foci of suppuration in the bones (osteo-\\nmyelitis), in the joints (pyaemia), in the serous cavities (empyema,\\npericarditis, peritonitis), in the lungs (see Sputum), in the genito-urinary\\ntract (see Urine), will show the infective micro-organism.\\nThe causal micro-organism is detected by cover-slip preparations\\nand cultures. (See Chapter XXI.)\\nGlanders.\\nA general febrile disturbance which attends this infection is similar\\nto that of the infective granulomata (Class IV. of infections). In severe\\ncases the symptoms are like those of an acute septicaemia. It is an\\ninfectious, constitutional disease, transmitted from horses to man,\\nappearing in an acute and chronic form, and characterized by an erup-\\ntion, ozaena, small tumors, ulcerations, cough, and death in coma or\\ncollapse in from one to four weeks in the acute form, or in three or\\nfour months in the chronic form, the symptoms in the latter resembling\\nat times syphilis and at times tuberculosis.\\nThe disease is rare in man. It may be acquired by direct inocula-\\ntion of an open wound with the pus from a glanderous ulcer or nasal\\nmucous membrane, or indirectly from infected straw or other material.\\nThe raw meat of a glandered animal also has infective power.\\nIn acute glanders the onset is marked by headache, slight fever, and\\npains in the limbs. If a wound has been infected this becomes pain-\\nful, swollen, and behaves like any poisoned wound. Sometimes a\\ndiffuse redness, resembling erysipelas, spreads from the infected point.\\nFagge refers to a case in which the first complaint was of pain in the\\nside and dyspnoea, so that acute pleuropneumonia was suspected.\\nAn eruption, consisting first of papules, which rapidly become flat\\nvesicles and then pustules or bullae, appears in the first day or two, or\\nsometimes not for a week or even longer (Fagge). The bullae or pus-\\ntules rupture and give vent to a thin purulent discharge.\\nThere may be hard, painful lumps in the muscles, with subsequent\\nsuppuration (farcy).\\nOzsena is not always present. It appears in the second or third\\nweek of the disease. It consists of a mucopurulent, then purulent,\\nfoetid discharge from the nose. The latter subsequently swells and\\nbecomes red and very painful. Ulcers and even necrosis of the sep-\\ntum are the lesions the same catarrhal condition may exist in the\\nthroat, eye, larynx, and mouth, accompanied at times by ulcers and\\nfalse membrane. The patient gradually sinks into a septicaemic condi-\\ntion, with irregular fever, dry brown tongue, albuminuria, delirium,\\ncoma, and collapse.", "height": "4416", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0357.jp2"}, "358": {"fulltext": "336 GENERAL DIAGNOSIS.\\nThe duration of the acute form is from one to four weeks. Only\\none in thirty-eight eases collected by Bollinger ended in recovery.\\nIn the chronic form there are ulcers upon the hand, face, forehead,\\nor elsewhere. In other cases the lesions are abscesses in connection\\nwith joints which are followed by persistent fistula?. In still other\\ncases there is pustular eruption. Ozsena may or may not exist. In\\nstill other cases the prominent symptoms are cough, bloody expectora-\\ntion, hoarseness, fever, and emaciation. Bollinger reports seventeen\\nrecoveries in a total of thirty-four cases of chronic glanders.\\nDiagnosis. Acute glanders is distinguished from rheumatism by\\nthe history of the case, the occupation of the patient, the existence of\\nan open, irritable sore, and the fact that while the joints may be\\npainful, they are rarely red and swollen, as in rheumatism. Subse-\\nquently the appearance of pustules, bulla?, and ozsena makes the case\\nclear.\\nThe same peculiar features serve to distinguish it from pyaemia,\\nmalignant pustule, and other infectious diseases.\\nIn a suspected case of chronic glanders a correct diagnosis might be\\narrived at by inoculating a mule or a horse with the nasal mucus or\\npus from a farcy.\\nBacteriological Diagnosis. The specific germ is the bacillus\\nmallei. This is a short, non-motile micro-organism resembling the\\ntubercle bacillus. It is 2 to 3/^ long, and 0.3 to OAju broad, frequently\\nhaving spores on the ends. It stains readily with all the basic aniline\\ndyes, although taking up the dyes irregularly.\\nThe diagnosis is readily made by the method of Strauss. A portion\\nof the suspected tissue or a culture from the lesions is inoculated into\\nthe peritoneal cavity of a male guinea-pig. If the case is one of glan-\\nders the testicles begin to swell in about thirty hours, and an orchitis\\nwith abscess develops. The diagnostic sign is the tumefaction of the\\ntesticles.\\nThe Mattein Test Mallein is the filtered products of the growth of\\nthe bacillus on fluid media. It is allied to tuberculin. The injection\\nof it in a suspected case produces a reaction similar in its course to\\nthe tuberculin reaction if the case is one of glanders.\\nCholera.\\nAn acute, specific, infectious disease, endemic in parts of India, but\\noccurring in epidemics elsewhere, characterized by the outpouring into\\nthe stomach and bowels of large quantities of a serous fluid resembling\\nrice-water, which fluid is usually vomited and discharged from the in-\\ntestines. It is further characterized by an algid state of collapse and\\nby painful muscular cramps.\\nThe specific poison of cholera is believed to be the comma-bacillus\\nof Koch and its ptomaine.\\nThe native habitat of cholera is India, particularly the neighborhood\\nof Calcutta here it is endemic, and thence it is liable to spread in suc-\\ncessive epidemic waves along the lines of travel by sea and land, over\\nthe whole world. It is scarcely, if at all, contagious the poison is", "height": "4416", "width": "2640", "jp2-path": "practicaltreatis00muss_0_0358.jp2"}, "359": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 337\\ncontained in the vomit and dejections, which contaminate the drinking-\\nwater, food, and clothing. The cholera-bacillus preserves its vitality\\nfor long periods of time in water, especially if the water is slightly\\nalkaline and contains vegetable matter, and in moist clothing, as rags.\\nThe period of incubation is probably short in the majority of cases,\\nlasting only a feAV days. Occasionally it is two weeks. There are\\nusually no definite symptoms during this time, but there may be a\\nsense of weakness, with loss of appetite and dyspeptic symptoms.\\nFiest Stage. The first stage, that of premonitory diarrhoea, is\\nbetter regarded as the beginning of true cholera. It is characterized\\nby profuse watery stools of a yellow or light-yellow color, and alkaline\\nin reaction. They are accompanied by a rumbling noise in the bowels,\\nbut are passed without pain. From six to a dozen of these passages\\noccur in twenty-four hours. The patient feels faint and exhausted\\nafter them, and may suffer with nausea, but vomiting is not usual.\\nIn severe cases there may be cramps in the calves of the legs. The\\nvoice is faint and husky, thirst intense, the tongue white and moist.\\nThe temperature is normal or slightly depressed.\\nThis stage may last from two days to a week, depending upon treat-\\nment. In some cases it is wholly absent, and the patient is ushered\\nabruptly into the second stage.\\nSecoxd Stage. This usually comes on during the night. The\\npatient is seized with vomiting, which is at first bilious, but the fluids\\nrapidly lose all color and become like rice-water. The stools likewise\\nresemble water in Avhich meal has been stirred, or in which rice has\\nbeen soaked a semi-transparent fluid, with particles of epithelium\\nresembling rice floating in it. This fluid seems to well up and re-\\ngurgitate rather than to be vomited from the stomach, and to gush in\\nquantities of a quart or two from the anus. Sometimes vomiting and\\ndiarrhoea occur at once. The patient has unquenchable thirst, and is\\ntortured with painful cramps of the toes, legs, belly, and diaphragm. As\\nthe discharges continue the patient becomes more and more exhausted\\nthe nose is pinched and twisted, the eyes sunken, the lips bluish, and\\nthe whole body may shrink beyond recognizable proportions.\\nThe skin is cold and moist, the breath icy, and the temperature\\nunder the tongue is sometimes as low as 78\u00c2\u00b0 to 80\u00c2\u00b0 F. In the vagina\\nand rectum it may be normal or slightly above normal. The patient,\\nhowever, often has a sensation of heat. The urine is very scanty, con-\\ntaining albumin and sugar, or it may be suppressed. The pulse is\\nvery small and feeble, 100 to 120. The mind is clear, but the patient\\nis listless, answering questions in an extremely faint voice and with\\nmanifest effort.\\nThird Stage. From this collapsed and algid condition the patient\\nmay slowly emerge, the skin becoming less cold, the cramps less severe.\\nA return of the secretion of urine is a hopeful sign. The reaction,\\nhowever, may simply introduce a low typhoid condition, with fever,\\ndry brown tongue, subsultus, low muttering delirium, and coma.\\nIn some cases serum is poured out into the stomach and intestines\\nand is retained there. The patient may be seized while walking with\\ndizziness, faintness, extreme prostration, and early collapse.\\n22", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0359.jp2"}, "360": {"fulltext": "338 GENERAL DIAGNOSIS.\\nIn other cases the patient is smitten down with profuse vomiting\\nand purging, dying algid and collapsed in a few hours, no reaction\\nappearing.\\nIn favorable cases the vomiting ceases, the stools become less fre-\\nquent, and are tinged with bile and have a faecal odor. The urine\\nincreases in volume, while the albumin diminishes. Convalescence is\\nvery protracted. Anaemia, great debility, feeble digestion, and some-\\ntimes obstinate diarrhoea delay complete recovery. Relapses are fre-\\nquent.\\nIn other cases reaction brings improvement in the gastro-intestinal\\nsymptoms, but uraemia develops, death following in convulsions or\\ncoma.\\nThe most frequent complications and sequelce are eruptions, chiefly\\nerythematous, ulcerations and bed-sores, parotitis, and a painful tetanic\\nspasm of the flexor muscles of the hands, forearms, legs, and feet, occur-\\nring between the tenth and fifteenth days of convalescence (Stills).\\nDiagnosis. The chief points in the diagnosis from other affections\\nare the knowledge of exposure to cholera the character of the vomit\\nand dejecta, which contain the comma-bacillus (for its detection see\\nunder Bacteriology) the cyanosis the rapid development of collapse,\\nwith cold skiu, icy breath, torturing cramps, and greatly shrunken\\nvisage and body.\\nCholera morbus differs in that the stools remain turbid with bile or\\nfaecal matter, or contain blood they never present the rice-water\\nappearance. Moreover, the passages are frequently preceded by col-\\nicky pains. Cyanosis and collapse are extremely rare. The stools\\ndo not contain the cholera-bacillus.\\nOther forms of acute toxic g astro-enteritis, whether from ptomaine-\\npoisoning or from corrosive poison, are to be distinguished by the\\nhistory, the difference in the character of the stools, and the compara-\\ntive absence of painful cramps in the legs, of cyanosis, and of collapse.\\nBacteriological Diagnosis. Koch remarks l As cholera resem-\\nbles in clinical symptoms cholera nostras, infantile cholera, certain\\nforms of peritonitis, certain organic poisons, and poisoning by arsenic,\\nit is important to attain some means of making a definite diagnosis.\\nSpirillum Choler^e Asiatics. The Comma-bacillus. The\\ncomma-bacillus of Koch is the specific causative agent of cholera. In\\na disease so wide-spread in times of epidemics, and so fatal, it is of\\ngreat importance to be able to recognize the bacterium that produces\\nit. Works on bacteriology give a fuller study than is permitted here,\\nand should be consulted. This is more especially true because, while\\nthe bacilli, as found in the stools, can be stained quite easily, and may\\nbe recognized by expert microscopists, in the great majority of cases\\ntheir recognition is only effected by bacteriological examination. They\\nhave no specific relation to dyes, as have tubercle bacilli.\\nMicroscopical Examination. The cholera bacillus is a short,\\nmore or less bent rod, both shorter and thicker than the tubercle\\nbacillus, and generally shaped like a comma. They are often found\\n1 Zeitschrift fur Hygiene und Infektionskranheiten, 1893, vol. xiv., No. 2.", "height": "4416", "width": "2640", "jp2-path": "practicaltreatis00muss_0_0360.jp2"}, "361": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 339\\nplaced end to end, and thus form a curve like a spiral. They are\\nalways present in the stools of cholera patients and sometimes in the\\nvomit. They are particularly abundant in the mucous floccules of the\\nrice-water discharges, and can be obtained from the linen soiled by\\nthe same. Cover-slip preparations are made from these portions by\\nplacing a uniform film on the slip, drying it in the air, and then pass-\\ning it through the flame of a Bunsen burner or spirit-lamp.\\nThe spirillum, or so-called comina-bacillus, consists of a slightly\\ncurved rod, with rounded ends, 0.8 to 2ii long by 0.3 to 0.4/i broach\\nIt is usually slightly curved like a\\ncomma, but may form a half -circle, or FlG 85\\ntwo may be joined like an S. Under j k\\ncertain circumstances they grow out III\\ninto long spiral threads. By Lo filer s 1 \\\\fi h ct m ,L l\\nmethod a single flagellum is found on\\nthe rods. It stains with anilines, but\\nslowly. An aqueous solution of fu\\nsin (Zeihrs red) is the best. (See\\nPlate III., Fig. 3, a; and Fig.^ 85). f \\\\i\u00c2\u00a3\\\\l\\\\ N v 61\\nIn addition to the cholera-bacilli, the (7 $t y I s h y\\nbacillus coli communis and other in- I j c J i\u00c2\u00a7V- I\\ntestinal bacteria are found. The i J t/^ i\\ncholera-bacilli lie in groups in the j U 1 v J fJ /.i\\nthread-like strands of mucus. They i J fop/l I X 4\\nform in heaps, the bacilli lying in the J I x fl\\\\\\\\\\\\\\nsame direction. Koch holds that this y j\\nmode of grouping is characteristic\\nand diagnostic. He further holds cholera spirilla oym on moist linen\\n^i L i -it t l X 600. (After Koch.) Cultivated from the\\nthat if bacilli coll are 111 close prox- dejections after two days.\\nimity to numerous scattered bacteria\\nresembling the cholera bacilli the case is one of Asiatic cholera.\\nThe bacillus of cholera nostras and one found in cheese by Deneke\\nresemble the comma-bacillus in shape, though somewhat larger, but\\nthey have bacteriological peculiarities by which they can be differ-\\nentiated.\\nBiological Properties. Aerobic (fac. anaerobic), motile, liquefying.\\nCultures. Growth. Grows in ordinary media at room tempera-\\nture faster in oven. Does not grow except between 14\u00c2\u00b0 to 42\u00c2\u00b0 C.\\nGelatin plates At the end of twenty-four hours small white colonies\\nappear deep in the gelatin. These grow toward the surface and liquefy\\nthe gelatin in a funnel-form, which gradually deepens, and at the\\nbottom of the colony is seen as a small white mass. Under low power\\nthe colony is white or pale yellow, margins uneven, texture granular,\\nsurface looks as if covered with bits of glass. \\\\Yhen liquefaction\\nbegins a dim halo forms about the colony, which by transmitted light\\nis roseate in hue.\\nStab-culture in Xutrient Gelatin. Develops all along the puncture,\\nliquefaction beginning near the surface, forming a funnel which en-\\nlarges, and finally the gelatin almost entirely liquefies. (See Fig. 87.)\\nOn potato a thin, transparent grayish-brown layer. Milk, bouillon,", "height": "4416", "width": "2640", "jp2-path": "practicaltreatis00muss_0_0361.jp2"}, "362": {"fulltext": "340\\nGENERAL DIAGNOSIS.\\nblood-serum, are all favorable. In media with other bacteria it soon\\ndies. Death-point, 52\u00c2\u00b0 5 In moisture it retains vitality for months,\\nbut is killed by drying.\\nFig. 87.\\nCholera spirilla. Tube-cultivations.\\n(Flugge.)\\na, after two days b, after tour days.\\nFmkler and Prior s comma-bacillus.\\nCultivation in gelatin.\\nc, two days d, four days old.\\nPeptone-cultivation. A small quantity of the dejection of some\\nflake of mucus is inserted with a platinum loop into a sterilized 1 per\\n?ent. peptone solution. The solution is maintained at 37\u00c2\u00b0 C. The\\ncholera bacteria are aerobic, and develop on the surface of the peptone,\\nwhile the faecal bacteria remain in the deeper layers. As soon as the\\npeptone is cloudy a drop from the surface is examined microscopically.\\nWithin six hours the surface is overwhelmed with a pure culture of\\ncholera bacilli. Later they are mixed with bacteria coli. The exami-\\nnation should be made from six to twelve hours after the peptone solu-\\ntion is inoculated. The peptone solution should be strongly alkaline,\\nand a 1 per cent, solution of common salt should be added. Care must\\nbe taken to see that the solution contains sufficient soda. In plate\\ncultivations the cholera-bacilli are overwhelmed by the fecal bacteria.\\nAgar-plate Cultivation. The growth is not so characteristic as\\nit is in gelatin. The cholera- bacilli form large colonies of light gray-\\nbrown transparent appearance. Colonies of other bacteria are less\\ntransparent. The colonies can be obtained in from eight to ten hours\\nafter exposure to a temperature of 37\u00c2\u00b0 C. Microscopical examination\\nof the colonies must be made.\\nCholera-red Reaction. Cholera-cultivations contain indol and\\nnitrous acid, and produce a red purplish color if sulphuric acid is added.\\nThis color is produced by other bacteria also, but by none other of the\\nbacteria that are curved. Care must be taken to make the cultiva-\\ntions with suitable peptone and to have the sulphuric acid free from\\nnitrous acid.", "height": "4416", "width": "2640", "jp2-path": "practicaltreatis00muss_0_0362.jp2"}, "363": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 341\\nTo determine its presence in the shortest time, inoculate diluted\\nbouillon. After ten to twelve hours a wrinkled film has formed.\\nMake another culture in the same way from this, then inoculate gel-\\natin plates and use color-test on these.\\nIxoculation. The agar-cultivations are employed. They must be\\nintroduced into the abdominal cavity of the guinea-pig. The injection\\nmust not be made into the intestine, a matter which requires considera-\\nble practice. Xo other spirillum or curved bacillus produces the symp-\\ntoms of cholera.\\nAcute Dysentery.\\nThe fever which attends this infection is, from a clinical stand-point*\\nthe least characteristic symptom. It varies in part with the age of the\\npatient. In the aged it is subnormal, normal, or moderate. In the\\nyoung it is usually very high. It differs with the character of the\\ninfection. If a mixed infection prevails the temperature is not unusual.\\nThe term dysentery is applied to an inflammation of the intestinal\\ntract, chiefly the colon, which is attended by the symptoms of intesti-\\nnal catarrh in intense degree, with mucus and bloody discharges and\\nthe general symptoms of fever and prostration, followed by extreme\\nexhaustion, and at times the occurrence of abscesses in the portal cir-\\nculation, or of paralysis, arthritis, nephritis, or profound anaemia. It\\nwas formerly thought to be an epidemic, mildly contagious disease.\\nAlthough of frequent occurrence sporadically, it is especially common\\nin jails and institutions, in camps, or where people are crowded together,\\nwhen at the same time hygienic conditions are most unfavorable. It\\nusually occurs in the summer or fall, and is attributed to the drinking\\nof impure water. A form most common in the tropics is called tropi-\\ncal dysentery. Recent investigations have shown that catarrhal dysen-\\ntery due to the above-mentioned circumstances may occur, and that\\nin addition tropical dysentery, which is not confined to the tropics,\\nis associated with inflammation and ulceration of the bowel, attended\\nby the amoeba dysenteric or A. coli.\\nCatarrhal Dysentery may be limited to simple inflammation of the\\nintestine, or may be followed by ulceration. Its first symptoms are\\nthose of intestinal catarrh. There is indigestion, with loss of appetite,\\nperhaps vomiting, and slight diarrhoea. These symptoms may be the\\nimmediate effect of the diarrhoea. At the end of three or four days a\\nchill may take place, showing the setting hi of an infection. The diar-\\nrhoea is attended by pain, at first seated around the umbilicus it then\\nbecomes marked in the course of the colon. The movements are fre-\\nquent, preceded by constant desire, and attended by extreme tenesmus.\\nThe stools, which were first faecal and fluid, soon become scanty, and\\nconsist almost entirely of mucus and blood. The symptoms of local\\nproctitis are severe there is a sensation of a hot mass in the rectum.\\nThere may be strangury, and prolapse of the anus may ensue.\\nWith the continuance of acute pain and frequent evacuations the\\nskin becomes hot and dry thirst, nausea, and occasionally vomiting\\noccur. The temperature continues at about 103\u00c2\u00b0 the pulse is rapid.\\nThe patient is weak and restless the tongue is red and raw.", "height": "4416", "width": "2648", "jp2-path": "practicaltreatis00muss_0_0363.jp2"}, "364": {"fulltext": "342 GENERAL DIAGNOSIS.\\nIf the disease is severe from the start, or the course is unfavorable, the\\nstools may contain pure blood, or they may be dark in color, and con-\\ntain shreds of membrane. Pain and tenesmus disappear, and the evac-\\nuations become constant or involuntary. Restlessness is aggravated the\\nextremities become cold mild delirium sets in. The tossing and rest-\\nlessness are quite characteristic, and are attended by sighing and some\\ndyspnoea. The pulse is rapid and feeble the heart-sounds are weak-\\nened the tongue becomes dry and brown, the mouth is parched, and\\nthirst is intense ulcers develop in the mouth and sordes collect around\\nthe teeth. The delirium increases to stupor, and from that to coma.\\nThe urine, at first high-colored and scanty, becomes bloody, and con-\\ntains albumin and casts. Although the fever continues during this\\nstage, the extremities become cool, perspiration breaks out over the\\nforehead, and, instead of typhoid symptoms, the symptoms of collapse\\nmay ensue. If the disease is prolonged and the bowels are controlled,\\nthe symptoms of pyaemia may develop.\\nThe anaemia that ensues is extreme, and there is great wasting.\\nConvalescence is slow and may be attended by chronic diarrhoea.\\nBefore it is established ulcers of the skin may form on various parts\\nof the surface of the body. Arthritis is of common occurrence, and\\nparalysis may occur during convalescence on account of peripheral\\nneuritis. Chronic dysentery may succeed the acute. It is thus seen\\nthat the attacks may be of moderate severity or extremely grave\\nduring the course of the latter gangrene of the lower bowel may take\\nplace.\\nAmoebic Dysentery Tropical Dysentery. This differs from\\ncatarrhal forms of dysentery in many respects. The onset may be\\nabrupt or gradual, as in the previous form, with symptoms of intestinal\\ncatarrh. In most of the cases a frequent and painless diarrhoea follows\\na period of slight ill health. The diarrhoea alternates with short\\nperiods of constipation the stools are watery and contain mucus, but\\nno blood. The course of the disease is irregular. There may be inter-\\nmissions and exacerbations of the diarrhoea without obvious cause. It\\nmay rapidly pass from one grade to another, or become chronic. One\\nform is the gangrenous, which may scarcely be appreciated by the\\nsymptoms until the autopsy shows it to have been present. True\\nrelapses are common, and the tendency to chronicity is very great.\\nThe milder cases are attended by weakness, emaciation, and pallor\\nthe expression is dull the skin is dry and sallow the tongue pale,\\nflabby, and moist, slightly furred the abdomen is normal or retracted\\nthe temperature does not rise above 100\u00c2\u00b0, and the pulse ranges from\\n70 to 90. Sleep is disturbed by frequent evacuations of the bowels.\\nIn the grave form the face is drawn, or cyanosed or flushed, the ex-\\npression anxious the mind is clear. Anorexia, intense thirst, and\\nsleeplessness are present. The abdomen is greatly retracted, and there\\nmay be free sweating. The temperature is normal or subnormal, the\\npulse small and rapid. Progressive anaemia and loss of flesh are\\nprominent and dominate the intestinal symptoms. The skin is dry\\nand harsh, and of a dull greenish-yellow color if the cases are pro-\\ntracted.", "height": "4416", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0364.jp2"}, "365": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 343\\nThe special features of amoebic dysentery are 1. The anosmia-\\nThis is due to diminution of the red cells and the haemoglobin, first,\\nbecause of the action of the amoebae upon the red blood-corpuscles,\\nwhich they destroy second, the direct loss of blood and, third, mal-\\nnutrition. The first is the most prominent.\\n2. Diarrhoea may be the only feature of the disease. It is charac-\\nterized by great variation in character and frequency in all grades and\\nduring different periods of the disease. Intermissions and exacerba-\\ntions may be observed at any time. The latter begin suddenly, and\\nsubside in the same manner. They last from two to ten days. The\\nintermissions continue from one day to three weeks, during which the\\nfaeces are soft, but contain mucus. Councilman and Lafleur have ob-\\nserved this periodicity to be most marked in cases complicated with\\nhepatic abscess.\\n3. The Stools. The stools are extremely variable according to the\\nseverity of the ulceration, and also vary in number and character from\\nday to day in individual cases. In the gangrenous form they number\\nthirty or forty in twenty-four hours at first, then decline, so that\\ntoward the end of fatal cases but three or four take place. At first\\nthe movements are small, and consist of mucus with more or less\\nbright blood and small faecal masses. As ulceration advances the stools\\nchange, they become more copious and watery, faeces are absent, blood\\nis not so frequent. Shreddy masses of grayish or yellow color, mixed\\nwith mucus, appear. If there is sloughing, they become greenish or\\ngrayish, resembling spinach, or reddish-brown and very liquid or pul-\\ntaceous. The odor is penetrating and offensive. Shreddy masses of\\nnecrotic tissue are discharged. Gray liquid movements, somewhat\\nslimy, contain more pus than the others. Small opaque, or translu-\\ncent, gelatinous grayish masses, one to three cubic millimetres in diam-\\neter, are found in the stools.\\nIn the more moderate types the stools at the outset are like those of\\ngangrenous dysentery if the attack is abrupt. If gradual, the stools\\nare faecal, liquid, containing mucus and streaks of blood and many of\\nthe gelatinous grayish masses. Stools of this character number from\\nfour to ten in twenty -four hours this may continue for weeks. During\\nthe exacerbations the stools resemble those of the second period of the\\ngangrenous form. In chronic dysentery there is not so much mucus\\nor blood, except in exacerbations. The stools are of the consistence of\\nthin gruel and have an earthy or dull-yellow color. Mucus is persist-\\nently present, however, in the intermissions, when the stools are soft\\nand faecal.\\nThe reaction of dysenteric stools is generally alkaline.\\nMicroscopical Examination. In the mucoid and bloody stools\\nof the acute stage red blood-corpuscles, leucocytes, and large, round,\\nor oval epithelioid cells are seen. The latter are often in groups of\\nthree or more. The nucleus is about the size of the red blood-corpus-\\ncle, the protoplasm granular. Their outline is sharp. They may be\\ntaken for amoebae. They are non-motile and refract light less strongly.\\nCercomonas intestinalis is present, but bacteria are not abundant. In\\nthe later periods the cell-elements are less numerous shreddy and", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0365.jp2"}, "366": {"fulltext": "344 GENERAL DIAGNOSIS.\\nmuscular detritus and bacteria are observed, with elastic-tissue fibres.\\nCharcot s crystals and phosphates are seen. In chronic dysentery the\\ncell-elements are still fewer and amoebae are easily detected.\\nAmoeba Dysenteeje. Amoebae are found at all periods of the dis-\\nease. They vary in different cases and at different periods in propor-\\ntion to the severity of the intestinal ulceration. (See section on the\\nFaeces.)\\nThey are most abundant in the grayish-yellow gelatinous masses,\\nnext in the particles of clear or opaque mucus, and least in the fluid\\nportions of the stools. In chronic dysentery they are found in all\\nportions. In the intermission of the diarrhoea they may be found in\\nthe particles of mucus adherent to the faeces. They disappear as recov-\\nery proceeds, although they may be seen after the evacuations become\\nnormal. They vary in size and activity. They are more common in\\nthe alkaline and neutral stools. They are scarce and are rarely motile\\nin acid stools. In the more active forms of the disease red corpuscles\\nare seen.\\nFor the detection of amoebae the following should be observed\\nFirst, the stools should be passed in a warm bed-pan and kept at a\\ntemperature of 30\u00c2\u00b0 to 35\u00c2\u00b0 C. until an examination is made. Second,\\nthe stools must be examined before they become acid. Third, the\\ngelatinous masses in the stools should be selected for examination.\\nThey contain amoebae in greatest abundance. A magnifying power of\\nfour hundred diameters is required, although they may be seen with less.\\nA y 1 oil immersion lens is the best.\\nDesceiption of the Amcebje. When inactive they are round or\\nslightly oblong, highly refractive, and contain vacuoles of greater or\\nFig. 88.\\nAmoebae coli. (Hallopeau.)\\nless size. The latter are clear, and vary from small points to one-third\\nof the diameter of the areola. The ectosarc and endosarc may or\\nmay not be sharply divided. If they are, the outer is hyaline or\\nhomogeneous, the inner is more refractive and contains vacuoles.\\nThey are difficult to recognize in this condition, being mistaken for\\nswollen connective-tissue cells. The amoebae frequently enclose red", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0366.jp2"}, "367": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 345\\ncorpuscles, pus-cells, blood-pigment, bacilli, and micrococci. In a\\nfresh state the nuclei cannot be made out because they resemble vacu-\\noles. The endosarc is not granular, is composed of a dense substance,\\nand is highly refracting. When active the movement is characteristic.\\nIt may be slow or rapid, and is of two kinds, a progressive movement\\nand one limited to the throwing out of pseudopodia. The movements\\nappear to be rhythmical in some cases, occurring at regular intervals.\\nThe movement is sudden and characterized by change in form of the\\npseudopodia. The ectosarc and endosarc are clearly defined usually.\\nThe pseudopodia are hyaline and homogeneous, like the ectosarc.\\nThe amoeba changes its position sometimes by enlargement of the\\npseudopodia, into which the inner contents of the older part follow.\\nThe movements are increased when the examinations are made on the\\nwarm stage. These amoeba? may be stained with various aniline dyes.\\nIn catarrhal dysentery the stools are uniform in character, quantity,\\nand frequency. The onset is sudden, and evacuations consist of bright\\nblood and viscid, clear mucus mixed with faecal matter. Soon they are\\ncomposed entirely of mucus and a little blood. The mucus is viscid.\\nIn a week or ten days the mucus changes and becomes grayish-white\\nin color is less blood-stained and brown pultaceous or fluid faecal\\nmatter appears in the stools. As the blood and mucus disappear\\nformed faeces return. In the prolonged cases there are soft, yellowish-\\nbrown, or greenish stools in addition to the bloody mucoid stools.\\nThe frequency is greatest at the onset, and progressively diminishes\\nuntil convalescence is established. The more frequent the evacuations\\nthe smaller the size of the stools. The mucoid stools are small, pulta-\\nceous, more bulky. On microscopical examination red and white cor-\\npuscles, cylindrical, epithelial, and oval epithelioid cells are seen. The\\nlatter are very characteristic, and occur singly or in groups. Bacteria\\nare more common as improvement sets in. In the pultaceous stools\\nthe cell-elements are scarce. In diphtheritic dysentery the stools are\\nwatery. They resemble wheat-washings evacuations such as are de-\\nscribed in cases of gangrenous dysentery. They are grayish-green or\\nreddish-brown and very offensive. Mucus is present in small amounts.\\nAt first unclotted blood is present, afterward minute dark-red clots are\\nseen. Shreddy and finely divided material, gray or reddish-brown in\\ncolor, is present, but there are no sloughs. The stools are not numer-\\nous at first, and average from seven to fifteen daily during the course\\nof the illness. The quantity passed is small. Cylindrical epithelial\\ncells are most abundant on microscopical examination. Red blood-\\ncorpuscles and leucocytes are observed, but fibrin constitute the larger\\nportion of the stool. In all the stools bacteria are present in great\\nnumbers.\\nOther Symptoms of Amcebic Dysentery. Abdominal pain is\\nconstant it occurs in the early stages of both forms and in acute\\nexacerbations. As the movements diminish the pain decreases. In\\nthe gangrenous form pain also disappears, although the intensity of\\nthe process is increasing. In chronic cases the colic is complained of\\nduring the exacerbations during the intervals a dull, aching, or burn-\\ning pain is complained of in the upper quadrants. In all cases the", "height": "4416", "width": "2656", "jp2-path": "practicaltreatis00muss_0_0367.jp2"}, "368": {"fulltext": "346 GENERAL DIAGNOSIS.\\npain is cramp-like, boring or burning in character, and usually pre-\\ncedes and accompanies movements of the bowels. When severe it is\\ngeneral but it is usually localized in the lower abdominal zone.\\nModerate tenderness on pressure is present in most cases along some\\npart of the course of the large bowel. In catarrhal dysentery tenesmus\\nis common in the amoebic form it is infrequent. A burning sensa-\\ntion in the rectum and at the anus during and after the passage of\\nfaeces is generally complained of. Nausea and vomiting occur at the\\noutset or at irregular intervals, being caused by improper food, or due\\nto complications. Hiccough occurs in the terminal stages.\\nFever. In amoebic dysentery fever is not a prominent feature,\\nalthough there is usually a moderate rise in temperature. In the\\ngangrenous form it is normal, or may be subnormal for days. Chronic\\ndysentery is afebrile. In exacerbations of diarrhoea slight fever may\\noccur. Complications cause a higher temperature. If fever is present\\nit may be remittent or intermittent in character, or, if the illness is\\nprolonged, first continuous, then remittent, and then intermittent. If\\nthe latter, the usual morning fall is observed, although an inverse\\ntemperature may be present. Rigors occur with the complications.\\nSweating is observed, with subnormal temperature, in the gangrenous\\nform. In cases of abscess the fever is intermittent or remittent.\\nIn chronic dysentery the skin is excessively dry. The circulation\\nand respiration are influenced by the pyrexia. Anaemia is pronounced.\\nWhen exhaustion ensues the pulse becomes more feeble, compressible,\\nand rapid. The urine is albuminous, and often contains casts. In the\\ngangrenous form there may be retention of urine.\\nThe complications of amoebic dysentery are 1. Hepatic abscess,\\nor hepato-pulmonary abscess. 2. Peritonitis. 3. Hemorrhage from\\nthe bowels.\\nHepatic Abscess. This complication may develop at any period\\nof the disease. The time of the disease when it occurs cannot be deter-\\nmined definitely. In the subacute cases it is liable to develop from the\\nfourth to the twelfth week. The abscess may develop on the convex\\nsurface of the right lobe of the liver near the coronary ligament. In\\nthese cases the lung also becomes involved. Councilman and Lafleur\\nsuggest that infection takes place by the peritoneum. (See Abscess of the\\nLiver.) While the symptoms of abscess of the liver will be treated\\nunder the section devoted to liver disease, it is important to note that\\nhepatic symptoms may occur in cases in which, on account of the mild-\\nness of the disease, the local bowel trouble may be overlooked entirely.\\n(See Amoebic Abscess of Liver Musser and Willard, Phil. Co. Med.\\nSoc.) If the association of hepatic pain with fever and discharge of\\nmucus from the bowels is observed, it is barely possible, even if an\\nexamination of the faeces cannot be made, that a hepatic abscess is\\npresent. If, in addition, cough and expectoration occur, involvement\\nof the lungs is possible.\\nHepato-pulmonary Abscess. The character of the expectoration\\npoints conclusively to the nature of the lung complication. After a\\nperiod of dry, hacking cough, sudden expectoration of mucopurulent\\nor bloody sputum takes place. It is of a dirty-red or brownish color,", "height": "4416", "width": "2648", "jp2-path": "practicaltreatis00muss_0_0368.jp2"}, "369": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 347\\nnot unlike anchovy sauce. From this time on this material is expec-\\ntorated in varying quantities after a paroxysm of coughing. The expec-\\ntoration is diffluent, tenacious, and frothy. It varies in color from\\nbright red to russet-brown it may be bile-stained. The sputa are\\nalkaline the odor is not putrid. At a later period they become more\\npurulent, and contain less blood. The sputum separates into three\\nlayers an upper frothy layer, a middle layer of turbid fluid, a thin\\nlayer of mucopus below. Large amounts may be coughed up in\\ntwenty-four hours the sputa contain, on examination, blood-cor-\\npuscles, leucocytes, round alveolar epithelial cells and polyhedral, fatty\\ndegenerated cells, which look like liver-cells. Elastic-tissue fibres from\\nthe lungs are found with crystals of hsematoidin and tyroshi, and Char-\\ncot s crystals. Bacteria are present. Amoebae are constantly present.\\nThey vary hi size and activity, but are larger than those seen in the\\nstools. The sputum should be kept warm and examined as soon as\\npossible.\\nPeeitonitis. Peritonitis from perforation is not a common com-\\nplication of amoebic dysentery, but takes place occasionally hi the gan-\\ngrenous form. Peritonitis without perforation may occur. The\\nsymptoms do not differ from peritonitis under other circumstances\\nHemorrhage from the bowel occurs and may be sufficiently profuse to\\ncause death. This accident may occur in the course of amoebic ab-\\nscess of the liver, as in a case reported by the author, in which there\\nwere no intestinal symptoms. Other complications which have been\\ndescribed under catarrhal and croupous dysentery are likely to occur\\nin this affection.\\nThe Diagnosis. The diagnosis of amoebic dysentery is made abso-\\nlute by finding the amoebae in the stools. The history and the course\\nof the illness must also be taken into consideration, the characteristics\\nof which have been previously detailed. The irregularity, and the\\nintermittency of the diarrhoea, the infrequency of tenesmus, the mod-\\nerate fever, the reaction of the stools, and their comparative freedom\\nfrom bacteria, are further corroborative points.\\nThe Plague.\\nThis infection is seen in two forms One, pestis major, is character-\\nized by inflammation of the glands of the body, known also as malignant\\nadenitis. Another, pestis siderans, is attended by intense septicaemia,\\nwith or without hemorrhages. Unlike the first variety, the glands are\\nnot enlarged. It is divided, in accordance with its special features,\\ninto septicemic, pneumonic, gastro-intestinal, nephritic, and cerebral\\nforms.\\nIt is an acute, specific, infectious, and contagious disease, occurring\\nin epidemics, characterized by high fever, sometimes by petechias and\\nother hemorrhages, and, in cases which last long enough, by buboes.\\nThe death-rate is extremely high.\\nThe plague is a disease of the East, being endemic in some parts of\\nIndia, but epidemics have occurred in Italy, Russia, China, Turkey,\\nEngland, and other parts of Europe.", "height": "4416", "width": "2644", "jp2-path": "practicaltreatis00muss_0_0369.jp2"}, "370": {"fulltext": "348\\nGENERAL DIAGNOSIS.\\nThe period of incubation is from two to seven days. The invasion\\nis marked by lassitude, languor, headache, and dizziness. The stupid\\naspect and staggering gait may lead to the belief that the patient is\\ndrunk. Chill or chilliness soon supervenes, followed by fever, which\\noften rises to hyperpyrexia, and is accompanied by unquenchable thirst,\\nand sometimes nausea and vomiting. Delirium and a typhoid condi-\\ntion follow, with a marked tendency to failure of the circulation and\\ncollapse. If the patient survive until the second or third day, glandu-\\nlar swellings develop in the groin, or axilla, or angle of the jaw.\\nOften they have to be sought for to be found. Sometimes they are\\nprominent and are followed by suppuration and even ulceration. Car-\\nbuncles are much rarer manifestations than buboes. Petechias, vibices,\\nhemorrhages into the kidney, and bloody vomit, occur in the worst\\ncases.\\nDiagnosis. The diagnosis is based upon the history, the clinical\\ncourse, and the results of bacteriological examination. The following\\ndescription from Abbott enables the diagnosis to be readily made\\nFig. 89.\\nA\\n*r i Ci J\\n,\u00c2\u00bbC\u00c2\u00bb\\nBacillus of bubonic plague: A, iu pus from suppurating bubo; B, the bacilli very much enlarged,\\nto show peculiar polar staining. (Abbott.)\\nThis organism is described as a short, oval bacillus, usually seen\\nsingle, sometimes joined end to end in pairs or threes, less commonly as\\nlonger threads. It stains more readily at its ends than at its centre.\\nIt is sometimes capsulated is non-spore-forming is aerobic, and is\\nnon-motile. It is found in large numbers in the suppurating glands,\\nand in much smaller numbers in the circulating blood. (See Fig. 89.)\\nIt is demonstrable in cover-slip preparations made from the pus", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0370.jp2"}, "371": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 349\\nand in sections of the glands by the ordinary staining methods. Yersin\\nstates that it retains its color when treated by the method of Gram,\\nwhile Kitasato says that it at one time stains by this method and at\\nanother it becomes decolorized. Aoyama observed that those bacilli\\nwithin the suppurating glands were decolorized, while those in the\\nblood retained the stain when treated by Gram s method.\\nThe duration is from six to ten days. If there is much suppura-\\ntion, convalescence is prolonged.\\nLeprosy.\\nA chronic, specific, infectious disease, characterized by the develop-\\nment of tubercles, anaesthetic patches, and neuritis, and followed by\\nulceration and destruction of tissue. The disease occurs especially\\nfrom puberty to the thirtieth year, and oftener in men than in women.\\nIt develops slowly and insidiously. Sometimes the first skin lesion is\\na crop of bulla?, suggestive of pemphigus. More commonly there\\nappear reddish or violet-colored patches, varying in size from a quarter\\nof an inch to two or three inches in diameter, and becoming of a darker\\nhue later. The next step is the formation of nodules, which are char-\\nacteristic of the disease. These may develop upon the patches already\\ndescribed, or in other places. They vary in size from a pea to a bird s\\negg or larger. They are most common upon the face and extensor\\nsurfaces of the arms, legs, fingers, and toes. The tubercles consist of\\nan infiltration into the true skin they are raised, firm, relatively pain-\\nless, and vary in color from red to copper. The face is characteristi-\\ncally distorted into a fierce expression (leontiasis). The tubercles may\\nbecome absorbed and leave atrophic areas, but generally they break\\ndown into eroding ulcers, which slowly burrow and increase in extent,\\neating off a portion of the nose, fingers, hands, and feet, and exposing\\nmuscles, tendons, nerves, bloodvessels, and bone. Tubercles form also\\nupon nerve-trunks, and ulcers upon the mucous membranes. (See the\\nNose and Larynx.)\\nIn other cases, or in combination with the tubercles, especially upon\\nthe lhnbs and trunk, there are anaesthetic areas. Ulcers may follow\\nwithout the previous occurrence of tubercles. With the anaesthetic\\npatches are associated crops of bullae, and neuritis.\\nThe further peculiarities of the disease are its long duration, its\\nslow progress interrupted by apparent healing of some of the ulcers\\nits afebrile course (the temperature is generally subnormal) its com-\\nparative painlessness, and the slight impairment of the general health.\\nDeath results from gradual wasting, or is hastened by some intercur-\\nrent affection.\\nDiagnosis. The specific cause of the disease is probably the bacillus\\nleprae of Hansen. It is found in the thin pus of the ulcers and in the\\nlesions themselves. It consists of rods 4 to 6/i long and \\\\fi broad, closely\\nresembling tubercle-bacilli. They stain in alkaline fluids, but do not\\nbleach after exposure to acids. Staining cover-slip preparations with\\nthe Ziehl-Neelsen fluid and decolorizing in acid and alcohol bring\\nthem out. They may be distinguished by yielding their color more", "height": "4416", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0371.jp2"}, "372": {"fulltext": "350\\nGENERAL DIAGNOSIS.\\nreadily, and bv taking easilv aniline-elves in simple watery solution\\n(Yon Jaksch). (See Plate III., Fig. 4; b.)\\nThe diagnosis from a tubercular syphilide is made by the history of\\nthe case, the possibility of infection, the bacteriological examination,\\nthe slow progress, and the inadequacy of specific treatment. The pres-\\nence of anaesthesia and of neuritis points to leprosy.\\nActinomycosis.\\nThe general symptoms attending this infection are like those due to\\nsuppurative infections. The fever is irregular, often intermitting.\\nIt is a specific infectious disease of cattle, occurring occasionally in\\nman, attacking especially the lower jaw, lungs, and intestines, and\\ncharacterized by a long duration, by the development of tumors and\\nmetastatic growths, and by pycemic symptoms.\\nIt is due to the actinomyces, or ray-fungus (see Fig. 91), which pro-\\nduces in cattle the disease known as big or lumpy jaw and swelled\\nhead. The fungus is conveyed in the food or drink, and gains entrance\\nto the body through abrasions in the mouth or a decayed tooth, or is\\ninspired into the lungs. Israel, Ponfick, and Bostrom have given us\\nthe greatest amount of information in regard to this parasite. It was\\ndiscovered in 1845, in human beings, by B. v. Langenbeck, and in\\n1877, in cattle, by Bollinger.\\nFig. 90.\\nCase of actinomycosis.\\nAt the seat of invasion a slowly growing, slightly painful tumor\\ndevelops. Bones are affected as well as soft tissues. These become\\nswollen and suppurate, the fungus being at all times obtainable. The", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0372.jp2"}, "373": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 351\\nfungous masses appear to the unaided eye as particles of yellow sand,\\nand are greasy to the touch.\\nPulmonic Form. Actinomycosis of the lung may be divided into\\nthree stages a latent stage, when the lung proper is affected an active\\nstage, when extension to the pleura and chest wall takes place and a\\nfinal or chronic stage, when perforation and the formation of a thoracic\\nfistula occur and the adjoining organs become affected. The symp-\\ntoms of the first stage are those of chronic bronchial catarrh, with\\nlater the occurrence of the physical signs of consolidation, especially\\nin the mamillary and axillary regions of the chest, in the middle zone\\nof the thorax. The apices and bases are rarely affected primarily.\\nThe symptoms of the second stage are those of pleurisy, with adhesions\\nand with or without effusion. At this time the disease may extend\\ndownward to the liver and peritoneum, or the pericardium may become\\ninfected. Fever and pain accompany these processes. On physical\\nexamination, in addition to the signs of the pulmonary and pleural\\nconditions above mentioned, swelling of the thoracic wall will be ob-\\nserved, not unlike that of an empyema which is about to perforate.\\nThe swelling, which is at first dense, and hard, and red, becomes softer\\nin small areas, and may fluctuate. Fluid, which is mucopurulent and\\nshows the parasite, may be removed by aspiration. Repeated dry taps\\nmay occur before the needle secures the. serous or sanguino-serous exu-\\ndation in the pleura. The sputa at this time may accidentally show\\nthe parasite, although this is rare. The expectoration is mucopuru-\\nlent, but it is said to never contain elastic fibres. The course of the\\ndisease at this time may extend over many months, in contradistinction\\nto empyema on the one hand or carcinoma on the other. In the final\\nstage ulceration of the swelling is seen in many places, fistula forms,\\nand the disease extends to adjacent structures. Secondary infection\\nmay occur and symptoms of pyaemia develop.\\nThe masses which form upon the intestinal mucous membrane may\\nlead to suppuration and perforation of the intestine. Metastasis to any\\norgan may occur, with resulting local symptoms. The duration depends\\nupon the organs involved in metastases. If metastases do not lead to\\nearly death, that result is brought about at the end of months or years by\\nslow pyaemia, with resulting amyloid degeneration and its consequences.\\nIt is usually associated with chronic inflammation and the produc-\\ntion of pus. The pus is peculiar. It is thin and viscid. Small\\nnodules of gray or yellow color, the size of a poppy-seed, can be seen\\nby the naked eye when it is spread out on a glass. With a low power\\nthese particles are aggregations of spherules, which with a higher\\npower are seen to be arranged in masses radiating from a common\\ncentre. Each separate spherule is pear-shaped. They have high re-\\nfractive power. In the centre of the masses a network of fibres is\\nseen. If the mass be broken up numerous club-shaped forms in the\\nperiphery are seen, while at the centre a sort of detritus alone is ob-\\nserved. The micro-organism belongs to the class of fission-fungi, and\\nthe club-shaped bodies are the degenerated forms. (See Fig. 91.)\\nGram s method of staining brings out the threads of the network\\nmost distinctly. The centre is made up of a network of minute spheri-", "height": "4416", "width": "2640", "jp2-path": "practicaltreatis00muss_0_0373.jp2"}, "374": {"fulltext": "352\\nGENERAL DIAGNOSIS.\\ncal organisms, with converging constituent threads. The whole is sur-\\nrounded by a delicate envelope. The pear-shaped bodies may be\\ndenned by Weigert s process. Make a solution of 20 c.c. of absolute\\nalcohol, 5 c.c. of concentrated acetic acid, 40 c.c. of distilled water, and\\nsufficient French extract of litmus to color it ruby-red after repeated\\nfiltering. In this solution the cover-glass preparations are allowed to\\nremain for an hour, and then rinsed with alcohol rapidly and placed\\nFig. 91.\\n?j^i^;S^ r\\nActinomyces.\\n11)\\na 2 per cent, gentian- violet solution for three minutes. The fluid\\nshould be boiled before use and filtered after cooling. The fungous\\nthreads are stained a ruby-red, while the central mass of actinomyces\\nis colorless.\\nDiagnosis. Simple microscopical examination is usually sufficient\\nto determine the nature of the fungus. The recognition is more posi-\\ntive if we bear in mind the peculiar character of the pus in which the\\nnodules and the club-shaped forms are seen. It must not be mistaken\\nfor the radiating leptothrix threads found in the mouth. Pure cultures\\nhave been obtained resembling macroscopically the cultivation of the\\ntubercle bacillus.\\nTetanus.\\nTetanus is an acute, infectious disease of the nervous system, the\\nessential characteristic of which is persistent tonic spasm of the muscles\\nof the jaws (lockjaw) and of the spinal and trunk muscles. The disease\\nbegins with the stiffness of the jaw, which steadily increases until,\\nwithin a few hours, there is complete tonic spasm of the jaw. The\\nneck-muscles, and then those of the spine and trunk, become rigid, so\\nthat the body is arched backward and may rest upon the heels and\\nhead (opisthotonos). The facial muscles share in the spasm, and by\\ntheir contraction produce a horrid, grinning countenance (rims sar-\\ndonicus). The contracted muscles become painful, and there is also\\nepigastric pain. The rigidity is persistent, but is interrupted by ex-\\nacerbations in which the phenomena already described are exaggerated,\\nand, in addition, respiration is embarrassed, the face becomes livid, the\\nskin bathed in sweat, and the patient is further distressed by increased", "height": "4416", "width": "2640", "jp2-path": "practicaltreatis00muss_0_0374.jp2"}, "375": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 353\\npain in the affected muscles. The body may be bent forward (empros-\\nthotonos) or laterally (pleurosthotonos). The temperature is not con-\\nstant. It may remain normal, be moderately elevated, or hyperpyrexia\\nmay be present, especially toward and after the end in fatal cases. The\\nspasm ceases during sleep, but subsequently returns.\\nThe cause of the disease is the bacillus of tetanus, which produces\\nthe convulsive poison tetanin. The bacillus is seen as a delicate, slen-\\nder rod, with a terminal spore. It stains with aniline dyes and Gram s\\nfluid. Cultivations may be made with the pus. It should be smeared\\nover the surface of slanted agar-agar or blood-serum in a sterilized\\ntube, placed at 37\u00c2\u00b0 C, for twenty-four hours, then heated to 80\u00c2\u00b0 C. in\\na water-bath from forty-five to sixty minutes. At the end of this time\\ngelatin plates or Esmarch tubes are to be made from the growth in the\\nheated tube these are to be kept in an atmosphere of pure hydrogen\\nat 20\u00c2\u00b0 to 22\u00c2\u00b0 C. Growth is favored by the addition to the gelatin of\\n2 per cent, of glucose. If the inoculation be made as a stab in a tube\\nabout three-quarters filled with gelatin, growth is seen only to within\\nabout 2 cm. of the surface of the media. Faint radiating strise or\\nthorn-like processes are seen. The development is rapid in agar-agar.\\nAfter an exposure of thirty hours to a temperature of 37\u00c2\u00b0 C. the\\nspores make their appearance. On gelatin the colonies are dense at\\nthe centre, with a more delicate periphery. The preparation becomes\\nfluid, and gas is evolved. It is strictly anaerobic. The accompanying\\nillustration from Abbott s work on Bacteriology shows its appearance.\\nFig. 92.\\n1 f\\na*\\nB\\nTetanus bacillus, a. Vegetative stage, from gelatin culture, b. Spore-stage, showing\\npin-shape. (Abbott.)\\nTetanus frequently follows an injury. Trismus neonatorum and\\npuerperal tetanus are names given to special varieties which occur in\\nnew-born children and in puerperal women. Tetanus is much more\\ncommon in men than in women, and Gowers states that three-fourths\\nof the cases occur between the ages of ten and forty. It is much more\\ncommon in hot than in cold countries, though cold is an exciting cause.\\nIn traumatic and puerperal cases the disease usually develops in\\nfrom a few days to two weeks from the time of injury or childbirth or\\nabortion. In new-born children it occurs usually during the first week.\\nIt lasts from two to six weeks, but may be fatal much earlier, or, in\\nrare cases, last even longer.\\nTetanus must be distinguished from strychnine-poisoning. In the\\nlatter the jaw-muscles are never involved early, if at all, and the mus-\\n23", "height": "4416", "width": "2652", "jp2-path": "practicaltreatis00muss_0_0375.jp2"}, "376": {"fulltext": "354 GENERAL DIAGNOSIS.\\ncles are relaxed between the paroxysms. It is distinguished from tetany\\nby the history and the distribution of the spasm, which in tetany is\\nconfined to the extremities. Bacteriological methods should be re-\\nsorted to.\\nTrichinosis.\\nUntil recently fever was not looked upon as an attendant of the\\ngross parasitic invasion which is considered below. The study of a\\nlarge number of cases shows that fever is present in various forms. In\\nnot a few, it is true, it may be very slight for a few days, and then\\nfall to normal, and even, especially in convalescents, be strikingly\\nsubnormal. In other instances the temperature curve may be markedly\\nintermittent. The chart from Osier s monograph shows this peculi-\\narity. (See Fig. 93.) Finally, the fever-range is not unlike that of\\ntyphoid fever in many instances. Striimpell observes that the fever is\\nseldom continuous for any length of time, and that its course is inter-\\nrupted by frequent and prolonged intermissions. Niemeyer compares\\nthe curve to that of typhus, and Eichhorst to that of typhoid fever.\\nThe infection is acute, caused by absorption of trichinae spiralis, and\\ncharacterized by fever, gastric and intestinal irritation, followed by\\npain and stiffness in voluntary muscles, oedema of the eyelids, face,\\nand feet, by profuse sweating, and by death or tardy convalescence.\\nThe trichinae are absorbed by human beings through raw or imper-\\nfectly cooked food, often in the form of sausage. The trichinae are\\nencysted when absorbed, but within forty-eight hours they are liber-\\nated in the intestine and can be found adherent to the mucous mem-\\nbrane. In the course of six or seven days each liberated female worm\\nproduces about 180 embryos, Avhich immediately penetrate the walls\\nof the intestine and travel or are carried to all parts of the body,\\nbecoming in turn encysted.\\nSwallowing of trichinous flesh does not necessarily produce symp-\\ntoms the trichinae may be destroyed in the stomach, or, if calcified,\\nmay pass through the intestine unchanged. When symptoms result\\nthe severity depends upon the number of trichinae which become liber-\\nated. The symptoms are sleeplessness, lassitude, anorexia, nausea,\\nvomiting, tenderness over the abdomen, and diarrhoea. Headache is\\na constant and marked symptom of invasion. Colicky pains attend\\nthe gastro-intestinal symptoms. These symptoms may not be marked\\nin the beginning of the disease or they may be so severe as to cause\\ndeath in two or three days. If the patient survive, toward the end of\\nthe week the voluntary muscles become stiff, painful, and contracted.\\nThe muscles feel hard and swollen. The eyelids, face, and sometimes\\nthe feet become oedematous. Depending upon the muscles involved,\\nthere are interferences with the eye-movements, contractions of the jaw-\\nmuscles, difficulty in breathing or in swalloAving, etc. The calves of the\\nlegs are especially involved. Recurrent oedema over the affected muscles,\\neyelids, and face is very common and characteristic. Profuse sweating\\nalso is very common, and at times there are severe neuralgic pains.\\nThe fever is usually moderate, but it may be high. It follows the\\ntypes described above. It is accompanied by malaise, with pains in", "height": "4416", "width": "2644", "jp2-path": "practicaltreatis00muss_0_0376.jp2"}, "377": {"fulltext": "THE DATA OBTAINED BY OBSERVATION.\\n355\\ncm\\n\u00e2\u0080\u00a2K SI\\nP9\\n91\\nWJ 8\\nSi\\n81\\n01\\n\u00e2\u0080\u00a2Wet\\n08\\n91\\nuoojsu[\\nJ\\nsz\\n91\\nWY 8\\nK\\n9Z\\nor\\n0008Q\\n-WY f\\nW\\npi\\n\u00e2\u0080\u00a2w SI\\ni\\n09\\n91\\n\u00e2\u0096\u00a0WJ 8\\n80\\n91\\n\u00e2\u0080\u00a2H J f\\nP9\\n91\\nnoojsr si\\n*9\\no-\\nIT 8\\nSi\\nPl\\n5O088T\\nWY\\n89\\nOS\\nco\\nCM\\n\u00e2\u0080\u00a2w SI\\nS\\n9S\\n81\\nI d 8\\nP9\\nPI\\nI\\n\u00e2\u0080\u00a2WJ\\nSi\\n91\\nuoojsr 21\\n5Z\\n05\\n\u00e2\u0080\u00a2H V 8\\nZl\\nOS\\n30 008\\nWY f\\n56\\no-\\nCM\\nCM\\nM SI\\n09\\n07,\\n\u00e2\u0080\u00a2WJ 8\\nSi\\n91\\nWJ\\nT\\n1J\\\\\\nX\\nI TO\\nmo\\nL\u00c2\u00ab\\nK\\ni p\\n1M.\\nnoo^[ z\\\\\\nT\\n*9\\nOS\\nWY 8\\n*8\\nOS\\n\u00e2\u0080\u00a2H-y f\\n\u00c2\u00abr\\n1\\nt-P\\nOS\\no\u00c2\u00bb08i\\nCM\\n\u00e2\u0080\u00a2M SI\\n5\\n91\\nss\\n\u00e2\u0080\u00a2wj 8\\n08\\nOS\\n\u00e2\u0080\u00a2WJ\\nL\\n7\u00c2\u00bb\\n08\\nOS\\nnoo^ 2i\\n4,\\n~n\\nZl\\nOS\\n\u00e2\u0080\u00a2WY 8\\nr\\n9i\\n91\\n005\\nWY f\\nSi\\n91\\no\\nCM\\nK SI\\ni\\nS9\\nPI\\n\u00e2\u0080\u00a2WJ 8\\nq\\nbj\\n12\\nia\\nism\\ntt.\\nSi\\nOS\\nI\\nWJ\\n08\\n91\\nc.\\n100.K Z\\n*S\\n08\\nOS\\nC\\n\u00e2\u0080\u00a2WY 8\\nA\\ni i\u00e2\u0080\u0094\\n08\\n91\\n0081\\n\u00e2\u0080\u00a2WY\\ni\\nOP\\nSI\\n0\\n\u00e2\u0080\u00a2K SI\\nr*\\n001\\n91\\n\u00e2\u0080\u00a2KJ 8\\nPS\\nOS\\nI\\nWJ\\ni\\nLX\\n3no\\nigi\\n100\\n\u00e2\u0080\u00a2K\\n=1.\\n08\\nOS\\nnoOiST SI\\n09\\n91\\nWY 8\\n001\\nor,\\n008\\nIT f\\ninn\\nA\\nN\\nI\\nPS\\nOS\\n00\\n\u00e2\u0096\u00a0H SI\\nPS\\nPS\\nWJ 8\\n~*v\\nRfi\\nPS\\n\u00e2\u0080\u00a2WJ fc\\nV\\nOS\\npr-\\nnoo^j 5x\\nPS\\nos\\nWY 8\\n08\\nPS\\nI\\n0SII\\nWY?\\ni\\nI\u00c2\u00bb\\nnod\\nBPI\\nli\\n91\\nPS\\nN\\n\u00e2\u0080\u00a2w SI\\n-K\\n1 X\\n3ui\\n^s\\ni n n\\nOS\\nPS\\n\u00e2\u0080\u00a2WJ 8\\nXI-\\nSun\\nSI\\n0\\n3\\n9i\\nPS\\nI\\n\u00e2\u0080\u00a2WJ\\nS3\\nOS\\nttootf z\\\\\\n;r\\n5i\\n91\\n\u00e2\u0096\u00a0WY 8\\nZl\\n91\\n088T\\nWY\\nr\\nA\u00c2\u00bb\\n8no\\nSP\\n00\\n22i\\nit\\nA\\nJ T S\\nP 0\\nZl\\n05\\nD\\n\u00e2\u0080\u00a2K ST\\n\u00e2\u0096\u00a0c 1\\nIA\\ns3i\\nods\\npi\u00c2\u00b0:\\n9G\\nPS\\n\u00e2\u0080\u00a2HJ 8\\nA\\no2a\\n\u00c2\u00abS\\nPl n i:\\n001\\n05\\nI\\nWJ\\nAJ\\nSue\\nigi\\n[00\\nX\\n*8\\nOS\\nuoo^ 2i\\n\u00e2\u0080\u00a2r\\nM.\\nIS\\na\\njmc\\nA 1\\nW\\nZl\\n05\\nWY 8\\n89\\nOS\\n005\\n\u00e2\u0080\u00a2WY\\ni\\nV\\nrn-\\nihioit\\nIPO\\n08\\nos\\nm\\n-i\\nE\\nQ-\\nH St\\ns\\nT\\nI\\n9*1\\nodg\\npjo\\n1\\n90\\nPS\\n\u00e2\u0080\u00a2WJ 8\\n*j\\n2a\\ndfl\\npi d\\n*0I\\nP3\\ns\\n\u00e2\u0080\u00a2WJ\\nuoi;\\nST IU\\nPV\\nss\\nPS\\nTEMP. 109\u00c2\u00b0\\n108\u00c2\u00b0\\n107\u00c2\u00b0\\n106\u00c2\u00b0\\n105\u00c2\u00b0\\n104\u00c2\u00b0\\n103\u00c2\u00b0\\n102\u00c2\u00b0\\n101\u00c2\u00b0\\n100\u00c2\u00b0\\n99\u00c2\u00b0\\n98\u00c2\u00b0\\n97\\nCO\\na.\\nCO\\nUU\\nCO\\no\\nCO\\nLU\\ncc", "height": "4416", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0377.jp2"}, "378": {"fulltext": "356 GENERAL DIAGNOSIS.\\nthe joints and muscles, preceding the true local muscle pain. The pulse\\nis very frequent if trichinae reach the heart. The later stages in fatal\\ncases are marked by insomnia, delirium, stupor, and coma.\\nThe duration varies from a few days to four or five weeks, or even\\nlonger. Muscular pains may persist for months after recovery. Death\\nresults from exhaustion, or from some complication, as pneumonia or\\nulceration of the large intestine.\\nThe Blood. Brown, in studying Dr. Osier s cases, found an increase\\nin the leucocytes, and on a differential count a great increase of the\\neosinophiles. The leucocytes were increased to 17,000 per c.mm.\\nThe eosinophiles increased from 2 per cent., the normal, to 37 per cent.,\\nand at one time to 68.2 per cent. In subsequent cases their average\\nincrease was as high as 48 per cent.\\nDiagnosis. The diagnosis is based upon the history, the peculiar\\nmuscular pains and swellings, the localization of the oedema, and the\\nleucocytosis and eosinophilia. The muscles are swollen and hard,\\npainful on pressure, and contracted. There is no involvement of the\\njoints, an important point in the diagnosis. The oedema (see Chapter\\nXL) is seen in the eyelids and over the eyebrows. It is of common\\noccurrence over the swollen and tender muscles. It is distinguished\\nfrom typhoid fever by the presence of vomiting, and oedema of the face\\nand eyelids, the development of muscular troubles, by the absence of\\nhebetude, delirium, and other typhoid symptoms, and absence of the\\ncharacteristic eruption and enlargement of the spleen.\\nMuscular rheumatism is distinguished by being limited to one part,\\nas the lumbar region, arm, or chest by its appearance following ex-\\nposure to draught and by the fact that it is not preceded by nausea,\\nvomiting, and diarrhoea, nor accompanied by oedema.", "height": "4412", "width": "2652", "jp2-path": "practicaltreatis00muss_0_0378.jp2"}, "379": {"fulltext": "CHAPTER XXI.\\nTHE DATA OBTAINED BY OBSERVATION\u00e2\u0080\u0094 {Continued).\\nExploratory puncture or aspiration for diagnosis: Instruments. Preparation of instru-\\nments. Preparation of skin. Point of puncture. \u00e2\u0080\u0094Exudations (Pus. Seropus.\\nGangrenous debris. Blood. Serum. Chyle): Pus. Blood-corpuscles Bac-\\nteria. Protozoa. Vermes. Crystals. Chemical examination: Seropurulent\\nexudations. Putrid exudations. Hemorrhagic exudations. Serous exudations.\\nChylous exudations. Pleural effusions. Transudations. The contents of cysts:\\nHydatid, ovarian, renal, pancreatic.\\nTHE EXAMINATION OF EXUDATIONS, TRANSUDATIONS,\\nAND CYSTIC FLUIDS.\\nExploratory Puncture or Aspiration for Diagnosis. The presence\\nor absence of fluids in the natural cavities of the body, as the peri-\\ncardium, the pleura, or the abdomen, or in the gall-bladder, must\\nfrequently be ascertained by means of puncture or aspiration. The\\nfluid is secured at the same time by the puncture for examination.\\nThe fluid of tumors or cysts is likewise withdrawn to complete a diag-\\nnosis by determining its chemical, microscopical, or bacteriological\\ncharacter. Certain rules of procedure are necessary, and, as they are\\ncommon to the method in whatsoever situation employed, may be con-\\nsidered in this section.\\nThe Instruments. If it is the desire of the observer to determine\\nthe presence of fluid, an ordinary grooved needle may be used. If,\\nhowever, fluid is to be obtained for examination, a syringe or aspirator\\nmust be used. An ordinary hypodermatic syringe, or the syringe of\\nPravaz, may be used if the needles are long enough. A special aspi-\\nrator made for diagnosis by instrument-makers is the best. The\\nneedles are sufficiently long, the barrel large enough to hold sufficient\\nfluid for any method of examination. If the diagnosis is to be fol-\\nlowed by treatment by aspiration, the apparatus of Dieulafoy, or any\\nequally perfect apparatus, may be used at once.\\nPreparation of Instruments. The instruments should be ster-\\nilized in a steam sterilizer, or boiled. This does not apply to the\\nneedles alone, but every portion of the instrument should be cleansed,\\nbecause, for instance, the contents of the barrel of the syringe pass\\nthrough the needle. After sterilization they should be carried to the\\npatient in sterilized test-tubes plugged with cotton-wool. When not\\nin use the needles should be kept in absolute alcohol and the syringe\\nin carbolic acid solution, 1 20. Before using, the carbolic acid should\\nbe washed from the syringe and needle with boiling water they are\\nthen to be sterilized as described. Unless the carbolic acid is removed\\nfrom the syringe its presence may serve as an antiseptic or disinfectant,", "height": "4416", "width": "2644", "jp2-path": "practicaltreatis00muss_0_0379.jp2"}, "380": {"fulltext": "358 GENERAL DIAGNOSIS.\\nand thus interfere with the culture-tests, to which the material drawn\\nis to be subjected.\\nPreparation of Skin. The skin should first be cleansed with\\nsoap and water, then with alcohol, then with a solution of carbolic acid,\\n1 20, or of the bichloride of mercury, 1 1000. After thorough\\ncleansing the parts should be kept covered with a towel soaked in\\nbichloride solution until the time of operation. At the time of punc-\\nture the surface should be made anaesthetic by ethylene chloride, the\\nrhigolene spray, by ice and salt, or, in adults, by the Schleich method\\nof subcutaneous anaesthesia. Care must be taken, if the patient is\\naged or poorly nourished, or the skin oedematous, not to freeze the skin\\ntoo much, on account of the danger of local gangrene.\\nThe Point of Puncture. The points selected for aspiration\\ndepend upon the cavity to be explored or the situation of the cyst.\\nThe Pleura. To withdraw the fluid within the pleura it is best\\nto select a point for aspiration in one of the lower interspaces of the\\nchest, because the fluid is more likely to accumulate in this position\\nand because complete aspiration can there be performed if necessary.\\nThe sixth or seventh interspace in the anterior axillary line, or the\\neighth or ninth interspace in the posterior axillary or scapular line,\\nmay be selected. On the right side the upper interspace of the two\\nshould be chosen on account of the position of the liver. If the con-\\ntents tend to point or break out at any particular spot on the surface\\nof the chest the puncture may be made in this area. In suspected\\nloculated empyema or effusions the point of puncture should be at the\\nsite of greatest dulness and least fremitus.\\nThe Pericardium. For aspiration of the pericardium three points\\nof election have been recommended First, the usual position of the\\napex-beat, in the fifth interspace, inside of the midclavicular line\\nsecond, the space between the ensiform cartilage and the left seventh\\ncartilage, the point advised by Roberts third, Potch has tapped the\\nfifth right interspace a number of times on the cadaver, and thinks\\nthat this situation is a proper one on the living subject. The writer\\nhas aspirated the pericardium in several instances inside of the normal\\nposition of the apex. Care must be taken to insert the needle slowly\\nand with the point directed downward and toAvard the left axilla when\\nthis position is selected.\\nThe Abdomen. It should be remembered that no attempts at\\npuncturing the abdomen should be made if pus is suspected, unless\\npreparations have been made to perforin laparotomy at once. Indeed,\\nthis exploratory operation is performed with so little detriment to the\\npatient by modern surgeons that, on the whole, it should be advocated\\ninstead of puncture. There are times, however, when the latter must\\nbe resorted to. The writer has performed it in a number of instances\\nalways refusing to do so in cases in which pus was probably present\\nin the peritoneal cavity, or in tumors, or in organs the seat of suppura-\\ntion without any danger having ever arisen. Explorations of this\\ncharacter are probably more feasible in connection with diseases of the\\nliver. It does not appear to be harmful to insert needles into that\\norgan, and valuable information is often gained thereby.", "height": "4412", "width": "2648", "jp2-path": "practicaltreatis00muss_0_0380.jp2"}, "381": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 359\\nIn aspiration of the abdomen, to determine the character of perito-\\nneal contents, the median line should be selected for the puncture. The\\nbladder must be emptied and a point midway between the umbilicus\\nand pubes selected.\\nThe Vertebral Canal. Spinal or Lumbar Puncture. Proposed\\nby Quincke, the procedure has been carried out by many clinicians and\\nhas proved to be a means of corroborating and even establishing a diag-\\nnosis. Cerebral lesions are diagnosed and intracranial pressure relieved\\nbecause of the continuity of the spaces in the brain and the spmal canal.\\n(See Cerebro-spinal Meningitis.)\\nMethod. The patient should lie on the right side, with the knees\\ndrawn up and the left shoulder turned forward. The puncture is made\\nby an antitoxin needle or the needle of a large hypodermic syringe,\\nwhich may then be used to withdraw the fluid. The syringe itself\\nmay be removed and the fluid allowed to ooze through the needle drop\\nby drop. A needle 4 cm. in length and 1 mm. in diameter is suitable\\nfor infants a longer needle for children over ten and adults. The\\npoint selected for puncture is midway between the third and fourth or\\nfourth and fifth lumbar vertebra?, below the spinous process, a little\\nto one side of the median line. The thumb of the left hand of the\\noperator placed between the spinous process may be used as a guide.\\nIf the needle is inserted to the right of the median line, preferably on\\nthis side, it should enter 1 cm. from the median line, on a level with\\nthe thumb, and be directed slightly upward and inward. At a depth\\nof 3 or 4 cm. in children and 7 or 8 cm. in adults the canal is entered.\\nThe fluid oozes drop by drop, and should be collected in a sterilized\\ntest-tube. It should not run down the sides of the tube. Five to\\nfifteen cubic centimetres should be withdrawn.\\nThe fluid is examined chemically, bacteriologically, and microscopi-\\ncally. Sugar has been found in brain-tumor and not in meningitis\\nalbumin is said to be less in the former than in the latter. In tubercu-\\nlous meningitis the fluid is usually clear and limpid in other forms\\ncloudy and turbid. Pus has been withdrawn in leptomeningitis. Blood\\nmay be found in hemorrhage into the lateral ventricles. The respective\\naffection is distinguished by the results of bacteriological examination.\\nCover-glass preparations are made of the fluid and cultivations taken\\nat once. In purulent meningitis streptococci, staphylococci, the pneu-\\nmococcus, and the meningococcus (diplococcus intercellularis) may be\\ndetected. In tubercular meningitis tubercle bacilli have been found,\\nespecially after sedimentation. After the fluid has been twenty-four\\nhours in a conical glass the fine clot which forms should be examined\\nfor bacilli. The absence of bacilli does not exclude tuberculosis. The\\npositive result, however, is diagnostic.\\nInoculation, as in a case by Lafleur, will cause tuberculosis in a\\nguinea-pig, and is diagnostic. A clear fluid does not exclude purulent\\nmeningitis usually, however, the fluid is purulent, turbid, or rich in\\nleucocytes.\\nSometimes, although the canal is entered, fluid is not secured, be-\\ncause the needle enters pseudomembrane, thick pus, or gelatinous fluid,\\nor because fluid is retained in the lateral ventricles.", "height": "4416", "width": "2640", "jp2-path": "practicaltreatis00muss_0_0381.jp2"}, "382": {"fulltext": "360 GENERAL DIAGNOSIS.\\nCysts or tumors, with fluid contents, should be punctured over the\\npoint which presents externally, at which place it is evidently in closer\\nproximity to the external wall.\\nThe Spleex. The spleen has been punctured for therapeutic and\\ndiagnostic purposes. If the organ is hard, as in chronic malaria, it\\nmay be done without danger but if it is enlarged and soft, as in infec-\\ntious diseases, such as typhoid fever, it is hardly justifiable to puncture\\nit, because of the danger of subsequent rupture. Risks attend the\\npuncture of other organs, as the kidney. The writer has seen a serious\\nhemorrhage follow such puncture, and, of course, septic inflammation\\nmay arise. Exploratory operation is more suitable for determining its\\ncondition.\\nThe Examination of Fluids and Discharges. While the fluids to\\nbe examined can be obtained by the above-mentioned method, it some-\\ntimes happens that they are discharged spontaneously, as in the case\\nof an empyema.\\nThe following general methods apply to the examination, in Avhat-\\never way material is obtained. When derived from the natural cavi-\\nties they are known as exudations or transudations. Fluids are also\\nobtained from cysts, but do not require different methods of exami-\\nnation.\\nThe naked-eye appearances are first noted then microscopical ex-\\namination with and without staining is resorted to. Chemical exami-\\nnation is also required. Often culture-preparations and inoculations\\nmust be resorted to, as in the case of pus or of serous exudation.\\nThe Exudations.\\nThey may be composed of pus, seropus, gangrenous debris, blood,\\nor pure serum or chyle. When pus, seropus, or putrid fluid is with-\\ndrawn, it implies absolutely an inflammatory origin. Blood and serum\\nmay be associated with inflammation, simple or infectious but may\\nalso point to impediments in the general or lymphatic circulation.\\nBlood or bloody serum is thought to be of tuberculous or cancerous\\norigin. Its absence does not imply the absence of either disease. A\\nchylous exudation is usually due to obstruction of the lymph-channels.\\nPurulent Exudations.\\nPus ranges in color from gray to greenish-yellow. It is turbid, of\\nhigh specific gravity, and alkaline. It varies in consistence. When\\nstanding after removal it separates into two layers the upper layer is\\nlight yellow and transparent, and the lower opaque. Pus may be\\nmixed with blood, and is then reddish-brown. (See Abscess of the\\nLiver.) When it has undergone decomposition it is thin, green, or\\nbrownish-red, of a penetrating odor.\\nMicroscopical Examination White Corpuscles. If the speci-\\nmen is fresh the cells exhibit the movements that are common in\\nleucocytes. If a solution of iodine and iodide of potassium is added\\nto them they change to mahogany color. If the pus is old and the", "height": "4412", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0382.jp2"}, "383": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 361\\ncells are dead, they are shrunken and granular. Enormous giant-cells\\nand cells loaded with fat are seen in pus.\\nRed Corpuscles. In fresh pus red corpuscles are also seen along\\nwith blood-pigment or hsematoidin-crystals.\\nIn addition to the corpuscles free fat-globules and fat-particles are\\nseen. Epithelium is rarely seen. In the pus from the pleural cavity,\\nif cancer is present, the vacuolated epithelial and endothelial cells\\nsometimes seen in cancer may be observed.\\nBacteria. Micro-organisms are always detected with the aid of\\nstaining-methods. (See Chapter XVII., Bacteriological Diagnosis.)\\nThe micro-organisms are usually the determining cause of the suppu-\\nration. Suppuration, however, may be caused by chemical substances,\\nalthough this is at least of rare clinical occurrence. Of the various\\nfungi found the micrococci and bacilli are the most numerous. The\\ncommonest of these are the staphylococcus pyogenes aureus and strep-\\ntococcus pyogenes the amoeba dysenterica, in abscess of the liver and\\nsecondary abscess of the pleura and lung. It was found in an abscess\\nof the jaw by Flexner. For further description of the pyogenic micro-\\norganisms, see below and Chapter XVI., The Infections.\\nThe Pyogenic Bacteria. 1. Staphylococcus Pyogenes Aureus.\\nThis micro-organism is found in acute abscesses and boils, sometimes\\nalso in infectious osteomyelitis and ulcerative endocarditis. In addi-\\ntion to other portals it may enter the tissue through abrasions or the\\nhair-follicles.\\nMorphology. In cover-glass preparations they appear as small\\nround bodies scattered among the pus-cells, rarely within them, single,\\nin pairs or in clusters. They stain readily with the basic aniline dyes.\\n(See Fig. 94.)\\nBiological Properties. It is aerobic, facultative anaerobic, grow r s\\nin milk, meat-infusions, gelatin, or agar at 18\u00c2\u00b0 C. Death-point is 56\u00c2\u00b0\\nFir. 94.\\n-M\\nPus with staphylococcus. X 800. (Flugge.)\\nto 58\u00c2\u00b0 C. after ten minutes exposure. Growth. Make plate-cultures\\non agar-agar. After tw T enty-four hours in the incubator the plate will\\nbe studded with yellow or orange-colored colonies, round, moist, and\\nglistening. In a gelatin stab-culture liquefaction occurs in thirty-six\\nto forty-eight hours along the puncture, forming a funnel. The whole\\nmass gradually liquefies. At the bottom of the funnel the microbes", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0383.jp2"}, "384": {"fulltext": "362 GENERAL DIAGNOSIS.\\ncollect as an orange-colored mass. On potato it grows as a brilliant,\\norange-colored, somewhat lobnlated layer. The growth gives off an\\nodor of sour paste. (See Plate VII., Fig. 3, and Plate III., Fig. 2, b.)\\n2. Staphylococcus Pyogenes Albus. It is also found in acute\\nabscesses, but less often than the aureus/ 7 and is less virulent.\\nIt is morphologically identical with the aureus, but develops no\\npigment. The surface-cultures are milk-white, and the mass at the\\nbottom of the liquefy mg gelatin is white.\\n3. Staphylococcus Epidermidis Albus (Welch) closely simulates\\nthe staphylococcus pyogenes albus. It is the most common micro-\\norganism on the surface of the body, and is often present in parts of\\nthe epidermis too deep for disinfection, save by heat. It is supposed\\nto be the usual cause of stitch-abscess.\\n4. Streptococcus Pyogenes. It is found in acute abscesses, ery-\\nsipelas, otitis media, puerperal metritis, infectious endocarditis, pseudo-\\ndiphtheria, scarlatinal angina, and most purulent inflammations of a\\nphlegmonous character. It is the organism most commonly found in\\ninflammations having a spreading tendency.\\nMorphology. Cover-glass preparations show spherical cocci of\\nvarying sizes, which form chains of four to twenty elements, the chains\\noften forming tangled masses. It is stained by the basic anilines or\\nby Gram s method. (See Fig. 95.)\\nBiological Properties. Grows in most media at a temperature\\nof 16\u00c2\u00b0 to 37\u00c2\u00b0 C. (best 30\u00c2\u00b0 to 37\u00c2\u00b0), but not on potato. It is facultative\\nanaerobic, and does not liquefy gelatin. On plates it forms a flat,\\ntransparent disk of about one-half millimetre diameter. In stab-cul-\\ntures it grows all along the puncture and forms a white opaque granu-\\nlar column. The death-point is 52\u00c2\u00b0 to 54\u00c2\u00b0, ten minutes exposure.\\n(See Plate VII., Figs. 1 and 2.)\\nFig. 95.\\nStreptococcus pyogenes in pus. X 800. (FlxJgge.)\\nInoculated, it causes erysipelatous or phlegmonous inflammation.\\n5. The Tubercle Bacillus. This is seen at times in pus removed\\nfrom phthisical cavities, and the pus of abscesses, particularly about\\nglands. It may be detected by methods of staining adopted in the\\nexamination of the sputum. Pus may be of tubercular origin, and the\\nmicro-organisms may not be detected by the usual microscopical\\nmethods. Its absence, therefore, does not imply the absence of tuber-\\nculosis. Culture-methods and inoculation should be resorted to, partic-\\nularly the latter.", "height": "4412", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0384.jp2"}, "385": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 363\\n6. The Bacillus of Syphilis. The pus under these circumstances is\\nusually derived from ulcers or inflammations, or from secretions about\\nthe vulva or prepuce. The actual relationship to syphilis has not been\\ndemonstrated.\\nLustgarten s method is as follows After immersion for twenty-four\\nhours at the ordinary temperature in the gentian-violet fluid of Koch-\\nEhrlich, the cover-glass preparation is removed and washed for a few\\nmoments with absolute alcohol. It is then placed for ten seconds in\\na 1 per cent, or 2 per cent, solution of permanganate of potash a\\nwatery solution of pure sulphurous acid is then poured over it, after\\nwhich it is washed in water. If the preparation still shows its color,\\nit must be reimmersed for a few seconds in the potash solution and\\nthen in the sulphurous acid, and again washed with water.\\n7. Actinomyces.\\n8. The Bacillus of Glanders.\\n9. The Bacillus of Anthrax.\\n10. The Bacillus of Leprosy.\\n11. The Bacillus of Tetanus.\\n12. The Bacillus of Influenza. (See Sputum.)\\n13. The Micrococcus Lanceolatus. The Pneumococcus. The\\npneumococcus is often found in the pus of empyema and pericarditis,\\nwhether from the pleural cavity or after it has burrowed from this\\nsituation. It occurs in cerebro-spinal meningitis. It is easily detected\\nby the usual staining-methods (for which see Sputum).\\n14. The Bacillus Ooli Communis. The bacillus coli communis is\\nfound more commonly in infections within the abdominal cavity. (See\\nFseces.)\\n15. The Gonococcus. It is constantly present in virulent gonor-\\nrhoeal pus, usually within the pus-cell or attached to the surface of\\nepithelial cells. Morphology. Micrococci, usually joined hi pairs or\\nfours, flattened and separated, when stained, by an unstained intercel-\\nlular space. Stains easily with anilines not by Gram s method.\\nNo other cocci are of the same shape, and at the same time within\\nthe cells, except one which, however, stains by Gram s method. (See\\nPlate III., Fig. 3, b.)\\nGrowth. Does not grow readily on ordinary media, but can be\\ncultivated on blood-serum and other special media, such as urine, agar,\\netc. 30\u00c2\u00b0 to 40\u00c2\u00b0 C. is best, and a moist atmosphere is needed. Growth\\nis slow and often fails. Forms a thin, scarcely visible layer, with\\nsmooth, shining surface, gravish-vellow by reflected light is aerobic.\\n(See page 308.)\\nProtozoa in the Pus. Cercomonads have been observed in the pus\\nof an empyema, probably from the lungs. Flexner has found the amoeba\\ndysenterica in the pus of an abscess of the jaw. It is found hi abscess\\nof the liver and secondary abscess of the lung. (See Sputum and Faeces.)\\nVermes. Filaria have been found in abscess of the liver. In the\\nsuppuration of hydatids the pus contains membrane and hooklets.\\nCrystals. Crystals of cholesterin are found in the pus from cold\\nabscesses, suppurating ovarian cysts, and foetid discharges. They are\\nsimilar to the crystals described under sputum.", "height": "4416", "width": "2668", "jp2-path": "practicaltreatis00muss_0_0385.jp2"}, "386": {"fulltext": "364 GENERAL DIAGNOSIS.\\nH^ematoidin-crystals indicate a previous hemorrhage they are\\nmost frequent in suppurating hydatid cysts. (See Fig. 96.) Fatty\\nneedles are found in old pus and gangrenous exudates. (See Fig 97.)\\nTriple phosphates are frequently seen in pus, and are of the same appear-\\nance as the phosphates in the urine. The carbonates and phosphates\\nare seen in foetid pus.\\nFig. 96. Fig. 97.\\nH*\\nPus from putrid empyema. (Eye-piece\\nRhombic crystals of hsemin. (Charles.) III., obj. 8, A. Reichert.) Shrunken leu-\\ncocytes. Fat-crystals. (Von Jaksch.)\\nChemical Examination of Pus. This does not yield any informa-\\ntion of diagnostic value.\\nSerum-albumin, globulin, and peptone are detected by methods em-\\nployed in the examination of urine. Fresh pus contains sugar. After\\nbeing boiled with an equal weight of sulphate of soda and filtered the\\nfiltrate is examined by the reagents used in examination of urine for\\nsugar. Pus also contains bile-pigments and biliary acids, cholesterin\\nand salts of sodium and the fatty acids in jaundice. Von Jaksch has\\nfound acetone in pleural exudations.\\nSeropurulent Exudations. They resemble purulent discharges,\\nchemically and morphologically. They point to antecedent inflam-\\nmation.\\nPutrid Exudations. The exudations are brown or brownish-green\\nin color. The odor is penetrating and offensive. They are usually\\nalkaline in reaction. On microscopical examination old leucocytes and\\ncrystals of fat, cholesterin, and hsematoidin are seen fission-fungi of\\nvarious forms are seen. (See Figs. 96 and 97.)\\nHemorrhagic Exudations. Hemorrhagic exudations contain red\\nblood-corpuscles and haemoglobin in large amount. Fatty endothelial\\ncells are found. Quincke states that when the glycogen -reaction is\\nshown, if the fluid is from the pleura, carcinoma is probably present.\\nA positive diagnosis depends upon the discovery of the epithelial cells\\n(see page 364), which are seen in cases of cancer. Hemorrhagic exuda-\\ntions in the pleura are due most frequently to cancer, to tubercle, or to\\nscurvy. To determine its exact nature (as to tubercle), inoculation\\nand cultures are sometimes necessary.", "height": "4408", "width": "2648", "jp2-path": "practicaltreatis00muss_0_0386.jp2"}, "387": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 365\\nSerous Exudations.\\nThe fluid is clear and light yellow or straw-colored. On standing a\\nwhite fibrinous clot is deposited. On microscopical examination, red\\nblood-corpuscles, leucocytes, fatty globules, and endothelial cells are\\nfound. They may be bunched in groups or scattered about. The\\nmicro-organisms, if present, are detected with difficulty. If ulcerating\\ntuberculosis of the pleura is present the bacillus may be found, but\\ntuberculous pleurisy may exist without ulceration, and hence the fluid\\nis clear of the bacillus. Cholesterin-crystals are found in old serum.\\nOn chemical examination the fluid contains more than 3 per cent, of\\nserum-albumin and globulin peptone is absent in pleural exudations\\nsugar in small amount and acetone are found.\\nThe specific gravity of the fluid is above 1018.\\nChylous Exudations. True chyle is found in fluids of low specific\\ngravity. Such an effusion is rich in fat and is due to leakage of\\nlymphatics into the peritoneal cavity. It is known as a chylous effu-\\nsion. Chyliform effusion is a term applied to the second variety of\\neffusions mentioned in this section. The fluid has the property of\\nchyle. Sometimes in peritoneal exudation, particularly if the patient\\nhas been upon a milk-diet, the fluid contains fatty matter, which gives\\nit a milky appearance. The same character of fluid is seen in obstruc-\\ntion of the thoracic duct.\\nSpecial Effusions. Effusions in the Pleuka. It is of the\\ngreatest importance to distinguish the various forms of infection.\\nBacteriological examination is often necessary. In purulent exuda-\\ntion, if micro-organisms are absent (staphylococcus and streptococcus),\\nit is probably tuberculous serofibrinous exudations are usually free\\nfrom fungi. When the micrococcus lanceolatus is found it is of favor-\\nable prognostic omen.\\nTo distinguish the effusion of inflammation from that of transudation\\n(obstruction) the specific gravity is of service. In the inflammatory\\neffusions the specific gravity is high they also contain a large amount\\nof fibrin and more than 3 per cent, of albumin.\\nTransudations.\\nThis class of fluids is serous, bloody, or chylous. The specific grav-\\nity is lower than in inflammatory effusion. The color is light and the\\nreaction usually alkaline. On microscopical examination but little is\\nfound. In pleuritic effusions there may be considerable endothelium,\\nwhich, if mixed with blood, may be due to carcinoma. Serum contains\\nalbumin and sugar, the former in great excess. Peptone is always\\nabsent. The fluid coagulates with difficulty on boiling.\\nPuneberg 1 lays stress upon the diagnostic importance of the amount\\n1 Runeberg (J. W. On the Diagnostic Importance of the Amount of Albumin in\\nPathological Transudations and Exudations. Berliner klin. Wochenschrift, 1897,\\nNo. 33.", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0387.jp2"}, "388": {"fulltext": "366\\nGENERAL DIAGNOSIS.\\nof albumin in pathological transudations and exudations. His experi-\\nence warrants the following statements\\n1. Inflammatory processes, 4 to 6 per cent, of albumin.\\n2. Venous stasis, 1 to 3 per cent, of albumin.\\n3. Marked kydrsemic conditions, as in amyloid degeneration or\\nnephritis, 0.1 to 0.3 to 0.5 per cent.\\n4. Combination of two or three of the above causes, 0.2 to 6 per\\ncent.\\nIn group two, even without inflammatory complications, a high per-\\ncentage may occur in old transudations.\\nContents of Cysts.\\nIn aspiration of the abdomen and of the pleura cysts are sometimes\\nevacuated, the nature of which is often determined by an examination\\nof the fluid. It is within the province of this work to discuss hydatid\\ncysts, pancreatic cysts, and the cystic kidney. As tumors of the ovary\\nso frequently resemble tumors in other situations, it is well also to\\ndiscuss in this section the nature of the fluid withdrawn from them.\\nHydatid Cysts. The fluid of hydatid cysts is clear, alkaline, and\\nof a specific gravity of 1010. It contains chloride of sodium in ex-\\ncess, grape-sugar in small amount, and very little, if any, albumin.\\nFig.\\nContents of an ovarian cyst. (Eye-piece III., obj. 8, A. Reichert.) a, squamous epithelial cells\\nb, ciliated epithelial cells c, columnar epithelial cells d, various forms of epithelial cells e, fatty\\nsquamous epithelial cells colloid bodies g, cholesterin-crystals. (Von Jaksch.)\\nOn microscopical examination booklets are found, as in the sputum\\nfrom hydatid cyst of the lung, as well as portions of membrane. The\\nmembrane is recognized by its peculiar transverse striation and the\\ngranular appearance of its inner surface. The heads or scolices are\\nsometimes found. Two circles of hooklets and four disks on the ante-", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0388.jp2"}, "389": {"fulltext": "THE DATA OBTAINED BY OBSERVATION. 367\\nrior aspect cross the head, which is separated from the hinder part by\\nan annular constriction. (See Sputum and Faeces.) If suppuration has\\ntaken place the original nature of the cyst cannot be made out unless\\nhooklets are found. After the fluid has been standing in a conical\\nglass vessel the bodies may be found in the sediment.\\nOvarian Cysts. The fluid from an ovarian cyst is of high specific\\ngravity, 1026, of alkaline reaction, contains but a small amount of\\nalbumin, and does not coagulate. On microscopical examination vari-\\nous forms of epithelial cells are seen, colloid bodies, and cholesterin-\\ncrystals. If hemorrhage has taken place in the cyst the color of the\\nfluid is correspondingly changed, and beside the squamous, columnar,\\nand ciliated varieties, some epithelium in the stage of fatty degenera-\\ntion and red and white blood-corpuscles are seen. In colloid cysts\\nthe usual concretions are found. (See Fig. 98.)\\nIn dermoid cysts, in addition to the above, squamous epithelium,\\nhairs, and fatty-, hsematoidin-, and cholesterin-crystals are detected.\\nOvarian fluid, contains albumin and methsemoglobin, or paralbumin.\\nThe latter is detected by mixing a portion of the fluid with three times\\nits bulk of alcohol. It is then allowed to stand for twenty-four hours,\\nwhen it is filtered. The precipitate is removed and suspended in water.\\nAfter filtering the filtrate is seen to be opalescent, and is tested as\\nfollows\\n1. On boiling no precipitate is formed, but the fluid becomes turbid.\\n2. There is no change with acetic acid alone.\\n3. The fluid becomes thick and of a yellowish tint when treated with\\nacetic acid and ferrocyanide of potassium.\\n4. There is a change to a violet color when treated with concentrated\\nsulphuric and acetic acids.\\nSome observers differ from the above statement in their description\\nof the fluid of an ovarian cyst all agree as to the large number of cell-\\nelements. At one time it was thought that the fluid contained a special\\ncell, but this view has been abandoned. In rare cases the specific\\ngravity may be lower than that of the fluid of ordinary ascites. A\\nfluid of low specific gravity, with a small amount of albumin, is said\\nto be characteristic of a cyst of the broad ligament.\\nCystic Kidney. The fluid from a cystic kidney can be recognized\\nby the properties it derives from the renal secretion. Urea and uric\\nacid in large amounts point to its true source. Renal epithelium is of\\nthe greatest diagnostic value. (See Urine.) If epithelium from the\\nurinary tubules can be detected after the fluid has settled the diagnosis\\nis absolute. (See Hydronephrosis.) It must not be forgotten that both\\nurea and uric acid may be found in other cysts, as in those of the\\novary, if they communicate with the urinary tract.\\nPancreatic Cysts. The fluid from cysts of the pancreas is of a\\nspecific gravity of 1012, but may be as high as 1028. It contains\\ncholesterin-crystals in abundance, and blood or pigment. Serum-\\nalbumin is present, but metalbumin is not found. Three diastatic\\nferments are present\\n(1) If on examination for sugar the latter is found to be a maltose,\\nits presence is of diagnostic significance.", "height": "4416", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0389.jp2"}, "390": {"fulltext": "368 GENERAL DIAGNOSIS.\\n(2) The most pronounced property of the pancreatic fluid, and that\\nby which we are enabled to distinguish it from other fluids, is the\\npower of digesting albumin without the presence of an acid.\\nBoas (Deutsche med. Woehenschr., 1890, Bd. xvi. p. 1095) developed\\nthe method of examination. The fluid is to be added to milk. After\\nthe casein is precipitated the biuret-test is applied, as follows Heat\\nthe substance with caustic potash and add drop by drop a 10 per cent,\\nsolution of sulphate of copper. If digested albumin is present the fluid\\nassumes a reddish-violet color. No other cystic fluid can dissolve\\nalbumin in alkaline solution.\\nIt is not necessary that albumin or fibrin should be employed in\\nperforming this test, as it is sufficient to add milk to the secretion\\nwhen in such cases the casein of the milk is precipitated, and the\\nbiuret test is applied to the resulting filtrate, and the test compared\\nwith a control-milk from which the casein has been removed (this can\\nbe done by adding very dilute acetic acid with constant stirring), the\\ndigestive property of the liquid under examination may be with cer-\\ntainty determined. The peptone would not be precipitated with the\\nalbumin, and as all albumins give the same reaction as peptone with\\nthe biuret test, the albumin should be removed before applying the\\ntest. It is removed from the filtrate by a saturated solution of ammo-\\nnium sulphate. Then test the resulting filtrate with the biuret test.\\nThen compare with the control-test as above.\\n(3) The pancreatic fluid also emulsifies fats. In large cysts, however,\\nparticularly if of long standing, the physiological properties of the\\npancreatic juice are sometimes wanting. 1 In the case referred to by\\nBoas and reported by Karewski, the old age of the cyst modified the\\ncharacter of the fluid, and hence rendered its nature doubtful. More-\\nover, in the exploratory puncture the stomach was penetrated. For\\ntwo reasons the author advises against exploratory puncture. First,\\nthe age of the cyst is not known, hence an analysis would be mislead-\\ning. Second, the danger of puncturing other organs is too great. Ex-\\nploratory laparotomy is preferable.\\n1 In a case operated on by Penrose the analysis of the fluid was as follows: Sp. gr.\\n1025; reaction slightly alkaline serum-albumin; no metalbumin; diastatic ferment\\nabsent maltose absent. By Boas method, power to digest albumin appeared to be\\ngreat but when the albumin remaining in the filtrate was removed from the pan-\\ncreatic fluid, it failed to show that peptone was formed. The method, therefore,\\nappears to be fallacious in this class of cases. The cyst was old, and the fluid no doubt\\nlost its physiological properties. Cholesterin was present in enormous amount ty rosin-\\ncrystals were very scarce.", "height": "4408", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0390.jp2"}, "391": {"fulltext": "CHAPTER XXII.\\nTHE BLOOD.\\nThe blood is a tissue, the origin, growth, and decay of the elements\\nof which has been the source of the greatest interest. It was the tissue\\nheld responsible in days gone by for many diseases, the origin of which\\nwas not known, so that skin eruptions, scrofula, and other affections\\nwere known as blood diseases. At present we hold such affections\\nonly blood diseases which show a demonstrable change in the physical\\nor morphological characteristics of the blood. There is either diminu-\\ntion of the red cells, increase or diminution of the white cells, or dimi-\\nnution of the haemoglobin. Strictly speaking, most of the blood dis-\\neases now so called are really diseases of the blood-making organs the\\nlymphatic glands or the spleen. It is interesting to note that as late\\nas 1866, J. Hughes Bennett included under diseases of the blood leu-\\ncocythaemia, chlorosis and anaemia, diabetes, the infectious diseases,\\nrheumatism, gout, and scurvy. The most recent text-book divides the\\nblood diseases into ancemia, with two subdivisions, and leuhcemia. Of\\ncourse, no one thinks of considering the infectious diseases blood diseases\\nany more than we think of considering typhoid fever an ulceration of\\nthe intestine.\\nAlthough the blood diseases are thus limited, it is none the less true\\nthat the blood may be the only tissue by an examination of which we can\\ndetermine the ailment from which the patient suffers. As has been\\npreviously related, many infections are recognized in this manner only.\\nThe symptoms of blood affections are due to the physical change in\\nthe blood and the effect of this altered blood upon the function or the\\nnutrition of the organs. Many functional symptoms thus arising may\\nbe the first indications of blood disease, as dyspnoea or palpitation,\\nboth very common symptoms. The symptoms may be subjective or\\nobjective, or both. The recognition of the former comes from the\\nhistory of the disease and the complaints of the patient. The latter,\\nor the objective symptoms, are determined by the physical examination\\nof the patient and the examination of the blood.\\nWe recognize scarcely any condition at the present day due to an\\nincrease of the bulk of the bloodor of the red cells. Plethora is hardly\\na clinical identity. The symptoms of blood diseases, therefore, are the\\nsymptoms of ancemia. In like manner, all the data obtained by inquiry\\nare those which belong to some form of anaemia.\\nTHE DATA OBTAINED BY INQUIRY.\\nThe Social History. Generally speaking, women, patients of\\nearly age, who have been subjected to want or had unusual care, or\\nfaulty nutrition, are those most liable to anaemia. No family predis-\\n24", "height": "4412", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0391.jp2"}, "392": {"fulltext": "370 GENERAL DIAGNOSIS.\\nposition exists to a marked degree apparently, although it is well\\nknown that pale people are a family class. The previous history\\nand the data to be elicited in investigating it are best appreciated by\\nturning to the classification of the cause of anaemia in succeeding pages.\\nThe history of the disease is usually that of gradual onset, although\\nsudden fright or any cause producing profound shock is said to cause\\nacute anaemia. But the reader must again be referred to the para-\\ngraphs just mentioned.\\nThe subjective symptoms are general. Languor, debility, and\\nfatigue are complained of. The patient with anaemia, may have one\\ngroup of symptoms preponderate. Thus headache, vertigo, restless-\\nness, noises in the head, and neuralgias may be the most prominent\\nsymptoms. Again, dyspnoea and air-hunger may be the most dis-\\ntressing, or cardiac palpitation may be the earliest symptom, with or\\nwithout cardialgia. Then gastro-intestinal symptoms are suggestive,\\nalthough not pathognomonic. The peculiar appetite of chlorosis is\\nwell known. The causeless vomiting of many forms of anaemia has\\noften been described. The bowels may be constipated or loose, varying\\nmore particularly because of the difference in the cause of the anaemia.\\nRinging in the ears has been referred to, and flashes of light, spots\\nbefore the eyes, and other visual phenomena may be complained of, and\\nshow their origin in the state of the blood. Other alteration of the\\nspecial senses are not marked in the course of any of the anaemias.\\nThese symptoms may occur singly or are combined in varying degrees.\\nTHE DATA OBTAINED BY OBSERVATION.\\nWhile diseases of the blood, and especially forms of anaemia, are\\nrecognized by an examination of the blood, much information can be\\nsecured by general physical examination. It is true no disease would\\nbe pronounced a blood affection unless that tissue is examined by the\\nmodern means of research.\\nAn examination of a case of anaemia includes a study of the appear-\\nance of the patient, the color or hue of the surface, and the occurrence\\nof oedema. Both these subjects are carefully considered in the chapters\\ndevoted to them respectively. Examination of the eye-grounds should\\nalways be made, when the findings discussed in the Chapter on the\\nEye may be present, if the case is one advanced in its course. No\\nconsideration of anaemia can be made, however, without an examination\\nof the organs thought to be engaged in the blood formation, hence the\\nstate of the glands and the size of the spleen are inquired into.\\nFinally, as evidence of the presence of anaemia, we observe frequently\\ncardio-vascular phenomena. The murmurs that are heard in the heart\\nand bloodvessels in this disease are fully discussed in the Chapter on\\nDiseases of the Heart, to which the reader is referred.\\nExamination of the Blood.\\nNormal Blood. Before a consideration of the examination of the\\nblood, it may be well to review the elements of which the blood is\\ncomposed.", "height": "4408", "width": "2652", "jp2-path": "practicaltreatis00muss_0_0392.jp2"}, "393": {"fulltext": "", "height": "4392", "width": "2556", "jp2-path": "practicaltreatis00muss_0_0393.jp2"}, "394": {"fulltext": "PLATE IX\\nFig. 1\\nBlood from Case of Pneumonia, showing Leucocytes.\\nFig. 2.\\nNormal Blood, showing Rouleaux and Leucocytes.\\nbase.", "height": "4388", "width": "2704", "jp2-path": "practicaltreatis00muss_0_0394.jp2"}, "395": {"fulltext": "THE BLOOD. 371\\nThe blood consists of corpuscles and serum. The corpuscles are\\nfour (1) Red blood-cells or erythrocytes (2) nucleated red blood-cells\\n(3) blood-plaques (4) leucocytes.\\nThe ordinary red blood-cells measure 3-2V0 inch the leucocytes,\\n-2 5 0-0 inch. In an adult man the red cells number from 5,000,000 to\\n5,500,000 to the cubic millimetre in an adult woman the number is\\nusually less, being from 4,500,000 to 5,000,000. There are 8000 to\\n10,000 leucocytes in a cubic millimetre of blood, or 1 to 350-600 red\\nblood-cells.\\nVarieties of Leucocytes. In the normal blood there are found the\\nfollowing varieties of leucocytes 1. Small mononuclear forms, which\\nare cells about the size of a red blood-corpuscle, and have a round,\\nlarge, deeply staining nucleus, surrounded by a narrow rim of non-\\ngranular protoplasm. These are known as lymphocytes. 2. Large\\nmononuclear leucocytes several times as large as the foregoing. They\\nhave a round or oval nucleus, with a relatively larger amount of non-\\ngranulated protoplasm. 3. Transitional forms, which resemble the last\\nnamed, except that the nuclei are indented or S-shaped. 4. Poly-\\nnuclear leucocytes. These are usually about the size of the foregoing\\nvariety, but they may be somewhat smaller. The nuclei are long and\\nirregular and stain deeply. The protoplasm contains granules that\\nstain by a combination of both basic and acid dyes, but by neither\\nalone. The cells are therefore called neutrophiles. 5. Leucocytes\\nsimilar to the last form, except that their protoplasm contains highly\\nrefractive granules that are stained by acid dyes alone. For this\\nreason they are usually called eosinophiles. The proportion of each\\nvariety in the normal blood is fairly constant lymphocytes, 15 to 25\\nper cent. polynuclear, 65 to 80 per cent. mononuclear and transi-\\ntional forms, 6 per cent. and eosinophils, 2 per cent, or less. (See\\nPlate IX.)\\nPhysical Appearance. For the purpose of examination of the blood\\na drop or two is quite sufficient. In olden times much stress was laid\\nupon the physical character of the blood drawn in bulk. The signifi-\\ncance of the buffy coat was dwelt upon by all clinicians, not alone\\nbecause of its value from a therapeutic stand-point, but also because it\\nwas held to indicate the type of the disease that was present. At pres-\\nent, however, we rely very little upon the results of the naked-eye\\nexamination. By this examination we may be able to distinguish\\nbright-red arterial blood from darker venous blood, and also when\\narterial blood has become deficient in oxygen from any of the causes\\nof veuous engorgement and cyanosis. In chlorosis and hydremias the\\nblood is pale, as though mixed with water, while in severe leukaemias\\nit has a slight milky tinge. On the other hand, in carbonic-oxide\\npoisoning the blood becomes of a brighter red, while in poisoning with\\nchlorate of potash and aniline, and in grave cases of poisoning with\\nnitrobenzol and hydrocyanic acid, it is brownish-red or chocolate-\\ncolored.\\nFor accuracy in diagnosis reliance must be placed upon instruments\\nof precision. These are the microscope, the hamioglobinometer, the\\nhsemocytometer. By this examination we determine (1) the size and", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0395.jp2"}, "396": {"fulltext": "372 GENERAL DIAGNOSIS.\\nshape of the red cells (2) the morphological characteristics of the\\nwhite cells (3) the number of the reel cells (4) the number of the\\nwhite cells (5) the presence of new elements as nucleated red cells\\nand myelocytes (6) the presence of parasites (7) and the amount of\\nhaemoglobin.\\nMethod. A drop of blood for this examination may be taken from\\nthe lobe of the ear or the finger-tip. The surface should be thoroughly\\ncleansed with alcohol, and dried carefully. If the finger is used, it\\nshould not be unduly constricted. The puncture should be made\\nforcibly and quickly, in order that the drop of blood may ooze freely.\\nIf it is difficult to secure the blood, it is well to allow the first or\\nsecond drop to escape before any is collected. When the flow is started\\nand the finger cleansed the succeeding drops are gathered on cover-\\nslips. If the lobe of the ear is selected, it should be steadied with the\\nfingers of the left hand, which at the same time stretches the skin. It\\nmay be necessary to puncture to the depth of one-eighth of an inch, or\\neven more if the skin is bloodless. The puncture should be made on\\nthe lower surface or edge of the lobe. A surgical needle, a small lancet,\\nor the bayonet-pointed instrument devised for the purpose, should be\\nused. The nib of a new steel pen, one-half of which has been broken\\noff, answers fully as well.\\nIt is well to remember the precaution insisted upon by all who ex-\\namine the blood frequently, to beware of bleeders. It sometimes\\nbecomes a very serious matter when hemorrhage is started in a patient\\nwho is the subject of haemophilia.\\nMode of Examination. As soon as the blood flows freely, without\\npressure, the apex of a drop may be touched by the cover-glass, which\\nhas been previously prepared. The cover-glass should not touch the\\nskin, and as soon as it is covered by the blood it should be placed face\\ndownward upon the slide, or if cover-slip preparations are to be made,\\nupon a corresponding cover-glass. The precaution must be taken to\\nhave the slide and cover thoroughly cleansed. It is well to keep them\\nin alcohol or in a weak acid solution after they have been previously\\ncleansed with soap and water, and when removed from the alcohol\\nsolution they should be thoroughly polished with a clean handkerchief.\\nThe blood will then spread evenly over the surface with the slightest\\npressure upon the cover-glass. If the slide and cover are warmed\\nslightly before using, it will not be necessary to use the pressure just\\nreferred to.\\nBlood collected in this way may be examined fresh or be put aside\\nfor staining and future examination.\\nExamination of Fresh Blood. By the examination of fresh\\nblood we learn of the presence of parasites and of the occurrence of\\nrouleaux formation. In a general way we can learn the number of\\nred and white cells respectively, the degree of coloring of the red cells,\\nthe shape and size of the red cells, and the presence of blood-plates.\\nAn unusual increase in leucocytes may be detected, and the diagnosis\\nof leukaemia made without further investigation.\\nCover-slip preparation*. For the purpose of future study, and\\nparticularly in order to determine the differential count of the white", "height": "4416", "width": "2680", "jp2-path": "practicaltreatis00muss_0_0396.jp2"}, "397": {"fulltext": "THE BLOOD.\\n373\\ncorpuscles, cover-slip preparations are made. The covers are cleansed\\nand the blood secured in the manner previously described. The cover-\\nglass, which has been touched to the summit of the drop, is let fall\\nupon another somewhat diagonally. (See Fig. 100.) The drop\\nFig. 99.\\nFig. 100.\\nProper method of holding a cover-gla:\\nIllustrating the position of cover-\\nglass during the spreading of hlood\\nfilms (Cabot.)\\nspreads over the adjoining surfaces of the cover-glass. As soon as the\\nspreading ceases, slide the glasses off, but do not lift them apart. Dr.\\nManson introduced the use of tissue paper drawn over a slide, with\\nthe object of getting a more uniform thickness of film. Pakes uses\\nthis method applied to cover-glasses, which should be not less than 1J\\ninch by f inch. The cover-glasses are held in a clip and smeared by\\nmeans of cigarette paper cut into strips across the direction of the rib.\\nThe cover-slip should be dried in a gas or alcohol flame at once, by\\nmeans of which the preparation is fixed.\\nFixation may also be done by alcohol and ether, or by corrosive\\nsublimate solution. The cover-glass should be immersed for one-half\\nhour in equal parts of alcohol and ether. After such fixation malarial\\norganisms and nucleated red corpuscles are more readily found.\\nFixation with formol is quickly secured. Dilute one part of formol\\nwith nine times its volume of water dilute one part of this mixture\\nwith nine times its value of alcohol. The resulting fluid will fix im-\\nmersed specimens in one minute.\\nFixation of heat is best when the white cells are to be studied. By\\nthis method it is best to put the cover-slips in a dry-heat sterilizer at\\na temperature of 110\u00c2\u00b0 or 115\u00c2\u00b0. If this cannot be done, place the\\ncover-slips on the end of a copper plate at least a foot long, the other\\nend of which is heated by a Bunsen burner or a gas flame. The cover-\\nslips should be placed on the plate at that point on which water boils\\nwhen dropped upon the surface of the copper. They should be placed\\nface downward and kept there from fifteen to twenty minutes. When\\nthey cool they are ready for staining.\\nStaining. The greatest care should be taken to have a perfectly\\nclean, dry cover-glass, which should be handled with forceps, to avoid\\nmoisture and soiling. (1) The prepared cover-glass, arranged as above,\\nshould then be immersed for a few minutes in a solution of eosin", "height": "4416", "width": "2652", "jp2-path": "practicaltreatis00muss_0_0397.jp2"}, "398": {"fulltext": "374 GENERAL DIAGNOSIS.\\nEosin 0.5\\nAlcohol (70 per cent.) 100.0\\nThis solution should be diluted one-half before using. (2) The\\ncover-glass should then be dried and stained for three or four minutes\\nin a saturated aqueous solution of methylene blue, also diluted one-half\\nbefore using (Chunzinsky-Plehn s mixture). Or, instead of the latter,\\nstain for half an hour to several hours in Delafield s hematoxylin. This\\nhematoxylin -stain is made in the following manner To 400 c.c. of a\\nsaturated solution of ammonia alum add 4 grammes of hsematoxylin-\\ncrystals dissolved in 25 c.c. of strong alcohol. Leave this exposed to\\nthe light and air in an unstoppered bottle for three or four days.\\nFilter and add 100 c.c. of glycerin and 100 c.c. of methylic alcohol.\\nAllow the solution to stand until the color is sufficiently dark. Then\\nfilter and keep in a tightly stoppered bottle. The stain should ripen\\nfor at least two months before using. For blood-work the solution\\nis used in its full strength. By this double stain, a modification of\\nEhrlieNs hcematoxylin-eosin mixture, the red corpuscles are stained red,\\nthe nuclei blue, the bodies of the leucocytes light lilac and their nuclei\\ndarker, the eosinophile granules a brilliant red.\\nEhrlich s Tri-aeid Stain. The Ehrlich tri-staining mixture is the\\nbest that can be selected for staining. Thayer says the following is a\\nsatisfactory modification of Ehrlich s formula\\nSaturated aqueous solution of acid fuchsin 2\\nWater 3\\nSaturated aqueous solution of orange-G. 6.25\\nSaturated aqueous solution of methyl-green 6\\nTo be added, drop by drop, while shaking the solution\\nWater .15\\nAlcohol 10\\nGlycerin 5\\nThe stain is spread over the cover-glass specimen with a glass rod,\\nand in from one to five minutes washed off with water. If the cover\\nglass has not been heated very long it will not be necessary to keep\\nthe stain long in contact with the blood, although specimens which are\\nheated an hour require at least five minutes for the stain to take.\\nAfter the specimen is stained and washed in water it should be dried\\nbetween layers of filter paper and mounted in balsam. It can then be\\nexamined at leisure with the twelfth oil-immersion with diaphragm\\nopen.\\nSpecimens heated for one or two hours stain better than those which\\nhave been treated only a short time. The red cells appear orange or\\nbuff, the nuclei of the colorless corpuscles green or greenish-blue, the\\nneutrophilic granules a violet or lilac color, the eosinophilic granules a\\ndeep red. The nuclei of nucleated red corpuscles, when present, are\\nstained an intense deep green, almost black. 1\\nAnother method much used and urged by Hewes is as follows\\nThe blood, after fixation, is subjected for four minutes to the modified\\nEhrlich stain, which is made as follows\\n1 Thayer, loc. cit.", "height": "4412", "width": "2652", "jp2-path": "practicaltreatis00muss_0_0398.jp2"}, "399": {"fulltext": "THE BLOOD. 375\\nEhrlich-Biondi-Heidenhain three-color mixture 1.7 grammes.\\nAcidfuchsin 0.05\\nAbsolute alcohol 2 c.c.\\nDistilled water 18 c.c.\\nAfter immersion wash the specimen in water and then subject it\\nfrom one-half to ten seconds to Loffier s solution of methylene-blue.\\nAgain wash the specimen, dry, and mount in balsam.\\nLoffler s solution is saturated alcoholic solution of methylene-blue,\\n30 c.c. potassic hydrate (1 10,000 solution), 100 c.c.\\nThe Red Corpuscles or Erythrocytes. In thickly spread blood\\nthe cells are arranged in the form of rouleaux. If such rouleaux are\\nabsent in a preparation thus poorly spread it is an indication of great\\nreduction in the red cells.\\nIn thinly spread films the red cells are recognized by their color and\\nshape. They vary from 6 to 9// in diameter. The lighter colored\\ncentre, due to the biconcavity of the corpuscle, sometimes causes con-\\nfusion. It must be remembered, too, that the corpuscles readily become\\ncrenated, an appearance which may be confounded with pigmentation\\nor other abnormal change. In them, too, a slight molecular movement\\nis sometimes seen, which must not be confounded with the amoeboid\\nmovements in dying cells or with the rapid motion of malarial pigment.\\nPoikilocytosis. The variations in size and shape are indications\\nof disease. In forms of anaemia the red cells may be larger than nor-\\nmal they may be irregular in shape, or they may be smaller than\\nnormal. Large cells are known as maerocytes, small cells as microeytes.\\nCells that are irregular in shape are known as poikilocytes. They may\\nbe oval, pointed, angular, or reniform.\\nAchromia. When the red cells are stained the haemoglobin takes\\nthe orange-G. of the tri-colored mixture of Thayer, causing the red\\ncells to be brilliant yellow or pale orange in tint. An idea of the\\namount of haemoglobin can thus be obtained. When the haemoglobin\\nis diminished the centre is pallid, although in extreme poverty of\\nhaemoglobin the colored rim may be a faint outline only (achromic\\nforms).\\nNucleated Red Corpuscles or Blasts. They contain one or\\nmore nuclei. The stroma takes the golden acid stain and the nucleus\\nthe pure basic stain. They are divided in accordance with their size,\\nand the depth of the color of the nuclei, into three varieties\\n(1) The normoblast. It is the size of a normal red blood-corpuscle.\\nThe stroma is golden in color the one or more nuclei are deeply\\nbluish-black, homogeneous. The nucleus occupies one-fourth to three-\\nfourths of the whole corpuscle. It is deeper in color than the nuclei\\nof the white blood-corpuscle. It is the parent cell of the red blood-\\ncorpuscle.\\n(2) The megaloblast. They are larger than a red blood-corpuscle.\\nThe color of the stroma is less intense than that of the normoblast, and\\nthe nucleus is blue rather than black, and not compact and homoge-\\nneous. The nucleus is more compact and more clearly defined than the\\nnucleus of a white blood-corpuscle. It is found on the marrow of the\\nembryo.", "height": "4416", "width": "2676", "jp2-path": "practicaltreatis00muss_0_0399.jp2"}, "400": {"fulltext": "376\\nGENERAL DIAGNOSIS.\\n(3) The microblast. They are smaller than the normal. There is\\nbut little stroma, and the nucleus is deep black\\nBlasts are found in anaemia. An excess of normoblasts indicates\\nvery active regeneration of blood.\\nPolychromatophiles. These are red blood-corpuscles in which\\nthe stroma takes not only the normal acid staining elements but also\\nthe blue basic or purple neutral stain. They are degenerate forms of\\nred blood-corpuscles.\\nDegenerate Forms. The coloring matter is irregularly distrib-\\nuted and the stroma appears disintegrated.\\nWhen thus stained we can readily find nucleated red cells, but the\\nfibrin or blood-plates, as a rule, are destroyed.\\nCounting the Corpuscles. It is of the greatest clinical impor-\\ntance to be able to estimate the number of red cells in a given quantity\\nof blood, in order that approximately at least we may know of its\\nglobular richness. For this purpose hsemocytometers are used.\\nThe hsemocytometers, or blood-counters, most frequently used in\\nthis country are those of Gowers and Thoma-Zeiss.\\nGowers 7 instrument (Fig. 101) consists (1) of a small pipette, A,\\nwhich, when filled, holds exactly 995 cubic millimetres it is for meas-\\nFlG. 101.\\nHreuiocytometer of Gowers.\\nuring the diluting fluid (2) a capillary tube, B, graduated for 5 cubic\\nmillimetres (3) a small glass jar, d, in which the dilution is made (4)\\na small glass stirrer, E, for mixing the blood and diluting fluid in the\\njar (5) a small lancet, F (6) a brass stage-plate, c, carrying a glass\\nslip on which is a cell one-fifth of a millimetre deep. The bottom of\\nthe cell is divided into one-tenth millimetre squares. On the top of\\nthe cell rests the cover-glass, which is kept in place by the pressure of", "height": "4416", "width": "2688", "jp2-path": "practicaltreatis00muss_0_0400.jp2"}, "401": {"fulltext": "THE BLOOD.\\n377\\ntwo springs proceeding from the ends of the stage-plate. 995 cubic\\nmillimetres of the diluting fluid are measured and blown into the\\nmixing-jar then 5 cubic millimetres of blood are added and the two\\nthoroughly mixed. A small drop of the mixture is then placed upon\\nthe cell, the cover-glass gently adjusted and held in place by the two\\nsprings. From five to ten minutes should be allowed to elapse, so\\nthat the corpuscles will have time to settle to the bottom of the cell.\\nThe stage-plate is then placed under a microscope, and the number of\\nred blood-cells in ten squares counted. This number multiplied by\\n10,000 gives the number in a cubic centimetre of pure blood. It is\\nbetter to count a large number of squares, take the average, and multi-\\nply by 100,000. This number is the product of the dilution (200) by\\nthe square surface of the cells, 100 (10 X 10), and again by 5, the\\ndepth of the cell 200 X 100 X 5 100,000. To facilitate seeing the\\nfine lines marking the squares, a soft black lead-pencil should be\\ngently rubbed over them before the drop of diluted blood is placed on\\nthe cell. Counting of the white cells is made much easier if the\\ndiluting fluid is colored a pale violet with a very small quantity of\\ngentian-violet. The white cells then appear a distinct blue, while the\\nred cells are unaltered. As diluting fluids, a 1 per cent, solution of\\ncommon salt, or a 2J per cent, solution of bichromate of potash, as\\nrecommended by Daland, may be employed or Toison s fluid can be\\nused.\\nToison s Fluid. It is made up as follows Distilled water, 160 c.c.\\nglycerin, 30 c.c. sulphate of soda, 8 c.c. chloride of soda, 1 gramme\\nmethyl-violet, .025 gramme.\\nAnother hsemocytometer is the Thoma-Zeiss (Fig. 102). It is pre-\\nferred by most clinicians. It consists of a heavy glass slip (a), in the\\nFig. 102.\\n0.100 mm.\\ntoo mm.\\n\\\\o\\\\\\nThoma-Zeiss blood-counting apparatus.\\nmiddle of which is a cell (B) exactly j-q millimetre in depth. The cell\\nis lhnited at the periphery by a circular gutter to prevent fluid placed\\nupon the cell from flowing beyond it between the slip and cover-glass.\\nThe floor of the cell is ruled into squares whose sides are mm.\\nDouble lines mark out large squares, each containing sixteen small", "height": "4416", "width": "2676", "jp2-path": "practicaltreatis00muss_0_0401.jp2"}, "402": {"fulltext": "378\\nGENERAL DIAGNOSIS.\\nsquares. Thick, carefully ground cover-glasses (D) are provided in\\nthe case. The ordinary Potain melangeur (8) is used to measure and\\nmix the blood. It consists of a capillary tube, the upper portion of\\nwhich is blown into a chamber {E) holding 100 c.mm. The stem of\\nthe tube is graduated at 0.5 and at 1 c.mm.\\nTo use the instrument, a drop of blood is obtained from the finger or\\nlobe of the ear, the point of the capillary tube is inserted into the drop,\\nand blood sucked up to the mark 1 c.mm. The point of the tube is\\nthen quickly wiped free from excess of blood and inserted into the\\ndiluting fluid, which is drawn up to the level of the mark 101. The\\nproportion of blood and diluting fluid is then 1 to 100 c.mm. The\\nblood and diluting fluid are now thoroughly mixed. The diluting fluid\\nin the stem of the melangeur is now blown out and a drop of the\\nblood-mixture placed on the cell. The cover-glass is adjusted carefully\\nto avoid bubbles and to prevent the escape of the fluid between it and\\nthe slip. The cover-glass is now pressed firmly down until Newton s\\ncolor-rings appear, and then the slip is allowed to stand for five or ten\\nminutes, until the corpuscles have settled to the bottom of the cell.\\nThe cell is ruled into 400 small squares, groups of sixteen squares\\nbeing separated by double lines. The surface of a square is ^oS square\\nmillimetre, and the depth of the cell be-\\ning y^ millimetre, the space overlying\\neach square is ^oVo a CUD ic millimetre.\\nFig.\\n103\\nf\\nA\\n\u00c2\u00b0o\\nJ c\\ne\\na\\nO I\\no\u00c2\u00b0o\\no O\\n8 o\u00c2\u00b0o\\nO O 0\u00c2\u00b00\\nc\u00c2\u00b0\u00c2\u00ab\\nc\\n8 o\\nC\\nof\\n5\\n.V\\n\u00c2\u00b0o o\\no o\\nv\\n1\\nf.\\nv;\\na o\\no 0,\\nV\\nr n\\nv i\\no\\nSo\\nJ J b\\n,v\\n0\u00c2\u00b0\\n%r o o\\n\u00e2\u0080\u00a2V:\\nIV.\\nAppearance of blood in the Thoma-\\nZeiss cells.\\nIn estimating the number of cor|^uscles in\\na cubic millimetre of blood, multiply the\\nnumber of corpuscles counted in all the\\nsquares by 4000 and the product by the\\ndilution, which is 1 to 100 or 1 to 200,\\naccording as 1 or 0.5 c.mm. of blood has\\nbeen used. The last product is now to be\\ndivided by the number of squares which\\nhave been included in the count, the quo-\\ntient being the number of corpuscles in a\\ncubic millimetre of blood. The results\\nare accurate in proportion to the care\\nexercised in the measurement of the blood and diluting fluid, and espe-\\ncially in proportion to the number of squares counted.\\nIn the estimation of ivhite blood-cells the pipette made by Zeiss is\\nemployed. In this instrument the blood is diluted ten times by a\\nsolution of one part of a J per cent, acetic acid solution to ten parts of\\ndistilled water. By means of this solution red cells are dissolved and\\nthe nuclei of the white cells are rendered distinct and easy of recogni-\\ntion. Toison s fluid, mentioned above, may also be used. The ordi-\\nnary Thoma-Zeiss slide is employed, and the average number of white\\ncells in each small square is multiplied by 40,000. To obtain accurate\\nresults four entire fields should be counted.\\nThe hcematokrit is an instrument devised for the estimation of the\\npercentage- volume of red corpuscles by means of centrifugal force. In\\nDalaud s article will be found a full description of the instrument, and\\nfrom the same article the following method of using it is abstracted", "height": "4416", "width": "2680", "jp2-path": "practicaltreatis00muss_0_0402.jp2"}, "403": {"fulltext": "THE BLOOD. 379\\nThe finger or ear and apparatus are prepared as above. An incision\\nis made deep enough to produce a good-sized drop of blood. This is\\ndrawn into a hsematokrit tube by means of suction through an attached\\nrubber tube, one finger being placed over the free end when the rubber\\ntube is removed, to prevent the loss of blood. The filled tube is then\\nplaced in the frame of the hsematokrit and a second prepared exactly\\nas the first. The larger wheel is then rapidly rotated for two minutes\\nat seventy-seven turns of the handle-crank per minute (giving alto-\\ngether 20,000 rotations of the frame), and the result read from the\\nscale multiplied by 2 gives the percentage-volume. It has been found\\nby experimenting that each division upon the scale of the haematokrit\\ntube represents 100,000 corpuscles. This procedure is not available\\nfor the determination of the volume of leucocytes unless the number\\nexceeds 20,000, at and above which number an approximate estimate\\nmay be readily determined. A distinct white band appearing between\\nthe red cells and the clear fluid, having the width of one line, may\\nbe considered as representing from 15,000 to 20,000 leucocytes.\\nNumber. The normal number of red cells as stated previously\\nis approximately 5,000,000 per cubic millimetre. They may be\\nreduced to 500,000. A reduction below 3,000,000 indicates grave\\nanaemia. When the reduction is less than 1,500,000 the anaemia is said\\nto be pernicious or malignant. It must be remembered that temporarily\\nthe red cells are reduced during menstruation and lactation. At\\npuberty there is also a reduction. On the other hand, when the blood\\nis concentrated by profuse sweating or exhaustive diarrhoea, the num-\\nber of red cells is increased, while they are lowered Avhen the blood is\\ndiluted by large draughts of fluid or by subcutaneous injections of fluid.\\nA cold bath may temporarily concentrate the peripheral blood, and\\nthereby increase the number of cells. Red cells are always lessened in\\nthe aged, and are reduced in number after great exertion. They are\\nincreased in number after fasting, and diminished after a meal, particu-\\nlarly if much fluid is taken.\\nOligocythemia. Oligocythemia is the name applied to a dimi-\\nnution in the number of red blood-cells, from whatever cause. It is\\nusually associated with oligochromcemia (deficiency of haemoglobin),\\nwhich, however, in idiopathic anaemia is absolute, not relative. Marked\\noligocythemia can be detected with the microscope alone, and can be\\nestimated accuratelv with the haemocytometer or haematokrit. (See\\nFig. 102.)\\nThe White Corpuscles. The white or colorless corpuscles are\\nrecognized by their absence of color, by their irregular shape and their\\nsize, which is larger than that of the red, and by the amoeboid move-\\nments which they undergo, particularly if placed on a warm stage.\\nThey number from 8000 to 10,000 per cubic millimetre. They are\\nreadily recognized by the peculiar affinity which they have for various\\naniline dyes. They appear as granular nucleated cells in stained\\nspecimens. The method of staining has been described, and the vari-\\neties of leucocytes found in normal blood indicated on page 371. In\\naddition to determining the number by counting, as described in the\\nparagraph which gives the method of counting the red cells, a so-called", "height": "4416", "width": "2668", "jp2-path": "practicaltreatis00muss_0_0403.jp2"}, "404": {"fulltext": "380 GENERAL DIAGNOSIS.\\ndifferential count is made. This count enables us to determine the\\nproportion of the many varieties of leucocytes.\\nIn counting the white blood-corpuscles, Phear advises the use of the\\ncamera lucida. The most convenient form is the Zeiss- Abbe drawing\\ncamera, used with the stage of the microscope in a horizontal position.\\nThe image of the field is projected on a piece of paper or card-\\nboard lying horizontally on the table immediately to the right of the\\nmicroscope stand. The ruled squares on the floor of the hsemocytom-\\neter cell are accurately marked out on the cardboard. The image of the\\ncorpuscles which lie on the unruled part of the cell floor is thrown\\nby means of the camera on the cardboard, and the corpuscles which\\nappear to lie over each square are enumerated and included in the\\ncount. It is convenient to use a mechanical stage. It is essential\\nthat the eye-piece, objective, and tube-length used during the count\\nshould be the same as on the occasion of marking out the squares on\\nthe cardboard. For the dilution of the blood, that recommended\\nby Sherrington, 1 consisting of distilled water, 300 cubic centimetres\\nsodium chloride, 1.2 grammes neutral potassium oxalate, 1.2 grammes,\\nand methylene-blue, 0.1 gramme, is excellent. The blood-corpuscles\\nare not stained, but their shape and color are preserved. The nuclei of\\nthe white corpuscles are in every instance stained, facilitating the dis-\\ntinction of the white from the red corpuscles. For the differential\\ncount of the white corpuscles it is desirable to work with an immer-\\nsion lens.\\nDifferential Counting. After the specimen is carefully stained with\\nthe triple solution it is ready for differential counting of the white cells,\\nas well as determining the presence of nucleated red cells. To make\\nthe differential count a large number of leucocytes should be studied.\\nThe best plan to pursue is to begin at the upper left-hand corner of the\\nblood film and count across the film to the right-hand corner. Then\\nmove the slide so that an adjacent field comes into view, when the pro-\\ncess is to be repeated. In this manner the entire field is covered. In\\nordinary leucocytosis a thousand leucocytes can be seen in a seven-\\neighth inch cover-glass specimen. We may find an abnormal variety\\nof leucocytes an abnormal proportion of some one of the normal\\nleucocytes an abnormal number of all the leucocytes.\\nFluid Preparations. Dr. A. G. Phear lays stress on the advan-\\ntages of fluid preparations over the cover-slip method. In the cover-\\nslip method leucocytes are inevitably flattened and distorted in the\\nprocess of making and fixing the film some are washed away during\\nthe staining others obscured by the red corpuscles. In the fluid\\npreparation the white cells are fixed and preserved as approximately\\nspherical bodies camera lucida drawings and measurements of them\\ncould be relied on as accurate. A solution of methylene-blue (0.2 per\\ncent.) in 40 per cent, alcohol is used for diluting the blood. The red\\ncorpuscles are laked so that the white cells alone remain conspicuous.\\nA small quantity of the diluting solution is added to a drop of blood\\non a glass slide and the two are thoroughly mixed by directing a cur-\\n1 Proceedings of the Royal Society, vol. lv.", "height": "4416", "width": "2684", "jp2-path": "practicaltreatis00muss_0_0404.jp2"}, "405": {"fulltext": "THE BLOOD. 381\\nrent of air through a pipette on to the surface of the fluid. The fluid\\nis allowed to spread as a thin film under a cover-glass and the edges\\nthen sealed with vaseline. The contour of the normal polymorpho-\\nnuclear cells is rounded. Their diameter vary from 9 to 10//. The\\ncomplex nucleus can be made out by changing the focus, the nucleus\\nbeing, in fact, an undivided elongated body, in places deeply con-\\nstricted, elsewhere bulged into rounded lobes. The lymphocytes and\\nthe large hyaline cells represent the extremes of cells, differing in the\\namount of protoplasm around the nucleus all grades are readily\\nfound. The nuclear diameter is fairly constant in these cells, varying\\nonly between 4.5 and 5.5//. Large oval cells, as much as 14// in\\nlength, with the nucleus large and irregular, usually reniform, are\\nseen. The protoplasm becomes rapidly and uniformly stained an\\nopaque blue color with methylene-blue. The coarsely granular or\\neosinophile cells (diameter from 9.5 to 10.5//) are at once recognized\\nin the film prepared with methylene-blue solution, notwii hstanding\\nthe absence of an acid dye the large refractile granules are tinged\\nwith a greenish color. The cells containing basophile granules (diam-\\neter about 8//) have a characteristic appearance. The protoplasm con-\\ntains granules of medium size, many of which are aggregated in one\\nor more deeply stained clumps near the surface of the cell. The non-\\ngranular part of the protoplasm is stained a peculiar mauve or purple\\ncolor. The nucleus is usually massed at the centre of the cell, and\\nstains a slate or grayish-blue color.\\nSeparate counts over different areas of one preparation gave uniform\\nresults, showing that the blood was evenly mingled with the diluting\\nfluid. Not less than 500 cells should be enumerated at a time the\\nmore the better. It was desirable to use a mechanical stage and to\\nwork with an immersion lens. The blood should always be procured,\\nif possible, before the first meal of the day is taken, since this is the\\ntime at which the influence of meals is least likely to be evident.\\nLeucocytosis. Leucocytosis is a temporary increase in the number\\nof white blood-cells of the same morphological varieties as in health,\\nwith an excess of the polynuclear forms (neutrophile leucocytosis).\\nSuch increase may be physiological or pathological, as indicated in the\\nfollowing\\nPhysiological Leucocytosis. (1) Pregnancy (14,000 and up-\\nward) (2) during digestion (from 1000 to 7000 above normal more\\nin children) (3) new-born (12,000).\\nPathological Leucocytosis. An excess of leucocytes occurs in\\nthe following diseases (1) Leukaemia (2) pernicious ansemia (3)\\nchlorosis (4) diseases of lymphatic glands (5) disease accompanied\\nby exudations, as pleurisy, pericarditis, meningitis, polyarthritis, and\\nespecially croupous pneumonia (6) inflammatory condition associated\\nwith exudation, as appendicitis, pyonephrosis, perinephritic abscess,\\ntonsillar and retropharyngeal abscess, acute pancreatitis, cholangitis\\n(7) many acute infectious diseases, as varicella, variola, vaccinia, epi-\\ndemic cerebrospinal meningitis cholera, typhus fever, trichinosis, glan-\\nders, diphtheria, scarlet fever, erysipelas, pyaemia and septicaemia,\\nrheumatism, abscesses, and gangrenous inflammation (8) after hemor-", "height": "4416", "width": "2676", "jp2-path": "practicaltreatis00muss_0_0405.jp2"}, "406": {"fulltext": "382 GENERAL DIAGNOSIS.\\nrhage and (9) just before death, leucocytosis of agony. On the other\\nhand, leucocytosis is not found in uncomplicated cases of (1) influenza\\n(Boston Medical and Surgical Journal, March 22, 1894) (2) uncom-\\nplicated cases of typhoid fever (3) tuberculosis when not associated\\nwith cavity-formation or hyperplasia of lymphatic glands (Stein and\\nErbman, Deutsch. Archiv. f. klin. Med., Bd. 56) (4) many forms of\\ncarcinoma and sarcoma, gastric ulcer and benign pyloric stenosis\\n(Schreuger, Zeitschr. f. klin. Med., 1895, 27, 475), although it may be\\npresent in gastric carcinoma.\\nLetjcopenia. Diminution of the number of leucocytes is seen (1)\\nin starvation, as in cancer of the oesophagus (2) the latter weeks of\\ntyphoid fever (3) leukaemia complicated by infection.\\nDiagnostic Value. The value in diagnosis of determining the\\npresence of leucocytosis is great. Its absence excludes the first series\\nof cases its presence the last. If leucocytosis is present in the course\\nof, or convalescence from, typhoid fever, it points to a complication, as\\nthrombosis. A post-febrile rise, due to a complication, may be distin-\\nguished from a true relapse by an increase of the white cells.\\nIt is best determined with a haemocytometer. Dry preparations,\\naccording to Ehrlich s method, are necessary for a study of the various\\nforms of leucocytes. (See under Leucocythaemia, page 396, and\\nPlate X.)\\nIncrease of Special Leucocytes. Lymphocytosis. A relative\\nincrease in the lymphocytes with or without a total increase of leuco-\\ncytes, is seen in infants, and is a common accompaniment to rickets\\nand hereditary syphilis. In some forms of scurvy it is also found.\\nIn adults lymphocytosis occurs in chlorosis and pernicious anaemia and\\nin secondary anaemia of syphilis and typhoid fever. It occurs in haemo-\\nphilia, in adenitis, and splenic tumors. Cabot states that it is also\\nfound at the end of scarlet fever and measles, in pneumonia with de-\\nlayed resolution, and in some forms of phthisis. The larger forms of\\nleucocytes are seen. Absolute lymphocytosis occurs in lymphatic\\nleukaemia.\\nEosinophilia. An increase in the percentage of eosinophiles, with\\nor without leucocytosis, is seen in many affections of the bones, in affec-\\ntions of the skin, and in diseases of the genital apparatus in females.\\nIt is also seen in certain disturbances of the sympathetic nervous\\nsystem, as in cyanosis and vasomotor troubles associated with menstru-\\nation and pregnancy. The bone diseases in which the eosinophiles are\\nincreased are osteomalacia, sarcoma, carcinoma, and in those affections\\nof the bone and marrow with which pernicious anaemia and splenic\\nmyelogenous leukaemia are seen. The skin diseases are urticaria,\\npellagra, herpetiform, dermatitis, and pemphigus, in herpes, eczema and\\nprurigo, psoriasis, lupus, and myxoedema. In the eruption of scarlet\\nfever and syphilis they are increased, but not in measles or smallpox.\\nIn various affections of the uterus and ovary, in functional disorders\\nconnected with the same, the eosinophiles are increased. They are\\nalso increased in gonorrhoea and prostatitis. They are increased in\\nthose infections in which Neusser s granules are found. Thayer, in\\nOsier s clinic, has found marked increase in the eosinophiles in trichi-", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0406.jp2"}, "407": {"fulltext": "PLATE X.\\nFIG. 1.\\nBlood from Case of Secondary Anaemia.\\ni. Poikilocytes. 3 and 6. Lymphocytes.\\n2. Macrocytes. 4. Nucleated red blood-corpuscle.\\n5. Polynuclear leucocytes.\\n(Oc. 4, ob. T immersion.) Drawn by J. D. Z. Chase.\\nFIG. 2.\\np\u00c2\u00b0 f\\ns*. o\\nLeukaemic Blood.\\n1. Polynuclear leucocytes. 3. Large mononuclear leucocyte.\\n2. Eosinophile cell (mononuclear). 4. Small lymphocyte.\\n(Oc. 4, ob. T V immersion.) Drawn by J. D. Z. Chase.", "height": "4416", "width": "2648", "jp2-path": "practicaltreatis00muss_0_0407.jp2"}, "408": {"fulltext": "", "height": "4380", "width": "2720", "jp2-path": "practicaltreatis00muss_0_0408.jp2"}, "409": {"fulltext": "THE BLOOD. 383\\nnosis in fact, recognizing this condition by the differential count.\\nDiminution in the eosinophils takes place during digestion, and in\\nmost of the infectious disorders accompanied by leukocytosis, and in\\ntyphoid fever and diphtheria. Malignant disease with hemorrhage\\nwhich causes leucocytosis is, however, associated with diminution of\\nthe eosinophiles. Neusser has indicated the following diagnostic points\\nof value in eosinophilia. They are given by Cabot as follows\\n1. In the diagnosis between puerperal mania and puerperal sepsis,\\neosinophilia points to the former.\\n2. Between a tumor connected with the genital system and one not\\nso connected, eosinophilia points to the former.\\n3. In determining whether a given case of hysteria, neurosis, or\\npsychosis is likely to be benefited by castration, the presence of eosino-\\nphilia favors the operation.\\n4. In malignant disease an eosinophilia points to a metastasis in the\\nosseous system (tumors of the spleen are not included in this rule).\\n5. In cases of doubtful syphilis, eosinophilia combined with lympho-\\ncytosis (see above) speaks in favor of syphilis.\\n6. The diagnosis of any obscure form of uric-acid diathesis is\\nhelped by finding an increase of eosinophiles.\\n7. In distinguishing malignant liver disease from other liver disease,\\neosinophilia points to the latter.\\nPathologic Leucocytes. Myelocytes. The occurrence of myelo-\\ncytes in the blood is pathological. Their well-known occurrence in\\nmyelogenous leukaemia and pernicious anaemia need not be referred to.\\nThey have been found, however, in a number of infections, but usually\\nonly when there is present a grave form of anaemia. Their occurrence\\nis not of great diagnostic value. They are non-amoeboid. They are\\nlarge mononuclear neutrophiles or eosinophiles, with large, well-\\ndefined, lateral, spherical nuclei. Occasionally they are small when\\nthey are recognized by the granules and the very pale large nucleus.\\nThe mast-zellen are mononuclear, coarsely granular basophiles. The\\nnucleus is fragmented or three-lobed.\\nNeusser s Granules. When making a differential count we also\\nstudy certain granules in the leucocytes. Neusser has described peri-\\nnuclear basophilic granulations in the leucocytes, which are demon-\\nstrated by staining the blood with the following modification of Ehr-\\nlich s triple stain\\nSaturated aqueous solution of acid fuchsin 50 c.c.\\nSaturated aqueous solution of orange-G. 70\\nSaturated aqueous solution of methyl green 80\\nAquae dest. 150\\nAbs. alcohol 80\\nGlycerin 20\\nThe granules in question occur as separate bodies or as groups, lying\\nin the protoplasm immediately around the nucleus. They are met\\nwith in the mononuclear forms in particular, and, according to Neusser,\\nare composed of some derivative of the nucleo-albumin and indicative\\nof increased uric-acid formation. The granules occur in gout, and also\\nin certain cases of myelogenous leukaemia, tuberculosis, diabetes, and", "height": "4404", "width": "2684", "jp2-path": "practicaltreatis00muss_0_0409.jp2"}, "410": {"fulltext": "384\\nGENERAL DIAGNOSIS.\\nother diseases. They are significant of a nric acid diathesis in the\\nclinical sense. In discussing Neusser s paper, Lonit called attention\\nto the fact that similar granules occur in the leucocytes of the bone-\\nmarrow of rabbits.\\nOther observers have found these granules in a variety of conditions,\\nand incline to regard them of less significance than Neusser is disposed\\nto admit.\\nThe Haemoglobin. An estimation of haemoglobin is made, in order\\nto determine the richness of red cells in this substance. For this pur-\\npose a hsenioglobinometer is used.\\nH^emoglobhstometers. Growers hsemoglobinometer (Fig. 104) con-\\nsists of (1) a closed tube, D, containing coloring-matter representing\\nthe color human blood should have normally if diluted one hundred\\ntimes (2) a corresponding empty tube, C, graduated in an ascending\\nscale from 10 to 120 (3) a capillary glass tube, b, marked at 20 cubic\\nmillimetres a small guarded lancet, F, and a small bottle with a pipette\\nstopper, A, for distilled water. A few drops of distilled water are\\nfirst placed in the empty tube, c, to prevent the coagulation of the\\nblood, which would occur if the blood were first put in the tube. The\\nfinger or lobe of the ear, previously cleansed with water and ether, is\\nthen deeply stabbed with the lancet, so that the blood will flow freely,\\ncare being taken to avoid squeezing the punctured part 20 cubic milli-\\nmetres of blood are then quickly drawn up in the capillary tube and\\nFig. 104.\\nGowers hsemoglobinometer.\\nat once blown into the graduated tube, which is shaken, to allow the\\nblood to become diffused in the water. The tubes containing the stand-\\nard coloring-matter and the diluted blood are now held up, side by\\nside, against a sheet of paper, and more distilled water added, drop by\\ndrop, with repeated shakings, until the colors in the two tubes match.\\nThe height to which the column of diluted blood and water has risen", "height": "4408", "width": "2708", "jp2-path": "practicaltreatis00muss_0_0410.jp2"}, "411": {"fulltext": "THE BLOOD. 385\\nin the graduated tube represents the percentage of haemoglobin con-\\ntained in the blood tested.\\nFleischl s haemometer consists of a. small metal table with an aper-\\nture in the middle, under which is a reflector made of plaster-of-Paris.\\nThe opening is occupied by a small well having a glass bottom and\\ndivided into two equal compartments. The standard color of the blood\\nat different dilutions is represented by a wedge of glass, colored with\\nCassius purple, which is, of course, pale in color at the extreme edge\\nand deepens in intensity with its thickness. This wedge of glass is\\nmoved under the table by a rack and pinion, and is accompanied by\\na graduated scale. One-half of the well receives simply the light from\\nthe plaster-of-Paris reflector, while the other rests upon the ruby glass\\nand obtains light through it. The light from a candle, gas-jet, or oil-lamp\\nmust be used. A small pipette and several capillary tubes about f\\ninch in length, and mounted on slender metal handles, are employed to\\nobtain the necessary amount of blood each one of them will hold\\nenough normal blood to produce, when properly diluted, a color corre-\\nsponding to that of the ruby glass at the 100 mark. For use, one end\\nof a capillary tube is carefully lowered upon a drop of blood, which\\nimmediately fills it the tube is then at once washed in one of the\\ncompartments of the well, which contains some water. The compart-\\nments are now equally filled with water, and the well so placed that\\nthe side containing blood receives yellow light, as from a candle,\\nwhile the other receives light through the wedge of glass. The glass\\nis now moved by the rack and pinion until the intensity of the color\\nin the two compartments is the same, and the percentage is then read\\noff through the small opening behind the well.\\nBoth Gowers and Fleischl s instruments are about equally accurate,\\nand both are graduated for a higher percentage of haemoglobin than is\\nthe average with Americans, which may be as low as 96 per cent.\\nColor-index. The haemoglobin usually increases or diminishes\\nwith increase and diminution of the red cells. If there is any variation\\nfrom this percentage the determination of this variation is known as\\nthe color-index. In a healthy individual with 5,000,000 red cells per\\ncm. the normal percentage of haemoglobin should be 100. We then\\nsay the color-index 1. If the haemoglobin is diminished, the color-\\nindex is less than 1. The color-index is estimated, first, by reducing\\nthe count of the cells to a percentage second, by dividing this percent-\\nage into the haemoglobin percentage. Thus if the normal percentage\\nof red cells is present that is 100 and the haemoglobin is reduced to\\n50 per cent., the color-index is y 5 or 0.5 a reduction of the red cells\\nto 2,500,000 cells 50 per cent, of the normal. INow, if the haemo-\\nglobin is 40 per cent., the color-index will be f or 0.8.\\nDiminution in the amount of haemoglobin is seen in anaemia, and\\nusually the reduction is lower than the reduction of the red cells. In\\nchlorosis the reduction in haemoglobin is very great, and in consequence\\nthe color-index is lower than in secondary anaemias. The average\\nhaemoglobin per cent, in a large number of chlorotic cases, studied by\\nCabot and by Thayer was about 42 per cent. At the same time in\\nmost of these cases the number of red corpuscles was over 4,000,000.\\n25", "height": "4416", "width": "2640", "jp2-path": "practicaltreatis00muss_0_0411.jp2"}, "412": {"fulltext": "386 GENERAL DIAGNOSIS.\\nMelanaemia. Melanaeinia is a rare condition, in which black,\\nbrown, or yellow granules are seen floating, either free among the\\nblood-cells, or, more commonly., enclosed in cells resembling leuco-\\ncytes. They are present in malarial fevers, particularly the chronic\\nforms, and in relapsing fever.\\nLipaemia is the presence in the blood of fat, usually in the form of\\nsmall droplets, easily detected by the microscope. The diagnosis can\\nbe confirmed by treating the fresh preparation with a 1 per cent, solu-\\ntion of osmic acid, followed by a weak aqueous solution of eosin. The\\nfat-drops will appear black among the faintly stained acid corpuscles.\\nA saturated solution of Soudan three in 96 per cent, alcohol will stain\\nfat drops bright red or orange. Lipsemia occurs in chronic alcoholism,\\nchronic nephritis, and diabetes, and after-injuries to the bone-marrow.\\nThe Acidity of Blood. The total acidity of the blood is best\\ndetermined by Landois titration-method, as follows Prepare a deci-\\nnormal solution of tartaric acid by dissolving 7.5 grammes of the\\nchemically pure salt in 1 litre of distilled water. By diluting centi-\\nnormal and millinormal solutions are obtained. Prepare a series of\\nsolutions as follows\\nI. contains 0.9 c.c. centinormal solution tartaric acid ~f 0.1 c.c. satu-\\nrated potassium sulphate solution.\\nII. contains 0.8 c.c. centinormal solution tartaric acid -f- 0.2 c.c. sul-\\nphate solution.\\nIX. contains 0.1 centinormal acid 0.9 c.c. sulphate solution.\\nX. contains 0.9 c.c. millinormal acid -J- 0.1 c.c. sulphate solution.\\nXVIII. contains 0.1 c.c. millinormal acid -j- 0.9 c.c. sulphate solution.\\nIn each of a series of watch-glasses mix 1 c.c. fluid (each watch-\\nglass containing a different strength, as in the series above given) with\\n0.1 c.c. of blood. This can be done by a graduated pipette. The\\npipette of a Thoma-Zeiss hsemocytometer answers very well.\\nTest the contents of each watch-glass with a strip of delicate litmus-\\npaper, and note in which solution the reaction is neutral. This opera-\\ntion must be done quickly, the whole process not taking more than one\\nand a half minutes (V. Jaksch).\\nSuppose 0.4 c.c. tartaric acid neutralizes 1 c.c. of blood now, 0.4\\nc.c. tartaric acid neutralizes 0.0016 gramme caustic soda. Therefore\\n0.1 c.c. blood 0.0016 sodic hydrate and 1 c.c. 0.16. The normal\\nalkalinity is 1 part XaOH to 26 to 30 parts of blood, or 1 c.c. blood\\n0.33 to 0.38 gramme XaOH.\\nThe alkalinity of the blood is diminished in\\n1. Fevers and cachexias.\\n2. Toxic conditions, as uraemia, diabetes, and jaundice. Or certain\\npoisons, as C0 2 and phosphorus.\\n3. Pernicious anaemia, simple anaemia, and leukaemia.\\n4. Chronic articular rheumatism and gout (not in acute articular\\nrheumatism). This may, perhaps, be due to the accompanying anaemia.\\nIt is increased, perhaps, in chlorosis, though this is doubted by some\\nauthorities.\\nUric Acid. GarrooVs test. By this test we can determine the pres-\\nence or absence of large amounts of uric acid in the blood. A few c.c.", "height": "4416", "width": "2720", "jp2-path": "practicaltreatis00muss_0_0412.jp2"}, "413": {"fulltext": "THE BLOOD. 387\\nof blood-serum or of serous fluid are placed in a watch-crystal add to\\nthis 6 to 10 drops of a 30 per cent, solution of acetic acid. Immerse a\\nthread of linen in the fluid, and keep it at a low temperature for from\\ntwelve to twenty-four hours. If uric acid is present in large amounts\\nat the end of twenty-four hours, crystals collect upon the thread. Their\\ntrue nature is determined by the microscope (see Urine) and the murex-\\nide test. The serum may be secured by a blister.\\nThe Specific Gravity. The specific gravity of the blood is best\\ndetermined by the following method\\nPrepare a series of solutions of water and glycerin in such proportions\\nthat they form a series gradually ascending in specific gravity from\\n1040 to 1080. Place from 80 to 100 c.c. of each solution in a series\\nof small glass jars and bring a drop of blood exactly in the middle of\\neach, as follows A hypodermic syringe is connected by a small\\nrubber tube with a right-angled glass capillary tube. A drop of blood\\nis obtained from the finger in the usual manner, and is drawn by means\\nof the syringe into the capillary tube. By a gentle motion of the\\nsyringe a small drop is expelled into the fluid from the point of the\\ntube. The drop will remain stationary if the specific gravity of the\\nfluid equals that of the blood it will sink if the fluid be of less specific\\ngravity than that of the blood, or will rise if the fluid be of greater\\nspecific gravity than the blood. By repeated examination the specific\\ngravity of any specimen can be easily determined. The glycerin mix-\\nture can be preserved by the addition of a small amount of thymol,\\nand may be used a second time but in this case it is necessary to rede-\\ntermine its specific gravity before each usage. By the specific gravity\\none can estimate the amount of haemoglobin because the former runs\\nparallel to the percentage of the latter. Two methods are employed\\nthe water and glycerin method and the method of Hammerschlag.\\nHammerschlag s method is as follows Mix in a urinometer glass\\nsuch quantities of chloroform and benzol that the specific gravity is\\nabout 1059. Take a drop of blood from the punctured ear by a medi-\\ncine dropper or a capillary tube, and blow it into the chloroform-benzol\\nmixture. The blood does not mix but floats like a red bead. Add\\nchloroform, drop by drop, if the blood sinks to the bottom. Add\\nbenzol if it rises to the top. After each addition stir the mixture with\\na glass rod. When the drop remains stationary in the body of the\\nfluid its specific gravity is the same as that of the fluid as a whole.\\nTake the specific gravity and you have the specific gravity of the blood.\\nAir should not be blown into the fluid with the blood drop. The fol-\\nlowing table gives the relations of the specific gravity to the haemo-\\nglobin, from which an estimate of the haemoglobin can be made\\nSpecific gravity.\\nHaemoglobin.\\n1033 to\\n1035\\n25\\nto\\n30 per cent\\n1035\\n1038\\n30\\na\\n35\\n1038\\n1040\\n35\\niC\\n40\\n1040\\n1045\\n40\\n11\\n45\\n1045\\n1048\\n45\\nil\\n55\\n1048\\n1050\\n55\\nu\\n65\\n1050\\n1053\\n65\\n(C\\n70\\n1053\\n1055\\n70\\nli\\n75\\n1055\\n1057\\n75\\nLi\\n85\\n1057\\n1060\\n85\\n(I\\n95", "height": "4412", "width": "2660", "jp2-path": "practicaltreatis00muss_0_0413.jp2"}, "414": {"fulltext": "388\\nGENERAL DIAGNOSIS.\\nThe specific gravity of the blood is normally less in women, and is\\ndiminished in severe symptomatic anaemias, pernicious anaemia, chlo-\\nrosis, leukaemia, and, according to Monti (Archiv. f. Kinderheilk., Bd.\\nxviii. S. 161), in nephritis. It is increased in infancy and acute febrile\\ndiseases, as pneumonia, pleurisy, etc. (Monti, ibid.), and also in diph-\\ntheria (Fibrenthal and Bernhard, ibid., Bd. xvii. H. 5 u. 6).\\nCoagulation Time. An estimate of the time required for the blood\\nto clot is valuable, particularly in prognosis. In case of jaundice, for\\ninstance, in which blood destruction is going on rapidly, it is well to\\nknow the clotting power of the blood, as surgical interference should be\\nresorted to in obstructive forms whenever the coagulation time is very\\nrapid. The method devised by Wright is the best at our command.\\nParasites in the Blood.\\nThe principal vegetable parasites are those associated with the infec-\\ntions and described in Chapters XIX and XX. They are (1) spirilla\\nof relapsing fever (2) tubercle-bacilli (3) anthrax-bacilli (4) bacilli\\nof glanders (5) typhoid bacilli (6) streptococci and staphylococci\\n(7) the bacilli of yellow fever.\\nThe animal parasites are (1) Filaria sanguinis hominis (2) dis-\\ntoma haematobium (3) plasmodium of malaria.\\nFig. 105.\\n-i\\ny^\\nFilaria alive in the blood. Instantaneous photomicrograph. Four hundred diameters\\nmagnification. Four millimetres Zeiss apochromatic. (F. P. Henby.)\\nThe Filaria Sanguinis Hominis. Filariae are found hi the blood\\nand lymph of persons who live in the tropics, and in a few instances\\nhave been found in native Americans (John Guiteras). They have a\\nblunt, rounded head with a tongue-like process and a long, pointed tail.\\nThey produce lymphatic swellings (particularly of the scrotum),\\nchyluria, and haematuria.\\nPatrick Manson 1 says the following are the commonest mistakes in\\nthe search for filariae (1) The use of too high a magnify ing-power\\n(2) employing too strong illumination (3) searching unmethodically\\nand in too small a quantity of blood (4) looking for filariae in blood\\ndrawn from the body at a time when the particular species sought for\\nis normally absent from the circulation. He describes three forms\\nFilaria sanguinis hominis noctuma (the ordinary form) filaria san-\\nguinis hominis diurna and perstans. The last appears to be the one\\nTrans. Seventh International Congress of Hygiene and Dermography, vol. i. p. 93.", "height": "4396", "width": "2720", "jp2-path": "practicaltreatis00muss_0_0414.jp2"}, "415": {"fulltext": "THE BLOOD. 389\\nassociated with the production of the disease known on the west coast\\nof Africa as sleeping sickness. He prefers dry preparations of the\\nblood, stained with a J per cent, eosin solution or a weak solution of\\nfuchsin (one drop of the saturated alcoholic solution to an ounce of\\nwater). If a thin film of blood, before it has fully dried, be held over\\nacetic acid so as to imbibe the fumes, and be then stained in a per\\ncent, solution of eosin, the blood is stained, but any filar iae remain\\npearly white.\\nThe filariae may have been discovered accidentally, or are sought for\\nbecause of hcemato-chyluria, or lymph-scrotum, elephantiasis, or varicose\\ngroin glands Demerara groin In the former the chyluria is inter-\\nmittent. Microscopically, the urine contains molecular fat-globules or\\ngranules and a few red corpuscles.\\nANEMIA.\\nAnaemia is a condition characterized by a reduction in the number\\nof red blood-cells, or of their haemoglobin, or of the albumin, or of all\\ncombined.\\nThe most casual observation may be sufficient for the recognition of\\nanaemia. The color of the surface, the appearance of the mucous mem-\\nbranes, and the evident breathlessness of the patient are indications of\\ndiminution in the amount of blood, or of some of its constituents, as the\\nred cells, or of the coloring matter of these cells. On inquiry it would\\nbe found that the patient is easily prostrated, that there is breathless-\\nness on exertion (aggravated on ascending any height), that there is\\npalpitation and perhaps cardiac oppression. The patient will com-\\nplain of neuralgias in various parts of the body, and especially of the\\nneuralgia so often seen in the inframammary region of the left side.\\n(See Pain.) Headache will be a more or less constant symptom, and\\nof this peculiarity, that it is increased when the patient goes up stairs,\\nand is often throbbing or pulsating. The anaemic subject has usually\\na poor appetite and suffers from gastralgia, although it must be re-\\nmembered that the gastric symptoms of anaemia are as often primary\\nas secondary. Many of the train of symptoms which attend neuras-\\nthenia occur in the course of anaemia.\\nOn physical examination of the patient the appearances as above\\nindicated are found, although grave anaemias may be present, and yet\\nthe lips are bright red, the color under the nails fair, and the cheeks\\nflushed, especially if the examination is made in the evening. Refer-\\nence must be made to the chapter on the Color or Hue of the Surface\\nfor a description of the appearances of anaemia.\\nA study of the heart and bloodvessels usually yields the physical\\nsigns that attend anaemia. The vascular phenomena are described in\\nthe section on Diseases of the Heart. Here, again, it must be remem-\\nbered that considerable anaemia may be present without any murmurs\\nin the bloodvessels.\\nThe Blood. The final diagnosis rests upon an examination of the\\nblood. Sometimes the most apparently anaemic subjects yield normal\\nresults in blood examination, while the most plethoric in appearance", "height": "4416", "width": "2700", "jp2-path": "practicaltreatis00muss_0_0415.jp2"}, "416": {"fulltext": "390\\nGENERAL DIAGNOSIS.\\nmay be very anaemic. The various forms of anaemia give rise to blood\\nchanges in a measure peculiar to the respective variety. The primary\\nanaemias, or haemolytic varieties, to which pernicious anaemia and chlo-\\nrosis belong, have characteristics which will be described in the special\\nsections.\\nIn anaemia from hemorrhage the red corpuscles may be reduced to\\n1,500,000. The haemoglobin is reduced to a degree greater than that\\nof the red cells. The leucocytes are increased in number, the polynu-\\nclear forms being relatively much less than the other varieties.\\nThe red corpuscles are paler than normal their white centres are\\nincreased in size. This is known as achromia. There is some poikilo-\\ncytosis. An excess of nucleated red corpuscles, or blasts, are seen in\\ngrave anaemias. If the normoblasts are in excess, active regeneration\\nis in progress if the megaloblasts, there is reversion to embryonal regen-\\neration, a serious import in an anaemia. A megaloblast anaemia is\\nassociated with general increase in size of red cells and an increase of\\nthe macrocytes. In fatal anaemia, as in purpura, the red cells are like\\nthose in the form just described, although nucleated red corpuscles\\nare absent. The white cells are also reduced, although the mono-\\nnuclear forms are numerous.\\nIn the oligocythaemic forms of anaemia, other than the hemorrhagic,\\nthe occurrence of poikilocytosis is constant and marked. Nucleated\\nred corpuscles are not common, but large nucleated cells in which\\nkaryokinetic figures occur. These corpuscles have pale staining\\nnuclei. Achromic forms, polychromatophiles, and degenerate forms\\nare seen. There is usually moderate leucocytosis.\\nFor clinical purposes it is necessary to make a number of divisions\\nof anaemia, though on etiological and pathological grounds many of\\nthem will no doubt soon be grouped together.\\nThe following classification of anaemias is helpful in the study of\\nanaemia. In it both pernicious anaemia and chlorosis are regarded as\\nhaemolytic in origin, the destructive agent probably being absorbed\\nfrom the intestine.\\nI Non-cytogenic,\\nAnaemia,\\nCytogenic,\\nHemolytic,\\nOligocythemic,\\nLeucocytic,\\nNon-leucocytic,\\nPernicious anaemia.\\nOther toxic anaemias.\\nChlorosis.\\nParasitic anaemia (some forms).\\nf Parasitic ansemia (some forms).\\nJ Post-hemorrhagic ansemia.\\nI Anaemia from loss of albumin.\\nI Anaemia of malnutrition.\\nr Spleno-myelogenic.\\nLeucocythaemia, Lymphatic.\\nI Medullary or myelogenic.\\nHodgkin s disease\\nI. Toxic Anaemias. The poison may be developed in the body or\\nintroduced from without. Toxaemia is, sometimes at least, a factor in\\nthe anaemias which develop in the course of acute infectious diseases or\\nduring convalescence from them. According to Hunter, pernicious\\nanaemia should be classed under this head. The metallic poisons, par-", "height": "4412", "width": "2712", "jp2-path": "practicaltreatis00muss_0_0416.jp2"}, "417": {"fulltext": "THE BLOOD. 391\\nticularly lead, mercury, arsenic, phosphorus, the potassium salts, espe-\\ncially the chlorate certain of the antipyretics, notably pyrodin and\\nthe aniline-preparations are capable of producing anaemia.\\nII. Parasitic Anaemias. Anaemia may be parasitic 1. To this\\nclass belongs the anaemia of malaria, which is believed to be due to\\nthe plasmodium malarice described by Laveran.\\n2. Certain intestinal worms are found associated with marked anaemias.\\n(a) The bothriocephalus latus sometimes produces a disease closely re-\\nsembling pernicious anaemia, but whether by direct destruction of the\\nblood, or by the development of toxic products, themselves destructive,\\nis uncertain it may be present in large numbers without giving rise\\nto anaemia.\\nFig. 106.\\nSevere anaemia (Reproduced from colored plate.) Dry preparation, x 300. Great poikilocytosis.\\nMany macrocytes and microcytes. To the left above, a mononuclear leucocyte.\\n(b) The ankylostomum duodenale is believed to be the cause of the\\nanaemia known variously as Egyptian or African chlorosis, tropical\\nanaemia, brick-burner s anaemia, etc.\\n._ (c) The anguillula intestinalis is the cause of Cochin-China diar-\\nrhoea and its associated anaemia.\\n3. The filaria sanguinis hominis may produce anaemia by blocking\\nup the lymph-channels.\\n4. The Bilharzia hcematobia may produce anaemia by inducing haema-\\nturia.\\nIII. Anaemia from Hemorrhage. Anaemia may be due to hemor-\\nrhage. In addition to accidental and post-partum causes, purpura,\\nhaemophilia, menorrhagia, and metrorrhagia are frequent causes.\\nIV. Anaemia from Constitutional and Local Diseases. Anaemia\\nis often a marked symptom of constitutional and local diseases, such as\\ntuberculosis, syphilis, cancer, rheumatism, scrofula, scurvy, rickets,\\nBright s disease, chronic catarrhal gastritis, and others. The anaemia\\nhere may be due to the malnutrition and interference with digestion", "height": "4416", "width": "2692", "jp2-path": "practicaltreatis00muss_0_0417.jp2"}, "418": {"fulltext": "392\\nGENERAL DIAGNOSIS.\\nbrought about by the disease, or, as in the case of Bright s disease,\\nin part to the direct loss of albumin, and in dyspeptic conditions to\\ninability to take and assimilate food.\\nIn many cases of simple symptomatic anaemia the spleen may become\\nprogressively enlarged, probably secondarily. In other cases there is\\nan enlargement of the spleen in Hodgkin s disease. In no case is\\nthere a primary splenic anaemia.\\nV. Anaemia of Malnutrition. Anaemia may also be the result of\\nmalnutrition from deficient or improper food, or from the poisonous\\ninfluences of unsanitary surroundings.\\nChlorosis.\\nChlorosis, or chloro-anaemia, is a form of anaemia occurring especially\\nin young girls about the period of puberty, and characterized by great\\npallor of the skin and mucous membranes, with a greenish tint of the\\nskin, a pearly eye, languor, weariness, suppression or irregularity of\\nFig. 107.\\nDATE\\nX\\nX X\u00c2\u00ab\\ny\\n\\\\y\\ny\u00e2\u0084\u00a2\\n\\\\y\\n2/\\ny^\\n*Xi\\n2/\\ny is\\nzy\\n3/\\ny 1\\ny\\ny*\\nyw\\n/if.\\nHO\\n105\\n100\\n5,000,000\\n95\\n90\\nf\\n85\\n80\\n4,000,000\\np*\\n75\\n4\\n70\\n65\\np*\\n60\\n3,000,000\\n55\\n50\\n45\\n40\\n2,000,000\\nV\\n35\\n30\\n25\\n4,\\n.J*\\n20\\n1,000,000\\n14,000\\ny\\\\\\n12,000\\nj.\\nS\\n,s*\\nN,\\n10,000\\ny\\nf\\n8,000\\nr-*\\n6,000\\n_\\nV\\n7\\n4,000\\nV\\n2,000\\nChlorosis. Straight lines, number of red cells; small dots, percent, of haemoglobin large dots,\\nnumber of white cells.\\nmenstruation, venous hum in the vessels, dyspnoea, palpitation, dizziness,\\nneuralgias, and an unstable condition of the nervous system. In spite\\nof the extreme pallor there is usually but little loss of flesh. The skin", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0418.jp2"}, "419": {"fulltext": "", "height": "4400", "width": "2692", "jp2-path": "practicaltreatis00muss_0_0419.jp2"}, "420": {"fulltext": "PLATE XI\\nFTG. 1.\\nO (D\\no Xg So* 3$\\no,\u00c2\u00b0 o\\nBlood from Case of Chlorosis, showing slight Staining of the Red\\nBlood-eorpuscles, and presence of Mononuclear Leucocytes.\\n(Oc. 4, oli. T V immersion.) Drawn by J. Z. Chase.\\nFTG. 2.\\nj n\\nQ\\nO J\\no\\nO o\\noO\\n00 g\\nBlood in Pernicious Anaemia, showing Maeroeytes\\nand Mieroeytes.\\nEos in slain, oc. 4. I). ._, oil immersion.) Drawn by J. 1). Z. Chase.", "height": "4412", "width": "2712", "jp2-path": "practicaltreatis00muss_0_0420.jp2"}, "421": {"fulltext": "THE BLOOD. 393\\nmay be pigmented, especially around joints. The bowels are usually\\nconstipated the urine abundant, pale, and of low specific gravity.\\nThe digestion is disturbed, the appetite capricious, and the patients\\nsometimes crave unwholesome things, such as earth, slate-pencils,\\nvinegar, and the like. Hyperacidity of gastric juice is commonly\\npresent. A systolic murmur over the base of the heart is common.\\nGastralgia is more common than in other forms of anaemia.\\nThe changes in the blood are very important. There is always a\\nmarked reduction in the haemoglobin, the percentage falling sometimes\\nto 30 or 25 per cent, of the normal. The red blood-cells are usually\\nalso reduced, but not in the same proportion as the haemoglobin. For\\nexample, there may be 4,000,000 red cells, but only 30 per cent, of\\nhaemoglobin. Sometimes there is no diminution in the number of red\\ncells the latter, however, appear pale (achromia), vary considerably in\\nsize, microcytes and occasionally poikilocytes are present, and, hi severe\\ncases, nucleated red corpuscles are found occasionally macrocytes\\noccur, but in general the size of the red cells is below that which is\\nusually found. The number of leucocytes varies but little from the\\nnormal, but there may be a slight increase. Occasionally there is a\\nrise of temperature, but it is probably due to some complication.\\n(See Plate XL, Fig. 1.)\\nThe cause of chlorosis has not been determined satisfactorily. Vir-\\nchow has established the existence of congenital narrowing of the blood-\\nvessels. Sir Andrew Clark thinks it is due to the absorption of\\npoisonous matter from the intestine the great benefit that follows\\nsaline purgatives in many cases indicates that faecal toxaemia is a factor\\nin these cases. Forchheimer 1 also looks upon it as intestinal in origin.\\nSex and puberty are predisposing causes but chlorosis may occur\\nin boys, and appear in girls before puberty, and in young women con-\\nsiderably after that period. The prognosis is favorable it may, how-\\never, be complicated with gastric ulcer, chorea, tuberculosis, and endo-\\ncarditis. Recovery is often slow and interrupted by relapses.\\nPernicious Anaemia.\\nPernicious or idiopathic anaemia is a form in which the diminution\\nof red blood-cells reaches an extreme degree. It occurs without ade-\\nquate known cause, and runs a progressive course with remissions it\\nusually terminates in death.\\nThe disease usually develops slowly and insidiously, the patient pre-\\nsenting the ordinary symptoms of anaemia pallor, weakness, shortness\\nof breath, palpitation, venous murmurs, loss of appetite, and impaired\\ndigestion. As the disease progresses the skin becomes of a pale lemon\\nhue, weakness and dyspnoea increase, the patient has attacks of dizzi-\\nness, faintness, and ringing in the ears there may be slight oedema,\\nand hemorrhages from the nose, the bowels, and into the retina occur.\\nThe hemorrhages are small and distinct in the skin and mucous mem-\\nbranes. The urine is of low specific gravity, and usually contains an\\nincreased amount of uric acid. According to Hunter, the urine should\\n1 Trans. Assoc. Amer. Phys., 1893.", "height": "4416", "width": "2692", "jp2-path": "practicaltreatis00muss_0_0421.jp2"}, "422": {"fulltext": "394\\nGENERAL DIAGNOSIS.\\nbe dark and contain a pathological amount of urobilin, some renal\\nepithelium, a few casts containing blood-pigment, and an increased\\namount of iron. The bowels may be disturbed by diarrhoea.\\nA peculiarity of the disease is the occurrence of fever of an irregular\\ntype. The temperature rarely rises higher than 102\u00c2\u00b0 or 103\u00c2\u00b0 in the\\nevenings, and is followed by a morning remission. It is not usually\\npresent in the early stages of disease, may be absent for weeks at a\\ntime when the disease is fully developed, and may cease entirely in the\\nlater stages. 1\\nIn spite of extreme exhaustion, ansemia, and wide-spread functional\\ndisturbance, there is no emaciation the patient appears well nourished.\\nThe blood appears pale and watery to the naked eye there is diffi-\\nculty in obtaining by puncture a sufficiently large drop for examina-\\ntion. The specific gravity is lowered, often being 1028 instead of\\n1055. It has been found deficient in fibrin, iron, and nitrogen.\\nThe blood-changes in idiopathic anaemia are characteristic, and are\\nessential to the diagnosis of the disease. In brief they are (1) Very\\ngreat reduction in the number of red blood-cells (2) an absolute dimi-\\nFlG. 108.\\n85 i\\nDATE\\n2^\\n10\\n2/^\\n10\\n/30\\n4/\\nX 11\\n19\\n6\\n80\\n4,000,000\\n75\\nr*\\n70\\n65\\ni\\n60\\n3,000,000\\ni\\n55\\ni\\n50\\n45\\n40\\n2,000,000\\nt\\n35\\n1\\nt\\n30\\n4\\n25\\n.__\u00c2\u00ab/\\nt\\nN,\\n20\\n1,000,000\\n15\\n10\\n500,000\\n250,000\\n200,000\\n6,000\\n4,000\\n-N\\n2,000\\nN-\\n_.\u00e2\u0096\u00a0*\\n^J*\\nPernicious anaemia. Straight lines, number of red cells small dots, per cent, of haemoglobin\\nlarge dots, number of white cells.\\nnution in the amount of haemoglobin, but as compared with the number\\nof red cells there may be a proportionate increase (3) considerable\\n1 See Idiopathic Anaemia: A Report of Three Cases. Mnsser, Phila. Co. Med.\\nSoc. Trans., 1885.", "height": "4416", "width": "2720", "jp2-path": "practicaltreatis00muss_0_0422.jp2"}, "423": {"fulltext": "THE BLOOD. 395\\nvariation in the size of the cells, the average size of the cells probably\\nbeing larger (4) poikilocytosis (5) nucleated red blood-cells (6)\\ndegenerative cells. (See Plate XI., Fig. 2.)\\nReduction in the number of red blood-cells (oligocythemia) reaches\\na more extreme degree in pernicious ansemia than in any other disease\\nthe number often falls below 1,000,000, and in one case reported by\\nQuincke 1 the number was only 143,000 per cubic millimetre. The\\nshape of many of the cells is altered they are oval, elongated, bent,\\nor have projections of their substance (poikilocytosis). The size of the\\ncells varies there are microcytes and megaloblasts but the occur-\\nrence of a distinct proportion of large nucleated red blood-cells (megal-\\noblasts) is regarded by Ehrlich as almost diagnostic. The average\\nsize of the red cell seems to be increased, and so is the proportionate\\namount of haemoglobin in each cell. The latter is a very character-\\nistic symptom (the only one, according to Hunter). There are also\\nred corpuscles which are stained by methylene-blue these are regarded\\nas degenerative by Ehrlich. The leucocytes are {t usually diminished\\nin number, showing a relative increase in the small mononuclear ele-\\nments (lymphocytes, small transparent forms), while the multinuclear\\nelements are relatively diminished, sometimes being under 50 per\\ncent. 2\\nThe blood condition is not constant, but is subject to wide varia-\\ntions. Von Xoorden has recently found that in a very short time a\\nchange in the form of the blood, a formal crisis, may occur. A\\nformal overflow of the blood with poly nuclear leucocytes and\\nnucleated red blood-cells takes place before a period of improvement.\\nWhereas, before a period in which the blood becomes worse and before\\nthe final stage, the blood becomes poor in leucocytes and nucleated red\\nblood-cells. 3\\nSecondary sclerotic changes in the spinal cord cause late symptoms\\nof locomotor ataxia.\\nThe etiology of the disease has not been determined satisfactorily.\\nIt is more common in Germany and Switzerland than in other parts\\nof Europe or in America. It occurs most frequently after the twen-\\ntieth year, and between that and the age of fifty. Excluding the\\ninfluence of pregnancy and parturition, sex makes no difference. Pre-\\nvious exhausting disease, chronic gastric and intestinal catarrh, great\\nphysical over-exertion, exposure, great shock or fright, precede in\\ncertain cases the development of the disease. It is probably due to\\nfaulty hsematogenesis and haemolysis.\\nPetrone and Halst regard the disease as infectious and its germ\\nidentical with that found by Frankenhauser. Von Jaksch supposes\\nthat it is brought about by a living contagium. Hunter traces the\\ncause to a poison produced by bacteria in the gastro-intestinal canal.\\nDiagnosis. The most important diagnostic features of the disease\\nare extreme oligocythemia, relatively high percentage of haemoglobin\\n(color-index high), great poikilocytosis, which may, however, occur in\\n1 Deut Arch, fur klin. Med., Bd. xx.\\n2 W. S. Thayer: Boston Med. and Surg. Journ., February 16 and 23, 1893.\\n3 Quoted by Weiss, Diagnostisches Lexikon.", "height": "4416", "width": "2692", "jp2-path": "practicaltreatis00muss_0_0423.jp2"}, "424": {"fulltext": "396 GENERAL DIAGNOSIS.\\nany severe anaemia, a noticeable number of large nucleated red blood-\\ncells (gigantoblasts), an average increase in the size of the cells, and\\nall this without emaciation or discoverable local disease which can bear\\na causative relation to the anaemia. In addition, retinal, subcutaneous,\\nand submucous hemorrhages, a urine with high specific gravity, high\\ncolor, with urobilin in excess, alternating with urine of low specific\\ngravity, in the absence of organic disease, point to pernicious or idio-\\npathic anaemia.\\nLeucocythsemia.\\nLeucocythaemia, or leukaemia, is a disease of the blood-making organs,\\ncharacterized by great and persistent increase in the white blood-cor-\\npuscles by a diminished number of red blood-cells, which are altered\\nin shape and size, and display nucleated and degenerate forms by a\\nlessened amount of haemoglobin, and by changes in the spleen, lym-\\nphatic glands, or medulla of bone. It is a persistent and progressive\\ncellular proliferation. It resembles a tumor of solid tissue in its cel-\\nlular overgrowth. The disease occurs twice as frequently in men as in\\nwomen, and two-thirds of the cases appear between the twentieth and\\nfiftieth years. In women, pregnancy, parturition, and the cessation of\\nmenstruation are causative factors, while in both sexes depressing influ-\\nences upon body or mind and antecedent disease, particularly malarial\\nfever, have a distinct influence.\\nThe first symptom noted is generally enlargement of the abdomen\\nsubsequently the patient complains of pains in the splenic region, weak-\\nness, dyspnoea, hemorrhage, oedema, and digestive derangements. Occa-\\nsionally profuse hemorrhage from trifling cause, as the drawing of a\\ntooth, has been the earliest symptom noted. The increase of white\\ncells and diminution of red cells is progressive, and soon makes itself\\nevident in the pallor of the skin and mucous membranes, and in\\nincreasing weakness and dyspnoea. Pallor is not a constant symptom\\nof leukaemia. A high grade of color is consistent with advanced\\nleukaemia.\\nIn the so-called spleno-meduUary form of the disease the spleen\\nsteadily enlarges, but may attain considerable size before the patient\\nbecomes aware of it. The enlargement is not usually painful, but gives\\nrise to a feeling of distention, weight, and dragging. There may be\\ntenderness on palpation and pressure, and sometimes the patient com-\\nplains of sharp, stabbing pains, due either to attacks of local peritonitis\\nor to sudden enlargement of the spleen and consequent stretching of\\nthe capsule. The splenic enlargement is uniform, so that its shape and\\ncharacteristic notch are unchanged. Moreover, the spleen remains in\\ncontact with the abdominal walls, lying in front of the splenic flexure\\nof the colon, pushing aside the descending colon and small intestine,\\nmoving with respiration, and presenting the usual physical signs of a\\nsolid organ. Not infrequently the enlargement is so great as to fill\\nthe left hypochondriac and iliac regions, and reach beyond the middle\\nline toward the right groin. Sometimes a venous hum can be heard\\nover it. Pallor, however, is not a constant symptom more frequently\\nthe cheeks are flushed and the lips red.", "height": "4416", "width": "2720", "jp2-path": "practicaltreatis00muss_0_0424.jp2"}, "425": {"fulltext": "", "height": "4400", "width": "2692", "jp2-path": "practicaltreatis00muss_0_0425.jp2"}, "426": {"fulltext": "PLATE XII.\\nFIG. t.\\nc\\n0S\\n#1\\n6\\ni. Globiferous cell.\\n3. Polynuclear cell.\\nLymph-gland, Retroperitoneal Region.\\nHardened in Alcohol Rosin s Stain. X 1500.\\n2. Globiferous cell containing polynuclear and eosinophile cells.\\n4. Mononuclear cell. 5. Globiferous cell. 6. Eosinophile cell.\\nFIG. 2.\\ns40MSSMm\u00c2\u00b1\\niSfe\\n1. Lymphocyte.\\nPolynuclear leucocyte\\nBlood Leukaemia.\\nHematoxylin and Eosin.\\n2. Kosinophile cell (mononuclear).\\n4. I. arg-e mononuclear leucocyte (myelocyte", "height": "4416", "width": "2728", "jp2-path": "practicaltreatis00muss_0_0426.jp2"}, "427": {"fulltext": "THE BLOOD. 397\\nAs the result of this enlargement the diaphragm is pushed upward,\\nincreasing the dyspnoea already caused by anaemia, and sometimes in-\\nducing palpitation. The gastric functions are disturbed from press-\\nure vomiting and other symptoms of dyspepsia are common.\\nA rise in temperature is a very common symptom. The fever is of\\nirregular type, usually with nocturnal exacerbations, the temperature\\nnot often rising above 102\u00c2\u00b0. The febrile type may be intermittent or\\nremittent, and sometimes there are periods of apyrexia.\\nThe pyrexia is said to be most marked toward the close of the\\ndisease. Gowers states that the cases in which there is most fever\\nare usually those of rapid course, considerable dropsy, and extensive\\nhemorrhage.\\nAs the disease progresses weakness increases anaemia becomes more\\nintense oedema, ascites, or hydrothorax occurs hemorrhages from the\\nnose, gums, bowels, stomach, lungs, or uterus further exhaust the patient\\ndigestion is poor and diarrhoea is common.\\nHeadache and tinnitus are frequent symptoms, occasionally delirium\\nand coma may occur, and deafness is not uncommon toward the close\\nof the disease. The eyes may be the seat of leuksernic retinitis.\\nThe liver is enlarged, often to a considerable degree, but without\\nspecial symptoms. The same is true of the lymphatic glands and other\\nadenoid tissue. (See Plate XII., Fig. 1.) The marrow of the bones\\nbecomes the seat of disease in some cases, but it does not usually give\\nrise to symptoms during life certain bones, however, may be tender. 1\\nThe Blood. The most characteristic and important changes from\\na diagnostic point of view occur in the blood. The blood when drawn\\nfrom the finger is strikingly pale and whitish, an appearance supposed\\nat one time by Bennett to be due to admixture of pus. It coagulates\\nslowly, is of lower specific gravity than normal, and its alkalinity is\\ndiminished. When placed under the microscope it is at once seen\\nthat the number of white cells is greatly increased. If a drop of\\nblood is mixed with some distilled water containing a small quantity\\nof gentian-violet, the white cells are stained a decided blue and can be\\npicked out with the greatest ease. Instead of there being one white\\ncell to 300 or 500 red, the ratio falls as low as 1 5 or 1 3, or even\\nlower. Authorities differ as to the degree of increase necessary to dis-\\ntinguish leucocythsemia from leucocytosis, some including all in which\\nthe ration is 1 50 or lower, and others excluding those in which the\\nratio is greater than 1 20 or 1 12. In leucocytosis the increase\\ntakes place solely in the polynuclear neutrophilic leucocytes.\\nNot only the white cells greatly increase in number, but they vary\\nconsiderably in size and react differently to staining-fluids.\\nEhrlich has described five varieties of leucocytes. The pathologi-\\ncal changes in the normal leucocytes in this disease are (1) The small\\nmononuclear elements are relatively diminished (2) the great differ-\\nence in size of the multinuclear elements (3) the presence of myelo-\\ncytic elements, in which the protoplasm is filled with fine neutrophilic\\n1 See A Case of Leucocythsemia. Musser and Sailer, Amer. Journ. of the Med.\\nSciences, 1896.", "height": "4416", "width": "2676", "jp2-path": "practicaltreatis00muss_0_0427.jp2"}, "428": {"fulltext": "398\\nGENERAL DIAGNOSIS.\\ngranules (4) the presence of a normal proportion of eosinophils in so\\nextensive an increase of leucocytes. 1 (Plate XII., Fig. 2.) (5) Large\\nmononuclear elements with karyokinetic figures (Miiller). (6) Mast-\\ncells. Satisfactory study of these can be obtained only by cover-glass\\npreparations.\\nFig. 109.\\nDATE\\n3\\n/17\\nX\\n7^\\n1/\\n21\\n7/\\n/30\\n8\\n8/\\n16\\n80fc\\n4,000,000\\n75\\n70\\n65\\n60\\n3,000,000\\n.ft\\nN 4\\n55\\nm*\\n50\\nt\\n45\\nf\\n40\\n2,000,000\\n35\\n30\\n25\\nA\\n20\\n1,000,000\\n15\\ny\\n10\\n500,000\\ny\\ns\\ns\\n250,000\\nV\\ns\\nV\\n200,000\\ny\\ny\\nf\\n100,000\\nf\\n90,000\\ni\\ni\\n80,000\\ni\\n70,000\\ni\\n60,000\\n50,000\\n40,000\\nV-\\ni-*\\n30,000\\nLeukaemia. Straight line, red cells small dots, haemoglobin large dots, white cells.\\nThe essential points in the diagnosis of leucocythaemia are 1. Such\\nan excess of leucocytes in the blood that the ratio of white to red falls\\nbelow 1 50 or 1 20 if the ratio is higher, the white cells should\\nshow a progressive increase. The individual leucocytes vary in size\\nand characteristics, as already described. 2. Enlargement of the spleen\\nor lymphatic glands. 3. The occurrence of hemorrhages and dropsies\\nunexplainable by disease of the heart, kidneys, or other organs. 4.\\nThe symptoms of anaemia of a high grade, as dyspnoea. 5. Leuksemic\\nretinitis. 6. Anaemic fever. 7. The presence of the myelocyte of\\nEhrlich, mast-cells/ and nucleated red blood-cells. 8. Specific\\ngravity below 1040. 9. Excess of uric acid in the urine.\\n1 W. S. Thayer, loc. cit.", "height": "4412", "width": "2728", "jp2-path": "practicaltreatis00muss_0_0428.jp2"}, "429": {"fulltext": "THE BLOOD. 399\\nThe lymphatic form of the disease is rare. It is characterized by\\nenlargement of the lymphatic glands and by the great increase in the\\nproportion of the lymphocytes. The total increase in the colorless\\nelements is not so excessive. Eosinophils and nucleated red cells\\nare rare. The myelocyte of Ehrlich is not present. A case of a purely\\nmyelogenous form has never been authenticated. Combination-forms\\nmay also occur. It must be remembered that the number of myelo-\\ncytes is no indication of the involvement of the bone-marrow.\\nIn secondary or so-called splenic ancemia we find the same enlarge-\\nment and the general symptoms, though hemorrhage is not so common.\\nLeucocythaemia is distinguished from it by the great excess of leuco-\\ncytes and by their special characteristics.\\nIn lymphadenoma, or Hodgkin s disease, there is extreme anaemia,\\nthough the excess of leucocytes found in leucocythaemia is seldom\\nreached, and the cells are smaller. The glandular enlargement of\\nlymphadenoma is an early and constant symptom, the spleen not being\\nmuch enlarged. The cervical glands are the ones usually first in-\\nvolved.\\nThe duration of leucocythaemia is usually two or three years but\\nsome cases terminate in six months or less, and some last six or seven\\nyears. The size of the spleen and the degree of oligocythemia appear\\nto have no influence. Gowers states that the cases in which enlarge-\\nment of the lymphatic glands is an early symptom run a course appar-\\nently much more acute than others, but he admits that the number of\\nsuch cases is comparatively small.\\nDeath results most frequently from gradual loss of strength. Hem-\\norrhage from various organs and surfaces is the immediate cause in\\nmany cases. It- occurs in about three-fourths of the cases, and, when\\nnot directly fatal, increases the pre-existing asthenia. Diarrhoea and\\npulmonary complications are not infrequent causes of death.\\nAcute Leukcemia. Cases have been described, especially in children,\\nin which there is a diminution of red cells of haemoglobin. Nucleated\\nred cells are present as well as an excess of white blood-corpuscles,\\nwhich consist almost entirely of large mononuclear elements, without\\ngranulation. There is usually fever, and the disease runs a course\\nmuch resembling an infectious one. The lesions are leucocytic infil-\\ntration of the various organs. 1\\n1 See Acute Leukaemia. Fussell, Jopson, and Taylor, Assoc. Am. Phys., vol. x.\\n1898 and Musser, Trans. Phil. Co. Med. Soc, 1887.", "height": "4416", "width": "2692", "jp2-path": "practicaltreatis00muss_0_0429.jp2"}, "430": {"fulltext": "CHAPTER XXIII.\\nTHE MORBID PROCESSES AND THEIR SYMPTOMATOLOGY.\\nKnowledge of symptoms of morbid processes essential they control conclusions drawn\\nfrom data. Morbid processes are few. I. Alterations in blood and circulation:\\nAnaemia and plethora Hyperemia, active and passive\u00e2\u0080\u0094 CEdema and dropsy\\nThrombosis and embolism Hemorrhage Blood-pressure. II. Disturbances\\nof nutrition: Inflammation Gangrene and necrosis Fever Atrophy and\\nhypertrophy. Degenerations Albuminous Fatty Colloid Mucous Pig-\\nmentary Calcareous Amyloid\u00e2\u0080\u0094 Fibroid. III. Anomalies of growth: Tumors\\nCysts Cancer.\\nAlthough we may have secured all the data obtainable by inquiry\\nand by observation, and, if possible, made a diagnosis based upon them,\\nit frequently happens that the conclusion arrived at is not final and per-\\nhaps cannot be, from the nature of the case. We are prompted, there-\\nfore, to view the case from a different stand-point, to utilize our\\nknowledge of the phenomena of morbid processes, and, for the purpose\\nof comparison, to review the features of such as apparently resemble\\nthe process under consideration. Thus, for instance, in an obscure\\ncase of fever, the objective and subjective phenomena have been fully\\ninquired into \u00e2\u0080\u0094we are unable to decide whether the disease under con-\\nsideration is a septic process with obscure lesion, a form of miliary\\ntuberculosis, or of malignant endocarditis. The known symptoms of\\neach are considered (our knowledge of such symptoms depending upon\\nour knowledge of the phenomena of the respective morbid process) and\\ncompared with the symptoms presented by the case in question. In\\nthis manner a diagnosis by exclusion is made. Moreover, after a diag-\\nnosis is made, a review of the symptomatology of morbid processes\\nserves as a check upon the conclusions that have been reached. We\\nshould also, after making a diagnosis, compare the symptoms of the\\nprocess as exhibited in the patient with the symptoms which we know\\nto be common in the suspected disease.\\nIt is necessary, therefore, that the student should fully know the\\nsymptoms of morbid processes. Each process is characterized by\\nspecial phenomena by which it can be recognized. The symptoms\\nare modified by the function and anatomical structure of the organ in\\nwhich the process takes place. Thus the pathological products of in-\\nflammation of the mucous membranes of the bronchial tubes and of\\nthe stomach are the same, but the symptoms differ, because of the\\ndifference in their functions, and hence we have cough in the former\\ncase, in the latter, vomiting. Very frequently the symptoms differ\\nbecause of the physical alterations. Thus inflammation of the pericar-\\ndium is similar to inflammation of the pleura, but the pressure-symp-", "height": "4412", "width": "2720", "jp2-path": "practicaltreatis00muss_0_0430.jp2"}, "431": {"fulltext": "MORBID PROCESSES AND THEIR SYMPTOMATOLOGY, 401\\ntoms of pericarditis are entirely different, because of the anatomical\\nrelations, from the pressure-symptoms of pleuritis.\\nThe morbid processes are not many. They include I. Alterations\\nin the blood and circulation II. Disturbances of nutrition III.\\nAnomalies of growth.\\nI. Alterations in the Blood and Circulation. The composition\\nand distribution of the blood affect all the tissues for weal or woe.\\nThe quantity of the blood alone will be referred to changes in quality\\nwill be considered under diseases of the blood. Practically the symp-\\ntoms, when the quality is affected, are those of ancemia plus the symp-\\ntoms (physical and functional) of the primarily diseased organ as the\\nspleen in leucocythaemia. The quantity may be increased or dimin-\\nished.\\n1. Increased Quantity of Blood, or Plethora. Formerly\\nthis was considered an entity, and the symptoms of flushed face, hot\\nand full head, throbbing pain, throbbing temporals, a full, strong\\npulse, sluggish intellect, were thought to indicate an excess of the\\ngeneral bulk of the blood. True plethora is rarely permanent. If\\ntransitory, the veins and not the arteries are overfilled. The symp-\\ntoms are not due to general plethora but to excess of blood-pressure\\nor to special fluxions of blood to superficial vessels, determined by a\\nnervous mechanism. Increase in one of the cellular elements of the\\nblood, the leucocytes, is not a plethoric condition.\\n2. Diminished Quantity of Blood, or Anaemia. Anaemia em-\\nbraces the diminution of the bulk of the blood as well as of the red\\nblood-cells and their haemoglobin.\\nThe term might be used for loss of the water of the blood, as in\\ncholera Asiatica (see Infectious Diseases), or in serous purging. The\\nsymptoms are those of collapse.\\nOligemia or spanaemia are terms that may be used to define the\\ngeneral thinness or poverty atrophy of the blood. Clinically, anaemia\\nis divided into simple anaemia, general poverty of the blood per-\\nnicious or idiopathic anaemia, reduction in the number of red cells\\nchlorosis, reduction in the quantity of haemoglobin leucocythaemia,\\nrelative loss of red and increase of white corpuscles. (See Diseases of\\nthe Blood.)\\n3. Local Disturbance of the Circulation. A. Hyperemia\\nor Congestion. The process may be acute or chronic. It is usually\\nlocal, although it may be general. When the latter, many organs may\\nbe simultaneously involved from a common cause.\\nAcute Hyperemia. The acute or active form of hyperaemia is\\nalways local and arterial. There is an excess of blood in the part.\\nIf the skin is the seat, there are redness and increased heat, and throb-\\nbing or pulsation may be seen. The parts are swollen. The excita-\\nbility of the nerves is increased, with local symptoms of warmth, fulness,\\nor itching.\\nThe morbid blushing, or flushing, that occurs at the menopause or\\nreflexly from internal disorder is a hyperaemia, and in erythema of the\\nskin hyperaemia is also very marked.\\n26", "height": "4416", "width": "2708", "jp2-path": "practicaltreatis00muss_0_0431.jp2"}, "432": {"fulltext": "402 GENERAL DIAGNOSIS.\\nCauses. Arterial hyperemia is caused by (1) neuroparalysis of the\\ninhibitory or vasoconstrictor fibres, of the cervical sympathetic,\\nsplanchnic, and other sympathetic and some mixed nerves, as the\\nsciatic (2) neurotonic stimulation of the actively dilating or vaso-\\nmotor dilator nerves, as the chorda tympani. There is relaxation of\\nthe arterial walls. This may also occur directly through the vasomotor\\nsystem, being induced by heat, electricity, or chemical irritants, or\\nfrom paralysis of muscular fibres, after spasmodic contraction due to\\ncold, as in frost-bite.\\n(1) Neuroparalytic Hyperemia. Destruction of the cervical sympa-\\nthetic nerve by abscess, wounds, or a tumor pressing upon it, produces\\nhyperemia of the side of the face, rise of temperature, and contraction\\nof the pupil. Later on the vascular conditions are reversed. Lesion\\nof the fifth nerve, or one of its branches, causes hyperemia of the iris,\\nthe conjunctiva, the cheek, the gums, and other structures supplied by\\nit, with associate loss of sensation followed, by atrophy. The sensory\\nsymptoms have nothing to do with the vascular paralysis.\\n(2) Neurotonic Hypoxemia. After wounds of the brachial plexus\\nhyperemia of the fingers is seen. (See Fingers.) The local temper-\\nature rises and there is neuralgic pain. Local hyperemia with hyper-\\nesthesia, known as erythromelalgia, belongs to the same class, being\\ndue to affections of the nerve-trunks, or the peripheral nerve-endings.\\nIt must be remembered that a reflex hyperemia is possible.\\nChronic oe Venous Hyperemia (passive congestion). The blood\\naccumulates in the veins, and, by backward pressure, in the capillaries.\\nThe venous capillaries are over-distended and, as compared with the\\narterial, much enlarged. They contain venous blood.\\nAny congested part, as the exterior, is bluish or purple in tint,\\noften swollen (clubbed fingers), cooler than normal, with lessened sen-\\nsation, and without pulsation. (See Cyanosis.) The dependent parts\\nare first affected, as the legs, or the lungs. In fevers a weak heart and\\nrecumbent posture predisposes to congestion of the lungs.\\nCauses. Obstructive heart and lung diseases cause general venous\\ncongestion. Local venous congestion is caused by tumors, the preg-\\nnant uterus, or collections of faeces pressing upon the veins. It is also\\ncaused by inflammation of the veins, and thrombosis.\\nB. Local Anjemia. This may be due to arterial thrombosis or\\nembolism, arterial obstruction through endarteritis, or to arterial spasm.\\nRaynaud s disease is a form of arterial spasm. The grave effects of\\narterial obstruction are seen in cerebral anemia from endarteritis, or\\nmyocarditis from obstruction of the coronary arteries.\\nC. GEdema and Dropsy. The changes of the circulation which\\nproduce these conditions have been referred to in previous chapters of\\nthis book. The symptoms and signs of the condition are also noted\\nin the same section.\\nD. Thrombosis and Embolism. The student should be familiar\\nwith the symptoms of these conditions, and, what is fully as important,\\nwith the causes that give rise to them. Thrombi may form in the\\nheart, the arteries, or the veins. Emboli may be formed in either\\nheart or vessels, but lodge in the vessels only.", "height": "4416", "width": "2720", "jp2-path": "practicaltreatis00muss_0_0432.jp2"}, "433": {"fulltext": "I\\nMORBID PROCESSES AND THEIR SYMPTOMATOLOGY. 403\\nThrombosis. The symptoms of thrombosis are 1. Mechanical.\\nThe channel is obstructed hyperemia, engorgement, oedema, and\\ncyanosis arise. Its most typical form is seen in femoral thrombosis,\\nwith cyanosis, and oedema of the leg. When an artery is obstructed\\nthe symptoms are like those of occlusion under other circumstances (see\\nEmbolism) when a vein, the mechanical symptoms vary according\\nto the particular vein affected. Thus, in thrombosis of the coronary\\nvein, the heart s action is interfered with. In thrombosis of the portal\\nvein, jaundice (not because of the obstruction), oedema (ascites), and\\ncongestion of mucous membranes (gastric and intestinal) occur, as from\\nobstruction in any vein. In thrombosis of the cerebral veins, disturb-\\nance of the function of the brain is seen of the pulmonary veins,\\ndyspnoea. 2. Inflammatory or septic. If it should happen that the\\nthrombosis developed secondarily to an innammation of septic origin,\\nas in the extension of an innammation into the radicles of the portal\\nvein from an abscess about the rectum or vermiform appendix, the\\nliver would be infected with micro-organisms. An infectious inflam-\\nmation with chills, fever, sweats, and other phenomena of a septic\\ncharacter would result (pyelophlebitis). 3. Embolic. From the throm-\\nbus emboli are sometimes swept off hence, embolic symptoms arise in\\nthe course of thrombosis.\\nWhile thrombosis is, as a rule, easily recognized, it is necessary to\\ncall attention to the very great importance of going a step farther to\\nlook for the cause. A thorough knowledge of the causes of thrombosis\\noften leads to the diagnosis of a thrombus when without such knowl-\\nedge its presence would never have been suspected. The causes are\\nnot many. 1. Stagnation or stoppage of blood. It is seen chiefly in\\nthe veins and the heart. External pressure upon the veins as upon\\nthe pelvic veins in pregnancy or abdominal tumor, upon the hemor-\\nrhoidal veins, upon the portal veins by tumor, upon the pulmonary\\nveins by mediastinal tumor. It must be remembered that some change\\ntakes place in the internal coat of the vein also, but that the pressure\\nis primary. Then we have weakness of the heart as a cause of stagna-\\ntion. Feeble contractions lead to the formation of cardiac thrombi.\\n2. Thrombosis from changes in the vessel s walls. The change is\\nusually inflammatory and often proceeds from wounds. If the wound\\nwas septic, the inflammation will be septic. In the heart, endocarditis\\nin the aorta, atheroma leads to the development of thrombi. 3. Throm-\\nbosis from the entrance of a foreign substance into the vessels. A\\ncarcinoma or other new growth may extend into the veins. Micro-\\norganisms penetrate the vein and cause inflammation and thrombosis,\\nor infect a previously existing thrombus. The clot is then broken and\\ndistributed throughout the system, causing pyaemia. 4. Thrombi are\\nproduced by extension. A clot enlarges by coagulating the blood next\\nto it. A large venous distribution may become blocked, as, first the\\nuterine veins, then the internal iliac, then the external iliac, and after\\nthat the femoral causing the affection which frequently occurs in the\\npuerperal form, phlegmasia alba dolens.\\nEmbolism. An embolus is a substance which is swept into and\\nplugs a vessel. It may be a fragment of a blood-clot (thrombus), vege-", "height": "4412", "width": "2664", "jp2-path": "practicaltreatis00muss_0_0433.jp2"}, "434": {"fulltext": "401 GENERAL DIAGNOSIS.\\ntations from valves of the heart, parasites, new growths which had\\nentered the veins, fat, or air. If obstruction of the vessel alone is pro-\\nduced, the embolism is said to be simple if a new process, as inflam-\\nmation, accompanies the obstruction, it is specific. Fragments from a\\nthrombus in the systemic veins may become an embolus and block\\nthe pulmonary artery a clot or portion of valve-leaflet from the left\\nheart may block a systemic artery, as a cerebral artery or the femoral\\nartery or its branches a clot in the portal vein may obstruct branches\\nin the liver.\\nThe symptoms occur suddenly and depend upon the artery obstructed.\\nThe cutting off of the blood-supply causes cessation of function beyond\\nthe point of obstruction. In pulmonary venous embolism dyspnoea is\\npronounced, the heart s action rapid and irregular, and many cases are\\nsaid to be heart-failure. In the middle cerebral artery the embolus\\ncauses aphasia and monoplegia or hemiplegia. In embolism of the\\npulmonary artery cough and hemorrhage with dyspnoea occur suddenly.\\nThe patient in whom this occurs usually has had antecedent mitral\\nregurgitation and dilated right heart.\\nThe blocking of an artery may lead to various symptoms. If, for\\ninstance, the main artery of the leg is blocked, anastomosis may be set\\nup if it does not, gangrene ensues. If an artery supplying any inter-\\nnal organ is blocked, anastomosis may occur, if the artery is not termi-\\nnal. If the artery is terminal, there results rapid necrosis or softening,\\nas in the brain gradual wasting, as of the kidney, or engorgement of\\nthe arterial area and diffuse hemorrhage. The latter is known as a\\nhemorrhagic infarct. This may occur in the lungs (pulmonary artery),\\nspleen, kidneys, retina, and, rarely, the intestinal canal. The symp-\\ntoms of hemorrhagic infarct are swelling and hemorrhage. In the\\nlungs, there are physical signs of consolidation, with haemoptysis,\\ncough, and dyspnoea in the kidneys, pain and hematuria in the\\nspleen, pain and at times enlargement in the retina, blindness with\\nophthalmoscopic changes in the intestine, pain and hemorrhage with\\nsloughing of mucous membrane. Infective emboli cause abscesses.\\nCapillary embolism is seen in the skin and mucous membranes in many\\ninfective diseases, notably ulcerative endocarditis. Fat-embolism occurs\\nin the pulmonary capillaries, and is due to fat-globules which some-\\ntimes enter the circulation in pregnant women, or in patients with bone\\ndisease, as osteomyelitis, or fractures. The symptoms are those of\\nintense dyspnoea. It may cause sudden death. Air-embolism. Air\\nmay enter wounds of the veins of the neck. It accumulates in the\\nheart, and as the ventricle cannot contract on it the blood is not pro-\\npelled. Death takes place with the symptoms of heart-clot, the heart\\nbeing in asystole.\\nHemorrhage. Hemorrhage may be arterial, venous, or capillary.\\nIt may occur because the blood soaks through the walls, by diapede-\\nsis or it may occur from rupture, or rhexis. Hemorrhage by dia-\\npedesis takes place in venous engorgement, stasis, or inflammation. It\\nis the small passive hemorrhage of congestion, as in pulmonary conges-\\ntion from heart disease it is venous or capillary the blood is dark.\\nHemorrhage by rupture is arterial, venous, or capillary. If the artery", "height": "4404", "width": "2720", "jp2-path": "practicaltreatis00muss_0_0434.jp2"}, "435": {"fulltext": "MORBID PROCESSES AND THEIR SYMPTOMATOLOGY. 405\\nruptures, it has been torn by violence, destroyed by ulceration or sup-\\npuration, or it is the seat of endarterial change. Veins are also diseased,\\nor their walls destroyed, before rupture takes place. Rupture of capil-\\nlaries occurs from violence or great internal pressure. In death from\\nsuffocation the capillaries are the seat of hemorrhage because of the\\nincreased venous pressure. Such capillary hemorrhage occurs in\\ntyphus, hemorrhagic smallpox, and scarlatina. The state of the blood\\nis sometimes the cause of hemorrhage, as in scurvy, purpura, and other\\nconditions. Hemophilia is a peculiar hereditary affection possibly\\ndue to the state of the blood, more likely, however, due to the condi-\\ntion of the bloodvessels.\\nThe special forms of hemorrhage and their symptoms, etiology, and\\ndiagnosis will be considered in the sections to which the names in the\\nfollowing list point\\nBleeding from the nose epistaxis.\\nVomiting of blood hcematemesis.\\nBleeding from the lungs hcemoptysis.\\nBlood passed with the urine hematuria.\\nBlood passed from the uterus Menorrhagia or metrorrhagia.\\nThere is also intestinal hemorrhage mekena.\\nHemorrhages underneath the skin are known as petechial if small,\\nand ecchymoses or suffusions if large.\\nHemorrhage into internal organs receives its name from the organ\\naffected, and is known as a parenchymatous hemorrhage. Apoplexy is\\napplied to hemorrhage into the substances of organs, particularly if it\\noccurs suddenly and is localized as pulmonary apoplexy, cerebral\\napoplexy, spinal apoplexy. Long usage has associated the term with\\nhemorrhage into the brain, so that it is applied to that form alone by\\nmost writers. Ho3matoma, or blood-tumor, is a collection of blood that\\nhas coagulated in a cavity, organ, or tissue. (See Ear.)\\nThe symptoms of hemorrhage vary in degree, depending upon the\\namount of blood which escapes from the vessel, and whether the hem-\\norrhage is external or internal. By external hemorrhage we mean one\\nwhich is accompanied by a discharge of blood visible to the bystander.\\nAn internal or concealed hemorrhage is not apparent by any outward\\nsign of blood.\\nThe symptoms by which external hemorrhage is recognized need not\\nbe detailed. The show of blood in situations or at times other than\\nnormal is sufficient. It must be remembered that arterial blood is\\nbright red, venous blood dark. It must also be remembered that the\\ncharacter of the blood coming from internal organs is modified by the\\nsecretion of the affected organ. Thus the blood from the stomach is\\ncoagulated and black, like coffee-grounds blood from the intestine,\\ntarry. The general symptoms of the various degrees of external hem-\\norrhage are similar to the symptoms of internal hemorrhage, which\\nwill be described later. Both vary with the rapidity of the flow of\\nblood. If the bleeding is slow, large quantities may be lost and more\\nor less profound anaemia result. It is often more difficult to determine\\nthe source of hemorrhage. The mode of recognition of the anatomical\\nvarieties of hemorrhage will be discussed under the respective systems", "height": "4416", "width": "2708", "jp2-path": "practicaltreatis00muss_0_0435.jp2"}, "436": {"fulltext": "406 GENERAL DIAGNOSIS.\\nwhich are the seat of the bleeding. Hemorrhage may take place in a\\ncavity, as the stomach, bowels, or bladder, and after the blood has\\nundergone changes it may cause symptoms of, and be discharged as,\\na foreign body.\\nAlthough internal hemorrhage presents vivid phenomena, they may\\nnot be characteristic, and its recognition is often impossible without\\nsome knowledge of the history of the case. The symptoms are com-\\nplex. First, we have pain, a symptom due to rupture of a vessel or\\nto the filling of a tissue with blood. In the beginning the pain is\\nsharp, severe, and of itself may cause shock. In the second place, the\\nsymptoms due to loss of blood arise. After pain, sudden prostration\\nensues pallor spreads rapidly the extremities become pallid and\\ncold a cold sweat breaks out on the forehead the features become\\npinched and shrunken the pulse becomes weak and rapid, and later\\nthready, or disappears altogether at the wrist the carotids pulsate\\nthe heart throbs violently and a diffuse impulse is seen, at first vigor-\\nous, soon like a slap against the chest-wall, and then it fades away\\ncompletely. On examination of the heart and vessels so-called anaemic\\nmurmurs are heard. The patient is restless, and sighs and yaAvns\\nfrequently. The respiration becomes slow and shallow. Nausea and\\nsometimes vomiting may occur. He may faint but once or repeatedly,\\nto be restored again and again, or the syncope may terminate in death.\\nIn the intervals between the syncopal attacks the mind is clear. If,\\nhowever, profound shock is associated Avith the hemorrhage, there is\\ndulness or stupor the intellect is dazed otherwise delirium and agi-\\ntation may be present. When the hemorrhage is profuse convulsions\\nmay take place. The temperature of the body falls. If the patient\\nhas fever at the time, the temperature suddenly falls to or below nor-\\nmal. We have, therefore, the following conditions in hemorrhage\\nsyncope, shock, and collapse. They may all be present in the same\\nsubject, or one or two may be absent. The same symptoms may, how-\\never, occur from other causes, which must be excluded. Sometimes the\\nshock may be due to the same cause as the hemorrhage. The causes of\\nshock are so evident that they serve to distinguish it from the collapse\\nof hemorrhage. They are injury, anaesthesia, railway accidents, surgi-\\ncal operations, perforative peritonitis, strangulated hernia, intestinal\\nobstruction, profound mental impression, and pain.\\nShock from hemorrhage must be distinguished from concussion.\\nIn the latter the intellectual disturbance occurs at once, and is more\\nmarked than the circulatory symptoms. The absence of the usual\\nphenomena of hemorrhage serves to distinguish syncope due to concus-\\nsion from that due to the many well-known causes of fainting.\\nThere are many forms of internal hemorrhage sufficiently grave to\\nhave a probably fatal result, or at least to create alarming symptoms.\\nIn the chest, diseases of the lungs or the aorta cause hemorrhage. In\\nconcealed pulmonary hemorrhage the blood accumulates in a large\\nphthisical cavity. When the aorta or an aneurism ruptures the blood\\nmay enter the mediastinum or the pleura. Under these circumstances\\na knowledge of the previous history is essential. Careful examination\\nof the lungs or of the heart or bloodvessels must be made in a case", "height": "4416", "width": "2704", "jp2-path": "practicaltreatis00muss_0_0436.jp2"}, "437": {"fulltext": "MORBID PRO CESSES AND THEIR SYMPTOMATOLOGY. 407\\nwhich presents the above-mentioned symptoms of internal hemorrhage.\\nInternal concealed hemorrhage into organs or cavities of the abdomen\\noccurs in gastric, duodenal, or intestinal ulceration in aneurism or in\\nulceration of large vessels, from septic inflammation around them. It\\nmust not be forgotten that alarming or fatal internal concealed hemor-\\nrhage may be due to haemophilia or purpura.\\nII. Disturbances of Nutrition.\\nHypertrophy and Atrophy. (See the Size, Chapter VI., and\\nMuscles.)\\nInflammation. Inflammation, a process largely attended with vas-\\ncular alteration, but also with disturbance of nutrition. It may be\\nacute or chronic. It is due to injury, mechanical, physical, chemical,\\nor vital. The invasion of micro-organisms or the irritation of their\\nproducts is the most frequent cause in cases that come within the\\nprovince of the physician. The symptoms are modified by the struc-\\nture affected and by the cause of the inflammation. The intensity and\\nthe character also modify them. The classical symptoms \u00e2\u0080\u0094pain, heat,\\nredness, and swelling are indicative of the tissue-process. In addition\\nwe have exudation and alteration of function. Pain varies in degree\\nwith the sensibility of the part. It is increased by pressure or move-\\nment, and by the functional activity of the affected organ. Heat is\\ndetected by the hand or surface-thermometer. It may be described by\\nthe patient, in abscess within the peritoneum, or pyosalpinx, as a ball\\nof fire. The surface-temperature over an inflamed lung or pleura is\\nhigher than over the healthy side. Redness can only be observed in\\nparts open to inspection, as the nasal, oral, faucial, and other cavities.\\nSwelling is observed with the redness it is shown by enlargement of\\nthe affected organ, if the latter can be measured by palpation or per-\\ncussion. Exudation takes place from mucous surfaces, into serous\\ncavities, into the connective or any affected tissue, or into tubes or\\nchannels (heart and bloodvessels, lymphatics, etc.). The symptoms\\nare characteristic discharges from mucous surfaces pressure and\\nphysical signs from accumulation in cavities symptoms of the obstruc-\\ntion of channels. Grave pressure-symptoms arise when the exudation\\npresses upon the nerves, nerve-centres, or nerve-tracts (brain cord,\\nperipheral nerves). The pressure-symptoms are often more pronounced\\nthan the inflammatory in simple or tuberculous meningitis. Alteration\\nof function The symptoms cannot be detailed here each organ and\\nstructure must be referred to. The function may be stimulated at\\nfirst, but is soon perverted, or suppressed.\\nGeneral Symptoms. Fever is the general expression of the local\\nprocess. It may be primary from reflex irritation of afferent nerves\\nwhich influence the heat-centre and disturb the thermotaxic mechan-\\nism. It may be secondary, the products of inflammation (pus, toxins,\\netc.) irritating the centres. The degree depends upon the cause. Active\\ninflammation may not be attended by fever. 1\\nSuppuration. The character of the fever indicates the variety of\\n1 Musser Abscess of Liver, Univ. Med. Magazine, 1892.", "height": "4416", "width": "2700", "jp2-path": "practicaltreatis00muss_0_0437.jp2"}, "438": {"fulltext": "408 GENERAL DIAGNOSIS.\\nthe inflammatory process. In most inflammations the fever is con-\\ntinuous. When there is suppuration, however, it becomes intermittent\\nor remittent. The presence of suppuration is also made known by\\nhectic, in which the fever is attended by chills and sweats. The appe-\\ntite is lost or impaired. There is also leucocytosis. The urine con-\\ntains a large amount of indican. In obscure inflammations about the\\nperitoneum the indicanuria points to a suppuration. While fever-\\nsymptoms in inflammation are similar, save in degree and in the pecu-\\nliar type of the temperature-range intermittent, remittent, or contin-\\nuous septic inflammations are attended early by cerebral symptoms,\\nprostration, and the typhoid state. (See Fever, pages 218 and 224.)\\nAs a corollary, when fever is present, local inflammation must be\\nsought for. Chronic inflammations may only give rise to altered func-\\ntion and cause exudation (swelling, effusion, etc.).\\nInflammation of Various Structures. The symptoms vary according\\nto the anatomical and physiological peculiarities of the structure.\\nInflammation of mucous membranes. Pain is not excessive heat is\\ncomplained of (rectum) redness is marked and varies with the in-\\ntensity from bright to dark red swelling is always present. In narrow\\nchannels, as the nose, or the gall-ducts, it causes occlusion. The\\nexudation is at first mucous, then mucopurulent, and then purulent.\\nBefore exudation there is a stage of dryness. The microscopical\\nappearance of the exudate varies with the anatomical character of the\\nmembrane affected. Its peculiar epithelium is always present, also\\nmicrococci, pus, red cells from the lungs or liver, special crystals.\\nThe functions are impaired. Fever is usually not very high and is\\ncontinuous. The causes are direct local irritants or congestions from\\nexternal impressions (cold\\nInflammation of serous membranes. Pain is extreme and may cause\\ncollapse. Heat, swelling, and redness cannot be estimated. The surface-\\ntemperature rises. Exudation occurs after a brief dry stage. The\\ncavities pleura, pericardium, peritoneum, joints, cerebro-spinal canal\\nare filled, causing mechanical symptoms and physical signs. Fever\\nis excessive in some forms. Function is impaired or abolished. Gen-\\neral symptoms are more pronounced. Shock or collapse is common in\\nperitonitis. The affections are always secondary to a general process\\n(rheumatism), to infection, to disease of neighboring structures, or to\\nBright s disease, diabetes, cancer, scurvy, or other diathetic condition.\\nInflammation of muscles (rare), of connective tissue, and of glands is\\ncharacterized by symptoms common to the morbid process, with alter-\\nation of function.\\nInflammation of bone and periosteum presents the same group of\\nsymptoms. The pain may be intense or of a dull, aching, or boring\\ncharacter.\\nInflammation of the heart and vessels is also attended by the cardinal\\nsymptoms. When the central organ is the seat of the disease pain is\\nnot common, but in the arteries or veins it is of frequent occurrence.\\nThe striking symptom, however, is the obstruction to the channels.\\nIt is characteristically seen in phlebitis, as of the femoral vein.\\nCEdcma of the leg, and cyanosis, reveal the obstruction. In the heart", "height": "4416", "width": "2712", "jp2-path": "practicaltreatis00muss_0_0438.jp2"}, "439": {"fulltext": "MORBID PROCESSES AND THEIR SYMPTOMATOLOGY. 409\\nthe acute process or the results of the process give rise to all the symp-\\ntoms of obstructive heart disease.\\nInflammations of the nerves, the spinal cord, and the brain are fol-\\nlowed more strikingly by pressure-symptoms and by the symptoms of\\ndegenerations secondary to the inflammatory process. Hence, while\\npain and tenderness are present in the exposed nerves, increased irrita-\\nbility, then abeyance, perversion, or abolition of function are the princi-\\npal signs of inflammation of these regions.\\nInflammation of internal organs, lung, liver, kidneys, and pancreas, is\\nmade known by pain (minimum amount) and swelling (enlargement of\\nliver), and by change in the function, indicated by modifications of the\\nrespective secretions as well as by functional and physiological symp-\\ntoms.\\nLocal Death, Necrosis, and Gangrene. If nutrition is not\\ncomplete, the life of the cell is endangered. This process is known as\\nnecrosis or gangrene. The nutrition is annulled 1. By stoppage of\\nthe circulation. 2. By the direct action of an irritant which destroys\\nthe cells. 3. By abnormal temperature. A combination of the three\\ncauses quickly produces gangrene. Stoppage of the circulation may\\nbe due to an embolus or thrombus, or to stagnation by pressure, or to\\ncapillary stasis alone. Sloughing and bed-sores ensue in the latter\\ninstance gangrenous eschars in the former. The cells are destroyed\\nby corrosives and caustics, by heat and cold, by bacteria. Where\\ndecomposition takes place, as in retained and infiltrating urine, cell-\\ndestruction and sloughing ensue. All pathogenic bacteria cause necro-\\nsis to a greater or less degree. Frost-bite and burn illustrate the destruc-\\ntive power of abnormal temperature.\\nNerve-lesions, trophic disorders, produce necrosis. We have, allied\\nto bed-sores and known as decubitus, a form of necrosis in spinal-cord\\ndiseases. The sloughing is extensive and rapid. Trophic disorders\\ncause paralytic hypersemia, and hence necrosis.\\nIt must not be forgotten that debility, cachexia, and feeble circula-\\ntion play a great part in assisting the local changes.\\nGangrene of internal structures concerns us. This form is nearly\\nalways due to stoppage of the circulation. It is seen in constriction\\nof the intestine, from hernia, or obstruction. It occurs in phthisis\\nfrom thrombi. Clinically, we see it frequently in diabetes. The lung,\\nthe brain, the intestines, are most frequently affected.\\nThe symptoms of necrosis or gangrene are modified by the tissue\\ninvolved, the function interfered with. If external, the decomposing\\nstructures emit a foul odor, there is rapid prostration and development\\nof the typhoid state. Fever ensues from intoxication by decomposing\\nsubstances saprsemia. Often the symptoms are latent. A man aged\\nsixty, in my ward, was about all the time. He died suddenly of pul-\\nmonary hemorrhage, the result of gangrenous ulceration of a large\\nvessel at the autopsy gangrene of the lung was found. The only\\nsymptom was the characteristic odor. In the course of inflammatory\\nprocesses the onset of gangrene is frequently attended by the cessation\\nof pain, the peculiar odor when it communicates with the exterior, and\\nthe development of exhaustion and the typhoid state. The character", "height": "4416", "width": "2712", "jp2-path": "practicaltreatis00muss_0_0439.jp2"}, "440": {"fulltext": "410 GENERAL DIAGNOSIS.\\nof the discharge points to gangrene. When the lungs are affected\\nthe expectoration is like prune-juice when the bowels, the discharge\\nis dark and putrid.\\nFever is a morbid process, with the cause and symptomatology of\\nwhich the student must be familiar. It has been fully treated in\\nprevious chapters. (See Fever.)\\nThe Degenerations. The symptomatology varies with the form\\nof degeneration and the organs affected. The prostration of the gen-\\neral economy is due to the same cause as the degenerations themselves.\\nAlbuminous degeneration occurs in fever, and causes the weak heart\\nand defective gland action. The weak heart of the convalescent period\\nin diphtheria and other infective diseases is well known.\\nFatty Degeneration and Infiltration. In fatty degenera-\\ntion there is cell-destruction. The brain, the heart, the kidneys in\\nBright s disease, the liver, all undergo degeneration. It may be due\\nto phosphorus-poisoning or to snake-bite. It is seen in acute yellow\\natrophy of the liver. It is caused by other toxic agents. Fatty infil-\\ntration or lipomatosis is seen in the fat heart of brewers, the en-\\nlarged liver, the excess of fat in the abdomen, etc. The affected\\norgans are enlarged, but they are functionally weak. Fatty infiltra-\\ntion of organs is recognized by its etiological associations. In alco-\\nholic subjects of sedentary habits, in subjects who eat an excess of\\nfatty foods, in overfed and pampered children, and in tuberculosis it\\nis commonly seen. In fatty infiltration the cells are not destroyed. If\\nwith the above conditions the liver is enlarged or the heart weak, or\\nboth, we may expect to find fatty infiltration. There is enlargement\\nof the affected organ, which is painless, smooth, not usually soft on\\npalpation. The condition occurs at any age, but usually in later life.\\nEmaciation may not be present. Lithsemia is common in fatty infil-\\ntration.\\nAmyloid Degeneration. This is rarely confined to one organ\\nof the body. The causes are syphilis, malaria, tuberculosis, and pro-\\nlonged suppuration. The liver and spleen are enlarged, hard, smooth,\\nand painless. There are great pallor, and oedema of the feet and face.\\nThere is ancemia, but no fever. The kidneys are affected, hence poly-\\nuria and low specific gravity of the urine a few casts are found. The\\nbowels are likely to be loose because the process has involved the intes-\\ntine. It occurs at any age. The diagnosis rests on the presence of a\\ncause, the painless enlargement of organs, the pallor, and the polyuria.\\nFibroid Degeneration. This is not so much a degeneration as\\nan overgrowth of connective tissue with coincident primary or second-\\nary atrophy of the parenchyma. The function of the organ is impaired\\nor abolished. Increase of connective tissue in the nerve-structures\\nis known as sclerosis, in the liver or kidney as cirrhosis. In the\\nartery it leads to the changes knoAvn as endarteritis. Whatever the\\npathology may be, whether atrophy of cell-elements of the affected\\nstructure be primary or secondary, the condition is productive of seri-\\nous, even grave consequences. It is part of the senile process. It\\nleads to the manifold symptoms of endarteritis it is the cause of\\nmany nervous affections which will be discussed in their proper sections.", "height": "4416", "width": "2720", "jp2-path": "practicaltreatis00muss_0_0440.jp2"}, "441": {"fulltext": "MORBID PROCESSES AND THEIR SYMPTOMATOLOGY. 411\\nThe varied phases of so-called interstitial nephritis are due to the\\nfibroid changes primarily in the kidneys, and secondarily in the arte-\\nrial system. In the lungs it attends emphysema, or may even be pro-\\nductive of that condition. The fibriod heart, is another manifestation\\nof the same process. The tubes and channels are closed by the same\\nprocess as in fibrous stricture of the duodenum. Wherever situated\\nits development means gradual abolition of function.\\nMucous Degeneration. This form of degeneration is seen in\\nmyxoedema. The albuminous intercellular substance is replaced in\\nthe connective tissue by mucin.\\nPigmentary, calcareous, and colloid degenerations are local morbid\\nprocesses without other symptoms than those of the primary affection.\\nIII. Anomalies of Growth.\\nTumors. Tumors, other than cancer or sarcoma, produce only\\nmechanical symptoms, and must be considered in their special section.\\nThe mechanical symptoms are due 1. To the tumor (foreign body).\\n2. To obstruction of any channel in near relation.\\nNew Growths. They cause local symptoms. This is most striking\\nin structures which must necessarily be destroyed as the growth in-\\ncreases in size, as in the brain or spinal cord, or where tubes or chan-\\nnels are closed, as in cancer of the stomach or oesophagus. Local symp-\\ntoms may precede the general symptoms on the other hand, general\\nsymptoms may arise for which no local cause can be assigned. The\\nlocal symptoms of cancer are variable and depend upon the anatomical\\nnature and physiological offices of the organ affected, and upon its\\nanatomical relation to surrounding organs. This class of symptoms\\nwill be referred to in the section on special diagnosis. Suffice it to\\nsay they cause gradual abolition of the function of the organ, or closure\\nof the channels in connection with it, as the intestinal canal, the pharynx,\\nor the hepatic ducts. Cancer and sarcoma are accountable for a group\\nof symptoms to which the term cachexia has been applied. In acldi-\\ndition, a few symptoms belong to the cancerous process wherever situ-\\nated. They may or may not all be present in the large majority of\\ncases one or more are wanting they should always be sought for in\\norder to confirm a diagnosis of cancer. These symptoms are\\n1. Pain, recognized by peculiar characteristics in most cases (a) It\\nis sharp and lancinating (b) it is paroxysmal (c) it is increased by\\nirritation, as food when the stomach is affected (a) it is increased by\\nfunctional activity, as speaking or swallowing in carcinoma of the\\nlarynx or pharynx (e) at the outlet of canals, as the bladder or\\nrectum, it gives rise to tenesmus.\\n2. Hemorrhage. If the malignant mass is in communication with\\nthe exterior, the blood may be discharged per vias naturales. In malig-\\nnant disease of the upper air-passages or the lungs hemorrhage is\\nlikely to occur. It is common in gastric carcinoma as well as in\\nuterine cancer. If the organs do not communicate with the exterior,\\nand the lesion gives rise to exudations or transudations, the latter are\\nfrequently bloody, as in carcinoma of the pleura or peritoneum.\\n3. Abnormal Discharge. This occurs especially in cancer of the", "height": "4416", "width": "2708", "jp2-path": "practicaltreatis00muss_0_0441.jp2"}, "442": {"fulltext": "412 GENERAL DIAGNOSIS.\\nhollow viscera and of the canal-structures. The discharge is the result\\nof inflammation, suppuration, and necrosis, and particularly microbic\\ninflammation. It is recognized by its more or less bloody character\\nand by its odor, which is peculiar. It is most offensive and pene-\\ntrating, and, particularly in uterine cancer, is almost pathognomonic.\\nEven the utmost cleanliness will not obviate it.\\n4. Tumor. It may be readily detected or elude all search. Some\\nswelling is certainly present. It is discovered by external examina-\\ntion, by the objective physical signs of enlargement or change of con-\\ntour of the affected organ.\\n5. Foreign Body. The growth gives rise to symptoms similar to\\nthose present when a foreign body is fixed in any portion of the\\nhollow viscera, as the respiratory tract, the gastro-intestinal, including\\nthe hepatic and the genito-urinary tract, a. Through reflex influence\\nan attempt is made to remove it, hence cough, vomiting, diarrhoea\\nwith tenesmus, repeated and painful micturition with tenesmus, etc.,\\nthe particular symptoms varying with the organ affected, b. Obstruc-\\ntion of the channels, with all the accompanying symptoms, depending\\nupon the location of the growth.\\n6. Temperature. A morbid process is often recognized by its nega-\\ntive symptoms, if the term may be used. Thus, fever is absent or the\\ntemperature is even subnormal in carcinoma.\\n7. The Cancerous Cachexia. Wherever situated the disease is\\nsooner or later attended by extreme general symptoms which are, in\\na measure, striking. It is to be admitted that cases of carcinoma often\\noccur without marked cachexia, a. One symptom may always be\\nlooked for it is emaciation. It may be rapid or gradual and extend\\nover one or two years toward the end it is always rapid. Ultimately,\\nif the patient does not succumb to other conditions, it presents an ex-\\ntreme picture. The eyes are sunken, all normal accumulations of fat\\ndisappear. The fat in the rectal fossse disappears, causing deep de-\\npression of the rectum. The abdomen is retracted. The appearances\\nare most striking in cancer of the oesophagus, b. Pallor (see Color)\\nthis may be present, c. Anwmia, with breathlessness, palpitation,\\nvertigo, d. Exhaustion. This with accompanying emaciation is pro-\\ngressive, and may be the first symptom. Progressive weakness is\\noften seen without fever or local disorder to account for it. Toward\\nthe end it becomes so extreme as to forbid exertion, e. Malnutrition.\\nEvidences of malnutrition appear the skin is hard and dry its elas-\\nticity is impaired and it becomes the field for parasitic invasion.\\nTinea and other parasites may flourish. Bacteria invade the suscepti-\\nble areas, and boils make their appearance. The secretions are per-\\nverted. In the mouth ulcers develop the fungi of this situation (the\\nthroat, etc.) become more active the gums are inflamed. In the later\\nstages the typhoid state 7 (see Fever) may ensue. If the gastro-\\nintestinal tract is invaded, symptoms of acute intoxication may arise.\\n8. Metastasis. We are often aided by the occurrence of this event,\\nparticularly by involvement of the glands. In gastric carcinoma\\nsecondary hepatic disease or enlarged glands above the left clavicle\\nare found in rectal carcinoma, secondary hepatic cancer. In many", "height": "4416", "width": "2728", "jp2-path": "practicaltreatis00muss_0_0442.jp2"}, "443": {"fulltext": "MORBID PROCESSES AND THEIR SYMPTOMATOLOGY. 41 3\\ninstances the presence of cancer is revealed by the metastasis, even\\nwhen the primary growth cannot be recognized.\\nThe diagnosis rests upon the above conditions. In obscure cases\\nthe age, the sex, the associate pathological conditions, the duration of\\nthe disease become important factors in the diagnosis. Cancer usually\\noccurs after forty, or, some authorities say, after fifty years of age.\\nThe female sex is most frequently affected. It may be associated\\nwith a history of previous lesion or irritation, as ulcer in vaginal,\\ngastric, or rectal cancer the irritation of teeth or a pipe in labial and\\nlingual cancer of gallstone in cancer of the bile-ducts of renal or\\nvisceral calculus in disease in that situation. A disease of grave and\\nmalignant character, the duration of which is over eighteen months or\\ntwo years, is not, in all probability, cancer.\\nMorbid Processes in Tubes or Channels. The effects produced by\\nobstructions.\\nWhen tubes or channels are the seat of disease symptoms arise apart\\nfrom the special morbid process, which are due to obstruction and are\\ncommon to all tubes or channels. The symptoms of obstruction of the\\nbloodvessels and lymph-channels cyanosis, oedema, gangrene (throm-\\nbosis and embolism) have been described. But in addition we have\\nhypertrophy, a secondary condition, not referred to above, which,\\nnevertheless, follows obstruction of any channel. In the cases of vas-\\ncular obstruction the hypertrophy is seen in the heart and the arteries.\\n(See Diseases of the Heart.)\\nIn obstruction, therefore, of tubes or channels we have to a greater\\nor less extent (1) hypertrophy behind obstruction (2) diminution of\\nthe normal flow of fluid and consequent accumulation of material\\nwhich normally passes through the channels (3) atrophy and cessa-\\ntion of functional activity beyond the point of obstruction (4) dilata-\\ntion of the primary hypertrophy (5) degeneration, ulceration, low-\\ngrade inflammation (bacterial), secondary rupture of the affected\\nviscera. The morbid anatomist can readily point out the examples of\\nthe morbid changes sequential to obstruction. Thus in cancer of the\\noesophagus there are hypertrophy of the muscular coats, regurgitation\\nof food, atrophy of the stomach, dilatation with accumulation of food,\\nsecretions from the glands of the oesophageal mucous membrane,\\nsecondary ulceration, rupture into the lungs, with gangrene or pneu-\\nmonia. In obstruction at the pylorus there are (1) hypertrophy (2)\\naccumulation (3) intestinal atrophy (4) dilatation of the stomach,\\nwith its train of symptoms. In obstruction of the biliary channels,\\nor the bladder, or ureters, the same secondary conditions arise plus\\nobstruction to the flow of bile or urine. Secondary symptoms arise\\nfrom accumulation of the non-escaping fluids. Subjective symptoms,\\nit may be said, are not marked there are pain and difficulty in the\\nperformance of the usual functions. It need scarcely be said that the\\nobstruction sometimes gives rise to symptoms which are due to the\\nabnormal obstructing material which acts as a foreign body. The\\nsymptoms are reflex and depend entirely upon the seat of the foreign\\nbody.", "height": "4416", "width": "2700", "jp2-path": "practicaltreatis00muss_0_0443.jp2"}, "444": {"fulltext": "414 GENERAL DIAGNOSIS.\\nThe causes of obstruction in whatsoever channel situated are, first,\\npressure from disease outside (growths, hernia) second, disease of the\\nwalls, with contraction third, occlusion by a foreign body, as gall-\\nstone, renal calculus, worms, or other material according to the channel\\nobstructed. The symptoms are most marked when the obstruction is\\ndue to disease outside the walls or to obstruction by occlusion within\\nthe walls.\\nIn all cases of obstruction, nasal, faucial, laryngeal, bronchial, oesoph-\\nageal, gastro-intestinal, biliary, renal, or pancreatic, look for the symp-\\ntoms of the secondary morbid change. Each form of obstruction will\\nbe specially considered elsewhere. (See Special Diagnosis.)\\nThe Bloodvessels. Blood-pressure. It must not be forgotten\\nthat the bloodvessels are in a measure distinct from other tubes,\\nalthough subject to the same laws, physiological and pathological.\\nThey contain fluids, and have a continuous function by which the\\nfluids are propelled. They are subject to the laws that govern the flow\\nof fluids under all circumstances in nature. Any derangement or\\ndisease will effect changes which are explainable by hydrostatic or\\nhydrodynamic laws. Fluids within vessels exert pressure. Pressure\\nproduced by weight of the fluid is known as the hydrostatic pressure\\nthat produced by the flow is known as the hydrodynamic pressure.\\nPressure can be gauged by proper instruments. In the case of fluid\\nin the bloodvessels it is called the blood-pressure. The blood-\\npressure is estimated at the pulse by the educated finger and by the\\nsphygmograph. A certain definite pressure is always present in\\nhealth. It is subject to slight fluctuations, but tracings with a sphyg-\\nmograph follow a definite course. In the description of the pulse,\\nmodifications of blood-pressure will be given in detail it is sufficient\\nhere to say a few words regarding hydrostatic and hydrodynamic\\npressure.\\nHydrostatic pressure is modified by the weight of the fluid. It is\\nof pathological importance in the veins only, and especially in those of\\nthe lower limbs. When the pressure is increased the increased weight\\nof the blood-column causes increased bulk and over-distention, as in\\nvaricose veins, unless the support to the blood-column is increased.\\nInflammations of the lower limbs are attended by venous accumulation\\nand followed by ulceration. For this reason dropsies arise more\\nreadily in these portions. The common occurrence of gout in the feet\\nmay be due to slow circulation.\\nHydrodynamic pressure is variable. Its changes indicate increase\\nor diminution of blood-pressure. The bloodvessels are resisting elastic\\ntubes the resistance is always equal to the pressure within, hence\\nblood-pressure and arterial tension are equivalent terms. We speak\\nof increased or diminished pressure, or correspondingly of high or low\\ntension. Now, the hydrodynamic or blood-pressure depends upon (1)\\nVariations in the volume of blood (2) variations in the capacity of the\\nvascular system (3) facility of the capillary circulation (4) the force\\nof the heart. The tension of the artery depends upon the same\\nconditions.", "height": "4416", "width": "2728", "jp2-path": "practicaltreatis00muss_0_0444.jp2"}, "445": {"fulltext": "MORBID PR CESSES AND THEIR S YMPTOMA TOL OGY. 415\\n1. Variations in the volume of the blood, a. Volume increased.\\nCauses absorption of fluid after meals or drinking to excess. Result\\nincreased blood-pressure and increased tension. Controlled in health\\nby action of the vasomotors relaxing the vessels, and by enlargement\\nof the veins. b. Volume diminished. Cause hemorrhage, serous\\npurging. Result diminished blood-pressure, lowered tension. Con-\\ntrolled in health by contraction of arteries through vasomotor nerves.\\nIn hemorrhage the loss of blood produces anaemia. The latter is a\\nstimulant to the vasomotor centre in the medulla, and produces con-\\ntraction of peripheral arteries and high tension.\\n2. Variations in the capacity of the vessels, a. Diminution of the\\ncapacity of the blood-channels (volume of blood not lessened). Cause\\ncutting off of a vascular area by ligation or obstruction, by narrowing\\nthe calibre of the wall, as in arterial spasm or endarteritis, by disease\\nof the kidneys, contracting the lessening channels in the aortic circuit,\\nor disease of the aorta, causing obstruction to the outflow of blood.\\nResult increased pressure, high tension. Controlled by normal regu-\\nlating vasomotor apparatus, or by diminution of the volume of blood.\\nb. Increase of capacity of blood-channels. Cause relaxation of mus-\\ncular coats of vessels. Result diminished blood-pressure, lowered\\narterial tension. Controlled by contraction of vessels or increase in\\namount of blood. In shock, the vasomotor sympathetic system of the\\nsplanchnic arteries is so disturbed that the arteries are dilated and all\\nthe blood is sent into the abdominal vessels (fall of pressure).\\nMode of action of the vasomotor apparatus. Centres in the medulla,\\nin the spinal cord, and locally in the sympathetic ganglia of different\\nparts, control the vasomotor nerves, which influence hydrodynamic\\npressure. 1. If the centres are stimulated, tonic contraction of the\\nvessels is produced. This may be general or local. Increased press-\\nure or heightened tension is the result. It may be reflex from the\\nperiphery, or due to some state of the blood. 2. If the centres are\\nparalyzed, or inhibited, or cut off from the arteries, the latter become\\nrelaxed (dilated). The pressure is lowered, the tension is less. Shock,\\npain, certain drugs, reflexes (probably) produce inhibition.\\n3. Facility of capillary circulation. Obstruction to outflow of blood\\nfrom capillaries into the veins increases blood-pressure. Cause the\\nsame as when arteries contract. Result increased blood-pressure, high\\ntension. Regulated in the same manner as arteries. Relaxed capilla-\\nries produce opposite conditions.\\n4. The force of the heart, a. Heart s action (left ventricle) increased.\\nCause hypertrophy, palpitation. Hence the greater force of blood-\\nimpact, greater resistance by arteries. The tonic resistance narrows\\nthe calibre of the vessels. Result increased pressure, higher tension.\\nb. Heart s action weakened. Hence, less force of blood, less resistance.\\nResult lessened pressure, low tension.\\nThe recognition of variations in tension. (See Pulse.)\\n1. High arterial pressure or tension. By (a) incompressibility and\\ntension of the arteries (b) accentuation of the aortic second sound\\n(c) prolongation of the left ventricle first sound (d) increased flow of\\nurine, pale and watery (e) characteristic pulse-tracing by sphygmo-", "height": "4416", "width": "2692", "jp2-path": "practicaltreatis00muss_0_0445.jp2"}, "446": {"fulltext": "416\\nGENERAL DIAGNOSIS.\\ngraph. If the high tension is permanent, hypertrophy of the\\nheart (g) atheroma, more or less.\\n2. Low arterial pressure or tension. By (a) soft, compressible, often\\ndicrotic pulse (b) enfeebled sounds, aortic second and left ventricle\\n(c) scanty, high-colored urine (d) special pulse-tracing. If perma-\\nnent, stases, congestions, cyanosis, with general weakness and impaired\\nnutrition.", "height": "4416", "width": "2712", "jp2-path": "practicaltreatis00muss_0_0446.jp2"}, "447": {"fulltext": "PART II.\\nSPECIAL DIAGNOSIS.\\nCHAPTER I.\\nTHE NOSE AND LARYNX.\\nThe Nose.\\nThe symptoms of disease of the nose result from disturbance of the\\nfunction or alteration of the structure of the organ and the morbid\\nprocess. Physiological symptoms Impairment of the sense of smell,\\nanaemia, and symptoms of obstruction may occur. Obstruction causes\\nretention of secretions. These secretions are exposed to infection.\\nPutrefaction and fermentation set in and give rise to offensive odors.\\nMore serious is the effect of the obstruction on the rest of the respira-\\ntory tract. The patient becomes a mouth-breather. The appearance\\nof the face is altered the voice changes, snoring is common, mastica-\\ntion is interfered with, and there is a diminution in the amount of air\\npassing to the lungs. As a result a vacuum is created which is com-\\npensated for by external pressure. In children the result is marked\\ndeformity of the chest, leading to the development of the pigeon or\\nchicken breast. (See the Lungs, Chapter II., Part II.) The general\\nsymptoms attending mouth-breathing will be referred to again.\\nSymptoms due to the Anatomical Structure. The nose is an open space\\nor a series of air-spaces lined with mucous membrane. The mucous\\nmembrane is the frequent seat of infectious inflammation, as in hay\\nfever, influenza, and measles. Most of the nasal symptoms are due to\\ndisease of the mucous membrane. The membrane is subject to affec-\\ntions that are common to all mucous membranes, and the subjective\\nand objective symptoms are similar to those that arise in other organs,\\nmodified by the function and anatomical arrangement.\\nThe abundance of bloodvessels and glands is the cause of one of the\\nsymptoms namely, the discharge. Moreover, the difficulty of removing\\nthe discharge from the various cavities in the nose in which they are\\npent up leads to putrefaction and odor. Because the air is constantly\\npassing over the parts, discharges are very liable to become dry, and\\nhence crusts and scabs form. Again, the vascidarity of the structures\\nof the nose is the cause of development of symptoms. The blood-\\nvessels are richly supplied with nerves, which cause them to contract\\nor dilate, on comparatively slight provocation, by reflex action. Chilli-\\nness of the body, or of local areas of the body, chilling of the extremi-\\n27", "height": "4416", "width": "2692", "jp2-path": "practicaltreatis00muss_0_0447.jp2"}, "448": {"fulltext": "418 SPECIAL DIAGNOSIS.\\nties, and other peripheral impressions, are followed by congestion of\\nthe nasal mucous membrane, which may go on to inflammation. The\\nvascularity predisposes to hemorrhage.\\nThe nose is richly supplied with nerves (in addition to the olfactory\\nnerve), which are susceptible to various irritations or impressions\\nimpressions made by the air laden with unusual material, as fumes of\\na chemical nature, emanations from animals, or plants, and certain\\nsubstances not yet isolated, which are decidedly irritating. There\\nis often local irritation from polyps and adenoid growths, and foreign\\nbodies, or enlarged bone. The nerves are connected by a mechanism\\ndirectly with the centres in the medulla, with particularly the pneumo-\\ngastric centre. The effect of peripheral nasal irritation may be felt\\nreflexly in the area of distribution of that nerve hence an unpleasant\\nodor may bring on sudden nausea or vomiting. But of more striking\\nand frequent pathological significance is the occurrence of asthma, or\\nsudden dyspnoea, from reflex excitation of the pulmonary division of the\\npneumogastric nerve.\\nMorbid processes in the nose are symptomatic of some general affec-\\ntions. The occurrence of asthma, or of deformity of the chest and\\ngeneral ill-development, has been spoken of. Acute inflammations are\\nsignificant of the exanthematous diseases, particularly measles. An\\nacute inflammation (as pointed out by Meigs), with great obstruction\\nof the nares and an abundant, puriform discharge, is a complication or\\nsymptom of Bright 7 s disease that may portend the onset of uraemia.\\nChronic inflammations may be due to syphilis or other chronic infection.\\nThe Data Obtained by Inquiry.\\nOf the data obtained by inquiry, that belonging to the social history,\\nthe family history, and the history of previous diseases yield but\\nlittle information of diagnostic value. It is true the acute inflamma-\\ntions secondary to measles and other exanthemata occur at an early\\nage, while the chronic attacks occur late in life, as do also tumors,\\nexcept adenoid. Foreign bodies are more likely to be found in chil-\\ndren and the feeble-minded. Those occupations which are in-doors, in\\noverheated apartments, and among noxious vapors predispose to\\ncatarrhs. In the family history we must look for gout, rheumatism,\\nsyphilis, and affections which lead to osseous changes. More marked\\nthan all is the influence of syphilis. A chief predisposing factor in\\nthe production of nasal disease is the morphological arrangement of\\nthe parts, which may be congenital, or the result of early infantile dis-\\nease. Thus, when congenital, the high palatal arch, etc., is looked\\nupon as the stigmata of degeneration.\\nOn inquiry of the history of previous diseases, we look for syphilis,\\nthe exanthemata of early life, the occurrence of gout or rheumatism,\\nand of those gastrohepatic and nutritional disorders which lead to\\ncatarrhs.\\nThe Subjective Symptoms. General. They are often accom-\\npanied by extreme distress, but do not lead to a fatal termination.\\nThe general subjective symptoms are like those of inflammation of\\nother mucous membranes.", "height": "4404", "width": "2688", "jp2-path": "practicaltreatis00muss_0_0448.jp2"}, "449": {"fulltext": "THE NOSE AND LARYNX. 419\\n1 Lassitude occurs when there is fever. It is a frequent precursor\\nof rhinitis, and is pronounced in croupous and diphtheritic rhinitis\\nextreme prostration may attend the latter.\\n2. Chilliness following the lassitude, or rigor, may occur in the\\nsame class of cases. If distinct rigors occur, an abscess in one of the\\ncavities may be suspected, if the subjective and objective symptoms\\npoint to it or glanders may be present.\\n3. Fever. This occurs in the inflammations it is never marked,\\nand. is not of diagnostic significance. It is most severe in glanders.\\nIt is then attended by general symptoms of rigor, with pain in the\\ntrunk and limbs. In the first twenty-four hours there may be nausea\\nand vomiting. Locally, a small pimple is seen which is quite painful.\\nA yellowish sanious discharge oozes from the nostrils. Hard pustules\\nappear about the nose and other parts of the body. (See Infectious\\nDiseases.) It is of low type in diphtheria, and of hectic character when\\nthere is abscess. High fever associated with inflammations of the nose\\npoints to influenza or one of the exanthemata as the primary cause of\\nthe rhinitis. Foreign bodies in the nose may cause fever. Emacia-\\ntion occurs with malignant growths.\\nLocal. Pain, varying in degree, occurs in all acute affections of\\nthe nose. Its seat and character are of some diagnostic significance.\\nSmarting or burning pain at the root of the nose accompanies acute\\nrhinitis and attends post-nasal catarrh. The pain is diffuse and indefi-\\nnite in dry catarrh and in diphtheria. The most severe pain occurs\\nwhen foreign bodies are present in the nose and in cases of glanders\\nand primary syphilis. Foreign bodies of a vegetable nature by swell-\\ning and germinating induce pain, Avhich increases gradually in in-\\ntensity.\\nIn tropical regions parasites may be found in the nostrils. They\\nare the larvse of the lucilia hominivora. It is said that the pain is so\\nsevere at the root of the nose, extending backward, as to cause mani-\\nacal delirium. Sleeplessness is marked, and there may be extensive\\ndestruction of the bones and skin. There is a fetid, sanious discharge.\\nPain Over the Frontal Sinus. The pain of an inflamed frontal\\nsinus is more severe than the pain of inflamed nostrils. It is some-\\ntimes intense and agonizing. Pain may be located in the cheek from\\ninflammation or tumors of the antrum. In disease of the nose, if the\\npain radiates to the ear, the Eustachian tubes are probably involved.\\nHeadache is frequently caused by nasal disease of all forms. (See\\nChapter IV., Part I.)\\nDisturbance of the Sense of Smell. (See the Nerves.) Anosmia and\\nParosmia. Loss of smell, or anosmia, occurs to a moderate degree in\\nall the inflammatory and obstructive diseases of the nose. The in-\\ntensity depends upon the degree of change in the mucous membrane.\\nIt may also be due to disease of the nerves or the olfactory centre in\\nthe brain. Parosmia is the perception of abnormal odors, and may\\nbe a neurosis or psychical difficulty entirely, and hence purely subjec-\\ntive, or there may be inability to distinguish an odor when presented\\nto the nostril. All odors may appear the same, or agreeable odors\\nmay seem to the patient very disagreeable. In addition, the patient", "height": "4416", "width": "2684", "jp2-path": "practicaltreatis00muss_0_0449.jp2"}, "450": {"fulltext": "420 SPECIAL DIAGNOSIS.\\nmay complain of the perception of an odor in connection with the\\nnasal disease with which he is affected. Parosmia is due to an involve-\\nment of the olfactory nerves.\\nA sense of dryness is a symptom of which the patient frequently\\ncomplains, particularly in the early stages of acute rhinitis and through-\\nout the entire course of dry catarrh, or atrophic rhinitis.\\nObstruction or Stenosis. This sometimes causes the greatest\\ndiscomfort to the patient. There may be simply a sense of stuffiness\\nand fulness in the nasal and frontal region, or complete obstruction,\\ncausing difficulty in breathing. In infants it prevents nursing, and\\nshould always suggest inherited syphilis. It occurs in all the obstruc-\\ntive diseases of the nose and nasopharynx, as acute rhinitis, chronic\\ninflammation (except the atrophic form), hyperemia, the hypertro-\\nphies, polyps, tumors, deviations of the septum, foreign bodies, and\\nadenoid vegetations.\\nDeafness is present when the Eustachian tubes are invaded or ob-\\nstructed from inflammation or stenosis. When associated with anosmia\\nit may be of central origin. Tinnitus aurium frequently accompanies\\nthe deafness.\\nCough. The discharge may pass into the pharynx and the larynx\\nand cause cough. (See Chapter on Cough.) It occurs, therefore, in\\nthe catarrhs and obstructive diseases, and is not diagnostic of any nasal\\ncondition. When the nostrils are too wide, as in atrophic rhinitis,\\ncough may occur because irritating particles are admitted through the\\nwidened aperture. A so-called reflex cough occurs in hypertrophic\\nand post-nasal disease.\\nReflex Neuroses.\\nHay Fever. Hay fever is an acute affection ushered in by paroxysmal\\nsneezing, itching, and smarting of the inner canthus of each eye, or of\\nthe throat or nose. After hours or days of sneezing coryza develops.\\nThe disease continues for a varying length of time, is more pronounced\\nat certain seasons of the year, particularly the late fall. Coughing may\\nbe an additional symptom, and paroxysms of asthma may develop\\nwhich are hard to distinguish from true bronchial asthma. The attack\\nmay be excited by vegetable emanations, particularly the pollen of\\nplants, but other emanations may also induce it. Certain conditions\\nof the nasal mucous membrane predispose to the attack. Local inflamma-\\ntion of the nose or obstructive diseases from hypertrophies are primarily\\npresent. To the exciting cause and the local predisposing cause may\\nalso be added a neurotic factor. The disease affects families of ner-\\nvous constitution, and may occur through several generations. It is\\nmore common in this country than in other countries, and dwellers in\\ncities are more subject to it than residents in the country. Asthma may\\nbe due to disease of the nose, but the only proof that it is of nasal origin\\nis that it disappears after the nose has been treated for the various ail-\\nments that are supposed to cause it.\\nIdiopathic Rhinorrhcea. Characterized by a sudden profuse\\ndisci large of yellowish water. It ceases as suddenly as it develops, and\\nis thought to be due to some functional derangement of the fifth nerve.", "height": "4408", "width": "2664", "jp2-path": "practicaltreatis00muss_0_0450.jp2"}, "451": {"fulltext": "THE NOSE AND LARYNX. 421\\nThe Data Obtained by Observation.\\nThe Objective Symptoms. Of the general objective symptoms,\\nfever has been noted. In certain affections of the nose defective de-\\nvelopment of the general system is observed. This is particularly the\\ncase in adenoid vegetations of the nasopharynx in children. (See\\nDiseases of the Pharynx.)\\nLocal Examination. The Exterior. The external appearance\\nof the nose is of diagnostic significance when marked deformity takes\\nplace. Its true shape is changed in myxoedema (q. v.). It is changed\\nin disease of the bone due to syphilis. The bridge of the nose is sunken\\nor depressed. It must not be confounded with the depression that\\noccurs in fracture. The nose may be broadened in cases of tumors of\\nan expanding nature in the nasal cavities. The local change soon\\nextends to the cheek. The nose is also the seat of eruptions, as acne\\nand hyperemia, but they are usually of local origin. They may be\\nsuggestive of a gouty diathesis.\\nInternal Examination. The examination of the cavities of the\\nnose consists of two procedures, both of which are necessary to deter-\\nmine with accuracy the condition of the organ. These are\\n1. Anterior Rhinoscopy. For this are needed a good light, a nose\\nspeculum of some form, probes, a 10 per cent, solution of cocaine, and\\na head-mirror with central opening.\\nThe examiner proceeds as follows The patient is seated facing the\\nsurgeon, with the light behind and at one side of the head, as nearly\\nas possible on a level with the eye of the operator. He must sit with\\nshoulders and head a little forward. The operator adjusts his head-\\nmirror so that the central aperture is in front of his own eye, and the\\nreflected light falls on the nose of the patient. It is very important\\nfor nose-examination that the operator look through the aperture and\\nnot under the mirror. The speculum is then taken in one hand and\\nthe nostril dilated, so that the view of the interior is unobstructed.\\nDo not try to dilate the bony part of the nose, but only the nostril.\\nProceed from before backward with the examination, carefully focus-\\ning the light on each part in succession, and gradually tilting the\\nhead of the patient backward. Thus the floor of the nose, the septum,\\ninferior turbinated bones, middle turbinated bones, and sometimes the\\nsuperior turbinated bones, are brought into view successively. In a\\nbroad nose one may at times see the posterior wall of the pharynx,\\nwhich is distinguished by its peculiar wave-like movement when the\\npatient swallows. The use of the probe is important, and without it\\nno positive diagnosis can be made. With the probe the operator tries\\nthe condition of the mucous membrane, tests the consistency of tumors\\nor hypertrophies, and so judges of the character of the condition. After\\nthis the enlarged parts should be touched with cocaine and the result\\nobserved. Contraction of a swelling under its influence proves its\\nvascular origin.\\n2. Posterior Rhinoscopy. This is the most difficult part of the ex-\\namination and requires much practice on the part of the operator.\\nThe instruments needed are a tongue depressor, head-reflector, two", "height": "4412", "width": "2708", "jp2-path": "practicaltreatis00muss_0_0451.jp2"}, "452": {"fulltext": "422\\nSPECIAL DIAGNOSIS.\\nsizes of throat-mirrors, a palate-hook or flat strings for holding for-\\nward the soft palate, and a curved applicator for cocaine, or a spray\\nbottle with tip turned upward.\\nThe patient is seated as before, the tongue held down by the tongue-\\ndepressor, and the patient is told to breathe freely through both mouth\\nand nose. The light is directed into the pharynx and a mirror of the\\nlargest possible size inserted carefully behind the soft palate. The\\nproper angle and the movement necessary to bring all parts into view\\ncan only be learned by practice. As a rule, it is best to hold the\\nFig. 110.\\nRhinoscopic mirror in position. (Boswokth.)\\nhandle well up at first, and note the condition of the vault of the phar-\\nynx, then gradually depress it, examining the choanal from above\\ndownward. Do not keep the mirror too long in the throat. It is\\nbetter to insert it several times than to weary the patient by attempting\\nto see everything the first time. After the choanse have been exam-\\nined a turn of the mirror to either side will bring into view the orifices\\nof the Eustachian tubes, and the examination is complete. If, after\\nrepeated attempts, it is found to be impossible to see the posterior\\nnares, one must first seek to accustom the patient to the presence of", "height": "4404", "width": "2664", "jp2-path": "practicaltreatis00muss_0_0452.jp2"}, "453": {"fulltext": "THE NOSE AND LARYNX. 423\\nthe instruments if this fails, it may be necessary to resort to the\\npalate hook or the cords to hold the uvula forward. The best hook is\\nWhite s. It is necessary to apply cocaine to the soft palate before in-\\nserting the hook. Another plan, which is preferred by some, is to\\ntake the flat cords used for corset-laces, soak them in mucilage and dry\\nthem. These are then stiff enough to pass through the nostril, yet\\nflexible enough to pull down and out through the mouth with forceps.\\nThen by drawing forward both ends the soft palate is pulled out of\\nthe way. This is almost always necessary when applications are to be\\nmade to any spot in the pharynx.\\nSometimes a view of the posterior nares may be obtained by making\\nthe patient breathe in short, quick gasps, by which the uvula is re-\\nleased. In ordinary breathing it is often tightly pressed against the\\nposterior wall of the pharynx.\\nFig. 111.\\n12\\nRhinoscopic image.\\n1. Vomer or nasal septum. 2. Floor of nose. 3. Superior meatus. 4. Middle meatus, 5. Superior\\nturbinated bone. 6. Middle turbinated bone. 7. Inferior turbinated bone. 8. Pharyngeal orifice\\nof Eustachian tube. 9. Upper portion of Rosenmiiller s groove. 11. Granular tissue at anterior\\nportion of vault of pharynx. 12. Posterior surface of velum. (Seiler.)\\nBy the above methods we are to determine the appearance and nutri-\\ntion of the mucous membrane, relative size of the cavities, the nature\\nof the discharge, and the presence of ulceration or perforation of the\\nnares. Deviations of septum, enlargement or contraction of turbinated\\nbones, the size of the cavities, and the presence of foreign bodies or\\nabnormal growths are also detected.\\nInspection. Appearance of the Mucous Membrane. The\\nobserver may find it unusually pale. This is seen in tuberculosis\\nand in atrophic rhinitis. If a protuberant mass is observed to be\\ntransparent and shining, as well as pale, it is due to a polypus. If the\\nmucous membrane is bright red, it may be due to acute inflammation,\\nto glanders, or to syphilis. It is dull red in chronic catarrhs and caseous\\nrhinitis. The coatings of the mucous membrane are of significance.\\nIf a dry mucus covers the part, it is due to dry catarrh; on the other\\nhand, a dirty-gray membrane is indicative of diphtheritic rhinitis.\\nIt is swollen and bathed with a serous, seropurulent, or purulent\\ndischarge, the character depending on the stage of inflammation. The", "height": "4412", "width": "2688", "jp2-path": "practicaltreatis00muss_0_0453.jp2"}, "454": {"fulltext": "424 SPECIAL DIAGNOSIS.\\ncontractile tissue over the turbinated bones is congested and swollen.\\nWhen probed it is elastic, and when cocaine is applied it shrinks.\\nIn chronic hypertrophic rhinitis the uvula is thickened and elon-\\ngated, on account of the hawking. The outer surface or the edges of\\nthe turbinated bones are enlarged throughout or in localities. The\\nmucous membrane covering these spots is thickened, hard, and rough.\\nIf cocaine is applied, the mucous membrane does not contract, as in\\nthe swelling due to hyperemia. The posterior ends of the inferior or\\nmiddle turbinated bones are enormously enlarged, forming round\\ntumors which obstruct more or less the posterior nares and project into\\nthe pharynx polyps and deviation of the septum complicate these\\ncases.\\nThe same appearances are seen in chronic post-nasal catarrh, and\\nin addition a mammillated and thickened appearance of the pharyngeal\\nmucous membrane and that of the posterior third of the septum. In\\ndry catarrh the mucous membrane is coated with mucus or covered\\nwith crusts. The membrane is thin, pale, hard to the touch, and cov-\\nered with a layer of dried secretions and crusts in atrophic rhinitis.\\nThe nasal passages are abnormally wide and one or both turbinated\\nbones are atrophied.\\nAbnormal Growths. A grayish yellow or greenish shiny mass, with\\na broad base, soft and yielding on probing, is a nasal polypus. It\\ncannot usually be circumscribed. The passages are enlarged in atrophic\\nrhinitis. One may be occluded by an enlarged turbinated bone or by\\ndeviation of the septum.\\nUlceration. Ulceration of the mucous membrane is usually a\\nmanifestation of lupus, tuberculosis, or tertiary syphilis. In lupus the\\nulceration has extended from the exterior. If ozsena is present in a\\npatient with lupus it is probable that there is also lupus of the nasal\\npassages. The ulcers may be followed by necrosis and caries of the\\nbones. If the ozsena is not removable by antiseptic sprays the bones\\nare probably affected. A discharge of sequestra makes the diag-\\nnosis positive. Rhinoscopy and careful palpation may reveal the ulcer\\nand a carious bone. Tuberculous ulcers are usually found in the septum.\\nThey are rarely primary. They present a whitish-gray surface, with\\nelevations of infiltrated tissue. They bleed on the slightest provoca-\\ntion. The mucous membrane surrounding them is torn. Tubercle\\nbacilli can be found in the scrapings from the ulcer. In syphilis the\\nulcers are situated anywhere in the nares. A history of infection, or\\nof secondary and tertiary manifestations, can be obtained. The stench\\nof the breath is sickening, and the patient complains of stenosis and\\nloss of smell. There is some localized tenderness, and sleeplessness,\\ndebility, and emaciation may ensue. They may be mere superficial\\nexcoriations, or deep serpiginous ulcers surrounded by an inflammatory\\nzone. Caries can be detected with a probe. The ulcerated surfaces\\nare covered with a dry, greenish crust. Foreign bodies usually cause\\nulceration if impacted.\\nNeuro-paralytic ulcers are painless and spread rapidly over consider-\\nable surface they follow paralysis of the fifth nerve. They are dry\\nand sluggish and do not extend to the skin. Post-febrile ulcers follow", "height": "4416", "width": "2648", "jp2-path": "practicaltreatis00muss_0_0454.jp2"}, "455": {"fulltext": "THE NOSE AND LARYNX. 425\\nmeasles, scarlatina, typhoid, and variola, and are due to rupture of\\nsmall abscesses, with the subsequent formation of ulcer. They are\\nusually anterior on the septum or inside the alee, and scabs form over\\nthe surface. They are very irritable. Ulcers may perforate the\\nseptum or the floor of the nose. They are usually due to syphilis.\\nSimple perforating ulcer of neuro-paralytic origin may also occur.\\nNasal Secretion. The odor of the discharge is suggestive of\\ndiphtheria and also of the presence of foreign bodies. The discharge\\nin the latter instance is sanious or purulent. Animal parasites, as\\nwell as pease and beans, cause pain, symptoms of obstruction, and ulcer-\\nation. In syphilis with caries the odor is marked, usually gangrenous.\\nAtrophic Rhinitis, or Ozsena. The odor is characteristic, and is\\ndiagnostic if syphilis is excluded. A sense of dryness is complained\\nof. Occasional obstruction arises from accumulation of crusts, other-\\nwise the passage is unduly open. There are constant hawking and\\nspitting of brownish-green crusts, which are often blood-tinged. Frontal\\nheadaches may occur in paroxysms. The patient is often depressed in\\nspirits. The bridge of the nose may fall in slightly.\\nPhysical Character. The character of the secretions is of diag-\\nnostic significance. They may be liquid, semi-solid, or solid. The\\nliquid secretions may be serous, mucous, or purulent. Serous secretions\\noccur in acute rhinitis, hay fever, and idiopathic rhinorrhoea, and follow\\nbursting of cysts. The secretion of mucus occurs in the later stages\\nof inflammation of the mucous membrane and in chronic forms. A\\nmucopurulent secretion is seen in chronic rhinitis, and pure pus in\\nabscesses of the septum or cavity. In hereditary syphilis it is at first\\nmucopurulent, then purulent, and then sanious. A sanious acrid dis-\\ncharge, with false membrane discharged or evident on inspection, is\\ndue to diphtheria. A fetid, sanious, or ichorous discharge, with fre-\\nquent attacks of epistaxis, attends malignant nasal growths. A dis-\\ncharge of blood is known as epistaxis. (See page 426.) The semi-\\nsolid secretions may be due to mucus alone, or to blood-clots mingled\\nwith serum or with pus. The latter occur in atrophic and hyper-\\ntrophic catarrhs.\\nCaseous Rhinitis. A semi-solid secretion is diagnostic. On exami-\\nnation the cavities in this affection are found to be filled with cheesy\\nmatters, easily broken up with the probe. The mucous membrane is\\ndull reel. The material is discharged in masses at intervals through the\\nmouth or nostrils, relieving the previous extreme stenosis. If neglected\\nfor a long time, deformity of the face and disease of the bones and car-\\ntilages ensue from pressure.\\nThe solid secretions may be mucous crusts, as in acute and chronic\\ncatarrhs, blood-crusts after epistaxis and traumatism, membrane in\\ndiphtheritic rhinitis, slough from ulcers, and rhinoliths. The latter\\nare gray or greenish-brown in color, hard and rough, either fixed or\\nmovable.\\nMicroscopical Character. The normal secretion from the nose con-\\ntains squamous and ciliated epithelium, isolated leucocytes, and vari-\\nous fungi. The fluid is thick, alkaline in reaction, and has a slight\\nodor. It contains mucin. In disease of the nasal cavities the fluid", "height": "4412", "width": "2684", "jp2-path": "practicaltreatis00muss_0_0455.jp2"}, "456": {"fulltext": "426 SPECIAL DIAGNOSIS.\\nchanges. In acute nasal catarrh it is more copious and thinner. It\\nremains alkaline, and contains epithelium and fungi. When the stage\\nof suppuration is reached, the secretion may consist entirely of pus.\\nCerebrospinal fluid may also be discharged through the nose in certain\\nbrain-tumors. In such fluid albumin is absent. Detection of this\\nfluid is of diagnostic value, as it points to the central lesion.\\nThe Charcot-Leyden crystals are found in the nasal secretion in\\nasthmatic patients, and sometimes in acute coryza.\\nBacteriological Character. In diphtheria the characteristic micro-\\norganism is seen. Recognition of glanders may be based upon finding\\nthe bacillus in the nasal secretion. (See page 336.) Cultivations\\nmay be made. The nature of ulcers may be determined by microsco-\\npical examination. The tubercle bacillus can sometimes be detected.\\nA pneumococcus or bodies that resemble it have been found in the\\nsecretion in ozsena. Thrush-fungi have also been found, as well as\\nsome mould fungi.\\nMouth-breathing. Much valuable information is obtained by\\nnoting the breathing and the condition of the voice. Mouth-breathing\\nmay be present if the face is drawn and vacant and there are cracks\\nand fissures in the mouth. The voice is usually nasal. The resonating\\nquality is lost entirely. Snoring accompanies these conditions. (See\\nObstructive Symptoms.)\\nPalpation. The probe is used to determine the character of en-\\nlargements or tumors, and the patulency of foramina also to examine\\nthe mucous membrane as to induration and the presence of caries or\\nnecrosis. By the finger the nasal pharynx is palpated to confirm the\\nresults of rhinoscopy. In this manner adenoid vegetations and hyper-\\ntrophy of the inferior turbinated bones are detected. The finger should\\nbe protected by the use of a mouth-gag or by a jointed thimble.\\nEpistaxis. The blood may flow in drops, or a continuous stream\\nmay pour out from the anterior nares. Sometimes it falls into the\\npharynx and is hawked up, or is swallowed and then vomited.\\nIt may be due to local causes, or to constitutional conditions. Trau-\\nmatisms (scratching the nose), new growths, and foreign bodies are\\ncausative agents it may be due to fractured skull. Local causes\\nOn inspection, the cause may be found in enlarged veins at the anterior\\ninferior portion of the septum, a bleeding ulcer, a new growth, or\\nthe ulceration of a foreign body. The general conditions which are\\ncausal are (1) Plethora (2) engorgement due to the ascent of an\\nelevation (3) all forms of anaemia (4) hemophilia (5) cerebral con-\\ngestion and severe headache (6) the commencement of fevers, particu-\\nlarly typhoid fever (7) early stages of leprosy. In children exposed\\nto the sun, and after exertion, it is of frequent occurrence, and is seen\\noften at puberty in delicate children.\\nDiseases of the Nose.\\nThe subjective and objective symptoms previously described are due\\nin general to inflammations, malformations, morbid growths, and foreign\\nbodies. They are recognized by their subjective and objective signs,\\nby rhinoscopic examinations, and by bacteriological and microscopical", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0456.jp2"}, "457": {"fulltext": "THE NOSE AND LARYNX.\\n427\\nresearch. The inflammations may be acute or chronic, primary or\\nsecondary. When secondary, both acute and chronic inflammations\\nmay be due to infections. To the acute varieties belong the acute\\ncatarrh of measles, glanders, hay fever or influenza to the chronic\\nbelong syphilis and tuberculosis.\\nSimple Acute Rhinitis. Acute Coryza, Cold in the Head.\\nUshered in with a feeling of lassitude, aching in the back and limbs,\\nand feverishness, a sense of fulness is felt in the nostrils, with sneezing.\\nAfter twenty -four hours an irritating discharge begins. During this\\ntime the malaise has increased. The pain in the forehead and cheeks\\nhas become more pronounced, and a nasal twang is given to the voice.\\nThe feverishness continues, reaching 101\u00c2\u00b0 in the more pronounced\\nFig. 112.\\nVertical section through nasal cavities. (Diagrammatic.) (Seiler.)\\n1. Superior turbinated bone. 2. Middle turbinated bone, with posterior hypertrophy,\\nof hypertrophied pharyngeal tonsil. 4. Inferior turbinated bone. 5\\nSection\\nOrifice of Eustachian tube.\\ncases, with thirst and loss of appetite. At the height of the fever, in\\ntwenty-four or forty-eight hours, a crop of herpes very often develops\\non the lips. The general symptoms then subside and the local symp-\\ntoms change. The discharge becomes thick and purulent, the fulness\\ncontinues, but the pain is diminished. The inflammation often extends\\nup to the tear-ducts and to the eyelids. The latter are congested and\\nsmart very much. Very frequently, also, the inflammation extends\\nto the pharynx, causing soreness of the throat and stiffness of the neck,\\nand the larynx even may be involved. A slight deafness may result\\nfrom the inflammation extendi og into the Eustachian tube.\\nChronic Rhinitis. Four varieties are distinguished, to all of which\\nthe term nasal catarrh is applied. In one there is hypertrophy of the", "height": "4408", "width": "2700", "jp2-path": "practicaltreatis00muss_0_0457.jp2"}, "458": {"fulltext": "428\\nSPECIAL DIAGNOSIS.\\nturbinated bones in the second there is extension of the disease to the\\npost-pharynx chronic post-nasal catarrh in the third there is abso-\\nlute dryness of the mucous membrane rhinitis sicca, or dry catarrh\\nin the fourth there is atrophy of the mucous membrane atrophic\\nrhinitis, or ozama.\\nChronic Hypertrophic Rhinitis. The affection comes on gradually\\nafter repeated acute attacks of coryza. The only symptoms may be\\nFig. 113.\\nDilated nostril, showing anterior hypertrophy. (Seller.)\\nslight fulness in the nose and a little hoarseness of the voice. In more\\nadvanced stages the symptoms of stenosis are marked with oral breath-\\ning, snoring, and nasal sound. There is a constant discharge of muco-\\npus backward into the pharynx, causing hawking. The hearing is\\nfrequently impaired, as well as the taste and smell. The discharge\\nFig. 114.\\nRhinoscopic image from a case of posterior hypertrophy on the middle turbinated bone. (Seiler.)\\noften affects the larynx, causing an irritating cough. The hypertro-\\nphied tissue on the turbinated bones, and the pressure of the bone on\\nthe septum, may lead to reflex attacks of asthma.\\nChronic Post-nasal Catarrh is an extension of the rhinitis into the\\npharynx. It is distinguished by discomfort or pain in the soft palate\\nand posterior nares. There are tingling and a sense of fulness at the\\nroot of the nose, with frontal headache the patient complains of a", "height": "4412", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0458.jp2"}, "459": {"fulltext": "THE NOSE AND LARYNX. 429\\nbad taste in the back of the mouth and of constant flow of thick secre-\\ntion into the pharynx, causing snoring and hawking. The same per-\\nversion of the senses of taste, smell, hearing, and of the voice occurs\\nas in acute rhinitis. Headache seems to be due to the condition of\\nthe pharynx. (See Atrophic Rhinitis, page 425.)\\nDry Catarrh, or Rhinitis Sicca, is also chronic in its course, accom-\\npanied by tingling and dryness of the nostrils. A faint, musty odor\\nis detected, but there is no discharge or sense of obstruction. In severe\\ncases there may be sharp pain in the nose extending to the forehead.\\nSyphilitic Coryza is seen in infants and young children affected\\nwith hereditary syphilis. The nostrils are swollen and red at the\\nedges, sometimes completely occluded, causing oral respiration and\\ninability to take the breast or bottle.\\nPustules, fissures, and ulcers are found in the nose and at the margin\\nof the orifices. They are also seen in the pharynx and larynx. Hem-\\norrhages may occur. Other evidences of hereditary syphilis are present.\\nThe Auxiliary Cavities of the Nose.\\nThe Antrum is subject to abscess, cysts and polypi, parasites, and\\ntumors.\\nAbscess. An odor somewhat like that of ozsena, a putrid taste,\\nnausea, anorexia, pain in the cheek and root of the nose, often neural-\\ngia in the frontal region, and malaise are present. A very character-\\nistic symptom is the discharge of pus from one nostril on leaning the\\nhead forward. There is often a bad tooth on the same side in the\\nupper jaw.\\nThe Sinuses. The frontal, ethmoidal, and sphenoidal sinuses are\\nsubject to inflammation, abscess, traumatism, and the irritation of\\nforeign bodies, usually parasites.\\nThe frontal sinuses are the only ones which exhibit external symp-\\ntoms. When these cavities are inflamed the patient complains of pain\\nand tenderness over the frontal protuberances if the process goes on\\nto the formation of abscess, there may be redness and swelling and\\nfinally fluctuation. If the communication is not closed, there is a\\nfetid discharge from the middle meatus.\\nWhen the sphenoidal and ethmoidal sinuses are affected there are no\\nexternal symptoms unless the enlargement is so great as to affect the\\norbit. There is deep-seated pain. Pus is seen exuding into the supe-\\nrior meatus and flowing backward into the pharynx. Parasites cause\\nintense pain and lead to abscess, caries, and necrosis. RMnoscopic\\nexamination in disease of the antrum shows rough hypertrophic en-\\nlargement on the under surface of the middle turbinated bone and a\\nflow of pus into the middle meatus. Sometimes a probe can be passed\\ninto the antrum from the nose. Often an exploratory puncture is\\nnecessary. When the foramen is obstructed there is a dull aching pain\\nin the upper jaw, with deformity of the orbit, face, hard palate, and\\nnostril. Fluctuation can usually be found at some point after a time.\\nThe laerymal duet and sac are often the seat of inflammation by ex-\\ntension, causing pain, obstruction in the nose, and epiphora. On", "height": "4412", "width": "2684", "jp2-path": "practicaltreatis00muss_0_0459.jp2"}, "460": {"fulltext": "430 SPECIAL DIAGNOSIS.\\nexamination pus will be seen flowing forward over the inferior meatus.\\nWhen the lacrymal probe is introduced the ducts are found to be\\npainful and obstructed, and pus exudes.\\nThe Larynx.\\nThe structural composition of the larynx does not differ from that\\nof other parts of the respiratory passage. Mucous membrane, connec-\\ntive tissue, cartilages, and muscle are similar to the same tissues situ-\\nated elsewhere.\\nThe result of their anatomical association in the larynx is the estab-\\nlishment of the functions of that organ, the formation of the voice and\\nthe admission of air. Now, the morbid processes that affect the larynx\\ndo not differ from morbid processes elsewhere in which similar tissues\\nare involved. Each tissue is liable to congestion, to inflammation, to\\ndegeneration, to new-growth formation the joints may become anky-\\nlosed, the muscles either paralyzed or the seat of spasm, and we have,\\ntherefore, all the symptoms common to morbid processes in each class\\nof tissue. We meet with other symptoms beside, which result from\\nthe anatomical position of the larynx and of its functions. The cords\\ncannot vibrate, or the muscles and articulations cannot move, and dys-\\nphonia or aphonia occurs. The narrow chink of the glottis soon be-\\ncomes occluded, giving rise to dyspnoea. Obstruction to the pathway\\nor pain from inflammation or ulceration causes dysphagia. The sensi-\\ntiveness of the mucous membrane provokes cough on the slightest\\nprovocation.\\nThe larynx is a highly specialized organ, and is well innervated.\\nLarge central nuclei, connected by a large nerve which passes over a\\ncircuitous route and which anastomoses with other nerve-cords, preside\\nover the function of phonation. Affections of the central nuclei, affec-\\ntions of the nerve-trunk or of adjacent structures exerting pressure\\nupon the trunk, have their expression in disorder of the larynx, par-\\nticularly if phonation is disturbed. In other words, the phenomena\\nof laryngeal disease may be symptomatic of affections of the brain or\\nof the nerve-trunk, as well as of the larynx. (See Nervous Diseases.)\\nOwing to the anatomical position and special function of the organ\\nthe symptoms of disease of the larynx are very striking, pointing at\\nonce to the seat of trouble. Laryngeal affections are not likely to be\\nmistaken for disease of contiguous parts, although retropharyngeal\\nabscess, abscess at the side of the pharynx, disease of the thyroid gland,\\nand inflammation of the lymphatics or cellular tissue in the neck may\\ncause symptoms suggestive of laryngeal disease.\\nFinally, morbid processes in the larynx determined by the symp-\\ntoms and physical appearances may be symptomatic of general processes\\nacute inflammation, of erysipelas, typhoid fever, smallpox, or measles\\nchronic inflammation or ulceration, of the rheumatic or gouty diathesis,\\nsyphilis or tuberculosis scars, of syphilis ankylosis, of rheumatic\\ngout. The laryngeal symptoms of brain disease or of affections of the\\nnerve-trunk have been referred to.\\nThe practical point of all this is that affections of the larynx are not.", "height": "4416", "width": "2660", "jp2-path": "practicaltreatis00muss_0_0460.jp2"}, "461": {"fulltext": "THE NOSE AND LARYNX. 431\\ndue to primary disease of that organ alone, but are often secondary\\neither to general processes or to local morbid processes elsewhere.\\nTherefore, when laryngeal symptoms or lesions are observed, seek\\nbeyond the larynx, as well as in it, for their cause.\\nThe Data Obtained by Inquiry.\\nThe Social History. Acute laryngeal diseases are more common\\nin childhood, chronic diseases in late life. Those occupations which\\ncompel the inhalation of noxious vapors or excessive use of the voice\\npredispose to laryngeal diseases. Alcoholic subjects and those who\\nuse tobacco to excess are liable to laryngeal affections. As with the\\nnose so with the larynx, no special disease is inherited and need be\\nlooked for in the family history. But we may inquire for a diathetic\\ncondition, as gout or rheumatism, which predisposes to a mucous mem-\\nbrane inflammation, or a family type which leads a parent to say his\\nchild has a tendency to croup, a popular expression which has in it\\nan element of truth. That condition or state which predisposes to\\ncolds belongs also to a family type.\\nOn inquiry as to previous disease various acute infections and syph-\\nilis and tuberculosis are to be looked for. In a study of the present\\ndisease it must be borne in mind that laryngeal affections notably may\\nbe secondary, and, therefore, the presence of other diseases must be\\ninquired into. Particularly do we inquire for nervous diseases, and in\\nchildren for rhachitis. One thing is to be borne in mind one attack\\nof acute laryngitis predisposes to subsequent attacks.\\nSubjective Symptoms. Pain. Pain in the larynx may be sharp,\\nstabbing in character, or simply a tickling or burning with a feeling\\nof pressure. It is increased by pressure and by speaking or swallow-\\ning. Pain is sometimes so intense as to render speaking and swallow-\\ning impossible. In acute laryngitis the pain is cutting and burning.\\nIn the milder inflammations, in dry catarrh, and in lupus it amounts\\nto soreness only. The pain is severe and sharp in cases of cancer and\\ntuberculosis, rarely in syphilis, and when foreign bodies are present in\\nthe structures. The pain may be very severe and intense when there\\nis destructive ulceration. It is a diagnostic symptom of perichondritis.\\nPerichondritis. Inflammation about the cartilages or perichondritis\\nis usually phlegmonous in character, and leads to the formation of\\nabscess. The collateral oedema is so great as to cause some obstruction,\\nwith cough and hoarseness. On palpation the larynx is extremely\\ntender. The pain is increased by movement of the larynx, as in speak-\\ning or swallowing. If the inflammation involves the arytenoid carti-\\nlages, pain extends toward the ear, the vestibule is swollen, the car-\\ntilage fixed. On the other hand, when the cricoid is diseased there\\nare pain on swallowing of solid food, on account of interference with\\nthe muscular attachments, dyspnoea, and paralysis of the posterior\\ncrico-arytenoid muscles.\\nInflammation of the thyroid cartilage may open externally or inter-\\nnally. In the latter case the abscess can be seen in the larynx. Dis-\\ncharge of pus and necrosed cartilage confirms the diagnosis. By means", "height": "4416", "width": "2692", "jp2-path": "practicaltreatis00muss_0_0461.jp2"}, "462": {"fulltext": "432 SPECIAL DIAGNOSIS.\\nof a sound the bare cartilage can be detected, giving further proof of\\nthe presence of the disease. The pain may extend to the ears in carci-\\nnoma. The pain is propagated by the auricular branches of the vagus.\\nParesthesia. Peculiar sensations are frequently complained of.\\nThey may be burning, tickling, or itching in character, or it may seem\\nas if a foreign body were present in the part, as a hair, or it may seem\\nlike a draught of cold air striking the parts. Sometimes after a foreign\\nbody has actually been present, the sensation of its presence will con-\\ntinue a long while after its removal. A sense of pressure or fulness,\\nthe feeling of a lump in the throat, is frequently complained of, pro-\\nvoking a desire to swallow. The patient will seek advice on account\\nof it. It is known as the globus hystericus, and is recognized by the\\nabsence of local changes in the larynx, by its association with other\\nphenomena of hysteria, and by its disappearance or aggravation under\\nthe influence of excitement. This abnormal sensation is seen in hys-\\nteria and hypochondriasis. It is one of the nerve-perturbations in\\nchlorosis and anaemia.\\nA feeling of dryness is frequently complained of, and attends the\\nfirst stage of acute, and any stage of chronic laryngitis. The sense of\\nfulness, or pressure, or feeling of the presence of a foreign body is com-\\nplained of in all forms of laryngitis, in croup, in oedema of the glottis,\\nor epiglottis, and in syphilitic infiltration.\\nHyperesthesia and Anesthesia. When there is hyperesthesia\\nthere is constant desire to cough (see page 435), and the act is induced\\nby the slightest irritation. The desire to cough, independently of the\\nact, however, is of itself an extreme annoyance. It is a disagreeable\\nsensation present in acute inflammations and in early phthisis. At\\ntimes of menstruation and during pregnancy both symptoms are fre-\\nquently complained of. Hyperesthesia is easily recognized with the\\nprobe. In ancesthesia particles of food fall into the larynx. The\\nmucous membrane is insensitive to the contact of the probe. Anaesthe-\\nsia occurs in hysteria, diphtheritic paralysis, paralysis of the superior\\nlaryngeal nerve, bulbar paralysis and cerebral softening or hemor-\\nrhage, or coma from any cause.\\nDysphoria. The most common symptom of affections of the\\nlarynx is disturbance of the function of speech. The voice is changed\\nin character, or may be lost in any affection which causes swelling of\\nthe mucous membrane, or occlusion of the orifice, or which interferes\\nwith the action of the vocal cords. The voice may be hoarse in acute\\nand chronic inflammations, in tumors and in specific ulcerations about\\nthe larynx, and in paralysis of the cords. From simple hoarseness it\\nmay vary in intensity to complete aphonia. Laryngoscopic examina-\\ntion is necessary in order to detect the presence or absence of paralyses.\\n(See Paralyses.)\\nChronic Laryngitis. Chronic hoarseness may be due to chronic\\nlaryngitis. This affection either originates in an acute attack or comes\\non slowly. Prolonged use of the voice in a higher key than natural,\\nor in the open air, the use of alcohol, constant exposure, are exciting\\ncauses. It is symptomatic of syphilis and tuberculosis. It frequently\\nresults from inflammation of the upper air-passages, particularly chronic", "height": "4416", "width": "2672", "jp2-path": "practicaltreatis00muss_0_0462.jp2"}, "463": {"fulltext": "THE NOSE AND LARYNX. 433\\npharyngitis. It occurs after middle life more frequently, and usually\\nin the male sex. There is discomfort on long speaking, with dryness\\nand tickling. At first the secretion of mucus is very slight, but after\\nhawking and coughing it increases in amount. Hoarseness occurs, and\\nif the patient is careless or persists in the baneful occupation, complete\\naphonia may result. The voice is clearest in the morning, after expec-\\ntoration of the mucus that accumulated in the night, but becomes husky\\ntoward night. The aphonia may occur in paroxysms, and is relieved\\nby coughing up a dry secretion. The cough is never severe. The\\nsputum is small in amount, glairy, and is often in little balls or crusts.\\nLupus. Slight hoarseness, deepening to dysphonia or even aphonia,\\nattended by soreness, and later some dysphagia, is seen in lupus. In-\\nfiltration and scar-contractions cause dyspnoea later in some instances.\\nDysphonia from inflammation or oedema is also a symptom of leprosy,\\nwhich, however, is present in other situations as well. The duration\\nmay be significant. Hoarseness of long duration (years) is said to be\\nprodromal of cancer (Ziemssen).\\nFunctional Dysphonia or aphonia may occur after excessive use\\nof the voice and in hysteria. Hysterical aphonia occurs in women\\nand young girls the laryngoscope reveals nothing the acts of cough-\\ning, laughing, and sneezing are normal, and a sound may be created\\nin either act it appears and disappears suddenly.\\nTone of the Voice. The character of the voice may change.\\nWhen one-sided paralysis of a cord is present the voice is flat and\\ntoneless. In cases of paresis of the tensors of the cords a falsetto voice\\nresults. Diplophonia occurs in one-sided paralysis, and in some cases\\nin which small tumors lying between the cords come up during the\\nact of phonation and form nodes. Two tones are formed at the same\\ntime. Frequently only certain tones are doubled.\\nDyspnoea. This is one of the frequent symptoms and the most\\nserious of laryngeal disease. It may be due (1) to obstruction by\\ninflammatory or oedematous swelling (2) to spasm (3) to tumors or\\nforeign bodies in the larynx (4) to the cicatrization of ulcers after\\nsyphilis or lupus (5) to paralysis of the abductors or adductors of the\\nlarynx. It may be, therefore, organic or spasmodic.\\nDuration. Dyspnoea from disease of the larynx may develop grad-\\nually and continue over a long period of time, or it may be acute in\\nonset, depending upon the character of the morbid process which has\\nbrought about the obstruction, Acute paroxysms of dyspnoea, one of\\nwhich may end in death, sometimes occur in the course of affections in\\nwhich chronic dyspnoea is present thus sudden oedema may occur in\\ncases of syphilitic or tuberculous ulceration.\\nLaryngeal Dyspnoea must be distinguished from other forms of\\ndyspnoea 1. Dyspnoea from diseases of the heart and lungs. 2.\\nDyspnoea from pressure upon the trachea. The larynx is not markedly\\nmoved during the respiratory acts, and the patient bends the head for-\\nward instead of backward. 3. Dyspnoea from pressure on the larynx.\\nCellulitis of the neck, tumors of the lymph-glands, goitre, and retro-\\npharyngeal abscess are provocative of this form of laryngeal dyspnoea.\\nExamination of the respective localities by inspection and by touch\\n28", "height": "4408", "width": "2660", "jp2-path": "practicaltreatis00muss_0_0463.jp2"}, "464": {"fulltext": "434 SPECIAL DIAGNOSIS.\\nreveals the cause. It may be worthy of remark that dyspnoea in\\ndiphtheria, frequently thought to be due to internal occlusion, may be\\ndue to pressure of enlarged glands on the bronchus and larynx.\\nInspiratory Dyspnoea. Dyspnoea may vary in degree from slight\\ninconvenience in breathing, noticeable to the patient, to the violent\\nstruggling for breath which is seen in cases of extreme stenosis of the\\nlarynx. If carefully observed in either case the larynx is seen to rise\\nand fall. In extreme forms of obstruction the head is bent back, the\\nneck stretched, the muscles of the neck contracted. The spaces above\\nthe sternum and at the sides of the trachea are drawn in with inspira-\\ntion, and the alse of the nose work vigorously. Further evidence that\\nsufficient air does not enter the lungs is found in recession of the epi-\\ngastrium and drawing in of the ribs at the base of the chest during\\nthe act of inspiration. The countenance is dusky or ashy-gray, the lips\\nbecome cyanosed, and the nails bluish as the dyspnoea persists and\\nincreases. A cold perspiration breaks out on the forehead, and finally,\\nfrom exhaustion, the respiration becomes slower and slower until mere\\ngasps are seen. The heart s action increases in frequency as the ste-\\nnosis increases. Death usually takes place from asphyxia, the child\\nfirst falling into a stupor, on account of carbonic-acid-poisoning.\\nSounds attend the act of inspiration, the character depending on the\\nnature of the obstruction. In obstruction from simple spasm, or from\\nintense inflammation of the larynx, without secretion, the sound of\\ninspiration is harsh and stridulous. In obstruction from oedema or\\nfrom exudation, as in laryngeal diphtheria, the sound of the inspiration\\nis loud and stridulous, but not shrill. The expiration is usually noise-\\nless and prolonged. The short, stridulous, or gasping inspiration is\\nfollowed by prolonged gentle expiration. In spasmodic croup the\\nexpiration is like snoring. The interval between expiration and inspi-\\nration is lessened, the respirations are hurried.\\nLaryngismus Stridulus. In this form of dyspnoea the act of\\nbreathing ceases in the midst of inspiration, and is attended by a\\ncharacteristic sound. It is seen usually in poorly nourished children.\\nIt is of frequent occurrence in rickets, its presence suggesting that\\ndisease when other manifestations of it are obscure.\\nThe symptoms occur suddenly and are very alarming. The child\\nawakes in the night, and suddenly stops breathing after a few short\\nwhistling inspirations. The child is seized with terror, which is de-\\npicted on the countenance the eyes stare the face is pallid at first,\\nbut rapidly becomes livid. The alee nasi are extended, the head is\\nthrown back, and the spine arched. A cold perspiration breaks out\\nover the forehead. Carpo-pedal spasms may occur and the urine and\\nfeces be discharged involuntarily. In a few seconds, or, at most, two\\nminutes, the child draws two or more deep, noisy inspirations, each\\none lessening in depth and sound, when color returns to the face, the\\ncyanosis gradually disappears, and the child becomes tranquil.\\nIn mild forms the child catches its breath. It holds its breath,\\nand then makes a noisy inspiration.\\nAttacks of laryngismus stridulus are more rare in adults. They\\nmay occur in hysterical subjects. In the attack there occurs a series", "height": "4404", "width": "2656", "jp2-path": "practicaltreatis00muss_0_0464.jp2"}, "465": {"fulltext": "THE NOSE AND LARYNX. 435\\nof long, harsh, whistling or striclulous inspirations, followed by short,\\nnoisy expirations. Rarely is there complete closure of the glottis.\\nIn both children and adults general convulsions may occur during\\nthe attack, or carpo-pedal spasms alone may be seen. Among adults\\nthe convulsions occur only in hysterical subjects.\\nThe diagnosis of laryngismus stridulus is based upon the absence of\\nlaryngeal symptoms prior to the attack, the absence of cough or hoarse-\\nness, and complete disappearance of all laryngeal symptoms when the\\nattack subsides. The absence of pain and fever and of laryngoscopic\\nsigns is noteworthy. This applies, of course, to spasm that occurs in-\\ndependently of laryngeal disease.\\nExpiratory Dyspncea. In some forms of laryngeal obstruction\\nthe exit of air is interfered with, as in a movable tumor below the vocal\\ncords. We have expiratory dyspnoea. The act of inspiration is com-\\nplete, the act of expiration is suddenly checked by the obstruction, on\\naccount of which the lungs become overfilled with air and an emphy-\\nsema develops.\\nDysphagia. Difficulty in swallowing is most marked when destruc-\\ntion of tissue in the larynx takes place, or when there is acute inflam-\\nmation about the muscles or their attachments hence, when ulcers,\\ntuberculous or malignant, are present, or perichondritis arises, the\\ndifficulty is so great as to prevent the taking of food.\\nDysphagia is recognized by pain and by the falling of particles of\\nfood into the larynx, exciting cough. It must be distinguished from\\nthe dysphagia of pharyngeal affections by ocular examination, the loca-\\ntion of the pain, and the non-association of rheumatism.\\nInflammation of the Epiglottis. When the epiglottis is the seat\\nof acute inflammation there is great dysphagia on account of pain, or on\\naccount of the obstruction. The sensation of a lump in the throat at\\nthe base of the tongue or the top of the larynx is complained of, and\\nthere is pain on swallowing. The pain becomes very intense at times.\\nFluids cannot be taken, for the fluid enters the larynx when the patient\\nattempts to swallow, because the epiglottis does not protect the glottis.\\nThe voice is usually clear throughout the attack, and the general symp-\\ntoms are not marked.\\nWhen the epiglottis is fixed or ulcerated, and in some forms of ulcer-\\nation of the larynx, the food enters the larynx, and hence produces\\ndysphagia.\\nMis-swallowing, or swallowing the wrong way, occurs in all\\nconditions in which food is allowed to enter the larynx. Although\\nconditions favorable for its occurrence are present, it may not take\\nplace unless the patient is off his guard during the act of swallowing,\\nas when he is laughing. It may then occur even in normal cases.\\nIt is associated with anaesthesia of the larynx, and occurs in central\\nnerve affections which cause that condition.\\nCough. (See Diseases of the Lungs.) Sometimes valuable infor-\\nmation is derived from the character and severity of the cough. Sev-\\neral forms are noted\\nFirst, the dry cough, as seen in acute laryngitis. It is almost con-\\nstant, and is aggravated when the patient speaks, takes fluid, or inspires", "height": "4416", "width": "2684", "jp2-path": "practicaltreatis00muss_0_0465.jp2"}, "466": {"fulltext": "436 SPECIAL DIAGNOSIS.\\ndeeply. In children it is abrupt, brassy, or metallic, stridulous or\\nwhistling, so-called croup-cough, as seen in cases of false croup\\nand laryngitis with oedema.\\nSecond, a dry hoarse cough occurs in the course of chronic laryngitis.\\nThird, cough with whoop. With the act of coughing a whooping\\nsound may be heard in inspiration. After rapid violent expiratory\\nacts the whoop takes place with inspiration. It is spasmodic and con-\\nvulsive, and is followed by retching, and often by vomiting. (See\\nPertussis.)\\nFourth, the cough is of such a character as to give one the idea that\\nit is suppressed in membranous and cedematous laryngitis.\\nFifth, a cough frequently occurs without any local anatomical changes\\nin the larynx, which seems to be purely of nervous origin. Two forms\\nare seen a. Paroxysmal. Severe coughing occurs suddenly, and can-\\nnot be controlled by the patient. It ceases without cause, returning\\nin a few hours. There is no expectoration, b. Continued and rhythmi-\\ncal. It is not so severe as in the paroxysmal form, but consists in a\\nregularly recurring cough more or less loud. It does not occur while\\neating or speaking and ceases entirely during sleep. It is usually\\nworse when the patient is under observation. Examination with the\\nlaryngoscope reveals absence of disease. This form of cough is seen\\nafter diphtheria, when sexual disturbances are present, at puberty, in\\ncases of anaemia and chlorosis, or of neurasthenia or hysteria. The\\ntone is usually high.\\nHemoeehage. Hard coughing or an unusual straining of the\\nvoice may lead to the occurrence of slight hemorrhage. Only after\\ninjuries are hemorrhages from the larynx at all copious. Moderate\\nhemorrhages occur in scurvy, haemophilia, hemorrhagic smallpox,\\ntyphus fever, and leukaemia.\\nDistuebance of Co-obdination. Several forms of such disturb-\\nance are seen. Spasm of the glottis may occur with each effort to\\nspeak, causing either serious interference or complete inability to utter\\na word, as in stuttering. Sometimes, instead of the glottis opening to\\ncomplete the act of inspiration, it may close. Sudden inspiratory\\ndyspnoea, therefore, occurs, and is attended with stridor.\\nSpasm of the glottis is a frequent complication of disease of the\\nlarynx. It is seen in crises, as in locomotor ataxia.\\nThe Data Obtained by Observation.\\nObjective Symptoms. The objective symptoms are determined by\\ninspection and palpation. Inspection of the exterior of the larynx re-\\nveals the presence of swelling, and the movements of the organ as a\\nwhole. Local swelling of the tissues over the larynx may occur in\\ninflammations of the cartilages they are usually of syphilitic origin,\\nbut may attend carcinoma or tumor. There is more or less marked\\nswelling in inflammation of the cartilages, which after a time fluctu-\\nates, and, when opened, discharges pus and necrosed cartilage. The\\nobjective signs of inflammation are noted.\\nThe movement of the larynx is increased in cases of dyspnoea. It", "height": "4416", "width": "2688", "jp2-path": "practicaltreatis00muss_0_0466.jp2"}, "467": {"fulltext": "THE NOSE AND LARYNX.\\n437\\nis accompanied by recession of the spaces above the sternum and the\\nclavicles, with clonic contraction of the sterno-cleido-mastoid muscle.\\nThe interior of the larynx is studied by inspection (laryngoscopy),\\nand by palpation (probe or fingers).\\nLaryngoscopy. The first requisite is a good light, sunlight, a good\\nstudent s-lamp, or an Argand or Welsbach gas-burner the electric\\nlight is not satisfactory. Second,^ good reflector is required. It may\\nbe attached to a head-band or a spectacle-frame. It should be concave\\nfor artificial light, plain for sunlight, and should be pierced in the\\ncentre. Third, laryngeal mirrors of different sizes and a curved probe\\ncomplete the instruments necessary for examination of the larynx.\\nFig. 115.\\nLaryngeal mirror in position, displaying the laryngeal image. (Cohen.)\\nExamination. The patient is seated with the source of the light\\nat one side and behind him the head and shoulders are brought well\\nforward and the head slightly raised. The operator takes a seat in\\nfront at a proper distance for the focal length of the reflector, and\\nfocuses the light on the patient s mouth, warms the laryngeal mirror", "height": "4416", "width": "2688", "jp2-path": "practicaltreatis00muss_0_0467.jp2"}, "468": {"fulltext": "438 SPECIAL DIAGNOSIS.\\nover the flame and tests its temperature on the back of the hand. It\\nshould be moderately heated, so that when it is placed in the mouth\\nthe vapor of the breath will not precipitate on its surface. The patient\\nmust open the mouth and protrude the tongue, which is grasped be-\\ntween the folds of a napkin by the thumb and fingers of the operator.\\nThe tongue should be gently but firmly grasped. The mirror is then\\ninserted carefully and quickly, face downward, into the pharynx.\\nCare must be taken not to touch the tongue or palate, otherwise the\\npatient may be made to retch and become alarmed. The mirror is\\npassed to the posterior wall of the pharynx, and so directed that the\\nimage of the larynx is reflected to the eye of the operator. The patient\\nis made to phonate a or ee, not ah, and then to respire.\\nThe various structures and the action of the cords are observed. The\\nappearances of the mucous membrane are studied during quiet respira-\\ntion.\\nThe epiglottis is very dependent, so that often the larynx can only\\nbe seen by having the patient stand while the operator remains seated.\\nThe patient s head is bowed on his chest and the examination proceeds.\\nThe first examination may not result satisfactorily, but little being\\nobserved on account of the spasm of the pharyngeal muscles. Re-\\npeated sittings may remove apprehension and accustom the mucous\\nmembrane to the presence of the instrument. This object may be\\nattained by administering bromides, or by applying cocaine to the\\npharynx.\\nThe probe is needed only to ascertain the consistency of tumors and\\ngrowths. Cocaine must be applied before it is used.\\nAppearance of the Larynx in Health. Fig. 115 shows the larynx\\nas it is seen in the laryngoscopic mirror. Above (upper part) is the\\narched epiglottis, below it the cavity of the larynx. In the centre are\\nthe vocal cords, white and glistening on each side of these the pink\\nfolds of the false cords. At the bottom of the mirror are the aryte-\\nnoid bodies, and between them the folds of the inter-arytenoid space.\\nBelow and outside the arytenoid bodies are the fossae. The mucous\\nmembrane is pink throughout except on the cords. In respiration\\nFig. 116. Fig. 117.\\nWmmi i k 9ir^\\nLaryngeal image during respiration. Laryngeal image during phonation.\\nthe arytenoids separate, carrying the ends of the cords which are\\nattached to them with them, and leaving a triangular opening the\\nglottis through which the rings of the trachea can be seen. (See Fig.\\n116.) In phonation the arytenoids approach each other, obliterating\\nthe inter-arytenoid space the inner edges of the cords come in con-\\ntact and close the glottis. (See Fig. 117.)", "height": "4416", "width": "2688", "jp2-path": "practicaltreatis00muss_0_0468.jp2"}, "469": {"fulltext": "THE NOSE AND LARYNX. 439\\nAppearance in Disease. A note must be made of the color of the\\nvarious parts, of the presence or absence of swelling, of ulceration, of\\nnew growths, and of alterations of the movements of the parts concerned\\nin phonation, particularly of the cartilages and the cords.\\nColor. The color is an indication of the degree of congestion.\\nAncemia of the larynx may be merely a part of a general anaemia from\\nany cause. In chlorosis it is seen before the external appearance is\\nmarked. An intense anamiia of the larynx is an early and valuable\\nsymptom of pulmonary tuberculosis. The mucous membrane is pale.\\nHypoxemia may be active or passive. It is readily recognized by\\nthe intense redness.\\nActive hyperemia occurs in acute laryngitis, either of the primary\\nor secondary forms.\\nPassive hyperemia occurs in general obstruction to the circulation,\\nas emphysema or valvular lesions pressure on veins by tumors\\nforced expiration and holding the breath hi paroxysmal cough, espe-\\ncially whooping-cough. Active hyperemias lead to catarrhs, passive\\nto oedema.\\nSwelling and Infiltration. Swelling of the epiglottis and of the\\naryteno-epiglottidian folds is seen in oedematous laryngitis, in acute,\\nsubmucous, and chronic laryngitis. In oedema of the glottis the swell-\\ning is below the vocal cords. The swelling may be circumscribed\\nand undergo suppuration. Swelling and oedema is also seen in peri-\\nchondritis.\\nTuberculosis. Swelling and infiltration succeeds the primary\\nansemia or catarrh of the first stage of laryngeal tuberculosis. At first\\nthere is slight intumescences of tubercular infiltration, not well out-\\nlined, and gray in color. They are most frequently found in the inter-\\narytenoid space, less often on the false cords and arytenoid cartilages,\\nrarely on the epiglottis.\\n1. A hill-like prominence between the arytenoid cartilages either in\\nthe middle or on one side. In phonation it presses between the cords.\\n2. When a false cord is affected the whole of it is usually infiltrated,\\nforming a tumor-like sAyelling which often hides the vocal cords.\\n3. Vocal cords. Usually only one cord is at first affected. It is\\nthickened and the free border is red. Sometimes the free edge seems\\nsplit. The infiltration may extend to the subcordal region and cause\\na hypoglottic laryngitis.\\n4. Epiglottis. Infiltration of the epiglottis is rarer than oedema\\nafter ulceration, and care must be taken not to confound these condi-\\ntions. The whole epiglottis, or only portions of it, may be affected.\\nIt is thickened and curled upon itself, and not freely movable.\\n5. Arytenoid cartilages. They appear enlarged and puffy, and often\\nfixed from perichondritis.\\nSyphilis. In syphilis w T e have three forms of swelling\\n1. Mucous Patches. These are flat elevations of 3 to 7 mm. diam-\\neter, oval or circular, and of a whitish-gray color. When the epithe-\\nlium is lost they appear yellow and purulent. There is no tendency\\nto ulceration, and the patches soon disappear, even without treatment.\\nThey occur usually from three to nine months after the infection.", "height": "4408", "width": "2688", "jp2-path": "practicaltreatis00muss_0_0469.jp2"}, "470": {"fulltext": "440 SPECIAL DIAGNOSIS.\\n2. Infiltrations. Usually these are overlooked, as they produce no\\nsymptoms. They are diffuse thickenings in various parts of the larynx,\\nmost often on the epiglottis. This may be uniformly thickened or\\nonly in part around the edge. The cords may be so swollen as to cause\\ndyspnoea. Usually an ulcerated spot is seen in the centre of the infil-\\ntration. The mucous membrane is either normal or reddened. Infil-\\ntrations appear three to four or more years after infection.\\n3. Gummata. They appear as round prominences of the same color\\nas the surrounding tissue. They occur on either side of the epiglottis,\\non the ary teno-epiglottic folds, often in the inter-arytenoid space, on\\nthe false cords, and on the under surface of the vocal cords. If they\\nbreak down, deep ulcers form, leading to extensive destruction of the\\nparts.\\nLupus. In lupus isolated or grouped nodes are seen flowing to-\\ngether into patches, situated on the epiglottis. The disease is usually\\npresent on the face or in the pharynx and mouth. In leprosy the\\nepiglottis is swollen, and nodes from the size of a pin-head to that of\\na pea are seen on the epiglottis, arytenoid bodies, and false cords.\\nFissures. Fissures and erosions are present in chronic laryngitis.\\nUlcers. Ulceration is seen in tuberculosis, syphilis, carcinoma, lep-\\nrosy, and lupus.\\nTuberculosis. Ulceration occurs in tuberculosis in the\\n1. Inter-arytenoid space. The mucous membranes are notched with\\nirregular projections. When the ulcer is visible it is irregular and of\\na dirty-gray color.\\n2. False cords. The ulcers are flat and aphthous, with a pale-white\\nbase and a membranous deposit. The mucous membrane sometimes\\nappears sieve-like.\\n3. Aryteno-epiglottic ligaments. The ulcers are superficial and run\\nlengthwise of the ligament.\\n4. Vocal cords. The ulcers are either on the upper surface or on\\nthe edge of the cords. The former are superficial and seldom destruc-\\ntive. Those on the edge are either small separate ulcers or long ones,\\naffecting the whole border. The circumscribed ulcers occur usually\\nat the posterior portion of the cord and on the processus vocalis. The\\nulcers of the whole border are often very destructive.\\n5. Epiglottis. Tubercular ulcers of the epiglottis occur only on its\\nlaryngeal side. They are either aphthous and superficial, or deep, and\\narise from the breaking down of previous infiltration. Sometimes\\ntubercles can be seen at the edge of the ulcers, but they are of no diag-\\nnostic value, as similar nodes are seen with non-tubercular ulcers. The\\nepiglottis is usually thickened and oedematous.\\nSyphilis. Syphilitic ulcers are circular, deep, with a sharp border\\nand inflammatory areola, and overlaid with a whitish-yellow deposit.\\nThey develop from an infiltration or a gumma, and not on an unchanged\\nsurface. Ulcers on the upper surface of the epiglottis are always\\nsyphilitic.\\nTumors Papilloma. The most common form of the benign\\ngrowth- is the papilloma. The growth may spring from the true or\\nfalse cords, the aryteno-epiglottic ligaments, rarely the posterior surface", "height": "4400", "width": "2664", "jp2-path": "practicaltreatis00muss_0_0470.jp2"}, "471": {"fulltext": "THE NOSE AND LARYNX. 441\\nof the epiglottis. The tumor has a broad base. There may only be\\none, or it may be multiple, and may vary in size from a split pea to a\\nwalnut. Three varieties are met with 1. Small warty growths,\\nusually on the cords, dark red in color, and seldom larger than a bean.\\n2. Groups of raised white papilla? on a broad base, also growing on the\\ncords. 3. Large, red, mulberry-shaped or caulifloAver-shaped growths,\\npartly villous, partly warty, which fill up the whole larynx.\\nFibroma. It appears as a hemispherical, pedunculated tumor of\\ndirty-white, reddish, or dark-red color, more or less dense in consist-\\nency. It is usually single, and grows most frequently from the cords.\\nWhen seen in its smallest size it is known as the singer s node. 7 It\\nmay be as large as a hazel-nut.\\nMalignant Tumors. In addition to the symptoms indicated in\\nbenign tumor, pain and hemorrhage occur. Both carcinoma and sar-\\ncoma are found the latter is very rare.\\nCarcinoma. The most common form is the epithelioma, although\\nthe medullary and scirrhus have been described. The epithelioma is\\nseen as a circumscribed, hemispherical, warty, or cauliflower-like forma-\\ntion, varying in size, or as a knotty infiltration projecting into the\\nlarynx. The medullary form is larger, soft and bloody, and rapidly\\nulcerates. Scirrhus is firm and hard. The structure of the larynx is\\ngradually invaded, with necroses of the tissues. Perichondritis and\\nabscess frequently ensue.\\nIn carcinoma of the cords two kinds of growth are seen.\\nIn the polypoid form the tumor develops on the cord like a warty\\ngrowth, sometimes papillary and of a reddish-gray color. In diffused\\ncancer of the cord the structures are red and knotty, and invade the\\nsurrounding tissue without distinct demarcation.\\nSarcoma. The tumor has a broad base, is shining in appearance,\\nand sometimes lobulated. Sometimes the structure is dark red or\\nyellow.\\nThe Epiglottis. The epiglottis is swollen and red in inflammation\\nof that structure, and may then be palpated with the finger.\\nSputum. The sputum from the larynx is generally scanty it is\\nnot frothy, and is colorless and transparent it is often discharged in\\nsmall globules it may be streaked with blood. Sometimes pseudo-\\nmembranes are coughed up. It is doubtful if purulent sputum ever\\ncomes from the larynx, excepting in cases of perichondritis in which\\nthe abscess bursts into the larynx. Laryngeal sputum is found in\\ncatarrh and malignant tumors. It is blood-streaked when the catarrh\\nis very intense, or after injuries.\\nFever. Fever is present in acute laryngitis and tuberculous ulcer-\\nation. It is high in acute laryngitis with stenosis in tuberculosis it\\nis of a hectic type.\\nAcute Laryngitis.\\nAcute laryngitis is an inflammation of the larynx, characterized by\\na sensation of fulness and dryness, with cough, hoarseness, and at times\\ndyspnoea. Several varieties are observed Simple acute laryngitis,", "height": "4416", "width": "2684", "jp2-path": "practicaltreatis00muss_0_0471.jp2"}, "472": {"fulltext": "442 SPECIAL DIAGNOSIS.\\nlaryngitis with great stenosis, laryngitis with membrane, laryngitis with\\nspasm.\\nIt is caused by exposure to cold or by the inhalation of acrid vapors.\\nOverstrain, as in singers, excessive use of the voice, particularly in the\\ncold air, may excite an attack. It may be symptomatic of the erup-\\ntive fevers, as measles or smallpox, or erysipelas. Its occurrence in\\nthe course of chronic diseases must be looked upon with alarm, partic-\\nularly in cases of Bright s disease, if dropsy is present in other situations.\\nThe attack begins with a feeling of chilliness, followed by fever of\\nvarying degree, but usually mild. The patient complains of a feeling\\nof pressure and dryness in the larynx, or as if a foreign body were\\npresent. Some pain gradually develops in the height of the attack,\\nnever so severe as to require an anodyne. From the first there is\\ncough. It is dry and hacking, and slightly painful. In the more\\nintense forms the cough is continuous, disturbing the patient night and\\nday. Paroxysms occur when the patient speaks or takes food. First\\nthe cough is dry within a short time it becomes moist, and expecto-\\nration of clear, transparent mucus takes place. The mucus may be\\ntinged with blood. At the end of forty-eight hours expectoration be-\\ncomes more yellowish and opaque. The voice may be merely hoarse,\\nor may be lost entirely. Sometimes aphonia without general symp-\\ntoms occurs in acute laryngitis. In laryngitis sicca cough and dyspnoea\\noccur in paroxysms and are not relieved until a dry secretion is coughed\\nup. The paroxysms take place at night or in the early morning, and\\nmay cause retching and vomiting. It is seen in adults.\\nAcute Laryngitis with Stenosis No doubt some of the cases of\\nso-called membranous croup in children are cases of acute laryngitis,\\nwith swelling and occlusion of the glottis by congestion and by tough\\nsecretion. OEdema may or may not be present. The attack begins\\nwith catarrhal symptoms. The child is languid, refuses to eat, is\\nthirsty and has some chilliness and rise of temperature. With the\\nslight cough, which may be shrill, there are hoarseness and some\\ndifficulty in breathing, but no pain on swallowing. On the second\\nday, or after the lapse of four or five days, during which time mild\\nfever continues, the catarrhal symptoms become more marked. The\\nvoice is more hoarse or may be suppressed. The harsh, clanging\\ncough becomes toneless, and soon the sound is suppressed. Dyspnoea\\nis most severe, and the aspirations are hurried and noisy, attended by\\nloud whistling inspiration, and snoring expiration. The stenosis is\\ninspiratory, and during the day or in the succeeding twenty-four hours\\nmay become very intense. It is attended with violent efforts at breath-\\ning and the occurrence of cyanosis in its most aggravated form. The\\nlarynx moves up and down, the head is thrown back. TJiere is reces-\\nsion at the root of the neck and along the margins of the ribs and the\\nepigastrium. The lower portion of the sternum may be drawn in.\\nDuskiness of the extremities and of the lips is observed as the stenosis\\nbecomes more marked, finally deepening into cyanosis. It may be\\nrelieved from time to time by removal of the obstruction, which occurs\\nafter cough, vomiting, or change of position. A paroxysm soon recurs.\\nWith each paroxysm lividity becomes more and more marked, the res-", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0472.jp2"}, "473": {"fulltext": "THE NOSE AND LARYNX. 443\\npirations continued hurried. The face becomes pale, the extremities\\ncold, and a cold sweat bathes the brow. Restlessness is characteristic.\\nThe child tosses about in the bed or from the bed 10 the arms of the\\nnurse. The heart s action is increased each hour in frequency as the\\nstenosis advances, and becomes weaker. As exhaustion ensues and\\nthe symptoms of obstruction become more marked, stupor deepening\\ninto unconsciousness develops. Convulsions may occur at the end.\\nThe attacks rarely recur if the patient once recovers. They follow\\nexposure to cold.\\nIf recovery takes place, the child usually becomes more free from\\ndyspnoea, the cyanosis fades, and the restlessness disappears. A pro-\\nlonged sleep follows relief, although the voice may remain hoarse or\\nsuppressed, and the cough continue many days.\\nLaryngeal Diphtheria. The same symptoms are seen in mem-\\nbranous croup and laryngeal diphtheria. In the latter affection there\\nmay be a history of exposure or of infection. At the commencement\\nof the attack the diphtheritic patches may be seen in the fauces or\\nnares. If a membrane can be secured and a bacteriological examina-\\ntion made, the diagnosis of diphtheria with stenosis is positive. En-\\nlarged glands in the neck, with marked physical depression, a mod-\\nerate degree or entire absence of fever, and the occurrence of early\\nalbuminuria, also point to diphtheria. The distinction between the\\ntwo affections is nevertheless quite difficult, and as long as there is a\\nshadow of doubt, for prophylactic reasons the case should be consid-\\nered one of diphtheria.\\nAcute Laryngitis, with Spasm. False Croup or Spasmodic\\nLaryngitis. In children, in addition, another form of laryngitis asso-\\nciated with spasm of the larynx is seen. The catarrhal symptoms\\nare mild, so that the child seems to be well during the day. Fever\\nis absent, and a slight cough or huskiness alone calls attention to the\\nlarynx. After the first three or four hours of quiet sleep the child\\nsuddenly awakes with a barking cough, sits up and struggles for breath.\\nThe dyspnoea continues from a few minutes to an hour or so, gradually\\nlessening, to disappear entirely as the child lapses into sleep. Through-\\nout the next day the child seems as well as on the previous day, and\\nthe succeeding night is again seized with another attack of croup.\\nThis may occur once or twice during the night. It seems to be influ-\\nenced by the weather. Damp days and an east wind are provocative\\nof an attack. It recurs frequently during the same season.\\n(Edema of the Larynx.\\nThis condition arises in the course of acute laryngitis frequently\\noccurs in chronic diseases of the larynx, particularly if ulceration is\\npresent and as a complication of erysipelas and diphtheria. In some\\ncases of Bright s disease it may develop suddenly.\\nIn the course of the above-mentioned disease symptoms of laryngeal\\nstenosis may occur suddenly. The voice becomes husky and sup-\\npressed, the dyspnoea is very extreme, so that in a few hours grave\\nsymptoms of obstruction arise. There is no cough. The patient com-\\nplains of the sensation of a foreign body, and tries to grasp it.", "height": "4416", "width": "2688", "jp2-path": "practicaltreatis00muss_0_0473.jp2"}, "474": {"fulltext": "444\\nSPECIAL DIAGNOSIS.\\nThe Diagnosis of Acute Diseases of the Larynx.\\nAcute affections of the larynx are distinguished from other diseases\\nwithout much difficulty. To recognize the various forms of acute\\nlaryngitis, however, is not easy. In all there is laryngeal stenosis to\\na certain degree, and practically the question to answer is, Which form\\nof stenosis is present The accompanying table shows the differential\\npoints for diagnosis. It is seen that the age, occurrence of previous\\nattacks, the character of the general symptoms, the existence of pre-\\nvious laryngeal disease, the association of faucial disease, the presence\\nor absence of membrane, and the results of laryngoscopic examination\\nmust be considered before making a positive diagnosis.\\nSimple Acute Laryngitis. Catarrh of\\nLarynx.\\nGradual onset of laryngitis, with dyspnoea\\nvery slight or absent.\\nAll ages.\\nFever of varying degree.\\nDry irritating cough.\\nMay be hoarseness.\\nPharynx reddened.\\nGradual increase and decline.\\nLarynx red and slightly swollen, as seen\\nby laryngoscope.\\nAcute Laryngitis with Spasm. Spasmodic\\nCroup.\\nMay be slight hoarseness or cough, or\\nnone. Suddenly, in night, child wakes\\nwith intense dyspnoea and crowing in-\\nspiration.\\nChildren.\\nTemporary high fever.\\nSlight brassy cough during day.\\nMay be slight hoarseness in day. Very\\nhoarse in attack.\\nLasts a few minutes to one hour. May\\nrecur, or no attack until next night.\\nSlight redness, or nothing seen by laryngo-\\nscope.\\n(Edema of Larynx.\\nSome inflammatory disease of larynx exists.\\nRapid development of dyspnoea, increasing\\nto great severity.\\nAll ages.\\nDepends on cause.\\nNo cough.\\nNo hoarseness.\\nIncreases steadily to climax, then death,\\nor decline of dyspnoea.\\nEpiglottis and aryteno- epiglottic folds\\nswollen, pale, and waxy.\\nAcute Laryngitis with Stenosis.\\nGradual onset of laryngitis, but dyspnoea\\ndevelops to great severity.\\nChildren.\\nFever of varying degree.\\nDry cough, often paroxysmal.\\nHoarseness.\\nPharynx reddened.\\nGradual increase, and either death of\\npatient or decline of dyspnoea.\\nSame, but swelling much greater.\\nLaryngismus Stridulus. u Child-crowing.\\nNo laryngitis. Sudden attacks of dyspnoea\\nwith crowing inspiration, either day or\\nnight. Very severe. May be general\\nconvulsions.\\nChildren or hysterical adults.\\nNo fever.\\nNo cough.\\nNo hoarseness.\\nOccurs often in rhachitic and hysterical\\ncases.\\nEnds suddenly, in at most two minutes,\\nand occurs often.\\nNothing seen in larynx.\\nMembranous Laryngitis. Croup\\nDiphtheria.\\nEpidemic.\\nGradually developing hoarseness and\\ncroupy cough, with low fever and lassi-\\ntude, then development of dyspnoea,\\ngradually and without intermission, as\\na rule.\\nChildren\\nLow fever and depression.\\nCroupy cough, later suppressed.\\nVery hoarse.\\nFauces red and often with membrane\\nalbuminuria paralysis.\\nIncreases steadily, broken by intense par-\\noxysms. Either death or gradual im-\\nprovement.\\nRed, swollen, with membrane.", "height": "4408", "width": "2656", "jp2-path": "practicaltreatis00muss_0_0474.jp2"}, "475": {"fulltext": "THE NOSE AND LARYNX. 445\\nForeign Bodies. Pertussis. Whooping-cough.\\nDuring eating or while holding object in Epidemic,\\nmouth sudden dyspnoea, varying in in-\\ntensity according to object.\\nAll ages.\\nNo fever.\\nIrritative, expulsive cough.\\nMay be hoarseness or not.\\nCough persists till removal of body, or\\noccasionally the larynx becomes accus-\\ntomed to its presence, and cough ceases.\\nSee the foreign body.\\nBronchitis, with cough developing in from\\none to three weeks. Then dyspnoea\\ncaused by severe paroxysm of coughing\\nabsent between them.\\nChildren.\\nOnly the fever due to bronchitis\\nIntense paroxysm of coughing.\\nNo hoarseness.\\nHemorrhages in various places from strain\\nor emphysema.\\nMay be death from exhaustion, or gradual\\nimprovement.\\nNothing seen, unless slight laryngitis.\\nAcute Submucous Laryngitis. The inflammation extends to the\\nsubmucous cellular tissue. It arises in the course of acute laryngitis,\\nand is the form seen in traumatism, or from burns and scalds. The\\nsymptoms are those of intense laryngitis, with stridor. They increase\\nin severity until stenosis arises. If the under surface of the cords is\\naffected, death will occur from asphyxia. Sometimes the inflamma-\\ntion is circumscribed and is followed by development of an abscess.\\nThe chronic form of submucous inflammation of the larynx is usually\\nseen in drunkards, and is recognized usually by the laryngoscopic\\nexamination. The symptoms are those of slight stenosis.\\nParalyses of the Laryngeal Muscles.\\nThey are divided for convenience into groups. The symptom is\\ndysphonia, which, with laryngoscopic appearances, leads to the recog-\\nnition of the paralysis.\\n1. Paralysis of the Tensors of the Cord. The crico-thyroid\\nmuscle is paralyzed the superior laryngeal nerve which supplies the\\nmuscle is concerned. The voice is deep and rough, and incapable of\\nproducing high tones. Usually, the whole nerve is involved, and the\\nresult is anaesthesia of the larynx and paralysis of the epiglottis.\\nLaryngeal Examination. The epiglottis is fixed, and falls back\\nagainst the tongue. The glottis opening is a wavy line.\\nCausal disease. The condition described occurs almost exclusively\\nafter diphtheria.\\n2. Paralysis of the Closers of the Glottis, or Adductors of the\\nCords. The muscles involved are the crico-arytenoideus lateralis,\\narytenoideus transversus, and the thyro-arytenoideus internus and\\nexternus. The nerve is the recurrent laryngeal.\\nThe symptoms are complete aphonia, coming on suddenly, and often\\ndisappearing as suddenly.\\nLaryngeal Examination. During phonation the cords remain in the\\ninspiratory position. The paralysis may affect one or both sides.\\nSometimes the arytenoideus transversus alone may be affected. Then\\nthere is hoarseness or aphonia. The anterior portions of the cords\\ncome together in phonation, but the posterior portions do not, leaving\\na triangular opening posteriorly. (See Fig. 118.)", "height": "4416", "width": "2668", "jp2-path": "practicaltreatis00muss_0_0475.jp2"}, "476": {"fulltext": "446 SPECIAL DIAGNOSIS.\\nOr, the thyro-arytenoideus interims alone may be affected. There\\nis then dysphonia or aphonia, as before, bnt the cords come together\\nat both extremities and remain apart in the middle, forming an oval\\nopening. (See Fig. 119.)\\nFig. 118. Fig. 119.\\nParalysis of the arytenoideus transversus in Paralysis of the thyro-arytenoideus interims\\nphonation. (Gottstein.) in phonation. (Gottstein.)\\nCausal Disease. These paralyses occur in hysteria, catarrh, or severe\\noverstrain of the voice.\\n3. Paralysis of the Openers of the Glottis, or Abductors of the\\nCords. The muscle affected is the crico-arytenoideus posticus, and\\nthe nerve is the recurrent laryngeal.\\nSymptoms. When one side is affected the respiration is free, but there\\nis stridor or forced inspiration. The voice is harsh.\\nLaryngeal Examination. One cord remains in the middle line. (See\\nFig. 120.)\\nWhen both sides are affected there is gradually developing inspira-\\ntory dyspnoea with stridor. The voice is nearly normal.\\nFig. 120.\\nParalysis of the left recurrent nerve inspiration. (Gottstein.)\\nLaryngeal Examination. The glottis is a narrow cleft which be-\\ncomes still narrower on inspection.\\nComplete Paralysis of the Recurrent Laryngeal Nerve. Symp-\\ntoms. Unilateral Paralysis. A weak, toneless voice which breaks\\ninto a falsetto when the patient endeavors to speak loud.\\nLaryngeal Examination. The cord and arytenoid body are in the\\ncadaveric position viz., half-way between the phonating and the inspi-\\nratory positions. In phonation the other cord passes beyond the middle\\nline, and the glottis is slanting. The edge of the paralyzed cord is\\nexcavated.\\nBilateral Paralysis. Aphonia and inability to cough and ex-\\npectorate.", "height": "4416", "width": "2664", "jp2-path": "practicaltreatis00muss_0_0476.jp2"}, "477": {"fulltext": "THE NOSE AND LARYNX. 447\\nLaryngeal Examination. Both cords are in the cadaveric position\\nand their edges excavated.\\nThe adductors are usually paralyzed before the abductors, and one\\ncan see all the intermediate stages by close watching.\\nCausal Disease. The conditions which give rise to the paralysis\\nare numerous. It may arise from simple catarrh or from hysteria.\\nMore often it is due to pressure on the vagus or recurrent laryngeal, or\\nsome disease affecting these nerves or their roots.\\nThe causes of pressure are Aneurism of the subclavian or aorta,\\nmediastinal tumor, tubercular bronchial glands, the apex of a tuber-\\ncular lung, cancer of the oesophagus, goitre, or carcinoma of the pleura.\\nThe diseases are Diphtheria, tumor, softening or hemorrhage into\\nthe brain, bulbar paralysis, neuritis, typhus, cholera, variola, articular\\nrheumatism, toxaemia sclerosis of the cord, progressive muscular\\natrophy, and paralytic dementia.\\nTumors of the Larynx.\\nBoth benign and malignant growths are seen. At first dysphonia\\nor aphonia takes place. The impairment of voice may continue for a\\nlong period of time before dyspnaia arises. This develops very gradu-\\nally, and in some few cases is attended by an irritative cough. The\\ngeneral symptoms are not marked in benign cases. In the malignant\\nforms they are pronounced, but characterized by the development of\\ncachexia later than in carcinoma elsewhere.\\nThe diagnosis of malignant disease of the larynx is based upon the\\nassociation of symptoms of laryngeal disease with pain, and with the\\ncharacteristic appearances found on inspection, on its occurring after\\nthe middle period of life, and lasting from six to nine months only,\\nwith the development of cachexia and emaciation without fever. En-\\nlargement of the cervical glands points to cancer. Simple and syph-\\nilitic perichondritis must be excluded.\\nTuberculosis of the Larynx.\\nThe existence of primary laryngeal tuberculosis is doubtful. It\\ncannot be proved clinically, and the majority of cases, at least, are\\nsecondary to tuberculosis of the lungs. The manifestations of tuber-\\nculosis of the larynx may be either a simple persistent catarrh, an in-\\nfiltration, or an ulceration. (See pages 439 and 440.) The symptoms\\nvary according to the lesion.\\na. Catarrh. There is a slight hoarseness and the voice tires easily.\\nOften paresthesia or peculiar sensations in the larynx are present.\\nCough, when due to this alone and not to the process in the lungs, is\\nshort and dry.\\nb. Infiltration. At first the symptoms are those of simple\\ncatarrh, then the alteration of the voice increases even to aphonia\\nthere is a feeling of dryness or soreness in the larynx, and dysphagia.\\nThe cough is very slight and is usually wholly disguised by the cough\\ndue to the disease in the lungs. There is some difficulty in expecto-\\nration.", "height": "4416", "width": "2664", "jp2-path": "practicaltreatis00muss_0_0477.jp2"}, "478": {"fulltext": "448 SPECIAL DIAGNOSIS.\\nc. Ulceration. The symptoms are the same as those of infiltra-\\ntion, but the dysphagia and pain are greater.\\nDiagnosis. Tuberculous ulcer occurs most frequently in the male\\nsex, and during the period ranging from eighteen to thirty years of\\nage. If the symptoms develop in the course of phthisis, or in case\\nthat affection cannot be recognized, if there is a history of infection, or\\nexposure, and if bacilli are found in the sputum, the diagnosis is not\\ndifficult. A portion of the diseased mass may be removed for micro-\\nscopic examination or inoculation. In examining the secretion for\\ntubercle bacilli, it is to be remembered that the exudation may have\\nbeen brought up from the lungs. The examination in cases of phthisis\\nis of little practical value, except to determine whether the ulceration\\npresent may be syphilitic and grafted upon a tuberculous disease of the\\nlungs. Enlargement of the glands of the neck is often present, but is\\nnot diagnostic.\\nFever is present, and, indeed, may be an important diagnostic\\nfeature in doubtful cases. The temperature should be taken every two\\nhours, for the morning or evening exacerbations may not be present.\\nEmaciation ensues, and sooner or later the hectic phenomena and signs\\nof tuberculosis in other structures arise. When tuberculous ulceration\\nof the larynx occurs in the course of local pulmonary tuberculosis the\\ndisease runs a much more rapid course.\\nThe laryngeal symptoms are not diagnostic. Pain may be the most\\ndistinct. The appearances observed by the laryngoscope are more\\ncharacteristic. Local anaemia with paresthesia, paresis of the cords,\\nand short cough, or an obstinate diffuse catarrh, are suspicious symp-\\ntoms. The peculiar ridged infiltration between the arytenoids is\\nalmost invariably tubercular.\\nIsolated thickenings anywhere in the larynx that taper off gradu-\\nally into the normal tissue can only be tuberculous or syphilitic. The\\nregularity and number, Avith anaemia and lack of inflammatory signs,\\nwill usually distinguish the tuberculous from the syphilitic. The\\nulcers are non-erosive. Syphilitic ulcers do not often occur, except on\\nthe edge and lingual side of the epiglottis and on the cords. They\\nextend more rapidly than the tuberculous, and may be continuous with\\nulceration in the pharynx. The area of ulceration may extend to the\\nbase of the tongue, which is very infrequent in tuberculous disease.\\nIn syphilitic ulceration scars or cicatrices are seen, but they are absent\\nin the tuberculous form. Laryngoscopic examination in tuberculous\\nulceration is difficult, as it causes great pain in syphilis comparatively\\nlittle pain attends examination. (See the Infections.)\\nSyphilitic Affections of the Larynx.\\nMucous patches, papules, infiltrations, or gummata may be present\\nin the larynx for some time without exhibiting any symptoms. Usu-\\nally a change in the voice is the first symptom noticed, due either to\\nthe catarrh or to ulcers, scars, infiltrations, or gummata affecting the\\ncords. There is often a feeling of pressure or a tickling sensation.\\nPain is not usual, and, when present, is very slight. Dysphagia", "height": "4412", "width": "2640", "jp2-path": "practicaltreatis00muss_0_0478.jp2"}, "479": {"fulltext": "THE NOSE AND LARYNX. 449\\noccurs only when the epiglottis is extensively ulcerated. There is\\nlittle or no cough.\\nThe diagnosis rests upon the history of infection, the objective signs\\nof syphilis indicated by pigmentation or recent eruption, scars, perios-\\ntitis or nodes on the bone, and enlarged glands. The laryngeal symp-\\ntoms are not diagnostic, save that pain is absent in spite of extensive\\nulceration, while difficulty of deglutition, on account of food entering\\nthe larynx, is of frequent occurrence. The laryngoscopic appearances,\\nas indicated above, are characteristic of this affection. In obscure\\ncases the distinctions spoken of in tuberculosis are of diagnostic value.\\nAlthough the patient may be broken down and cachectic the febrile\\nrange is not high, unless perichondritis occurs, or pneumonia sets in,\\non account of food in the air-passages.\\nThe Larynx in Other Diseases.\\nLaryngeal symptoms due to lesions of the nervous system are found\\nunder the following circumstances. (See Cerebral Localization.)\\nCerebral Hemorrhage. 1. Aphasia. The movement of the\\nmuscles is normal, but they cannot be controlled by the will. Caused\\nby hemorrhage in the cortex or along the course of connective fibres.\\n2. Recurrent paralysis. Due to hemorrhage in the medulla.\\n3. Symptoms of bulbar paralysis. Same cause.\\nEncephalomalacia. (Softening.) When in the brain, aphasias\\nresult Avhen in the medulla, bulbar symptoms.\\nTumors of Cerebrum. The symptoms are, according to location,\\naphonia, aphasia, or paralysis of the cords.\\nBulbar Paralysis. We have, of course, the other symptoms of\\nthe disease. The voice becomes weak and monotonous without modu-\\nlation. High tones are impossible. It progresses to hoarseness and\\nfinally aphonia. Particles of food and drink enter the larynx. Paresis\\nor paralysis of the cords.\\nMultiple Sclerosis. The speech is low, uncertain, and scanning,\\nlater hoarse. Laughing and crying are accompanied by peculiar yawn-\\ning inspirations. Laryngoscopical examination Slight paresis of the\\ncords is seen.\\nPosterior Sclerosis (Tabes). The muscles act very slowly.\\nSometimes symptoms of irritation, as tickling or burning in the larynx,\\nwith a dry cough, occasionally severe paroxysms of coughing, even to\\nspasm of the larynx, occur. Laryngeal crises. In rare cases a\\nphonetic spasm has been observed. Less often paresis or paralyses of\\nthe various muscles occur, most frequently the posticus, next the\\nrecurrent. Sensibility may or may not be disturbed.\\nAmyotrophic Lateral Sclerosis. There is a mixture of bulbar\\nwith spinal symptoms. (See Sclerosis.)\\nProgressive Muscular Atrophy. The same mixture of symp-\\ntoms occurs very late.\\nParalytic Dementia. There may be disturbances in articula-\\ntion, with paresis and paralysis of the cords.\\nChorea. There may be a tremor of the cords from under-tension,\\nbut probably no true choreic movements.\\n29", "height": "4412", "width": "2660", "jp2-path": "practicaltreatis00muss_0_0479.jp2"}, "480": {"fulltext": "CHAPTER II.\\nDISEASES OF THE LUNGS AND PLEUE^E.\\nThe lungs are composed of a relatively small amount of tissue.\\nThey are made up of tubes and canals. The tissue which composes\\nthe structure of the lungs independently of the canals, the connective\\ntissue, is liable to the same morbid processes that affect it in other situ-\\nations. But, curiously, it is not often subjected to irritants which cause\\nacute inflammation, while chronic inflammations occur secondarily, in\\nthe large majority of cases, to processes in the channels. Diseases of\\nthe lungs are really the disease of its channels, and the symptoms that\\narise are due to morbid alterations of them (1) by processes common\\nto the structure of such channels and (2) by obstruction of them.\\nThere are three sets of channels First, for the passage of air second,\\nfor the flow of blood and, third, for the flow of lymph. The symp-\\ntoms, therefore, are due to the morbid process or to obstruction of the\\nchannels just mentioned.\\nPhysical Classification. The various affections of the lungs occur\\nwithout any change in the volume of air in the lungs, or are attended\\nby an increase or diminution in the amount of air.\\nI. Diseases with Normal Amount of Air.\\nAffections of the Bronchial Tubes, except Asthma.\\nII. Diseases with Increased Amount of Air.\\nEnlargement of the Chest. The enlargement with in-\\ncreased amount of air may be unilateral or bilateral. It\\nseems paradoxical that the more air there is in the thorax,\\nthe greater is the need for air, and hence the occurrence of\\ndyspnoea.\\n1. Asthma.\\n2. Emphysema.\\nIII. Diseases with Diminished Amount of Air.\\nA. The Consolidations. The consolidations may be local,\\nunilateral, or bilateral.\\n1. The congestions.\\n2. Pulmonary embolism and thrombosis.\\n3. Pneumonia.\\n4. Bronchopneumonia.\\n5. Chronic interstitial pneumonia.\\n6. Pulmonary tuberculosis.\\n7. Abscess of the lung.", "height": "4416", "width": "2664", "jp2-path": "practicaltreatis00muss_0_0480.jp2"}, "481": {"fulltext": "DISEASES OF THE LUNGS AND PLEURJE. 451\\n8. Gangrene of the king.\\n9. Collapse of the lnng.\\n10. Cancer and other new growths of the lnng.\\n11. Hydatid disease of the lnng.\\nB. Diseases of the Pleura.\\n1 Diminished amount of air from inhibition of movement,\\non account of pain.\\n2. Diminished amount of air from the physical condition\\nwithin the thorax.\\nThe Morbid Processes.\\nAffections of the lungs may be divided into the neuroses, the con-\\ngestions, the inflammations, the degenerations, the morbid growths and\\ngross parasites. Influences operating through the pneumogastric and\\nphrenic nerve may be responsible for respiratory neuroses. The con-\\ngestions are so intimately associated with vascular phenomena that the\\nlatter may be included in the process. The inflammations are limited\\nto the bronchi, to the alveoli, and to the connective tissues surround-\\ning both. The intimate relation of the small bronchi, the alveoli, and\\ntheir surrounding connective tissues implies their conjoint involvement\\nin many processes.\\nA. The Neuroses.\\nB. The Congestions.\\n1. Active, including hemorrhagic infarct.\\n2. Passive.\\nSubsidiary hemorrhage.\\nC. The inflammations, chiefly infectious.\\n1. The Bronchi.\\nAcute.\\nChronic.\\n2. Bronchi and alveoli.\\nBronchopneumonia (an infection).\\n3. Bronchi, alveoli, and connective tissue.\\nPneumonia.\\nTuberculosis.\\nAbscess of the lung.\\nGangrene.\\nChronic interstitial pneumonia pneumonokoniosis.\\nSyphilis of the lung.\\nD. The Degenerations.\\nEmphysema.\\nBronchial dilatation.\\nE. Morbid growths.\\nF. Gross Parasites.\\nHydatid disease.\\nSymptoms Due to the Morbid Process. The air-tubes are lined\\nwith mucous membrane, which is subject to morbid processes that\\nattend any such lining congestion, or acute and chronic inflammation", "height": "4408", "width": "2664", "jp2-path": "practicaltreatis00muss_0_0481.jp2"}, "482": {"fulltext": "452 SPECIAL DIAGNOSIS.\\nwith a flux as the characteristic symptom. The muscle and elastic\\ntissue of the canal become involved in the process. The former un-\\ndergoes spasm, with or without mucous membrane inflammation\\n(asthma). Grave consequences do not arise until degeneration takes\\nplace, then the power of confining the air or driving it out is lost,\\nand emphysema results.\\nIn the blood-canals, hyperemia (congestion), embolism and throm-\\nbosis, and secondary oedema take place in the lymph-canals, inflam-\\nmation (acute and chronic pleurisy), and transudation (hydrothorax or\\nhemothorax). Now, the symptoms that arise in each or all of the above\\nprocesses pain, local discomfort, mucous or purulent discharge, serous\\nor purulent exudation, and fever are not different from those which\\nare found in diseases of similar tissues in other localities. (Compare with\\naffections of mucous membranes in other organs or of serous membranes).\\nSymptoms Due to Obstruction of Channels. In addition to these,\\nhowever, there is a group of symptoms due to obstruction of the various\\nchannels, and hence, interference with the function of the lungs. The\\nsymptoms are purely mechanical.\\n1. Dyspnoea occurs from obstruction of either the bronchial tubes\\nor bloodvessels in addition to causes mentioned below. It is as pro-\\nnounced in asthma or capillary bronchitis as in embolic obstruction\\n(fat-embolism) or congestion and stasis in the bloodvessels. It occurs\\nwhen the canals are occluded by extrinsic causes foreign bodies in\\nthe bronchi or pleural effusions.\\n2. Cyanosis. As a sequence of the above symptoms we have\\nanother vivid picture the development of cyanosis from interference\\nwith aeration.\\nSymptoms Due to Altered Muscle or Nerve Mechanism.\\nOther structures (the bony thorax and its muscles) are required for\\nthe performance of the function of the lung, the aeration of blood.\\nOf these we have more particularly first, muscles, to hasten the\\nmovement of the air and, second, a nervous mechanism to control\\nthe movement of the muscles. 1. Inactivity of the former, from pain,\\nfrom debility, or from paralysis through disease of the nerves, practi-\\ncally occludes the canals, for the normal contents slacken or cease\\ntheir movement, and therefore the amount of air is lessened hence\\ndyspnoea. 2. The nervous mechanism not only controls the large\\nmuscles of the exterior, through a centre stimulated or depressed\\nby various influences, chiefly the blood, but also receives and sends\\nimpressions to the muscles of the tubes, giving rise to (a) cough\\nor (b) bronchial spasm with dyspnoea. This nervous mechanism by its\\ncentre of control is in relationship with higher and lower centres, and\\nthe nerve that connects it with the bronchial tubes supplies other organs\\nor anastomoses with other nerves. Hence, we may have A. A central\\naffection, causing pulmonic symptoms from the following causes 1.\\nBecause higher centres influence the lower pulmonary centre, as we see\\nin hysterical cough, or emotional cough, and in asthma respiratory\\nneuroses. 2. Disease affecting the region of the centre, as in tumor or\\nin bulbar or glosso-labio-laryngeal paralysis. 3. Irritants acting upon\\nthe centre, as urea, exciting ursemic asthma. B. An affection of the", "height": "4412", "width": "2640", "jp2-path": "practicaltreatis00muss_0_0482.jp2"}, "483": {"fulltext": "DISEASES OF THE LUNGS AND PLEUEJE. 453\\nnerve-trunk, as from the pressure of an aneurism or morbid growth.\\nC. Reflex influences through the pneumogastric and correlated nerves.\\nThe asthma of nasal disease, or of peripheral irritation, and reflex\\ncough (neuroses) are of this nature. Corollary Lung symptoms, chiefly\\ndyspnoea and cough, may be due to local causes (affections of the mus-\\ncles), or to causes at a distance, operating directly through the pneu-\\nmogastric centre, or the nerve-trunk, or by anastomoses in a reflex\\nmanner. The practical deduction is to look further than the lungs in\\nthe investigation of pulmonic symptoms. Lung symptoms are not\\noften expressive of disease in other parts, nor are diseases of the lungs\\nsymptomatic of disease in other organs.\\nAffections of the Pleura. In diseases of the pleura, one side is\\nusually affected. Simple inflammation and inflammation with exuda-\\ntion into the pleural cavity occur. In both forms there is diminution\\nof movement, and hence less air entering the affected lung, although\\nthe cause is different in each case. In acute inflammation, the dimin-\\nished amount of air is for physiological reasons the movement of the\\naffected side is inhibited by pain hence diminution of expansion and\\nlessened ingress and egress of air. Enfeeblement of breath-sounds and\\nfremitus, with diminished expansion, alone indicate the diminution.\\nOn the other hand, in acute inflammation with exudation, the amount\\nof air is diminished for physical reasons. The effusion encroaches\\nupon and causes diminution of the air-space, and hence lessens the\\namount of air. It Avill be remembered that the physical signs of dimi-\\nnution in the amount of air from effusion are quite distinct from the\\nphysical signs due to consolidation.\\nThe Lungs and Heaet. The relationship of the pulmonary vas-\\ncular channels to the remainder of the circulation is very close. Over-\\nfilling of the pulmonic bloodvessels, and hence dyspnoea, may be due\\nto alterations or changes in the central pump, the heart or in the\\nvessels between\u00e2\u0080\u0094 as from the pressure of an aneurism. The nature\\nand importance of lung symptoms cannot be appreciated without an\\ninvestigation of the heart and the blood-ways. Many pulmonic con-\\ngestions are due to dilatation of the heart, and are relieved by digitalis.\\nAt the other end of the beam, it may be noted that lung diseases cause\\nheart disease from backward pressure of blood-columns in over-\\ndistended vessels, a dilated right heart follows.\\nSpace forbids tracing out the effects of the blocking of channels, but\\nit is suggestive that all the aeration of the body takes place through\\nthe first set of tubes, that all the blood of the body passes through the\\nsecond, and that the third is an enormous drainage-area of lymph.\\nThe student can readily appreciate how profoundly diseases of the\\nlungs must affect the general system. Apart from the nerves, the tie\\nthat binds the other organs to them is the blood. In proportion as the\\nlungs enrich them with oxygen, the other organs act with vigor. Im-\\nperfect oxygenation soon causes diminution of all function, with the\\nsecondary effect on the blood of the production of ancemia, which, with\\nits long train of symptoms, is seen in all chronic lung affections.\\nRelative Value of Subjective and Objective Symptoms. The\\nsubjective symptoms are few, and, as will be seen later, are common", "height": "4416", "width": "2656", "jp2-path": "practicaltreatis00muss_0_0483.jp2"}, "484": {"fulltext": "454 SPECIAL DIAGNOSIS.\\nto so many pulmonary diseases that they are of little diagnostic value.\\nThe objective symptoms are more decisive, and the laws of physics as\\napplied to the lungs aid in the distinction. The effect of the occlusion\\nof channels is mechanical or physical, and hence a physical change in\\nthe lung follows. The objective symptoms occur (1) because of the\\nphysiological movement of air. Sound attends the movement of air\\nin health if the air-movement is checked, no sounds occur, or abnor-\\nmal breath-sounds and new sounds (rales) are created. They also\\noccur (2) because of physical changes in the structure. Air is replaced\\nby solid structure the physical condition of the lung changes. The\\nobjective signs of these conditions are determined by inspection, palpa-\\ntion, percussion, and auscultation.\\nDiagnosis. The diagnosis of disease of the lungs is attained by the\\ncollection and consideration of data obtained both by inquiry and by\\nobservation. By observation the objective phenomena are secured,\\nfirst, by physical examination second, by an examination of the\\nsputum and, third, by an examination of the fluids secured by punc-\\nture.\\nIt is not usually difficult to distinguish diseases of the lungs from\\naffections of other structures. It is true, pleurisy and pleurodynia are\\noften distinguished with difficulty. We are called upon, also, to decide\\nbetween pleurisy and subdiaphragmatic inflammation, a pleural and\\nhepatic inflammation, a pleuritis and pericardial inflammation, and\\nbetween cardiac and pulmonary disease, especially when both are pres-\\nent and it is desirable to determine which is the primary affection.\\nThe contiguous relations of the organs make this necessary, and with\\ncare in ascertaining the history and the subjective and objective symp-\\ntoms the distinction may not be difficult.\\nIn chronic disease, affections of the lungs, of the mediastinum, and\\nof the great vessels must be distinguished from one another. An\\naneurism or mediastinal disease may simulate chronic phthisis.\\nInfections. It often happens in a pulmonary disease that some of its\\npronounced symptoms may strongly point to an infection other than\\nthat of the lungs thus the cerebral symptoms of pneumonia may be\\nheld to be due to meningitis, or the fever thought to be due to typhoid\\nfever. On the other hand, the presence of a pulmonary affection, as\\ntuberculosis, may explain the nature of the morbid process in other\\norgans or structures. Hence, in all cases in which there is a possibility\\nof secondary tuberculosis the lungs should be examined to determine if\\nthey are the seat of the primary disease. In this way the true nature\\nof a meningitis, a peritonitis, or other tubercular affection may be recog-\\nnized. So, too, in secondary anaemia and in protracted debility of un-\\nknown source the lungs should be examined. It must be borne in\\nmind also that in chronic diseases, as chronic renal disease, chronic\\narthritis, diabetes, etc., pulmonary tuberculosis may set in most insidi-\\nously. In the same class of diseases pneumonia is frequently a ter-\\nminal infection, and likewise runs an insidious course. Finally, in\\nthe extremes of life pulmonary infections, as pneumonia, present symp-\\ntom- out of the usual run. In infancy and childhood the cerebral\\nsymptoms may mask the pulmonary symptoms in senility the ab-", "height": "4412", "width": "2672", "jp2-path": "practicaltreatis00muss_0_0484.jp2"}, "485": {"fulltext": "DISEASES OF THE LUNGS AND PLEURJE. 455\\nsence of cough or expectoration may lead to the dismissal of all thought\\nof pulmonary disease. In short, the lungs should be examined in all\\naffections.\\nThis injunction is particularly to be observed, as lung diseases are\\noften secondary to other diseases phthisis, to tuberculosis elsewhere,\\npneumonia or pleurisy to all infectious disorders, to Bright s disease,\\ncancer, and diabetes. Above all, the possibility of a hydro thorax,\\nsecondary to causes of transudations, must be borne in mind.\\nThe Data Obtained by Inquiry.\\nThe Social Histoey. A glance at the various processes which\\ntake place in the lungs readily lead one to infer the social history.\\nAge. In the earlier and later periods of life bacterial invasion is\\nmore likely to take place hence, at these extremes streptococcus and\\npneumococcus infections are common tuberculosis, on the other hand,\\nis more common in early adult life, although it does not respect age.\\nThe degenerations are more common later in life, as we may say of the\\nmorbid growths, both obeying the usual rules concerning the course of\\nthese processes. The sex. As the infections predominate and as one\\nat least is more liable to develop in those whose resistance is lessened,\\nit follows that tuberculosis is more frequently seen in the female sex.\\nThat sex which follows occupations compelling the inhalation of irri-\\ntating particles the male is more liable to have fibroid and other\\ninflammations of the lungs.\\nThe Occupation. From this we gather little of diagnostic value,\\nsave that the chronic inflammations are more prone to occur in those\\nwho inhale solid particles, as miners, stone-cutters, etc., while tubercu-\\nlosis attends those whose occupations are debilitating and require in-door\\nduties. Nor does a knowledge of the habits lend much aid save as\\nthey depress the system and render it more vulnerable to bacterial\\naction. It is needless to say clothing, exposure, residence, and the\\ndiet may be hygienic factors in the life of the patient. The amount\\nof exercise, etc., must be inquired into in each case.\\nInfections. It is readily seen, however, that the facts in the social\\nhistory of diagnostic importance are just those facts which are predis-\\nposing factors in many infectious disorders. Most lung diseases are,\\ntherefore, correlated in their antecedents with the infections. It must\\nbe borne in mind it is always well to trace the source of the infection if\\npossible.\\nThe Family Histoey. Heredity plays a serious part, and hence\\nthe family history should be sought for, particularly in the study of\\nthose affections which are of tuberculous origin. The tendency of this\\ninfection to follow in successive strains is well known. In like man-\\nner we inquire in cases of asthma and other neuroses for evidence of\\ntheir occurrence in previous generations a well-known clinical fact.\\nThen emphysematous changes seem to be a peculiarity of certain fam-\\nilies.\\nThe Occueeence of Peevious Diseases is to be inquired for.\\nPneumonia is likely to be followed by other attacks. Pleurisy is", "height": "4416", "width": "2664", "jp2-path": "practicaltreatis00muss_0_0485.jp2"}, "486": {"fulltext": "456 SPECIAL DIAGNOSIS.\\nrelated to, and may be an expression of rheumatism it may be pre-\\nceded by other rheumatic phenomena it may be the earliest expres-\\nsion of tuberculosis, and may precede the latter by two or more years,\\nan interval of health separating the two. Then it must be borne in\\nmind pulmonary tuberculosis may succeed a long antecedent joint or\\nglandular tuberculosis a history of which should be inquired for.\\nThe state of the circulation should be studied, and the occurrence of\\nprevious heart disease sought for. In affections of the pleura we must\\ninquire for previous infections and note the presence or absence of\\ndisease of contiguous structures, as the ribs and muscles of the chest\\nand the viscera below the diaphragm.\\nThe Subjective Symptoms. Dyspnoea. Dyspnoea, in its true\\nsense, means difficult breathing. The respirations are deeper than\\nnatural, but of normal frequency, or they may only be more frequent\\nthan they should be, or they may be both deeper and more frequent.\\nThe patient is usually conscious of suffering or of some distress in\\nbreathing. Lung disease without dyspnoea While a common, indeed\\nalmost constant symptom of lung disease, it does not follow that be-\\ncause a patient has extensive disease of the lung he need suffer from\\ndifficult or hurried breathing. This is because the system requires no\\nmore air than the capacity of the lung is able to supply. The change\\ntakes place very gradually, but many persons with chronic fibroid\\nphthisis, or with emphysema, in both of which the disease may be\\nextensive, may not have dyspnoea, unless an unusual demand is made\\nupon the system. The subjects are under-weight, move slowly, and\\notherwise show that they are deprived of an essential to active being.\\nVarieties of Dyspncea Depending upon Cause.\\nI. Anything which cuts off or lessens the normal amount of air re-\\nquired for oxygenation of the blood. A. Obstruction of the air-pas-\\nsages. B. Diminution of air-space from causes within and outside of\\nthe thorax. C. Interference with the action of the muscles concerned\\nin breathing.\\nII. Affections which lessen the amount of blood, as obstructive\\nheart disease. Rarely, tumors pressing upon the bloodvessels.\\nIII. Affections in which the red blood-corpuscles are diminished\\nanaemia.\\nIV. Pulmonary embolism and thrombosis. In cases of weak heart\\nthe vessels become occluded. After labor a clot of blood may escape\\nfrom a uterine sinus, be carried to the right heart, and thence to the\\npulmonic veins. The clot may arise from inflammation of the veins\\nin any situation.\\nV. Fat-embolism. Foreign substances in the blood, as fat, occur-\\nring in parturient women three or four days after labor, after frac-\\ntures, and in diabetes.\\nVI. Dyspnoea due to interference with the nervous mechanism of\\nrespiration, a. Tumor, hemorrhage, or degeneration about the respi-\\nratory centre in the medulla. 6. Irritation of the centre by toxic\\nagents, as in uraemia, diabetes, auto-intoxication from gastro-intestinal\\ndisorder. To this class belongs u heat dyspnoea/ which occurs in all\\nf eb rile conditions. The warm blood acts as a direct irritant to the", "height": "4416", "width": "2664", "jp2-path": "practicaltreatis00muss_0_0486.jp2"}, "487": {"fulltext": "DISEASES OF THE LUNGS AND PLEURAE. 457\\nrespiratory centre in the medulla oblongata (Landois). This explains\\nthe dyspnoea of fever and the curious fact pointed out by Cohnheim,\\nthat the respirations in pneumonia lessen as soon as the fever disap-\\npears, notwithstanding the persistence of the physical condition, which\\nmay have accounted for the dyspnoea. Reflex dyspnoea (asthma, q. v.)\\nbelongs to this variety. The dyspnoea of hysteria is of the same class.\\nAnything which cuts off or lessens the normal amount of air required\\nfor oxygenation of the blood causes more or less dyspnoea.\\nA. Obstruction of the Air-passages.\\n1. Occlusion of the nares, unless compensated by mouth-breathing.\\n2. Enlargement of the tonsils, retropharyngeal abscess, or any ob-\\nstruction in the throat, from diphtheritic or (Edematous swelling.\\n3. Disease of the larynx, causing stenosis, also causes a characteristic\\nform of dyspnoea known as inspiratory dyspnoea. (See Disease of the\\nLarynx.)\\n4. Obstruction of (a) the trachea or (6) the bronchus from external\\npressure or from a foreign body. It must be distinguished from\\ndyspnoea, the origin of which is higher up in the air-passages, by\\ncareful inspection.\\na. Tracheal Obstruction. In this form of dyspnoea there is no\\nincreased movement of the larynx. There is no change in the voice,\\nexcept that it may be weakened, and the sonorous quality diminished.\\nThe voice will be modified, however, if there is at the same time\\ndisease of the larynx from syphilis, or paralysis of the muscles\\nfrom pressure on the recurrent laryngeal nerves by the same cause as\\nthe tracheal stenosis. If so, on laryngoscopic examination the tumor\\npressing upon the larynx can be seen at times, especially if the larynx\\nis healthy.\\nExpert operators can secure quite an extensive view of the wind-\\npipe, particularly if the head is bent slightly forward and the patient\\nis seated in the upright posture. A mirror must then be placed\\nagainst the soft palate, with the surface more horizontal than usual.\\nBy this means an aneurism may be seen bulging into the trachea. It\\nmust not be mistaken for pulsation of the lower end of the trachea,\\ndue to transmission of the impulse of the aorta to the trachea, which\\nhas been shown to occur in healthy persons.\\nThe dyspnoea is expiratory, and is never so extreme as in laryngeal\\nstenosis. The lower ribs are therefore not sucked in during inspira-\\ntion until late in the disease. A stridor attends the dyspnoea, which is\\nheard with the stethoscope over the trachea, as well as over every part\\nof the chest. Sometimes a point over the trachea can be determined\\nat which the sound is heard loudest. The point may indicate the seat\\nof a stenosis. Sometimes the sound is more marked over the larynx\\nthan over the sternum, when the lower part of the trachea is obstructed.\\nDemme has pointed out that in cases of prolonged obstruction in the\\nlower air-passages the upper portion of the thorax may diminish in\\nsize. Not only is the dyspnoea constant, but paroxysms may take\\nplace in which the distress is very severe. These paroxysms of dysp-\\nnoea may be due to spasm of the vocal cords but it is very likely that\\nthey are due, as Bristowe has shown, to swelling of the mucous mem-", "height": "4416", "width": "2668", "jp2-path": "practicaltreatis00muss_0_0487.jp2"}, "488": {"fulltext": "458 SPECIAL DIAGNOSIS.\\nbrane, or to mucus which has accumulated at the point of obstruction\\nand cannot be dislodged, or to spasm of the muscular tissue of the\\ntrachea itself. In addition to the subjective symptom of want of breath\\nthe patient may complain of pain or oppression behind the sternum,\\nor possibly only of a slight soreness. Cough usually attends the dysp-\\nnoea, with expectoration of mucus. Sometimes the mucus is blood-\\ntinged, and even streaks of blood may be expectorated after a consid-\\nerable time, in cases of leaking aneurism.\\nIf the obstruction is due to a foreign body, the dyspnoea is of the\\nsame type, but occurs suddenly.\\nb. Bronchial Obstruction. Laryngeal movement is not in-\\ncreased and the voice is not changed. If a bronchus is obstructed,\\nthe lung of the unobstructed bronchus becomes the seat of emphysema.\\nWhen obstruction takes place gradually, compensatory emphysema\\noccurs, developing slowly, not rapidly as in the former instance, the\\ndegree depending upon the amount of obstruction in the opposite\\nbronchus. The physical signs over the lung of the obstructed bron-\\nchus are pronounced. The vesicular murmur is absent, the fremitus\\nis absent, the movement of the affected side is impaired. With these\\nchanges the percussion-sound is normal at first, although its limits are\\ninfluenced less by forced inspiration and expiration later, it progresses\\nfrom impaired resonance and dulness. As the case advances, the affected\\nside may fall in and measure less than the opposite side. A snoring or\\nwhistling sound may be heard over the root of the lung, between the\\nscapula and vertebrae, or moist rales may be present.\\nThe causes of tracheal and bronchial obstruction are (a) External\\npressure. First, tumor of the thyroid gland second, thoracic aneu-\\nrism third, mediastinal tumor from other causes than aneurism, as\\ndisease of the glands, cancerous or tubercular, or mediastinal abscess\\nfifth, cancer of the oesophagus; and, finally, in rare cases, a dilated\\nauricle, (b) Diseases of the walls of the trachea. They cause obstruc-\\ntion by narrowing the calibre. Syphilis is the most frequent cause of\\nsuch obstruction, (c) Foreign body. The presence of a foreign body\\nwithin the lumen causes obstruction. The foreign body may remain\\nfree for a time, moving up and down as the patient coughs, and, indeed,\\nit may be felt against the side of the trachea when the finger is placed\\noutside the neck. Later, the foreign body usually becomes fixed in the\\nright bronchus, or one of its main divisions, because the opening of\\nthe right bronchus is more direct than that of the left. In some in-\\nstances the body may be dislodged and fall into the opposite bronchus.\\nRarely it falls first into the left.\\nB. Diminution of the Air-space in the Lungs. All forms of\\npulmonary disease attended by consolidation, by compression of the\\nlung, or occlusion of the small bronchi, are included under this sub-\\ndivision. The degree of dyspnoea, of course, depends upon the extent\\nof the diminution in the air-space. In pleural effusions from any cause\\nthe air-space is lessened and dyspnoea occurs. In bilateral effusions it\\nis more marked than in unilateral. The severity of the dyspnoea de-\\npends somewhat upon the rapidity with which the effusion takes place.\\nIn cases of sudden effusion of air, as in pneumothorax, the dyspnoea is", "height": "4412", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0488.jp2"}, "489": {"fulltext": "DISEASES OF THE LUNGS AND PLEURJE. 459\\nvery alarming at first, but, as accommodation takes place, it is grad-\\nually relieved. In rapid effusion of sernm it is also serious.\\nThe characteristic form of dyspnoea due to lessened air-space is seen\\nwhen obstruction of the air-tubes takes place on account of spasm.\\nAsthma.\\nAsthma is a chronic disease caused by spasmodic narrowing of the\\nbronchial tubes, and characterized by paroxysmal attacks of dyspnoea,\\ndiminished respiratory movement of the chest, prolonged expiration,\\nattended by a wheezing sound and sibilant rales, and ending abruptly\\nwith the expectoration of tenacious mucus. The attack may be limited\\nto a single nighty or may be prolonged for days, with nocturnal exacer-\\nbations.\\nPremonitory symptoms are said to occur in about one-half the cases.\\nThese are for the most part nervous, such as headache, neuralgia, irri-\\ntability of temper, vertigo, drowsiness. Hyde Salter found that there\\nwere premonitory symptoms in 111 out of 226 cases collected by him.\\nIn 63 they were nervous, in 8 there was profuse diuresis, and in 14\\nthey were connected with the digestive system.\\nThe attack itself usually begins during sleep, and often at a regular\\ntime. It may, however, begin during the day, and at a certain hour,\\nindependently of sleep. The onset is manifested by tightness across\\nthe chest and more or less difficulty in breathing. This dyspnoea in-\\ncreases rapidly and often reaches an extreme degree. The face becomes\\npale and anxious, and may be covered with a cold perspiration the\\nlips are dusky from insufficient oxygenation of the blood. The patient\\nfeels smothered, and makes frantic efforts to get his breath, rushing to\\nan open window, no matter how cold the weather, or, if unable to\\nleave the bed, sitting up with the hands pressed upon the bed so as to\\ngive purchase to the accessory muscles of respiration. Notwithstand-\\ning that great respiratory efforts are made, the chest moves but little,\\nbecause the lungs are already distended to the extent of a full inspira-\\ntion. The patient is unable to expel the contained air, owing to the\\nspasm of the bronchial tubes.\\nThe frequency of respiration is diminished, sometimes to one-half\\nthe normal the rhythm is also altered, inspiration being short and\\ngasping, and followed without pause by expiration, which is much\\nprolonged and accompanied by a wheezing sound audible to bystanders.\\nThere is an increased amount of air in the thorax, and inability to\\nremove it. The chest is enlarged barrel-shaped the movement of\\nthe chest is lessened and strikingly out of proportion to the muscular\\nexertions. The diaphragm is lowered.\\nThe physical signs are hyper-resonance on percussion on ausculta-\\ntion, faint, short inspiration, prolonged expiration, and sibilant and\\nsonorous rales, more marked on expiration.\\nThe duration of an attack of asthma varies from half an hour to a\\nday or two. In patients with chronic bronchitis it may be prolonged\\nfor a week or two, with remissions during the day. It may subside\\nabruptly or by degrees.", "height": "4416", "width": "2644", "jp2-path": "practicaltreatis00muss_0_0489.jp2"}, "490": {"fulltext": "460 SPECIAL DIAGNOSIS.\\nSubsidence of an attack is marked by expectoration, the sputa having\\nspecial characteristics. (See under Sputum.) At first it is made up of\\nrounded gelatinous masses, which, when unfolded in water, are seen to\\nbe made up of spirals. Later it becomes mucopurulent.\\nCurshmann s spirals and the Charcot-Leyden crystals are. nearly\\nalways found. The leucocytes are increased, and 25 per cent, of them\\nare eosinophiles.\\nThe causative factors in asthma are various. About twice as many\\nmales as females are affected, and there is a marked hereditary ten-\\ndency in some families. There is probably some special peculiarity in\\nasthmatic patients, but just what it is has not been determined. It may\\nreside in the lungs, and may be part of a general constitutional irrita-\\nbility (Salter). Bronchitis, emphysema, and heart disease act as causes,\\nand so do syphilis, malarial poisoning, and chronic Bright s disease.\\nThe above description applies to that form of dyspnoea treated of\\nin the text-books as spasmodic asthma, a respiratory neurosis which\\nfor lack of knowledge is classified as a disease. Up to this time the\\ndyspnoea is paroxysmal. Sooner or later it becomes constant. When\\nthe dyspnoea associated with asthma becomes constant other changes\\nhave taken place in the lungs. First, there is persistent bronchitis\\nsecond, the presence of emphysema. Indeed, in many cases it is diffi-\\ncult to ascertain the exact sequence of affections. In emphysema of\\nthe lungs dyspnoea is constant, but, on exposure to cold or on account\\nof an attack of indigestion, more severe paroxysms may occur, as well\\nas asthmatic attacks, although the patient is not an asthmatic. On the\\nother hand, a patient may have had asthma for a number of years,\\nduring which attacks of dyspnoea occurred only in paroxysms. As\\ntime passes the paroxysms become more and more frequent, and\\nemphysema develops. With the advent of emphysema the dyspnoea\\nbecomes more constant.\\nAsthma, as above described, is a type of dyspnoea of nervous origin.\\nIt has just been said that it is due to spasm of the bronchial tubes.\\nThis may occur from a number of causes (a) It may be of central\\norigin, from irritation of the pneumogastric centre (b) it is just possi-\\nble that some disturbance of the trunk of the pneumogastric nerve will\\nalso cause asthmatic dyspnoea but what concerns us most is (c) the\\nparoxysmal dyspnoea which arises reflexly from irritation of the ter-\\nminal endings of the pneumogastric nerve, or of nerves intimately\\nassociated with the pneumogastric, in the medulla. (1) Disease in the\\nupper air-passages, as polyps, or a hypertrophy of the turbinated\\nbones, or adenoid growths, are the most frequent source of paroxysmal\\ndyspnoea. Not only in permanent disease of this character do we have\\nsuch dyspnoea, but temporary irritants applied to the nares likewise\\nproduce it. Various odors, the irritation of micro-organisms, or of\\npollen, or emanations from vegetable life, provoke attacks of nasal\\ncongestion and reflex dyspnoea. The irritation is propagated through\\nthe ethmoidal and posterior nasal branches of the nerve, the Vidian\\nand nasopalatine nerves, to the septum, and the anterior palatine to\\nthe middle and low turbinates. (2) Irritation in the fauces and larynx is\\nnot so likely to cause dyspnoea, yet there is no doubt that the presence", "height": "4408", "width": "2648", "jp2-path": "practicaltreatis00muss_0_0490.jp2"}, "491": {"fulltext": "DISEASES OF THE LUNGS AND PLEUB^E. 461\\nof a constant irritant in these situations tends to provoke, or keep in a\\nstate of excitability, the respiratory tract, so that asthma is more likely\\nto persist. (3) To this class of cases belongs the irritation of the terminal\\nbranches of the pneumogastric nerve in the stomach. Peptic asthma,\\nor the asthma of indigestion, may owe its origin to these causes. Often\\nthe irritation is central, due to the irritating influence of an abnormal\\nproduct of indigestion upon the respiratory centres in the medulla.\\n(4) For the same reason we have asthma due to other poisonous sub-\\nstances circulating in the blood, as the poison of uraemia. The dysp-\\nnoea due to this condition usually occurs in paroxysms, but may become\\nconstant. Sometimes it is the first intimation of the presence of renal\\ndisease. The dyspnoea of diabetic coma may occur from the same\\ncause. The nature of both is recognized more particularly by their\\nassociate symptoms. The condition of the urine, the odor of the\\nbreath, and the exhalations, the presence of hypertrophy of the heart\\nand of an accentuated second sound, point to a ursemic origin. The\\nhistory and symptoms of diabetes, the odor of acetone on the breath,\\nthe presence of sugar in the urine, the absence of organic pulmonary\\ndisease, point to diabetes. The dyspnoea of uraemia cannot be distin-\\nguished from other forms of dyspnoea, except by the exclusion of\\ncardiac and lung disease. It is often difficult to do this, because\\nuraemia so frequently develops after the hypertrophied heart has failed,\\nso that the physical signs of dilatation may be sufficient to explain the\\ndyspnoea. The dyspnoea of diabetic coma, known as air-hunger, is\\ncharacterized by slow and deep respirations. Cheyne-Stokes respira-\\ntion is due to the same cause namely, irritation in the medulla, as in\\nother forms of nervous dyspnoea. It must not be forgotten that the\\ndyspnoea of uraemia may present the Cheyne-Stokes phenomenon.\\nDiminution of Air-space from Extrapulmonary Causes.\\nAnything which crowds upon the thorax, interfering with pulmonary\\nexpansion, causes dyspnoea. This is notably the case in affections\\nbelow the diaphragm. Hence, in enlargements of the various organs\\nof the abdomen, as the liver, spleen, kidneys, pancreas (cystic disease),\\nand uterus, dyspnoea always occurs. In accumulations of gas (flatu-\\nlency), or of fluid (ascites), the diaphragm is pressed upward and\\nencroaches on the thoracic capacity. In abdominal tumor, as of the\\novary, the omentum, and of the organs above mentioned, dyspnoea is\\na distressing feature.\\n0. Interference with the Action of the Muscles. Practically\\nany derangement of the action of the respiratory muscles diminishes\\nthe air-space, as expansion of the lungs is interfered with. Neverthe-\\nless, the cause of the dyspnoea is extrapulmonary. It is due to weak-\\nness or paralysis of the muscles concerned in breathing, or to inhibi-\\ntion of their action on account of pain, or to interference with their\\naction on account of obesity, myxoedema, or oedema, or on account of\\nactual disease, as in trichinosis or myositis.\\n1. Phrenic dyspnoea is a peculiar form due to paresis of the phrenie\\nnerve and consequently to interference with the action of the diaphragm.\\nIt may not be observed as long as the patient is at rest. Upon slight\\nexertion the effort distresses him and causes an increase in frequency", "height": "4416", "width": "2652", "jp2-path": "practicaltreatis00muss_0_0491.jp2"}, "492": {"fulltext": "462 SPECIAL DIAGNOSIS.\\nof the respirations. After a few steps a sense of suffocation ensues,\\nor upon ascending an elevation the patient must stop frequently to\\ntake breath.\\nOther physiological processes are affected in phrenic dyspnoea. In\\nthe act of sighing the patient feels as though the abdominal organs\\nwere drawn up into the chest. Any straining effort, as defecation, is\\nrendered difficult. The voice is weak, and there is difficulty in cough-\\ning and sneezing, because a full inspiration cannot be taken. A slight\\nattack of bronchitis may be very serious on this account. On inspec-\\ntion during inspiration, instead of the natural expansion of the ribs and\\nchest, the epigastrium and the hypochondriac regions are drawn in.\\nDuring expiration they are pushed forward. The thoracic movements\\nare reversed. The abnormality may be detected on palpation with\\nboth hands below the cartilages of the ribs, even better than by inspec-\\ntion. Unilateral paralysis of the diaphragm causes drawing in of the\\ncorresponding hypochondriac region.\\nIn progressive muscular atrophy, in general lead-poisoning, and in\\nmultiple neuritis from other causes, paralysis of the diaphragm may\\ntake place. It is said to occur in hysteria, and Walshe states that he\\nhas seen it after diphtheria. In fatty degeneration of the diaphragm,\\non account of inflammation extending from the peritoneum to the pleura,\\nthe same phenomenon has been seen. It may occur in trichinosis.\\nParalysis of the diaphragm must be distinguished from inaction.\\nIf during the act of inspiration one or both hypochondriac regions are\\ndrawn in, it is diagnostic of inaction rather than of paralysis whereas\\nparalysis of the diaphragm is always accompanied by paralysis of other\\nmuscles.\\nDyspnoea due to paralysis of other respiratory muscles can be recog-\\nnized on careful inspection and palpation. The atrophied groups of\\nmuscles are readily observed. Electricity may aid in the diagnosis.\\n2. Pain inhibits muscular action. The source of the pain may be\\nin the pleura, the muscles, or the intercostal nerves. Frequently it is\\nbelow the diaphragm, as in peritonitis, hepatitis, etc., interfering with\\nthe action of that muscle. The dyspnoea that occurs from pain, as\\npleuritis, or inflammation of the chest-wall, is recognized by the posture\\nwhich is taken in order to relieve the affected side, by local tender-\\nness, and by the physical signs of pleurisy or of pleurodynia.\\nClinical Varieties. We observe whether dyspnoea is (a) influenced\\nby exertion (b) modified by the frequency of respiration or (c) by\\nthe respiratory rhythm and (d) is constant or paroxysmal.\\n(a) Influenced by Exertion. 1. Shortness of breath may be\\napparent on exertion only, as in cases of simple debility, or of inter-\\nference Avith respiratory action on account of obesity. It is the form\\nof shortness of breath seen in anaemia and in moderate cardiac debility.\\nIt may not be observed by the patient unless he walks hurriedly or\\nascends a flight of stairs. 2. Shortness of breath independent of exer-\\ntion is of more serious import, and is due to a number of causes. It\\nis the shortness of breath that is seen in severe cardiac and pulmonary\\ndisease. To the latter belong asthma and emphysema, bronchial ob-\\nt ruction, pulmonary consolidation and compressions (by effusions).", "height": "4412", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0492.jp2"}, "493": {"fulltext": "DISEASES OF THE LUNGS AND PLEUBM. 4G3\\n(b) The Frequency of Respiration. Dyspnoea varies clinically\\nin the frequency of the respiration. In its most extreme form it is\\nknown as orthopnoea, when the upright posture of the trunk is assumed.\\n(See Posture.)\\n1. Respiration Slow or Normal, a. Dyspnoea may be characterized\\nby deep inspirations, the frequency of respiration being less than nor-\\nmal. This is one of the forms of dyspnoea seen in diabetic coma\\nbreathlessness without dyspnoea. It is most characteristic, and\\nassociated with nausea, vomiting, and coma, while the breath and urine\\nsmell of acetone, b. The breathing may be slow and stertorous. Such\\nbreathing is likewise associated with coma, but the coma is of central\\norigin, due chiefly to apoplexy or tumor. It may be observed that\\nrespirations with dyspnoea are usually central or toxic.\\nToward the end of life the respirations, even though hurried before,\\nbecome slower from carbon dioxid intoxication.\\n2. Respirations Increased. The respirations may be hurried and\\ncreate distress in simple nervousness alone, and hurried respiration is\\nquite common in cases of hysteria. In the latter affection the frequent\\nbreathing is often attended by distress. The respirations are quick-\\nened, and are half the normal pulse-rate or even as frequent as the\\npulse. The term panting is applied to such respiration. The same\\ncharacter of breathing is seen in exophthalmic goitre. The rate of\\nrespiration is increased in all forms of dyspnoea upon exertion (see\\nabove), and in all forms due to heart or lung disease.\\n(c) The Rhythm. Alternately slower and shallower breathing, and\\nthen quicker as well as deeper, is seen in the peculiar form of breath-\\ning known as Cheyne-Stokes respiration. It includes a period of\\napnoea, with simultaneous alterations in the size of the pupils. (See\\nUraemia and Diseases of the Brain.)\\n(d) Dyspnoea may further be divided clinically into constant and\\nparoxysmal dyspnoea. Constant dyspnoea implies a persistence of the\\ncause. Paroxysmal dyspnoea does not include the form that is in-\\ncreased by exertion a form which in one sense may be paroxysmal.\\nIt is seen in its most typical form in asthma. It is often of cardiac\\norigin, but may be due to central or reflex causes. It occurs usually\\nat night. Constant dyspnoea is frequently subject to aggravations\\nparoxysmal in occurrence. Asthma is the type of true paroxysmal\\ndyspnoea.\\nDiagnosis. While dyspnoea is usually easy of recognition, it must\\nnot be forgotten that attacks of acute indigestion, with thoracic symp-\\ntoms of oppression, may simulate the oppression of dyspnoea. This\\nform of dyspnoea is temporary, however, and not associated with in-\\ncreased rapidity of respiration. Dyspnoea is recognized by increase in\\nrapidity of chest-movement, with increased action of all the muscles\\nof respiration, both the essential and the auxiliary muscles. At the\\nsame time the expression is characteristic. The alee nasi move, the\\neyes and countenance are indicative of more or less agony, the pupils\\nare dilated. As the dyspnoea continues cyanosis develops, and fre-\\nquently a cold sweat breaks out. This may be limited to the forehead\\nand face and to the extremities, or may become general. The hands", "height": "4416", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0493.jp2"}, "494": {"fulltext": "464 SPECIAL DIAGNOSIS.\\nand feet become cold. Stupor sets in, carpo-pedal spasm or general\\nconvulsions follow, the respirations become slower, and death takes\\nplace in coma or from heart-failure (asystole).\\nThe dyspnoea of emphysema is characteristic it is due to inability\\nto empty the chest of air {expiratory dyspnoea). The inspiration is\\nshort and quick the expiration is prolonged, and all the auxiliary\\nmuscles are called upon to complete the act. The powerful abdominal\\nmuscles are seen to contract vigorously, and thus aid in pressing up\\nthe diaphragm. The quadratus lumborum and serratus posticus supe-\\nrior et inferior draw down the ribs. The scaleni are strongly con-\\ntracted, the serratus magnus, latissimus dorsi, and the pectorales all\\naid in elevating the ribs. Knowledge of the processes involved in\\nforced expiration renders the diagnosis comparatively easy. The con-\\ntraction of the broad abdominal muscles confirms the diagnosis.\\nCough in Pulmonary Affections. (See Larynx.) Coughing is a\\nreflex act. A deep inspiration is taken, followed by closure of the\\nglottis, succeeded immediately by a sudden expiratory effort, during\\nwhich the glottis is opened, causing a loud sound with the forcible\\npassage of air outward, along with any substances in the air-vessels.\\nCauses. The pulmonic irritation, on account of which the act takes\\nplace, usually begins in the respiratory mucous membrane. The cough\\nis then used to expel accumulations of mucus or pus, or foreign sub-\\nstance. It occurs in all forms of bronchitis and in the lung affections\\ngenerally in which bronchitis is associated. The cough of phthisis, if\\nnot laryngeal, is due to a localized bronchial catarrh. Nodules outside\\nof the bronchi, situated in the lung substance, do not provoke the act\\nof coughing, as we see in the calcareous and fibrous nodules of healed\\ntuberculosis. The irritation is not limited to the mucous membrane\\nof the bronchial tubes, but occurs in the mucous membrane of any por-\\ntion of the respiratory tract. A foreign body of any kind in the\\nbronchus sets up cough. It is notably present in pharyngeal and\\nlaryngeal diseases. The cough of the latter is of peculiar character,\\nAvhich renders it easily distinguished from cough due to other causes.\\nIt must not be forgotten that the presence of an irritant does not\\nalways excite cough. Thus, when the sensibilities are obtunded, as\\nin typhoid fever, in disease of the brain, or in the last stages of any\\ndisease, the presence of mucus will not excite cough, and yet it is\\nknown to be in the trachea, on account of the rattling which takes\\nplace. In cases of phthisis sudden checking of the cough and expecto-\\nration, on account of weakness, is of bad prognosis and denotes ap-\\nproaching death. It is also a bad sign in pneumonia.\\nCentral and Reflex-cough. Cough may also occur from\\ncauses outside of the air-passages. It may be of centric origin. Kohts\\nhas found by experiment that irritation of the floor of the fourth ven-\\ntricle, above the centre for respiration, excites a cough. This centric\\norigin may possibly explain the cough of hysteria, and the short, bark-\\ning cough which arises in hysterical or nervous states, when the patient\\ni. afflicted with the idea that he is about to have hydrophobia. Irrita-\\ntion of nerves which are in anatomical relation with the pneumogastric\\nalso excites cough.", "height": "4412", "width": "2644", "jp2-path": "practicaltreatis00muss_0_0494.jp2"}, "495": {"fulltext": "DISEASES OF THE LUNGS AND PLEURAE. 465\\nEar-cough. The most characteristic cough of this form is that\\ndue to the presence of a foreign booty in the meatus of the ear, or to\\ndisease of that organ. It is sometimes difficult to examine the exter-\\nnal auditory meatus, because coughing is excited. The afferent nerve\\nwhich receives the irritation is the auriculotemporal branch of the\\nfifth nerve, according to Dr. Fox, and not the minute auricular twig\\nof the vagus.\\nTooth-cough. The same authority points out the occurrence of\\ncough from the irritation of the stump of a tooth, and refers to cough\\nin infants during the first dentition.\\nStomach-cough. The popular opinion that cough is very fre-\\nquently due to the stomach is not substantiated by the experiments\\nof Kohts. Nevertheless, Ave frequently observe cough in patients who\\nare suffering from mild gastric catarrh, the treatment of which relieves\\nthe cough. This is in all probability due to the fact that with the gas-\\ntritis there is a secondary pharyngitis, and, as the former is relieved,\\nthe latter, which causes the cough, disappears entirely.\\nIt will be seen, therefore, that when investigating the cause of a\\ncough in diseases in which this symptom is prominent, it is necessary\\nnot only to make examination of the respiratory tract throughout its\\ncourse, but also to examine the condition of the ears and the teeth,\\nand to bear in mind its possible centric origin.\\nClinical Characteristics. The cough may be dry or moist. A\\ndry cough occurs when there is an irremovable source of irritation\\n(see dry cough of laryngeal disease). It is seen in the first stage of\\nbronchitis. It occurs in the earlier stages of phthisis. As a short,\\nhacking, suppressed cough it occurs in pleurisy in the first stage. In\\nthe second stage it is superficial, as if the sound-waves were checked.\\nIt is characteristic and most familiar, although described with diffi-\\nculty. It is the best type of cough due to irritation outside of the\\nrespiratory tract. The ear-cough and tooth-cough partake of this char-\\nacter. In cases of emphysema the cough may be dry and unproduc-\\ntive for a long time, and only be relieved after a small pellet of tough\\nmucus is discharged. In the same category belong the nervous cough,\\nwhich is nothing but a bad habit; the cough of hysteria, and the cough\\nof a peculiar barking character that occurs at puberty, which Sir\\nAndrew Clark has described.\\nThe moist cough is attended by expectoration of a mucus, muco-\\npurulent, purulent, or bloody character, which is comparatively easily\\nremoved.\\nDry and moist or loose cough may be either constant or paroxysmal,\\nor both. Constant cough implies a persistence of the cause, which is\\nstrictly pulmonary, as in pleurisy, phthisis, bronchitis, and consolida-\\ntions generally paroxysmal, a recurrence of cause when pulmonary,\\nor a reflex or central cause.\\nUnder some circumstances the cough is almost constant. The irri-\\ntation is constantly present. A large amount of secretion is rapidly\\npoured out, keeping up a constant cough. This is seen in bronchorrhoea\\nand bronchial dilatation and in the later stages of tuberculosis. In\\nthese affections the moist cough may occur three or four times in\\n30", "height": "4408", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0495.jp2"}, "496": {"fulltext": "466 SPECIAL DIAGNOSIS.\\ntwenty-four hours, during which time an enormous amount of sputum\\nis thrown off. The cavity is thereby emptied, the accumulation of\\nmatter in which excites coughing only after a certain level is reached.\\nIn this affection the cough is further characterized by aggravation on\\nchange of position.\\nThe moist cough may occur in paroxysms only, each paroxysm being\\nrelieved by the removal of the irritation, the subsequent paroxysm\\nnot taking place until the irritating secretion has reaccumulated. In\\ncases of bronchitis of the second stage paroxysms of cough may occur\\nevery few hours, or the cough may take place once in the twenty-four\\nhours, usually in the morning on arising. The accumulated secretions\\nof the night are disposed of, and then the patient remains free from\\nannoyance. Paroxysmal coughs occur in cases of cavities, either of the\\nlung or of the pleura opening into the lung. Cough is excited when-\\never the cavity fills with secretion. The paroxysm may occur daily\\nor several times a day. The association with retching and vomiting\\nis of some diagnostic significance. It is seen not only in whooping-\\ncough, but also in phthisis. In pertussis the character of the cough is\\nof special diagnostic significance it occurs in paroxysms. The expira-\\ntory efforts are frequent and rapid, followed by a noisy, prolonged\\ninspiration, during which the characteristic whoop is created. At the\\nsame time the appearance of the countenance is marked. The face is\\ncyanosed, the eyes stare, the appearance of distress is most striking.\\nThe labored efforts at coughing frequently terminate in an attack of\\nretching or vomiting.\\nThe diagnostic significance of cough is estimated by the character\\nby the sound whether constant or paroxysmal by the frequency of\\nthe paroxysm by its development at particular times or under partic-\\nular circumstances, as on arising in the morning, or change to a cold\\natmosphere, or speaking, or upon movement, as in phthisis. By the\\nsound, laryngeal and bronchial, coughs are distinguished. The diag-\\nnostic value of cough further depends on a knowledge of its duration\\nand the character of the expectoration. (See Sputum.)\\nThe Sound. The character of the cough sound, however, is usually\\nmodified by the condition of the larynx, for which consult the section\\non Laryngeal Diseases.\\nHemorrhage. Hemorrhage of the lungs occurs from disease or\\nfrom rupture of adjacent bloodvessels into the air-passages. It is not\\nin itself a symptom of lung disease. A hemorrhage may be small in\\namount and continue over a considerable period of time, or it may be\\ncharacterized by a sudden profuse discharge, which at once terminates\\nthe life of the patient.\\nCause. A. Affections of the lungs.\\n1. Congestion of the lungs will lead to hemorrhage. The amount of\\nblood is small it may be limited to streaking of the expectoration, or\\na few mouthfuls may be discharged. In (a) organic heart disease this\\nform of hemorrhage is seen. It is also a characteristic feature of\\nthe first stage of (6) croupous pneumonia. The rusty-colored sputum\\nis due to the rupture of the capillaries. In (c) hemorrhagic infarcts", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0496.jp2"}, "497": {"fulltext": "DISEASES OF THE LUNGS AND PLEURA. 467\\nhemorrhage occurs, and is diagnostic if attended by the sudden forma-\\ntion of a consolidated area in the lung. In (d) phthisis it also occurs\\n(see below).\\n2. Tuberculosis. In tuberculosis hemorrhage may occur either\\nas the first symptom of the disease, on account of collateral conges-\\ntion around infiltrated areas, or (6) later, on account of ulceration of\\nan artery when excavation of the lung has taken place. In the early\\nstages the hemorrhage is usually profuse, but not fatal. It may\\noccur repeatedly during a series of weeks, excited, no doubt, by the\\nviolent non-productive cough which attends the earlier stages of this\\ndisease. In the later stages, when the vessels are ulcerated, the patient\\nmay have repeated hemorrhages, varying from a few ounces to half a\\npint or a pint. They may occur daily, or be repeated at intervals of\\na week or more for a long period of time. After the hemorrhages that\\noccur at long intervals the patient experiences much relief. Indeed,\\nthe dyspnoea, cough, and chest oppression subside in a remarkable\\ndegree, and the occurrence of another hemorrhage is often predicted\\nby a gradual recurrence of these symptoms. Death does not usually\\nensue on account of the large hemorrhage from phthisical ulceration,\\nand yet it may possibly take place. The writer has seen four instances\\nof hemorrhage into a large cavity, three with external hemorrhage,\\nwhich caused death instantly. Hemorrhage with the expectoration of\\ncalcareous masses recurs (c) frequently in patients with healed or qui-\\nescent tubercle.\\n3. Cancer. Hemorrhage recurring frequently is significant of can-\\ncer of the lungs, in the absence of other causes.\\n4. Plastic Bronchitis. It is of common occurrence in plastic bron-\\nchitis, when large bronchial casts are expelled.\\n5. Gangrene. In gangrene of the lung it frequently occurs, often\\ncausing death. The odor and sputum indicate the true nature of the\\nprimary lesion.\\nB. Disease outside of the respiratory tract. (1) Aneurismal disease\\nof the bloodvessels, which are in intimate relation with the trachea and\\nbronchus, frequently causes ulceration into these tubes, with hemor-\\nrhage. The hemorrhage is usually profuse and often induces sudden\\ndeath. Sometimes the profuse hemorrhage may be preceded for days\\nby small hemorrhages. The physical signs of aneurism are sufficient\\nto explain the cause. The bleeding can sometimes be seen in the\\ntrachea, when an aneurism of the innominate artery or the aorta presses\\nupon that tube. (2) In diseases of the heart it does not usually take\\nplace until the later stages of the disease, and is associated with second-\\nary congestion of the lungs. It may, however, be an early symptom\\nin mitral stenosis. The hemorrhages may amount onlv to staining of\\nthe sputum, or several times during the day an ounce or more of blood\\nmay be expectorated.\\nC. Affections of the blood or bloodvessels, with hemorrhages in\\nother portions of the body. Thus, it may occur in haemophilia, in\\npurpura, in scurvy, and in anaemia. It occurs in jaundice with hemor-\\nrhages in other situations.", "height": "4404", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0497.jp2"}, "498": {"fulltext": "468 SPECIAL DIAGNOSIS.\\nD. Gouty endarteritis. In the aged of both sexes, hemorrhages\\ntake place independently of disease of the heart or of the parenchyma\\nof the lungs. Sir Andrew Clark and others have spoken of these\\nhemorrhages and attributed them to gouty changes in the vessels as\\nwell as to degenerations of lung-tissue, on account of which the rap-\\nture took place.\\nE. Without known cause. In certain instances pulmonary hemor-\\nrhages occur in which it is quite difficult to find any cause for the dis-\\ncharge. It is quite common to see hemorrhage occur in females some-\\ntimes at the menopause, in other cases during menstruation, or, again,\\nperhaps vicariously, when menstruation does not occur. A number of\\ncases that have come under the writer s observation have had this ten-\\ndency for years without the development of pulmonary disease, and,\\napparently, without much influence on the general health. Indeed, it\\nmay be said that recurrent hemorrhage from the lungs in women, in\\nthe absence of organic disease, is not of grave significance.\\nThe Symptoms. The only symptom may be the presence of blood\\nhi the expectoration, or the discharge of a small amount of blood with\\nslight cough. In either instance, unless the patient s mental condition\\nis rendered obtuse by disease, the hemorrhage is alarming to him. He\\nis much perturbed, and there may be palpitation of the heart, besides\\nother nervous phenomena. Apart from the nervousness excited by\\nthe sight of blood, small hemorrhages, and even hemorrhages of mod-\\nerate amount, do not cause any other symptoms.\\nThe symptoms of a large hemorrhage depend upon the amount of\\nblood that is lost. They may amount to faintness and giddiness only,\\nAvith or without pallor. If more pronounced, syncope may take place\\nextreme pallor develops the pulse becomes rapid, small, and feeble\\nthe extremities are cold, and the face bathed in perspiration. If the\\npatient recovers from the syncope, he is extremely restless, sighing and\\nbreathing hurriedly. There may be some nausea. Moderate delirium\\nand mild febrile symptoms often follow the restlessness. If the hem-\\norrhages do not recur and the patient s fears are calmed, the color will\\ngradually return and the heart s action become stronger and slower.\\nThese symptoms occur whether the hemorrhage is due to disease of the\\nlungs or to aneurism rupturing into the bronchus. If the hemorrhages\\nare large, they differ somewhat in the two conditions. If a large aneu-\\nrism ruptures, the blood rapidly wells up into the throat and pours out\\nthrough the nostrils and mouth with great rapidity. With such hem-\\norrhage the end may come in a few minutes. In pulmonary hemor-\\nrhages the discharge is not so profuse, and is attended by coughing.\\nWith each cough blood is raised to the amount of a full mouthful at a\\ntime. The blood discharged from the lungs is bright in color, very\\nfrothy, being mixed with air. There are no clots in the discharged\\nfluid. The blood from an aneurism is also bright red, but is not frothy,\\nunless the discharge is very slow, and becomes mingled with air in the\\nvessels. In rare cases of pulmonary hemorrhage an abundant stream\\npours out, which is dark in color, free from clots, and not mixed with\\nair (large cavity).", "height": "4400", "width": "2652", "jp2-path": "practicaltreatis00muss_0_0498.jp2"}, "499": {"fulltext": "DISEASES OF THE LUNGS AND PLEURjE. 469\\nDiagnosis. Hemorrhage from the lungs must be distinguished from\\nhemorrhage from the upper air-passages, the mouth, the stomach, and\\noesophagus. Thus a discharge of blood from the mouth may occur\\nfrom cracks in the pharynx, or varicose veins. It is not abundant,\\nand the hemorrhage is mingled with mucus, which is streaked with\\nblood. Hemorrhage from the gums may be taken for pulmonary hem-\\norrhage, unless there is stomatitis, or inflammation of the gums from\\nscorbutus or ptyalism. In stomatitis its color is somewhat different. It\\nis thin, fluid blood, often offensive, of cherry-juice color. Hemorrhage\\nfrom the lungs is distinguished from hemorrhage from the stomach by\\nthe difference in the way in which it is discharged, and the difference\\nin the character of the blood. If from the stomach the blood is vom-\\nited. It is mixed with particles of food or other gastric contents. It\\nis dark in color, often of the appearance of coffee-grounds it is not\\nmixed with air, and hence is not frothy. The rapid hemorrhage from\\nulceration of an aneurism into the oesophagus, or rupture of varicose\\nveins at the lower end of the oesophagus, cannot be distinguished by\\nthe appearance from the hemorrhage of an aneurism which may have\\nruptured into a bronchus. The recognition is dependent upon the\\nphysical signs and the previous history of the patient s illness.\\nPain. Pain is rarely a symptom of disease of the lungs unless the\\npleura is involved. In a case of bronchitis there may be some sore-\\nness and oppression behind the sternum, but otherwise pain is absent.\\nIn pleurisy pain occurs before the exudation. It is sharp and lanci-\\nnating, and so severe as to impede respiration and cause the cough to\\nbe short and catchy. It is usually seated at the base of the chest, in\\nthe lateral or anterior region. It occurs when the patient attempts to\\ntake a full breath. Before the inspiratory excursion is half completed\\nit is checked involuntarily, on account of the pain. The patient s hand\\nis placed upon the affected part and he involuntarily leans to that side.\\nThe pain of pleurisy may be increased by local pressure, but general\\npressure, as from the whole hand, a broad bandage, or a large strap of\\nadhesive plaster, always gives relief. In the pleurisy that attends\\nphthisis pain is quite common. It is of the same character as the pain\\nof acute plastic pleurisy, but varies in situation and in degree. The\\npain occurs in paroxysms. It follows a slight exposure to cold, undue\\nexertion, or fatigue. It may continue for twenty-four hours, and dis-\\nappear until a repetition of the cause brings it on again. It must be\\ndistinguished from the myalgia of phthisis due to cough and exposure.\\nIn myalgia the muscles and fascia? at the bony attachments are very\\ntender.\\nThe pain of pleurisy must be distinguished from pleurodynia, from\\nintercostal neuralgia, and from the pain due to the disease of the ribs.\\nIn pleurodynia the muscles are sensitive if pressed between the fingers\\nor palpated. An enlarged area is affected, but physical signs of pleu-\\nrisy or pneumonia cannot be elicited. Cough is absent, and so, usu-\\nally, is fever. It is associated with pain in other muscular or fibrous\\nstructures. There may be a previous history of exposure to cold and\\ndampness. Usually there is a history of lithaemia or frequent myalgia.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0499.jp2"}, "500": {"fulltext": "470 SPECIAL DIAGNOSIS.\\nIntercostal neuralgia is sometimes difficult to distinguish. The pain\\nis sharp, localized, and may modify the movements of the chest. Gen-\\neral pressure relieves it local pressure at the points where the termi-\\nnal filaments of the nerve come to the surface may increase it. The\\nso-called Valleix s tender points are, however, not always present in\\ncases of intercostal neuralgia. The patient is usually anaemic, often\\nthe subject of uterine or other exhausting disease, and may suffer from\\nneuralgia in other situations. Cough and physical signs are absent.\\nFracture of the rib, or caries of the rib, may be recognized by the local\\ntenderness and by the signs of these conditions. Localized pleurisy\\nmay attend both, however indicated by more severe pain on cough\\nor full breathing. Caries or fracture is determined by pressure upon\\nthe diseased rib, which elicits the crepitus of fracture. An empyema\\nthat is about to point will cause pain in some area of the chest. The\\npain is usually seated at the points of election for the discharge of the\\nempyema, and is soon followed by swelling, with heat and redness of\\nthe skin, and the occurrence of oedema.\\nMore or less constant pain at the apices, undoubtedly independent\\nof affections of the muscles, is a suspicious sign of tuberculous disease\\nin that situation. It may be aggravated by pressure.\\nThe Data Obtained by Observation.\\nThe Objective Symptoms. By physical examination of the lungs\\nwe ascertain (1) their degree of activity (movement) (2) the physical\\ncondition of their parts subjected to examination but the disease is not\\ndiagnosticated. If abnormal signs are detected, they simply indicate\\nan abnormal condition of the part, which condition may be clue to any\\nnumber of diseases. As the lungs in health contain air, any physical\\nchange that takes place causes either an increase or a diminution in the\\namount of air. This may be general (bilateral), or limited to one side\\n(unilateral), or to a smaller area (local). In examining the lungs we\\nmight be content to answer the question, Is there an increased or a\\ndiminished amount of air in the parts suspected to be the seat of dis-\\nease A correct answer to this question, and to an inquiry as to the\\ncase of the increase or diminution, would explain any abnormal phys-\\nical condition. The answer is determined by percussion. Fortunately,\\nhowever, we have as adjuncts the phenomena that can be elicited by\\nmeans of inspection, palpation, and auscultation. These methods of\\nexamination depend upon the movements of the lungs and the sounds\\nproduced in breathing and speaking.\\nValue of Inspection and Palpation. Too much emphasis has\\nbeen laid in the past on auscultation and percussion in the study of\\nlung diseases. It is the habit to rely too much on these methods, to\\nthe exclusion of the simpler and quite as valuable methods inspection\\nand palpation. The latter have been employed for a long time in the\\nstudy of the objective phenomena of disease. The former are com-\\nparatively modern methods, and have required special cultivation of\\nsenses not usually employed in observation, in addition to exhaustive", "height": "4416", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0500.jp2"}, "501": {"fulltext": "DISEASES OF THE LUNGS AND PLEUBJS. 47 1\\ncomparative research, to put the findings on an accurate basis.\\nNaturally, they have been given undue prominence as methods of\\ndiagnosis. The pernicious habit of examining the patient without\\nremoving the clothing, either from haste upon the part of the physician\\nor false modesty upon the part of the patient, has unfortunately also\\nled to the neglect of inspection and palpation. It is proper to\\ninsist that the data obtained by inspection and palpation are as\\nimportant and valuable as those obtained by other means. They are\\neven more suggestive or diagnostic of physical conditions. The phe-\\nnomena observed are more positive and surrounded by fewer qualifica-\\ntions.\\nThe Regions of the Chest. For the purpose of bearing in mind\\nthe relations of the organs to the surface of the chest, and the localiza-\\ntion and proper recording of the seat of the disease, the chest is divided\\ninto regions. The regions correspond to anatomical points on the sur-\\nface of the chest, and are subdivided by transverse and vertical lines.\\nKnowledge of the landmarks which indicate on the surface the position\\nof the parts underneath is of great importance in diagnosis. The\\nregions in the anterior portions of the chest are The supraclavicular\\nregion, above the clavicle the infraclavicular region, below the clavi-\\ncle, extending to the third rib the mammary region, from the third\\nto the sixth rib. In the axilla two regions suffice\u00e2\u0080\u0094 the upper and\\nlower the position of the disease being more definitely determined by\\nassociation with ribs and interspaces. Posteriorly the regions are\\nthe suprascapular, above the scapula the scapular region, and the\\ninfrascapular region the region between the scapula and the spine is\\nknown as the interscapular region. The vertical lines are to the\\nright and left of the median line (1) The parasternal line, which is\\ndrawn downward midway between the edge of the sternum and\\nthe second line, which is (2) the mid-clavicular line, drawn from the\\nmiddle of the clavicle, generally passing through the nipple in males\\n(3) the anterior axillary line, drawn from the anterior fold of the\\naxilla (4) the mid-axillary line, from the centre of the axilla (5)\\nthe posterior axillary line, from the posterior fold of the axilla. In\\nthe back one line is sufficient the scapular line, drawn through the\\nangle of the scapula when the arm is at rest at the side of the patient.\\nFor transverse lines the ribs and interspaces are used. In this way\\nthe exact location of a diseased area can be indicated. In order that\\naccuracy may attend its localization, knowledge of the methods of\\ndetermining the landmarks, and especially of counting the ribs, is\\nessential.\\nThe Angles of the Thorax. The costal angle is the angle of\\nthe rib. It varies during the act of respiration. In inspiration the\\nrib rises as the sternum projects, and apparently elongates the angles\\nbecome more obtuse in expiration the sternum falls, the ribs become\\nmore slanting, and the angle is more acute.\\nThe epigastric angle. This angle is formed by the convergence of\\nthe ribs of both sides to the xiphoid cartilage of the sternum. On in-\\nspiration it is obtuse, increasing as the ribs rise in expiration it is\\nmore acute.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0501.jp2"}, "502": {"fulltext": "472 SPECIAL DIAGNOSIS.\\nMethod of Counting Ribs and Interspaces. The first rib\\ncorresponds to the clavicle the first interspace is the region between\\nthe clavicle, or first rib, and the second rib the subsequent number\\nof an interspace corresponds to the number of the rib above it. The\\nfollowing, from Holden, is of great importance to remember, particu-\\nlarly when the ribs of fat persons are counted\\na. The finger passed down from the top of the sternum soon comes\\nto a transverse projection, slight, but always to be felt, at the junction\\nof the first Avith the second bone of the sternum. This corresponds\\nwith the middle of the cartilage of the second rib.\\nb. The nipple of the male is placed in the great majority of cases\\nbetween the fourth and fifth ribs, about three-quarters of an inch ex-\\nternal to their cartilages.\\nc. The lower external border of the pectoralis major corresponds\\nwith the direction of the fifth rib.\\nd. A line drawn horizontally from the nipple round the chest cuts\\nthe sixth intercostal space midway between the sternum and the spine.\\nThis is a useful rule for localization in tapping the chest.\\ne. When the arm is raised the highest visible digitation of the serra-\\ntus magnus corresponds with the sixth rib. The digitations below\\nthis correspond respectively with the seventh and eighth ribs.\\nThe scapula lies on the ribs from the second to the seventh, inclu-\\nsive.\\ng. The eleventh and twelfth ribs can be felt, even in corpulent\\npersons, outside the erector spina?, sloping downward.\\nh. One should remember the fact that the sternal end of each rib is\\non a lower level than its corresponding vertebra. For instance, a line\\ndrawn horizontally backward from the middle of the third costal car-\\ntilage, at its junction with the sternum, to the spine, would touch the\\nbody, not of the third dorsal vertebra but of the sixth. Again, the\\nend of the sternum would be at about the level of the tenth dorsal\\nvertebra. Much latitude must be allowed here for variations in the\\nlength of the sternum, especially in women.\\nIt is important to recognize the relation of the ribs to the vertebrae.\\nThe first rib articulates with the first dorsal vertebra, which can be\\nlocated by the position of the prominent spine of the seventh cervical\\nvertebra even in very fat people this prominence can be recognized.\\nThe remaining ribs, except the tenth, eleventh, and twelfth, have\\nfacets of articulation on two vertebra? as the second rib, with the\\nfirst and second thoracic vertebra?. The eleventh and twelfth articu-\\nlate with the eleventh and twelfth thoracic vertebra?.\\nTopographical Anatomy. The following anatomical points are\\nworthy of remembrance\\nThe top of the sternum is on a plane with the lower border of the\\nsecond dorsal vertebra behind. The junction of the first and second\\nportions of the sternum is known as the angle of Ludwig. It is oppo-\\nsite the middle of the second rib, and is on a plane with the lower\\nborder of the fourth dorsal vertebra. The junction of the body of the\\nsternum to the xiphoid cartilage is on a plane with the lower border of\\nthe eighth dorsal vertebra.", "height": "4416", "width": "2656", "jp2-path": "practicaltreatis00muss_0_0502.jp2"}, "503": {"fulltext": "", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0503.jp2"}, "504": {"fulltext": "PLATE XIII.\\nFig. 1. Anterior Aspect.\\nFig. 2. Posterior Aspect.\\nSituation of the Viscera.\\nJut lines of heart and vessels-broad red lines. Margins of lungs and oi individual lobes-dotted green lines.\\nLimits of pleural sacs-solid green lines. Liver-red shading. Stomach-green shading.\\n(In part after His-Spalteholz and Luschka.)", "height": "4384", "width": "2644", "jp2-path": "practicaltreatis00muss_0_0504.jp2"}, "505": {"fulltext": "", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0505.jp2"}, "506": {"fulltext": "PLATE XIV.\\nFig. 1. Right Lateral Aspect.\\nFig. 2. Left Lateral Aspect.\\nSituation of the Viscera.\\nMargins of lungs and of individual lobes dotted green lines. Limits of pleural sacs solid green lines.\\nLiver and srjleen solid red lines. Diaphram dotted red lines. Stomach (portion not\\ncovered by lung) green shading. (In part after Luschka.)", "height": "4416", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0506.jp2"}, "507": {"fulltext": "DISEASES OE THE LUNGS AND PLEURAE. 473\\nThe apex of the diaphragm is on a level with the eighth dorsal ver-\\ntebra.\\nThe trachea bifurcates at the plane which includes the angle of Lud-\\nwig and the fourth dorsal vertebra.\\nPurulent effusions in the left pleural sac frequently point at the\\nfifth interspace, beneath the nipple, because this is the weakest point\\nof the chest-covering. A little external to the inferior angle of the\\nscapula and the eighth and ninth interspaces a similar weak point is\\nfound.\\nLimits of the Lungs. The apices of the lungs reach three to\\nseven centimetres (one and one-fifth to two and three-quarter inches)\\nabove the clavicles in front behind they rise as high as a line drawn\\ntransversely through the spinous process of the seventh cervical verte-\\nbra. The lower anterior margin of the right lung, when the chest is\\npassive, commences at the insertion of the sixth rib into the sternum,\\nand runs parallel with the upper border of the sixth rib to the axillary\\nline. At this point it descends to the upper margin of the seventh rib.\\nOn the left side the lower limit extends as far downward as the right.\\nPosteriorly both lungs reach to the tenth rib. With full inspiration\\nthe lungs descend both in front and behind almost the extent of one\\ninterspace, while in deepest expiration they are elevated almost to the\\noriginal position. The u complemental space of Gerhardt is the space\\nat the lower margin of the lung, and at the point at which the left lung\\noverlaps the heart, in which, during expiration, the surfaces of the\\nvisceral and parietal pleura come together. In inspiration the thin\\nlayer of the lung in both situations insinuates itself into this space.\\nThe heart interferes with the extension of the left lung. The space\\nis triangular in shape, extending in the median line from the fourth to\\nthe sixth rib. The left edge of the triangular area corresponds to the\\nedge of the left lung, which, notched for the heart, diverges from the\\nmedian line and runs along the cartilage of the fourth rib.\\nPosition of the Lobes. Plates XIII. and XIV. illustrate the\\nposition of the lobes of the lungs. In the right lung the upper lobe\\nin front extends to the fourth rib, in inspiration laterally to the third,\\nand behind to the spine of the scapula. The lower lobe begins with\\nthe spine of the scapula and extends to the tenth rib behind, and from\\nthe fourth to the tenth ribs, when fully expanded, in the axillary\\nregion. The middle lobe is not seen behind it extends between the\\nthird and fourth ribs in the axillary region in inspiration. In front it\\nextends from the lower margin of the upper lobe to the sixth rib.\\nThe upper lobe of the left lung extends to the sixth rib in front and\\nto the fourth interspace at the side. Behind, a small portion extends\\nabove the spine of the scapula, while the lower lobe extends from the\\nspine of the scapula to the base of the lung behind. At the sides it\\nextends from the lowest limit of the upper lobe to the level of the\\neighth rib.\\nInspection. By inspection we learn (1) the appearance of the ex-\\nternal surface, (2) the shape and size, and (3) the movements of the\\nchest. The second indicates the capacity of the lungs the last, the", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0507.jp2"}, "508": {"fulltext": "474\\nSPECIAL DIAGNOSIS.\\ndegree of functional activity. The X-rays are also employed to con-\\nduct inspection.\\nMethods. The patient must be seated, if possible, in an easy\\nposition, with the light falling directly on the part or from the side.\\nHe should be viewed by the observer standing, first in front, then be-\\nhind, and also from the side. To observe the anterior portion it is\\noften well to stand behind the patient and look downward over the\\nshoulders. The arms should fall by the side the breathing should be\\nquiet and undisturbed by talking or unusual movements.\\nThe Skin and Subcutaneous Tissue. In health the normal\\ncovering should be supple, elastic, and of the color previously described.\\nIt is pale in ansemia and wasting diseases yellow in jaundice pig-\\nmented generally or locally from causes previously mentioned. It is\\nthe particular seat for the parasitic disease, tinea versicolor, and is the\\nseat of sudamina as well as other non-specific eruptions. The veins\\nover the surface of the chest should not be very distinct. They are\\ndistinct when there is interference with the circulation in the mediasti-\\nnum from the pressure of an aneurism or morbid growths obstructing\\nthe veins. They, along with the cervical veins, may also be enlarged\\nin dilatation of the right heart. The capillaries along the base of the\\nchest are often enlarged or more distinct than usual, and arranged in a\\nbow corresponding to the attachment of the diaphragm. This bow\\nis frequently seen in intrathoracic obstruction. CEdema or subcutane-\\nous emphysema occurs as indicated under general inspection. If there\\nis too much fat over the surface of the chest, the muscles may be want-\\ning in tone, and an estimation, therefore, of respiratory capacity cannot\\nbe made. Wasting of the fat and muscles is seen in phthisis, carci-\\nnoma, diabetes, muscular atrophy, and paralysis. The degree of soft-\\nFro. 121.\\nTransverse section of healthy adult chest upon level of sterno-xiphoid articulation.\\nCircumference 89 centimetres.\\nness of the ribs can be estimated in a measure by the undue depression\\nof the ribs at the costo-cartilaginous articulations, and at the base of", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0508.jp2"}, "509": {"fulltext": "DISEASES OF THE LUNGS AND PLEURjE.\\n475\\nthe chest (about the sixth rib), during the act of inspiration. It is an\\nindication of rickets. Rigidity of the thorax, equal to the senile fixa-\\ntion, occurs in some adults in middle life, and Roberts points out that\\nin young subjects it may be due to congenital syphilis.\\nThe Shape and Size of the Chest. We appreciate the shape of\\nthe chest in health by an estimation of the relations of the antero-pos-\\nFlG. 122.\\nTransverse section of healthy male adult chest. Semi-circumference, right side, 16% inches\\nleft side, 16% inches expansion, 3% inches. (Ward 6, Philadelphia Hospital.)\\nterior and the transverse diameters and by the shape of the transverse\\nsection of the chest. The latter is an ellipse, and has been described\\nFig. 123.\\nTransverse section of an infant s chest, aged nine months. A circle within shows the similarity.\\nas reniform (see Fig. 121). The antero-posterior diameter is about\\none-fourth less than the transverse. Measurement with the cyrtometer", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0509.jp2"}, "510": {"fulltext": "476 SPECIAL DIAGNOSIS.\\n(see Mensuration) verifies the result of inspection with mathematical\\nprecision. In children the transverse section is different. It is more\\ncircular, and the antero-posterior and transverse diameters are almost\\nequal. (See Fig. 123.) Marked deviations from such section, or in\\nthe relations of the diameters, are seen in abnormal types of chest.\\nIt is difficult to describe the shape of the chest in health. By re-\\npeated practice we readily form a judgment of the true shape. No\\nrule has been applied to the relation of the length of the chest to the\\nlength of the body, but it would seem that there is some such propor-\\ntion. (See Mensuration.) In health the chest should be symmetrical,\\nthe right side probably a little larger than the left. In the ideal chest\\nthe muscles of respiration should be well developed and there should\\nbe a moderate amount of subcutaneous fat. The sternum should pro-\\nject forward from above downward, and the portion joining the manu-\\nbrium and the gladiolus should be a little more prominent than the\\nother part. It is not unusual to see a clearly marked demarcation\\nbetween the upper and middle portions of the sternum, or an undue\\nprojection of one or more of the upper ribs, and some striking changes\\nabout the xiphoid cartilage, none of which are indications of disease.\\nThe xiphoid may be depressed, on account of which a crater form or\\nfunnel-shaped depression is seen (occupation). The tip of the cartilage\\nis sometimes drawn inward, but more frequently the reverse is noted.\\nThe Movements of the Chest. The frequency, the rhythm, the\\ndegree of expansion, and the so-called diaphragm-phenomena are\\nstudied. A complete respiratory act consists of two events, inspiration\\nand expiration. Inspiration is active expiration passive. The latter\\nact is a trifle longer than the former, as may be illustrated by the\\nfollowing proportion Insp. Exp. 5 6. A pause follows the act\\nof expiration. The chest increases in circumference and in vertical\\nlength (descent of diaphragm) in inspiration as the lung expands with\\nair. The term expansion is applied to the result of inspiration its\\ndegree varies.\\nThe frequency and character of the movements in health vary in the\\ntwo sexes. The respirations are from 16 to 24 in the minute in a\\nhealthy adult. In the female they may be 20 to 22. In children the\\nfrequency of respiration is much greater under one year, 44 per\\nminute, and at five years 26. They are increased in frequency in the\\nstanding position. They are lessened in the horizontal position, in-\\ncreased during bodily exertion, with increased temperature of the air,\\nand during digestion. The hand placed on the epigastrium facilitates\\ncounting of the respirations.\\nThe movements of the chest in quiet breathing are more marked in\\nthe lower half in male adults, and thus the costo-abdominal or dia-\\nphragmatic type of breathing is seen. The sternum rises, the ribs are\\nelevated, and at the same time are drawn forward and outward. The\\nantero-posterior and vertical diameters increase. The costal angle and\\nepigastric angle become more obtuse. The diaphragm acts conjointly\\nwith the external muscles of the thorax, and, as it descends, the epi-\\ngastric region swells with each inspiratory effort. In expiration the", "height": "4408", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0510.jp2"}, "511": {"fulltext": "DISEASES OF THE LUNGS AND PLEUBJE. 477\\nsternum falls, the ribs become more slanting instead of horizontal, the\\nepigastrium retracts, the angles become acute. The antero-posterior\\nand transverse diameters lessen. The upper half of the chest moves\\nmore actively in women, and hence the costal or upper thoracic type of\\nbreathing is seen. The areas below the clavicles and the upper por-\\ntion above the sternum swell more distinctly during inspiration. The\\nmovements of the lower portion, and especially of the diaphragm, are\\nlimited.\\nThe costal type occurs most frequently in children. The type of\\nbreathing is costal in both sexes during sleep the same type is ob-\\nserved during deep respiration.\\nThe Diaphragm-phenomena (Litten). The diaphragm and walls of\\nthe thorax approach each other during expiration, and come in apposi-\\ntion at the end of this act. During inspiration they become separated.\\nIn persons whose chest-walls are not too thick the movements of the\\ndiaphragm are indicated on the surface by the rise and fall of a\\nshadowy line. The patient must lie on his back with his face from\\nthe light and head slightly elevated. The light should fall from\\nbehind. The observer stands a distance of three or four feet with his\\nback to the light. The chest is scanned at an angle of about forty-\\nfive degrees. In the act of inspiration a horizontal shadow or undula-\\ntion is seen to start on either side about the sixth interspace and\\npasses downward during inspiration over a distance of two or more\\ninterspaces, and even to the margin of the ribs. In expiration the\\nshadow begins below and moves upward to the starting-point.\\nAbsence of the phenomena is noted when there is fluid or air in the\\npleural cavity, when the pleural cavity is obliterated by adhesions,\\nwhen there is pneumonia of the lower lobe and in emphysema of the\\nlungs, and intrathoracic tumors low down in the chest. Tumors or\\nfluid accumulations below the diaphragm do not lessen the phe-\\nnomena.\\nBy this phenomena the volume or vital capacity of the lungs can be\\nestimated. In normal individuals the shadow should move more than\\ntwo and a half inches. If there is lessening of the extent of move-\\nment the respiratory capacity is diminished. In this manner tubercu-\\nlosis may be suspected. Limitation of the excursion of the diaphragm\\nX-ray investigations have forcibly taught us is one of the earliest\\nsigns of tuberculosis. This limited excursion can be detected in proper\\nsubjects by Litten s method, although it must be remembered that\\ngeneral debility and emphysema lessen the excursion on both sides.\\nIn splenic and hepatic enlargements the normal shadow continues, but\\nin a large collection of ascitic fluid it may be detected with difficulty,\\nor may be absent.\\nThe Shape and Size of the Chest in Disease. The chest may\\nbe enlarged or diminished in size. Such change may be general or\\nbilateral, unilateral or local.\\nGeneral or Bilateral Changes in Shape. Enlargement The\\nu barrel-shaped chest, the type of bilateral enlargement of the chest,\\nis seen in health Avhen it is in the state of full inspiration. All the", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0511.jp2"}, "512": {"fulltext": "478\\nSPECIAL DIAGNOSIS.\\ndiameters are increased, particularly the anteroposterior the length\\nis shortened. The diameters are almost equal, and the transverse sec-\\ntion approaches a circle. This occurs because in all figures of fixed\\nlength, in order that the area may be increased, a change to a circular\\nform must take place. (See Figs. 125 and 126.) The ribs are ele-\\nvated and almost horizontal, the epigastric angle is obtuse. The ster-\\nnum and the spine are arched the former at the angle of Ludwig.\\nThe shoulders are rounded and elevated, and the scapula? lie flat against\\nthe thorax. All the muscles of respiration stand out prominently, the\\nFig. 124.\\nEmphysema with enlargement of the chest. The antero-posterior diameter is much increased.\\n(Ward 6, Philadelphia Hospital.)\\nneck and upper trunk muscles particularly. The individual with\\nbilateral enlargement of the chest presents a striking appearance. The\\nneck is short, the arms are short there is undue fulness above the", "height": "4412", "width": "2684", "jp2-path": "practicaltreatis00muss_0_0512.jp2"}, "513": {"fulltext": "DISEASES OF THE LUNGS AND PLEURA.\\n479\\nclavicles. As this enlargement is attended with dyspnoea, the face is\\ndrawn and anxious, and the lips usually faintly livid, or purple.\\nFig. 125.\\nBilateral enlargement of emphysema.\\nInner line emphysematous chest.\\nOuter line a circle drawn to show how nearly the emphysematous\\napproaches the circular shape.\\nDotted line natural adult chest.\\nA dual measurement in centimetres.\\nCircumference\\nTransverse\\nAntero-posterior\\nnatural 89.0\\n29.6\\n22.25\\nemphysematous, 87.75.\\n27.25.\\n25.4.\\n-(Dr. Gee.)\\nThe movement of the chest in bilateral enlargement. Expansion is\\nlessened. The respiratory capacity is diminished. The chest is in a\\nstate of full inspiration, and the attendant dyspnoea is known as expi-\\nratory dyspnoea. The respirations are hurried, the inspirations short,\\nfollowed by prolonged expiration. While the expansion of the chest\\nin health extends over an area of three or four inches, when the chest\\nis bilaterally enlarged it may be lessened to one and a half inches, or\\neven be as low as half an inch. Both the costal and the diaphragmatic\\ntypes of breathing are seen in a state of exaggeration. In men the\\ndiaphragm acts very vigorously at times. Expiration is three or four\\ntimes as long as inspiration.\\nCause. The increase in size is due to enlargement of the normal\\ncontents of the chest or to the presence of abnormal contents. In\\nnearly all cases it is due to an increased amount of air within the\\nthorax (normal contents), as in emphysema. In a few instances en-\\nlargement of both sides is seen in cases of bilateral pleural effusion but,\\nas considerable effusion would be incompatible with life, the enlarge-\\nment from this cause is never very great. It is said that such enlarge-\\nment may occur in rapidly growing cancer of the lungs.", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0513.jp2"}, "514": {"fulltext": "480\\nSPECIAL DIAGNOSIS.\\nIt mast be remembered that emphysema can exist without bilateral\\nenlargement of the chest.\\nBilateral Diminution in Size. The type is seen in the so-called\\nphthisical or tuberculous chest. The chest is long, the antero-posterior\\ndiameter small (see Fig. 126), the transverse relatively very much in-\\ncreased. The angles are acute, the ribs are slanting, the epigastric\\nFig. 126.\\nThe flat oi phthisical chest, short antero-posterior, long transverse diameter. (Gee\\nangle is particularly sharp. The shoulders fall, and hence the scapulae\\nare prominent so marked in many cases that the term alar or\\nwinged chest has been given to it. The anterior plane is often\\nflattened, and hence the term flat chest is employed. This change\\noccurs because the curve in the cartilage of the true ribs becomes\\nstraight. The movement or expansion is lessened just as the respiratory\\ncapacity is diminished.\\nWith this type of chest we see the neck long, the larynx (Adam s\\napple) very prominent, the arms long. -The patient is loosely put\\ntogether the length of the long bones is increased.\\nIt is known as the phthisical, phthisinoid, or tuberculous chest. (See\\nFigs. 126 and 127.) Although the term tuberculous is applied to the\\nchest of this description, it does not necessarily imply that an individual\\nwith such a chest has, or will have, tuberculosis. It is true that in\\nindividuals with such type of chest the vulnerability to the action of\\nthe tubercle bacillus is more marked, and they are more liable to have\\nthe disease. Nevertheless a very large number of individuals go\\nthrough life with such chests and die of other diseases. If they are\\nnot exposed to the infection, they will certainly escape the disease.\\nCause. Bilateral diminution means diminution of contents. The\\nextent of air-surface is lessened.\\nThe Chest of Rhachitls. Another type of diminished size of\\nchest is constantly referred to. It is known as the chest of rhachitis\\n(see Fig. 129), and arises in infancy, on account of this disease of\\nthe bones. Many other shapes are seen, to which various names have\\nbeen given. Among the more common is what is known as the", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0514.jp2"}, "515": {"fulltext": "DISEASES OF THE LUNGS AND PLEURJE.\\n481\\npigeon-breast. (See Rhachitis, and The Head.) The chest is\\nusually shortened, the sternum is much more prominent than in health,\\nthe lower portion projecting to an unusual degree. The portion of\\nthe chest at the junction of the cartilages and the ribs is depressed.\\nThis tends to throw the sternum further outward. The transverse\\nsection of such chest resembles a triangle with the portions where the\\nbase-line joins the ribs rounded. (See Fig. 131.) The sternum is de-\\nFlG. 127\\nFig. 128.\\ni\\ny i\\nI\\nThe phthisical chest. (Full-blooded Indian, Philadelphia Hospital.\\npressed and the osteo-cartilaginous articulations are more prominent in\\nsome forms of rickety chest. In others the ribs and sternum from\\nabove to the fifth rib are prominent, and from thence downward to the\\nbase are drawn in. In the chest of rhachitis the costal anole is usually\\nvery acute. (See Fig. 130.)\\nhands, had been applied\\nIt often looks as if pressure, as by the\\nto the sides of the chest about the anterior\\n31", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0515.jp2"}, "516": {"fulltext": "482\\nSPECIAL DIAGNOSIS.\\naxillary line, causing the anterolateral portion to sink inward, while\\nthe antero-meclian portion is projected forward.\\nFig. 129.\\nTransverse section of a rhachitic chest at level of sixth thoracic vertebra.\\n32% inches right half, 16% inches; expansion, 2 inches.\\nCircumference,\\nThe chest of rickets is attended by enlargement of the articulations\\nof the cartilaginous and bony portions of the rib the rhachitic rosary\\nand by changes in the other bones.\\nFig. 130.\\nFig. 131.\\nJ\\n7\\nChest of rhachitis. (Eichhokst\\nCircumference 42.75 centimetres.\\nRickety chest. Dotted line indicates the shape of\\nchest in an infant about the same age. (Gee.\\nThe rhachitic chest must not be confounded with similar changes in\\nshape due to abnormal conditions of the upper respiratory apparatus\\nin early childhood. In cases of adenoid disease of the pharynx (see", "height": "4416", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0516.jp2"}, "517": {"fulltext": "DISEASES OF THE LUNGS AND PLEURAE.\\n483\\nDiseases of the Pharynx) the change in shape of the chest has been\\nnoted.\\nThe Transverse Groove. This is a depression observed in many\\nindividuals. It extends from the median line along the base of the\\nthorax to the axilla its upper limit is on a level with the xiphoid\\ncartilage. It slopes downward toward the axilla. It is caused in early\\nlife by the pressure of the external columns of air on the soft bony\\nthorax when the lungs are not completely filled with air. Hence, it\\nindicates nasal, faucial, or bronchial obstruction in early life, from\\nadenoid disease, bronchial catarrh, or other causes. It may mark the\\nupper limit of the liver on the right side as it was in infancy.\\nFig. 132.\\ni\u00c2\u00a3S\\nUnilateral enlargement of chest (right side), artificially produced by injecting air into the right\\npleural cavity. Unbroken line outline before injection. Broken line outline after moderate\\ndistention. Dotted line: outline after extreme distention. Figures at bottom of vertical line\\nindicate the antero-posterior diameter; along horizontal line, transverse semi-diameter remain-\\ning figures, right and left semi-circumference?. (Gfe.)\\nThe shape of the chest just described (rhachitic) does not indicate\\nany disease of the lungs it does indicate deficient respiratory capacity,\\nand is, of course, the tell-tale by which rhachitis of early life or early\\nlaryngeal and nasal obstruction are recognized.\\nDeformities. The rhachitic chest mast not be confounded with\\ndeformities of the chest which may be congenital in origin, the result\\nof occupation (shoemaking), or of vertebral disease (Pott s disease).\\nThe funnel-breast (trichterbrust) is congenital and often seen in several\\nmembers of a family (Warthin). It is associated with other stigmata\\nof degeneration. The lower sternum forms a deep concavity. (See\\nFig. 133.)\\nUnilateral Changes in Shape. Unilateral Enlargement. This\\ncan usually be seen more prominently at the base. The length is in-\\ncreased. The ribs are elevated, the side more rounded, the costal\\nangle more obtuse. The interspaces are frequently effaced, or fuller\\nthan on the corresponding side. The movement may be increased or", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0517.jp2"}, "518": {"fulltext": "484\\nSPECIAL DIAGNOSIS.\\ndiminished, depending upon the cause. The nipple is diplaced out-\\nward. The scapula of the affected side is also displaced outward, and\\nhence the distance from it to the spine is greater than on the opposite\\nside. (See Fig. 132.)\\nFig. 133.\\nFunnel -breast (trichterbrust).\\nCause. Enlargement of one side means enlargement of contents.\\nIt may be due (1) to increase of the normal contents, as in compensa-\\ntory emphysema, in which there is an increased amount of air in the\\nlung, or (2) to the presence besides of abnormal contents, as fluid or\\nair in the pleural sac. It is the most characteristic sign of pleural\\neffusion. When the normal contents are increased the movement is\\nincreased when the pleural cavity is filled it is diminished.\\nUnilateral Contraction or Diminution in Size. The costal\\nangles are sharper, the plane of the anterior or posterior portion, or of\\nboth, is depressed, and approaches the transverse median plane of the\\nchest. (See Fig. 134.) The affected side looks flat before and behind.\\nThe semi-circumference is lessened, as well as the diameter through\\nthe nipple or any fixed point. The interspaces are lessened in width\\nand may be drawn in. The ribs are closer together, and may almost\\noverlap. The movement of the side is lessened.\\nCause. Any diminution of contents will cause diminution of the\\naffected side. This may occur from obstruction or compression of the\\nbronchi of that side lessening the amount of air in that portion of the", "height": "4416", "width": "2648", "jp2-path": "practicaltreatis00muss_0_0518.jp2"}, "519": {"fulltext": "DISEASES OF THE LUNGS AND PLEURAE.\\n485\\nthorax. Theoretically, it may occur in a case in which there is com-\\nplete occlusion of the main bronchus. The condition is rare, and is\\naccompanied by marked associate emphysema of the other lung. The\\nunilateral change is most frequently seen in cases of chronic pleurisy\\nand fibroid phthisis. A large portion or even the whole of the lung\\nmay be bound down and compressed by thickened adhesions. The\\npleural cavity of the side thus affected, save where encroached upon\\nby the heart or by invasion of an emphysematous portion of the lung\\nof the corresponding side, is completely obliterated.\\nFig. 134.\\nUnilateral retraction of chest, consequent upon cirrhosis of left lung, in a girl of fourteen years.\\nThe figures indicate antero-posterior and transverse diameters and semi-circumferences of right\\nand left half of chest. (Gee.)\\nLocal Changes in Size and Shape. Enlargement and diminution\\nare also seen.\\nLocal Enlargement is particularly noted in the region of the\\nheart and great vessels, and will be considered when this division of\\nthe subject is discussed. A local enlargement in the lower anterior or\\nlateral region of the chest may occur in cases of empyema, in which\\nthe pus tends to be evacuated, or in pulsating pleurisy. Enlargement\\nin diseases of the mediastinum is usually seen in the region of the heart\\nand vessels, to which reference must also be made.\\nLocal Contraction. This may be seen either at the apex or the\\nbase. At the apex the local contraction or diminution in size is seen\\nabove and below the clavicle. The term flattening is applied to this\\ncondition. The interspace is sunken and the ribs depressed. It may\\nbe more readily seen when looked at from behind. Flattening may\\nalso be either in the lateral or posterior region at the base. The an-\\nterior and lateral, or the lateral and posterior, region is combined in the\\nlocal contraction.\\nCause. The physical condition is the same as in unilateral or gen-\\neral contraction contraction or diminution in size of the structures\\nunderneath. Anything which lessens the amount of air will cause\\nlocal diminution in size, or flattening of the surface. This is notably", "height": "4416", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0519.jp2"}, "520": {"fulltext": "486 SPECIAL DIAGNOSIS.\\nseen in tuberculosis, in which affection three processes, alone or in com-\\nbination, lessen the amount of air First, occlusion of the bronchioles\\nby tubercles and by inflammatory products, causing collapse of the\\nalveoli second, the overgrowth of connective tissue which attends the\\nmore chronic forms of tuberculosis third, a localized pleurisy. Local\\npleurisy, with organization and contraction of the inflammatory exudate,\\nalso causes diminution of the amount of air underneath the part, or\\ndiminution of the contents from compression of the adjacent lung\\nstructure. In local contractions movement of the part is generally\\ndiminished.\\nGeneral Review. It must not be forgotten that the element of\\ntime is necessary to produce changes in shape and size of the chest,\\nwith the exception of unilateral enlargement. In emphysema the\\nchange in shape takes a long time to develop. The unilateral and local\\ncontractions are of slow progress, and hence, it must follow, require\\nmore or less chronic disease for their development. The occurrence of\\npleural effusion may cause unilateral enlargement very rapidly.\\nThe Movements of the Chest in Disease. Bilateral Changes.\\nFrequency. The movements are increased in nearly all forms of\\ndyspnoea. (See Dyspnoea.) The frequency of movement varies in many\\naffections. They are more markedly increased in the acute lung affec-\\ntions attended by fever, and are especially more rapid in children.\\nIncreased frequency of respiration does not necessarily indicate pulmo-\\nnary disease. It is always seen in fever, and is a marked phenomenon\\nof hysteria. Conditions outside of the chest increase the frequency, as\\nenlargement of the abdomen from any cause encroaching upon the\\ncapacity of the chest. The respirations are lessened in frequency in\\ncases of disease of the medulla in which there is pressure upon the\\nrespiratory centre, and in some forms of poisoning, as that due to\\nopium.\\nAlterations in the Rhythm of Movement. Alterations hi\\nthe character and rhythm of the movement are observed by inspection.\\n(See Dyspnoea.) The movements may be (1) slow, and either shallow or\\ndeep (2) rapid and shallow or deep (3) irregular in rhythm. The\\nrelations of the act of inspiration to that of expiration in health are as\\n5 to 6 in women, children, and the aged, 6 to 8. The expiration is\\nlonger. The expiration may be prolonged, so that it is far greater in\\nlength than inspiration. Length of inspiration increased. The degree\\nof expansion and the duration of inspiration are increased when there\\nis obstruction in the trachea or larynx. Such increased expansion of\\nthe upper chest is usually associated with retraction of the soft parts\\nof the thorax, especially at the base. The ribs and the tissues along\\nthe margins of the thorax are drawn in with each inspiration. The\\nspace occupied by the lung above the clavicle may also be retracted.\\nThe transverse groove is more pronounced. If the difficulty in breath-\\ning continues, the indrawing becomes very marked, and, if the ribs\\nare soft, permanent. Expiration prolonged. Inspiration is short and\\nquick in cases of emphysema. The expiration is correspondingly pro-\\nlonged, and the muscles of expiration are seen to be brought into full\\naction.", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0520.jp2"}, "521": {"fulltext": "DISEASES OF THE LUNGS AND PLEURAE. 487\\nIn the consideration of dyspnoea we shall describe the appearance\\nand posture of the patient and the action of the muscles of respiration.\\n(See Subjective Symptoms.)\\nIrregular Rhythm. By inspection the Cheyne-Stokes type of\\nbreathing can be noted. Respiratory pauses of half to three-quar-\\nters of a minute alternate with a short period of increased activity, dur-\\ning which time twenty to thirty respirations occur. The respirations\\nconstituting this series are shallow at first, but gradually they become\\ndeeper and more dyspnceic, and finally become shallow or superficial\\nagain. The acts of respiration are carried on by an alternation of\\npauses and periods of modified or tidal breathing. Sometimes con-\\nsciousness is abolished during the pause. Often the pupils are con-\\ntracted and inactive. When the respirations begin they dilate.\\nUnilateral Changes in Movement. Increased movement of\\none side is seen when the lung of that side is acting vigorously from\\ncompensation, the other lung being disabled by disease. The whole\\nside moves more rapidly and vigorously. The increased movement is\\nassociated with enlargement of the affected side and hyper-resonance\\non percussion. Unilateral diminution in movement occurs when there\\nis diminution of the respiratory surface, occlusion of the bronchial\\ntubes, or from causes outside of the lung. The air-space is lessened in\\ncases of pneumonia, tuberculosis, or any affection which fills bronchi-\\noles and alveoli with inflammatory exudation or fluid. The air-space\\nis particularly lessened by the compression of effusions in the pleura,\\nof contracted and thickened exudations, and of adhesions.\\nImpaired motion due to pleural effusion is almost always unilateral,\\ndevelops gradually, following an attack of acute pleurisy, is unattended\\nby pain on respiration, but is attended frequently by great embarrass-\\nment of the respiration, and sometimes by orthopnoea. Fever is usu-\\nally moderate in uncomplicated cases. It is to be recognized by the\\nclinical signs mentioned and by the physical signs of fluid in the\\npleura.\\nImpaired motion from chronic pleurisy is of long standing and\\ngradual development. The chest-wall upon the affected side is re-\\ntracted, and may be very markedly sunken. In the absence of accom-\\npanying lung trouble there is no pain and no fever. It is to be dis-\\ntinguished from other types of impaired motion by the sinking in of\\nthe affected side, in sharp contrast with the hypertrophy of the other\\nside by the absence of fever and pain by its chronicity and by the\\nphysical signs of thickened pleura and compressed lung. Impaired\\nmotion from pneumothorax develops suddenly, generally in a person\\nwith tuberculosis of the lungs. Its appearance is usually precipitated\\nby coughing, and its sudden development is marked by intense pain,\\ndistention of the affected side, great difficulty in breathing, and a very\\nanxious expression of countenance. The escape of air into the pleural\\ncavity is followed by the development of pleurisy with effusion, so that\\nthe affection presents the physical signs of air and fluid in the pleural\\ncavity.\\nThe motion of the affected side is sometimes impaired in pneumonia,\\nwhen a large portion or the whole of one lung is involved, and the air-", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0521.jp2"}, "522": {"fulltext": "488 SPECIAL DIAGNOSIS.\\nvesicles are so occluded that very little air can get in. The physical\\nsigns in these cases resemble those of pleurisy with effusion very\\nclosely, but the diagnosis can be made by noting the acute onset of\\nthe disease, with high temperature and frequent respiration, without\\nantecedent pleurisy, and by the presence of cough with expectoration\\ncontaining the pneumococcus.\\nOcclusion of the bronchus, with diminution of the movement of the\\ncorresponding side, is seen in rare cases in which a foreign body fills\\nthe lumen of the tube, or in more common cases of pressure externally\\nupon the bronchus by an aneurism or mediastinal tumor.\\nImpaired motion from pressure on a bronchus by an aneurism or\\nenlarged lymph-gland produces the physical signs of collapse of the\\nlung, coupled with those peculiar to the cause of the occlusion of the\\nbronchus. It develops gradually, the patient having no pain in the\\nlung.\\nOutside of the lung lessened movement is caused by (1) interference\\nwith the muscular activity of that side from rheumatism of the inter-\\ncostal or respiratory muscles (2) pain seated either in the ribs or in\\nthe pleura. It may be due to acute pleurisy, the patient checking the\\nmotion of the affected side as much as possible, and breathing with the\\nabdominal muscles, because chest respiration causes acute pain. Im-\\npaired motion from this cause or from pleurodynia may be suspected\\nwhen it has come on suddenly, and when respiration causes acute suffer-\\ning, usually depicted in the face. Pleurodynia and pleurisy are to be\\ndistinguished from each other by the presence in the one case of tender\\nmuscles, a more constant and less stabbing pain, and absence of fever,\\ncough, and rales and, in the case of pleurisy, by the occurrence of\\nstabbing pain in respiration, absence of local tenderness, and presence\\nof fine, dry, or coarse rales on inspiration, with cough and fever.\\nLocal diminution of the movement or deficient expansion occurs\\nunder the same conditions that produce flattened and local contraction,\\nand for the same reason. Hence deficient expansion is observed in the\\nearly stages of phthisis, or in local pleurisies.\\nImpaired motion, due to consolidation of the lung in tuberculosis, is\\nusually limited to one of the apices, and is accompanied by flatten-\\ning of the affected apex and emaciation. The condition is of gradual\\ndevelopment, and presents the usual signs of tubercular consolidation\\nof the lungs (q. v.).\\nSometimes the impaired motion and flattening are due to a super-\\nficial cavity from tuberculosis or abscess, and when the walls are very\\nthin they may be seen to flap feebly with respiration.\\nRarer causes of impaired motion of the lung are cancer and hydatid\\ncyst (q. v.).\\nFluoroscopic or X-ray Examination. Through the efforts\\nof Williams, Leonard and others the X-ray has become an aid to the\\ndiagnosis of pulmonary affections. F. H. Williams has paid especial\\nattention to thoracic diseases. I quote from some of his brilliant studies\\nthe results secured by such examination of the lungs\\nIn health the lungs are readily traversed by the ray they appear\\nin the fluoroscope as light areas on either side of the backbone and", "height": "4412", "width": "2652", "jp2-path": "practicaltreatis00muss_0_0522.jp2"}, "523": {"fulltext": "DISEASES OF THE LUNGS AND PLEUEJE. 489\\nthe heart. The lower portions of the lungs, bounded by the dia-\\nphragm, are seen to move up and down through a distance of about half\\nan inch during quiet breathing, and to descend during full inspiration\\nto a point about two and one-half inches below its level in expiration.\\nThe pulmonary is lighter in deep inspiration than during expiration.\\nThere are three principal ways in which the fluoroscope may lead us\\nto suspect disease in the chest (1) The appearance of the dark areas\\nwhich occur in tuberculosis, pneumonia, carcinoma, diaphragmatic\\nhernia, gangrene of the lungs, and in echinococcus cyst, infarction,\\npleurisy, empyema, etc., due to the increase in density, which, by ob-\\nstructing the passage of the ray, diminishes the normal brightness in\\nthe chest or changes its normal outlines (2) the occurrence of abnor-\\nmal brightness which is found in emphysema and pneumothorax con-\\nsequent upon decrease in density, which makes the lung area appear\\nlighter than in health as seen in the fluoroscope (3) the restriction of\\nthe maximum excursion of the diaphragm and its altered position and\\ncurve from that observed in health.\\nIn tuberculosis the consolidated portion of the lung appears darker\\nthan normal in the fluoroscope. The expansion of the lung is reduced.\\nThe excursion of the diaphragm downward is diminished during full\\ninspiration, but this muscle is carried up into the thorax as high, or it\\nmay be even higher than in health. From time to time the fluoro-\\nscopic pictures show the apex of one lung darker, as already stated\\nthe clavicle and upper ribs less marked on the diseased than on the\\nnormal side the darker area extending more and more as the disease\\nprogresses. Then the apex of the other lung begins to darken and this\\narea continues to extend. The diminishing excursion of the dia-\\nphragm, which is also a characteristic feature of this disease, may like-\\nwise be observed, and sometimes may be the earliest sign.\\nIn pneumonia the affected areas are easily recognized in the fluoro-\\nscope, and in a central pneumonia may be seen when auscultation and\\npercussion do not reveal them. The excursion of the diaphragm is\\nalso restricted, and the heart may be much displaced to the right, if\\nthe pneumonia is only on the left side. A secondary empyema, fol-\\nlowing pneumonia, can be seen by the X-ray. The pleuritic effusion\\nwhich sometimes accompanies pneumonia may be proved to exist if a\\ndark area and the outline of the diaphragm below the dark pneumonic\\nportion is not visible in the fluoroscope.\\nIn both these affections the outlines of the lower part of the chest\\nare dulled or obliterated, especially the diaphragm line. If the effusion\\nis large the whole chest is dark, and the heart and mediastinum are\\ndisplaced. In a circumscribed pleurisy or empyema an exploring\\nneedle may fail to reach the desired spot, but we may sometimes, by\\nmeans of the fluoroscope, exactly outline the limits of the fluid.\\nLungs that are less dense than normal, as in emphysema, give a\\nbrighter area than in health, and the distended lung reaches lower in\\nthe chest than normal. The maximum excursion of the diaphragm is\\nmuch less than in health, as this muscle does not rise so high in expi-\\nration. These two signs are characteristic of emphysema. The en-\\nlarged ventricles and also the dilated right auricle are seen in late", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0523.jp2"}, "524": {"fulltext": "490 SPECIAL DIAGNOSIS.\\nstages the heart also lies in a more vertical direction, and its position\\nis not much changed by a deep inspiration.\\nIn pneumothorax the diaphragm is very low, loses its normal curve\\nand movement on the affected side, and the heart and mediastinum\\nare seen to be displaced to the healthy side.\\nPalpation. By palpation the results of inspection are confirmed,\\nthe character and consistence of tumors ascertained, the vocal fremitus\\ndetermined, and fluctuation detected.\\nMethod. The surface should be bared, although the fremitus can\\nbe detected through a thin layer of linen or gauze. To detect the\\nfremitus in front, it is often well to stand behind the patient, with the\\npalms of the hands placed over the surface of the chest in front. The\\nopposite position is taken to detect the fremitus behind. The axillary\\nregion must also be investigated. The hands should be warmed and\\napplied evenly to the surface. The two sides must constantly be com-\\npared, either by simultaneous application of the hands on the two\\nsides, or by applying the hand first on one side, then on the other.\\nThe Vocal Fremitus. Cause. The columns of air in the bronchial\\ntubes are thrown into vibration during the act of speaking. The vibra-\\ntions are transmitted to the hand on the surface of the chest. They\\nare known as the vocal fremitus. In infants the cry must be relied\\nupon instead of the spoken voice.\\nThe fremitus on the right side at the apex is stronger than on the\\nleft, because the right bronchus is larger than the left, its angle with\\nthe trachea is more acute, and the bronchus going to the right upper\\nlobe is two and one-half inches nearer the larynx than the left (Cary,\\nEwart). The fremitus is stronger in persons with deep, low-pitched\\nvoices, because the vibrations are not so rapid. It is more distinct,\\ntherefore, in males than in females, and in individuals with a bass\\nvoice. The vocal fremitus is felt more distinctly in persons with thin\\nchest- walls. Thick chest- walls and large mammary glands interfere\\nwith the transmission of fremitus. The fremitus is not distinct in\\nchildren because the vibrations are too rapid.\\nIt is well to become familiar with the vibrations produced by fixed\\nmonotones, in order to appreciate the fremitus. The patient is asked\\nto count one, two, three, or to repeat ninety-nine three or four times.\\nIt is well to observe a fixed rule as to the words used, in order to have\\ndefinitely in the mind the character of the vibrations in health, and\\nthe departures from the normal in disease.\\nVocal Fremitus in Disease. The vocal fremitus may be increased,\\nmay be diminished, or may be absent.\\nVocal Fremitus Increased. When the lung is consolidated,\\nvibrations are transmitted to the hand with greater force. Fremitus\\nis increased in all consolidations, as in pneumonia, tuberculosis, and\\nhemorrhagic infarct. (See Fig. 135.) The fremitus may be absent\\nin rare cases of pneumonia, in which the large tubes are occluded by\\nexudate. The fremitus is increased in the later stages of tuberculosis,\\nwhen cavities have formed, if the walls are dense.\\nVocal Fremitus Diminished. Anything intervening between\\nthe lung and the surface of the chest which interferes with the conduc-", "height": "4412", "width": "2660", "jp2-path": "practicaltreatis00muss_0_0524.jp2"}, "525": {"fulltext": "DISEASES OF THE LUNGS AND PLEURA.\\n491\\ntion of the vibrations diminishes the fremitus. The fremitus is dimin-\\nished in cases of thickened pleura, and in thin layers of pleural effu-\\nsion. The fremitus is lessened if the columns of air in the bronchi\\nare smaller on account of diminution in the calibre, as in bronchitis or\\nin emphysema and asthma. The fremitus is lessened in cavities filled\\nwith fluid, or when the bronchus is occluded.\\nVocal Fremitus Absent. 1. The vocal fremitus is absent when\\nthe columns of air are obstructed entirely by occlusion of the bronchus,\\nas by the external pressure of a tumor, aneurism, or enlarged gland. 2.\\nThe fremitus is absent in accumulations in the pleura of air or of fluid,\\ncausing interference with the vibrations. (See Fig. 136.) The well-\\nknown illustration of striking a stone underneath the surface of the\\nwater implies. If the ear of the listener is above the water, the sound\\ncannot be heard. If the ear is underneath the water, the sound is\\nheard a long distance from its origin. Vocal fremitus is absent in\\npneumothorax, in hydrothorax, in pyothorax, and in hemothorax.\\nThe same physical condition is present Avhen the pleura is greatly\\nthickened, and hence the fremitus is also absent.\\nFig. 135.\\nFig. 136.\\nConsolidation Pneumonia. Vocal fremitus\\nincreased. (Gibson and Rdssell.)\\nPleural effusion. Vocal fremitus absent\\nat a. (Gibson and Russell.)\\nThe vibrations produced by the passage of air through mucus or\\nfluid in the bronchial tubes are transmitted to the hand when it is laid\\non the surface of the chest. It is known as the rhonchial fremitus.\\nThey are felt during inspiration. They may be felt all over the chest\\nin bronchitis, or in asthma, as distinct vibrations, sometimes coarse, or\\nagain fine, indicating rapidity of movement. The vibrations may be\\ntransmitted over a localized area in phthisis, due to air passing through\\nfluid in the cavity. They are distinct in children in cases of bron-\\nchitis, and are often the source of much alarm to the parents.\\nFmction-fremitus. An exudation of lymph on the surface of the\\npleura often causes a vibration which may be transmitted to the hand.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0525.jp2"}, "526": {"fulltext": "492 SPECIAL DIAGNOSIS.\\nIt is known as a friction-fremitus, and is felt in inspiration. It is\\nusually felt at the base of the chest, in front, laterally, or posteriorly.\\nIt is not modified by coughing, and is increased by full breathing.\\nThe rhonchi, on the other hand, are influenced by cough and breathing.\\nFluctuation is detected by palpation in some cases of effusion,\\nparticularly if the intercostal spaces are swollen and tense, or if an\\nempyema is about to point. In rare instances it may be detected by\\nstriking the chest opposite the palpating hand.\\nPercussion. By percussion, (1) sounds are elicited, (2) the degree\\nof resistance to the percussing-finger estimated. When a part is per-\\ncussed the sounds produced are noises or tones. If a tone, the vibra-\\ntions are uniform and will be in unison with a tuning-fork if a noise,\\nthe vibrations produced are without uniformity. We speak of the\\npitch, the volume, the duration, and the quality of the sound. The\\npitch depends upon the rapidity of vibrations, the number that occur\\nin a definite period of time. It may, therefore, be high or low. In\\nsounds that are high in pitch the vibrations are rapid. In sounds\\nthat are low in pitch the vibrations are correspondingly slower in the\\nsame period of time. The volume or intensity of the sound depends\\nupon the amplitude of the vibrations, and varies directly as the square\\nof the amplitude. It is modified by the degree of force used in the\\nproduction of the sound. Duration explains itself. These charac-\\nteristics bear certain relationships. Sounds that are high in pitch are\\nof diminished volume or intensity, and of short duration. The accom-\\npanying diagram shows the relation of the characters of the sound.\\n(See Fig. 137.) On the other hand, sounds that are low in pitch have\\nFig. 137.\\nFlatness.\\nDull tone.\\nTracheal or tubular tone.\\nResonant tone.\\nTympanitic tone.\\nVolume and duration.\\nDiagrammatic sketch of the relations of the character of tone. The perpendicular\\nline represents the pitch. The transverse line the volume and duration.\\ncorrespondingly greater volume or intensity and longer duration. The\\nthree characteristics determine the quality of the sound. The term\\nclearness is applied to sounds which have the character of tones.\\nThey are low in pitch, of good volume, and long duration. Sounds\\nthat are high in pitch, of small volume, and short duration are of a\\ndull quality. Noises, highest in pitch and least in volume and dura-\\ntion, are absolutely dull or flat. The former are indicative of the pres-\\nence of air the latter, of the absence of air. The tones, or clear\\nsounds, are naturally produced over structures containing air. The", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0526.jp2"}, "527": {"fulltext": "DISEASES OF THE LUNGS AND PLEURJE. 493\\nproduction of a tone implies the presence of air in a sac. Structures\\nin which the proportion of air to solid material varies yield sounds\\nwhich vary between clearness and muffling, to absence of tone or dul-\\nness. Resonance and tympany are clear sounds which will be ex-\\nplained later.\\nMethod of Procedure. Due attention should be paid to the\\npresence or absence of tenderness, which necessarily modifies the results\\nobtained by this method of exploration. Definite information can be\\nsecured by light percussion, even when there is a good deal of tender-\\nness. In children percussion should be the final step in the examina-\\ntion.\\nImmediate Percussion. The chest may be tapped by the finger\\nor hand directly. This was the original method of percussing the\\nchest. It is known as the immediate method. When the fingers are\\nemployed it is known as palpatory percussion. One finger is sufficient.\\nThe pulp, as most sensitive, may give the blow. Or the tip, the finger\\nbent at a right angle, may be used. By this method the sense of resist-\\nance is better appreciated.\\nMediate Percussion. The method now employed is that in which\\na medium is placed between the chest- wall and the instrument used for\\npercussing. This medium is called a pleximeter. It may be a small\\nplate of ivory of suitable size to place between the ribs, or, better still,\\nthe fingers of the hand not used in tapping. The plessor is used to\\ncreate the sound. It may be a small hammer. The one usually selected\\nis of moderate weight, has a firm, light, slightly flexible handle and\\nmetal head, the poles of which are tipped with rubber. For purposes\\nof class demonstration, a plessor of this character, with an ivory plex-\\nimeter, is of value but for bedside-work the fingers of the physician\\nare better.\\nThe Use of the Pleximeter. The pleximeter must be placed\\nin close contact with the surface of the chest in performing percussion.\\nIf the finger is used as a pleximeter, in percussing the anterior portion\\nof the chest, for instance, it must be placed parallel with the ribs. It\\nmust not cross them. If it is not in close contact with the chest, the\\ncushions of air between the two will modify the sound, so that accurate\\ndata are not obtained. Interspace after interspace should be percussed\\nin this manner from above downward. At the same time, if neces-\\nsary, the pleximeter may be placed over the corresponding ribs, but\\nparallel with them. With a little practice the method of applying the\\npleximeter can soon be acquired.\\nThe Use of the Plessor. This requires considerable practice On\\nthe part of the student. If a metal instrument is used, care should be\\ntaken to acquire the habit of percussing under all circumstances with\\nthe same degree of force. If the finger of the operator is employed as\\na plessor, several points in the procedure must be remembered. It is\\nbetter to use one finger, preferably the middle finger. Some operators\\nuse more than one finger, but with a little practice a sufficient degree\\nof force can be given with one to elicit the sounds essential for distinc-\\ntion. The finger should be bent at right angles and kept in a fixed\\nposition. It must be made to strike the pleximeter perpendicularly", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0527.jp2"}, "528": {"fulltext": "494 SPECIAL DIAGNOSIS.\\nto its plane. If the blow is given at any other angle to the part per-\\ncussed, a true sound cannot be obtained. The blows must be regular\\nand the force even. The character of the part investigated will deter-\\nmine the degree of force that should be used. (See Method of Percus-\\nsion, page 493.) The force of the blow is to come from the wrist alone,\\nneither the arm nor the forearm must come into play. Beginning\\nanteriorly with the supraclavicular fossse, and proceeding downward\\nan interspace at a time, comparison should be made Avith the other side\\nat each step. The axillary portions, and the posterior portions from\\nsupraspinous fossa? to base, should then be examined in the same way.\\nHearing and Feeling Combined. Another excellent plan is to secure\\ninformation by the sense of touch, as well as by the sound. The\\nsecond, third, and fourth fingers of the percussing hand are flexed at\\nan angle of 45 degrees. The tips are brought down on the pleximeter\\nfinger and kept there for a few seconds, when the blow may be re-\\npeated. The perpendicular blow is not used. The sound produced\\nis not loud. It is most useful in diseases of the lungs, spleen, and\\nliver, and where strong percussion cannot be used, as in perityphlitis\\nand cholecystitis.\\nPosition of the Patient. The best position is the standing one,\\nwith the arms allowed to drop loosely at the sides, the head straight,\\nnot thrown back, and the shoulders allowed to fall a little forward if\\nthey are inclined to do so. Any position which throws the chest-mus-\\ncles into contraction tends to defeat the object of the examiner who\\nseeks to elicit the chest-sounds. In percussing the posterior portions\\nof the chest it is desirable to have the patient stoop forward with arms\\nfolded. While this renders the muscles more tense, it has the advan-\\ntage of exposing a larger portion of the chest.\\nWhen the patient is confined to bed he should, if not too ill, be\\nallowed to sit up during percussion, as contact with the bed or with\\npilloAvs deadens the sounds elicited. This fact should be borne in mind\\nwhen from any cause it is not desirable to have the patient sit up.\\nAll clothing should be removed, if possible. A thin undershirt may\\nbe permitted from motives of delicacy, or parts only of the chest be\\nexposed at one time if there be danger of chill.\\nThe Sounds in Health. Four types of sounds can be produced by\\npercussing over the trunk for the purpose of study. 1. Resonance\\nover the lungs. 2. Tympany over the caecum. 3. A modified tym-\\npanitic or so-called tubular or tracheal sound over the trachea. 4.\\nDulness over the heart. Modifications of these types represent all\\nsounds produced under every variety of circumstances. They will be\\nconsidered in the order of their importance. The term resonance is\\napplied to the clear sound that is produced over the lungs on percus-\\nsion. It is due to the vibration of the chest- walls and of the air in\\nthe bronchi. Pulmonary resonance is a term also used to indicate\\nthe same sound. While, as stated above, the sound produced is called\\na tone, yet on account of the relation of the air to the solid structure\\nof the lung, the air being confined in innumerable sacs, a true tone is\\nnot produced i. e., the sound cannot be pitched with another tone or\\nmade to vibrate in unison with one. For practical purposes, however,", "height": "4416", "width": "2660", "jp2-path": "practicaltreatis00muss_0_0528.jp2"}, "529": {"fulltext": "DISEASES OF THE LUNGS AND PLEUB^E. 495\\nthe term tone may be used convertibly with clearness and\\nresonance. Its characteristics cannot be defined accurately, and\\nmust be learned by repeated practice.\\nModifications in Health. The degree of clearness or resonance\\ndiffers in various parts of the thorax. It is purer in the upper axil-\\nlary region, at the angle of the scapula behind, and on the anterior\\nsurface of the chest, in the second interspace. It is slightly higher in\\npitch at the right than at the left apex. It is modified by the condi-\\ntion of the chest-walls. Thick chest-walls, accumulations of fat, the\\nmammary gland, and the scapulae impair the resonance and necessitate\\ndeep percussion to bring out the true sounds. In persons with thin\\nchest-walls the resonance is clear and more pronounced. The elasticity\\nof the chest-walls also modifies it. In the aged it is less clear because\\nof rigid chest-walls. In children, in whom the chest-walls are elastic,\\nthe resonance is much fuller or clearer, and approaches more nearly the\\ncharacter of a tone. The sounds vary, within certain limits, in different\\nindividuals with perfectly healthy, normal chests, as may be seen from\\nthe above. Moreover, a sound normal in one part of the chest may\\nin another part indicate disease.\\nIt follows that percussion-sounds do not have an absolute value\\ntheir significance depends upon the individual and upon the part of the\\nchest examined. The student should learn from the outset to com-\\npare the sounds developed by percussion of symmetrical portions of\\nthe chest, and thus determine the normal for the individual. Below\\nthe third rib on the left side the dulness of the heart destroys the value\\nof comparative percussion. Significance Excess of clearness or reso-\\nnance hyper-resonance means excess of air, as in vicarious emphys-\\nema. Diminution of clearness means diminution of air increase of\\nsolid structure.\\nAbnormal changes in resonance caused by disease will be considered\\nlater.\\nTympany. When a single cavity with smooth walls, containing\\nair, is percussed, the sound that is produced is a tone of low pitch, of\\nconsiderable volume or intensity and of long duration. The term\\ntympany is applied to this sound. In health it can be elicited\\nover the stomach when it is free from food, over the large intestine,\\nand at times over the small intestine. In addition to the low pitch\\nand large volume, it possesses a peculiar metallic quality which is\\ncharacteristic. It may be said to be a hollow sound. It is a\\nquality of sound with which the student should become familiar, for\\nvariations are characteristic of abnormal physical conditions in the\\nlung and in the abdomen. It must be remembered that tympany can\\nbe developed normally over the posterior portions of the lungs of in-\\nfants and children. The relation of this sound to resonance, or the\\nsound produced on percussing the healthy lung, and to dulness pro-\\nduced over airless structures, may be appreciated by reference to the\\ndiagram modified from Gee. (See Fig. 137.) In pitch, in volume, and\\nin duration it is lower than the resonant and tracheal tones. The latter\\nstands midway between tympany and dulness. As intimated pre-\\nviously, all varieties of sounds that may be produced, and which occupy", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0529.jp2"}, "530": {"fulltext": "496 SPECIAL DIAGNOSIS.\\npositions between the extremes noted in the triangle, are dependent\\nentirely upon the proportion of air to solid material.\\nThe tracheal tone is a clear tone produced over the trachea when the\\nmouth is open moderately. It is clear, higher in pitch than resonance,\\nand of a tympanite or tubular quality.\\nDulness. The sound over the heart is dull, and may be useful to\\ncompare with dull sounds yielded over areas usually resonant. If a\\ndull sound has some pitch and duration, some tone is mingled with it.\\nIf dulness is absolute, it is without pitch and is a noise. The signifi-\\ncance of dulness has been described it means the absence of air. Ab-\\nsolute dulness implies that the airless part underneath is in immediate\\ncontact with the surface of the chest. Relative dulness implies the in-\\nterposing of air-containing structures between the airless structure and\\nthe chest-wall. The portion of the heart or liver in contact with the\\nchest-wall yields absolute dulness when percussed the portion over-\\nlapped by lung yields relative dulness. Absolute dulness is readily\\nelicited, and with ordinary percussion is a fixed area. All observers\\nwill usually secure the same size of absolute cardiac dulness, for in-\\nstance. Relative dulness depends so much upon the method of per-\\ncussion, light or strong, and upon the ear of the observer, that for its\\nextent each observer will have a different opinion. The personal\\nequation is a disturbing factor in the estimation of its extent. It must\\nbe remembered in disease of the lungs, of the bloodvessels, and medi-\\nastinum the location of the lesion is usually made out by the detection\\nof relative dulness, or of changes in the pitch, quality, and duration of\\nthe sound, indicating less air in the part percussed. Such changes are\\nmore diagnostic if the effects of breathing (respiratory percussion), of\\nthe position of the patient, and of the force of percussion (light or\\nstrong) are considered.\\nThe Pitch. The estimation of the pitch of the sound is of the\\nhighest importance. It is the one distinctive attribute or characteristic\\nwhich is of special diagnostic significance as to the physical condition\\nof the part. It requires considerable practice to estimate it correctly.\\nIts significance in relation to dulness and tympany has been men-\\ntioned. Although a high-pitched sound may be considered a dull\\nsound, this is not necessarily so. A sound of high pitch need not be\\nmarkedly dull\u00e2\u0080\u0094 indeed, it may be moderately clear. Under the right\\nclavicle in health the pitch is higher than under the left, but not dull\\nin character.\\nThe student may become familiar with the pitch, and with altera-\\ntions in it, by percussing over a portion of the lung clearly resonant,\\nas in the third interspace and thence downward on the right side. As\\nthe interspaces in apposition with the liver are reached the pitch\\nchanges. The fulness of the sound is lessened it becomes more\\nshallow. The increase in rapidity of the vibrations can almost be\\nappreciated, and, as they increase, the heightened pitch caused by them\\ni- recognized. This normal increase in pitch is due to a thin layer of\\nLung hacked up behind by the solid liver. Change in pitch makes it\\npossible to outline organs and pursue topographical percussion.\\nThe Degree of Resistance. This is estimated by the sense of\\ntouch. When organisms containing air are percussed the resistance", "height": "4404", "width": "2568", "jp2-path": "practicaltreatis00muss_0_0530.jp2"}, "531": {"fulltext": "DISEASES OF THE LUNGS AND PLEURjE. 497\\nappreciated by the finger percussed is small, or, indeed, may be said\\nto be absent entirely. The sensation of the finger is as if the parts\\nunderneath bounded away. When the air decreases and the propor-\\ntion of solid structure increases more resistance is felt. It is of the\\ngreatest importance to carefully educate the finger in this sense of\\nresistance. It is often difficult to determine the pitch exactly, and the\\nsense of resistance furnishes an additional means of detecting the pres-\\nence or absence of solid structure. Palpatory percussion indicates\\nthe sense of resistance to a better degree than any other method.\\nSuperficial and Deep Percussion. In superficial percussion the\\nblows are directed lightly over the part percussed, so as to bring out\\nthe sound yielded by the portion directly underneath the surface.\\nHence superficial percussion is applicable over the thinner portions of\\nthe lung. It enables one to bring out areas of absolute dulness.\\nLight percussion is necessary in children and in patients with sore\\nchest-walls, or when they have just had a hemorrhage. In deep per-\\ncussion the blows are given with enough force to influence the struc-\\ntures situated deeply in the lung or overlapped by the edges of the\\nlung. It is necessary, therefore, in cases of deep-seated consolidation,\\nand in cases of aneurism covered by lung, in order to define its limits.\\nIt is employed to determine the true height of the liver and the relative\\narea of dulness of the heart.\\nAuscultatory or Stethoscopic Percussion. This is a valuable\\nmeans of defining the exact outline of a dull. area, as an aneurism or\\ntumor within the chest, or of determining the limits of organs even\\nof similar physical structure. The stethoscope is placed over the organ\\nthe border of which is to be defined, and percussion is begun some\\ndistance from it. It is conducted toward the stethoscope, and the dull\\nsound of the non-resonant structure is transmitted to the ear beyond\\nlimits not determined by ordinary methods. If the tympany of the\\nstomach is to be distinguished from the tympany of the colon, place\\nthe stethoscope over either one of the organs. Percuss with the finger-\\ntips directly on the surface by immediate percussion. Begin at the\\nstethoscope and percuss from it. As soon as the limit of the structure\\npercussed is reached a difference of tone or pitch is observed which\\ncannot be detected by other means. In this manner the dulness of the\\nliver can be told from that of pulmonary consolidation or pleural effu-\\nsion the dulness of an effusion from a consolidation of the lung which\\nrises higher than the effusion, as in pleuropneumonia. Mediate per-\\ncussion may also be employed.\\nRespiratory Percussion. (Da Costa.) The difference in the sound\\nelicited in full inspiration and in full expiration is marked in health.\\nIn general it may be said the sound becomes more resonant and higher\\nin pitch in full inspiration. In ordinary bronchitis the same change\\nis observed as in health on the other hand, in bronchitis with much\\nsecretion and in bronchopneumonia the marked difference between inspi-\\nration and expiration does not hold. In phthisis the difference between\\nthe two sides of the chest can be made more plain by respiratory per-\\ncussion. By the varying changes in pitch and duration, cavities are\\ndetected. (Gerhardt s sign.)\\n32", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0531.jp2"}, "532": {"fulltext": "498 SPECIAL DIAGNOSIS.\\nObject of Percussion. The object of percussion is to estimate\\nthe proportion of air to the solid tissue contained in the chest. We\\ncan thus determine (1) the size of the lungs (2) the presence or\\nabsence of disease causing abnormal physical conditions (3) the size\\nof the other organs in the thorax (topographical percussion), and (4)\\nin the case of the abdomen the position and size of its organs and the\\npresence of tumors or other solid structures.\\nThe Size of the Lungs. Increase in size The boundaries of the\\nlung have been described. If the resonance extends beyond these\\nboundaries, it may be said that the lungs are enlarged. This is seen\\nin emphysema. The area of resonance in this affection extends above\\nthe clavicles to a greater height than in health. It encroaches upon,\\nand may altogether displace, the normal area of cardiac dulness it\\nextends one and a half to two inches beyond the lower limits of the\\nhealthy lung. The upper border of liver-dnlness is, therefore, lower\\ninstead of beginning in the fifth or sixth space it begins an inch or two\\nbelow. Diminution in size Shrinkage of the apices (one or both)\\ntakes place in phthisis, hence the resonance of health does not extend\\nas high up in the neck. Shrinkage or contraction may take place\\nalong the lateral borders or lower edges, on account of phthisis or re-\\ntracting pleurisy, causing diminution in size of the lung and spurious\\nenlargement of the heart or liver. In diseases below the diaphragm,\\neffusion or enlarged liver, the size of the lungs varies. (For heart\\nand liver, see the special chapter devoted to these organs.)\\nThe Sounds in Disease. It may be said in general that when a\\nsound is produced in the thorax which varies from the normal resonant\\ntone it indicates an abnormal physical condition, or, in a word, disease.\\nExactly corresponding portions of the two sides must be compared.\\nChange in tone may be general or local. The areas over both lungs\\nmay yield a different percussion-note from the normal (bilateral); the\\nchange may be limited to one side (unilateral); or it may be found in\\nsmall areas (local).\\nIncreased Resonance or Tracheal Tone. The resonance may\\nbe increased or diminished. When the resonance is increased the sound\\nis abnormally clear. If it is fuller and clearer than in health, without\\nthe characteristics of the tympanitic note, it is known as hyper-reso-\\nnance or exaggerated resonance or a tracheal tone. The physical con-\\ndition which causes exaggerated or hyper-resonance is increase in the\\namount of air. This increased amount of air may be general, unilat-\\neral, or local. When general (bilateral) it gives the characteristic sound\\nheard in emphysema. In this affection the amount of air is so great,\\nand the tension of the chest-walls so exaggerated, that hyper-resonance\\nand sometimes a pure tympanitic sound band-box resonance) are\\nproduced over the entire thorax. At the same time normally dull\\nareas are encroached upon. The heart-dulness is effaced, the liver\\ndulness lowered. The same increased resonance may be present in\\nacute miliary tuberculosis. Unilateral increase in resonance or tym-\\npany occurs when there is an increased amount of air in one lung, on\\naccount of compensatory enlargement (vicarious or compensatory em-\\nphysema), or on account of an increase of air in the pleura. Local", "height": "4400", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0532.jp2"}, "533": {"fulltext": "DISEASES OF THE LUNGS AND PLEURA. 499\\nincrease of resonance occurs when a local area of the lung is acting in\\na compensatory manner. This is seen in cases of phthisis in which the\\nalveoli or lobules surrounding small areas of consolidation are very\\ndistended. The exaggerated note may aid in the recognition of a deep\\nconsolidated area. The same note, hyper-resonance or skodaic reso-\\nnance, is obtained over a portion of the lung above the line of pleural\\neffusion, and above the line of consolidation in pneumonia.\\nFig. 138. Fig. 139.\\nDiagram showing at x moderate dulness Diagram showing heightening of pitch an-\\nover tubercular infiltration. (Gibson and teriorly at x from consolidation posteriorly\\nRussell.) (shaded points). (Gibson and Russell.)\\nDiminished or Impaired Resonance. The normal tone or reso-\\nnance is impaired or muffled that is, the pitch is higher, while the\\nvolume is lessened and the duration shorter in cases of incipient con-\\nsolidation of the lung, and in small pleural effusions when a thin layer\\noverlaps the lung. It is the first change toward dulness. It is par-\\nticularly noted in the early stages of phthisis, when the lung area,\\nusually the apex, is the seat of small areas of tuberculous infiltration.\\nThe relative amount of air to solid structure is lessened. Impaired\\nresonance is the result. As the disease advances the note changes grad-\\nually to dulness.\\nPitch. Gibson and Russell have pointed out the change in quality\\nof sound with change in pitch. (See Fig. 139.) If, for instance, the\\napex of the lung is percussed in front, when there is an effusion of fluid\\nbehind, or a consolidation of small area directly on the opposite surface\\nof the lung, the pitch is higher, compared with the sound in the oppo-\\nsite lung at the corresponding point, although the quality is clear. A\\nclear sound of heightened pitch is diagnostic of airless structure behind\\nair-containing structure.\\nTympany in Disease. Significance If a tympanitic note is\\nelicited over a part where in health resonance should be found, it is an\\nindication of disease. It signifies (1) that air is confined in a space\\n(cavity), or that there is an excess of air in many sacs, as in the lungs\\nin emphysema (2) that the tension of the lungs is less than normal\\nthe lung is relaxed, as it is above the limits of a pleural effusion. A", "height": "4404", "width": "2548", "jp2-path": "practicaltreatis00muss_0_0533.jp2"}, "534": {"fulltext": "500\\nSPECIAL DIAGNOSIS.\\nFig. 140.\\ntympanitic sound from the chest occurs 1. Bilaterally, in cases of\\nemphysema. 2. Unilaterally, in cases of pneumothorax and compen-\\nsatory emphysema. In pneumothorax the pitch may be raised if there\\nis much tension it is then known as a dull tympany. 3. Locally,\\na. It is limited to the lobe of the lung in some cases of compensatory\\nemphysema, b. It may occur in the early stages of pneumonia, or in\\nthe later stages of complete consolidation. In the former it is due to\\nrelaxed tension in the latter, to the air in the bronchus, the lumen of\\nwhich is free. c. In cases of pleural effusion, owing to alteration in\\nthe tension of the lung, a tympanitic note is\\npresent above the layer of fluid, d. In phthisi-\\ncal excavations at the base of the apex, and in\\nbronchial dilatation, if the cavity communicates\\nwith the air, and has moderately thin, elastic\\nwalls, and is at the same time empty, a tym-\\npanitic note is produced. The musical pitch\\nof the note depends upon the volume of air,\\nthe size of the opening, and tension of the\\nwall. Large volume of air, low pitch large\\nopening, low pitch greater tension, higher\\npitch. Small volume, high pitch small open-\\ning, high pitch less tension, low pitch. (For\\nmodifications of tympany, see Special Sounds\\nand Cavities.)\\nDulness in Disease. The note is high in\\npitch, small in volume, and short in duration.\\nAbsence of air, or a relatively small amount\\nin proportion to solid structure, is present. The\\nconditions which give rise to it are all forms\\nAt the apex complete duiness of consolidation and pleural effusions. The\\nand bronchial breathing, from ex t en t and the degree of duiness depend upon\\ntuberculous consolidation; in x\\nthe middle portion impaired tn e proportionate amount of solid to air-con-\\nresonance, from disseminated taiiiing material. Moderate duiness is seen in\\ntubercles; below exaggerated tubercular disease, with moderate infiltration\\nresonance, from compensatory n -p^. n r -i -n i\\nemphysema. ne lung (see Jb lg. lo8), and m small patches\\nof catarrhal pneumonia, in pulmonary conges-\\ntion, and in atelectasis and physical conditions in which there is solid\\nmaterial in greater proportion than in health. Absolute or complete\\nduiness occurs when the air is completely absent, as in the stage of\\nhepatization of acute pneumonia, in hemorrhagic infarction, in con-\\ndensation from pressure, in pleurisy with large effusion, or great thick-\\nness of the pleura, and in tumors. Flatness is applied to the extreme\\ndegree of duiness. (See Fig. 141.)\\nWe have, therefore, all gradations of the dull sound, from simple\\nimpaired resonance in incipient tuberculosis of an apex of the lung, as\\ndetermined by careful comparison of the two apices, to absolute flatness\\nor deadness.\\nMethod of Percussion The kind of percussion necessary to bring\\nout the duiness will depend upon the extent and the distance from the\\nsurface of the disease. When the consolidation or thickening is super-", "height": "4400", "width": "2624", "jp2-path": "practicaltreatis00muss_0_0534.jp2"}, "535": {"fulltext": "DISEASES OF THE LUNGS AND PLEURJE.\\n501\\nficial, light percussion will discover it, whereas strong percussion would\\nbring out the resonance of the deeper healthy lung-tissue to such an\\nextent as to mask completely the superficial dulness. On the other\\nhand, when the airless consolidated tissue is deep-seated and sur-\\nrounded by healthy lung, strong percussion is required to discover it.\\nFig. 141.\\nExaggerated breath-sounds. Skodaic resonance\\nRetracted lung.\\nAir. Tympany. Metallic tinkling\\nand amphoric breathing.\\nSuccussion on shaking.\\nLoss of\\nFluid. Flat on percussion,\\nvocal] resonance and fremitus. Ab-\\nsent breath-sounds.\\nPneumothorax resonance over retracted lung. Tympany over air. Dulness or\\nover fluid. (Gibson and Russell.)\\nAgain, when the airless tissue occupies a small focus and is sur-\\nrounded by healthy lung, as in pneumonia beginning centrally and\\nwhen there are small airless foci, perhaps surrounded by emphysema,\\nas occurs sometimes in disseminated tuberculosis, percussion is often\\nwholly negative.\\nSpecial Sounds. Special percussion-sounds, or sounds the quality\\nof which differs from the ordinary tympanitic sound, are present in\\nsome physical conditions. Of these the amphoric, or metallic, and the\\ncracked-pot percussion-sounds are most familiar. The amphoric sound\\nis tympanitic, but has a metallic clang, or echo, which is an overtone.\\nThe prolongation of the sound is compared to an echo. It is like the\\nsonorous ring of the voice when one utters a tone in an empty hall.\\nIt can be imitated by percussing an empty vessel. It is heard best in\\ncases of pneumothorax (see Fig. 141) and in phthisical excavation\\nwhen the cavity is large, superficial, with smooth walls, and when it\\nhas open communication with a bronchus. The cracked-pot sound, as\\nthe name indicates, resembles that produced when a cracked metal\\nvessel is tapped it is simulated by clasping the hands loosely at right-\\nangles to each other and striking them over the knee. It is heard\\nbest over cavities which communicate directly with a bronchus, espe-\\ncially if the chest-wall is thin and yields to the percussion-stroke.\\nThe cavity is usually at the apex. In order to elicit the sound the\\npatient should be made to keep the mouth open. The sound should\\nbe created at the time of expiration, and the percussing finger should\\nbe retained instead of elevated after striking the pleximeter.", "height": "4416", "width": "2588", "jp2-path": "practicaltreatis00muss_0_0535.jp2"}, "536": {"fulltext": "502 SPECIAL DIAGNOSIS.\\nIn some rare cases this sound can be elicited in health. It may be\\ngenerated if the chest of a healthy screaming infant is percussed. In\\nthis instance it is due to the compressed air forcibly throwing the vocal\\ncords into vibration. The other pathological conditions in which the\\nsound occurs rarely are pleurisy, when the chest is percussed above the\\neffusion, pneumonia before consolidation has taken place, and pneumo-\\nthorax if there is a free communication between the cavity and a\\nbronchus. In the latter instance the sudden rush of air into the bron-\\nchus produces this sound. This is proved by the fact that it can be\\ncreated when the chest is percussed in a case of empyema, after the\\nfluid has been evacuated by a free incision. It is to be noted that,\\nwhile corroborative, it is not of itself positive evidence of any single\\ncondition.\\nAuscultation. Sounds are produced in the act of breathing. They\\nare heard by the application of the ear directly to the chest-wall or\\nthrough some medium. They are created both in inspiration and in\\nexpiration: They vary in character in accordance with the situation.\\nMethod. If possible, the patient should sit upright in an easy, un-\\nrestrained position. For auscultation in front, the arms should hang\\ncarelessly by the side. For auscultation behind, the patient should fold\\nthe arms and lean slightly forward. For comparison both sides should\\nhave the same freedom of movement, which would not be attained if\\nthe patient assumed a lateral or side posture or attitude. Auscultation\\nshould be practised in quiet, in full and in forced inspiration and ex-\\npiration.\\nAuscultation is practised by two methods First, the ear is applied\\ndirectly to the chest, a thin towel or napkin free from starch alone\\nintervening. This is known as the immediate or direct method. It is\\nof service to ascertain the general character of the sounds. It has the\\ndisadvantage of imperfect localization. Second, by means of the stetho-\\nscope and phonendoscope the mediate or indirect method is practised\\nbut it is disadvantageous in infants, because they cannot be kept quiet\\nor are sensitive to its pressure, and in children because instruments\\nare alarming.\\nThe advantages of the stethoscope over direct methods of ausculta-\\ntion are seen when it is necessary to localize sounds. The definite\\nlocalized area in which the sound is produced can be ascertained, and\\nsounds in close proximity differentiated. Its use is essential in the\\nstudy of heart-sounds. In addition, the operator is more likely to\\nescape from contagious diseases and vermin. Moreover, on the score\\nof delicacy, the stethoscope is preferable.\\nThe stethoscopes used are single and double, and vary in form with\\nthe practice of the operator. It should be an absolute rule with\\nthe student to become familiar with and use one form of stethoscope\\nonly. The single stethoscope is very good to localize and determine\\nthe relation of sounds. It also transmits the shock of an aneurismal\\nvessel or of the heart. The objection to it is that the weight of the\\nhead causes pain if the chest is sore, and the pressure of the instrument\\nmay modify sounds if bloodvessels are auscultated, or sounds in close\\nproximity to the ear, as a friction. In the use of the single stetho-", "height": "4408", "width": "2576", "jp2-path": "practicaltreatis00muss_0_0536.jp2"}, "537": {"fulltext": "DISEASES OF THE LUNGS AND PLEURAE. 503\\nscope the student should be particular, first, to see that the portion\\napplied to the chest is perpendicular to the plane of the area over which\\nauscultation is practised. Otherwise slight tilting of the instrument\\nwill take place and outside noises be transmitted through the tube.\\nThe operator should place himself in an unconstrained position and\\nsee that his head is accommodated to the position of the instrument,\\nnot the latter to the head. If the parts over which auscultation is\\npractised are covered with hair, an extraneous sound from friction is\\nproduced. Oil should be applied to obviate this. The double stetho-\\nscope is the most suitable for class instruction. It can even be applied\\nover parts that are quite tender. The rule of application to the chest\\nis the same as for the single stethoscope. The ear-pieces should fit\\ncomfortably. The humming sound in the tube is confusing at first.\\nThe Sounds in Health. It may be well to call attention to the\\nconfusion that always arises when the student is examining the chest\\nfor the first time. The probability is that the coincidence of heart-\\nsounds and lung-sounds in the chest prevents the discrimination of\\nthe latter sounds. If attention is paid to the respiratory rhythm\\nthey can be distinctly isolated. When the student is ausculting the\\nlungs he should place his hand on the thorax or the epigastrium and\\nfix his attention upon the two acts of respiration inspiration and ex-\\npiration. Note the occurrence of each movement, the expansion of\\ninspiration and the contraction of expiration Then analyze carefully\\nthe sounds during each event of a respiratory act. Having fixed the\\nattention on respiration, noted its divisions, and excluded cardiac\\nrhythm, note (1) the character of the sound in inspiration (2) the\\ncharacter of the sound in expiration (3) the relative length of the two.\\nBy this means the sounds of respiration are accurately ascertained, and\\nconfusing extraneous sounds, as from the heart, distinctly eliminated.\\nBronchial Breathing. If the stethoscope is placed over the\\ntrachea at the top of the sternum, a sound characterized as follows\\nwill be heard First, it attends inspiration and expiration with a defi-\\nnite pause between second, the inspiration and expiration are nearly\\nequal in length third, they are of a tubular, blowing character. The\\nexpiration is perhaps a little stronger and longer than the inspiration.\\nIf the mouth is closed, there is no change except that both inspiration\\nand expiration are harsher and sharper. Bronchial breathing is the\\nterm applied to the sound which is heard in this situation. It is one\\nof the normal sounds of the chest. It may be heard behind, at or a\\nlittle below the seventh cervical vertebra, feebler in quality than in\\nthe trachea, and in the interscapular space over the large bronchi as\\nthey leave the trachea. A sound heard in these areas, bronchial in\\ncharacter, is normal.\\nVesicular Breathing, or the Respiratory Murmur. If the\\near is applied over the anterior portion of the chest, or, better still, in\\nthe upper axilla or below the angle of the scapula behind, a sound is\\nheard both on inspiration and expiration. It differs from bronchial\\nbreathing, however, in that inspiration and expiration are changed in\\nlength. The sound of inspiration is twice or three times as long as\\nthe sound of expiration. The sound of inspiration is soft, breezy, or", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0537.jp2"}, "538": {"fulltext": "504 SPECIAL DIAGNOSIS.\\nsighing in character, increasing in intensity to the end of full inspira-\\ntion. It is immediately followed by expiration, which diminishes in\\nintensity as the air is expelled, and terminates when one-half or two-\\nthirds of the expiratory act is completed. The sounds can be imitated\\nbv breathing with the lips in the position required to pronounce f\\nor v.\\nCause of the Sounds. The sound is caused by the passage of air\\nthrough the nares into the wider pharynx when the mouth is closed.\\nThe sounds heard over the bronchi, the terminal bronchioles, and the\\nvesicles are probably created in the upper air-passages and transmitted\\nto the ear through the medium of the bronchi. Bronchial breathing\\nis the sound unmodified, transmitted to the ear, weakened only by its\\ndistance from the upper air-passages. The vesicular breath-sound is\\nthe same sound modified on account of the intervention of the air-\\nvesicles between the ear and the larger bronchi. The sound is thus\\nsmothered or dampened down. It was held that part of the sound of\\nvesicular breathing, if not the whole, was due to expansion of the vesi-\\ncles and rush of air through the bronchioles. The proof, however,\\nseems to be in favor of the first view given, chiefly because, when the\\nvesicular tissue is removed, as in pneumonia or other consolidation,\\neven far distant from the trachea, bronchial breathing is produced.\\nModifications of the Sounds in Health. Exaggerated Breath-\\nsounds. Bronchial breathing and vesicular breathing are increased in\\nloudness and sharpness by strong, rapid breathing. In some persons\\na sound is heard which partakes of the qualities of both bronchial\\nbreathing and the vesicular sound. It is noticed in the interscapular\\nregion about the level of the spines of the scapulae, replacing the pure\\nbronchial breathing which is heard in other individuals. Its characters\\nare, first, soft, blowing inspiration, or loud, harsh inspiration second,\\nslightly prolonged blowing expiration, more exaggerated, louder, but\\nnot harsher, than in health. The term broncho-vesicular is applied to\\nthis kind of breathing. It is due to the fact that the sound produced\\nin the upper air-passages is conducted to the ear less dampened down\\nor modified, because the air-vesicles which surround the bronchus are\\nhere smaller in number than are found in the remainder of the lung.\\nThe sounds are increased in children, in whom there are combined\\ngreater elasticity of the chest-wall and greater friction throughout the\\nsmaller bronchi, which are relatively larger. So distinct and charac-\\nteristic is the sound in children that the term puerile respiration is\\napplied to it. The sounds of inspiration and expiration are both in-\\ntensified or sharper than in healthy adults the latter is relatively pro-\\nlonged.\\nFeeble Breath-sounds. The sounds are modified by the condition\\nof the chest-walls. If they are thick, or there is an abundance of fat,\\nthe sounds are fainter or lessened in intensity. Feeble respiratory\\npower, in wasting and exhausting diseases, causes feeble breath-sounds.\\nThe condition of the upper air-passages, even if not pathological, mod-\\nifies the sound. If the glottis is small, or there is a disturbed relation-\\nship between the nose and pharynx, the sounds will be modified.\\nThey are usually weakened.", "height": "4400", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0538.jp2"}, "539": {"fulltext": "DISEASES OF THE LUNGS AND PLEURJE. 505\\nThe Sounds in Disease. It is well for the student to bear in mind\\nthat sounds heard in the chest which are departures from the normal\\nsounds always indicate disease.\\nVesicular Breathing Exaggerated. Bilateral, The vesicu-\\nlar breathing or respiratory murmur is increased, first, when there\\nis increase in the force of breathing when normal respiration is in-\\ncreased and the patient takes full, deep breaths. It is seen in some\\nforms of dyspnoea, as at the acme of Cheyne-Stokes breathing, or in\\nthe dyspnoea of diabetic coma. It may be increased or exaggerated\\nin certain forms of bronchitis, particularly when the small tubes are\\nnarrowed by inflammatory swelling.\\nUnilateral exaggeration or increase of vesicular breathing is heard\\nwhen the lung is acting vigorously or in a compensatory manner. The\\nstrong inspiration followed by strong and relatively prolonged expira-\\ntion of an actively moving lung signifies almost certainly disease of the\\nlung of the opposite side.\\nLocal exaggeration of vesicular breathing, the inspiration harsh, is\\nnoted in cases of phthisis in its earliest stages. It should be compared\\nwith the sound of the opposite side, when the difference can easily be\\nascertained. It is heard over the apex, in pneumonia or pleurisy of\\nthe base, and vice versa.\\nVesicular Breathing, Diminished or Absent. Bilateral. (1)\\nIt is lessened in all cases in which the expansion is interfered with. In\\nfeeble persons the respiratory murmur is weak, particularly at the\\nbases posteriorly. If the muscles of respiration are paralyzed or en-\\nfeebled, the murmur is also lessened. If the expansion is interfered\\nwith, on account of disease of the diaphragm, or pressure upward by\\naccumulations in the abdomen, it is weakened.\\n(2) Anything which lessens the amount of air supplied to the chest\\ndiminishes the vesicular breathing. It is, therefore, lessened in cases\\nof occlusion or obstruction of the nares, the pharynx, or the larynx.\\n(3) Thickened chest- walls that occur from disease, as oedema, weaken\\nthe respiratory sound.\\n(4) The vesicular breathing is weakened throughout the entire extent\\nof the lung in emphysema. The enfeebled respiratory forces and the\\nshort act of inspiration in this affection cause less air to enter the already\\noverfilled chest. Moreover, in the bronchitis that attends emphysema\\nthe bronchioles are all more or less occluded, and hence the air-supply\\nis diminished. These conditions lead to feeble respiratory murmur\\nexcept at the anterior margins of the lungs.\\nUnilateral diminution of breath-sounds occurs (1) when there is nar-\\nrowing of the bronchus, as in cases of aneurism or mediastinal tumor\\n(2) when there is pleural effusion, which (a) lessens the amount of air-\\npressure by compression of the lung and (6) interferes as a different\\nconducting medium. (See Fig. 136.) If pain in pleurisy, pleurodynia,\\nor neuralgia is present on one side, the breath-sounds of the affected\\nside will be lessened. Not only in pleural effusions from serum, blood,\\npus, or air, but also in thickened pleura there is weakness or faintness\\nof the respiratory murmur. It should not be forgotten that effusions\\nand thickenings of the pleura rarely take place bilaterally when they", "height": "4416", "width": "2592", "jp2-path": "practicaltreatis00muss_0_0539.jp2"}, "540": {"fulltext": "506 SPECIAL DIAGNOSIS.\\ndo occur the breath-sounds are weakened, but not to the same extent\\nas when an effusion is limited to one side.\\nLocal diminution of breath-sounds occurs in the early stages of phthisis\\nor in the earliest stages of pneumonia.\\nAlteration of the Rhythm. We take cognizance of the rhythm\\nof the sounds. In health the movement of inspiration and that of\\nexpiration are almost equal, but, as previously noted, the sound of in-\\nspiration is heard during the entire act, while that of expiration occu-\\npies the first third or so of the act. The sound produced during\\nexpiration may even be less than half the length of that produced\\nduring inspiration. The following proportion represents relative\\nlengths Ins. Exp. 3 1.\\nExpiration Prolonged. The first notable change in the rhythm\\nof respiration may be prolongation of expiration. When the expira-\\ntion is prolonged it equals inspiration, or may even be longer. This\\nis due to the difficulty of getting the air out of the chest expiratory\\ndyspnoea, a physical condition which enables the sound of expiration\\nto reach the ear. Hence, prolongation of expiration all over the chest\\nis seen in emphysema and asthma. In this condition the inspiration\\nis short, the expiration prolonged. Although distinct throughout the\\nchest, it is more pronounced above the clavicles and along the free\\nmargins of the lung anteriorly. It is prolonged in bilateral broncho-\\nvesicular breathing (q. v.).\\nLocal prolongation of the expiration is of great diagnostic significance.\\nIt occurs when areas of the lung are partially consolidated and the\\nelasticity thereby impaired. The respiratory murmur is harsh, or\\npuerile, or it may be weak. This condition obtains in tuberculosis,\\nand is one of the first physical signs of this affection.\\nJerking or Interrupted Inspiration. Instead of the smooth,\\neven, sighing, or breezy inspiration the sound is created in puffs or\\njerks, so that during the act of inspiration, as the chest expands, a\\nnumber of successive vesicular sounds are heard until the act is com-\\npleted. The physical condition which causes jerking inspiration, or\\ncog-wheel breathing, is found in the earlier stages of tuberculosis,\\nwhen the various bronchioles are more or less occluded by outgrowths\\nof tubercle. The air, therefore, enters different lobules at different\\nperiods of time, thereby giving rise to this peculiar broken sound. It\\nmust not be confounded with the same character of breathing that is\\nheard adjacent to the heart, due to the pressure of that organ, or of\\nstructures in intimate relation therewith, upon portions of the lung, on\\naccount of which air enters various areas in puffs. On the other hand,\\njerking inspiration sometimes occurs in health. It is simulated by the\\njerky act of inspiration in nervous patients. It is of no significance\\nunless attended by other physical signs.\\nIn cases of adhesion at the apex, particularly of the left lung, the\\nsame puffing or jerking inspiration is often heard. It is also present\\nin aneurism, or disease of the aorta, pressing upon a bronchus, causing\\nthe air to enter the part in an intermittent manner. When pathologi-\\ncal jerking breathing is present, the expiration is prolonged, and, if the\\ncase is under observation a sufficiently long time, bronchial breathing", "height": "4404", "width": "2576", "jp2-path": "practicaltreatis00muss_0_0540.jp2"}, "541": {"fulltext": "DISEASES OF THE LUNGS AND PLEUBJE.\\n507\\nwill usually replace the jerky respiratory murmur in progressive con-\\nsolidations. Small, moist rales, excited by coughing or a full breath,\\nusually attend jerking breathing when it is pathological.\\nBronchial Breathing. The normal situation of bronchial breath-\\ning in health has been indicated. If the same kind of breathing is\\nheard in any other portion of the lung it is pathological. It is gener-\\nally indicative of the presence of consolidation. The spongy lung-\\ntissue is replaced by solid conducting material, by which the bronchial\\nsound is conducted to the ear. It is heard, therefore, in all pathologi-\\ncal conditions in which consolidation takes place. It is the typical\\nform of breathing heard in pneumonia, in consolidation of the lung due\\nto tuberculosis (see Fig. 142), in hemorrhagic infarcts, and in lung\\nsyphilis. It must not be forgotten, however, that cases of pneumonia\\ndo exist without this type of breathing. This is the case when the\\nlarge bronchus supplying the lungs, or the bronchioles, are occluded by\\ninflammatory exudate. In tuberculous consolidation it may be absent\\nfor similar reasons. In central pneumonia, where consolidation is deep-\\nseated and surrounded by lung-tissue, bronchial breathing may not be\\nheard, or it may be postponed until the third or fourth day of the disease,\\nby which time consolidation will have reached the surface of the lung.\\nFig. 142.\\nConsolidated area.\\nFremitus increased.\\nVocal resonance increased.\\nDulness on percussion.\\nBronchial breathing.\\nIncreased vocal resonance\\nand fremitus. Dnlness.\\nCavity with cavernous\\nbreathing and gurgling\\nrales. Pectoriloquy.\\nHyper-resonance on per-\\ncussion.\\nConsolidation bronchial\\nbreathing. Increased\\nfremitus and resonance.\\nDulness on percussion.\\nTubercular infiltration.\\nImpaired resonance on\\npercussion.\\nCongestion\u00e2\u0080\u0094 crepitant and\\nsubcrepitant rales.\\nShowing phthisis at various stages. (Gibson and Russell.)\\nIn certain cases of pleurisy with effusion bronchial breathing exists.\\nThe accumulation is not great enough to compress the lung completely.\\nThe bronchial tubes remain patent, while the vesicular structure is\\ncompressed. Low-pitched bronchial breathing is heard under these\\ncircumstances. It is more pronounced at the upper layer of the effu-\\nsion. It is. always heard close to the spine posteriorly, where the lung\\nis compressed. Sometimes it is heard above the limit of the effusion,\\nin all probability because of relaxed tension of the lung.\\nVarieties of Bronchial Breathing. Its special characteristics\\nmust be borne in mind. (See p. 503.) It must not be forgotten that", "height": "4416", "width": "2592", "jp2-path": "practicaltreatis00muss_0_0541.jp2"}, "542": {"fulltext": "508 SPECIAL DIAGNOSIS.\\nbronchial breathing is not represented accurately in every instance by\\nthe sounds heard over the trachea. Its character may be modified and\\nyet approach that type of breathing. The modification occurs in one\\nor both of the two portions that go to make up the sound (1) The\\nblowing element may not be as distinct in inspiration as in expiration\\n(2) in rare cases, the characteristic blowing sound may not continue so\\nlong during expiration as to equal the inspiratory sound. On the other\\nhand, (3) the bronchial breathing may vary in pitch. At times it is\\n(a) high in pitch, both in inspiration and expiration, but with a pure\\nblowing quality (harsh) attending each. It may be (6) soft and low in\\npitch attending both acts. The strong, high-pitched sound emitted\\nby breathing deeply when the lips and tongue are placed in position\\nto pronounce ch is termed tubular breathing. It is the characteristic\\nsound of croupous pneumonia. (4) The loudness of the sound may\\nalso vary. This depends largely upon physical peculiarities of the\\nindividual. The condition of the chest-walls and the force of breathing\\ndetermine it.\\nWhen pleurisy with effusion coexists with pneumonia, the bronchial\\nbrea thing, which should be audible, is feeble and distant. Under the\\nsame circumstances a bleating sound replaces bronchophony. (See\\n-Egophony.)\\nMode of Determination. Breathing which may, during very\\nquiet respiration, appear to be normal, is sometimes discovered to\\nbe bronchial when the patient has a spell of coughing and then takes\\nseveral deeper breaths than usual in rather quick succession. Some-\\ntimes the noise made in nasal respiration obscures the pulmonary\\nsounds. The patient should be instructed to breathe with the mouth\\nopen, to take somewhat deeper breaths than usual, and to let expiration\\nfollow at once upon the close of inspiration. Many patients when told\\nto take deep breaths expand their lungs to the utmost, and then hold\\nthe air in a while, and allow it to pass out slowly. Such a method\\nusually defeats the purpose of the examiner, which is first to note the\\nrelative length of inspiration and expiration, and then the quality of\\nthe two sounds, first, as compared with each other, and, secondly, as\\ncompared with the normal. In listening for bronchial breathing the\\nattention should be fixed more upon the length and quality of the expi-\\nratory sound, and it is, therefore, important that the patient breathe so\\nas to bring out its characteristics more clearly this he can do by\\ntaking several moderately deep breaths in quick succession and with\\nthe mouth open.\\nModifications of Bronchial Breathing. If a case of tubercu-\\nLous consolidation is watched, it will be found after a time that the\\nbronchial breathing becomes lower in pitch. It is heard in inspiration\\nand expiration, but a more hollow quality attends the sound. From\\nthe hollowness of the tone the word cavernous has been applied to the\\nbreath-sound it is due to the formation of a cavity in the consolida-\\ntion, or to a dilated bronchus. It is a sign of a cavity. (See Fig. 142.)\\nCavernous breathing may have a metallic quality, and is then called\\nm j oric. It is analogous to the sound produced by blowing across\\nthe open mouth of a jar. A large cavity with smooth walls that com-", "height": "4412", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0542.jp2"}, "543": {"fulltext": "DISEASES OF THE LUNGS AND PLEUBJE. 509\\nmunicates with the air is the cause of the development of such sound.\\nIt is heard also in pneumothorax, when such communication exists.\\nThe metallic tone is analogous to the metallic percussion-sound. It\\noccurs under the same physical circumstances. The physical condition\\nwhich causes it may be so marked that the same character of tone is\\nimparted to rales produced in the cavity, or to the heart-sounds which\\nare transmitted by the solidified area surrounding the excavation.\\nBronchovesicular Breathing in Disease. The physical con-\\ndition is more or less consolidation surrounded by vesicular structure,\\nas in the early stages of tuberculosis. It is found midway in the\\nchange from respiratory murmur to bronchial breathing in progressive\\nconsolidations. The inspiration is higher in pitch the expiration\\nprolonged, harsh, and blowing or the former may be bronchial or\\ntubular, the latter absent. It may, however, be indistinct or masked\\nby rales. It is sometimes heard in the earlier stages of pneumonia,\\nand is the modified bronchial breathing heard over small consolidated\\nareas in capillary bronchitis and catarrhal pneumonia, with collapse of\\nlobules. The term transition breathing has been applied to this\\ncharacter of breath-sounds.\\nNew Sounds. The foregoing sounds are modifications of the nor-\\nmal sounds heard during the act of breathing. New sounds or adven-\\ntitious sounds are created in the lungs or in the pleura. In the lungs\\nthe term rales is applied to them, and in the pleura they are known as\\nfriction-sounds. Under the same head may be classified the succussion-\\nsound and metallic tinkling.\\nBales. Bales are sounds created in the bronchi, bronchioles, and\\nair-vesicles, or in pathological excavations (cavities). They are due\\n(1) to the passage of air through bronchial tubes which are narrowed,\\neither on account of swelling of the mucous membrane or on account of\\nspasm or (2) the passage of air through fluid (mucus, serum, pus,\\nblood). The former are called dry rales the latter moist rales, or\\ncrepitation. When the dry rales are continuous i. e., heard during\\nboth the acts of inspiration and expiration they are known as rhonchi.\\nDry rales are musical moist rales are not. When heard over con-\\nsolidated areas, the latter are, however, usually accompanied by over-\\ntones (resonance transmitted from the bronchi), and are then clear and\\nsharp consonirende Basselgerausche, Skoda.\\nDry Bales are divided into sonorous and (b) sibilant. The\\nformer are large rales, the character of which is indicated by the name.\\nThey are created in the large bronchial tubes. They are coarse, low-\\npitched musical sounds. Sibilant rales are created in small tubes, and\\nare high-pitched, whistling sounds. Both are heard only over the\\nareas of their creation, although the sonorous rale may be transmitted\\nall over the chest. They may be heard at the same time. The dry\\nrales are heard in the early stages of bronchitis, when the mucous\\nmembrane is swollen and thickened, but has not begun to secrete\\nmucus or mucopurulent matter. They are also heard in asthma\\nin which there is spasm of the bronchial tubes, and in the chronic\\nbronchitis of emphysema. In the latter the smaller rales are more\\ncommon.", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0543.jp2"}, "544": {"fulltext": "510 SPECIAL DIAGNOSIS.\\nMoist Rales, or Crepitation. They may be divided into large\\nor small rales the latter are also called subcrepitant. (See Fig. 142.)\\nThe crepitant rale is a fine rale, said to be created in the alveoli, due\\nto inflation of the cells, the walls of which have been held together by\\nexudation or fluid (oedema). It is a fine rale distinctly localized, resem-\\nbling the sound produced by rubbing a lock of hair between the fingers\\nor by putting salt on a hot plate. In the early stages of pneumonia\\nand in oedema of the lungs it is said to be pathognomonic. It may,\\nhowever, be heard whenever there is a small amount of fluid in the\\nalveoli and feeble respiratory action. The small, moist or subcrepitant\\nrales are created in the smaller bronchioles and the alveoli. They may\\nbe general or local. If general, they are due to bronchitis in the\\nsecond stage. There is an abundance of secretion in the terminal air-\\npassages which is thrown into vibration by the current of air during\\nthe act of breathing. The element of moisture is pronounced and\\ngives to them their quality, to which the term crackling is some-\\ntimes applied. They are found in congestion with outpouring and\\nstagnation of secretion in oedema and whenever fluid is drawn into\\nthe bronchi, as when there has been a hemorrhage in the upper pas-\\nsages. Small moist rales in local areas are found in phthisis, partic-\\nularly at the end of the first stage, on account of the local bronchial\\ncatarrh, and in the second stage for the same reason. They occur in\\nthe early stage of pneumonia, particularly in the area of the lung which\\nis the seat of collateral oedema adjacent to the consolidation. They\\nare also heard in the later stages of pneumonia when resolution has\\ntaken place. If this is reached, however, they may be replaced by\\nlarge rales. They may be heard around any consolidation because of\\ncongestion, oedema, or catarrh. It must not be forgotten that cough\\nor forced inspiration must be excited before rales can be definitely ex-\\ncluded.\\nLarge moist rales, or mucous rales, occur in the larger bronchial tubes,\\nor in cavities, from the same causes that produce small rales. The\\nfluid, however, is larger in amount, the air-current stronger, and the\\nspace for vibration is greater. While sometimes present in bronchitis,\\nthey are heard in their most marked form in the third stage of phthisis.\\nThey are described as bubbling and gurgling rales, and are very char-\\nacteristic after a full breath or a cough. (See Fig. 142.)\\nRales are to be distinguished from other adventitious sounds.\\nAlthough in some instances, as when rales are heard over the bases of\\nthe lungs, it is almost impossible to distinguish them from friction\\nsounds, they have nevertheless certain marked characteristics. We\\nrecognize rales, first, by the qualities previously mentioned. Second,\\nby their location; if the adventitious sounds are general, they are due\\nto rales. Third, rales are modified by cough or breathing. They may\\nbo intensified by either act, or, after the completion of the act, may\\ndisappear entirely. On quiet breathing, in the early stages of tuber-\\nculosis, for instance, they may not be heard at all. It is absolutely\\nnecessary, before excluding them, to have the patient cough and then\\nt;i l a full breath. Fourth, they vary in position. This may occur from\\nhour to hour. If the chest is examined in the morning, they may", "height": "4400", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0544.jp2"}, "545": {"fulltext": "DISEASES OF THE LUNGS AND PLEUBJE. 51 1\\nbe more pronounced, for instance, at the base. At another time in the\\ntwenty-four hours they are distinct at the apex. They are more likely\\nto be present at the base if the patient is kept in the recumbent posture.\\nFifth, they vary in character. At one time small, moist rales are\\nheard in a short time they are replaced by larger rales. Dry rales\\nare regularly followed by moist rales in the course of bronchitis. In\\na case of bronchial asthma all sorts of rales may be heard in a few\\nhours. Sixth, they are distant. They seem to be further away from\\nthe listening ear than are friction-sounds.\\nRales in the bronchi must not be confounded with the crepitant or\\nfine crackling sound which is heard at the base of the lung in patients\\nwho have been ill with the exhaustive fevers and who have not taken\\nfull breaths for some time. They disappear after the patient has in-\\nspired deeply half a dozen times.\\nRales throughout the lung are not, in themselves, diagnostic of any\\naffection save bronchitis, in which, with the absence of other physical\\nsigns, their occurrence all over the chest is significant. In the absence\\nof this affection rales at the base of both lungs are due to congestion.\\nRales at one apex, with failing health, point to the onset of tubercu-\\nlosis.\\nFriction-sound. In health the two surfaces of the pleura rub\\ntogether without making any sound. If they are inflamed, the sur-\\nfaces are roughened, as swelling and dilatation of the capillaries pro-\\nduce a more or less granular surface, or because of transudation of fluid\\nor lymph. Under these circumstances rubbing together of the two\\nsurfaces creates a sound, to which the term friction is applied. It is\\nheard at the end of inspiration, and may continue during expiration.\\nIt is a localized sound, usually at the seat of pain it is near the ear,\\nand is not modified by cough or full breathing, except occasionally\\nby the latter when repeated. It occurs in nests or bunches.\\nIt may be increased by the pressure of the stethoscope. Moreover, it\\nis a fixed sound, in that it does not disappear until effusion takes place.\\nIt may reappear again when the fluid subsides. The above character-\\nistics distinguish it from rales. Both, however, may occur together.\\nAlthough almost always of respiratory rhythm, when the pleurisy is\\nin the neighborhood of the heart, the friction may be of cardiac\\nrhythm. Under these circumstances it is more distinct during the act\\nof inspiration. It is heard as a systolic rubbing, often of respiratory\\nrhythm, along the borders of the heart.\\nWe not only distinguish the friction-sound by the characters just\\nindicated, but also by the presence of pain, which renders its existence\\nmore probable. Usually it is heard at the base, in the nipple-line in\\nfront, or at the angle of the scapula behind, and frequently in the\\naxillary region.\\nIn addition to the friction-sound of acute pleurisy, dry creaking\\nsounds, not unlike the sounds produced when an old door is swung on\\nrusty hinges, or when new leather is bent, are heard in cases of old\\npleurisy. Other physical signs of pleural adhesions are present, and a\\nfriction-fremitus is often transmitted to the hand. An old or dry fric-\\ntion is often heard at the apex, in the neighborhood of old cavities. It", "height": "4416", "width": "2592", "jp2-path": "practicaltreatis00muss_0_0545.jp2"}, "546": {"fulltext": "512 SPECIAL DIAGNOSIS.\\nattends both inspiration and expiration, is not modified by cough, nor\\nhas it any of the elements of the moisture that attends moist rales.\\nThe patient may be cognizant of the grating or rubbing sensation, and\\nbe able to describe the sensation during each breath. It may continue\\na long time after an acute pleural effusion has disappeared, and is\\nsometimes the source of anxiety upon the part of the patient.\\nPvasmic deposits in the lungs, infarction, bronchiectasis with reactive\\npneumonia, and pleurisy with emphysema, are first revealed by pleu-\\nritic frictions (Vierordt). At the base of the right lung they may\\nbe the first indication, or at least an early one, of hepatic abscess\\n(Clark). The pleural friction in the hepatic region must not be con-\\nfounded with peritoneal friction of respiratory rhythm. In a case\\nof secondary cancer of the liver a friction-sound was heard in the\\nseventh interspace from perihepatitis over a cancerous nodule.\\nMetallic Tickling. The impression imparted to the listener is\\nthat of the falling of some material into fluid in a hollow space. The\\nphysical condition is that of a cavity partly filled with fluid, partly\\nfilled with air, into which there is dropping from an opening above.\\nIt is seen in hydropneumothorax or pyopneumothorax and in a few\\ncases of large cavities. The air-chamber acts as a consonance-box and\\nresonator, and gives a metallic quality to the sound. Other physical\\nsigns of cavity and fluid are associated. It may be heard when the\\npatient is breathing quietly, or only after coughing. Sometimes only\\ntinkling is heard, or the sound of a number of drops is transmitted.\\nThe latter occurs after coughing.\\nBell-tympany. The bell-sound is heard when air is confined in\\nthe pleura. If the stethoscope is placed over the pleural cavity, and\\ntwo coins are used as plessor and pleximeter, a distinct metallic or\\nanvil-sound is transmitted to the ear. The cavity containing air can\\nbe clearly outlined if the metal pleximeter is moved about. As soon\\nas it passes over a part of the chest under which no air is confined the\\nsound is not heard. Although heard in nearly all cases of pneumo-\\nthorax, there are some cases in Avhich it cannot be elicited, probably\\nbecause of the small size of the aperture in the pleura.\\nSuccussion. The ear is placed to the side of the chest, and the\\npatient s body moved suddenly by himself or by the observer. A\\n-plashing sound is heard. It can only be produced when there is air\\nas well as fluid present in a cavity. It was first described by Hippo-\\ncrates, and the term Hippocratic succussion has been given to it.\\nIt is characteristic of hydropneumothorax, although not present in all\\ncases of this disease. The sound may be audible at a distance. Metal-\\nlic tinkling can usually be heard at the same time.\\nAuscultation of the Voice. When the ear or stethoscope is applied\\nto the surface of the chest and the patient is asked to speak, the vibra-\\ntion- of the air in the trachea and bronchial tubes are transmitted to\\nili\u00c2\u00ab chest-wall and become audible. The sound is known as the vocal\\nresonance, it is a si ^n which goes hand-in-hand with vocal or tactile\\nfremitus and is modified by the same conditions which modify the\\nlatter. While, in general, conditions which increase the fremitus\\nincrease the vocal resonance also, this is not invariably the case.", "height": "4408", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0546.jp2"}, "547": {"fulltext": "DISEASES OF THE LUNGS AND PLEURAE. 513\\nSometimes one is increased and not the other, without there being any\\nevident reason for it.\\nVocal Resonance in Health. It varies in health conjointly with\\nthe fremitus. The sound is purring or buzzing. It is heard more\\npronouncedly at the right apex than at the left in persons with thin\\nchest- walls in individuals in whom the voice is low in pitch and\\nstrong. It is lessened, therefore, in females and children. It dimin-\\nishes the further away the ear gets from the larynx, and hence is\\nfeebler at the bases. It is immaterial what words are selected by the\\npatient to create the resonance. It is important for the student, how-\\never, to become familiar with the resonance of a definite series of words\\nwhich when pronounced do not need any marked change in inflection\\nof the voice. The words one/ two, three, or ninety-nine,\\nspoken repeatedly, are selected. The patient should not raise or lower\\nhis voice during the act of speaking. Symmetrical portions of the two\\nsides of the chest must be examined successively.\\nVocal Resonance Increased. Increased vocal resonance de-\\npends upon the intensity or extent of the cause. When slightly above\\nnormal it is referred to as slight increase, or when the voice is trans-\\nmitted comparatively distinctly to the ear it is known as bronchophony.\\nThis may be heard in health over the trachea, or over the bronchi be-\\nhind. When heard over the vesicular structures of the lung, it indi-\\ncates that the vibrations are transmitted to the ear by some better\\nconducting material. This is usually a consolidated lung, and hence\\n1. In all cases of consolidation the resonance is increased, that is, bron-\\nchophony is created but in pneumonia, if the bronchus is occluded by\\nexudate, it is absent. 2. If the lung is collapsed but the bronchi open,\\nthe resonance is increased. 3. It is also increased in cavities. Some-\\ntimes the resonance is intensified and the sound is even more pro-\\nnounced than when heard over the trachea.\\nPectoriloquy. The voice may be so distinctly transmitted that\\nwe have the impression that the patient is speaking into the mouth of\\nthe stethoscope. If the patient speaks slowly the words may be dis-\\ntinctly heard. It is more striking when the patient whispers. The\\nterm whispering pectoriloquy is then applied to it. It is detected\\nover a cavity if it communicates with a large bronchus, and sometimes\\nin consolidation of the lung.\\nVocal Resonance Diminished. Vocal resonance is diminished\\nor absent when anything cuts off the supply of air, and intercepts the\\nvibrations from the part over which the observer is auscultating. Frem-\\nitus and resonance are absent over the area supplied by a bronchus\\nwhich is occluded by external pressure, as an aneurism. Diminution\\nor absence of vocal resonance is more marked in cases of pleural effu-\\nsion (serum, blood, pus, or air) or thickened pleura. The vibrations\\nare impeded because of the difference of conducting material. The\\ndegree of diminution depends upon the amount of effusion.\\nModifications of Vocal Resonance. 1. At the uppermost\\nlimit of the pleural effusions, at which point the layer of fluid is thin,\\nthe resonance is transmitted in a modified form. It is tremulous and\\nbleating in character, and is known as cegophony because it resembles\\n33", "height": "4416", "width": "2592", "jp2-path": "practicaltreatis00muss_0_0547.jp2"}, "548": {"fulltext": "514 SPECIAL DIAGNOSIS.\\nthe bleat of a goat. It is especially heard at the angle of the scapula,\\nor below it in cases of moderate effusion. It is due to the fact that\\nthe fundamental tones are intercepted by the fluid, while the other\\ntones are allowed to pass through and give the peculiar bleating sound\\n(Gee). 2. The vocal resonance may have a metallic character in pneu-\\nmothorax when there is free communication with the bronchus.\\nCavities. Pulmonary cavities are due to destruction of lung by\\nabscess, gangrene, or tuberculosis, or to dilatation of the bronchi.\\nAs there is usually a local increase in the amount of air in cavities,\\nthere is in consequence a local area of exaggerated resonance, or tym-\\npany, and with it the occurrence of cavernous breathing, or breathing\\nof an amphoric type. The presence of a cavity, however, is often diffi-\\ncult to recognize, because of the relation to the surrounding structure\\nor because of fluid contents. If the lung about it is the seat of con-\\nsolidation, the physical signs of this consolidation may over-ride the\\nsigns of a cavity. If compensatory emphysema surrounds the cavity,\\nit may be almost impossible to recognize it. Moreover, the contents\\nof the cavity render the recognition of its presence difficult. If it con-\\ntains a large amount of fluid, the signs of consolidation alone may be\\npresent. Much attention has been paid to the recognition of cavities,\\nand some methods have been proposed by which it is thought they can\\nbe distinguished. While it is a satisfaction to determine exactly the\\npresence and location of a cavity, it is not an essential to diagnosis.\\nTo confirm the presence of an excavation, even if the physical signs\\npoint to its occurrence, the diagnosis should be controlled by exami-\\nnation of the sputum. If, on such examination, yellow elastic tissue\\nis found, the presence of a cavity is more probable. The methods\\nemployed to determine their presence absolutely have been named after\\nthe observers who devised them.\\nFirst, WintricNs change of sound. If the cavity communicates with\\na large column of air in the bronchus, and percussion is employed with\\na moderate degree of force, the note will change as the patient alter-\\nnately opens and closes the mouth. If the mouth is open wide, the\\nsound is louder and more distinctly tympanitic and higher in pitch.\\nIf the mouth is closed, the sound is correspondingly lessened and not\\nso tympanitic. Indeed, sometimes a sound is obtained with scarcely\\na trace of tympany. This change of sound is in all probability due to\\nchange in the resonant cavities in the upper respiratory tract. It must\\nnot be confounded with Williams tracheal tone, which can be\\nelicited near the junction of the clavicle and sternum on the left side,\\nin cases of consolidation of the underlying portion of the lung, partic-\\nularly if the force of the blow is directed toward the trachea. Strong\\npercussion is necessary to bring out Williams tone.\\nSecond, interrupted change of sound, also described by Wintrich, is\\ndistinguished from the simple change, in that it occurs in different\\npositions of the body. It may be heard when the patient is in an\\nupright position, and disappear when he assumes the recumbent posture\\n01* the converse may be true. The change in position changes the\\nrelation of the bronchus to the cavity, on account of which the varying\\ntympanitic sound is produced.", "height": "4408", "width": "2576", "jp2-path": "practicaltreatis00muss_0_0548.jp2"}, "549": {"fulltext": "DISEASES OF THE LUNGS AND PLEUBJE. 515\\nThird, Gerhard? s change of sound. This change depends upon the\\nalteration of the level of the fluid when the patient assumes the up-\\nright, or the dorsal position. It is not necessary that the cavity com-\\nmunicate with the large bronchus. It is a positive symptom of a cavity,\\nbut rarely present. The sound changes in pitch and in the degree of\\ntympany. It may be absolutely dull over the lower part of the cavity\\nwhen the upright position is assumed, because the fluid gravitates to\\nthis portion and comes in contact with the chest-wall.\\nFourth, Friedreich s respiratory change of sound. Respiratory per-\\ncussion. (Da Costa.) The pitch of the sound becomes higher at the\\nend of a deep inspiration. It depends upon increased tension of the\\nchest-wall and lung-tissue, and the wall of the cavity, during the act\\nof inspiration. It may be a source of confusion, which is obviated by\\npercussing at the same stage of the breathing each time, or percussing\\nonly on superficial breathing.\\nFifth, Seitz has called attention to a form of breathing named meta-\\nmorphosing. Inspiration begins harshly bronchial, then becomes faintly\\nbronchial, the latter sound being heard also in expiration. It is said\\nto be a sure sign of cavity.\\nResume. The student must bear in mind in auscultation to note\\n(1) If the sounds are increased or diminished in intensity (2) the\\nrhythm of the inspiratory and expiratory sounds (3) if the respiratory\\nmurmur is replaced by bronchial breathing or its modification (4) the\\npresence of new sounds (rales and friction) (5) the voice-sounds.\\nMensuration. By mensuration or thoracometry, the results secured\\nby palpation are confirmed more accurately. The size and the degree\\nof expansion of the chest are ascertained. Hence the circumference\\nand diameter of the chest are determined and the differences in the\\nshape and movement of two sides made manifest. If the measure-\\nment is taken from day to day, it can be graphically recorded by\\ntracing sections on paper, and delicate changes can thus be definitely\\nascertained. The circumference of the chest is measured by means of\\nthe ordinary tape-measure or by metal tapes joined together by a\\nhinge. The latter can be made to fit the circumference of the chest\\naccurately, and are essential in order to transfer the section to paper.\\nThe middle of the hinge is held firmly over the spinous process of the\\nvertebra, while the two limbs are carried around the chest, moulded\\nto all inequalities, and crossed in front, one above the other a mark\\nis made on each Avhere it crosses the middle line. Measurements\\nshould be taken at about the level of the nipples, and two inches below\\nthem, and care should be taken to have the level the same in front and\\nbehind. They should be taken in full inspiration and expiration, and\\nin repose. The outline secured by this method need not be disturbed,\\nas by flexion on the hinges we are enabled to remove it intact. The\\ntapes are carefully transferred to a sheet of paper, on which imaginary\\ndiameters have been marked. After fixing the corresponding points of\\nthe tapes on the lines of the respective diameters, the outline can then\\nbe traced.\\nWoillez s cyrtometer is a chain with links which is used to ascertain\\nthe exact circumference. The diameter of the thorax is secured by", "height": "4404", "width": "2560", "jp2-path": "practicaltreatis00muss_0_0549.jp2"}, "550": {"fulltext": "51C SPECIAL DIAGNOSIS.\\nmeans of caliper compasses. The antero-posterior diameter should be\\ntaken on a level with the nipple and the insertion of the second rib\\nbehind the transverse diameter at the highest points of the axillae.\\nThe length of the chest may be ascertained by measuring in the mid-\\nclavicular line from the clavicle to the border of the ribs. It is im-\\nportant to remember that the right side of the chest measures a little\\nmore than the left in people who are right-handed.\\nThe respiratory capacity is estimated by measurement of the circum-\\nference of the chest. This is secured by taking the measurement at\\nthe end of complete expiration and then at the end of complete inspi-\\nration. In health the difference between the two should be from five\\nto ten centimetres (two to four inches). If the expansion is less than\\ntwo inches, it is considered deficient by insurance companies, and the\\nrisk is not regarded as first-class. The expansion is less in women.\\nIn taking the measurement the observer must be particular to keep the\\nterminal portion of a tape-measure fixed in the median line of the\\nstructure. The other portion is to be held in the hand, so as to move\\nwith inspiration and expiration. Always mark in advance the ante-\\nrior mesial line and note the exact level at which measurements are\\nmade when they are taken daily. Deficiency of chest-expansion not\\nonly indicates the presence of a local morbid process notably incipi-\\nent tuberculosis, but it also indicates lack of strength and of muscular\\ndevelopment, of physiological deficiencies, rather than physical, and is\\nan unerring guide to the need of respiratory gymnastics.\\nSpirometry. By means of the spirometer Dr. John Hutchinson\\nhas been able to estimate the quantity of air taken in with each inspi-\\nration and discharged with expiration. By it the respiratory or vital\\ncapacity is estimated. The data ascertained are not of much diagnostic\\nsignificance, although if measurements are made from day to day we\\nmay be able to estimate the extent of recovery from disease of the lung\\nwhich was incapacitated. When, however, there is an important\\ndiminution of lung-capacity, tuberculosis may be suspected, before\\nsubjective and objective signs warrant a diagnosis. We can also esti-\\nmate the degree of interference with breathing by disease below the\\ndiaphragm. Spirometry is of particular value because it shows in a\\ngraphic manner the need for respiratory gymnastics. By means of\\nWaldenburg s pneumotometer the respiratory pressure of air on inspi-\\nration and expiration is determined. Expiratory pressure is dimin-\\nished in emphysema, and the degree of diminution may furnish a clue\\nto the severity of the disease or the degree of improvement. It is\\nto be remembered that the expiratory pressure always exceeds the inj\\nspiratory pressure in health by as much as 20 to 30 millimetres, accord-\\ning to Waldenburg. It is natural to find that inspiratory pressure is\\nlessened in stenosis of the air-passages, in phthisis and in pleural effu-\\nsions, although it is not of diagnostic significance.\\nThe following measurements, secured by laborious investigation, are\\nexeellenl criteria from which pathological inductions can be made.", "height": "4392", "width": "2584", "jp2-path": "practicaltreatis00muss_0_0550.jp2"}, "551": {"fulltext": "DISEASES OF THE LUNGS AND PLEURAE.\\n517\\nMeasurements of the Chest and Lung Capacity.\\n(Otis, Boston Medical and Surgical Journal, 1895.)\\nTable I. Chest Measurements.\\nGirth muscular. Men\\nAverage of Dr. E 0. Otis, 1000 measurements,\\nbetween sixteen and forty years of age\\nAverage of Dr. Hitchcock, of Amherst College,\\n8000 measurements\\nAverage of E. Hitchcock, J., of Cornell College,\\n15,000 measurements\\nGirth, muscular. Women:\\nMt. Holyoke and Wellesley students. Measure-\\nments of Miss Wood and Dr. Mary Colton\\nChest, respiratory. Men:\\nAverage of Dr. E. O. Otis, 1000 measurements\\nChest, respiratory. Women\\n50 per ct. of 1500 of Wellesley students, Miss Wood\\nDepth of chest. Men\\nAverage of Dr. E. O. Otis, 1250 measurements in\\nrepose and 362 inflated\\nDepth of chest. Women\\n50 per ct. of 1500 students at Wellesley, Miss Wood\\nBreadth of chest. Men\\nAverage of Dr E. O. Otis, 400 measurements\\nRepose,\\ninches.\\nInflated,\\ninches.\\nDifference,\\ninches.\\n34.0\\n36.1\\n2.1\\n34.6\\n36.5\\n1.9\\n34.5\\n36.3\\n1.8\\n29.5\\n31.5\\n3.0\\n31.1\\n33.1\\n2.0\\n24.6\\n27.2\\n2.6\\nTable II.\\nMen\\n6.9\\n9.9\\nCapacity of Lungs.\\n8.3\\n10.8\\nAverage of Dr. E. O. Otis, 1000 measurements\\nHitchcock, 8000 measurements\\nHitchcock, Jr., 15,000 measurements\\nWomen\\nMt. Holyoke and Wellesley students, measurements of Miss Wood\\nand Dr. Mary Colton\\n50 per cent, of 1500 Wellesley students, Miss Wood\\n0.8\\n0.9\\nCubic inches.\\n240.6\\n230.0\\n236.6\\n145.8\\n150.3\\nTable III. Comparison of the vital or lung capacity and the amount of\\nair expelled after an ordinary quiet respiration.\\nAverage of Dr. E. O. Otis, 150 measurements.\\nVital capacity, or the amount of air exhaled after a full inspiration\\nAmount of air exhaled after an ordinary quiet respiration\\nDifference, or complemental or reserve air\\nDifference as given by Hermann\\nAverage Lung Capacity for Height (Otis).\\nCubic inches.\\n230.5\\n129.3\\n101.2\\n97.6\\nHeight.\\n66 to 67 inches inclusive.\\n167.7 to 170.3 centimetres.\\n67 to 68 inches inclusive.\\n170.3 to 172.8 centimetres.\\n68 to 69 inches inclusive.\\n172.8 to 175.4 centimetres.\\n69 to 70 inches inclusive.\\n175.4 to 177.9 centimetres.\\n70 to 71 inches inclusive.\\n177.9 to 180.5 centimetres.\\n71 to 72 inches inclusive.\\n180.5 to 183.0 centimetres.\\nGeneral average\\nLung capacity.\\n231.62 cubic inches.\\n3797 cubic centimetres.\\n237.10 cubic inches.\\n3903 cubic centimetres.\\n244.44 cubic inches.\\n4007 cubic centimetres.\\n259.34 cubic inches.\\n4250 cubic centimetres.\\n261.38 cubic inches.\\n4284 cubic centimetres.\\n261.34 cubic inches.\\n4284 cubic centimetres.\\nAverage for each inch or\\ncentimetre in height.\\n3. 4 -4- cubic inches.\\n22.4 cubic centimetres.\\n3.46 cubic inches.\\n22.7 cubic centimetres.\\n3.5 cubic inches.\\n23.06 cubic centimetres.\\n3.66 cubic inches.\\n24.06 cubic centimetres.\\n3.64 cubic inches.\\n23.9 cubic centimetres,\\n3.5 cubic inches.\\n23.03 cubic centimetres.\\n3.52 cubic inches, for each inch of height.\\n23.19 cubic centimetres, for each centimetre of height.", "height": "4416", "width": "2548", "jp2-path": "practicaltreatis00muss_0_0551.jp2"}, "552": {"fulltext": "518 SPECIAL DIAGNOSIS.\\nPowel lays great stress upon the fact that in phthisis the inspiratory\\ncapacity is diminished, but the expiratory power remains normal.\\nCombination of Physical Signs. In order to determine the physi-\\ncal condition of the lung, it is necessary to draw conclusions from the\\nresults obtained by all the methods of physical examination. It is the\\nexception that any one sign is pathognomonic of a physical condition.\\nIf the student will glance over the abnormal physical conditions which\\nmay take place in the lung, he will find that they may be divided,\\nfirst, into physical changes in the lung proper, and, second, into physi-\\ncal changes in the pleura. With regard to the lung, it will be further\\nnoted that the changes are due to an increased amount of air or to a\\ndiminution in the amount of air.\\nIncrease in the amount of air may be general, unilateral, or local,\\nand is indicated by a combination of physical signs which are usually\\nunerring. On inspection (a) enlargement, general, unilateral, or local\\n(b) increased action in general emphysema, although with diminished\\nrespiratory excursion when unilateral or local, increased action and\\nincreased expansion (compensatory emphysema). On palpation, in-\\nspection confirmed, and vocal fremitus diminished when the increased\\namount of air is general, slightly increased when it is unilateral or\\nlocal. On percussion in each instance exaggerated resonance or tym-\\npany. On auscultation, when general (emphysema), feeble respiratory\\nmurmur, with prolonged expiration when unilateral or local, exagger-\\nated respiratory murmur. The difference in the physical signs of\\nincreased amount of air is not due to the difference in quantity, but\\nto the associate physical condition and the force of the movement of\\nthe air. The diminished expansion and feeble respiratory murmur in\\nemphysema are due to inability to exhale the air because of the dimin-\\nished elasticity of the lung, while the bronchioles occluded from bron-\\nchitis lessen the fremitus. In cavities local increase of air the\\nphysical condition of the .tissue which surrounds them modifies the\\nphysical signs.\\nDecrease in the Amount of Air. The diminution in the amount of\\nair from change in the physical condition of the lung is due to consoli-\\ndation or to collapse. The latter occurs when the bronchus is obstructed,\\nthe former in congestion, pneumonia, gangrene, abscess, forms of tuber-\\nculosis, and hemorrhagic infarct. The physical signs are the same\\nunder all circumstances, except in collapse expansion lessened, fremi-\\ntus increased, dulness, bronchial breathing. The signs vary with the\\ndegree of consolidation as follows Slight increase to greatly increased\\nfremitus, impaired resonance to complete dulness, broncho-vesicular to\\nbronchial breathing. In tuberculosis there may be flattening of the\\nchest-wall, but otherwise the signs are the same. The presence of\\nnew sounds depends upon the amount of secretion or fluid, as is the\\ncase when there is increase of air in the part.\\nBroadly speaking, therefore, in affections of the lung proper, the two\\nconditions just mentioned must be differentiated air increased, air\\ndiminished. We do not refer to bronchitis, because no physical change\\ntakes place in the lung, and the signs depend upon the amount of\\nfluid in the tubes.", "height": "4400", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0552.jp2"}, "553": {"fulltext": "DISEASES OF THE LUNGS AND PLEURjE. 519\\nThe Pleura. If satisfied that the physical condition is not due to\\nchange in the lung structure, the state of the pleura must be investi-\\ngated. Here, too, the physical condition may be due to an excessive\\naccumulation of air or to an accumulation of fluid or solid material.\\nIn effusion there is enlargement of the affected side, diminished move-\\nment, diminution of fremitus and of vocal resonance. When air is\\npresent, however, there is tympany when fluid, there is dulness on\\npercussion.\\nThe problem may, however, be looked at from another side. 1. The\\npercussion-note is tympanitic and indicates that there is an increased\\namount of air. Is this in the pleura or in the lung If in the pleura, it\\ncan only be unilateral, and is recognized by diminution of the move-\\nment and of fremitus, as against increased movement and fremitus\\nwhen due to unilateral increase of air in the lung proper (compensatory\\nemphysema). 2. The percussion-note is dull and iudicates the absence\\nof air. Is this in the pleura or in the lung A distinction between\\nconsolidation and pleural effusion must be made. In consolidation\\nthere are increased fremitus, increased vocal resonance, bronchial breath-\\ning, and dulness on percussion. There may or may not be contrac-\\ntion. In pleurisy with effusion, diminished or absent movement, absent\\nfremitus and resonance, dulness on percussion, feeble, distant, or absent\\nbreath-sounds. The distinction of the two physical conditions seems\\neasy, and yet the physical signs may not be sufficiently definite to\\nwarrant a positive conclusion. There are cases in practice in which it\\nis almost impossible to determine which is present. It has been stated\\npreviously that bronchial breathing may be present in pleural effu-\\nsions. To add to the difficulty in certain cases of consolidation it may,\\nhowever, be absent, and so may the vocal fremitus and resonance.\\nApart from the associate general and local symptoms, we must look\\nto two methods of corroborative proof of the presence of fluid. First,\\nexploratory puncture and, second, displacement of organs. The former\\nhas been spoken of. The latter includes displacement of the heart to\\nthe right or to the left, depending upon the seat of the effusion dis-\\nlocation of the liver and, in cases of left pleural effusion, obliteration\\nof the half -moon space (Traube s line).\\nSputum.\\nThis term is applied to all the products of secretion of the mucous\\nmembrane of the respiratory tract, and other substances that may be\\nbrought up through the respiratory tract. The characters of sputa in\\ndisease vary with the part affected, as well as with the pathological\\nnature of the disease. It is always well to examine each specimen\\nboth macroscopicatty and microscopically.\\nMethod of Collection. Sputum that is to be examined should\\nbe collected in perfectly clean vessels, containing no fluid, preferably\\nin glass or white earthenware spittoons, and care should be exercised\\nagainst the entrance of any extraneous substances, as tobacco or parti-\\ncles of food from the mouth, or from outside sources, or from the\\nstomach through vomiting. Tobacco, prunes, and bread crusts are at", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0553.jp2"}, "554": {"fulltext": "520 SPECIAL DIAGNOSIS.\\ntimes mistaken for blood. It is also necessary to see that the matter\\nsent for examination is derived from the lungs, and is not simply the\\noral and faucial accumulation. If practicable, the mouth and pharynx\\nshould be first rinsed with a warm alkaline solution. The true sputum\\nis coughed up.\\nAVe usually require in the examination one or two glass dishes or\\nplates, a large and a small piece of window-glass, mounted needles, and\\nforceps for microscopic work, in addition to these, a good microscope\\nand accessories, and certain staining fluids. Sputa which upon exam-\\nination has been found to contain tubercle bacilli should not be allowed\\nto dry in the air, but should be thoroughly mixed with a 1 20 car-\\nbolic acid solution, or a 6 per cent, formalin solution should be added\\nto the sputa after the examination is completed.\\nIn describing sputum we note the quantity in twenty-four hours\\nits color, odor, specific gravity, its composition and consistency, whether\\nmucous, purulent, mucopurulent, frothy, watery, bloody, tenacious or\\nviscid, and whether it is made up of separate layers or is homogeneous.\\nThe quantity in twenty-four hours varies from a few c.c. to even\\n1000 c.c, as in a discharging empyema.\\nThe color changes with the composition and the nature of the disease.\\nThus, in acute bronchitis and oedema of the lung it is white in puru-\\nlent sputa, no matter what the cause, it is yellow or greenish-yellow\\nin pneumonia, rusty in abscess of the liver with amoebse character-\\nistics, brownish-red or like anchovy sauce.\\nThe odor is characteristic in a few cases only. That of bronchiec-\\ntasis, gangrene, and putrid bronchitis is particularly heavy and fetid\\na characteristic which renders its origin almost unmistakable.\\nThe reaction is always alkaline.\\nThe specific gravity may vary from 1.0043 (mucus sputum) to\\n1.0375 (serous). (Von Jaksch).\\nVarieties of Sputum. Mucus sputum, on account of the mucin,\\nis usually glairy, clear, and tough. It is seen in acute bronchitis in\\nthe early stage, and in oedema of the lung. In health a small amount\\nof mucus is expectorated, which in cities and smoky towns is apt to\\ncontain black pigment-particles, due to inhaled soot.\\nPurulent sputum is composed almost entirely of pus. Typical\\npurulent sputum is that from an empyema discharging through a bron\\nchus. It may also occur in bronchiectasis, chronic bronchitis, abscess\\nof the lung, of the liver, or more rarely of the mediastinum, discharging\\nthrough a bronchus or it may be the discharge of a tubercular\\nvomica. The special condition can usually be determined by micro-\\nscopical examination and the accompanying symptoms and signs.\\nMucopurulent Sputum. It is most common to have mucus and\\npus mixed together in varying proportions, and then it is termed\\nmucopurulent. Such sputa may be found in the same conditions as\\npurulent sputa. AVhen flat, coin-shaped masses are formed, sinking\\nto the bottom if the vessel contains water, as in phthisis and chronic\\nbronchitis, it is known as nummular sputum; or it may be more\\nspherical, and is then called globular. At times the sputa may be\\nscon to separate into three distinct layers, the upper frothy, mucopuru-", "height": "4408", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0554.jp2"}, "555": {"fulltext": "DISEASES OF THE LUNGS AND PLEUEJE. 521\\nlent, greenish-yellow, or dirty-green, sometimes lumpy, sometimes\\ncomposed of shreds the middle thin and watery, with shreds from\\nthe upper layer and the bottom layer, apparently made up of pus\\nand debris, opaque, and without air-bubbles. It points to gangrene\\nof the lung in most instances, but may also occur in bronchiectasis.\\nWatery or serous sputum is the result of oedema of the lung.\\nSuch sputum, also called albuminous expectoration, is discharged after\\nparacentesis of the chest. Beginning during or as late as two hours\\nafter the operation, from one to three pints may be discharged in a few\\nhours.\\nBloody Sputum Haemoptysis. As blood in sputum is always\\nof importance, the entrance of substances as mentioned above, which\\nsimulate it in appearance, should be guarded against. It may be seen\\nin greatly varying quantities and have many different sources, and it\\nmay be of slight or grave significance. It may come from the gums,\\nnose, pharynx, or larynx, and in all cases such sources should be exam-\\nined. Again, there may be cases in which bleeding from the stomach\\n(hrematemesis) or oesophagus simulates hemorrhage from the lungs,\\nbut still more often people speak of vomiting blood that really has\\ncome from the lungs. Usually that from the lungs is much more\\nfrothy and bright-red, Avhile that from the stomach is darker and\\nacid, and may contain particles of food. Diagnosis is more difficult\\nwhen some blood from the lungs is first swallowed and then vomited.\\nUsually there is a distinct history of preceding cough, and for some\\ntime afterward small amounts of blood continue to be expectorated.\\n(See Lungs Hemorrhage.)\\nSmall amounts of blood streaking the mucus sputum or appearing\\nin small clots often come from the throat or nose or upper air-pas-\\nsages, but may come from the lungs. Mucopurulent sputum streaked\\nwith blood is frequently indicative of phthisis. In pneumonia the\\nrusty sputa are the result of an admixture of mucus and blood, and\\nusually contain small air-bubbles. When the blood-coloring matter\\nis changed there may be a yellowish or greenish tinge. In certain\\ncases of chronic pneumonia, in which the blood remains longer in the\\nlung-tissue, the expectoration has a darker color. The same color may\\nbe observed when there is a slight leakage from an aneurism. Pneu-\\nmonia accompanied by expectoration of large amounts of blood is often\\nof tuberculous origin. Blood may be mixed with the greenish expec-\\ntoration of gangrene. According to Finlayson, this is especially true\\nin children. In chronic valvular disease of the heart, and in oozing\\nfrom aneurism, frothy mucus containing more or less blood is com-\\nmonly seen. Currant-jelly sputa are more or less characteristic of\\nmalignant growths of the lungs, while the expectoration from a liver\\nabscess with amoebse is reddish-brown in color, from the mixture of\\nblood, pus, and bile-elements, and is not unlike anchovy sauce.\\nWe may have hemorrhage from the lungs as part of a general hemor-\\nrhagic tendency, as in purpura and hemorrhagic smallpox in so-called\\nvicarious menstruation there may be haemoptysis. But a patient\\npresenting such symptoms should be examined with the greatest care,\\nto exclude actual pulmonary complication. When great quantities of", "height": "4412", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0555.jp2"}, "556": {"fulltext": "522\\nSPECIAL DIAGNOSIS.\\nblood are expectorated we suspect tuberculosis of the lung, aneurism, or\\ncardiac valvular disease.\\nThe unaided eve may distinguish other foreign substances, such as\\nfibrinous and spiral casts of the bronchi or trachea but full considera-\\ntion of them will be given further on.\\nMicroscopical Examination of the Sputum. (See Fig. 143.)\\nWhite blood-corpuscles, usually of the polymorphonuclear variety,\\nare present in all sputa, but in varying numbers and size. They are\\nmost abundant in purulent sputa. Often they contain fat-drops and\\npigment-particles. In stained preparations of sputa in cases of acute\\ncroupous pneumonia, influenza, pneumonia, or phthisis, frequently\\nmany of the leucocytes contain large numbers of organisms i. e., pneu-\\nmococci, influenza bacilli, or tubercle bacilli.\\nRed blood-corpuscles are to be found in most sputa. They\\nmay be so few as not to give a red color. The source is often high up\\nin the respiratory tract. When they are present in large numbers the\\nsputum is more or less tinged, and in haemoptysis it is almost wholly\\nmade up of red cells. Usually each cell is well preserved, but they may\\nappear as pale bodies or as rings, the pigment remaining in the sputum\\nas pigment-particles or as crystals of haematoidin, as in pneumonia.\\nEosinophile cells are frequently found in large numbers in the\\nsputum in cases of asthma. They are also present in the sputum in\\nacute and chronic bronchitis and in phthisis. Their presence in the\\nsputum in cases of phthisis is considered by Teichmuller to be of\\nfavorable import.\\nFig. 143.\\nM\\nV3\\n-\u00e2\u0096\u00a0s\\n-I\\nW\\nVarious objects from sputum. 1, squamous epithelium 2, red blood-corpuscles 3, polynuclear\\nleucocytes 4, alveolar cells 5, myelin-cells 6, pigment-cells 7, elastic-tissue fibres 8, squamous\\ncells 9, hsematoidin-crystals 10, phosphate crystals 11, fungi 12, fat-globules 13, free pigment.\\n(Original observation.)\\nEPITHELIUM. Two general varieties are found in the sputum squa-\\nmous and cylindrical. The former comes from the mucous membrane\\nof the mouth, the tongue, tonsils, true vocal cords, and perhaps from\\ntli salivary and .small bronchial glands. It has no clinical impor-\\ntant. (See Fig. 143.)", "height": "4400", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0556.jp2"}, "557": {"fulltext": "DISEASES OF THE LUNGS AND PLEURjE.\\n523\\nCylindrical cells in sputum are rarely perfect. It is uncommon to\\nfind the cilia intact, and still more so in motion, while the body of the\\ncells is likely to be changed. They are found in inflammations of\\nthe trachea and bronchi, or the posterior nasal fossa a locality where,\\nit must be remembered, ciliated epithelium exists.\\nAlveolar epithelium, so called, when found in the sputum,\\nis more important than the above, as different observers consider its\\npresence to have more or less clinical significance. The cells are ellip-\\ntical or round, somewhat larger than white corpuscles, with a single\\nnucleus, which is indistinct without the addition of acetic acid. The\\nprotoplasm is granular and contains particles of iron-dust, carbon, or\\nblood-coloring matter, and often fat-drops. The cells may also have\\nundergone complete fatty degeneration, and they have been considered\\nthe source of my elm-drops in the sputum.\\nBizzozero has shown that alveolar epithelium not only occurs in\\nalmost all pulmonary affections, but also at times in normal sputum.\\nDetection. A small bit of sputum is placed on a microscope-slide\\nand a cover-slip applied. Examine with varying powers, and again,\\nafter acetic acid is added, stain the cells with an aqueous solution of\\nm ethyl ene-blue.\\nFrequently in cases of heart disease with failing compensation, espe-\\ncially where the mitral valve is affected, the alveolar cells may contain\\nlarge amounts of blood pigment.\\nGiant cells have been found in the sputum of phthisis cases.\\nElastic Fibres. As the presence of elastic fibres in sputa is of\\nmuch import, denoting destruction of the lung-tissue, bronchi, or the\\nlarynx or bloodvessels, their presence from food remaining in the\\nmouth must be especially guarded against. They may be mistaken\\nFig. 144.\\niff\\nElastic fibres of lung-tissue obtained from sputa after digestion in caustic soda.\\n(Drawn by Dr. John Wilson.)\\nfor fat-crystals. They are found as single threads in bundles, or show-\\ning an alveolar arrangement. They are to be recognized by the double\\ncontour and curling ends, and at times by their alveolar arrangement.\\nThey may be due to tuberculosis, abscess of the lung, bronchiectasis,\\ngangrene of the lung, pneumonia (von Jaksch), and rarely to destruc-\\ntive diseases of the larynx. In a very great majority of cases they are", "height": "4416", "width": "2572", "jp2-path": "practicaltreatis00muss_0_0557.jp2"}, "558": {"fulltext": "524 SPECIAL DIAGNOSIS.\\ndue to tuberculosis. It is uncommon to find them in gangrene, proba-\\nbly because, as Traube first suggested, they are destroyed by a ferment.\\n(See Fig. 143.)\\nElastic tissue from the alveoli often shows the diagnostic alveolar\\narrangement the fibres that form a bronchus are branched those\\nfrom eroded artery appear in the form of a network, or the fibres are\\nbound together. (See Fig. 144.)\\nDetection. The method employed by Osier, modified from Sir Andrew\\nClark s, is the best. A small amount of the thick, purulent portions\\nof sputiun is pressed out in a thin layer between two pieces of plain\\nAvindow-glass, 15x15 cm. and 10x10 cm. The particles of elastic\\ntissue appear on a black background as grayish-yellow spots, and can\\nbe examined in situ under a low power. Or the upper piece of glass is\\nslid off till the piece of tissue is uncovered, when it is picked out and\\nexamined on a microscopic slide, first with a low power, as the one or\\none-half inch objective, and then with a higher power. At first there\\nwill be some difficulty in distinguishing with the naked eye between\\nelastic fibres and particles of bread or milk globules, or collections of\\nepithelium and debris, but with practice such mistakes can be avoided,\\nand the microscope always reveals the difference. This method is\\nmuch easier of accomplishment and quite as satisfactory in results as\\nthe one generally employed\u00e2\u0080\u0094 boiling an equal quantity of sputum and\\nsolution of caustic potash (8 to 10 per cent.) for a short time, and then\\nallowing it to stand for twenty-four hours in a conical glass. The\\nelastic tissue remains intact and is found in the sediment.\\nConnective tissue and cartilage, in fragmentary bits, are rare\\nconstituents of sputum. The former may occur with abscess or gan-\\ngrene of the lung, and the latter when there is ulceration of the\\nlarynx.\\nFibrinous Coagula. These striking, tree-like bodies are found\\nin the sputa of plastic bronchitis, and at times in that of pneumonia,\\nphthisis, and in diphtheria and croup when there has been an exten-\\nsion into the bronchi. They are usually mixed with mucus, and are\\nrolled up into a mass. Their peculiar form is best seen when they\\nare washed and unravelled in water. They are then seen to be a com-\\nplete mould of a small bronchus with its ramifications. The size varies\\ngreatly. They may be many centimetres long. In fibrinous bron-\\nchitis the size and shape of the moulds in different attacks may be\\nexactly similar, as if they came from the same bronchus. They are\\ngrayish-white in color, hollow, and on transverse section are seen to\\nbe made up of cast upon cast. Leucocytes, blood-cells, and alveolar\\nepithelium are found hi the meshes by the microscope, and at times\\nCharcot-Leyden crystals and Curschmann s spirals also. They are\\nalmost pathognomonic of fibrinous bronchitis. When they occur in\\nany number in pneumonia they make the prognosis unfavorable.\\nBlood-casts of the smaller bronchi have been found in cases of haemop-\\ntysis. They are rare, and have no apparent connection with the fibrous\\ncoagula.\\nSpirals. Under this name are included spiral bodies that are\\nfound in the sputa of bronchial asthma, and occasionally in that of", "height": "4404", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0558.jp2"}, "559": {"fulltext": "DISEASES OF THE LUNGS AND PLEURAE. 525\\npneumonia and capillary bronchitis (von Jaksch), and chronic pulmo-\\nnary tuberculosis (Vierordt). At the beginning of an asthmatic attack\\ntough rounded balls are expectorated perles of Lsennec-- which, if\\nfreed from the mucus surrounding them and spread out on a glass with\\na dark background, may be seen by the naked eye to have a twisted\\nspiral form. With the aid of the microscope they are found to be\\nmade up of spirally arranged mucin in a more or less tight twist, with\\nmany cells from the alveoli and bronchi. In some of these spirals a\\nshining central thread runs through the entire length like a core, re-\\nmarkable for its clearness and its high refractive index. The fine\\nfibres composing the spiral may be closely arranged or not. Epithe-\\nlium and Charcot-Leyden crystals may be found lying among the coils.\\nThe main constituent of the spirals is mucin, and Osier has suggested\\nthat the central thread is made up of transformed mucin. On the\\nother hand, von Jaksch believes it to be chemically distinct from the\\nmucin spiral and to approach rather to the character of fibrin. Vier-\\nordt considers it either made of tightly twisted central fibres or to be\\nan optical image of a core-cavity. They are probably the result of an\\nacute bronchiolitis. Why they should assume this remarkable form\\nis still an open question. It has been suggested (Osier) that the\\nciliated epithelium of the bronchi may have a rotary action, and their\\naction, combined with the spasm of the bronchioles, causes the spiral\\nformation.\\nSections for Microscopical Examination. Schmidt (Zeitschrift\\nf. him. Med., 1892, p. 476) fixes sputum in J per cent, salt solution\\nsaturated with mercuric chloride, hardens in alcohol, and sections in\\nthe usual manner. For hardening sputum Zenker s fluid has been\\nfound most satisfactory. After hardening the sputum is embedded in\\nparaffin and cut. In many cases it is advisable to roll up the sputum\\nin a little ball before fixation. For the study of spirals thick pieces\\nshould be embedded in celloidin for the study of the cellular elements,\\nthin sections are embedded in paraffin.\\nSections of sputum with mucin swell when treated with watery\\nsolutions of the dyes hence the celloidin should be first removed to\\nprevent folding of the sections. All specimens of sputum, except the\\nvery thin ones, can be prepared in the manner described.\\nThe spirals are best stained with Weigert s fibrin-method they\\nstain blue. Yet they i. e., the central threads are not fibrin (1)\\nBecause they are perfectly homogeneous (2) they assume a violet\\ncolor after prolonged staining fibrin is always blue (3) unformed\\nblue masses are found which could only be compact mucin masses\\n(4) their specific mucin reaction with thionin (5) the greenish color\\nassumed when Ehrlich s triacid stain, as modified by Babes, is used.\\n(See Fig. 145.)\\nThat there is a connection between the spirals and Charcot-Leyden\\ncrystals seems very probable, as the latter are absent from the sputum\\nat the beginning of an attack of bronchial asthma but if a portion of\\nsuch sputum is allowed to stand for twenty-four to forty-eight hours,\\ntaking care that evaporation does not take place, crystals will be found.\\nAs has been said, the crystals are often found among the spirals, and", "height": "4416", "width": "2584", "jp2-path": "practicaltreatis00muss_0_0559.jp2"}, "560": {"fulltext": "526\\nSPECIAL DIAGNOSIS.\\nthis when they are seen nowhere else. Later on the spirals disappear,\\nbut crystals derived from them continue to be expectorated. (See\\nFig. 145.)\\nThe method of examining for spirals is as given above.\\nFig. 145.\\nSpirals from bronchial tubes. X 80. (Alter Leyoen.\\nCrystals. Charcot-Leyden, cholesterin, hsematoidin, fatty, tyrosin,\\noxalate of lime, and triple phosphate crystals are to be found in sputa\\nunder various conditions.\\nCharcot-Leyden crystals are octahedral, sharply pointed, color-\\nless or slightly bluish, soluble in warm water, alkalies, and acetic and\\nmineral acids. The practised, unaided eye may recognize these as\\nsmall yellowish bodies, not unlike grains of sand; under the micro-", "height": "4404", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0560.jp2"}, "561": {"fulltext": "DISEASES OF THE LUNGS AND PLEURJS. 527\\nscope they are unmistakable. Their size varies greatly. They occur\\nmost abundantly during (invariably) and after an attack of bronchial\\nasthma they have also been seen in sputa of acute and chronic bron-\\nchitis and tuberculosis. They are identical with crystals found in\\nsemen, feces, and leukemic blood and bone-marrow. Their connec-\\ntion with spirals has been mentioned above. Schreiner considers them\\nto be the phosphate of an unknown base, which Ladenburg and Abel\\nthink may be identical with sethyleninim or di-aethyleninim. This\\nidentity, however, is disputed by Th. Kohn.\\nDetection. Examine the sputum of an asthmatic patient a day or\\ntwo after the beginning of an attack for round, hard, yellowish bodies,\\nand place these under the microscope with different powers. They\\nare readily recognized. (See Fig. 146.)\\nCharcot crystals. (Scheube.)\\nCholesterix Crystals. These crystals are similar to those of\\ncholesterin found elsewhere, being thin rhombic plates, often with\\nirregular corners and high refractive index. They are soluble in ether\\nand, when treated with dilute sulphuric acid and tincture of iodine,\\nbecome violet, blue, or green, and then red. They may be present in\\nthe sputum of tuberculosis, abscess, and hydatid abscess of the lung,\\nand in pus from an abscess of another organ, as the liver. They have\\nbut little clinical significance.\\nELematoidix Crystals. Haematoidin crystals are at times recog-\\nnizable by the naked eye as distinct spots of yellowish or brownish-\\nred color. Under the microscope they have a brownish-yellow or\\nruby-red color, and are either in the form of small rhomboid prisms or\\nof fine needles, single or arranged in bunches of various shapes, or as\\nfree pigment-particles without crystalline form smaller particles may\\nbe contained within a leucocyte. Their presence indicates that blood\\nhas remained in the respiratory tract for some time before being expec-\\ntorated, or that an abscess has discharged into a bronchus. They occur\\nin phthisis, following hemorrhage in thoracic aneurism when blood\\nis oozing into the lung in gangrene in abscesses discharging through\\na bronchus. Von Jaksch states that when the crystals are contained\\nin cells there has been a preceding hemorrhage, but that when there\\nis considerable free hsematoidin one infers that an abscess of a neigh-\\nboring organ has discharged into the lung.", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0561.jp2"}, "562": {"fulltext": "528 SPECIAL DIAGNOSIS.\\nFatty Crystals. Crystals of margaric acid occur as long, thin\\nneedles, greatly curved or bent at one end like a fish-hook, and either\\nsingly or in bundles. They are found in unhealthy pus as in gan-\\ngrene, putrid bronchitis, bronchiectasis, and tuberculosis in the plugs\\nformed in inflamed tonsils and in purulent sputum in general which\\nis allowed to stand in a warm place. They dissolve in ether and boil-\\ning alcohol this characteristic, together with the regularity of their\\ncurve, should distinguish them from elastic fibres, with which they\\nare sometimes confused by beginners.\\nTyeosix crystals have been found in the sputum of putrid bron-\\nchitis and empyema discharging into the lung, and usually in conjunc-\\ntion with leucin. They are most abundant in sputum that has been\\nallowed to stand for some time. Under the microscope they appear\\nas fine needles, and can be mistaken for fatty crystals. They are with-\\nout diagnostic importance.\\nOxalate of lime and triple phosphates have been noted\\noccasionally in sputa the former in a case of diabetes, and also in an\\nasthmatic the latter occur only in alkaline sputa, as they are soluble\\nin acids.\\nUric acid crystals have been observed by Moore in the sputum\\nof a gouty patient.\\nConcretions are rarely present in the sputum. They arise usually\\nfrom the bronchial glands or lungs, from foci of tuberculosis which\\nhave become healed with the deposition of lime-salts. They may be\\nsingle or multiple. Hievoiles reports finding tubercle bacilli in the\\ncentre of one of these concretions.\\nCorpora Amylacea. Starch-like bodies have been found in the\\nsputum after pulmonary hemorrhage and in that of pulmonary gan-\\ngrene. They have the shape of starch-corpuscles, and sometimes give\\nthe amyloid reaction with iodine or iodide of potassium. They are\\nat present without clinical significance.\\nParasites.\\nA. Animal Parasites. Echinococcus cysts are to be found in spu-\\ntum, generally broken into fragments, and only very rarely in a per-\\nfect whole, when there is rupture of a cyst of the liver or lung into a\\nbronchus. Scolices and free booklets from the same may be recog-\\nnized, and pieces of the cyst-wall will be known by their remarkable\\nformation. Their presence is of great clinical value.\\nInfusoria have been found in the expectoration from gangrene of\\nthe lungs. They belong to the monad and cercomonad varieties.\\nDistoma haematobium eggs may occur in sputa when the lung-tissue\\nis broken down by its presence, the eggs being thrown off in the sputum.\\nThe distoma Westermanii or pulmonale is found in the sputum in\\nJapan in certain cases resembling phthisis. Both the worm and the\\nova may be present in the sputum.\\nAmceba Dysenteries (Amoeba Coll). Of far more interest and im-\\nportance is the presence of this parasite in the expectoration. A full\\ndescription of the amoeba will be given in the article on Dysentery.", "height": "4404", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0562.jp2"}, "563": {"fulltext": "DISEASES OF THE LUNGS AND PLEVRJE. 529\\nThey are the same in every respect when found in the sputum, except\\nthat they are often slightly larger. The sputum containing the amoeba\\nis partly diffluent, tenacious, frothy, bright red in color at first, due to\\nthe presence of blood, and later brick or brownish-red, sometimes bile-\\nstained. Small yellowish-white cheese-like particles are seen. Upon\\nexposure to the air the sputum becomes thin, syrupy, and oily, and it\\nthen looks much like anchovy sauce. The sputa are alkaline and of\\na faintly sweetish odor, never putrid. Later on they become more\\npurulent, somewhat nummular, reddish-yellow, and contain less blood.\\nIf there is a favorable termination, they become more fluid and frothy,\\nwith less blood and pus, and, on standing, show the three layers.\\nThe quantity varies from 25 c.c. to 500 c.c. in twenty-four hours.\\nUnder the microscope will be found, beside the amoeba, red blood\\ncorpuscles, leucocytes, alveolar and oval epithelium, and bodies look-\\ning like degenerated liver-cells without a nucleus occasionally elastic\\nfibres, hsematoidin, leucin, tyrosin, and Charcot-Leyden crystals and\\nbacteria are seen. The cheesy particles are made up of amorphous\\ngranular matter and oil-globules. Amoebae are constantly present in\\nvarying numbers, usually not so many as in the stool, but somewhat\\nlarger. The number varies from day to day, and diminishes with the\\ndisappearance of the cough and expectoration. The sputa should be\\nexamined as soon after their discharge as possible, and in the interim\\nshould be kept at a temperature of 30\u00c2\u00b0 to 35\u00c2\u00b0 C. If examined on a\\nwarm stage, active movements of the amoeba? will be kept up much longer.\\nThey should be examined under various powers J, -1 or l and y 1\\ninch objectives. Of these the 1- or T inch will be found most suitable\\nfor following the movements. They measure from 10// to 20 jul. They\\nwill be readily recognized by their size, formation, and movements.\\nThat they have important clinical value is true, as cases have been\\nreported in which the observer diagnosticated hepatic or hepato-pul-\\nmonary abscess secondary to amoebic dysentery, by the peculiar anchovy-\\nsauce expectoration and subsequent detection of the amoebae.\\nB. Vegetable Parasites. Fungi Non-pathogenic Moulds.\\nO idium albicans may be a constituent of the sputum when the bronchi\\nare invaded by it, but usually it is from the saliva. Certain other\\nmoulds have lately been considered to cause disease of the lungs by\\nmultiplication, but nothing very definite has resulted from the experi-\\nments thus far made.\\nYeast-fungi. Von Jaksch reports having seen scattered yeast-\\ncells in the pus from a phthisical cavity. Otherwise we have no\\nknowledge of yeast being found in sputa.\\nFission-fungi. Leptothrix. Leptothrix occurs alone, in the\\nsputum or in the bronchial plugs, in putrid bronchitis, along with the\\nfatty acid and haematoidin crystals. It is probably derived from the\\nmouth, having thence entered the air-passages, or it is taken up from\\nthe mouth by the expectoration. It is recognized by its staining blue\\nwith iodine and potassium iodide.\\nSarcin^e Pulmonalis. Sarcinae may be seen in sputa. They are\\nlarger than sarcinse ventriculi, with which they have no connection,\\nnor have they pathological significance when present in sputa.\\n34", "height": "4408", "width": "2652", "jp2-path": "practicaltreatis00muss_0_0563.jp2"}, "564": {"fulltext": "530 SPECIAL DIAGNOSIS.\\nNon-pathogenic bacilli and cocci may occur in all sputa, but are\\nwithout significance. They are more numerous in fetid sputa. They\\nstain with methylene-blue and other simple dyes.\\nPathogenic Fungi. Tubercle Bacillus. The organism which\\nis the cause of tuberculosis is a rod, straight or slightly curved, without\\nmotion, varying in length from 2 t u to o/ul (about J to J the diameter of\\na red corpuscle). It usually has a beaded appearance when stained,\\ndue to the spores, which do not take up the stain that affects the rod\\nas a whole, and which often bulge slightly beyond the edge. It is\\nprobable that this beaded appearance is caused by the contraction and\\nbreaking up of the stainable portion, permitting us to see the empty\\nspaces between the fragments and the other membrane. Bacilli pre-\\nsenting this appearance are supposed to be undergoing degeneration.\\nAttention has recently been called to the presence in the sputum of\\nbranching forms of the tubercle bacillus. The bacillus of tuberculosis\\ncannot be recognized in the sputum unless stained, and in the staining\\nit shows a peculiarity which belongs to but few organisms the smegma\\nbacillus, the bacillus of leprosy, and the bacillus of syphilis. As under\\nordinary conditions these bacilli are not met with, this peculiarity in\\nstaining in a vast majority of cases is diagnostic of tubercle bacilli.\\nRecently, Pappenheim found in the sputum from a case of gangrene\\nof the lung stained by Gabbet s method numerous bacilli which were\\nconsidered to be tubercle bacilli. At the autopsy no evidence of tuber-\\nculosis could be found. Further examination led Pappenheim to\\nbelieve that these bacilli were smegma bacilli. A similar case has\\nbeen recently seen where large numbers of bacilli were present in the\\nsputum in a case of gangrene of the lung secondary to a sub-dia-\\nphragmatic abscess, which, stained by Gabbet s method, were consid-\\nered to be tubercle bacilli. The autopsy showed no evidence of tuber-\\nculosis, macroscopically or microscopically. Inoculation from the\\nlung into a guinea-pig was also negative. Fraenkel has observed\\nsimilar bacilli in the sputum when stained by Gabbers method from\\npatients with bronchiectasis.\\nPreparation of Sputum and Method of Staining Tubercle\\nBacilli. A small amount of the purulent portion of the sputum is\\nspread in a thin and uniform layer on a perfectly clear cover-glass by\\nmeans of forceps, needles, or the oese, which must previously be\\nheld a moment in the flame of a Bunsen burner or spirit lamp or\\nby pressing a small amount of sputum between two cover-glasses,\\nthen sliding them apart. It is then dried in the air, or more quickly\\nby holding the cover-glass with forceps some distance above the flame\\nof a burner or lamp. Finally, it is to be passed three or four times\\nthrough the flame and so fixed. The edge of the cover-glass, with\\nsputum side up, is then grasped with forceps and covered with the\\nstaining solution, care being taken to prevent the fluid from extending\\nto the under surface, and held in or just above the flame, until the\\nsolution boils for a second or two or a bubble rises. When the excess\\nof the solution is washed off in water, the slip is treated with the\\ndecolorizing agent until the color is almost or wholly removed. It is\\nagain washed in water to remove the excess of the decolorizer, and", "height": "4412", "width": "2584", "jp2-path": "practicaltreatis00muss_0_0564.jp2"}, "565": {"fulltext": "", "height": "4412", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0565.jp2"}, "566": {"fulltext": "PLATE XV\\nFIG. 1.\\nPneumococci from a Case of Empyema.\\n(Oc. 4, ob. ^f immersion.) Drawn by J. D. Z. Chase.\\nFIG. 2.\\nA\\nf\\ni\\\\~\\n,1 iSfe\\nTubercle-bacilli (red). Streptococci (blue chains).\\n(Oc. 4. j 2 oil immersion.) Drawn by J. I). Z. Chase.", "height": "4416", "width": "2568", "jp2-path": "practicaltreatis00muss_0_0566.jp2"}, "567": {"fulltext": "DISEASES OF THE LUNGS AND PLEURA. 531\\nmounted for examination, or given a contrast-stain the latter is pref-\\nerable.\\nA second rapid method is as follows Select with the sterilized\\noese a suspicious yellowish particle from the sputum smear it thinly\\nover one end of a slide which has previously been passed several times\\nthrough the flame of an alcohol lamp or Bu risen burner. Dry by\\nholding over flame fix by passing several times through the flame.\\nCover the dried sputum with the desired stain, and steam gently for\\ntwo minutes over the alcohol or low Bunsen flame the slide can be\\nheld in the fingers, or, after heating, can be laid aside for a moment\\nwash off the excess of stain with water, then cover the stained sputum\\nwith decolorizing agent and counter-stain, which should not remain\\nmore than thirty seconds. Wash away excess with water, dry the\\nslide by blowing upon it through a pipette, and cover with a clear cover-\\nglass, using distilled water as a mount. This method is extremely\\nsatisfactory for ordinary clinical work, especially with Ziehl s and\\nGabbet s solution.\\nIf fuchsin has been used to stain the tubercle bacilli, methylene-\\nblue is a good contrast-stain while if gentian-violet was selected\\nBismarck-brown is better in contrast. These contrast-stains are made\\nas needed by dissolving enough of the dye in a few c.c. of water to\\nmake the solution as seen through a test-tube of 14 mm. diameter only\\ntransparent, and then filtering or, a concentrated watery solution\\nmay be made for stock just as the concentrated alcoholic solutions of\\nfuchsin and gentian-violet were made, diluting a small quantity of\\nthis when needed with enough distilled water to make it just trans-\\nparent in a similar test-tube. To apply the contrast-stain, place a few\\ndrops on the cover-glass that has been prepared as above stained,\\ndecolorized, and washed allow it to remain thirty or forty seconds,\\nwash off in water, and mount for examination on a glass slip, in water,\\noil of cloves, or Canada balsam. A drop of water will serve perfectly\\nwell for examining when the preparation is not to be preserved. In\\nthe microscopical examinations a y 1 inch oil-immersion lens and Abbe\\ncondenser, or, at the least, a or J inch objective is used. If gentian-\\nviolet has been used, the tubercle bacilli appear as dark-blue rods, with\\nall other bodies brown, if Bismarck-brown is used for contrast-stain\\nwhile with fuchsin staining for tubercle bacilli, and methylene-blue as\\na contrast, the former will be found as red rods in a blue field (back-\\nground). (See Plate XV., Fig. 2.)\\nThe above rapid method of staining takes much less time than the\\nmethod usually described, and gives most satisfactory results. The\\nsteps in the old method are the same as given above, except that\\ninstead of placing the staining solution on the smeared and dried cover-\\nglass, and holding it in or above the flame until the solution boils, the\\ncover-glass is floated in a cold solution, in a watch-glass, sputum side\\ndown, for twenty-four hours, or in a hot solution for six to eight min-\\nutes, or until moisture appears on the upper surface of the cover-glass.\\nThe remaining steps are similar.\\nTubercle bacilli do not stain with the simpler dyes, but when stained\\nby .solutions of dyes made more penetrating by the addition of aniline", "height": "4408", "width": "2580", "jp2-path": "practicaltreatis00muss_0_0567.jp2"}, "568": {"fulltext": "532 SPECIAL DIAGNOSIS.\\noil, carbolic acid, or like substances, they retain the color when subjected\\nto decolorizing agents. In this they differ from all other organisms,\\nexcept, as stated, the smegma bacillus, the bacillus of leprosy, and the\\nbacillus of syphilis.\\nThe Smegma Bacilli. Pappenheim distinguishes them from tubercle\\nbacilli by staining with a solution of corallin in absolute alcohol satu-\\nrated with methylene-blue, when decolorization takes place without acid.\\nIf fat acids and myaline are present in the sputa, the bacilli are, in all\\nprobability, not tuberculous. They are not found in mucopurulent,\\nbut in putrid, sputum.\\nHouselPs method of staining them is the best. After the preparations\\nare stained in carbol-f uchsin they are placed in a mixture of 3 per cent.\\nHC1 in absolute alcohol for ten minutes. They stain best with an\\nalcohol solution of methylal-blue, which decolorizes the micro-organism.\\nA number of methods have been devised for the detection of the\\ntubercle bacillus by means of its peculiar action toward stains. The\\nmost satisfactory are those known as the Koch-Ehrlich, Ziehl-Neelson,\\nGabbet, and Gibbes. These methods differ chiefly in the solutions used.\\nSlightly modified from the original in execution, they are as follows\\nA. Koch-Ehrlich method\\nSolutions Used.\\nI. Concentrated alcoholic solution of fuchsin or gentian-violet.\\nII. Saturated solution of aniline oil in water.\\nIII. Thirty per cent, solution of nitric acid in water (decolorizing solution).\\nI. Place in a clear bottle fuchsin or gentian-violet in substance to\\none-fourth its capacity, and fill with alcohol (95 per cent.) shake well\\nand cork and allow it to stand for twenty-four hours. If all the dye has\\nbeen dissolved, add more and shake, and let stand for another twenty-\\nfour hours, and so on until some of the dye remains permanently\\nundissolved at the bottom of the bottle. This solution remains good\\nuntil used.\\nII. To about 100 c.c. of distilled water, in a flask or other suitable\\nvessel, add aniline oil, drop by drop, shaking the flask continuously,\\nuntil the solution is opaque, or drops of the oil float on the surface,\\nthen filter through moist filter-paper until the filtrate is perfectly\\nclear. This solution must be made fresh as needed.\\nIII. Mix a few c.c. of nitric acid and water in about the above pro-\\nportion, never stronger, each time bacilli are to be stained.\\nThe Koch-Ehrlich solution is made by adding 11 c.c. of the fuchsin\\nor gentian solution (No. I.), and 10 c.c. of absolute alcohol to 100 c.c.\\nof the clear aniline nitrate (No. II.). It should not be used after it is\\na week old.\\nB. Ziehl-Neelson method\\nSolutions Used.\\nI. Carbolic-fuchsin solution\\nDistilled water 100 c.c\\nCarbolic acid (crystalline) 5 grammes.\\nAlcohol 10 c.c.\\nFuchsin in substance 1 gramme.", "height": "4400", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0568.jp2"}, "569": {"fulltext": "DISEASES OF THE LUNGS AND PLEURJE. 533\\nThis solution can also be prepared by adding saturated alcoholic\\nsolution of fuchsin (see above) to a 5 per cent, watery solution of car-\\nbolic acid, until a metallic lustre is seen on the surface of the fluid.\\nThis solution does not decompose so easily as those made with aniline\\noil.\\nII. Decolorizing solution of nitric acid, and\\nIII. Contrast stain of methylene-blue, as above.\\nThe preparation and staining are exactly the same as in method A.\\nThe tubercle bacilli are stained red, the other bodies blue.\\nC. Gabbet s method\\nSolutions Used.\\nI. Carbolic-fuchsin solution (as in B).\\nII. Methylene-blue solution\\nMethylene blue 1 2 grammes.\\nSulphuric acid 25\\nDistilled water 75 c.c.\\nThis solution is apt to decompose if old.\\nPreparation of Slips and Staining. The cover-glass is pre-\\npared and stained with the carbolic-fuchsin solution and washed in\\nwater as in A. Then (instead of decolorizing with nitric acid or add-\\ning in contrast-stain) the slip is washed for twenty to thirty seconds in\\nthe methylene-blue solution, until a faint blue replaces the red tinge\\nin the (slip) sputum the excess of the solution is washed off in water,\\nand the slip is mounted and examined as above. The tubercle bacilli\\nare stained red and the other bodies blue. In sputum from gangrene\\nof the lung and bronchiectasis, decolorization with alcohol, in addition,\\nmust be employed to eliminate the presence of the smegma bacillus.\\nThe writer has found that this method can be rapidly applied, and\\nthat it gives good results he recommends it highly.\\nD. Gibbes method\\nSolutions Used.\\nI. a. Fuchsin 3 grammes.\\nMethylene-blue 1\\nMix thoroughly in a mortar.\\nb. Aniline oil 5 c.c.\\nAlcohol 20 c.c.\\nDissolve and add b to a slowly, stirring vigorously until a is evi-\\ndently dissolved, then add 20 c.c. of distilled water, and keep in a\\nstoppered bottle, ready for use.\\nPrepare slip and stain with this solution, as with the others, up to\\nthe point of decolorizing. Then wash with alcohol until the dye ceases\\nto come away. Mount and examine as above. Tubercle bacilli will\\nbe stained dark red, the other objects dark blue.\\nWhen the bacilli are few in number, Biedert proposes that the fol-\\nlowing preliminary steps be taken About -4 c.c. of sputum are mixed\\nwith 8 c.c. of Avater and 1 c.c. of solution of caustic soda, and boiled a\\n1 An alcoholic solution of methyl-blue should first be made, and then added, drop\\nby drop, with constant stirring, to the sulphuric acid and water.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0569.jp2"}, "570": {"fulltext": "534 SPECIAL DIAGNOSIS.\\nfew minutes, when about 15 c.c. of water are added and the whole\\nagain boiled until a homogeneous fluid is formed. This is allowed to\\nstand in a conical glass for twenty-four to forty-eight hours, when the\\nsediment is stained by the Ziehl-Neelson or Gabbet method. Or, the\\nhomogeneous fluid can be put at once in a centrifugal machine, and the\\nresulting sediment stained.\\nSputa hardened in Zenker s fluid, embedded in paraffin and cut, has\\nproven most satisfactory in the study of the branching forms of the\\ntubercle bacillus, the study of giant-cells in the sputum in phthisis,\\nand in the study of bacteria in the sputum in cases of pneumonia.\\nIt is well to remember that, in the absence of a proper decolorizing\\nagent, hot water applied for some minutes has been shown to decolor-\\nize very satisfactorily.\\nImportance. The greatest importance attaches to the presence or\\ncontinuance of tubercle bacilli in sputa. It indicates tuberculosis of\\nthe lung or larynx in the vast majority of cases of the former.\\nThey are often to be found in the sputum when physical signs are\\nnot yet present or are indefinite. The number varies so greatly in\\ndifferent cases, and in the same case at different times, that a in recent\\nattack it is impossible to judge of the extent of the disease by the\\nnumber present in a given preparation. 1\\nThe absence of bacilli from sputa has no true value unless negative\\nresults are obtained after many trials and careful examination by an\\nexperienced observer, using good stains. Hence, too great care cannot\\nbe taken in each and every step.\\nBiological Properties. The tubercle bacillus is difficult to cul-\\ntivate, as it grows readily only in conditions found within the body.\\nThe best medium is blood-serum. The cheesy mass from the sputum\\nor the tubercular nodule from a tissue is placed on the surface of the\\nserum and rubbed carefully over it. It is best to make twenty or\\nthirty such inoculations. The tubes must then be sealed to prevent\\nevaporation and drying, and exposed for twelve days to a temperature\\nof 37.5\u00c2\u00b0 C. When a pure culture is obtained further cultivations may\\nbe made on agar-agar, to which 6 per cent, of glycerin has been added.\\nThe pure cultures appear as dry masses on the surface of the medium,\\neither as flat scales or clumps of mealy-looking granules. They are\\nof a dirty drab or brownish-gray color. (See Plate VII., Fig. 6.) The\\nbacillus is parasitic, aerobic, non-motile (facultative anaerobic).\\nPneumococcus. Diplococcus Pneumoniae. Micrococcus Lan-\\nceolatus. The causative factor in most cases of acute croupous pneu-\\nmonia in its typical form is a paired lancet-shaped coccus, often irreg-\\nular in size, with a tendency to chain formation. Frequently oval or\\nconical forms are present, and there is apt to be variation in the size\\nof the two cocci forming the pair. The organism has a distinct cap-\\nsule. In the sputum of croupous pneumonia these pneumococci are\\nusually present in large numbers. Their presence within leucocytes\\n1 A Method for the Examination of the Actual Number of Tubercle Bacilli in\\nTuberculous Sputum. By George H. F. Nuttall, M.D., Ph.D., Johns Hopkins\\nHospital Bulletin, May, 1891. The method is of pathological but not of diagnostic\\ninterest.", "height": "4404", "width": "2560", "jp2-path": "practicaltreatis00muss_0_0570.jp2"}, "571": {"fulltext": "DISEASES OF THE LUNGS AND PLEURA. 535\\nand their tendency to chain formation has been especially noted in\\nsuch cases.\\nPneumococci are stained in cover-glass preparations with the ordi-\\nnary aniline dyes, as given above. The capsule may be stained and\\ndifferentiated in the same way, but it more often requires a special\\nmethod. Welch recommends the following Spread and dried cover-\\nglass preparations are treated first with glacial acetic acid, which is\\nallowed to drain off, and is replaced (without washing in water) with\\naniline oil-gentian-violet solution. (See under Tubercle Bacilli.) The\\nstaining solution is repeatedly added to the surface of the cover-glass\\nuntil all of the acid is displaced. The specimen is now washed in a\\nweak salt solution (about 2 per cent.), and examined in the same, not\\nin balsam. The capsule and coccus can then be differentiated. Spu-\\ntum stained by Gram s method, thoroughly decolorized by alcohol,\\ncounter-stained with a watery solution of eosine, or a 1 per cent, aque-\\nous solution of aurantia, has been found satisfactory for microphoto-\\ngraphic work. Degenerative and involution forms are constantly met\\nwith. There will be variations in size and shape, and the capsule may\\ncontain onlv remains of a coccus, or be entirelv empty. (See Plate\\nXV.)\\nBiological Properties. The pnenmococcus is not motile. It\\nstains by Gram. It grows well on blood-serum. The growth is\\nminute, transparent, colorless colonies, resembling drops of dew. A\\nfavorable growth of very minute colonies appears in glycerin agar-\\nao;ar. Bouillon is faintlv clouded. Litmus milk will sometimes\\nturn pink and coagulate. Growth on other culture media is usually\\nfeeble. The tendency to form chains is especially observed in the\\nwater of condensation on blood-serum tubes. The lancet shape of\\nthe cocci enables them to be differentiated from the streptococcus.\\nThe capsules are not usually observed in the cultures with ordinary\\nmethods of staining.\\nBy inoculation into susceptible animals a typical fibrinous pneumo-\\nnia is developed. The pathogenic power attenuates rapidly in cul-\\ntures, but recovers its virulence by passing through susceptible animals.\\nThis micro-organism is found in nearly all cases of acute croupous\\npneumonia, and in many cases of bronchopneumonia. Its presence\\nhas also been observed in health in the saliva. It is found also in\\nacute pleuritis, endocarditis, pericarditis, peritonitis, acute purulent\\nmeningitis, and otitis media. Its presence in empyema is considered\\nof favorable import. It has also been found in cases of synovitis,\\nosteomyelitis, and abscess formation in various situations. It may\\ncause a general septicaemia i. e., pneumococcus septicemia.\\nBacillus Mucous Capsulatus. This organism is found in the\\nsputum in health in a certain number of cases. In association with\\nthe pneumococcus it can cause pneumonia. It can also produce pneu-\\nmonia by itself in rare instances.\\nIn three fatal cases of pneumonia due to the capsule bacillus alone,\\nthere have been found in the sputa large numbers of capsule bacilli.\\nThese were frequently inside of leucocytes, and many alveolar cells\\nwere filled with these bacilli.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0571.jp2"}, "572": {"fulltext": "536 SPECIAL DIAGNOSIS.\\nBacillus of Influenza. This organism is found in the sputum\\nin cases of influenza or influenza pneumonia. It was first isolated\\nfrom the sputum by Pfeiffer. The organism appears as a small\\nbacillus with rounded ends. Its length varies somewhat, and thread-\\nlike, involution forms may appear. It stains more deeply at the ends\\nthan at the middle, and the long forms may show irregularity of stain-\\ning. It does not grow on the ordinary media. It is best cultivated\\nupon agar-agar slants, upon the surface of which has been smeared a\\nfew drops of blood. The colonies appear after twenty-four to thirty-\\nsix hours as minute, colorless, watery, clear, dew-like colonies, best\\nseen with a hand lens. In the sputum these bacilli are frequently\\npresent in large numbers in cases of influenza, and their presence fill-\\ning up the protoplasm of the leucocytes and the purulent sputum of\\npneumonia is not uncommon. Thin smears of the sputum, stained\\nwith aniline oil-gentian-violet, somewhat decolorized with alcohol, and\\ncounter-stained with a 1 per cent, aqueous solution of aurantia, have\\nshown these bacilli much better than the ordinary methods of staining\\nwith Loffler s methylene-blue or dilute carbol-fuchsin.\\nWhooping-cough. Minute bacilli have been discovered in the\\nsputum in cases of whooping-cough by Czplewski, Koplik, Zusch, and\\nothers. At present the results are not sufficiently uniform to prove\\nthese bacilli of etiological value in the disease.\\nActinomyces. When the lungs or pleura are infected by this\\nfungus actinomyces may be found in the sputum. The disease in\\nthese organs is rare. Macroscopically they appear as small kernels,\\nyellowish-white or greenish-yellow, and having the shape of a millet-\\nseed. Under the microscope they are recognized by the rounded,\\nclub-like bodies projecting from all sides of an unformed central mass.\\nThey are seen better when not stained. (See page 352.)\\nChemistry of Sputum. As the chemical examination of the\\nsputum does not aid us in diagnosis, it has but little or no value.\\nMucin, nuclein, and serum albumin are constituents of sputa in health.\\nPeptone is present whenever there is pus, and is especially marked in\\npneumonia. Volatile fatty acids, such as butyric and acetic, occur at\\ntimes, markedly so in pulmonary gangrene. Glycogen has been\\nobtained by Solomon, and a ferment resembling one of the pancreatic\\nferments has been detected, especially in pulmonary gangrene and\\nputrid bronchitis. Of inorganic substances, chlorides of soda and\\nmagnesia phosphates of soda, lime, and magnesia sulphates of soda\\nand lime carbonate of soda, lime, and magnesia and in a few cases\\nphosphate of iron and silicates have been obtained (Von Jaksch).\\nSPECIAL DIAGNOSIS.\\nPictoric Records of Physical Signs.\\nIn order to draw accurate conclusions from the various data obtained during\\nthe physical examination of a patient, the physician must carry in his mind the\\nresults of the inspection, the palpation and percussion, and the auscultation of\\neach individual part of the thorax and abdomen. For the beginner the grouping", "height": "4400", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0572.jp2"}, "573": {"fulltext": "PLATE XVI\\nFIG. 1. Anterior Aspect.\\nI M\\n1\\n1\\na\\n1\\nW Wm\\n1\\nEC\\n3^\\nd\\n\u00e2\u0096\u00a0C/ A\\nS^-P\\ni -fFM\\nNil\\n1\\nFIG. 2. Posterior Aspect.\\nPhysical Signs in Health.\\nNormal percussion outlines of the viscera. Normal heart and breath sounds\\nVertical lines for localization.", "height": "4412", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0573.jp2"}, "574": {"fulltext": "", "height": "4408", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0574.jp2"}, "575": {"fulltext": "DISEASES OF THE LUNGS AND PLEURJE. 537\\ntogether of these phenomena according to regions of the body, instead of by\\nmethods of examination, is extremely difficult. He is taught to examine the\\nthorax, first, by inspection, then by palpation and percussion, and, finally, by\\nauscultation and in following this routine the results of the examination\\nnaturally divide themselves into the signs obtained by this method or that. In\\nmaking the diagnosis, however, the grouping must be rearranged, for in order to\\ndetermine the condition of a certain organ or part of an organ, all the local\\nphenomena, by whatever method recognized, must be considered in their rela-\\ntion to one another and not merely as isolated facts. By weighing all the\\nevidence obtained by the various methods of examination, and by balancing the\\nrelative importance of this sign or that, a verdict is finally reached in regard to\\nthe condition of the part in question. Only after the status of each organ has\\nbeen thus separately determined can a complete diagnosis of the case be made\\nwith certainty.\\nIn describing in the text the physical signs of the various diseases of the\\ninternal organs, it is necessary, in order to avoid endless confusion, to consider\\ndata in the order in which they are elicited i. e., grouped according to the\\nmethod of their recognition. To redescribe them grouped according to regions\\nwould involve constant repetition, and would still fail to give a clear picture of\\nthe sign-complex of the part. And yet it is essential that this picture should be\\nso clear and well defined that the physician, in summing up the examination,\\nhas but to glance at the part in order to call up to his mind all the various data\\nobtained by its examination. Experience adds daily to the facility with which\\nthis piece of mental gymnastics is performed, and it finally becomes half-auto-\\nmatic, but for the beginner it is most discouragingly difficult. He may, how-\\never, obtain great assistance in acquiring the right habit of thought by system-\\natically writing down each sign as it is perceived, and by grouping with it the\\nother signs belonging to the same region. This he may do by means of short\\ndescriptions, or, better still, he may employ symbols to represent the various\\nsounds, etc., and may mark them directly on the patient s body, or may fill them\\nin on blank diagrams of the thorax and abdomen, and thus obtain a complete\\nand vivid picture of the results of the examination of each separate region\\nThe practical value of this method, both as an aid to the beginner and as an\\neasy and accurate means for preserving records, has been widely recognized,\\nand numerous symbols have been devised, to represent graphically the various\\nphysical signs. Those suggested by Wyllie, of Edinburgh, and by Sahli, of\\nBern, are among the best. Many of the symbols used in the following plates\\nwill be recognized as borrowed from the above authors.\\nExplanation of the Symbols Used in the Plates Illustrating Special\\nDiseases.\\nPercussion Sounds. Superficial dulness (also called absolute dulness) is\\nalone indicated in the following plates. As has already been stated, the per-\\nsonal equation enters so largely into the determination of the extent of deep\\n(relative) dulness that it is scarcely possible to make any positive statements in\\nregard to the areas over which it is obtained in health and in disease. Absolute\\ndulness is, on the other hand, easily recognized, and it is, therefore, far better\\nthat the student first become thoroughly familiar with this, about which there\\ncan be little or no question, before being taught what, in the case of relative\\ndulness, is after all merely the expression of the individual skill and acuteness", "height": "4416", "width": "2584", "jp2-path": "practicaltreatis00muss_0_0575.jp2"}, "576": {"fulltext": "538 SPECIAL DIAGNOSIS.\\nof ear of the instructor. With a clear picture of the areas of superficial dulness\\nonce firmly fixed in the mind, the student should for himself determine just how\\nfar he individually is able to rely upon his perception of deep dulness. As his\\nskill in percussion increases, and as his ear becomes better trained, he will find\\nhimself progressively better able to make use of deep dulness as an aid in diag-\\nnosis. He should, however, remember that many skilled diagnosticians are\\ncontent to rely almost exclusively upon superficial dulness.\\nBlue shading Areas of superficial dulness the intensity of the color ex-\\npresses the intensity of the dulness.\\nHR Hyper-resonance.\\nT Tympany the pitch is indicated by a dot above or below\\nthe letter.\\nBreath- sounds. An ascending line indicates inspiration a descending line\\nexpiration. The length of the line shows the length of the sound, the thickness,\\nits intensity. A dot above or below the line indicates high or low pitch. Two\\ncross lines are used to designate bronchial breathing a single cross line indi-\\ncates broncho vesicular breathing. An interrupted line stands for cog-wheel or\\ninterrupted breath-sounds.\\nNormal vesicular breath-sounds.\\nWeak vesicular breath-sounds.\\nS\\\\ Harsh vesicular breath-sounds (puerile breathing).\\nHarsh vesicular inspiration, prolonged vesicular expiration.\\njJ Sharp vesicular inspiration, slightly prolonged vesicular expi-\\nration.\\nInterrupted (cog-wheel) breath -sounds.\\nBronchial breath-sounds (bronchial breathing), inspiratory\\nand expiratory.\\nBronchovesicular inspiration, low-pitched bronchial expira-\\ntion.\\nRales. Dry rales are represented by undulating lines, the length corresponding\\nto the duration, while a dot above or below the line indicates the pitch.\\n^v^v^a Sonorous rales.\\n^w Sibilant rales.\\nMoist rales are represented by circles the diameter of which indicates the size\\nof the rales. An ascending line drawn through the circle shows that the rale is\\nheard during inspiration, a descending line that it is heard during expiration.\\nThe clear, sharp, moist rales heard over consolidated areas, rales with over-tones,\\nare indicated by large or small dots, according to their size.\\nSmall, moist (subcrepitant) rales.\\nMedium-sized moist rales.\\nft Large moist rales heard during both inspiration and expira-\\ntion.\\no Lan e and small moist rales.\\nO", "height": "4404", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0576.jp2"}, "577": {"fulltext": "DISEASES OF THE LUNGS AND PLEURA. 539\\nSmall moist rales heard over consolidated areas.\\nMedium-sized moist rales heard over consolidated areas.\\nLarge moist rales heard over consolidated areas\\nLarge and small moist rales heard over consolidated areas,\\nCrepitation.\\nrC A, Crepitant rales,, to be heard only during inspiration.\\nFriction Rub.\\nAV\\\\Aaa Friction rub, as heard over any serous surface.\\nHeart-sounds. The symbols used to indicate the feet in Latin poetry are\\nmade to represent the heart-sounds. The straight line indicates the longer, the\\ncurved line the shorter sound. The thickness of the lines shows the relative as\\nwell as the absolute loudness.\\nu Normal heart-sounds as heard over the mitral and tricuspid\\nregions.\\nu Normal heart-sounds as heard over the aortic and pulmonic\\nregions.\\nNormal first sound, accentuated second.\\nww Loud first sound, reduplicated second.\\nLoud first and second sounds of equal intensity.\\nMurmurs. Murmurs are represented by short parallel lines either increasing\\nor diminishing in length, according as the murmur increases or diminishes in\\nintensity. The thickness of the lines shows the loudness of the murmur, the\\nnumber of lines shows its duration.\\nIllllin. A soft murmur, commencing distinctly and gradually fading\\naway.\\nIlfllin. A loud murmur of the same character.\\n\u00e2\u0096\u00a0ill A short loud murmur, increasing in intensity (type of pre-\\nsystolic murmur).\\nLoud first sound, slightly accentuated second sound; short\\nloud presystolic murmur, increasing in intensity to end with\\nthe first sound long, soft, systolic murmur.\\nFremitus.\\nF Increased fremitus.\\nF Diminished fremitus.\\nNoF Absent fremitus.\\nOther Symbols.\\nX Impulse.\\nM Margin (of an organ).\\nR Eetraction.\\nB Bulging.\\nv Visible.\\np Palpable.\\nXvp Visible and palpable impulse.\\nIV|vp Visible and palpable margin,\\n\u00e2\u0096\u00a0l|l!l", "height": "4416", "width": "2592", "jp2-path": "practicaltreatis00muss_0_0577.jp2"}, "578": {"fulltext": "540 SPECIAL DIAGNOSIS.\\nThe Neuroses.\\nThe neuroses are affections of the lungs unattended by structural\\nchange. To this class belong the varieties of rapid breathing, of slow\\nbreathing, of cough and of dyspnoea which appear to arise without\\nstructural change, and which are discussed exhaustively in the section\\ndevoted to the subjective symptoms. Among other neuroses, asthma\\nis fully treated of, and other forms of dyspnoea and cough are\\nconsidered. Reference need not be made further to the respiratory\\nneuroses other than to bear in mind that their presence may or may\\nnot be unattended by organic change in the lungs. On the other\\nhand, we are likely to find the general phenomena or stigmata which\\nare associated with neuroses of other organs, as well as the lungs.\\nHence, the condition of neurasthenia is likely to be present on the one\\nhand, or the numerous stigmata of hysteria may be found on the other.\\nThe Congestions.\\nCongestion of the Lungs. Active Congestion. In active con-\\ngestion there is an increased amount of blood, which diminishes the\\nair-space by encroachment and causes more or less consolidation. The\\nsigns of that physical condition are present increased fremitus, im-\\npaired resonance or dulness, and bronchial breathing. They are\\nobserved on both sides, usually at the bases. Dyspnoea, cough, and\\nfrothy, bloody expectoration attend the fluxion. No cases have yet\\nbeen reported in which bacteriological examination of the sputum was\\nmade. Of course, the micrococcus lanceolatus is not found.\\nIf the above signs and symptoms develop suddenly within twenty-\\nfour hours a fluxion to the lung has in all probability taken place.\\nIf the patient is subject to heart disease, or if he has been exposed to\\nand has inhaled hot vapors or irritants, the probability of fluxion is\\nincreased. The occurrence of fever Avould point to pneumonia as the\\ncause of the objective and subjective symptoms.\\nPassive Congestion. The physical condition that results is con-\\nsolidation, manifesting itself by slight dulness and feeble or bronchial\\nbreathing the bronchial mucous membrane is also congested, giving\\nrise to abundant large rales. The affection is bilateral and usually\\nconfined to the posterior portions of the bases. It is also secondary.\\na. Mechanical congestion occurs when the flow of blood to the heart is\\nobstructed, as in organic valvular disease or insufficiency. Rarely the\\npressure of tumors on the pulmonary veins acts in a similar manner.\\n6. Hypostatic congestion occurs in fevers, as protracted typhoid, and\\nin prolonged general exhaustion or adynamia. Ascites or other affec-\\ntions below the diaphragm, which lessen the respiratory excursion,\\ncause this form. Dyspnoea, cough, and expectoration of blood-stained\\nsputum are common. The sputum contains alveolar cells, often pig-\\nmented, but no micro-organisms.\\n(Edema. The air-cells and alveolar walls are filled with serous\\nexudation, as in oedema of the skin. It is frequently due to the weak-\\nness of the heart, which occurs at the end of long-continued diseases", "height": "4412", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0578.jp2"}, "579": {"fulltext": "DISEASES OF THE LUNGS AND PLEURA. 541\\nof an exhaustive nature, particulaly if the heart is overtaxed. It\\noccurs, therefore, in the terminal stages of chronic Bright s disease, of\\norganic heart disease, of the anaemias and cachexias. Both congestion\\nand oedema occur in cerebral affections.\\nSymptoms. They are those of congestion in a more aggravated\\nform. Dyspnoea, cough, and the expectoration of large quantities of\\na seromucoid fluid are seen. The diagnosis is based upon the result\\nof physical examination and the history of the above causal factors.\\nIn cases of myocarditis or acute dilatation of the heart, in valvulitis\\nwith failing compensation, oedema of the lungs often takes place sud-\\ndenly. It may follow some unusual exertion. Its onset is attended\\nwith more or less collapse, increased pulse-rate, hurried, oppressed,\\nnoisy breathing, cyanosis, and an anxious expression. The physical signs\\nare an unusual number of small rales throughout the chest, apparently\\ncreated in the air sacs, and imperfect resonance, showing that some\\nlobules are collapsed.\\nPulmonary Embolism and Thrombosis. Pulmonary embolism\\nconsists in plugging of the pulmonary artery or its branches by coagula\\nformed in the right heart or in the veins. The symptoms depend upon\\nthe size of the occluded vessel and upon the nature of the embolus i. e.,\\nwhether septic or not. If the artery itself is plugged, death takes place\\nsuddenly or after a short interval, with symptoms of syncope or asphyxia.\\nSymptoms. If a large branch is plugged, the first symptom is gen-\\nerally intense dyspnoea, which may amount to an agonizing craving\\nfor air. Pain in the chest, which may or may not be acute, is com-\\nplained of, and may be referred to the seat of the embolus. Cough is\\nnot a common symptom, and may be altogether absent. The breath\\ning is considerably altered it is usually increased in frequency, and\\nmay be much hurried it may or may not be shallow, and Avhile the\\npatient can take a deep inspiration, it does not give relief to his dysp-\\nnoea. At times it is irregular and gasping.\\nThe face is pale or may be cyanosed, and is apt to be bathed in per-\\nspiration. The veins are swollen and prominent. The heart s action\\nis irregular and may be tumultuous. Exophthalmos has been ob-\\nserved. The temperature falls below normal, but a febrile rise may\\noccur later. The intellect is unclouded.\\nThe physical signs are indefinite. The respiratory murmur is rough-\\nened and exaggerated in most, but not in all cases. Fox states that\\nrales are very rarely heard. Collapse, oedema, and bronchitis are possi-\\nble results. A systolic blowing murmur may be heard over the heart\\nand pulmonary artery, and in protracted cases albuminuria and oedema\\nmay be met with.\\nWhen the embolus is septic, a septic pneumonia or metastatic abscesses\\nare probable results in cases not immediately fatal.\\nWhen the emboli produce hemorrhagic infarcts the symptoms are\\nmilder, and consist principally in dyspnoea, pulmonary hemorrhage,\\nand palpitation. The onset is sudden and accompanied by a fall in\\ntemperature. The physical signs indicate consolidation, if the pneu-\\nmonia or infarcted area is of moderate size. It may be discovered at\\nthe root of the lungs in the interscapular region.", "height": "4416", "width": "2592", "jp2-path": "practicaltreatis00muss_0_0579.jp2"}, "580": {"fulltext": "542 SPECIAL DIAGNOSIS.\\nHaemoptysis is a common symptom when the embolus has arisen in\\nthe heart. The amount of blood varies from a copious expectoration\\nto the rusty sputum seen in pneumonia it may persist for weeks.\\nPleurisy and pleural effusion are frequent complications chills occur\\nsometimes, and pneumonia, with corresponding rise of temperature,\\nmay develop.\\nThe most important points in diagnosis are the sudden onset of the\\ndyspnoea and other pulmonary symptoms, and the detection of a con-\\ndition which would give rise to emboli, such as puerperal fever or\\nheart disease.\\nThe Inflammations.\\nThe Bronchi. Inflammations of the bronchi are distinguished from\\nother diseases of the lungs chiefly by the difference in the physical\\nsigns. Except in capillary bronchitis, the general and subjective\\nsymptoms are not so severe as in other affections.\\nSigns Peculiar to Inflammations of Bronchi. We are aided\\nin the recognition of bronchial affections, first, by the fact that they\\nare bilateral second, that the bases are usually affected third, that\\nthere is diminution of fremitus determined by palpation fourth, that\\nthere is absence of dulness on percussion fifth, that rales are more\\npronounced in proportion to other physical signs, and more general\\nthan in other lung affections.\\nBronchitis. Bronchitis is an inflammation of the mucous mem-\\nbrane of the bronchial tubes. It may be acute or chronic, may in-\\nvolve any part of the bronchial tree, the large, the middle-sized, or\\nthe most minute branches, and may be primary, or occur secondarily\\nto some general disease, or to disease of the heart or kidneys.\\nAcute bronchitis occurs most frequently by extension of the\\ncatarrhal inflammation from the nose and throat but in some persons\\nit develops so suddenly that it appears to be primary in the tubes.\\nWhen the larger or middle-sized tubes are involved, the patient com-\\nplains of soreness or rawness underneath the sternum, especially at its\\nupper part. There are frequently a feeling of tickling in the throat,\\nand a sense of weight or oppression on the chest. Chest pain is due\\nto myalgia or the strain upon the muscles from coughing. The cough\\nis at first hard and dry, and often produces pain of a tearing character\\nin the muscles of the chest and abdomen. The cough is apt to be\\nA\\\\ r orse when the patient first lies down, and again on rising, especially\\nafter a night s rest. Fever is usually slight and of short duration.\\nThe respirations are accelerated, but not markedly, and there is no\\ndyspnoea. The expectoration is at first a white, frothy, viscid mucus,\\nsubsequently becoming more abundant and mucopurulent.\\nPhysical Signs. In uncomplicated cases there are no changes in the\\nphysical structure of the lungs. On examination of the chest the per-\\ncussion-note is found to be clear the respiratory murmur more rough-\\nened and harsher than normal, but not broncho vesicular or bronchial\\naccompanying breathing there are heard sibilant and sonorous rales,\\nand, in the later stages, some large and medium-sized mucous rales.\\nThe rales vary in position from time to time, and especially after", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0580.jp2"}, "581": {"fulltext": "DISEASES OF THE LUNGS AND PLEURAE. 543\\ncoughing. Vocal resonance and fremitus are unaltered. A fremitus\\nmay be produced by sonorous rales.\\nThe cough and expectoration usually last for some time after fever\\nhas subsided. The duration of the disease is from a few days to sev-\\neral weeks. It is never fatal except in the very old and very young,\\nor in those who are much debilitated.\\nThe diagnosis of acute bronchitis is easily made by noting the fact\\nthat the disease runs an acute course, marked by fever, cough, and ex-\\npectoration and that the physical signs are negative, except as to\\nroughening of the respiratory murmur and the existence of bronchial\\nrales, heard on both sides of the chest.\\nFrom croupous pneumonia and local tuberculosis of the lungs it is\\ndistinguished by the absence of dulness on percussion, bronchial\\nbreathing, and increase of vocal resonance and fremitus by the\\nabsence, in other words, of the ordinary signs of consolidation. From\\npneumonia it is further distinguished by the milder character of the\\nsubjective symptoms, and by the fact that in bronchitis the physical\\nsigns are almost always bilateral, in pneumonia generally unilateral.\\nIt is further distinguished from tuberculosis by the slow progress of\\nthe latter, which involves the apices preferably, whereas bronchitis is\\nmore marked at the bases and by the occurrence, sooner or later, of\\nhectic fever and emaciation, which are absent in bronchitis. Doubt\\nwill exist only at first the progress of the case will in time make\\neverything clear. Systematic examination of the sputum is an impor-\\ntant diagnostic aid, and will lead to the differentiation of many cases\\nof bronchitis from tuberculosis and from pneumonia. In infants and\\nchildren especially, bronchitis is at times so rebellious to treatment\\nthat tuberculosis is suspected.\\nIn bronchopneumonia (catarrhal pneumonia) there is a diffuse bron-\\nchitis associated with small areas of pneumonic consolidation. It is\\ndistinguished by having graver general symptoms and by the presence\\nof small areas over which there are dulness on percussion and bronchial\\nbreathing, associated with physical signs of bronchitis already de-\\nscribed.\\nAcute miliary tuberculosis of the lungs is very easily mistaken for\\nbronchitis, because dulness, if present, amounts to nothing more than\\ntympanitic dulness, because the signs are diffused through both lungs,\\nand because the respiratory murmur is fainter than normal, but only\\nslightly roughened. Close inspection of the patient will, however,\\nmake it evident that his condition is worse than could be accounted\\nfor by bronchitis alone. The fever is higher, the respirations more\\nfrequent, pallor, with a dusky or faintly cyanotic hue intermingled, is\\ncommon, perspiration is more pronounced. A primary focus or a\\nsource of infection may be discovered.\\nAcute bronchitis may be mistaken for spasmodic laryngitis (croup).\\nIt is distinguished by the fact that the spasms are less pronounced in\\nbronchitis, and there is fever in addition to the physical signs. In\\nbronchitis the breathing is rarely so stridulous as in laryngeal spasm.\\nWhooping-cough cannot be distinguished positively from bronchitis\\nbefore the characteristic whoop appears but it may be suspected when", "height": "4412", "width": "2584", "jp2-path": "practicaltreatis00muss_0_0581.jp2"}, "582": {"fulltext": "544 SPECIAL DIAGNOSIS.\\nthe child has been exposed to contagion, and when the coryza and\\nredness of the fauces persist in spite of treatment.\\nIn the diagnosis of bronchitis it is more often difficult to determine\\nthe primary cause than it is to distinguish it from other pulmonary\\naffections. Yet the former is more important it must be borne in\\nmind that bronchitis is a frequent accompaniment of many febrile dis-\\neases, such as typhoid fever, measles, and whooping-cough of diseases\\nof the heart and kidneys, and of septic diseases and blood disorders.\\nThe primary will not be likely to be mistaken for the seconday dis-\\norder if one is upon his guard and insists upon finding a cause for each\\ncase that presents itself.\\nMeasles can usually be diagnosticated from the first by the coryza,\\nbut especially by the red spots upon the anterior half-arches of the\\nsoft palate, which appear usually several days before the eruption upon\\nthe body.\\nBronchitis is a common and important early symptom of typhoid\\nfever. The latter disease may be suspected when the fever, prostra-\\ntion, and headache are greater, and, especially if these symptoms coex-\\nist with a loose condition of the bowels, chilliness, and occasional nose-\\nbleed.\\nChronic bronchitis occurs most frequently in middle or later\\nlife. Its special feature is long duration, without fever, and with\\ncomparatively little impairment of the general health. Cough is not\\nconstant there are periods when it is entirely absent the disease\\nthen returns, perhaps with increased severity, and lingers indefinitely.\\nChronic bronchitis in its milder form consists in what is often\\ncalled winter cough. It attacks especially persons past middle life\\nwho have emphysema. It appears with the cold weather, and lasts\\nuntil the following summer. The cough is not severe, though some-\\ntimes paroxysmal, and expectoration is scanty, non-purulent, and may\\nbe confined to the morning. Dyspnoea is not marked unless there is\\nconsiderable emphysema. Acute exacerbations occur from time to\\ntime, and the tendency of the disease is to become worse from year\\nto year, and to be more continuous, even persisting all summer.\\nIn the dry catarrh, or catarrhe sec of Lsennec, paroxysms of cough\\noccur on the slightest provocation, with the expectoration of small,\\nhard pellets, or without any expectoration. The patients are emphy-\\nsematous.\\nThe diagnosis is made by noting the long duration of the disease\\nwithout impairment of the general health, its relation to season, and\\nthe absence of physical signs of involvement of lung tissue.\\nThe physical signs of chronic broncriitis are those of bronchitis of\\nthe larger and middle-sized tubes. Large moist rales are more or less\\nabundant, depending upon the degree of swelling of the mucous mem-\\nbrane, and the quantity and fluidity of the secretions. The respiratory\\nmurmur is roughened and less intense than normal.\\nr Fox says that in chronic bronchitis there is commonly hyper-\\nresonance from coexisting emphysema, but under acute exacerbations\\nthe bases may be dull from congestion or oedema. Respiration is\\nharsh, and in some cases of senile bronchitis expiration may be both", "height": "4412", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0582.jp2"}, "583": {"fulltext": "DISEASES OF THE LUNGS AND PLEURAE. 545\\nprolonged and high pitched, when other signs of dilatation of bronchial\\ntubes are absent. The percussion-note is clear.\\nThe sputa of the severe forms of chronic bronchitis are usually\\ncopious and mucopurulent, the latter predominating. They vary in\\ncolor from yellowish-white to ashy, greenish, or black when the lungs\\nare anthracotic or collapsed.\\nThe subjective symptoms of the patient consist, in ordinary cases, of\\na moderate amount of dyspnoea, and tightness across the chest. At\\nthe onset of a fresh attack the symptoms may be those of acute bron-\\nchitis. The cough is paroxysmal, somewhat resembling that of whoop-\\ning-cough, but without the characteristic whoop. It is usually severest\\non lying down and when rising in the morning.\\nThe quantity and character of the sputa vary more than in acute\\nbronchitis. Sometimes they are very copious, consisting of serum\\nmixed with mucus, constituting bronchorrhoea. More commonly they\\nare scanty, glairy, and tenacious.\\nChronic bronchitis may be the result of repeated acute attacks, or,\\nrarely, of only one. It is frequently found in association with gout,\\nchronic heart disease, chronic endarteritis, Bright s disease, emphy-\\nsema, asthma, and chronic alcoholism. It may alternate with other\\ngouty affections, as articular inflammation or eczema, being relieved\\nwhen the other manifestations are more marked. It also accompanies\\ntuberculosis of the lungs. Climate and season have a marked influ-\\nence the disease is worse in damp, cold climates, and in the winter\\nmonths.\\nChronic bronchitis can be diagnosticated from the cough of aneurism\\nby the absence of the stridulous breathing, due to paralysis of one-half\\nof the vocal cords, and by the local signs of a tumor of the vessel.\\nOther tumors may cause cough by pressure, and the possibility of their\\nexistence should, therefore, be borne in mind.\\nCapillary Bronchitis, or Suffocative Catarrh, is bron-\\nchitis of the smaller tubes. It occurs most frequently as an extension\\nof the catarrhal process from the larger tubes, but sometimes seems to\\nattack the smaller tubes from the beginning, or coincidently with the\\nlarger tubes. Infants, young children, and the aged are most liable to\\nit. It begins with a succession of chills or chilliness, followed by high\\nfever. The temperature may rise to 104\u00c2\u00b0. The skin is hot, the face\\nflushed. The head and neck and the upper portion of the trunk may\\nbe covered with perspiration. The pulse rapidly increases in frequency.\\nThe aspect of the patient from the first shows that the illness is\\ngraver than ordinary bronchitis. The face expresses anxiety, and in\\nchildren the alse nasi dilate in respiration, which is both accelerated\\nand difficult (dyspnoea). The respirations may be as many as 60 or\\n80 to the minute, the pulse not being correspondingly rapid. Dysp-\\nnoea is more or less constant, but becomes urgent in paroxysms, and\\nthe patient may have to be propped up in bed to enable him to breathe\\n(orthopnoea). It is expiratory: inspiration may be free and easy, or\\ndifficult but expiration is always difficult and prolonged. In children\\nthe pause in the act of breathing takes place at the end of inspiration,\\ninstead of expiration.\\n35", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0583.jp2"}, "584": {"fulltext": "546 SPECIAL DIAGNOSIS.\\nCough is more frequent and violent than in ordinary bronchitis, and\\nthe expectoration is viscid and difficult to raise. As the disease pro-\\ngresses, dyspnoea becomes more intense, and signs of insufficient aera-\\ntion of the blood make their appearance (cyanosis). The lips and\\nfinger-nails become bluish, and the extremities cool and clammy. If\\nthe patient is unable to expel the tenacious secretions from his bron-\\nchial tubes, the further progress of the case is that of rapidly develop-\\ning cyanosis the breathing continues frequent, but is shallow and\\nmore labored. Children often have convulsions, followed by coma and\\ndeath, while old persons sink into coma without preceding convulsions.\\nThe physical signs (Plate XVII.) are those of bronchitis of the larger\\nand smaller tubes sibilant and sonorous rales, if present at first, give\\nway to fine subcrepitant and crepitant rales, which speedily become\\nmoist and very abundant. As an ordinary bronchitis, the bases of\\nthe lungs posteriorly are the parts most involved. The percussion-note\\nof both lungs remains clear, but there is apt to be increased resistance.\\nThe fremitus may be lessened in some areas, increased in others. If\\nan area of dulness appears, it may be due to pneumonia or to collapse\\nof the lung if the former, there is usually an access of fever.\\nThe sputum contains mucus, pus, occasionally blood-cells, granular\\nmatter, and sometimes fibrinous casts of the tubes. The micro-organ-\\nisms found are the micrococcus lanceolatus, streptococcus pyogenes, and\\nstaphylococcus aureus et albus. Mixed infections are usually present.\\nPlastic bronchitis is a form of bronchitis, usually chronic, the\\ncharacteristic feature of which is the expectoration of fibrinous casts,\\nwhich, when unravelled under water, are found to be solid casts of\\nthe smaller bronchial tubes. The casts are often tree-like in shape,\\nshowing that a bronchial tube and its smaller subdivisions have been\\noccluded by the casts.\\nPersons of all ages are liable to it, but it affects males about twice as\\noften as females.\\nThe subjective symptoms are cough and dyspnoea haemoptysis\\noccurs in about one-third of the cases (Biermer). 1 The cough occurs\\nin paroxysms, which are frequent and severe relief follows expecto-\\nration of the casts.\\nHemorrhage may appear only as streaks of blood upon the casts, or\\nmay be considerable, and follow their dislodgement. The casts them-\\nselves when ejected are usually coated with mucus, so that they appear\\nas solid masses of sputum their arrangement into cylinders may not\\nbe suspected until they are agitated in Avater. The size of the cylin-\\nder varies from that of the little finger to that of a bodkin, but they\\ndo not often exceed the size of a goose-quill. The larger casts may\\nbe hollow, but the smaller ones are solid, and are arranged in layers.\\nThey are whitish or gray in color, and firm in consistence, but become\\nsofter as the disease improves. Microscopically, the casts are nearly\\nstructureless, consisting of a fibrillated base, with pus and mucous cor-\\npuscles, a few gland-cells, and, occasionally, blood-cells in the outer\\nlayers. Charcot-Leyden crystals and Curschmann s spirals are found.\\n1 Virchow: Handbuch der spec. Path. u. Ther., Bd. v., Abth. 1.", "height": "4408", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0584.jp2"}, "585": {"fulltext": "PLATE XVII\\n1 m\\nVJ*;\\nFIG. 2. Posterior Aspect.\\n^4\\nCapillary Bronchitis (early stage).\\nRough or sharp breath sounds-expiration in places prolonged. Sonorous,\\nsibilant and small moist rales. Local increase of fremitus.", "height": "4397", "width": "2607", "jp2-path": "practicaltreatis00muss_0_0585.jp2"}, "586": {"fulltext": "", "height": "4412", "width": "2552", "jp2-path": "practicaltreatis00muss_0_0586.jp2"}, "587": {"fulltext": "DISEASES OF THE LUNGS AND PLEURJS. 547\\nThe acute form is rare, and out of ten cases accepted by Biermer six\\nproved fatal. The disease begins A\\\\ r ith fever, dyspnoea appears early,\\nsevere paroxysms of cough occur, sometimes hemorrhage. Death\\nresults from asphyxia. Grave symptoms are excessive dyspnoea,\\nscanty expectoration, and drowsiness. Copious expectoration is a\\nfavorable sign.\\nThe Physical Signs. The casts obstruct the bronchial tubes. There\\nis less air entering the part, hence there are diminished fremitus and\\nrespiratory murmur over the portions of lung supplied by the obstructed\\ntubes. If collapse ensues, there is dulness on percussion if the casts\\nare dislodged, the murmur becomes normal, or but slightly roughened.\\nIn unaffected portions of the lung resonance is clear or exaggerated,\\nand the respiratory murmur remains unaltered.\\nFuller says (quoted by Peacock in Diseases of Chest) that the upper\\nportions of the lungs are oftener affected than the lower portions.\\nFetid or Putrid Bronchitis is the name applied to the condi-\\ntion in which the sputa have a highly offensive odor and are copious\\nand semi-putrid. The odor is said by some to be due to microscopic\\nsloughs, and by others to a special bacillus.\\nPutrid bronchitis may accompany (1) dilatation of the bronchial\\ntubes (2) chronic pneumonia (3) phthisis or (4) empyema with a\\nfistulous communication with a bronchus or (5) it may occur indepen\\ndently. The subjective symptoms are cough, irregular fever, and\\noccasional chills. The physical signs are those of chronic bronchitis,\\nor of bronchitis and the conditions with which it may be associated\\n(q. v.). It is diagnosticated from gangrene by the absence of physical\\nsigns of disintegration of lung-tissue and by the absence from the\\nsputum of fragments of lung-tissue and elastic fibres. Nevertheless,\\ngangrene of the lung may be the final result of putrid bronchitis.\\nThe sputa of fetid bronchitis have an odor of gangrene or faeces.\\nOn standing they separate into three layers. The upper one consists\\nof a greenish, fluid, or frothy layer the second is sero-albuminous\\nand the third a thick granular deposit in which are small masses, the\\nsize of peas (Dittrich s plugs), and flake sconsisting of granular detritus,\\nand containing fat-crystals and bacteria, the oidium albicans, and crys-\\ntals of leucin and ty rosin. (See Sputum.)\\nInfectious Bronchitis. In addition to the bronchitis that attends\\nthe infectious disorders mentioned above, three forms are seen of an\\ninfectious nature which are properly classified among the infectious\\ndiseases. It is proper to refer to them now, as bronchitis is usually\\nthe most pronounced local manifestation. They are influenza, whoop-\\ning-cough, and hay-fever. The last only will be spoken of at present.\\nHay- fever. Hay-fever is a specific catarrh of the respiratory pas-\\nsages, caused by the pollen of certain plants, principally the grasses.\\nThe attack begins with itching, burning, and lacrymation of the eyes,\\nand pain in the brow or eyeballs. Subsequently there is itching or\\npricking of the nasal mucous membrane, frequent sneezing, and an\\nirritating watery discharge. The mucous membrane of the nose is\\nred and swollen. A similar condition obtains in the throat when that\\nis affected. If the disease attacks the bronchial mucous membrane a", "height": "4412", "width": "2564", "jp2-path": "practicaltreatis00muss_0_0587.jp2"}, "588": {"fulltext": "548 SPECIAL DIAGNOSIS.\\nbronchitis is set up, which, if it differs at all from ordinary bronchitis,\\nis more persistent and attended by greater dyspnoea, with asthmatic\\nattacks.\\nCollapse of the Lung. Collapse of the lung is a condition pro-\\nduced by exhaustion of air from the air-vesicles. It may affect alyeoli\\nhere and there, or a large section of the lung. Formerly such collapse\\nwas invariably looked upon as pneumonia, until Legendre and Bailly\\nproved by forcible inflation that the air- vesicles had simply collapsed\\nfrom absence of air. Collapse occurs most frequently in the course of\\nbronchitis and in cases with feeble respiratory power. The bronchial\\ntwigs supplying certain air-vesicles, or tubes supplying sections of lung,\\nbecome occluded to such a degree that no air can enter. The air\\nalready contained in the vesicles then becomes exhausted gradually\\nuntil the vesicles are completely airless. The vesicles or sections of\\nlung involved then return to the foetal condiiion. When the collapse\\nis congenital the term atelectasis is preferable. Anything which in-\\nduces great muscular weakness predisposes to collapse of the lung\\nhence, in the aged and feeble, in Avasting diseases, and in low febrile\\ndiseases of long standing, collapse is very apt to occur. But bronchitis\\nis the most frequent and direct cause. The secretions which are\\npoured out, and the swelling of the mucous membrane, occlude the\\ntubes, and if the patient have not strength enough to expel the secre-\\ntions, and by forced inspiration expand the collapsing vesicles, collapse\\nensues.\\nDiagnosis. The diagnosis of the condition in life is difficult. The\\nsite of collapse, being airless, is, of course, dull on percussion. The\\nrespiratory murmur is more likely to be faint or absent than to be\\nincreased in intensity or approach the bronchial. Nevertheless, there\\nis sometimes heard a faint broncho vesicular expiration.\\nWhen oedema is superadded to collapse, moist crepitant rales are\\nheard, difficult if not impossible to distinguish from those of pneumo-\\nnia. Respiration is embarrassed, and is accompanied by sucking-in of\\nthe lower part of the chest in inspiration. Sometimes the plug of\\nmucus which occludes the tubes becomes dislodged while the physician\\nis auscultating, and then the respiratory murmur will be heard, accom-\\npanied by a succession of crepitant rales, which disappear after a few\\ninspirations. The dull areas, as a rule, are less persistent than those\\nof pneumonia thus it may be found at successive examinations that\\none area has cleared up and another has become dull. Stress is laid\\nby some writers upon the signs of emphysema surrounding collapsed\\nareas. But this does not give assistance in the cases in which most\\nhelp is required cases in which there is diffuse bronchitis with more\\nor less oedema.\\nSubjectiye symptoms are those of dyspnoea and insufficient oxygena-\\ntion of the blood. If these are developed suddenly, and are accom-\\npanied by the appearance of dull areas in the lung without bronchial\\nbreathing, the diagnosis is tolerably certain but when scattered lob-\\nules only are involved, the physical signs of collapse are absent, and\\nits existence must be a matter of inference.\\nFrom lobar pneumonia the diagnosis is easily made by the difference", "height": "4408", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0588.jp2"}, "589": {"fulltext": "", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0589.jp2"}, "590": {"fulltext": "PLATE XVIII,\\nFIC. 1.\\nBroncho- pneumonia.\\nConsolidation in the right upper and the left lower lobes. Physical signs\\nof bronchitis over both lungs.", "height": "4396", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0590.jp2"}, "591": {"fulltext": "DISEASES OF THE LUNGS AND PLEUEJE. 549\\nin the physical signs, and by the absence in pulmonary collapse of\\ninflammatory symptoms, by the lower temperature, and the difference\\nin onset.\\nThe diagnosis from bronchopneumonia, or catarrhal pneumonia, is\\nbeset with greater difficulties. But here also the low temperature,\\nand the fact that the physical signs and the location of the dull areas\\nare subject to rapid changes, are of aid in diagnosis.\\nThe Bronchi, the Alveoli, and Connective Tissue.\\nBronchopneumonia, or Catarrhal Pneumonia, is a pneumonia\\noccurring secondarily to bronchitis, and is characterized by the devel-\\nopment of areas of consolidation in both lungs and the persistence of\\na bronchitis of the middle-sized or smaller tubes. In proportion as\\nthe areas of consolidation are large, the symptoms and physical signs\\napproach those of lobar pneumonia. It is more common in children\\nand in debilitated persons. It is the chief form in infants. 1. It is\\nfrequently secondary to measles, diphtheria, scarlet fever, and per-\\ntussis. 2. As aspiration pneumonia, it occurs when food, septic parti-\\ncles, blood, or tissue enter the lungs during the loss of sensibility of\\nthe larynx in apoplectic, ursemic, or other forms of coma, and in opera-\\ntions about the upper air-passages and mouth. It is a fatal complica-\\ntion of tracheotomy. 3. It is frequently of tuberculous origin.\\nCatarrhal pneumonia, except the aspiration-form, develops gradu-\\nally, and it may not always be easy to mark the point at which the\\nbronchitis which precedes merges into pneumonia but as a rule there\\nare more or less chilliness (rarely a decided chill) and an access of\\nfever. There is usually greater prostration than in the lobar form, in\\nproportion to the amount of pneumonia present. The pulse is more\\nfrequent and more likely to be feeble. Cough and expectoration are\\nmarked symptoms. The sputum is tenacious and glairy, not rusty.\\nIt contains streptococci and staphylococci in much greater numbers\\nthan are found in ordinary bronchitis fatty epithelial cells, epithe-\\nlium, fat-globules, and diplococci.\\nDyspnoea is more extreme than in lobar pneumonia. The respira-\\ntions are excessively rapid 60 to 80 per minute cyanosis rapidly\\nensues. The finger-tips become blue, the face dusky. The fever\\ndoes not rise as high as in the lobar form. At first the skin is hot\\nand dry later it becomes cold and clammy, and in the tuberculous\\nform sweats are common. The duration of the disease is usually much\\nlonger than in lobar pneumonia.\\nThe physical signs (Plate XVIII.) are those of bronchitis, with here\\nand there larger or smaller areas of consolidation, over which the rales\\nare finer and closer set the percussion-note is dull, and the respiratory\\nmurmur bronchial or bronchovesicular. An entire lobe may be consoli-\\ndated. Areas of collapse and portions more or less oedematous combine\\nto make the more complex physical signs. While both lungs are affected,\\nthey are not usually so to the same extent. It is said that the apices\\nare more prone to involvement in this than in the lobar form and some\\nwriters (Osier) look upon it almost, if not always, of tubercular origin.", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0591.jp2"}, "592": {"fulltext": "550 SPECIAL DIAGNOSIS.\\nIn the common form seen in infants the symptoms of asphyxia set\\nin at variable periods in the course of the disease. General cyanosis\\nsupervenes. Stupor sets in, the hurried respirations grow shorter and\\nmore gasping, the pulse becomes excessively rapid and feeble, the ex-\\ntremities cool and clammy with the stupor the cough abates and the\\nbreathing becomes more shallow. The lungs fill up with fluid mucus,\\nand the child drowns in its own secretions, or cardiac paralysis sets in\\nafter dilatation of the right heart.\\nDiagnosis. The affection is distinguished (1) by its pathological\\nantecedents and causal relations (2) its gradual onset (3) its distri-\\nbution in both lungs (4) the preponderance of physical signs of bron-\\nchitis over those of consolidation (5) the extreme dyspnoea and cyan-\\nosis with a lower temperature than in lobar pneumonia (6) the onset\\nof carbondioxide-poisoning (7) the long duration and gradual decline.\\nThe tuberculous form is distinguished by (1) the history of exposure to\\ninfection or of a focus of infection in the body, glands, or joints (2)\\nthe longer course (3) delayed asphyxia (4) rapid emaciation (5)\\ndiffused sweats (6) physical signs of consolidation and subsequently\\nof cavity at the apex and (7) absolutely by tubercle bacilli in the\\nexpectoration coughed up or vomited. I have seen a child aged fifteen\\nmonths, of a tuberculous mother, completely recover. The tuberculous\\nform is common in colored infants.\\nBacteriological Diagnosis. Examination of the sputum shows an\\nabundance of the streptococci and staphylococci and the special micro-\\norganism which belongs to the primary infection, as that of influenza,\\ndiphtheria, and tuberculosis.\\nLobar Pneumonia, or Croupous Pneumonia. (Plate XIX.) This\\ninflammatory affection of the lung may be due to one of many micro-\\norganisms (single infection), or it may be a mixed infection. For its\\nconsideration, the reader is referred to the Infectious Diseases, Chapter\\nXX., Part I.\\nChronic Interstitial Pneumonia. Cirrhosis, fibroid phthisis, and\\nchronic interstitial pneumonia are names given to a condition of\\nchronic induration of the lung, caused by interstitial overgrowth of\\nfibrous tissue. Obliteration of the air-vesicles and contraction of the\\nlung result from the overgrowth. The bronchi are frequently dilated,\\nand cavities and gangrene may occur. The disease is rare except as\\nthe result of tuberculosis, but it may follow pneumonia and pleurisy, and\\nit is said to be caused by inhalation of fine particles of steel or cotton.\\nPneumonohoniosis is the term, first employed by Zenker, for the\\nchronic interstitial pneumonia from the inhalation of dust.\\nPhysical Signs. (See Plates, Bronchiectasis.) Inspection. The dis-\\nease is unilateral. The chest- wall is retracted. The ribs are drawn\\ntogether, so that the interspaces are obliterated. The shoulder is drawn\\nover the sunken thorax. The spinal column is curved. The heart is dis-\\nplaced. It is drawn toward the affected side. If the right lung is the seat\\nof disease, an impulse is seen to the right of the sternum if the left, the\\nprecordial area of impulse is increased and extends upward. There is\\nno expansion whatever (immobility) of the affected apex or base. The\\nlieal thy lung is the seat of compensatory emphysema. (See Fig. 147.)", "height": "4412", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0592.jp2"}, "593": {"fulltext": "Lobar Pneumonia.\\nConsolidation of the right lower lobe. Transmitted bronchial breathing and\\nsigns of bronchitis over the left lung posteriorly.", "height": "4416", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0593.jp2"}, "594": {"fulltext": "", "height": "4400", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0594.jp2"}, "595": {"fulltext": "DISEASES OF THE LUNGS AND PLEURA. 551\\nFig. 147.\\nFibroid (tuberculous) phthisis right apex. Heart displaced as indicated by oval.\\nPalpation. Inspection is confirmed. Fremitus is increased, espe-\\ncially at the apex. At the base, pleural thickening lessens the frem-\\nitus.\\nPercussion. The physical signs show increased density of lung\\ntissue, with dulness on percussion, or, over a dilated bronchus, a tym-\\npanitic or amphoric note.\\nAuscultation. The respiratory murmur is bronchial, or, over a\\ndilated bronchus, has a hollow sound. At the base breath-sounds are\\nfeeble, distant, or absent. Rales are also heard.\\nThe disease runs a very chronic course, attended by cough, and\\nmucopurulent and sometimes bloody expectoration, even hemorrhage\\nbut there is no fever and not much loss of flesh. Dyspnoea occurs on\\nascending heights only. Dilatation of the right heart is likely to\\nensue, with cardiac murmurs and increased lateral dnlness and increase\\nof dyspnoea. Death is hastened by the disease, and is often brought\\non by acute pneumonia.\\nIn pneumonokoniosis (also known as anthracosis, coal-miner s dis-\\nease siderosis, from metallic dust chalicosis, from mineral dust, as\\nm stone-cutter s phthisis) there is a history of exposure to the irri-\\ntating particles for a considerable period, during which time cough", "height": "4416", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0595.jp2"}, "596": {"fulltext": "552 SPECIAL DIAGNOSIS.\\ndevelops, gradually increases, and the general health fails. Emphy-\\nsema simultaneously arises, causing dyspnoea. The patients wheeze,\\ncough in paroxysms, and expectorate sputum Avhich contains the dust-\\nparticles. In anthracosis it is black. On microscopical examination\\nthe special dust-particles are often found. The symptoms of emphy-\\nsema and chronic bronchitis predominate. Tubercular infection may\\ntake place late in the disease.\\nPulmonary Tuberculosis. For convenience of diagnosis the specific\\ninflammation of the lungs caused by the bacillus tuberculosis will be\\nconsidered in this section. If a strict etiological classification were\\nfollowed, it would be considered among the infectious diseases.\\nClinically, we see tuberculosis in the lungs manifesting itself in one\\nof the forms of acute pneumonic phthisis, acute miliary tuberculosis,\\nand chronic ulcerative phthisis. (See Chapter XX., Part I.)\\nDefinition. Tuberculosis of the lungs, pulmonary phthisis, and\\nconsumption are names applied to an infectious and mildly contagious\\ndisease of the lungs, caused by the tubercle bacillus, appearing in an\\nacute and chronic form, and characterized by cough, fever, sweats,\\nmore or less rapid emaciation, purulent expectoration containing elastic\\nfibres, and tubercle bacilli, and by peculiar physical signs.\\nAcute Pulmonary Tuberculosis, Acute Phthisis, Acute\\nPneumonic Phthisis, Galloping Consumption, may be primary, or\\nbe secondary to a localized area in the lung, causing rapid infection, or\\nto tubercular pleurisy, tubercular peritonitis, or to tuberculosis of some\\nother organ. Its onset is usually marked by cough, fever with or\\nwithout chills, dyspnoea, and sometimes haemoptysis. The fever rises\\nto 103\u00c2\u00b0 or 104\u00c2\u00b0, and is of a continued type (lobar-pneumonic form),\\nor rapidly assumes a hectic type, accompanied by restlessness and ex-\\nhausting night-sweats, anorexia, anol rapid emaciation. Prostration is\\nextreme, but the mind is at first clear anol the spirits cheerful. Cough\\nincreases, the expectoration, at first mucoid and scanty, but often tinged\\nwith blood, becomes more copious and mucopurulent. The bowels\\nmay be loosened or constipated. The urine may show the cliazo-\\nreaction.\\nWhen death takes place without more decided pulmonary symptoms\\nthe tuberculosis has been seconolary to tuberculosis elsewhere, or death\\nis the result of a general miliary tuberculosis.\\nWhen the acute pulmonary tuberculosis is primary, the character of\\nthe disease is soon maole clear by the early development of consolida-\\ntion of the lungs, usually of an apex first, rapidly followed by soften-\\ning and the formation of cavities. The sputum becomes mucopuru-\\nlent, is frequently streakeol with blood, and pure blood is often coughed\\nup. The sputum contains yellow elastic tissue and abundant tubercle\\nbacilli. The patient often presents a cachectic appearance emaciation\\nhas been very rapid, and has reached an extreme degree there is fre-\\nquently a red flush about the cheek-bones, which, with the bright eyes,\\ncontrasts strongly with the hollow cheeks and temples, and the white\\nwasted hands and clubbed fingers with bluish nails.\\nThe patient s mental attitude is often peculiarly and characteristi-\\ncally hopeful. He expresses himself as better each olay, though he is", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0596.jp2"}, "597": {"fulltext": "", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0597.jp2"}, "598": {"fulltext": "PLATE XX.\\nFIG. 1. Anterior Aspect.\\nF+^X\\nFIG. 2.\u00e2\u0080\u0094 Posterior Aspect.\\nAcute Pulmonary Tuberculosis.\\nConsolidation of the entire right upper lobe and of the left apex.", "height": "4380", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0598.jp2"}, "599": {"fulltext": "DISEASES OF THE LUNGS AND PLEURAE. 553\\noccasionally subject to despondency, and is sure that if he could only\\ngain a little strength he would soon be well.\\nSometimes, especially in children, the disease is latent. The patient\\nsuffers from weariness, the cheeks flush easily, the pulse is readily dis-\\nturbed, there are nocturnal fever and occasional sweats. Emaciation\\nproceeds very gradually, and a long time may elapse before any dis-\\nease is demonstrable.\\nIn a few cases the cerebral symptoms are so pronounced as to mask\\nthe pulmonary, and in other cases there is actual coincident involve-\\nment of the cerebral meninges.\\nThe physical signs (Plate XX.) are those of consolidation, often with-\\nout conjoint pleurisy. The apex is usually first invaded. There are\\ndiminished movement, increased fremitus, and dulness on percussion.\\nAt first the breathing is bronchovesicular. It rapidly becomes bronchial.\\nAt first small moist rales are detected. Later they become large and\\ngurgling. A pleural friction may be heard. It may be first heard above\\nthe spine of the scapula behind, above the clavicle in front, or high up\\nin the axilla. The upper lobe of the right lung may be affected first,\\nor the anterior portion of the middle lobe. The physical signs may\\nbe observed first in the. axillary region of either side. The consoli-\\ndation extends to the remainder of the lung, being preceded by phys-\\nical signs indicating gradual encroachment upon the air-containing\\nstructure. The respiratory murmur is harsh, but soon becomes\\nbronchovesicular and then bronchial. (Lobar-pneumonic form.) As\\nconsolidation progresses in the middle and lower portions of the affected\\nlung, signs of cavity or multiple cavities appear in the upper. (The\\nwhole of a lobe may be the seat of small cavities filled with muco-\\npurulent or purulent fluid.) Cavernous breathing and pectoriloquy, or\\nthe bronchial sniff of consolidation, become more pronounced. The\\ndull note of consolidation is relieved by a dull tympanitic or full tym-\\npanitic note. Now moist rales of all degrees are heard. (Broncho-\\npneumonic form.) Above they are gurgling below, small and large\\nmoist rales. If the progress is not too rapid throughout the lung first\\naffected, signs of invasion are found in the remaining lung, usually at\\na point corresponding to the primary focus in the original lung. The\\napex, therefore, is first invaded in most cases. Infection of the second\\nmay begin earlier than the signs in the first lung would lead one to\\nanticipate. The rapid invasion of one lung compels compensatory\\nemphysema of the other. The increased movement, with harsh or\\npuerile breathing, without change in fremitus or in pitch and tone on\\npercussion, masks any small consolidations.\\nThe expectoration becomes more purulent as the disease progresses,\\nand may be blood-tinged. It is copious and possesses some fetor. It\\nis found to swarm with bacilli and to contain yellow elastic tissue.\\nHemorrhage may take place. The general symptoms become more\\nalarming. The fever becomes of a hectic type. The patient rapidly\\nemaciates. Cyanosis is shown in the dusky countenance and blue\\nfinger-tips. The exhaustion becomes extreme. Pallor, with flushed\\ncheeks and an anxious countenance, is seen. The sweats are profuse.\\nThe appetite is lost. Diarrhoea may set in. Remissions may take", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0599.jp2"}, "600": {"fulltext": "554 SPECIAL DIAGNOSIS.\\nplace, even in acute cases for a time the fever and more aggravated\\npulmonary symptoms are in abeyance. The typhoid state ensues in\\nsome cases. Death takes place from exhaustion and heart-clot or from\\nmeningeal tuberculosis. The duration is from two to six weeks.\\nDiagnosis. In the earliest stages, before the invasion of new terri-\\ntory is pronounced, the cases are involved in doubt. It may be con-\\nfounded with pneumonia until the sputum is secured and bacilli are\\nfound.\\nIn pneumonia we have the pronounced rigor, the rapid rise of tem-\\nperature, the altered pulse-respiration ratio, the hot, dry skin, the sticky,\\nviscid sputum, containing the pneumococcus, the peculiar changes in\\nthe urine, leucocytosis, the occurrence of herpes, the termination by\\ncrisis, to point to the nature of the process. Emaciation is not\\nmarked there are no such profuse sweats as the repeated drenchings\\nwe see in pneumonic phthisis anaemia is not so pronounced. Then\\ncavity-formation does not take place, or at least rarely. In pneumonia\\nthe fever is of a continued type in phthisis it is often intermittent\\nor remittent. The sputum is more purulent in acute pneumonic\\nphthisis. Finally, the history of exposure to infection, the primary\\noccurrence of tuberculosis elsewhere, the secondary occurrence of tuber-\\nculosis in other organs after the lung-invasion, the longer duration\\naid in determining the true affection. Inoculation of animals may be\\nresorted to in doubtful cases.\\nAcute miliary tuberculosis (pulmonary type) is attended by\\nhigh fever, rapid emaciation, hurried breathing, rapid pulse, duskiness\\nof face and extremities, more or less stupor, delirium, and the develop-\\nment of the typhoid state, with prostration and the occurrence of pro-\\nfuse sweats. Intestinal symptoms, as flatulency and distention, may\\nbe pronounced, and diarrhoea may form a prominent feature. Physical\\nsigns are negative or are those of bronchitis. There is resonance or\\nhyper-resonance on percussion. The latter is not uncommon. The\\nonset is abrupt or may follow a period of malaise. In some instances\\nthe tuberculous process is more advanced in some situations than in\\nothers, giving rise to special local symptoms. Thus, recently, a patient\\nwas admitted to the Presbyterian Hospital with stupor and moderate\\ndelirium. He had fever, rapid pulse and breathing, and a peculiar\\ndry, harsh skin. There were albuminuria, casts and blood in the\\nurine, and it was thought he had uraemia. The temperature-range\\nwas irregularly intermittent. The diagnosis was established later be-\\ncause of the development of undoubted secondary tuberculosis in\\nother organs. At the autopsy general tuberculosis was found, with\\nprimary tuberculous ulceration in the bladder, the ureters, and renal\\npelves.\\nDiagnosis. Hurried breathing and cyanosis are distinctive feat-\\nures, out of all proportion to the physical signs, and, on this account,\\nof diagnostic significance. It must be distinguished from typhoid\\nfever, septicaemia or pyaemia, and malignant endocarditis. It is dis-\\ntinguished from typhoid fever by the absence of successive stages in\\nthe course of the disease in typhoid fever the evolution of the disease\\nis more characteristic than its symptoms. The headache of the first", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0600.jp2"}, "601": {"fulltext": "DISEASES OF THE LUNGS AND PLETJRjE. 555\\nweek finally disappearing, is noteworthy. The special range of tem-\\nperature, the onset, the fastigium, and the defervescence at definite\\nperiods in the evolution of the disease, are of diagnostic value. Cyan-\\nosis is more constant and marked in tuberculosis. The skin and capil-\\nlaries have more tone in typhoid fever than in tuberculosis, at least in\\nthe first two weeks. Hyperemia follows irritation in typhoid pallor,\\nwith duskiness, in tuberculosis. The eruption, with its specific mode\\nof development, belongs to typhoid fever alone. The stools, the en-\\nlarged spleen, the vascular tone are suggestive of typhoid fever. The\\nspleen enlarges earlier in the disease in typhoid fever. Bacteriological\\nexamination may be of service. The occurrence of intestinal hemor-\\nrhage, pointing as it does to typhoid fever, is a welcome sign in cases\\nin which the diagnosis is obscure. I have never seen it in tuberculo-\\nsis. In typhoid fever the reflexes (knee-jerk) are never absent in\\ntuberculosis, if the meninges are involved, they are variable, present\\none day, absent the next. The diazo-reaction in typhoid is of some\\nservice, although it also occurs in tuberculosis. (See Urine.) It does\\nnot come on until later than the fifth day in typhoid fever. It disap-\\npears at a certain time in the involution of typhoid it continues in-\\ndefinitely in tuberculosis. (See Chapter XIX., Part I.)\\nThe distinction of tuberculosis from septicaemia or pyseniia and\\nmalignant endocarditis is often difficult. We must search for local\\nareas of septic or pysemic infection. The ears, the teeth, the bones,\\nthe veins, the heart, the pelvic organs in females, the rectum, the\\ngenito-urinary tract \u00e2\u0080\u0094must be carefully examined. Hemorrhagic in-\\nfarcts, or metastatic abscesses, may be found which point to the origi-\\nnal conditions. The eye-ground may show hemorrhages. The skin\\nand mucous membranes may exhibit minute capillary hemorrhages or\\ninfarcts. They are the size of a pin-head, do not disappear on press-\\nure, and are not elevated. The spleen is more likely to be enlarged\\nin the septic affections. The respirations are not so rapid as in tuber-\\nculosis. Cyanosis is a distinctive feature of tuberculosis. The physi-\\ncal signs of endocarditis may be determined, and subsequently embo-\\nlism or thrombosis prove the nature of the process.\\nChronic Tuberculosis, Chronic Ulcerative Phthisis. Chronic\\ntuberculosis or phthisis is much more common than acute tuberculosis,\\nfrom which it is distinguished by its slow progress and by periods of\\nremission, during which the disease may be arrested temporarily or\\npermanently.\\nIt may begin in a variety of ways. The most common mode of\\norigin is in an ordinary bronchitis with which pleurisy is occasionally\\nassociated. Previous to this the patient may have been in good health,\\nbut generally the health has been impaired for some time. The bron-\\nchitis may be simple or part of influenza, measles, whooping-cough, or\\nsome other specific disease.\\nThe bronchitis usually proves obstinate, and by and by there is\\nfound at the apex of the lung a small area over which, on percussion,\\nthere is increased resistance, with slight impairment of resonance, as\\ncompared with the other side the respiratory murmur is broncho-\\nvesicular, sometimes jerky in rhythm, and the vocal resonance and", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0601.jp2"}, "602": {"fulltext": "556 SPECIAL DIAGNOSIS.\\nfremitus slightly increased or unaltered. Such physical signs are met\\nwith more frequently at the right apex than at the left, and oftener in\\nthe suprascapular fossa than anteriorly. The next most frequent seat\\nis probably between the clavicle and second rib anteriorly.\\nThe patient will be found to have lost strength, and usually some\\nweight. There is often a slight evening rise of temperature, and occa-\\nsionally nocturnal perspirations. The appetite is impaired, and. ano-\\nrexia may exist. Cough is rarely absent, especially during the night\\nor on waking in the morning it may, however, be so slight as appar-\\nently to have escaped the notice of the patient. When characteristic\\nit is dry and hacking. Expectoration is scanty and mucoid, but occa-\\nsionally it may be tinged with blood. It should be remembered that\\nchildren and old persons sometimes do not expectorate, and that, as a\\nrule, Avomen are more inclined to suppress expectoration than men.\\nNo tubercle bacilli may be found in the sputum after repeated exami-\\nnation but if examinations are continued, they will appear sooner or\\nlater.\\nInstead of developing after a bronchitis, as we have just described,\\nit may set in suddenly under the guise of a pneumonia, more frequently\\nof the catarrhal form. The symptoms and physical signs do not differ\\nessentially from those of pneumonia, except that the expectoration is\\nmore likely to be profuse, mucopurulent, and blood-streaked, and\\nbacilli are found in it the fever is more hectic in type, and night-\\nsweats are common. The consolidation is found at the apex. After\\nthe patient convalesces from such an attack he continues weak, does\\nnot gain flesh readily, still has a cough with expectoration, evening\\nfever with occasional night-sweats, and an area of consolidation usually\\nat an apex of the lung. Over this area, in addition to the usual signs\\nof consolidation (bronchial or feeble breathing, dulness, etc.), moist or\\ndry subcrepitant rales are heard.\\nIn some cases fever, emaciation, and weakness progress for some\\ntime before pulmonary symptoms arise.\\nIn still other cases the invasion of the disease is by sudden haemop-\\ntysis, which is oftener copious than not. Several such hemorrhages\\nmay occur in rapid succession, or there may be only one. Moreover,\\nits disappearance may not be followed, or at least not immediately, by\\nany farther pulmonary symptoms or physical signs more commonly,\\nhowever, it is followed by fever, cough, expectoration, and physical\\nsigns of incipient consolidation, usually at the apex.\\nIn still other, but rarer cases, the pulmonary disease is latent, being\\nmarked by gastric or peritoneal symptoms, or by a general ansemia.\\nBy whatever path invasion comes, the physician should be on the\\nlookout for it, especially in a young adult predisposed by heredity or\\nenvironment to tuberculosis. The recognition of the disease in its\\nearly stage requires the greatest skill, which in turn is recompensed\\nwith the highest reward, since the disease is then curable.\\nThe further progress of a case of tuberculosis of the lungs, after con-\\nsolidation has once become manifest, is very variable. It may be\\narrested at this point permanently, cure resulting from cicatrization.\\nMore frequently there is temporary arrest of the process fever lessens", "height": "4412", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0602.jp2"}, "603": {"fulltext": "", "height": "4416", "width": "2556", "jp2-path": "practicaltreatis00muss_0_0603.jp2"}, "604": {"fulltext": "PLATE XXI.\\nFIG. 1. Anterior Aspect.\\nF+.\\n\u00e2\u0080\u00a2A.\\n^A.\\nV\\nFIG. 2.\u00e2\u0080\u0094 Posterior Aspect.\\nMr4\\nChronic Pulmonary Tuberculosis.\\nConsolidation with cavity formation. Chronic pleurisy with loss of respiratory\\nmovement of lung margins. Retraction.", "height": "4396", "width": "2572", "jp2-path": "practicaltreatis00muss_0_0604.jp2"}, "605": {"fulltext": "DISEASES OF THE LUNGS AND PLEUBjE. 557\\nor ceases entirely, the pulse resumes its normal rate, appetite improves,\\nand there is a gain in flesh and strength. Cough and expectoration\\nare more likely to persist than the other symptoms, but with the other\\nimprovement they diminish in frequency and copiousness. There are\\nfewer rales, but the signs of consolidation are still present, though\\nthere is no further extension of the process. Often, after a cavity has\\nbeen found, the disease is arrested, or progresses very slowly.\\nAfter a longer or shorter time, as the result of reinfection from the\\nold focus excited by acute bronchitis or by some depressing influence,\\nthe tuberculosis is relighted, so to speak, and runs much the same\\ncourse, the lung being left more diseased and the general health worse\\nafter every such attack. Nevertheless, there may be long intervals\\nbetween such attacks, the patient in the meantime continuing in fair\\nhealth. Thus the disease may linger or recur for years, the patient\\nnot ill enough to be confined to the house, and not well enough to\\nstand hard work or great exposure. Slowly, by ulceration and suppu-\\nration, the lung- tissue is wasted and cavities are formed. Before there\\nare large cavities at an apex the base of the same lung becomes consol-\\nidated by the production of tuberculous material, and before one lung\\nis extensively diseased the apex of the opposite lung is attacked, the\\nprocess being repeated in it if the patient lives long enough. Instead\\nof reinfection from an old focus, new infection may take place, giving\\nrise to the old train of symptoms, or setting up more acute disease.\\nDuring this time the patient is liable to an attack of acute pneumonia,\\npleurisy, bronchitis, or general miliary tuberculosis. He is also liable\\nto sudden death by hemorrhage. In a number of cases the intestines\\nand peritoneum become affected, and abdominal pain and diarrhoea\\nare superadded as symptoms.\\nAs a rule, the patient gradually sinks. The later stages are marked\\nby increasing cough and dyspnoea, which are very distressing and pre-\\nvent sleep. Expectoration is more copious, purulent, and is raised\\nwith increasing difficulty.\\nThe appetite is poor and capricious, or anorexia is complete. The\\nheart becomes more and more feeble, the fever is hectic and accom-\\npanied by exhausting night-sweats, the feet and limbs swell, and acute\\ncramp-like pains are felt in the legs, probably caused by thrombosis of\\nthe veins.\\nEmaciation is extreme, scarcely anything but skin and bone being\\nleft. Death occurs from perforation of an intestinal or gastric ulcer,\\nfrom hemorrhage, or more commonly from exhaustion, and from\\nasphyxia caused by oedema of the lungs.\\nThe physical signs (Plate XXI.) depend upon the lesions. It is often\\npossible to detect all stages of the tubercular process, from early consoli-\\ndation to large cavity, in the same patient. The signs of consolidation\\nhave been sufficiently dwelt upon. When softening begins, the percus-\\nsion-note continues dull and the breathing bronchial but it is often\\ndifficult to make out the quality of the breath-sounds because they are\\nfeeble and obscured by numerous moist crackling rales and moist sub-\\ncrepitant rales from disintegration of lung-tissue and bronchitis. After\\nthe patient has coughed several times and expectorated, and then takes", "height": "4416", "width": "2576", "jp2-path": "practicaltreatis00muss_0_0605.jp2"}, "606": {"fulltext": "558 SPECIAL DIAGNOSIS.\\na long breath, the quality of the breathing becomes perceptible. As\\nthe lung-tissue is further softened and removed by expectoration cavi-\\nties are formed. These, if large enough and superficial, give a tym-\\npanitic note on percussion, and, if there is communication with a bron-\\nchus, a cracked-pot sound. The breath-sounds are hollow and the\\nrales are bubbling and gurgling, or large and mucous.\\nThe normal vocal resonance is replaced by bronchophony and pec-\\ntoriloquy. Tactile fremitus may or may not be increased. (See Cavi-\\nties.)\\nBut if the walls of the cavity are thick from indurated tissue, the\\npercussion-note will be dull and the breathing bronchial. If the tissue\\ncomposing the wall is less thick and dense, percussion produces a\\nwooden sort of resonance. If much normal lung-tissue intervenes, the\\npercussion-note will be clear.\\nAs tuberculosis of the lungs progresses, the clavicles and ribs be-\\ncome more and more prominent from the loss of fat, and local flatten-\\ning of the chest, with impaired expansion, marks the seat of the disease.\\nThe Diagnostic Features. The striking phenomena of tuberculosis\\nwhich are considered in the diagnosis are emaciation, anaemia, fever,\\ncough, dyspnoea, chest-pain, hemorrhage, the expectoration, and the\\nobjective symptoms. Of less diagnostic value, but important as col-\\nlateral data, are the aspect, the occurrence of vomiting and diarrhoea,\\nand of symptoms of secondary tuberculosis in other organs. Age and\\noccupation may, to a certain extent, aid in the diagnosis.\\nEmaciation. This is always seen, even in acute forms of tubercu-\\nlosis. It is rapid in the acute, slow and progressive in the chronic\\nforms. In the latter there may be a temporary improvement in this\\nrespect. It must not be confounded with muscular atrophy, and the\\nemaciation of carcinoma, diabetes, anorexia nervosa, and other exhaust-\\ning diseases. Anosmia is always pronounced. It may be associated\\nwith leucocytosis if there is cavity formation. The reduction of red\\ncells and diminution of haemoglobin are marked. Fever. This symp-\\ntom is always present. The temperature should be taken every two\\nhours for a time, to determine accurately the degree and course. It\\nmay be intermitting, remitting, or continuous. It may be intermitting\\nin some acute forms, the morning fall reaching, or going below, normal.\\nThe difference between morning and evening temperature may not be\\nmore than a degree. In the acute form it is high and continuous, and\\nsoon may be attended by the typhoid state. In the more chronic cases\\nit may be intermittent at first, then continuous, and finally intermittent\\nagain. In the later stages the intermitting fever is due to a mixed\\ninfection, or sapraemia, from the purulent contents (staphylococcus and\\nstreptococcus infection) of the lung cavities. 1 (See Fig. 148 and Fig.\\n14D). The intermittent fever of the early stages has frequently been\\nmistaken for malaria. (See Fever.) The occurrence of fever in a\\n1 Leyden has pointed out that intermitting fever is part of the tuberculous process,\\nand not a streptococcus or staphylococcus infection, as formerly held, because pus micro-\\norganisms are not found in the purulent contents of cavities, and because in other\\nforms of tuberculosis, as empyema or joint-disease, they are notably absent, and yet\\nsuch form of fever exists. Deutsche medicin. Wochenschrift, Sept. 14, 1894.", "height": "4408", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0606.jp2"}, "607": {"fulltext": "DISEASES OF THE LUNGS AND PLEURJE.\\n559\\npatient who has been losing flesh, and is otherwise in poor health,\\nexcludes cancer and diabetes and other afebrile causes, and points\\nstrongly to tuberculosis. It must not be forgotten that in chronic\\ntuberculosis in the aged the temperature may not rise above 100\u00c2\u00b0\\noften, indeed, it is subnormal.\\nFig. 148.\\nContinued fever of tuberculosis.\\nFig. 149.\\no l\\\\\\n,|e m\\nE\\nM\\nz m\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nM E\\nM\\nE\\nw\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\nM\\nE\\n-1\\nWrr\\ni\\n1\\nft\\nI\\n1\\nT\\n1\\n1!\\nU\\n1\\n1\\nj\\nft\\nf\\nt_\\nA\\nA\\nt\\nV\\nv\\nt\\n1\\n1\\nIOO\u00c2\u00b0\\n1\\nA\\ni\\nI\\n1\\nJ\\n1\\n1\\n1\\nj\\n7\\nI\\n1\\nv\\ny\\nJ\\n1\\ny\\nJ\\nu\\ny\\ny\\n9\u00c2\u00bb--\\nI\\nf\\ni\\nIntermitting fever of tuberculosis.\\nWe must consider, therefore, that fever, the cause of which is not\\nobvious, may be due to tuberculosis and that if, when such probable\\ncausal conditions as gastro-intestinal catarrh or infectious disorders\\n(malaria) and suppurations are eliminated, the fever still persists, then\\nthe fever is probably of tuberculous origin.\\nSweats. Frequent sweating may be the first symptom complained of\\nby the patient. It may occur with the tripod of symptoms of the\\nintermitting febrile range chill, fever, and sweat. It would be likely\\nto occur at night under these circumstances. It may occur at any\\ntime, however. Night-sweats are alarming to the mind of the", "height": "4416", "width": "2592", "jp2-path": "practicaltreatis00muss_0_0607.jp2"}, "608": {"fulltext": "560 SPECIAL DIAGNOSIS.\\nlaity, and are really of diagnostic significance. The perspiration\\nawakens the patient at night because it is so profuse. It may be only\\nmoderate, not rousing the patient until morning. It may be general\\nor local. Local sweats are confined to the head and neck. Anwmia.\\nThis quite rapidly becomes marked. It is recognized by the color of\\nthe surface and by an examination of the blood. When collateral\\ninflammation is present, leucocytosis is seen. Cough. Cough is one\\nof the earliest symptoms. It may be the only symptom for some time.\\nIt is often dry and hacking at first and may continue so for a long\\ntime. Later it is accompanied by mucoid and then mucopurulent\\nsputa, which contain the characteristic elements. (See Sputum.) Dysp-\\nnoea is almost always present. The degree varies with the association\\nof fever. When the latter is present dyspnoea is more pronounced.\\nIt is more pronounced in acute cases. In miliary tuberculosis the\\nfrequency of respirations that attends the dyspnoea is out of all pro-\\nportion to the physical signs. In this form cyanosis is more marked.\\nIn chronic localized phthisis the dyspnoea may only occur on exertion,\\nafter eating, or upon excitement. The bloodless lips may have a con-\\nstant bluish hue. The fingers are dusky and become clubbed. In\\nthe later stages the dyspnoea is constant and in proportion to the extent\\nof involvement of the lungs and the degree of fever. Although of\\ndiagnostic significance only when associated with other symptoms, it\\nis most distressing, and is the cause of constant demand for relief.\\nChest-pain. This is due to localized pleurisy or to myalgia. The\\nlatter may be seated in muscles strained by coughing. Pleuritic pains\\nmay occur in any situation, and vary in position from time to time.\\nThey may be due to extensive inflammation or to tuberculous pleurisy.\\nConstantly recurring and unilateral chest-pains, with or without signs\\nof pleurisy, with cough and emaciation, are significant of the disorder\\nunder consideration. (See Pain.)\\nHemorrhage. This symptom is alarming, and, in the large majority\\nof cases, is due to pulmonary tuberculosis. It may mark the onset of\\nthe acute disease, and continue irregularly throughout its course or\\nrecur several times before the advent of more common symptoms of\\nthe chronic form. It may occur at intervals of a few months or a\\nyear, before emaciation, cough, and characteristic expectoration set in,\\nor before bacilli are found in the sputum. Each attack is attended\\nby fever, usually, and followed by anaemia and prostration. If hemor-\\nrhage of the lungs (see Symptoms) occurs in a young adult without\\ncause (as aneurism or cardiac disease, etc.), it must be looked upon\\nwith suspicion. The likelihood of tuberculosis is increased if the\\nbleeding occurs in a patient of tuberculous aspect in whom a family\\nhistory of tuberculosis is found, and who has been exposed to infec-\\ntion. In the aged it may occur from a localized area of disease.\\nHemorrhage is also common in the late stages of tuberculosis. It is not\\nat this period of diagnostic value as to the primary cause. It is usually\\ndue to the erosion of an artery in a cavity. Hemorrhage also occurs\\nin tuberculosis daring the quiescent period. The progress of the disease\\nis arrested. The discharge of blood is accompanied by the expectoration\\nof pulmonoliths, calculi formed by the degeneration of caseous areas.", "height": "4416", "width": "2536", "jp2-path": "practicaltreatis00muss_0_0608.jp2"}, "609": {"fulltext": "DISEASES OF THE LUNGS AND PLEURjE. 561\\nVomiting (see Gastrointestinal Disease) is a symptom which is often\\npresent in the early stages of tuberculosis of the lungs, and frequently\\nmasks the true condition. The vomiting may lead to the belief that\\na local gastric catarrh or diarrhoea is to blame for the general symp-\\ntoms. The occurrence of fever with the gastric symptoms should lead\\nto an examination of the lungs.\\nThe occurrence of diarrhoea and symptoms of tuberculosis in other\\norgans may thoroughly establish the diagnosis in tuberculosis of the\\nlungs with otherwise obscure pulmonary symptoms. The intestinal\\ndischarges may contain tubercle bacilli, or they may be found in the\\nurine, in joint-suppuration or glandular enlargement.\\nThe Sputum (q. v.). The diagnosis is absolute when tubercle bacilli\\nare found in the expectoration. Nummular sputa are more common\\nin phthisical excavation. The sputum is discharged in tough coin-\\nshaped masses, which sink when expectorated into a vessel containing\\nwater. Fragments of lung-tissue (yellow elastic) point to tuberculo-\\nsis, bat are possible under other circumstances.\\nThe Physical Signs. The aspect of the patient is always suggestive,\\nand is an aid to the recognition of the condition. The tuberculous or\\nphthisical chest, the long neck and arms, the pale face, the occasional\\nhectic flush, the clubbed fingers, the emaciation of the many subjects\\nwe see in our infirmaries, fix in our minds a composite picture the\\nrecognition of which goes far to diagnosticate the insidious disease.\\nThe objective signs point to an invasion of air-containing structure\\nby solid material, with collapse of lobules, leading to consolidation,\\nfollowed by cavity-formation, and in both stages by the occurrence of\\npleurisy. Local contraction (flattening) and impaired movement at an\\napex, with inspiratory depression above the clavicles, with suppressed\\nbreath-sounds and prolonged expiration, with impaired resonance, are\\nthe earliest signs of tuberculosis. In the chronic cases, contraction,\\nimpaired movement, dulness and increased resistance from thickened\\npleura may override the signs of consolidation. ISTo one physical sign\\nis of diagnostic significance. The combination of signs, and the orderly\\nprocession by which they advance as the physical conditions progress,\\nare the most diagnostic.\\nThe Size of the Lung. In the diagnosis of pulmonary tuberculosis\\nthe physical examination must be directed to a determination of the\\nsize of the lung, and of the extent of its expansion, by which we judge\\nof the amount of air entering the lung, as well as to the presence of\\nconsolidation.\\nThe tuberculosis process is associated with diminution in the bulk\\nof the lung usually. We can estimate the size and the degree of ex-\\npansion by inspection, palpation, and percussion. The so-called dia-\\nphragm-phenomena is studied and the X-rays employed. Any dimi-\\nnution in the excursion in the shadow of the diaphragm is evidence of\\ndiminished bulk of the lung or of diminished expansion. By palpa-\\ntion, with mensuration, measurements are taken. By percussion we\\nestimate the lung boundaries. The degree of expansion can be deter-\\nmined by securing the limits of liver dulness and cardiac and splenic\\ndulness in ordinary breathing, and then at the end of full inspiration", "height": "4404", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0609.jp2"}, "610": {"fulltext": "562 SPECIAL DIAGNOSIS.\\nand expiration. Valuable information is thus secured. Of course,\\nemploying inspection and palpation the two sides of the lung must be\\ncompared. Percussion enables one to determine fairly early the pres-\\nence of consolidation. In thin subjects the change in the note is more\\nreadily elicited than in fat or muscular subjects.\\nOn auscultation in the early stage of tuberculosis roughness of\\nrespiratory murmur with prolonged expiration, feeble respiratory mur-\\nmur, and jerking or cog-wheel respiration are common signs. These\\nsigns change gradually into bronchovesicular and then bronchial types\\nof breathing. Crackling rales or clicking sounds and consonating rales\\nattending these modifications of breath-sounds are of the greatest diag-\\nnostic importance. They must be brought out frequently by cough\\nand then full inspiration.\\nThe Site of the Lesion. The situation of the physical signs is diag-\\nnostic. Percussion should be directed especially over those parts of\\nthe lung in which an infection is liable to occur, as the clavicular and\\nsubclavicular spaces, the anterior border of the upper lobe, the tongue-\\nlike part of the left upper lobe, which overlaps the heart, the supra-\\nspinous space, the upper interscapular region, and the upper borders\\nof the lower lobes posteriorly. The latter is best secured by having\\nthe patient place the hand of the arm of the side percussed on the\\nshoulder of the opposite side. The scapula is thus removed from the\\nsurface of the lung to be examined.\\nIt is necessary also to consider carefully the general conditions.\\nWe inquire the age, adolescence and early adult life being the common\\nperiods in which pulmonary tuberculosis develops. The occupation, 1\\nthe history of exposure to the disease, the history of predisposition to\\ntuberculosis in the family, the history of previous, now arrested, tuber-\\nculosis, as in joint-disease, or glandular tuberculosis (scrofula), are\\ndata deserving special consideration, as they may furnish corroborative\\nevidence of the presence of the disease.\\nDiagnosis. The presence of tuberculosis is presumed upon in a\\npatient with pulmonary symptoms\u00e2\u0080\u0094 as a hereditary predisposition,\\nabnormalities in the form of the chest and imperfect development, or\\nhypoplasia of the circulatory organs. If the patient is under weight\\nand has a poor appetite, and at the same time is undergoing unusual\\nstrain or anxiety, the possibility of tuberculosis is increased. Often,\\nbefore the physical signs of tuberculosis can be established, the shrewd\\nphysician will fear recurrence of tuberculosis if there are signs of\\nanaemia, progressive loss of weight, slight fever, disturbed digestion, a\\nfrequent pulse, and persistent and localized bronchial catarrh. The\\nexamination of the lungs, the examination of the sputa, and the tuber-\\nculin test must be employed as soon and as often as practicable. (See\\nDiagnosis of Tuberculosis, Chapter XX., Part I.)\\nThe diagnosis is established by finding tubercle bacilli in the sputum.\\nTheir absence, in spite of the most careful search, is against the tuber-\\n1 Several undoubted instances are recorded in which hospital residents and young\\nphysicians working in laboratories in which tuberculosis is studied, or constantly ex-\\nit mining sputum, have been infected in the course of their studies.", "height": "4408", "width": "2552", "jp2-path": "practicaltreatis00muss_0_0610.jp2"}, "611": {"fulltext": "DISEASES OF THE LUNGS AND PLEURA. 563\\nculous origin of the disease. (See Diagnosis of Tuberculosis, Chapter\\nXX, Part I.)\\nIn subsequent chapters the differential diagnosis of tuberculosis and\\nother diseases will be pointed out. It must not be forgotten that the\\ndisease may set in as the terminal affection in many diseases. Thus,\\nin diabetes, in insanity, in chronic cerebral or spinal disease, and in\\nother affections, tuberculosis may develop insidiously, and finally cause\\ndeath.\\nIt must be distinguished from chronic gastric disorders, and partic-\\nularly anorexia nervosa. It must not be confounded Avith malaria.\\nIt must be distinguished from simple anaemia, the cause of which may\\nbe recognized with difficulty. It must be distinguished from chronic\\nbronchitis with bronchiectasis, from pulmonary gangrene and carci-\\nnoma. Finally, it must not be mistaken for cancer of the oesophagus\\nand aneurism of the aorta, two divergent conditions which may have\\npulmonary symptoms simulating phthisis.\\nGangrene of the Lung. Gangrene is a rare disease of the lung,\\nand, like abscess, always secondary. It may be produced by any cause\\nwhich so obstructs the circulation that a portion of the lung dies in\\nbulk. The gangrene may be circumscribed or diffused it results\\nmost frequently from pneumonia, but may be due to injury, to a gen-\\neral septic condition, or to embolism. It is rather frequently met with\\nin the insane, possibly owing to particles of food which have found\\ntheir way into the lung. Aspiration bronchopneumonia, bronchiectatic\\nand tuberculous cavities, sometimes lead to gangrene. Gangrene in\\nthe lung, as elsewhere, occurs in diabetes.\\nSymptoms. When it occurs in the insane, or is of embolic origin,\\nit may remain latent, and in septicaemia it may be overlooked, on\\naccount of the general symptoms. In well-marked cases, however,\\nthe symptoms are characteristic. Symptoms and physical signs of\\npulmonary disease precede the specific symptoms of gangrene. With\\nthe onset of a moderate fever haemoptysis may occur at once or be\\npreceded by the expectoration of a brownish, purulent sputa having a\\nmost intense and persistent gangrenous odor. It contains fragments\\nof lung-tissue, altered blood, and putrid debris. (See Sputum.) It\\nseparates into the three characteristic layers in a conical glass. The\\nfetor of the breath and the characteristic sputum is diagnostic.\\nThe disease usually occupies the lower or middle lobe of the lung.\\nThe physical signs are those of cavity. The disease could with diffi-\\nculty be distinguished from abscess were it not for the characteristic\\nsputum, though in gangrene there is greater tendency to a general\\nseptic condition, with profuse sweats and collapse.\\nAbscess of the Lung. Abscess of the lung may originate in causes\\noutside the lung, or in causes within the lung. To the former class\\nbelong those produced by suppurating bronchial glands, abscess of the\\nmediastinum opening into the lung, cancer of the oesophagus with\\nulceration, and abscess of the liver, suppurating hydatid cyst, or sub-\\ndiaphragmatic abscess in general, bursting into the lung. Intra-pul-\\nmonary causes are tubercle, septic emboli, in which case the abscesses\\nare multiple and subpleural, and pneumonia. In the aspiration form", "height": "4408", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0611.jp2"}, "612": {"fulltext": "564 SPECIAL DIAGNOSIS.\\nof lobular pneumonia abscesses occur. Rarer causes are the presence\\nof tumors and obstruction of the bronchi.\\nAbscess of the lung is therefore always secondary. Its diagnosis\\ndepends upon the demonstration of a consolidation in which a cavity\\nsubsequently forms, taken in connection with the history pointing to a\\ndefinite cause. The sputa are copious, purulent, often odorless, some-\\ntimes offensive, but always without the fetor of gangrene. They\\ncontain elastic fibre, but no bacilli except in tuberculous cases. (See\\nSputum.) In embolic abscess the signs of pleural friction can only be\\ndetected at times. Of course, the constitutional symptoms of suppura-\\ntion are present.\\nThe Degenerations.\\nEmphysema. Emphysema consists in an excessive, permanent,\\nand unnatural distention of the air-cells, or in extravasation of air\\ninto the interlobular or subpleural cellular tissue. (Lsennec.)\\nEmphysema may be unilateral or bilateral. Local and unilateral\\nforms are usually compensatory. Bilateral emphysema may be hyper-\\ntrophic or atrophic.\\nIt is more common in men than in women. Its symptoms are more\\ncommon in childhood and after middle age. Two factors are essential\\nin its causation. First, defective development of the elastic tissue of\\nthe lungs. Second, increased intra-alveolar air-pressure. The latter\\nis due to a number of causes. In childhood, no doubt, nasal and naso-\\npharyngeal obstructions are operative. In adults occupations which\\nnecessitate continuous and severe muscular effort, especially if coupled\\nwith forced expiration with closed glottis, act as causes. Such occupa-\\ntions are blacksmithing and playing upon wind instruments. Diseases\\nwhich cause much coughing or respiratory effort, such as chronic bron-\\nchitis and whooping-cough, act in the same manner. Chronic mitral\\nvalvular disease and the lessened elasticity of the lung-tissue of ad-\\nvancing age both favor congestion of the lung, and thereby predispose\\nto emphysema. The disease is hereditary several members of a\\nfamily are affected. It occurs in many in childhood, is in abeyance\\nin adult life, and reappears in old age.\\nSymptoms. The prominent symptoms in hypertrophic emphysema\\nare dyspnoea, cyanosis, and cough, with expectoration from associated\\nbronchitis. There is no fever. The dyspnoea is in proportion to the\\ndegree of emphysema, and is aggravated by the coexistence of bron-\\nchitis, asthma, and eccentric hypertrophy of the right ventricle, which\\nare very frequent complications in cases of long standing. When\\nthe degree of emphysema is only moderate, dyspnoea is not complained\\nof except upon climbing or walking briskly, or after a hearty meal.\\nBut when the degree of emphysema is great, dyspnoea is constant it\\ninterferes with all exertion, frequently necessitates orthopnoea, and\\nprevents continuous speech, so that patients speak in broken sentences\\nor syllables.\\n[i/anosis is marked. The livid lip is common in the asylums for\\nold men. The face is of a dingy pale color, but becomes bluish on\\nexertion. The extremities are also dusky, and the blueness is general", "height": "4412", "width": "2576", "jp2-path": "practicaltreatis00muss_0_0612.jp2"}, "613": {"fulltext": "", "height": "4416", "width": "2592", "jp2-path": "practicaltreatis00muss_0_0613.jp2"}, "614": {"fulltext": "PLATE XXII.\\nFIG. 1. Anterior Aspect.\\nFIG. 2. Posterior Aspect.\\nEmphyzema.\\nHyperresonance. Enlargement of lungs and diminished respiratory movement\\nof margins. Diminished fremitus. Signs of bronchitis.", "height": "4328", "width": "2712", "jp2-path": "practicaltreatis00muss_0_0614.jp2"}, "615": {"fulltext": "DISEASES OF THE LUNGS AND PLEURM. 565\\nin severe cases. This cyanosis, the round shoulders, and the drawn,\\nchronically anxious expression, if I may so term it, make it easy to\\npick out the emphysematous subjects in a ward of chronic cases.\\nRespiration is not accelerated, and may be diminished in frequency.\\nIt is often accompanied by wheezing when chronic bronchitis coexists.\\nThe cough varies greatly in frequency it may be altogether absent,\\nsince its presence simply indicates an associated bronchitis. This bron-\\nchitis may for years be present only in the winter. In children it may\\nbe associated with asthma. It may arise on changes of the weather\\nfinally it becomes chronic. The expectoration is that of chronic bron-\\nchitis (q. v.). It is rarely stained with blood.\\nPhysical Signs. (Plate XXII. The physical signs of emphysema\\ndepend upon its degree and upon whether it is complicated with\\nchronic bronchitis or not.\\nInspection: In well-marked cases the chest is barrel-shaped (see\\nunder Inspection). There is little movement of the chest in respi-\\nration, because the lung is already in a condition of full inspiration\\n(expiratory dyspnoea). Vocal fremitus and resonance are usually dimin-\\nished. Percussion The percussion-note is abnormally clear, and may\\neven be tympanitic. Hyper-resonance is typical of the disease. When the\\ndistention is extreme the note may be woodeny. The lungs are enlarged.\\nThe heart-dulness becomes obliterated by the overlapping lung. The\\nupper margin of the liver falls one or two interspaces below the normal.\\nThe resonance extends higher above the clavicles than normal.\\nOn auscultation the inspiration is found to be distant and feebler\\nthan normal, while the expiration is prolonged, and may become three\\nor four times the length of the inspiration. Grazing or rubbing\\nsounds have been described and attributed to the friction of distended\\nvesicles against the pleura. Other adventitious sounds are due to an\\nassociated bronchitis, pleurisy, or tuberculosis. But bronchitis is such\\na common accompaniment of emphysema that the rales of the former\\nbecome almost symptomatic of the latter. Their character in emphy-\\nsema does not differ from that in chronic bronchitis (q. v.).\\nThe Heart. The apex-beat is absent. There is epigastric pulsation\\nor systolic shock. The normal area of heart-dulness is encroached\\nupon by the distended lung, and the heart itself is pushed to the right,\\nthe apex-beat being frequently at the xiphoid cartilage. If the em-\\nphysema attain a very high degree, there may be no perceptible dulness,\\nexcept on very strong percussion over the cardiac region. The heart-\\nsounds appear feebler and more distant than normal. The right ven-\\ntricle becomes dilated and hypertrophied, as the result of the pulmo-\\nnary congestion produced by emphysema. The pulmonary second\\nsound is accentuated. A tricuspid regurgitant murmur may be heard.\\nVenous congestions are common in the later stages. Albuminuria is\\ncommon. (Edema of the feet and limbs may occur, but general ana-\\nsarca is rare.\\nThe general health suffers by loss of strength and capacity for\\nphysical and mental work, rather than by loss of flesh. The patients\\nare large-chested, stoop-shouldered, and short-breathed, and have an\\nanxious expression of countenance.", "height": "4412", "width": "2576", "jp2-path": "practicaltreatis00muss_0_0615.jp2"}, "616": {"fulltext": "566 SPECIAL DIAGNOSIS.\\nDiagnosis. This is based upon the history (heredity, occupation,\\nlong duration), the occurrence of dyspnoea and cyanosis, and of winter\\ncough or chronic bronchitis, and upon the physical signs.\\nEmphysema can be distinguished from pleural effusion and from\\naneurism, which may cause dyspnoea, by the universal hyper-resonance\\non percussion. Pleural effusion, which also causes bulging, is usually\\nunilateral, and the percussion-note is flat. The area of dulness of the\\nheart and aorta is diminished in emphysema.\\nPneumothorax, which most resembles emphysema in its physical\\nsigns, develops suddenly, affects one side, and has a hollow, tympan-\\nitic note on percussion. The succussion-splash, metallic tinkling, and\\ncoin-test have no counterpart in emphysema moreover, the antecedent\\nhistory and mode of development are different.\\nAtrophic emphysema is due to the degeneration of age. The lung is\\nreduced in size. The diameters of the chest are lessened. The ribs\\nare oblique. There is atrophy of the chest-muscles. The patients\\nhave dyspnoea. There are other signs of senility.\\nIn interlobular emphysema the physical signs are the same as those\\nof vesicular emphysema, but it develops suddenly and is liable to be\\nfollowed by emphysema (intercellular) of the neck, which on palpation\\ngives a peculiar crepitation. The friction-sound and crackling which\\nhave been described as occasional adventitious sounds in vesicular\\nemphysema are more commonly heard in the interlobular form.\\nIt is caused by rupture of the air-cells, and hence occurs in diseases\\nin which a great strain is put upon them especially, therefore, in\\nwhooping-cough, but also occasionally in pulmonary hemorrhage and\\npneumonia violent coughing and laughing, and great straining, as in\\nchild-labor, are capable of producing it.\\nBronchiectasis. Dilatation of the bronchi occurs secondarily to\\naffections which tend to weaken the walls of the tubes and to lessen\\ntheir elasticity. Hence, it is found in chronic bronchitis with emphy-\\nsema, in chronic phthisis, in catarrhal pneumonia in children, in\\nchronic obstruction from external pressure or foreign bodies. (See Ob-\\nstructions.) It also occurs when the lungs contract in fibroid pneu-\\nmonia, or in pleural thickening. It occurs in two principal forms\\nthe simple, in which the affected tubes are uniformly dilated and the\\nsaccular, in which larger or smaller pouches are formed. It is com-\\nmoner in males than in females, and probably begins most frequently\\nin adult or middle life. One lung only is affected in about one-half\\nthe cases, and when both lungs are affected (chronic bronchitis and\\nemphysema) it is not often to the same degree.\\nThe subjective symptoms consist of cough, expectoration, and a\\nvariable amount of dyspnoea. Eventually there may be some loss of\\nflesh and strength.\\nThe cough is usually paroxysmal. It may occur only in the morn-\\ning after the dilated tube fills. It may follow change in position. A\\nparoxysm is followed by copious expectoration, sometimes amounting\\nto a pint and a half in twenty-four hours. It is grayish-brown and\\nmucopurulent, faintly or extremely fetid. The sputa contain mucus,\\npus, fasts of the tubules, and various salts. Charcot-Levden and fattv", "height": "4412", "width": "2652", "jp2-path": "practicaltreatis00muss_0_0616.jp2"}, "617": {"fulltext": "", "height": "4412", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0617.jp2"}, "618": {"fulltext": "PLATE XXIII.\\nFIG. 1.\u00e2\u0080\u0094 Anterior A\\nspect.\\nStf\\nFIG. 2. Posterior Aspe\\nBronchiectasis.\\nChronic pleurisy with induration of the right lower lobe and bronchiecta.\\nVicarious emphyzema of the left lung. Bronchitis.", "height": "4372", "width": "2712", "jp2-path": "practicaltreatis00muss_0_0618.jp2"}, "619": {"fulltext": "DISEASES OF THE LUNGS AND PLEURAE. 567\\ncrystals, vibrios, leptothrix, and bacteria (Fox) can be found on micro-\\nscopical examination. Elastic fibres are found only if the tubes are\\nulcerated. In a conical glass the sputum separates into three layers\\na frothy brown top, a thin mucoid layer in the middle, and a granular\\nlayer below. Hemorrhage is rare, but may occur even when tubercu-\\nlosis is absent.\\nDyspnoea is not usually severe, except when the dilatation is compli-\\ncated by disease of the heart or lungs, or during an acute attack of\\nbronchitis.\\nPhysical Signs.. (Plate XXIII.) The physical signs differ according\\nto the extent and variety of the dilatation. In simple dilatation there\\nmay be nothing different from the signs found in chronic bronchitis,\\nexcept a tendency to more bronchial respiration, with rales having a\\nmetallic quality. Percussion will vary according to the degree of altera-\\ntion of the lung-tissue surrounding the affected bronchi, and according\\nto the extent of the dilatation and its proximity to the surface. In the\\nsimple forms the percussion-note, if altered, is somewhat less resonant\\nand higher in pitch, whereas in saccular dilatations, favorably situated\\nfor percussion, the note is tympanitic if the pouch is empty. On aus-\\ncultation in simple dilatation the breathing approaches the bronchial,\\nand is accompanied by bronchial rales. In saccular dilatation the\\nsounds are practically those of a cavity, respiration varying from bron-\\nchial to amphoric. Vocal resonance and tactile fremitus are usually\\nboth increased, but the latter may be diminished.\\nDiagnosis. The diagnosis of simple dilatation from chronic bron-\\nchitis may be impossible, but copious and fetid expectoration indicates\\nthe former. The diagnosis of the saccular form from tuberculosis of\\nthe lung with cavity is difficult. Wilson Fox says the severe cases\\nare usually associated with consolidation of the lung or with tubercle\\nbut even without the presence of the latter they often present phthisi-\\ncal symptoms retraction of the chest, with the physical signs of exca-\\nvation, pains in the side, haemoptysis, pyrexia, nocturnal perspiration,\\nand diarrhoea which may all coexist with only an induration of the\\nlung and dilatation of the bronchi. The diagnosis must be made by\\nnoting the persistency of the physical signs, which change but little\\nand are not progressive as are those of tuberculosis the protracted\\ncourse of the disease the character of the sputum and the compara-\\ntively slight impairment of the general health.\\nThe Morbid Growths.\\nCancer and Other New Growths of the Lung. The new growths\\nmay be primary or secondary. The latter are most common. Of\\nprimary cancer, the epithelioma is most common encephaloid and\\nscirrhus come next. Sarcoma is sometimes primary. Secondary new\\ngrowths succeed disease in the abdominal organs, the genito-urinary\\ntract, the bones, the breast, and the eye.\\nSymptoms. The general symptoms of malignant growths accom-\\npany the thoracic symptoms. Chest-pain, dyspnoea, cough, and a\\npeculiar expectoration belong to the latter. The pain is due to asso-", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0619.jp2"}, "620": {"fulltext": "568 SPECIAL DIAGNOSIS.\\nciate pleurisy the dyspnoea is paroxysmal. (See Dyspnoea from Press-\\nure on Bronchi.) The expectoration is dark, like prune-juice. Signs\\nof intrathoracic pressure are seen. The external thoracic veins are\\nenlarged. The face and arms may be cyanosed, or one arm only may\\nbe affected. The heart may be dislocated, the trachea changed in its\\ncourse compression of trachea and bronchus causes dyspnoea.\\nPhysical Signs. In primary cancer the affection is unilateral in\\nsecondary forms, bilateral. The physical signs are those of pleural\\neffusion or of local consolidation. The consolidation may be massive\\nand not partake of the shape of a lobe. Often signs of effusion and\\nconsolidation are combined (enlargement, immobility, absent fremitus,\\nbut bronchial breathing). In the secondary forms the disease is bilat-\\neral. The signs are mixed. They indicate diminished air in the lung\\nstructure. Care must be taken not to overlook the pleural effusion\\nwhich accompanies the process, the removal of which gives temporary\\nrelief. In both forms external lymphatic glands, particularly the\\ncervical, may be enlarged.\\nDiagnosis. The diagnosis is based upon (1) The age (after forty)\\n(2) the occurrence of emaciation (3) the duration of the disease, often\\nrapid, rarely beyond eight months (4) the presence of primary disease\\nelsewhere (5) the presence of moderate fever (6) the signs of intra-\\nthoracic pressure (7) the involvement of lymphatic glands (8) the\\noccurrence of irregular areas of consolidation and of pleural effusion,\\nalone or combined (9) the characteristic expectoration (10) dyspnoea\\ndue to pressure on the bronchus or trachea (11) the absence of bacilli\\nfrom the sputum.\\nAn effusion can often be recognized only after puncture. Hemo-\\nthorax is not necessarily present.\\nGross Parasites.\\nHydatid Disease of the Lungs. The lungs are affected hi about\\n1 1 per cent, of the cases of hydatid disease. The symptoms, according\\nto Wilson Fox, consist of dyspnoea, pain hi the chest, cough, occasional\\nhaemoptysis, and sometimes the expectoration of hydatids, the sputa\\nbeing otherwise bronchitic, or presenting the characteristics of pneu-\\nmonia or gangrene when these complications are present. Gradually\\nweakness increases, sometimes with pyrexia, which, when combined\\nwith emaciation, may impart to the case a considerable resemblance to\\nphthisis pressure-symptoms occasionally occur, and the physical signs\\nare either of consolidation of the lung or of pleural effusion, together\\nwith certain peculiarities depending on the size and site of the tumor.\\nGraham states that they are more frequent in the right lung and more\\ncommon at the base, causing marked bulging of the thoracic wall.\\nWhen the physical signs are those of pleural effusion, localization of\\nthe fluid to a definite area takes place, and hence is not related to the\\nshape of the pleural cavity. The breathing may be tubular there is\\ncondensed lung between the hydatid and the thoracic wall. The symp-\\ntoms present cough, dyspnoea, anaemia, emaciation, and clubbing of\\nfingers too often lead to the diagnosis of phthisis. Haemoptysis", "height": "4416", "width": "2712", "jp2-path": "practicaltreatis00muss_0_0620.jp2"}, "621": {"fulltext": "DISEASES OF THE LUNGS AND PLEURA. 569\\noccurs in many cases. The temperature is normal an important\\npoint in diagnosis. If the cyst ruptures, the sputum is diagnostic.\\nComplications often mask the diagnosis. It must be distinguished\\nfrom pleurisy, localized empyema, pulmonary abscess, phthisis, actino-\\nmycosis, and mediastinal tumors.\\nDiseases of the Pleura.\\nThe large lymph-structures which cover the lung and line the inside\\nof the thorax are often the seat of disease. It is usually of an inflamma-\\ntory nature. Hence, pleurisy, or pleuritis, is the most common affec-\\ntion of the pleura. It may be, as to distribution, bilateral or unilateral\\nas to extent, local or general as to the nature of the inflammation,\\nplastic, serous, or purulent. The inflammation may be acute or chronic.\\nIt is rarely primary. It arises in the course of general disease, or is\\nthe result of the extension of inflammation, chiefly of an infectious\\nnature, from neighboring structures.\\n1. Disease of the ribs or vertebrae, diseases of the mediastinum, of\\nthe aorta, oesophagus, and especially of the lung, give rise to various\\nforms of pleurisy, depending upon the nature of the primary affection.\\n2. Diseases below the diaphragm. Abscess of the liver perfora-\\ntive inflammation of other viscera adjacent to the diaphragm abscess\\nof the spleen or pancreas pus in the pelvis or about the appendix,\\nmay give rise to purulent pleurisy by the pus burrowing upward or\\nby infection through the lymph-channels.\\n3. Disease of the lungs. In the large majority of cases pleurisy in\\nsome form occurs in the course of pulmonary disease. In all surface\\ninflammations of the lungs there is associate pleurisy. It is seen in\\npneumonia, in tuberculosis, in gangrene, and in abscess.\\nPleurisy may be simple or purulent. Empyema is always due to\\ninfection from the exterior, as the ribs from the lungs (pneumonia)\\nsuppuration below the diaphragm or to general infective processes,\\nas septicaemia, pyaemia, and tuberculosis.\\nThe general diseases in the course of which pleuritis arises are\\nusually infective, or of such nature as to cause irritating products to\\ncirculate in the blood. Of the former, the most common is tuberculo-\\nsis the next most common are septicaemia and scarlatina while to the\\nlatter class belong Bright s disease, gout, diabetes, rheumatism, and\\nscurvy. Purulent pleurisy is more common in children than in adults\\nin males than in females and more common in tuberculous pleurisy\\nand pyaemia than in rheumatism and Bright s disease.\\nAcute Pleurisy. Acute pleurisy may be primary, or may be sec-\\nondary to disease of the lung, or be part of a general infection. Three\\nstages in the morbid processes usually occur, although it may be\\narrested in the first stage.\\nSymptoms of the First Stage. Dry Pleurisy. The onset of the dis-\\nease is usually abrupt, and is marked by fever, Avhich may or may not\\nbe preceded by chill, and is followed by pain in the side, dyspnoea,\\nand cough. The pain is sharp, stabbing, or tearing in character, and\\nis usually, but not always, referred to the seat of pleurisy. This is", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0621.jp2"}, "622": {"fulltext": "570 SPECIAL DIAGNOSIS.\\nmost frequently on a level with the nipple, or a little below this, and\\nmore often anteriorly or in the axilla than posteriorly. The pain is\\ncaused by the rubbing together of the inflamed surfaces of the pleura,\\nand hence is excited by respiration and cough. For this reason the\\npatient is inclined to restrict the motion of the affected side as much\\nas possible he does this by leaning over toward that side and by\\npressing his elbow in against the chest-wall. Pain is usually the first\\nsymptom noticed by the patient. The cough is dry and painful.\\nFever is moderate.\\nPhysical Signs. The physical signs in primary cases are a friction-\\nsound heard on inspiration and expiration. This friction-sound may\\nbe a nest of fine, dry, crepitant rales, which are very superficial, and\\nappear to be just under the ear or a coarse rubbing sound, heard over\\na larger surface, and resembling a bronchial rhoncus, from which it can\\nbe distinguished by its persistence after the patient has coughed. The\\nlungs themselves present nothing abnormal.\\nIf the inflamed surfaces become glued together by plastic lymph,\\nrecovery usually occurs very soon, though pain often persists for a\\nlong time in lessened degree, and the pleurisy is liable to be re-\\nlighted.\\nSymptoms of Second Stage, or Stage of Effusion. If effusion takes\\nplace, the two layers of the pleura become separated hence, pain and\\nfriction-sound cease, and physical exploration shows that a collection\\nof fluid intervenes between the chest-wall and the lung.\\nThe physical signs (Plates XXIV. and XXV.) of this stage are\\n(1) enlargement of the affected side, increase in semi-circumference,\\nwith fulness of interspaces (2) diminution of movement (3) absence\\nof vocal fremitus and resonance (4) dulness or flatness (deadness) on\\npercussion, with great increase in the resistance to the pleximeter\\nfinger (5) absent or greatly diminished respiratory murmur (6) dis-\\nplacement of organs.\\nThe dead percussion-note being caused by fluid, it follows that its\\nupper level will change with the position of the patient if the fluid is\\nfree. If the upper level is at the third interspace when the patient is\\nsitting up, it will fall to the fourth or lower when he is lying down.\\nThis change of level cannot be appreciated when the effusion is very\\nlarge. Moreover, above the line of dulness the percussion-note is hyper-\\nresonant or tympanitic Skoda s resonance. Toward the spine on the\\naffected side there may be partial resonance and bronchial breathing,\\nbecause here the lung is compressed against the vertebrae. In large\\neffusions the tympanitic resonance in the second interspace does not\\nchange when the mouth is opened that is, Williams tracheal tone\\ncan often be elicited. The upper limit of dulness in large pleural\\neffusions is higher at the spine and slopes downward, and is lowest in\\nfront. This parabolic line is only obtained when the patient is in the\\nerect posture. In moderate effusions the line of dulness is lowest near\\nthe spinal column, rises in the middle of the scapula and slopes down-\\nward, assuming the shape of the letter S as it passes toward the front\\n(Garland). The patient should take deep breaths before the percus-\\nsion is performed. At the left base in front the semilunar space is", "height": "4416", "width": "2660", "jp2-path": "practicaltreatis00muss_0_0622.jp2"}, "623": {"fulltext": "", "height": "4416", "width": "2564", "jp2-path": "practicaltreatis00muss_0_0623.jp2"}, "624": {"fulltext": "PLATE XXIV.\\nB\\nFIG. 2. Posterior Aspect.\\nPleurisy with Effusion (right-sided).", "height": "4408", "width": "2712", "jp2-path": "practicaltreatis00muss_0_0624.jp2"}, "625": {"fulltext": "PLATE XXV.\\nFIG. 1. Anterior Aspect.\\nM/fv\\nFIG. 2. Posterior Aspect.\\nv.-\\nPleurisy with Effusion (left-sided).", "height": "4360", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0625.jp2"}, "626": {"fulltext": "", "height": "4412", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0626.jp2"}, "627": {"fulltext": "DISEASES OF THE LUNGS AND PLEURAE.\\n571\\nobliterated, dulness continuing to the margin of the ribs. In small\\neffusions the dulness may be limited by the posterior axillary line,\\nresonance being present in the lateral and anterior regions.\\nOn auscultation below the upper level of the effusion posteriorly the\\nvoice frequently has a metallic quality resembling the bleating of a\\ng 0a t cegophony. It occurs usually when the effusion is moderate,\\nand may be heard only over a limited area. It is commonly heard at\\nor above the angle of the scapula. Bronchophony may be heard when\\ntubular breathing is present.\\nWhile the respiratory murmur is, as a rule, absent, breath-sounds\\nmay be heard, and are then weak and distant, or bronchial. In such\\ncases there may or may not be adhesions. Bronchial breathing may\\nbe present along the spine in small effusions, and in large effusions in\\nthe interscapular region. Bronchial breathing, tubular in character,\\nis said to be almost constant in children. It may also occur when\\npneumonia coexists. In one of the cases in my ward the signs were\\nlike those of a large cavity at the right base, but the immobility, the\\nabsent fremitus, the enlargement, and the exploratory puncture dis-\\nproved its presence.\\nAt the level of the fluid a friction-sound may persist. Above the\\nlevel of fluid anteriorly the breath-sound may be bronchial or broncho-\\nvesicular, associated sometimes with fine rales, due to compression and\\nslight oedema.\\nFig. 150.\\n104\u00c2\u00b0\\n103 c\\n102\\n10L\\n100 c\\n:*as*\\n_^ _;_ _-_ _^ _-_ _ s _\\n=s?\\nIt\\nI\\n1\\nSB\\nSi\\nfcsd\\nPleurisy with effusion. Recovery. (Two days omitted.)\\nDisplacement of Organs. If the effusion is on the left side, the\\nmediastinum and heart become displaced to the right, and the apex-\\nbeat may be found in the epigastrium, or even to the right of it. The\\noccurrence of displacement of the heart must also be judged by the\\nposition of maximum intensity of the heart-sounds, as the heart may\\nbe behind the sternum. At the same time the semilunar space (Traube s\\nline) is lower than usual or entirely effaced. On the left side inaction\\nof the diaphragm may be observed, and the tissues at the costal margin\\nfall in with each inspiration. If the effusion is on the right side, the", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0627.jp2"}, "628": {"fulltext": "572 SPECIAL DIAGNOSIS.\\ndiaphragm, and with it the liver, is depressed, and the mediastinal\\ncontents are moved to the left.\\nThe subjective symptoms during this stage are slight or moderate\\nfever, sometimes intermittent in character, with recurring chills con-\\nsiderable dyspnoea, occasionally amounting to orthopnoea when the\\neffusion is very extensive and dry cough, which adds greatly to the\\ndyspnoea. There is frequently some evidence of insufficient oxygena-\\ntion of the blood when this amounts to cyanosis, the condition is one\\nof great danger. The urine presents changes in amount. In ad-\\nvancing effusion the amount lessens very much it increases in amount\\nwith the decline of the fluid. Pleurisy may be complicated with bron-\\nchitis, pneumonia, and pericarditis.\\nEmpyema. The above-mentioned physical signs apply chiefly to\\nserous effusions. They are also present in effusions of pus. Other\\nphysical phenomena, however, and different general symptoms distin-\\nguish the two kinds of effusions, although it must be confessed that\\naspiration must often be resorted to before a positive diagnosis can be\\nmade.\\nPhysical Signs. The physical signs of empyema are the same as\\nthose of other effusions within the pleura. In addition, especially in\\nchildren, local oedema of the chest-wall may be found. Another sign\\nwas pointed out by Bacelli, and is held by others to be of diagnostic\\nsignificance. In purulent effusions the fremitus produced by the whis-\\npering voice is not transmitted to the hand laid over the effusion,\\nwhereas in serous effusions such vibrations are transmitted. In locu-\\nlated empyema the diagnosis is very difficult. In one of my cases\\ndulness continuous with that of the heart extended to the second rib\\nand laterally to the post-axillary line. The dulness occupied three\\ninterspaces. Additional physical signs were immobility, prominence\\nof interspaces, localized above the heart, absent fremitus and resonance.\\nThere were no breath-sounds, but an abundance of rales, apparently\\nvery superficial. The rales complicated the physical signs. Martin\\noperated for me and removed two ounces of pus from a small abscess\\nabove the heart and between the lobes.\\nIn empyema a local area may become more prominent and the sur-\\nface assume an inflammatory appearance. It is an indication of dis-\\ncharge of the abscess through the chest-wall. It is usually found in\\nthe fifth interspace in front, or below the angle of the scapula behind\\nempyema necessitatis. (For a microscopical and chemical description\\nof the Effusion within the Pleural Sac, and of the morphological\\nelements of the purulent effusions, see Chapter XXL, Part I.)\\nGeneral Symptoms. The general symptoms are more marked in\\nempyema than in simple serous effusion. The temperature is higher\\nfrom the onset. It soon becomes intermittent or remittent. Chills\\nor chilliness may attend the beginning of each febrile paroxysm, and\\nsweats occur with the daily fall of temperature, or at irregular periods\\nduring the twenty-four hours. The heart s action is more rapid and\\nthe pulse more feeble, soon becoming dicrotic. Examination of the\\nurine may aid in the distinction of the two forms of the effusion.\\nAlbumosuria occurs in purulent pleurisy. It must be remembered", "height": "4408", "width": "2560", "jp2-path": "practicaltreatis00muss_0_0628.jp2"}, "629": {"fulltext": "DISEASES OF THE LUNGS AND PLEURJE.\\n573\\nthat albumosuria occurs in suppuration from other causes. Thus, in\\nphthisis with suppuration of a cavity pleural effusion may develop.\\nThe albumosuria that attends the primary process must not be mis-\\ntaken for that which occurs in empyema. Indican is also present in\\nexcess in the urine in suppurations. Before a decisive conclusion is\\narrived at two or more examinations of the urine should be made.\\nExamination of the blood may aid in arriving at a conclusion. In\\npurulent effusion there is usually leucocytosis.\\nFig. 151.\\nlU-t\\n1\\nft\\n103\\n-I\\nI\\nA\\nA\\nh\\n-f[~\\nH\\n1\\n102 r\\n~T\\\\-\\nU\\nl\\\\\\n1\\nrn\\n_j\\n1\\ni\\nt\\nDC\\ni\\nI\\nior\\nV 1\\nY\\nV\\nJ|\\n1\\nV\\n100\\n1\\nII\\nr\\nv\\n99\u00c2\u00b0\\nw\\n98 c\\ni/\\n1\\nDAY OF DIS.\\n4\\n5\\n6\\n7\\nu\\n15\\n16\\n17\\nIS\\n1!)\\n21\\n31\\n32\\n33\\n34\\n35\\n30\\n30\\nPULSE\\nf\\nm\\nH\\nf\\nf^\\nM\\nV V\\n.-fc s \\\\v\\nxX Y\\nX V\\nRESP.\\nV\\n0\\n\u00c2\u00b0K*\\n9\\n96\\n$4\\nv\\nn\\nn\\nA/ v\\nV -A\\nDATE\\n12 17\\n18\\nVJ\\n0\\ni\\n28\\n39\\n\u00e2\u0096\u00a0M\\n31\\n2\\n2 13\\nii\\n13\\nHi\\n17\\n18\\n18\\nEmpyema following pneumonia. (Fever absent from seventh to fourteenth day.)\\nNotwithstanding the positive physical signs of effusion the character\\nof the effusion may not be recognized until perforation into the bron-\\nchus has taken place. The peculiar character of the expectoration that\\nattends this accident is described in the section on Sputum.\\nHydrothorax. This is an accumulation resulting from a transuda-\\ntion. (For character of the fluid, see Chapter XXL, Part I.) It\\noccurs in the course of diseases which produce anasarca, as failing\\norganic heart disease, chronic Bright s disease, and debilitating diseases,\\nas scurvy. Locally, it may attend carcinoma of the pleura or obstruc-\\ntive disease of vessels within the mediastinum.\\nThe physical signs of hydrothorax are those of effusion in acute\\npleurisy. The general symptoms belong to the primary disorder.\\nDyspnoea may develop gradually and even amount to orthopnoea.\\nIt is distinguished from inflammatory effusions by the character of the\\nfluid, by the absence of the general symptoms of inflammation, by its\\ninsidious development, and by its bilateral distribution.\\nHemothorax. The transudation of blood into the cavity of the\\npleura occurs rarely from the rupture of an aneurism into the sac.\\nThe fluid is then pure blood. Serous effusions in which a large amount\\nof blood is found point to primary carcinoma of the pleura, or to tuber-\\nculous disease. Both specific processes of this serous membrane may\\noccur, however, without the transudation of sero-bloody fluid.\\nThickened Pleura. Chronic inflammation, with thickening of the", "height": "4416", "width": "2612", "jp2-path": "practicaltreatis00muss_0_0629.jp2"}, "630": {"fulltext": "574 SPECIAL DIAGNOSIS.\\npleura from excessive development of connective tissue, occurs in\\ntuberculosis and in cases of combined pleuritis and peritonitis. The\\nthickening of the pleura is usually more marked at the base.\\nThe physical signs (Plate XX VI.) are pronounced, and are those\\nof effusion, but without enlargement of the chest. There are marked\\ncontraction and diminution in movement of the affected side. The\\nfremitus is absent. There is dulness on percussion, or even flatness.\\nThe breath-sounds are distant or are absent. Along the vertebrae,\\nespecially opposite the angle of the scapula, bronchial breathing may\\nbe heard. The subjective symptoms of cough and dyspnoea are pres-\\nent. The degree of cough depends upon the condition of the lung.\\nIf there is bronchitis or tuberculosis, the cough is excessive. The\\namount of dyspnoea depends upon the degree of compression of the\\nlung by the thickened pleura.\\nTuberculous Pleurisy. 1 The affection may be acute or chronic.\\nIt may occur primarily, be a part of general tuberculous infection, or\\noccur secondarily to disease of the lungs: It may give rise to all forms\\nof the inflammatory process First, dry pleurisy second, pleurisy\\nwith effusion third, pleurisy with great thickening. Often the dis-\\ntinction between tuberculous pleurisy and pleurisy due to other causes\\ncannot be determined positively. If it is associated with tuberculosis\\nin other organs, or the patient is of tuberculous habit and exposed to\\ninfection, or if there has been a history of previous tuberculosis, the\\npleuritic infection is probably of tuberculous origin. If the affection\\nis bilateral and associated with peritoneal inflammation, and at the\\nsame time no other cause exists for serous membrane inflammation,\\nthe probability of its tuberculous origin is very strong.\\nPulsating Pleural Effusion. Wilson has made the most recent\\nstudies of this rare affection. The effusion within the pleura pulsates\\nsynchronously with the ventricular- systole the pulsation is detected\\nusually by inspection and palpation. In some instances its presence\\nis only determined by palpation. It may be confined to two or three\\ninterspaces, or occupy the anterior aspect of the thorax and the axil-\\nlary region on the left side. Rarely the pulsation is behind. It is\\nusually situated on the left side. The original effusion is purulent in\\nthe large majority of cases. The physical signs and general symptoms\\nof empyema are present. Nevertheless, the disease simulates aneurism\\nof the aorta. The latter affection, however, is accompanied by vascu-\\nlar symptoms and physical signs in the course of the aorta. Pulsating\\nempyema is distinct in movement from the pulsation of the aorta and\\noccupies a different anatomical site.\\nDiaphragmatic Pleurisy. In diaphragmatic pleurisy there is in-\\ntense pain in the epigastrium. Gueneau de Mussy 2 regards a pain\\nalong the tenth rib, extending from the anterior extremity to the\\nsternum and xiphoid cartilage, as pathognomonic. Other symptoms\\nare nausea, vomiting, and hiccough. The dyspnoea often amounts to\\northopnoea, or the patient sits stooping forward. The anxiety of the\\n1 See Notes on Tuberculous Pleurisy. Musser, American Climatological Associa-\\ntion, 1893.\\n2 Arch. gen. de Med., 1853, vol. xi. Quoted by Fox.", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0630.jp2"}, "631": {"fulltext": "PLATE XXVI\\nFibroid Phthisis with Chronic Pleurisy.\\nHeart drawn toward the right and aorta uncovered by retraction of lung\\nmargin. Vicarious emphyzema of left lung.", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0631.jp2"}, "632": {"fulltext": "", "height": "4416", "width": "2552", "jp2-path": "practicaltreatis00muss_0_0632.jp2"}, "633": {"fulltext": "DISEASES OE THE LUNGS AND PLEURAE. 575\\npatient is very great. The fever is usually higher than in ordinary\\npleurisy, and there may be delirium. Effusion may lessen the pain.\\nPeritonitis may occur at the same time, or be secondary to the pleurisy.\\nDiagnostic Features. The special features of diagnostic impor-\\ntance that are observed in the course of pleurisy are the pain, the\\ndyspnoea, the cough, the fever, the physical signs of effusion within\\nthe pleura, and the results of exploratory puncture. Pain The pain\\nis short, sharp, lancinating, and is usually recognized quite readily by\\nits character and location. It must be distinguished from the pain\\ndue to pleurodynia and intercostal neuralgia. The pain of pleurisy is\\nassociated with cough and is increased by breathing. It causes dimi-\\nnution of movement of the affected side. The patient is compelled to\\nsit up in bed, or lie on the side which is the seat of pain. Cough In\\nthe first stage the cough is short, suppressed, dry, and painful. It is\\nconstant. In the second stage it changes in character. There is no\\npain, there is no expectoration. It is frequent and irritating, and of\\na peculiar sound which is difficult to describe, and yet, when once\\nheard, is most suggestive in subsequent cases. It is short and lacks\\nresonant quality, as if the fluid in the chest stopped the sound-waves.\\nDyspnoea in the first stage is due to pain, in the second stage to the\\nlarge effusion which encroaches upon the normal air-space. It is not\\ndiagnostic. The physical signs of pleural effusion have been frequently\\nreiterated. The most decisive are diminution or absence of move-\\nment, enlargement of the affected side, absence of fremitus, flatness on\\npercussion, fulness of intercostal spaces, and the displacement of organs.\\nThe latter is of the greatest diagnostic importance in the distinction\\nbetween consolidation and effusions. The results of exploratory punc-\\nture lead to decisive conclusions usually, although it must not be for-\\ngotten that effusions may be loculated and therefore missed by the\\naspirating-needle. Or the enormously thickened pleura may intervene\\nbetween the exudation and the surface of the chest, and prevent with-\\ndrawal of the fluid. Finally, effusions may complicate inflammatory\\nprocesses, as pneumonia, tuberculosis, or abscess of the lung. Securing\\nfluid for diagnosis by aspiration, therefore, does not necessarily exclude\\nthese conditions, and hence, before the process is decided to be within\\nthe pleura alone, the sputum and other conditions must be taken into\\nconsideration.\\nDifferential Diagnosis. Acute plastic pleurisy is diagnosticated from\\nacute pneumonia by the friction-sound and the maintenance of the clear\\npercussion-note and normal respiratory murmur, with unaltered vocal\\nresonance and fremitus. When effusion takes place the chest is en-\\nlarged and immobile, especially on the affected side the interspaces\\nare filled out and the diaphragm is depressed these changes do not\\noccur in pneumonia. Moreover, the percassion-note in pleural effusion\\nis flat, with greatly increased resistance the shape of the upper line\\nof dulness is diagnostic the respiratory murmur is feeble and distant,\\nor entirely absent, except along the spine, where the compressed lung\\nyields bronchial breathing, and also above the line of effusion, where\\nthe lung yields exaggerated breathing. In pneumonia, on the other\\nhand, the percussion-note is dull, without greatly increased resistance,", "height": "4416", "width": "2572", "jp2-path": "practicaltreatis00muss_0_0633.jp2"}, "634": {"fulltext": "576 SPECIAL DIAGNOSIS.\\nand the breath-sounds are bronchial. In addition, in pleurisy, the\\nvocal resonance and fremitus are usually almost if not entirely absent,\\nand posteriorly at the level of the effusion segophony may be detected.\\nIn pneumonia, on the contrary, vocal resonance and fremitus are\\nincreased in intensity. In pleurisy with effusion the movable organs\\nare dislocated and Traube s line is obliterated.\\nFinally, the fever of pneumonia is much higher and more continu-\\nous than that of pleurisy, the respirations more frequent, the cough\\nlooser, and in typical cases followed by rusty sputa. (Compare the\\ntemperature chart in article on Pneumonia.) A crucial test is aspiration\\nwith a hypodermic needle in pleural effusion, serum is withdrawn\\nin pneumonia, a few drops of thick blood.\\nIn pleurodynia there is also severe pain in one side but the pain is\\nmore continuous than that of pleurisy, and consists of a constant aching\\nor a burning sensation. It is made worse by twisting or turning, as\\nwell as by breathing. The side is also tender to the touch. The pain\\nis not so sharply localized as that of pleurisy, and may leave one side\\nand affect the other. It is unaccompanied by fever or friction-sound,\\nand is frequently found in rheumatic subjects.\\nIn intercostal neuralgia there is the same absence of fever and fric-\\ntion-sound. The pain, however, is sharply localized, as in pleurisy,\\nbut is of the darting, neuralgic character, and is associated with tender-\\nness at the points of exit of the intercostal nerves. It is most common\\nin women, especially if they have uterine disturbances. It is more\\nfrequent on the left side, and just beneath the mammary gland.\\nChronic Pleurisy. Chronic dry, or plastic, pleurisy is the result of\\nan acute attack, or develops insidiously if tuberculous. It causes\\ngreat deformity of the chest from contraction, and compensatory\\nemphysema of the healthy lung. The heart is dislocated or cannot\\nbe found on physical examination, because it is overlapped by lung or\\nis drawn behind the sternum. There is considerable spinal curvature,\\ndislocation of the scapula, deformity of the shoulder, and indrawing\\nand overlapping of the ribs at the base of the chest.\\nChronic pleurisy with effusion results from an acute attack of pleurisy,\\nin which the fluid remains unabsorbed, or from subsequent attacks.\\nThe physical signs are the same as in acute effusion. So far as subjec-\\ntive symptoms go it may remain latent patients so affected not infre-\\nquently go about their work with comparatively little dyspnoea. There\\nmay be an evening rise of temperature and acceleration of the pulse.\\nChronic effusions are more likely to be purulent in children than in\\nadults. When empyema results, the fever becomes hectic there are\\nchills and sweats, pysemia develops, and death is likely to occur from\\nsome intercurrent suppuration, as cerebral abscess.\\nAfter chronic effusion the chest is rarely restored to its original shape,\\neven if the effusion is finally absorbed. The affected side becomes\\nmotionless and retracted. In process of time the spme may be bent.\\nThe opposite lung becomes hypertrophied. The patient is usually in\\nprecarious health, liable to acute attacks of pain in the affected side,\\nand liable also to be carried off by phthisis or some intercurrent affec-\\ntion. Rarely the patient may maintain good health complete cure", "height": "4408", "width": "2576", "jp2-path": "practicaltreatis00muss_0_0634.jp2"}, "635": {"fulltext": "", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0635.jp2"}, "636": {"fulltext": "PLATE XXVII.\\nFIG. 1.\u00e2\u0080\u0094 Anterior Aspect.\\nW t\\nFIG. 2.\u00e2\u0080\u0094 Posterior Aspect.\\nff^\\n\\\\V\\nPneumothorax (left-sided).", "height": "4340", "width": "2576", "jp2-path": "practicaltreatis00muss_0_0636.jp2"}, "637": {"fulltext": "DISEASES OF THE LUNGS AND PLEURA. 577\\nis even possible, with restoration of the retracted side to, or almost to,\\nnormal dimensions, especially in children.\\nPneumothorax. Pneumothorax consists in an accumulation of air\\nin the pleural cavity, accompanied or followed by an outpouring of\\nfluid, which may be serous or purulent, constituting respectively hydro-\\npneumothorax and pyo-pneumothorax.\\nPneumothorax may originate 1. In causes external to the chest,\\nby perforation of the chest-wall and pleura. 2. In perforation of the\\nlungs, bronchi, or oesophagus. 3. It may be caused by gases devel-\\noped from an existing effusion.\\nThe most frequent cause is tuberculous disease of the lung, and next\\nan empyema out of 121 cases collected by Saussier, 81 were due to\\nphthisis and 29 to empyema. It may occur very early in tuberculosis\\nof the lung, and may even be the first symptom of that disease.\\n(See cases referred to by Fox and recorded by Louis and Chomel).\\nThe left side is affected not quite twice as often as the right the\\ndisease is usually unilateral. The onset of the condition is usually\\nsudden. During a paroxysm of coughing or vomiting, or without\\nimmediate cause, there is an escape of air into the pleura, and in the\\nmajority of cases the patient at once complains of acute pain in the\\nchest and excessive dyspnoea with great dread of impending suffoca-\\ntion. The patient often sinks into collapse from shock, but sudden\\ndeath is rare. If the escape of air into the pleura is gradual, there\\nwill be less pain and dyspnoea.\\nPhysical Signs. (Plate XXVII.) The chest is distended, especially\\non the affected side the percussion-note is a bell-like tympany except\\nwhen the distention is excessive and the air contained is under great\\ntension, when the note is proportionately duller and higher in pitch; the\\ndiaphragm is depressed and the heart displaced, unless adhesions pre-\\nvent it. In left pneumothorax it may beat on the right side, the whole\\nmediastinum being pushed to the right in right pneumothorax the\\nmediastinum may be pushed to the left nipple hence there is reso-\\nnance over the normal cardiac region. The pitch of the percussion-\\nnote may be raised when the mouth is closed, and lowered when it is\\nopen (Wintrich s change of note), and a cracked-pot sound can be\\nelicited in some cases, but this occurs only when the communication\\nwith the pleura remains open.\\nA valuable sign of pneumothorax is the coin-test, or, as Trousseau\\nnamed it, the Bruit d airain. A silver coin is laid upon the chest and\\nstruck with another, while the auscultator applies the stethoscope oppo-\\nsite to the point struck, or over any part of the side distended by air.\\nThe ringing coin-sound is reproduced with great intensity. It is path-\\nognomonic, and the outlines of the cavity can be traced by it.\\nWhen fluid is present, as it usually is, there will be the ordinary\\nsigns of a pleural effusion, which have been sufficiently dwelt upon.\\nThe fluid is more mobile in pneumothorax, however, than in simple\\npleurisy, so that its level changes more quickly with change of posture\\nof the patient, and Hippocratic succussion is readily obtained. This\\nmovable dulness is a very valuable sign indeed, almost pathognomonic.\\nAs the lung is compressed against the spine by the air, as it is by\\n37", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0637.jp2"}, "638": {"fulltext": "578 SPECIAL DIAGNOSIS.\\nthe fluid in pleurisy, the breath sounds are feeble or absent, except\\nover the root of the lung, where the breathing is bronchial. But if\\nthe lung is not completely collapsed, amphoric breathing may be heard,\\nthe air-chamber of the pleura acting as a consonance-box it may be\\nheard with both inspiration and expiration, or only with expiration.\\nMetallic tinkling is a sound believed to be due to the vibration of\\nbubbling bronchial rales re-echoed through the air-chamber, or to\\ndrops of fluid falling from above upon the surface of the effusion. Re-\\nechoing, with metallic quality, may also accompany the heart-sounds,\\nand in cases in which the respiratory murmur is amphoric the vocal\\nresonance is of the same character. Vocal fremitus is generally\\nabsent.\\nDifferential Diagnosis. Pneumothorax is most likely to be\\nconfounded with (1) emphysema (2) tuberculosis of the lungs with\\nlarge cavities (3) cases of pleural effusion in which above the upper\\nlevel of the fluid the lung is markedly hyper-resonant and (4) abscess\\nbelow the diaphragm containing air (pyo-pneumothorax subphrenicus).\\n1. Emphysema can be distinguished by its slow onset, its relatively\\nslight impairment of the general health, by the fact that it is bilateral,\\nwhereas pneumothorax is almost always unilateral, and by the exist-\\nence of feeble breathing with greatly prolonged expiration. Amphoric\\nbreathing and resonance, metallic tinkling, and signs of fluid are all\\nabsent in emphysema.\\n2. When the pneumothorax is circumscribed the physical signs re-\\nsemble those of pulmonary cavity. But over a large cavity the chest\\nis usually flattened cracked-pot sound and alteration in pitch upon\\nopening and closing the mouth are more common in cavity than in\\njmeumothorax. Displacement of viscera does not necessarily occur\\nin phthisical cavity, the coin-test is negative, succussion cannot be pro-\\nduced. Fremitus is absent in pneumothorax and increased over a\\ncavity.\\n3. The hyper-resonance above a pleural effusion develops with a very\\ndifferent clinical history, is accompanied by increase of fremitus with\\nbronchial or, at times, amphoric breathing, and changes when the\\npatient s mouth is open or closed. The percussion-note usually lacks\\nthe metallic quality heard in pneumothorax, metallic tinkling is absent,\\nthe coin-test is negative.\\n4. Pneumothorax must be distinguished from abscess below the dia-\\nphragm containing air (pyo-pneumothorax subphrenicus). Often the\\ndistinction is difficult. The constitutional symptoms of supjDuration\\nare present. Leyden points out the importance of remembering the\\nsequence of events in the development of the disease. When the\\nabscess is situated below the diaphragm, abdominal symptoms precede\\nits development, and early in the course of the disease there is absence\\nof respiratory symptoms. If the patient has had gastric ulcer, this\\nwould point to subphrenic abscess, as most of the cases of subphrenic\\nabscess are secondary to gastric ulcer. Moreover, in subphrenic abscess\\nthe heart is not displaced nor the interspaces bulging. Indeed, the\\nviscera below the diaphragm are more likely to be displaced than those\\nabove it. In pneumothorax, according to Leyden, the respiration is", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0638.jp2"}, "639": {"fulltext": "DISEASES OF THE LUNGS AND PLEURJE. 579\\nnormal under the clavicle, and the transitions from the normal to the\\nmetallic and amphoric sounds lower down are abrupt. In pyopneu-\\nmothorax on the left side the semilunar space disappears. In sub-\\nphrenic abscess the amphoric sounds laterally or posteriorly may be\\nabove and below the diaphragm, or they may be loudest at the epigas-\\ntrium. In addition, in pyo-pneumothorax subphrenicus, as Mason\\npoints out, adhesions of the lung to the diaphragm and parietes can be\\nmade out, particularly if the case has been under observation in its\\nearlier stages and dry pleurisy has been discovered. Abscess in this\\nlocation and slight fluctuation are likely to develop with associated\\neffusion. The limited extent of the effusion is of diagnostic import in\\nfavor of sub-diaphragmatic inflammation.", "height": "4412", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0639.jp2"}, "640": {"fulltext": "CHAPTER III.\\nDISEASES OF THE HEABT, THE BLOODVESSELS, AND THE\\nMEDIASTINUM.\\nThe symptoms of disease of the heart are due to the anatomical\\nstructure of the organ, to its physiological offices, and to the morbid\\nprocess. The heart is a hollow muscular structure which hangs in a\\ncavity and encloses cavities separated by valves. Both sets of cavities\\nare lined by serous membrane. The serous membranes are subject to\\nthe same diseases, and present the same symptoms as diseased serous\\nmembranes elsewhere. In inflammation of the external membrane\\nthe surfaces rub together and create a sound of friction. The external\\nserous cavity may also become filled with the products of exudation or\\ntransudation. Physical signs are produced. They are the physical\\nsigns of a localized increase of contents as determined by inspection,\\npalpation, and percussion, and of physical interference with the heart s\\naction. The heart-muscle is also subject to the same morbid processes\\nas other muscular structures. They are hypertrophy and atrophy\\ninflammation, acute and chronic, with overgrowth of connective tissue\\nand degenerations. The symptoms are likewise the same. Increase\\nor diminution in the power of the muscle is associated with correspond-\\ning change in size, which is determined by physical signs. Above\\nall, however, such change modifies the heart s action so that strength\\nor weakness of the muscle shows itself in excessive or deficient vascu-\\nlar pressure. The latter is more particularly an object of observation\\nbecause of the congestions, dropsies, and cyanosis that ensue.\\nThe heart is constantly subjected to internal pressure. Dilatation\\nof the cavities or a portion of cavity (aneurism) follows previous dis-\\nease of the muscle or increase of internal pressure, and causes physical\\nsigns of enlargement. Degeneration of the heart-muscle, nearly always\\nsecondary to deficiency of vascular supply, is also attended by symp-\\ntoms of weakness and physical signs of enlargement (dilatation), or of\\ndiminution in size (atrophy). When dilatation occurs the orifices of\\nthe cavities enlarge, the valves cannot close them, and symptoms of\\nincompetency and of blood-regurgitation result.\\nThe serous membrane that lines the cavities of the heart and, with\\nthe subserous tissues, makes up the structure of the valves, is subject\\nto inflammations, the symptoms of which are common to all serous\\ninflammations. The swellings and outgrowths that attend such in-\\nflammation occlude the orifices and prevent closing of the valves. A\\nphysical interference with the heart s function is produced, recognized\\nby physical signs. The successful effort of the heart-muscle to over-\\ncome such obstruction on the one hand (hypertrophy), or its failure on\\nthe other (dilatation), again leads to the production of symptoms and", "height": "4408", "width": "2568", "jp2-path": "practicaltreatis00muss_0_0640.jp2"}, "641": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 581\\nsigns. The serous membranes, and hence the valves, are exposed to\\ncauses which excite inflammation. By virtue of the position of the\\nheart at the centre of the circulation, the blood, infectious or irritative,\\nas in rheumatism and Bright s disease, constantly bathes the vulnerable\\nstructure. For the same anatomical reason positive symptoms arise,\\nnot common to serous membrane inflammation that is, embolic phe-\\nnomena. (See Symptoms of Morbid Processes.) Hence, the physical\\nsigns (objective symptoms) of cardiac disease may be due to primary\\nand secondary morbid anatomical changes. They may be due (1) to\\nvalvulitis as indicated by signs of (a) obstruction or regurgitation at\\nthe valve-orifice, or (b) of embolic phenomena (2) to secondary changes\\nin the heart-muscle as seen in (a) change in the size and strength of\\nthe organ (hypertrophy or dilatation), and (b) in consequence of the\\nlatter, signs of congestion, oedema, cyanosis, etc.\\nIt is the function of the heart to propel the blood. It has been\\nshown how interference with the action of the muscle and with the\\nconsequent flow of blood through the cavities and orifices modifies the\\nfunction. The functional power is increased or diminished by the\\nphysical changes. The evidence of increased power is increased force\\nof the heart-beat, and increased pressure in the arteries (pulse).\\nDiminished power shows itself in symptoms of diminished blood-\\nsupply to parts, and in stagnation of the blood that is sent to the\\nperiphery. The former is more pronounced in cerebral anaemia, and\\nphysiological weakness of organs or the organism as a whole the\\nlatter, in congestion and dropsies.\\nThe functional activity of the heart is controlled by a nervous mech-\\nanism, any alteration of which alters cardiac action and consequently\\nproduces symptoms. Just as with the larynx, a break in the cardiac\\nmechanism may be in the centres in the medulla, the centres in the\\nmuscle, or in the sympathetic nerves to and from the heart. The rich\\nanastomosis of these nerves exposes the heart to disturbance by reflex\\ninfluences. We should suppose such extensive innervation would in-\\nvite frequent cardiac perturbation. In a measure it does, but, fortu-\\nnately, so perfect is this mechanism that the inhibitory fibres control\\nsuch perturbation to a large extent, and we do not see such pronounced\\nsymptoms as occur in the larynx. The symptoms which point to dis-\\nturbance of the cardiac mechanism are alterations in the rhythm of the\\nheart. Its action may on this account be increased or diminished in\\nfrequency, or it may be irregular or intermittent. Such alterations of\\nrhythm may be due to organic disease of the centres, notably the pneu-\\nmogastric from apoplexy, softening, or tumor in the medulla, or to\\nstimulation or depression of the centres by toxic substances in the blood,\\nas in uraemia, acetonemia, or autogenetic or other toxaemias, or by nico-\\ntine or other extraneous material. The altered rhythm may be, and most\\nfrequently is, of reflex origin. It may be due to disease of the nerves,\\nas the pneumogastric or sympathetic, from pressure upon the nerve-trunk\\nby tumor or inflammatory growth. The most pronounced symptom of\\naltered rhythm of which the patient is cognizant is palpitation. The\\nexciting cause of this, as well as other rhythmical changes, must, in the\\ngreat majority of cases, be sought for beyond the domain of the heart.", "height": "4416", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0641.jp2"}, "642": {"fulltext": "582 SPECIAL DIAGNOSIS.\\nAY bile the symptoms or signs of cardiac disease are often due to\\nmorbid processes in the organ or its membrane, it must be remembered\\nthat grave and persistent subjective and objective symptoms may be\\ncaused by, or at least associated with, disease of contiguous structures\\noutside of the pericardium. The symptoms are not excited through\\nthe nervous system, but are produced by mechanical encroachment upon\\nthe organ, as in pleurisy with effusion, mediastinal disease and disease\\nof subdiaphragmatic viscera. They will be referred to in the study of\\nobjective symptoms. Care must be taken never to overlook the possi-\\nbility of their presence.\\nIn the study of the symptomatology of cardiac disease the student\\nmust bear in mind two things first, that the cause of the morbid pro-\\ncesses and of the symptoms (pain and palpitation) may be elsewhere\\nthan in the heart and, second, that the ultimate object of the exami-\\nnation is to determine the muscular power of the heart. He will soon\\nlearn that with that power intact the functions can be performed, not-\\nwithstanding the presence of marked physical abnormalities.\\nThe recognition of disease of the heart is not usually attended by\\nmuch difficulty, except in some special lesions. The non-recognition\\nof cardiac disease is due to faults in the examination. The physician\\nis too often satisfied with the recognition of the remote process, as a\\ncongestion or functional weakness in some organ. Safety lies, as has\\noften been said, in the examination of all the organs of the body.\\nOften, for instance, indigestion from gastric catarrh is not relieved, for\\nthe cause, mitral regurgitation, is not recognized.\\nThe Data Obtained by Inquiry.\\nThe Social History. The incidents in the social history to be\\nconsidered in the determination of the presence of cardio-vascular dis-\\nease are those which notably influence by strain, excitement, or wear\\nand tear, the cardio-vascular mechanism those which alternately in-\\ncrease and diminish cardiac action, open and shut, dilate and contract\\nperipheral vessels. Whether it be symptoms of functional disorder or\\nof organic disease we wish to unravel, we must inquire as to the use\\nof stimulants, of tea, coffee, tobacco, and other narcotics or poisons as\\nto mental anxiety or physical strain as to excesses of various kinds.\\nExcess in any form induces vascular Avear and tear. Tersely put by\\none of our most distinguished clinicians, the devotee at the shrine of\\nVenus, Bacchus or Mars, is too frequently the victim of vascular dis-\\nease. Occupations which invoke such vascular excitations are sugges-\\ntive diagnostic factors.\\nThe age in which we are wont to find cardio-vascular affections\\nvaries with the character of the lesion. Apart from congenital cardiac\\naffections, acute inflammations are more common at the age when infec-\\ntious are more operative, as in the early decades. On the other hand,\\nand it goes without saying, degenerative lesions are found in later life.\\nBut as man is no older than his arteries, and as these degenerative\\nLesions may occur in comparatively early life, from a cardio-vascular\\nstand-point, a man may be senile at thirty-five or even earlier. Sex", "height": "4412", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0642.jp2"}, "643": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 583\\ninfluences diagnosis in so much as the one sex is more exposed to the\\ncausal influences of cardiac lesions. Females are more prone to acute\\ninfectious processes and to the neuroses from immobile nervous systems.\\nMales to degenerative lesions and the intoxication neuroses.\\nFamily History. Inquiry in this direction yields information of\\ngreat diagnostic value. The gouty and rheumatic diatheses, with\\ntheir long train of associated disorders, which predisposes to cardio-\\nvascular affections, are notably inherited. Moreover, the tendency to\\natheroma of vessels is itself pronouncedly hereditary.\\nThe History of Previous Disease. The occurrence of any one\\nof the numerous infections may have been the initial step in the pro-\\nduction of the affections we are considering. The determination of\\nthe nature of a cardiac lesion may hinge upon the correct decision of\\nthis question. The infection of acute rheumatism is of course to be\\neagerly sought for. A history of chorea, of various skin affections\\nrelated to gout and rheumatism, of eye affections, of tonsillitis, of other\\naffections related to the so-called uric-acid diathesis, must be sought\\nfor. If found, such history is more than suggestive.\\nThe Subjective Symptoms. A. Symptoms Referred to the\\nHeart. Pain. 1. In Disease Outside of the Heart. Although pain\\nin the region of the heart may be a symptom of disease of that organ\\nor of the pericardium, in the large majority of instances it is due to\\nother causes. The physician is frequently consulted by the anxious\\npatient on account of pain, other than heart-pain, but referred to this\\nregion, or more precisely to the fifth or sixth interspace on the left\\nside. The causes of such pain are various (1) Neuralgia (2) pleu-\\nrodynia (3) myalgia (4) local pleurisy (5) periostitis. The neu-\\nralgias may be associated with points of tenderness, Avhich are usually\\nthe seat of the greatest intensity of the pain. These points of tender-\\nness correspond with the positions at which the nerves have their\\nexit through the fascia to the surface, and are found along the\\nsternum, in the course of the mid-axilla, and along the vertebra?. The\\npain is paroxysmal, occurs at variable periods of the day, and in\\nanaemic subjects or in the course of neurasthenia. It may precede the\\ndevelopment of herpes zoster. In these cases the exact nature of the\\npain is not known until the eruption appears. In gout or diabetes we\\nmay have local neuritis, which causes neuralgic pain in this situation.\\nPleurodynia, which is thought to be an affection of the pleural\\nnerves, is more general. The pain is increased by pressure of the\\nfinger-tips, although it is not localized. It is relieved by pressure of\\nthe whole hand. In myalgia, which is seen so frequently in phthisis,\\non account of severe coughing, in rheumatism and in debilitated subjects\\ngenerally, the pain is more or less diffuse, interferes more or less with\\nmovements of the chest, is relieved by uniform general pressure, and\\nis usually associated with myalgia in other organs. The pain of pleu-\\nrisy is recognized by the fact that it usually inhibits the act of breath-\\ning, and is associated with cough, and because friction-sounds may be\\ndetected. Periostitis. In disease of the ribs of the prsecordia the pain\\nis associated with tenderness and swelling. One or more of the costo-\\nsternal articulations may be extremely tender. The pain and tender-", "height": "4416", "width": "2572", "jp2-path": "practicaltreatis00muss_0_0643.jp2"}, "644": {"fulltext": "584 SPECIAL DIAGNOSIS.\\nness are due to the periostitis of syphilis or to that which follows\\ntyphoid fever. In one of my cases the rib had to be resected. It\\nmay be due to the internal pressure and erosion of ribs in aneurism.\\nThe same affection may cause neuralgic pains in the nerves. Abscess.\\nPain in this region may, in rare instances, be due to localized tuber-\\nculous abscess between the pericardium and the walls of the thorax.\\nOne such case was under my care. The abscess developed secondarily\\nto empyema and occupied the precordial region, causing bulging.\\nThe pain was intense, and was only relieved after the caseating pus\\nwas removed by incision.\\nPain in the epigastrium is often held to be due to cardiac disease.\\nIt is usually due to gastralgia, or, as it is sometimes termed, cardial-\\ngia. It is recognized by the location of the pain and its association\\nwith gastric symptoms, as flatulency, weight, fulness, and acidity. In\\ngastric ulcer the epigastric pain is localized, accompanied by tender-\\nness on pressure, and is increased by food. However, acute, severe,\\nand excruciating pain in the epigastrium may be due to rupture of the\\nheart and also to pericarditis.\\n2. In Disease of the Pericardium. Pain in the region of the heart\\nis sometimes due to affections of the pericardium. Pericarditis is the\\nmost common. While centralized in the heart-region, it may radiate\\nto the left shoulder and extend down the arm. It is paroxysmal and\\nmay have some of the characteristics of angina. It is increased by\\nmovement, by pressure, and by the action of the diaphragm. The\\npatient is often obliged to sit up in bed and suffers from orthopnoea.\\nIt may be referred to the epigastrium. A pericardial friction-sound is\\nusually detected. Pain due to disease of the aorta. Acute inflammation\\nof the aorta is also the cause of cardiac pain. The pain extends along the\\ncourse of the aorta, may be referred to the sternum, and extends along\\nthe spine. The pain is severe, causing an anxious countenance and\\nan expression of extreme suffering. In gouty subjects with atheroma\\npain may occur in this situation in paroxysms. There is usually val-\\nvular disease at the aortic orifice. Similar pain occurs in syphilis and\\nin alcoholic subjects, and may be due to malaria. It is a visceral\\nneurosis, or a form of neuralgia.\\nPain in the region of the heart is frequently due to aneurism. The\\npain is usually due to pressure of the aneurism upon adjacent struc-\\ntures. If it presses on the bone and causes erosion, the pain is of a\\nboring character, localized at one point. It has been previously re-\\nferred to. In aneurism alone, without pressure, the pain is of a dull\\naching character, increased by movement, relieved by rest, or by\\nchange of position. When nerves are pressed upon, pain may be acute\\nand of a neuralgic nature. It may follow the course of the nerves and\\nbe associated with numbness or sensations of tingling. The long dura-\\ntion of the pain, its localization, and its aching character are sufficient\\nto exclude angina pectoris. When the pain is unilateral it may be\\ndue to pressure of an aneurism upon the nerves at their exit from the\\ncanal the pain extends along the course of the intercostal nerves. It\\ni- severe and burning, but there are no localized points of greater in-\\ntensity. The pain may extend down the arms, and, when the abdomi-", "height": "4412", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0644.jp2"}, "645": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 585\\nnal aorta is affected, it may extend down the legs. If rupture of the\\naneurism takes place, the pain is sudden and sharp. Death, however,\\nensues quickly, so that the pain will rarely be complained of.\\n3. In Disease of the Heart. Three forms are seen (1) Pain due to\\ndisturbances of the rhythm (2) pain due to valvular disease (3) pain\\ndue to angina pectoris.\\nDisturbance of the Rhythm. Palpitation, intermission, and irregu-\\nlarity of the heart occur in the large majority of cases without pain.\\nParoxysms of palpitation are sometimes attended with severe precor-\\ndial pain and distress. This occurs in the reflex palpitation, which,\\nas will be seen, is due to disease in other situations in the palpitation\\nof Graves disease and of anaemia. The palpitation of organic disease\\nis induced by exertion. The rapid action of the heart is painful and\\nthe throbbing is complained of as causing distress.\\nWhile intermission and irregularity may continue without pain at\\ntimes, the patient is conscious of this disturbance of the rhythm, and\\ncomplains of the stoppage, which then is attended by distress, some-\\ntimes amounting to severe pain. This is particularly the case when\\nthe heart-action is tumultuous, as the disturbance of rhythm seen in\\npericarditis and in valvular disease.\\nPain due to Valvular Disease. In disease of the aortic valves pain\\nis of more frequent occurrence than in other valvular lesions. It is\\nusually complained of in the region of the aorta at the base of the\\nheart, and is aggravated by exertion. (See Atheroma.)\\nPain due to Angina Pectoris. Heberden was the first to describe the\\nattacks of angina pectoris, which, in its typical form and in association\\nwith disease of the heart, is not of common occurrence. The pain of\\nangina is severe and is associated with the most intense anguish. It\\ncomes on suddenly, and may occur in paroxysms. The patient real-\\nizes that the pain is in the heart, and complains of feeling as if the\\norgan were held in a vise. From the heart it radiates to the neck\\nand down the arms. It extends particularly to the left arm, and may\\nbe severe in the wrist or in the ends of the fingers. With the pain\\nthere is a sense of impending death with sinking and depression. The\\npain lasts but a few seconds or minutes, and during that time the face\\nof the patient becomes pale or of an ashy hue, perspiration breaks out\\non the forehead, the extremities become cold, the breathing is short.\\nProstration usually follows the attack, but the precordial distress dis-\\nappears entirely. The attack may occur in patients who are entirely\\nfree from organic disease of the heart. It is most commonly, however,\\nassociated with some lesion. The lesions frequently found are disease\\nof the coronary arteries, atheroma of the aorta, aortic valvular disease,\\nand myocarditis with fatty degeneration. It occurs after middle life,\\nand is more frequent in males. It may occur without exciting cause,\\nor follow undue exertion, exposure to cold, mental excitement, or pro-\\nfound emotion.\\nThe points upon which the diagnosis is based are 1. The seat of\\nthe pain. This is usually behind the middle or the lower part of the\\nsternum, and more to the left than to the right. Thence it extends to\\nthe posterior portion of the axilla or it may radiate up to the neck.", "height": "4416", "width": "2564", "jp2-path": "practicaltreatis00muss_0_0645.jp2"}, "646": {"fulltext": "586 SPECIAL DIAGNOSIS.\\nIn some instances it extends to the occiput. Frequently the pain ex-\\ntends to the left arm as far as the elbow or even the fingers. It may\\nextend to the abdomen or to the right arm. I have seen it affect both\\narms. It is not influenced by external pressure. 2. The sense of\\nconstriction with the indescribable torture are most characteristic. 3.\\nThe respirations are shallow, or may even cease, but there is no dysp-\\nnoea. 4. The patient is terrified and restless. 5. The pale face, ex-\\ntremely anxious countenance, the cold sweat on the forehead, make a\\nstriking picture, which when once seen can never be forgotten. 6.\\nSuch extreme depression and sensation of impending death occur in no\\nother affection. Particularly characteristic is the immediate relief,\\nwithout hysterical manifestations or dyspeptic symptoms of any kind,\\nwhich follows an attack. 7. During the attack the frequency of the\\npulse is not much influenced, and the action of the heart may be uni-\\nform and regular. Rarely its frequency may be lessened. The tension\\nof the pulse is increased during the attack.\\nSome authors speak of various grades of angina, and call all forms of\\nprecordial pain and oppression, with radiation of the pains to the arms\\nand neck, mild forms of angina. Such attacks have often obvious\\ncauses in disturbance of digestion and in emotional excitement. When\\nassociated with increased arterial tension and signs of arterio-sclerosis,\\nthey may be of an anginoid nature. The greatest difficulty exists in\\ndistinguishing them from true angina. Hysterical or pseudo-angina\\ncan be distinguished only with extreme difficulty. It occurs much\\nmore frequently than true angina. One attack seems to predispose to\\nothers. It occurs in females who present other symptoms of hysteria.\\nIt occurs usually before forty years of age. The attacks most fre-\\nquently come on at night, and may be periodical. They are particu-\\nlarly associated with menstrual disorders. The pain is less severe and\\nthe oppression is not so marked in pseudo-angina coldness of the\\nhands and feet, with the occurrence of syncope, or a general feeling of\\nsinking, are common symptoms. The pain is of long duration and is\\nassociated with great agitation. It is preceded by neuralgia, and\\nneuralgic pains persist after the attack. Low tension, feeble second\\nsound, and soft arteries may be present, although the opposite is also\\nseen. The disease is never fatal. In one of my patients attacks of\\nhysterical haemoptysis alternated with the anginal attacks.\\nPalpitation. In palpitation the patient is conscious of the action\\nof the heart. Although it may occur in organic disease, it is more\\nfrequently due to disease outside of the heart.\\nSymptoms. The symptoms vary in degree. En mild forms the\\npatients may complain of a fluttering or a sensation of sinking in the\\nprecordial region. In the more severe forms the heart beats violently\\nagainst the chest. The arteries throb, the action of the heart is in-\\ncreased, and the area of impulse against the chest-wall is enlarged and\\nvisible. The patient complains of distress in the precordial region.\\nThe pulse may be increased to 150. In nervous palpitation the face\\nbecomes flushed, and after the attacks large quantities of urine are\\npassed. Sometimes, in this form of palpitation, exertion relieves the\\nattack. On examination, the sounds are found to be normal, but they", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0646.jp2"}, "647": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND- MEDIASTINUM. 587\\nare clear and metallic in character. The diastolic sounds are greatly\\naccentuated. If anaemia is present, murmurs due to that condition\\nare increased in intensity. The attack may last but a few minutes or\\ncontinue for hours.\\n(a) It is most common in cases in which the nervous system gener-\\nally is in a state of increased excitability. Attacks occur at puberty\\nand at the menopause. It is very common in hysteria and neuras-\\ntheniac It follows emotional disturbance. It is more frequent in women.\\n(6) It is due to the action of the toxic substances, as tobacco, tea and\\ncoffee, and alcohol.\\n(c) From strain and over-exertion, particularly if associated with ex-\\ncitement, palpitation may occur and continue for a long period. This\\nis the form of irritable heart described by Da Costa, common in young\\nsoldiers during the war.\\n(d) In valvular disease of the heart when compensation fails, and\\nin myocarditis, attacks of palpitation occur, distinctly from exertion.\\nIntermission and Irregularity. When the patient feels the alter-\\nation in rhythm, it is usually due to nervous disturbance. In organic\\ndisease it is not, as a rule, appreciated by the patient. Although not\\na subjective symptom alone, it may be well to speak of irregularity in\\nthis connection.\\nArrhythmia is the general term applied to irregularity of the action\\nof the heart. When the heart intermits that is, when one or two\\nbeats are dropped at intervals of half a minute, a minute, or longer\\nwhen the beats are unequal in volume and force, or occur at unequal\\ndistances in time, the heart s action is irregular. The causes of dis-\\nturbance of the rhythm have been classified by Baumgarten 1 as follows\\n1. Central causes in the medulla either from organic disease, as\\nhemorrhage or concussion, or from physical influences. 2. Reflex\\ninfluences, as in dyspepsia and diseases of the liver, lungs, and kid-\\nneys. 3. Toxic influences tobacco, coffee, and tea are common causes\\nvarious drugs, such as digitalis, belladonna, and aconite. 4. Changes\\nin the heart itself. Mural changes, as in dilatation, fatty degeneration,\\nand myocarditis changes in the cardiac ganglia sclerosis of the cor-\\nonary arteries.\\nIt must not be forgotten that both irregularity and intermittency\\nmay occur in persons otherwise in good health, and continue for a long\\nperiod of time without any evidence of arterial or cardiac disease.\\n(For the varieties of arrhythmia, see The Pulse.)\\nB. Symptoms Referred to the Circulation. 1. Pulsation of\\nthe Arteries. Pulsation of the arteries, especially the carotids, the\\nabdominal aorta, and the brachial arteries, occurs in anaemia, and is\\ncommon in emotional disturbances. Such pulsation, as of the abdomi-\\nnal aorta, may be reflex from organic disease in the vicinity. Similar\\nlocalized pulsation in the innominate arteries may be mistaken for\\naneurism. The pulsation that attends organic heart disease may be\\ndue to hypertrophy of the heart, but is particularly characteristic of\\naortic regurgitation.\\n1 See Transactions of the Association of American Physicians, vol. iii.", "height": "4416", "width": "2572", "jp2-path": "practicaltreatis00muss_0_0647.jp2"}, "648": {"fulltext": "588 SPECIAL DIAGNOSIS.\\n2. Hemorrhages. In the description of valvular lesions it will\\nbe seen that hemorrhages from the lungs occur quite frequently in\\ndisease of the mitral valve. The hemorrhage may be due to conges-\\ntion, to actual rupture of the vessels, or to hemorrhagic infarct. (See\\nPulmonary Hemorrhage.) It may simulate hemorrhage due to tuber-\\nculosis.\\n3. Cyanosis. Cyanosis is a symptom of common occurrence in the\\ncourse of organic heart disease.\\n4. Dropsy. The dropsy of heart disease occurs after failure in\\ncompensation in the course of valvular disease, and in dilatation of\\nthe heart. It may disappear entirely, if the conditions are improved,\\nor become permanent and progressive. In general, it may be said to\\nbe distinctly a phenomenon of mitral regurgitation and secondary\\ntricuspid regurgitation. It occurs in a lesser degree in mitral obstruc-\\ntion, and still less in disease at the aortic orifice.\\nC. Symptoms Referred to the Lungs. The chief subjective\\nsymptom is dyspnoea. Dyspnoea, due to disease of the heart, is clini-\\ncally divided into (1) dyspnoea caused or increased by exertion (2)\\nparoxysmal dyspnoea (3) orthopnoea (4) rhythmical dyspnoea, or\\nCheyne-Stokes respiration. The dyspnoea of effort comes on after\\nthe slightest exertion. In paroxysmal dyspnoea the attack comes on\\nwithout apparent cause. It must be distinguished from the paroxys-\\nmal dyspnoea of uraemia, asthma, or emphysema. The physical signs of\\nlung disease usually point to the latter. The paroxysmal dyspnoea of\\nheart disease is attended by more violent efforts in breathing than the\\nphysical state of the lungs admits, and the difficulty attends both in-\\nspiration and expiration. Wheezing is not so marked as in forms of\\nasthma. There is some obstruction to the outgoing of air but, on\\naccount of air-hunger, all the efforts of the patient are exerted to fill\\nthe chest. In paroxysmal dyspnoea the breathing usually becomes\\nquiet if the patient is placed in a comfortable position, provided there\\nis no lung or pleural complication. The position does not modify the\\nsevere dyspnoea of asthma or emphysema. Orthopnoea has been\\ndescribed previously.\\nCough. Cough is of frequent occurrence in heart disease. The\\ncauses are various. It may be due to pressure upon the bronchus or\\nthe pneumogastric nerves, as in pericardial effusion. It may be due\\nto the passive congestion of the lungs which occurs in failing compen-\\nsation. If hemorrhagic infarcts take place, cough may be present. It\\nattends the bronchopneumonia that follows. In cough from pressure\\nof an aneurism a metallic brassy sound is created. (See The Larynx.)\\nIt occurs in paroxysms, and may be associated with alterations in the\\nvoice. It may result in the expectoration of blood-tinged sputum,\\nwhich may be due to the gradual rupture of the aneurism.\\nD. Symptoms Referred to the Nervous System. The symptoms\\nare usually due to disturbance of the cerebral circulation, because either\\nan insufficient quantity of blood ,or improperly oxygenated blood is\\nsupplied to the brain. Vertigo, faintness, and languor are complained\\nof in the first instance. Dulness, stupor, and moderate delirium (car-", "height": "4412", "width": "2552", "jp2-path": "practicaltreatis00muss_0_0648.jp2"}, "649": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 589\\nbon-dioxide poisoning) may occur in the later stages in the second\\ninstance. In the course of organic heart disease epilepsy or epileptiform\\nconvulsions may arise, on account of embolism or thrombosis. Chorea\\nis of common occurrence, and apparently of the same cause as the\\nheart disease. China may be due to hemorrhage into the brain, to\\nembolism, or to thrombosis. Hemorrhage occurs in patients in whom\\nthere are usually found hypertrophy of the left ventricle, atheroma of\\nthe arteries, and renal disease. Embolism occurs in valvular disease,\\nparticularly in aortic regurgitation and mitral obstruction. We may\\nhave the occurrence of paralysis for the same reason, with or without\\ncoma. The Stokes- Adams syndrome of vertigo, syncope, loss of con-\\nsciousness, and slow pulse pseudo-apoplexy is seen in myocarditis\\nand endarteritis.\\nThrombosis in the course of heart disease is usually due to disease\\nof the bloodvessels rather than to disease of the heart itself, although a\\nweakening of the heart, as in dilatation, is a factor predisposing to the\\ndevelopment of thrombosis.\\nE. Symptoms Referred to the Alimentary Canal. In the\\ncourse of organic heart disease dyspepsia and forms of catarrhal gastritis\\nand enteritis are of common occurrence. Patients complain of various\\nforms of indigestion, or of nausea and vomiting. While water-brash and\\nflatulence are caused primarily by the condition of the heart, they may\\nin their turn cause symptoms of palpitation and cardiac distress. These\\ngastric difficulties are more particularly seen in diseases of the auriculo-\\nventricular valves, and are associated with congestion and secondary\\ncirrhosis of the abdominal viscera.\\nF. Symptoms Referred to the Throat. The patient may com-\\nplain of pain in the throat. This may be paroxysmal, and is some-\\ntimes said to be due to angina pectoris. Hoarseness or modifications\\nof the voice are occasional symptoms of pericarditis. They are of fre-\\nquent occurrence in the course of aneurism due to pressure upon the\\nrecurrent laryngeal nerves.\\nG. Symptoms Referred to the Kidneys. The kidneys are inti-\\nmately related with the heart at a distant point in the circulation, and\\nare frequently the seat of changes due primarily to disease of the central\\norgan of circulation. The changes in the urine will be referred to\\nagain suffice it to say, that in the course of mitral and tricuspid\\ndisease and dilatation, scanty urine, of high color, loaded with urates,\\ncontaining a small amount of albumin, is quite common and indicative\\nof passive congestion of the kidney. It may result in cyanotic indura-\\ntion or interstitial nephritis. On the other hand, the urine may be of\\nlow specific gravity and pale in color. There may or ma3 r not be\\ntraces of albumin. The change is due to a granular, contracted kidney\\nwhich is associated with hypertrophy of the left ventricle and arterial\\nsclerosis. Bloody urine is usually due to renal embolism when it occurs\\nsuddenly in the course of organic heart disease. It may be due to\\nthe emboli that are found in septic endocarditis. Renal disease in all\\nforms may complicate disease of the heart. (See Kidney Disease.)\\nThe Subjective Symptoms of Arterial Disease. The patient\\nmay have symptoms of congestion or of anaemia of the brain. Headache,", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0649.jp2"}, "650": {"fulltext": "590 SPECIAL DIAGNOSIS.\\nvertigo, photophobia, tinnitus, and paresthesia, due to either cause, may\\nprevail. (See also Cerebral Thrombosis.) The diseased vessels prevent\\nthe blood from reaching the extremities, hence they are cold. Pain is\\ncommon only when atheroma or aneurism is present (q. v.). Throbbing\\nor pulsation is complained of. It may be a striking feature of hysteria\\nand neurasthenia. The abdominal aorta is frequently thus affected.\\nThe pulsation may be constant or intermittent. There may be dys-\\npeptic symptoms. The pulsation of the carotids may cause disagree-\\nable sensations in the head, and the beating transmitted to the ear be a\\nsource of extreme annovance.\\nThe Data Obtained by Observation.\\nBefore describing the methods of observation it is well to review\\nsome of the facts of anatomy and physiology essential to the accuracy\\nof any observations.\\nTopographical Anatomy. (Plate XIII.) Outline of Heart\\non Chest-wall. 1\\nTo have a general idea of the form and position of the heart, map\\nits outline on the wall of the chest as follows\\nTo define the base i. e., the part to which its great vessels are\\nattached draw a transverse line across the sternum, corresponding\\nwith the upper borders of the third costal cartilages continue the line\\nhalf an inch to the right of the sternum and one inch to the left.\\n(b) To find the apex, mark a point about two inches below the left\\nnipple, and one inch to its sternal side. This point will be between\\nthe fifth and sixth ribs.\\n(c) To find the lower border (which lies on the central tendon of the\\ndiaphragm), draw a line, slightly curved downward, from the apex\\nacross the bottom of the sternum (not the ensiform cartilage) as far\\nas its right edge.\\n(d) To define the right border (formed by the right auricle), continue\\nthe last line upward with an outward carve, so as to join the right\\nend of the base.\\n(e) To define the left border (formed by the left ventricle), draw a\\nline curving to the left, bat not including the nipple, from the left\\nend of the base to the apex.\\nSuch an outline shows that the apex of the heart points downward\\nand toward the left, the base a little upward and toward the right\\nthat the greater part of it lies in the left half of the chest, and that\\nthe only part which lies to the right of the sternum is the right auricle.\\nA needle introduced in the third, fourth, or fifth right intercostal\\nspace close to the sternum would penetrate the lung and the right\\nauricle.\\nA needle passed through the first intercostal space close to the right\\nside of the sternum would pass through the lung and enter the supe-\\nrior vena cava above the pericardium.\\n1 From Hoi don Landmarks, Medical and Surgical.", "height": "4408", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0650.jp2"}, "651": {"fulltext": "DFSEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 591\\nThe best definition of that part of the precordial region which is\\nless resonant on percussion was given by Dr. Latham years ago in his\\nClinical Lectures. Make a circle of two inches in diameter round\\na point midway between the nipple and the end of the sternum. This\\ncircle will define sufficiently, or for all practical purposes, that part\\nof the heart which lies immediately behind the wall of the chest and\\nis not covered by lung or pleura.\\nValves of the Heart. The aortic valve lies behind the third\\nintercostal space, close to the left side of the sternum.\\nThe pulmonary valve lies in front of the aortic behind the junction\\nof the third costal cartilage with the sternum, on the left side.\\nThe tricuspid valve lies behind the middle of the sternum, about\\nthe level of the fourth costal cartilage.\\nThe mitral valve (the deepest of all) lies behind the third intercostal\\nspace, about one inch to the left of the sternum.\\nThus these valves are so situated that the mouth of an ordinary-\\nsized stethoscope will cover a portion of them all, if placed over the\\nsternal end of the third intercostal space, on the left side. All are\\ncovered by a thin layer of lung therefore we hear their action better\\nwhen the breathing is for a moment suspended.\\nPhysiology. Action of the Heart The heart beats that is, alter-\\nnately contracts and dilates or relaxes 65 to 85 times per minute in\\nan adult. In females, the frequency varies from 75 to 85 in males\\nfrom 65 to 75. With each beat, blood is propelled throughout the\\nvascular channels of the body, and drawn from them to the heart-\\nchamber. The first effect is produced by the contraction of the heart,\\nor the systole the second by the relaxation, or diastole. Other events,\\nas the act of respiration, contribute to the completion of the outflow\\nand inflow of blood, particularly to the latter.\\nThe completion of the act of contraction and the act of dilatation\\nmake up one revolution of cardiac action, or, as it is termed, a cycle-\\nEvents of the Cardiac Cycle. The following events make up the\\ncardiac cycle. The act of contraction is the systolic period of the\\ncycle that of relaxation is the diastolic period. During the systole\\n(1) the ventricles contract (2) the auriculo-ventricular valves close\\n(3) the blood is propelled from the ventricles into the vessels, the\\ncolumns of blood in the aorta and pulmonary artery receive a shock\\nfrom the impact of the new volume of blood, and their bulk increases.\\nThe movement of the blood-wave from this cause and from the con-\\ntraction of the large vascular trunks produces pulsation of the periph-\\neral vessels, which is known as the pulse. The contraction is imme-\\ndiately followed by relaxation the diastole. (1) The blood-columns\\nin the aorta and in the pulmonary artery fall back upon the valves\\nguarding their outlets, the aortic and pulmonary valves. At the same\\ntime (2) the auricles are filled by the blood pouring in from the veins.\\n(3) The auricular muscles contract upon the blood in the chamber,\\ndriving it into the ventricles.\\nThe systolic and the diastolic periods of a cardiac cycle are nearly\\nequal in the length of time occupied in their occurrence. The systolic\\nperiod occurs at the same time, or is synchronous with the apex-beat", "height": "4416", "width": "2556", "jp2-path": "practicaltreatis00muss_0_0651.jp2"}, "652": {"fulltext": "592 SPECIAL DIAGNOSIS.\\nand carotid pulse, and precedes by a fraction of a second the radial\\npulse. It is immediately followed by the diastolic period, which,\\ntherefore, follows the carotid and radial pulse.\\nInspection. The Heart. The Method of Examination. The\\npatient should be stripped, and a good light should fall directly, as well as\\nobliquely, on the surface. The patient can be examined in any position,\\nand indeed for accuracy should be examined both in the upright and\\nrecumbent postures. This is particularly true when the pulse-rate is\\ntaken and when auscultation is practised. The sounds vary frequently\\nin different positions. Some diagnostic significance is attached to\\nIhese variations. It is necessary sometimes to have the patient lean\\nforward, to bring the heart into more immediate contact with the\\nchest- wall.\\nThe examination should not be confined to the heart and vessels.\\nThe reader will remember that in the account of the exterior and\\nof local areas it was pointed out that various abnormal conditions\\nmay be due to disease of the heart. In the examination, therefore,\\nof a case of suspected heart disease, observation is made of the gen-\\neral and of the local color, as of the lips, the fingers, and the con-\\njunctivse, to determine the presence of cyanosis, pallor, or jaundice\\nof the feet, to discover dropsy the face, to note the appearance of\\nthe countenance the neck, to note the state of the vessels the eyes,\\nto note their prominence the thorax, to ascertain the presence of\\ndyspnoea.\\nThe Pr^ecordia. The prsecordia is the region of the chest which\\noverlies the heart. In the study of the appearance of the prsecordia\\nwe observe 1. The degree of prominence or swelling. 2. The impulse\\nand other pulsations. 3. The interspaces. 4. The hue of the surface.\\nThe Prominence. The prsecordia may be unduly prominent in\\nchildren who have had rickets and possibly some cardiac hypertrophy\\nin childhood. It persists in later life. The ribs as well as the soft\\ntissues are prominent. The lower end of the sternum may project.\\nSwelling also occurs in hypertrophy or dilated hypertrophy of the\\nheart, in pericardial effusions, localized pleural effusions and pointing\\nempyema, and in aneurisms in the region of the heart. In pericardial\\neffusion ribs and interspaces project. The latter are full or even with\\nthe surface. The prominence of cardiac disease is observed between\\nthe third and seventh ribs on the left side, and extends from the left\\nnipple to the sternum, and even as far as the right nipple. The dis-\\ntance from the middle of the sternum to the mid-axilla is greater on\\nthe left than on the right side. Local bulging may be seen at the\\napex in cases of aneurism of the heart.\\nThe prsecordia may be sunken. Old pericarditis, but more fre-\\nquently old empyema, causes sinking in of the region. It may be a\\nresult of rickets or of spinal curvature.\\nThe Impulsp:. The normal impulse is that portion of the heart\\nwhich strikes the chest-wall, and is improperly known as the apex-beat.\\nIt is evident in health in the fifth interspace just inside of the mid-\\nclavicular line. It can readily be detected by inspection with a good\\nlight, in patients with moderately thick chest-walls. It is due to the", "height": "4412", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0652.jp2"}, "653": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 593\\nimpulse of the right ventricle, three-fourths of an inch above the apex,\\nagainst the chest-wall when the heart contracts, and hence it is systolic\\nin time.\\nChanges of Position in Health. It is not a fixed point in\\nhealth. It moves with the movements of the body, and hence, when\\nthe trunk is inclined to the left, the impulse falls toward the left\\naxilla as far outward as the mid-clavicular line or even beyond that\\npoint. It moves toward the right and downward in full inspiration,\\nor may disappear entirely toward the completion of that act. It may\\nnot be observed if there is a large amount of subcutaneous fat, or if\\nthe mammary gland intervenes. It becomes more conspicuous at the\\nend of expiration or when the body is inclined forward. In children\\nit is higher (fourth interspace) and more to the left. It is depressed\\nin old people. It must be remembered that in transposition of the\\nviscera the position of the impulse is changed.\\nChange of Position in Disease. The apex-beat, or the lowest\\npoint of impulse, may be displaced or may be absent entirely. These\\nchanges are due either to (a) disease outside of the pericardium, to (6)\\ndisease within the pericardium, or to (c) disease of the heart itself.\\nI. Displaced to the Left. This occurs from (a) Alterations\\noutside of the Pericardium. When the right lung is the seat of exten-\\nsive compensatory emphysema, or the right pleura is filled by a large\\neffusion, the impulse is displaced to the left. On the other hand,\\nfibroid phthisis of the apex of the left lung, or pleural adhesions which\\nhave become attached to the pericardial sac, with, probably, coincident\\npericarditis, pull the heart to the left, thereby changing the position of\\nthe impulse. In disease of the mediastinum the heart is pushed down-\\nward and toward the left. An aneurism, an abscess, or enlarged glands\\nin this situation may invade the normal cardiac territory and cause\\ndislocation of the heart.\\nIn disease of the abdomen the impulse is displaced. If the liver\\nand spleen are enlarged, or the abdomen distended by ascites, the\\ndiaphragm is raised, and, therefore, also the heart. The impulse is\\nthen seen to the left of the normal position, and may be one or two\\ninterspaces higher than normal. A common physical change in the\\nstomach dilatation is a frequent source of displacement of the im-\\njmlse. The dilatation may be temporary from flatulency or may be\\ndue to organic disease.\\n(6) Alterations within the Pericardium. In cases of pericardial\\neffusion the impulse is shifted to the left and upward. It is seen in\\nthe fourth and even as high as the third interspace, and sometimes\\nonly an impulse is noted in the second interspace. This, however, is\\nnot the true apex. Instead, we undoubtedly see in pericardial effu-\\nsions the impulse of the right auricle and the conus arteriosus against\\nthe chest-wall.\\n(c) Diseases of the Heart. The impulse is diplaced to the left in\\ndilatation and hypertrophy of the heart. In the latter it is also dis-\\nplaced downward. It may be as low as the sixth or seventh interspace\\nand extend as far to the left as the anterior axillary or the mid-axil-\\nlary line.\\n38", "height": "4404", "width": "2580", "jp2-path": "practicaltreatis00muss_0_0653.jp2"}, "654": {"fulltext": "594\\nSPECIAL DIAGNOSIS.\\nII. Displaced to the Right, (a) Alterations outside of the Peri-\\ncardium. The heart is dislocated to the right in left pleural effu-\\nsion, and in emphysema of the left lung. We find, moreover, in\\npleural contractions and fibroid phthisis of the right lung the heart\\ndrawn to that side. Under these circumstances the impulse is noted\\neither in the epigastric region, along the margin of the ribs, or even\\nFig. 152.\\nNormal and abnormal impulses.\\n1. Normal position of impulse. 2. Displacement to left and downward. 3. Displacement to left\\nand upward. 4. Impulse from enlarged right ventricle. 5. Displacement to right. 6. Dilated\\nright auricle. 7. Displacement in fibroid phthisis. 8. Impulse of conus arteriosus. (Errata\\n8 should be in 2d interspace parasternal line.) 9. Fibroid phthisis, right lung.\\nto the right nipple-line, in any interspace from the third to the sixth,\\nalong the right edge of the sternum. The impulse in the epigastric\\nregion usually represents the hypertrophied right ventricle, which\\nusually attends the lung-changes that cause displacement of the apex-\\nbeat. The impulse along the right edge of the sternum may be the\\napex-beat, or the right auricle and the right ventricle brought in appo-\\nsition to the chest- wall by the cardiac dislocation. The apex or the tip\\nof the heart is, in all probability, displaced but little beyond the mid-\\nsternal line. (6) The impulse is not displaced to the right in alter-\\nations within the pericardium, or (c) in disease of the heart.\\nIII. Absent. Following the same order, we find that the impulse\\nmay be absent entirely in (a) disease outside the pericardium, on account\\nof which something intervenes between the heart and the chest-wall.\\nHence, in emphysema of the lungs and in compensatory emphysema\\nof the left lung the impulse is entirely effaced in (b) disease of the\\npericardium the impulse is absent when there is large effusion. The\\nabsence here succeeds the dislocation to the left, and with its efface-\\nment the impulse in the second and third interspaces disappears. In\\ndisease of the heart the impulse is absent when the heart is dimin-\\nished in size, as in atrophy, or in myocarditis, or when weakened by\\nfatty degeneration or dilatation\\nThe Extent of the Impulse. In health the impulse is limited\\nin extent to about one square inch. The area of impulse may be in-", "height": "4404", "width": "2552", "jp2-path": "practicaltreatis00muss_0_0654.jp2"}, "655": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 595\\ncreased when the individual leans forward, and at the end of expira-\\ntion. It is more evident when the chest-walls are thin, and less when\\nthey are thick.\\nExtent in Disease. The area of impulse may be increased. The\\ncauses are (a) Diseases outside of the pericardium. The area is in-\\ncreased in chronic phthisis with fibrous adhesions, and in pleural adhe-\\nsions when the lung is drawn away from the surface of the heart. It\\nis increased when the heart is pushed against the chest- wall, as in\\naneurism or in diseases of the mediastinum, from inflammation or\\ncancer, or other mediastinal growth. The impulse is seen not only in\\nthe third and fourth interspaces, but also as high as the second, and is\\nnot limited to the spaces between the sternum and parasternal lines,\\nbut may extend beyond the mid-clavicular line. It may not be systolic in\\ntime only, but diastolic, presystolic, and systolic, and have the appearance\\nof a peristaltic wave from base to apex. The time coincides not only\\nwith contraction of the ventricles, but also of the auricles, and of the\\nclosure of the semilunar valves. (b) Disease of the pericardium tends\\nto increase the area of impulse if moderate effusion is present. It will\\nbe seen as a diffuse wave occupying the second, third, and fourth in-\\nterspaces. It is also increased in pericardial adhesions, without increase\\nin strength, (c) Disease of the heart. The heart must be enlarged,\\nand hence must either be hypertrophied or dilated. The extent of\\nimpulse varies. In hypertrophy the impulse may be communicated\\nto the sternum, so that the lower part heaves with each contraction.\\nIt falls below the fifth interspace and toward the left, particularly if\\nthe left ventricle is the seat of the enlargement. If the right ventricle\\nis hypertrophied, the impulse is very marked in the third, fourth, fifth,\\nsixth, and even the seventh interspaces near the termination of the\\ncartilages, or in the epigastrium along the border of the ribs of the\\nleft side. It may be seen in anaemia in this situation, particularly in\\npersons whose respirations are habitually shallow. Sometimes, when\\nassociated with and displaced by lung disease, it is seen to the right\\nof the xiphoid cartilage.\\nNew Impulse. New areas of impulse, the heart not dislocated,\\narise from enlargement of one of the cardiac chambers or from disease\\nof the bloodvessels. A new area of impulse in the second or third\\ninterspace on the left is from the conus arteriosus, or is due to hyper-\\ntrophy and dilatation of the right ventricle or it may be due to\\nretraction of the lung in that region. It may be due to a dilated right\\nauricle, and is then seen in the fifth right interspace along the sternum.\\nIf the impulse is noted in the course of or adjacent to the aorta, it is\\nindicative of aneurism.\\nThe Interspaces. They are retracted possibly from pericardial\\nadhesions they are full or bulging in effusion. This retraction may be\\nlimited to the apex or may occur in each interspace over the precordial\\nregion. It may occur with the systole or with the diastole. It may\\noccur in hypertrophy of the heart, and is then systolic in time. It is\\nof some, although doubtful, diagnostic significance when it is systolic\\nin time, as it is said to indicate adhesions of the pericardium. The\\ntraction at the systole of the heart causes the interspaces to be drawn in.", "height": "4416", "width": "2548", "jp2-path": "practicaltreatis00muss_0_0655.jp2"}, "656": {"fulltext": "596 SPECIAL DIAGNOSIS.\\nOn inspection behind, a systolic retraction of the interspaces is seen\\nin adherent pericardium, known as Broadbentfs sign.\\nColor of Surface. Only when purulent pericardial effusion is\\nabout to rupture, or an empyema to discharge, do we note redness or\\nother change in hue of the surface of the prsecordia, not observed over\\nthe remainder of the thoracic surface.\\nThe Arteries. By inspection we may be able to determine pulsa-\\ntion or any undue swelling or other change in the course of the vessels.\\nWith the exception of pulsation in the carotids, which may temporarily\\nincrease under excitement, pulsation of the vessels is not usualy seen\\nin health. In old people we can see the pulsation of the aorta (rarely)\\nat the episternal notch, and often in others, the temporals, the innomi-\\nnate, the carotids, the subclavians, the brachial and radial arteries, the\\nabdominal aorta in thin subjects, the femoral arteries and the posterior\\ntibials.\\nThe Arteries ix the Neck. Temporary pulsation of the carotid\\narteries from excitement has been mentioned. It is commonly seen\\nin ansemia, and is quite marked in exophthalmic goitre. It is striking in\\naortic regurgitation. It often attends the vascular changes of old age.\\nIt may be due to atheroma or aneurism. It is always suggestive of\\naortic valvular disease. The innominate artery, as well as the carotids,\\noften pulsates visibly in the neck, and may be so large as to simulate\\naneurism. The subclavians may pulsate for the same reasons they\\nmay also be seen to pulsate if the lungs are consolidated or shrunken\\nby disease. If the patient is young, the throbbing is more likely to be\\nof neurosal or hseniic origin. In later life, if such pulsation is asso-\\nciated with a more or less defined swelling or tumor, with other phys-\\nical signs of aneurism, that disease is doubtless present.\\nThe Thoracic Aorta. An impulse of the thoracic aorta is usually\\nfrom aneurism. The pulsation is not always due to disease. The aorta\\nmay be pushed against the chest- wall, or the lung-structure which over-\\nlaps it normally may be withdrawn.\\nTumor. An enlargement or swelling in the course of the aorta may\\nbe due to aneurism of that vessel. It must be distinguished from\\nthe tumor of mediastinal disease, and of empyema.\\nThe Abdominal Aorta. Pulsation of the abdominal aorta is\\noften the cause of serious distress. The violent throbbing keeps the\\npatient awake at night, and makes him more and more nervous and\\nirritable. The pulsation is usually seen in the epigastrium. It is\\nmore frequent when the vessel is not diseased, in neurasthenic subjects.\\nIt occurs reflexly in patients with dyspepsia or organic disease in the\\nupper abdominal tract. The shock of the pulsation is transmitted to\\nthe hand with considerable violence. The impulse is diffused, but\\nnot expansile.\\nEpigastric pulsation also may be due to the transmission of the im-\\npulse of the aorta by enlargement of the pancreas, or tumors of the\\nstomach or the omentum. The transmitted pulsation is distinct. The\\nimpulse is a transmitted one when the tumor can be defined and when\\na sensation of lifting is transmitted to the hand. The physical signs\\nof aniiirism are absent. If the patient lies on the abdomen, or in the", "height": "4412", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0656.jp2"}, "657": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 597\\nknee-chest position, the tumor falls away from the aorta, and the im-\\npulse is not readily transmitted. Epigastric pulsation is also caused\\nby aneurism of the abdominal aorta. The pulsation is distensile or\\nexpansile, and the aneurismal sac can be defined at times. The other\\nphysical signs of aneurism are usually present namely, thrill, dulness\\nover the tumor, a murmur on auscultation. In these conditions, how-\\never, we cannot always rely on the physical signs alone the history\\nof the subjective symptoms and of disease of other structures must be\\ncarefully inquired into. Aneurism rarely occurs without some evi-\\ndence of arterial sclerosis or some physical effect upon the circulation.\\nAccentuation of the aortic second sound, variations in the femoral\\npulse, high arterial tension, and the usual evidences of sclerosis favor\\naneurism. While functional epigastric pulsation usually occurs in\\nneurotic subjects, and, hence, in the earlier periods of life, yet such\\npulsation is frequently seen at the climacteric and in the neurasthenia of\\nold age. Late in life, with such impulse, fibrous thickening about\\nthe pylorus, or contraction of the omentum, may easily be confounded\\nwith malignant disease. Cancer of the stomach has been diagnosticated\\nunder these circumstances when the pulsation was simply reflex from\\nchronic gastritis. Some time ago a private patient in the Presbyterian\\nHospital had extreme pulsation of the abdominal aorta, with great\\nlocal discomfort, on account of the throbbing. She was sixty-five years\\nof age, and had within the past two years nursed her son through\\ntuberculosis. She failed in health, and came to the hospital emaciated,\\nwith some chronic gastritis and diarrhoea. On examination, a distinct\\ntumor was felt above the umbilicus, which she had been told was due\\nto carcinoma. It was hard and painless the physical signs of aneurism\\nwere not present the pulsation was extreme. A second tumor, not so\\nlarge, was felt in the right hypochondriac region. Both tumors were\\ndull upon percussion and surrounded by tympanitic areas. They were\\nalso movable. While it was impossible to be sure of the nature of the\\ntumors, it seemed to me they were tuberculous, or simply fibrous, and\\nwould not influence the patients immediate welfare. Under treat-\\nment, the pulsation disappeared the gastro-intestinal symptoms were\\nrelieved entirely the patient rapidly gained in weight and strength\\nthe tumors continued, but they are not so distinctly outlined because\\nthe previously scaphoid abdomen has become distended (two years\\nunder observation). The questions arose for decision Was the epi-\\ngastric pulsation due to a throbbing aorta or transmitted by an ob-\\nscurely defined probable tuberculous mass in that region No doubt\\nit was the vessel alone that caused the impulse. The diagnosis must\\nbe made by carefully weighing all concomitant circumstances and phe-\\nnomena that surround cancer. (See Symptomatology of Morbid Pro-\\ncesses.) Fecal accumulations in the colon may be made to heave by\\nthe beat of the aorta and cause exaggerated epigastric impulse. The\\nbowels must be emptied before definite conclusions are arrived at.\\nAn epigastric impulse due to one of the above-mentioned causes\\nmust not be confounded with the impulse of hypertrophy of the right\\nventricle, or to the shock of the hypertrophied heart transmitted to\\nthe left lobe of the liver. In hypertrophy of the right ventricle or", "height": "4412", "width": "2568", "jp2-path": "practicaltreatis00muss_0_0657.jp2"}, "658": {"fulltext": "598 SPECIAL DIAGNOSIS.\\ndislocation of the heart from disease within the chest, the impulse may\\nbe seen to the right or left of the xiphoid cartilage. The symptoms\\nand signs of right-ventricle hypertrophy explain the pulsation.\\nThe Smaller Arteries. By inspection of the arteries beyond\\nthe abdominal aorta we can often recognize more distinctly the condi-\\ntion known as arterio-sclerosis. Examination of the femoral, poplit-\\neal, tibial, brachial, and radial arteries reveals dilated, tortuous, hard,\\noften pulsating vessels in endarteritis. Elongation of the artery, so\\nthat instead of a straight tube it becomes a sinuous canal, turning\\nand twisting at short intervals, is seen. (See Arterio-sclerosis.) But\\npulsation of the above-mentioned peripheral arteries may be due to\\nother causes. In hypertrophy of the left ventricle arterial pulsation\\nis prominent, although more marked in the vessels near the heart, as\\nthe carotids. In regurgitation at the aortic orifice, pulsation is also\\nfrequently seen.\\nCapillary Pulse. The capillary pulse is seen under the finger-\\nnails or in the skin after hyperemia is induced by firmly stroking the\\nskin with the nail. It may be seen inside the lips, if a piece of glass is\\npressed against them. There is rhythmical pulsation of the capillaries,\\nfrom which the surface becomes alternately white and red. It is a\\nsign of aortic insufficiency.\\nThe Veins. Diseases of the veins are largely surgical and do not\\nfrequently come under the notice of the physician. Alterations in the\\nveins from physical causes in the circulation, local or general, are of\\nfrequent occurrence, and are of the greatest diagnostic significance.\\nThe venous phenomena are physiological and pathological evidences\\nof the circulation of the blood in the veins.\\nExamination is limited largely to the jugular veins in general affec-\\ntions of the circulation to other subcutaneous veins in addition in\\nlocal affections. The examination is made by inspection, to determine\\nthe size and degree of pulsation of the veins by palpation, to confirm\\nthe results of inspection and to determine the presence of a thrill by\\nauscultation, to determine the presence of murmurs.\\nBy inspection we note the presence of A. Enlargement of the veins.\\nThe change in size may be general or local. In both instances there\\nis interference with the venous return of blood.\\n1. General enlargements may be observed in all the veins, but\\nis more readily studied in the jugular reins of the neck. Associated\\nwith the enlargement, general venous engorgement is observed, and\\nhence oedema (which obscures external veins), cyanosis, effusions in\\nserous cavities, and congestion of internal organs attend the pathologi-\\ncal venous phenomena. It must follow that a central disturbing influ-\\nence upon the circulation is present, and so we find interference with\\nthe circulation in the right heart to be the causal factor. This inter-\\nference is due to dilatation of the right auricle and ventricle, which in\\nturn may have arisen from valvulitis, myocarditis, pericarditis, or, on\\naccount of increased pulmonic blood-pressure, from emphysema and\\nother pulmonary obstructions. In rare instances pressure upon the\\ncavae by a mediastinal tumor may cause general over-fulness of the\\nveins.", "height": "4404", "width": "2564", "jp2-path": "practicaltreatis00muss_0_0658.jp2"}, "659": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 599\\nThe jugular veins, both internal and external, are seen to be dis-\\ntended, even in stout people. The observation can better be made by\\nviewing the head when it is turned to the opposite side from the vein\\nwhich is under examination. The external jugular can almost always\\nbe seen the internal jugular frequently when engorged. They may\\nalso be felt under these circumstances. The position of the veins can\\nbe more readily distinguished by observing their relation to the sterno-\\ncleido-mastoid muscle. The inter oal jugular vein is seen in the inter-\\nsterno-cleido-mastoid fossa, just behind the sterno-clavicular articula-\\ntion. Here the jugular bulb is seen, and at this point in the veins\\nthe bulbar valves are situated. When abnormally full it may project\\nbeyond the surface and rise one-fourth or one-half inch above the\\narticulation. The over-fulness is more marked in the dorsal than in\\nthe upright posture.\\nLocal Enlargements. Local increase in fulness of the veins is due\\nto narrowing or closure of the venous trunk by pressure or by throm-\\nbosis. A mediastinal tumor pressing upon the cava will cause abnor-\\nmal fulness of the jugulars. The veins of the scalp become distended\\nand tortuous in thrombosis of the longitudinal sinus. Enlargement\\nof the veins of the arm or leg points to compression or thrombosis\\nof the axillary or femoral vein respectively. The enlargement is\\nassociated with oedema of the respective extremity. Enlargement of\\nthe superficial veins of the thorax is seen in intrathoracic pressure\\nfrom tumor or aneurism, rarely in dilatation of the heart. En-\\nlargement of the veins of both legs may be due to obstruction of\\nthe vena cava or both iliac veins. The latter is liable to occur in\\npelvic tumors. When there is engorgement of the portal vein collat-\\neral circulation is frequently carried on through the abdominal veins.\\nThe veins are enlarged and, in some instances, the veins about the\\nnavel enormously distended, because of a permanent patulous umbilical\\nvein. The crown of veins caput Medusae is significant of cirrhosis\\nof the liver and of pyelo-thrombosis. Enlargement of the veins of\\nthe extremities, from the causes above mentioned, must not be con-\\nfounded with the unilateral or bilateral varicosity that occurs during\\nand after pregnancy, after prolonged intra-abdominal pressure from\\nother causes, or in inflammation of the veins in the course of septic\\ndiseases, as typhoid fever.\\nB. Pulsation of the veins. The circulation in the veins differs from\\nthat in the arteries. The blood-flow is continuous. Two circumstances\\nmodify it respiratory movements and cardiac action.\\nPulsation due to Respiratory Movements. The modification is par-\\nticularly seen in the veins of the neck. During inspiration all of the\\nveins empty rapidly, while in forced expiration, or with strong effort,\\nas seen in coughing, the discharge from the veins is checked and\\nthey become full and even over-distended. When the fulness of the\\nveins is normal the respiratory alterations are not observed, except\\nthe swelling that occurs in severe coughing, as in whooping-cough.\\nWhen they are abnormal, as from right-sided cardiac dilatation (q. v.),\\nthey show a corresponding to-and-fro swelling synchronous with respi-\\nratory movements. Upon coughing, the jugular bulb may appear as", "height": "4416", "width": "2568", "jp2-path": "practicaltreatis00muss_0_0659.jp2"}, "660": {"fulltext": "600 SPECIAL DIAGNOSIS.\\na rounded pulsating bunch between the heads of the sterno-mastoid\\nmuscle. The internal jugular may also swell and contract. Increased\\npulsation with fulness of the veins is seen during the labored expira-\\ntion of asthma and emphysema.\\nAlteration of the respiratory movements of the veins is observed in\\ncases of pericarditis or of mediastino-pericarditis. Normally the vessels\\nare drawn upon and bent during the act of inspiration inspiratory\\ncollapse. In the above pathological conditions they swell up in inspira-\\ntion and empty during expiration, directly opposite to the normal state.\\nPulsation due to Cardiac Movements. The Venous Pulse. The car-\\ndiac movements also modify the movements of the blood in the veins.\\nThey cause rhythmical pulsation, or the venous pulse. This may be\\ncommunicated from the carotids underneath or occur in the veins.\\nThe so-called true and false pulses are thus produced. The true venous\\npulse is divided into the (1) negative and (2) positive pulse, the former\\nbeing the pulse of health, the latter the pathological venous pulse.\\n1. The normal or negative venous pulse is so designated because it is\\nnot due to positive action of the heart, causing retrogression of blood.\\nIt can be demonstrated by pressure of the finger on the middle of the\\nveins. Pulsation ceases below because the blood does not regurgitate\\nfrom the heart it does not pulsate above, or the pulsation lessens\\nmaterially, indicating non-transmission from the carotid. The negative\\nvenous pulse is presystolic in time, and can only be seen in the external\\njugulars. The vein collapses during the systole and distends or pul-\\nsates before the systole, hence is presystolic. This may be observed\\nby inspection, keeping in view also at the same time the apex or\\ncarotid pulse. The systolic collapse occurs quickly. The presystolic\\npulsation follows slowly, with an appreciable interval between the\\ntwo. The presystolic distention occurs during the time that the auri-\\ncle is filled with blood the collapse occurs w T hen the auricle is empty\\nthat is, during the ventricular systole. When the auricle is dis-\\ntended the flow of blood from the veins is impeded, and hence the\\njugulars are overfilled. When the auricle is empty the flow of blood\\nfrom the veins is favored, hence the vein collapses (the systole).\\nDiagnosis It may be distinguished from pulsation in the artery\\nby the time, by the greater size of the surface-pulsation on account\\nof the greater size of the vein, by the impression of undulation rather\\nthan shock received by the finger, by the impression of passive force\\nrather than of active power. Sometimes it is extremely difficult to\\nrecognize the normal or negative venous pulse on account of undula-\\ntions in the veins produced by the blood-flow and transmitted carotid\\ni mpulse.\\n2. The positive venous pidse is systolic in time. It is due to positive\\naction of the heart. It is pathognomonic of tricuspid regurgitation\\n(q. v.). When the right ventricle contracts the regurgitant blood-\\nwave is transmitted into the cava through the incompetent valves.\\nIt appears first in the internal jugulars or their bulbs, because of the\\ndirect course of the innominate and right jugular from the cava. Sub-\\nsequently the left may become affected. If the valve in the vein is\\ncompetent, the systolic regurgitant wave is seen there only. The pul-", "height": "4400", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0660.jp2"}, "661": {"fulltext": "DISEA SES OF HEART, BL OD VESSELS ANB MEDIA STIN U3I. 601\\nsation of the enlarged bulb is seen in the inter-sterno-cleido-mastoid\\nfossa. Usually the valve is insufficient, or rapidly becomes so, and\\nthe systolic back-wave therefore extends upward. The same wave is\\ntransmitted to the viens of the liver, causing systolic swelling and dias-\\ntolic collapse of the liver. These conditions are produced, as pre-\\nviously mentioned, in right-sided dilatation of the heart, providing\\nthere are moderate force and sloAvness of the heart s action. When\\nthe heart becomes very weak and rapid the pulsations disappear.\\nDiagnosis 1. The negative, true, or normal pulse is distinguished\\nfrom the pathological or positive pulse, and from the transmitted pul-\\nsation, by its time. It is timed by the apex-beat, or the carotid pulse\\nof the opposite side. The negative pulse (normal) is presystolic, the\\ncollapse of the vein systolic the positive pulse (pathological) is sys-\\ntolic in time. The patient should hold his breath, as increased respi-\\nratory movement will modify the venous pulsation. 2. The imparted\\nor false pulse is transmitted from the carotids, and can be recognized\\nby stopping the flow of blood by pressing the finger or barrel of the\\nstethoscope on the vein in the middle of the neck, after it has been\\nemptied by pressure upward. If the pulsation is communicated (false\\npulse), the vein remains empty in the portion nearest the heart, and\\nfills up in the peripheral portion, while the pulsation ceases toward the\\ncentre (below) and increases in the periphery (above the finger). If\\nthe carotid artery is pressed upon as near the heart as possible, the\\ntransmitted pulse will cease. In the positive pulse the portion near\\nthe heart slowly fills from below upward.\\nIn congenital heart disease with patulous foramen ovale the positive\\nvenous pulse may sometimes be seen, but is extremely rare.\\nDiastolic collapse is seen in pericarditis, as observed by Friedreich.\\nThe collapse occurs at the time of the cardiac diastole. It is distin-\\nguished from the true pulse as follows compress the jugular vein,\\npulsation ceases above and below the seat of compression.\\nPulsation of other veins. Quincke has described venous pulse in\\nthe hand and back of the foot, with the capillary pulse in aortic re-\\ngurgitation and in anaemia. It is probably only the arterial pulse\\npropagated through the capillaries. The positive pulse may be seen\\nin the veins of the face, in the cutaneous veins of the arm and hand,\\nand in the superficial mammary veins, and in the veins of the legs.\\nPalpation. The Heart. Palpation confirms inspection as to the\\nshape of the prsecordia, the position and the extent of the impulse, and\\nthe condition of the intercostal spaces. In addition, we determine by\\npalpation the character and strength of the impulse, and the presence\\nor absence of valve-shock and of thrills or of friction. Palpation also\\nreveals oedema of the surface and fluctuation.\\nThe Impulse. In a normal chest with moderate walls a slightly\\nprolonged, moderately strong shock is transmitted to the hand when\\nplaced over the prsecordia. It is synchronous with the cardiac and\\nprecedes the radial pulse. It is, therefore, systolic in time. It is\\nstronger when the patient leans forward, exhales freely, removing the\\nlung from the surface, and when the chest-walls are thin it is weaker\\nin opposite conditions.", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0661.jp2"}, "662": {"fulltext": "602\\nSPECIAL DIAGNOSIS,\\nCharacter and Strength of Impulse. A. Strength increased. 1.\\nOveraction. In the violent action of the heart that attends palpita-\\ntion, and in the increased action in the early stages of fevers or of in-\\nflammation, the force of the cardiac impulse is much increased. 2.\\nDisease, (a) Alterations outside of the pericardium. Increase in the\\nextent of the impulse is attended by increased strength when the heart\\nis hypertrophied or the lung retracted, (b) Alterations within the peri-\\ncardium. In pericardial adhesions the heart is held more firmly\\nagainst the wall and may give the appearance of strength to the im-\\npulse, (c) Disease of the heart. True increase in force of the impulse\\nis seen in disease of the heart. When the organ is hypertrophied or\\nthe seat of dilated hypertrophy the force of the impulse is increased,\\nsometimes to an almost unbearable degree. Uplifting of the precor-\\ndial area or even of the lower half of the anterior part of the chest is\\nseen. The hand or the head laid over the heart is forcibly lifted with\\neach systolic contraction. This great force is most pronounced in\\nthe enormous hypertrophy that occurs in cases of aortic obstruction.\\nIt is the impulse and force of the so-called cor bovinum. In dilatation\\nthe impulse is diffused and wavy.\\nFig. 153.\\nAbnormal palpable impulse and thrills.\\n1. Diastolic impulse palpable from closure of pulmonic valve. 2. Presystolic impulse in mitral\\nobstruction in third, fourth, and fifth interspaces. 3. Thrill at aortic orifice systolic, obstruction\\ndiastolic, regurgitation. 4. Thrill at pulmonary orifice systolic, obstruction diastolic, regurgi-\\ntation. 5. Thrill at mitral orifice systolic, regurgitation diastolic, obstruction presystolic, ob-\\nstruction. 6. Thrill at tricuspid orifice.\\nB. Strength lessened. This occurs from causes which diminish the\\nextent of the impulse or cause it to be absent entirely, as when mate-\\nrial intervenes between the heart and the chest-wall, or the heart\\nis weakened by disease. Hence (following the classification above) (a)\\nin emphysema of the lung (b) in pericardial effusions (c) in fatty\\nheart, or myocarditis, in dilatation, and simple weakness of the heart,\\nthe strength of impulse is lessened.\\nValve-shock. The shock of the closure of the valves can be felt\\nby the hand when placed evenly over the prsecordia. The shock from", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0662.jp2"}, "663": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 603\\nthe pulmonary and aortic valves is best transmitted. It is felt most\\ndistinctly in persons with thin chest-walls, and when there is height-\\nened tension either in the aorta or pulmonary artery. The shock\\nfollows the impulse. It may be localized more accurately with the\\nfinger-tips in the third or fourth interspace along the left edge of the\\nsternum. The shock of the auriculo- ventricular flaps is also trans-\\nmitted. The shock is synchronous with the first sound. It is felt in\\nthe left fourth interspace near the sternum, sometimes over it. It is\\ndue to dilatation of the heart, and is more readily felt in thin-chested\\npersons.\\nThrills. A thrill is produced when the blood is thrown into\\nvibration by passing over a rough surface. It may be created with\\nthe systole or during the diastole. It can only be created at the time\\nblood is passing through the orifices. 1. The most common seat of\\nthe thrill is the apex. If the hand is placed in close proximity to the\\nsurface of the chest at this point, a vibration or tremor is transmitted\\nto it in most cases of mitral obstruction. The blood is passing from\\nthe auricle to the ventricle as this takes place before the systole, the\\nthrill is felt before the impulse or carotid pulse. It is presystolic in\\ntime. It is sometimes difficult, however, to distinguish it from the\\nimpulse. Its character cannot well be described. The hesitating,\\njogging maimer of the vibrations or the thrill is clearly transmitted to\\nthe hand. 2. The next most frequent seat of thrill is the second costal\\ncartilage on the right. Here the thrill or vibration is systolic in time\\nand is caused by obstruction at the aortic orifice. It may be felt away\\nfrom the heart, in the aorta, or in the carotids. The aortic cusps are\\nthickened, contracted, and stiffened by a sclerotic endocarditis, or the\\norifice is occluded by valvulitis. 3. Sometimes a thrill is felt at the\\napex with the systole -first sound. This occurs rarely, but must not\\nbe confounded with the before-first-sound thrill. It is never so dis-\\ntinct, and is not made up of a series of vibrations. It is due to re-\\ngurgitation at the mitral orifice. 4. Rarely a thrill is felt at the second\\ncostal cartilage on the right, with the second sound. It may be felt\\nalong the course of the sternum also, and is due to regurgitation\\nthrough the aortic orifice. The systolic thrill must not be confounded\\nwith the thrill elicited over the aorta or at the aortic cartilage, which\\nis due to aneurism. 5. At the second costal cartilage on the left a\\nthrill is sometimes felt. It is systolic in time and is not transmitted.\\nIt is due to obstruction at the pulmonary orifice. 6. At the lower\\nportion of the sternum a thrill systolic in time is also felt, due to tri-\\ncuspid regurgitation. Care must be taken not to confound the above-\\nmentioned thrills with those due to aneurism. (See Aneurism.)\\nPericardial Friction. In addition to the thrills, a friction or\\nto-and-fro rubbing is transmitted to the hand in cases of pericarditis,\\nin the first stage. The friction may be felt all over the heart region,\\nbut is pronounced in the third or fourth interspace. It may be de-\\ntected on slight pressure or only when the tips of the fingers are pressed\\nfirmly against the interspaces.\\nIt is important to remember that the position of the patient weakens\\nor modifies the thrill or friction. When the patient is lying down it", "height": "4408", "width": "2580", "jp2-path": "practicaltreatis00muss_0_0663.jp2"}, "664": {"fulltext": "604 SPECIAL DIAGNOSIS.\\nmay not be felt. The upright posture or leaning forward makes it\\nevident, and hence the patient should be instructed, if possible, to\\nassume this position in the examination.\\nThe Arteries. The results of inspection are confirmed. In addi-\\ntion, the artery is examined, to determine its tension, the character of\\nthe coats, and the presence of thrills. Pulsation of organs. It is said\\nthat in aortic regurgitation an arterial liver-pulse, similar to the venous\\nliver-pulse, can be felt when the hands are placed over that organ.\\nSimilar pulsation may be felt in the spleen.\\nIn examining the arteries it is important, as will be detailed in the\\nchapter devoted to the pulse, to compare the arteries of the two sides.\\nOften the pulse-wave is found to be unequal in force, in volume, and\\nin time. This is almost always due to obstruction to the passage of\\nthe blood. When not due to endarteritis or to aneurism, it is due to\\nthe pressure of a tumor on the vessel somewhere in its course. A\\nthrombus or embolus in the artery may likewise cause the condition.\\nA difference in the radial and the femoral pulse points to obstruction\\nin the thoracic or abdominal aorta. Anatomical variations must be\\nremembered.\\nThe Pulse. The pulse is an index to the force, frequency, and\\nrhythm of the heart s action and of the pressure, or tension, which is\\nmaintained in the arteries.\\nGeneral Observations. The frequency of the pulse before birth\\nis from 120 to 140 beats in the minute. From this time it is dimin-\\nished in frequency up to adult life, 72 being then accepted as an aver-\\nage the number of beats, however, is often under 72, and sometimes\\nover that. In old age the pulse-rate is again increased. Sex has some\\ninfluence. The rate is slightly higher in females than in males of the\\nsame age.\\nThe frequency of the pulse is subject to diurnal variations, at times\\ncorresponding with the diurnal rise and fall of temperature. The rate\\nwill, therefore, be highest in the afternoon and evening and lowest in\\nthe early morning hours.\\nThe position of the body has also a modifying influence. The pulse\\nis more frequent when a person is standing than when he is sitting,\\nand more frequent when he is sitting than when he is lying doAvn.\\nWalking, running, bodily and mental exertion, fear, and excitement\\nall tend to accelerate the pulse.\\nDuring and for one or two hours after a meal the pulse-rate is higher,\\nespecially if an alcoholic or other stimulant, such as coffee, has been\\ntaken.\\nHow to Take the Pulse. To make a correct count of the fre-\\nquency of the pulse, the conditions just mentioned, as normally modi-\\nfying its rate, should be borne in mind. If the object of the count\\nis to determine the rate which is normal for a particular individual,\\nseveral counts will be necessary at different times and under different\\nconditions, such as sitting and standing. The best time for the physi-\\ncian to take the pulse will have to be determined by his own judgment\\nin each case. If the patient comes to his office and is excited by the\\nprospect of an examination, it will be well to wait until he becomes", "height": "4396", "width": "2560", "jp2-path": "practicaltreatis00muss_0_0664.jp2"}, "665": {"fulltext": "DfSEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 605\\ncalm. On the other hand, if he is calm at first, a count at that time\\nis to be preferred to one made after the patient has been disturbed by\\na physical examination. In the same manner, on visiting a patient at\\nhis house, the judgment of the physician must decide whether to count\\nthe pulse immediately on his arrival or to postpone it until, by general\\nconversation, all apprehension and alarm on the part of the patient\\nhave been allayed. In general, it may be said that if the physician\\nfinds upon his arrival that the pulse is more frequent than the condi-\\ntion of the patient would lead him to expect, he should wait a while,\\nendeavor to find out whether anything has served temporarily to dis-\\nturb the circulation, and then make the count when the conditions are\\nmost favorable. Some patients are so nervous that the mere act of\\nplacing the finger upon the wrist sends the pulse-rate up ten or twenty\\nbeats in the minute. In such cases an effort should be made to obtain\\na count without the patient s knowledge by observing the pulsations\\nof the temporal or carotid. In other cases it may be well to entrust\\nthe counting of the pulse to the nurse or to a member of the family.\\nIn infants and young children, count while they are asleep. In\\nfebrile conditions the count is more likely to be too high than too low.\\nIn hospital practice, or when a nurse is constantly in attendance, the\\npulse and respiration should be taken at the same time as the temper-\\nature. But the nurse must be warned against taking them under\\ndissimilar conditions upon successive days. For example, the pulse\\nshould not be taken one day while the patient is lying down, quiet\\nand comfortable, and compared with the count of the next day when\\nthe patient is sitting up or has jnst had some hot liquids, or a spell of\\ncoughing, or been subjected to some other disturbing influence.\\nThe preferable position is the recumbent one in the case of patients\\nin bed, and in the sitting position in those not confined to bed. Care\\nshould be exercised in all cases to see that the patient s position is\\ncomfortable and that nothing obstructs the artery or interferes with\\nthe unimpaired flow of the blood.\\nThe wrist is the place usually selected at which to feel the pulse.\\nAt this point the radial artery passes over the radius, and can readily\\nbe compressed and its character made out. An old-fashioned rule\\nprescribes that three fingers should be applied to the artery, the index-\\nfinger of the physician being nearest the heart. In particular cases it\\nmay be advisable to count the pulse at the temporal or carotid artery.\\nThe fingers should be applied so that the beats can be most distinctly\\nfelt. The beats are counted for fifteen seconds by the second hand of\\na watch when only an approximate count is desired, or when time is\\na factor, and then multiply by four. It is better to count the pulse\\nfor half a minute, and still better for a full minute.\\nThe arteries of the two sides must be compared. Difference in the\\nforce, volume, and time may be due to the anomalous distribution of\\narteries. In disease, it may occur in aneurism and atheroma, in press-\\nure on the trunk from external disease, and in embolism and throm-\\nbosis.\\nCondition of the Walls of the Artery. The condition of\\nthe artery is often of more importance than the pulse-rate. A healthy", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0665.jp2"}, "666": {"fulltext": "(306 SPECIAL DIAGNOSIS.\\nradial artery, in a person not advanced in years, can be compressed\\neasily against the radius without the finger being able to differentiate\\nthe artery from the other tissues. But as age advances, and as the\\nresult of certain constitutional diseases syphilis, gout, chronic endar-\\nteritis, alcoholism, and others the artery tends to become thicker, so\\nthat in pronounced cases it cannot be obliterated, but is rolled like a\\ncord or pipe-stem between the compressing fingers and the bone.\\nSmall specks or plates of atheroma, feeling like hard particles in the\\ncoats of the artery, may be detected. The artery has a beaded feeling.\\nFatty degeneration of the organs is likely to occur when the arteries\\nare in this condition, and apoplexy is to be feared.\\nTension. Tension is the word used to express the degree of blood-\\npressure that is, of distention of the arteries. Normally, the pulse\\nnearly or quite subsides between the beats, but little pressure being\\nrequired to obliterate it. High tension may be said to exist when the\\nartery remains continuously full between the beats (Broadbent). It is\\nproduced by plethora increased heart-action contraction of the\\narterioles, as by chill and obstruction in the capillaries. The condi-\\ntions which bring about obstruction in the capillaries in the order in\\nwhich they are enumerated by Broadbent are 1. Age. The liabil-\\nity to high arterial tension increases with the age, especially after\\nmiddle-life. 2. Heredity. There is in some families a marked ten-\\ndency to high tension. The younger members show its effects in head-\\naches and bilious attacks, while the older ones develop chronic heart\\ndisease and apoplexy. 3. Disease of the kidney. Parenchymatous,\\nbut especially interstitial nephritis, is associated with high arterial\\ntension this, with accentuation of the aortic second sound, is one of\\nthe early and, therefore, one of the most valuable indications of chronic\\nBright s disease. 4. Gout. Gout and lithsemia are almost always\\naccompanied by high arterial tension. 5. Diabetes in old persons\\nassociated with gout. 6. Lead-poisoning. 7. Pregnancy. 8. Anaemia.\\n9. Emphysema and chronic bronchitis. 10. Mitral stenosis.\\nAs regards arterial tension in persons presenting signs of angina\\npectoris, Sansom asserts that if the tension is increased, even though the\\nsigns are not typical, the fear, present or remote, of true angina is justified.\\nOn the other hand, if there is persistent low tension, especially during\\nthe painful crisis, it is almost certain the affection is a false angina.\\nLoiv tension of the pulse is characterized by a softness and a com-\\npressibility in excess of the normal. This, like the high tension pulse,\\nmay be a family peculiarity. It is met with in conditions of great\\ndepression and exhaustion, and wherever there is a marked cardiac\\nweakness. It is most common in fever, particularly in typhoid, in\\nwhich also an accompaniment of low T -tension pulse namely, dicrotism\\nis met with in a marked degree. Pat persons are apt to have low-\\ntension pulses, and it may occur in any person temporarily under the\\ninfluence of external warmth and moisture, such as a hot bath, or after\\ntaking hot drinks, or under the influence of depressing emotions, and\\nafter diarrhoea, or copious urination.\\nVolume. The volume of the pulse should be noted. It is usually\\nlarge in conditions of pyrexia and when the tension is low. A small", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0666.jp2"}, "667": {"fulltext": "DISEA SES OF HE A RT, BLOOD VESSELS A NL MEDIA STIN UM. 607\\npulse is met with in many conditions other than weakness of the\\nheart-muscles. In aortic stenosis the pulse is small and in mitral\\nstenosis it is small, of high tension, and frequently irregular. In gen-\\neral contraction of the arterioles, as happens under the influence of a\\nchill, the pulse is small. In Bright s disease it is sometimes very\\nsmall, slow, and hard. Some care will be required to differentiate such\\na pulse from a weak pulse. In acute peritonitis the pulse is apt to be\\nsmall and hard.\\nRhythm. The rhythm of the pulse is of diagnostic importance.\\nIn health one beat succeeds another at equal intervals of time, and the\\nsuccessive beats are of the same force and quality. Here, also, how-\\never, as in other conditions, there are variations within physiological\\nlimits. In some persons the pulse-rate is somewhat accelerated during\\nrespiration and becomes slower in the pauses which follow breathing.\\nIn disease, disturbance of the rhythm occurs as intermission or as\\nirregularity. Intermission signifies a dropping of a pulse-beat sev-\\neral normal pulse-beats succeed each other, and then the pulse is absent\\nduring the time occupied by one or two beats. The intermission may\\noccur at regular or at irregular intervals that is to say, every third,\\nfifth, or sixth beat may be wanting, or the intermission may be irregu-\\nlar now a second, the next time a fifth or a third beat being absent.\\nMoreover, the intermittent pulse may be constant, or it may, and more\\nfrequently is, only occasional. It is not characteristic of any one dis-\\nease or condition, and it may exist without the patient s knowledge\\nand without producing any perceptible effect upon his health. Some-\\ntimes it is met with in a fatty heart, and this disease may be suspected\\nif the intermittent pulse is associated with a weak first sound of the\\nheart without valvular lesion, and evidences of failing circulation, such\\nas oedema of the feet. More frequently, however, the intermittency\\nis a symptom of nervous depression, or is caused by tea, coffee, tobacco,\\nor digitalis. So far as prognosis is concerned, it is much less serious\\nthan irregularity. Broadbent says he has met with it at the age of\\neighty, when it was known to have existed for forty years.\\nIrregularity is characterized by differences in time, force, or volume\\nof successive beats. A full beat is succeeded by another, which is\\nsmaller and weaker, or successive beats occur at irregular intervals\\nof time. Irregularity may or may not be associated with intermission.\\nIn advanced cases of mitral stenosis the pulse is both irregular and\\nintermittent. The irregularity may be habitual or occasional the\\nformer is due most frequently to mitral lesions, but sometimes occurs\\nwithout assignable cause, and is attributed to disturbance of the nerve-\\nsupply the latter is due to digestive disturbances and to the effect of\\nnicotine and digitalis. Irregularity is not incompatible with health,\\nbut is much more likely to be of serious import than intermission. It\\noccurs in diseases of the brain, in degeneration of the heart as well as\\nin valvular lesions, and in grave cases of febrile diseases, such as\\ntyphus and typhoid, when the heart-muscle is involved. Some cases\\nof Graves disease are characterized by great irregularity instead of\\nexcessive rapidity of the pulse. Irregularity may occur in rheumatoid\\narthritis also, though increased frequency is the rule.", "height": "4416", "width": "2556", "jp2-path": "practicaltreatis00muss_0_0667.jp2"}, "668": {"fulltext": "\u00c2\u00a308 SPECIAL DIAGNOSIS.\\nFrequency. The frequency of the pulse is of aid in diagnosis.\\nIncreased frequency. 1. The pulse is increased in frequency in all\\nthe febrile diseases, and generally in the proportion of eight to ten\\nbeats for each degree of rise in temperature above 98.3\u00c2\u00b0. But there\\nare important exceptions. In typhoid fever the pulse is slower in pro-\\nportion to the temperature and the gravity of the disease than in most\\nof the other acute febrile diseases. It may not beat above 85 in mild\\ncases, and in severe cases frequently does not rise above 100. Conse-\\nquently a pulse of 120 is of much graver import than it would be in\\nother diseases. It may be more frequent during convalescence than\\nduring the febrile stage. This pulse-rate helps to differentiate it from\\ntuberculosis, malignant endocarditis, and septicaemia.\\n2. The pulse of scarlet fever often aids materially in diagnosis. A\\npulse of 120 to 160 is the rule from the development of the sore-throat\\nto the completion of the eruption. In measles, rubella, diphtheria,\\nand follicular tonsillitis it is much slower during the early stages.\\n3. In Gh aves disease great frequency of the pulse is the essential\\nand most constant symptom of the disease. The pulse may be con-\\nstantly considerably over 100, and in attacks of palpitation 200 or\\nmore. In these attacks there may or may not be precordial distress\\nand mental anxiety. Here belong the cases described as paroxysmal\\nhurry of the heart, etc., the thyroid and ophthalmic symptoms being\\nabsent.\\n4. Cases have been reported of extreme frequency of the pulse\\n(160 to 240) without palpitation, dyspnoea, or any signs of Graves dis-\\nease. Some of the patients have been able to perform much bodily\\nand mental labor, notwithstanding that the rate mentioned was main-\\ntained persistently for weeks. To this class of cases the name tachy-\\ncardia has been provisionally applied until their pathology is under-\\nstood.\\n5. In all forms of valvular disease, except aortic stenosis with fail-\\ning compensation, the pulse may be increased in frequency. In col-\\nlapse in weakening of the heart and in central or peripheral vagus\\ndisease, the pulse is increased. Mitral stenosis may be latent until\\ngreat excitement, overexertion, and particularly running or forced\\ninarches bring on palpitation, or simply abnormal and persistent fre-\\nquency of the heart s action, with or without dyspnoea.\\n6. Attention has been called, especially by Dr. J. Kent Spender, to\\nacceleration of the pulse as an early symptom of rheumatoid arthritis.\\nThe pulse increases gradually until it reaches a range of 110 to 120, and\\nit persists at that rate with little diurnal variation, even after the\\narthritic symptoms subside.\\n7. In locomotor ataxia permanent moderate acceleration of the pulse\\n(90 to 100) is a frequent symptom.\\n8. Infections. In the puerperium increased frequency with irregu-\\nlarity of the pulse is a surer indication of intra-uterine mischief than\\nis the temperature. So, too, in all cases of inflammation so situated\\nthat the products are absorbed into the circulation and not discharged\\nexternally, the pulse shows by its increased frequency that a septic\\nprocess is going on.", "height": "4408", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0668.jp2"}, "669": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 609\\nDiminished Frequency. A slow pulse (bradycardia), under 60, like\\na frequent pulse, is sometimes habitual, and sometimes a family char-\\nacteristic. Pathologically, it is met with in conditions which increase\\nthe resistance in the arteries, such as Bright s disease, especially acute\\nglomerulo-nephritis but it is especially common in jaundice. The\\nbile-acids have the effect of retarding the action of the heart.\\nA slow pulse is met with in certain forms of heart disease, as aortic\\nstenosis, but it is not constant in any of them. It occurs in fatty de-\\ngeneration, especially when due to obstruction, by atheroma or other-\\nwise, of the coronary arteries. W. J. Pettus has reported a case of\\nbradycardia associated with aneurism of the right sinus of Valsalva,\\ninvolving the orifice of the right coronary artery. When it appears\\nin the late stages of valvular affections or specific diseases with cerebral\\nsymptoms it is usually a sign of danger. It is seen in articular rheu-\\nmatism (Atkinson). According to Riegel, it is most common in con-\\nvalescence from acute disease, particularly pneumonia, typhoid fever,\\nerysipelas, and rheumatic fever. It is also frequently encountered in\\ndiseases of the digestive organs and of the urinary organs, particularly\\nacute nephritis. Moreover, it is generally slow in myxoedema, and both\\nslow and irregular in epilepsy. It is slow, not uncommonly, also, in\\nmelancholia and in the early stages of cerebral meningitis and in tumors\\nand cerebral hemorrhage.\\nThe Sphygmograph. The sphygmograph, as its name implies, is\\nan instrument for recording in writing the volume, force, frequency,\\nFig. 154.\\nDudgeon s sphygmograph.\\ntension, and general characteristics of the pulse. Many forms of the\\ninstruments have been devised since the first one of Marey. The later\\nmodels have the advantage of simplicity and ease of application. One\\nof the most convenient is Dudgeon s. It has its faults, particularly\\nin exaggerating the vibrations when the pulse is large and the heart is\\nacting violently nevertheless, with care, trustworthy tracing can be\\n39", "height": "4416", "width": "2556", "jp2-path": "practicaltreatis00muss_0_0669.jp2"}, "670": {"fulltext": "610 SPECIAL DIAGNOSIS.\\nobtained in all ordinary cases. No matter what instrument is used,\\nthe value of the tracing depends very largely upon the personal skill\\nand experience of the one who takes the tracing hence the sphygmo-\\ngraph occupies a position very different from the thermometer and\\nother instruments of precision. While it is true that a person can\\nlearn to detect nearly all the variations of the pulse by palpation alone,\\nyet the tracing has the great advantage of permanency, and many per-\\nsons are led to palpate the pulse more carefully by seeing in a sphyg-\\nmographic tracing a dicrotism or irregularity which had escaped their\\nattention.\\nThe expansile pulsation of the artery is communicated by a system\\nof levers to a needle, which graphically records the qualities of the\\npulse upon smoked paper.\\nDirections for Using Dudgeon s Sphygmograph. 1. Wind up, by\\nthe button, the clockwork contained in the box. The clockwork\\ncarries the smoked paper under the writing-needle.\\n2. See that the patient is in a comfortable position, and have him\\nhold toward you either hand w T ith wrist exposed, fingers gently flexed,\\nand muscles relaxed.\\n3. Apply the instrument by slipping the band over the hand, the\\nfree end of the band being passed through the retaining clamp. The\\nmetal box is placed toward the elbow.\\n4. Now adjust the instrument by placing the bulging button which\\nconnects the levers directly over the radial artery at its most accessible\\npoint.\\n5. Keep the instrument accurately in place with the left hand, and\\ndraw the band through the clamp with the right until the writing-\\nneedle plays freely with each pulsation of the radial artery, then fasten\\nthe band by screwing up the clamp.\\n6. Introduce the smoked paper between the rollers and under the\\nwriting-needle.\\n7. Vary the pressure by means of the thumb-screw, which connects\\nwith an eccentric, until the best apparent amplitude of vibration is\\nobtained.\\n8. Instruct the patient not to move the fingers or hand, and further\\nsteady them for him with your own right hand.\\n9. Start the clockwork by pushing the bar at the top of the clock-\\nwork box.\\n10. Allow the paper to run through, and then stop the clockwork.\\nThe clockwork is so regulated that five inches of smoked paper\\npass through in ten seconds, so that six times the number of pulsa-\\ntions recorded on the paper represent the pulse-rate per minute. Each\\ninstrument, however, should be tested and its time determined. The\\nclockwork should be wound up for every tracing.\\nConsiderable practice will be required to take a tracing rapidly and\\naccurately, in spite of the simplicity of the mechanism.\\nSeveral tracings should be taken at different pressures and com-\\npared, or, what is better, as suggested by Sansom, stop the clockwork\\nand alter the pressure two or three times, so as to have the effect of\\nvarying pressures on one tracing.", "height": "4416", "width": "2560", "jp2-path": "practicaltreatis00muss_0_0670.jp2"}, "671": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 611\\nThe technique of sphygmography needs a few words. Smoked\\npaper is generally used for the tracings. A paper glazed upon one\\nsurface and rough upon the other has some advantages. This paper\\nhas to be cut in strips about seven-eighths of an inch wide and six\\ninches or more long. The cutting should be done with care so that\\nthe edges are smooth and even, otherwise the paper sticks in the in-\\nstrument and the tracing is spoiled. The glazed surface is blackened\\nby holding it above the flame of a small piece of burning gum cam-\\nphor. For convenience a strip of tin, bent upon itself at each end, so\\nas to catch and hold about an inch of the ends of the paper, may be\\nused to prevent the fingers from becoming blackened and to preserve\\nthe ends of the paper unblackened for memoranda. The blacking\\nshould not be too thick, otherwise the needle will not plough through\\nit easily, and the white line of the tracing Avill not be distinct. After\\nthe tracing has been made, the name of the patient, the diagnosis of\\nhis disease, the date of the tracing, and the amount of pressure em-\\nployed should at once be scratched with a fine-pointed pen upon the\\nblackened surface beneath the tracing, or written in ink upon the un-\\nblackened end of the paper. The tracing is then ready for preserva-\\ntion. This is done by dipping it into a solution of shellac or in tinc-\\nture of benzoin (gum benzoin 5j alcohol f5vj) the alcohol evaporates\\nand leaves a smooth, glazed surface. Dr. Dudgeon recommends as a\\nvarnish a solution of gum damar oj, rectified benzoline f5vj. When\\nthe tracing is likely to be subjected to friction, a second or third coat\\nshould be applied subsequently.\\nExplanation of the Normal Pulse-tracing. With each contraction of\\nthe left ventricle a volume of blood is forced into the aorta, which dis-\\ntends it, the distended impulse being transmitted by a wave-like\\nmotion to remote arteries. This distending impulse lifts the button of\\nthe lever sharply upward, forming the so-called percussion up-stroke,\\nFig. 155.\\na, b, percussion up-stroke a, b, e, percussion wave c, d, e, tidal wave e,f, g, dicrotic wave\\nd, e,f, aortic notch g, diastolic period.\\na b but the distending impulse is exaggerated by the system of\\nlevers, and having been thrown up too high, the lever falls by its\\nown weight too low, so that it is again caught and lifted by the tidal\\nblood, forming the tidal-Avave, c d e. The gradual descent of the lever\\nis again interrupted at efg, forming a wave, called the dicrotic wave,\\ndue to the recoil of the blood from the closure of the aortic valves.\\n(Fig. 155.)\\nRoy and Adami believe that the apex (h, b, d) of the percussion-\\nwave is due to the sudden pulling down of the auriculo-ventricular", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0671.jp2"}, "672": {"fulltext": "012 SPECIAL DIAGNOSIS.\\nvalves by the papillary muscles during the first rapid part of their\\ncontraction. Hence they call the wave the papillary wave.\\nThe second wave (c, d, e) corresponds in time, they say, with the\\noutflow from the ventricle due to the continued contraction of the\\nheart-wall and papillary muscles after the flaps have been pulled down.\\nHence, they prefer to call this wave the outflow remainder, instead\\nof tidal wave.\\nInterpretation oe Pulse-tracings. Sphygmographic tracings\\nmust be interpreted in accordance with the known peculiarities of the\\npatient, his history, and the associated physical signs.\\n1. The Amplitude. The height of the percussion-stroke varies con-\\nsiderably in health. It is increased in conditions which bring about\\nlow tension and rapid systolic contraction of the heart. Hence the\\nfebrile pulse is usually one of considerable amplitude. It is increased\\nalso very markedly in aortic regurgitation. Suddenness of systole\\nrather than force determines the height of the up-stroke. (See Fig.\\n156).\\nFig. 156.\\nTracing from a case of aortic regurgitation.\\n2. Obliquity of the Percussion-stroke. Normally the percussion-\\nstroke ascends vertically from the base-line. A tendency to incline\\nforward indicates a weak and laboring heart or an aneurism inter-\\nposed between the radial artery and the heart. In the latter case\\nthere is also a tendency to rounding of the summit of the percussion-\\nwave, and the up-stroke is generally short. There is usually also\\nirregularity in successive pulsations, some showing the gradual ascent\\nand rounded summit much better than others. Sometimes, however,\\nwhen aneurism exists, there is no evidence of it in the tracing, and\\ndifferences upon the two sides are not always significant. (See Fig.\\n157.)\\nFig. 157.\\nTracing from a case of aneurism of the aorta.\\nDisease at the aortic orifice and the intervention of a considerable\\nquantity of subcutaneous fat or of any growth superficial to the vessel\\nmay cause a marked obliquity of the percussion-stroke. Sansom\\nasserts that, such causes excluded, as well as aneurism and organic\\ndisease of the aorta and its valves, a sloping line of ascent, observed\\nunder various gradations of pressure, indicates feebleness of the left\\nventricle. He considers it of higher diagnostic value than irregularity,\\nwhich lie says is often neurotic.\\n3. Increased Breadth of the Apex of the Percussion-ivave. The\\nbreadth of the apex of the percussion-wave indicates the time during", "height": "4412", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0672.jp2"}, "673": {"fulltext": "DISEASES OF HE A RT, BLOOD VESSELS AND MEDIASTIN UM. 613\\nwhich the artery is kept full by the systole of the left ventricle.\\nWhen the left ventricle acts slowly and forcibly the arteries will be\\nkept distended for a longer time, and this distention will be manifest\\nin broadening of the apex of the tracing. (See Fig. 158.) The degree\\nFig. 153.\\nSJ\\nFrom a case of aortic stenosis, showing increased tension and the pulsus bisferiens.\\nof distention of the artery is called tension, hence a broadening of the\\napex is an evidence of high tension. As the word high does not\\nindicate the duration of the tension, Sansom has very properly sug-\\ngested that we should speak of persistent high tension as prolonged\\ntension. This, then, is the significance of the broad top of the tracing.\\n(See Fig. 159.)\\nFig. 159.\\nFrom a case of mitral stenosis, showing increased tension and some irregularity.\\nProlonged arterial tension occurs when there is a strong heart acting\\nslowly, a large volume of blood, or obstruction in the capillary circu-\\nlation. (For specific causes, see under Tension.)\\nThe amount of pressure required to develop the characteristics of a\\npulse, and, still more, the amount required to obliterate it, are good\\nindexes of the degree of tension present. Some pulses, however,\\nappear to the touch to be of prolonged tension, but a sphygmogram\\ndoes not show it. Such cases are often explained by the fact that the\\nheart has begun to fail under the strain put upon it by prolonged\\nobstruction in the capillaries. There may be regurgitation also from\\nthe mitral or aortic orifice.\\n4. Acute Angle of the Percussion-wave. When the heart s action is\\nfeeble or sudden, the volume of blood small, or the resistance in the\\nFig. 160.\\nLow tension with irregularity, from cases of mitral regurgitation.\\ncapillaries much diminished, the up-stroke of the tracing is vertical,\\nand the down-stroke forms an acute angle with it. The dicrotic wave\\nis pronounced, and often descends unduly low, sometimes to the base-\\nline. These are the characteristics of low tension. (See Fig. 160.)\\nWhen the dicrotic wave springs from a lower level than the base-line", "height": "4416", "width": "2564", "jp2-path": "practicaltreatis00muss_0_0673.jp2"}, "674": {"fulltext": "614\\nSPECIAL DIAGNOSIS.\\nof the tracing it is hyper dicrotic. When the dicrotic wave is wholly\\neffaced in the succeeding up-stroke it is monocrotic.\\nWhile di erotism is commonly associated with low-tension pulses, it\\nis occasionally met with also in high-tension pulses. Sansom says,\\nhowever, that he has scarcely ever observed the conjunction of broad\\nsummit and marked dicrotism without the patient s manifesting the\\nsign of failing heart.\\n5. Irregularity of the Base-line. This occurs normally in some\\npersons as the result of respiration, especially deep breathing. It\\noccurs in respiratory diseases also, and in affections causing dyspnoea.\\nDecided undulation of the base-line, the curves being irregular, occurs\\nin tubercular meningitis.\\n6. Differences in the Height of Successive Percussion-waves or in their\\nDistance from- Each Other. These are written evidences of disturb-\\nance in the rhythm of the heart. The first expresses irregularity in\\nvolume of successive beats, and the second irregularity in time. When\\nthis latter amounts to the omission of a beat it is called intermission.\\nAll these changes are shown in Fig. 161.\\nFig. 161.\\nFrom a case of advanced mitral stenosis, showing extreme irregularity and intermission.\\nThe Veins. Thrombosis. This is usually detected by palpation,\\nand occurs most frequently in the femoral vein. The vein is trans-\\nformed into a firm, round cord, and is distinguished from the artery\\nby the absence of pulsation. Thrombosis in these veins and in the iliac\\nveins higher up occurs in acute infectious diseases and in the debility\\nof the aged. Dropsy in the area of distribution of the veins is per-\\nceived.\\nPercussion By means of percussion the shape and size of the heart\\nand changes in the area of cardiac dulness are determined. (See the\\nLungs for discussion on percussion.) To determine the size of the\\nheart, both superficial or light, and deep, or strong, percussion must be\\nemployed. By the former we determine the area of superficial or\\nabsolute cardiac dulness by the latter, the area of deep cardiac dulness.\\n1. The Area of Superficial or Absolute Cardiac Dulness.\\n(See Plate XVI.) It is the area not covered by the lung at the time\\nor inspiration. The lungs overlap the heart, and, in inspiration, allow\\na small area to be in contact with the chest-wall. The percussion-force\\nemployed must be light, so as not to elicit the resonance of the extreme\\nthin edge of the lung. The area extends from the fourth to the sixth\\ncostal cartilages. The right border may be roughly defined by a line\\ndrawn along the left edge of the sternum from the upper border of the\\nfourth rib downward the left border by a line extending from the upper\\nborder of the fourth rib at the left edge of the sternum to a point", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0674.jp2"}, "675": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 615\\nmidway between the parasternal and the mammillary line in the fifth\\ninterspace. The lower border is continuous with liver dulness.\\nMethod. The right border is determined by percussing from right\\nto left toward the median line. Always begin to percuss far enough\\nfrom the heart to get the clear pulmonary note. To insure uniformity,\\nselect a definite area from which to start in all cases. Apply the\\nfinger vertically at first. The right border may correspond with a\\nline outside of or along the right edge of the sternum, with the median\\nline or the left edge of the sternum, or even beyond the latter. After\\nthe edge of modified resonance is reached, percuss with the finger par-\\nallel to the ribs, to control the result previously secured, and as each\\ninterspace is percussed the upper limit of liver-dulness and the tri-\\nangle (Ebstein s) between the liver and heart may be determined.\\nThe left edge is determined by percussing in vertical lines from a\\npoint near the axilla toward the heart. Opposite the second and third\\ninterspaces the aorta on the right side, and the pulmonary artery on\\nthe left, will cause impairment of the normal pulmonary resonance.\\nThe student should acquire the habit of proceeding from definite fixed\\npositions toward the heart, and to observe the changes during inspira-\\ntion and expiration. The lower border and rounded apex of an en-\\nlarged heart cannot be defined if the stomach contains food or fluid.\\nIt is triangular in shape, with the apex pointing downward.\\nThe cardio-hepatic triangle is the more or less resonant area in the\\nright fifth interspace which separates the right heart and the liver.\\nThe apex of the triangle points to the sternal edge, the base to the\\naxilla. The upper side corresponds to the right border of the heart\\nthe lower is the upper limit of the liver.\\nChanges in Size. The superficial area of dulness or absolute dulness\\nis increased in pericardial effusion in enlargement of the heart and\\nwhen the heart is pushed against the chest-wall. It is replaced by\\nresonance in emphysema, and hence absent entirely, as the lung over-\\nlaps or completely covers the heart. It is absent when the heart is\\ndrawn under the lungs by adhesions and when there is air in the\\npleural or pericardial sac.\\nAbsolute Dulness Increased. The increase in the area of abso-\\nlute dulness in all directions occurs in hypertrophy of the heart and in\\npericardial effusions. The increase in width at the base of the heart\\noccurs in dilatation, pericardial effusion, and aneurism of the aorta.\\nChange in the position of the heart, a general idea of which is obtained\\nby inspection and palpation, always changes the shape and extent of\\nthe dulness. The heart should be accurately delimited when displace-\\nments have taken place.\\nIncrease of Dulness Upward. In addition to general increase\\nin cardiac dulness, one of the boundaries or a portion of the boundary\\nmay be increased or extended beyond the normal line. Thus the area\\nof dulness may extend upward. It may be followed by extension of\\nthe right and left boundaries. The relative area of dulness is abol-\\nished. The change from pulmonary resonance to dulness is abrupt and\\ndecided. The area of dulness becomes pyramidal or pyriform in shape.\\nIt is due to effusion in the pericardium. Upward increase of dulness", "height": "4416", "width": "2568", "jp2-path": "practicaltreatis00muss_0_0675.jp2"}, "676": {"fulltext": "61 (J SPECIAL DIAGNOSIS.\\nmay be due to disease of the vessels. Increase in the area of dulness\\nover the bloodvessels is usually due to aneurism. It may be general,\\nas in dilatation of the aorta, or local, as in aneurism. Extension of\\nthe d ulness outward or upward from the normal line may be found at\\nthe right of the sternum (aneurism of the ascending aorta), or over the\\nfirst bone of the sternum (aneurism of the transverse aorta), or to the\\nleft just above the cardiac area. In the last case the dulness is an\\nextension upward of the normal area of cardiac dulness with rounding\\nof the area affected the aneurism is situated at the beginning of the\\naorta.\\nIncrease to the Left. Increase in dulness to the left occurs in\\nenlargement of the heart from hypertrophy or dilatation. If the dul-\\nness extends outward to the left and retains the triangular shape, with\\nthe apex pointed, it is due to hypertrophy of the left ventricle. If, on\\nthe other hand, it becomes quadrilateral in shape, with the apex\\nrounded, it is due to dilatation of the left ventricle. The results of\\npalpation and inspection aid- in detecting the presence of one or the\\nother of the two conditions.\\nIncrease to the Right. The area of dulness extends to the\\nright. It is due to hypertrophy and dilatation of the right auricle and\\nventricle. If the auricle is dilated, the right edge is extended beyond\\nthe normal in the third and fourth, or as high as the second interspace.\\nWith this increase in dulness there are also seen an epigastric impulse,\\nvenous turgescence, and pulsation of the veins of the neck or of the\\nliver.\\nDeep Cardiac Dulness. Many authorities consider the deep or\\nrelative area of cardiac dulness of importance in diagnosis. The percus-\\nsion must be strong. The best method is that advised by Gibson and\\nRussell. Their directions are as follows Begin in the upper left\\ninterspaces sufficiently far out from the sternum to secure pulmonary\\nresonance. For instance, in the second interspace begin in the mid-\\nclavicular line and percuss strongly. As soon as a slight alteration in\\nthat sound is noted, the point is indicated by a mark. The second or\\nthird and succeeding interspaces are percussed in like manner, bearing\\nin mind that the percussion must begin further out in each interspace,\\nin order to get pure resonance. As dulness is secured in each space a\\nmark is made. This is continued to the apex if that is visible, or to\\nthe base of the chest. By joining the marks in each interspace with\\nthe line at the base of the heart, the left border of the cardiac dulness\\ncan be fixed. The authors correctly point out that in this way the\\ntrue apex of the heart is found, enabling auscultation to be conducted\\nmore accurately.\\nThe right edge of the vessels and of the heart is defined in the same\\nway. The difference in the sound, in passing from the lung to the\\nheart, is not so distinct along the right border as along the left. The\\nauthors include the dulness which is due to the vessels at the base of\\nthe heart, and hence begin percussion in the higher interspaces. This\\nthey deem is proper, because it is impossible to delimit the two. The\\ndulness of the vessels is not so marked, however, and may be indicated\\nby simple change in pitch in the percussion-note. The lower border", "height": "4412", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0676.jp2"}, "677": {"fulltext": "DISEASES OF HE A RT, BLO OD VESSELS AND MEDIA STIN UM. 6 1 7\\nof cardiac dulness is ascertained with difficulty, because of its close\\napposition with the liver. At times there is a difference in the char-\\nacter of the dulness between the two organs. It can be well made out\\nby stethoscopic percussion. This may not be so pronounced as we pass\\nfrom the heart to the liver in the median and parasternal lines.\\nToward the apex the difference is more apparent.\\nPleximetric Percussion. For more accurate cardiac percussion,\\nSansom recommends the use of a pleximeter designed by himself, by\\nwhich delicate shades in dulness can be readily heard. The pleximeter\\nis a thin, flat, oblong plate one inch by half an inch, which has on its\\nupper surface a column rising from the middle, one and a half inches\\nin height, which is surmounted by a second plate three-eighths to\\nthree-fourths of an inch, set parallel with the lower plate. The instru-\\nment is held between the forefinger and middle finger of the left hand,\\nthe sensitive tips of the fingers resting on the upper surface of the\\nlarger horizontal plate. The lower surface of this latter is held close\\nto the wall of the chest, and percussion with one or two fingers of the\\nright hand with an even and not too forcible stroke from the wrist is\\nmade upon the upper plate. The resulting vibrations are transmitted\\nto the ear and are also appreciated by the digital sense of touch, so\\nthat both senses aid in the determination of the nature of the sound\\nproduced.\\nMethod. The pleximeter is placed with its long diameter parallel\\nwith the sternum, about midway between the axilla and the right ster-\\nnal border. Percussion is made upon the summit of the column by\\none or two fingers, and the pleximeter is moved, always in parallel\\nlines, nearer and nearer to the sternum. A line is reached where the\\nvibrations are modified. Incline the pleximeter so that the vibrations\\ncome from its left edge. This edge, or line, is practically the line of\\ndemarcation of the dulness, and should be indicated with an aniline\\npencil. It corresponds to the outline of the right border of the heart.\\nThe process must be repeated at higher and lower levels until the entire\\nright border of cardiac or aortic dulness is ascertained. In passing, it\\nmay be stated that percussing from above downward with the long\\ndiameter of the pleximeter horizontal instead of vertical leads to the\\nupper limit of the liver as indicated by modified vibrations. At\\nabout the fifth right intercostal space a short curved line is thus\\nmade out along the right edge of the sternum, which indicates the\\noutline of the right auricle at the point where it joins the liver-\\ndulness. Above this, as far as the second rib, the line indicates the\\noutline of the right border of the auricle and the aorta. The outline\\nof the auricle may be in the mid-sternum of the aorta, at the right\\nedge. In percussing the left side of the chest the same method is\\nadopted. Begin at the level of the second rib, two or three inches\\nbeyond the left edge of the sternum, and move to the right. Join the\\nlines of modified vibrations, and in this manner the left border of car-\\ndiac and aortic dulness is secured. The outline of the apex of the\\nheart is readily mapped out. Over the tympanitic stomach light per-\\ncussion is necessary. To narrow the area of percussion about the apex,\\nthe percussion may be performed on the larger plate, while the smaller", "height": "4416", "width": "2560", "jp2-path": "practicaltreatis00muss_0_0677.jp2"}, "678": {"fulltext": "618 SPECIAL DIAGNOSIS.\\nis applied to the chest. The vibrations over the liver and over the\\nright ventricle are difficult to distinguish, although sometimes so differ-\\nent that demarcation of the border of the ventricle presents no difficulty.\\nBetween the apex of the left ventricle and the left lobe of the liver the\\nspace is easily marked out.\\nA correct outline of the heart and of the vessels is thus obtained.\\nThe upper limit of dulness is formed by the right auricle, the aorta,\\nand the pulmonary artery. Any bulging or undue expansion is due\\nto aneurism or aneurismal dilatation of the aorta. The space be-\\ntween the apex and the left lobe of the liver defines the lower border.\\nSansom points out that by this method of percussion the following\\nabsolute data can be obtained A projection to the right of the area\\nof the upper part over the second and third interspaces points to aneu-\\nrism of the aorta or of the innominate artery. It may be traced to the\\nleft side of the sternum, on account of saccular dilatation of the aorta.\\nIf the dulness at the upper part extend greatly to the left, an increase\\nin size of the pulmonary artery may be suspected. Along the mid-\\nsternal region, extension beyond the right side joining the line indi-\\ncating the upper border of the liver indicates distended inferior cava.\\nThis distention occurs in right-sided dilatation of the heart, and the\\ndulness may also be due to dilatation of the adjoining auricle. The\\noutline of dulness obtained over the apex of the heart, if pointed, indi-\\ncates hypertrophy a more rounded outline shows dilatation. In un-\\ncomplicated hypertrophy the line of the right ventricle forms a much\\nless obtuse angle with the liver-dulness than in dilatation. Of great\\ndiagnostic value is the diminution of the area of dulness from atrophy\\nof the heart as observed in wasting, as in cancer, and in tuberculosis\\nit may also be observed in typhoid fever. In the above-mentioned\\nconditions it is a bad prognostic sign.\\nAdjacent Dulness. Care must be taken not to confound the\\ndulness of pleural effusion or consolidated lung with the cardiac\\ndulness.\\nKepercussion. Modification of the vibrations felt by the fingers\\non the pleximeter, as pointed out by Sansom, may indicate an abnormal\\nchange in physical condition impossible to detect in any other way.\\nIt is to be remembered that over the lungs the vibrations are exces-\\nsive over solid structures they are modified or lessened. Now, the\\nchange from vibrations to absence of vibrations may be gradual or\\nabrupt. Sansom determines this by percussion, after the heart has\\nbeen outlined in the above-mentioned manner. In percussing from\\nthe lung to the heart area, if the modified vibrations occur abruptly,\\nit is very probable that there is pericarditis with effusion or thickened\\npericardium or if, on percussing from above downward, there is\\npericardial effusion, no vibrations are to be elicited over the area de-\\nlimited that is, the absence of vibrations is noted over the whole\\narea whereas, in ordinary conditions, when the pericardium is unaf-\\nfected, in percussing from above downward over the area which had\\nbeen delimited on the right and left sides respectively, a line will\\nbe reached where the vibrations become modified. This line com-\\nmences a little above the ensiform cartilage and inclines toward the", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0678.jp2"}, "679": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 619\\nleft border of the cardiac dulness at the level of the fourth rib and\\nthird interspace. Vibrations are more marked above than below the\\nline. The line at which the lessened vibrations begin points out the\\ncommencement of the thick wall of the ventricles the portion above\\n(more vibratory) indicates the position of the right auricle and vessels.\\nIf the pleximetric percussion is employed, areas of superficial and deep\\ndulness need not be estimated.\\nThe Apex Impulse. Whichever method of percussion is em-\\nployed, it will be often observed that the spot marked by inspection\\nand palpation as the apex impulse is far outside of the left border of\\ncardiac dulness. In hypertrophy of the left ventricle it may be a con-\\nsiderable distance to the left. In dilatation the difference is not so\\nmarked. The percussion-lines are made when the heart is away from\\nthe chest, and henCe are within the systolic apex-beat.\\nMethod of Graphic Record. (See also page 536.) We are indebted\\nto Sansom and Ewart for a method of recording the outlines of the\\nareas of dulness and the position of the apex-beat and other pulsations,\\nwhich is of great value for class-demonstration, and for permanent\\nrecords to compare with other records taken from time to time. The\\npoints of pulsation and border-lines of dulness are marked by a derma-\\ntographic pencil. Various colors may be used in order to indicate the\\ndifferent data. The landmarks, etc., are outlined by a camel s-hair\\npencil dipped in olive oil. The episternal notch, the clavicles, the\\nintercostal spaces, the ensiform cartilage and nipples, etc., the percus-\\nsion-outlines, and other recorded marks are passed over with the oiled\\npencil. A sheet of tissue-paper, or of copying-paper, is then gently\\nplaced over the whole, so that the oil-marks are imprinted. After the\\npaper is removed the oil-outline is colored with the dermatographic\\npencil, and a permanent record is preserved. By this plan of record-\\ning a maximum of precision is attained. Outlines can be measured\\nand positions defined by mathematical data. The name of the patient,\\nthe date of observation, with a brief history of the case, should be\\nattached to the chart. If the colored pencil-marks on the patient s\\nchest are objectionable, the outline may be made with the colorless\\noil-pencil at the various steps of the examination. After they are trans-\\nmitted to the paper they may be made more distinct with the colored\\npencils. Packard fits to the chest a square of coarsely woven muslin\\nand outlines the ribs and sternum, etc., which are seen through the\\nmeshes. With colored pencils, dull areas, etc., the site of organs, the\\nposition of murmurs, are then designated.\\nEwart has shown that after long intervals the size of the chest and\\nabdomen is apt to alter from various circumstances growth, muscu-\\nlar development, habit of sitting, etc. He therefore points out the\\nadvisability of using the sternum, which is immovable, for the sake of\\nfuture comparison.\\nSense of Resistance. Ebstein delimits the heart by the sense of\\nresistance, change in size being noted by increase or diminution of the\\narea, which in health gives a sense of resistance to the percussing finger.\\nAuscultation. Method. Either method of auscultation may be\\nemployed. By the immediate method we may form a general notion", "height": "4416", "width": "2572", "jp2-path": "practicaltreatis00muss_0_0679.jp2"}, "680": {"fulltext": "620\\nSPECIAL DIAGNOSIS.\\nas to the condition of the heart-sonnds. The mediate, however, is pref-\\nerable, because it is essential to localize the sounds that are heard, and\\nbecause, if the double stethoscope is used, we can percuss the cardiac\\narea. The patient should be in a comfortable position. The muscles\\nshould not be strained. The general directions for performing auscul-\\ntation must be followed. Before he begins the observer has, if pos-\\nsible, determined the presence of the impulse, or found the radial or\\ncarotid pulse. By this means the time of the heart is taken and the\\nrelation of the events of the cardiac cycle to each other is ascertained.\\nWith each normal impulse or carotid pulse a systole takes place hence\\nthey are synchronous. The systole occurs just before the radial pulse.\\nBy auscultation we determine (1) the normal sounds of the heart,\\nincluding their rhythm, their character and the seat of maximum in-\\ntensity (2) modifications of the normal sounds as regards (a) loudness\\nand (6) rhythm (3) the presence of abnormal sounds or murmurs.\\nI. The Normal Sounds. The stethoscope is placed over the heart\\nand the finger on the impulse or the radial pulse a sound will be noted\\nat the time of the impulse or the systole, followed almost immediately\\nby another sound and then a period of silence. The sounds that attend\\nthe systole are known as the systolic, or first sounds. The sounds that\\nfollow are known as the diastolic, or second sounds. The sounds and\\nFig. 162.\\nDiagrammatic representation of the movements and sounds of the heart. (Afier Sharpey.) This\\ndiagram shows merely the general relations of the several events, and does not represent exact\\nmeasurements.\\nIn a heart beating seventy-two times a minute, Foster estimates each entire cardiac cycle as\\noccupying about 0.8 sec, of which 0.3 sec. represents the duration of the systole of the ventricle,\\n0.4 sec. the diastole of both auricle and ventricle, or the passive interval, and 0.1 sec the systole\\nof the auricle.\\nOnly one pause is marked here\u00e2\u0080\u0094 sometimes called the long pause some writers describe\\na short pause also\u00e2\u0080\u0094 indicated in the diagram by the small space between the first and the\\nsecond sound.\\nsilence mark the completion of a cardiac cycle as far as the ear is con-\\ncerned. (Fig. 162.) A definite relationship in time exists in the car-\\ndiac cycle. Cause. Four sounds are created during a cycle, one at", "height": "4412", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0680.jp2"}, "681": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 621\\neach, valve. The sounds created with the systole (systolic sounds) are\\ndue to contraction of the right ventricle and closure of the tricuspid\\nvalve and on the opposite side, of the left ventricle and the mitral\\nvalve. The rash of blood along the course of the vessels and the\\nshock of the heart may contribute somewhat to the systolic sound.\\nThe sounds heard in the beginning of the diastole (diastolic sounds)\\nare due to closure of the aortic and pulmonary valves. They are due\\nto the tension produced on the valves as the respective arteries con-\\ntract upon the columns of blood. The closures of the valves make\\nup most, if not all, of the sounds. To review two sounds occur with\\nthe systole, one from closure of the mitral, another from closure of\\nthe tricuspid valve two with the diastole from closure of the aortic\\nand pulmonary valves, respectively. In health the sounds of the sys-\\ntole blend because synchronous, giving the impression at a common\\npoint of one sound. Analysis of the sound in the respective valve\\nareas will show that the systolic sound is made of two sounds. The\\nsounds of the diastole may or may not blend. Often there is an appre-\\nciable difference between the two.\\nRecognition of the Respective Sounds. To distinguish the sounds we\\nstudy their rhythm or time, their character, their position of maximum\\nintensity, and their direction of transmission. We distinguish the first\\nfrom the second sounds by their rhythm and character, and then differ-\\nentiate the sounds respectively of the systole and of the diastole by\\ntheir point of maximum intensity.\\n(a) The Rhythm or Time. The sounds that are heard at the time of\\nthe normal impulse or just before the radial pulse are the systolic or\\nfirst sounds the sounds that follow the impulse are the second sounds.\\nThe sounds that follow the long silence are the systolic or first sounds\\nthose that precede the long silence are diastolic or second sounds.\\n(b) Character of the Sounds. The systolic sounds are pro-\\nlonged, somewhat dull in character, low in pitch, and resemble the\\nsound produced by the pronunciation of the syllable ubbP The\\ndiastolic sounds are short, sharp, and quick, and resemble the sound\\nproduced by the pronunciation of the syllable duppP The syllables\\nubb, dupp indicate the character of the sounds in health. Modifica-\\ntions in the intensity of the sound are due to changes in the tension of\\nthe valve-curtains, and are dependent upon the force of muscular con-\\ntraction, which, if strong, renders the valves more tense. Experiment\\nand the results of disease have aided in proving these points.\\n(c) Position of Maximum Intensity. In general the first sounds\\nare loudest at the lower part of the prsecordia, the second at the upper.\\nBut we especially distinguish the independent valve elements which\\nmake up the systolic and the diastolic sounds in the following manner.\\nThe sounds produced by the closure of the valves are created, as the\\ntopography of the heart shows, quite near to each other, but by con-\\nduction of the sound they are transmitted away from the respective\\nvalves in particular directions, and heard loudest in definite areas on\\nthe chest.\\nThe Systolic or First Sounds. Two sounds are created. The\\nvalves which cause the sound are near to each other. Because of their", "height": "4416", "width": "2556", "jp2-path": "practicaltreatis00muss_0_0681.jp2"}, "682": {"fulltext": "622\\nSPECIAL DIAGNOSIS.\\nanatomical relations the sounds are conducted into different areas, by\\nvirtue of which they are differentiated. The Mitral Valve Sound.\\nThe sound produced by the closure of the mitral valve is created oppo-\\nsite the fourth interspace near the sternum. It is transmitted to the\\nsurface of the chest by the thickened left ventricle, and hence is heard\\nAreas of cardiac murmurs (Gairdner for the areas and Luschka for the anatomy). The out-\\nlines of organs, which are partially invisible in the dissection, are indicated by very fine dotted\\nlines while the areas of propagation of valvular murmurs, as described in the text, have been\\nroughly marked by additional much coarser and more visible dotted lines\u00e2\u0080\u0094 the character of the\\ndots being different in each of the four areas A capital letter marks each area viz., A, the circle\\nof mitral murmurs corresponding with the left apex; B, the irregular space indicating the ordi-\\nnary limits of diffusion of aortic murmurs, corresponding mainly with the whole sternum, and\\nextending into the neck along the course of the arteries C, the broad and somewhat diffused\\narea occupied by tricuspid murmurs, and corresponding generally with the right ventricle D, the\\ncircumscribed circular area over which pulmonic murmurs are commonly heard loudest.\\nReference letters r. au. right auricle a. o. arch of aorta v. i. the two innominate veins\\nv. c. vena cava descendens p. pulmonary artery 1. au. left auricle 1. v. left ventricle\\nr. v. right ventricle. (Finlayson.)\\nloudest where that is nearest the chest, namely, at the apex the mitral\\narea. The Tricuspid Valve Sound. The sound produced by the\\nclosure of the tricuspid valve is transmitted by the right ventricle, and\\nis heard loudest over the lower portion of the sternum the tricuspid\\narea.", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0682.jp2"}, "683": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 623\\nThe Diastolic or Second Sounds. Two sounds are created.\\nThe valves at which they are produced are also in close proximity.\\nTo distinguish the two sounds it is necessary to auscnlt over areas into\\nwhich they are transmitted. They may often be distinguished by\\nFig. 164.\\n1. Mitral area.\\nThe valve areas.\\n2. Tricuspid area. 3. Aortic area. 4. Pulmonary area.\\ntheir slight difference in time, the aortic preceding the pulmonic by a\\nfraction of a second. The Aortic Valve Sound. The sound produced\\nby the closure of the aortic valve is heard loudest at the second costal\\ncartilage on the right, because the aorta which conducts the sound is\\nnearest the surface of the chest at this point the aortic area. This\\ncartilage is known as the aortic cartilage. The Pulmonary Valve\\nSound. The sound produced by the closure of the pulmonary valve is\\nconducted to the left and heard loudest in the second interspace near\\nthe left edge of the sternum the pulmonary area.\\n(d) The Direction of Transmission. The first sounds are trans-\\nmitted toward the axillae. They may be heard all over the cardiac\\narea, but the position of maximum intensity is in the lower portion and\\ntoward the left. The second sounds are loudest at the base of the heart.\\nThey may be propagated beyond the prsecordia toward the neck, and\\nbe heard loudest in the vessels of the neck.\\nPrecise Location and Differentiation of Each Sound.\\nThis may be determined by listening with the bell of the stethoscope\\nover each area. Then move the bell of the stethoscope gradually from\\none area into the other. As the sound of the original area lessens the\\nsound of the approached area is observed. The change from one to\\nthe other is often very marked. 1. Mitral first or systolic sound, heard\\nloudest at the apex, inward to the parasternal line, upward to the third\\ninterspace. 2. Tricuspid first or systolic sound, heard loudest at the\\nlower part of the sternum and toward the left to the parasternal line as\\nhigh as the third rib. 3. Aortic second or diastolic sound, heard loudest\\nat the aortic cartilage, propagated into the vessels of the neck, and also", "height": "4416", "width": "2572", "jp2-path": "practicaltreatis00muss_0_0683.jp2"}, "684": {"fulltext": "624 SPECIAL DIAGNOSIS.\\nheard at and outside of the apex-beat. It is louder than the pulmo-\\nnary second sound in health. 4. Pulmonary second or diastolic sound,\\nlocalized to the second interspace and the third rib.\\nII. Modifications of the Sounds. The sounds, singly or com-\\nbined, may be increased or diminished in intensity or accentuation.\\nThev may be altered in rhythm.\\nSounds Increased, a. Causes outside of the pericardium. 1. Any-\\nthing which brings the heart closer to the ear of the observer. Thus,\\nin patients with thin chest-walls, when the heart is pushed to the sur-\\nface of the chest (mediastinal tumor) or the lung removed (pleural\\ncontraction). 2. Anything which conducts the sounds, as consolidated\\nlung in the vicinity, or a pneumothorax, or pulmonary cavities, b.\\nAffections of the pericardium, as pericardial adhesions, c. Conditions of\\nthe heart. 1. Hypertrophy. 2. Overaction, as in palpitation, fevers,\\nanaemia, exophthalmic goitre.\\nSounds Weakened, a. Causes outside of the pericardium. 1. Gen-\\neral exhaustion. 2. Thick chest-walls, large mammary gland. 3.\\nEmphysema of the lungs overlapping the heart, b. Affections of the\\npericardium, as fluid or air in the pericardial sac. c. Conditions of\\nthe heart. Atrophy myocarditis some cases of dilatation.\\nIn short, loudness of all the sounds occurs from (a) conditions out-\\nside of the heart heart nearer chest-wall, consolidation of lungs, cavi-\\nties (6) conditions of the heart itself hypertrophy overaction.\\nWeakness of the sound occurs from (a) Conditions outside of the\\nheart thick chest-walls, emphysema, general exhaustion (6) affec-\\ntions of the pericardium effusions (c) affections of the heart atro-\\nphy dilatation myocarditis.\\nModifications of Individual Sounds. The above applies to all\\nthe sounds. Increase or diminution of the systolic or of the diastolic\\nsounds, or of any one of the four sounds, may be present.\\nIncrease in Loudness of the Systolic Sound. Increased loud-\\nness of the first sound is noted when the muscle is hypertrophied, and\\nthe tension on the valves thereby increased. In hypertrophy of the\\nleft ventricle the increase is most marked. The sound is duller and\\nhas a prolongation which is very characteristic. In hypertrophy of\\nthe right ventricle the sound is dull and prolonged over the sternum,\\nbut not to the same degree as when the left is hypertrophied.\\nIncrease in Loudness of the Diastolic Sound. Either of the\\nsecond or diastolic sounds may be increased in loudness or accentuated.\\nFig. 165.\\nA\\nNormal first Accentuated\\nand second sounds. first sound.\\n1. The Aortic Diastolic Sound. Anything which causes increased\\ntension in the aortic circulation, and hence increased contractile force\\nof the aorta, will increase the intensity or accentuation of the second\\nsound. In hypertrophy of the heart the aortic sound is accentuated", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0684.jp2"}, "685": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 625\\nbecause there is corresponding increased contraction of the aorta, fol-\\nlowing the forcible expulsion of the blood from the ventricle. Increase\\nin arterial tension is also due to increased contraction of the aorta when\\nthere is peripheral resistance to the outflow of blood. It is associated\\nwith the following conditions which cause accentuation of the second\\nsound Atheroma of the aorta, or of the arteries in general aneurism\\nof the aorta disease of the kidneys, and particularly in that form in\\nwhich there are also general arterial changes namely, chronic inter-\\nstitial nephritis. It is true that the accentuation may be partly due\\nto the hypertrophy of the heart which coexists.\\nAccentuation of the aortic second sound occurs independently of per-\\nmanent change in the arteries. If for any reason there is spasm of the\\nperipheral capillaries, as from a chill, from epilepsy, from nervousness\\ndue to hysteria, tension in the arteries is heightened, and hence the\\nsecond sound accentuated. It is seen that accentuation of the second\\nsound is, therefore, a marked index of the state of the vascular system\\nin general it is not an evidence of disease of the heart alone. In\\ncertain fevers and in states of the blood in which the vasomotor nerves\\nare irritated, causing peripheral contraction, as in scarlatina, accentu-\\nFig. 166.\\nn\\nNormal first and Accentuated\\nsecond sounds. second sound.\\nation of the second sound is observed, often before the development of\\nlocal inflammatory diseases due to the same cause, as nephritis in scar-\\nlatina. The occurrence of this complication may be suspected when\\naccentuation of the aortic second sound is heard.\\n2. The Pulmonary Diastolic Sound. This is due to the same phys-\\nical condition which causes accentuation of the aortic second sound.\\nAnything which heightens the tension in the pulmonary artery will\\ncause increased loudness. In health the pulmonary second is not so\\nloud as the corresponding aortic sound. If, therefore, we find in the\\nsecond or third left interspace the sound as loud as an aortic sound, or\\nlouder, it can be said that the pulmonary second sound is accentuated.\\nIt is due 1. To any condition which causes congestion within the\\nlungs, the right ventricle being at the same time of normal or increased\\nstrength. It is heard in the early stages of pneumonia, and, if the\\ncourse of the disease continues favorable, may remain accentuated to\\nthe end. If, on the other hand, the circulation is embarrassed, and\\nthe right heart is failing, it will become fainter, and may be scarcely\\nrecognizable. Such change in the sound accompanies increase of respi-\\nratory distress, and indicates that the right heart is becoming ex-\\nhausted. It is, therefore, an ominous sign in acute pulmonary disease.\\nIf the case is unfavorable, the signs of right-sided dilatation will sub-\\nsequently occur. 2. It occurs in emphysema of the lungs. Notwith-\\nstanding the covering of the heart by the lung, the sound can be heard,\\n40", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0685.jp2"}, "686": {"fulltext": "626 SPECIAL DIAGNOSIS.\\nand may be the only one of the four sounds which can be distin-\\nguished. 3. In valvular disease of the heart seated at the mitral orifice\\naccentuation of the pulmonary second sound is heard, due to increased\\ntension in the pulmonary artery. In mitral obstruction the blood is\\nretained in the auricle and pulmonary veins, causing a resistance to\\nthe force of the right ventricle. Increased tension in the pulmonary\\nartery is the result, with exaggerated strain upon the valves. In\\nmitral regurgitation, with the systole the blood is thrown back into\\nthe auricle, and consequently meets with blood coming from the lungs.\\nThis in time increases the amount of blood and of blood-pressure in\\nthe pulmonary artery. A heightened tension results. Skoda pointed\\nout the significance of this association. Sometimes in doubtful cases,\\neither in the presence or absence of a murmur at the mitral orifice, the\\noccurrence of this sign makes it more than probable that there is mitral\\nvalvulitis.\\nDiminished Accentuation of Feebleness of the Sounds. 1.\\nFeebleness of the Mitral Sound. Feebleness of the mitral sound ob-\\nserved at the apex of the heart may be an indication of weakness of\\nthe muscle from dilatation, atrophy, or myocarditis. It must be remem-\\nbered, however, that weakness of the ventricle is not attended by en-\\nfeeblement of sound alone, but that when the right or left ventricle is\\nAveakened the duration of the sound is lessened. The loudness remains\\nthe same, or may be increased. Note, then, that a short systolic sound,\\nFig. 167.\\nn\\nEL\\nNormal first and Diminished\\nsecond sounds. first sound.\\nloud, sharp, flapping, sometimes reverberating, heard at the apex, indi-\\ncates dilatation or feebleness. The tension of the ventricles and valves\\ncreating the sound is increased by internal pressure. The systolic\\nsounds become like the diastolic, and may be distinguished by the ear\\nwith difficulty but if the time is taken with the finger on the apex-\\nbeat or carotid artery, if the heart s action is slow the distinction can\\nreadily be made.\\nDiminished Accentuation of the Aortic Sound. This is an indication\\nof cardiac weakness, and is apt to ensue in the course of fevers when\\nexhaustion takes place. It is a sign of myocarditis and of degenera-\\ntion of the muscular walls of the heart. Under these circumstances\\nthe systole of the ventricle is also weakened.\\nFeebleness of the aortic second sound, With hypertrophy and hence\\nstrong contraction of the ventricle, occurs when the aortic leaflets are\\nswollen or enlarged and thickened. This condition of the valves is due\\nto atheroma, and is in all probability associated with atheroma of adja-\\ncent vessels, as the coronary arteries. It is, therefore, a sign of serious\\nimportance.\\nDiminished Accentuation of the Pulmonary Sound. This is of impor-\\ntance in the course of valvular disease of the heart, providing previous", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0686.jp2"}, "687": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 627\\naccentuation has been observed. If the marked loudness gives way to\\nfeebleness, there is strong probability that the right heart is under-\\ngoing dilatation with regurgitation at the tricuspid orifice. While\\naccentuation of the pulmonary second sound in valvular disease is of\\ngood omen, enfeeblement of the sound is of bad prognostic omen, indi-\\ncating weakness of the right ventricle.\\nAlterations in the Rhythm. Foetal rhythm of the heart\\nEmbryocardia a term first used by Huchard to designate a condition\\nin which the pauses between the heart-sounds are of equal length. The\\nfirst and second sounds are exactly alike, resembling the beat of the\\nfoetal heart. The sign is of importance in prognosis. In acute dis-\\nease and in fever it indicates enfeeblement of the heart and reduction\\nof arterial tension. In the later stages of Graves disease it is a fore-\\nrunner of death. It is distinguished from the rapid beat of the heart\\nin tachycardia by the fact that in the latter condition the normal\\nrhythm is preserved.\\nCantering Rhythm of the Heart The ear recognizes three sounds.\\nThe usual sounds may or may not be attended by murmur, and the\\ninterpolated sound may be dull, or short and sudden. It may occur at\\nvarious periods in the cardiac cycle, either just before the systolic sound,\\njust after the diastolic sound, or during the diastolic pause. The rhythm\\nrecalls the sound of a horse cantering. It was termed by Bouillaud\\nthe bruit de galop. When the interpolated sound resembles the first\\nor second it is similar to reduplication of the sounds. It has been\\nobserved in hypertrophy of the heart, especially of the left ventricle\\ndilatation of the heart in adherent pericardium with dilated hyper-\\ntrophy in myocarditis, in the course of fevers and in excessive\\nanaemia. It is heard loudest over the right and left ventricles.\\nPotain thinks it is due to tension communicated to the wall of the\\nventricle by the entrance of blood into its cavity, and is more marked\\nwhen the wall is least extensible, as in hypertrophy on the one hand\\nor exhaustion of the muscle in either of the two the walls vibrate\\nmore readily. The triple rhythm is of bad prognostic omen in chronic\\nBright s disease.\\nReduplication of the Sounds. Reduplication, or apparent\\ndoubling of the heart-sounds, occurs in various forms. In health the\\nsystolic sounds are created synchronously a fraction of a second, not\\nappreciated by the ear, separates the diastolic sounds. In so-called\\nreduplication one systolic sound may follow the other, or the aortic and\\npulmonary diastolic sounds may be created at distinct intervals. As\\nhas been stated, in galloping rhythm the idea of reduplication is some-\\ntimes transmitted to the ear. Reduplication may take place in health\\nunder the influence of respiratory movements. The systolic sounds\\nmay be doubled at the end of expiration and the commencement of\\ninspiration, while the diastolic sounds are doubled at the end of inspi-\\nration and the commencement of expiration. In mitral disease redu-\\nplication, or want of synchronous closure of the two valves, is of fre-\\nquent occurrence. The heart-sounds are doubled and heard over the\\nbase of the heart. Reduplication of the systolic sounds occurs in\\nchronic Bright s disease.", "height": "4412", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0687.jp2"}, "688": {"fulltext": "628 SPECIAL DIAGNOSIS.\\nReduplication, or Doubling of the Systolic Sounds, is heard over the\\napex or the right ventricle. Several explanations have been given\\nfor the cause of the reduplication. At first it was thought to be due\\nto want of synchronism in the action of the ventricles that one ven-\\ntricle contracted before the other, due to the fact, of course, that the\\npresence of blood stimulates one but not the other. By Hayden it\\nwas thought that reduplication of the first sound was due to the two\\nmajor elements of the sound acting asynchronously, the muscular sound\\nD\\nFig. 168.\\nV\\na. b\\nNormal first and Reduplicated\\nsecond sounds. first sound.\\ntaking place before the sound produced by the tension of the valves.\\nDr. George Johnson took the view that the reduplication was due to\\nthe contraction of the auricle and ventricle that the sound produced\\nby the former was heard on account of hypertrophy of the auricle, and\\nheard first because of the natural order of precedence. Thus far the\\nreasons for each view have not been fully established.\\nSansom believes that reduplication of the first sound is due to the\\nshock communicated to the contents of the ventricle just before systole\\nthat is, during the auricular-systolic period in other words, it is\\ndue to the indirect effect of the auricular systole. The contraction of\\nthe auricle makes tense the auriculo-ventricular valve of the left side.\\nIf it occurs late in the diastole, or just before the systole, reduplication\\nof the first sound is caused if early in the diastole, reduplication of\\nthe second sound is created.\\nReduplication of the Diastolic Sounds. While held by some authori-\\nties to occur in a large proportion of healthy individuals at the end of\\ninspiration and the commencement of expiration, other observers,\\nequally careful, think that it is extremely rare. It is of frequent\\noccurrence in the patients of the Philadelphia Hospital. This is no\\ndoubt due to the fact that so many of the inmates are the subjects\\nof all forms of lung disease, or disease of the vascular system, with\\nmuscular degeneration of the heart, that the equability of the pul-\\nmonic circulation is disturbed. There is no doubt that it can be\\nmodified or induced by inspiration. It is usually heard at the end of\\ninspiration and commencement of expiration. Actual reduplication of\\nthe second sound occurs when the normal asynchronism of the closure\\nof the aortic and pulmonary valves is exaggerated. It has been found\\nthat the valve of the pulmonary artery closes a fraction of a second\\nafter the aortic valve. The ear usually fails to appreciate the differ-\\nence unless there are differences of blood-pressure when doubled, and\\ntherefore appreciated, it is indicative of a difference in blood-pressure\\nbetween the two sides of the circulation. Increased resistance in\\neither will lead to increased tension, quickened recoil, and hence quick-\\nened closure of the valve. The conditions that are associated with the", "height": "4404", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0688.jp2"}, "689": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 629\\ndoubling of the second sound are (1) and most frequently, mitral sten-\\nosis (2) obstruction of the circulation in the lung tuberculosis, em-\\nphysema, and bronchopneumonia (3) dilatation of the right ventricle\\n(4) myocarditis. The sound is heard at the second and third costal\\ncartilages along the left edge of the sternum. It is frequently heard\\nat the fourth and fifth cartilages on the left side. In cases of mitral\\nstenosis it is heard near the apex.\\nFig. 169.\\nQ_D D\\na. b\\nNormal first and Reduplicated and\\nsecond sounds. accentuated second sound.\\nIllustrating diagrammatically modifications of the heart-sounds. (Gibson and Russell.)\\nSimulated doubling, or false reduplication, is a sound produced at\\nthe mitral orifice. It is difficult to tell it from true doubling or redu-\\nplication. It is most distinct at the base of the heart along the left\\nedge of the sternum. Occasionally it is more distinct near the apex\\nthan elsewhere. It occurs with the conditions found in true doubling\\nand in mitral obstruction. Cause. Sansom, Cheadle, and others dis-\\ntinctly point out that this double second sound is of frequent occur-\\nrence, and that it is heard most frequently at the apex. Sansom\\nthinks that the cause for simulated doubling of the second sound is\\nthe same as for doubling of the first. There is, first, the normal second\\nsound second, a tension of the mitral curtain producing the second\\nsimulated sound. This tension is due to the shock of the blood coming\\nfrom the auricle to the ventricle.\\nIII. Abnormal Sounds or Murmurs. Abnormal sounds may be\\nheard over the heart in addition to or replacing the normal sounds.\\nThese sounds are produced in the pericardium, in the heart, or in the\\nbloodvessels. They are divided into friction-sounds and murmurs.\\nThey are recognized because they are a departure from the normal\\nsounds or because they are superadded sounds.\\nAbnormal Sounds in the Pericardium. They are known as\\nfriction-sounds and splashing or bubbling sounds. The former occur in\\nthe first stage of pericarditis, and are due to the rubbing together of\\nthe inflamed surfaces, either the congested, vascular pericardium, or\\nthe membrane bathed in exudation, or covered by lymph. The fric-\\ntion-sound is recognized by (1) its character, (2) time, (3) position, (4)\\ntransmission, (5) movability, (6) modification by position of patient,\\npressure, course of disease, etc. 1. The pericardial friction is usually\\nof a to-and-fro character, and can be recognized as distinct from the\\nheart-sounds. It resembles the rubbing or scraping together of two\\nroughened surfaces. 2. It is not necessarily synchronous with each\\nsound. It is a to-and-fro sound, systolic and diastolic in time. It\\nmay, however, be only systolic or only diastolic. 3. It is heard over\\nthe body of the heart, usually in the third and fourth interspaces, or\\neven over the right ventricle. 4. It is not transmitted away from the", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0689.jp2"}, "690": {"fulltext": "630 SPECIAL DIAGNOSIS.\\nheart. Its location may shift from day to day in the precordial area.\\n5. It may be modified by pressure or by respiratory movement, or be\\ninfluenced by the position of the patient. It may disappear entirely\\nin the upright posture. An impression of nearness to the ear is given\\nby the sound observed in the first stage of pericarditis. It may be in-\\ncreased or lessened in loudness by a deep inspiration. It disappears\\nduring the period of effusion, to return after that is absorbed.\\nDiagnosis. It must be distinguished from the pleural friction, which\\ndisappears if the patient is asked to hold his breath. The pericardial\\nfriction is of cardiac rhythm, the pleural friction of respiratory rhythm.\\nIt must also be distinguished from the so-called exocardial friction-\\nsounds. The pleura adjacent to the pericardium may be inflamed.\\nWith each beat of the heart the rough surfaces of the pleura are agi-\\ntated and generate a friction. It is seated along the edges of the right\\nauricle or left ventricle. It is systolic in rhythm, but has the special\\ncharacteristic that it is modified by respiration. It may be arrested if\\nthe patient holds his breath. It is increased by inspiration, or dimin-\\nished in expiration when the lungs recede from the heart in expiration.\\nThe pericardial friction must be distinguished from the crepitations\\nand rales of cardiac rhythm produced by the impact of the heart\\nagainst the lung. They disappear when the breath is held. The dis-\\ntinctions between pericardial frictions and cardiac murmurs will be\\nconsidered later.\\nSplashing sounds are heard when there are air and fluid in the peri-\\ncardium. They may be bubbling or gurgling or resemble the sound\\nof a water-wheel. They continue when the breath is held.\\nAbnormal Sounds in the Heart and Vessels. Murmurs.\\nIf the student listens with the stethoscope over a large superficial\\nvessel, and does not employ pressure, he will not detect any sound.\\nIf, however, pressure is employed, a sound or murmur is produced.\\nThe passage of the blood through the vessel produces no sound because\\nthe vessel or tube is of equal calibre. The pressure of the stethoscope\\nalters the calibre and compels the fluid to pass through a narrow orifice\\ninto a wider space. In this manner a fluid vein is produced. The\\nvibration of the molecules of the agitated fluid vein produces a sound\\nor murmur. The loudness of the sound depends upon the swiftness\\nof the flow. The sound in this instance is carried in the direction of\\nthe blood-current, hence the murmur is known as an onward murmur.\\nThe reverse may take place. The fluid may flow backward from a\\nwider into a narrower space without the production of sound if, how-\\never, the fluid breaks on bevelled edges, as the leaflets of heart-valves\\nprojecting into the current, the fluid is again thrown into vibration and\\nproduces noise. If there is considerable constriction by the bevelled\\nedge, the sound is carried farthest against the natural flow of the fluid\\nhence the term backward murmur. Some authors hold that mur-\\nmurs are also due to lateral vibrations of the walls of the heart or of\\nthe vessels. Some murmurs may resemble tones, and are called musi-\\ncal murmurs. Such murmurs are due either to the vibrations of the\\nsolids set up by the vibrating fluid vein, or to the vibrations of the\\nfluid vein alone.", "height": "4412", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0690.jp2"}, "691": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 631\\nMurmurs are divided into two classes, in accordance with their seat\\nof development. Murmurs originating in the heart are known as car-\\ndiac murmurs. Murmurs originating in the bloodvessels are vascular\\nmurmurs. (See The Arteries.) Cardiac and vascular murmurs are\\ndivided into (1) organic murmurs, if due to physical changes of the\\nheart or vessels (2) inorganic, functional, or hcemic, if due to changes\\nin the quality of the blood. (See Functional Murmurs.) Cardiac\\nmurmurs are always generated at the orifices from disease or from\\nincompetency of the valves, or from patulous non-valve opening. The\\norifices are valvular and non-valvular.\\nMurmurs at Valvular Orifices. The valvular orifices and\\ntheir anatomical relations have been described. Murmurs are produced\\nat these orifices when they are open or when normally they should be\\nclosed. If the murmur is produced when the orifice is open it is\\nbecause there is narrowing of the orifice or dilatation of the cavity\\n(relative narrowing). The murmur, then, is always produced with the\\nnatural current of blood, and hence is known as an onward or obstructive\\nmurmur. It always or nearly always implies organic disease at the\\nvalve-orifice, hsemic murmurs excluded. If the murmur is produced\\nwhen the orifice should be closed, and hence when the valve leaks, it is\\nbecause the valves are diseased and cannot shut the orifice, or because\\nthey are too small incompetent to shut it. Such murmurs are pro-\\nduced against the natural current of blood, and are known as backward\\nor regurgitant murmurs.\\nMurmurs at Non- valvular Orifices. The orifices of the vena\\ncavse and of the pulmonary veins, and of the perforations of the septa\\nin congenital heart disease, are non-valvular. They are at times the\\nseat of murmurs as in open foramen ovale or perforated ventricular\\nseptum.\\nDiagnosis of Murmurs. The student has learned that an abnor-\\nmal sound or a murmur is present. It is necessary then to determine,\\nfirst, at which orifice the murmur is produced (the seat of the murmur)\\nand, second, the kind of murmur obstructive or regurgitant. Mur-\\nmurs are therefore studied as heart-sounds are studied, as to their\\nposition of maximum intensity, their time, and the direction of their\\ntransmission. The position of the murmur indicates which valve-\\norifice is affected, the time and the direction of transmission, and the\\nkind of murmur.\\nThe Position of Maximum Intensity of the Murmur. The\\nOrifice Affected. We are enabled accurately to determine the orifice\\nat which the murmur is generated by noting the position of maximum\\nintensity of the murmur. This corresponds to the area at which the\\nnormal sound of the respective valve is heard loudest. It may be re-\\nmembered that the cardiac orifices are closely situated, and that, there-\\nfore, the murmurs must be generated within a small area, so small that\\nit would be impossible to ascertain at which valve-orifice the murmur\\nis created, were it not for the fact that under the laws of conduction of\\nsound the murmurs are conducted away from their point of origin to\\ncertain definite stations, where in health the respective valve-sound is\\nalso heard loudest.", "height": "4416", "width": "2572", "jp2-path": "practicaltreatis00muss_0_0691.jp2"}, "692": {"fulltext": "632\\nSPECIAL DIAGNOSIS.\\n1. Murmurs at the Apex the Mitral Area. A murmur heard\\nloudest, or with the greatest intensity, at the apex is known as a mitral\\nmurmur. It is created at the mitral orifice, but is conducted to the\\napex by the left ventricle, which is nearest the chest- wall at this point.\\n(See 1, Fig. 164.)\\n2. Murmurs at the Xiphoid Cartilage the Tricuspid Area. The\\nmurmur is heard loudest at the xiphoid cartilage or the head of the\\nfourth or fifth rib. It is created at the tricuspid orifice, and is heard\\nmost distinctly over the lower portion of the sternum, and along the\\nleft edge, because the right ventricle is in apposition with the chest-\\nwall at this spot. (See 2, Fig. 164.)\\n3. Murmurs at the Second Costal Cartilage or Second Interspace on\\nthe Right the Aortic Area. When a murmur is heard with great-\\nest intensity at this point it is usually generated at the aortic orifice,\\nand is conducted to this region by the aorta, which comes nearest to\\nthe surface of the chest at this point. (See 3, Fig. 164.)\\n4. Murmurs in the Second Left Interspace the Pulmonic Area. A\\nmurmur heard loudest at the second interspace along the left edge of\\nthe sternum is generated at the pulmonary orifice it is heard loudest\\nin this area because the pulmonary artery is nearest the chest at this\\npoint. (See 4, Fig. 164.)\\nThe Rhythm or Time of the Murmur. The Kind of Murmur.\\nHaving determined the point of maximum intensity of the murmur,\\nhence the valve at which it has its origin, we next wish to determine\\nthe kind of murmur. A murmur which is produced at orifices when\\nthey should be closed is known as the murmur of regurgitation, as the\\nvalve permits the blood to flow backward. A murmur that occurs\\nFig. 170.\\nMaximum inteusity of murmur of mitra 1 regurgitation systolic transmitted to trie left.\\nwhen the blood should in health be passing through an orifice is known\\nas a murmur of obstruction, as the flow of blood is obstructed. We\\nhave to determine whether the murmur at an orifice is due to regurgi-\\ntation or to obstruction. This is ascertained by the time of the murmur.", "height": "4412", "width": "2560", "jp2-path": "practicaltreatis00muss_0_0692.jp2"}, "693": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 633\\nThe time of the murmur is determined by the heart-sounds, by the\\nimpulse, and by the pulse.\\nMurmurs with the Systole.\\n1. In the Mitral Area. In health, during this time, the auriculo-\\nventricular valve is closed. The murmur indicates there is such dis-\\nease as to permit of a backward flow of blood, or of regurgitation, into\\nthe auricle. It is the murmur of mitral regurgitation. It may be due\\nto disease of the valves or to incompetency. (See Fig. 170.)\\nFig. 171.\\nMaximum intensity of murmur of tricuspid regurgitation systolic.\\n2. In the Tricuspid Area. As on the left side, the murmur in this\\narea is due to valvular disease or valvular incompetency, which per-\\nmits of regurgitation, tricuspid regurgitation. (See Fig. 171.)\\nFig. 172.\\nPosition of maximum intensity and directions of transmission of murmur of aortic obstruction.\\n3. In the Aortic Area. During this time the blood is flowing from\\nthe ventricle into the aorta. If there is disease which causes obstruc-\\ntion at the orifice the murmur of aortic obstruction is produced. The", "height": "4416", "width": "2576", "jp2-path": "practicaltreatis00muss_0_0693.jp2"}, "694": {"fulltext": "634\\nSPECIAL DIAGNOSIS.\\nmurmur may be due to anaemia to disease of the aorta, or to its mal-\\nposition. (See Fig. 172.)\\n4. In the Pulmonary Area. The pulmonary orifice is affected in\\nthe same way as the aortic orifice under the same circumstances. The\\nmurmur is due to pulmonary obstruction. It is exceedingly rare. It\\nis more frequently hsemic. (See Fig. 175.)\\nMurmurs with the Diastole.\\n1. In the Mitral Area. The blood is flowing from the left auricle\\nto the left ventricle. Disease of the valves obstructs the flow. The\\nmurmur occurs in the beginning, in the middle, or at the end of the\\nlong silence. Mid-diastolic and late diastolic, or because it occurs\\nbefore the systole, presystolic, are the terms applied to this murmur.\\nIt is the murmur of mitral obstruction. (See Fig. 173.)\\nFig. 173.\\nMaximum intensity of murmur of mitral obstruction presystolic, localized or transmitted as\\narea shows.\\n1. Normal impulse. O. Area of reduplication of second sound.\\n2. In the Tricuspid Area. It occurs for the same reason and at the\\nsame time as the diastolic murmurs generated at the mitral orifice.\\nIt is rare, although more common than usually supposed, to find tri-\\ncuspid obstruction.\\n3. In the Aortic Area. The aortic valve closes in the diastole. A\\nmurmur indicates it is so diseased that it cannot prevent blood flowing\\nbackward or regurgitating into the ventricle. It is the murmur of\\naortic regurgitation. A murmur of the same time and in the same\\nsituation may be due to dilatation or aneurism of the aorta. (See Fig.\\n174.)\\n4. In the Pulmonary Area. A diastolic murmur in this area is due\\nto regurgitation at the pulmonary orifice. (See Fig. 175.)\\nMurmurs are divided as to time into systolic and diastolic murmurs.\\nThe above shows that we may have practically only three systolic and\\ntwo diastolic murmurs. The systolic murmurs are aortic obstruction\\nand mitral and tricuspid regurgitation. The diastolic murmurs are\\naortic regurgitation and mitral obstruction.", "height": "4412", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0694.jp2"}, "695": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 635\\nThe Direction of Transmission. It depends upon the situation\\nof the murmur and the time at which it is produced. Some murmurs\\nare not transmitted. The transmission is usually in the direction of\\nthe currents which produce them.\\nFig. 174.\\nPositions of maximum intensity and directions of transmission of murmur of aortic regurgitation.\\nMurmurs in the Mitral Area. To the axilla. A murmur which is\\nproduced at the apex with the systole, caused by regurgitation at the\\nmitral orifice, is transmitted into the axilla, and may be heard at the\\nangle of the scapula. The murmur which is produced in the same\\narea before the systole obstruction is usually not transmitted. It is\\nheard at the apex, or a little inside of the apex, or may rarely have its\\npoint of maximum intensity in the third interspace. Sometimes it is\\ntransmitted to the axilla and to the angle of the scapula. (See Figs.\\n170 and 173.)\\nMurmurs in the Tricuspid Area. The murmur of tricuspid regurgi-\\ntation is not transmitted. It is heard over a relatively large area, de-\\npending upon the intensity of the sounds.\\nMurmurs in the Aortic Area. Upward and Along the Vessels. The\\nmurmur, systolic in time, heard at the second costal cartilage on the\\nright, due to aortic obstruction, is transmitted in the direction of the\\nblood-current. The sound is conducted by the vessels and by the\\nfluid it is, therefore, heard along the course of the aorta and in the\\ncarotid arteries. Downward to the Apex. The murmur of aortic re-\\ngurgitation, heard in the same area, is transmitted downward along the\\ncourse of the sternum. It may be transmitted to the apex, or may\\nbe heard along the sternum only. The left ventricle conducts this\\nmurmur. (See Figs. 172 and 174.)\\nCharacter of the Murmurs. Murmurs are further distinguished\\nby their character and the degree of loudness. By the character of the\\nmurmurs we are aided (1) in distinguishing them from heart-sounds\\n(2) in estimating the nature of the lesion that produces the murmur\\n(3) in judging, in the case of murmur of mitral obstruction, of the\\npresence or absence of that disease.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0695.jp2"}, "696": {"fulltext": "636\\nSPECIAL DIAGNOSIS.\\nDistinction from Normal Sounds. Normal sounds are sounds\\nof tension murmurs are sounds of rhythmical vibration. The normal\\nsounds of the heart have been described by the syllable ubb dupp,\\nod, and abnormal sounds of endocardial origin by uf uv,\\nFig. 175.\\nMaximum intensity of pulmonary systolic murmur.\\nO Area of murmur of anaemia.\\nush, or by full vowel sounds as oo,\\nit 99 it\\nah, and aw,\\nby musical tones, or by interrupted tones, or by general sounds, as\\na urr 77 or a orr\\nThe Nature of the Lesion. The murmurs may be rough or rasping,\\nmusical or whistling in character. They may be high or low in pitch.\\nMurmurs that are rough and high in pitch are usually due to disease\\nof the valves, causing thickening or stiffening of the leaflets, or to the\\nprojection of an atheromatous plate into the lumen of the orifice. Such\\nconditions occur in chronic endarteritis and chronic endocarditis or\\nvalvulitis. On the other hand, murmurs that are soft and low in pitch\\nare usually due to a physical condition which causes swelling of the\\nvalve or occlusion by soft exudations they are heard in endocarditis\\nof rheumatic origin, or the malignant form of endocarditis. The only\\nmurmur which has special characteristics is the murmur of mitral\\nobstruction. It is a prolonged murmur of a churning or grinding char-\\nacter, sometimes rippling, and as if fluid were being forced through a\\nnarrow channel. It is usually presystolic, but may occur in the middle\\nof the diastole.\\nLoudness. The loudness of the murmur is not of special signifi-\\ncance, although, in general, it may be said that it indicates good com-\\npensation, and that the heart muscle is sufficiently strong to meet the\\ndemands of the circulation. Murmurs are louder in the recumbent\\nthan in the erect posture in some instances, especially mitral and tricus-\\npid murmurs. Murmurs are often more distinct after exertion. Loud\\nmurmurs may become weak, and this change in character of the sound\\nis of serious omen. They may disappear in the course of fevers and\\nin the dying state.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0696.jp2"}, "697": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 637\\nDisappearance of Murmur. The student will often find that\\nafter a patient has been under treatment for a short time the murmurs\\ndisappear. This is probably due to the fact that there is complete\\ncompensation. In the terminal stages of cardiac disease they disap-\\npear because of weakness of the heart muscle. Rarely they disappear\\nbecause the roughened valve causing them has been repaired. (See\\nDisappearance of Murmurs/ 7 by the author. British Medical Journal,\\n1897.) In other cases it may be necessary to bring out a faint mur-\\nmur or increase its intensity by having the patient move about this\\nrenders it more distinct by inducing more rapid action of the heart.\\nThe Significance of Murmurs. Murmurs heard at the various\\norifices indicate either (1) disease of the valves (2) incompetency of\\nthe valves (3) disease of the blood or (4) disease of the vessels in\\nintimate relation with the heart. The systolic murmur at the second\\ncostal cartilage on the right may be heard when there is disease at the\\naortic orifice, causing obstruction in atheroma of the aorta in cases\\nof aneurism just above the valves in anaemia, and chlorosis, and in\\nsome vasomotor neuroses, as Graves disease. Before concluding that\\nthe murmur is due to disease of the valves we must be able to exclude\\nthe other conditions. Atheroma of the aorta, is most difficult to distin-\\nguish from obstruction, because the character of the murmur is the\\nsame and the associated conditions are similar. In both there may be\\na previous history of gout, rheumatism, syphilis, or alcoholism. The\\nlatter are associated with atheroma in other arteries of the body, and\\nwith degenerative changes that accompany atheroma. In young sub-\\njects, in whom there has been a direct history of rheumatism, or when\\nthe process has followed septicaemia, the probabilities are, in nearly\\nall the cases, that the murmur is due to aortic obstruction. To dis-\\ntinguish the murmur of anaemia, chlorosis, or Graves diseases is often\\ndifficult. The associate symptoms in each case are different, however,\\nand with the changes in the blood indicate the nature of the murmur.\\nIn other valve areas the chief task is to decide whether the murmur\\nis orgamc, due to valvulitis, or whether it is functional, due to incompe-\\ntency or to anaemia.\\nMurmurs due to Incompetency. The valves are sometimes\\nunable to close properly. The cavity of the ventricles may increase\\nin size, so that the valves do not coapfcate to close the widened orifice.\\nThe tricuspid and mitral valve leaflets often become thus incompetent.\\nMitral and tricuspid regurgitation ensue. The murmurs are soft and\\nlow in pitch and not widely transmitted the heart is dilated.\\nMurmurs of Anemia. The murmurs of anaemia have some char-\\nacteristics which aid in distinguishing them from true organic mur-\\nmurs. The most important of these are (1) The situation of the mur-\\nmur (2) its character (3) the direction in Avhich it is transmitted (4)\\nthe time (5) the associate signs (6) the secondary heart-muscle changes.\\n1. The murmurs of anaemia may be heard at any orifice, but are usually\\nheard at the second costal cartilage, or the third interspace, on the left\\nside. They are generated at the pulmonary orifice, or in the cone of\\nthe right ventricle. The murmur at the pulmonary orifice may be\\nheard as high as the second interspace, but otherwise is not transmitted.", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0697.jp2"}, "698": {"fulltext": "638\\nSPECIAL DIAGNOSIS.\\nMurmurs of anaemia are also heard at the apex, at the aortic cartilage?\\nand over the tricuspid area. They are comparatively infrequent in\\nthese situations, but partake of the same nature as the murmur heard\\nat the pulmonary orifice. 2. They are soft in character and low in\\npitch. They are louder in the recumbent than in the upright posi-\\ntion. Their loudness is increased by violent cardiac action. They\\nare loudest just at the end of expiration or beginning of inspiration.\\n3. They are not transmitted away from the heart. 4. They are systolic\\nin time. 5. They are associated with murmurs in other parts of the\\nvascular system, as the murmur in the jugular veins. Its characteris-\\ntics and mode of recognition will be described elsewhere. 6. Mural\\nchanges, as general dilatation, fatty degeneration, or hypertrophy may\\nbe present but single chambers do not undergo change. The murmur\\nof anaemia may usually be considered to be temporary.\\nFig. 176.\\nMaximum intensity of murmurs of anaemia, systolic. iSansom.)\\n1 Pulmonary artery, 59 per cent. 2. Apex, 7 per cent. 3. Right v. and conus, 11 per cent.\\n4. Aortic area, 11 per cent. 1 and 2. Pulmonary and apex coexisting, 9 per cent.\\nFunctional Murmurs not Anemic. Drummond divides func-\\ntional murmurs into three classes cardio-haemic or anaemic cardio-\\nmuscular or neuro-typtic, and cardio-respiratory. The first has been\\nconsidered above. The eardio-muscular murmur attends excited action\\nof the heart. It is heard loudest at the fourth left interspace close to\\nthe sternum loudest in the upright posture loudest at the end of\\nexpiration. It disappears at the end of inspiration, or when the patient\\nlies on the side. Of course, it is increased by exertion and excitement.\\nIt is rough or whizzing in character. The cardio-respiratory murmur\\nis fairly common. It is most marked in inspiration, but may be heard\\nin both acts. It is systolic in time, and is heard loudest at the apex,\\nbut I have often heard it along the left border of the heart, as high as\\nthe second rib and in the axilla, and at the angle of the scapula. It is\\nshort and whiffing, and the sound gives one the impression that the\\nheart is striking the lung.\\nInfluence of Pressure. Pressure exerted, Sewall says, while using\\nthe flexible stethoscope over the second costal interspace annuls in part,", "height": "4416", "width": "2592", "jp2-path": "practicaltreatis00muss_0_0698.jp2"}, "699": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 639\\nor wholly, the second sound of the heart but if the ascending aorta\\nbe dilated or the site of an aneurism, the second sound persists strongly\\nnotwithstanding firm pressure.\\nFurther, firm pressure removes\\n(A) 1. Hsemic murmurs over the base of the heart (save Jenner s\\npulmonary murmurs).\\n2. An aortic obstructive murmur of the apex.\\n3. When mitral and aortic regurgitant murmurs coexist, the\\naortic murmur is diminished in the greater degree.\\n4. Aortic regurgitant murmurs over the second right intercostal\\nspace.\\nWhile it does not markedly affect\\n(B) 1. Mitral regurgitant murmurs heard over the apex or\\n2. Mitral obstructive murmurs over the same spot.\\n3. Tricuspid regurgitant murmurs over the area of greatest in-\\ntensity.\\n4. Aortic regurgitant murmurs over the apex (see (A), No. 3).\\nSecondary Effect of Valve-lesions on the Heart and Pulse.\\nThe secondary effect of valve-lesions on the heart and pulse aid in the\\ndiagnosis. While we are enabled by the time of the murmur, the posi-\\ntion, and the direction of transmission to affirm the nature of the dis-\\nease at the respective valve-orifices, other physical signs further aid\\nus in determining more precisely the lesion and its seat. They are\\nderived from the heart and the pulse. They depend upon the second-\\nary effect of the lesion upon the heart and upon the circulation. In\\naortic obstruction, on account of obstruction to the flow of blood, the\\nleft ventricle hypertrophies moreover, the blood stream is lessened in\\nvolume, and hence the pulse is small and of high tension. The physi-\\ncal signs of hypertrophy and small pulse are corroborative evidence of\\nthis lesion at the left orifice. In aortic regurgitation the blood flows\\nback into the ventricle. On this account, therefore, some dilatation\\ntakes place, a dilatation which, if compensation is perfect, is overcome\\nby hypertrophy. The signs, however, of enlarged left heart are pres-\\nent, as shown by inspection, palpation, and percussion. But the pulse\\nof aortic regurgitation is of the greatest diagnostic significance. With\\nthe finger on the radial, the impression is at once received of recedence\\nof the pulse- wave as soon as it strikes the finger. This is more marked\\nif the hand is elevated. It is the water-hammer, or Corrigan s, pulse.\\nIn mitral regurgitation the left auricle does not change, but the stress\\nis thrown upon the right side of the heart, and we have the signs of\\nright-sided hypertrophy and dilatation but more marked than this is\\nthe evidence of high tension of the pulmonary artery, shown by accen-\\ntuation of the second sound. (See p. 625.) In mitral regurgitation,\\nthe blood flows back into the auricle, and when the right heart weak-\\nens engorges the venous system. The arterial system is in consequence\\ndevoid of blood, and hence the arteries are empty. The pulse is small\\nand feeble. The depleted coronary arteries do not nourish the ven-\\ntricles, hence dilatation or failure in nutrition soon ensues, and the", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0699.jp2"}, "700": {"fulltext": "640 SPECIAL DIAGNOSIS.\\nheart is further weakened. In addition to being small and feeble, the\\npulse, on account of inefficient and hurried contractions of the ventricle,\\nis irregular and intermittent.\\nIn mitral obstruction, in addition to the characteristic murmur, the\\nthrill is of great significance. Moreover, the left auricle hypertrophies,\\nand shortly afterward the right heart. It is accompanied by an ac-\\ncentuated pulmonary second sound, and frequently by doubling of that\\nsound. The pulse is small and feeble.\\nMultiple Cardiac Murmurs. More than one murmur may be\\nheard over the heart. The number depends upon the number of\\nvalves that are the seat of disease and the lesions at the orifices. We\\nmay have valvulitis of the aortic, mitral, and tricuspid valves conjoined.\\nMore commonly one valve is diseased, giving rise to a murmur, while\\nanother valve is incompetent, on account of dilatation, and a murmur\\nthus generated at its orifice It is common to see aortic obstruction\\nfrom valvulitis and mitral regurgitation from incompetency mitral\\nobstruction or regurgitation from valvulitis, and tricuspid regurgita-\\ntion from incompetency. I have seen double aortic disease (combined\\nobstruction and regurgitation), double mitral disease, and tricuspid\\nregurgitation. The diagnosis of the various murmurs will be dis-\\ncussed in the chapter on Valvulitis.\\nThe Arteries. The stethoscope should always be used in examining\\nthe arteries. The double stethoscope is preferable, as strong pressure\\nmust be avoided upon the vessels. When the single stethoscope is used\\nsome diagnostic value attaches to the character of the shock that is trans-\\nmitted to the head. The arteries open to auscultation are the carotids\\nwhen the neck is slightly extended the subclavian the innominate\\nabove the stern o-clavicular articulation the brachial artery in the\\nbend of the elbow, with the arm slightly extended and the crural\\nartery just below Poupart s ligament. The normal systolic and dias-\\ntolic heart-sounds are often heard in the carotid and subclavian arte-\\nries. The systolic sounds may be heard over the abdominal aorta,\\ndue to tension of the vessels. The diastolic sound is rarely heard in\\nthis situation. In the other vessels no sounds are heard.\\nInduced or pressure-murmur. By pressure with the stethoscope over\\none of the vessels its calibre is modified and a murmur created. This\\nmurmur corresponds in time with the pulse, hence it is systolic, and\\nincreases or diminishes in intensity, depending upon the amount of\\npressure placed upon it. Just here may be mentioned the systolic\\nhumming which is heard in children between the third month and the\\nsixth year over the fontanelles and sometimes over the rest of the\\nhead. (See The Head.)\\nAbnormal Sounds. Abnormal sounds or murmurs are due to\\nalterations of the blood, disease outside of the vessels causing pressure,\\nand disease of the vessels. Murmurs from disease of the vessels, as\\nthe aorta, are discussed under the head of arterio-sclerosis or aneurism.\\nConduction Murmurs. Murmurs may be propagated into the\\narteries. A systolic murmur created at the aortic orifice may be heard\\nin the vessels of the neck and along the aorta. On the other hand,\\nin aortic regurgitation, the diastolic sound normal in the carotid and", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0700.jp2"}, "701": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 641\\nsubclavian disappears, and the diastolic murmur is not heard. Double\\nSounds of the Vessels. Double sounds are sometimes heard in the\\ncrural artery under the following circumstances (1) In aortic insuffi-\\nciency (2) in mitral stenosis (3) in lead-poisoning (4) in pregnancy.\\nDuroziez s double murmur, heard when greater pressure is used by the\\nstethoscope, occurs in aortic regurgitation when there is good compen-\\nsation. Many authorities refer to this as a valuable diagnostic sign\\nin this affection. The double sound in all instances occurs with large\\nand quick pulse. It is probably caused by sudden collapse of the\\nartery, and the reflux blood-current which is possibly an aortic regur-\\ngitation.\\nMurmurs due to Alterations of the Blood. They are gen-\\nerated in anaemia and chlorosis. They are called functional murmurs,\\nto distinguish them from murmurs due to disease of the vessels. They\\nare systolic in time. They are soft and low in pitch, often of a musical\\ncharacter. The degree of loudness may vary with the position of the\\npatient. They are increased by excitement. The intensity of the mur-\\nmur increases in the course of fevers.\\nMurmurs in Relaxed Vessels. Murmurs in the vessels, appar-\\nently of functional origin, are sometimes heard. The vessels are\\ndilated from actual disease. The increased calibre favors the develop-\\nment of a murmur by the creation of a fluid vein. Dilatation of the\\ninnominate artery sometimes takes place, giving rise to a murmur, which\\nin loudness and character simulates the murmur of aneurism. A\\nfunctional murmur is sometimes heard in the vessels, independently of\\ndisease, in cases of aortic regurgitation. The murmur is systolic in\\ntime.\\nPressure-murmurs. Pressure of the stethoscope, or that caused\\nby diseases outside of the bloodvessels. When heard over the subclavian\\nartery, the pressure-murmur may be due to adhesions or consolidation\\nat the apex of the lung. It is more frequently heard at the left, and\\nmay only be present during full expansion of the lung. It is due to\\ntemporary pulling or bending of the artery during deep breathing.\\nWhen it occurs on both sides it is not of much significance. Murmurs\\nin the axillary artery, or in any arteries surrounded by enlarged lym-\\nphatic glands, are created by their pressure. Murmurs in the thyroid\\ngland have been referred to. (See Goitre.)\\nMurmurs due to Disease of the Arteries. In the aorta the\\nmurmurs are due to aneurism or atheroma, or both., They may be\\nsystolic or diastolic. In the smaller vessels both conditions may be\\npresent, although atheroma is the usual one. The murmur is systolic\\nin time, rough in character, strong or weak. It is associated with\\nother signs of atheroma.\\nThe VeinS. In health no sounds are heard. Two conditions\\ncontribute to the creation of a murmur in the veins (1) Change in the\\ncharacter of the blood (2) dilatation with the occurrence of positive\\nvenous pulse.\\nThe Venous Hum. In anaemia and chlorosis, and sometimes in\\nhealthy patients, a hum or murmur, or buzzing sound is heard over\\nthe jugular veins. It is louder on the right side than on the left. It is\\n41", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0701.jp2"}, "702": {"fulltext": "642 SPECIAL DIAGNOSIS.\\nsoft and low in pitch, and may be musical it has been described as\\nhumming or whizzing. It is continuous. For its detection a double\\nstethoscope should be used, as pressure increases it, and the patient\\nshould not turn the head to one side, as it is increased when this posi-\\ntion is taken. The murmur is modified by the respiration and by the\\ncardiac action. It is louder in deep inspiration when the blood is\\ngoing more rapidly to the thorax. It is also louder in the upright\\nposition. It is frequently louder during the diastole. The increased\\nloudness at these periods occurs because, from the sucking action\\nduring inspiration and during the diastole, the blood is more rapidly\\ndrawn toward the heart. The murmur is caused by the flow of blood\\nfrom the narrow jugular into its wider bulb, producing a fluid vein.\\nLater authorities believe it to be due to lateral vibration of the walls\\nof the veins. Similar murmurs are heard in other veins, as in those\\nof the extremities when the anaemia is profound. They are stronger\\nduring the diastole of the heart. The venous hum is sometimes heard\\nat the lower border of the liver, to the right of the median line, in\\ncirrhosis of the liver. It is created in the enlarged collateral veins.\\nIt may be modified by pressure of the stethoscope. It may be heard\\nin this situation in emaciated and cachectic subjects not the subject of\\ncirrhosis. The venous hum may be heard in the innominate veins\\n(first and second interspaces and right costo-clavicular articulation), in\\nthe subclavian and axillary veins.\\nPericarditis.\\nInflammation of the Pericardium. The inflammation may be\\nacute or chronic. It is also divided according to the nature of the in-\\nflammation into simple fibrinous inflammation and inflammation with\\neffusion. The effusion may be serous, bloody, or purulent, depending\\nupon the nature of the inflammation. Pericarditis, either acute or\\nchronic, is also divided into primary or secondary pericarditis. The\\nprimary form is of extremely rare occurrence. Indeed, it may well\\nbe doubted whether, in common with the inflammations of serous\\nmembranes in general, pericarditis is ever primary, or so-called idio-\\npathic, in origin.\\nCauses. 1. Extension from Neighboring Structures. Extension of\\nthe inflammation from infected tissues in the vicinity is a common\\ncause of pericarditis. It may follow a pleurisy and partake of the\\nnature of the primary pleural inflammation. It often attends em-\\npyema, either from extension of the infection to the pericardium or\\nfrom rupture into the pericardial sac. It may follow all forms of in-\\nflammation of the mediastinum. Disease of the ribs adjacent to the\\npericardium may set up pericarditis, acute and chronic. It attends\\non the course of aortic aneurism, at times, but more frequently in-\\nfectious endocarditis and myocarditis. Inflammations below the\\ndiaphragm frequently give rise to pericarditis. Peritonitis, when\\ngeneral or local sub-diaphragmatic abscess suppurative gastritis,\\nwith perforation of the stomach abscess of the liver suppurating", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0702.jp2"}, "703": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 643\\nhydatid, and other forms of suppuration below the diaphragm, belong\\nto the latter.\\n2. General Infections. The general diseases causing inflammation of\\nthe pericardium are those which affect serous membranes. They are\\nInfectious diseases, particularly scarlet fever, measles, erysipelas, and\\ntvphoid fever. All forms of septicaemia may be attended by inflamma-\\ntion of the pericardium. Tuberculosis is a frequent cause of pericar-\\nditis. Inflammation of this membrane frequently arises in the course\\nof rheumatism. It may occur in the course of the disease, or attend\\nsome of the affections which are themselves manifestations of rheuma-\\ntism, such as acute tonsillitis. In the course of certain dyscrasise the\\npericardium is frequently the seat of inflammation because more vulner-\\nable. This is particularly the case in scurvy. It occurs also in Bright s\\ndisease, and may be the first manifestation to the patient of this disease,\\nparticularly in the chronic form of nephritis. It occurs in the course\\nof gout.\\nThe various forms of pericarditis may occur at any age, although\\nthat which attends scarlatina and rheumatism occurs in early life, while\\nlate in life it is an attendant upon chronic Bright s disease and gout.\\nAcute Fibrinous or Plastic Pericarditis.\\nThis is probably the most common form that is seen. It is the\\nvariety that attends Bright s disease, rheumatism, and tuberculosis.\\nIt may be wanting entirely in symptoms. An examination of the\\nheart in the routine of duty may reveal its presence by physical signs.\\nIn the course of one of the primary causal diseases, if the tempera-\\nture rises a little higher than it should, or convalescence is delayed,\\npericarditis should be suspected. Again, if the pulse is more rapid\\nand quicker than customary at the period of disease the examina-\\ntion is made, or out of proportion to the temperature, the disease\\nshould be suspected. There may be altered rhythm or tumultuous\\naction. In other instances the patient may complain of pain in the\\nregion of the heart. It is usually localized in the fourth or fifth inter-\\nspace. It is not very severe and not influenced by pressure. Some-\\ntimes the pain is complained of at the xiphoid cartilage. In rare\\ninstances it may resemble angina. The pain and the occurrence of\\nfever further call attention to the heart.\\nPhysical Signs. Inspection. Nothing unusual is observed, although\\nthe heart may be seen to beat more violently against the chest- wall.\\nThe impulse is diffused.\\nPalpation. A friction-fremitus may be detected, due to the rub-\\nbing together of the roughened pericardial surfaces. It is not always\\npresent. It may be felt when the whole hand is laid over the prsecor-\\ndia, or by palpation with the tips of the fingers. It is most marked\\nover the right ventricle, particularly in the fourth interspace, and is\\nincreased when the patient leans forward.\\nAuscultation. A friction-sound is usually present. It may be present\\nwhile the fremitus is absent but, on the other hand, if the fremitus", "height": "4408", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0703.jp2"}, "704": {"fulltext": "644 SPECIAL DIAGNOSIS.\\nis present, we can always hear the friction. It is heard over the -region\\nwhere the fremitus is felt.\\nPoint of Maximum Intensity. It may be heard along the course of\\nthe sternum It is usually heard in the third or fourth interspace,\\nbut may be heard as high as the second, adjacent to the sternum in\\neither interspace. Sometimes it is heard at the second costal cartilage\\non the right, rarely at the apex. The point of maximum intensity\\nmay vary with the position of the patient.\\nTime. It is both systolic and diastolic. In some cases it may be\\nonly systolic in time, or it may be of a galloping nature, representing\\nthree sounds during the cardiac cycle. Again, the to-and-fro sound is\\nnot synchronous with the systolic and diastolic sound, although it\\noccurs but oncq in the cardiac cycle. It may begin after systole, and\\nbe completed before the end of the diastole. The impression that it\\nis a superadded sound is most positive.\\nDirection of Transmission. It is localized, and not transmitted.\\nCharacter. It is a to-and-fro rubbing, scratching, or grating sound\\nit gives the impression of being near the ear. It may be modified by\\nthe pressure of the stethoscope and by the position of the patient. It\\nmay be heard in the erect and disappear in the recumbent posture.\\nDiagnosis. Acute pericarditis without effusion is not recognized\\ngenerally, because it is not sought for. In the larger number of\\ncases, as previously intimated, there have been no indications of dis-\\nease of the pericardium during life. If sought for, however, the diag-\\nnosis is usually easy. The pericardial friction may be mistaken for\\nan organic heart-murmur or for pleural or pleuro-pericardial friction.\\nIt is often difficult to distinguish the to-and-fro friction from the mur-\\nmurs of double aortic disease. If attention is paid to the general and\\nlocal phenomena, the mistake is not likely to be made. The location\\nof the murmurs in organic heart disease, the direction of the transmis-\\nsion, the character of the murmur, the peculiar character of the pulse,\\nand the secondary effects upon the muscles of the heart, point to the\\ndiagnosis of valvular lesion. The pleuro-pericardial friction which\\nsimulates pericardial friction usually occurs in the course of phthisis\\nor pleuropneumonia. It is modified by respiratory movement (1) It\\nmay disappear, or at least diminish, if the breath is held (2) a full expi-\\nration may cause its disappearance. While it is of cardiac rhythm it\\nis modified by the respiratory rhythm, so that on inspiration it is\\nusually more marked. The pleuro-pericardial friction is not so\\nstrikingly modified by position. Pleural Friction. This is of respira-\\ntory rhythm and ceases with cessation of breathing. The pericardial\\nfriction persists even if the breath is held.\\nPericarditis with Effusion.\\nI know of no affection which is more frequently overlooked during\\nlife than pericardial effusion This is because it develops without\\nsymptoms. In plastic pericarditis we have referred to the occurrence\\nof pain. This may occur before the effusion in the latter form, but is", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0704.jp2"}, "705": {"fulltext": "", "height": "4392", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0705.jp2"}, "706": {"fulltext": "PLATE XXVIII\\nFIG. 1.\\nHP\\nPericarditis With Effusion.\\nFIG. 2.\\nSyst. ret/:\\ny\\nAdherent Pericardium. Chronic Left-Sided Pleurisy.", "height": "4316", "width": "2612", "jp2-path": "practicaltreatis00muss_0_0706.jp2"}, "707": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 645\\nusually moderate. As with dry pericarditis, however, it may, in rare\\ninstances, be very severe, anginous in character, and be increased by\\npressure over the heart or on the pit of the stomach.\\nThe symptoms are usually due to the special character of the inflam-\\nmation and the presence of fluid in the pericardium.\\n1. General Symptoms. In non-suppurative cases the symptoms\\nare usually cerebral. Delirium may be moderate or maniacal. It\\nmust not be confounded with the delirium which occurs in the course\\nof acute rheumatism with hyperpyrexia. In addition, choreiform\\nmovements have been described. They may, however, be of rheu-\\nmatic origin. Other cerebral symptoms, as hemiplegia and convulsive\\nattacks, occur in the course of pericarditis, probably due to an associ-\\nated endocarditis, causing embolism. In some cases albuminuria is\\nfound.\\nThe general symptoms of pericardial effusion depend upon the\\nnature of the primary disease and the character of the fluid. In\\ntuberculous pericarditis, emaciation, irregular fever, sweats and prostra-\\ntion ensue. In purulent pericarditis there may be recurring chills with\\na temperature-range decidedly intermitting, along with other phenom-\\nena of purulent accumulation. In a case recently seen (1895) the\\npatient was extremely debilitated and prostrated on account of pneumo-\\nnia following influenza. He was extremely anaemic, and the blood-\\ncount showed diminution of red cells to one-half without other change.\\nEvery fourth day after a chill the temperature would rise to 103\u00c2\u00b0 or\\n104\u00c2\u00b0. A friction-sound was detected after the second chill. It disap-\\npeared, but the physical signs of effusion were not positive. From\\nthe first the heart s action was so weak that the sounds were scarcely\\ndiscernible. At the autopsy four or five ounces of pus were found in\\nthe pericardial sac. The purulent accumulation was the only lesion\\nto account for the symptoms, and, we would say now, was no doubt\\na pneumococcus infection.\\n2. Local Symptoms The local symptoms are due to the accumu-\\nlation of fluid within the pericardium. Dyspnoea is the most common.\\nThe degree depends upon the amount of effusion. If the latter is\\nlarge, there may be extreme orthopnoea if the effusion is present for\\na considerable time, it may give rise to no symptoms. Dysphagia.\\nIn large effusions this may occur, on account of pressure upon the\\noesophagus. Altered Cardiac Rhythm. The effect of the effusion upon\\nthe heart is to interfere with its action. Although usually regular,\\non the slightest exertion or the least excitement it palpates violently or\\nbecomes irregular. The heart s action is increased in frequency when\\nthe effusion is very large it may be not only irregular, but also inter-\\nmittent. Aphonia may occur from pressure upon the recurrent laryn-\\ngeal nerve. Cough of an irritative character is sometimes noted. The\\npulsus paradoxus may be present.\\n3. Physical Signs. (Plate XXVIIL, Fig. 1.) Inspection.\\nThere is bulging of the praecordia, particularly in children. The ribs\\nand interspaces are prominent. In adults the interspaces are even with\\nor distended beyond the surface of the ribs, and are sometimes widened.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0707.jp2"}, "708": {"fulltext": "646 SPECIAL DIAGNOSIS.\\nThe enlargement may extend to the antero-lateral region of the left\\nchest. The large effusion interferes with expansion of the lung on the\\nleft side, and hence movement is diminished. The epigastrium may\\nbe prominent, on account of displacement downward of the diaphragm\\nand liver. The apex-beat is absent or faintly seen, displaced upward\\nand to the left. It does not extend as near the left border of dulness\\nas in dilatation. It may be seen in the fourth interspace, or a faint\\nimpulse may be observed in the second and third interspaces beyond\\nthe mid-clavicular line.\\nPalpation. The impulse is feeble and diminishes in force as the\\neffusion increases. The position of the apex as determined by inspec-\\ntion is confirmed. Ewart points out that the first rib is palpable at\\nits sternal attachment in pericardial effusion. The pericardial fric-\\ntion which may have been present at first disappears with the effusion.\\nFluctuation may be detected in large effusions. The liver in large\\neffusions is depressed and readily palpable.\\nPercussion. The area of precordial dulness is increased. There\\nis increase of the lateral boundaries and great increase of absolute dul-\\nness. The increase of area is usually in all directions, although in-\\ncrease of the dulness upward and to the left only is very common. It\\nmay extend as high as the second rib. As pointed out by Rotch,\\ndulness in the fifth right interspace in the angle formed by the right\\nborder of the heart and the right lobe of the liver is common in effu-\\nsion. It may be an early sign of effusion. Ebstein calls this region\\nthe cardio-hepatic triangle, and points out that the dulness is absolute\\nin effusion, although impaired in normal states because of proximity to\\nthe liver.\\nPulmonary resonance is modified posteriorly in large effusions. The\\ndulness in large effusion includes the axillary region, so that it may\\nsimulate a pleural effusion. The dulness, however, does not extend\\nbelow the eighth rib in this region, whereas, in pleural effusion, dul-\\nness always extends to the bottom of the pleural sac. In a large peri-\\ncardial effusion the semilunar space of Traube is obliterated.\\nAuscultation. The sounds are feeble and distant. They may be\\nscarcely heard at all over the precordial region. The sounds at the\\nbase of the heart are diminished in intensity. If a friction-sound was\\nheard at the beginning, it disappears entirely as the effusion is poured\\nout. In moderate effusions the friction may be heard when the erect\\nposture is assumed.\\nIt must not be forgotten that the physical signs, and especially the\\nchange in impulse and the area of precordial dulness, are modified by\\nthe position of the effusion. Accumulations occur behind the heart or\\nabove it, and in these situations interfere least with the displacement\\nor the enfeeblement of the apex-beat. The area of dulness, however,\\nis increased upward.\\nIn cases of large effusion the compression of the lung may cause\\nbronchial breathing to be heard posteriorly or in the axillary region.\\nIn a case under my care the diagnosis of pericardial effusion was\\nreadily made, but the enormous effusion so markedly simulated an", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0708.jp2"}, "709": {"fulltext": "DISEA SES OF HE A BT, BLO OD VESSELS A ND MEDIASTIN UM. 647\\neffusion into the pleural cavity that both serous cavities were believed\\nto contain fluid. Aspiration was performed in the sixth interspace in\\nthe anterior axillary line. The fluid was removed from the peri-\\ncardium as was afterward determined. During life pressure-signs\\nlaryngeal stridor, difficulty of deglutition, and extreme dyspnoea were\\npresent. Early vomiting, epigastric pain and tenderness, slight de-\\nlirium, albuminuria, and an excessively weak, rapid pulse occurred in\\nthe course of the disease. The patient was a male, twenty years of\\nage. The effusion was due to tuberculous pericarditis, secondary to\\ntuberculosis of the bronchial glands. The physical signs were prom-\\ninence of the prsecordia bulging of the interspaces on the left side\\ndiminished expansion of the left side anteriorly, laterally, and poste-\\nriorly increased expansion at the extreme apex of the lung. The\\nvocal fremitus was absent below the second interspace in front, below\\nthe third in the axilla, and diminished below the spine of the scapula\\nbehind. There was dulness from the second left rib in front to\\nthe margin of the thorax from the fourth to the eighth rib in the\\naxilla below the eighth rib, tympany. The dulness extended be-\\nyond the margin of the sternum on the right side, almost to the\\nright nipple-line, in the fourth and fifth interspaces. Posteriorly, dul-\\nness from the middle of the scapula to the base of the thorax, except\\nalong the vertebrae, where, from the seventh to the ninth rib, there\\nwas tympany. The physical signs of pericardial effusion on auscul-\\ntation were marked. In the axilla the breath-sounds were absent.\\nThere were bronchial breathing and bronchophony behind from the\\nspine of the scapula to the base along the vertebra?. They were most\\nmarked opposite the angle of the scapula, where the above-noted tym-\\npany was observed. In the mid-scapular line the breath-sounds dimin-\\nished from above downward, and were absent at the base. It is seen\\nthat the physical signs of pleural effusion were present posteriorly and\\nlaterally, due to the enormous effusion. At the autopsy the pericar-\\ndium was found to contain sixty-four ounces of fluid.\\nPleural effusions may be excluded in similar cases by the absence\\nof dulness in the axillary region below the eighth rib by increase in\\ndulness beyond the right edge of the sternum and, at the same time,\\nby the absence of signs indicating dislocation of the heart to the right.\\nDiagnosis. Pericardial effusion must be distinguished from dilata-\\ntion of the heart. Although feeble and diffuse, the expansile shock of\\nthe impulse is more distinct than in dilatation. This distinction is not\\ngenerally difficult if the patient has been under observation during the\\ndevelopment of the disease. The impulse is not always absent in dila-\\ntation. Fluctuation may be detected. The area of dulness in dilata-\\ntion does not extend upward except in cases in which the right auricle is\\nenlarged. The dulness does not extend downward in dilatation with-\\nout a similar displacement of the apex impulse. The shape of the\\ndulness differs. In dilatation the dulness is square in shape in\\neffusion it is triangular or pear-shaped, with the base downward. In\\ndilatation the sounds are accentuated, and are of a valvular character\\nin effusion they are muffled. Dilatation does not cause the pressure-", "height": "4416", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0709.jp2"}, "710": {"fulltext": "648 SPECIAL DIAGNOSIS.\\nsymptoms that occur in effusion. In pericardial effusion Bamberger s\\nsign is of importance. When the patient is sitting upright an area of\\ndulness about the size of a silver dollar can be marked out at the\\nangle of the scapula. Over it, dulness, increased fremitus, and bron-\\nchial breathing are made out. If the patient leans forward, the dulness\\nand the other signs of consolidation disappear, to return when he sits\\nupright. In children pseudo-pleuritic signs are often present poste-\\nriorly dulness, pleuritic friction, broncho-cegophony but will disap-\\npear if the patient is put in the knee-chest posture. It is of diag-\\nnostic significance to have change of the rhythm and the character of\\nthe sound from day to day, or of its degree of loudness on movement\\nof the patient.\\nIn pericarditis with effusion, after its absorption, the friction-sound\\nmay return. Often it may disappear entirely and all signs of pericar-\\ndial inflammation subside. In plastic pericarditis and pericarditis with\\neffusion adhesion of the two layers of the pericardium may take place.\\nEffusions into the pericardial sac of serum, of blood, or of air, may\\ntake place without previous inflammation.\\nHydro-pericardium. This may occur in the course of general\\ndropsy from kidney or heart disease. It may not prove fatal of itself,\\nbut when associated with effusion in the pleural sac it contributes to\\nthe orthopnoea, which may cause death. Rarely after scarlet fever,\\neffusion into the pericardial sac may be the only dropsical symptom.\\nThe physical signs are those of effusion. It is not attended by fever.\\nIt is frequently overlooked, because investigation beyond the pleura\\nis not made after an effusion into that cavity has been found.\\nHaemo-pericardium. This occurs on account of rupture of an\\naneurism of the first part of the aorta, of the heart itself, or of the\\ncoronary arteries. Wounds of the pericardium and heart cause hsemb-\\npericardium. The extension of the ulceration of malignant endocar-\\nditis to the surface may cause gradual effusion of blood. (See Keat-\\ning, Transactions of the Philadelphia Pathological Society.) The physical\\nsigns are those of effusion. Death usually takes place before there has\\nbeen time to make a sufficiently accurate examination to determine its\\npresence. Rapid heart-failure due to compression is the cause of death.\\nIn the case referred to above, and in cases of rupture of the heart, the\\npatient may live for many hours with dyspnoea and progressive weak-\\nening of the heart. In tuberculosis and cancer the effusion is fre-\\nquently blood-stained.\\nPneumo-pericardium. This occurs very rarely, and is due to per-\\nforation from without by a stab-wound, or perforation from the lung,\\noesophagus, or stomach. A purulent exudation may undergo decom-\\nposition, causing an accumulation of gas. If it arises from perforation,\\nacute pericarditis is set up. The accumulation of gas causes tympany\\nover the movable area of percussion-dulness. The most striking sign\\nis noted on auscultation. Churning, splashing, or metallic sounds are\\nheard, drowning the feeble heart-sounds. Death usually occurs quickly.\\nAdherent Pericardium. (Plate XXVIIL, Fig. 2.) Chronic adhe-\\nsive pericarditis may follow the acute form or, particularly if tubercu-", "height": "4416", "width": "2592", "jp2-path": "practicaltreatis00muss_0_0710.jp2"}, "711": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDLASTINUM. 649\\nlous, develop independently and progress slowly. Inspection and Palpa-\\ntion. Indrawing of the interspaces may be seen at the time of the systole\\nof the ventricles even the ribs are said to be drawn in. This indrawing\\nis most marked at the apex, and must not be confounded with the retrac-\\ntion that occurs in the third and fourth interspaces with the ventricular\\nsystole. The recession is synchronous with the systolic shock. In some\\ncases the systolic movement over the prsecordia is of an undulatory\\ncharacter. Walter Broadbent calls attention to systolic retraction of the\\nback in the region of the eleventh or twelfth rib as a valuable sign.\\nThe apex is displaced outward and the area of impulse is increased. The\\nincrease in area of impulse is due to the hypertrophy which always\\nattends universal adhesion of the pericardium. After the systole there\\nis frequently felt a quick rebound, known as the diastolic shock, which\\nis said to be characteristic of pericardial adhesions.\\nIn pericardial adhesions Friedreich s sign, collapse of the cervical\\nveins, during the diastole of the heart, is seen. We may also see in-\\nspiratory swelling (Kussmaul). In addition, the pulsus paradoxus\\nis significant of the presence of pericardial adhesions, or rather of the\\ndilatation that succeeds the adhesions. The pulse is small and feeble\\nduring inspiration, assuming greater strength during the period of ex-\\npiration.\\nPercussion. The area of cardiac dulness is increased usually up-\\nward, extending as high as the first interspace. The area of dulness\\nis frequently not modified by respiration that is, it is not lessened\\nwhen the patient takes a full breath, when the lungs should expand\\nover the precordial region. This is particularly the case when there\\nis pleuritis associated with pericarditis, a common association in the\\nlar^e majority of cases.\\nAuscultation. On auscultation the signs vary. The sounds are due\\nto hypertrophy or to dilatation and it must not be forgotten that\\nthey frequently arise on account of pericardial adhesions. In the\\nformer condition the first and second sounds are accentuated in the\\nlatter, a murmur may be heard at the apex, loud and systolic in time.\\nIn pericardial adhesions the physical signs depend upon the condi-\\ntion of the heart muscle at the time of the examination. At first we\\nhave the physical signs of hypertrophy, with retraction of the inter-\\nspaces, particularly at the apex, or the space at the xiphoid cartilage.\\nThis is particularly the case in young subjects. In the later period of\\nthe disease the physical signs of dilatation arise, indicated by increase\\nin transverse dulness, enfeeblement of impulse and of sounds, with the\\ndevelopment of a murmur at the apex, undulation of the veins in the\\nneck, and the pulsus paradoxus. The physical signs of associate pleu-\\nrisy aid in the recognition of adherent pericardium. Diminution of\\nthe breath-sounds, increase in the area of cardiac dulness, lessened\\nfremitus in the neighborhood of the heart pointing to pleural thickening,\\nare associate evidence. Sansom considers the presence of pulmonary\\ntuberculosis of value, as pointing to the occurrence of pericardial adhe-\\nsions, for the associate pleural adhesions are likely to be attended by\\ntuberculous pericarditis.", "height": "4416", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0711.jp2"}, "712": {"fulltext": "650 SPECIAL DIAGNOSIS.\\nI have learned to suspect adhesive pericarditis in a young subject\\nthe victim of valvulitis, when the symptoms do not yield to treatment\\nin short, when the heart is not affected by digitalis. Unfortunately,\\nthe physical signs are often not conclusive.\\nThe subjective symptoms of adherent pericardium are those of dilata-\\ntion or hypertrophy of the heart, whichever one of the two is in excess.\\nIndurative mediastino-jiericarditis with adhesion may occur with or\\nwithout fibrous inflammation and adhesion of the structures in the\\nanterior mediastinum. The pericardium is adherent and thickened.\\nRarely the anterior mediastinum alone is a mass of fibrous inflamma-\\ntion. Peritonitis and perihepatitis may be found. The entire process\\nmay be tuberculous. The symptoms are dyspnoea, venous engorgement,\\ncyanosis, enlargement of the liver, ascites, and dropsy. The physical\\nsigns are those of extreme cardiac dilatation the pulsus paradoxus\\ncollapsing jugular veins during diastole, due to the dragging upon the\\ninnominate veins and cava by the fibrous adhesions, or to stretching\\nand narrowing of the aortic arch by these adhesions or inspiratory\\nswelling of the veins of the neck. A friction-sound, systolic in time,\\nheard over the sternum, increased when the arm is held up mediasti-\\nnal friction, so called, has been described in this affection.\\nIt usually follows an acute chest-affection, occurs most frequently in\\nyoung adults, and in males. It should also always be suspected in\\ncases of dilatation and valvulitis in which compensation does not take\\nplace, notwithstanding the best treatment.\\nEndocarditis.\\nEndocarditis may be acute or chronic. In either form it is usually\\nsecondary. The acute form is divided into simple and so-called malig-\\nnant, infectious, or mycotic endocarditis.\\nSimple Endocarditis. Acute endocarditis rarely occurs primarily.\\nIt usually occurs secondarily to general morbid processes. The patho-\\nlogical antecedents are acute rheumatism, tonsillitis, whooping-cough,\\nscarlet fever, gonorrhoea, rarely smallpox and typhoid fever. It is of\\ncommon occurrence in pneumonia and tuberculosis. It is frequent in\\nchorea. In the simple form it occurs in septic inflammations and in\\ndebilitating diseases, as cancer. It may occur in gout and develop in\\nthe course of Bright s disease.\\nSymptoms. The symptoms of simple endocarditis are scarcely ob-\\nserved during the early course of the disease. The process is latent,\\nand there are no indications of cardiac disease. The physical signs\\nalone betray its presence. Unless these are sought for the disease is\\noverlooked. The subjective symptoms are negative. In the course\\nof rheumatism or chorea, or during convalescence from the former, the\\npatient may complain of palpitation, and increased frequency and\\nirregularity of the heart. At the same time there may be a rise in\\ntemperature, not attended by any increase of the rheumatic symptoms,\\nwhich should call attention to the cardiac complication. The rise is\\nnot marked, and may not assert itself during the severity of the disease.", "height": "4416", "width": "2624", "jp2-path": "practicaltreatis00muss_0_0712.jp2"}, "713": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 651\\nPhysical Signs. On examination a murmur is detected in one of\\nthe cardiac areas. The murmur is soft, low in pitch, and follows the\\nlaws of transmission, according to its situation. Instead of a distinct\\nmurmur a roughening of the first sound alone may be heard. Pre-\\nceding the murmur the heart s action may be quickened and arhythmi-\\ncal the first sound may change in character from day to day or be\\naccentuated the second reduplicated at the apex and accentuated.\\nThe new sounds may disappear at first when the patient sits up later\\nthey persist. The murmur must not be mistaken for the murmur at\\nthe apex in cardiac dilatation or the murmur which may be heard in\\nthe course of fevers or the murmur of anaemia, which may rapidly\\ndevelop in rheumatism and other affections.\\nMalignant Endocarditis. Unlike simple endocarditis, the malig-\\nnant form very rarely develops in the course of rheumatism and\\nchorea. (See the Infections.) It occurs more frequently in pneumonia\\nthan in any other disease. It arises in the course of erysipelas, septi-\\ncaemia, puerperal fever, and gonorrhoea. It may occur in dysentery.\\nIt is usually a streptococcus infection.\\nSymptoms. The symptoms are (1) those due to the morbid process\\nthe infection (2) the physical signs (3) those due to emboli. The\\ngeneral symptoms due to the specific morbid process are septic in nature.\\nThe febrile phenomena may be one of four groups (1) The fever is\\nparoxysmal. Chills and fever occur daily or at intervals of two or\\nthree days, resembling types of malarial fever. Each paroxysm is\\nattended by profuse sweats. Rapid exhaustion ensues. The fever,\\ninstead of being distinctly intermittent, may be irregularly intermit-\\ntent. (2) The fever is excessive and continued, and a typhoid state\\nfrequently sets in. The temperature is irregular extreme prostration,\\nlow delirium, sordes, subsultus, and other symptoms of that state arise.\\n(3) The fever is moderate and continued. Physical examination, how-\\never, reveals the presence of marked endocarditis. In this group\\nchronic heart disease has usually preceded the affection. The duration\\nmay be prolonged. (4) The fever may be remittent. Petechial rashes\\nand erythema are common, so that, as pointed out by Osier, the disease\\nmay resemble the eruptive fevers. The sweating is profuse, contrib-\\nuting to the profound exhaustion which usually ensues. A septic\\ndiarrhoea occurs. In a few rapidly fatal cases jaundice has occurred.\\nAgain, the symptoms may be almost exclusively cerebral, resembling\\ncerebro-spinal or basilar meningitis.\\nThe embolic phenomena are due to escape into the blood-current of soft\\nvegetations from the valves of the left heart (for the right heart is\\nrarely affected), which are carried by the blood-stream into distant\\npoints of the circulation. Emboli occur in the brain, producing\\naphasia or hemiplegia they occur in the retina, causing some com-\\nplaint as to vision, but are accurately recognized by ophthalmoscopic\\nexamination. They occur in the kidneys, producing bloody urine and\\nrenal pain. In nearly all cases the spleen is the seat of embolism, and\\nin some instances infarctions may take place in this organ alone. The\\nspleen is always enlarged, and the infarct may cause pain and increased", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0713.jp2"}, "714": {"fulltext": "652 SPECIAL DIAGNOSIS.\\ntenderness on pressure. Emboli in the skin and mucous membranes\\npresent the most striking phenomena. The hemorrhages underneath\\nthe skin are minute. They are seen in the extremities, but may also be\\nfound on the trunk. They occur in the mucous membranes, as those of\\nthe mouth and tongue. They are seen in the bulbar conjunctivae, and\\nin the conjunctivae of the lids.\\nPhysical Signs. Repeated examinations are necessary in some cases,\\nto determine the presence of a murmur, or to decide whether a previ-\\nously existing organic lesion is the seat of an acute process. Varia-\\ntions in the character of the murmur from day to day are characteristic\\nof malignant endocarditis. In organic heart disease with dilatation and\\nfailure of compensation, irregular fever followed by embolic phenom-\\nena points to the occurrence of an infectious process on the antecedent\\nvalvulitis.\\nDiagnosis. This form of endocarditis is of infectious origin. The\\ndiagnosis rests upon proof that an infection is present, and is made by\\nthe methods described in Chapter XIX., Part I., which should be\\nreviewed by the reader. The history of an infection in some part of the\\nbody is most important in the diagnosis. The presence of the infection,\\nas well as its nature, may be disclosed by an examination of the blood.\\nWhen embolic phenomena are present the diagnosis is made without\\nmuch difficulty. The more pronounced general symptoms distinguish\\nit from simple endocarditis. The temperature-range, the septic and\\ntyphoid symptoms, belong to the malignant form. The more pro-\\nlonged cases with moderately continuous fever, without apparent\\nprimary cause, are frequently confounded with typhoid fever. This is\\nreadily appreciated when the symptoms of the two are compared. In\\nboth there is fever of a continued type, with the symptoms of the\\ntyphoid state, including delirium. In both there are enlargement of\\nthe spleen, diarrhoea, and abdominal tenderness. In both there may\\nbe infarctions, although they are extremely rare in typhoid fever, and\\nonly occur late in the disease. In both there is progressive exhaus-\\ntion. But in endocarditis the onset may be more abrupt. The fester\\ndoes not present the regularity of type that is seen in the development\\nof typhoid. In endocarditis there is more chest oppression and\\ndyspnoea early in the disease than in typhoid fever. In endocarditis\\nthe source of the infection may be discovered in the genito-urinary\\norgans, the lungs, the bones, etc. The diazo-reaction is found in\\ntyphoid fever after the fifth day, but rarely, if ever, in endocarditis.\\nThe results of bacteriological examination, and especially of serum\\ndiagnosis, distinguish the two affections. This ought to be of value in\\nendocarditis, because the process is usually due to a staphylococcus or\\nstreptococcus infection. Either micro-organism may be found in any\\nsuppurations which may possibly be present or in the blood. In a child\\nrecently seen by me in the relapse of an attack of typhoid fever, malig-\\nnant endocarditis was thought to be present, because of a loud and rough\\nmurmur at the pulmonary orifice. Fortunately the murmur was present\\nin the apyretic period, and as the child was anaemic its exaggeration\\nwas ascribed to the fever.", "height": "4416", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0714.jp2"}, "715": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 653\\nMalignant endocarditis must be distinguished from cerebrospinal\\nfever, and from smallpox of the hemorrhagic type. We must rely on the\\nlocal cardiac symptoms and physical signs, and the preponderance of\\nthese over the other symptoms. Of course, the prevalence of an\\nepidemic and a history of exposure are of service in the distinction\\nbetween the diseases. Examination of the blood excludes the forms\\nof malaria which formerly were mistaken for endocarditis.\\nChronic Endocarditis. Chronic endocarditis may follow the acute\\nform or develop in the course of atheroma or of endarteritis due to\\nalcoholism, the poison of syphilis or of gout. If associated with endar-\\nteritis, the endocardial change may be part of the general degenerative\\nchanges which occur in the aging process. It may be of dynamic\\norigin, often following prolonged heavy muscular exertion, by which\\nthe valves, particularly at the aortic orifice, have been subjected to\\nstrain. The process is slow and insidious, and leads to the changes in\\nthe valve-segments which constitute chronic valvular disease.\\nSymptoms. The symptoms of chronic, or sclerotic, endocarditis are\\nthe symptoms of chronic valvular disease. Insufficiency or obstruc-\\ntion, or both combined, take place at the affected valve-orifice. The\\noutflow of blood is retarded in obstruction. Backward flow, or regur-\\ngitation, takes place in insufficiency in the opposite direction from\\nthe normal blood-current. When there is obstruction hypertrophy\\nusually develops to meet it. If the obstruction is moderate, and the\\nperson remains in good health, the hypertrophy is sufficient to over-\\ncome the obstruction. In this manner the effect of the valve lesion is\\ncompensated. On the other hand, when blood is permitted to flow\\nby regurgitation backward into the cavity that is, in the opposite\\ndirection to its usual course it meets a blood-current flowing to this\\ncavity in the normal direction, and the result is overdistention, or over-\\nfilling, of the cavity. Dilatation ensues, and may persist. If the re-\\ngurgitation takes place suddenly, the dilatation continues if gradually,\\nas in chronic endocarditis, the dilatation is attended with hypertrophy.\\nThus, when there is regurgitation from the left ventricle into the left\\nauricle, on account of incompetency at the mitral orifice, the auricle\\nbecomes overdistended with blood, for it is filling with blood from the\\npulmonary veins at the same time. This overdistention can only be\\novercome by some hypertrophy. When this is not sufficient the blood\\nis obstructed in the pulmonary circulation, with the consequences here-\\nafter to be mentioned.\\nThe symptoms of chronic endocarditis are latent if the lesions are\\ncompensated if not, symptoms of failure in compensation occur or\\ndilatation of the heart arises. The physical signs are those of chronic\\nvalvulitis. The character of the signs depends upon the lesion of the\\naffected valve.\\nDisease of the Coronary Arteries.\\nAtheroma, associated with the process in other vessels,, or distinctly\\nlocalized to the coronary arteries, affects these vessels. Its causal\\nfactors are those of endarteritis elsewhere. Its influence on the nutri-", "height": "4416", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0715.jp2"}, "716": {"fulltext": "654 SPECIAL DIAGNOSIS.\\ntion of the heart, either by sudden obstruction of the vessels by an\\nembolus or by their gradual closure, is apparent.\\nSymptoms. If an atheromatous coronary artery is suddenly ob-\\nstructed by an embolus, death may be immediate. This is a common\\ncause of sudden death. In other instances thrombosis may take place,\\nfollowed by anaemic infarction, myocarditis, and mural aneurism. In\\nthis class of cases the onset of the symptoms may be sudden. Praecor-\\ndial oppression or angina pectoris may be the first indication. Succeed-\\ning this, dyspnoea, dilatation of the heart, and venous stasis occur. The\\npresence of an aneurism may be made out. The heart s action is per-\\nsistently rapid and may be arhythmical. If there has not been pre-\\nvious valvulitis, no murmurs are heard until dilatation ensues. The\\npatient may live three or four weeks, or as many months.\\nIn a third group of cases occlusion, either from the endarteritis or\\nfrom a slowly forming thrombus, is so gradual as to lead to myocar-\\nditis only with the attending symptoms.\\nDiagnosis. Unfortunately, too often the diagnosis can only be pro-\\nvisional. Sudden death may be attributed to coronary artery disease\\nif there has been a history of previous attacks of angina, if there is\\nevidence of arterial disease elsewhere, and if dyspnoea or anginoid\\nsymptoms preceded the fatal termination. Thrombosis, secondary to\\natheroma, may be suspected if a patient, in whom there is no valvular\\ndisease, no pulmonary or renal disease, is seized with angina pectoris\\nor dyspnoea providing tachycardia and arhythmia follow, and in a\\nshort time cardiac dilatation, venous stasis, etc. In a male, aged forty-\\nthree years, Avithout syphilis, but with a history of antecedent rheuma-\\ntism, an attack of angina pectoris followed some unusual exertion.\\nPrior to this he had been in the most perfect health. The attack was\\nfollowed by dyspnoea and remarkably rapid heart-action without appar-\\nent cause. The physical signs of acute congestion of the lower lobe of\\nthe right lung followed within twenty-four hours of the attack of angina.\\nThe patient was ill three months. He improved somewhat, but rapidity\\nof the heart s action and some stasis in the lung persisted. Gradually\\ncardiac dilatation ensued, with a murmur in the tricuspid area. Death\\ntook place from pulmonary congestion. At the autopsy the coronary\\narteries were atheromatous the left was filled with an old thrombus\\nthere was extensive myocarditis and an aneurism of the left ventricle.\\nIn another case, male, aged seventy-two years, with general atheroma\\nbut no valvulitis, sudden precordial distress, tachycardia, and persist-\\nent dyspnoea were followed by cardiac dilatation, mitral incompetency,\\ngeneral anasarca.\\nI have said elsewhere, a persistently rapid pulse, uninfluenced by\\ndigitalis, indicates pericardial adhesion in the young the same pulse\\nuninfluenced by treatment points to coronary artery disease in the\\nmiddle-aged and senile.\\nMyocarditis.\\nMyocarditis may be acute or chronic. The entire muscle or only\\na portion may be affected. General myocarditis is always acute. The", "height": "4416", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0716.jp2"}, "717": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 655\\nlocal form may be acute or chronic, depending upon the degree of\\nthe primary cause. The local variety is usually due to a thrombus\\nin the terminal endings of the coronary artery, which cuts off the\\nblood-supply. The changes are those of myocarditis, to which may be\\nadded necrosis of small areas and the development of aneurism.\\nEtiology. Pathological antecedents of acute general myocarditis are\\nthe fevers, particularly typhoid and typhus fever, pneumonia, diphthe-\\nria, and septic fevers generally. Chronic myocarditis is usually asso-\\nciated with atheroma, one of the causes of which occurs in the later\\nstages of Bright s disease. (See Atheroma.) The result of myocar-\\nditis, when acute, is dilatation of the heart, fatty heart, or aneurism of\\nthe heart. Chronic myocarditis is followed by fatty heart, by dilata-\\ntion, by the so-called fibroid heart or fibrous myocarditis, and by aneu-\\nrism. The above facts in etiology are important in diagnosis.\\nSymptoms. The symptoms of acute myocarditis are vague. In\\nthe course of, or in the convalescence from, an infection the patient may\\ncomplain of some oppression in the prsecordia and suffer from dyspnoea\\nattacks of syncope may occur, and sighing may be frequent. The\\npulse becomes more rapid and weak, but is usually not irregular. The\\ncirculation is much depressed, the hands may be cold, the face pallid.\\nThese symptoms may be accounted for by the extreme exhaustion alone\\nthat follows fever. No doubt some myocarditis accounting for the\\nsymptoms exists in all cases, particularly if there is prolonged high\\ntemperature. Often the patient does not complain of any cardiac symp-\\ntoms. Death takes place suddenly, either in the course of the dis-\\nease or after it has spent its force, from acute dilatation or cardiac\\nparalysis. This is particularly true in pneumonia and diphtheria. In\\nthe latter affection the sudden appearance of cardiac symptoms, dysp-\\nnoea, cyanosis, and cold extremities may be due to paralysis of the\\nheart.\\nPhysical Signs. Enfeeblement of the heart-sounds, sometimes with\\naccentuation of the mitral first sound, is observed. The impulse and\\napex-beat are scarcely perceptible, or absent altogether. If acute dila-\\ntation supervenes the area of dulness may be ii: creased.\\nThe symptoms of chronic myocarditis are obscure and indefinite, and\\nin the majority of cases depend upon the secondary changes that have\\ntaken place in the heart muscle. If there is atrophy of the fibroid\\nheart, the pulse is feeble, slow, and irregular. It may be as slow as\\nthirty or forty beats to the minute. Irregularity is not necessarily\\npresent, but intermittency is of frequent occurrence. The patient com-\\nplains of dyspnoea aggravated by exertion. Attacks of angina pectoris\\nare likely to occur. The symptoms of dilatation of the heart may\\nensue later, with oedema, cyanosis, and congestions. A symptom-com-\\nplex, known as the Stokes- Adams syndrome, is often seen, character-\\nized by dyspnoea, coma, and slow pulse a pseudo-apoplexy. In fatty\\ndegeneration of the heart the pulse is increased in frequency there are\\ncardiac irregularity, palpitation, and dyspnoea. These, however, are also\\nthe symptoms of dilatation, which usually succeeds the degeneration.\\nThe heart-sounds are weak. If dilatation has set in, a murmur is heard", "height": "4412", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0717.jp2"}, "718": {"fulltext": "656 SPECIAL DIAGNOSIS.\\nat the apex, with gallop-rhythm of the heart. In fatty degeneration\\nattacks of collapse with slow pulse are common. Shortness of breath\\non exertion may occur. Cardiac asthma occurs at night, and sighing\\nand yawning are of frequent occurrence during the day. The patient\\nusually sleeps badly. The cerebral functions are more or less in abey-\\nance, the action of the mind is sluggish the patient may have delu-\\nsions or become maniacal. Cheyne-Stokes breathing was formerly\\nthought to be of diagnostic significance.\\nChronic myocarditis must be distinguished from fatty overgrowth of\\nthe heart. This cardiac change is frequently seen in brewers and\\nsaloon-keepers, and is usually associated with obesity. The pulse may\\nbe feeble, the heart-sounds weak and muffled. The patients are sub-\\nject to attacks of asthma, and frequently have bronchitis and emphy-\\nsema. Vertigo is of common occurrence. Death may occur during\\nsyncope.\\nAneurism of the Heart.\\nAneurism of the valves, following endocarditis, cannot be recognized\\nduring life. Aneurism of the walls usually results from chronic myo-\\ncarditis. The aneurism develops in the left ventricle at the apex.\\nThe symptoms are indefinite. In rare cases a marked bulging has\\nbeen noted in the region of the apex, and the tumor may perforate the\\nchest-wall. A projection beyond the normal line of cardiac dulness\\nmay be detected by stethoscopic or plessimetric percussion. The\\nsymptoms are those of myocarditis and of dilatation of the heart.\\nRupture of the heart is one of the causes of sudden death, often\\nwithout previous symptoms. The accideut takes place during exer-\\ntion. Quain collected one hundred cases, in seventy-one of which\\ndeath took place without previous warning. In other instances there\\nwas a sense of anguish, and suffocation in the cardiac region. The\\nphysical signs of slowly developing pericardial effusion may be ascer-\\ntained if the leakage from rupture is slow in progress.\\nChronic Valvular Disease.\\nValvular disease includes valvulitis and valvular incompetency\\nthere is either obstruction or regurgitation at the orifices affected.\\nValvulitis may exist with or without symptoms valvular incompe-\\ntency is always accompanied by symptoms. Valvulitis implies organic\\ndisease of the valves valvular incompetency, regurgitation through\\norifices, the valves of which cannot close it, but they may or may not\\nbe diseased. Valvulitis may be recognized by physical signs of (1)\\nthe lesion, (2) the secondary effects of the lesion on the heart and cir-\\nculalion hypertrophy or dilatation. Valvular incompetency occurs\\nusually in dilatation, and may be secondary to valvulitis. It is recog-\\nnized by both signs and symptoms. Valvular disease is without symp-\\ntoms as long as the heart-muscle enlarges sufficiently to keep in balance\\nthe impaired circulation compensation is then said to be complete.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0718.jp2"}, "719": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 657\\nWhen compensation is broken we then have the subjective symptoms\\nenumerated above, all in consequence of dilatation of the heart. It\\nmay be said that valvulitis is of no significance as long as compensation\\nis perfect. To review valvulitis may be attended by physical signs\\nin the heart and vessels only, or by its own physical signs, the physical\\nsigns of dilatation, and the symptoms of the latter. In the considera-\\ntion of valvular disease it is more profitable to take up the symptoms\\nof each valve-lesion, bearing in mind that two or more of the valves\\nmay be diseased at the same time, or that both obstruction and regur-\\ngitation may be present at the same time at the same valve-orifice.\\nAortic Regurgitation, Insufficiency or Incompetency. This may\\nexist for a long time without presenting any symptoms. It occurs\\nmore frequently in men than in women, and is more common in the\\nlater periods of life. It may be due to congenital malformation, to\\nacute endocarditis, or, as is most frequently the case, to chronic endo-\\ncarditis, particularly when it follows strain or undue exertion alco-\\nholism and syphilis are also frequent antecedents. In rare cases it\\nfollows rupture of the valves. Relative insufficiency or incompetency\\nis of very rare occurrence. Insufficiency is frequently combined with\\nobstruction.\\nOn account of regurgitation, or insufficiency, at the aortic orifice the\\nblood falls directly into the left ventricle during the diastole. There\\nis, first, a relative diminution in the amount of blood in the artery\\nand, second, an increased amount of blood in the ventricle, because the\\nregurgitated column of blood meets the blood from the auricle which\\nis filling the chamber at the same time. Dilatation of the left ventri-\\ncle ensues, and is followed by hypertrophy. Dilated hypertrophy thus\\narises. The heart becomes enormously enlarged. This is one of the\\nconditions in which enormous cardiac enlargement takes place so-\\ncalled cor bovlnum. If this valve-lesion occurs at the period of life\\nand from the causes above mentioned, it is attended by more or less\\nsclerosis of the arteries.\\nSymptoms. They may be entirely absent as long as perfect com-\\npensation exists. This is particularly the case if there is but little\\ngeneral arterial sclerosis. Coincident lesions of other valves tend to\\nbreak the compensation. The earlier symptoms are those due to\\narterial anaemia, particularly anaemia of the brain. They are head-\\nache, dizziness, and flashes of light before the eyes. The patient has\\nan anaemic appearance, and soon begins to suffer from shortness of\\nbreath. This at first develops upon slight exertion. Palpitation and\\noppression about the chest are complained of, readily excited by undue\\nexertion. Pain is a common symptom. It may be in the region of\\nthe praecordia, of a dull, aching character, and radiate to the neck and\\ndown the arms, particularly on the left side. The anginoid pains may\\nbe followed by attacks of true angina pectoris. The latter are more\\ncommon in aortic regurgitation than in any other valve-lesion.\\nAs compensation fails venous stasis occurs and the dyspnoea in-\\ncreases. The latter is worse at night and compels the patient to sleep\\nin a semi-erect posture. Congestion of the lungs takes place, giving\\nrise to cough. Hemorrhage occurs, but not so frequently as in mitral\\n42", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0719.jp2"}, "720": {"fulltext": "658 SPECIAL DIAGNOSIS.\\ndisease. (Edema of the feet sets in, but general anasarca is not com-\\nmon. GEderna of the feet may be due to the attendant anaemia.\\nIn aortic insufficiency sudden death is of common occurrence. This\\nmay take place at night during an attack of dyspnoea, or occur sud-\\ndenly upon the slightest exertion, such as straining at stool, or ascend-\\ning a height, or walking more quickly than usual.\\nThe Physical Signs of Aortic Regurgitation. (Plate XXIX., Fig. 1.)\\nInspection. The apex beat is downward, outward, and to the left. It\\nmay be as low as the seventh interspace, and as far out as the anterior\\naxillary line. The area of cardiac impulse is increased. It occupies\\nthe whole prsecorclia, and heaving of the lower half of the chest may\\nbe seen. In young subjects there is precordial bulging.\\nPalpation. The impulse is strong and heaving. After compensa-\\ntion fails it is indefinite and wavy. A thrill, diastolic in time, may\\nbe felt if the hand is placed about the middle of the sternum.\\nPercussion. The area of dulness is increased. The extent is greater\\nthan that in any other valve-lesion, and the enlargement is more par-\\nticularly downward and to the left.\\nAuscultation. At the second costal cartilage on the right a murmur\\nis heard, diastolic in time. This may be its seat of maximum inten-\\nsity. (See Fig. 175.) It is transmitted along the course of the ster-\\nnum toward the apex. In some instances the seat of maximum intensity\\nis at the fourth left costal cartilage, or even at the apex. The second\\nsound is absent in the large majority of cases. In some instances,\\nhowever, both murmur and second sound may be heard at the same\\ntime. Other murmurs also may be associated with aortic regurgita-\\ntion, not always due to disease of the aortic valves\\n1. A systolic murmur at the second costal cartilage on the right,\\ntransmitted into the vessels of the neck, short, rough, and high in\\npitch. It is due to roughening of the valve-segments, or to atheroma\\nof the aorta.\\n2. A murmur at the apex, rumbling in character, localized to this\\narea, usually presystolic in time. It is the murmur described by\\nFlint, who attributes it to flapping of the mitral segments, which\\nduring diastole are not forced back against the heart-wall, on account\\nof the dilatation of the ventricle. They remain in the blood-current\\nand produce relative narrowing.\\n3. A systolic murmur in the mitral area, low in pitch, due to dila-\\ntation. This occurs when failure in compensation takes place.\\nExamination of the Arteries. Pulsation of the peripheral vessels is\\nmore common in aortic regurgitation than in any other valve-lesion.\\nThe carotids throb, the temporals pulsate, the brachial and radial arte-\\nries are conspicuous. Pulsation of the retinal arteries is seen with the\\nophthalmoscope, and has often led to the recognition of the disease by\\nthe ophthalmologist who had been consulted for other conditions. The\\npulsation is of a jerking character in the neck it may simulate the\\npulsation of an aneurism. The aorta can be seen and felt at the supra-\\nsternal notch. The abdominal aorta pulsates vigorously in the epigas-\\ntrium. The pulse is significant in aortic regurgitation. The so-called\\nwater-hammer, or Corrigan s, pulse is observed. The pulse is quick", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0720.jp2"}, "721": {"fulltext": "PLATE XXIX.\\nFIG. 1.\\nI A IV^^MHv\\nw yfl iiife^-\\nAortic Regurgitation.\\nFIG. 2.\\nW/\\nv x\\n^O\\nAortic Obstruction.", "height": "4392", "width": "2652", "jp2-path": "practicaltreatis00muss_0_0721.jp2"}, "722": {"fulltext": "", "height": "4396", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0722.jp2"}, "723": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 659\\nand jerking, and after striking the finger immediately recedes. It is\\nmost marked when the arm is held up. On auscultation of the arteries\\ndouble murmurs may be heard in the carotids and subclavians, and in\\nrare instances they are present in the femorals. (See Pulse.)\\nThe Capillary Pulse. This is seen beneath the finger-nails, or on the\\nsurface of the skin, as the forehead, when a line is drawn across it. The\\nhyperemia produced on either side of the line becomes alternately red\\nand pale. Capillary pulse also occurs in anaemia, and at times in\\nneurasthenia.\\nAortic Obstruction. Aortic obstruction occurs in the aged, and\\nwith atheroma of the arteries. It causes some diminution in the\\namount of blood in the peripheral circulation, resulting in poor nutri-\\ntion and the development of anaemia.\\nSymptoms. Anaemia develops first, and embolic phenomena may\\noccur later. The symptoms may be latent until the occurrence of em-\\nbolism. This accident is not uncommon, on account of the position of\\nthe aortic valve. The emboli are distributed throughout the arterial\\ncircuit, and may lodge in the brain, kidneys, or spleen. When the\\nobstruction is pronounced the blood-supply in the arteries is dimin-\\nished. Cerebral anaemia takes place, causing dizziness and fainting.\\nSleep is more disturbed than in other valve affections, because of the\\ncerebral anaemia. Palpitation and cardiac pain occur, but are not so\\ncommon as in aortic regurgitation. When compensation fails, dilata-\\ntion of the left ventricle ensues, followed by pulmonary congestion\\nand stasis in the systemic circulation.\\nThe Physical Signs. (Plate XXIX., Fig. 2.) There is hyper-\\ntrophy of the left ventricle. Inspection. The apex-beat is displaced\\ndownward and outward. The impulse is strong during the period of\\nhypertrophy. When compensation fails the physical signs of dilatation\\nensue. In many cases, from the very first, there may be considerable\\nhypertrophy without the visible impulse, because of associate emphy-\\nsema, which is common to old men with this lesion.\\nPalpation. At the base of the heart, and in the aortic area, a thrill,\\nsystolic in time, may be felt. When present, it is usually very distinct,\\nand is transmitted along the course of the vessels. The impulse is slow\\nand heaving, if hypertrophy is present if dilatation, feeble and indis-\\ntinct.\\nPercussion. The area of dulness is increased, in the earlier stages,\\nto the left and downward. After compensation is broken, dilatation\\nwith increased area of dulness ensues.\\nAuscultation. A murmur is heard of maximum intensity at the\\nsecond costal cartilage to the right, systolic in time, and transmitted in\\nthe course of the bloodvessels. (See Fig. 174.) It is usually harsh\\nand loud, but may be musical. As the heart weakens, the intensity\\nof the murmur lessens and its roughening disappears. It becomes soft\\nand low in pitch. The second sound, if there is no regurgitation, is\\nmuffled or may be absent. The pulse is small and regular. The ten-\\nsion is usually increased.\\nDiagnosis. A systolic murmur at the aortic orifice may be due to\\naortic obstruction, atheroma or dilatation of the aorta, ulcerative aor-", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0723.jp2"}, "724": {"fulltext": "660 SPECIAL DIAGNOSIS.\\ntitis, or anaemia. Huchard describes a murmur in this situation, with\\nvibratory thrill, due to aberrant chordae tendineae. The murmur of\\naortic stenosis is distinguished from the others by its character, by\\nthe presence of thrill, by the character of the pulse, and by its associa-\\ntion with hypertrophy of the left ventricle. A murmur due to athe-\\nroma of the aorta, particularly in the course of renal disease, is also\\nassociated with hypertrophy of the left ventricle. The diagnosis from\\naortic obstruction is often difficult or impossible. Slowness of the pulse\\nis more characteristic of aortic obstruction. The murmur of anaemia is\\nsofter and low in pitch. There is no thrill, and the left ventricle is not\\nhypertrophied. Anaemic murmurs may be heard elsewhere. In athe-\\nroma the second sound is usually accentuated, and in anaemia also it is\\nintensified.\\nMitral Incompetency or Regurgitation. The regurgitation may\\nbe due to disease of the valves (organic) from previous endocarditis,\\nor to inability of the segments to close the orifice (incompetency), which\\nhas become enlarged as part of the dilatation of the cavities. The latter\\noccurs in dilatation of the left ventricle. It takes place when the\\nmuscle is weak in fevers and in anaemia. It is thus seen that the mur-\\nmur of mitral insufficiency is one of the most commonly observed of all\\nvalve-murmurs. Its ready production and often equally ready removal\\nwith treatment make it the least serious. It must not be forgotten\\nthat insufficiency from disease of the valves and from disease of the\\nmuscles must, if possible, be distinguished from each other. The\\nhistory of the case is essential in determining the diagnosis.\\nDisease at the mitral orifice producing insufficiency has more serious\\neffect upon the pulmonic and arterial circulation than disease at any of\\nthe other orifices. These effects must be understood in order to appre-\\nciate the symptoms of mitral incompetency. They are as follows 1.\\nWith each systolic contraction the blood flows back, on account of the\\ninsufficiency, to the auricle, where it soon meets a volume of blood\\ncoming from the lungs. The combined volumes of blood overdistend\\nthe auricle. Dilatation ensues, and because of increased work to get\\nrid of the increased contents, hypertrophy follows. Dilated hypertro-\\nphy of the left auricle is the first effect. 2. As a result of the above,\\na larger amount of blood is forced from the left auricle into the left\\nventricle dilatation and subsequent hypertrophy of this chamber also\\nfollow, to remove the fluid. 3. On account of the overdistended auri-\\ncle the pulmonary veins are not fully emptied during the diastole of\\nthat chamber. The veins are therefore engorged and interfere with\\nthe flow of blood through the pulmonary circuit. In consequence of\\nthe impeded flow of blood the vessels in the pulmonary circuit are\\ndilated and overdistended. The right ventricle is compelled to act\\nmore vigorously, and even then cannot empty itself freely. Dila-\\ntation and hypertrophy of the right ventricle ensue. 4. This causes\\nobstruction of the flow of blood from the right auricle to the right\\nventricle dilatation and hypertrophy of its chambers follow. If\\nperfect compensation ensues through hypertrophy of both ventricles,\\nengorgement in the lungs may not be observed. Moreover, the left\\nventricle is allowed to send out sufficient blood to supply the wants of", "height": "4412", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0724.jp2"}, "725": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 661\\nthe system. This compensation may continue for years. If it fails,\\neither from increase in the valve-lesion, or valvular incompetency, or\\nfrom weakening of the muscle, a normal amount of blood is not dis-\\ntributed throughout the aortic area, but is thrown back upon (1) the\\nleft auricle (2) the pulmonary circulation (3) the right heart and,\\nfinally, the systemic veins. For a time the pulmonary circuit will\\nalone be engorged, subsequently the systemic veins become congested\\nbecause of dilatation of the right auricle and incompetency of the tri-\\ncuspid valves. We then have the secondary effects of stasis upon the\\nvarious organs of the body, with cyanotic induration and the develop-\\nment of dropsies. Mitral incompetency without disease of the valves is\\nof frequent occurrence in emphysema of the lungs and in Bright s dis-\\nease, and is a condition which always attends hypertrophy and dilata-\\ntion, or may take place from various causes. (See Hypertrophy and\\nDilatation.)\\nSymptoms. As to the general symptoms In a large number of\\ncases perfect compensation may continue for a long time. No subjec-\\ntive symptoms arise nor are there symptoms due to dilatation. If\\ncompensation is not perfectly effected from the first, or is broken sud-\\ndenly or gradually, the symptoms of dilatation arise.\\nIn patients in whom compensation remains only fairly good we have\\nthe characteristic appearances of heart disease. It is to this class of\\npatients that the general descriptions of heart disease apply. The face is\\npale and pinched, the lips and ears dusky, the capillaries of the cheeks\\nenlarged, the finger-nails clubbed, particularly in children shortness of\\nbreath on exertion may be the only symptom complained of, and this\\nmay exist for years. The patients are, however, liable to attacks of\\nbronchitis and of pulmonary hemorrhage. Palpitation may occur in\\nthis as in other forms of heart disease, and from the same cause.\\nWhen the compensation is broken, symptoms referable to the heart\\nand to engorgement of systemic and pulmonary veins occur. Of the\\nformer palpitation with a sense of oppression is the most common\\npain is rare.\\nVenous engorgement leads to congestions, cyanosis, and dropsies.\\nWe now have the symptoms of dilated right heart superadded. The\\nlungs are the first to be congested. Dyspnoea becomes constant and\\nis aggravated by exertion. Cough is present, excited by exertion or\\nspeaking. With the cough there is bloody expectoration. Cyanosis\\noccurs. Congestion of other organs follows. The liver is enlarged\\nobstruction in the portal area is prominent chronic gastritis or gastro-\\nintestinal catarrh ensues. The spleen is enlarged ascites develops,\\nand hemorrhoids and congestion in the rest of the portal area are seen.\\nThe kidneys are congested the urine is scanty, albuminous, and con-\\ntains casts and blood-corpuscles. At the same time that the internal\\nviscera are congested dropsies take place, beginning in the feet and\\nextending to the rest of the body. Dropsy may have been present in\\nthe feet before symptoms of portal congestion ensued.\\nThe patient may be relieved and compensation continue for a long\\ntime. Frequent attacks of dilatation of this character may take place,\\ntheir recurrence being due to lack of care in hygienic matters, or", "height": "4416", "width": "2664", "jp2-path": "practicaltreatis00muss_0_0725.jp2"}, "726": {"fulltext": "662 SPECIAL DIAGNOSIS.\\nfailure in health from other causes. Finally, however, the compen-\\nsation cannot be restored the stases persist the dropsies become\\nmore marked, and the symptoms of cyanotic induration and secondary\\nscleroses of the internal organs follow. It must not be forgotten that\\nthis is the chief form of organic heart disease seen in children.\\nPhysical Signs. (Plate XXX., Fig. 1.) On inspection the pre-\\ncordial area appears prominent the apex-beat is displaced to the left\\nand downward, rarely below the sixth interspace. It may extend to\\nthe anterior axillary line. The cervical veins pulsate and are dis-\\ntended. The area of impulse is increased.\\nPalpation. The character of the impulse depends upon the stage\\nof the disease at which the case is examined. At the time of full com-\\npensation it is strong and even. When this is broken, it is feeble and\\ndiffuse. A thrill is extremely rare.\\nThe Bloodvessels. The amount of blood in the arteries is dimin-\\nished. There is notable absence of visible pulsation in the arteries.\\nThe pulse at first is full and regular. It is notably small in volume\\nand soft. As soon as failure of compensation takes place the pulse\\nbecomes irregular. The irregularity may be that of time as well as of\\nvolume.\\nPercussion. The area of dulness is increased to the left. The trans-\\nverse diameter of the heart is much increased because of dilatation\\nof both chambers. The area extends beyond the right margin of the\\nsternum to the extent of an inch or more and to the left as far as the\\nmid-clavicular line, sometimes to the anterior axillary line. The\\ncardio-hepatic triangle is preserved.\\nAuscultation At the apex, the mitral area, a murmur is heard.\\nThe point of maximum intensity is in this region. It is systolic in\\ntime it may replace the first sound entirely. It may be soft and low\\nin pitch, or rough, high in pitch, even musical in character. It is\\ntransmitted to the axilla and the angle of the scapula. (See Fig. 171.)\\nIn some instances it may be heard loudest along the left border of the\\nsternum. The pulmonary second sound is accentuated the accentu-\\nation is loudest in the pulmonary area at the second left interspace.\\nIt may be very loud over the right ventricle, between the paraster-\\nnal line and tlie left edge of the sternum. The murmur of mitral\\ninsufficiency is modified by the position of the patient and intensified\\nafter exertion. It may be present when the patient is lying down,\\nand disappear in an erect posture. It may disappear when the patient\\nis quiet and return after exertion. Other murmurs are sometimes heard\\n1. A presystolic murmur, soft or rumbling. 2. When dilatation\\nensues a low-pitched systolic murmur is heard at the ensiform carti-\\nlage and at the lower left border of the sternum. It is due to tricus-\\npid regurgitation.\\nOf special diagnostic significance are the position of the murmur\\nand the direction of its transmission accentuation of the pulmonary\\nsecond sound enlargement of the transverse diameter of the heart,\\ndue to dilatation of both ventricles.\\nDIAGNOSIS. This is usually easy if the physical signs are sought\\nfor. Very often examination of the heart is neglected, and the patient", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0726.jp2"}, "727": {"fulltext": "PLATE XXX,\\nMf\\nMitral Regurgitation.\\nFIO. 2.\\nthrill\\nXm\\nM^\\nMitral Stenosis.", "height": "4392", "width": "2684", "jp2-path": "practicaltreatis00muss_0_0727.jp2"}, "728": {"fulltext": "", "height": "4412", "width": "2588", "jp2-path": "practicaltreatis00muss_0_0728.jp2"}, "729": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 663\\nis treated for the symptoms that arise from congestion of the viscera.\\nWe have often seen chronic gastritis or gastro-intestinal catarrh, clue\\nto mitral insufficiency, not relieved because the primary lesions had\\nnot been ascertained. In the same way cardiac cough or dyspnoea may\\nbe overlooked. It is important in the diagnosis to determine, if possi-\\nble, the nature of the insufficiency, whether it is due to disease or\\nincompetency of the valves. As previously mentioned, the history is\\npossibly the only means by which a diagnosis can be made. If a\\nmitral murmur ensues in old people, in whom there has been physical\\ncause for the development of dilatation and hypertrophy, as in emphy-\\nsema or arterio-sclerosis, it is usually due to relative incompetency of\\nthe valve. It must not be forgotten that the mitral area is the seat of\\na number of murmurs due to various causes. (See Auscultation.)\\nMitral Stenosis. Obstruction to the flow of blood from the auricle\\nto the ventricle is due to valvulitis, or endocarditis, and particularly\\nthe endocarditis of early life. It is of much more frequent occurrence\\nin women than aortic disease. It is much more often seen in young\\nadults and children, because its etiological factors, rheumatism and\\nchorea, are then more prevalent.\\nOn account of the obstruction at the orifice changes ensue in the\\nauricle. These changes depend in a measure upon the nature of the\\nlesion. In the so-called buttonhole contraction they are very marked.\\nThe orifice may be so obliterated in rare cases as to admit only a small\\nprobe. Dilatation and hypertrophy of the left auricle ensue if the\\nvalve-changes take place gradually. The walls of the auricle are\\nthickened to three or four times their natural size. On account of the\\ndilatation of this auricle the outflow from the pulmonary veins is im-\\npeded, which in turn obstructs the circulation of blood through the\\nlungs. As a consequence, dilatation and hypertrophy of the right ven-\\ntricle occur. As a result of this we have, later on, the occurrence of\\nrelative incompetency at the tricuspid orifice, with engorgement of the\\nsystemic veins. The left ventricle does not take part in any changes.\\nIt retains its normal size, but it may look small in comparison with\\nthe right ventricle.\\nSymptoms. If hypertrophy of the right ventricle ensues, the com-\\npensation may be sufficient to prevent the occurrence of symptoms for\\nmany years. The disease may exist for a number of years without\\ndiscomfort to the patient. Because of its rheumatic origin a fresh\\nendocarditis may develop, particularly as most of the subjects are\\nyoung. The old valve lesion invites infection, and so a recurrent form\\nof endocarditis is induced. If fresh endocarditis occurs, embolic symp-\\ntoms are likely to follow. Embolism takes place particularly in the\\nbrain, causing hemiplegia or aphasia. When failure of compensation\\ntakes place the symptoms described in mitral incompetency arise.\\nThey are the symptoms of dilatation of the heart, and may recur\\nfrequently during a long period of years.\\nDropsy, however, is not so common as in mitral regurgitation.\\nVisceral stases are common when compensation fails, and in many\\ncases we find enlargement of the liver continuing for a long period.\\nAscites may in rare cases be the only manifestation of mitral obstruction.", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0729.jp2"}, "730": {"fulltext": "664 SPECIAL DIAGNOSIS.\\nPhysical Signs. (Plate XXX., Fig. 2.) The physical signs of\\nmitral obstruction are more striking and more diagnostic of the lesion\\nthan the physical signs of any other form of organic heart disease.\\nInspection. As the disease develops in children with soft ribs the\\nlocal deformities are very marked. For the same reason precordial\\nbulging is more prominent. Because the right ventricle is hypertro-\\nphied, the sternum and the fourth, fifth, and sixth costal cartilages pro-\\ntrude. The apex impulse is not usually displaced, certainly not beyond\\nthe mid-clavicular line. The impulse is not marked at the apex. In\\nthe third and fourth interspaces a visible impulse is seen along the\\nmargin of the sternum. After dilatation the extent of impulse dimin-\\nishes and the veins of the neck become engorged, the blood regurgi-\\ntating into them during the systole.\\nPalpation. In the large majority of cases a distinct fremitus or\\nthrill is felt more marked in the fourth or fifth interspace, inside of\\nthe nipple. It is usually localized to a small area, is increased during\\nexpiration, and is of a twisting, grating, or grinding character. It is\\nmade up of a series of small shocks increasing in intensity, culminating\\nin a sudden, sharp shock, which occurs at the time of the impulse.\\nThe thrill and systolic shock are pathognomonic, and may be present\\nwhen other signs, as the murmur, are absent or indistinct. The car-\\ndiac impulse is felt strongest at the lower margin of the sternum and\\nin the third and fourth interspaces, in some cases even in the second.\\nIt is due to an enlarged and dilated right ventricle.\\nThe Pulse. With perfect compensation the pulse is slow, regular,\\nand firm, although small. If the orifice is much narrowed, small,\\nweak, and irregular in force and rhythm. When compensation fails\\nand the right heart is dilated the pulse becomes rapid, quick, weak,\\nsmall in size, and irregular in force and rhythm. The dilatation\\nmay be so great that the right auricle and overdistended veins may\\npress upon the aorta or the innominate and subclavian arteries. The\\npulse on that side will be lessened in volume. 1\\nPercussion. The area of cardiac dulness is increased upward and\\nto the right and left of the margin of the sternum. Sometimes it ex-\\ntends upward as high as the second rib this increase is quite charac-\\nteristic.\\nAuscultation. At the apex, or just inside of the position of the\\napex-beat, a murmur is beard, its point of maximum intensity dis-\\ntinctly localized to this spot. It is usually not transmitted. (See Fig.\\n172.) It is of a churning and grinding character, or vibratory and\\npurring. It is usually high in pitch and rough. It occurs synchro-\\nnously with the thrill, and terminates with a loud shock that is heard\\nsimultaneously with the first sound. It is, therefore, presystolic in\\ntime. As has been said of the thrill, so it may be said of this murmur,\\nthat it is the only murmur that is pathognomonic of a special lesion.\\nIt indicates narrowing of the mitral orifice. The only exception, in\\nwhich the lesion is absent, although the murmur is present, is found\\nin the class of cases described by Flint, referred to in the section on\\n1 Popoff British Medical Journal, 1893.", "height": "4400", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0730.jp2"}, "731": {"fulltext": "", "height": "4388", "width": "2652", "jp2-path": "practicaltreatis00muss_0_0731.jp2"}, "732": {"fulltext": "PLATE XXX\\nFIG. 1.\\nSysm sftuts\\nu\u00c2\u00bb\\nTricuspid Regurgitation.\\nFIG. 2.\\nTHriflf?)-+\\nTricuspid Stenosis.", "height": "4416", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0732.jp2"}, "733": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 665\\naortic regurgitation. The first sound is loud, clear, and abrupt it\\nmay be thumping.\\nthe presystolic murmur may occupy the entire period of the dias-\\ntole, but in the large majority of cases it occurs in the latter half only,\\nduring which the auricular systole occurs. In some instances it is\\nheard in the middle of the diastole.\\nAssociate Murmurs. 1. At the same time a systolic murmur may\\nbe heard at the apex, soft and low in pitch. It may be transmitted\\ninto the axilla. It is usually due to associate mitral regurgitation. 2.\\nAt the lower portion of the sternum a systolic murmur may be heard,\\ndue to dilatation and incompetency at the tricuspid orifice. Murmurs\\nin the aortic region are not usually heard.\\nThe second sound at the pulmonary orifice is usually accentuated. It\\nis heard in the second and third interspaces along the left edge of the\\nsternum it may be heard at the apex. Reduplication of the first\\nsound is often observed. Reduplication of the second sound is very\\ncommon. After compensation is broken other murmurs may be heard,\\nand the presystolic murmur changes in character. It may disappear\\nentirely and be replaced by a sharp first sound. The short, high-\\npitched systolic shock may continue, although the murmur disappears.\\nIt disappears probably because the left auricle has become weakened.\\nThe tricuspid murmur continues during this period.\\nThe points of distinction of mitral obstruction are (1) the position of\\nthe murmur (2) its restricted area (3) its peculiar character (4) the\\nsystolic shock which takes the place of the first sound (5) the thrill (6)\\nthe impulse and increased area of dulness upward (7) accentuated\\npulmonary second sound (8) reduplication (9) the absence of the pulse\\nof aortic regurgitation and of hypertrophy of the left ventricle.\\nPresystolic Murmur not due to Valvulitis. A presystolic\\nmurmur without mitral obstruction may occur in aortic regurgitation\\nand in adherent pericardium.\\nTricuspid Regurgitation or Incompetency. Structural disease at\\nthe tricuspid orifice is of comparatively rare occurrence. Insufficiency\\nis more frequent, and is due to dilatation, with relative insufficiency of\\nthe valve-orifice. It occurs secondarily to obstructive lung diseases,\\nas emphysema and cirrhosis, and is secondary to regurgitation at the\\nmitral orifice, which leads to stasis in the lungs.\\nSymptoms. The symptoms were detailed in speaking of the mitral\\nvalve affections. They are those of obstruction in the pulmonary cir-\\nculation and engorgement of the systemic veins.\\nPhysical Signs. (Plate XXXI., Fig. 1.) Inspection. The physical\\nsigns of dilatation of the right heart are seen. An impulse in the epi-\\ngastrium is noted. This is seen especially between the xiphoid cartilage\\nand the left margin of the ribs. Pulsation to the right of the sternum\\nand in the second and third intercostal spaces may also be observed.\\nThe veins of the neck are also seen to pulsate. In addition to the wavy\\npulsation, regurgitation of the blood into the right auricle causes trans-\\nmission of the pulse-wave into the veins. The pulsation is systolic in\\ntime. It is more marked in the right jugular than in the left, and in\\nthe external than in the internal veins. With the pulsation, regurgi-", "height": "4416", "width": "2648", "jp2-path": "practicaltreatis00muss_0_0733.jp2"}, "734": {"fulltext": "QQQ SPECIAL DIAGNOSIS.\\ntation is readily observed by emptying the external vein. Place the\\nfinger firmly on the vein jnst above the clavicle, move it along the\\ncourse of the vein in the direction of the inferior maxillary bone. The\\nvein is thus emptied of blood, and with each systole of the heart it will\\nbe seen to fill np from below in rhythmical pulsation. The veins are\\nincreased in size. This is more noticeable during the act of coughing\\nor when the patient holds his breath in full inspiration. In rare in-\\nstances the pulsation is transmitted to the subclavian and axillary veins.\\nPalpation. By palpation the above conditions are also determined.\\nThe impulse over the lower sternum and in the epigastrium is noted\\nto be forcible.\\nThe regurgitant pulsation is transmitted to the descending vena cava\\nas well as to the ascending. The hepatic veins also distend during\\nthe systole. So-called pulsation of the liver is produced. With one\\nhand on the fifth and sixth costal cartilages and the other over the\\nliver in the axillary region, rhythmical expansile pulsation may be\\nrecognized. It is not of common occurrence, but is absolutely diag-\\nnostic of regurgitation at the tricuspid orifice.\\nPercussion. The area of cardiac dulness is increased transversely\\nand upward, as described in mitral stenosis. It extends often far be-\\nyond the right edge of the sternum.\\nAuscultation. At the xiphoid cartilage, the lower end of the ster-\\nnum or the head of the fourth rib, a murmur is heard. It is sys-\\ntolic in time, usually low in pitch, and is heard loud to the left of the\\nsternum, within an inch of the apex, and to the right of the sternum\\nand the outer limits of percussion-dulness. (See Fig. 173.) It is not\\nfurther transmitted. Other murmurs are heard, due to the primary\\norganic disease. If the heart is weak, the lesion may not be produc-\\ntive of a murmur. The pulmonary second sound is accentuated.\\nTricuspid Stenosis. Stenosis at this valve-orifice is generally of\\ncongenital origin. In rare instances it may be secondary to lesions in\\nthe left heart. It is accompanied by dilatation of the right auricle.\\nThe physical signs (Plate XXXI., Pig. 2) are the same as in stenosis\\nat the mitral orifice, except for the alteration in their position. In\\nsome instances a presystolic thrill has been observed, and with it a\\npresystolic murmur at the lower end of the sternum or toward the right\\nof it. The area of dulness is increased as in right-sided dilatation.\\nCyanosis is a prominent symptom and may be intense.\\nDisease of the Pulmonary Valve. Diseases of the pulmonary\\nvalve are extremely rare and are almost always congenital.\\nPulmonary Insufficiency. (Plate XXXIL, Fig. 1.) The physical\\nsigns arc due to regurgitation into the right ventricle. The maximum\\nintensity of the murmur is in the second pulmonary interspace, and it\\nis transmitted down the sternum. It cannot be distinguished from\\naortic regurgitation, except by the pulse.\\nPulmonary Stenosis. (Plate XXXIL, Fig. 2.) In stenosis of the\\npulmonary valve a systolic murmur and thrill are detected to the left of\\nthe sternum in the second interspace. The murmur is not transmitted\\nto the vessels of the neck. The pulmonary second sound is weak.\\nThe effect on the heart is the production of right-sided hypertrophy.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0734.jp2"}, "735": {"fulltext": "PLATE XXXII\\nFIG. 1.\\n-rr-..\\nUiir-\\nPulmonary Insufficiency.\\nFIG. 2.\\nX.\\nPulmonary Stenosis.", "height": "4368", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0735.jp2"}, "736": {"fulltext": "", "height": "4400", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0736.jp2"}, "737": {"fulltext": "", "height": "4372", "width": "2612", "jp2-path": "practicaltreatis00muss_0_0737.jp2"}, "738": {"fulltext": "PLATE XXXIII.\\nFIG. 1.\\nV\\nCombined Mitral and Aortic Insufficiency and Stenosis.\\nFIG. 2.\\nStfsM. kills.\\n-^m..\\nMf\\nCombined Mitral and Tricuspid Insufficien\\ncy.", "height": "4408", "width": "2612", "jp2-path": "practicaltreatis00muss_0_0738.jp2"}, "739": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 667\\nCombined Valvular Lesions. (Plate XXXIII.) It must not be\\nforgotten that there may be disease causing both obstruction and re-\\ngurgitation at the same time and at the same orifice, or that two or\\nmore valves may be the seat of disease in the same individual. It is\\nnot impossible, for instance, to have aortic obstruction and regurgita-\\ntion, mitral obstruction and regurgitation, and tricuspid regurgitation.\\nAortic obstruction or insufficiency is frequently combined with mitral\\ninsufficiency. Aortic and mitral insufficiency occur together most fre-\\nquently in children aortic obstruction and mitral obstruction in adults.\\nWhen more than one valve is diseased the site of the various lesions\\nis based upon the time, the position of maximum intensity, and the\\ndirection of transmission of the murmurs. Students often experience\\ndifficulty here. A systolic murmur may be heard in the aortic area and\\nin the mitral area at the same time. If it is observed that each pro-\\ngressively weakens as the stethoscope is moved toward the middle of\\nthe precordial area, it may be inferred that the murmur, systolic in\\ntime, is due to two lesions. As previously intimated, the direction of\\nthe transmission of the murmur further aids in the diagnosis.\\nEnlargement of the Heart.\\nEnlargement of the heart is due to hypertrophy or to dilatation. In\\nhypertrophy there is increased thickness of the muscular walls. This\\nmay be general or limited to the walls of one chamber. Hypertrophy\\nis further divided into simple hypertrophy, in which the cavity or\\ncavities are of normal size, and eccentric hypertrophy, in which, with\\nincrease in the wall, there is enlargement of the cavities. This is\\nhypertrophy with dilatation. The left ventricle is most frequently the\\nseat of hypertrophy when one chamber is involved. The cause of\\nhypertrophy is obstruction to the flow of blood increased work is fol-\\nlowed by increased size of the muscle. General hypertrophy or hyper-\\ntrophy of the left ventricle occurs from diseases of the heart itself, or\\nfrom affections of the bloodvessels.\\nA. Diseases of the heart. 1. Disease of the aortic valves. Hyper-\\ntrophy of the left ventricle always follows. 2. Mitral regurgitation.\\n3. Pericardial adhesions. 4. Myocarditis of the fibrous variety. 5.\\nNeuroses with overaction and frequent palpitation, as in exophthal-\\nmic goitre and from the effects of tea, tobacco, and alcohol. In peri-\\ncardial adhesions and myocarditis hypertrophy arises because of the\\ninability of the heart to do the work expected of it. There is no ob-\\nstruction in the course of the vessels or at the orifices. The struggle\\nto keep up causes the hypertrophy. In neuroses there is absence of\\nobstruction, but the rapid action causes hypertrophy.\\nB. Affections of the bloodvessels which cause hypertrophy are 1.\\nGeneral arterial sclerosis. 2. Increased arterial tension due to con-\\ntraction of the peripheral arteries, as in Bright s disease, and in tox-\\nemias from lead, the poison of gout and of syphilis. 3. Increased\\nblood-pressure from prolonged muscular exertion. 4. Narrowing of\\nthe aorta from external pressure and from congenital stenosis or the\\ndevelopment of an aneurism.", "height": "4416", "width": "2612", "jp2-path": "practicaltreatis00muss_0_0739.jp2"}, "740": {"fulltext": "6(38 SPECIAL DIAGNOSIS.\\nHypertrophy of the Bight Ventricle. Obstruction to the flow of blood\\nin the pulmonary area is the usual cause of hypertrophy of the right\\nventricle. This obstruction occurs in lesions of the mitral valve, caus-\\ning pulmonary stasis and disease of the lungs, causing compression\\nof the bloodvessels, as in emphysema or cirrhosis. It occurs if there\\nis disease of the right heart with obstruction of the valves. Thus in\\nobstruction at the pulmonary orifice the right ventricle undergoes\\nsecondary hypertrophy.\\nHypertrophy of the Auricles. Simple hypertrophy of the left auri-\\ncle with dilatation develops in mitral stenosis. Hypertrophy of the\\nright auricle occurs in tricuspid obstruction and in right-sided dilata-\\ntion with tricuspid regurgitation.\\nSymptoms. The symptoms of hypertrophy of the heart are general\\nand local. The former are not common. They are due to increased\\ntension in the cerebral vessels because of increased force of the heart,\\nusually causing congestive headaches, noises in the ears, flashes of light,\\nand flushing of the face.\\nGeneral symptoms arise in hypertrophy of the left ventricle because\\nthe increased force causes reactive spasm of peripheral vessels, and\\nhence increased tension in the vascular system. In Bright s disease,\\nfor instance, or heightened arterial tension from other causes, endarter-\\nitis develops in the large vessels, on account of the strain put upon them.\\nThis is seen particularly in the aorta and its divisions. Whether\\natheroma is primary or secondary, its presence, with hypertrophy of\\nthe left ventricle, indicates that rupture of the vessels somewhere in the\\nperiphery may take place. This occurs most frequently hi the brain,\\ncausing apoplexy.\\nLocally, the patient complains of fulness and discomfort, particularly\\nmarked when lying down on the left side. In the hypertrophy that\\naccompanies the tobacco-heart, or the irritable heart of soldiers, there\\nmay be some pain. On the other hand, the organ may be enormously\\nenlarged without the patient complaining of discomfort about the heart.\\nPalpitation is not of common occurrence except in neurasthenic subjects.\\nPhysical Signs. The hypertrophy causes precordial bulging, if\\nit has developed early in life, when the ribs are soft. The intercostal\\nspaces are widened and the area of impulse is much increased. The\\nnormal impulse is changed in position. It is downward and to the\\nleft, often extending as far as the axilla in hypertrophy of the left\\nventricle.\\nPalpation. The impulse is forcible and heaving. The head is\\nvisibly raised with each systole when placed upon the chest for auscul-\\ntation. The impulse is slow. This slow, heaving impulse distin-\\nguishes it from the forcible impulse of dilated hypertrophy, which is\\nsudden and abrupt. Inspection is confirmed as to the position of the\\napex. In moderate hypertrophy the apex extends to the sixth inter-\\nspace in the mid-clavicular line. In large-sized hypertrophy it may\\nextend to the seventh interspace. The heart may be apparently\\nhypertrophied in fibrous and fatty myocarditis. The impulse may be\\nabsent in emphysema, in fatty overgrowth of the heart, and in persons\\nwith thick chest-walls.", "height": "4416", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0740.jp2"}, "741": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 669\\nThe Pulse. The frequency of the pulse is not affected. It is full,\\nregular, and strong. The tension is increased. In dilated hyper-\\ntrophy the pulse is full but soft, and more rapid than in simple hyper-\\ntrophy. When failure of the heart takes place the pulse increases in\\nfrequency and becomes intermittent and irregular. When valve-lesions\\nare present the pulse is modified accordingly.\\nPercussion. The area of dulness is increased both upward and\\ntransversely. It may begin as high as the second interspace and ex-\\ntend two inches beyond the left mid-clavicular line, and an inch beyond\\nthe right edge of the sternum transversely. In simple hypertrophy\\nthe area is ovoid.\\nAuscultation. When the valves are healthy, prolongations of the first\\nsounds occur. They are also at times duller than in health. The dull,\\nprolonged first sounds distinguish hypertrophy from dilatation, for in\\nthe latter they are clear and sharp. The second sounds are clear and\\nloud. The degree of accentuation depends upon the state of the per-\\nipheral arteries. If there is heightened tension, the second sound may\\nbe reduplicated. If valvular disease is present, the sounds are modified.\\nHypertrophy of the Right Ventricle. Increased pulmonary\\ntension from resistance in the pulmonary circulation may always be\\nlooked for. If there is complete compensation, no symptoms are ob-\\nserved, or only those of dyspnoea on extra exertion. Hypertrophy of\\nthis ventricle persists for a long period of time without the grave local\\nchanges in the heart, or secondary changes in the peripheral vessels,\\nwhich occur in left ventricle hypertrophy. In dilated hypertrophy,\\nwhen the dilatation is in excess, tricuspid regurgitation takes place,\\nwith the development of venous stases. Induration of the lungs may\\nsucceed the persistent engorgement of the capillaries. Pulmonary con-\\ngestions and apoplexy may also occur.\\nPhysical Signs. The physical signs of hypertrophy of the right\\nventricle have been partially referred to under the various valve affec-\\ntions. There is bulging of the lower part of the sternum and carti-\\nlages. The epigastric impulse in the angle between the ensiform carti-\\nlage and the ribs has been referred to. The impulse may be in the\\nsixth interspace. It is diffuse it may extend upward as in mitral\\nstenosis. Cardiac dulness is increased toward the right an inch or\\nmore beyond the border of the sternum. The heart-sounds are not\\nmuch changed unless there is dilatation. The tricuspid sound is clear\\nand sharp when this occurs. The pulmonary second sound is accentu-\\nated, and reduplication may take place. The radial pulse is small.\\nIf there is tricuspid regurgitation, the physical signs that attend it\\nare present.\\nHypertrophy of the Left Auricle. This is present in mitral\\nstenosis, but cannot be determined by physical signs, save possibly by\\ngreater increase of dulness to the left of the sternum in the second\\nand third interspaces. Barr states that dulness above the supraster-\\nnal mammillary line toward the left clavicle indicates enlargement of\\nthe left auricle, as in mitral stenosis. The line above mentioned is\\ndrawn from the middle of the suprasternal notch to the normal site of\\nthe left nipple on the fourth rib.", "height": "4416", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0741.jp2"}, "742": {"fulltext": "670 SPECIAL DIAGNOSIS.\\nHypertrophy of the right auricle with dilatation occurs\\nunder the same circumstances as hypertrophy of the ventricle. It\\nusually dilates more than the left auricle in left ventricle hypertrophy.\\nThere is increased area of dulness in the third and fourth right inter-\\nspaces abnormal pulsation is sometimes observed in this situation\\nbefore the systole, with the signs of tricuspid regurgitation.\\nDiagnosis. The forcible impulse in nervous palpitation of the\\nheart must not be confounded with true hypertrophy, although it\\nmust not be forgotten that hypertrophy frequently follows neurotic\\npalpitation, as in the smoker s heart, or in exophthalmic goitre.\\nThe enlargement must not be confounded with enlargement of the\\narea of cardiac dulness in the precordial region from other causes,\\nsuch as pericardial effusion aneurism and mediastinal tumor, push-\\ning the heart against the chest-wall disease of the lungs, on ac-\\ncount of which they are withdrawn from the surface of the heart, as\\nin phthisis or chronic pleurisy and displacement of the heart from\\npressure, as in effusion on the left side of the chest, or in disease below\\nthe diaphragm. The cause of hypertrophy should be ascertained, for\\nit is a valuable aid in diagnosis. It must not be forgotten that emphy-\\nsema of the lung may mask a considerable hypertrophy of the heart\\nby causing diminution of the area of dulness.\\nDilatation of the Heart. Enlargement due to dilatation of the\\nheart is common. The condition usually succeeds hypertrophy.\\nThickening of the muscles attends dilatation of the cavities, as in\\ndilated or eccentric hypertrophy. The dilatation occurs because of in-\\ncreased pressure within the cavities or because of weakening of the\\nheart- walls, the pressure within being normal.\\n1 Increased pressure within the walls is due to an increased amount\\nof blood within the chamber from regurgitation, or from an obstacle\\nto the outward flow of blood. Simple hypertrophy occurs first in\\nmany cases in others, hypertrophy with dilatation in not a few,\\ndilatation takes place at once. In dilatation the chamber does not\\nempty itself during the systole. It is seen physiologically after the\\nexertion of ascending a great height. It may remain within the\\nbounds of physiological action. Temporarily, as any one can show\\nby running violently, the dilatation is attended by increased epi-\\ngastric pulsation and increased cardiac dulness. The tricuspid valves\\ntemporarily become incompetent, owing to their safety-valve action.\\nThe latter may continue after the acute strain, the heart always show-\\ning symptoms of the condition, or it may disappear entirely. An\\nexcessive dilatation results in heart-strain, with cardiac distress and\\ndyspnoea, symptoms due to overdistention and paralysis of the heart.\\n(See Symptoms.) Dilatation occurs in all forms of heart-lesions pre-\\nviously described. The most typical is seen in aortic regurgitation,\\nwhen the left ventricle becomes the seat of dilatation, and in mitral\\nregurgitation when the left auricle becomes the seat of dilatation.\\n2. Disease of the heart-walls, lessening the resisting power, the nor-\\nmal pressure within the cavities being maintained, invites dilatation.\\nIn myocarditis, in infections, acute dilatation may ensue. It occurs in\\nscarlatinal dropsy, typhoid fever, rheumatic fever, and erysipelas.", "height": "4416", "width": "2640", "jp2-path": "practicaltreatis00muss_0_0742.jp2"}, "743": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 671\\nThe heart-muscle changes in acute endocarditis and pericarditis, on\\naccount of which dilatation may ensue. In ansemia and chlorosis the\\nsame process may take place. In chronic myocarditis dilatation takes\\nplace at the apex. When pericardial adhesions are present the fibrous\\novergrowth invades the interstices of the myocardium, thereby weaken-\\ning the heart-muscle. Dilatation may follow.\\nSymptoms. The symptoms of dilatation are the reverse of those\\nof hypertrophy. When the latter fails the blood is not expelled from\\nthe chambers in systole, so that the cavity is overdistended with\\nblood that accumulates in the diastole. Weakening of the muscles\\nalso favors the development of dilatation. As soon as dilatation be-\\ncomes permanent, incompetency of the valves takes place. In obstruc-\\ntive heart disease the left side is first affected. It may be compen-\\nsated for by hypertrophy of the right side. When this fails venous\\nengorgement and dropsy ensue. The symptoms have been described\\nunder chronic valvular disease. In acute dilatation there is a sudden\\noccurrence of dyspnoea. Pain, or at least precordial oppression, may\\nbe complained of. The heart s action increases in frequency. The\\npulse is rapid, feeble, irregular, and may scarcely be felt at the wrist.\\nPhysical Signs* Inspection. The apex is displaced to the left,\\neven as far as the axillary line, but rarely downward, unless hypertro-\\nphy precedes the dilatation. The impulse is diffused and undulatory\\nin appearance. The apex-beat may be defined with extreme difficulty.\\nIt may be visible when the patient leans forward, yet not felt.\\nWith the diffused area of impulse a quick apex-beat may be felt\\nmuch weakened, however. When the right ventricle is dilated, the\\nimpulse is seen and felt to the right or left of the xiphoid cartilage,\\nand there is a wavy pulsation along the left edge of the sternum\\nin the fourth, fifth, and sixth interspaces. If the dilatation is extreme,\\ninvolving the right auricle, a pulsation at the third right interspace\\nclose to the sternum may be felt. Tricuspid regurgitation is then\\npresent.\\nThe area of dulness is increased in the same directions as in hyper-\\ntrophy, if the two coexist. In general, it may be said the increase\\nextends outward to the right or left, the direction corresponding to\\nthe ventricle affected. It is increased upward along the left edge of\\nthe sternum in left auricle dilatation. (See Mitral Valvulitis.) When\\nthe whole heart is dilated the increase of dulness is in a transverse\\ndirection on both sides. The apex is rounded or square, not pointed,\\nas in hypertrophy indeed, it retains the oval shape of the dulness\\nof a normal heart. As dilatation occurs so frequently in emphysema\\nof the lungs, the modification of the percussion-sound must be re-\\nmembered.\\nAuscultation. The systolic sounds are short and sharp. They are\\nhigh-pitched and resemble the diastolic. The latter may become\\nenfeebled when the dilatation becomes excessive. The right and left\\nfirst sounds may differ somewhat in intensity, and reduplication may\\noccur. The sounds may be obscured by murmurs. The murmurs\\nare due to previous valve disease or to incompetency, on account of\\ndilatation. The action of the heart is irregular and intermittent. The", "height": "4416", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0743.jp2"}, "744": {"fulltext": "672 SPECIAL DIAGNOSIS.\\npulse is correspondingly small. In dilatation the alteration of the\\nrhythm is extreme. There may be embryocardia or foetal-heart rhythm,\\nin which the first and second sounds are alike, and the long pause is\\nshortened. More frequently we have galloping rhythm of the heart.\\nIt must not be forgotten that, as dilatation ensues, murmurs of various\\nvalve-lesions may disappear, particularly the murmur of mitral steno-\\nsis. On the other hand, in the earlier stages particularly, murmurs\\ndevelop, on account of incompetency at the auriculo- ventricular orifices,\\nin addition to the primary organic murmur. These murmurs in turn\\nmay disappear, if the dilatation is controlled by careful treatment.\\nDiseases of the Arteries.\\nArterial Sclerosis or Arterio-capillary Fibrosis. This\\noccurs as the result of wear and tear of life and as the accompaniment\\nof age. The time of its onset depends upon the quality of the arterial\\ntissue which the individual inherited, and upon the amount of wear\\nand tear. It may occur early in life, and entire families may show\\nthis tendency. Very frequently the sclerosis develops from intoxica-\\ntions of the system, on account of which persistent spasm of the small\\nvessels is set up for blood of an impaired quality is passed with greater\\ndifficulty through the capillaries, as was taught by Bright. The blood-\\ntension is raised thereby. The poison of alcohol, of lead, of gout, and\\nof syphilis leads to this condition. The poison of syphilis and of gout\\nmay set up directly an inflammation and degeneration of the arteries.\\nIn renal disease arterial sclerosis is of common occurrence. The rela-\\ntion to the renal lesion differs. It may be primary or secondary.\\nWhen primary, the morbid cause operates upon the kidneys as well as\\nthe arteries. When secondary a morbid poison is retained within the\\nsystem by the diseased kidneys, the action of which is such as to cause\\nperipheral spasm and heightened tension.\\nOverfilling of the bloodvessels from excessive eating and drinking\\nis thought by some to cause arterial sclerosis through constant overdis-\\ntention of the vessels. In overwork of the vessels and excessive strain\\nthere is either heightened tension or increased peripheral resistance,\\nthe effect upon the bloodvessels being the same in either case. The\\nresult of the above causes is thickening of the intima, followed by\\nchanges in the media and adventitia, terminating in endarteritis de-\\nformans of the large arteries.\\nSymptoms. The symptoms vary. They may be general or local.\\nThe disease may be present and the patients die from other causes.\\nLocal symptoms are due to rupture of the vessels, as in apoplexy from\\ncerebral hemorrhage, or to their obstruction, as the coronary artery, or\\nto rupture of an aneurism.\\nPhysical Signs. Arterio-sclerosis is recognized by inspection,\\npalpation, and auscultation of the bloodvessels, and by observation\\nof the condition of the heart. The superficial bloodvessels are elon-\\ngated and tortuous, and pulsate visibly. On palpation the artery feels\\nvery hard to the touch it resists compression it is corded or rounded\\nunderneath the finger, and readily rolled about. The pulse shows at", "height": "4416", "width": "2568", "jp2-path": "practicaltreatis00muss_0_0744.jp2"}, "745": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 673\\nonce high tension the wave is slow in ascent, continues long under-\\nneath the finger,- and subsides slowly. If in the interval of the beats\\nthe vessel remains full, the pulse, as previously noted, is obliterated\\nwith difficulty. Sphygmographic tracings are characteristic. (See\\nPulse.) If, after pressure on the radial artery, it can still be felt be-\\nyond the point of compression, its walls are sclerosed whereas, if\\nafter such compression the artery is obliterated beyond the point of\\ncompression, the hardness and firmness of the pulse previously ob-\\nserved are due to vascular tension and not to thickened walls. The\\ntwo conditions should be distinguished. Hypertrophy of the heart\\noccurs early in the course of the sclerosis, on account of peripheral\\nresistance. The hypertrophy involves the left ventricle, and is not\\nattended by dilatation. The apex-beat is out beyond the mid-clavicu-\\nlar line the impulse is heaving and forcible. The second sound at\\nthe aortic cartilage is characteristic. It is clear and ringing it is heard\\nin the course of the bloodvessels, and is most distinct at or just beyond\\nthe apex. Right-sided hypertrophy and dilatation are not generally\\npresent. Auscultation of the larger arteries, as the carotids, the abdom-\\ninal aorta, and femorals, shows a systolic murmur usually rough and\\nhigh in pitch. All the above-mentioned conditions may be present,\\nand yet the patient remain in good health. The hypertrophy appar-\\nently compensates for the arterial occlusion. There may be no renal\\ndisease, or moderate renal cirrhosis may be present, indicated by tran-\\nsient albuminuria, polyuria, and hyaline tube-casts. The subsequent\\nsymptoms are due largely to closure of one or more vessels in the\\nperipheral circulation, to the development of an aneurism or dilatation\\nof the aorta, to failing hypertrophy of the heart, or to the development\\nof renal cirrhosis.\\nThe blocking of peripheral arteries is due to embolism or throm-\\nbosis, more frequently the latter, and to rupture of peripheral vessels,\\nor, in all probability, miliary aneurisms. When occlusion of the\\nvessels takes place in arteries which supply the extremities gangrene\\nmay occur. Sometimes the occlusion is due to simple narrowing of\\nthe vessels alone. Gangrene of the feet is frequently seen secondary\\nto bad arteries. If the occlusion takes place in the vessels of the\\nbrain, various secondary lesions are produced. In more or less gen-\\neral occlusion from sclerosis of the smaller arteries acute and chronic\\nsoftening occur. Hemiplegia, monoplegia, or aphasia may occur tem-\\nporarily, if relieved by collateral circulation, or permanently, from\\nembolism, thrombosis, or rupture of the vessels. Hence, apoplexy is\\nalmost always due to primary disease of the arteries, upon which, in\\nthe large majority of cases, miliary aneurisms have existed. If the\\ncoronary arteries are blocked, thrombosis with sudden death takes\\nplace, or chronic myocarditis may develop, with subsequent aneurism\\nand rupture. Angina pectoris, with or without thrombosis of the\\ncoronary artery, is always associated with arterial sclerosis.\\nFailure of the hypertrophied heart leads to dilatation with all the\\nsymptoms as previously described, including cyanosis, visceral conges-\\ntions, and dropsies. The murmur at the apex, due to incompetency\\nfrom dilatation, may simulate chronic valvular disease, although the\\n43", "height": "4416", "width": "2620", "jp2-path": "practicaltreatis00muss_0_0745.jp2"}, "746": {"fulltext": "674 SPECIAL DIAGNOSIS.\\nlatter may never have been present. The sclerosis ma) T advance more\\nrapidly in the kidneys than in the other portions of the circulation\\nlater, on account of the contracted kidney, symptoms of interstitial\\nnephritis may arise.\\nAneurism.\\nA true aneurism is formed by the distention of one or more of the\\narterial coats. It is usually fusiform, but may be cylindrical. It may\\nbe circumscribed or sacculated. The fusiform and saccular are the\\nforms most commonly seen. False aneurism or dissecting-aneurism\\narises from laceration of the internal coat of the artery. The blood\\ndissects between the layers. It occurs in the aorta. It may begin at\\nthe heart and separate the coats as far down as the iliac arteries.\\nArterio-venous aneurism is seen when communication between an artery\\nand a vein has been set up. If a sac intervenes, it is called a vari-\\ncose aneurism. Sometimes communication is direct, the vein becoming\\ndilated, tortuous, and pulsating. It is known as an aneurismal varix.\\nAn aneurism may occur in the course of arterial sclerosis from\\ndiffuse distention of the coats. Its typical form is seen in dilatation of\\nthe aorta with one or more sacculated aneurisms on its surface.\\nSacculated aneurism occurs from rupture of the tunica media, indepen-\\ndently of general disease of the arteries, and in arterial sclerosis. The\\nmost common seat is the ascending portion of the aorta. It occurs\\nearly in the course of arterial sclerosis. Such form of aneurism is\\nseen in the smaller vessels. Aneurisms also arise after the lodgement\\nof an embolus, permanently plugging the vessel. The proximal end\\nof the vessel becomes dilated.\\nMycotic aneurism, first described by Osier and exhaustively by\\nEppinger, occurs in malignant endocarditis. The aneurisms are small\\nin size and multiple, and not recognized during life. They arise from\\nthe injury produced by the local infection of bacteria in different por-\\ntions of the vascular system.\\nAneurism of the Thoracic Aorta. The causes which produce\\narterial sclerosis are operative in the thoracic portion of the aorta\\nchiefly physical overwork, alcohol, syphilis, and gout. It may be\\nsituated just beyond the aortic ring, at the junction of the ascending\\nand transverse aorta, in the transverse, or at the beginning of the\\ndescending, portion of the thoracic aorta. The larger aneurisms are at\\nthe two bends of the aorta.\\nSymptoms. The symptoms of aneurism are largely due to press-\\nure, and depend upon the position of the aneurism and the direction of\\nits growth.\\nAneurisms, however, may exist without symptoms or appreciable\\nphysical signs. Even in a patient who has been under careful obser-\\nvation, sudden death may take place from rupture of a concealed\\naneurism, the presence of which had not been suspected during life.\\nOn the other hand, cases occur with characteristic pressure-symptoms\\nand with no physical signs. Pressure -symptoms depend entirely upon\\nthe position of the tumor.\\nAneurisms of the ascending portion of the arch cause dislocation of", "height": "4428", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0746.jp2"}, "747": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 675\\nthe heart outward, or toward the right pleura or forward, appearing\\nat the second or third interspace, causing erosion of the ribs and ster-\\nnum. The vena cava is compressed, causing enlargement of the veins\\nof the head and arms the subclavian vein may be compressed alone,\\ncausing enlargement and oedema of the right arm. Localized oedema\\nmay result, confined to the thorax. (See CEdema.) If the aneurism\\nis large, the inferior vena cava may be pressed upon, causing oedema\\nof the feet. The right laryngeal nerve may be involved, causing\\naphonia and dyspnoea. Pain attends the aneurismal process.\\nFig. 177.\\nAneurism of ascending portion of arch of aorta. Tumor in first and second interspaces,\\nextending into neck. Portion of sternum atrophied.\\nAneurisms of the transverse portion of the aorta project below, for-\\nward, or backward. When forward, they produce tumors behind the\\nmanubrium, which from pressure cause destruction of the bone if the\\naneurism projects backward, marked pressure-symptoms are produced.\\nWhen the trachea is pressed upon, it causes dyspnoea and cough, which", "height": "4404", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0747.jp2"}, "748": {"fulltext": "676 SPECIAL DIAGNOSIS.\\nis paroxysmal. (See Dyspnoea.) The oesophagus may be pressed\\nupon, causing dysphagia. The left recurrent laryngeal nerve may be\\npressed upon, causing paralysis of the corresponding cord, with aphonia.\\n(See Larynx.) Pressure on a bronchus may produce bronchorrhoea\\nand dilatation, which in turn may lead to localized abscess. The\\ngrowth may extend upward, involving the coats of the innominate and\\ncarotid arteries on the right side, or carotid and subclavian on the left,\\nmarkedly interfering with the pulse of the two sides. Pressure on\\nthe sympathetic nerve is likely to take place in this situation, with\\ncontraction of one of the pupils, although at first it is sometimes\\ndilated. The thoracic duct is sometimes compressed, leading to rapid\\nwasting.\\nIn the descending portion the pressure-signs of aneurism are often not\\nso marked. The vertebra? are likely to be pressed upon in this situation.\\nThe pain, therefore, is most intense. The oesophagus and left bronchus\\nare compressed. Dysphagia and bronchiectasis, the latter causing\\nbronchorrhoea with subsequent gangrene, are likely to occur. The\\ncough and the fever in bronchorrhoea, together with emaciation, simu-\\nlate phthisis, for which aneurism is often mistaken. The physical\\nsigns of phthisis are usually pronounced in this situation, and, with the\\npresence of bacilli in the sputum, render the diagnosis easy. In these\\ncases rupture takes place into the bronchus or into the oesophagus.\\nIn one of my cases, which had been treated for tuberculosis because of\\nsmall hemorrhages, with the conditions above-mentioned, death took\\nplace from rupture into the bronchus, causing sudden profuse hemor-\\nrhage. When the aneurism is adherent to the oesophagus and slowly\\nulcerating into it, rupture may take place, followed by instantaneous\\ndeath. The vertebrae may be eroded and symptoms of spinal com-\\npression arise.\\nI once saw an autopsy performed by a medico-legal expert on a case of\\nsudden death from gastric hemorrhage. The source of the hemorrhage\\ncould not be ascertained. There was blood in the stomach. When he\\nwas about to give up the search, the oesophagus and aorta were sug-\\ngested for examination. A small aneurism was found which had\\nulcerated and then ruptured into the gullet. In another the aneurism\\nhad ruptured into the pleural sac, causing internal concealed hemor-\\nrhage and death.\\nSpecial Symptoms. While pressure-symptoms are the most striking\\nsymptoms of this affection, pain, which is usually due to pressure,\\nmust be referred to. It is an important constant symptom. It is\\nsharp and lancinating, and may occur in paroxysms. It is more\\nsevere and constant when bone is eroded by pressure on the vertebrae,\\nor the thorax in front. The gnawing pain that attends ulceration of\\nbone is relieved, if it, as the sternum, is perforated. Anginal attacks\\nmay attend the neuralgic pains just described. Pain sometimes fol-\\nlows the course of the nerves, extending down the arm or to the neck,\\nor along the course of the intercostal nerves.\\nCough. The cough is peculiar. It is paroxysmal in many cases\\nand of a brazen, ringing character, indicating its laryngeal origin, due\\nto pressure upon the recurrent laryngeal nerves. It is frequently", "height": "4416", "width": "2656", "jp2-path": "practicaltreatis00muss_0_0748.jp2"}, "749": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 677\\nparoxysmal when the pressure is directed upon the windpipe or bron-\\nchus. In the former instance the cough is dry, in the latter tracheal\\nand bronchial. It is attended by a thin, watery expectoration which,\\nif bronchiectasis with fermentation ensues, becomes thick and ropy.\\nDyspnoea occurs more frequently in aneurism of the transverse portion,\\ndue (1) to pressure on the recurrent laryngeal nerves (2) to compres-\\nsion of the trachea (3) to compression of the left bronchus. Marked\\nstridor attends the first form. When one of the recurrent laryngeal\\nnerves, more particularly the left, is pressed upon, there is spasm or\\nparalysis of the muscles of the vocal cord, causing hoarseness and loss\\nof voice. Laryngoscopic examination should not be neglected, for\\nparalysis of the abductor muscles without symptoms may be present.\\nHemorrhage. The hemorrhage may be gradual when there is\\nslight leakage into the trachea at the point of compression. The\\namount of blood lost is small. It may take place externally. (See\\nFig. 178.) Profuse hemorrhages, causing sudden death, occur from\\nFig. 178.\\nAneurism of ascending and transverse portions of aorta projecting forward, destroying ribs and\\nsternum. The skin ulcerated, and gradual external leakage took place. The bleeding continued\\nin small amounts for a long time.\\nrupture into the trachea or bronchus, and from perforation into the\\nlung. With regard to difficulty of deglutition, it may be said that the\\nsound should never be passed in suspected cases of aneurism, on\\naccount of the danger of rupturing the sac.\\nClubbed Fingers. In intrathoracic aneurism clubbing of the fingers\\nand incurvation of the nails of one hand are sometimes seen, although\\ncomparatively rarely.\\nCompression and pressure on the sympathetic system of nerves has\\nbeen referred to. In addition to pupillary changes there may be pallor", "height": "4416", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0749.jp2"}, "750": {"fulltext": "678\\nSPECIAL DIAGNOSIS.\\nof one side of the face. When the pupil is dilated this pallor may\\naccompany it, on account of stimulation of the vaso-dilator fibres.\\nWhen the cilio-spinal branches of the sympathetic are pressed upon,\\nthe dilator fibres are paralyzed. If the pupil contracts, there are also\\nhyperemia of the side of the face and unilateral sweating.\\nPhysical Signs. (Plate XXXIV., Fig. 1.) Inspection. In\\nhealth the position of the aorta cannot be recognized. Pulsation may\\nbe seen at the episternal notch in rare instances, particularly in women,\\nindependently of disease of the aorta it is due to nervous palpitation.\\nAn aneurism may exist without any external visible signs. On the\\nFig. 179.\\nAneurism. General endarteritis and valvulitis.\\nTR. Thrill and impulse. Murmur.\\nother hand, pulsation may be seen at either side of the sternum above\\nthe level of the third rib, most commonly in the second interspace on\\nthe right side. The impulse may be seen alone without visible swell-\\ning the chest must be viewed from different situations in order to\\ndetect it. An oblique light falling on the surface is sometimes neces-\\nsary. When the innominate artery is involved the pulsation is observed\\nin the neck, above the sterno-clavicular junction, or above the sternum.\\nWith the abnormal impulse a swelling or tumor is often present.\\nIt may be large enough to press the upper portion of the sternum and\\nadjacent ribs forward. In other instances a tumor the size of the half", "height": "4416", "width": "2676", "jp2-path": "practicaltreatis00muss_0_0750.jp2"}, "751": {"fulltext": "PLATE XXXIV.\\nV]\\nwk\\nAneurism of the Arch of the Aorta.\\nfto. 2.\\nTumor\\nW*\\nW\\nTumor of the Anterior Mediastinum.", "height": "4396", "width": "2700", "jp2-path": "practicaltreatis00muss_0_0751.jp2"}, "752": {"fulltext": "", "height": "4412", "width": "2676", "jp2-path": "practicaltreatis00muss_0_0752.jp2"}, "753": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 679\\nof a lemon may be seen along the edge of the sternum. The most fre-\\nquent site is the first and second right, or the second left interspace.\\nThe skin over the tumor, as in the case of which an illustration is\\ngiven, may ulcerate and be the seat of persistent small hemorrhages.\\nThe apex-beat of the heart is displaced downward and outward from\\npressure.\\nIf the aneurism is seated in the ascending portion of the aorta, just\\nbeyond the aortic ring, a pulsating tumor may be seen in the third\\ninterspace at the left edge of the sternum. If in the ascending por-\\ntion, beyond the heart, the tumor is in the first or second interspace\\nalong the right edge of the sternum. If the aneurism is in the trans-\\nverse portion of the aorta, the upper portion of the sternum is fre-\\nquently made to protrude, or the tumor projects upward into the fossse\\nof the neck. If in the descending portion, it is in the second or third\\ninterspace on the left side. In this portion of the aorta a tumor is\\nseen in the left scapular region in rare instances.\\nPalpation. Palpation must be employed by the usual method\\nbimanual palpation must also be used, one hand placed upon the ster-\\nnum and the other upon the vertebra?. Moderate pressure should be\\nexerted. Palpation should also be employed at different periods of\\nrespiration. At times signs are only yielded at the end of complete\\nexpiration. It must further be said that palpation must be employed\\nboth with the tips of the fingers and with the palm of the hand applied\\nto the surface.\\nPossible position of impulse in aneurism arranged in order of frequency.\\nBy palpation the area and degree of pulsation are determined. If\\nthe aneurism is large or has perforated, the impulse is expansile and\\nheaving in character. The sac may be soft and fluctuating, but usually\\npresents considerable resistance. In addition to the systolic impulse\\nthe diastolic shock is also felt. This is a most conclusive physical\\nsign. A thrill is frequently present, systolic in time, usually due to\\ndilatation of the arch at times, to sacculated aneurism. Without\\nvisible tumor, pulsation and thrill may be felt in the suprasternal\\nnotch, if the head is bent forward, so that the tissues are relaxed, and", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0753.jp2"}, "754": {"fulltext": "680 SPECIAL DIAGNOSIS.\\nthe fingers pushed down toward the aorta. When the aneurism is\\nfilled or filling with clot, the tumor may be seen and felt, but no im-\\npulse will be transmitted to the hand or thrill be felt by the fingers.\\nPercussion. Percussion furnishes the most reliable evidence of the\\npresence of an aneurism or aneurismal dilatation in cases in which the\\ntumor is not too deep-seated or small in size. The dulness may be\\nrelative only. (See Cardiac Percussion.) The area of dulness is\\nincreased somewhere in the course of the aorta. It may be observed\\nprojecting outward at the right edge of the sternum when the ascend-\\ning portion of the aorta is the seat of disease, or over the entire upper\\npart of the sternum, extending toward the left, when the transverse\\nportion is diseased. It may be observed as an extension of cardiac\\ndulness upward in the second and third interspaces. Sometimes dul-\\nness is detected in the scapular regions, particularly of the left side.\\nThe percussion-tone is flat, and there is marked sense of resistance.\\nPercussion must be employed with the patient in the upright and in\\nthe recumbent posture.\\nRespiratory Percussion. The character of the tone and the shape of\\nthe dulness must be noted at the end of full inspiration and of full\\nexpiration.\\nFig. 181.\\nAneurism of aorta.\\nArea of absolute dulness, dark line. Area of relative dulness, broken line.\\nAuscultatory percussion is of the utmost value, and the method of\\npercussion taught by Sansom and Ewart must be carefully followed.\\nAn aneurismal tumor may be present without thrill or murmur, but\\nyields signs of dulness on percussion.\\nAuscultation. As just stated, murmurs may not always be pres-\\nent. They depend upon the amount of fibrin in the sac. When pres-\\nent the murmur is systolic in time, heard with maximum intensity\\nusually over the abnormal area of impulse or tumor, or over the in-\\ncreasing area of dulness. It is transmitted in the direction of the", "height": "4416", "width": "2656", "jp2-path": "practicaltreatis00muss_0_0754.jp2"}, "755": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 681\\nvessels, and may be heard louder in the vessels of the neck and along\\nthe course of the aorta. Often a double murmur is heard, the diastolic\\nsound being due to associated regurgitation at the aortic orifice. Some-\\ntimes the diastolic murmur alone may be heard. Increase in intensity\\nor accentuation of the aortic second sound is pronounced. The sound\\nis ringing in character, and is rarely absent in large aneurisms.\\nThe Peripheral Vessels in Aneurism. The pulse in the two radial\\narteries may show a marked difference both in volume and in time.\\nThe difference may indicate the position of the aneurism. If the\\npulse of the right radial is smaller than the left, the aneurism may\\nbe in or near the innominate artery if the opposite, it is near or in-\\ncludes the orifice of the left subclavian. In the same way the differ-\\nence in time may also aid in determining the location. Osier refers\\nto obliteration of the pulse in the abdominal aorta and its branches.\\nIn one case he could not feel throbbing in the aorta and the femorals,\\nalthough the circulation was unimpaired. The aneurism was in the\\ndescending portion of the aorta, and its pulsation was seen in the left\\nscapular region. The sac was sufficiently large to act as a reservoir,\\nwhich filled during the ventricular systole, and from which the blood\\npoured toward the periphery in a continuous stream instead of being\\nintermittent.\\nTracheal Tugging. Tracheal tugging may be obtained in one of two\\nways. By the old method the patient should be sitting or standing,\\nwhile the observer sits or stands to one side, and faces him. With the\\nhand furthest from the patient steadying the head, the observer gently\\nbut firmly grasps the surface of the cricoid cartilage with the thumb\\nand finger of the other hand, while the head is slightly thrown back.\\nThe head is then flexed, so that the neck is no longer stretched. The\\npatient is then told to hold his breath completely, and any up-and-down\\nmovement of the trachea is immediately transmitted to the observer s\\nfingers. One must not mistake the transmitted pulsation in the\\ncervical vessels for such movement and great care should be exer-\\ncised to see that the breathing is entirely stopped.\\nIn the other method, as proposed and practised by Ewart (British\\nMedieal Journal, March 19, 1892), the observer stands behind the\\npatient, steadying the latter s head against his body, and the cricoid is\\nfirmly held between the tips of the first or middle fingers. The\\nwriter, after considerable experience, prefers this second method, on\\naccount of delicacy of touch, firmness of grasp, and comfort to the\\npatient.\\nDiagnosis. The special points of diagnosis are the etiological\\nfactors the antecedent pathological conditions, as arterial sclerosis\\nthe occurrence of pain the occurrence of pressure-symptoms and\\nthe physical signs. These have been sufficiently dwelt upon, and it is\\nnot necessary to consider them again. It must not be forgotten that\\naneurism may be present without diagnostic physical signs, and, on\\nthe other hand, the pressure-symptoms may also be in abeyance. If\\none of the two is present in the male subject past forty, with a pre-\\nvious history of syphilis, gout, alcoholism, or muscular strain, the\\nprobability is that an aneurism exists. The pressure-symptoms", "height": "4416", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0755.jp2"}, "756": {"fulltext": "682\\nSPECIAL DIAGNOSIS.\\nalways point to some form of intrathoracic disease as the cause of this\\ngroup of symptoms. Thus, in cancerous disease of the lymphatic\\nglands, or other tumors within the mediastinum, pressure-symptoms\\nexactly simulating aneurism may be present and also the physical signs\\nof a tumor. The tumor, however, rarely projects externally, and still\\nmore rarely pulsates. If pulsation is present, it is not of the expan-\\nsile character seen in aneurism, nor is there as decided a systolic shock\\nwhen the ear is held against the chest. By the same method we ob-\\nFlG. 182.\\nX-ray appearance in aneurism. (Pepper and Leonard.)\\nserve the shock of the heart-sounds, which are notably lessened or\\nabsent in tumors from other causes than aneurism. In deep-seated\\ntumors with pressure-symptoms the condition of the arteries, apart\\nfrom aneurism, is of diagnostic importance. Accentuation of the\\naortic second sound, with hypertrophy of the heart, points to aneu-\\nrism. The presence of tracheal tugging is also a valuable diagnostic\\npoint in its favor. In tumor, and especially in cancer, there are\\nemaciation and development of a cachexia, which is, as is well known,", "height": "4396", "width": "2668", "jp2-path": "practicaltreatis00muss_0_0756.jp2"}, "757": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 683\\nmost pronounced in cancer of the oesophagus. Cancer of the oesopha-\\ngus, from its frequent point of election near the left bronchus, often\\nsimulates the pressure-symptoms of aneurism.\\nAneurism must be distinguished from the pulsation of the aorta\\nwhich is seen in aortic regurgitation. This pulsation is usually asso-\\nciated with dilatation, the latter causing increased dulness, which may\\nadd further to the confusion. Exaggerated pulsation without dilata-\\ntion may, as Bramwell has recorded, be the cause of dulness and pul-\\nsation over the aorta. The subjects are under forty, neurotic, and\\nusually anaemic.\\nIt is not, as a rule, difficult to distinguish between pulsating empy-\\nema and aneurism. Wilson points out that aneurism bears a definite\\nrelation to the central long axis of the chest. The area of dulness of\\naneurism is circumscribed, and is usually the seat of murmurs or other\\nsounds synchronous with the rhythm of the heart. The signs of pul-\\nsating empyema are usually upon the left side and at a distance from\\nthe median line. The percussion-dulness is at the base of the chest and\\nquite extensive. Arterial murmurs are not present. The pulsation\\nis influenced by pressure and by respiratory movements.\\nIn mediastinal cancer we are aided by the discovery of enlargement\\nof the glands in the axillary or some other situation, or by a history\\nof the growth elsewhere.\\nAneurism must not be confounded with phthisis. The diseased\\nvessel may occlude a bronchus and cause collapse and bronchial dila-\\ntation hemorrhage may occur bronchorrhoea and cough always\\nensue. Fever is not marked, which fact, with tracheal tugging, vas-\\ncular physical signs, and the absence of tubercle bacilli, points to\\naneurism.\\nX-ray Examination. By virtue of the large amount of blood in an\\naneurism, the tumor is not pervious to the X-rays, and in consequence\\nis readily seen by fluoroscopic examination. Williams and others have\\nbeen very successful in recognizing an aneurism even when it could\\nnot be made out by physical signs. Such examination must be resorted\\nto in all cases. (Fig. 182.)\\nDiseases of the Mediastinum.\\nInflammation of the mediastinum may be limited to the glands or\\nthe connective tissue. Moderate inflammation of the glands, lymph-\\nadenitis, occurs in bronchitis and pneumonia, particularly if bronchitis\\nis of specific origin, as in measles or influenza. It is said that such\\ninflammation is of common occurrence in whooping-cough, and may\\nbe the exciting cause of the paroxysms. DeMussy and Guiteras have\\nfound physical signs of enlargement, characterized by dulness in the\\nupper part of the interscapular region, in cases of this disease and of\\ninfluenza. Other authorities, as Osier, dispute the possibility of this\\noccurrence, or at least of its recognition by physical signs. Tubercu-\\nlous inflammation of the lymphatic glands of the mediastinum may\\ngive rise, however, to local physical signs. Abscess of the glands\\ncannot be distinguished during life.", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0757.jp2"}, "758": {"fulltext": "684 SPECIAL DIAGNOSIS.\\nTumors of the Mediastinum.\\nCancer and sarcoma are the most frequent forms of tumor in this\\nlocality. Hare found the proportion in 520 cases to be as follows\\n134 of cancer, 98 of sarcoma, 21 of lymphoma, 7 of fibroma, 11 of\\ndermoid cyst, 8 of hydatid cyst, and the remainder of lipoma, gumma,\\nand enchondroma. With the application of more correct histological\\nmethods we now know that sarcoma is more common than carcinoma.\\nThe tumor is most frequently found in the anterior mediastinum when\\none region alone is affected. The disease may be either primary or\\nsecondary. In sarcoma it is usually primary. Males are chiefly\\naffected, and most often between thirty and forty. The thymus gland,\\nthe lymphatic glands, the pleura, or the oesophagus is the source of\\norigin in all cases, the former the most frequent.\\nThe symptoms of mediastinal tumor are chiefly due to pressure.\\nDyspnoea is early and constant, and may be laryngeal, or tracheal\\nfrom pressure on that tube. In some instances encroachment upon\\nthe heart or the vessels causes dyspnoea. Again, the dyspnoea may\\nbe due to a pleural effusion which accompanies the growths. Cough\\nof a peculiar character occurs. It is laryngeal, and of a dry, brazen\\nquality. Aphonia may arise from pressure upon the recurrent laryn-\\ngeal nerves. (See Diseases of the Larynx.) If the bloodvessels are\\npressed upon symptoms of obstruction occur, depending upon the ves-\\nsel occluded. CEdema of the upper extremities may occur. If the\\noesophagus is pressed upon, there is difficulty in deglutition. In some\\ninstances the sympathetic nerve is pressed upon, causing hypersemias\\nand pupillary changes.\\nThe physical signs (Plate XXXIV., Fig. 2) are those of a tumor\\nin the anterior portion of the chest, frequently in the prsecordial area,\\nwhich may or may not pulsate dislocation of the heart, not limited\\nto any position great dulness and resistance frequently conduction\\nof lung-sounds and heart-sounds to some distance at times a systolic\\nmurmur increased size and pulsation of the veins and physical signs\\nfrom pressure. (See Aneurism.) It must be remembered that pain is\\nmore common in aneurism, fever and emaciation in mediastinal growths.\\nTumors of the anterior mediastinum present the physical signs, in\\nfront, of a prominence more or less marked, often including projection\\nof the sternum an irregular area of dulness rarely transmitted pul-\\nsation more frequently transmitted heart-sounds and lung-sounds.\\nIt is the form in which phenomena from pressure upon the veins are\\nmost marked. Symptoms from arterial pressure (difference in pulse),\\npressure on the vagus and sympathetic are less frequent. Dyspnoea\\nmay occur.\\nTumors of the middle and posterior mediastinum are characterized by\\npressure upon the bronchi and structures adjacent thereto, hence we\\nhave symptoms from pressure upon the oesophagus, aorta, and the nerves.\\nDyspnoea and cough are the most pronounced symptoms, while phe-\\nnomena from pressure on the vagus, cardiac palpitation, vomiting,\\netc., are not uncommon. Emaciation and a cachexia are more marked", "height": "4412", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0758.jp2"}, "759": {"fulltext": "DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 685\\nthan in tumors in other regions. Pepper and Stengel consider that\\nfever attends growths in this region with greater frequency.\\nTumors of pleural origin have symptoms of acute or subacute pleu-\\nritis, with or without effusion. The fluid secured by puncture is\\nusually bloody, rarely chylous, and may contain suspicious vacuolated\\nepithelial cells. A mass may be suspected if there is great resistance\\nto the trocar. If the tumor ulcerate into the lung, the sputa may con-\\ntain characteristic groups of cells, while hemorrhagic oozing may be\\nsuspicious.", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0759.jp2"}, "760": {"fulltext": "CHAPTER IV.\\nDISEASES OF THE MOUTH, FAUCES, PHAEYNX, AND\\n(ESOPHAGUS.\\nThe Mouth.\\nThe mouth is affected by comparatively few diseases, and most of\\nthese are the result of infection or of trauma, or, rarely, are tropho-\\nneurotic. The cavity forms a good breeding-place for all forms of\\norganisms, and were it not for the secretions and constant cleansing of\\nthe mouth by the passage of food and its physiological labors, diseases\\nwould be very common. Indeed, it is possible that such diseases do\\nnot take place at all unless there is such perversion of the normal\\nsecretion as destroys its antiseptic or antimicrobic qualities. We know\\nbut little specifically concerning the changes in the secretions. Clini-\\ncally, we do know, however, that in conditions of poor nutrition, in\\nwasting diseases generally., and probably in connection with the rheu-\\nmatic diathesis, there is such change in the secretions as permits patho-\\ngenic micro-organisms to exercise their influence upon the mucous\\nmembrane. The result of their action is seen in various forms of in-\\nflammation.\\nSymptomatology. The symptomatology of mouth-affections is\\nthe symptomatology of inflammation pain, heat, redness, and swelling.\\nThe Data Obtained by Inquiry.\\nThe subjective symptoms are not characterized by great gravity,\\nbut they are most annoying.\\nPain. This symptom is most aggravating, because it is excited by\\nthe many functional acts connected with the mouth. It occurs in all\\ninflammations and ulcerations except those due to syphilis. It is\\naggravated by food, by movements of the lips, cheeks, or tongue, and\\nby attempts to discharge saliva. The absence of pain is observed in\\ngangrene.\\nHeat. The patient complains of heat of the mouth in inflammations.\\nDryness. This symptom is complained of in fevers, and by those\\nwho are compelled to sleep with the mouth open. It may be a condi-\\ntion of itself, as the following shows\\nDry Mouth. Xerostoma. Hutchinson first described a condition\\nof the mouth in which dryness was the chief complaint. The secre-\\ntions arc suppressed entirely, the tongue red and dry, the mucous mem-\\nbrane of the cheeks and palate smooth, shining, and dry. Functional\\nmovements are very difficult. The majority of the cases are in women\\nin whom the general health is always impaired. Hay den thinks that", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0760.jp2"}, "761": {"fulltext": "DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 687\\nthe secretion of the salivary and buccal glands is modified as the result\\nof a central nervous disturbance. In xerostoma there is also dry-\\nness of the nostrils and eyes, with intolerable itching. In a case which\\nHarris reported both parotid glands were enlarged and firm but painless.\\nThere is some dryness of the mouth in fevers. It is also symptom-\\natic of chronic gastritis, and may occur in diabetes.\\nThe Data Obtained by Observation.\\nThe objective symptoms are determined by inspection and palpation.\\nBy these means we observe the color of the parts of the mouth,\\nchanges in temperature, as well as in the size and shape (swelling).\\nThe teeth, gums, and tongue are also examined.\\nColor. The normal redness of the mucous membrane may be in-\\ncreased or diminished in intensity. Pallor is associated with anaemia.\\nIncreased redness attends inflammation, and with it the temperature\\nis raised. The mucous membrane is yellow in jaundice, bluish in\\ncyanosis. Both of the latter changes are observed to greater advan-\\ntage under the tongue. The mucous membrane is the seat of pig-\\nmentation in Addison s disease and in argyria. In the former, small\\noval purplish spots are seen. They must not be confounded with the\\npigmented spots common after stomatitis in negroes. Eruptions occur\\nin the mouth and may precede external eruptions. This is notably so\\nin measles. In this affection the eruption is seen on the hard and soft\\npalate twenty-four hours before the development of the rash. In\\nsmallpox and chickenpox the vesicles are seen.\\nShape. Swellings are seen usually as the result of disease of struc-\\ntures about the mouth. The floor of the mouth is encroached upon by\\nglands underneath or by swelling of the cellular tissue. Bone diseases\\nand some teeth affections cause swellings. The dental arch must be\\nobserved. Narrowing of the arch is due to adenoid disease or to the\\nhabit of thumb-sucking in childhood, much more likely the former.\\nFoetor. The odor imparted to exhaled air is peculiar in mouth-\\naffections. It may be a simple foetor or of a metallic or gangrenous\\nodor. Foetor attends all inflammations it is more pronounced in\\nulcerative and mercurial stomatitis. In the latter it may be metallic.\\nHemorrhage. Petechia? in purpura hemorrhagica submucous hemor-\\nrhages in scorbutus and severe forms of purpura morbus maculosus\\nwerlhojii are common on the cheeks and on the gums. In ulcerative\\nendocarditis hemorrhagic infarcts are seen. In grave anaemias petechia?\\nare also seen.\\nCapillary oozing of blood takes place from the mucous membranes\\nin low typhoid states. The accumulated blood collects about the\\nteeth, on the tongue, etc., and in febrile states becomes dry. Dry\\nincrustations are known as sordes.\\nSalivation. Increased flow of saliva occurs in all inflammations\\nunless attended by high fever. It may be constantly discharged by\\nthe patient or dribble in a continuous stream. (See Saliva.)\\nSecretions of the Mouth. The Saliva. The saliva is derived from the\\nparotid, submaxillary, and sublingual glands, and from the mucous", "height": "4416", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0761.jp2"}, "762": {"fulltext": "688\\nSPECIAL DIAGNOSIS.\\nglands within the mouth. The mouth should be washed with a warm\\nalkaline solution and afterward with cold water, in order that the saliva\\nobtained may be perfectly pure for examination. After the washing the\\nglands may be stimulated by the application of dilute acid on a glass\\nrod. The normal amount secreted in twenty-four hours varies from\\ntwo to three pints. It is of a light bluish color, or colorless. It is\\nsomewhat stringy. On standing, two layers form in a conical glass,\\nthe upper clear, the lower cloudy. The reaction of saliva is alkaline.\\nMicroscopical Examination. The following formed elements are\\nobserved 1. Salivary corpuscles of the appearance of, but larger and\\nmore granular than, a white corpuscle. 2. Epithelium. The squa-\\nmous variety derived from the mouth is seen. The cells are large in\\nsize and of polygonal shape. 3. Fungi. In health the mould and\\nyeast fungi are seldom found. In disease they are present in large\\nnumbers fission-fungi are met with in great numbers, both in health\\nand in disease. In health small and large colonies of micrococci are\\nfound along with abundant bacilli. Miller has studied the micro-\\norganisms of the mouth carefully and exhaustively (see The Dental\\nCosmos), both by microscopical examination and culture-methods.\\nThe following are found to be pathogenetic (1) The leptothrix buc-\\ncalis 2) vibrio buccalis (3) spirochete dentium (4) micrococcus\\ntetragenus (5) the micrococcus de la rage (6) the micrococcus of\\nsputum septicemia (7) the bacillus of decaying teeth, three varieties\\nof the staphylococcus (8) the bacillus crassus sputigenus (9) the\\nbacillus salivarius septicus and bacillus septicus sputigenus.\\nFig. 183.\\nBuccal secretion. (Eye-piece III., obj., Reichert, 1/15, homogeneous immersion Abb6 illumina-\\ntion, open condenser.) Friedlander s and GUnther s method. (Von Jaksch.)\\na, epithelial cells; 6, salivary corpuscles; c, fat-drops d, leucocytes; e, spirochsete buccalis;\\ncommon bacilli of mouth g, leptothrix buccalis h, i, k, different fungi.\\nOf course, in the saliva the thrush-fungus, actinomyces, the tubercle\\nbacillus, and the bacillus of diphtheria are found. It must not be\\nforgotten that the diplococcus pneumoniae or micrococcus lanceolatus,\\nwhich is the specific cause of pneumonia, is found in the saliva of some\\npersons in health. It is also called the bacillus sputi septicemici.\\nChemical Examination. The chemical characters of the secretion\\ndepend upon the activity of the different glands. The saliva con-", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0762.jp2"}, "763": {"fulltext": "DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 689\\ntains a trace of albumin, found by heating a ferment which changes\\nstarch into sugar mucin and occasionally sulphocyanide of potas-\\nsium. In disease, as the quantity is diminished rather than increased,\\nexaminations have rarely been made. In ptyalism the saliva should\\nbe collected after rinsing the mouth frequently, especially after eating.\\nThe reaction is found to be alkaline, and the specific gravity low, 1002\\nto 1006. Albumin is tested for by the usual methods. The sulpho-\\ncyanides are detected by a solution of chloride of iron. When this is\\nadded to the fluid a bright red color appears which does not disappear\\nwith heat a similar color, due to the precipitation of meconic acid,\\nmay be obtained by the same test from the saliva in opium-poisoning.\\nSugar is tested for by the methods used in the examination of the\\nblood. The diastatic ferment is detected by adding 5 c.cm. of saliva\\nto 50 c.cm. of starch solution and placing the mixture in a warm\\nchamber or a water-bath heated to 40\u00c2\u00b0 C. After an hour s time the\\nfluid will show the presence of grape-sugar. Nitrites are detected by\\nadding a little saliva to a mixture of starch paste, iodide of potassium,\\nand dilute sulphuric acid. If the nitrites are present, a blue color\\nresults.\\nSaliva in Disease. In catarrhal stomatitis the secretion is in-\\ncreased. It is acid and contains epithelium in excess. In ulcerative\\nstomatitis it is also increased, is of a dark-brown color, foetid, and alka-\\nline. It contains degenerated epithelium, leucocytes, blood-corpuscles,\\nand many forms of fungi. It is increased in pregnancy, in rabies, and\\nin glosso-labio-laryngeal palsy. I have seen it in excess in the con-\\nvalescence of typhoid fever. It is increased by the internal use of\\njaborandi.\\nFig. 184.\\nO idium albicans, the vegetable parasite of muguet or thrush. (Reduced from Ch. Eobin.)\\nThe reaction becomes acid in diabetes, gout, rheumatism, and mer-\\ncurial poisoning. Urea may be found in cases of nephritis, particu-\\nlarly in uraemia. There is no sugar in diabetes. Fenwick has inves-\\ntigated the changes in the sulphocyanide of potassium in disease. By\\na scale of colors he was enabled to compare the saliva in which sulpho-\\ncyanide of potassium had been detected in health with the saliva in\\nvarious diseases. He believes that the amount of this ingredient is\\nindicative of the degree of functional activity of the organs of nutri-\\n44", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0763.jp2"}, "764": {"fulltext": "690\\nSPECIAL DIAGNOSIS.\\ntion. It is increased in acute inflammation and in the earlier stages of\\ncancer and phthisis in acute congestion of the liver from stimulants\\nor food excess and in rheumatism, gout, and the convalescence of\\ntyphoid fever. Where the power of the nutritive organs is diminished\\nthe sulphocyanide of potassium is lessened, as in late phthisis and\\ncancer, the later stages of chronic diarrhoea and dysentery, chronic\\ncatarrhal jaundice, in ascites, and in the passive congestion of the\\nabdominal viscera. Fenwick believes that tedious recovery and fre-\\nquent relapses will occur if this element is found in excess in acute\\nrheumatism.\\nThrush. The fungus peculiar to this disease is found. Saliva is\\nincreased it is usually acid. The disease is characterized by the\\nformation of small patches on the mucous membrane, which in a few\\ndays coalesce and form a mass which may cover the entire mouth and\\nextend to the fauces. Before coalescing they are firmly adherent.\\nSubsequently they loosen. On microscopical examination, in addition\\nto epithelial cells, leucocytes, and unorganized elements, the character-\\nistic parasite is seen. It is of ribbon-shape, varying in length, and\\ncomposed of long segments which often contain highly refractive nuclei\\nat either end. The segments are homogeneous they vary in length,\\nthose nearest the extremities being somewhat shorter. When mounted\\nin glycerin they are readily seen. Spores are also seen.\\nThe Leptothrix Buccalis. The latter is seen in ribbon-like bundles\\ncomposed of numerous segments it stains a bluish-red in potassic iodide\\nsolution. It is most frequently seen in the tartar of the teeth.\\nFig. 185.\\nLeptothrix buccalis from the gums at edges of teeth. X 350.\\na, the filaments separated b, masses of filameuts.\\nThe Gums. The gums and the mucous membrane of the mouth are\\ninvolved in inflammations and ulcerations, and in certain metallic\\npoisonings. The gums swell and grow spongy in inflammations.\\nThe Gingival Line. In cases of tuberculosis a red line at the\\njunction of the gums and the teeth is frequently seen. At one. time it\\nwas thought to be of diagnostic value. It is seen, however, in other\\ncachectic conditions, as carcinoma, and at times in diabetes.", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0764.jp2"}, "765": {"fulltext": "DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 691\\nThe Gums in Scurvy. In scurvy the gums are swollen and spongy.\\nThey bleed easily, and are usually streaked with blood. Ulcers form\\nalong the margin of the teeth. There is not much foetor of the breath.\\nIn mild cases the inflammation may be limited to the gums of four\\nor five teeth. The gums of decayed teeth are usually the seat of the\\nmost marked inflammation. Infants may have scurvy as well as\\nadults especially if fed exclusively on sterilized milk or malt prepa-\\nrations. (See Scurvy-rickets.)\\nThe Gums in Lead-poisoning. The Blue Line. In lead-poisoning\\na blue line is seen at the margin of the gums. The line is preceded by\\na row of separate black dots occupying the seat of the papillse of the\\nmucous membrane. If examined with a magnifying glass, the line is\\nreadily seen to be an interrupted one. It does not always extend\\nalong the entire margin, but may be limited to a few front teeth in either\\nthe upper or lower jaw. In the more advanced cases there is some\\nsalivation and a sweetish metallic taste in the mouth and metallic foetor\\nof the breath.\\nThe Teeth. In all diseases of the gastro-intestinal tract it is im-\\nportant to investigate the state of the teeth. Cases of indigestion are\\noften due to defective mastication, rendered so by decayed teeth. Per-\\nsistent aural, nasal, and ophthalmic affections may have their primary\\norigin in disease of the teeth. Caries of the teeth may cause headaches\\nor neuralgias, near or remote (see Headache), and may explain many\\ncases of foul breath. Pitting of the surface of the teeth and thinning\\nof the enamel in transverse grooves are held by some to be due to mer-\\ncury. There is no doubt that infantile stomatitis, independent of mer-\\ncury, is the cause of these changes. They must be distinguished from\\nthe so-called Hutchinson s teeth. In stomatitis the molars are often\\nhoneycombed to an extreme degree, the incisors becoming affected\\nnext. In addition to pitting and erosion the color may be darker. A\\ntransverse furrow crosses all the teeth at the same level.\\nThe Teeth in Gout. Erosion of the teeth takes place in gouty sub-\\njects. There are wasting and loss of polish of the labial surface, fol-\\nlowed by deep grooves which extend into the body of the teeth.\\nPyorrhoea alveolaris is another expression of gout. There is, first,\\nusually a marginal inflammation of the gums second, inflammation\\nand necrosis of the pericementum third, loosening of the teeth and\\nthe formation of so-called calculi.\\nThe Teeth of Congenital Syphilis. The upper central incisors of the\\npermanent set are affected. They are dwarfed, narrowed, and short.\\nFig. 186.\\nvoter\\nNotched teeth. Malformation of permanent teeth found in hereditary syphilis.\\n(Mr. Jonathan Hutchinson.)\\nThe middle lobe of the tooth is so atrophied as to leave a single\\nbroad vertical notch in the edge of the tooth. A narrow furrow some-", "height": "4416", "width": "2640", "jp2-path": "practicaltreatis00muss_0_0765.jp2"}, "766": {"fulltext": "692\\nSPECIAL DIAGNOSIS.\\ntimes passes upward from the notch on both anterior and posterior sur-\\nfaces, nearly to the gum. It is seen from the above that the appear-\\nances of the permanent teeth may be an index of the condition of\\nnutrition of the child in infancy.\\nTeething. During the period of infancy it is well to remember\\nthe influence of the eruption of the teeth upon the general constitution.\\nWhile many prominent authorities believe that the eruption takes place\\nwithout the occurrence of general or reflex symptoms, equally careful\\nobservers, on the other hand, believe that nervous phenomena often\\nattend the process. The latter class of observers attributes the fever-\\nislmess, insomnia, restlessness, loss of appetite, and gastro-intestinal\\ndisturbance to this cause. Convulsions at this period are believed to\\nbe due to the pressure of the tooth, which cannot break through the\\nmucous membrane, upon highly sensitive nerves at the root. Even in\\nlater life reflex convulsions are held by some to be due to the teeth.\\nSlowness in the development of the teeth may be due to rhachitis,\\nwhich should be looked for. The student should be familiar with the\\nperiods of development, the number of teeth that appear at each period,\\nand the date of the eruption.\\nDates of Eruption op the Teeth.\\nMilk Teeth.\\n2M 1C 41 1C 2M\\n2M 1C 41\\nEruption of central incisors about\\nlateral incisors\\nfirst molars\\ncanines\\nsecond molars\\n1C 2M\\n20\\n7th month. 1\\n9th\\n15th\\n18th\\n24th\\n3M 2B\\nPermanent Teeth..\\n1C 41 1C 2B\\n3M 2B 1C 41 1C 2B\\nEruption of anterior molars about\\ncentral incisors\\nlateral incisors\\nanterior bicuspids\\nposterior bicuspids\\ncanines\\nsecond molars\\nthird molars (wisdom teeth) about\\n3M\\n3M\\n32\\n7th year.\\n8th\\n9th\\n10th\\n11th\\n11th\\n12th to 14th year.\\n18th to 25th\\nStomatitis. This inflammation is not limited to the mouth alone,\\nbut extends to structures within the mouth, as the gums, and may\\ninvade the tongue. The inflammation is recognized by the subjective\\nand objective signs common to such inflammations. There is pain,\\nand hence the child (for it usually occurs in children) refuses to nurse\\nor take the bottle, or cries when food is given. The pain is accom-\\npanied by fcetor of the breath. This occurs in all forms of stomatitis.\\nIts origin, as well as the origin of the pain, is readily determined by\\ninspection.\\n1 Lower incisors first.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0766.jp2"}, "767": {"fulltext": "On inspection we note the usual signs of inflammation. They are\\nrarely general, being, as a rule, localized to small areas, which may\\nrapidly become ulcerated. When general the mucous membrane is red\\nand hot the color extends to the gums, lips, and tongue. This is seen\\nin the catarrhal form the follicles are also enlarged. The tongue be-\\ncomes red and smooth, or may be covered with a white coating, through\\nwhich the prominent red fungiform papilla? project. Accompanying the\\ninflammation there is increased secretion, which dribbles from the mouth,\\nor is constantly discharged by older patients. The red hue of the mucous\\nmembrane is attended by swelling. The heat of the mouth is often suffi-\\ncient to raise the temperature of the exhaled air, so that the breath is hot.\\nA peculiar form of inflammation of the mouth is seen in gouty sub-\\njects. It occurs at intervals. Pain is not so marked, but the heat,\\nredness, and burning are associated with a superficial glossitis and sali-\\nvation. The saliva is highly acid, and causes a dermatitis on the chin.\\nOther mucous membranes are involved at the same time, as the vagina.\\nAn acid mucoid discharge sets up irritation at the vaginal outlet and\\ncauses much distress.\\nAphthous Stomatitis. Local areas of intense inflammation are\\nsometimes followed by ulceration. Thus in aphthous stomatitis small\\nyellowish-white spots appear, at first discrete, but soon dotted over the\\nmucous membrane inside of the cheeks, in the roof of the mouth, along\\nthe sides of the gums, and on the tongue. They subsequently break\\ndown into shallow ulcers with raised red margins.\\nAphthous ulceration is seen in foot-and-mouth disease. The local\\nprocess is characterized by greater swelling, with softening and ulcera-\\ntion of the soft parts, than in other stomatitis. In foot-and-mouth\\ndisease there is a history of infection, profuse diarrhoea, followed by\\nconstipation, and considerable physical depression.\\nUlcerative Stomatitis. The disease occurs in ill-nourished sub-\\njects, and is often intercurrent with exhaustive disease, as chronic diar-\\nrhoea. It may be seen in epidemic forms in camps and in penal and\\nother institutions, on account of unsanitary conditions. In ulcerative\\nstomatitis the inflammation is more pronounced on the gums. They\\nare swollen, red, and covered with ulcers. The gums in which teeth\\nremain are affected, and the ulcers are usually at the gingival border.\\nGums without teeth are not affected. The ulcers are covered with\\nyellowish material. The flow of saliva is much increased in this affec-\\ntion. It is acid in reaction. The submaxillary glands are enlarged.\\nThe foetor of the breath is very great.\\nParasitic Stomatitis. Thrush. In parasitic stomatitis, or thrush,\\nraised white patches are seen looking like small curds of milk. The\\npatches vary in size, and on the tongue may cover an area as large as\\na three-cent piece. (See page 690.) The white patches are distinguished\\nfrom milk-curds because they cannot be removed by the napkin or\\nbrush. The parasite has been called the o idium albicans (see Fig. 184)\\nbut Forchheimer prefers to group it under the saccharomyces.\\nStomatitis Materna. Painful ulcers occur in the mucous mem-\\nbrane of the lips and cheeks in nursing- women. They are solitary,\\nand interfere with mastication.", "height": "4416", "width": "2640", "jp2-path": "practicaltreatis00muss_0_0767.jp2"}, "768": {"fulltext": "694 SPECIAL DIAGNOSIS.\\nGangrenous Stomatitis. The affection appears as a gangrenous\\ninflammation of the gums, mucous membrane, and deeper tissues of\\nthe cheek. At first a small, dark red, hard spot is seen, which in-\\ncreases in size, and becomes of a purplish color. The cheek rapidly be-\\ncomes swollen, tense, and brawny. On the surface of the more indu-\\nrated portions a bleb forms which soon breaks with rapid ulceration.\\nThe ulcer is dark and gangrenous and soon perforates the cheek. It\\nextends to the jaw and is followed by necrosis of that bone/ The\\ncharacteristic odor of gangrene attends the process. While the affec-\\ntions previously mentioned are generally dependent upon poor nutri-\\ntion, gangrenous stomatitis is always secondary to depraved, depressed,\\nor debilitated states of the system. Cases may occur simultaneously\\nin asylums for children in which the hygienic conditions are bad and\\nthe food-supply poor.\\nMercurial Stomatitis. Mercurial stomatitis, or ptyalism, par-\\nticularly affects the gums. It also involves the salivary glands.\\nThe inflammation is caused by mercury. It may occur from the\\nmedical use of the drug, particularly in persons who are unduly sus-\\nceptible, or are not particular in regard to mouth-cleansing. The in-\\nflammation is painful and attended by profuse discharge of saliva,\\nhence the name, salivation. The tongue is swollen, marked on the\\nsides by the teeth, and may be protruded with difficulty on account\\nof its size. It is tender to the touch. It is covered with a heavy,\\ncreamy coating. The gums are swollen, red, sore, and bleed on the\\nslightest touch. Ulcers along the border occur, may become diffused,\\nand in some instances extend to the jaw. The teeth become loosened.\\nThe foetor of the breath is heavy, offensive, and of a metallic character.\\nThe inflammation is usually preceded by a metallic taste in the mouth,\\nand the patient notices pain on mastication, which increases in severity\\nas the inflammation develops. In mild cases it is limited to the gums,\\nin others the tongue and salivary glands and the mucous membrane of\\nthe mouth are affected.\\nLeprosy. This affection frequently invades the mouth. The nod-\\nular and ulcerative lesions are seen. It is always associated with the\\ncharacteristic lesions of the skin. Scraping or sections would show\\nthe characteristic micro-organism.\\nGlanders may invade the mouth from the nasopharyngeal space.\\nActinomycosis results from the entrance of the ray-fungus through\\ncarious teeth or an abraded mucous membrane. Often there is first\\ndisease of the alveolus, as pyorrhoea, or a periosteal abscess then the\\njaw is involved. Before this a general stomatitis may be set up.\\nUlcers. In addition to the above forms of ulcerative stomatitis,\\nsolitary ulcers are seen in herpes, secondary to gastric or uterine dis-\\nturbances, and syphilis. The herpetic ulcers are of frequent occur-\\nrence at the menstrual period or during the course of lactation. The\\ntendency to their formation is often hereditary. I have seen them\\noccur at the menstrual period or in pregnancy in the women of three\\ngenerations. In the secondary stage of syphilis mucous patches are\\nseen as bright red, symmetrical, oval, or crescentic patches or erosions,\\noccurring on the mucous membrane, sometimes on the tongue and", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0768.jp2"}, "769": {"fulltext": "DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 695\\nfauces. They are generally covered with a scanty grayish-white secre-\\ntion, and are not usually painful.\\nSublingual Ulcer. This form occurs on the frsenum of the tongue.\\nIt is seen in whooping-cough, and is due to the rubbing of the tongue\\nagainst the teeth in the act of coughing.\\nScleroderma. This rare tropho-neurosis occasionally invades the\\nmouth. It is characterized by a submucous infiltration of cartilaginous\\nhardness, the surface of which is denuded of epithelium or covered\\nwith crusts. The invasion comes from the nostrils or the nasopharynx.\\nLater the infiltration changes to a yellowish-red or a tendinous-like\\nscar.\\nThe Tongue.\\nExamination of the tongue is made for diagnostic purposes with a\\ngreater show of wisdom on the part of the examiner, and greater satis-\\nfaction to the patient, but with less satisfactory results from a diag-\\nnostic stand-point, than the examination of any other portion of the\\nbody. The mucous membrane of the tongue is examined because it\\nis the only mucous membrane of the body, except the oral and faucial,\\nwhich is open to inspection, and is, therefore, supposed to enable us to\\njudge of the effects of general diseases upon mucous membranes. It\\nis thought to be indicative of disorders of the gastro-intestinal tract\\nbecause of its relations with it, but recent studies by Hutchinson,\\nButlin, and other observers have resulted in the promulgation of differ-\\nent views. Both the above-mentioned distinguished gentlemen are\\nsurgeons, and look upon the tongue as a local organ. Investigating\\nit as such, they concluded that the changes in the coating, which had\\nbeen considered to have so much clinical significance, depended largely\\nupon parasitic invasion, and were not due to changes in the epithelium.\\nThe parasitic invasion, they hold, is largely dependent upon local con-\\nditions, which, it is true, are on their part dependent upon a state of\\nthe system. Since the writings of Hutchinson and Butlin, Dickin-\\nson returned to the investigation on the lines laid down by older\\nteachers, and has, in a measure, restored the tongue to its original\\nposition as a diagnostic feature in an estimation of the state of the\\ngeneral system and in diseases of the gastro-intestinal tract.\\nWe study the tongue to ascertain its color the character of erup-\\ntions if they are present the occurrence of indentations, excoriations,\\nfurrows, or fissures the occurrence of ulcers and of patches. Plaques,\\nnodes, and nodules are also seen on the tongue. Inflammation of the\\ntongue occurs, and it is the seat of atrophy and hypertrophy and of the\\nvarious tumors in the parasitic diseases. The movements of the tongue\\nare also observed, as an indication of the power of muscles which are\\nunder centric influence closely related to important centres in the\\nmedulla oblongata. Surgical affections of the tongue will not be con-\\nsidered local affections will only be referred to in connection with\\ngeneral diseases.\\nDiscolorations of the Tongue. Yellowish-white, oblong patches,\\nsoft, but slightly raised, are sometimes seen along the sides of the\\ntongue xanthelasma. They are sharply defined, and vary in size from", "height": "4416", "width": "2656", "jp2-path": "practicaltreatis00muss_0_0769.jp2"}, "770": {"fulltext": "696 SPECIAL DIAGNOSIS.\\na split pea to a three-cent piece. Xanthelasma is also situated upon\\nthe eyelids and upon the palms of the hands, rarely in other portions\\nof the body. It occurs in jaundice, or in persons who are said to be\\nsubject to bilious attacks.\\nPigmentations. Dark purple, bluish-black, or black marks are\\nseen on the tongue as well as on the surface of the lips, where they\\nmay be brown. They are sharply defined, neither raised nor de-\\npressed, and vary in size. Such pigmented spots are seen after glos-\\nsitis and in Addison s disease. In the latter affection other pigmented\\nareas are found. Bloodstains are observed in purpura. Bright red\\nspots the size of a split pea or larger, patches, known as ecchymoses,\\nare of frequent occurrence. They are not removed by pressure.\\nHemorrhagic infarcts are sometimes seen on the tip of the tongue.\\nBlack Tongue. This rare condition is of parasitic origin. It has\\nrecently been described anew by Cohen. It is also known as nigrities.\\nThe affected portion is of a brownish-black or black color, varying\\nin size and usually situated in the middle of the dorsum of the tongue.\\nIt looks like an iron- stain, and in some instances the surface is rough-\\nened. The papillae are abnormally enlarged. It usually begins as a\\nsmall spot, and extends slowly, so that at the end of a month the\\ndorsum is covered. The centre is blacker than the circumference.\\nAfter the entire dorsum is covered the spot begins to disappear from\\nthe circumference toward the centre, and is followed by desquamation.\\nThis series of phenomena is repeated and the entire affection subsides\\nslowly. Desquamation may last from a few days to two months. The\\npapilla? of the affected surface, too, look like a field of corn laid by\\nthe wind and rain. The sensations of taste and touch are not altered,\\nbut a feeling of dryness is marked. It must be remembered that\\na black tongue is sometimes the result of deliberate deception.\\nInflammation of the Tongue. Acute glossitis is a rare affection,\\nmore common in adults than in children, and more frequent in men than\\nin women. It occurs more frequently in the summer. The onset is rapid.\\nAfter a short period of tenderness on mastication the movements of the\\ntongue are stiff and painful, or there are pains in the muscles of the neck\\nand submaxillary region. In a few hours the tongue swells. It rapidly\\nincreases, and at the end of fifteen to twenty hours is three times its\\nnatural size, protrudes from the. mouth, is indented by the teeth, and\\nis almost immovable, feeling heavy, painful, and tender. It is coated\\nwith a thick fur on the dorsum. Salivation accompanies these symp-\\ntoms, speech is impossible, dysphagia extreme, and dyspnoea not un-\\nusual. The glands underneath the jaw are swollen. The temperature\\nrises to 101\u00c2\u00b0, rarely above it, even if the case is severe. Death may\\noccur in a few hours from suffocation, or after a longer interval from\\ndiffuse suppuration, gangrene, exhausting septic fever, or pneumonia.\\nGangrene is more frequent than spontaneous resolution. If resolution\\nis to be established, the swelling begins to subside in three or four\\ndays. Small ulcers form on the surface of the tongue, and by the end\\nof a week its normal appearance is regained. The fever and distress-\\ning symptoms subside with the local swelling. It is said to be due to\\ncolds, to bites and stings of animals, to mercury, and to corrosive and", "height": "4408", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0770.jp2"}, "771": {"fulltext": "DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 697\\nacrid substances. It may occur in fevers. The diagnosis is easy. It\\nmust be distinguished from acute oedematous swelling due to salivary\\ncalculus or affections of the floor of the mouth. Acute ranula some-\\ntimes causes considerable swelling of the tongue, simulating acute\\nglossitis. Hemiglossitis sometimes occurs. The local symptoms are\\nnot so great, because only half of the mouth is occluded. I saw a case\\nin which the inflammation was limited to half the side of the tongue\\non the posterior surface. It went on to suppuration, but was not\\nattended by serious symptoms, except discomfort in eating. It was\\npreceded by a definite nodule in the substance of the inflamed part.\\nGlossitis from mercurial poisoning has been described in connection\\nwith stomatitis.\\nChronic superficial inflammation of the tongue may also occur. The\\nsurface is smooth and deprived of papillae over the affected area, which\\nis redder than natural. The margin of the raw patch is sharply de-\\nfined, but the area has no depth. The epidermis alone is removed.\\nWhen associated with dyspepsia it covers a considerable area of the\\nsurface of the tongue. The tongue may be deprived of papillae on the\\nanterior part of the dorsum while the fungiform papillae remain. The\\ntongue is enlarged and the borders marked by the teeth. The surface\\nlooks glossy. The tongue feels stiff and uncomfortable. Movement is\\nirksome, irritating foods are painful. Spirits and tobacco cause dis-\\ntress. Indiscretions in diet and slight traumatism quickly produce\\nfresh inflammation. One observer, Hack, has described a form of\\nglossitis hereditary and peculiar to women. He observed a row of long,\\noval areas, caused by previous inflammation. They commenced in early\\nchildhood. The tongue was smooth over remaining large areas, with\\nred excoriations here and there. There was no syphilis.\\nSequelce of glossitis. Indentations occur when the tongue is swollen,\\nas in mercurial and other forms of glossitis. The borders of the tongue\\nare indented by the pressure of the teeth. But in states of debility\\na flabby tongue with indented borders is often seen. Sometimes the\\nswelling is so great that the pressure of the teeth causes ulceration.\\nFurroivs, or grooves and tvrinkles, are seen on the dorsal aspect\\nof the tongue. They are not necessarily tokens of disease in many\\npersons they are of constant occurrence. Furroivs vary from a few\\nlines to an inch or more in length. In many this is most striking in\\nthe middle line of the tongue. The median furrow is liable to become\\nulcerated on slight provocation. The edges of the fissures are smooth\\nand without papillae or fur. Other furrows are directed horizontally\\nand vary in depth. They may be curved and forked. They are more\\nfrequent in older persons, especially if the tongue is too large to lie\\nwithin the circle of the teeth. They are an evidence of past inflamma-\\ntion, or rarely of hypertrophy. They resemble the median furrows as\\nregards smoothness and absence of fur. Inflammatory furrows occur\\nin chronic superficial inflammation, but more commonly after chronic\\ninflammation which has left the tongue enlarged. The furrows are\\nsometimes so abundant that the surface of the tongue looks like the\\neyelid. The raised areas become sore, due to irritation of a foreign\\nbody (food) or a tooth. They are an indirect result of inflammation.", "height": "4416", "width": "2652", "jp2-path": "practicaltreatis00muss_0_0771.jp2"}, "772": {"fulltext": "698 SPECIAL DIAGNOSIS.\\nTrue inflammatory furrows, described as dissecting glossitis by Wun-\\nderlich, occur. Dissecting glossitis is only a more aggravated form of\\nsuperficial glossitis. Furrows of this character may be due to syph-\\nilis, and dissecting glossitis sometimes has a syphilitic origin. Fissures\\nand clefts are frequently caused by the rubbing and deep indentation\\nof a rough and jagged tooth. The area around the fissure is inflamed\\nand its base indurated. The sides and bottom are ulcerated. It is\\nrecognized by its relation with the offending tooth. It may be mis-\\ntaken for syphilis, another common cause of fissures.\\nSyphilitic Lesions. It must be remembered that the tongue is\\nalways predisposed to inflame and ulcerate in syphilis. In secondary\\nsyphilis fissures are always found on the borders of the tongue they\\nare almost certain to occur if the teeth irritate the border. They may\\nbe due to the ulceration of a mucous tubercle which is developed upon\\nthe border of the tongue. The ulcer is stellate, and gradually deepens\\nuntil it becomes a foul fissure. Two processes cause the ulceration\\nthe specific infection and the irritation of the teeth. Syphilitic ulcers\\nare not very angry, as are non-syphilitic sores and fissures which may\\noccur in persons in poor health. They may be sensitive, however, on\\naccount of the involvement of the tongue. The absence of active in-\\nflammation, the large number of sores and fissures, and the associa-\\ntion with other lesions of the disease upon the tongue, cheeks, and lips\\npoint to their syphilitic origin. Tertiary syphilitic ulcers are more\\npronounced and deeper than other forms. They may be as long as\\ntwo or three inches they are sinuous and branched. Gummata may\\noccur on the tongue at the same time. The gummata may be circum-\\nscribed or linear, and may break down and ulcerate. Sclerosis of the\\ntongue, as described by Fournier, follows the healing of these ulcers.\\nIt is curious to note that the lymphatic glands are seldom enlarged in\\nassociation with syphilitic fissures. The fissures must be distinguished\\nfrom carcinoma and tuberculosis. In carcinoma there is a distinct\\ntumor, which may become fissured. Tuberculous ulceration is a sign\\nof the presence of tubercle in other organs. The tuberculous fissures\\nare small, at first single tubercle, however, rarely begins as a fissure,\\nbut as tuberculous ulcers on the tip or borders of the tongue. They\\nare stellate or irregularly branched. They are shallow at first, and\\ndeepen later, but do not widen in a corresponding manner. The\\nlymphatic glands are always involved. (See Tuberculous Ulcer.)\\nUlcers of the Tongue. They may be simple, aphthous, or trau-\\nmatic. Simple ulcers follow long-standing superficial glossitis. They\\nform in the centre of the tongue, or of the inflammatory area.\\nThey are due to sloughing, or simple melting away of epithelium.\\nThe ulcer is smooth, red, glazed on the surface. The edges are callous\\nand inactive, and the shape irregular. It is sensitive, and may be pain-\\nful. The signs of chronic glossitis continue with it. Dyspeptic or\\ncatarrhal ulcers occur on the tip, or on the dorsum near the tip. The\\ndorsum of the tongue, from the tip backward, is very red, and filiform\\npapillae are absent. The ulcers are small and superficial without defi-\\nnite shape or character, except that they are red and irritable. Dys-\\npeptic ulcers may occur from the breaking down of vesicles on the", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0772.jp2"}, "773": {"fulltext": "DISEASES OF MOUTH, FAUCES, PHARYNX, CESOPHAGUS. 699\\ntongue. They are small, circular, well-defined ulcers, with sharp-cut\\nedges, in size from a pin s head to a split pea, and are the source of\\nconsiderable pain and much annoyance. They are recurrent. Saliva-\\ntion may attend them. Aphthous ulcers are seen in children and adults,\\nand when multiple are attended with the same symptoms as aphthous\\nulcers of the mouth, with slight fever. Foetor is characteristic. When\\nsingle they occur with indigestion, or in women at the menstrual period.\\nThe tendency to their formation is inherited. Traumatic ulcers from\\nsharp teeth may persist a long time if the general health is bad. When\\nindolent they may be mistaken for syphilitic, tuberculous, or cancer-\\nous ulcers. The rapidity of formation, the location opposite a rough\\ntooth, and the absence of other signs of syphilis point to the true\\nnature of the ulcer. Chancre can be excluded by the greater hard-\\nness and circumscription of the lesion, its seat near the tip, and its\\nassociation with enlargement of the lymphatic glands. The latter is\\nnot present in traumatic ulcer, unless it is acute and angry. Traumatic\\nulcer is distinguished from tuberculous ulcers by the absence of signs\\nof tubercle in other organs and by the result of an examination of the\\nscrapings of the ulcer from cancer by the age. In cancer all the\\nglands become affected later.\\nExcoriations on the surface of the tongue, or rawness, arise from\\ninjury, and may also be seen in dyspepsia.\\nTuberculous Ulcer. The tuberculous ulcer presents an uneven,\\npale, flabby surface, covered with a yellowish-gray viscid or coagulated\\nmucus. The edges are sometimes sharp-cut, sometimes bevelled,\\nseldom elevated. They are not usually very red. There is but little\\nsurrounding inflammation, and the adjacent portions of the tongue are\\nbut slightly swollen. The borders of the ulcer may be sinuous, and\\nthe shape oval or ovoid, or elongated. In the neighborhood of an\\nulcer a number of tiny yellowish gray points may be observed. The\\nulcer is painful, and attended by salivation. I saw in the Philadelphia\\nHospital a case of tuberculous ulcer of the tongue, in a young man\\ntwenty-five years of age, with pulmonary and intestinal tuberculosis.\\nThe dorsum of the tongue was covered with a dozen ulcers, with sharp-\\ncut edges and pale, flabby granulations, without induration or inflam-\\nmation around them. They were yellowish-gray, and tubercle bacilli\\nwere found in the scrapings. Tuberculous ulceration must always be\\ncarefully distinguished from syphilitic and cancerous. The associate\\nsymptoms are often most reliable. Ulcers due to lupus are also seen\\nupon the tongue.\\nPatches and Plaques. Space forbids further consideration than\\nthe naming of the plaques which are seen on the tongue. First, there\\nis the smoker s patch, on the middle of the dorsum about the point\\nwhere the tobacco-pipe rests, or where the stream of smoke from the\\npipe or cigar strikes the tongue. This is a slightly raised area of oval\\nshape. It is not ulcerated, but is smooth and red, or livid. Some-\\ntimes it is bluish-white or pearly in appearance. The smoothness is\\ncharacteristic. White and bluish-Avhite patches or plaques are seen in\\nleucoma, leucoplakia, ichthyosis, keratosis, and are also known as opaline\\nplaques. The smoker s patch belongs to the same class, and is proba-", "height": "4416", "width": "2656", "jp2-path": "practicaltreatis00muss_0_0773.jp2"}, "774": {"fulltext": "700 SPECIAL DIAGNOSIS.\\nbly an early stage of these affections. It is a whiteness, or white\\nopacity of the surface of the tongue, usually on the dorsum. It is\\nalmost always the result of the direct action of irritants. These patches\\nare unknown under twenty years of age, do not commence after sixty,\\nand very rarely attack women. They are not attended by subjective\\nsymptoms usually. There may be a sensation of induration and dry-\\nness. The course is always chronic.\\nWandering Rash. Ringworm, or circular exfoliations the geo-\\ngraphical tongue occurs most frequently in children. One or more\\npatches on the dorsum of the tongue are observed, smooth and red,\\nbut not depressed or elevated. The filiform papilla? have been shed.\\nThe patch spreads and becomes a ring, circular or oval. The border\\nis faintly or decidedly yellow, and usually slightly raised and sharply\\ndefined. The circles may widen and contract from time to time. No\\nsubjective symptoms are noted except itching in a few cases. The\\ncause is not known. The diagnosis is easy. It may continue for\\nmonths or years.\\nMucous patches are multiple lesions of syphilis in the mucous\\nmembrane. They have been referred to in the section on Diseases of\\nthe Mouth.\\nEruptions. Eruptions of variola, measles, and erysipelas are seen\\non the tongue. Herpes and aphthous ulcers, preceded by vesicles, are\\nmet with on the surface of the tongue.\\nNodes. Nodules in the tongue are always tuberculous or syphilitic.\\nAtrophy. Atrophy of the tongue is very unusual. Hemiatrophy\\nmay occur as the effect of central or peripheral causes, as softening,\\nhemorrhage, or tumors of the region of the hypoglossal nucleus. Other\\ncentres near the nucleus are affected, hence other forms of paralysis are\\nseen, due to the lesions of the medulla. These are seen in progressive\\nmuscular atrophy and bulbar paralysis, and in cases of hemiplegia.\\nIt is not difficult to recognize it on inspection. The functions of the\\ntongue are not affected.\\nHypertrophy. Enlargement of the tongue, or macroglossia, is gen-\\nerally congenital, but may occur late in life. The tongue enlarges, and\\nis accompanied by pressure symptoms due to such enlargement.\\nHypertrophy of the tongue is sometimes seen in idiots and cretins.\\nThe hypertrophy is more frequently the result of lymphatic obstruc-\\ntion, on account of which there is lymph-stasis. The diagnosis is easy.\\nInflammatory hypertrophy occurs in stomatitis, and syphilitic hyper-\\ntrophy occurs with gummata.\\nCysts. Various cysts occur in the tongue. Mucous cysts and\\nblood-cysts are the most common. The cysticercus cellulosse and the\\nechinococcus occur rarely. Ranula is a cyst underneath the tongue\\nthat causes suffering from mechanical obstruction. It is easy of recog-\\nnition.\\nParasitic Disease. Thrush is the most common. Other infections\\nof the mouth extend to the tongue in most instances.\\nThe Tongue in General and Remote Disease. The Coating.\\nWith a view to estimate the condition of the system in general by\\nthe appearances of the tongue, excluding all local conditions, the", "height": "4408", "width": "2696", "jp2-path": "practicaltreatis00muss_0_0774.jp2"}, "775": {"fulltext": "DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 701\\nfollowing characteristics are observed First, the color second,\\nthe fur third, the degree of moisture and, fourth, the movements.\\nThe student should bear in mind that changes in the condition of\\nthe tongue are frequently of local origin that dryness, for in-\\nstance, may be due to the open mouth, or that a coating may be\\nunusually marked because the tongue had not been used in mastica-\\ntion. Often coating is seen on one side of the tongue. This has been\\nreferred to as due to disease of the nerves of one side. It is just as\\nlikely to be due to an absence of mastication on that side of the mouth,\\nthe bolus of food being kept on the other side because of pain, diseased\\nteeth, or other local cause.\\nClinical experience has shown that certain conditions in the tongue\\nare associated with certain general conditions which render the appear-\\nance somewhat diagnostic. The term diagnostic must be qualified,\\nbecause the changes are so often local, or are modified by conditions\\nindependent of the general system. For convenience, the classification\\nof Dickinson as to the appearance of the tongue in disease may be\\nutilized. In the Lumleian lectures this eminent authority described\\nthe average healthy tongue based on extensive observations. Depart-\\nures from the normal were arranged and afterward classified. It re-\\nsulted in the formation of eleven classes\\n1. The Stippled oe Dotted Tongue. The tongue is moist and\\ndotted with little white points, due to an excess of white epithelium\\non the papilla?. It is usually seen hi persons in poor health without\\nfever. It is not, therefore, a febrile tongue, nor one indicative of\\ngrave constitutional disease. It is seen in cases of chronic disease,\\nusually one in which there are no grave symptoms.\\n2. The Dry Stippled Tongue. This is found in mildly acute dis-\\neases, or in cases in which the constitutional disturbance is more marked.\\n3. The Stippled and Coated Tongue. The patients in whom\\nthis is found are very frequently the subjects of acute and constitu-\\ntional affections. Fever is more frequently present with this variety\\nof fur.\\n4. The Coated Tongue. There is excess of white epithelium on\\nthe papilla?, and the coat is continuous. The intervals between the\\npapilla? are more commonly filled up with epithelium and accidental\\nmatters than in the preceding types. It is seen in acute and febrile\\ndiseases, and whether moist or dry, in pneumonia, pleurisy, and typhoid\\nfever. It is associated with a far greater degree of prostration and\\npyrexia, while the saliva is absent in the larger proportion of cases.\\n5. The Strawberry-tongue. The tongue is coated and injected\\nthe fungiform papilla? shine through the coat, particularly at the tip\\nand edges. It is the tongue of scarlet fever, but may often be seen in\\nany acute febrile disorder. In scarlet fever, however, it appears by\\nthe second or third day most marked after the second. Pyrexia is\\nmore common in this class than in the preceding.\\n6. The Plaster-tongue. A thick, uniform coat, edges abrupt\\nand striking, covers the tongue. The papilla? are elongated and the\\nintervals crowded with accumulations, among which are bacteria it\\nis the tongue of acute febrile disease. Fever was marked in a number", "height": "4416", "width": "2644", "jp2-path": "practicaltreatis00muss_0_0775.jp2"}, "776": {"fulltext": "702 SPECIAL DIAGNOSIS.\\nof cases Dickinson studied, and prostration was a common attendant.\\nSaliva Avas deficient.\\nIt is thus seen that, beginning with the healthy tongue, Dickinson\\ndescribed a series of groups, in each succeeding one the coating becom-\\ning more marked, with or without moisture. The clinical association\\nthat he found is a common experience. Each successive group was\\nattended by more fever, greater exhaustion, and less saliva than the\\npreceding group, and in each the tongue became more and more furred.\\n7. The Furred or Shaggy Tongue. When moist the papillae\\nare greatly elongated, composed mostly of horny epithelium. It has\\nthe same appearance as if the tongue were dry. The moist, furred\\ntongue is not so common as the other. It is most commonly seen in\\nold age and in constipation. The dry, furred, or shaggy tongue may\\nsucceed the dotted tongue or the coated tongue in the course of ad-\\nvancing disease. It is the result of disease and want of moisture.\\nThe saliva is deficient it indicates that there has been fever, and that\\npossibly but little food was taken.\\n8. The Incrusted, Dry Brown Tongue. Over the surface of\\nthe tongue there is a dry, thick, felted coat, which is continuous and\\ndips down betAveen the papillae. The coat is largely made up of para-\\nsitic material. In the course of fevers it is the outcome of a preceding\\ncondition, the coated tongue, and is indicative of the typhoid state. It\\noccurs in the fevers with high temperature, but may be seen in condi-\\ntions of Ioav temperature, as from cancer, phthisis, albuminuria, chronic\\nnervous diseases. There is much depression or prostration associated\\nwith it, and there is absence of saliva. If the patients with a dry\\nbrown tongue recover, it retrogresses to the furred or incrusted tongue,\\nwhich in turn becomes bare gradually, at first in small layers the latter\\nis thin, usually dry, but is more moist than the dry broAvn tongue.\\nAs the incrustation disappears it may become bare, red, and dry.\\n9. The red dry tongue indicates a more serious condition usually\\nthan the dry and broAvn. It is the tongue of chronic wasting diseases.\\nIt occurs in phthisis in the later stages, and, as the raw-beef tongue, is\\nassociated with dysentery and also with liver abscess. There may be\\nfever associated Avith the cases. It is in a measure the tongue of\\nchronic diarrhoea. The tongue is shrunken, red, polished, and smooth.\\nThe papillae have disappeared and the epithelium is stripped off in\\npatches. It may be associated with aphthae. If the patient is to im-\\nprove, the redness fades, the papillae become softer, and the moisture\\nreturns.\\n10. Red and Membranous otherwise as (9) the red denuded\\ntongue.\\n11. Cyanosis, or Venous Congestion of the Tongue. The\\ntongue is of a bluish or purplish color, the surface is smooth and Avet,\\nand the papillae are almost indistinguishable. It is not confined to\\norganic heart disease or cyanosis. It is of quite frequent occurrence\\nin albuminuria. With the venous congestion in the albuminuric cases\\nthere is always a superabundance of deep epithelium. When the sur-\\nafce is examined it looks as if the papillae Avere fused together and\\noverlaid by a moderate coat.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0776.jp2"}, "777": {"fulltext": "DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 703\\nClassification of Tongues.\\nTo the naked eye.\\n1. Healthy, moist.\\nMicroscopically.\\nWhite epithelium in small amount on papillae, not\\ncontinuous or superabundant.\\n2. Stippled, moist, dotted with\\nwhite.\\n2(D). 1 Stippled, dry.\\nExcess of white epithelium on papillae, not extend-\\ning between them.\\nDitto.\\n3. Stippled coated moist.\\nCoat continuous in parts.\\nWhite epithelium on papillae in excess, with partial\\nfilling of intervals.\\n4. Coated white moist. Coat\\ncontinuous.\\n4(D). Coated white, dry. Coat\\ncontinuous.\\nExcess of white epithelium in papillae. Intervals\\nmore or less filled up with epithelium and acci-\\ndental matter.\\nDitto.\\n5. Strawberry, coated -(-injected,\\nespecially showing in fungi-\\nform papillae.\\nLike the coated or plastered, but with more injec-\\ntion.\\n6. White, plastered, thick, uni-\\nform coat edges abrupt and\\nstriking.\\nMore elongation of papillae than with coated\\ntongue, more filling of intervals with superficial\\naccumulation.\\n7. Furred or shaggy, moist.\\nGreatly elongated papilla 3\\n7 (D). Furred or shaggy, dry.\\nExtravagantly Ion? papillae, mostly of horny epi-\\nthelium.\\nDitto.\\n8. Incrusted, dry, brown thick,\\nfelted dry coat over papilla?.\\nContinuous crust on and between papillae, largely\\nof parasitic matters.\\n9. Furred or incrusted, becom-\\ning bare. Generally dry.\\nCrust breaking away, together with more or less of\\nnormal surface.\\n10. Eed, denuded. Absence of\\nnormal covering.\\nGeneral absence of all epithelium excepting the\\nMalpighian layer sometimes of that also.\\n11. Red, smooth, dry, membranous\\ncovering.\\nLevel membrane replacing epithelial processes.\\n12. Cyanosed.\\nInjected; hypernucleated excess of deep epithe-\\nlium.\\nMoisture of the Tongue. The moisture is due to the saliva,\\nany deficiency of which causes dryness of the tongue. It is natural,\\ntherefore, to conclude that any changes in the moisture of the tongue\\nare due to altered secretion of the salivary glands. This is almost\\nahvays deficient when fever is present, and hence the tongue is dry.\\n1 The letter D is used to imply dryness. Thus, to Class 2 a certain description is\\nattached. Class 2 D presents the same characteristics with the addition of dryness.", "height": "4416", "width": "2640", "jp2-path": "practicaltreatis00muss_0_0777.jp2"}, "778": {"fulltext": "704 SPECIAL DIAGNOSIS.\\nAt tlie same time, it must be remembered that this failure of secretion\\nof the salivary glands does not depend upon gastro-intestmal disturb-\\nance.\\nDryness of the tongue, it must not be forgotten, may be due to in-\\ncrease of evaporation from keeping the mouth open, as well as to\\ndiminution of the salivary secretion. All states, therefore, in which\\nthe mouth is open will lead to dryness of the tongue. Again, in\\nchronic fever, dryness of the tongue is a constant characteristic.\\nDryness is due to the effects of the temperature upon the secretions\\nin general, but it is not the effect of high temperature, curiously,\\nbut rather a temperature which has persisted for a considerable\\nlength of time. Thus, in pneumonia, with a temperature of 105\u00c2\u00b0,\\nthe tongue may be moist whereas, in typhoid fever, with a tem-\\nperature of 103\u00c2\u00b0, the tongue is dry. General dehydration of the\\nbody causes dryness of the tongue, even without local diminution of\\nsecretion. This dehydration is seen in diarrhoea, in which disease\\nsimple or uncomplicated dryness of the tongue is the common symp-\\ntom. It is curious to observe that in cholera the tongue remains moist\\neven until death whereas, if the patient is about to improve and the\\ndischarges cease, reaction and fever setting in, the tongue begins to dry\\nand becomes quite brown. Local causes may explain this. The watery\\nvomit may keep the tongue moist, and the temperature of the body\\nmay contribute to the change. Next after diarrhoea we have excessive\\ndischarge of urine as a frequent cause of dryness. Hence, in diabetes\\nin all forms extreme dryness of the tongue is seen. The osmotic action\\nof the sugar in the blood is the cause of a reaction in diabetes mellitus,\\njust as it is in cases of dehydration of the lens in cataract. The final\\ncause of dryness of the tongue is prostration. Asthenia in all forms\\ncontinuing over a moderate period of time, as a week or ten days,\\ncauses lingual dryness.\\nThe Effects of Food. These must be studied before deciding\\nupon the clinical significance of changes in the tongue. The immedi-\\nate results of taking of food influence the coating and the degree of\\nmoisture. The act of eating cleanses the tongue. In disease, there-\\nfore, in which this act is not performed, it is natural that we observe\\nmore fur on the surface, and in conditions in which diet is limited to\\nfluids the effect is marked. In cases of liquid diet the tongue is likely\\nto remain furred. It is particularly seen in patients who are kept\\nupon a milk-diet exclusively.\\nThe Tongue in Relation to Diseases of the Alimentary Canal.\\nSo much has been written on this subject that it is well to give the\\nexperience of Dickinson briefly. He has not been able to discern\\nany relationship between any state of the tongue and dyspepsia, or\\nulcer of the stomach, apart from that which might occur from loss of\\nappetite or restriction in the amount of food. With regard to the\\nbow els, some forms of constipation are often connected with changes\\nin the tongue, but such connection is not constant. The author rather\\ntli inks it to have been a coincidence, and cannot even point to the\\ndiagnostic significance of the tongue in obstruction. The state of the\\ntongue in the latter condition is dependent not upon the intestinal", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0778.jp2"}, "779": {"fulltext": "DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 705\\nlesion but upon the constitutional disturbance. A dry tongue is well\\nknown to occur in acute obstruction, due to deficiency of salivary\\nsecretion. In chronic obstruction, unless, however, there is consti-\\ntutional disturbance, the tongue will not change. In diarrhoea all con-\\nditions of dryness, furring, and incrustation are observed. The\\nabsence of saliva, dehydration, and pyrexia help the desiccation. In\\ndiarrhoea and dysentery, therefore, the change in the appearance of\\nthe tongue is more marked than in any other disease.\\nOther Diseases. As regards the relation of the tongue to other\\nindividual diseases but little can be said. Of more direct association,\\nwe have the cyanotic tongue in heart disease the dry tongue in\\nchronic albuminuria and diabetes mellitus the strawberry-tongue of\\nscarlet fever and the dry brown tongue of typhoid fever. Of course,\\nthe so-called typhoid tongue represents but one stage of typhoid fever.\\nThroughout the disease it may present all varieties in direct succes-\\nsion, from the stippled, the coated, the plastered, the furred, to the\\nincrusted. In lobar pneumonia the same changes occur as the disease\\nadvances. In bronchitis the lower degrees of coating are presented,\\nwhile in rheumatism the variety is considerable. In conclusion, it\\nmay be stated that the tongue seldom points to solitary organs or iso-\\nlated disorders, but is a gauge of the effects of disease upon the system.\\nThe Tongue in Prognosis and Treatment. Clinical observers\\nagree with Dickinson, that the condition of the tongue is due very\\nlargely to the four states with which he has associated it dehydra-\\ntion, exhaustion, pyrexia, and local conditions about the mouth. As\\nthese conditions modify the state of the tongue, it is evident that the\\nfirst sign of improvement, as return of moisture, denotes a diminution\\nin temperature. Its appearance is, therefore, of good prognostic omen.\\nThe degree of fever, the state of the nervous system, the maintenance\\nor abeyance of secretions, and the failure of vitality, are indicated by the\\ncondition of the tongue. The return of moisture, the removal of fur, the\\nsubsidence of tremor, at once indicate that the patient is getting better.\\nThe persistence and increase of these signs show that the disease is get-\\nting the better of the patient. As to indications for treatment, the dry-\\nness, furring, and incrustation are connected with the want of saliva.\\nThe processes by which this want is brought about differ. They have\\npreviously been referred to, and the indications for treatment are obvious.\\nOne can infer from the state of the saliva the condition of the intesti-\\nnal canal, a matter of the highest importance practically. There is no\\ndoubt that, except possibly in diabetes, when there is diminished\\nsaliva, there is also diminished gastro-intestinal secretion. Such\\ndiminution is followed by loss of appetite and impairment of digestion.\\nThe indication is at once to administer material that is digested with\\nthe least difficulty. Hence, liquid food and stimulants are to be used.\\nThe dry and bare tongue is of serious prognostic omen in all conditions.\\nWhile it may be due to want of saliva alone, it also occurs as a part\\nof the failure of nutrition in hectic fever, suppuration, and other condi-\\ntions. It is an indication for the use of tonics, stimulants, and liquid\\nand highly nutritious food. The weak pulse does not more surely tell\\nof an asthenic tendency than the red, dry, and polished tongue.\\n45", "height": "4416", "width": "2652", "jp2-path": "practicaltreatis00muss_0_0779.jp2"}, "780": {"fulltext": "706 SPECIAL DIAGNOSIS.\\nMovements of the Tongue When the patient is asked to put out\\nhis tongue it is done without other movement than that required for\\nits ejection. Interference with its motility occurs in disease, when the\\nprojection is attended by abnormal movement. It may be tremulous,\\nas in alcoholism or in simple weakness alone. It may be slow or im-\\npeded in the various stages of paralyses. It is tremulous and the seat\\nof fibrillar contractions in general paralysis. It cannot be projected\\nat all in glosso-labial paralysis it can be projected, but with difficulty,\\nand may have to be aided by the finger, in general paralysis and diph-\\ntheritic paralysis, progressive muscular atrophy, and hemiplegia, be-\\ncause the paralysis is only partial. The tongue points to the paralyzed\\nside of the body in hemiplegia when the face is involved.\\nAngina Ludovici. Angina Ludovici is characterized by slight\\ninflammatory congestion of the throat out of proportion to the symptoms\\nof the inflammation in the external structures. Woodeny induration\\nof the connective tissue, which will not pit on pressure spreading of\\nthis induration, which is circumscribed, so that it is bound sharply by\\nunaffected cellular tissue, is characteristic. The induration may extend\\nfrom the rami of the jaws to the face. With this there is a hard swell-\\ning in the tongue and along the lower jaw, causing thickening of the\\nfloor of the mouth. This is observed by palpation with the finger in\\nthe mouth. The glands are not affected. For a long time the nature\\nof this affection was not known. It is now believed to be due to\\nactinomyces. (See Parker, Lancet, 1879, and Anderson, Transactions of\\nthe Medico-Chirurgical Society, 1891.)\\nThe Fauces and Pharynx\\nThe passageway between the mouth and the respiratory passages is\\nlined with mucous membrane, which is subject to diseases to which\\nthey are liable. The symptoms thereof are similar to the symptoms\\nof mucous membrane inflammation elsewhere. The large muscles of\\nthe pharynx which aid in deglutition are subject to affections which\\nbelong to muscular tissue generally, hence rheumatic inflammation and\\nloss of power of muscle, or paralysis occurs. Paralysis of the pharynx\\nhas not the same practical importance in diagnosis of central lesions as\\nparalysis of other structures, such as parts of the larynx. This is due to\\nthe fact that the nerve-supply of the pharynx is derived from a nerve\\n(glosso-pharyngeal) which supplies other structures, paralysis of which\\nis more evident than pharyngeal paralysis, more readily ascertained,\\nand which causes more pronounced symptoms. (See Cerebral Nerves.)\\nFrom its exposed situation the pharynx is particularly liable to infec-\\ntion from micro-organisms. The infection may extend from the mouth,\\nor from the nares above, or the micro-organisms may affect it primarily.\\nThe fauces and pharynx may be the seat of morbid processes which\\noccur secondarily to diseases in other portions of the body with a mod-\\nerate degree of frequency. Inflammations of the mucous membrane\\nof the pharynx are of rheumatic or gouty origin in a large number\\nof cases. Indeed, gouty inflammation of the pharynx seems to be\\nmore common than gouty inflammations of mucous membranes in other", "height": "4404", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0780.jp2"}, "781": {"fulltext": "DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 707\\nsituations. The large majority of subacute or chronic pharyngeal in-\\nflammations are secondary to dyspepsia. They also occur from exten-\\nsion of the disease from cavities related to the pharynx.\\nAffections of the tonsils are usually more common in rheumatic\\nstates, and bear some relationship to the rheumatic diathesis. Inflam-\\nmation of the tonsils may follow acute rheumatism or may alternate\\nwith it. A patient who is predisposed to rheumatism may at one\\nseason have tonsillar inflammation, at another rheumatism. The\\nwriter has seen tonsillitis immediately followed by rheumatism, and\\nthen the latter replaced by the former.\\nApart from what has just been said, diseases of the pharynx bear\\nbut little, if any, diagnostic relationship to disease elsewhere. While\\nthere may be cyanosis of the mucous membrane, or tuberculous ulcer-\\nation, or other changes which we have noted, the signs of the primary\\ndisease are so much more marked that we need not rely upon the\\nappearance of the pharynx or symptoms of pharyngeal disease for\\ndiagnostic purposes. The only general affection which may be diag-\\nnosticated from the appearance of the pharynx alone is measles. In\\nobscure cases of sudden fever, with nasal catarrh, the appearance of\\nthe eruption in the situation just indicated may lead to the recogni-\\ntion of measles when the external eruption is not apparent. For\\nthe purposes of the therapeutist it should be borne in mind that symp-\\ntoms referable to the pharynx are very frequently due to disease in\\nthe nares, particularly in that portion of the pharynx which is not\\nopen to direct inspection the nasopharynx.\\nThe general symptoms of pharyngeal disease are not marked, except\\nin diphtheria, in erysipelas, in retropharyngeal abscess, and in affec-\\ntions of the tonsils. In the latter the general symptoms appear to be out\\nof proportion to the local process. The high fever, the intense head-\\nache and backache, and rapid pulse, seem to point to a process which in\\nextent and severity should far surpass that which occurs in the tonsils.\\nAs a passageway or channel, affections of the pharynx are liable to\\nobstruct it, causing symptoms of occlusion. As a channel for the pas-\\nsage of air, obstruction in the pharynx will lead to dyspnoea. In addi-\\ntion to its function as a simple channel, the pharynx is concerned in\\nthe act of deglutition. When, therefore, there is obstruction of the\\npharynx, deglutition is made difficult, or may even become impossible.\\nAttention cannot be too strongly directed to the investigation of the\\nnasopharynx in children who are poorly developed physically and men-\\ntally, and who present appearances that, to the practised eye, are most\\nfamiliar. The experienced observer will at once judge, and judge cor-\\nrectly, that this combination of symptoms is due to disease in the naso-\\npharynx. Reference must be made to the remarks on adenoid vegeta-\\ntions of the nasopharynx, but it is proper to state here the relationship\\nand the importance of investigating the structures in the class of cases\\njust indicated.\\nThe Data Obtained by Inquiry.\\nPain. In affections of the fauces and pharynx pain is one of the\\nmost common subjective symptoms. It is due to the fact that the", "height": "4416", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0781.jp2"}, "782": {"fulltext": "708 SPECIAL DIAGNOSIS.\\nfunctional acts of the pharynx require movement of all the struc-\\ntures. When they are the seat of inflammation, or ulceration, the\\nmovement excites pain. It is, therefore, a symptom of great severity\\nin inflammation of the tonsils and pharynx, of rheumatism of\\nthe muscular structure of the pharynx, and of tuberculous and can-\\ncerous ulceration. Pain hi the pharynx is a frequent accompaniment\\nof post-nasal inflammations, although the pharynx itself is not\\naffected.\\nDryness. Dryness of the fauces, with a tickling sensation and a\\nmore or less constant desire to hawk, occurs in pharyngitis. Hawk-\\ning, however, is not a symptom of disease of the pharynx alone. It\\nmay also be due to disease in the posterior nares.\\nThe Odor of the Breath. In follicular tonsillitis the breath has\\na peculiar odor. This is more marked in the milder forms of inflam-\\nmation, with retention of the secretion of the glands. The odor is in-\\ntense and foetid. In cancer and syphilis there is also foetor of the\\nbreath. The foetor may be of diagnostic significance in distinguishing\\ncancer from tuberculosis.\\nDysphagia. The symptom varies in degree from slight difficulty\\nin swallowing to complete prevention of the act. Any disease which\\noccludes the passageway causes dysphagia pain is also a cause. It\\nis, therefore, present in all painful affections of the pharynx. Dysp-\\nnoea is seen in tumors, hi inflammation of the tonsils, in the rare form\\nof erysipelas of the pharynx, and in retropharyngeal abscess. It\\noccurs from occlusion of the passages, and is more marked in retro-\\npharyngeal abscess and erysipelas than in other conditions. In cer-\\ntain forms of abscess of the tonsils it may be very extreme.\\nSpasm of the pharynx is a subjective symptom complained of in some\\ncases of pharyngitis. The degree of spasm or the amount of choking\\nsensation is largely dependent upon the neurotic constitution of the\\nindividual. It may be extreme when only a moderate amount of inflam-\\nmation is present. It is seen in the most aggravated form in hydrophobia.\\nThe Data Obtained by Observation.\\nExamination of the Fauces. Method. For this purpose examin-\\nation is made by the unaided eye, illuminating the throat as in the ex-\\namination of the larynx. The difficulties of examination arise from the\\ntongue and the uvula. The mouth should be opened as wide as is con-\\nsistent with comfort and in an unrestrained manner. The tongue is\\npressed out of the way by the use of a tongue-depressor. In many cases,\\nhowever, even with the tongue-depressor, the tongue muscles will con-\\ntract and the organ bunch up in the mouth. Moderate, quiet, full\\nbreathing, gently opening the mouth as the deeper inspirations are made,\\ncauses the tongue to relax and lie in the bottom of the mouth, and at\\nthe same time elevates the uvula. At the time of a full breath the\\npart may be inspected throughout. Sometimes the fauces can be ex-\\namined if the tongue is protruded and held with a soft napkin between\\nthe finger and thumb by the patient. In the fauces the tonsils and\\nuvula are to be observed, following out the routine method of ascer-", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0782.jp2"}, "783": {"fulltext": "DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 709\\ntaming all facts. Attention is then paid to the posterior wall of the\\npharynx, with the same object in view.\\nInspection. In examining the fauces and pharynx observation is\\nmade of the color of the parts, the appearance of the mucous mem-\\nbrane and its glands, the appearance and position of the uvula, the\\nsize of the tonsils, the character of the secretions on the pharynx, and\\nthe presence or absence of swellings and abnormal exudations.\\nColor. The color of the mucous membrane is generally dark red.\\nIn the acute forms of pharyngitis the color is bright red. In cases of\\nheart disease, when there is cyanosis, the veins are congested and the\\nsurface dusky. In obstruction of the superior vena cava by tumor there\\nis a cyanotic hue of the surface of the pharynx.\\nAppearance of Surface. The capillary vessels may pulsate in aortic\\nregurgitation. Bleeding-points may be seen over the surface of the\\npharynx, the discharges of blood from which may simulate pulmonary\\nhemorrhage. The blood may be swallowed and then vomited, and\\nhence gastric hemorrhage is simulated. When the hemorrhage occurs\\nat night it is seen on the pillow as yellowish stains. It is often due\\nto adenoid vegetations in the nasopharynx. In chronic pharyngitis the\\nmembrane is dry, the glands are prominent, and the secretion viscid.\\nOn examination of the posterior wall of the healthy pharynx little\\nelevations due to glands are seen upon its surface, and moderate-sized\\nvessels are seen coursing through the mucous membrane.\\nEruptions. Eruptions may be observed in the pharynx in some of\\nthe specific fevers. Thus, in measles, the appearance of the rash on\\nthe pharynx and on the soft palate may be observed before the devel-\\nopment of the rash on the skin. The eruption of scarlatina is also seen\\nin the pharynx, and the papules and pustules of variola are frequently\\nobserved in that situation.\\nUlceration. Follicular Ulceration. Small superficial ulcers cor-\\nresponding to the follicles may be seen over the posterior wall of\\nthe pharynx. They occur in chronic catarrh, and are due to in-\\nflammation of the follicles. In addition, ulcers secondary to infectious\\nprocesses are sometimes seen, as in typhoid fever. In syphilis, in the\\nsecondary stage, small, shallow ulcers are seen on the posterior wall of\\nthe pharynx. They do not cause pain. Mucous patches are observed\\nat the same time, not only on the pharynx, but also in the mouth.\\nIn the tertiary stage deep ulcers, followed by scars, are seen on the\\nposterior Avail of the pharynx. Although the absence of pain renders\\nit probable that they are of syphilitic origin, nevertheless the history\\nof infection and of the primary lesion, and the evidence of the disease\\nin other structures, ought to be secured before a diagnosis is fully estab-\\nlished. In the tertiary forms it may be necessary to resort to the\\ntherapeutic test. (See The Infections Syphilis.)\\nTuberculous ulcers are irregular in shape, and the floor grayish.\\nThey are seen in tuberculosis in its later stages. They are the source\\nof extreme pain. There is usually ulceration in the larynx at the same\\ntime, and, in extremely rare cases, tuberculous ulceration of the tonsils.\\nIn tuberculous ulceration, after the application of cocaine, a portion\\nmay be scraped off and examined microscopically for tubercle bacilli.", "height": "4416", "width": "2656", "jp2-path": "practicaltreatis00muss_0_0783.jp2"}, "784": {"fulltext": "710 SPECIAL DIAGNOSIS.\\nCancer of the pharynx is rare, and is usually secondary, the dis-\\nease having spread from other situations.\\nExudations. On the pharynx the exudation may be due to\\ndiphtheria, to pseudocliphtheria, or to thrush. The method of dis-\\ntinguishing the various forms will be considered in the articles on the\\nrespective affections. In diphtheria the membrane is made up of\\nfibrin arranged in a network, in the meshes of which epithelium,\\nblood-corpuscles and pus-corpuscles and micro-organisms are found.\\nWhen removed, hemorrhagic abrasions and raw purulent inflammatory\\nareas remain. Two forms of bacilli are found in the membrane the\\npseudodiphtheritic bacillus and the true, or Klebs-Loffler bacillus.\\n(See Bacteriology.) The Loffler bacillus is best detected by cultiva-\\ntions. After the membrane is removed and washed in a 2 per cent,\\nsolution of boric acid, it is cultivated in blood-serum. The pseudo-\\ndiphtheritic bacillus likewise grows, but its appearances are different.\\nAnaesthesia. Some of the results of inspection may be confirmed\\nby means of the probe, and alterations in the sensibility of the phar-\\nynx may be detected. Sensations may be absent in the whole poste-\\nrior wall of the pharynx. Loss of sensation may occur in hysteria, in\\nbulbar paralysis, and in diphtheritic paralysis. On the other hand,\\nthere may be an apparent hyperesthesia. In some individuals the\\npharynx is particularly sensitive to the presence of foreign bodies, such\\nas inflammatory exudates, and may resent their presence by sudden\\ncoughing and retching. Inflammations increase the hyperesthesia of\\nthe pharynx. The condition is sometimes observed in hysteria.\\nThe Uvula. In health it hangs midway from the palate. It varies\\nin shape from congenital causes, and may be elongated, on account of\\ndisease. This takes place particularly if there has been hawking or\\ncoughing, on account of chronic nasal catarrh. When elongated it is\\npointed and may extend almost to the base of the tongue. The uvula\\nmay be swollen and oedematous. The oedenia is usually associated\\nwith subcutaneous oedema in acute Bright s disease. It may occur\\nin debility. In both conditions it may become so enlarged as to\\ninterfere with swallowing and breathing. In some cases of pharyn-\\ngitis the uvula is the seat of intense inflammation and great oedema.\\nIn addition to the constant cough which it causes there may be dysp-\\nnoea and repeated attacks of choking.\\nHemorrhagic infarcts may take place in the uvula. In two in-\\nstances under the writer s care the intense infarction led to sloughing,\\nand in one the uvula was swallowed.\\nThe Cervical Glands. The pharynx is in such intimate rela-\\ntion with the large lymphatic glands in the neck that diseases of the\\nformer are frequently attended by enlargement of the latter. The\\nglands at the angle of the jaw are increased in size. The glands ex-\\ntending along the vessels of the neck may also be enlarged. In cases,\\ntherefore, of enlargement of the glands in this situation, it is absolutely\\nessential to examine the fauces and pharynx.\\nThe Tonsils. The tonsils are situated at the sides of the pharynx,\\nbetween the anterior and posterior folds of the palate. They are\\nsmall bodies, not larger than a filbert in the adult. Their entire", "height": "4408", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0784.jp2"}, "785": {"fulltext": "DISEASES OF MOUTH, FAUCES, PHARYNX, OESOPHAGUS. 71 1\\nsurface can be seen by ordinary inspection. If enlarged, the posterior\\nsurface cannot be seen, although a larger view may be obtained by\\ncausing the patient to gag or retch, during which they are brought\\nforward to the light. They are pathologically of much importance.\\nThey are made up of glandular structure arranged in follicles and held\\ntogether by connective tissue. The crypts of the follicles open on\\nthe surface, and in disease are visible. The diseases of the tonsils\\nhave nothing to do with their function as far as known. The tissue\\nand gland follicles are liable to inflammations, which may be bacterial\\nor may be the result of rheumatism. The tonsils become enlarged\\nthe swelling takes place rapidly in the acute forms. They may be\\nsimply enlarged and the covering membrane intensely red. In other\\nforms of inflammation the surface may be dotted over with white\\npoints, due to exudation from the follicles these may be covered with\\na white or grayish membrane, which is removed with difficulty, leaving\\nan abraded surface beneath. Repeated attacks of inflammation cause\\nchronic enlargement of the tonsils. They are enlarged sometimes to\\na great degree, filling almost entirely the lumen of the fauces. The\\nsurface is irregular, and may be scarred. The mouths of the follicles\\nmay be dilated. By virtue of their position, enlarged tonsils from any\\ncause are a source of dyspnoea and dysphagia. The tonsils may be\\nthe seat of sarcoma and tuberculosis.\\nUlcees. Tuberculous ulceration is rare. In a patient, a lad of\\nsixteen years, under the writer s care, the large tonsils were of a honey-\\ncombed appearance, on account of the grayish, irregular ulceration.\\nDeglutition was absolutely impossible, on account of pain, and the\\nyoung man died of starvation.\\nExudations on the tonsils are due to inflammation of the follicles,\\nto diphtheria, to the pseudodiphtheritic inflammation Avhich attends\\nscarlatina, or which arises secondarily to other infectious debilitating\\ndiseases, and to thrush.\\nLeptothrix of the Tonsils. In healthy persons the plugs\\nwhich block the tonsillar crypts are found to be made up of cells and\\nsegmented fungi. The latter stain bluish-red with iodo-potassic iodide\\nsolution. Sometimes the micro-organisms extend beyond the follicles,\\ncovering the surface of the tonsils with patches of various size. They\\nare thus seen in follicular tonsillitis.\\nTonsillitis. Acute inflammation of the tonsils may affect the folli-\\ncles, to which form the term follicular tonsillitis is applied, or it may\\nbe limited to the mucous membrane, when it is known as catarrhal\\nor erythematous tonsillitis. If with the catarrhal inflammations vesi-\\ncles appear on the surface of the mucous membrane, the term herpetic\\ntonsillitis is used. When the inflammation extends to the stroma of\\nthe glands it goes on to suppuration. It is characteristic of all forms\\nof acute tonsillitis to recur frequently in the same subject. The rela-\\ntionship to rheumatism has been spoken of. This relationship applies\\nto both the acute and the suppurative forms. The various forms of\\ntonsillitis occur at any age, although it is least common under ten\\nyears of age the suppurative form occurs most frequently in adoles-\\ncence. Tonsillitis occurs in both sexes. It may follow exposure to", "height": "4416", "width": "2652", "jp2-path": "practicaltreatis00muss_0_0785.jp2"}, "786": {"fulltext": "7 1 2 SPECIAL DIA GNOSIS.\\nwet and cold, although patients who are subject to the attacks bear\\nexposure, unless they are at the same time unduly fatigued. The fol-\\nlicular form of tonsillitis is apparently associated with bad drainage\\nor other unhygienic conditions, which makes it possible that noxious\\nemanations act as an exciting cause. Several persons of the same\\nfamily may be affected at one time, so that it is often difficult to dis-\\ntinguish the cases from diphtheria. The disease, however, is not con-\\ntagious. Persons brought in contact with the family, but who do not\\nreside in the same house, escape the disease. This applies as well to\\nchildren, who would, if the cases were diphtheritic, be most liable to\\nbecome infected. The disease occurs more commonly in the spring\\nthan in any other season of the year, more especially in cold and wet\\nseasons.\\nSymptoms. In follicular tonsillitis, with or without a rigor, but\\nalways with chilly sensations, the temperature rises rapidly to a great\\nheight. The subjective sensation of fever is very quickly noticeable\\nto the patient, and is generally more pronounced than in other affec-\\ntions. With the chill and during the rise of temperature there are\\nsome frontal headache and severe pain in the back and limbs. The\\npain in the back is most excruciating. In a short time the patient\\ncomplains of pain in the throat. Swallowing is difficult, and there is\\na sense of fulness. The throat is dry and burning. On examination\\nthe tonsils are found to be swollen, and a yellowish- white exudation is\\nseen on the crypts. In twenty-four hours the points may coalesce to\\nform a patch. The glands expand slightly, and may extend only\\nslightly beyond the arches, or, in younger subjects, one-quarter of the\\nway into the lumen of the fauces. Sometimes one gland is affected\\nbefore the other. The difficulty in deglutition increases and the voice\\nbecomes nasal. There is usually some enlargement of the cervical\\nglands. The general symptoms continue for forty-eight hours, the\\ntemperature remains at 105\u00c2\u00b0, and the pulse is very rapid. After the\\nfirst twenty-four hours the pain in the back lessens. The tongue is\\ncoated and the breath heavy. The urine is loaded with urates. At\\nthe end of the fifth day the fever, which subsides gradually, has disap-\\npeared. The local symptoms, however, may remain longer that is,\\nthe tonsils are still enlarged and the exudation disappears slowly.\\nSometimes the prostration and general symptoms are very severe, so\\nthat after the fever has subsided convalescence may be very slow.\\nAlbuminuria, due in all probability to the fever, frequently occurs\\nin some cases, undoubtedly, acute nephritis attends the attack and\\nretards the convalescence. In a case under the writer s care the\\npatient first had acute rheumatism this was replaced by a severe attack\\nof tonsillitis, during which albumin, blood, and granular casts were\\nfound in the urine. The swelling of the tonsils subsided in due course,\\nbut the Bright s disease continued for a long period, finally ending,\\nhowever, in complete recovery.\\nIn herpetic tonsillitis the severe pain and intense general symptoms\\narc out of proportion to the local lesion.\\nIn suppurative tonsillitis the constitutional disturbance is also very\\ngreat. The temperature rises high, 104\u00c2\u00b0 to 105\u00c2\u00b0, and the pulse is", "height": "4404", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0786.jp2"}, "787": {"fulltext": "DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 713\\nvery rapid, from 110 to 130 in the adult. The inflammation usually\\nbegins in one tonsil, and the other may be involved later. The\\ntonsils at first are enlarged and firm and very red. There is swelling\\nof the surrounding tissues. In twenty-four hours deglutition becomes\\nalmost impossible, and there is salivation. At the end of forty-eight\\nhours the patieut presents a striking appearance. The glands of the\\nneck are enlarged, the patient is unable to open his mouth, the voice\\nis nasal or almost suppressed there is dribbling of saliva from the\\nmouth. The face may have a dusky hue in spite of the capillary con-\\ngestion due to the fever. There is constant desire to discharge saliva\\nand accumulated secretions from the back part of the mouth. The\\npatient cannot lie down. The pain is extreme, and is aggravated by\\nswallowing. It is sometimes of a throbbing character, and often shoots\\nto the ears. Indeed, earache may be the chief complaint. The patient\\ndoes not take food, and exhaustion soon ensues. During the twenty-\\nfour hours before rupture takes place the previously reddened face\\nbecomes blanched from exhaustion. The fever is continuous during\\nthis time, with great rapidity of the pulse. The patient may be delirious.\\nSometimes the delirium is marked and the patient resists efforts to keep\\nhim in bed.\\nThe suffering is out of proportion to the danger of the case. About\\nthe fourth or fifth day suppuration is over, and if the finger can be\\ninserted into the mouth between the almost closed teeth, fluctuation\\nis detected. In cases in which the mouth is opened a little more\\nfreely, in addition to the swelling of the tonsils below the arches,\\nmarked swelling and projection forward of the half-arches may be\\nseen. The fluctuation may be detected through the anterior fold of\\nthe palate, and, if lancing is to be performed, the pus can only be\\nreached through this structure. In short, a peritonsillitis takes place.\\nAfter spontaneous rupture, which usually takes place into the mouth,\\ninstant relief is experienced. Rupture may take place into the pharynx\\nand cause suffocation from entrance of pus into the larynx. In rare\\ncases it has opened into the carotid artery, causing instant death from\\nhemorrhage.\\nDiagnosis. The diagnostic features of acute tonsillitis are the\\nsudden high fever, severe backache and headache, pain in the throat,\\nand albuminuria. The characteristic appearance of the face, the sali-\\nvation and pain, with suppressed voice and difficult deglutition, should\\ndistinguish it from trismus or tetanus. In both the jaws are closed.\\nIt must not be confounded with smallpox, which it resembles during\\nthe first twenty-four hours.\\nCases of follicular tonsillitis are frequently mistaken for diphtheria.\\nThe follicular inflammation in tonsillitis is limited to the gland, on\\nwhich patches of a yellowish-gray color, easily removed without leaving\\nbleeding surfaces, are seen. In diphtheria the membrane is of an ashy-\\ngray color, not in points or small patches, or separated by red tonsillar\\ntissue it extends to the pillars of the fauces, and may appear on the\\nuvula. There are, nevertheless, many cases which are doubtful, when a\\nbacteriological diagnosis must be resorted to. (See Bacteriological Ex-\\namination.) A history of exposure sometimes helps us to arrive at a", "height": "4416", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0787.jp2"}, "788": {"fulltext": "714 SPECIAL DIAGNOSIS.\\nconclusion. The cases that particularly increase our anxiety are those\\nof adults who are subject to attacks of follicular tonsillitis. In the\\ngrave and extensive forms of diphtheria with asthenic symptoms (sep-\\nticaemia) the diagnosis is not difficult.\\nEnlargement of the Tonsils. Chronic Tonsillitis. The ton-\\nsils may be enlarged, on account of repeated attacks of acute inflamma-\\ntion or from chronic inflammation. They do not appear to cause\\nserious symptoms unless associated with adenoid vegetations in the\\nnasopharynx. They may interfere with hearing, however, and with\\nbreathing, and cause snoring at night. Foetor of the breath may be noted,\\nparticularly if the secretion lodges in the crypts. The latter may be\\nrecognized by its characteristic yellowish color and by its odor on\\nremoval. The enlarged tonsils are irregular in contour.\\nForeign bodies in the tonsils are not of common occurrence. They\\ngive rise to local symptoms, as the sensation of the presence of a mass\\ncausing repeated efforts at swallowing. If calculi are present the\\npatient may complain of a rough sensation. The calculi follow frequent\\nattacks of quinsy. Hydatids are sometimes located in the tonsils.\\nAdenoid Vegetations of the Nasopharynx. Adenoid vegetations\\ncause more or less obstruction in the nasopharynx. The symptoms\\nmay be classed as primary and secondary. The former are local, and\\ndue to the foreign substance, per se the latter are local and general.\\nThe former are catarrhal the latter the result of stenosis.\\nLocal Symptoms. In a large number of cases there is discharge\\nfrom the nose. This may be mucopurulent, or be associated with\\ncrusts. If the discharge is not constant, the child is subject to coryza,\\nwith its customary discharge, on the slightest provocation. With or\\nwithout the chronic purulent nasal discharge mucus and blood may\\nbe passed at night and found on the pillow in the morning.\\nThe hearing is frequently impaired. There may be simply dulness\\nof hearing, or it may amount to marked deafness, either because of\\npressure of the adenoid vegetations, or extension of secondary inflam-\\nmation to the Eustachian tubes. The senses of taste and smell are often\\nmuch impaired. There is increase in the secretion of pharyngeal\\nmucus, which in older persons causes difficult expectoration.\\nRhinoscopic Examination. The roof of the pharynx is covered\\nwith rounded or villous projections, often concealing the posterior\\nnares. Rarely the villi may be seen projecting below the soft palate.\\nIn children the examination is difficult, and hence digital exploration\\nmust be used under an ansesthetic. The finger readily detects the\\nmasses, which sometimes are soft, at other times tough and of fibrous\\nor cartilaginous consistency.\\nThe Appearance. The expression of the face is characteristic.\\nIt is dull and stupid, and may be drawn. (Fig. 187.) The mouth is\\nkept open in breathing. The lips are dry, and may be cracked. They\\nare thickened. The palatal arch is high and narrowed.\\nThe nostrils are flattened laterally. Rarely they may be depressed.\\nIn one instance, which the writer saw with Dr. Harrison Allen, the\\nexterior of the nose suggested inherited syphilis, all the more because", "height": "4412", "width": "2688", "jp2-path": "practicaltreatis00muss_0_0788.jp2"}, "789": {"fulltext": "DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 715\\nFig. 187.\\nof our knowledge of the possible presence of the disease. There were\\nno other evidences of hereditary syphilis in the child or in any mem-\\nber of the family.\\nThe Voice. It is thick and muffled, becoming indistinct upon the\\noccurrence of slight cold.\\nThe Chest. While there is a general lack of physical development,\\nthe appearance of the chest is most striking. The cases have been\\nfrequently mistaken for rickets, however in this country adenoid veg-\\netations are a common cause of chest-\\ndeformity, whereas in England and on\\nthe continent rickets is the most frequent\\ncause. The ribs are prominent in front,\\nthe sternum is angulated forward at the\\nmanubrio-gladiolar j unction and grooved\\nat the gladiolar-xiphoid junction. A\\nsaucer-shaped depression is found at\\nthe lower costal cartilages. The ribs\\nbehind are closely compressed, so that\\nthe intercostal spaces at the lower part\\nof the chest are obliterated. The chicken-\\nbreast appearance is most striking, with\\nthe depression in the lower portions of\\nthe chest. The diaphragm may be\\ndrawn in during inspiration in the\\nmiddle and lateral thoracic regions.\\nIn addition to the chicken or\\npigeon-breast the more advanced\\ndeformity known as the funnel-breast 7\\nor trichterbrust is seen. In children\\nwho suffer from asthma and bronchitis,\\nthe chest becomes emphysematous.\\nMental and Nervous Symptoms.\\nHeadache, listlessness, and indisposition\\nfor mental exertion are marked. The\\npatients are usually backward in their\\nstudies and are unable to fix their at-\\ntention for any length of time upon any\\nsubject. The child is forgetful and can-\\nnot study without effort. Aprosexia is\\nthe term applied to this condition.\\nChoreiform spasm of the face occurs\\nin connection with it. Enuresis is a\\nfrequent associate symptom. The child\\nis subject to frequent attacks of indiges-\\ntion. I have seen the following occur in many cases Prior to opera-\\ntion the child had an abnormally poor appetite and was subject to fre-\\nquent attacks of indigestion, characterized by vomiting, with fever.\\nAfter the operation the appetite improved and continued good, and\\nthe attacks of indigestion disappeared entirely. The cases had been\\nunder observation before and after the operation for a number of years.\\nAppearance in adenoid disease.\\n(D awson- Willi ams", "height": "4416", "width": "2620", "jp2-path": "practicaltreatis00muss_0_0789.jp2"}, "790": {"fulltext": "716 SPECIAL DIAGNOSIS.\\nThe indigestion seems to have been due to the fact that, owing to the\\nobstruction, the child would have to eat rapidly, in order to keep the\\nlumen of the mouth free for breathing purposes. The rapid eating,\\nof course, prevented proper mouth-digestion, and hence the occurrence\\nof gastric catarrh.\\nSymptoms from Embarrassed Respiration. In addition to\\nmouth-breathing, the patient snores at night, and sleep is always dis-\\nturbed. The respirations are irregular, with a pause between, fol-\\nlowed by noisy inspirations. The difficulty of breathing is the cause\\nof restlessness, and the child will often wake up in the night with\\ndyspnoea. Night-restlessness, with dyspnoea and irregular respirations,\\nshould point, therefore, to obstruction in the nasopharynx.\\nDiagnosis is based upon the facies, which is very characteristic, and\\nthe physical examination. In children, digital examination is neces-\\nsary. The finger can readily detect small, flat bodies or grape-like\\nmasses in the nasopharynx.\\nThe student cannot become too familiar with the symptoms and\\nsigns of adenoid disease of the nasopharynx. There is no doubt that\\nin our large cities this local affection is of more common occurrence\\nand more disastrous in its results than any other that we have to deal\\nwith in children. It may be said that in children in poor health,\\nanaemic, with impaired digestion, and lack of muscular and physical\\ndevelopment, if the causes are not due to impure air and improper\\ndiet, or to improper sanitation generally, it is almost certain that there\\nis disease of the nasopharynx. The writer has seen a very large num-\\nber of cases in recent years in his practice, and has had the satisfac-\\ntion of seeing the entire picture of the child change after proper opera-\\ntions. It may be said in passing that this change does not take place\\nat once, but after three to twelve months the child will be fully\\nrestored in physique, if during that time attention is paid to proper\\nexercise and the development of the chest. Notwithstanding all this,\\nhowever, the natural shape of the chest and appearance of the face are\\nonly resumed gradually.\\nInflammations of the Pharynx. Inflammation of the pharynx,\\nacute pharyngitis, or sore-throat, follows cold or exposure, particularly\\nafter the patients have been physically depressed. The acute inflam-\\nmation may be associated with rheumatism or gout. The inflammation\\noften involves the tonsils as well as the pharynx. The symptoms are\\npain on swallowing, with dryness and a constant desire to hawk and\\ncough, on account of the tickling sensation. There may be slight\\nlaryngitis and inflammation of the Eustachian tubes, with deafness.\\nStiffness of the neck and enlargement of the cervical glands attend the\\nlocal inflammation. The general symptoms are not marked. The\\nattack is ushered in by chilliness and slight fever. On examination\\nthe mucous membrane is seen to be congested, dry, and glistening,\\nand covered in spots with sticky secretions. The uvula may be very\\nmuch swollen. When the submucous tissues are involved the parts\\nare more swollen and there is greater dyspnoea. The dysphagia is\\nmore marked, although the pain is not any greater. The fever is\\nhigher. The larynx is always involved, causing aphonia.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0790.jp2"}, "791": {"fulltext": "DISEASES OF MO UTH, FA UCES, PHAR YNX, CESOPHA GUS. 717\\nPhlegmonous Inflammation. A diffused inflammation of this\\ncharacter occurs. The writer saw one case with dyspnoea, nervous\\nsymptoms, and high temperature, simulating severe pneumonia.\\nPneumonia was thought to be present because there were congestion\\nand oedema of the lungs. It occurred during the prevalence of the\\nrecent epidemic of influenza. The disease began in the pharynx the\\ntissues were swollen and infiltrated. The early symptoms were phar-\\nyngeal. The dysphagia was extreme, and there was an abundant\\nmucopurulent expectoration, which did not contain pneumococci.\\nDeath took place on the ninth day from exhaustion. The autopsy\\nshowed a high degree of congestion of the lungs, and phlegmonous\\ninflammation of the pharynx, larynx, and trachea. While, therefore,\\nthe recognition of an acute phlegmonous inflammation is not difficult,\\nit must not be forgotten that it is a grave disease, which may present\\nsuch marked pulmonary and systemic symptoms as to lead to the sus-\\npicion of pneumonia.\\nAngina Ludovici is an inflammation of the cellular tissue of the\\nfloor of the mouth and neck. It is probably a form of actinomycosis.\\nThe swelling is most marked below the jaw of one side. The symp-\\ntoms are very intense and both local and general. There are general\\nseptic symptoms from the outset. With the swelling there are oedema\\nand board-like induration. Redness and the rapid formation of an\\nabscess occur rarely. The throat is not affected. Death takes place\\nfrom reflex suffocation or in coma. (See The Mouth.)\\nRheumatic pharyngitis is of short duration, without objective\\nsymptoms. Pain is intense, deglutition difficult. The usual concomi-\\ntants of rheumatism are present. It frequently gives place to torti-\\ncollis, lumbago, or rheumatism in some other situation.\\nChronic pharyngitis follows acute attacks, and is a frequent\\naccompaniment of nasal catarrh. It is common in smokers and alco-\\nholic subjects the use of the voice in loud tones, as by clergymen,\\nauctioneers, etc., is also a cause. It is a frequent attendant upon in-\\ndigestion, due probably to the eructations. The objective signs are\\nrelaxation of the mucous membrane, with dilatation of the veins. The\\nmembrane is covered with a thick secretion, which is dry and glisten-\\ning. In the granular form the wall of the pharynx is covered with\\nmillet-seed projections and is congested. Tough mucus is seen in\\nsmall areas.\\nRetropharyngeal Abscess. The inflammation may begin in\\nthe submucous connective tissue, and a retropharyngeal abscess form.\\nThere are high fever and dysphagia, with stiffness of the neck and\\nenlarged glands. On examination a projection into the pharynx can\\nbe seen or distinctly felt on the posterior wall. The disease may be\\ndifficult of recognition in infants, in whom it is not possible to get a\\ngood view of the pharynx. On the other hand, it may be simulated\\nby disease of the cervical vertebrae, in which there may be stiffness,\\ndifficulty in deglutition, and possibly a tumor. It must not be for-\\ngotten that retropharyngeal abscess may result from caries of the cer-\\nvical vertebrae. In children the abscess is attended with dyspnoea and\\nalteration in the voice, so that laryngeal disease may be suspected. I", "height": "4416", "width": "2644", "jp2-path": "practicaltreatis00muss_0_0791.jp2"}, "792": {"fulltext": "718 SPECIAL DIAGNOSIS.\\nrecall a case of retropharyngeal abscess in which the dyspnoea was so\\nsevere as to suggest croup in fact, preparations for tracheotomy were\\nmade, when sudden rupture of the abscess revealed the nature of the\\ndisease. Fortunately the child had been kept in the upright position,\\nso that pus was discharged into the mouth, or suffocation would have\\nensued.\\nInflammation of the Parotid Gland. First, specific inflammation\\nor parotitis (see Mumps) second, symptomatic parotitis occurs in\\ntyphoid fever, pneumonia, pyaemia, and septicaemia. The process is\\nintense, characterized by swelling, redness, and heat over the parotid\\ngland. There are pain and difficulty of mastication suppuration\\nrapidly ensues in the septic form. It is thought to be an unfavor-\\nable symptom, but I have seen two cases in typhoid fever get well.\\nIn a case of septicaemia it did not advance to suppuration. Stephen\\nPaget has described a symptomatic inflammation in disease of the\\nabdomen and pelvis. He collected 101 cases, 50 of which were due\\nto injury, disease, or temporary derangement of the genital organs,\\nas by slight blows, or in females to the introduction of a pessary. It\\nmay occur before the menstrual period or during pregnancy. Septi-\\ncaemia or pyaemia does not attend the process indeed, many of the\\ncases are afebrile. In 78 cases, 45 suppurated and 33 resolved with-\\nout suppuration.\\nGowers describes a case of parotitis which occurred in the course of\\nfatal peripheral neuritis.\\nThe (Esophagus.\\nThe oesophagus is open to all affections which arise in mucous mem-\\nbranes, although its histological structure, its position, and its func-\\ntions largely protect it from involvement in disease. Should morbid\\nprocesses arise, the symptoms expressive of these processes are the\\ncommon symptoms of disease of the mucous membrane. But the oesoph-\\nagus is a closed tube, the function of which is to convey food from\\nthe pharynx to the stomach. It is subject to all the affections common\\nto channels. Any disease of the tube interferes with its function,\\nmade evident by the symptom common to all disorders of the oesoph-\\nagus dysphagia. As this symptom occupies a position of such promi-\\nnence in the symptomatology of disease of this tube, it is evident that\\nthe diagnosis of disease resolves itself into the differentiation of all\\nforms of difficulty of deglutition.\\nBefore beginning the discussion along the lines indicated, the sub-\\njective and objective symptoms of disease of the oesophagus must be\\nconsidered.\\nThe Subjective Symptoms. Pain is a common symptom of dis-\\nease of the oesophagus. In acute inflammation it is extreme, and is\\ncomplained of in the neck, between the shoulders, and along the verte-\\nbrae for a short distance. Its character depends upon the cause. Severe\\nburning pain, often agonizing, is due to inflammation caused by hot\\nor caustic fluids. Absence of pain after the ingestion of such sub-\\nstances, or its disappearance in a short time, points to extreme corro-\\nsive action and gangrene. Pain attends and is a part of the symptom", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0792.jp2"}, "793": {"fulltext": "DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 719\\ndysphagia (q. v.). Cough attends such diseases of the oesophagus as\\nexert pressure upon the bronchus, as carcinoma.\\nThe Objective Symptoms. Stiffness of the neck is seen in acute\\ninflammation of the oesophagus and in peri-oesophageal abscess it\\nmay also occur in traumatism. The expectoration in diseases of the\\noesophagus is characteristic. It is usually a glairy mucus, often frothy\\nor viscid. It is not coughed up, but after welling into the pharynx\\nis hawked up. It is abundant in acute and chronic inflammation and\\nin cancer.\\nHemorrhage from the (Esophagus. Hemorrhage from the\\noesophagus occurs from varicosity of the veins at the lower portion of\\nthe gullet. It may occur in old people, from senile disease of the\\nliver, kidney, and spleen, or at any age in cirrhosis of the liver. In\\nhemorrhage from the oesophagus the blood is usually bright in color,\\nhas not been acted on by an acid, as in hsematemesis, and is, therefore,\\nalkaline in reaction, and is not discharged by vomiting, although vom-\\niting may occur after the blood is poured out. In a grave case of\\npurpura under the care of the writer hemorrhage took place from the\\nlower end of the oesophagus. Small bleedings from the oesophagus are\\nusually indicative of cancer, especially if, in addition to the hemor-\\nrhage, there are present the symptoms of occlusion. Hemorrhage is\\nalso seen in foreign bodies (1) from trauma (2) from ulceration.\\nEmaciation is the most characteristic general symptom of oesophageal\\ndisease. It is, of course, more striking in cancer, but occurs to a mod-\\nerate degree in all forms of stricture. Factor of the breath attends\\ndilatation of the oesophagus.\\nEmphysema of the subcutaneous connective tissue should always lead\\nto investigation of the oesophagus. Usually it is found to have been\\npreceded by pronounced symptoms of disease of the oesophagus. In\\nrare cases ulceration of the oesophagus may progress without symp-\\ntoms, and extend into the air-passages. The passage of air through\\nthe fistulous communication causes subcutaneous emphysema. It is of\\nfrequent occurrence wheu foreign bodies lodge in the gullet.\\nPhysical Examination. Examination of the oesophagus is made\\nby inspection and auscultation, and by means of palpation with or\\nwithout a bougie.\\nInspection can be made only with an endoscope.\\nAuscultation of the oesophagus, while the patient is swallowing\\nfluids, sometimes confirms the results obtained by instrumental palpa-\\ntion as to the seat of an obstruction. A gurgling sound is audible to\\nthe left of the spine as the fluid passes the obstruction.\\nPalpation. The oesophagus behind the trachea in the neck may be\\npalpated when it is enlarged, as in abscess. Palpation yields the\\nmost positive results.\\nIt must not be forgotten that the normal constriction of the oesoph-\\nagus is situated nearly opposite the fourth dorsal vertebra, ten inches\\nfrom the teeth. The bougie is used to determine the cause of diffi-\\nculty in swallowing. If the cause is due to paralysis or to spasm of\\nthe oesophagus the bougie can usually be passed with ease. If, on\\nthe other hand, it is due to organic disease, an obstruction will be", "height": "4408", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0793.jp2"}, "794": {"fulltext": "720 SPECIAL DIAGNOSIS.\\nfound. In organic disease this is generally in the upper half of the\\noesophagus. If near the pharynx, the obstruction is due to cicatricial\\nstricture. If the obstruction is encountered nine inches from the teeth\\nor about the position of the bronchus, it is usually due to cancer.\\nThe bougie should not under any circumstances be passed if there are\\ngrounds for believing there is an aneurism. Fatal rupture has fol-\\nlowed its passage under such circumstances.\\nMethod. The patient should be seated with the head thrown back\\nsufficiently far to make the passage from the pharynx to the oesopha-\\ngus almost continuous. The operator may stand behind or in front of\\nthe patient. The bougie, held like a pen, should be passed through\\nthe pharynx, guided by the fingers, close to its posterior wall. But\\nlittle force should be used. It should be passed slowly, when the\\ngagging will soon be overcome. The bougie should be warmed and\\noiled before it is introduced. The handles should be flexible, the bulb\\nolive-shaped.\\nObstruction of the (Esophagus. Dysphagia is a symptom com-\\nmon to all diseases of the oesophagus. It may vary from simple pain-\\ndysphagia to complete obstruction of the tube. Dysphagia from ob-\\nstruction of the oesophagus is due (1) to disease outside of the canal\\n(external pressure), (2) to disease of the canal itself, and (3) to the pres-\\nence of a foreign body in the canal. In the consideration of this symp-\\ntom, therefore, these conditions must be studied.\\n1. External Pressure. The oesophagus at different parts of its\\ncourse is in intimate relationship with the trachea, the thyroid gland,\\nthe carotid artery, the left bronchus, the bronchial glands, the arch of\\nthe aorta, and the descending aorta. Disease of these structures at-\\ntended by enlargement may, therefore, cause difficulty in swallowing.\\nIt is not likely that difficulty of deglutition from disease of the trachea,\\nthyroid gland, or carotid arteries will be overlooked. If the trachea\\nis affected, dyspnoea will be a prominent symptom if the thyroid\\ngland, dyspnoea will be associated with dysphagia, and the enlarged\\ngland will be visible from the outside. Disease of the vertebrae is\\nnot likely to cause obstruction of the oesophagus, for it would not press\\nthat organ against any other solid structure. Disease of other struc-\\ntures, however, may cause difficulty of deglutition by pressing the\\noesophagus against the vertebrae. Within the thorax, disease of the\\nmediastinal glands, aneurism of the arch, or descending portion of the\\naorta, an enlarged left auricle, a pericardial effusion or disease of the\\nleft bronchus might cause constriction of the oesophagus. The medi-\\nastinal glands are enlarged from tuberculosis, carcinoma, sarcoma, or\\nsyphilitic disease. The occurrence of physical signs of a mediastinal\\ntumor, with a history of syphilis or the general symptoms of tuber-\\nculosis, sarcoma, or carcinoma, would point to the presence of these\\naffections. In aneurism of the aorta, in its arch or transverse portion,\\nthe physical signs and subjective symptoms of aneurism with accent-\\nuation of the aortic second sound and the presence of atheroma\\nwould lend color to the view that the obstruction was of this nature. In\\nboth instances just mentioned the obstruction rarely goes to the extent\\nof preventing the passage of liquids. In enlargement of the left auri-", "height": "4416", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0794.jp2"}, "795": {"fulltext": "DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 721\\ncle and in pericardial effusion the degree of difficulty may amount\\nsimply to a temporary sense of obstruction or pain about the point\\nwhere food passes these structures. If the early physical signs are\\nassociated with an enlarged auricle, with mitral stenosis, or with peri-\\ncardial effusion, the diagnosis of the causal condition is easy. It is\\nparticularly important, in considering difficulty of deglutition from\\nexternal pressure, to remember that the oesophagus is in close relation\\nwith the bronchus on the left side, at about the fourth dorsal vertebra\\n\u00e2\u0080\u0094ten inches from the teeth in case it is desirable to investigate the\\nobstruction with a probe. Obstruction from aneurism of the descend-\\ning portion of the arch of the aorta is also located at the upper portion\\nof the oesophagus, nine inches from the incisor teeth.\\n2. Organic Disease. Difficulty of deglutition, due to disease of\\nthe oesophagus itself, occurs in acute inflammation, in chronic inflam-\\nmation, and in stricture, which is always the result of traumatic in-\\nflammation, syphilis, or cancer.\\nAcute inflammation is recognized by severe pain on swalloAving. It\\nis associated with the sensation of a foreign body in the lower portion\\nof the throat. There may be tenderness on pressure along the course\\nof the pharynx. The pain is aggravated by speaking. The pain may\\nextend along the vertebral column to the cardiac end of the stomach,\\nand is usually of a burning or raw character. When the inflammation\\nis due to traumatism, as the swallowing of acids or other caustics, the\\nmouth and pharynx show the effects of the inflammation, and, in addi-\\ntion, there is agonizing, burning pain at the root of the neck and be-\\ntween the shoulders. The inflammation is usually attended by erosion\\nof the mucous membrane, and hence not only frothy mucus of a glairy\\ncharacter is expectorated, but also blood and shreds of membrane.\\nThe effect of the corrosive poisoning on the general system is marked.\\nThere is great prostration. Because of the accompanying gastritis\\nthere is intense thirst. Acute inflammation of the oesophagus may\\nend in ulceration or in resolution. The traumatic inflammation is\\nfollowed by chronic inflammation, which ultimately results in stricture.\\nChronic inflammation is attended by pain in the act of swallowing\\nliquids are swallowed readily, but solids with great difficulty. Viscid\\nmucus is expectorated, usually in large amounts.\\nAbscess of the (Esophagus. The acute inflammation may terminate\\nin abscess. The abscess usually develops slowly, with pain on swal-\\nlowing and on movements of the neck. When the abscess is high\\nup in the gullet it may present on the exterior of the neck. If it is\\nsituated outside of the oesophagus, and is secondary to disease of the\\nvertebrae, it. is slow and chronic in its course fever and rigors attend\\nits development.\\nStricture of the oesophagus due to the healing of ulcers, following\\ntraumatic inflammation, is recognized, first, by the gradual development\\nof the symptoms, by the painless nature of the obstruction in the large\\nmajority of cases, and by its seat. It is readily found by the use of a\\nbougie the patient can sometimes localize the area in the upper por-\\ntion of the oesophagus. The difficulty of deglutition continues over\\nsuch a long period of time that the nutrition is but slowly interfered\\n46", "height": "4416", "width": "2648", "jp2-path": "practicaltreatis00muss_0_0795.jp2"}, "796": {"fulltext": "722 SPECIAL DIAGNOSIS.\\nwith, but gradual emaciation with coincident anaemia develops eventu-\\nally.\\nCarcinoma of the (Esophagus. In cancer of the oesophagus dys-\\nphagia is the most prominent symptom. It comes on gradually. The\\npatient expectorates a considerable quantity of frothy mucus, often\\ncontaining blood, and revealing, on careful examination, cancerous\\ntissue at times. Pain is not generally very severe. Cough is usually\\npresent, due to pressure of the cancerous mass on the recurrent laryn-\\ngeal or pneumogastric nerve. Sometimes the cancer develops in the\\nanterior wall, and ulcerates into the trachea or bronchus. When this\\ncomplication takes place the cough is violent. Dyspnoea from pressure\\nis likely to occur. Perforation of the oesophagus into the air-passages\\nis followed by pulmonary abscess or gangrene, or the sudden appear-\\nance of dyspnoea, and shortly the onset of aspiration pneumonia.\\nWhen ulceration causes a pulmonary oesophageal fistula the condition\\nmay simulate that of phthisis.\\nThe difficulty of deglutition due to cancer must be distinguished\\nfrom that of traumatic or syphilitic stricture and from spasmodic stric-\\nture and paralysis of the oesophagus. The history of the case aids in\\nthe recognition of traumatic or syphilitic stricture, Avhile the ready\\npassage of a bougie indicates that the difficulty is spasm or paralysis.\\nCancer usually occurs late in life and is attended with rapid emacia-\\ntion. Its complications, more common than in other obstructions, are\\nattended with fever and rapid prostration. Cancer may be distin-\\nguished from disease outside of the oesophagus by the condition of the\\nstomach beyond the point of stricture. If there is cancer, atrophy is\\nmore likely to take place, the change in size being recognized by a\\ntube or by inflating the stomach with air or fluids.\\nSarcoma of the oesophagus is very rare. It occurs most frequently\\nin males and presents symptoms like those of carcinoma.\\n3. Foreign Body. Stricture or difficulty of deglutition from the\\npresence of foreign bodies is usually recognized with ease. The diffi-\\nculty of deglutition is due both to the foreign body and to the spasm\\nexcited by the mass. In consequence of the latter regurgitation of\\nfood takes place. In the first place, there is a history of the swal-\\nlowing of a foreign material. Sudden pain succeeds the act, while\\nthere are great anxiety and distress, particularly if the body is a large,\\nhard mass. Not only is there difficulty in deglutition, but also dysp-\\nnoea. The latter is due to pressure, but is aggravated by the nervous\\nstate. When the foreign body is small the dysphagia is moderate in\\ndegree and the reflex irritation slight, although nausea and vomiting\\nmay be common. If it cannot be removed, ulceration and abscess\\nresult, the further course of which depends upon the seat of the ob-\\nstructing material. Pain, hemorrhage, subcutaneous emphysema, and\\nthe emission of air are symptoms which follow. The exact location\\nof the foreign body may be ascertained by the use of the Rontgen rays,\\nas in the remarkable case of White s.\\nHarrison Allen 1 in his exhaustive essay, calls attention to several\\n1 Foreign Bodies in the (Esophagus. Allen New York Medical Journal, August\\n17, 1895.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0796.jp2"}, "797": {"fulltext": "DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 723\\nfeatures. Many of the symptoms are primary and some are secondary.\\nThe former are due to the trauma and the presence of the foreign body\\nthe latter to the secondary ulceration. This softening and ulceration\\nof the walls may take place rapidly. Allen does not think that pain\\nor the occurrence of convulsions is of much significance, but that em-\\nphysema, the excessive secretion of mucus, and the emission of air are\\nimportant signs. Anxiety he considers of very common occurrence\\nand very suggestive. The excessive secretion of ropy mucus, saliva-\\ntion included, is, in Allen s judgment, pathognomonic of disease in\\nthe pharyngo-larynx or in the oesophagus, at or above the level of the\\nleft bronchus. This secretion may be an early indication of cancer of\\nthe oesophagus. It may occur in aneurism.\\nDilatation of the (Esophagus. Primary dilatation of the oesopha-\\ngus is an extremely rare affection. The chief symptom is the regurgi-\\ntation of food, which is neutral or alkaline, and may be returned some\\ntime after the act of swallowing. The patient sometimes complains of\\na sensation of distention along the course of the oesophagus, with heat\\nand burning. The odor of the breath is foetid. If the oesophagus is\\nnot deflected, a bougie can be passed through its course.\\nIf the dilatation is secondary, the amount of dysphagia depends\\nupon the obstruction. Food, however, is not returned immediately.\\nAfter remaining an indefinite time, not longer than two hours, it is\\nregurgitated unchanged. Bougies, of course, do not pass. In saccu-\\nlated dilatation, which usually takes place in the posterior wall near\\nthe pharynx, a bougie may sometimes pass, and at other times may be\\ncaught in the sac. The sac may be enlarged, so as to retain a consid-\\nerable amount of food, which is regurgitated some time after it is swal-\\nlowed. A sacculated diverticulum, from traction on the outside of\\nthe oesophagus, may occur when there is glandular disease of the neck,\\nwith adhesions to the oesophagus.\\nFunctional Affections of the (Esophagus. The functional affec-\\ntions are quite as common as organic disease. They are of longer\\nduration, but are unattended by the same grave effects upon the gen-\\neral system. Spasm is one of the most frequent affections. It may\\nbe so intense as to lead to temporary stricture. It usually occurs in\\nwomen. The attack comes on suddenly during the act of swallowing\\nfood. The food is at once regurgitated. After the subsidence of the\\nperturbation, swallowing can be accomplished, if it is done slowly.\\nIt usually occurs in hysteria. The patient may have had some slight\\naccident in the performance of the ordinary act of deglutition, out of\\nwhich grew the idea that swallowing cannot be accomplished. In\\nconsequence, the further acts are performed with trepidation, and slight\\nemotional disturbance at the table may cause a recurrence of the sud-\\nden spasm.\\nUnfortunately calling attention to the act of swallowing always has\\nthe effect of embarrassing the patient, and the taking of a meal under\\nunusual circumstances is sure to be attended by complete dysphagia.\\nSometimes the idea is conceived that certain forms of food alone can-\\nnot be swallowed. It is usually thought that solid food gives the\\ndistress. Mitchell says that the dysphagia occurs early in cases of", "height": "4416", "width": "2640", "jp2-path": "practicaltreatis00muss_0_0797.jp2"}, "798": {"fulltext": "724 SPECIAL DIAGNOSIS.\\nhysteria unless relieved, the hysterical symptoms are likely to be\\ntransferred to the stomach. I saw a female patient who, after an\\nordinary choking attack, for several years could not swallow food in\\nthe presence of strangers, or after the slightest emotional disturbance,\\nor if hurried. The spasm disappeared after treatment with bougies.\\nIn paralysis difficulty of deglutition is the main symptom. The\\ncourse of oesophageal paralysis depends upon its cause. The larynx is\\nusually affected at the same time, so that laryngeal symptoms are\\npresent. Paralysis generally comes on very gradually. It may be\\ndue to cerebral hemorrhage, tumor, bulbar paralysis, or to general\\nparalysis of the insane. The bougie passes easily, and does not cause\\nirritation. In paralysis there is no regurgitation of food.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0798.jp2"}, "799": {"fulltext": "", "height": "4380", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0799.jp2"}, "800": {"fulltext": "PLATE XXXV.\\nQuadrants of the Abdomen. Position of the Viscera.\\nLiver and colon\u00e2\u0080\u0094 red lines. Stomach, kidneys and bladder solid green lines.\\nPancreas\u00e2\u0080\u0094 dotted green lines.", "height": "4416", "width": "2720", "jp2-path": "practicaltreatis00muss_0_0800.jp2"}, "801": {"fulltext": "CHAPTER V.\\nDISEASES OF THE STOMACH, INTESTINES, AND PERITONEUM.\\nThe abdomen is divided arbitrarily into regions, to enable us to\\nlocate the various organs in health and in disease. Simplicity is essen-\\ntial, and a method of delimitation that is commonly used in the subdi-\\nvision of other regions should be adopted, for the sake of uniformity of\\ndescription and to assist the memory of the learner. For these reasons\\nBallance s method of dividing the surface is the best. This author\\nincludes the abdomen within a circle which has the umbilicus as its\\ncentre. The circle is divided into quadrants by diameters drawn at\\nright angles, corresponding to the median and transverse umbilical\\nlines. The portions to the right of the middle lines are the right\\nupper and lower quadrants, respectively the portion to the left, the\\nleft upper and lower quadrants. (See Plate XXXV.)\\nWith the abdomen thus divided, the umbilicus and fixed bony struc-\\ntures in the periphery of the circle serve as points from which meas-\\nurements are made to indicate the exact position of the structure. The\\ncircle may be further divided by other radii. To locate a tumor in\\nthe right lower quadrant, for instance, the umbilicus, pubic bone, and\\nanterior spine of the ilium may be used as points from which to meas-\\nure the distance. Measurements may also be made along the radii\\nextending from the umbilicus to fixed points. The following illus-\\ntrates a useful method A tumor is situated in the right lower quad-\\nrant the centre of the tumor is two inches below a point on the transverse\\numbilical line, three inches from the centre it is also three inches\\nto the right of a point on the median line, two inches from the umbili-\\ncus. The size of the tumor can be defined by measurements from its\\nown centre. Organs bisected by the median line, as the bladder and\\nuterus, can be described as situated in the median line, so many inches\\nto the right and left, as the case may be, and so many inches from the\\npubis.\\nThe right upper quadrant includes the right lobe of the liver, the\\ngall-bladder, the hepatic flexure of the colon, and part of the trans-\\nverse colon, a portion of the pancreas, the pyloric orifice near the me-\\ndian line, and, deeper, the upper half of the kidney the left upper\\nquadrant, the left lobe of the liver, the stomach, part of the transverse\\ncolon and the splenic flexure, the pancreas, the upper portion of the\\nkidney and the spleen the right lower quadrant, the caecum, the ascend-\\ning colon, appendix vermiformis, right tube and ovary, a portion of\\nthe bladder and uterus, and, above, the lower part of the kidney at the\\nend of full inspiration the left lower quadrant, the corresponding tube,\\novary, and portions of the bladder and uterus, the descending colon,\\nand the sigmoid flexure, but not likely the lower part of the kidney,\\nas it is one-half inch or more higher than the right (Holden). About", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0801.jp2"}, "802": {"fulltext": "726 SPECIAL DIAGNOSIS.\\nthe centre and extending to the periphery on all sides are the small and\\nlarge intestines.\\nThe Data Obtained by Inquiry. The Subjective Symptoms\\nof Abdominal Disease.\\nThis class of symptoms will be discussed in the articles devoted to\\naffections of the particular organs of the abdomen, because the symp-\\ntoms are usually directly referred by the patient to the affected organs.\\nThey are local sensations of heat, fulness, or distention, of burning,\\nof pain, of weight, or of undue motion. Local sensations of weight,\\nfulness, or distention are due to enlargements or to displacements of\\norgans (liver, kidneys), or to tumors. Heat or burning is described\\nin inflammatory tumors, as pyosalpinx. It is often difficult for the\\nsufferer to define the location of pain in the abdomen and describe its\\nfeatures. Moreover, the pain is frequently due to disease of the walls\\nof the abdomen, which may increase the confusion. Pain must be in-\\nvestigated by an examination of each structure in close proximity to\\nthe part complained of. The state of the function of each organ must\\nalso be inquired into.\\nPain Confined to the Abdominal Walls. The skin, the\\nnerves, the muscles and fascia, the connective tissue, may be the seat\\nof pain. If the skin is affected, the pain is usually localized and of\\nmoderate degree of severity. There is superficial tenderness. There\\nare evidences of inflammation, as erythema or ulcers. Pain due to\\naffections of the nerves is seen in simple neuralgia and herpes zoster.\\nHerpes zoster is recognized by the localized neuralgic character of the\\npain in the distribution of superficial nerves and the peculiar eruption\\nwhich follows. Neuralgias are recognized by the well-known points\\nof tenderness, the intermittent character of the pain, and the association\\nwith anaemia neuritis may be present, with the usual objective signs.\\nRheumatism. The muscles and fascia may be the seat of rheuma-\\ntism, causing severe pain. The muscles are tender. Movement always\\nincreases the pain, and sighing, laughing, or coughing aggravates it.\\nThe pain may be diffuse and severe, causing it to be confounded with\\nperitonitis. The presence of rheumatism in other muscles, of moderate\\nfever without gastro-intestinal disturbance, of uric acid and urates in\\nexcess, due to the rheumatic diathesis, point to the true condition.\\nReferred Pain. A common cause of pain in the abdomen is dis-\\nease of the vertebrae, with pressure upon the peripheral nerves at their\\nemergence from the spinal column. The pain is situated in the median\\nline, either below the ensiform cartilage or around the navel it is an\\nintermittent pain. Aneurism of the abdominal aorta, with pressure\\nupon and erosion of the vertebrae, causes the same kind of pain.\\nPain within the Abdomen. The seat of the pain, if general or\\nlocal, will be considered in discussing the special organs and their\\ndiseases. In general, it may be said that the seat of the pain is a fair\\nindex of disease of some structure in the part indicated. When the\\npain is general it points to rheumatism or to peritonitis.\\nCharacter of Pain. Attacks of severe pain in the abdomen may be\\nsudden in onset, or the culmination of slight sensations of discomfort", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0802.jp2"}, "803": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 727\\nprogressively increasing in severity. The pain may be of brief dura-\\ntion or may continue over a long period of time. Sadden acute pain\\npoints to inflammation, to perforation of some one of the hollow viscera,\\nto gastralgia, to enteralgia, flatulent distention of the stomach or of\\nthe intestines, or to occlusion of channels, of which the abdomen\\ncontains so many. Attacks of sudden pain are spoken of as colic;\\nthe onset is sudden the pain is paroxysmal each spasm of pain may\\nbe attended by vomiting, rapid pulse, cold extremities, cold sweat, and\\nmore or less collapse, except in lead-colic. Such pain is seen in intes-\\ntinal colic, hepatic colic, renal colic, and in uterine and vesical colic.\\nSudden acute pain occurs in perforation of some one of the hollow\\nviscera, indicated by the history and location of the disease of the part\\naffected and the character of the symptoms attending the pain. Thus,\\nin a case of gastric ulcer, sudden pain indicates possible perforation,\\nwhich may take place in the course of the disease. Chronic pain points\\nto ulcer, to chronic processes, or to gastric or intestinal neurosis.\\nThe Data Obtained by Observation.\\nThe Objective Symptoms. It must be remembered that objective\\nsymptoms of abdominal change are not alone due to disease of the ab-\\ndominal contents, but also to disease elsewhere. Thus the abdomen\\nmay be enlarged from the ascites of cardiac or renal disease, contracted\\nin tuberculous meningitis.\\nDisease or paralysis of the diaphragm alters the appearance of the\\nupper half of the abdomen and its movements in respiration. Fluctu-\\nating changes in size occur in hysteria and gastric neurasthenia, and\\npermanent change in tuberculous meningitis.\\nInspection. We note the appearance of the abdominal walls, the\\nmovements of the abdomen, its general shape and size,local enlargements.\\nThe Abdominal Walls. A glance suffices to tell of the thick-\\nness of the abdominal walls. Thin walls are due to absence of adipose\\ntissue and of muscular structure associated with general atrophy (see\\nEmaciation), on the one hand, or sometimes in consequence of intra-\\nabdominal pressure. Frequent pregnancies, previous ascites or ante-\\ncedent growths (ovarian tumor) lead to atrophy of the muscles the\\nrecti separate and hernia-like protrusion of abdominal contents results.\\nFurthermore, a conical projection of the lower median portion of the\\nabdomen is brought about, especially if ascites is present. Such pro-\\njections are often confusing when tapping is to be resorted to. Thick\\nwalls are due to oedema or to increase in fat.\\nThe Color. The abdomen, in general, partakes of the hue of the\\nskin. It is darker around the umbilicus. In Addison s disease a dis-\\ntinct areola often forms. The median line, from the umbilicus to the\\npubis, darkens in pregnancy the brown line. It is sometimes\\nseen in men. The skin of the abdomen is the seat of specific erup-\\ntions, as in typhoid fever, and of sudamina. The walls may be pale\\nand glistening in oedema.\\nMarkings. In first pregnancies and great ascites, less frequently in\\nobesity and tumors, strice are produced in the parts of the skin where", "height": "4416", "width": "2648", "jp2-path": "practicaltreatis00muss_0_0803.jp2"}, "804": {"fulltext": "728 SPECIAL DIAGNOSIS.\\nthe tension has been greatest. In pregnancy they form sinuous lines\\nupon the lower lateral portions of the abdominal wall and upon the\\nupper inner portions of the thighs. When first developed they are red-\\ndish, but subsequently become, by a process of fading, more glistening\\nand white than the rest of the skin. They are also known as water\\nlines, and linece albicantes. Rarely they are seen after typhoid fever.\\nThe umbilicus may project from hernia or may be prominent in\\nascites. The veins about the umbilicus are often enlarged in cirrhosis\\neven to such an extent as to produce a large soft tumor, the caput\\nMedusce. Not infrequently the walls around the umbilicus are infil-\\ntrated with carcinoma, occurring secondarily to gastric carcinoma.\\nIn tuberculous peritonitis, as pointed out by Henry, this infiltration,\\nmore inflammatory, however, is seen. Removal of such nodules for\\nmicroscopical study often establishes a correct diagnosis of the internal\\ndisease.\\nGlands. Sometimes isolated lymphatic glands are seen in the ab-\\ndominal wall. They may be utilized by a microscopical examination\\nto confirm any suspicion of malignant disease.\\nThe Veins. Enlargement of the superficial veins is a common\\naccompaniment of cirrhosis of the liver, adhesive pyelophlebitis, and\\nof any cause which obstructs the free circulation in the inferior vena\\ncava. In order to complete the collateral circulation they may anasto-\\nmose with the mammary veins above or the epigastric veins below.\\nThe caput Medusce has already been described.\\nThe Movements. (See the Lungs Dyspnoea.) The movements of\\nthe abdomen are of respiratory, vascular, gastric, and intestinal origin.\\nMuch is learned by carefully observing them.\\nRespiratory Movements. The upper half of the abdomen swells or\\nrises synchronously with inspiration. In enlargement of the abdomen\\nand in tumors within the upper half the movement is restricted. In\\nparalysis of the diaphragm it falls in with inspiration, reversing the\\nnormal movement. If such paralysis is limited to one side, as in large\\npleural effusions, the inspiratory collapse is unilateral. In laryngeal\\nand tracheal obstruction, inspiratory retraction is noteworthy and its\\nextent significant of the amount of obstruction. Respiratory move-\\nment causes the liver to rise and fall. In persons with thin walls, its\\nshadow can be seen to descend with inspiration, the extent indicating\\nthe degree of respiratory expansion, the size and position of the liver.\\nSuch information is of great value. A tumor connected with the liver\\nand an enlarged gall-bladder will move synchronously with respira-\\ntion. Other growths are fixed, unless adherent to the liver. Rarely\\nan exception is seen in movable right kidney.\\nVascular Movements. They are noted in the median line and usually\\nin the upper half of the abdomen. In moderately thin subjects the\\naorta may be the cau^e of such pulsation. (See Epigastric Pulsation.)\\nIf the pulsation is wide and extends to the right or left of the median\\nline, an aneurism may be suspected, or the impulse may be trans-\\nmitted to a growth overlying the aorta, as a carcinoma of the stomach.\\nAneurism of the coeliac axis will give rise to a movement near the\\numbilicus and to the right or left of the median line. Pulsation of the", "height": "4412", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0804.jp2"}, "805": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 729\\nliver, of vascular origin, and hence rhythmical with cardiac pulsation\\nis seen in the hepatic area in right-sided dilatation of the heart.\\nGastric and Intestinal 3fovements. Peristaltic movement, either of the\\nstomach, the large or the small intestine, may be seen through the\\nabdominal walls. In gastric dilatation and gastroptosis the waves may\\nbe seen in rhythmical succession, from left to right, in the centre of\\nthe abdomen. Their general course may be from the left upper to the\\nlower right quadrant. If of the large intestine, the waves are confined\\nto the course of this canal if in the small intestine, to the region around\\nthe umbilicus. It is due to obstruction of the pylorus, if gastric, or\\nof the lumen of the bowels if intestinal. The application of a cold\\nnapkin will excite the movements.\\nThe Shape. In general enlargement the shape is uniform. In\\nlarge accumulations of fat, in women with relaxed abdominal walls,\\nthe abdomen may be pendulous. In ascites the tissue over the umbil-\\nicus may protrude, changing the uniform appearance. Abdominal\\nenlargements due to ascites, in women whose abdominal walls have\\npreviously been relaxed, sometimes assume a peculiar cone-shape the\\nbase corresponding to the plane of the abdomen, the apex rising below\\nthe umbilicus. This is particularly the case if the patient has had to\\nassume the semi-erect position for some time. It is often difficult to\\ndecide where to tap in such cases. In local enlargements the surface\\nis often irregular, the prominences corresponding to the seat of the\\nenlargement. The shape changes in hysterical distention. In enlarge-\\nment due to wasting disease of the viscera, as cancer of the retroperi-\\ntoneal glands, the abdomen retracts in the later stage of the disease,\\ncausing undue prominence of the viscera affected.\\nGeneral Enlargement of the Abdomen. The abdomen\\ndiffers very much in size in different persons, depending not only upon\\nthe thickness of the fat in the abdominal walls and omentum, but\\nupon the calibre of the intestines themselves, which are apt to be much\\ndistended in those accustomed to eat large meals. In general, the\\nbelly is more protuberant in infants and children than in adults.\\nEnlargement occurs in obesity, and it is often difficult to tell whether\\nthe excessive deposit of fat in the abdominal walls and omentum\\naccounts for the whole enlargement or only serves to mask the presence\\nof a tumor. Enlargement of the belly is only a part, though fre-\\nquently the most pronounced evidence of obesity whereas, in enlarge-\\nments of the abdomen from tumors and ascites, there is usually a\\nmarked contrast between the size of the abdomen and that of the rest\\nof the body.\\nAscites.\\nIn enlargement from ascites, when the patient is lying upon his back,\\nthe front of the abdomen is flattened, while the flanks bulge. If he\\nturns upon his side, the flank which is uppermost becomes hollowed\\nout and the front of the belly is prominent. This is the appearance in\\nmoderately large effusions which have existed long enough to stretch\\nthe lateral abdominal muscles. When the effusion is enormous all\\nparts of the belly are distended, and the abdomen is barrel-shaped\\nno change of shape occurs upon change of posture.", "height": "4416", "width": "2648", "jp2-path": "practicaltreatis00muss_0_0805.jp2"}, "806": {"fulltext": "730 SPECIAL DIAGNOSIS.\\nAscites is the accumulation of fluid in the peritoneal cavity. The\\ncauses may be local or general. Its local origin may be, first, simple,\\ncancerous, or tuberculous inflammation of the peritoneum second,\\nportal obstruction from disease of the liver, as cirrhosis, or disease of the\\nportal veins, either from compression or inflammation. Tumors of the\\nabdomen are often attended by ascites, particularly solid tumors of the\\novary. The general causes of ascites are those which give rise to dropsy.\\nPhysical Signs. (Plate XXXVI.) Inspection. The abdomen is\\nuniformily enlarged. The surface is usually smooth. The skin is\\ntense if the effusion is large, and linece albicantes may be seen. The\\nnavel may project. If the ascites is due to liver disease or disease of\\nthe portal vein, the superficial veins enlarge, although the enlargement\\nis sometimes seen when any effusion continues a long period of time.\\nPalpation. On palpation fluctuation can usually be detected. Care\\nmust be taken not to confound the wave of the abdominal walls,\\nproduced by percussion, with the wave of true fluctuation the former\\nmust be cut off by the hand of an assistant placed vertically in the\\nmedian line. The left hand should be applied firmly against one side\\nof the abdomen, while with the right percussion or tapping is gently\\nperformed at the opposite point. The points selected should be at\\nabout the level of the fluid. At first the hand should be placed on the\\nflank, and if the fluctuation is not revealed, then with each successive\\npercussion it should be brought forward toward the median line.\\nSometimes light percussion will yield the sign, at others more firm per-\\ncussion must be employed. The faintest tap may be sufficient. In\\norder to ascertain the position of solid organs in ascites, dipping is em-\\nployed. This consists in suddenly pressing the tips of the fingers over\\nthe organ sought for. The fluid is thus displaced and the edge or\\nsurface of the organ readily felt.\\nWhen the abdomen is percussed in the usual manner there is dulness\\nover the fluid. As the fluid gravitates to dependent portions the dul-\\nness is found in these parts. Sometimes the colon gives rise to tym-\\npany in the flanks, as pointed out by Tyson. When the patient is\\nlying down, it is in the flanks, and may extend around the lower por-\\ntion of the abdomen. If the patient stands up, the dulness may reach\\nto the umbilicus in the median line and to the. same level in the mid-\\nclavicular line.\\nAspiration In ascites it is important to ascertain the nature of the\\nfluid. This can only be done by aspiration. If the fluid is serous, it\\nhas the characteristics belonging to that fluid. Hemorrhagic effusions\\nusually occur in cancer and tuberculosis, although both of these dis-\\neases may occur with clear serum. In ruptured tubal pregnancy the\\neffusion is hemorrhagic. In rare cases a chylous, milky fluid is found\\nin disease of the lymphatics. In one instance this occurred from per-\\nforation of the thoracic duct. Chylous ascites may, however, be due\\nto an excessive milk-diet. In other instances it is due to filaria. The\\npatient on a mik-diet is often lipaemic, in consequence of which effu-\\nsions are made turbid.\\nThe subjective symptoms are those due to the cause of the ascites and\\nto mechanical pressure.", "height": "4408", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0806.jp2"}, "807": {"fulltext": "PLATE XXXV J\\nAscites.\\nBlue shading shows level of dulness in recumbent posture. Dotted lines\\nindicate change of level of fluid in other postures.", "height": "4228", "width": "2644", "jp2-path": "practicaltreatis00muss_0_0807.jp2"}, "808": {"fulltext": "", "height": "4408", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0808.jp2"}, "809": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 731\\nAscites must be distinguished from enlargement of the abdomen due\\nto ovarian tumor, enlargement due to pregnancy, and enlargement due\\nto an overdistended bladder. In ovarian tumor the development at\\nFig. 188.\\nAscites. Upper limits of dulness indicated by the dotted line. Umbilicus prominent.\\nfirst takes place to the right or left of the median line. When large\\nthe signs may be in the central region of the abdomen. The flanks,\\nhowever, are always tympanitic on percussion. On vaginal ex-\\nFlG. 189.\\nAscites from sarcoma of ovary. Dislocation of liver and spleen, x is apex beat, not lifted\\nbecause of fallen abdominal organs.\\namination the local disease may be ascertained. A distended bladder\\nshould always be thought of, and catheterization performed in doubt-\\nful cases. Cysts of the pancreas may be mistaken for ascites, and", "height": "4416", "width": "2640", "jp2-path": "practicaltreatis00muss_0_0809.jp2"}, "810": {"fulltext": "732 SPECIAL DIAGNOSIS.\\nlarge hydatid cysts connected with the liver may simulate an accumu\\nlation of fluid in the peritoneal cavity. The history and the appear-\\nance of the fluid on aspiration point to the diagnosis.\\nEnlargement from accumulation of gas within the bowels is gen-\\neral, and may attain a very high degree, giving the abdomen a uni-\\nform arched appearance resembling a barrel. The diaphragm may be\\npressed upward so far as to interfere seriously with respiration and\\nheart-action. In debilitated children the enlargement due to flatulency\\nis associated with flaccid abdominal walls, causing lateral and central\\nenlargement. Moderate degrees of distention from gas in the intes-\\ntines may be the result of eating certain articles of food, such as tur-\\nnips or beans. Excessive accumulations are met with in typhoid\\nfever peritonitis, operative and non-operative and in stenosis of the\\ncolon or rectum from any cause. They are also common in hysteria.\\nIn the last month or two of pregnancy enlargement of the abdomen\\nis general, especially in a woman who has previously borne children.\\nGeneral enlargement of the abdomen may be due also to fecal accu-\\nmulation, cancer of the peritoneum, to hydatid cyst, and to cancer of the\\nbowel.\\nIt has been observed in children in dilatation of the colon. The dila-\\ntation may take place temporarily in constipation with obstruction. In\\nrare cases it may become permanent. In such the distention of the\\nabdomen is enormous. It often begins in childhood and continues\\nthrough adult life. Congenital obstruction, the eating of oatmeal and\\nsimilar food, with attendant constipation are causes. The bowels are\\nconstipated. The constipation may continue for several weeks, during\\nwhich period there is increasing dulness in the tract of the colon, with\\nFig. 190.\\nCase of dilatation of colon. (Griffith\\nfecal tumors distinguished by palpation. This condition is relieved\\nby diarrhoea, which may continue for two or three days, during which\\nenormous amounts of feces are passed. It may be preceded by vomit-\\ning of a fecal character. After the bowels are open the distention\\ncontinues, the dulness being replaced by tympany. The abdomen was", "height": "4412", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0810.jp2"}, "811": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 733\\nuniformly enlarged in Hughes 7 and Osier s cases. Coils of the intes-\\ntine, with waves of peristalsis, were seen through the thin abdominal\\nAvails. Formad s patient was an adult. It must be remembered, as\\ndescribed on page 729, intestinal peristalsis is observed in constriction\\nof the bowels. The motion of the intestine above the seat of stricture\\nis wave-like or worm-like, and the bowel itself dilated.\\nFrom a consideration of the recorded cases of so-called idiopathic\\ndilatation of the colon, Treves believes that, although enormous dilata-\\ntion of the large intestine may undoubtedly occur in adults indepen-\\ndently of mechanical obstruction, in children it is probably due to\\ncongenital defects in the terminal part of the bowel.\\nEnlargement of the abdomen simulating ascites may be due to retro-\\nperitoneal and peritoneal lipomata. Fluctuation even may be detected,\\nbut repeated puncture fails to secure fluid the negative aspiration\\nshould always suggest lipoma. This is all the more likely if the en-\\nlarged abdomen is due to a slowly growing tumor, which is probably\\nmore visible on one side than the other, but wdiich causes little if any\\ngeneral disturbance except progressive emaciation, dyspnoea, and some-\\ntimes oedema of the legs. The tumor is usually crossed by a portion\\nof the intestine.\\nOther causes of abdominal enlargement are diseases of the liver and\\ngall- bladder. When these are enlarged a local swelling may be de-\\ntected in the right upper quadrant but when they attain very large\\ndimensions, as happens not infrequently in cancer, amyloid disease,\\nand hydatid liver, inspection may be able to detect only general en-\\nlargement, with small prominences corresponding with cancerous nod-\\nules or small cysts.\\nSplenic enlargements, which attain the greatest size, are from leu-\\nkaemia or chronic malarial poisoning, and are usually visible only as\\ngeneral enlargements of the belly. There may, however, be greater\\nprominence over the lower left ribs and in the left upper quadrant\\nposteriorly.\\nIn diseases of the kidney producing great enlargement there is usu-\\nally visible a prominence in the lateral and lumbar region of the side\\ncorresponding with the kidney involved, unless there is considerable\\nemaciation anteriorly the enlargement, if any be visible, usually\\nappears to be general.\\nEnlargements of the abdomen which begin in the lower quadrants\\nare usually of pelvic origin. The most common are those due to preg-\\nnancy, retroperitoneal sarcoma, cysts of the ovary or parovarium, fibroids\\nand fibro-cysts of the uterus, and abscesses or effusions (chronic perito-\\nnitis). A greatly distended bladder may cause confusion it is a good\\nrule to be sure that the bladder is empty, by having a catheter passed\\nbefore proceeding further with the examination.\\nLocal Enlargement or Tumors of the Abdomen. In the\\nspace below the xiphoid cartilage and between the ribs (epigastrium)\\nlocal enlargements may be due to a distended or dilated stomach or to\\na tumor of the pylorus, which is almost always cancerous. Promi-\\nnence in this region is seen in large eaters. But enlargement in this\\nregion is sometimes due to cysts, sclerosis or cancer of the pancreas,", "height": "4416", "width": "2652", "jp2-path": "practicaltreatis00muss_0_0811.jp2"}, "812": {"fulltext": "734 SPECIAL DIAGNOSIS.\\nto aneurisms, to cancer of the large intestine or tumor of the left lobe\\nof the liver. It is in this region or to the left of the median line and\\nnearer the umbilicus that the effusions into the lesser peritoneal cavity\\nare found.\\nA rigid rectus muscle is capable of simulating a tumor. Likewise,\\nin hysterical subjects, rigid abdominal muscles, with tympanites, give\\nrise to a swelling known as phantom tumor. Such swellings are\\nless constant in shape and character than genuine tumors, and although\\ndull on percussion appear more superficial they sometimes disappear\\nunder friction with the hand, and certainly under full anaesthesia the\\nstigmata of hysteria are present.\\nEnlargements in the right upper quadrant (right hypochondrium)\\nare most frequently due to diseases of the liver (g. v.) and to affections\\nof the gall-bladder. Less frequently, a much enlarged kidney or a\\nhydronephrosis causes swelling in this region. The differential diag-\\nnosis is made by the history of the case and by noting the direction in\\nwhich the tumor has grown, by examination of the urine, and by the\\nrelation which the ascending colon bears to the tumor kidney tumors\\ncarry it in front of them as they grow hence, their dulness is obscured\\nby the superficial tympany of the colon.\\nPrimary malignant disease of the suprarenal bodies a rare affec-\\ntion is often attended by a tumor in the upper abdomen (Rolleston\\nand Marks, American Journal of the Medical Sciences, 1898.) The\\nclinical picture is not one of Addison s disease even when both the\\norgans are invaded. Some of the symptoms occur partially, as pig-\\nmentation, vomiting, asthenia, pain in the back. The growth extends\\nforward, and resembles in many respects renal tumor. It also, how-\\never, may resemble tumors of the liver, enlarged gall-bladder, or pan-\\ncreatic cyst.\\nEnlargement in the right lower quadrant (right iliac region) is most\\nfrequently due to affections of the caecum and appendix, to tumors of\\nthe ovary, and to pelvic abscesses.\\nThe diseases of the ccecum and appendix causing enlargement in the\\nright iliac fossa are fecal accumulation, typhlitis, fecal abscess, peri-\\ntyphlitic abscess, carcinoma, and stricture of the ileo-caecal valve.\\nThe diseases of the ovaries and tubes causing enlargement in this\\nregion are ovarian tumors, cysts of the broad ligament, pelvic abscess\\n(usually tubal in origin), and extra-uterine pregnancy.\\nOther affections which need to be considered are tubercular peri-\\ntonitis, acute and chronic, and enlarged or movable kidney.\\nEnlargement in the left upper quadrant (left hypochondriac region)\\nis due to dilatation or carcinoma of the stomach enlargement of the\\nspleen, movable kidney, or tumors of the kidneys, and effusion in the\\nlesser peritoneal cavity. Enlargement in the left lower quadrant (left\\niliac region) is due to tumors (cancerous) of the sigmoid flexure and to\\nthe tumor due to volvulus, and to the same causes of enlargement of\\nthe right side which are possible on the left.\\nEnlargement about the centre of the abdomen (umbilical region) may\\nbe due to umbilical hernia, to a floating kidney, spleen, or liver, or to\\ntubercular disease of the omentum or mesenteric glands. It is seen", "height": "4412", "width": "2648", "jp2-path": "practicaltreatis00muss_0_0812.jp2"}, "813": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 735\\nin retroperitoneal sarcoma. It is seen in cases of dilatation after a full\\nmeal. This region is frequently enlarged, in conjunction with a more\\nprominent swelling extending from the sternum, in cancer of the stom-\\nach and from the ribs on the right in cancer of the liver or gall-\\nbladder, or other diseases of these viscera from the ribs on the left, in\\neffusions into the lesser peritoneal cavity, disease of the pancreas or\\nthe spleen.\\nUndue projection of the vertebrce must not be mistaken for tumors.\\nEnlargement above the pubis (hypogastric region) is due most fre-\\nquently to enlargement of the uterus from pregnancy, fibroid tumors,\\nor fibro-cysts, or to distention of the bladder but it is also common\\nin gastric dilatation and gastroptosis flattening of the upper half is\\nthen seen, and the lesser curvature is then made out.\\nEnlargement in the lateral regions and behind {lumbar region) may\\noccur in malignant tumors of the kidney, in hydronephrosis and\\npyonephrosis, in perinephritic abscess, and in renal cysts of large size.\\nUsually renal enlargements of any kind are not observed behind,\\nhowever. It may also, in the left side, be due to perigastric sub-\\ndiaphragmatic abscess and to enlargement and displacement of the\\nspleen. On the right side the cause may be enlargement of the liver,\\nor a hydatid cyst, or a retroperitoneal sarcoma.\\nDiminution in Size. The abdomen is diminished in size in\\nwasting diseases, or such as result in insufficient food being taken.\\nThis class comprises cancer of the oesophagus and stomach, chronic\\nlead-poisoning, anorexia nervosa, and chronic diarrhoea and tubercu-\\nlosis of childhood. In the second stage of tubercular meningitis in\\nchildren there is retraction of the abdomen. The wasting of the sub-\\ncutaneous and the omental fat and atrophy of the abdominal organs\\ncause the abdomen to be concave or scaphoid.\\nPalpation and Percussion of the Abdomen. Palpation and per-\\ncussion in diseases of the abdomen may be discussed together.\\nPosition of Patient. Generally the best position is the recumbent\\none, because it admits of examination without too great exposure, and\\nbecause in that position the abdominal muscles are partly relaxed.\\nWhen the muscles need to be still further relaxed the patient should\\nlie upon the back, with the head and thorax partly elevated and the\\nknees drawn up. In certain obscure tumors much can be learned by\\nhaving the patient rest on the hands and knees, or assume a knee-\\nchest position. By this means we can determine if the pulsation is\\ndue to aneurism or to a tumor. The latter falls away from the vessels,\\nand hence pulsation is lessened thereby in the knee-chest position.\\nA tumor surrounded by coils of intestine may thus become more pal-\\npable. A good plan to secure relaxation for palpation of the liver\\nand spleen is to have the patient sit on a chair with the body leaning\\nforward then flex the thighs, supporting the feet on a stool or the\\nrung of another chair.\\nMethod. The examining hand should be warm, as the application\\nof a cold hand throws the abdominal muscles into involuntary contrac-\\ntion. By grasping the abdominal walls between the thumb and fingers\\ntheir thickness and the relative proportion of fat can be estimated.", "height": "4416", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0813.jp2"}, "814": {"fulltext": "736 SPECIAL DIAGNOSIS.\\nSo, too, the presence or absence of oedema of the skin can be readily\\ndetected. This oedema is general, but is especially marked in the\\nlateral and posterior portions of the abdomen. Relaxed abdominal\\nwalls occur after dropsy and pregnancy. Redundant skin remains\\nin folds when pinched up. This is particularly so in abdominal\\ncancer.\\nWhen it is desired to explore deeply the patient should be instructed\\nto breathe with the mouth open, and the examining hand pressed\\nfirmly in during respiration, and held there, if need be, during several\\nlong respirations. The palm of the hand should be laid upon the sur-\\nface after the muscles are relaxed the flexed fingers may be used to\\npalpate. The same procedure is adopted when we desire to get the\\npercussion-note of a body lying deep in the abdomen the finger is\\npressed firmly and deeply in, and then percussed. In this way any\\nsuperficial resonance due to overlying intestine is largely eliminated.\\nWhen palpating to determine the lower edge of the liver or spleen\\nthe palmar surface of the fingers is pressed into the abdomen at differ-\\nent levels from below upward until the edge is felt. The edge of\\nthe right lobe of the liver in its normal position extends to the margin\\nof the ribs. It may be detected by pressing the fingers in as de-\\nscribed and having the patient take a long breath.\\nBy palpation the information obtained by inspection is confirmed\\nthe character of the abdominal walls and of swellings is determined\\nthe precise location of pain is ascertained the condition at the hernial\\nrings and the movability of tumors are investigated. The condition\\nof the integument should first be determined. Passing the hand gently\\nover it is sufficient to decide whether it is normal, smooth and elastic,\\nor harsh and dry. Any marked unevenness, such as is produced by\\numbilical and inguinal hernia, by stria?, or by large tumors of the\\npylorus, or cancerous nodules, and hydatid cysts of the liver, can\\nreadily be detected. The degree of tension of the abdominal walls is\\neasily appreciated. It is increased, of course, in all forms of great en-\\nlargement, but not equally some persons are so sensitive to touch\\nthat any attempt at palpation throws the abdominal muscles into such\\nrigid contraction that examination is impossible. Rigidity of the\\nabdominal walls may be the only sign of acute peritonitis. It is com-\\nmon in local peritonitis. The recti muscles contract quickly on hurried\\npalpation. Local contractions point to inflammation underneath. In\\ntuberculous peritonitis we see distention with board-like rigidity or\\npreternatural hardness. The term carreau is used by the French for\\nthis condition. Peritoneal friction may be detected most frequently\\nover the liver and in chronic peritonitis.\\nPalpation and Percussion of the Lower Quadrants. On\\nthe right side, the groups of affections connected with the caecum and\\nappendix, the uterine appendages, and the peritoneum, which cause\\nenlargement in this region, have been mentioned already under local\\ninspection of the abdomen. Palpation and percussion, however, are\\nthe methods which afford the most exact information of their physical\\ncharacteristics, and, with the clinical history, enable us to distinguish\\none from the other.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0814.jp2"}, "815": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 737\\nDiseases of the Appendix and Cazcum. The information supplied by\\npalpation and percussion in perforation of the appendix will depend\\nupon the rapidity with which perforation has supervened and upon\\nthe stage at which the examination is made.\\nGenerally speaking, after the sudden onset of pain in the right iliac\\nfossa, in a person previously in good health, there is tenderness on\\npalpation in that region. This tenderness is first localized, but may\\nspread with great rapidity over the whole abdomen. Or the tender-\\nness may at first be general, and subsequently become localized over the\\nappendix. Subsequently, the tension in the part is increased, the over-\\nlying abdominal muscles are rigid (spasm) and firm, and the percussion-\\nresonance impaired. Examination with the finger in the rectum may\\ndiscover a tense, swollen appendix, or a tumor in the pelvis.\\nBat the disease may be fulminating in character, perforation being\\nfollowed by the rapid development of peritonitis, with collapse, so\\nthat when the patient is seen there will be no more tenderness over\\none part of the abdomen than over another.\\nAgain, the appendix may be subject to repeated attacks of inflam-\\nmation without perforation, but with the development of local peri-\\ntonitis. There is increased thickness in the region of the caecum,\\ntenderness, diminished resonance, and increased resistance to the\\npercussed finger. Sometimes an enlarged and hardened appendix can\\nbe made out by palpation, both during an attack and in the intervals.\\nIn still other cases, of slower development, a distinct perityphlitic\\nabscess develops. In addition to local pain and tenderness a swelling\\nappears above Poupart s ligament. The skin over it becomes brawny\\nand pits on pressure with the finger-tips. The tumor is dull on percus-\\nsion, and on palpation obscure deep-seated fluctuation may be secured.\\nA fluctuating tumor may also be made out by rectal examination with\\nthe finger.\\nIn fecal impaction of the ccecum a tumor forms, following the course\\nof the caecum, and directed upward from Poupart s ligament. It is\\nusually oblong and rounded, and may appear uneven or lumpy on\\ncloser palpation it is not tender unless the caecum itself becomes in-\\nflamed. It has a doughy consistency. Fecal tumors give rise to\\nsome distention of the abdomen. To distinguish these tumors from\\nsolid growths, Gersuny calls attention to the adhesive symptom.\\nIf strong pressure is slowly made with the finger tips on the tumor,\\nand then the pressure be withdrawn gradually and the hand removed\\nfrom the abdomen, a peculiar sensation due to the separation of the\\nintestinal mucous membrane from the fecal matter is transmitted to\\nthe hand. If the feces are dry and hard, the sensation may not be\\nobserved until an oil enema is used. When the feces are soft natur-\\nally or artificially, the tissues remain depressed and only gradually\\nseparate from the mass and return to their normal position. Slowness\\nof the separation of the abdominal walls from the tumor is also charac-\\nteristic of the fecal accumulation. The diagnosis is made by the situ-\\nation and character of the tumor, and the absence of pain, tenderness,\\nand constitutional symptoms, and by its disappearance under the influ-\\nence of purgatives.\\n47", "height": "4416", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0815.jp2"}, "816": {"fulltext": "738 SPECIAL DIAGNOSIS.\\nIf the impaction causes a localized colitis, or so-called typhlitis, the\\ntumor is tense, tender, and painful, dull on percussion, the dulness\\nbeing sharply limited by the boundaries of the caecum.\\nAppendicitis.\\nThis is by far the most important affection of the intestinal tract.\\nIt is of frequent occurrence compared with intestinal obstruction, and,\\nif recognized, is amenable to relief in a very large percentage of the\\ncases whereas intestinal obstruction is more frequently fatal. We\\nsee twenty-five cases, at least, of appendicitis in all its forms to one\\ncase of any form of obstruction. Its importance, therefore, is readily\\nrecognized. Appendicitis occurs most frequently in the young in\\nthe large proportion of cases under thirty. I have seen it as early as\\ntwo years of age, although from the fifteenth to the thirtieth year it\\nis more frequent than at any other period. The symptoms vary, but\\nclinically may be divided into those of appendicitis without perforation\\nand appendicitis with perforation. Appendicitis without perforation\\nis characterized by relapses, and is known also as recurring appendicitis.\\nAppendicitis without Perforation. Cases of catarrhal appen-\\ndicitis probably occur, although I am not prepared to say that\\ncatarrhal inflammation of the appendix gives rise to marked local\\nsymptoms, for in cases on the post-mortem table in which the lesions\\nof catarrh were found there had not been any symptoms during life,\\ndue either to intestinal catarrh or to any symptoms pointing to appen-\\ndicitis in any form. Moreover, many cases in which the attacks of\\nappendicitis had at first been slight, finally developed into appendicitis\\nwith perforation. In the milder cases, if operative measures are re-\\nsorted to during the intervals between the attacks, the appendix is\\nalways found to contain a fluid loaded with micro-organisms which\\nare capable of causing purulent inflammation, as the staphylococcus or,\\nstreptococcus. Clinically, therefore, all forms of appendicitis should\\nbe considered infectious, Avith, on the one hand, escape of the contents\\ninto the bowel, and natural relief of the symptoms or, on the other,\\ncomplete obstruction with perforation. After removal of the appendix\\nin cases of recurring appendicitis, I have always found pus or a muco-\\npurulent material which was charged with streptococci or staphylococci,\\nas well as the bacillus coli communis, natural to the intestinal canal\\nin this region.\\nSymptoms of the Attack. After exposure to cold rarely, fre-\\nquently after an indiscretion in diet, the patient is seized with pain,\\nreferred to the right lower quadrant of the abdomen. It is paroxysmal\\nin character, increasing in intensity, and may be complained of as\\ncolicky. The pain is usually such as to require the patient to take to\\nbed and attempt to secure relief by local applications. The severity\\nof the pain may be so slight that the patient pays but little attention\\nto it. He may even go about his business during the time and seek\\nprofessional advice at the office of a physician. Such cases as these\\nare attributed to ordinary cholera morbus or intestinal indigestion.\\nThe attack may be only moderately severe, particularly if there is", "height": "4416", "width": "2656", "jp2-path": "practicaltreatis00muss_0_0816.jp2"}, "817": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 739\\ndiarrhoea. With the onset of the pain vomiting usually occurs. The\\nbowels may be open or they may be confined. Vomiting may not\\noccur if there is diarrhoea. It is usually attended by some nausea,\\nalthough this is not marked. The vomiting is complete, there is no\\nretching. It occurs at intervals, between which there is comparative\\ncomfort. The contents of the stomach are ejected, and then mucus.\\nIf the patients are to get well, vomiting does not return unless ex-\\ncited by food. If peritonitis supervenes, vomiting returns in the course\\nof two or three days. If in bed, the patient lies on his back with\\nhis right leg flexed.\\nEven with a mild degree of pain the skin is hot and temperature\\nslightly raised. In the cases in which the pain is more severe the\\ngeneral reaction is greater. The temperature rises rapidly to 102\u00c2\u00b0 to\\n103\u00c2\u00b0. The skin is hot and dry, the face flushed. The pulse in a\\nyoung adult rises to 90 and 95. It is full and strong. On account\\nof the pain there is some restlessness. In some cases the patient com-\\nplains more of the fever than of the pain after its first severity has\\nsubsided. The tongue is coated appetite is lost.\\nOn physical examination the area Avhich was the seat of pain is\\nfound to be tender. When examined with the tip of the finger press-\\ning firmly, a point of more marked tenderness can usually be found\\non a line midway between the anterior superior spine of the ilium and\\nthe umbilicus. It is known as McBurney s point, and is most charac-\\nteristic. It indicates the site of the diseased appendix. The swollen\\ntender appendix may occasionally be palpable. On inspection the\\naffected area is slightly or may be considerably enlarged. Comparison\\nmust be made with the opposite side. It will be seen that the usual\\ndepression in front of the anterior spine, or the cavity toward the loin,\\nis not so deep as on the opposite side. In front the surface may be\\neven with the plane of the ilium. On palpation, in addition to ten-\\nderness and pain at the point previously indicated, fulness and en-\\nlargement can be distinguished. There is resistance to pressure and\\nmore or less rigidity of the abdominal muscles. On careful measure-\\nment the semi-circumference will be found in most instances to be\\nlarger than the semi-circumference of the opposite side. When\\nbimanual palpation is performed, the left hand being placed in the\\nloin behind and the right over the abdominal surface, resistance, in-\\nduration, and rigidity can more easily be detected. On percussion\\nthere is change in the note compared with that of the opposite side,\\nand change in the percussion-note during the course of the disease.\\nThis is particularly the case if the symptoms go on to perforation.\\nOn careful deep percussion a dull tympanitic tone is elicited, or a\\ndistinct area of dulness can be mapped out, but in some instances the\\ndistended caecum yields tympany, which is greater than on the opposite\\nside.\\nThe pain is usually referred to the region above mentioned. The\\npain may be in the lower quadrant on the left side instead of the right.\\nIt is seen in those cases in which the appendix normally dips into the\\npelvis. It may also be referred to the bladder or genitals, and be\\nattended with vesical tenesmus and frequent micturition. The char-", "height": "4416", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0817.jp2"}, "818": {"fulltext": "740 SPECIAL DIAGNOSIS.\\nacter of the pain and the bladder symptoms are such as to simulate an\\nattack of renal colic, with the passage of sand. On account of the\\nlocality of the pain it may be attributed to the Fallopian tube or ovary,\\nand thought to be due either to pain on account of disease of these\\norgans or to dysmenorrhea. It is not likely to be mistaken for the\\npain of dysmenorrhea if the patient is subject to pain at the usual\\nmonthly period. If, however, the physiological and the pathological\\naffection should take place at the same time, or the latter occur about\\nthe time of the monthly period, a mistake in diagnosis may occur,\\nparticularly as increased abdominal pain may cause a uterine discharge.\\nThe occurrence of fever would exclude dysmenorrhea in cases in\\nwhich this symptom was present. The pain and leg-flexion simulate\\nhip-joint disease.\\nAfter the first twenty-four hours, during which the above-mentioned\\nsymptoms described take place, the fever continues. There is anorexia,\\nbut vomiting occurs only at long intervals if at all. The local symp-\\ntoms continue, although modified usually by methods of treatment which\\nare applied. Both general and local symptoms frequently subside after\\na free movement of the bowels, which occasionally takes place sponta-\\nneously. In other cases constipation continues a week or ten days,\\nand even over a longer period.\\nAfter five or six days at the farthest the fever subsides, the local\\ndistention lessens, the paroxysms of pain disappear, and convalescence\\nensues. There may, however, be localized tenderness for a consider-\\nable period of time, and diarrhea, or at least two or three evacuations\\neach day, for a week or more. In rare instances peritonitis supervenes\\nwithout the occurrence of perforation. Its onset under these circum-\\nstances is gradual, bat the symptoms are like those of peritonitis\\nunder other circumstances. Infection takes place directly through the\\nappendix.\\nWhen the fever continues, with mild diarrhea, intestinal pain, and\\nflatulency, the case may be mistaken for typhoid fever. The tempera-\\nture is, however, more remittent in character in appendicitis, and the\\ndiarrhea is not characteristic of typhoid fever. The eruption of\\ntyphoid fever does not occur, the spleen is not enlarged, and the symp-\\ntoms of the typhoid state do not ensue. The diazo-reaction, the\\nbacteriological examination of the stools, and the serum test, may aid\\nin forming a conclusion.\\nRecurrent Appendicitis. Frequent attacks of mild appendicitis\\noccur they may occur as frequently as every three months, or the\\ninterval may be as long as a year. The attacks are similar to the\\nattacks just described, although the duration is shorter. The local\\nsymptoms in some instances are more marked, because there has been\\na localized peritonitis previously. The induration is greater, and dul-\\nness more marked. In some instances the attacks are comparatively\\nmild, continuing but twenty-four hours, and are described as attacks\\nof colic. Often they have been treated by the patient himself, by\\nhousehold remedies alone. The patient spends a night in agony, with\\ncramps, but the next day follows his usual habits. It is possible\\nthat there has been no fever with the attacks, but in all cases of", "height": "4416", "width": "2736", "jp2-path": "practicaltreatis00muss_0_0818.jp2"}, "819": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 741\\nrecurrent appendicitis which I have seen, fever, although often slight,\\nhas been a constant accompaniment.\\nAppendicitis with Perforation. Before perforation takes place\\nthe patient may have had symptoms of the mildest form of appendi-\\ncitis for two or three clays, or they may have extended over a long\\nperiod of time, without any symptoms except colicky pain. As obser-\\nvations are not made, the presence of fever cannot in such a case be\\nutilized as a diagnostic feature. The perforation may take place early\\nin the course of an acute attack, and result in localized peritonitis and\\nabscess, or in diffuse peritonitis. If the latter, after the characteristic\\nsymptoms of appendicitis the symptoms of intense peritonitis set in. The\\nabdomen rapidly becomes distended, the characteristic vomiting ensues,\\nand collapse develops. Perforation under these circumstances has\\noccurred within the first twenty-four or at most within forty-eight hours.\\nLocal inflammation about the appendix does not take place, and the local\\nsigns of an inflammatory tumor are not present, although tenderness\\nat the special point can be elicited.\\nAbscess. If the perforation is more gradual, and there has been time\\nfor the occurrence of local inflammation about the appendix, by which\\npus is prevented from infecting the general peritoneum, or if perforation\\ntakes place behind, in the connective tissue which surrounds the mass,\\nin which situation there is always inflammation, the local signs of ab-\\nscess or inflammatory tumor occur. There is swelling of the affected\\nside the normal outline is effaced. The area is indurated, and the\\nearly pronounced rigidity gradually gives way to a boggy sensation,\\nwith the appearance of cedema of the skin. This can be elicited by\\npressure over parts that are hard and resisting, as the spine of the\\nFig. 191.\\nAcute appendicitis, with perforation and abscess. Female, set 8. Operation on seventh day.\\nilium. Fluctuation can often be detected by bimanual palpation.\\nDulness is found, although in some instances it may be very slight,\\nthere being scarcely an appreciable change in pitch. Both light and\\ndeep percussion must be performed, and compared with the results of", "height": "4416", "width": "2612", "jp2-path": "practicaltreatis00muss_0_0819.jp2"}, "820": {"fulltext": "742 SPECIAL DIAGNOSIS.\\npercussion in the opposite region. Palpatory percussion may alone\\nindicate the departure from normal. Examination per rectum may\\nyield much information. An induration may be felt about the brim\\nof the pelvis or the rectal fossa, which fluctuates and may eventually\\nsoften. With the finger in the rectum, and pressure above, better\\nresults may be obtained. If the symptoms of peritonitis do not arise,\\nor rapid infection of the system take place, the signs of abscess become\\nmore and more marked. The surface becomes reddened, and point-\\ning may take place toward the groin or opposite the spine of the\\nilium. Sometimes the swelling increases in the direction of the loin,\\nand the abscess may point in that situation.\\nAs the abscess develops the general symptoms change. They now\\nbecome the symptoms of suppuration. The fever is remitting or inter-\\nmitting. There may be chills. Sweats are common, and there are\\nloss of appetite and diarrhoea. Until recently it was customary to see\\nabscess develop in some other situation, or symptoms occur from bur-\\nrowing of the pus in various directions. It may extend upward along\\nthe back of the colon, underneath the diaphragm, and thence to the\\npleura and lung, and be expectorated. The abscess may open into the\\nrectum or into the bladder. If the local inflammation is virulent,\\neven if peritonitis has not taken place, the symptoms of septicemia\\nmay rapidly ensue. This sometimes occurs quite early in the disease.\\nThere may be vomiting and septic diarrhoea, and slight delirium at\\nnight. An excessively rapid and feeble pulse is seen in one instance\\nit was irregular. Extreme prostration ensues, followed by symptoms\\nof the typhoid state.\\nGangrenous appendicitis is most treacherous. The early symptoms\\nare like an acute attack all symptoms then subside. Unless the\\ntemperature is taken or the physical examination is very painstaking,\\nthe patient is allowed to get up. The course may be afebrile. In a\\nfew days or a week an abscess forms about the slough, and then the\\nusual phenomena of suppuration set in or perforation may occur.\\nIt is clear that in cases of appendicitis we must attempt to recog-\\nnize (1) The inflammation before perforation has taken place (2) the\\noccurrence of perforation (3) the occurrence of peritonitis due to\\neither of the two conditions (4) the occurrence of abscess (paratyph-\\nlitis and perityphlitis) and (5) the occurrence of septicaemia.\\nTyphlitis is an inflammation of the caecum due to accumulation of\\nfecal or foreign substances. The inflammation may remain as a local-\\nized enteritis, or may be followed by ulceration. In the majority of\\ncases the ulceration is due to pressure by the contained foreign mate-\\nrial or feces. The inflammation occurs in early life usually. The\\npatients have been subject to constipation. The attack may follow\\nsome error in diet. There are pain in the right iliac fossa, constipa-\\ntion, and nausea. Moderate fever develops. On examination there\\nis fulness in the right iliac region, and the right thigh may be flexed,\\nthe caecal region is tender to pressure, and a doughy, sausage-shaped\\ntumor may be outlined. The more severe symptoms last two or three\\ndays. Local tenderness may continue a week or even longer. The\\ntumor gradually disappears. If ulceration takes place, inflammation", "height": "4412", "width": "2680", "jp2-path": "practicaltreatis00muss_0_0820.jp2"}, "821": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 743\\nabout the caecum ensues. An abscess forms gradually in the flank.\\nPerityphlitis is the term applied to this secondary abscess, although,\\nas the term has been confused with paratyphlitis, it had better not\\nbe used in this connection.\\nAbscess about the head of the caecum is due (1) to appendicitis, of\\nwhich sufficient mention has been made (2) to perforation of the\\ncaecum, on account of typhlitis (3) to perforation, on account of cancer\\nof the intestine (4) abscess secondary to kidney disease, perinephritic\\nabscess (5) to abscess secondary to disease of the vertebrae. The\\nphysical signs are those of abscess due to perforation of the appendix.\\nThe symptoms are the local symptoms of abscess and the general symp-\\ntoms of suppuration.\\nFecal abscess, arising from ulceration of the colon, may be sus-\\npected, according to Fenwick, when there is a localized abdominal\\nswelling, immovable in respiration or by a moderate amount of pressure\\nwith the fingers, the size and shape being altered when diarrhoea\\noccurs, and when percussion over the tumor gives a tympanitic or a\\nmore forcible stroke, a dull sound, or when an emphysematous sensa-\\ntion is communicated to the fingers.\\nPericecal abscess follows the stercoral typhlitis which occurs as the\\nresult of cancer in the course of the large intestine. The history of the\\ncase points to the true nature of the disease. Abscess may occur\\nbehind the caecum in cases of caries of the vertebrae and in some rare\\ninstances of empyema in which the pus has dissected downward.\\nAppendicitis must be distinguished from perinephritic abscess and\\nthe abscess which follows perforation of the intestine or caecum at this\\npoint. Perinephritis can scarcely be distinguished unless there has\\nbeen a previous history of renal calculus and pronounced evidence of\\ndisease of that organ preceding the formation of the abscess.\\nHip-joint disease must be distinguished from appendicitis. The leg\\nis flexed, the patient complains of pain about the region of the hip\\nunless careful observation has been made in the beginning of the\\nattack, the early march of appendicitis may not be recognized. The\\ntwo are confounded after abscess-formation. The flexed leg of appen-\\ndicitis can be extended under ether, and examination then shows the\\njoint to be free from disease.\\nFenwick says that acute tubercular peritonitis may be confounded\\nwith perforation of the appendix. In both there may be pain and\\ntenderness in the hypogastrium, dulness on percussion, and fever.\\nIn tubercular peritonitis the onset is more gradual, the pain and ten-\\nderness more general, and there is no distinct tumor or increased tension\\nin the hypogastrium. If there is dulness on percussion, the line gen-\\nerally varies with the position of the patient. Diarrhoea is urgent,\\nand there are, in most cases, some signs of consolidation of the lungs.\\nThe absence of tumor in the right iliac region and in front of the\\nrectum is the chief point of distinction for when perforation occurs\\nin phthisical subjects there is generally very slight pain, and severe\\ndiarrhoea is often the only prominent symptom. The appendicitis\\nitself may be of tuberculous origin, as in several cases reported by the\\nwriter.", "height": "4416", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0821.jp2"}, "822": {"fulltext": "744 SPECIAL DIAGNOSIS.\\nReturning to palpation and percussion of the lower quadrants, we\\nfind in intussusception a tumor, often detected in the right lower quad-\\nrant or to the right of the navel. It is generally distinct, of the shape\\nof the bowel, not very tender, and harder than the tumor of appendic-\\nular inflammation. The diagnosis from the latter is made by the\\ndifference in the character of the tumor, by the pain being colicky and\\nrecurring in paroxysms, by vomiting and constipation being more\\nmarked, and by the tenesmus and passage of blood and mucus from\\nthe bowel. The last-named symptom and the tumor, with a constant\\ndesire to defecate, are the most characteristic features of intussuscep-\\ntion. A tumor may be detected within the rectum by digital explora-\\ntion, if the intussusception is low down. There may be distinct\\nhemorrhage, or the passage of the invaginated portion of the bowel per\\nrectum. Intussusception is the most frequent cause of intestinal ob-\\nstruction in infants and young children. It occurs nearly twice as\\noften in males as in females. Stercoraceous vomiting is not so common\\nas in other forms of acute obstruction of the bowel.\\nIn pelvic abscess a swelling sometimes makes its appearance on the\\nright side, above Poupart s ligament. It is, perhaps, situated more\\ntoward the median line than perityphlitic abscess, and it is less defined\\nthan the tumor of typhlitis but the diagnosis from these affections\\nmust be made by the history, which is usually that of an antecedent\\nsalpingitis or of previous abortion or miscarriage. Vaginal examina-\\ntion discovers that palpation of the uterus causes pain that the\\nuterus is fixed, instead of being freely movable, and that the pelvis\\nis blocked up by an exudate on the affected side.\\nIn pelvic hcematocele a tumor may form in the lower half of one of\\nthe lower quadrants. It is distinguished from appendicitis, perityph-\\nlitic abscess, and pelvic abscess by the absence of fever and constitu-\\ntional signs of suppuration from perityphlitic and pelvic abscess by\\nits sudden onset, probably at a menstrual period by the less degree\\nof tenderness, and by the anaemia and collapse which follow its appear-\\nance. It is almost invariably the result of a ruptured extra-uterine\\npregnancy. Hence, it may be preceded by the passage of decidua and\\nthe objective signs of pregnancy. It is distinguished from pelvic\\nabscess by its occurrence in a woman without antecedent tubal or\\nuterine disease, and by the less degree of tenderness of the uterus and\\nrelative absence of fixation.\\nIn stricture of the ileo-ccecal valve due to cancer there is frequently a\\ntumor in the right lower quadrant, between the umbilicus and anterior\\nsuperior spinous process of the ilium, or between the latter and the\\nribs. The diagnosis is made by noting the fact that the tumor has\\ndeveloped gradually, that the patient has suffered with colicky pain,\\nvomiting, and constipation, possibly preceded by diarrhoea, and that\\nperistaltic movements of the intestines can readily be seen through the\\nabdominal walls. The abdomen at the site of the tumor is somewhat\\ndistended. The tumor itself is irregular and tender, and is dull on\\npercussion.\\nThe disease is very rare, and is said by Fenwick to be more common\\nin women from twenty to forty years of age.", "height": "4400", "width": "2720", "jp2-path": "practicaltreatis00muss_0_0822.jp2"}, "823": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM 745\\nIn tumors of the right ovary there is at first a gradual enlargement\\nin the right groin, unaccompanied by pain, fever, or impairment of\\nhealth until the tumor has attained considerable size. They are usually\\ncystic, and fluctuation can be obtained. The tumor is dull, and by\\nbimanual examination, with the fingers of one hand in the vagina, the\\ntumor can be traced into the broad ligament, and the displacement of\\nthe uterus which it occasions made out. The cystic ovarian tumors\\ngrow from the starting-point in the direction of an axis diagonally\\ntoward the median line. There is dulness in front of the abdomen\\nand a clear percussion-note or tympany in the flanks. (Fig. 192.)\\nFig. 192.\\nPosition of an ovarian tumor of the right side, in various stages of enlargement. The shading\\nindicates the percussion-dulness in ovarian dropsy of moderate extent the umbilical region is dull\\nfrom the presence of fluid, and the flanks remain clear. The outer circle shows a further extent\\nwhich the dulness may reach in ovarian dropsy. (Bright.)\\nPalpation and Percussion in the Left Lower Quadrant.\\nEnlargements in this region are due most frequently in women to\\novarian tumors, pelvic abscess, pelvic hematocele, and fibroids of the\\nuterus, the diagnostic points of which have been referred to already\\nunder palpation and percussion of the right iliac region. In addition\\nto the affections named, enlargements are occasionally met with from\\nfecal accumulations in the flexure of the colon, cancer of the descending\\ncolon, tubercular peritonitis, and enlargements or displacements of the\\nspleen and kidney (q. v.). Fecal abscess also may occur here, and the\\ntumor of intussusception may be detected on the left side.\\nPalpation and Percussion above the Pubis. Enlargements\\nin this region may be due to fibroid tumors of the womb. They occur\\nmost frequently in sterile women, and are accompanied usually by\\nhemorrhage. Bimanual examination of the uterus will reveal an un-\\nevenness of surface of the womb if the tumor is external, and passage of\\nthe sound will detect any growth projecting into the cavity of the womb.\\nThe enlargement may be due to a distended bladder. It is a good\\nrule always to be sure that this viscus is empty before beginning an\\nexamination.\\nIn acute tubercular peritonitis a swelling may develop in this region.\\nIt appears gradually, is diffused and free from tenderness, but is pre-", "height": "4416", "width": "2644", "jp2-path": "practicaltreatis00muss_0_0823.jp2"}, "824": {"fulltext": "746 SPECIAL DIAGNOSIS.\\nceded by pain and fever. There is no palpable tumor, but the percus-\\nsion-note is dull and the tension is increased. Moreover, the level of\\ndulness is apt to vary with change of posture. The general health is\\nmarkedly affected, loss of flesh is rapid, and diarrhoea and sweats are\\ncommon. A focus of disease may be discovered in the lungs.\\nPalpation and Percussion of the Eegion below the Ster-\\nnum. Enlargement in this region is most frequently due to affections\\nof the stomach (q. v.). It is not uncommon, however, to find here a\\ncancerous nodule projecting from the surface of the liver, or a hydatid\\ncyst of the same organ. The diagnosis must be made by determining,\\nwith the aid of palpation and percussion, whether the tumor is con-\\ntinuous with the liver, the effect of respiration upon it, and its apparent\\ndepth from the surface, tenderness, fluctuation, etc., and by a study of\\nthe subjective symptoms pointing to disease of the stomach or liver.\\n(See Diseases of the Liver.)\\nMuch more rarely enlargement here may be from tumor of the pan-\\ncreas, such as cyst, abscess, or cancer. According to the studies of\\nFitz, the former is marked by deep-seated colicky pain occurring in\\nparoxysms, by discharges from the bowels of matter resembling saliva,\\nby the detection of fat in the stools and sugar in the urine, by saliva-\\ntion, and by the occurrence of jaundice.\\nCancer of the pancreas is recognized by the detection of a painful\\ntumor in the epigastrium. The pain is not aggravated by the taking\\nof food, but is said to be increased by the erect posture. The bowels\\nare constipated, and the stools may or may not be fatty. Emaciation\\nis progressive, as in all cancerous affections, and in the last stages\\nthere may be occasional vomiting and persistent jaundice.\\nPalpation and percussion of the upper right quadrant is\\nlimited largely to an investigation of changes in the liver and gall-\\nbladder, and is discussed in the section devoted to them.\\nPalpation and Percussion of the Upper Left Quadrant.\\nEnlargement in this region is generally due to disease of the spleen\\n(q. v.). It may be due to fecal accumulation in the left transverse and\\ndescending colon. This condition is recognized by the painlessness\\nand doughy consistence of the tumor, and by careful inquiry as to the\\ncondition of the bowels. Constipation will, of course, exist, but both\\npatient and physician may be misled by apparent diarrhoea, or even\\ndysentery there will be fluid or semi-fluid dejections mingled with\\nscybala, and sometimes mucus and blood.\\nAn interesting cause of swelling in this region, and in the lumbar\\nregion, is perigastric, or subdiaphragmatic abscess, a collection of pus\\nwalled in by the stomach, spleen, diaphragm, colon and the abdomi-\\nnal walls.\\nThe most common cause is the irritation of a gastric ulcer which\\nhas nearly or quite perforated, and has formed adhesions with sur-\\nrounding viscera. This was the cause in forty-one out of fifty-two\\ncases analyzed by Fenwick, while in six it was associated with cancer\\nand in four with abscess commencing externally. Pain in the epigas-\\ntrium or abdomen was the chief subject of complaint, and in most of\\nthe cases there was dyspepsia, sometimes vomiting. It is singular", "height": "4408", "width": "2768", "jp2-path": "practicaltreatis00muss_0_0824.jp2"}, "825": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 747\\nthat hsematemesis was mentioned in only two cases. Fenwick thinks\\nthat in every case of perigastric abscess, except in persons affected\\nwith phthisis, cancer, or some other chronic exhausting malady, the\\nfirst formation of the abscess will be accompanied by either collapse\\nand signs of general peritonitis, or by sudden and severe pain in the\\nepigastrium, attended with indications of local peritonitis.\\nFever is a prominent symptom, but physical signs are absent. A\\ntumor, according to the same author, is rarely distinguishable except\\nwhen the cause is cancer. It is dull, but afterward tympanitic on\\npercussion, and not movable on inspiration or external pressure. The\\ntension of the abdominal muscles prevents successful palpation. There\\nmay be arching outward of the ribs. The displacement of surround-\\ning viscera will depend upon the size of the abscess and the extent\\nof adhesions. The diaphragm is pushed upward, and dulness may\\nextend as high up as the angle of the scapula, in which case a pleural\\neffusion is simulated. Breathing is embarrassed by the upward press-\\nure upon the lung and heart. Sometimes when gas is formed in connec-\\ntion with the abscess, amphoric sounds on auscultation and percussion\\nare heard both in the abdomen and over the thorax. To this condi-\\ntion the name pyo-pneumothorax subphrenicus has been applied. The\\nabdomen then becomes tense, tender, prominent, and tympanitic on\\npercussion. (See p. 578.) It must be distinguished from left pneu-\\nmothorax. Air in the pleural cavity pushes the left wing of the dia-\\nphragm down, and hence increases the area of percussion-dulness and\\nthe palpability of the left lobe of the liver and spleen. In subdia-\\nphragmatic abscess with gas, the liver and spleen are not palpable,\\nnor can their area be limited by percussion. The heart is dislocated\\nin pneumothorax, and its area tympanitic on percussion, while the im-\\npulse is seen in the epigastrium or to the right of the sternum. In\\nsubphrenic pneumothorax the heart is elevated, and the impulse seen\\nin the nipple-line. At the same time there is tympany in the lower\\nhalf of the cardiac area of dulness. Pyo-pneumothorax subphrenicus\\nmust not be mistaken for dilatation of the stomach.\\nPalpation and Percussion of the Loins. Enlargements in\\nthese regions may be due to affections of the hidney (g. v.). They\\nmay, however, be due to enlargement or displacement of the spleen\\nand liver (q. v.), or to tumors of the retroperitoneal glands. On the\\nleft side the possibility of perigastric abscess must be borne in mind,\\nas sometimes the dulness and increased tension of the tumor extend\\nas far down as the lumbar region.\\nPalpation and Percussion about the Centre of the Abdo-\\nmen. Umbilical hernia, cancers of the stomach, liver, and intestine,\\nsarcoma of the retroperitoneal glands, hydatid cysts of the liver, and\\ntumors of the gall-bladder, together with floating hidney, spleen, and\\nliver, all at times cause tumors which may be felt in this region. They\\nmust be distinguished from each other by methods already referred to\\nunder the organs named. The general principle upon which to proceed\\nis to endeavor, by palpation and percussion, to discover the organ to\\nwhich the tumor belongs. To this end careful inquiry should be made\\nas to the time the tumor has been known to exist; its effect, if any,", "height": "4416", "width": "2648", "jp2-path": "practicaltreatis00muss_0_0825.jp2"}, "826": {"fulltext": "748 SPECIAL DIAGNOSIS.\\nupon the general health its effect upon the function of the possible\\norgans affected, and particularly as to the presence or absence of\\nvomiting, constipation, diarrhoea, or jaundice.\\nTumor hi the region about the umbilicus may be from tubercular\\ndisease of the mesenteric glands (tabes mesenterica). It occurs nearly\\nalways in children, and presents the physical signs and symptoms of\\ntubercular peritonitis, with the addition that enlarged mesenteric\\nglands may sometimes be felt. Children grow pale and anaemic,\\nwaste away, have apparently causeless diarrhoea, the passages being\\nfoul and the food undigested. The abdomen is large, but appears\\nlarger when compared with the emaciated body. It is tender, its walls\\nare thickened and less elastic than normal. Signs of tubercular dis-\\nease in other organs may be detected.\\nFacts gathered in this way, carefully analyzed, and then studied\\nwith reference to the physical properties of the tumor (hard or soft,\\nfluctuating, doughy, or not), will generally suffice for a probable diag-\\nnosis. A positive diagnosis often cannot be made at the first examina-\\ntion, and sometimes is possible only after watching the progress of the\\ncase for a considerable time.\\nEnteroptosis.\\nIt is by inspection, palpation, percussion, and auscultation that we\\ndiscover the anatomical cause for the symptom-group about to be de-\\nscribed. Attention to this affection may only be called by the sub-\\njective symptoms.\\nThis disease or physical condition, called sometimes Glenard s dis-\\nease, after the physician who first called attention, in 1885, to its\\nexistence, has received, of late, much study. It is characterized by the\\nfalling down or descent of a number of the abdominal organs. This\\noccurs on account of relaxation of the supporting ligaments, the num-\\nber of which Glenard puts at six. This relaxation is largely due to a\\nflabbiness and hence lack of support of the abdominal wall or to\\nstrain from undue physical exertion or to the abuse of cathartics or\\npossibly to injury. It is far more common in females who have borne\\nchildren. It may be the result of feeble muscle-tone, following pro-\\nlonged illness. The degree of descent, and hence the severity of the\\nsymptoms, may vary from slight displacement of one or two organs to\\nthat of the large intestine, the stomach, the liver, the spleen, and the\\nright kidney (sometimes both). In moderate cases but two of the liga-\\nments are relaxed the ligamentum colico-hepaticum and the ligamen-\\ntum gastro-colicum in the more severe all are affected.\\nSymptoms. The objective symptoms are due to the slight displace-\\nment, and are either purely physical or arise from the alteration of the\\nfunction of the stomach and the intestines.\\nThe subjective symptoms are due to the same cause. The displace-\\nment gives rise to local symptoms of weight, heaviness, and abdominal\\ndistress, amounting in some instances to pain, especially when in the\\nupright position, and to protracted and pronounced neurasthenia.\\nLater, we have the subjective symptoms of dyspepsia, gastritis, gastric", "height": "4400", "width": "2752", "jp2-path": "practicaltreatis00muss_0_0826.jp2"}, "827": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 749\\ndilatation, and intestinal atony, while the neurasthenic symptoms grow\\nmore aggravated.\\nThe earliest objective symptoms are (1) Pulsation of the abdomi-\\nnal aorta (2) a linear tumor or band about midway between the\\nxiphoid cartilage and the umbilicus, extending transversely from four\\nto six inches in length (3) gastroptosis, or descent of the stomach\\n(4) movable right kidney. Later, the liver may fall from one to four\\ninches, the spleen become palpable, and the left kidney movable. The\\ntransverse tumor above mentioned was held by Glenard to be the\\nthickened transverse colon. Ewald, however, seems to have demon-\\nstrated that it is the pancreas. The displacement of the viscera is\\nrecognized by the methods previously detailed for physical examina-\\ntion of the various organs. The patient must always be examined in\\nthe erect as well as in the recumbent position. Care must be taken to\\ndistinguish gastric dilatation from gastric descent. This can be done\\nby careful percussion after inflation with air, by gastric diaphany, by\\nmeasurement with a sound, and with fluids. Glenard laid much stress\\nupon the splashing sound. This may or may not be present it may\\nbe of gastric or intestinal origin, usually the former. It does not\\ndepend upon the displacement as much as upon the occurrence of gas-\\ntric dilatation. It occurs in other affections.\\nAn objective sign of diagnostic value, attention to which has been\\ncalled by Treves, is the relief the patient experiences when the lower\\nhalf of the abdomen is supported by a belt or by the hands of the\\npatient or surgeon, when in the upright position.\\nThe objective signs of gastric origin depend upon functional or\\norganic disease of that organ. We may have, on the one hand, only the\\nperverted gastric secretion and digestion that go with gastric neuroses\\non the other hand, we may have the perverted gastric secretion of gas-\\ntritis, gastric atrophy, or dilatation, and the evidences of diminished\\ndigestive, motor, and absorptive power of these affections.\\nThe subjective symptoms also depend upon the functional or organic\\nchanges in the stomach and intestines, upon the displacement of the\\norgans, with or without the above, or upon the associate physical mus-\\ncular condition of the individual and the state of the nervous system.\\nGlenard divided the progress of the subjective symptoms into three\\nperiods\\nIn the first there is gastric atony, when the patient experiences\\nweight and burning after eating a short period of wakefulness about\\ntwo o clock a.m. a loose stool in the morning loss of strength.\\nIn the second period the patient cannot eat fats and starches, and the\\nsubjective symptoms arise late in the period of digestion. A dragging\\nsensation or a feeling of emptiness occurs about three hours after meals.\\nThe patient awakens at two o clock a.m., and remains awake for two\\nor three hours. Constipation, at times alternating with diarrhoea, is\\npresent. There is continued loss of strength, and a tired feeling is\\ncomplained of on rising.\\nIn the third period the symptoms of neurasthenia are most pro-\\nnounced. The patient is emaciated, and complains of a constant weight\\nand of cramps in the stomach. Constipation is obstinate, and the stools", "height": "4416", "width": "2612", "jp2-path": "practicaltreatis00muss_0_0827.jp2"}, "828": {"fulltext": "750 SPECIAL DIAGNOSIS.\\nare scybalous and mucous. The patient is much prostrated and suffers\\nfrom sleeplessness. The constipation and the intestinal distress are\\naggravated by aperients. Enemata must be resorted to, to relieve\\nthe symptoms. Intestinal catarrh or membranous enteritis is very\\nlikely to follow.\\nPain throughout the abdomen, especially when walking about or in\\nthe erect posture, is frequently complained of. Some authorities speak\\nof tenderness on pressure over the solar plexus and of tender points\\nalong the vertebra.\\nThe disease is overlooked and the symptoms are attributed to neuras-\\nthenia. It is often difficult to estimate which of the two preponderates.\\nDiseases of the Peritoneum. Peritonitis.\\nInflammation of the peritoneum may be acute or chronic. It may\\nbe general or localized. Acute inflammation is rarely primary it\\nmay occur in the later stages of chronic Bright s disease, or other dys-\\ncrasia, as a terminal infection. If it follows exposure to cold, or\\ntrauma, it is called traumatic peritonitis. It is due in the large\\nmajority of cases to extension from organs which the peritoneum\\ncovers, or to perforation of one of the abdominal organs. In the first\\ninstance it may follow inflammation of any portion of the gastro-\\nintestinal tract, of the pelvic viscera, and suppurative inflammation of\\nthe spleen and liver and of the pancreas.\\nPeritonitis an Infection. In all instances the primary inflammation\\nin the organs mentioned is due to some micro-organism, as the staphy-\\nlococcus, the streptococcus, or the bacillus coli communis, and the\\nperitoneal inflammation to subsequent extension of the infection. In\\nperitonitis from perforation the element of infection is also the most\\nimportant part in the process, as in ulcer of the stomach or bowels. In\\ninflammation of the gall-bladder perforation may take place, with result-\\ning peritonitis. Abscess in the liver, spleen, or kidneys, bursting into\\nthe peritoneum, also leads to general peritonitis. The most common\\nforms, however, are due to appendicitis or disease of the Fallopian\\ntubes. Acute peritonitis may also occur in tuberculosis and in other\\nsystemic infections by direct infection.\\nSymptoms. The onset of acute peritonitis depends in a measure\\nupon the cause. When there is perforation the onset is sudden.\\nChilly feelings or a rigor occur, with intense pain in the abdomen.\\nThe pain is at first localized, but rapidly becomes general. It is con-\\nstant, increases in exacerbations, and is very intense, aggravated by\\nmovements and by pressure. The patient lies on the back with the legs\\ndrawn up. The dorsal decubitus is assumed, in order that the tension\\nof the abdominal muscles may be relieved. The location of the pain\\ndepends upon the seat of primary infection this is usually in the\\nright or left lower quadrant, more marked about the tubes or the\\nappendix. In perforation of an ulcer of the stomach the pain may\\nbe located in the back, or in the chest or shoulders.\\nPhysical Examination. On palpation the abdomen is extremely\\nsensitive. The patient is unable to bear the weight of clothing or ex-", "height": "4416", "width": "2736", "jp2-path": "practicaltreatis00muss_0_0828.jp2"}, "829": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 75 1\\nternal applications. The abdomen gradually becomes distended, and\\nis tympanitic on percussion. The distention may become so great as\\nto push up the diaphragm and interfere with the respirations, so that\\nthey are shallow, and may dislocate the heart, so that the apex-beat is\\nseen in the fourth interspace. The splenic dulness may be obliterated\\nentirely and the liver-dulness reduced. It is said that in some in-\\nstances this may be obliterated, although recent observations show\\nthat such obliteration only occurs in the anterior portion of the abdo-\\nmen. Liver-dulness persists in the axillary region, though diminished\\nin extent. This obliteration could only take place in perforative peri-\\ntonitis. Osier points out that in pneumoperitoneum from perforation\\nthe anterior hepatic dulness may be obliterated, although dulness in\\nthe lateral region continues, on account of the effusion of fluid. If a\\npatient with gas in the peritoneum is turned on the left side, a clear\\nnote is heard beneath the seventh and eighth ribs (hepatic region).\\nThe abdominal muscles are more or less rigidly contracted. Spasm of\\nthe muscle over the seat of primary inflammation takes place at once,\\nand is a valuable indication of the origin of the infection. In some\\ncases, usually when the inflammation is due to the streptococcus, there\\nis not much distention of the abdomen, or it may be flattened entirely\\nwith board-like rigidity. In these instances pain is not so marked, and\\ntenderness may not be complained of.\\nThe respirations are hurried and the superior thoracic type of breath-\\ning is seen, because the action of the diaphragm is painful. The act of\\nspeaking or coughing increases the pain, and the patients are unable\\nto take a full breath without suffering. With the occurrence of pain\\nand local signs vomiting usually sets in. It is painful and at first\\nis complete, the contents of the stomach being ejected and then a yel-\\nlowish bile-stained fluid later, the vomit becomes greenish in color.\\nComplete vomiting is replaced by simple regurgitation of fluid, so that\\non the slightest motion of the patient, or on taking a small amount of\\nfluid, the characteristic greenish-colored fluid is regurgitated without\\naction of the diaphragm. This may be almost continuous for from\\ntwenty-four to forty-eight hours. The tongue is at first furred, but\\nlater becomes dry, and often is cracked and red. The bowels are con-\\nstipated. They may be loose at first, but constipation is characteristic.\\nThe intestines are paralyzed from overdistention and from oedema of\\nthe walls due to inflammation.\\nThe general symptoms are marked. After the chill the temperature\\nrises to 104\u00c2\u00b0 or 105\u00c2\u00b0. In septic cases it continues at this point, or\\nmay rise to a greater height. If cases progress rapidly, a temperature\\nof 105\u00c2\u00b0 or 106\u00c2\u00b0 on the second or third day is not uncommon. In\\nother cases after the initial rise the subsequent elevation is not so great,\\nbut there is not much difference between morning and evening temper-\\nature unless there is an abscess.\\nThe urine is scanty micturition may be frequent and painful, par-\\nticularly if the inflammation began in the pelvic organs. The urine\\nusually contains a large amount of indican in the suppurative form.\\nThe appearance of the patient at the height of the disease is charac-\\nteristic. The expression is anxious, the face is pinched, the eyes", "height": "4416", "width": "2640", "jp2-path": "practicaltreatis00muss_0_0829.jp2"}, "830": {"fulltext": "752 SPECIAL DIAGNOSIS.\\nsunken. Vomiting causes wasting. The collapse is marked, with\\nthe characteristic facies previously described. (See Expression.) The\\npulse is rapid and feeble and soon becomes thready, ranging from 110\\nto 150. In the first stages it may be small and hard. Attention has\\nbeen called frequently to the peculiar wiry pulse of the early stage of\\nperitonitis.\\nIn severe cases death may take place in from thirty-six to forty-eight\\nhours. Usually a fatal termination does not take place for five or six\\ndays, and may be delayed longer. The vomiting persists, collapse\\nwith falling temperature ensues, the pulse becomes rapid and thready.\\nThroughout the entire attack, unless symptoms of septicaemia are\\nmarked, the mind is clear. The patient dies of paralysis of the heart.\\nSepticemic symptoms are indicated by a dusky color of the face, rapid\\nand irregular pulse, slight delirium, dry, brown tongue, and other evi-\\ndences of the typhoid state.\\nIf the cases are prolonged, some effusion may take place into the\\nperitoneal cavity. Dulness is noted in the flank, and if it is possible\\nto move the patient, it alters with the position. If recovery takes\\nplace, particularly in tuberculous cases, the affection may become cir-\\ncumscribed and be indicated by dulness, which is not movable.\\nDiagnosis. It is essential in making a diagnosis to ascertain, if\\npossible, the primary source of the infection or inflammation. To\\ndetermine this we inquire the age, sex, and history of previous disease\\nof the patient. In young male adults appendicitis is first to be thought\\nof in females inflammation of the pelvic organs. In chlorotic sub-\\njects, if the pain is high up, a history of ulcer of the stomach must be\\ninquired for. Later in life, particularly if there has been jaundice,\\nthe possible history of frequent attacks of gallstones and of hepatic\\ndisturbances must be ascertained. All forms of intestinal obstruction\\nmust be sought for. Frequently, however, a definite cause cannot be\\nascertained. If it occurs in the course of typhoid fever, it is usually\\ndue to perforation, but the occurrence of pain may not be complained\\nof, on account of the mental state of the patient. Under other circum-\\nstances the symptoms cannot be overlooked.\\nAcute peritonitis must be distinguished from entero-colitis. The\\ndistinction is not usually difficult if attention is paid to the develop-\\nment of the case. The pain is not so severe in entero-colitis it is\\nmore colicky in character. The general tenderness is not so great as\\nin peritonitis, and the distention does not interfere with respiration to\\nsuch a marked degree. Diarrhoea is more common in entero-colitis\\ncollapse, if present, is not so pronounced.\\nAcute hemorrhagic pancreatitis may simulate peritonitis in the sudden\\nintensity of pain and the occurrence of shock.\\nThe diagnosis from obstruction of the bowel is difficult in the absence\\nof a distinct history, but in peritonitis we do not have stercoraceous\\nvomiting until late. The tympanites and the pain are more general.\\nPeritonitis frequently accompanies or is due to obstruction. A\\ntumor, if present, may point to the true nature of the case, and, if\\nthere is any discharge from the rectum, invagination may be the ex-\\nciting cause.", "height": "4416", "width": "2668", "jp2-path": "practicaltreatis00muss_0_0830.jp2"}, "831": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 753\\nPeritonitis is simulated by a condition to which the name hysterical\\nperitonitis has been applied. It occurs in hysterical subjects, and\\nevery feature of the true form is imitated. The mode of onset, the\\ndecubitus, the difficulty in micturition, and the local distention and\\ntenderness of the abdomen are characteristic of both. In a few cases\\nwhich we have seen the vomiting is not of the nature of true periton-\\nitis, either in the mode of ejection or the character of the fluid. It\\nmust not be forgotten that even the temperature may be elevated and\\ncollapse take place in the hysterical form. In the cases which I have\\nseen the abdominal facies does not develop, while, on the other hand,\\nthe facies of hysteria, with the self-interest which the patient exhibits,\\nand the precision with which symptoms are narrated, coupled with\\nemotional or other manifestations of hysteria, point to the true nature\\nof the affection. Other symptoms of hysteria may arise. The case is\\njudged by the history of these associated manifestations and the per-\\nmanent stigmata of the disease. There is always a positive absence of\\ncause and of disease in any of the abdominal viscera. Sometimes, in\\nthese cases, if the attention of the patient is diverted, the tenderness\\non pressure may not be complained of. I am not familiar with the\\nresults of examination of the urine in this form of peritonitis. Indi-\\ncan should not necessarily be increased, as we find it to be in acute\\nsuppurative peritonitis.\\nRheumatism of the Abdominal Walls. There is absence of a history\\nof sudden acute pain followed by general pain. The fever is not so\\ngreat. The respirations are not interfered with, the pulse is not so\\nrapid, and symptoms of collapse do not supervene. A rheumatic\\npharyngitis or inflammation of muscles in some other portion of the\\nbody may occur simultaneously.\\nLocal Circumscribed Peritonitis. The causes of localized\\nperitonitis are those of general peritonitis that is, extension of inflam-\\nmation from neighboring viscera, or perforation of the viscera. In the\\nlatter instance the inflammation does not become general, if rapid local\\ninflammation shuts off the perforated area from the general cavity of\\nthe peritoneum. Local peritonitis of mild degree, and local or cir-\\ncumscribed peritonitis with suppuration, are therefore found in the\\nregions previously indicated, from which a general peritonitis may\\ndevelop. The inflammation, however, if retained by a limiting wall,\\nmay, after suppuration has taken place, gradually extend and the pus\\nburrow in various directions. In such cases of localized peritonitis as\\nmay exist in the upper half of the abdomen, a sub-diapJwagmatic\\nabscess may form, or an abscess containing air and pus, known as pyo-\\npneumothorax subphrenicus. If the inflammation is secondary to\\ndisease of the pancreas, it may be limited to the lesser peritoneum and\\ncause the physical signs of effusion in this cavity. (See Disease of\\nthe Pancreas.) Sub-diaphragmatic abscess is not limited to the lesser\\nperitoneum. It can only be recognized by the history of the previous\\ndisease, which may cause perforation, and by the general symptoms of\\nabscess. If the abscess is on the left side, there is an extension of\\ndulness upward toward the scapula, the lower limit of the lungs in\\nhealth ceasing at the eighth or ninth interspace. There may also be\\n48", "height": "4416", "width": "2612", "jp2-path": "practicaltreatis00muss_0_0831.jp2"}, "832": {"fulltext": "754 SPECIAL DIAGNOSIS.\\ndulness in the axillary region. If the abscess is on the right side, it\\nmay simulate enlargement of the liver, and be characterized by marked\\nincrease in dulness anteriorly, laterally, or posteriorly. Localized peri-\\ntonitis in the lower half of the abdomen is due to disease of the vermi-\\nform appendix, or to disease of the Fallopian tubes. The localized\\nsigns are, first, those of pain and tenderness second, the development\\nof tumor.\\nChronic Peritonitis. The symptoms of diffuse peritonitis, chronic\\nin course, may follow the acute, or may occur in the course of tuber-\\nculosis. The intestines and peritoneum are matted together. General\\npain and tenderness, Avith a prolonged period of ill health, attend the\\ndiffuse form. (See Tuberculous Peritonitis.) In the chronic forms,\\nif there is considerable fibrous proliferation, even though not can-\\ncerous or tuberculous, the abdomen becomes retracted, the muscles\\nrigid, the note over the abdomen modified or dull tympanitic. The\\nmodification may be detected in the upper half of the abdomen par-\\nticularly, and especially over the liver. Sometimes a fremitus can be\\nfelt. The patients are under weight and without strength. The pain\\nmay continue a long time. It finally results, at least clinically, in\\nsuch compensation that the patient is able to continue his usual occu-\\npation. Localized bands form, and may cause local sensations of a\\ndragging character, or pain with drawing or pulling sensations but,\\nsave the local symptoms, these are not serious, unless it should happen,\\nas has been seen in intestinal obstruction, that coils of intestine are\\ntwisted about the bands or caught in them, thus leading to obstruction.\\nCancer of the Peritoneum.\\nIt usually occurs in the aged, and follows cancer in other organs,\\nas the stomach, liver, or uterus. Occasionally it is primary. The\\nomentum is indurated, and forms a mass which lies transversely across\\nthe abdomen in the upper zone. Ascites usually develops, and the\\nexudation is bloody. The disease occurs more frequently in women\\nthan in men. With the development of ascites there is emaciation.\\nThe surface of the indurated omentum is irregular. It may be pain-\\nful on pressure. A tumor of the same physical character is seen in\\ntuberculous peritonitis, and I have seen several such tumors in the\\naged without apparent cause, unless from proliferative peritonitis. (See\\nTumor.) Progressive emaciation, chronic ascites without cause, and\\na localized tumor without the occurrence of fever point to the proba-\\nble nature of the case. Sometimes pain is the most pronounced symp-\\ntom. If these symptoms are present with signs of cancer in some\\nother organs, as the stomach, rectum, or uterus, there is probably\\nprimary cancer of the peritoneum.\\nRetroperitoneal sarcoma, or Lobstein s cancer, is central or lateral,\\ndeep-seated, and usually fixed. It is accompanied by the general symp-\\ntoms of cancer and by ascites. The growth is very large. It can be\\ndetected above the sacrum by rectal examination. The intestines are\\nin front of the growth, causing an unusual sensation to the hand, as in", "height": "4416", "width": "2648", "jp2-path": "practicaltreatis00muss_0_0832.jp2"}, "833": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 755\\nBurrow s case, like a hydatid fremitus. Lockwood s cases were\\nbelieved to be solid ovarian tumors.\\nSarcoma of the glands and the tissues in the above mentioned space\\nis, according to J. Dutton Steele, slightly more common in males than\\nin females more common in the first decade or after the fiftieth year.\\nIts duration is about nine months. Of the sixty-five cases collected by\\nSteele 39 per cent, were spindle-celled sarcoma, 34 per cent, round-\\ncelled sarcoma, 14 per cent, lympho-sarcoma, and 13 per cent, were\\nmixed cases. The growth originates in the lymph glands or in fibrous\\nconnective tissue about the kidney, the spinal column, the pelvis, or\\nthe sheaths of the bloodvessels. The onset is insidious. The first\\nsymptoms are the presence of a tumor, or the effects of pressure upon\\nthe vessels, nerves, or viscera of the abdominal cavity they depend\\nupon the site of the tumor. Varicocele is of frequent occurrence. It\\nis often impossible to distinguish it from malignant disease of the kid-\\nney or of the suprarenal bodies. The diagnostic features are (a) the\\nrapid growth (b) the position of the colon, which is pushed in front\\nof it, particularly if the tumor is lateral (c) the pressure symptoms\\n(d) the tumor may move with respiration or independently, and may\\nfluctuate.\\nTuberculosis of the Peritoneum.\\nThe tuberculous process in the peritoneum may be either acute or\\nchronic. In rare instances it may continue without any symptoms,\\neither local or general.\\nAeute tuberculous peritonitis may exactly simulate suppurative peri-\\ntonitis, although usually the course is more prolonged and the fluctua-\\ntions of temperature less pronounced. In other respects, it cannot be\\ndistinguished from acute general peritonitis, save by the absence of\\nthe causes of the latter. A history of exposure to tuberculous infec-\\ntion, or the presence of tuberculosis in some other portion of the body,\\nmay be of service in determining the nature of the case. Often there\\noccurs in a short time associate tuberculosis of other serous membranes,\\nso that tuberculous pleurisy or tuberculous pericarditis will supervene,\\nan associate process which does not take place in ordinary peritonitis.\\nThere is diarrhoea in most cases at least it has been present in the\\nfew instances ivhich I have seen of this form of tuberculosis. Never-\\ntheless, the diagnosis is sometimes impossible. Henry has called\\nrenewed attention to the occurrence of inflammation about the navel as\\na sign of tuberculous peritonitis. He believes the periumbilical ery-\\nthema is pathognomonic of the affection.\\nAcute tuberculosis of the peritoneum may precisely simulate appen-\\ndicitis in, first, the local symptoms and signs and, second, the subse-\\nquent infection of the peritoneum. In acute tuberculous appendicitis,\\nhowever, the signs of a tumor are not so marked as in true appendi-\\ncitis. Nevertheless, in one instance, Keen operated upon a patient of\\nmine, a healthy laborer in a rolling-mill, who had the classical symp-\\ntoms of appendicitis. At the operation the appendix was found to be\\nperforated and hanging in a local abscess. A fecal, fistula ensued\\nwhich did not heal, and within two months the patient died of general", "height": "4408", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0833.jp2"}, "834": {"fulltext": "756\\nSPECIAL DIAGNOSIS.\\ntuberculosis. The appendix was the seat of primary tuberculous\\nulceration. In a second instance the appendicitis arose in the course\\nof tuberculosis.\\nIn a third instance the patient, aged forty-five years, was admitted\\nto my wards in the Philadelphia Hospital, with high fever and pain\\nin the abdomen, at first more marked along the margin of the\\nliver. By the end of twenty-four hours it became more decided in\\nthe right lower quadrant of the abdomen tenderness at McBurney s\\npoint was distinct the area was enlarged and dull on percussion, the sur-\\nface slightly oedematous. Fluctuation could not be detected. Exten-\\nsion of the leg was painful. Rapid general peritonitis ensued, during\\nwhich the surgeon saw him, but declined to operate until the subsi-\\ndence of the attack. When the attack subsided the local signs of\\ntumor were not present. The fever persisted irregularly for a short\\ntime, while the more acute peritoneal symptoms subsided then the\\nright pleura became infected, and cough ensued with expectoration of\\nmucopurulent fluid. It did not contain tubercle bacilli, however.\\nSubsequently the left pleura and the pericardium became involved.\\nDuring the entire course of the disease there were diarrhoea, most pro-\\nnounced sweats, rapid emaciation, and exhaustion. Death took place\\nat the end of five weeks, and at the autopsy general serous tubercu-\\nlosis was found.\\nFig. 193.\\n\u00c2\u00b0MEMEMEMEM\u00c2\u00a3ME. MEMEMEMEMEMEMEMEMEMEMEME-ME\\nz =t 1\\nIOO Eg :i\\nE E 3\\nr 1 t\\n99 ~A t i r J a i E =3 f\\nz\\\\ t i 3 3 It t n\\n98 E 3 c =1 i^|i|\\n1 a Er raja 3=1\\nS 3 1 in Si I\\n971 d pi r h i i\\nr? E 3 g ff\\n96 t J I I SI\\nd= 5 v\\n5 3\\n95 1 1\u00e2\u0080\u0094\\nTuberculous peritonitis. Subnormal temperature.\\nWhile in a number of instances the symptoms are acute and alarm-\\ning, in the larger proportion of cases the process is more chronic, and\\nis attended by characteristic local and general symptoms. In the pro-\\nlonged and moderate cases there may be continued fever of moderate\\ndegree, or it may be remitting in type. In old people the temperature\\nis frequently subnormal. (See Fig. 193.) There is more or less\\nrapid emaciation. The sweating is profuse and characteristic. The\\nfever is high but irregular in type, in more severe cases approaching\\nthe remittent form. The general symptoms resemble typhoid fever.\\nIndeed, symptoms of the typhoid state may ensue.", "height": "4416", "width": "2652", "jp2-path": "practicaltreatis00muss_0_0834.jp2"}, "835": {"fulltext": "", "height": "4380", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0835.jp2"}, "836": {"fulltext": "PLATE XXXVII.\\nTuberculosis of the Peritoneum.\\nAbdominal exudate (not freely movable); omental tumor. Consoli-\\ndation at apices.", "height": "4400", "width": "2664", "jp2-path": "practicaltreatis00muss_0_0836.jp2"}, "837": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 757\\nThe Local Symptoms. Four classes are seen (1) Abdominal en-\\nlargement with effusion (2) enlargement with tumors (3) a combina-\\ntion of the two (4) enlargement without evidence of fluid or tumor\\nin the abdomen. In the latter form and in the forms in which tumors\\nare present the abdomen subsequently may undergo retraction.\\n1. Enlargement with Effusion. The local symptoms and physical\\nsigns are those of ascites. The abdomen is never as distended, however,\\nas in the ascites of cirrhosis of the liver. Often the fluid is confined\\nby adhesions which may distinctly localize it in the right or left quad-\\nrant of the abdomen, in which situation fulness and fluctuation may\\nbe readily detected.\\n2. Tuberculosis with Tumors. (Plate XXXVII.) The tumors are\\nusually in the upper zone of the abdomen, and may be localized in either\\nquadrant, or extend from the right to the left. They are usually due\\nFig. 194.\\nTuberculous peritonitis pulmonary tuberculosis. The site of cardiac impulse.\\nto tuberculosis of the omentum, with secondary contraction. In some\\ninstances a hard, indurated tumor, somewhat tender on pressure, may\\nextend across the abdomen midway between the xiphoid cartilage and\\nthe umbilicus. It may be as low as the umbilicus, and vary from two\\nto four inches in width. It may be continuous with the liver-dulness.\\nIn other instances more distinctly localized masses may be felt. These\\nmay be to the right or to the left of the umbilicus. In other instances\\nthey are hard, slightly tender, with an irregular surface. They may\\nbe movable and vary with the position of the patient. I have", "height": "4416", "width": "2588", "jp2-path": "practicaltreatis00muss_0_0837.jp2"}, "838": {"fulltext": "758 SPECIAL DIAGNOSIS.\\nnever seen tuberculous masses in the lower quadrants. In chil-\\ndren with tabes mesenterica they may be made out close to the verte-\\nbral column in the median line, extending to the brim of the pelvis,\\nalthough at the lower portion they are not so distinct. The dulness\\nover the tumors is varying, depending upon the relation to the bowels\\nand the degree of intestinal distention. Instead of dulness a modified\\ntympany may be observed, or muffled resonance.\\n3. Cases in which Effusion and Tumors are Present at the Same Time.\\nThese present symptoms common to the two conditions, although the\\ntumors are not so distinctly defined.\\n4. Absence of Effusion and Tumors. When effusion and tumors\\nare not present the thickened peritoneum and more dense intestinal\\nwalls lead to a modified dulness over the entire abdomen. When re-\\ntraction takes place the resonance is of a woodeny character, the abdo-\\nmen is more or less tender, and ill-defined indurations may be present.\\nThe term carreau is applied to this induration.\\nIn not a few instances the local physical signs may apparently be due\\nto inflammation of the liver, on account of extensive perihepatitis. In\\nthe case of a child under my care the local signs during life were of\\nthis character, and the symptoms were simply those of loss of appetite,\\nwith discomfort, weight, and fulness below the sternum. Both the right\\nand left lobes of the liver were covered with an enormous thickening\\ndue to tuberculous inflammation. Simple plastic peritonitis occupied\\nthe lower zone.\\nApart from the general symptoms and the local physical signs the\\nother symptoms are not distinct save those due to tuberculosis in other\\nsituations. The appetite is usually poor, there is some atonic dyspep-\\nsia, vomiting may occur at regular intervals the bowels may be con-\\nstipated, although in my experience they have usually been relaxed.\\nThe patient becomes anaemic, the skin harsh and dry. Emaciation\\nmay progress to an extreme degree. Eruptions and boils may break\\nout, some oedema of the ankles may occur. Death takes place from\\nexhaustion and from the development of tuberculosis in other localities.\\nThe diagnosis is difficult. Cases belonging to the first and fourth\\nclasses above mentioned probably present the greatest difficulties.\\nThe age modifies the difficulty of diagnosis. Peritoneal tumors, with\\nor without effusion in young subjects, are almost always due to\\ntuberculosis. In the aged they must be distinguished from carci-\\nnoma or chronic peritonitis from other causes. The association of\\ndiarrhoea with the symptoms is rather against carcinoma. Sacculated\\neffusions may be confounded with abdominal tumors, as of the ovary.\\nThe resemblance is more pronounced if the tubercles develop primarily\\nin the tubes or uterus. In a recent case the autopsy disclosed a large\\ncaseating ulcer inside of the uterus, and tuberculosis of the Fallopian\\ntubes and peritoneum. The right tube was chiefly affected. The\\neffusion during life was sacculated in the right lower quadrant, was not\\nmovable with the patient, and fluctuated both on external palpation\\nand with bimanual palpation per vaginam. It was impossible to dis\\ntinguish it except that there was dulness instead of resonance in the\\nflanks. As Osier has pointed out, the association with salpingitis", "height": "4412", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0838.jp2"}, "839": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 759\\nmust arouse suspicion, particularly if at the same time disease is found\\nin some other organ of the body, as the apex of the lungs or the\\npleura. In males the primary lesion is often in the testicles. The\\nhistory of the case and the development of the disease in an irregular\\nmanner, associated with gastro-intestinal disturbance rather than dis-\\nturbance of uterine function, are points in favor of tuberculosis. Tym-\\npanites is of frequent occurrence.\\nDiseases of the Stomach.\\nThe stomach is a canal in which the food is detained for the purpose\\nof solution. Its walls are made up of mucous membrane, muscle, and\\nperitoneum. It is richly supplied with bloodvessels. Because of its\\ngreat functional activity it has an abundant nerve-supply. It is, more-\\nover, surrounded by rich plexuses of sympathetic nerves, through which\\nand its special nerve, the pneumogastric, it is in intimate relation with\\nevery organ of the body.\\nThe Symptomatology The local symptoms of disease of the stomach\\nare dependent upon (1) The morbid process which affects it (2) the\\neffect of the process upon the anatomical structure of the organ (atro-\\nphy, dilatation, tumor), whereby the size is affected (3) the effect\\nupon its function.\\n1. The Morbid Process. The symptoms due to the morbid process are\\nnot different from the symptoms of similar morbid processes elsewhere,\\nsave that they are modified by the function of the organ or its special\\nconstruction as a canal. Hence, congestions are attended by discharge\\nof mucus inflammations are attended by pain and by a flow of mucus\\nand pus ulcers by pain and the accidents of ulceration (hemorrhage)\\nmalignant disease by pain and swelling (tumor), and its accidents, hemor-\\nrhage and obstruction while to each belong the general phenomena\\nwhich attend it. But the stomach is highly sensitive and resents the\\nintrusion of disease or of that which (1) causes disease or (2) irritates\\nthe affected part. Expression of this resentment is shown in hyper-\\nsesthetic symptoms (see the Neuroses), as pain; in the abolition or\\nderangement of function and in the great pathological reflex act of\\nthe stomach vomiting. It will be seen later that this may be a symp-\\ntom of every local morbid process of the organ, either directly because\\nof the disease or of its exciting cause, both of which are operative in\\nirritant inflammations or indirectly because the process has set up\\nundue sensitiveness. In the latter instance any material, as food, which\\nthe stomach is accustomed to receive, becomes as much an irritant as\\nmucus, pus, or blood.\\n2. Anatomical Symptoms. The morbid processes modify the ana-\\ntomical structure and lead to other morbid conditions, as we see when\\ndilatation succeeds inflammation or obstruction of the orifices. The\\nsymptoms of the secondary conditions are the same as elsewhere in\\natrophy, diminution in size in dilatation, increase in size, with retention\\nand fermentation, and finally discharge of the contents by vomiting.\\nNerve Mechanism. In the consideration of the symptomatology of\\ngastric diseases the anatomical relation, by its vascular and nervous", "height": "4416", "width": "2644", "jp2-path": "practicaltreatis00muss_0_0839.jp2"}, "840": {"fulltext": "760 SPECIAL DIAGNOSIS.\\nconnection, must be considered. The student is sufficiently familiar\\nwith physiology and pathology to know that each organ has a represen-\\ntative in the central nerve-mass, the brain, and that disease in one\\norgan will influence the function and create morbid symptoms in\\nanother which is related to it through intimate nervous connections.\\nThe central representative or centre is influential in proportion to\\nthe power and activity of its peripheral adjunct. It is, moreover, in-\\nfluenced by higher centres, the psychical, and it in turn modifies them.\\nIt influences or modifies lower centres, (1) functional, (2) vasomotor,\\n(3) motor, or (4) sensory. The result of this mechanism is 1. That\\nfunctional alteration or organic disease of (a) the gastric centre, or (6)\\nof centres of higher control, or (c) of the nerve that connects the centre\\nand the organ pneumogastric nerve\u00e2\u0080\u0094 produces gastric symptoms. 2.\\nThat gastric diseases produce symptoms in other organs, as cardiac\\npalpitation (reflex). 3. That disease of other organs produces gastric\\nsymptoms or disease, as the vomiting of pregnancy, or of renal calculus,\\nor of disease of the testicle, or the gastritis of nephritis. Thus vomiting\\nis caused by emotion (high centre), influencing the pneumogastric (lower\\ncentre) by a tumor pressing or destroying the pneumogastric centre\\nor by a tumor, as aneurism, pressing on the pneumogastric nerve.\\nI have taken the simplest illustration. When we come to the study\\nof gastric neuroses the extraordinary influences of the nervous mechan-\\nism will be appreciated or, when hysteria is studied, the physiology\\nof its extreme gastric symptoms will be recognized. When the mech-\\nanism and clinical course of vomiting are studied it will be found\\namong other causes to be frequently due to affections of the blood, the\\npoisons of which irritate cerebral centres or nerve plexuses in the\\nstomach.\\nVascular Mechanism. But gastric diseases also arise because of the\\nvascular supply. Thus in heart disease with venous stasis the gastric\\nveins become the seat of congestion, with consequent gastric catarrh\\nor hepatic disease will cause portal congestion and gastric catarrh.\\n3. Functional Symptoms. Any local disease of the stomach must\\ninfluence its function therefore, conversely, functional symptoms\\nmust be present in all local diseases. But functional disorder may be\\npresent without local anatomical change the impairment is nearly\\nalways induced through the influences of the nervous system. The\\nfunctions of the stomach are to digest and to absorb the products of\\ndigestion. The former function is motor and chemical, the complete-\\nness of which depends upon mixture of the food with, and solution in,\\nthe gastric juice. The symptoms, therefore, must be due to changes\\n(1) in the motor, (2) in the secretory, and (3) in the absorptive func-\\ntions of the organ. The functions may be increased or diminished\\nthe former are the primary and usually temporary aberrations the\\nlatter succeed the former, and are permanent. The functional symp-\\ntoms, therefore, are the symptoms of what we know as indigestion or\\ndyspepsia. They are described in the account of the subjective symp-\\ntoms and also in the section on Gastric Neuroses.\\nToxic Symptoms. The toxic symptoms arising in gastric disease are\\nworthy of a few words. They are nervous symptoms due to the", "height": "4412", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0840.jp2"}, "841": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 761\\nabsorption of ptomaines or imperfect products of assimilation. If\\nabsorption of the toxines takes place suddenly and in large amounts,\\ncoma and convulsions occur (Kussmaul s symptom) or, if gradually,\\nhypochondriasis, melancholia, mental depression, with vasomotor phe-\\nnomena of various kinds, arise.\\nIt is observed, therefore, in unravelling the symptomatology of gastric\\ndisease, that we must first note (A) The subjective symptoms due\\n(1) to morbid processes, (2) to alterations of function, (3) to alterations\\nof size (sense of fulness, etc.). (B) The objective symptoms due (1)\\nto morbid processes, (2) to alterations of function, (3) to alterations of\\nsize.\\nDiagnosis from Disease of Contiguous Organs Functionally Related.\\nThe student will soon learn that diseases of the stomach which are\\nfunctional in character cannot be differentiated with ease from diseases\\nin other organs functionally related. He will find that to draw hard-\\nand-fast lines between gastric and intestinal indigestion, or between\\nso-called disordered gastric and hepatic function, is generally impos-\\nsible. Organs which are closely related in physiological function, and\\nwhich have nerve-supply and blood-supply in common, cannot be dif-\\nferentiated when disordered function is considered. Hence, indigestion\\nand biliousness, or simple acute gastritis and duodenitis, are beyond\\nthe pale of close discrimination. In fact, the symptoms of each blend\\nin a manner.\\nIn addition to the examination of the stomach, in order to judge cor-\\nrectly of the nature of gastric lesions, as may be inferred from what\\nhas been written above, we must ascertain (1) whether the gastric symp-\\ntoms are dependent upon disease of other organs particularly the eye,\\nnose, and genitalia, the heart and kidneys by an examination of each\\norgan and (2) whether other symptoms are created by gastric disease.\\nThe Stomach in Other Diseases. Diseases of the stomach may\\nfrequently mask other diseases in other words, patients will complain\\nof gastric symptoms which are but concomitant phenomena, behind\\nwhich there are graver conditions. Thus, in disease of the kidney, in\\nphthisis, in chronic bronchitis, in emphysema, in valvular disease of\\nthe heart, catarrh of the mucous membrane of the stomach is of fre-\\nquent occurrence, depending upon the primary disease.\\nIn tuberculosis the local gastric symptoms often are the more promi-\\nnent features. Thus in the earlier stages of phthisis loss of appetite\\nand vomiting are of constant occurrence. The dyspeptic symptoms\\nin a large number of cases precede the pulmonary symptoms, and may\\nbe so pronounced as to mask them entirely. The patients are usually\\ndelicate and anaemic they complain of loss of appetite and mild indi-\\ngestion there is some regurgitation of food they are feeble and\\nlanguid. They are treated for chronic catarrhal gastritis, but do not\\nimprove. On examination of the lungs the physician is surprised to\\nfind a small area of consolidation, and upon inquiry will find subjec-\\ntive symptoms of tuberculosis to have been present for a considerable\\ntime. Every practitioner is familiar with the scores of patients with\\nphthisis, even when the disease is far advanced, who believe that their\\nsymptoms are entirely due to disorder of the stomach. In addition", "height": "4416", "width": "2640", "jp2-path": "practicaltreatis00muss_0_0841.jp2"}, "842": {"fulltext": "762 SPECIAL DIAGNOSIS.\\nto the early catarrh that precedes tuberculosis, other gastric symptoms\\nmay occur. The well-known association of simple ulcer and phthisis\\nis familiar. Both occur at the same time of life, yet the gastric symp-\\ntoms may prevent investigation into those of pulmonary origin. In\\nancemia and chlorosis changes in the digestive tract are common. On\\naccount of the general blood-condition the functions of the stomach\\nare impaired. Here, too, we frequently have the association of nicer\\nwith the general condition. Danger of overlooking either is not so\\ngreat as in tuberculosis.\\nIn valvular affections of the heart, chronic catarrh of the stomach\\nmay result from venous congestion. The symptoms may point to the\\ngastric condition alone. In all cases of chronic gastric catarrh it is\\nnecessary to examine carefully into the condition of the heart. Over\\nand over again patients apply for treatment not on account of cardiac\\nsymptoms, but because of gastric disorder. They will be treated in\\nvain unless the primary cardiac affection is ascertained. Many cases of\\ngastric catarrh have been cured by the use of digitalis. In disease of\\nthe kidneys the stomach is frequently involved. Vomiting and other\\nsymptoms of gastric disorder may occur long before dropsy or any\\nobjective sign which would lead to a correct diagnosis. The gastric\\nsymptoms are due to chronic uraemia. In other conditions of the\\ngenito-urinary tract gastric symptoms also occur. This is particularly\\nnoticeable in long-standing retention from chronic obstruction. Renal\\ntumors may cause only disturbances of digestion, while gastric symptoms\\ndue to movable kidney are well known. The symptoms in the latter con-\\ndition arise, first, from mechanical causes, as the pressure of the kidney\\non the pylorus, and, secondly, from the influence on the nervous system.\\nDisease of the Liver. The intimate relationship of the liver and\\nthe stomach is such that when one is the seat of serious functional dis-\\nturbance the other is likely to be affected. Frequently it is impossi-\\nble to draw fast lines as to which organ is the primary seat of disorder.\\nThe abuse of alcohol frequently induces chronic gastritis, and also\\ncauses cirrhosis of the liver. On the other hand, cirrhosis of the liver\\nis frequently the cause of chronic gastritis secondary to the portal\\ncongestion.\\nDiseases of the Nervous System. The relationship of disease of the\\ncentral nervous system to disturbance of the gastric functions has\\nfrequently been adverted to. (See Vomiting.) In sclerosis of the\\nposterior columns of the cord this is more striking than in any other\\nspinal disease. Not only do we have gastralgia and gastric crises, but\\nmoderate symptoms of indigestion, with hyperesthesia and slight gas-\\ntralgia, may be the first symptoms of locomotor ataxia.\\nDiabetes. Diabetes may continue (in its course) for a long period\\nof time, during which the patient is thought to have stomach-trouble,\\nbefore an examination of the urine reveals the true nature of the case.\\nOpinions differ as to the relationship of gout and rheumatism to\\ngastric disorder. Some writers believe that a specific gouty inflammation\\nof the stomach, due to the uric-acid diathesis, is of frequent occurrence,\\nand that one of the prominent manifestations of gout is dyspepsia in\\nall its forms. The French consider gastric disturbances to be frequent", "height": "4412", "width": "2676", "jp2-path": "practicaltreatis00muss_0_0842.jp2"}, "843": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 763\\nexpressions of the rheumatic diathesis. The relationship of the two,\\nhowever, is thus far not fully developed, although, in these conditions,\\nit is not usual to overlook the presence of either of the diatheses when\\nsymptoms of gastric disturbance occur. It is essential to bear in mind\\nthat in persons of a rheumatic or gouty diathesis gastric disturbances\\nare more likely to occur than in healthy individuals their successful\\nmanagement depends upon the recognition of the fundamental diathesis.\\nIt is more than probable that gastric disorders, along with defective\\nmetabolism, is primary in both affections.\\nThe Data Obtained by Inquiry.\\nThe Social History. In no other group of diseases than in\\nthose about to be considered, unless those of the nervous system, is it\\nmore important to inquire into the social history. This is true, because\\nmost of the so-called gastric disorders have their foundation in neuras-\\nthenic states, the probability of which, of course, must be carefully\\nsifted from the many possibilities. Age. Early age predisposes notably\\nto gastro-intestinal disorder. In later life the catarrhs which arise\\nfrom improper exposure or indiscretions in eating or occupation are\\ncommon. The menopause is often associated with gastric disorders.\\nThe sex is not of great diagnostic significance, except from its relation-\\nship to the excesses in eating and drinking of one class. Those occupa-\\ntions which prevent out-door exercise, or which compel exposure to\\ntoxic substances, or require stooping or constrained positions, or over-\\ntax the eyes, invite gastric diseases. Habits of eating and drinking,\\nboth as to time and mode of eating, and the character of food and\\ndrink, must be brought out in the inquiry. The use of tobacco and\\nother stimulants and narcotics must be noted. The hours devoted to\\nvacation and work are to be learned, as fatigue bears a great part\\nin gastric disease.\\nThe Family History. Heredity plays but a small part except\\nin gastric carcinoma and in gastric neurasthenia.\\nThe History of Previous Disease. The occurrence of infec-\\ntious diseases antecedent to the gastric disorder must be inquired about,\\nfor, either because of the attendant gastritis or of the resulting defec-\\ntive innervation, they predispose to gastric disease. The excessive\\nfeeding in the convalescence of typhoid fever, it seems to the writer,\\nis frequently the cause of gastric dilatation. Any prolonged illness\\nwhich weakens the muscular system and lowers the tone of the nervous\\nsystem will be likely to cause gastric disease.\\nIt will be learned elsewhere that gastric affections occur secondary\\nto many local diseases, as of the heart, the lungs, and the kidneys.\\nInquiry as well as an objective investigation must be made, to deter-\\nmine the presence of possible primary diseases. Disorders which inter-\\nfere with the mechanical support to the intra-abdominal organs must\\nbe inquired for. Pregnancy, antecedent ascites, or a large tumor may\\nso weaken the abdominal muscles as to lead to gastro-enteroptosis.\\nFinally, a history of the ingestion of corrosive poisons must be sought\\nfor in cases of gastritis.", "height": "4416", "width": "2640", "jp2-path": "practicaltreatis00muss_0_0843.jp2"}, "844": {"fulltext": "764 SPECIAL DIAGNOSIS.\\nIt is very important to learn whether the patient has been subjected\\nto the various causes of neurasthenia, which, with the history of the\\noccurrence of neuropathic symptoms, make valuable data, pointing to\\nthe nature of many gastric neuroses.\\nThe Subjective Symptoms. The following subjective symptoms\\nmay be complained of Disorder of appetite, bad taste in the mouth,\\nthirst, eructations, pyrosis, distress or weight after meals, burning after\\nmeals, flatulency, nausea, vomiting, constipation, diarrhoea, pain, vertigo,\\nand cardiac palpitation. Nearly all the subjective symptoms are gastric\\nneuroses, and will be detailed in the chapter devoted to the neuroses.\\nBad Taste. It is usually due to acute catarrh. It may be present\\nin chronic catarrh. It is said to be characteristic of the acute form of\\ngastritis popularly known as biliousness.\\nThirst. Thirst is not a symptom of gastric disorder alone it is a\\nsymptom of diabetes and all conditions in which the body has lost\\nfluids, as water by sweating, vomiting, or purging, or by evaporation\\nand combustion (fever) or blood by hemorrhage. It is common in\\nacute and chronic gastritis, particularly in the alcoholic form.\\nDistress, Weight, and Burning. They are frequent complaints,\\nand may come on immediately after meals. They may be due to dys-\\npepsia, hyperacidity, dilatation, bacterial fermentation, and flatulency.\\nThey exist in varying degrees, either singly or combined. (See Gas-\\ntric Hyperesthesia.)\\nNausea. This symptom is usually associated with vomiting. In\\nsome persons it is impossible to excite vomiting, although they may\\nsuffer intolerably from nausea. Nausea is akin to vomiting in its\\nmechanism and clinical associations (g. v.). It is a common incident\\nin chronic interstitial nephritis. In old people, with arterial sclerosis\\nand defective renal elimination, it is common. It may be due to irri-\\ntating ingesta, to hyperacidity, to gastrectasia, or to toxins formed\\nwithin the stomach.\\nVomiting. Vomiting takes place when the stomach is compressed\\nby the abdominal muscles and diaphragm, coinciclently with relaxation\\nof the so-called cardiac sphincter of the oesophagus. Sometimes there\\nare nausea and violent efforts at expulsion on the part of the stomach,\\nbut no vomiting occurs, because the cardiac orifice of the stomach is\\nnot opened at the same time. Again, there may be profound relaxa-\\ntion of the oesophagus, but no compression of the stomach by the dia-\\nphragm and abdominal muscles. Both factors must operate at the\\nsame time to result in vomiting. This explains why it is that some\\npersons suffer extreme nausea and have even violent retching, but are\\nunable to vomit.\\nIt is to modern physiologists Schiff and Budge and Brunton that\\nwe owe a correct explanation of the physiology of vomiting.\\nFrom them we learn that there is a nervous centre for vomiting,\\nwhich is seated in the medulla oblongata, in close proximity to and\\nintimately connected with the respiratory centre. It is to this centre\\nthat impressions are sent from the brain itself or from various portions\\nof the body by their nerve-supply, and from this centre motor im-\\npulses are transmitted to the muscles concerned in the act of vomiting,", "height": "4412", "width": "2676", "jp2-path": "practicaltreatis00muss_0_0844.jp2"}, "845": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 765\\nand to the stomach and oesophagus. In his usually graphic manner\\nBrunton has described the entire mechanism.\\nBy a very good diagram (see Fig. 195) the author indicates the\\nafferent nerves which transmit impulses to the vomiting-centre, ex-\\nciting it to action. They are pharyngeal branches of the glosso-\\npharyngeal pulmonary branches of the vagus gastric branches of\\nthe vagus gastric branches of the splanchnic renal, mesenteric,\\nuterine, ovarian, and vesical nerves. Fibres pass downward from the\\nbrain, conducting impressions to the vomiting-centre from the organs\\nof special sense, from the brain-substance or its membranes when the\\nseat of disease, or from central ganglia excited by emotion or imagi-\\nnation.\\nFig. 195.\\nLIVER AND\\nGALL-BLADDER\\nKIDNEY\\nAND URETER\\nNERVOUS CENTRE\\nOF VOMITING IN\\nTHE MEDULLA\\nOBLONGATA\\nSPINAL CORD\\n\u00e2\u0080\u00a2--VAGUS\\nPULMONARY\\nBRANCHES\\nSPLANCHNICS\\nGALL-DUCT\\nRENAL NERVES\\n__.J MESENTERIC\\nNERVES\\nUTERINE\\nNERVES\\nThe nervous mechanism of vomiting.\\nFrom this it is seen that vomiting is a reflex act that its mechanism\\nis quite simple and that a proper understanding of this mechanism\\nis essential to a correct appreciation of its pathology and treatment.\\nReference has not been made to the vomiting that occurs in the initial\\nstage of many fevers, and in septicaemia, uraemia and allied affections,\\nand to the vomiting of hysteria. In the former it is doubtless due to\\nthe direct action of the poisoned blood on the centre, but it can also\\nreadily be seen to be due to the propagation of impulses to the centre\\nfrom the brain that is irritated by the blood. If the phenomena of\\nhysteria are due to an abeyance of the processes of inhibition, the\\noccurrence of vomiting can be said to arise from the non-control, by", "height": "4416", "width": "2640", "jp2-path": "practicaltreatis00muss_0_0845.jp2"}, "846": {"fulltext": "766 SPECIAL DIAGNOSIS.\\nhigher centres, of this centre. (From Vomiting, Physiological and\\nClinical. Trans. Penna. State Med. Soc, 1887. Musser.)\\nThe significance of vomiting in a given case can sometimes be deter-\\nmined very readily, and sometimes it remains in doubt after very\\ncareful examination and questioning of the patient. In seeking for\\nan explanation of vomiting it is of importance to find out the previous\\nhealth of the patient whether it occurred after the patient had been\\nill for a longer or shorter time, or suddenly, when he was in apparent\\nhealth, or whether it formed one of the initial symptoms of an acute\\ndisease.\\nAgain, inquiry should be made as to the supposed cause of the\\nvomiting whether it was excited by the taking of food, drink, or\\nmedicine, or by some disgusting sight or odor.\\nFurther, the time of the occurrence of the vomiting should be ascer-\\ntained, as well as its frequency, and whether preceded by nausea, pain\\n(noting its locality), injury, coughing, jaundice, or constipation.\\nThe position of the patient at the time the vomiting occurs some-\\ntimes furnishes a valuable clue to its cause.\\nThe effect of the vomiting is sometimes of aid in diagnosis. In\\nulcer and migraine, for example, it affords marked relief.\\nFinally, the appearance and quantity of the matter vomited are\\nvery important. (See Objective Signs.)\\nCharacter. Vomiting may occur occasionally, persistently, or peri-\\nodically. It may be projectile and painless, or difficult and painful.\\nThe former is characteristic of cerebral disease or reflex vomiting\\nthe latter of local gastric disease. When vomiting occurs suddenly,\\nwithout antecedent illness, it usually indicates some local affection of\\nthe stomach, or is due to some nervous impression, or marks the onset\\nof some acute general disease.\\nVomiting in Gastric Disease. The local affections of the stomach\\nattended by vomiting are acute and chronic gastritis (especially the\\ncatarrhal form), dyspepsia, ulcer, cancer, and dilatation.\\nIn acute gastritis there will be a history of an acute illness marked\\nby severe local and general symptoms. The cause of the gastritis may\\nbe found to be overeating of highly seasoned or indigestible food abuse\\nof alcohol, narcotics, or sedatives drinking water to which the patient\\nis unaccustomed poisoning with such drugs as arsenic and mercury\\nsudden changes in atmospheric conditions in susceptible persons. The\\nvomiting is preceded by nausea, epigastric pain and tenderness, and\\noften followed by profound prostration.\\nThe vomited matters consist, first, of the contents of the stomach\\n(which may throw light on the cause of the attack), then of mucus,\\nsaliva (which has been swallowed), bile, and, in grave cases, altered\\nblood.\\nIn chronic gastritis vomiting often occurs in from half an hour to an\\nhour and a half after eating, the food being only partly digested and\\nsometimes coated with mucus. It does not produce the prostration\\nthat vomiting in acute gastritis does, and is followed by some relief to\\nthe gastric uneasiness and pain. The emaciation may suggest cancer\\nof the stomach.", "height": "4404", "width": "2688", "jp2-path": "practicaltreatis00muss_0_0846.jp2"}, "847": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 767\\nIn ulcer of the stomach vomiting is rarely absent. It occurs usually\\nsoon after taking food, and its occurrence affords relief to the gastric\\npain. There is nothing characteristic in the vomit unless it contains\\nblood. Welch thinks that gastric hemorrhage in recognizable amount\\noccurs in about one-third of the cases.\\nIn cancer of the stomach vomiting is an almost constant symptom,\\nbut it may not occur until comparatively late in the disease, or, more\\nrarely, may be one of the earliest symptoms. Usually it does not\\nappear until dyspeptic symptoms have persisted for some time. There\\nis no uniformity in the frequency of its occurrence or in the character\\nof the vomit. As a rule, vomiting occurs at a longer interval after\\ntaking food than in the case of ulcer, and the ejection of food does not\\ngive as much relief to the patient. Vomiting may occur every day or\\nseveral times a day in the early stages, but if dilatation of the stomach\\ndevelops, as it usually does in cancer of the pylorus, vomiting may be\\ndeferred for several days, and then be correspondingly more copious\\nin amount. Blood, frequently altered by gastric juice so as to resem-\\nble coffee-grounds, is a common constituent of the vomit. (See Under\\nInspection.)\\nVomiting in Infections. Vomiting frequently marks the onset of acute\\ndiseases, especially pneumonia and the eruptive fevers said yellow fever.\\nExcessive vomiting generally indicates that the case will be severe.\\nReflex Vomiting. Nausea and vomiting are excited in some persons\\nby the sight of blood, or by a horrible or loathsome spectacle others\\nare more susceptible to foul odors and disgusting tastes.\\nVomiting is frequently reflex, that is to say, irritation at some point\\nis transmitted by the proper afferent nerve to the vomiting-centre and\\nthen reflected to the stomach. Vomiting of this character occurs in\\npregnancy, diseases of the appendix vermiformis, ovaries, uterus, bladder,\\nprostate gland, lungs, nose, eyes, kidneys, intestine, peritoneum, liver, gall-\\nbladder, and bile-ducts.\\nVomiting is found to be of reflex origin when there is no local affec-\\ntion of the stomach present and no general disease to account for it,\\nand when a remote source of irritation can be discovered, the removal\\nor mitigation of which checks this vomiting. The particular organ\\nwhich is the source of the irritation must be determined by a careful\\nphysical examination guided by the indications furnished by the age,\\nsex, time of occurrence, habits, and other symptoms which accompany\\nthe vomiting.\\nThe nausea and vomiting from which many women suffer during\\nthe early months of pregnancy are most marked on rising in the morn-\\ning they are aggravated if the patient has been on her feet much or\\nhas been subjected to any exhausting or worrying influence on the\\nother hand, they are relieved by quiet and the recumbent posture. In\\ndiseases of the ovary, uterus, bladder, and prostate there are local pain,\\ncatarrhal symptoms, inflammation or noticeable enlargement.\\nThe lungs are probably not often the cause of reflex vomiting.\\nRarely, however, phthisis is so masked by gastric symptoms and vomit-\\ning as to be overlooked. More frequently it is the act of coughing\\nand the effort to expel the sputa from the throat that produce the", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0847.jp2"}, "848": {"fulltext": "768 SPECIAL DIAGNOSIS.\\nvomiting. Expectoration tickles the throat, and may have the same\\neffect as the finger or feather in inducing vomiting. This seems to be\\nthe explanation of the vomiting which follows a hard spell of coughing\\nin pertussis.\\nPeritonitis may be suspected to be the cause of vomiting if there has\\nbeen injury to the peritoneum from a surgical operation, or if it has\\nbeen exposed to infection through the uterus and tubes, or from disease\\nof organs surrounded by it, as the vermiform appendix. Vomiting\\nmay be the only symptom present except collapse. The fluid is not\\nonly ejected, but regurgitated, and may appear to flow from the stom-\\nach. Large amounts of fluid are discharged, clear or of a green color.\\nIn the vomiting due to the passage of a renal calculus or gallstone\\nthe colicky pains and their location definitely point to the source.\\nVomiting in Toxwmias. Vomiting is also a marked symptom of tox-\\naemias they produce vomiting probably by direct irritation of the\\nvomiting-centre. Among such diseases are the specific fevers, notably\\nscarlet fever and yellow fever sewer-gas poisoning diseases of the liver\\nand kidney, which produce cholwmia and urwmia, particularly cirrhosis\\nof the liver and interstitial nephritis.\\nCyclic Vomiting. This condition was described by Ley den in 1882\\nas periodic vomiting. Cases in children have been recorded by Snow\\nand others. Clinically, the vomiting is sudden in onset, severe, and\\nconsists first of the contents of the stomach, and later of acid mucus.\\nThere is usually a febrile reaction at the onset, but this may be absent\\nin adults. The abdomen is almost invariably retracted. There is\\nusually a degree of prostration which is out of proportion to the local\\nmanifestations, and may be dangerous. There may be narcosis, del-\\nirium, or great restlessness. These gastric crises recur at intervals of\\nsix weeks to six months, and will recur periodically in spite of the\\nutmost care as to diet. This disease is probably a gastric neurosis,\\nand has analogies with migraine. There is no reason to believe that\\nit is reflex in origin. It may be due to the accumulation of toxic sub-\\nstances.\\nThe vomiting of urcemia usually occurs in the morning. It is ac-\\ncompanied by nausea and depression. Whenever morning nausea and\\nvomiting occur in an adult without obvious local cause the urine should\\nbe examined. Other confirmatory signs are high-tension pulse, accent-\\nuation of the aortic second sound, and hypertrophy of the heart.\\nCerebral Vomiting. Vomiting due to cerebral disease is well recog-\\nnized. In early life it is a characteristic feature of meningitis and\\ntumor of the brain. It is likewise of moment in later life. I am\\nof the conviction, however, that it is not sufficiently recognized as one\\nof the first symptoms of apoplexy. True, we find that apoplexy occurs\\nafter a full meal, when the attack is associated with indigestion, with\\nefforts at vomiting and I do not here refer to such cases, but to cases\\nof painless, often watery vomiting, occurring without nausea and with-\\nout retching. A sudden, violent expulsion of the stomach-contents,\\nceaseless, unrelieved by remedial measures, has been seen by the writer\\nto precede other signs of apoplexy by from thirty minutes to twenty-\\nfour hours. In all cases of apoplectic character the pulse is sIoav and", "height": "4416", "width": "2656", "jp2-path": "practicaltreatis00muss_0_0848.jp2"}, "849": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 769\\nfull, while in nausea and vomiting from other causes, in the aged par-\\nticularly, it is weak and feeble. Moreover, some alteration of breath-\\ning is noticed. It is either irregular, or slow, or unduly hurried. It\\nproves the intimate relation of the vomiting and the respiratory centres.\\nFurther, strength is seen, not weakness in the apoplectic the face is\\ncongested, not pallid as in simple sick stomach. The other peculiari-\\nties of cerebral vomiting have been indicated.\\nCrises. Sudden attacks of vomiting with hyperacidity, with or\\nwithout pain, often occur in locomotor ataxia. Such attacks occur in\\nother affections, as hysteria. They occur in movable kidney, and are\\nknown as Dietl s crises.\\nDiagnosis. Vomiting is readily recognized. It is often productive\\nof serious symptoms. It may cause apoplexy or cerebral congestion\\nit may cause acute overdistention of a dilated heart, as in aortic re-\\ngurgitation. If it continues for any length of time, and much fluid is\\nejected, it is attended by anuria, and rapidly followed by collapse. It\\nalso induces thirst.\\nFlatulency. Flatulency is an accumulation of gas in the stomach\\nor intestines. It is a very common source of complaint on the part of\\npatients. Gastric flatulency is marked by a distention of the stomach,\\nwith the discomfort Avhich it occasions, and by the eructation of gas at\\nvariable intervals after the taking of food. When the gas is the result\\nof the fermentation which accompanies the production of the fatty\\nacids flatulency is frequently accompanied by pain, which is relieved\\nby eructations. When the distention is great or long continued, dis-\\nturbances in the action of the heart, particularly palpitation and inter-\\nmittency, are likely to occur. Occasionally it interferes with the\\nbreathing, and, from the apprehension which this symptom and palpi-\\ntation excite, faintness and inaptitude for mental and physical work\\nmay arise.\\nFlatulence may be due to carbonic acid, which is generated and re-\\ntained on account of motor deficiency. It is seen in the middle-aged\\nand in the old. Air swallowed with the food or the saliva is an occa-\\nsional cause. Flatulence may also be due to the regurgitation of\\npancreatic juice, as in fixation of the stomach- wall and open pylorus.\\nIt comes on four or five hours after eating, and is caused by de-\\ncomposition of the carbonates of the pancreatic juice setting free car-\\nbonic acid. Flatulence from bacterial fermentation is seen in dilatation\\nof the stomach, and is usually continuous. It also occurs in chronic\\nindigestion. Flatulence in rare instances is due to disturbance of the\\ninterchange of gas between the blood and the contents of the stomach.\\nNormally it is known as g astro-intestinal respiration.\\nExcessive flatulency is a common manifestation of hysteria. Such\\npatients may complain of something rising into the throat from the\\nstomach and smothering them (globus hystericus). There may also be\\ntympanites, and even phantom tumor. It may be necessary to anaes-\\nthetize the patient completely, to diagnosticate the latter from genuine\\ntumor.\\nVertigo. The stomach is but one of a number of sources of ver-\\ntigo. Some patients find by experience that certain articles of food,\\n49", "height": "4416", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0849.jp2"}, "850": {"fulltext": "770 SPECIAL DIAGNOSIS.\\nsuch as oysters or lobsters, have to be avoided because they produce\\nvertigo, although digestion is good, and more indigestible articles can\\nbe taken without inducing any such result.\\nIn other cases acute indigestion from overeating, particularly if it\\nresult in the development of an acid condition of the stomach, is apt\\nto be accompanied by vertigo when the stomach symptoms are most\\nsevere. Usually the vertigo is associated with headache, more or less\\nintense it is relieved by lying down and closing the eyes, but does\\nnot wholly disappear until all the symptoms gradually subside after\\nfree vomiting. Some persons are subject to so-called blind head-\\naches headaches accompanied by dimness of vision, more or less\\nmental confusion, and uncertainty of gait, possibly with staggering, and\\noften with vertigo. Such headaches appear to be due to an acid con-\\ndition of the stomach, and are relieved by alkalies or vomiting.\\nIt is difficult to separate the vertigo of chronic gastric or gastroin-\\ntestinal dyspepsia from that of lithsemia or latent gout. Probably\\nboth are due, not to any local irritation transmitted to the brain, but\\nto the circulation in the blood of toxic products of digestion which\\nact upon the brain. The vertigo is not so severe as in acute indiges-\\ntion or acute dyspepsia, but is constant. In some patients it is asso-\\nciated with an unconquerable aversion to walking alone upon the street.\\nPain. Cardialgia is a form of discomfort in the epigastrium\\nscarcely amounting to pain, but attended by heartburn or acidity.\\nGastrodynia is a violent pain spoken of as cramp or spasm of the\\nstomach. The pain is transient. Gastralgia is a form of pain with\\nfeatures like that of neuralgia, occurring when the stomach is empty.\\n(See Gastric Neuroses.)\\nLocation. Pain in the Epigastrium. Pain referred to the stomach\\nis situated in the upper zone of the abdomen, below the ensiform carti-\\nlage, between the ribs of the two sides, usually in the median line. It\\nmay be along and under the left ribs. Pain in this situation may be\\ndue to a number of causes 1. To myalgia, neuritis, or neuralgia of\\nthe intercostal nerves, which terminate in this situation. (See Abdom-\\ninal Pain.) 2. Localized peritonitis or perigastritis, which may be\\nsecondary to or caused by infection or injury of the peritoneum from\\ndisease of contiguous organs. 3. Affections of the pancreas may cause\\npain a. Pancreatic colic, a rare condition associated with diarrhoea,\\nintestinal dyspepsia, and salivation. The pain is paroxysmal, the\\nattacks lasting two or three hours. 6. Pain due to carcinoma of the\\npancreas, darting or lancinating in character, associated usually with\\ntumor, jaundice, and emaciation, c. Pain due to pancreatic hemor-\\nrhage. It is sudden and extremely severe, attended by collapse. 4.\\nPain in this situation may be due to aneurism of the aorta or of the\\ncoeliac axis. It is constant, of a boring character, and may be associ-\\nated with shooting pains along the course of the lumbar nerves. The\\nphysical signs of aneurism are present. 5. Pain in this region may be\\ndue to hepatic colic. 6. It may be due to disease of the vertebrae.\\nWe should look for the sixth or seventh dorsal vertebra to be affected,\\nhence higher up posteriorly than the area affected in front would indi-\\ncate. 7. Affections of the stomach. Of these we have a. Gastralgia", "height": "4412", "width": "2676", "jp2-path": "practicaltreatis00muss_0_0850.jp2"}, "851": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 771\\nin all its forms. (See Gastric Neuroses.) b. Acute and chronic gas-\\ntritis, c. Gastric ulcer, d. Carcinoma of the stomach. To the first\\nclass belongs a peculiar pain which occurs in locomotor ataxia, and\\nwhich, on account of its sudden onset, with alarming and frequently\\nrepeated vomiting, is known as a gastric crisis.\\nPain in the Left Hypochondrium. It may be due to a dilated stomach\\nor distended colon.\\nPain of Gastric Origin. In diseases of the stomach pain is a very\\ncommon symptom. It is of all degrees, from a mere sense of discom-\\nfort or uneasiness to agony. In atonic dyspepsia there may be no local\\ngastric symptoms except a feeling of weight and fulness, while in ner-\\nvous dyspepsia there is usually uneasiness or discomfort after eating.\\nIn gastralgia the pain is characteristic it usually comes on while the\\nstomach is empty, and frequently recurs daily at the same hour. At\\nfirst the pain is slight and easily borne, but it gradually increases in\\nseverity. Each succeeding paroxysm is worse than the preceding one,\\nuntil a climax of agony is reached. In character the pain is gnawing\\nand cramp-like, doubling the patient up, and after subsiding leaving\\nhim moist with cold sweat and in partial collapse.\\nIn catarrhal dyspepsia there are pain and uneasiness in the stomach\\nafter eating, with tenderness on pressure. If flatulence coexists, there\\nwill be temporary relief to the discomfort upon the eructation of gas.\\nIn idcer there is a more or less constant feeling of soreness in the\\nepigastrium. After taking food the dull pain is aggravated and becomes\\nsharply localized. Frequently there is pain in the back at the same\\npoint, a little to the left of the spine and between the midscapular\\nregion and the lumbar vertebrae. The pain usually occurs sooner after\\ntaking food than in the case of cancer, and is more frequently relieved\\nby vomiting. Attacks of gastralgia are not rare, and the pain may\\nshoot down the arm.\\nIn gastric cancer pain may be wholly absent throughout the entire\\ncourse of the disease but, as a rule, pain is more continuous than in\\nulcer, less severe, not so sharply localized, does not come on so soon\\nafter taking food, and is not relieved to the same degree by vomiting.\\nParoxysms of gastralgia are not so common.\\nIn acute gastritis the pain and its character vary with the intensity\\nof the inflammation. If due to the irritation of some toxic agent\\nwhich has been swallowed, the pain is severe and burning if the\\nresult of imprudence in eating and drinking, the pain is of a dull,\\nsickening character. In either case there is more or less tenderness on\\npressure. Sometimes, in mild cases of catarrhal gastritis, firm press-\\nure from a broad surface affords at least temporary relief to the dis-\\ntress.\\nTime of Pain. The significance of pain depends on the time of its\\noccurrence. Pain coming on before eating or when the stomach is\\nempty is due to gastralgia. It is relieved by food. When it comes\\non after eating, it is usually due to organic disease of the stomach, as\\nulcer or carcinoma but it may be due to neurasthenia. It must not\\nbe confounded with the pain that occurs from two to four hours after\\nmeals, caused by intestinal indigestion or some pancreatic affection.", "height": "4416", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0851.jp2"}, "852": {"fulltext": "772 SPECIAL DIAGNOSIS.\\nWhen the pain is diffused, it is due to hyperacidity and bacterial fer-\\nmentation, as in dilatation, catarrhal gastritis, and simple indigestion.\\nWhen localized, it is due to ulcer or cancer, and is associated with ten-\\nderness. It may extend to the back.\\nAlterations of Appetite. Loss of appetite, or anorexia, may be\\ndue to a number of diseases. It is present in all forms of organic disease\\nof the stomach except occasionally in ulcer. In the majority of cases of\\nthis affection it is present. It may or may not be present in gastric neu-\\nroses. Every one is familiar with the loss of appetite due to nervous\\nimpressions, as emotions, anxiety, or mental care. It is of frequent\\noccurrence in disorders remote from the stomach, which modify the\\ncondition of the organ reflexly. In the section on Vomiting will be\\nfound statements showing the influence of central disease and disease\\nof distant organs upon the stomach. Through the same channels and\\nthrough the same mechanism, and hence by the same group of causes,\\nloss of appetite may be produced. Loss of appetite is a constant\\naccompaniment of the moderate gastritis which attends all fevers.\\nReference cannot well be made to all the conditions which induce this\\nsymptom. In all forms of anaemia, in all chronic wasting diseases, and\\nin functional and organic disease of the nervous system the appetite is\\nlost. The writer has been particularly impressed with the importance\\nof determining the presence or absence of suppuration in some portion\\nof the body, in all cases in which there is loss of appetite or disgust for\\nfood, the cause of which is not of gastric origin.\\nBoulimia, or excessive appetite, sometimes occurs. It is popularly\\nthought to be due to worms in children. It is a common symptom in\\nthe earlier periods of diabetes, and is said to be present in disease of\\nthe mesenteric glands. It occurs also in gastric neuroses. Perversion\\nof the appetite, in which all sorts of substances are greedily swallowed,\\noccurs in hysteria, dementia, and pregnancy. It is known as pica.\\nRegurgitation of gases or food matter is a frequent symptom of\\ngastric disorder. It is also known as belching or eructation. It may\\nbe limited to the discharge of gas, although sometimes imperfectly\\ndigested food also regurgitates. (See Rumination.)\\nRegurgitation of the gastric juice alone causes an unpleasant taste,\\nand the fluid is hot and acrid. The juice is usually brought up in the\\nbelching of gas.\\nPyrosis, or waterbrash, is a common symptom in some forms of\\ndyspepsia. It may occur in the morning when the stomach is empty,\\nat which time large amounts of fluid are ejected. The fluid is thin\\nand watery, sometimes acid, sometimes tasteless. In other cases the\\nfluid is slightly alkaline. The fluid is ejected without vomiting.\\nSometimes the discharge begins immediately after eating. The late\\nDr. Chambers thought that the fluid was saliva which was swallowed\\nand retained in the lower part of the oesophagus by a spasm of the\\ncardiac orifice, and when a sufficient amount was collected, gushed back\\ninto the mouth. Pavy and Hand field Jones believe that the fluid is\\nsecreted by the stomach, while, on the other hand, Roberts, who found\\nthe liquid to possess diastatic power, believes it to be due to saliva.\\nAcid eructations from hyperacidity or fermentation occur one or two", "height": "4416", "width": "2676", "jp2-path": "practicaltreatis00muss_0_0852.jp2"}, "853": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 773\\nhours after meals. They rarely occur in dilatation, but are common\\nin overfeeding.\\nPalpitation. Increased action of the heart is a common symptom\\nof indigestion due to flatulency or an overloaded stomach. It occurs\\nin the middle period of life, in the anaemic and neurotic, in cardiac\\ndisease, and in those who use tea and tobacco to excess.\\nCough. Cough is a frequent symptom of gastric disorder. It may\\nbe due to the pharyngitis, which has been set up by acid eructations\\nit may be mechanical, when a distended stomach presses upon the dia-\\nphragm, or it may be reflex. Cough after meals in patients with\\ntuberculosis or other pulmonary affection is usually due to pressure\\nupon the diaphragm.\\nDyspnoea. This occurs in many cases of dyspepsia if the subject\\nis the victim of asthma, is anaemic, or subject to cardiac disease. In\\nasthma it is usually reflex in anaemia it is due to atony of the stomach\\nand gaseous accumulation in cardiac disease it is mechanical from the\\npressure of a gaseous distended stomach.\\nHiccough, or singultus, is a spasm of the diaphragm. The con-\\ntractions take place at more or less regular intervals, attended by a\\npeculiar clicking sound. This sound is due to the sudden passage of\\nair through the glottis. Hiccough may be a serious symptom. It\\nmay last but a few minutes or continue for several days. In the latter\\ncase it causes extreme exhaustion. Its occurrence in chronic disease\\nis of bad prognostic omen.\\nDrowsiness is frequently seen in dyspeptics after meals. Sleepless-\\nness is of frequent occurrence. It may be due to the irritation of food\\nremaining in the stomach over night or to the absorption of toxic products.\\nConstipation. This symptom will be discussed in the chapter on\\nIntestinal Diseases. It is present with gastric dilatation. In pyloric\\nstenosis it is always present.\\nDiarrhcea. The digestion is impaired and peristalsis is in excess.\\nLienteric diarrhoea is an accompaniment of a gastric motor neurosis,\\nor it may be due to the absence of HC1. In gastrectasia the fer-\\nmentative products set up gastro-intestinal catarrh, which induces\\ndiarrhoea.\\nThe Data Obtained by Observation.\\nThe Objective Symptoms. One of the objective expressions of the\\nmorbid process or of altered function is seen in changes in the charac-\\nter of the contents of the stomach. The contents are obtained for\\nexamination when discharged from the stomach (vomit) or when re-\\nmoved artificially (washings). Both fluids are studied by inspection,\\nincluding microscopical examination and by chemical and bacteriologi-\\ncal examination. The sense of smell enables one to differentiate many\\nvarieties of fluids. Alteration of function is also seen in alteration of\\ndigestion, and is estimated by chemical and physiological methods.\\nThe activity of the digestion must be determined by ascertaining the\\nduration of digestion and its degree of completeness, which depend upon\\nthree factors (1) The motor power (2) the absorptive power (3)\\nthe digestive power of the gastric secretions.", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0853.jp2"}, "854": {"fulltext": "774 SPECIAL DIAGNOSIS.\\nTo secure objective data, therefore, the following are necessary\\nI. Physical examination, to determine tenderness and the size, posi-\\ntion, and movement (peristalsis) of the stomach.\\nII. Examination of the gastric contents.\\nIII. Examination of the digestive power of the stomach.\\nIV. Examination of the motor power of the stomach.\\nV. Examination of the absorptive power of the stomach.\\nI. Physical Examination of the Stomach. Inspection.\\nDirect inspection of the stomach region often affords much positive in-\\nformation. When there is much loss of abdominal fat and the stomach\\nis well distended its outlines can sometimes be traced with the eye.\\nThe best position is behind and above the patient s head while he is\\nlying down. If the lower curvature can be traced considerably below\\nthe navel, the stomach is almost certainly dilated, and if, at the same\\ntime, there is a prominent swelling in the pyloric region, accompanied\\nby progressive loss of weight and cachexia, the dilatation is probably\\ndue to cancer of the pylorus. A marked groove extending from the\\numbilicus to the ribs, about or to the left of the nipple-line, is seen in\\ncases of dilatation when the stomach has fallen. It is the position of\\nthe lesser curvature. The lower border is also marked by a groove\\nextending in a curve from the pubis toward the first groove.\\nPeristaltic waves may be seen to move spontaneously, or after tap-\\nping the region or applying an ether spray or faradism. When the\\npylorus is obstructed anti-peristaltic waves may also be seen. The\\nwaves of the muscular contraction begin at the cardiac end or fundus,\\nand extend to the pylorus hence, they begin under the ribs of the\\nleft side and extend downward toward the right lower quadrant. They\\nvary in extent with the amount of dilatation. (See page 729.)\\nDistention of the stomach with carbonic oxide (see Percussion), or,\\nbetter, with air by means of a hand-bulb syringe, frequently brings\\nthe outlines of tumors of the pylorus plainly into view, while at the\\nsame time any tumor lying behind the stomach becomes less distinct,\\nand false tumors due to spasm of the gastric muscular coat vanish. Dis-\\ntention also helps to map out the whole stomach and to separate it from\\nsurrounding viscera. It enables one to estimate the size and position of\\nthe stomach. Hence, by this means descent can be told from dilatation.\\nGastrodiaphany or Transillumination of the Stomach. Einhorn has\\nsucceeded in transilluminating the stomach by an Edison lamp fastened\\nto a soft-rubber tube. The wires to the battery are carried through\\nthe tube. After the stomach contents have been removed the patient\\nis to take one or two glassfuls of water. The apparatus after lubri-\\ncation is then inserted. The examination must be made in a dark\\nroom. By means of gastrodiaphany the position and size of the stom-\\nach are determined, to a certain extent, and the presence of tumors of\\nthe anterior wall of the stomach is recognized. The results are not\\nstrictly accurate, however, as transillumination of the intestines is\\nbrought about if they are empty. The form and size of the stomach\\nare not so readily brought out as the topographic relation of tumors of\\nthe stomach and those in the vicinity of that organ. It is of service\\nin some cases to distinguish dilatation from gastroptosis.", "height": "4408", "width": "2672", "jp2-path": "practicaltreatis00muss_0_0854.jp2"}, "855": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 775\\nRontgen Light. The outline of the stomach may be observed by\\nthe use of X-rays, provided the patient has been given 10 or 20 grains\\nof subnitrate of bismuth.\\nPalpatio^. Palpation of the stomach is closely associated with\\nauscultation, inasmuch as the former also elicits sounds (succussion,\\ngurgling) which are helpful in diagnosis. The hand must be placed\\nflat upon the abdomen and pressure made by bending the ends of the\\nphalanges. To make deep palpation, gradually increasing pressure\\nwith a rotary movement must be employed. It may be of advantage\\nto palpate in the knee-elbow position, so that deeply seated tumors, if\\nmovable, may fall to the abdominal wall. (See Auscultation.)\\nBut palpation elicits information independently of auscultation,\\nchiefly in conditions of disease. Epigastric pulsation is common in\\nanaemia in nervous dyspepsia in valvular disease of the heart, par-\\nticularly tricuspid regurgitation, producing a liver-pulse and in the\\nrare cases of aneurism of the abdominal aorta.\\nIncreased resistance may be due to the hypertrophy of the muscular\\ncoat which coexists with distention of the stomach. When the stomach\\nis shrunken and the resistance increased, it may be due to a diffused\\ncarcinoma of the walls of the stomach or, rarely, to the so-called\\nfibroid stomach, the atrophy and thickening of the walls being due\\nto chronic gastritis.\\nIncreased resistance limited to the pylorus is found in carcinoma.\\nThe same effect produced by a tense right rectus muscle must be ex-\\ncluded.\\nPosition of Gastric Tumors. Cancers of the pylorus are situated\\nusually between the xiphoid cartilage and the umbilicus, frequently a\\nlittle to the right of the median line but they may be found below\\nthe umbilicus, and, exceptionally, still lower down. Adhesions to\\nneighboring organs commonly prevent the tumor from being moved.\\nWhen it has formed adhesions to the liver or diaphragm it moves with\\nrespiration.\\nAs a rule, tumors due to gastric cancer are small, hard, and irregu-\\nlar, and gradually increase in size.\\nNon-malignant tumors are occasionally found, and also tumors due\\nto adhesions around old ulcers, and to puckered scars. The latter are\\ndistinguished from cancerous tumors, not by the physical examination,\\nbut by their duration and clinical history.\\nAnother method of determining the position and size of the\\nstomach is by internal exploration combined with external palpation.\\nA bougie is introduced into the stomach and swept over its entire in-\\nternal surface, the position of the bougie being followed from point to\\npoint by the palpating hand. This method is not advisable when it is\\npossible to make a diagnosis without it.\\nPain and Tenderness. Tenderness is elicited by palpation in gas-\\ntritis, in dyspepsia, especially the catarrhal form, in ulcer, and in\\ncancer. In gastritis and dyspepsia the tenderness is usually diffuse\\nand is not constant in cancer the tenderness is usually limited to the\\nseat of the tumor, but is not so marked nor so sharply localized as in\\nulcer. In ulcer tenderness is rarely absent even when there is no", "height": "4416", "width": "2612", "jp2-path": "practicaltreatis00muss_0_0855.jp2"}, "856": {"fulltext": "776 SPECIAL DIAGNOSIS.\\npain, it is very decided, and is so localized, sometimes, that it can be\\ncovered with the tip of the finger. Pain in the stomach from ulcer is\\nchronic, circumscribed, and variously described as burning and wound-\\nlike. It is aggravated by palpation, and by food or drink, especially\\nhot stimulating drinks, and relieved by cold, soothing drinks. It is\\naccompanied frequently by pain in the corresponding vertebrae.\\nDiffuse pain is met with in acute and chronic gastritis, and in cancer\\nof the stomach-walls.\\nPercussion. Position of the Stomach. (Plate XXXVIII., Fig. 1.)\\nThe stomach does not occupy a fixed position, and is a distensible\\norgan. It is depressed by downward pressure of the diaphragm in\\ndeep inspiration, by emphysema, left pleural effusions, enlargements\\nof the liver and spleen, and tight lacing it is raised by any causes\\nwhich greatly distend the bowels or peritoneal cavity tympanites,\\nperitoneal effusions, tumors, etc. Moreover, after food is taken, the\\nstomach is distended and its position changed, being rotated anteriorly\\nfrom below, the greater curvature rising and looking more forward,\\nwhile the anterior surface has a more upward presentation.\\nThe cardiac orifice of the stomach is fixed by its passage through\\nthe diaphragm and by peritoneal attachments which it receives there.\\nIt is behind the sternal insertion of the left seventh rib. The pylorus,\\non the contrary, is freely movable when the stomach is empty it is\\nnearly in the median line, but when the stomach is full it is pushed\\nseveral inches to the right it lies between the right sternal and para-\\nsternal lines, on a level with the tip of the xiphoid cartilage.\\nObrastzow (JDeut. Arch, fur Min. Medicin, Bd. xliii. 5, 417-456)\\ndivides the space between the navel and the xiphoid cartilage into\\nthree equal parts, and says that the lower border of the stomach, both\\nin men and in women, is in the lower or supra-umbilical third.\\nIn children under fifteen years the lower border rarely extends to\\nthe umbilical line after fifty years, on the contrary, it often extends\\nbelow the navel. In conditions of bad nutrition it falls nearly to the\\nnavel.\\nAccording to Pacanowski and Wagner, the upper border of the\\nstomach, in the left parasternal line, lies at the lower border of the fifth\\nrib or in the fifth intercostal space, rarely at the fourth rib or in the\\nsixth intercostal space. In the left nipple-line it lies from the fifth\\ninterspace to the sixth rib, occasionally in the fourth interspace or at\\nthe seventh rib. In the anterior axillary line it lies at the lower\\nborder of the seventh or eighth rib, rarely above the sixth rib, never\\nunder the eighth rib.\\nTraube has called special attention to the left lower portion of the\\nthorax which projects over the stomach, the half -moon-shaped space.\\nThe upper limit is a crescentic line starting from the sternum in the\\nsixth interspace and extending, in a curved line corresponding approx-\\nimately to the curve of the rib, to the axillary line. It is known as\\nTraube s line. In health this space gives a tympanitic note, unless\\nthe stomach or transverse colon is full, or the omentum very fatty.\\nIn left pleural effusion it is dull. (See Diseases of Lungs.)\\nA part of the anterior portion of the stomach and its lower border", "height": "4416", "width": "2680", "jp2-path": "practicaltreatis00muss_0_0856.jp2"}, "857": {"fulltext": "PLATE XXXVIII\\nFIG. 1.\\nSolid red\\nNormal Position and Displacements of the Stomach.\\nline _Normal position of distended stomach. Bine line-Atonic\\nclililation. Dotted reel line\u00e2\u0080\u0094 Gastroptosis.\\nFIG 2.\\nTumorj^\\n~J Sjdash y/;;\\nMv\\nN3\\no\\nCarcinoma of the Stomach with Pyloric Stenosis.\\nMetastases in the Liver.", "height": "4392", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0857.jp2"}, "858": {"fulltext": "", "height": "4392", "width": "2672", "jp2-path": "practicaltreatis00muss_0_0858.jp2"}, "859": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 777\\ncan be determined by percussion. Ordinarily, the most suitable posi-\\ntion for examining the stomach is the recumbent one, with the knees\\ndrawn up, so as to relax the abdominal muscles.\\nThe stomach contains air at all times, but the amount varies greatly.\\nThe percussion-note is tympanitic, high in pitch, frequently with a\\nmetallic ring its quality is peculiar stomach tympany.\\nThe percussion-area of the stomach is increased (1) by causes exter-\\nnal to the stomach contraction of the liver, old pleurisy with retrac-\\ntion of lung, emphysema, former pregnancies, bad nutrition, and\\ntumors pulling down the stomach (2) by intrinsic causes distention\\nof the stomach.\\nConversely, the percussion-area is diminished by causes external to\\nthe stomach enlargement of the liver and spleen, left-sided pleural\\neffusion, pneumothorax, and hypertrophy of the heart.\\nActual diminution in size of the stomach itself is difficult to demon-\\nstrate clinically with certainty. If upon inflation the great curvature\\nremains at a higher level than 3 to 5 cm. above the umbilicus, diminu-\\ntion in size is highly probable. But even then the lower border may\\nbe prevented from descending by adhesions to surrounding viscera.\\nEnlargement of the stomach is generally due to dilatation, and is\\nbest marked clinically by a low position of the greater curvature.\\nDilatation of the stomach, according to Boas, can be separated from\\ndescent of the organ only when the greater curvature is more or less\\nbelow the level of the navel, and when the greatest height of the stom-\\nach exceeds 10-14 cm. (4 to 5 J inches). But descent and dilatation\\nare frequently present together. (Plate XXXVIII., Fig. 1.) It\\nmust not be forgotten that when there is descent the normal tympany\\nis lowered and the tympanitic area above the ribs is replaced by dulness.\\nSometimes when the stomach is distended by air the right margin\\nwill be seen to extend far beyond the ordinary limits. Michaelis\\npoints out that this may be due to defective motor power, especially\\nif the right margin is more than 9 cm. from the median line. The\\ndistention to the right is due to actual enlargement and not to disloca-\\ntion. The author believes that dilatation of the antrum of the pylorus\\ncauses this enlargement. Enlargement of the stomach downward is\\nusually associated with good motor power, whereas enlargement to the\\nright is an indication of feeble motor power.\\nAuscultatory percussion is a most satisfactory method of determining\\nthe borders of the stomach and its size. Its area can readily be de-\\nfined from that of the liver, spleen, and colon First, with the stomach\\nnormal second, inflated by gas third, filled with fluid. It is well\\nto determine the results in the recumbent posture, and then in the\\nupright, so as to determine if the stomach falls from its normal posi-\\ntion. Liquid maybe injected through the stomach-tube, or the patient\\nmay drink successive portions, percussion being employed after each\\namount (eight ounces) taken. After the site of the dulness is fixed,\\nhave the patient lie down. The fluid falls backward and the air in\\nthe stomach comes anteriorly the dull note is replaced by a tympan-\\nitic note. The change is a sign the fluid is in the stomach, and serves\\nto distinguish stomach from colon tympany. The force required for", "height": "4416", "width": "2640", "jp2-path": "practicaltreatis00muss_0_0859.jp2"}, "860": {"fulltext": "778 SPECIAL DIAGNOSIS.\\npercussion should be very light indeed, a fillip with the nail is some-\\ntimes sufficient. It may even be well to allow the blow to glance from\\nthe surface, as the perpendicular stroke brings out the general abdomi-\\nnal resonance. The use of coins is sometimes of advantage. In dila-\\ntation of the stomach the percussion-note sometimes varies in tone over\\nthe viscus from dull to tympanitic, or vice versa, because the organ con-\\ntracts under the influence of the blows. Some have described a clink-\\ning percussion-sound, not unlike that of the cracked pot, over the\\nthorax.\\nAuscultatory friction is also employed in the same manner as auscul-\\ntatory percussion, while rubbing the finger tips over the surface lightly.\\nAs long as the rubbing is made over the hollow organ over which the\\nstethoscope is placed, and not moved more than two inches from it,\\nthe friction is heard distinctly.\\nIn order to separate stomach tympany from that of the colon, which\\nresembles it, the stomach may be distended with gas, while the colon\\ncontains solid or liquid matter or, if the colon be filled with gas, the\\npatient may be allowed to stand and drink a glass or two of water.\\nIn either case the contrast between a dull and a clear note marks the\\nboundary between stomach and colon.\\nZiemssen recommends carbonic acid (developed by mixing sodium\\nbicarbonate and tartaric acid) to distend the stomach the quantity\\nemployed for adult men is seven grammes of bicarbonate of soda and\\nsix grammes (one and one-half drachms) of tartaric acid. Adult\\nwomen should receive one gramme less of each.\\nAs carbonic acid sometimes causes an uncomfortable oppression,\\nordinary air is preferred by some. It can be forced in by a hand-\\nbulb syringe attached to an ordinary stomach-tube. The percussion-\\nnote over tumors of the pylorus is imperfectly tympanitic. Welch\\ndescribes it as tympanitic dulness. Less frequently it is dull, and\\nrarely it is flat.\\nAuscultation. Auscultation can determine whether or not there\\nis obstruction at the cardiac orifice. On listening over the oesophagus\\nwith the stethoscope, when the patient is swallowing a liquid, a spurt-\\ning sound is heard, followed in from five to ten or twelve seconds by\\na second sound, which marks the escape of the fluid from the cardiac\\norifice of the oesophagus into the stomach, so-called deglutition-mur-\\nmur. When there is obstruction of the cardiac orifice the second\\nsound may be delayed as long as a minute.\\nWhen the stomach is partly filled with fluid a succussion or splashing\\nsound can be produced by moving the patient quickly from side to\\nside, or by quickly compressing the stomach and allowing it to rebound\\nagain immediately. Such compression may be made alternately, first\\nin the neighborhood of the fundus of the stomach and then in the\\nregion of the umbilicus. Both hands should be employed. The\\nsplashing sounds are also developed by rapidly tapping, with the finger\\ntips held perpendicularly, the region between the ribs and the trans-\\nverse umbilical line on the left side. The ear need not be applied to\\nthe body, but kept near by while the movements are made. Such\\nsounds are abnormal if they are heard long after digestion should be", "height": "4400", "width": "2744", "jp2-path": "practicaltreatis00muss_0_0860.jp2"}, "861": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 779\\ncompleted and the stomach empty. If they are heard more than three\\nhours after a light, or six hours after a full meal, it indicates slow\\ndigestion or deficient motility, and gives the approximate position of\\nthe lower boundary of the stomach.\\nNormally, after drinking fluids, a splashing sound is not developed\\nlower than the umbilical line. If it is heard below this line, it is an\\nindication of dilatation or of deep position of the whole stomach. Dil-\\natation is very probable if the splashing sound is heard below the navel\\nin a fasting stomach. A good idea of the extent and location of the\\nsplashing, and hence of the lower boundary, can be secured, if aus-\\ncultation is conducted when inflation is practised with air.\\nFurthermore, this sound is a sign of atony. If 50 to 100 grammes\\nof water be swallowed, no splashing sound is heard unless there is\\natony of the stomach-walls but, if the atony is pronounced, a smaller\\nquantity will be sufficient to develop the sound. It is to be remem-\\nbered that the splashing sound of itself does not indicate disease. It\\nis significant only when taken with other signs, and also when it is\\nfound after more than one examination.\\nII. Examination of the Gastric Contents. Either the con-\\ntents are secured with a stomach-tube or the vomitus is examined.\\nMode of Procedure. 1. A test-breakfast (Ewald), or a test-dinner\\n(Leube), is administered, or the fasting stomach contents removed.\\nEwakVs test-breakfast It consists of one or two ounces (35 grammes)\\nof bread and a cup of tea (j- litre), or the same amount of water.\\nLeube-Riegel test-dinner A large plate of soup (400 c.c), a large por-\\ntion of beefsteak or other meat, some potatoes, and a roll are taken,\\nand examination is made three or four hours after the meal. (See\\nBoas Meal. Lactic Acid.) 2. Remove the contents of the stomach\\none hour after breakfast is taken, by aspiration or by expression.\\nAspiration consists in the withdrawal of the stomach-contents by suc-\\ntion either with the ordinary stomach-pump, by means of a bottle\\nexhausted of air, as employed for paracentesis, and connected with the\\nstomach-sound, or by connecting the sound with a hand-ball aspirator\\nor Politzer bulb.\\nExpression consists in compression by the abdominal muscles, as if\\nstraining in defecation. The patient takes a deep inspiration and then\\ncontracts the muscles as above. If the tube is long enough it can be\\nbent, so as to assist expression with siphonage.\\nAspiration is less disagreeable to the patient, and is necessary when\\nthe stomach-contents are not fluid enough to flow easily.\\nExpression is not to be employed when there are old ulcers, ulcer-\\nating carcinoma, phthisis with antecedent haemoptysis, or a disposition\\nto menorrhagia.\\nThese methods supply the most reliable information of the condition\\nof the stomuh and its secretions because, when once withdrawn, the\\ncharacter of the secretions can be ascertained accurately and the quan-\\ntity measured moreover, being able to choose the time of examination,\\nwe can decide whether or not what is found corresponds with health, and\\nif not, in what particular it indicates disease. These methods permit a\\ndiagnosis to be made before other methods supply sufficient data.", "height": "4416", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0861.jp2"}, "862": {"fulltext": "780 SPECIAL DIAGNOSIS.\\nA soft-rubber tube, with two good-sized openings near its distal ex-\\ntremity, should be selected. Stockton suggests a tracing of rings\\naround the tube one inch apart, beginning twenty inches from and\\nending thirty inches from the lower extremity, for the purpose of\\nmeasuring the length of the tube inserted. In healthy adults the dis-\\ntance from the incisor teeth to the lower border of the stomach is about\\ntwenty-two inches. In dilatation it may be from twenty-four to\\nthirty. The distance is partly determined by success in the siphon-\\nage. If the return flow of fluid does not take place, it is well either\\nto withdraw the tube or push it further on for, if too long, it may\\ncurve above the level of the fluid, or, if too short, it may not reach\\nthe fluid.\\nAfter the tube is moistened, oiled, or coated with the white of an\\negg, the patient should be seated, and the tube at once passed to the\\nback of the pharynx, and, with or without guiding by the finger,\\npushed toward the oesophagus. It is at once grasped by the oesopha-\\ngus or lower pharynx, and, if the patient is instructed to swallow and\\nto breathe slowly, it is rapidly carried downward by deglutition.\\nMucus that accumulates in the mouth after the tube is passed should\\nbe allowed to dribble outward and not be swallowed. It is often of\\nadvantage to reassure the patient by having him pronounce the letter\\na or some small syllable. It is not necessary to extend the head\\nbackward. The tube is then attached to the apparatus used for para-\\ncentesis, or to a tube entering a bottle in which a vacuum is created by\\nan ordinary rubber bulb apparatus or to the aspirator of Boas, which\\nis a modification of the ball-syringe. A valve is placed between the\\nstomach-sound and the syringe.\\nIf a hard tube is used, it must be guided by the operator, who\\nshould stand back of the patient, supporting the head, which should\\nnot be thrown too far backward. The tube can be passed by the oper-\\nator seated in front of the patient. This kind of tube is used with\\nthe stomach-pump.\\nNormal Gastric Contents. The amount of fluid, after digestion\\nof a test-breakfast m has continued for one hour, is from 30 to 40 c.c.\\nAfter filtering the filtrate is clear, yellow, or yellowish-brown in color.\\nIf the digestion is normal, the fluid should contain free hydrochloric\\nacid and no lactic acid. It should also contain pepsin, rennin (the\\nmilk-curdling ferment), and organic acids. Albuminoids should be\\nconverted into proteoses and peptone, and starches into achroodextrine,\\ndextrose, or maltose.\\nPhysical and Chemical Examination. The steps taken are\\nas follows\\nA. Physical examination\\n1. The reaction.\\n2. The odor.\\n3. The character and quantity. Inspection.\\nB. Chemical examination.\\nIt is to be observed that perfect familiarity with the products of\\nand the length of time required by normal digestion is very essential.\\n1. Reaction. The normal reaction of the contents of the stomach", "height": "4412", "width": "2712", "jp2-path": "practicaltreatis00muss_0_0862.jp2"}, "863": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 781\\nis usually acid, from the hydrochloric acid of the gastric juice. It\\nmay be alkaline in cases of hemorrhage, or in the vomiting known as\\nwaterbrash.\\n2. Odor. The odor is sour normally, but it may be aromatic from\\nthe presence of the fatty acids, fecal in obstruction of the bowels with\\nfecal vomiting, and, finally, may indicate the nature of poisonous in-\\ngesta ammonia, phosphorus, carbolic acid. The dark, frothy mate-\\nrial from a dilated stomach is of a foul, yeasty odor.\\n3. Inspection of the Stomach-contents. By ordinary inspec-\\ntion the quantity and the charade?* of the vomitus or stomach-contents\\nare noted. With the aid of the microscope the various micro-organ-\\nisms are sought for. In this manner most valuable information as to\\nthe digestive, motor, and absorptive power is ascertained. Not only\\ndo we learn whether digestion has taken place or not, but also the\\nvariety of food that is undigested\u00e2\u0080\u0094 albuminoids or hydrocarbons.\\nThe Quantity. Fasting Stomach. If a person has taken no food or\\ndrink between the evening meal and the following morning, the\\nstomach should not contain more than three and one-half fluidounces\\nmore than this is abnormal.\\nThe Character. By it we learn the digestive power. If undigested\\nfood is found after digestion should be normally completed, there is\\ndeficient digestive energy. No undigested food should be found longer\\nthan six or seven hoars after an ordinary meal of mixed foods.\\nBy inspection of the gastric contents we learn much regarding the\\nmotor power. Boas states that an abnormally great quantity of solid\\nmatter and a small amount of chyme indicate an abnormal retention of\\nthe latter, which is usually brought about by motor weakness (atony,\\ndilatation of the stomach), or dilatation in conjunction with insufficient\\nabsorptive power. Sometimes, when there is a large residue in the\\nstomach, the contents separate into three layers. The uppermost is\\nmucus or undigested food the second, generally the thickest layer,\\nconsists of fluid and the lowest layer is chyme. Such a formation,\\nhe says, points to abnormally long retention as the result of stenosis\\nand consecutive dilatation, or to motor weakness.\\nThe stomach should be empty much sooner if only starches are\\ntaken, as in Ewald s test-breakfast. One hour after the administra-\\ntion of a test-breakfast of 35 grammes of white bread and 300 grammes\\n\u00e2\u0080\u00a2of water there should remain 40 c.c. Hence, if after such a break-\\nfast there is found a much greater quantity, then motor or absorptive\\ninsufficiency may be considered to exist. A filtrate of 100 to 300 c.c.\\nis very probably due to organic obstruction to the outflow, stenosis of\\nthe pylorus, adhesions, or dislocation of the pylorus. Of course, to\\nmake sure that the stomach contains nothing at the time of giving the\\nbreakfast, it must first be emptied. The character of the food taken\\nis observed, as undigested particles may be seen in the contents.\\nWe can discover by inspection if food is brought up by vomiting or\\nregurgitation. Regurgitation of food from the oesophagus can be told\\nfrom vomiting by the appearance of muscle-fibres, if meat has been\\ntaken. If it is vomited, the fibre is in a state of disintegration if\\nnot, it is whole.", "height": "4416", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0863.jp2"}, "864": {"fulltext": "782 SPECIAL DIAGNOSIS.\\nMucus is found in small quantity normally, but is increased in\\ncatarrhal affections of the mouth, throat, or stomach. When its source\\nis the mouth, saliva also is generally present. Mucus is recognized by\\nits stringy, tenacious character. Chemical diagnosis. Add the mucus,\\ngently shaking, to cold water pour off the supernatant water add\\na little liquor potassse. The mucus is dissolved by the alkali. To\\nthe solution add acetic acid a precipitate is formed which is insol-\\nuble in an excess of acetic acid. In this manner mucus is distin-\\nguished from the precipitate of syntonin, as the latter is soluble in\\nan excess. Pigmented mucus in vomitus is usually from the bronchial\\ntubes.\\nBile and intestinal juice may be regurgitated into the stomach as the\\nresult of violent emesis, or when the pylorus is much relaxed, or in\\nstenosis of the duodenum below the common duct bile is then present\\nin large quantity if the stomach is dilated. 1 Bile is recognized by the\\nusual tests (see under Examination of Urine), and intestinal juice by\\nits peculiar properties and the presence of leucin and tyrosin. Absence\\nof bile in the vomitus is an indication of pyloric stenosis.\\nBlood is found in ulcer cancer acute, especially toxic, gastritis\\ninjuries to the mucous membrane from the use of the sound for expres-\\nsion, and violent retching. It is also common in cirrhosis of the liver,\\nand may occur in purpura, peliosis rheumatica, the hemorrhagic\\ndiathesis, and in yellow fever. Blood mixed with gastric mucus may\\ncome from the lung, the act of coughing having excited vomiting.\\nIf the blood is unaltered, it can be distinguished from all other sub-\\nstances by microscopic examination. Occasionally the blood has the\\nappearance of coffee-grounds. The hemorrhage has taken place slowly\\nunder these circumstances. In fact, the more rapid the bleeding the\\nbrighter the red color of the blood. The hcemin test serves to distin-\\nguish it. The suspected material is filtered and a little of the nitrate\\nevaporated in a watch-glass when dry a small portion is mixed with\\nfinely pulverized salt upon a glass slide it is then covered with a\\ncover-glass and one or two drops of glacial acetic acid allowed to flow\\nunder the cover-glass. The acetic acid is evaporated by slowly heat-\\ning the slip over a small flame, and when dry a few drops of water\\nare allowed to flow under the cover-glass, to dissolve the salt. If the\\nvomit contained blood, brown rhombic crystals of hrenrin (hydrochlo-\\nrate of hsemin) will appear under the microscope. As they are very\\nsmall, a magnification of about 300 diameters will be necessary to\\nbring them readily into view. The guaiacum test may be fallacious,\\nas the same color-reaction takes place when bile or saliva or a starch,\\nlike potato, is in the test-liquid. It is performed as follows Add two\\nor three drops of the tincture of guaiacum to a small portion of the\\ngastric contents in a test-tube and pour ozonic ether on the surface.\\nWhen the liquids meet a blue color develops. Bile may be distin-\\nguished from blood by Gmelin s test for the former color-reaction\\nwith nitric acid. If blood is present in the stomach-contents, it may\\nbe detected by the test for iron. To the gastric contents, coffee-\\n1 Hochhaus. Berlin, klin. Woch., 1891, No. 17.", "height": "4400", "width": "2712", "jp2-path": "practicaltreatis00muss_0_0864.jp2"}, "865": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 783\\ngrounds/ in a porcelain capsule, add a small quantity of potassium\\nchlorate and a few drops of a strong acid, HC1. Heat over a flame\\nand add a few drops of a 5 per cent, solution of potassium ferrocya-\\nnide. If iron is present, Prussian blue is formed.\\nPus is rarely present in sufficient quantity to be detected by the\\nnaked eye, but it sometimes occurs in phlegmonous gastritis and when\\nan abscess has ruptured into the stomach. In microscopic amounts\\nit may be found in severe catarrhal affections. Pus may be in\\nthe vomitus and yet come from the lungs. It is usually a muco-\\npus, and is told by the pigmented pellets or strings of mucopurulent\\nmaterial.\\nFecal matter is vomited in complete obstruction of the bowels, and,\\naccording to Vierordt, in severe diffuse peritonitis. It is recognized\\npartly by its appearance and partly by its odor.\\nWorms are sometimes vomited the round worms not so very infre-\\nquently oxyurides and ankylostomata rarely.\\nFig. 196.\\nMicroscopical appearance of stomach-contents.\\n1, red blood -corpuscles 2, leucocytes; 3, squamous epithelium; 4, fat-globules; 5, starch gran-\\nules; 5 starch changed by action of the gastric juice 6, muscular fibre 7, sarcinse ventriculi\\n8, fat-crystals 9, piece of orange 10, phosphatic crystal 11, yeast fungi 12, bacilli and micrococci\\nMicroscopical Examination. The illustration (Fig. 196) shows the\\nvarious matters which may be found in vomited matter. Briefly, they\\nare columnar and squamous epithelium white blood-corpuscles acted\\non by gastric juice red blood-corpuscles. The corpuscles are usually\\nisolated. The red are rarely perfect, and in the white little more than\\nthe nucleus remains. From the food we may also find muscle-fibres,\\nfatty globules, and fat-needles, elastic fibres and connective tissue,\\nstarch-granules, and vegetable cells. Muscle-fibres are recognized by\\ntheir transverse striation. Fat-globules are soluble in ether, and are\\nrecognized by their refracting powers. Starch-granules stain blue\\nwith iodo-potassic-iodide solution.\\nIn addition, fungi of many forms are found, as the mould-fungi", "height": "4404", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0865.jp2"}, "866": {"fulltext": "784 SPECIAL DIAGNOSIS.\\nthe yeasts (torulse), and fission-fungi. The latter are recognized after\\nstaining by the iodo-potassic-iodide solution, which colors them blue.\\nThe most important fission-fungi are the sarcinse ventriculi. They\\nare of a dark gray tint, stain mahogany-brown to reddish-brown with\\nthe above-mentioned solution, and resemble in shape corded bales of\\ngoods. (See Bacteriological Diagnosis.) The torulce and sarcince are\\npresent when fermentation is in progress, and hence indicate delayed\\ndigestion from motor insufficiency or deficient digestive energy.\\nB. Chemical Examination. A chemical examination is made to\\ndetermine (1) the presence of free acids (2) the degree of total acidity\\nof the stomach-contents (3) the presence of free HC1 (4) the presence\\nof lactic acid (5) the presence of volatile acids (6) the presence of\\nproducts of digestion and the digestive power (7) the presence of\\npepsin (8) the presence of rennin (9) the carbo-hydrates. Hydro-\\nchloric acid is the normal acid of the gastric juice. Normally lactic\\nacid is found during the first half-hour of digestion, when starches\\nhave been taken. When only meats have been taken lactic acid is\\nnot found early in digestion. The secretion of hydrochloric acid is not\\ndelayed until then, but is at first combined, and cannot be detected\\nas free acid until half or three-quarters of an hour afterward.\\n1. Free Acids. The most sensitive test for free acids is Congo red.\\nFilter-paper soaked in a saturated solution of the dye and allowed to\\ndry is turned a deep blue if free acid is present. Prepared with a\\nweak solution, the filter-paper is turned to a light blue by HC1 and\\nviolet by organic acids. Wolff was able to detect one part of HC1\\nin 20,000 parts of water. When no reaction is obtained, therefore,\\nentire absence of acidity may be assumed.\\nBenzo-purpurin test-papers are made as follows Soak strips of\\nfilter-paper in a saturated solution of benzo-purpurin and dry. They\\nare purple. If hydrochloric acid is present they are turned dark blue.\\nThe color is not removed by shaking with ether. If organic acids\\n(butyric or lactic) are present, it is turned brownish-black, but the\\ncolor is removed by shaking with ether. Von Jaksch states that if\\nhydrochloric acid and the organic acids are present a brownish-black\\ncolor is also produced, hence the dark blue and the volatile brownish-\\nblack reactions only are important.\\nThe presence of free acids, as indicated by the Congo red or benzo-\\npurpurin tests, shows that\\na. HC1 inorganic acid may be present alone.\\n6. Lactic, butyric, or acetic acid organic acids one or all, may be\\npresent without HC1.\\nc. HC1 and one or more of the organic acids may be present together.\\nFree acidity may be due (1) to fixed acids\u00e2\u0080\u0094 hydrochloric or lactic\\nacid, fixed acidity (2) to volatile acids butyric or acetic acid, volatile\\nacidity.\\n2. The Total Acidity. This is determined by titration. The\\nstomach-contents must be well shaken if there is mucus in excess, it\\nmust be strained off through coarse muslin. Fill a Mohr s burette\\n1 Trans. Philadelphia County Medical Society, 1889, vol. x. p. 305.", "height": "4416", "width": "2732", "jp2-path": "practicaltreatis00muss_0_0866.jp2"}, "867": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 785\\nwith a decinormal solution of caustic soda. 1 To 10 c.c. of the filtered\\ngastric fluid add two drops of a saturated alcoholic solution of phe-\\nnolphthalein. Allow the caustic-soda solution to drop slowly from the\\nburette into the fluid, until a faint rose-red color is produced which does\\nnot disappear on shaking. The color is produced by the action of\\nthe alkali on the phenolphthalein. Four to 6 c.c. of the caustic soda\\nsolution are required to neutralize the acid in normal digestion. The\\ndegree of acidity is expressed in percentage. Thus if 4 c.c. neutralize\\n10 c.c, the total acidity will amount to 40 per cent., or if 6 c.c. are\\nrequired, to 60 per cent.\\nIf more or less than the amount just indicated of the alkaline solu-\\ntion is required to neutralize the acid, the total acidity is increased or\\ndiminished, and hence is abnormal.\\nTopfer s method To 10 c.c. of stomach-contents in a beaker, add\\n3 to 4 drops of a 1 per cent, solution of sodium alizarin sulphonate,\\nthen add a decinormal solution of sodium hydrate until a violet tint\\nappears corresponding to the hue produced by adding 4 drops of\\nalizarin solution to 5 c.c. of a 1 per cent, solution of sodium carbonate.\\nThe solution reacts to all factors producing gastric acidity except com-\\nbined HC1.\\nMartin recommends the following modification of the above To\\n20 c.c. of the stomach-contents add three or four drops of a saturated\\nalcoholic solution of phenolphthalein, and dilute with water to 300\\nc.c. Place 150 c.c. of this mixture in each of two flasks, and place\\nthem side by side on a sheet of white paper. To one of the flasks add\\ndecinormal solution of sodium hydrate until a red color appears the\\nexact time of appearance can be determined by comparison with the\\nliquid in the other flask. When a pinkish tinge appears the acid\\nliquid is neutralized. A control estimation may be made with the\\nsecond flask.\\nEwald s method of expressing the total acidity is by a number.\\nThe number is the same as the quantity of decinormal sodium hydrate\\nsolution requisite to neutralize 100 c.c. of the gastric contents. Thus\\nif 50 c.c. of the soda solution neutralized 100 c.c. of the stomach-con-\\ntents, the acidity of the latter would be expressed by the figure 50.\\nThe figures can be converted into terms of hydrochloric acid, as a deci-\\nnormal solution of sodium hydrate is a liquid of a constant strength,\\n100 c.c. of which exactly neutralize 0.365 gramme of hydrochloric\\nacid. It may be expressed in terms of hydrochloric acid. If 50 c.c.\\nof decinormal sodium hydrate are required to neutralize 100 c.c. of the\\nstomach-contents, this would be equal to 0.18 gramme per cent, hydro-\\nchloric acid, as 3.65 grammes hydrochloric acid are neutralized by the\\n4 grammes of soda in a litre (1000 c.c.) of the decinormal solution.\\n3. Free Hydrochloric Acid. The gastric contents are now\\nfiltered. Tropceolin 00 is declared by Boas to be an absolutely certain\\ntest for HC1. A saturated alcoholic solution is of an orange-yellow\\n1 Decinormad solution of sodium hydrate is of the strength of 4 grammes of\\npure sodium hydrate to the litre of distilled water. The sodium hydrate must be\\npure and made from sodium. This weight of sodium hydrate (4 grammes) will exactly\\nneutralize 3.65 grammes of hydrochloric acid.\\n50", "height": "4416", "width": "2588", "jp2-path": "practicaltreatis00muss_0_0867.jp2"}, "868": {"fulltext": "786 SPECIAL DIAGNOSIS.\\ncolor. Three or four drops of it are placed in a white porcelain dish\\nand spread upon the sides by rotating it. The same amount of the\\nfluid to be tested is then allowed to trickle down the sides of the dish\\nand intimately mixed with the tropseolin. (Or evaporate the dye to dry-\\nness and then add the suspected liquid.) Upon heating the dish over\\na small flame splendid lilac-blue to blue streaks, characteristic of HC1,\\nwill appear if that acid is present. No organic acid gives the same\\ncolor.\\nTropseolin paper is turned brown by gastric juice containing HO,\\nthe brown changing to blue upon the paper being heated. Organic\\nacids give a brown color also, but it disappears upon heating.\\nTopfer s test for the detection of free HC1 is as follows Dimethyl-\\namidoazobenzol is employed in a 0.5 per cent, solution of alcohol.\\nTo a few cubic centimetres of filtered stomach-contents one to four\\ndrops of the reagent are added in a test-tube or beaker. If hydro-\\nchloric acid is free a rose-red color is produced when the filtrate is\\nadded to the reagent. The drug reacts to HC1 only when the latter\\nis in a free state. Its reaction is not interfered with by salts, peptone,\\nglucose, chloride of sodium, or starch. If organic acids are present\\nin a concentration of from 0.5 to 0.8 per cent, a reaction may be\\nbrought about, providing albumin or peptone is present.\\nPhloroglucin vanillin, introduced by Giinzburg, is also a very sensi-\\ntive test for HC1. The following combination is said by Boas to be\\nmore sensitive than the ordinary one, which contains only 30 grammes\\nof absolute alcohol\\nPhloroglucin 2.0 (gr. xxx).\\nVanillin 1.0 (gr. xv).\\nAlcohol (80 per cent 100.0 (fgiij).\\nThree drops are put into a porcelain dish and an equal quantity of\\nthe stomach filtrate. Upon cautious heating over a small flame a beau-\\ntiful carmine surface is formed, especially at the edges. The same\\ncolor is not produced by inorganic acids. Filter-paper soaked in it and\\nmoistened with a few drops of stomach-filtrate, containing HC1,\\nchanges on heating to a beautiful carmine, which is unaltered upon the\\naddition of ether. Gunzburg s original test is employed with the same\\nsolution, except that 30 parts of alcohol are used. One drop of the\\nsolution and one drop of the fluid to be examined are evaporated to\\ndryness on a water-bath. The appearance of a rose-red color indicates\\nthe presence of hydrochloric acid.\\nCongo-red Test. Boas method is a modification of that of Mintz.\\nTen c.c. of the gastric fluid are shaken with 100 c.c. of ether until\\norganic acids are removed. The Congo-red test is then employed\\nuntil the grayish-blue discoloration cannot be secured.\\nBoas Resorein Test. Dissolve 5 grammes (gr. lxxv) of resorcin\\nand 3 grammes (gr. xlv) of cane-sugar in 100 c.c. (f\u00c2\u00a7iijss) of weak\\nspirit. Apply the test in exactly the same way as Gunzburg s. A\\nsimilar rose-red coloration, if free hydrochloric acid be present, is pro-\\nduced. It is the cheapest solution that can be employed.\\nCaution. In testing for the presence of HCl it is better to give the\\npatient a meal which is known to be digestible within a certain time", "height": "4416", "width": "2720", "jp2-path": "practicaltreatis00muss_0_0868.jp2"}, "869": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 787\\nby stomachs in a normal state, otherwise HC1 may appear to be absent,\\nbecause it is still combined with albuminoids. Ewald s test-breakfast\\nis the simplest. In one hour the contents of the stomach may be aspi-\\nrated and tested for HC1.\\nAmount of Free HCL If by previous tests HC1 is found alone, its\\npercentage is easily calculated. To a measured quantity of the gastric\\nfluid add, drop by drop, from a burette a decinormal alkaline solution\\nuntil the acid is neutralized. This can be determined by checking\\nthe titration from time to time, and examining with Gimzburg s reagent.\\nOne c.c. of the alkaline solution is equivalent to 0.003646 HCl, the\\nlimit of Giinzburg s reaction. Multiply the number of c.c. required\\nto neutralize 10 c.c. of the gastric solution by 0.003646, and again by\\n10, the result will be the percentage of acidity. If 6 c.c. are used, the\\npercentage will be 6 X 0.003646 X 10 0.218, within the normal\\nrange, which is from 0.14 to 0.24 per cent. Gunzburg s test can be\\nused to estimate the quantity of HCl. This is applied by diluting the\\nstomach-contents until the test is not responded to. In health the\\nlimit of response is found when one part of HCl is found in 20,000\\nparts of the fluid. In abnormal conditions, when the gastric fluid is\\ndiluted one-half, the proportion is 2 to 20,000, or 1 to 10,000. If the\\nfluid is diluted to ten times its original strength, it is 10 to 20,000, or\\n1 to 2000.\\nThe following method is reliable and easy of employment. To two\\nor three drops of Topfer s solution of dimethylamidoazobenzol are added\\n10 c.c. of gastric contents, and a decinormal soda solution allowed to\\nflow in, drop by drop, until a yellow color takes the place of the red.\\nThe number of c.c of solution of soda which will neutralize the free\\nHCl in 100 c.c. of stomach-contents is multiplied by 0.00365. The\\nresult is the percentage of HCl. If 4 c.c. of soda solution is required\\nto remove the red color, multiply 0.00365 by 40, the number equals\\n0.14 per cent, free hydrochloric acid.\\n4. Lactic Acid. If the stomach-contents are colorless, apply the\\nfollowing tests if they are yellowish, make an ethereal extract, as\\ndescribed below, and then use the tests. Its presence may be deter-\\nmined by Uffelmann s reagent Mix one drop of pure carbolic acid\\nwith five drops of a dilute solution of neutral ferric chloride. Add\\nsufficient water to render the whole of an amethyst-blue color. To\\nthis add a few drops of the gastric fluid. A mere trace of lactic acid\\nwill change the blue to a light yellow or greenish yellow. The test\\nfor lactic acid is simulated when phosphates, glucose, or alcohol are\\npresent in the gastric juice. The lactic acid should be removed by\\nextracting with ether, as follows 50 c.c. of gastric contents are re-\\nduced to 10 c.c. by heat in an evaporating-dish over a water-bath.\\nAfter the concentrated solution cools add 50 c.c. of ether. The vola-\\ntile acids are driven off by heat, the lactic acid is dissolved by ether,\\nand hydrochloric acid remains in the residue. Apply the test for lactic\\nacid to the ethereal extract if it is acid. The following is more deli-\\ncate Add one drop of liq. ferri perchloridi to 50 c.c. of water add\\nsuspected solution the presence of lactic acid causes a yellow coloration.\\nBoas uses the following When a substance containing lactic acid", "height": "4416", "width": "2588", "jp2-path": "practicaltreatis00muss_0_0869.jp2"}, "870": {"fulltext": "788 SPECIAL DIAGNOSIS.\\nis heated with oxidizers, such as manganese dioxide and sulphuric acid,\\nthe lactic acid is decomposed into formic acid and acetic aldehyde the\\nlatter is detected by the formation of iodoform with an alkaline solu-\\ntion of iodine peptone and alcohol, which react similarly, are elimi-\\nnated by concentrating the nitrate to a syrup. As carbohydrates also\\nyield aldehyde when treated with oxidizers, a watery solution of an\\nethereal extract of the condensed gastric nitrate of a trial-meal free from\\nlactic acid must be used.\\nArnold (Joum. Am. Med. Assoc, Chicago, 1898, vol. viii. p. 21)\\ngives a new test for the detection of lactic acid in the stomach-con-\\ntents.\\na. 0.2 c.c. saturated alcoholic solution of gentian-violet in 500 c.c.\\nof distilled water.\\nb. Tinctura ferri perchloridi (U. S. Pharm., 1890), 5 c.c. distilled\\nwater, 20 c.c.\\nA drop of solution b, added to 1 c.c. of solution a in a porcelain\\nbasin, gives a blue color, which changes to a green or yellow-green on\\nthe addition of a few drops of filtered stomach-contents should lactic\\nacid be present.\\n5. The Volatile Acids. These acids are best detected by their\\nsmell, their volatility, and their reaction.\\nButyric acid is recognized by the pungent odor of rancid butter\\ngiven off when the stomach-contents are evaporated. It is recognized\\nby the following reaction To a small quantity of the liquid add a\\nsmall quantity of alcohol and two drops of strong sulphuric acid\\nheat for a short time a characteristic smell of butyric ether, like that\\nof pineapple ram, is given off.\\nButyric acid is also detected by Uffelmann s reagent. A few c.c. of\\nthe filtered gastric fluid are shaken with three or four times the amount\\nof ether. The ether is poured off when it rises on the top, and fresh\\nether added and the washing repeated. After the third washing the\\nether that cannot be poured off is evaporated by means of a water-\\nbath. Add a few drops of water to the residue and then an equal\\namount of the reagent. The characteristic color is produced. It\\nstrikes a tawny yellow color with a reddish tinge. As much as one\\npart of the reagent in 2000 is required.\\nIn addition to Uffelmann s test the volatile acids may be detected\\nby boiling a few c.c. in a test-tube, over the mouth of which blue lit-\\nmus-paper is attached. If acid is present, its vapor will change the\\nblue to red. Acetic acid is recognized by its odor, particularly after\\nheating the solution. It may be detected as follows Secure an\\nethereal extract of the gastric contents (as above), evaporate in a water-\\nbath, and dissolve the residue in water. Neutralize the watery solu-\\ntion with sodium carbonate, and then add neutral ferric chloride solu-\\ntion. A blood-red color results if acetic acid is present.\\nAlcohol is detected by its odor and by Lieben s iodoform-test.\\nDistill the stomach-contents, add to a portion a small quantity of liquor\\npotassae, and then a few drops of iodine-iodide of potassium solution.\\nA precipitate of iodoform takes place slowly if alcohol is present. If\\nacetone is present, it forms rapidly.", "height": "4416", "width": "2704", "jp2-path": "practicaltreatis00muss_0_0870.jp2"}, "871": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 789\\n6. The Products of Digestion. The ultimate products of diges-\\ntion are the proteoses and peptones. If they are present in the stomach-\\ncontents, it shows that hydrochloric acid and pepsin must have been\\nsecreted in the stomach. If vomiting occurs soon after food is taken,\\nor if there is obstruction at the lower end of the oesophagus, these\\nproducts are not present. Syntonin is a product of digestion which\\nprecedes the two above given. To ascertain if digestion has taken\\nplace, it is necessary only to test for syntonin and then employ the\\nbiuret test. Syntonin is detected by neutralizing the gastric contents\\nwith a solution of sodium hydrate. The precipitate is syntonin, which\\nis soluble in an excess of alkali, and may be again precipitated by an\\nalkali. After nitration and removal of the syntonin, proteoses and\\npeptone are detected by the biuret test.\\n7. Pepsin. If HC1 is present, add 5 c.c. of a gastric nitrate to a\\nsmall piece of egg-albumin. Allow digestion to take place for several\\nhours at 37\u00c2\u00b0 to 40\u00c2\u00b0 C. Non-digestion indicates absence of pepsin.\\nIf HC1 is absent, pepsinogen is found alone. Add two drops of a\\n25 per cent. HC1 solution to 10 c.c. of the gastric contents. Add to\\nthis solution a small portion of egg-albumin. If it is dissolved, pep-\\nsinogen was converted into pepsin by HC1.\\n8. Rennin (the milk-curdling ferment). This may be detected as\\nfollows From 5 to 10 c.c. of cow s milk of neutral reaction is boiled and\\nadded to neutralized and filtered gastric juice. Place the mixture on a\\nwarm bath heated to 30\u00c2\u00b0 or 40\u00c2\u00b0 C. The casein of the milk is precipi-\\ntated in flakes in from twenty to thirty minutes if the ferment is present.\\n9. The Carbohydrates. Add a few drops of Lugol s solution to\\nthe gastric contents. If starch is present, it turns blue. If erythrodex-\\ntrin, it becomes purple. If the digestion has proceeded so far as to\\nchange starch into dextrose, the iodine hue remains unchanged. The\\nstarches should be completely digested an hour after they are taken\\ninto the stomach, hence in health the iodine hue should not change after\\nthis time.\\nIII. The Digestive Power. Giinzburg has introduced the use\\nof iodide of potassium in the following way From three to five grains\\nare placed in a rubber tube with extremely thin walls the ends of\\nthe tube are then bent and brought into apposition with each other\\nand fastened in that position with three fibrin threads made firm by\\npreservation in alcohol. The whole packet is then pressed into an\\nempty gelatin capsule and given to a patient to swallow one-half hour\\nafter a test-breakfast. The saliva is tested for iodine every fifteen\\nminutes. The more rapid the solution of the capsule and fibrin\\nthreads the sooner the iodine can be absorbed and appear in the\\nsaliva, and hence this rapidity is an index of the digestive energy.\\nThe method is liable to fallacies. Solution of the fibrin may take\\nplace in the intestine instead of the bowel, and the threads may be\\nloosened by the acids of fermentation instead of by digestion. Never-\\ntheless, the test is a valuable one, especially when aspiration is inad-\\nmissible.\\nThe digestive power can be estimated by ascertaining (1) the pres-\\nence of gastric juice and (2) its activity.", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0871.jp2"}, "872": {"fulltext": "790 SPECIAL DIAGNOSIS.\\n1. The Gastric Juice. Wash out the fasting stomach with 400 c.c.\\nof lukewarm water test by litmus-paper for neutrality, then inject\\n50 c. c. of a 3 per cent, solution of soda. Allow the solution to remain\\ntwelve minutes and then remove by washing out the stomach with\\n400 c.c. of water. If the HC1 secretion is normal, the soda solution\\nis neutralized. If it is deficient, the solution remains alkaline. The\\npresence of pepsin is then to be determined.\\n2. The Activity of the Gastric Juice. The white of one or two eggs\\nshould be boiled in four ounces of water and then administered.\\nRemove the stomach-contents one-half hour later. The stomach should\\nbe emptied by lavage beforehand. The residue removed will show\\nif digestion is complete, and proteoses and peptones may be tested for\\nby the biuret reaction.\\nTest for the Activity of the Gastric Juice and of the Movements by a\\nTest-meal. Ewald s test-breakfast must be employed if the patient\\ncannot bear more solid food, otherwise Leube s test-meal should be\\nused. If digestion is normal, the stomach-contents removed from five\\nto seven hours after a test-meal are neutral and contain a few flakes of\\nmucus. At the end of five hours the stomach-contents are acid and\\ncontain peptone, some undigested muscle-fibres, and starch-grains. If\\nthe stomach contains undigested food at the end of seven hours, the\\ncontents are acid and contain peptones, indicating delay in digestion.\\nIY. The Motor Power. Ewald and Sievers have suggested the\\nuse of salol fifteen grains are given, and normally salicylic acid\\nshould be detected in the urine in from forty to sixty minutes, or in\\nseventy-five minutes at the latest. If it is deferred still longer, motor\\ninsufficiency is indicated. The sign is of value only when the excre-\\ntion is delayed. Urine containing salicylic acid gives a dark, brown-\\nish-red color upon the addition of a drop of tincture of the chloride of\\niron.\\nKlemperer s oil-test is more accurate, although disagreeable. One\\nhundred grammes of oil are placed in the stomach by the stomach-\\ntube. In two hours the stomach-contents are removed by aspirating,\\npreviously adding a little water. The amount of oil is dissolved by\\nether, the solution evaporated, and the residuum of oil weighed. Sev-\\nenty-five to eighty per cent, of the oil should be discharged in two\\nhours.\\nV. The Absorptive Power. Penzoldt and Faber recommend the\\nadministration of three grains of chemically pure iodide of potassium\\ni. e., free from iodic acid a short time before dinner. Any frag-\\nments of free iodine adhering to the iodide of potash are first carefully\\nwashed away. The saliva is tested for iodine with starch-paper and\\nfuming nitric acid. If absorption is active, a violet color is obtained\\nin from six and one-half to eleven minutes, and a blue color in from\\nseven and one-half to fifteen minutes. Zweifel directs that 3 grains\\n(0.2 gramme) of iodide of potassium be administered in a gelatin cap-\\nsule, and 3 J oz. of water (100 c.c.) taken iodine is detected in about\\neight minutes in the saliva. The character of the food taken is said\\nto have considerable influence in retarding the appearance of the reac-\\ntion, so that the blue reaction may not appear for forty-five minutes.", "height": "4416", "width": "2732", "jp2-path": "practicaltreatis00muss_0_0872.jp2"}, "873": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 791\\nBoas states that in dilatation of the stomach the reaction may be de-\\nlayed to two hoars, and in cancer as long as eighty-two minutes.\\nBoth motor and absorptive power are recognized also by digestive delay.\\nClinical Value of a Chemical Examination of the Vomitus or Stomach-\\ncontents. It cannot be gainsaid that the chemical examination of the\\nstomach-contents is of the utmost clinical value. It is just as certain,\\nhowever, that the results attained by such examination should not be\\nfinal in the formation of a diagnosis that alone they do not meet the\\nexpectations of clinicians. This is particularly so when we attempt to\\ndeduce a scientific therapeusis from such examination. To rely upon\\nthe results of such examination alone would lead to failure. The diag-\\nnosis, and, therefore, the rational therapeusis, must rest not alone upon\\na chemical examination, but also upon other methods of examination\\nof stomach-contents, the physical examination of the stomach, the his-\\ntory and progress of the case, and the subjective symptoms. In short,\\na general view must be taken, and all methods of inquiry employed.\\nDiseases of the stomach require for their correct estimation broader\\nlines of investigation than almost any other organ of the body. More-\\nover, the practitioner must not be discouraged if he cannot employ\\nchemical methods with the skill of the laboratory expert. The simple\\nmethods detailed above can be conducted by any educated physician.\\nFor practical purposes, it is only necessary to determine the total acid-\\nity, the presence of free acids, the presence of free HC1, the presence\\nof lactic acid and of the volatile acids.\\nFinally, the clinician must not be discouraged if the stomach-\\ncontents cannot be secured, on account of the contraindications pre-\\nviously detailed. An approximate diagnosis probably not so precise\\nor final can usually be made by means of a physical examination of\\nthe stomach and a consideration of the symptoms.\\nThe results of the chemical examination have the clinical value\\nestimated herewith. In the first place, we find whether the acidity\\nis increased or diminished.\\n1. Diminished acidity, or anacidity, means deficiency in the amount\\nof HC1 secreted. Diminished acidity may be due to functional or\\norganic disease of the stomach. It occurs in fever, in chlorosis, and\\npernicious anaemia, chronic wasting diseases, including tuberculosis,\\nand acute infectious diseases from functional disturbance of nervous or\\nhsernic origin. It occurs in chronic dyspepsia from irregularities in\\ndiet. It is also deficient in congestion, acute catarrh or atrophy of the\\nmucous membranes, and in carcinoma, which apparently modifies gas-\\ntric secretion.\\n2. Increased acidity may be due to an increase of hydrochloric acid\\nhyperacidity, or to an increase of the organic acids increased acidity,\\na. Hypersecretion of HC1 takes place in the early stages of gastric\\nirritation dyspepsia. It may be increased in gastric ulcer, b. In-\\ncreased acidity (organic acids) may be due to excess of (1) lactic acid\\n(2) of butyric acid, and (3) of acetic acid. Excess of lactic acid is due\\nto fermentation of carbohydrates from the growth of the bacillus acidi\\nlactici or bacillus lactis aerogenes of butyric acid, to butyric acid\\nfermentation of acetic acid, to alcoholic fermentation of the above-", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0873.jp2"}, "874": {"fulltext": "792 SPECIAL DIAGNOSIS.\\nmentioned class of foods. Alcoholic fermentation is often due to the sar-\\ncina?. In short, these acids result from bacterial fermentation, a process\\nwhich takes place only when there is delayed motor power, or when\\nthe normal antiseptic the HC1 is absent or diminished. Hence, we\\nfind these acids in weakness of the muscles, as in dilatation, in organic\\nobstruction of the pylorus, and in cancer of the stomach while the\\nbacteria are found on microscopical examination.\\n3. Free hydrochloric acid is diminished in acute and chronic catarrh\\nof the stomach (gastritis), in chronic dyspepsia, in ulcer of the stomach\\nand duodenum, in gastric atrophy, in dilatation, in gastric carcinoma\\n(early stage), and from all general causes which lessen the total acid-\\nity, including diabetes and Addison s disease. Of course, deficiency\\nof hydrochloric acid means deficiency of functional activity, and goes\\nhand-in-hand with diminished motor and absorptive power. The acid\\nis increased in the early stages of irritative dyspepsia and in ulcer of\\nthe stomach, and at different periods in the gastric neuroses. The\\nmost common causes of increase of HC1 are the gastric neuroses.\\nHydrochloric acid is absent entirely in advanced chronic gastritis and\\nin the gastric neuroses. In the former there are evidences of fermen-\\ntation. HC1 is often absent in cancer, but unless constantly absent,\\nand two or more other facts of value can be secured, the diagnosis\\ncannot be made on the chemical examination alone.\\n4. Lactic acid. Its presence points to fermentation, hence it is asso-\\nciated with lesions that are accompanied by bacterial fermentation.\\nIt is present in carcinoma, as pointed out by Boas. Fermentation\\nis not the only condition in which it occurs. It is nearly always found\\nafter a meal of meat, and is known as sarcolactic acid. It may occur in\\nchronic catarrhal gastritis. In cancer of the stomach lactic acid is the\\nmost common objective sign. Its absence does not exclude carcinoma.\\nIt may be detected before a tumor is palpable. Therefore, if lactic\\nacid is present and free HC1 absent, cancer can be pretty safely diag-\\nnosticated, particularly if stagnation of stomach-contents is also pres-\\nent. Boas recommends a meal which will not yield sarcolactic acid.\\nIt consists of one to two litres of oatmeal gruel, to which a little salt\\nmay be added. It should be removed by expression one hour after it\\nhas been taken. It is well to remove all food by lavage six hours\\nbefore the test-meal is given.\\nThe clinical value of the remaining chemical tests and investigations\\nneed not be explained. They indicate inability of the gastric function\\nto accomplish digestion, but do not point to any special gastric affec-\\ntion. They are of value in distinguishing between gastric neuroses and\\nan organic disease. In both there are pronounced gastric symptoms\\nif the examination shows normal digestive powers, a neurosis is indi-\\ncated.\\nGastkic Hemorrhage. Hemorrhage of the stomach, hwmateme-\\nsis, or vomiting of blood, is due to an organic lesion, or the effects of\\nacute irritant poisoning. The blood is vomited. Care must be taken\\nto see that the blood is not from the upper air-passages, and previously\\nswallowed. If hemorrhage is profuse, the blood may cause irritation\\nof the larynx, and provoke paroxysms of coughing. It is often cliffi-", "height": "4404", "width": "2768", "jp2-path": "practicaltreatis00muss_0_0874.jp2"}, "875": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 793\\ncult, therefore, to distinguish between hemorrhage from the lungs and\\nhemorrhage from the stomach.\\nHiEMATEMESIS. HAEMOPTYSIS.\\n1. Previous history points to gastric, j 1. Cough or signs of some pulmonary-\\nhepatic, or splenic disease.\\n2. The blood is brought up by vomiting,\\nprior to which the patient may experience\\na feeling of giddiness or faintness.\\nwith particles of food, and has an acid re\\naction. It may be dark, grumous, and\\nfluid.\\n4. Subsequent to the attack the patient\\npasses tarry stools, and signs of disease of\\nthe abdominal viscera may be detected.\\nor cardiac disease precedes, in many cases,\\nthe hemorrhage.\\n2. The blood is coughed up, and is usu-\\nally preceded by a sensation of tickling in\\nthe throat. If vomiting occurs, it follows\\nthe coughing.\\n3. The blood is usually clotted, mixed i 3. The blood is frothy, bright red in\\ncolor, alkaline in reaction. If clotted, it is\\nrarely in such large coagula, and muco-\\npus may be mixed with it.\\n4. The cough persists, physical signs of\\nlocal disease in the chest may usually be\\ndetected, and the sputa may be blood-\\nstained for many days. Osler.\\nThe hemorrhage may continue within the stomach without exciting\\nvomiting. The general symptoms of hemorrhage may appear, first, as\\npallor, dimness of vision, giddiness, or faintness. The blood which\\ncomes from the stomach is usually acted upon by the gastric juice, and\\nis dark, clotted, and partly digested. It is often mixed with food.\\nIts reaction is acid. In large hemorrhages the blood may be fluid\\nand of a scarlet color but if retained for any length of time, it is\\ncoagulated. The vomited matter has the appearance of coffee-grounds,\\nwhen there is a small amount of blood. When large in amount and\\ndigested, it appears like tar.\\nVomiting is usually followed by movements of the bowels. The\\nmatter discharged is of characteristic appearance. It is black or tarry.\\nIt is distinguished from hemorrhage of the intestinal canal below the\\nduodenum by the color of the blood. In intestinal hemorrhage the\\nblood is dark red, and not necessarily tarry. The dark stools must not\\nbe confounded with the same character of stools seen when iron or\\nbismuth is taken. In rare instances a hemorrhage into the stomach\\nmay take place from disease of the lower part of the oesophagus.\\nCauses. 1. General diseases, from changes in the blood, cause gas-\\ntric hemorrhage, as scurvy, purpura, hemorrhagic smallpox, yellow\\nfever, acute yellow atrophy of the liver, and severe anaemia, leukaemia,\\nHodgkin s disease, and pernicious anaemia. 2. Ulcer of the stomach.\\n3. Cancer of the stomach. 4. Ulcer of the duodenum. 5. Portal\\ncongestion, as in cirrhosis of the liver, and other forms of chronic\\nhepatic disease. 6. Disease of the spleen. 7. Congestion due to dis-\\nease of the heart. 8. In chronic Bright\\\\s disease with atheroma. 9.\\nRupture in aneurism. 10. Vicarious menstruation. 11. Cohen asserts\\nthat it occurs in vasomotor ataxia.\\nProfuse and sudden hemorrhage, in the absence of well-marked\\nsymptoms of disease, is in nearly all cases due, either to latent ulcer,\\nor to congestion of the stomach from early cirrhosis of the liver.\\nGeneral Examination. The objective examination has thus far\\nbeen confined to a study of the stomach. The student will infer from\\nthe previous chapters that in order that on the one hand the possible", "height": "4416", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0875.jp2"}, "876": {"fulltext": "794 SPECIAL DIAGNOSIS.\\ncause of the gastric disorder may be determined, or, on the other, the\\neffect of gastric disorder upon the other organs ascertained, they must\\nbe examined carefully. Moreover, valuable data in the recognition of\\ngastric affections and the diagnosis of the various forms are secured by\\nsuch examination. The general appearance of the patient, the state of\\nnutrition, and the degree of strength furnish suggestive facts in the\\ndiagnosis. As well said by Stockton\\nThe preoccupied and dejected manner observed in those suffering\\nfrom continued gastric flatulency the restless, discomposed behavior,\\nthe stooped posture and half-surprised expression often seen in the\\nvictims of gastralgia the emaciated, weak, and cachectic appearance\\nfrequently accompanying chronic food stagnation, are good examples\\nof the value of the general appearance in the diagnosis.\\nIt must be remembered that any local source of irritation distant\\nfrom the stomach, as the eyes, the nose and pharynx, the uterus and\\novaries, and the rectum, may be the primary cause of gastric disorder.\\nThe study of the hepatic and intestiual functions assist in the diag-\\nnosis. Examination of the urine and the blood may enable us to\\ndetermine the nature of a gastric morbid process. Even the study of\\nthe skin is of importance.\\nA sallow, earthy-colored skin, showing improper secretion a dry,\\nharsh skin, with too rapid loss of epithelium, showing poor nutrition\\na skin showing oedema, poor capillary circulation, lividity, or acne\\ncertain forms of eczema, excess of pigment, or syphilides may afford\\nimportant information as to the digestion, inasmuch as some of these\\nmay be the results and others accompaniments of gastric disturbance\\n(Stockton).\\nThe Blood. Examination of the blood enables us to determine\\nthe degree of anaemia which may be the cause of digestive failure.\\nThe examination must be exhaustive. If a leucocytosis is present, the\\ngastric neuroses may be excluded. In carcinoma there is not only a\\nsevere secondary ansemia, but also poikilocytosis and a multinuclear\\nleucocytosis. Such changes are without doubt the result of interference\\nwith the digestion because of motor inactivity. Moreover, certain\\ngastric diseases have specific effects upon the blood. Gastric ulcer\\nmay be distinguished from gastric carcinoma, by the fact that digestive\\nleucocytosis occurs in the former while it is absent in the latter.\\nThe Urine. No study of a gastric disorder is complete without\\nan exhaustive examination of the urine. For diagnostic, but chiefly\\nfor therapeutic purposes, the presence of renal insufficiency, hyper-\\nlithuria, indicanuria, glycosuria, peptonuria, and albuminuria must be\\ntested for.\\nThe Reaction. The reaction of the urine is modified by the state of\\nthe stomach. In health the urine is alkaline after a full meal of ordi-\\nnary character. When HC1 is absent from gastric contents, this normal\\nalkalinity does not occur. Alkalinity is rarely seen in gastric carci-\\nnoma.\\nThe Chlorides. The chlorides are lessened when a small amount of\\nfood is taken a similar cause lessens the amount of urea. Both are\\ndecreased in carcinoma and in benign diseases of the stomach. But", "height": "4412", "width": "2732", "jp2-path": "practicaltreatis00muss_0_0876.jp2"}, "877": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 795\\nthe chlorides are diminished in carcinoma without a proportionate\\nlessening of the urea. It is this disproportion which is of diagnostic\\nvalue, as pointed out by Nothnagel, in carcinoma ventriculi.\\nDiseases of the Stomach Characterized by Fever, with Pain and\\nVomiting.\\nAcute Gastritis. The simple variety of acute gastritis varies\\naccording to the cause, from a slight attack of vomiting after indiscre-\\ntion in diet, Avith ordinary symptoms of indigestion, to the more severe\\nforms ushered in by chill and attended with fever.\\nIn the mild forms there is a sense of fulness and discomfort in the\\nepigastrium, attended with nausea. The appetite is lost, and there\\nmay be disgust for food, and the flow of saliva is increased. There is\\nundue acidity. On examination the epigastrium is found to be tender.\\nThe onset of the attack is attended with giddiness, flashes of light\\nbefore the eyes, frontal headache, and some prostration. The pulse is\\nincreased in frequency. When this nausea is most pronounced the\\nface is pale and the extremities cold. Vomiting then occurs, the\\nmatter ejected consisting of ingesta only slightly changed, with mucus\\nand watery fluid. It is very bitter. It is often colored green from\\nbile-pigment. Another attack of vomiting may be sufficient to give\\nrelief, or it may be repeated for twenty-four to forty-eight hours every\\nhour or two. After the stomach is relieved of food, mucus and bile\\nalone are vomited.\\nExamination of Stomach-contents. The reaction of the vomited\\nmatter is neutral or faintly acid. No free hydrochloric acid is present,\\nbut later lactic and fatty acids are found. Pepsin is diminished in\\nquantity.\\nTwelve to twenty-four hours after the gastric symptoms intestinal\\nsymptoms may arise. Borborygmi and colicky pains are complained\\nof, followed by diarrhoea, with some tenesmus.\\nHerpes labialis may occur, and some writers speak of a peculiar\\nodor which is exhaled from the skin. The more severe cases are\\nushered in with chill followed by fever. The local symptoms are\\nmuch aggravated. The tongue is furred, and the breath foul. The\\nvomiting is frequent and severe. The skin is livid and the pulse be-\\ncomes rapid.\\nDiagnosis. In the acute cases attended by fever it may be mistaken\\nfor meningitis, peritonitis, or hepatitis. The same gastric symptoms\\nmay usher in an attack of pneumonia. The possibilities of a mistake\\nare to be borne in mind, and in all cases of vomiting with fever due\\nregard must be paid to the possibility of the gastric symptoms being\\nsymptomatic only. It must be borne in mind that the same group\\nof symptoms that belong to gastritis accompanies the exanthematous\\ndiseases, and diphtheria, dysentery, pyaemia, and puerperal fever.\\nThey may be of reflex origin, or due to the action of fever, poison, or\\nptomaines on the stomach. Ewald calls it sympathetic gastritis when\\nthe symptoms are the same as in the simple variety, masked, however,", "height": "4416", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0877.jp2"}, "878": {"fulltext": "796 SPECIAL DIAGNOSIS.\\nby the primary disease. Sometimes, however, as in the eruptive\\nfevers, attention is directed to the state of the stomach, to the exclusion\\nof other conditions. And often, to the surprise of the student, an erup-\\ntion or inflammation ensues, which indicates the true nature of the case.\\nIn cases of gastritis, therefore, endeavor to find a local cause for the\\nsymptoms. If there is no history of indiscretions in diet, of exposure,\\nof exhaustion, or mental shock, on account of which digestion might\\nbe arrested, then inquire for a history of exposure to contagious dis-\\neases and look for the earlier evidences of exanthemata. If the result\\nof the examination is still unsatisfactory, examine the condition of\\neach individual organ, particularly bearing in mind meningitis, pneu-\\nmonia, peritonitis, nephritis, and general infections.\\nMycotic and diphtheritic gastritis occur secondarily to typhoid fever,\\npneumonia, pysemia, smallpox, and sometimes diphtheria. The mucous\\nmembrane may be covered with patches in areas or throughout its\\nwhole extent.\\nSome special micro-organisms irritate the gastric mucosa, as the\\nanthrax bacillus and the sarcinse and yeast fungi in cancer and dilata-\\ntion of the stomach. Rarely tuberculous inflammation with ulceration\\ntakes place, and other micro-organisms have been described. Klebs\\nfound the bacillus gastricus with numerous spores in the tubules, as\\na consequence of which a gastritis was set up.\\nThe mucous membrane itself escapes infection from micro-organisms,\\nbecause of the character of its secretion. The acid gastric juice is\\nantagonistic to and causes the death of micro-organisms. Tuberculo-\\nsis, for instance, rarely attacks the stomach for this reason.\\nPhlegmonous Gastritis. This is a very rare affection, in which\\nthe inflammation is seated in the submucosa and leads to perforation.\\nThe onset is sudden. The chief local symptom is intense pain in the\\nepigastrium, with a burning sensation. There are great acidity, dry\\ntongue, and absolute anorexia. The fever is high and characterized\\nby delirium. Chills usually accompany it. The pulse is small, rapid,\\nand irregular. The matters vomited are first mucus, then pus. The\\npatient is extremely restless and anxious, even delirious, and early\\npasses into coma. Death takes place from collapse. It is impossible\\nto make an absolute diagnosis, as local peritonitis and abscess of the\\nliver are characterized by the same symptoms. In abscess a tumor\\nmay form in the epigastrium. It may occur idiopathically, but it fre-\\nquently occurs in septicaemia, and follows trauma.\\nToxic Gastritis. This form of gastritis is allied to the former in\\nthe severity of general symptoms. It is the result of the swallowing of\\nirritating poisons, of which phosphorus, arsenic, bichloride of mercury,\\nand caustic acids and alkalies are the most common. It is attended by\\ninflammation of the mouth, oesophagus, and stomach. There are sali-\\nvation and dysphagia, and constant vomiting of blood, often with shreds\\nof mucous membrane. The patient is restless, and may have convul-\\nsions collapse readily develops. In mild cases, in which the local\\neffects of the corrosive substance have been mitigated by proper anti-\\ndotes, sloughs occur, leaving behind ulcers on the mucous membrane,\\nwhich, after healing, result in deformity or stenosis of the oesophagus.", "height": "4404", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0878.jp2"}, "879": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 797\\nSome cases are attended by other symptoms peculiar to the special\\npoison. Thus with arsenic there are choleraic symptoms in phos-\\nphorus-poisoning the symptoms come on late after its ingestion, and\\nare attended by jaundice and symptoms of acute yellow atrophy.\\nDiseases of the Stomach Characterized by Indigestion.\\nFunctional Disorders of the Stomach. The Neuroses. Func-\\ntional disturbances of the stomach are due to impairment of the motor\\npower of the stomach, impairment of the secretory function and of the\\nsensory function. The following table of Ewald, as given by that\\ndistinguished authority, is a classification of the various neuroses mid-\\nway between the symptomatic and the etiological\\nThe Neuroses of the Stomach.\\n1. Conditions of Irritation.\\na. Sensory. b. Secretory. c. Motor.\\nHyperesthesia. Hyperacidity. Eructation.\\nNausea. Hypersecretion. Pyrosis.\\nHyperorexia. Vomiting.\\nAnorexia ex hyperesthesia. Colic.\\nParorexia. Tormina ventriculi.\\nGastralgia.\\n2. Conditions of Depression.\\nPolyphagia. Anacidity. Atony.\\nAnaesthesia. Insufficiency of the pylorus and\\ncardia.\\n3. Mixed Form.\\nGastro -intestinal neurasthenia (dyspepsia nervosa).\\n4. Eeflexes from Other Organs upon the Gastric Nerves\\nReflexes from the brain, eyes, spinal cord, kidneys, liver, sexual organs, and\\nintestines manifest themselves in the forms mentioned in 1 and 2.\\nIt must not be supposed that each of the above-named symptoms\\noccur in an individual, or that functional disturbances may be limited\\nto alterations of the sensory and secretory or the motor apparatus, re-\\nspectively. They do not occur, as Ewald states, as distinct indepen-\\ndent diseases, but usually in groups, either appearing simultaneously\\nor closely following one another during the course of the malady, pass-\\ning before us like an ever-changing scene. They may arise directly\\nfrom disease of the stomach, or reflexly from disease of other organs,\\nas the brain, the spinal cord, uterus, kidneys, liver, eyes, and nose.\\nEtiology. Gastric neuroses are of most frequent occurrence in\\nwomen, especially during the years from puberty to the menopause.\\nThe accidents of childbirth are predisposing factors. In both sexes\\nthey are of most frequent occurrence after the age of twenty years,\\nbecause individuals are subjected to causes which lead to neuroses at\\nthis period of life. The gastric neuroses occur in all conditions of\\npatients. They are more likely to occur in those who are poorly nourished\\nor anaemic although persons who are distinctly robust may also suffer.\\nWhile more common in the residents of cities, they may occur in\\nfarmers and others accustomed to an open-air life. Although we are", "height": "4412", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0879.jp2"}, "880": {"fulltext": "798 SPECIAL DIAGNOSIS.\\noftenest called upon to treat them among the better classes, neverthe-\\nless a large number of cases are seen among the poor. To analyze\\nmore closely the predisposing causes, we have to study individually\\nall conditions and circumstances in life which lead to wear and tear,\\nas in business or social affairs. The causes which Beard and others\\nhave forcibly pointed out as factors in the production of neurasthenia\\nare especially prevalent in this country.\\nIn men, excessive devotion to business, or dissipation in women,\\nexcesses in social life, or the restraint of home cares, with, unhappily,\\ntoo often, the irritation of marital relations, are the predisposing\\nfactors which lead to the development of this class of cases. Often\\npatients in the large cities are subject to the neuroses in the spring\\nafter the dissipations of the winter. Behind this excess there is, no\\ndoubt, in the majority of cases, a nervous temperament that is respon-\\nsible for the bringing out of the symptoms, particularly if, combined\\nwith this temperament, the patients live in an unhygienic way in\\nregard to exercise, ventilation of their dwelling-places, and drainage,\\ncombined with improper diet.\\nSymptoms. With the gastric neuroses other symptoms of neurasthe-\\nnia are present, and the patient may seek advice for these symptoms,\\nsuch as headaches of various kinds, changes in the mental condition,\\nvertigo, insomnia, neuralgias, and all forms of paresthesia. Intimately\\nconnected with the neurasthenic state is that of hysteria, and therefore\\nin gastric neuroses hysterical manifestations are most common. It may\\nbe impossible completely to define the border-line between neurasthe-\\nnia and hysteria, and the gastric symptoms of the former are the gas-\\ntric symptoms of the latter. While, therefore, general neurasthenic\\nsymptoms are prominent, in order to reach a diagnosis upon which\\nproper lines of treatment can be based, the condition of the individual\\nmust be viewed as a whole, and no one symptom or group of symptoms\\nexaggerated in our minds.\\nVarieties. Ewald has divided the neuroses into those which arise\\nfrom (a) irritation, those which arise from (b) depression, and (c) those\\nin which both are combined mixed neuroses.\\n(a) 1. Sensory Neuroses of Irritation. HYPEKiESTHEsiA. The\\nfirst result of irritation is hyperesthesia of the stomach, which is indi-\\ncated by a feeling of fidness and tension, and of nausea. The sensation\\nis allied to the normal, and is also seen in chronic gastritis, as well as\\nin hysteria, meningeal irritation, cerebral tumors, and other diseases\\nof the nervous system. The increased irritability is such that the\\ngentlest irritant excites discomfort or a painful sensation. There is a\\ncontinuous sensation of heat or cold, of gnawing, or pulling, or burning\\nin the organ. The local sensation reflexly influences the physical life\\nof the patient, so that hypochondriasis in some form attends it. The\\nsensations may be relieved by food, to become worse if the stomach is\\nemptied, although in the larger number of cases the trouble is aggra-\\nvated during digestion. The sensations are likely to be aggravated by\\nfasting a longer period than usual, or by restriction of the diet. Ex-\\ncesses may aggravate them, and, on the other hand, they are said to\\nfollow debilitating states. Some foods, such as shell-fish, crabs and", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0880.jp2"}, "881": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 799\\nlobsters, or oysters, and strawberries, are likely to increase the peculiar\\nsensations in the epigastrium, exciting mild depression, or burning, or\\neven nausea. The excitation from these foods is usually due to pecu-\\nliar idiosyncrasies of the individual. On account of the same idiosyn-\\ncrasies, pruritus, erythema, and urticaria occur, with headache and\\nsome fever.\\nDeviations from the Sense of Hunger. Hyperorexia.\\nWhen hunger is exaggerated it is known as boulimia, or hyperorexia.\\nIt may be temporary or permanent. When permanent it is obstinate,\\nweakening, and exceedingly unpleasant. It may occur alone or be a\\nsymptom of various diseases of the nervous system, as manifest disease\\nof the brain, neurasthenia, hysteria, and psychoses. It complicates\\nsuch disorders as diabetes, and may be of temporary duration in con-\\nvalescence from acute disease. The disorder accompanies migraine, or\\nhypochondriasis, and exophthalmic goitre. Analogous to it is perver-\\nsion of the appetite, as seen in pregnancy, in children, and in mental\\ndisorders.\\nAnorexia. Loss of appetite, or repugnance to food. In the first\\ninstance, there is simply loss of appetite in the second, there is repug-\\nnance toward food, or nausea at the sight of it. Loss of appetite\\naccompanies dyspepsia in all forms. In the gastric neuroses it occurs\\nspontaneously, or is due to hyperesthesia of the stomach, and therefore\\nmay arise from central or peripheral conditions of irritation. It is\\ncommonly seen following central nerve perturbation. The patient is\\nhungry, and sits down to the meal fully prepared to satisfy himself.\\nThe first mouthful is at once followed by anorexia, which may almost\\namount to nausea. On account of these symptoms the patient eats less\\nand less of solid food, which soon results in disturbance of nutrition\\naffecting the higher centres. On the other hand, profound mental dis-\\nturbance may be an exciting cause, so that after the death of a friend,\\nor shock of any kind, the patient is unable to take food. Loss of appe-\\ntite may be the only manifestation of the gastric neurosis, but because\\nnutrition is so seriously interfered with, it soon results in other local\\nor general symptoms. Fen wick points out that its relationship to ema-\\nciation and enfeeblement is such that grave organic diseases may be\\nsimulated. Thus it may be mistaken for phthisis, and a general ex-\\namination alone is sufficient to distinguish it.\\nGastralgia. Pain in the stomach occurs in organic disease, as in\\nulcer or cancer, or forms of gastritis. It also attends a gastric neurosis,\\nand may be the only symptom of this neurasthenic state. Such pain\\nis functional, and is found in anaemic, neurotic women. It may, how-\\never, occur in all classes. It is characterized by sudden pain in the\\nepigastrium, usually without regularity, though at times it may be dis-\\ntinctly periodic. There may not be any definite relationship between\\nthe attack of pain and the taking of food, though it is most apt to\\noccur when the stomach is empty. Some kinds of food may aggravate\\nit, though, in general, eating relieves the pain. If the epigastrium is\\nexamined, it will be found to be free from tenderness, and indeed\\npressure with the palm of the hand may give relief. The pain is of\\nan agonizing character, sometimes sharply localized, or again diffuse.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0881.jp2"}, "882": {"fulltext": "800 SPECIAL DIAGNOSIS.\\nIt may even resemble the girdle-sensation. On account of the severity\\nof the pain the patient may be compelled to double himself up to relax\\nthe abdominal muscles. The breath is short, and speaking is done in\\na whisper. The attack is attended by more or less collapse, and the\\npatient may complain of the sensation of impending death. There is\\npallor of the face, which is distorted with pain, and the brow is covered\\nwith perspiration. The pain may radiate along the spinal nerves in\\nclose situation to the stomach, and there is often vigorous pulsation of\\nthe abdominal aorta.\\nThe attack may last but a few minutes or continue for hours. It\\nsometimes terminates suddenly with vomiting, or is relieved as soon\\nas food is taken. After the attack the patient is exhausted and re-\\nlaxed, and passes an abundance of urine of low specific gravity.\\nThe gastralgias that are due to disease of the central nervous system\\nare often most puzzling. Rosenthal has written exhaustively on this\\nsubject. Types of gastralgia of this character are seen in the gastric\\ncrises of tabes, first described by Charcot. Recent observers have\\nfound that it is due to sclerotic degeneration of the vagus nucleus.\\nThe patient is suddenly seized with severe pains, which may begin in\\nthe groin and ascend along both sides of the abdomen to the epigas-\\ntrium, to which point they are fixed. Pain in the shoulders occurs at\\nthe same time. The pains are characteristic of lumbar ataxia in their\\nlightning-like rapidity. With the pain the heart s action is increased\\nin rapidity and force. There is no rise in temperature. At the same\\ntime there is uninterrupted and painful vomiting, which is attended by\\nnausea and vertigo. The gastric pain may continue uninterruptedly\\nfor two or three days. It belongs to the pre-ataxic period, so-called,\\nbut is almost sure to continue throughout the whole course of the dis-\\nease. The nature of the stomach-contents bears no relation to the\\npain. The frequency of the attacks is variable. They may recur at long\\nperiods, or as frequently as once a month or once a week. Another\\nspecial characteristic is the sudden relief that is given without cause.\\nNeurasthenic Gastralgia. Neurasthenic gastralgia occurs in\\npatients who are suffering from neurasthenia, and is divided by Rosen-\\nthal into two forms, the one irritative, the other depressant these are\\nrelated by transitional forms. The early symptoms of neurasthenia\\n(q. v.), particularly in the irritative form, with painful points in the\\nnape of the neck and between the scapulae, or often lower down on the\\nvertebrae, with neuralgias and paresthesia in the upper and lower ex-\\ntremities, are attended by periodical gastralgia. The gastralgia is\\ncharacterized by a boring sensation which, during the attack, radiates\\nover the lower ribs to the median line. It is accompanied by vaso-\\nmotor symptoms and symptoms of cerebral anaemia. In the depressant\\nform the patient complains of weight and fulness, or a dragging sensa-\\ntion after eating, which is constant instead of paroxysmal. The neu-\\nralgic pains are not so marked, motor exhaustion is not so prominent,\\nand the pain in the back is not so intense as in other varieties. In\\nboth instances on deep pressure over the region of the nerve-plexuses\\nwhich follow the bloodvessels in the abdomen, there is sharp and un-\\npleasant pain radiating to the epigastrium. Burkart considers these", "height": "4416", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0882.jp2"}, "883": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 801\\npainful points to be present in all cases, while Bichter believes that\\npressure over the stomach and abdomen is not painful. With such\\npain there is usually increased pulsation of the abdominal aorta, partic-\\nularly during the time of the paroxysm. In neurasthenic gastralgias\\nthere is increased sensitiveness to the electrical current and increased\\nirritability of the sensory nerves of the trunk, which may also be ex-\\ntended to the limbs.\\nNeurasthenic gastralgia must be distinguished from the gastralgia\\nof organic disease and the gastralgia of hysteria. The gastralgia of\\norganic disease is recognized by observing the condition of the stomach\\nwhen fasting and by studying the secretion. In organic disease there\\nis retarded digestion in gastric neuroses digestion is completed in the\\nnormal limit of time seven hours. Hysterical gastralgias are recog-\\nnized by the presence of the usual symptoms of hysteria, in which the\\npsychical factors occupy a prominent place, associated with convul-\\nsions, paralyses, pupillary inequalities, hemianesthesia, and electrical\\nsensibility. Most characteristic, however, is the alternation of hysteri-\\ncal gastralgias with neuralgia, or neuroses in other organs.\\n(a) 2. Secretory Neuroses of Irritation. Hyperacidity and\\nHypersecretion. Hyperacidity is the increase of the normal\\namount of hydrochloric acid secreted, due to a neurosis of the secretory\\nfunction. Hyperacidity begins when the amount of acid in the fluid\\nwithdrawn from the stomach in the usual way is between 60 and 70\\nper cent. It must not be forgotten that it is a symptom of gastric\\nulcer, but it exists as a neurosis independent of any organic lesion of\\nthe stomach. It has been observed in nervous diseases, as hysteria\\nand melancholia, and as a reflex symptom in gallstones and renal\\ncalculus.\\nHypersecretion occurs in two forms, the periodical and constant.\\nThe acid is not necessarily increased. The periodical occurs after eat-\\ning it has no direct connection with food. It is seen in neurasthenia\\nand locomotor ataxia. In chronic hypersecretion the gastric juice,\\nwhich is usually hyperacid, is in excess, so that the fasting stomach\\nmay contain large quantities, even to a pint and a half, without food\\nand only slightly tinged by bile. In chronic hypersecretion the diges-\\ntion of starches is delayed, but that of albuminoids is very prompt.\\nAfter an abundant meal consisting of meat and starches the meat dis-\\nappears entirely. Hypersecretion occurs in about half of all the stom-\\nach disorders, according to Riegel. It is more common in men than\\nin women. The acid fluid causes the hypersesthetic conditions in the\\ngastric region previously described. Pain and eructation, heartburn\\nor gastralgia, vomiting of sour masses, occur with the digestive dis-\\nturbances of chronic gastritis. The tongue is usually clean and the\\nappetite increased rather than diminished. As a result, atony of the\\nmuscular coat takes place, followed by gastrectasia. The neurosis is\\nthen converted into an organic lesion, and the symptoms of dilatation\\narise.\\nReichman s disease is a hypersecretion of the gastric juice, and there\\nare two forms the acute, which is generally of nervous origin, and\\nthe chronic. The latter is seen in emaciated persons the stomach is\\n51", "height": "4404", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0883.jp2"}, "884": {"fulltext": "802 SPECIAL DIAGNOSIS.\\ndilated, and succussion-splash is readily obtained. The diagnosis is\\nmade in part by examination of the gastric contents, which are re-\\nmoved five to six hours after the meal. The quantity will be found\\nlarge. On standing, the material becomes separated into three layers\\nan upper, frothy layer a middle, turbid, yellowish layer, and a\\nlower, consisting of starchy matter. In order to determine that hyper-\\nsecretion exists, the stomach-contents are removed in the evening, and\\nthe viscus washed out thoroughly until the water is no longer acid in\\nreaction. The patient receives no food until the next morning, when,\\nafter the proper interval, the contents of the stomach are again evacu-\\nated. From 30 to 600 c.c. (1 to 19 ounces) of fluid will now be\\nobtained, which, on examination, proves to be active gastric juice.\\nThe disease is chronic.\\nIn order to make a diagnosis the secretions must be secured while\\nfasting. The patients usually improve on albuminous food, which\\ndifferentiates it from gastralgia and pyrosis of acid fermentation.\\nAlkalies give temporary relief.\\nGastroxynsis is a gastric neurosis in which, after mental overexertion\\nor profound emotional disturbance, there is sudden vomiting of acid\\nfluid, continuing for a considerable time. It is closely allied to\\nmigraine.\\n3. Motor Neuroses of Irritation. Eructations. Eructations\\nand belching are phenomena of the gastric neuroses of motor origin.\\nThey usually occur in hysterical subjects rather than in neurasthenics.\\nIn the latter they are associated with other sensations, particularly op-\\npression and tension in the epigastrium. In hysteria they occur alone.\\nThere is increase in the contractility of the stomach, the pyloric\\nsphincter contracts powerfully, and the stomach is distended gas is\\nexpelled at the cardiac end of the stomach. They may be due to\\nparalysis of the cardiac end of the stomach rather than to contraction\\nof the pyloric end. They occur involuntarily generally. They must\\nnot be confounded with the pseudohysterical vomiting which Bristowe\\nhas described. In the latter instance the gas is raised from the oesoph-\\nagus by contraction of the muscles of the neck. Hysterical eructation\\nis very frequently of oesophageal origin. The belching is loud and\\nmay occur in paroxysms. The gas is odorless, and hence is distin-\\nguished from the gas of dyspepsia and fermentation it is hi all proba-\\nbility the result of the swallowing of air.\\nPyrosis. Pyrosis, or heartburn, is the raising of sour masses from\\nthe stomach. The stomach-contents are not necessarily hyperacid.\\nIf acid, as in the normal gastric juice, or hyperacid, the regurgitation\\ncauses severe acrid and burning sensations. It is probably due to\\nheightened contractility of the muscular coat of the stomach with\\npyloric contraction, which overcomes the weaker cardia.\\nPneumatosis. Excess of gas in the stomach. When the stomach\\nis overdistended the diaphragm is pushed up, pressing on the heart.\\nThe patients are seized with severe dyspnoea. At first inspiration is\\ndifficult, and finally both inspiration and expiration become difficult.\\nPalpitation of the heart and pulsation of the peripheral arteries take\\nplace. There is fulness of the head and a sensation of impending", "height": "4412", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0884.jp2"}, "885": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 803\\ndeath. The patient may become unconscious. Relief can only be\\nafforded by belching, when the attack rapidly subsides. Introducing\\na stomach tube gives immediate relief.\\nNervous Vomiting. (See Subjective Symptoms and Gastroxyn-\\nsis).\\nTormina Yentriculi. Peristaltic Unrest. Characterized by\\nborborygmi and gurgling, which begin immediately after eating, are\\nheard at a considerable distance, and are a source of great annoyance.\\nIt is a common symptom of the gastric neuroses.\\nRumination (Merycismus). Rumination is a rare condition in\\nwhich the patients regurgitate and chew the cud like ruminants.\\n(b) 1. Secretory Neuroses of Depression. An acidity. An-\\naciclity of the gastric juice as a neurosis is found in hysterical persons\\nand in neurasthenics. (See chemical examination Absence of Hydro-\\nchloric Acid).\\n(b) 2. Sensory Neuroses of Depression. Anaesthesia. In con-\\nditions of depression polyphagia, or the want of a feeling of satiation\\noccurs if gluttony is excluded, it is a morbid condition of extreme\\nrarity.\\n(b) 3. Motor Neuroses of Depression. Atony, or Atonic Dys-\\npepsia. It accompanies gastritis it also occurs as a primary neurosis.\\nThe innervation of the nerve-centres regulating peristalsis is disor-\\ndered. The primary disorder may be local or central. The movement\\nof the chyme is tardy or insufficient. Atony should be applied to the\\ndisease of the motor function only or, as Rosenbach states it, to insuf-\\nficiency of the stomach. The symptoms develop gradually. At first\\noppression during digestion occurs, with swelling and fulness of the\\nstomach.\\nThere is mental and physical torpor during the time of the digestive\\nact. The symptoms become aggravated, and eructations occur, vomit-\\ning begins, and gradually the fermentative symptoms become most\\npronounced. At this period it is putrid, or fermentative dyspepsia.\\nBy the usual tests the motor power of the stomach is found to be\\ndiminished. The secretions are also scanty.\\nRelaxation at Orifices. Relaxation of the Cardiac and Pyloric\\nEnds of the Stomach from Conditions Besembling Paralysis. When\\nthe cardiac end is relaxed eructations and regurgitations occur. If\\nlarge quantities of the material from the stomach are regurgitated and\\nexpectorated, the condition is pathological. It may lead to serious\\nchanges in nutrition. It may exist for years without bad results. It\\nmust not be confounded with the regurgitation from diverticula of the\\noesophagus. In the latter regurgitation is produced at will.\\n(c) Mixed Neuroses. Nervous Dyspepsia. According to Ewald,\\nthis is the true gastric neurasthenia, which combines all forms of gas-\\ntric neuroses. The clinical picture is made up of a combination of\\nvarious neurosal symptoms. Leube considers nervous dyspepsia a\\ngroup of symptoms of a cerebral nature due to abnormal irritability\\nof the sensory nerves of the stomach during the normal digestive\\nprocesses, the symptoms of which are hyperesthesia and nausea, hy-\\nperorexia, anorexia, parorexia, and gastralgia. He thinks the true", "height": "4404", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0885.jp2"}, "886": {"fulltext": "804 SPECIAL DIAGNOSIS.\\npeptic activity of the stomach is unchanged. Although the anatomical\\nor physiological explanation of the condition is difficult, the clinical\\nsymptoms are those of irritation of paralysis, the manifestations of\\nwhich are intermingled, sometimes one and sometimes the other being\\nmost prominent. (See table, page 797.)\\nThe one characteristic feature is that the symptoms are mild. With\\nsevere forms of gastralgia nervous vomiting and boulimia do not occur.\\nSymptoms of intestinal indigestion are usually associated in a mild\\ndegree. Constipation is of the most common occurrence, although in\\nsome cases there is diarrhoea. In other cases the intestinal indigestion\\nis much aggravated, with mild gastric disturbances and anorexia, repug-\\nnance toward taking food, furred tongue and mild nausea, constipation\\nand colicky pain, either diffuse or in separate painful spots. The\\nabdomen is distended and tympanitic, sometimes to a marked degree.\\nIt is called flatulent dyspepsia. Along with the gastric and intestinal\\nsymptoms, the general nervous symptoms to which the term neuras-\\nthenia is applied are present. These nervous manifestations sometimes\\nprecede the local gastric symptoms, but as the latter develop the former\\nbecome more aggravated. The dyspeptic conditions, as Ewald puts\\nit, are on a neurotic basis, or are such as may occur in the form of reflex\\nneuroses in chlorosis, menstrual disorders, uterine and ovarian disease,\\nand intense physical or psychical excitement. As far as we know there\\nare no great alterations in the chemical functions when anatomical and\\npathological changes are absent. An indigestion of short duration, a\\nmild catarrh, recurring hyperemia, have been the primary cause of\\nnervous symptoms in the digestive organs.\\nDiagnosis. There are no characteristic symptoms, and the student\\nmust bear in mind that it may be necessary to make several examina-\\ntions and listen to the story of the subjective symptoms frequently\\nbefore a conclusion can be arrived at. This is all the more necessary\\nbecause of the frequency in which organic lesions and neurasthenic con-\\nditions are present at the same time. The course of the disease must\\nbe observed for a long time, all possible causal factors investigated, and\\nall the general signs of neurasthenia carefully considered. In addition,\\nit may be necessary to use therapeutic tests. If the possible organic\\ndiseases are not relieved by such measures, there must be a deeper basis\\nfor the gastric symptoms. Just as in neurasthenia and in neurasthenic\\nstates elsewhere, the peculiarities, idiosyncrasies, and all the associations\\nin the life of the individual must be considered in connection with the\\ngeneral and local symptoms of the neurasthenic state. Great stress must\\nbe placed upon the study of individual symptoms, their mutual rela-\\ntionship, and their changeable occurrence. In gastric neurasthenia\\ngastralgia is more diffuse than the pain of ulcer or cancer of the stom-\\nach. It is not so much dependent upon food as either of the others,\\nparticularly ulceration. In gastric neurasthenia vomiting is rare. The\\nvomiting is composed of mucus mixed with bile and food in various\\nstages of digestion. It is never bloody, nor does it contain decomposed\\nmasses. Hysterical vomiting occurs with ease and regularity compared\\nwith the vomiting of neurasthenia. The vomiting in neurasthenia is\\nbitter, due to the presence of peptones. In gastric neurasthenia the", "height": "4412", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0886.jp2"}, "887": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 805\\nstools are changeable in character. They do not contain undigested\\nremnants of food, or mucus, or blood. The form of the feces is variable.\\nDifferential Diagnosis. Neoplasms, ulcers, strictures, and dilatation are\\ndistinguished by physical signs or characteristic symptoms. In gastric\\nneurasthenia the stomach should be empty seven hours after taking a\\nmeal. The results of the chemical examination are not sufficiently\\ndefinite for diagnostic purposes, for at times the same chemical changes\\nare present, as in ulcer, carcinoma, and chronic catarrh. The diag-\\nnosis must be based largely, as previously intimated, upon prolonged\\nobservation and a carefully taken history, and upon the general condi-\\ntion of the patient. The cases must not be mistaken for costal neural-\\ngia, although it is not usually easy to be led astray. Reflex gastric\\nneuroses are seen, as indigestion, gastralgia, or vomiting. The types\\nare interchangeable, although vomiting occurs in the more acute reflexes,\\nindigestion in the more chronic. The cerebral disorders which give\\nrise to vomiting are meningitis, abscess, and tumor. The vomiting\\nmay be transitory, or may be persistent. There is usually hypersecre-\\ntion of the gastric juice. The vomiting may usher in the disease or\\ndevelop during its course. If vomiting is of long standing its possibly\\nreflex origin should always be investigated. (See Vomiting.)\\nGastralgia is sometimes a reflex from lesions in the cervical and\\ndorsal portions of the cord not only in the posterior columns, but also\\nhi disseminated sclerosis. Vomiting occurs, and the attack is known\\nas a gastric crisis.\\nChronic dyspepsia is a frequent reflex disorder of diseases of the\\nsexual organs, as amenorrhoea and dysmenorrhea, in the climacteric\\nperiod, and in chronic inflammations of the uterus. In malpositions\\nand tumors, and in pelvic exudations with traction, in ulcers, in ova-\\nrian tumors, the so-called dyspepsia uterina of Kisch is common.\\nChronic Gastritis. Causes. 1. Previous attacks of acute gastritis.\\n2. The local irritation of badly cooked or poorly masticated food,\\nand of alcoholic and other beverages.\\n3. The local irritation of urea in chronic Bright s disease, and of\\nproducts of putrefaction in constipation.\\n4. In anaemia chronic gastritis is of frequent occurrence, and in\\nvenous congestions from any cause, but particularly from disease of\\nthe heart or diseases which interfere with the portal circulation. It\\noccurs secondarily to diabetes, gout, rheumatism, nephritis, and tuber-\\nculosis.\\n5. It is a constant attendant upon local disease of the stomach, as\\ncancer, dilatation, and ulcer, and of local disturbance of the circulation.\\nThe symptoms are those of chronic indigestion. There is a dry,\\npasty, or salty taste in the mouth, especially in the morning. The\\ntongue is coated over its entire surface, or has red patches at the base\\nits papilla? are always swollen and its edges marked by the teeth.\\nAphthae recur frequently. The lips are dry and often chapped.\\nThe appetite is poor or capricious. Although there is no great\\nthirst, the patients crave fluids with their meals, and acid drinks are\\ngrateful. After eating there is a feeling of oppression and disten-\\ntion in the epigastrium, frequently followed by belching. The gaseous", "height": "4416", "width": "2660", "jp2-path": "practicaltreatis00muss_0_0887.jp2"}, "888": {"fulltext": "806 SPECIAL DIAGNOSIS.\\neructations are odorless or foul, and rancid regurgitation with pyrosis\\nis frequent. The acidity is due to fatty acids and not to hydrochloric\\nacid, as in hypersecretion. Vomiting is invariably present, but occurs\\nirregularly. It is usually preceded by nausea. The most character-\\nistic form is that in which mucus is vomited in the morning on rising.\\nConstipation usually exists it may alternate with diarrhoea. There\\nare flatulency and rumbling in the intestines.\\nGeneral Symptoms. The nervous symptoms are the most pronounced.\\nThe mental activity is diminished, there is a feeling of languor or\\ntorpor, especially after eating. Headache is frequent after eating, and\\nthe patient may become morose and hypochondriacal. Attacks of ver-\\ntigo are common. Itching of the skin and coldness of the extremities\\nare not rare. Sleep is deeper and longer than is natural, but is dis-\\nturbed by dreams, and is not refreshing. Yawning is frequent. Phar-\\nyngitis usually attends the attack, with hacking cough and expectora-\\ntion, or hawking of mucus.\\nThe pulse may be weak and irregular, and at times there is an even-\\ning rise of temperature. The urine is scanty, high-colored, and usually\\nloaded with urates.\\nThree forms are seen (1) Simple chronic gastritis (2) chronic\\nmucous gastritis the term chronic catarrh of the stomach is applied\\nto both conditions. If the condition lasts a long time, it results in (3)\\natony, with dilatation of the stomach, or with atrophy. Atrophy, or\\natrophic gastritis, is secondary to the chronic form, or to stenosis of the\\noesophagus, or to cancer. The symptoms are those of pernicious anae-\\nmia. Cirrhosis of the stomach is also a sequence of gastritis. It is\\nrare, and the symptoms are not characteristic of a spinal lesion. They\\nare those of the primary disease.\\nExamination of the Stomach-contents. In simple gastritis the stom-\\nach, after digestion is completed, contains a small amount of slimy\\nfluid. Hydrochloric acid is diminished in quantity after a test-break-\\nfast lactic acid and the fatty acids are present, as previously noted.\\nPepsin and the milk-curdling ferment are absent or diminished. In\\nmucous gastritis there is subacidity. It differs from the simple form\\nin the excess of mucus only. In atrophy the hydrochloric acid and\\npepsin are diminished, or absent altogether after the test-breakfast.\\nThe fasting stomach is empty. There are no fermentation acids.\\nAtrophy must be distinguished from cancer and subacid neuroses.\\nThe latter occur in younger individuals than those subject to atrophy.\\nA bloody tinge in the stomach-contents, or hemorrhage, may be the\\nonly distinguishing mark of cancer. It is often impossible to make\\na diagnosis.\\nDiagnosis. The diagnostic features of chronic gastritis are First,\\nlong duration second, persistence of local symptoms third, recur-\\nrence of local symptoms after food, the symptoms being aggravated by\\nstimulants, or stimulating food fourth, moderate pain fifth, absence\\nof cachexia sixth, absence of tumor seventh, flatulency. Hemor-\\nrhage is rare, and there may or may not be vomiting, while the quan-\\ntity of hydrochloric acid is variable. Finally, the cause is usually\\ndefinite.", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0888.jp2"}, "889": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 807\\nDilatation of the Stomach (Gastr ectasia). (See Plate XXXVIIL,\\nFig. 1.) It is caused by obstruction at the pyloric orifice, either from\\ncancer, the cicatrix of an ulcer, or fibrous stricture. It follows atony\\nand degeneration of the walls of the stomach which occur in the course\\nof chronic gastritis. It may attend paralysis of the stomach. Excessive\\neating or drinking are the only probable causes independent of organic\\ndisease. Hence, we have (1) obstructive and (2) atonic dilatation.\\nThe dilatation may be acute. The term acute paralytic distention is\\nalso applied to this condition. The cases are extremely rare. There\\nis sudden enlargement of the upper portion of the abdomen, with\\npressure upon the surrounding structures. The heart is dislocated and\\nits action much interfered with collapse follows and may end in\\ndeath. At first there may be some belching, but the patient is soon\\nunable to remove the gas, and suffers from extreme discomfort, palpi-\\ntation, and dyspnoea. The vomiting may occur at once or later. It\\nis persistent and excessive. On physical examination the stomach\\nyields the same physical signs as in chronic dilatation.\\nChronic dilatation develops slowly. The symptoms of it are super-\\nimposed upon the causal disease. There is marked dyspepsia, with\\nflatulency, pyrosis, and other symptoms of fermentation. The tongue\\nis pale and furred, or red, smooth, and shiny or it may be soft and\\nflabby. If frequent vomiting has attended the causal disease, it now\\noccurs at longer intervals the amount is excessive, greater than the\\nnormal stomach would hold, and is made up of partially digested and\\nfermented food and large amounts of mucus. The stomach-contents\\ncontain sarcinse, torulse, and other products of fermentation. Hydro-\\nchloric acid is usually absent, but there is a large excess of lactic\\nand fatty acids. The patient loses flesh and strength becomes irri-\\ntable, depressed, and more or less melancholy. The patient is subject\\nto vertigo and to attacks of nocturnal asthma. The nervous symptoms\\nof chronic gastritis are also present.\\nSleeplessness is quite common. In some cases there is excessive\\nthirst because of the small amount of nutriment and fluid absorbed.\\nCardiac palpitation and irregularity are common, and dyspnoea may\\noccur on account of the distention. Tetany has been observed in cases\\nof dilatation, especially after lavage.\\nPhysical Examination. The diagnosis is not complete without physi-\\ncal examination. On inspection the abdomen is large and prominent,\\nand the outline of the stomach can sometimes be seen. Peristaltic\\nmovements of the organ are often seen. The movement is from left\\nto right. The heart is lifted upward. On palpation the peristalsis can\\nbe felt, and with one hand on the stomach, tapping with the other, a\\nsplashing sound can be detected. Or the hand may be placed over the\\nstomach (patient standing) and the body quickly shaken. On palpa-\\ntion the striking or pushing hand should be compressed over the false\\nribs. A tumor can sometimes be felt in the region of the pylorus, or\\nbelow the umbilicus. On percussion, when the stomach contains gas,\\na tympanitic note is heard. After drinking water dulness may be de-\\ntected between gastric and intestinal tympany if the patient stands up.\\nThe dull note disappears when he resumes the recumbent posture.", "height": "4416", "width": "2644", "jp2-path": "practicaltreatis00muss_0_0889.jp2"}, "890": {"fulltext": "808 SPECIAL DIAGNOSIS.\\nBefore taking water tympany is not so marked in the upright as in\\nthe recumbent posture, because the stomach is dragged back or down.\\nThe tympany extends high up in the chest on the left side, so that\\nTraube s half-moon space is exaggerated. It may extend as high as\\nthe fourth interspace on the left side. Cardiac dulness is increased\\nand the apex of the heart is lifted upward and to the left. In the\\naxillary region the tympany may extend as high as the sixth rib.\\nThere is usually atrophy of the spleen, so that unless very careful\\nlight percussion is performed the splenic dulness cannot be brought\\nout. The lower limit extends below the transverse umbilical line, and\\nmay even extend midway to the pubis. If there is gastroptosis, the\\nhalf -moon space becomes dull on percussion, the stomach tympany fall-\\ning to a lower level. On auscultation succussion can easily be elicited.\\nSometimes the sound is sizzling, as if there was effervescence. Heart-\\nsounds may be transmitted clear and metallic over the tympanitic\\nstomach. With auscultatory percussion the border of the stomach can\\noften be denned accurately. Percussion must be commenced far away\\nfrom the stomach-limit and conducted toward it. (See Examination\\nof the Abdomen.)\\nStenosis of the Pylorus. Usually, obstruction is caused by malig-\\nnant disease. Hypertrophic stenosis occurs in rare instances and leads\\nto dilatation, as indicated above. The condition may be congenital or\\nacquired.\\nAcquired stenosis may be the result of chronic gastritis, or develop\\nindependently, sometimes as part of a general proliferation of connec-\\ntive tissue. (See case of author, Path. Soc. Trans., vol. xi. 1881-83,\\np. 216.) If, to the physical signs of tumor of the pylorus, be added\\nthe signs and symptoms of dilatation, we have the clinical picture of\\nhypertrophic stenosis of the pylorus. It is extremely rare to find\\ncomplete obstruction.\\nCongenital hypertrophic stenosis, as Metzler and Caudley point\\nout, has for its characteristic features (1) Vomiting, occurring with-\\nout apparent cause and persisting in spite of treatment (2) the ab-\\nsence of bile from the vomited matter (3) obstinate constipation (4)\\nmarasmus (5) the presence of a tumor in the region of the pylorus\\n(6) the absence of abdominal distention except from dilatation of the\\nstomach itself in some instances and (7) the absence of signs or\\nsymptoms of gastritis and of the more common forms of intestinal\\nobstruction. Diagnosis depends entirely on the characteristic symp-\\ntoms arising during the first few weeks of life and the presence of a\\ntumor.\\nDiseases of the Stomach Characterized by Pain and Vomiting.\\nCancer of the Stomach. The clinical symptoms are varied. Gas-\\ntric cancer may occur Avithout any symptoms whatever, and be discov-\\nered after death from other causes. On the other hand, general maras-\\nmus and cachexia may be present, without local symptoms. In some\\ncases the gastric symptoms are slight, and obscured by the symptoms\\nof secondary growtli in the liver or peritoneum.", "height": "4412", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0890.jp2"}, "891": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 809\\nTvpical cases are those which occur late in life, with symptoms of\\nchronic gastritis. These symptoms may continue for months before\\nanything further is observed. Gradually the uneasiness and discom-\\nfort after eating increase to actual pain. Loss of appetite is marked,\\nand in spite of careful treatment there is loss of flesh and strength.\\nThe usual vomiting of chronic gastritis gradually becomes more fre-\\nquent. The general appearance of the vomitus is at first like that of\\nchronic gastritis. Soon it becomes streaked with blood, or a moder-\\nately large hemorrhage may take place. The vomited matter is dark\\nin color, like coffee-grounds in appearance. The relation of vomiting\\nto the time of taking meals depends upon the seat of the disease. If\\nat the cardiac end of the stomach, the vomiting may take place at\\nonce. If in the greater curvature, within twenty minutes or one\\nhour and a half after taking food. If at the pyloric orifice, the vomit-\\ning is delayed several hours. As the disease advances, and obstruc-\\ntion becomes more complete at the cardiac orifice, food is immediately\\nregurgitated, unless secondary dilatation of the oesophagus takes place.\\nWhen there is gastric dilatation the vomiting may take place at longer\\nintervals and be characteristic of the vomitus of dilatation. Constipa-\\ntion is the rule.\\nTumor. After the symptoms of chronic gastritis have continued for\\nsome time without relief a tumor may be detected, depending upon its\\nsituation and size. (See Tumors of Abdomen.) If the growth is situ-\\nated at the cardiac orifice of the stomach, it is often impossible to\\ndetect it. If at the pyloric orifice, the tumor is found to the right of\\nthe median line above the umbilicus, but may be forced down by\\nthe weight of the stomach and felt at the umbilicus. (See Plate\\nXXXVIII. Fig. 2.) When dilatation follows pyloric tumor it may\\nbe still lower down, as in a case of the writer s, in which it was found two\\ninches below and to the right of the umbilicus. In tumor of the greater\\ncurvature the mass is detected below the margin of the ribs on the left\\nside, and may be as low down as the umbilicus. If the greater curvature\\nis involved, the organ usually atrophies, and hence the physical signs\\nindicating the lower border of the stomach are higher up than in health.\\nIt is necessary to exclude tumors due to other causes. This is some-\\ntimes difficult indeed, as far as the location and physical characters\\nare concerned, often impossible. The most pronounced diagnostic\\nfeature of tumor of the pylorus is the occurrence of secondary dilata-\\ntion of the stomach. For a differential diagnosis of tumors in this\\nregion, see Palpation of Abdomen.\\nSymptoms due to Metastasis. The liver is the most frequent seat of\\nsecondary growths. The organ enlarges, and its surface is covered\\nover with nodules. (See Plate XXXVIII. Fig. 2.) Jaundice occurs\\nin rare instances. The enlarged liver mayGOver the stomach and hide\\nthe local mass. The inguinal glands enlarge. At times there is en-\\nlargement of the supraclavicular glands, suggestive also of intra-abdom-\\ninal carcinoma, from other causes.\\nThe general symptoms are those of emaciation and cachexia. The\\nemaciation is extreme, and in some cases may be out of proportion to\\nthe local symptoms.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0891.jp2"}, "892": {"fulltext": "810 SPECIAL DIAGNOSIS.\\nThe symptoms of cachexia are those of emaciation and anaemia.\\nThe ancemia becomes profound. The pallor of the face is striking,\\noften it is of a yellowish and straw-colored hue. It must not be con-\\nfounded with jaundice examination of the conjunctivae is usually\\nsufficient to distinguish the two. The skin is flabby, and the subcu-\\ntaneous fat is entirely lost the emaciation is not so marked as in cancer\\nof the oesophagus, except when there is complete cardiac stricture.\\nThe nutrition of the skin suffers, boils are common, and ulcers may\\noccur. Subcutaneous hemorrhages are seen in the terminal stages on\\nthe backs of the hands, on the dorsum of the feet, on the legs and\\narms. There is slight oedema of the ankles.\\nGeneral atrophy of the internal organs takes place, so that the heart\\nbecomes small it loses its strength, the patient becomes weaker and\\nweaker, the pulse rapid and feeble.\\nIf fever occurs in the course of the disease, it is usually due to sec-\\nondary accidents, as suppuration in a tumor, or perforation with septic\\nperitonitis. The usual course of the temperature is normal until the\\nlater stages, when it is subnormal.\\nExamination of the Stomach-contents. Hydrochloric acid may or\\nmay not be absent, depending upon the amount of gastric catarrh.\\nLactic acid, on the other hand, is commonly present even in the earli-\\nest stages, and when associated with absent HC1 is very diagnostic.\\nBoas test-breakfast must be given. For an accurate diagnosis re-\\npeated examinations must be made. Other general and local condi-\\ntions, as fevers on the one hand, or dilatation on the other, are attended\\nby absence of hydrochloric acid at times. In carcinoma it is the per-\\nsistence of the absence which is diagnostic. Pepsin and the milk-\\ncurdling ferment are not changed.\\nThe Urine. Indican in increased amount, acetone and diacetic acids\\nmay be present in the urine otherwise there is no change.\\nDiagnosis. In the diagnosis of gastric cancer the following must be\\nborne in mind 1. The age of the patient. 2. The occurrence of\\ncauseless dyspepsia without relief. 3. Rapid loss of flesh and strength,\\nwith cachexia. 4. The occurrence of pain in the epigastrium, contin-\\nuous, increased by food, but not relieved by vomiting, as in ulcer,\\nand not distinctly localized. 5. Tumor hard, circumscribed, fol-\\nlowed by the physical signs of dilatation, if in the pylorus. 6. Vom-\\niting is necessarily associated with the taking of food, in which frag-\\nments of cancer may be found blood-cells are common they may be\\ndetected on microscopical examination, or by the test for hsemin. 7.\\nExamination of stomach-contents, (a) Except in dilatation the fasting\\nstomach is empty (6) hydrochloric acid is often absent, whereas lactic\\nacid is present (c) delayed absorption is present, indicated by motor\\ntests. 8. Hemorrhage. In small amounts, usually of characteristic,\\ncoffee-ground appearance. 9. Metastases above the left clavicle in\\nthe liver in the inguinal glands rarely in the lungs and peritoneum.\\n10. Eichhorst speaks of persistent itching of the skin and insomnia as\\ncharacteristic symptoms. 11. Finally, the comparatively short dura-\\ntion of the case. Rarely does it extend over a period of two years.", "height": "4404", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0892.jp2"}, "893": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 811\\nDifferential Diagnosis of Gastric Cancer, Gastric Ulcer, and\\nChronic Gastritis. (Welch.)\\nGastric Cancer.\\n1. Tumor is present in three-\\nfourths of the cases.\\n2. Rare under forty years of\\nAverage duration about one\\nyear, rarely over two years.\\nGastric hemorrhage fre-\\nquent, but rarely profuse\\nmost common in the ca-\\nchectic stage.\\n5. Vomiting often has the pe-\\nculiarities of that of dila-\\ntation of the stomach.\\nFree hydrochloric acid usu-\\nally absent from the gastric\\ncontents in cancerous dila-\\ntation of the stomach lac-\\ntic acid much increased.\\n10.\\nGastric Ulcer.\\nTumor rare.\\nChronic Catarrhal Gastritis.\\nNo tumor.\\nMay occur at any age after May occur at any age.\\nchildhood. Over one-half of\\nthe cases under forty years\\nof age.\\nDuration indefinite\\nfor several years.\\nGastric hemorrhage less fre-\\nquent than in cancer, but\\noftener profuse not uncom-\\nmon when the general\\nhealth is but little im-\\npaired.\\nVomiting rarely referable to\\ndilatation of the stomach,\\nand then only in a late stage\\nof the disease.\\nFree hydrochloric acid usu-\\nally present in the gastric\\ncontents.\\nmay be Duration indefinite.\\nGastric hemorrhage rare.\\nVomiting\\npresent.\\nmay or may not be\\nCancerous fragments may Absent,\\nbe found in the washings\\nfrom the stomach or in the\\nvomit (rare).\\nSecondary cancers may be Absent,\\nrecognized in the liver, the\\nperitoneum, the lymphatic\\nglands. and, rarely, in other\\nparts of the body.\\nFree hydrochloric acid may be\\npresent or absent.\\nAbsent.\\nCachectic appearance usually\\nless marked and of later\\noccurrence than in cancer,\\nand more manifestly depen-\\ndent upon the gastric dis-\\norders.\\nLoss of flesh and strength\\nand development of ca-\\nchexia usually more mark-\\ned and more rapid than in\\nulcer or in gastritis, and\\nless explicable by the gas-\\ntric symptoms.\\nEpigastric pain is often Pain is often paroxysmal,\\nmore continuous, less de- more influenced by taking\\npendent upon taking food, food, oftener relieved by\\nless relieved by vomiting, vomiting, and more sharply\\nand less localized than in localized than in cancer,\\nulcer.\\n11. Causation not known.\\nCausation not known.\\nAbsent.\\nWhen uncomplicated, usually no\\nappearance of cachexia.\\nThe pain or distress induced by\\ntaking food is usually less severe\\nthan in cancer or ulcer. Fixed\\npoints of tenderness usually ab-\\nsent.\\nOften referable to some known\\ncause, such as abuse of alcohol,\\ngormandizing, and certain dis-\\neases, as phthisis. Bright s dis-\\nease, cirrhosis of the liver, etc.\\nMay be a history of previous simi-\\nlar attacks. More amenable to\\nregulation of diet than is cancer.\\n12. No improvement, or only Sometimes a history of one or\\ntemporary improvement, more previous similar at-\\nin the course of the dis- tacks. The course may be\\nease. irregular and intermittent.\\nUsually marked improve-\\ni ment by regulation of diet.\\nCases of cancer of the stomach may present only symptoms of anae-\\nmia. In this manner the disease has been confounded with pernicious\\nancemia. The blood is never reduced in cancer to the degree it is in\\npernicious anaemia, nor does it present the characteristics found in\\nanaemia.\\nUlcer of the Stomach. Simple round ulcer of the stomach may\\noccur at any age but is most common in young anaemic women. It", "height": "4416", "width": "2648", "jp2-path": "practicaltreatis00muss_0_0893.jp2"}, "894": {"fulltext": "812 SPECIAL DIAGNOSIS.\\nmay be the result of an erosion of hemorrhagic infarcts by the gastric\\njuice. Stockton believes it to be a neuropathic change.\\nThe Symptoms. The symptoms are variable. The cases have\\nbeen divided by Welch into four classes (1) Those in which there are\\nno symptoms whatever, the ulcer having been found after death from\\nother diseases (2) no symptoms until the sudden occurrence of hemor-\\nrhage, or perforation (3) the symptoms of chronic gastritis or gastral-\\ngia only (4) typical cases, with the characteristic symptoms, pain,\\nhemorrhage, and vomiting. The symptoms of gastric ulcer may develop\\nsuddenly.\\nPain. The pain is localized it is usually confined to a small area\\nin the epigastrium. It may be seated behind the cartilage of the sixth\\nand seventh ribs, or may be complained of in the back, between the\\neighth and ninth dorsal vertebrse, extending as low down as the first\\nand second lumbar. It is of a burning or gnawing character, is in-\\ncreased by food, and comes on in from two to ten minutes after the\\ningestion of food. It is relieved by vomiting, or after the act of diges-\\ntion is completed but a persistent, dull pain or a feeling of soreness\\nremains. In addition to the ordinary pains, there may be attacks of\\ngastralgia. The pain is increased by pressure. It may be modified\\nby the position of the patient. It may be relieved by lying on the\\nback when the ulcer is in the anterior wall or relieved by lying on\\nthe abdomen when in the posterior wall.\\nVomiting. Vomiting occurs shortly after the ingestion of food. It\\nis not attended by retching. The vomited matter may contain blood.\\nThe vomited matter and the contents of the stomach contain hydro-\\nchloric acid, which may be in excess. Eichhorst thinks it is always in\\nexcess.\\nHemorrhage. Blood in the vomitus gives it a brown or reddish\\ncolor. It may be detected by the usual methods. Hemorrhage may\\noccur, however, independently of the act of vomiting. It varies in\\namount from half a pint to a quart. It may be so severe as to cause\\ncollapse. Sometimes, instead of being discharged as a profuse hemor-\\nrhage, the blood may gradually ooze from, the ulcer and collect in the\\nstomach before being vomited. It is then altered by the acid gastric\\njuice. Sometimes the blood is not vomited, but passed by stool, which\\nis then tarry. Tarry stools also follow the vomiting of blood. In the\\ncourse of ulcer a hemorrhage may be so severe that death takes place\\nbefore vomiting occurs. The stomach is then found to be filled with\\nblood.\\nThe stomach bougie should not be used the nature of the contents\\nmust be determined by an examination of the vomited matter.\\nThe General Symptoms. If the cases are of long standing, the\\nface is anxious and the lines are sharpened. If there is much hemor-\\nrhage, anaemia ensues. There is not much wasting and no fever.\\nChronic dyspepsia and constipation may be present during the intervals\\nin which the severe symptoms are in abeyance. The period of abey-\\nance varies, and the symptoms may come on without cause, as in gas-\\ntric crises, during which time the vomiting may persist for two or three\\ndays. I saw a young girl of twenty years with most severe gastric", "height": "4408", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0894.jp2"}, "895": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 813\\nhemorrhage and classical symptoms of ulcer. With careful treatment\\nshe improved. After marriage she remained well until pregnancy.\\nDuring the first periods of this condition vomiting was extreme it\\nthen subsided, whereupon, without warning, a gastric crisis took place.\\nThe vomiting of blood continued for many days, and the symptoms of\\ngastric ulcer remained for a month.\\nOne of the characteristic features of the disease is the recurrence of\\nsymptoms after a long period of abeyance. A patient under my care\\nduring the last ten years has had three undoubted attacks. It is pos-\\nsible that during each period ulcers healed, to be followed after a time\\nby the occurrence of new ulcers.\\nDiagnosis. The diagnostic features are 1. The age. 2. The long\\nduration. 3. The occurrence of emaciation up to a certain point only\\nmost of the patients are under-weight and have a gaunt look, particu-\\nlarly males. 4. The characteristic pain. 5. The vomiting. 6. The\\nhemorrhage. 7. The periods of relief from symptoms. 8. The absence\\nof marked nervous symptoms which attend gastric neuroses. 9. The\\nabsence of dilatation of the stomach. 10. The hyperacidity of the\\ngastric juice.\\nThe Accidents of Ulcer of the Stomach. 1 The occurrence of perfo-\\nration. Sudden severe pain, with collapse. The pain is usually in\\nthe epigastrium, but may be in the back as high as the seventh or\\neighth dorsal vertebra.\\n2. Hemorrhage, which may cause death immediately, with either\\nvomiting of blood or retention in the stomach.\\n3. With healing of the ulcer, stenosis at the pyloric orifice may take\\nplace, with subsequent dilatation of the stomach.\\nDiseases of the Intestines.\\nThe intestine is a canal of varying dimensions, the physiological\\noffice of which is to propel material received from the stomach, and to\\npermit of the digestion and absorption of that which is to serve for the\\nnutrition of the body. The canal is richly supplied with bloodvessels\\nand lymphatics. It is made up of mucous membrane, muscle, and\\nperitoneum. For the purpose of digestion, fluids are secreted, either\\nfrom the intestinal glands or large neighboring glands which discharge\\ninto the canal.\\nDiseases which affect the canal impair or cause an abeyance of the\\nphysiological offices. As these offices absorption and digestion are\\nessential to nutrition, it is not surprising that the body-weight and\\nstrength are impaired. We know too little about the function of diges-\\ntion to utilize such knowledge in diagnosis. Intestinal digestion is\\nalso dependent upon the healthy performance of the functions of the\\nliver and pancreas. It is difficult to draw fine lines of distinction even\\nin health, and intestinal pathology is closely interwoven with hepatic\\nand pancreatic pathology.\\nAlterations of the function of the intestine as a canal give rise to dis-\\ntinctive symptoms. Either its movements are too frequent and rapid,\\ncausing diarrhoea, or too sluggish, causing constipation. Obstruction of", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0895.jp2"}, "896": {"fulltext": "814 SPECIAL DIAGNOSIS.\\nthe canal leads to symptoms common to such a condition (see Morbid\\nProcess), modified by the physiological duties and the anatomical\\nstructure of the canal.\\nThe morbid processes are hyperemias, inflammations, degenera-\\ntions, and new growths. The symptoms that attend these processes\\nare not different from the symptoms that attend such processes in\\nsimilar structures elsewhere. It must not be forgotten that the function\\nof the canal is influenced by each process. On account of the process\\nwe may have pain and fever on account of the impaired function,\\npain, flatulency, diarrhoea, or constipation, change in the character of\\nthe stools, and impaired nutrition. Some of the above morbid processes\\nmay lead to the mechanical condition, obstruction.\\nThe morbid alterations of the intestinal tract are ascertained by\\ndata obtained by inquiry and by observation. The data obtained by\\ninquiry include the subjective symptoms pain, and discomfort from\\nflatulency. By observation the general condition of the patient, the\\npresence of tenderness, alterations in the size and shape of the abdo-\\nmen, and other physical phenomena are observed. The feces are care-\\nfully studied, with the object of determining modifications of the\\nfunction of the bowel, the presence of ingredients due to some morbid\\nprocess, as serum, blood, pus, or mucus, or of extraneous matter, as\\nworms or foreign substances. The feces are studied by the naked eye,\\nby the microscope, and by bacteriological methods.\\nOne symptom may be the chief manifestation of a disease, as pain\\nof lead-colic, diarrhoea of several morbid disorders, constipation of\\nothers. In the discussion of the special symptoms a consideration of\\nthe diseases of which the symptom is the main expression will be\\ntaken up.\\nParasites. The intestine is the recipient of material for nutrition.\\nParasitic forms of animal life, or their ova or spores, may enter the in-\\ntestine with the food. They either remain in the intestinal tract or\\nwander into other structures. They include animal and vegetable\\nparasites, such as forms of protozoa, vermes, and fungi. While the\\ncanal is open to infection by various micro-organisms, it is the natural\\nhabitat of others, which may become deleterious agencies when the\\nconditions of their environment are changed. Thus the bacillus coli\\ncommunis is, in man, with normal epithelial structure and normal\\nsecretions, an innocuous parasite which, when inflammation sets in,\\nmay become nocuous.\\nThe symptoms produced by the protozoa and fungi, or by their prod-\\nucts, the ptomaines, are of an infectious or toxic nature. Inflamma-\\ntion is produced locally.\\nThe symptoms of worms, if retained in the intestinal canal, are (1)\\nKeflex in nature (2) symptoms due to catarrhal inflammation (3)\\nsymptoms due to action of the parasite on the blood anaemia (4)\\nsymptoms due to wandering of the parasite, as in trichinosis. (See\\nFeces.)\\nSymptoms of the Taznioz and Bothriocephali. There may be no symp-\\ntoms save discharge of the parasite or portions of it by the rectum.\\nIn others the symptoms of intestinal dyspepsia or intestinal catarrh", "height": "4408", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0896.jp2"}, "897": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 815\\nare observed. Headache, giddiness, lassitude, and itching at the nose\\nand at the anus are said to be present. The patient becomes hypo-\\nchondriacal. Convulsive disorders occur. Hysteria, forms of epilepsy,\\ngrinding of the teeth at night, and restlessness attend the habitation of\\nthe parasite in the intestine. In all convulsive disorders the possi-\\nbility of worms as a cause must be remembered.\\nSymptoms of Ascarides. (1) Gastro-intestinal catarrh (2) symp-\\ntoms of obstruction (rare) (3) symptoms due to wandering as to the\\nhepatic duct to the stomach, or to the vagina (4) nervous symptoms\\nof reflex origin (5) the worm or its ova in the feces.\\nSymptoms of Oxyuris Vermicular is. (1) Gastro-intestinal dyspepsia\\nor catarrh (2) itching or heat at the anus, worse in bed (3) vesical\\nand rectal tenesmus (4) erythema about the anus (5) priapism (6)\\nvulvitis and vaginitis (7) the worms in the feces.\\nThe Strongylus. The symptoms are local, with the symptoms of\\nprofound anaemia. The discovery of the ova in the feces distinguishes\\nthis form of anaemia from other varieties.\\nThe symptoms due to the presence of the trichina spiralis and filaria\\nwill be discussed in appropriate sections. (See Blood and Infectious\\nDiseases.)\\nThe Intestines in other Diseases. The relationship of intes-\\ntinal disorders to affections of other viscera will be discussed with each\\nsymptom. It must not be forgotten that derangement of this tract\\nmay have its origin in local causes or in causes remote from the intes-\\ntinal tract, or in some general condition of the individual. Thus diar-\\nrhoea may be due to inflammation which is primarily local, or which\\nmay be secondary to infection. Nothing is more common than to see\\ndiarrhoea in a general infection, such as septicaemia. In exophthalmic\\ngoitre the diarrhoea is not due to a local cause, but to some as yet un-\\nknown nerve disorder. Constipation may be due to central brain dis-\\nease, to a general condition like diabetes, or be of local origin.\\nIt must be remembered that the diagnosis of an intestinal lesion\\nis never complete without determining its causes. Thus enteritis and\\nulceration occur in typhoid fever, in cholera, and in other infectious\\ndisorders, all of which are to be passed in review in making up a diag-\\nnosis. Diarrhoea is a symptom in Bright s disease, and the causal rela-\\ntionship must always be borne in mind.\\nDifferential Diagnosis. Intestinal disease or disorders are not usually\\nconfounded with disease of other structures. It is worthy of remark,\\nas a fact which is sometimes overlooked, that symptoms of intestinal\\nobstruction are frequently due to peritonitis. Tumors of the intestine\\nmust be distinguished from tumors of the peritoneum, the stomach,\\npancreas, and liver, and the uterus and ovaries. The history, the seat\\nand physical character of the tumor, and the associate symptoms point\\nto the true condition.\\nArteries of the Intestine. The intestines are supplied by the mesen-\\nteric arteries. Its branches may become the seat of emboli. The\\nsymptoms are sudden pain, intestinal hemorrhage, and discharge of a\\nportion of intestine. The patients are the subjects of atheroma or heart\\ndisease.", "height": "4416", "width": "2648", "jp2-path": "practicaltreatis00muss_0_0897.jp2"}, "898": {"fulltext": "816 SPECIAL DIAGNOSIS.\\nThe Subjective Symptoms.\\nThe Data Obtained by Inquiry. Pain. Colic. Colic is the term\\napplied to paroxysmal pain in the abdomen. It is characterized by\\nsuddenness of onset and by alteration of intestinal function. It attends\\nall forms of inflammation of the intestinal tract. It is applied to a\\npeculiar affection known as lead-colic, due to local effects of lead. The\\nterm colic is also applied to painful affections of the hepatic ducts,\\npancreatic ducts, the ureters, and the uterus. Intestinal colic is the\\nform at present referred to. In addition to the inflammation of the\\nintestinal tract, it may be due to indigestion with flatulency. When it\\noccurs suddenly without local cause it is known as enteralgia.\\nIntestinal Colic. The colic of intestinal indigestion occurs sud-\\ndenly, or it may be preceded by signs of intestinal indigestion. The\\npain is chiefly in the umbilical region and radiates from that point.\\nIt is relieved by moderate pressure or warmth. The patient is rest-\\nless and irritable. The face is anxious. The pain causes him to\\nroll about and double up. There is a cold sweat, and the pulse is\\nsmall and hard. Prostration or collapse rapidly ensues. Nausea and\\nvomiting follow the pain, and there are gaseous eructations. Disten-\\ntion. The abdomen is distended and tympanitic on percussion. The\\npain may be relieved by the passing of flatus. Cramps. Spasm of\\nthe muscles of the calves is common. The cramps are very painful\\nthe muscles become knotted. The hands and feet are also cramped.\\nThe pain is said to be due to spasm of the intestine, and is known also\\nas spasmodic colic. It is certainly due to distention or to irritation.\\nIf the intestinal colic is due to indigestible food, it may have been pre-\\nceded by an attack of acute indigestion, and the griping pains may\\nhave developed at long intervals, with gastric and intestinal flatulency.\\nVomiting may precede or attend the attack, and diarrhoea follow. If\\nthe colic is due to gas alone, there is great tympanites. If it is due\\nto feces, it has been preceded by a history of constipation, and there\\nmay be fecal masses detected in the rectum or along the colon.\\nFever. The presence of fever is against intestinal colic, and points\\nto inflammation in some portion of the abdomen moreover, in inflam-\\nmation the pain is constant, but localized and aggravated by pressure.\\nThe skin is hot and dry.\\nDiagnosis. The sudden severe pain, often relieved on the discharge\\nof gas, with gastro-intestinal disorder, tympanites, the occurrence of\\ncramps in the extremities, and the localization of pain to the umbili-\\ncus, all point to the true nature of the affection. A history of indis-\\ncretion in diet, or exposure, aids in the diagnosis. In colic the pain\\nmay come on suddenly, or increase gradually from a sense of discom-\\nfort or soreness. The pain at its height is described as agonizing, and\\nof a boring or shooting character, abating for a time and then in-\\ncreasing, until the patient rolls and twists in agony and breaks out into\\na cold sweat. The pain may shoot from the seat of greatest intensity\\nto the shoulders, back, chest, or iliac region.\\nIt must be distinguished from enteralgia. The latter comes on\\nslowly and lasts for hours or days. The pain is situated around the", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0898.jp2"}, "899": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 817\\numbilicus, and is relieved by deep pressure, although the skin may be\\nhypersesthetic. Sometimes the abdomen is retracted there are no\\nsigns of indigestion, and flatulency and borborygmi are absent.\\nLead Colic. If the enteralgia is due to lead, there is a history of\\nexposure to that metal. The blue-line on the gums, with obstinate\\nconstipation but no vomiting, and the occurrence of neuritis due to\\nsaturnine-poisoning, point to the true nature of the case.\\nHepatic Colic. In hepatic colic the pain is situated in the region\\nof the liver, and may radiate to the shoulder or back. It is sometimes\\nfixed in the right parasternal line about the cartilages of the sixth and\\nseventh ribs. The attack is attended by vomiting, usually of bilious\\nfluid. It occurs in women most frequently the patients are almost\\nalways over forty years of age. It may be followed by jaundice. There\\nis local tenderness, and there may be some swelling in the region pre-\\nviously mentioned. The bowels are constipated, and after the attack\\nmay contain gallstones.\\nRenal Colic. In renal colic pain begins in the kidney and then\\nextends along the ureter. It is always more localized to the right or\\nleft of the median line in the abdomen. It is more frequently in the\\nlower portion of either of the upper quadrants, three inches to either\\nside of the median line, depending upon the kidney affected. From\\nthis region the point of maximum intensity and of local tenderness\\nmoves to the lower quadrant toward the median line in the oblique\\ndirection, rarely getting an inch below the transverse umbilical line.\\nThe pain then extends to the region above the pubes and down the\\nthighs. From the first there is increased frequency of micturition.\\nThe urine is scanty, high-colored, and may contain blood. With the\\nfree micturition relief follows.\\nLocal Peritonitis. Pain over the liver, spleen, and kidneys is gener-\\nally due to involvement of the peritoneal coverings of these organs,\\nand partakes of the character of local peritonitis. It may, however,\\nbe due to malignant, ulcerative, or inflammatory disease, and the diag-\\nnosis must be made by noting the character of the pain, its intensity,\\nduration, seat, and the other general and local symptoms with which\\nit is associated.\\nRectal Pain. Pain in defecation may be due to piles, internal or\\nexternal, or to fissure, or may be the result simply of the passage of\\nan unusually large, hard mass. Pain from fissure is most acute and\\nspasmodic, and persists for some time after defecation. Fibroid stric-\\nture of the rectum causes more pressure and straining at stool than\\nreal pain but cancer is apt to be extremely painful.\\nUterine Colic. In uterine colic the pain is situated in the pelvis.\\nThere is some abnormality of discharge, and a history of uterine dis-\\nease. Care must be taken not to confound the sudden pain of extra-\\nuterine pregnancy with intestinal colic or other forms of abdominal\\npain. In extra-uterine pregnancy the pain is in the lower quadrants of\\nthe abdomen to the right or left of the median line. It is sudden and\\nintense, attended by more or less collapse. It may be attended by\\nall the symptoms of internal hemorrhage. It may cause vomiting.\\nThe history of cessation of menses, or other signs of pregnancy, of\\n52", "height": "4416", "width": "2644", "jp2-path": "practicaltreatis00muss_0_0899.jp2"}, "900": {"fulltext": "818 SPECIAL DIAGNOSIS.\\ndischarge of decidua, with the local signs on physical examination\\nindicate the true nature of the pain.\\nPancreatic Pain. In disease of the pancreas, either from the passage\\nof calculi (extremely rare) or because of pancreatic hemorrhage, there\\nmay be sudden severe pain. The pain is localized to the region below\\nthe sternum. It may be severe in the back and extend up the thorax.\\nIt occurs in paroxysms, and is attended by great anxiety and collapse.\\nGastric Pain. Intestinal colic must be differentiated from pain\\nof gastric ulcer, gastric cancer, and gastralgia. The characteristics of\\npain in these affections have been discussed. When perforation occurs\\nin gastric ulcer the pain is usually seated in the epigastrium, but may be\\ncomplained of in the back as high as the mid-scapular region. It is\\nsudden and severe, preceded by a history of ulcer and attended by\\ncollapse. There are no evidences of indigestion. Perforation of the\\nbiliary passages is attended by pain in the hepatic region. The pain\\nis sudden and is usually preceded by symptoms due to derangement of\\nthe biliary passages from obstruction by gallstones.\\nAppendicitis. Intestinal colic must not be confounded, although\\nit frequently has been, with the pains that attend appendicitis. This\\nis particularly the case with relapsing appendicitis. In this form only\\nmild fever attends the attack. The patient is seized with severe pain,\\nwhich may be described as occurring in the lower right quadrant, but\\nis sometimes complained of about the umbilicus. It frequently follows\\nindiscretion in diet, and may be attended by vomiting, and is likewise\\nusually relieved by eructation, but not by the passage of gas, a point\\nof great importance in the diagnosis. The attack occurs mostly in\\nyoung subjects, and lasts from twelve to twenty -four hours. It may\\nbe so severe as to cause collapse. If fever attends it, and there is\\na mass present, the diagnosis is much easier. In the relapsing as well\\nas the true form there is tenderness at McBurney s point. (See Ap-\\npendicitis.)\\nPeritonitis. Intestinal colic must not be confounded with peri-\\ntonitis, which may follow in any of the above conditions, or develops at\\nother points in the abdomen. The purulent peritonitis that succeeds\\npyosalpinx may be attended by severe pain without much reaction.\\nThe pain, however, although complained of about the umbilicus, can be\\nlocalized by pressure in the lower quadrant and in the pelvis. It may\\ndisappear after eight or ten hours, to be followed by a recurrence.\\nThe recurrence of pain is usually attended by fever. In the first\\ntwenty-four hours the bowels are loose, or at least readily moved. If\\nthe peritonitis continues beyond this period, it is often impossible to\\nmove the bowels.\\nIntestinal Obstruction. Intestinal colic must not be confounded\\nAvith organic disease of the bowels with resulting obstruction. In\\nthese affections there are sudden constipation and rapid prostration.\\nThe vomiting, if present, persists and soon becomes stercoraceous. In\\nintussusception the stools are characteristic. Strangulation, or ileus, is\\nassociated with a history of previous peritonitis or the presence of hernia.\\nIn the latter there may be signs at the hernial points. In the obstruc-\\ntion from external pressure the presence of tumors has been known", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0900.jp2"}, "901": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 819\\npreviously or can be recognized. In fecal obstruction or the obstruc-\\ntion by gallstones, the local signs may be pronounced, and the pain is\\nusually in the ileo-caecal region. The affection is acute. Pain that\\nextends over a long period of time, that is not due to an acute process,\\nor attended by sev3re acute symptoms, has been considered elsewhere.\\n(See Abdomen.)\\nRheumatism and Neuralgia. Intestinal colic may be mistaken for\\nrheumatism of the abdominal walls. In the latter there may be a\\nhistory of exposure. The muscles are extremely tender. There are\\nno gastro-intestinal symptoms, the urine is loaded with uric acid and\\nurates, and there may be muscular pain in other situations, or a pro-\\nnounced history of previous attacks of rheumatism. In lumbo-abdom-\\ninal neuralgia the pain may simulate intestinal colic. Pressure-points,\\nwhere the respective nerves have their exit through the fascia, are\\ndetected.\\nPain in Vertebral Disease. Just here may be considered the\\npain about the navel, which occurs in paroxysms, due to disease of the\\nvertebrae. There may be caries from tuberculous disease or from\\npressure of an aneurism or malignant growths. Examination of the\\nvertebrae may determine its nature.\\nDiarrhoea. Diarrhoea is a symptom of disorder of the intestine,\\nAvhich in turn is itself the cause of symptoms, just as jaundice, a symp-\\ntom of hepatic disorder, is the cause of various symptoms. In diar-\\nrhoea there is increased frequency of the movements of the bowels.\\nThis is due to increased peristalsis of the intestine, which occurs from\\na number of causes. Not all increased peristalsis results in diarrhoea.\\n(A) Nervous diarrhoea. Increased peristalsis may be due to some im-\\npression upon the nervous mechanism of the intestine. This may\\nexplain the diarrhoea of emotion, or that which occurs from other\\npsychical influences. (B) Catarrhal diarrhcea. In the larger number\\nof cases the diarrhoea is due to catarrhal inflammation of the intestinal\\ntract. The causes of the catarrhal inflammation are many, and have\\nbeen divided into primary and secondary causes. Primary catarrh is\\ndue to the direct influence of causal factors upon the mucous mem-\\nbrane. (1) It is seen after cold or exposure (2) it occurs from the\\ndirect irritation of undigested food, and (3) from the action of irri-\\ntants, as of bacteria or the products of bacteria. Catarrhal inflamma-\\ntion due to micro-organisms is the most frequent form that occurs in\\nchildren.\\nSecondary catarrhs follow other lesions of more pronounced charac-\\nter, as ulcers. The catarrh, and hence the diarrhoea, that attends the\\nulceration of typhoid fever, the ulceration of dysentery, or that occurs\\nin Bright s disease, and the diarrhoea that attends carcinoma or other\\norganic disease of the bowel, is of this nature. In addition, a catarrh\\nof the bowels arises from venous stasis in the mucous membrane, with\\nchronic congestion. This occurs in organic heart disease with conges-\\ntion of the liver.\\nDiarrhoea is a symptom of the action of certain poisons, such as\\nmercury, arsenic, and other corrosive agents. The diarrhoea which", "height": "4416", "width": "2652", "jp2-path": "practicaltreatis00muss_0_0901.jp2"}, "902": {"fulltext": "820 SPECIAL DIAGNOSIS.\\noccurs from the irritant action of food-products and in cholera infantum\\nis due to a toxic ptomaine.\\nDiarrhoea sometimes fulfils a vicarious office. This is the case with\\nthe diarrhoea which comes on in cases of chronic Bright s disease, and\\nin acute Bright s disease before the supervention of uraemia. When\\ndiarrhoea occurs in a person with pallor, dimness of vision, and oedema\\nthe urine should always be examined.\\nThe Symptoms of Diaeehosa. The Motions. Increased move-\\nments of the bowels. The frequency of the movements varies with the\\ncause. In the diarrhoea of nervous origin, usually after five or six\\nmovements have occurred, the patient is relieved, because by this time\\nthe cause for the nervousness has disappeared. In catarrhal diarrhoea\\nthe number varies from half a dozen in twenty-four hours to the same\\nnumber in an hour. Indeed, in some severe cases the evacuations\\nmay be almost constant.\\nCharacter of the movements. The movements may be (1) fecal, with\\na small amount of water. They are light in color, softer than natural,\\nbut yet retain their form. They are the kind of movements seen in\\nsimple catarrh.\\n2. The fecal matter is mixed with undigested food. The feces are\\nin scybalous masses, and the watery element is increased. They are\\nthe stools of the so-called dyspeptic diarrhoea.\\n3. Along with the feces more or less mucus is seen. The amount of\\nmucus depends upon the seat as well as the intensity of the inflamma-\\ntion. Inflammations of the large intestine are attended with mucous\\ndischarge. It may be mixed with and stained by feces so that it can\\nbe recognized only by close inspection. In milder degrees of catarrh\\nit is seen on the surface of the fecal masses.\\n4. The feces disappear almost entirely, and instead the evacuations\\nare watery. The watery evacuations may be discolored, as in the pea-\\nsoup evacuations of typhoid fever, or they may be almost clear water,\\nas in the rice-water discharges of cholera.\\n5. The evacuations may contain blood. Bloody discharge usually\\naccompanies the discharge of mucus when the catarrh is in the lower\\nbowel blood may occur independently of the mucus. If with the\\nmucus, it tinges it in reddish specks, or small amounts of free blood\\nare seen. The blood may be bright in color, and then usually comes\\nfrom the rectum. It must be remembered that the blood may be from\\nhemorrhoids, or fissure, which is unduly irritated by the diarrhoea. It\\nis then bright red and unmixed with the movement, and from its\\nposition can readily be seen to have followed it. On the other hand,\\nit may be due to cirrhosis of the liver, with venous congestion. It\\nmay be due to the ulceration of typhoid fever, and the intense inflam-\\nmation of enteritis. It is a symptom of carcinoma of the bowel, and\\nis of frequent occurrence, almost pathognomonic, in intussusception.\\nIt must be remembered that blood of this character is discharged from\\nthe bowel independently of diseases of that tube, as in purpura, scurvy,\\nand other blood diseases. (See Arteries of the Intestines, page 815.)\\nIf mixed with the movement, the blood may be black, as in all forms\\nof melcena, or it may be dark red in color. The black blood usually", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0902.jp2"}, "903": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 821\\ncomes from the stomach or the first part of the duodenum, and may\\nbe the result of ulceration, or even from the swallowing of blood.\\nMicroscopical and Bacteriological Examination. (See Feces.) In\\nsimple catarrhal inflammation of the tubules, on microscopical examina-\\ntion, but little is found except an excess of epithelium from the mucous\\nlining. In more intense inflammations, in addition to epithelium, we\\nfind pus and blood and mucus. Micro-organisms are found, the kind\\ndepending upon the cause of the diarrhoea. In health, Booker has\\nfound at least forty varieties of micro-organisms, many of which, in\\nall probability, are not pathogenic. In health, the bacillus coli com-\\nmunis and the bacterium lactis aeriformis are found. In the diarrhoea\\nof children both forms are present in excessive numbers, because con-\\nditions favoring their growth arise, and in all probability are the cause\\nof the irritation of the bowel. In that form of inflammation of the\\nbowel known as dysentery, in addition to the bacteria that attend in-\\nflammation, the amoeba coli is often present. It has been found that\\ndysentery may be due to a number of causes, but that the so-called\\ntropical dysentery is due to the protozoa first described by Kartulis,\\nin Egypt, and in this country by Osier. (See Feces.)\\nPain. The symptoms that attend increased movement of the bowels\\ndepend upon the cause and also have direct relationship to the fre-\\nquency of the evacuation. The most frequent symptoms are pain,\\nflatulent distention, with borborygmi and tenesmus. The pain depends\\nlargely upon the cause. If the irritant is a product of indigestion, or\\na bulky mass, pain is more or less severe. It is situated in the centre\\nof the abdomen, and may extend all over it. Pain occurs before the\\nevacuation it is sharp, lancinating, and is usually relieved by the\\nmovement. If the inflammation is in the large intestine, the pain may\\nbe complained of in the course of the large bowel or be more intense\\nover the caecum and the sigmoid flexure. The rectum may be the\\nseat of pain or of painful sensations. This has been described as a\\nfeeling of a hot ball in the lower pelvis.\\nFlatulent Distention. The flatulent distention is not very great\\ngenerally. The abdomen is distended, tympanitic on percussion, and\\ntender on palpation, both of which may be more marked in the middle\\nof the abdomen if enteritis alone is present, or it may extend along\\nthe course of the colon, as in the so-called entero-colitis of children.\\nWith the distention there are borborygmi. The rumbling usually\\nsubsides after the evacuation.\\nTenesmus occurs in all forms of diarrhoea if the evacuations have\\nbeen frequent. After the discharge of the contents of the bowel, par-\\nticularly if from the rectum, the tenesmus is much more severe, and may\\nbe of constant occurrence. In the severe cases the tenesmus may be\\nalmost continual. On account of it prolapse of the bowel is apt to ensue.\\nGeneral Symptoms. The general symptoms that attend diarrhoea\\ndepend upon the cause. In simple diarrhoea there might be slight\\nfeverishness only, with a little weakness. In diarrhoea, with excessive\\nmovements, with mucus, with or without blood, the fever is marked\\nand may rise as high as 103\u00c2\u00b0. The fever that attends dysentery is\\nhigh, and usually rises rapidly at the beginning.", "height": "4416", "width": "2644", "jp2-path": "practicaltreatis00muss_0_0903.jp2"}, "904": {"fulltext": "822 SPECIAL DIAGNOSIS.\\nProstration. More or less prostration attends all cases. It is, how-\\never, more marked when there are frequent watery evacuations. In\\nits most pronounced degree it is seen in cholera and cholera infantum.\\nCollapse rapidly ensues under these circumstances, on account of the\\ndepleting effects of the excessive watery discharge. In catarrh of the\\nintestines secondary to typhoid fever and other conditions the general\\nsymptoms depend upon the primary disease.\\nChronic Diarrhcea. Chronic diarrhoea may be due to chronic\\ninflammation of the bowels, as in chronic intestinal catarrh. It may\\nbe secondary to the ulceration of dysentery, tuberculosis, syphilis, or\\ncancer. It is the common diarrhoea of amyloid disease. In chronic\\ndiarrhoea the number of the stools varies, but seldom amounts to more\\nthan ten to fifteen in a day. In chronic intestinal catarrh three or four\\nmovements occur in the twenty-four hours. They usually occur in\\nthe morning, the first evacuation taking place immediately on rising\\nand the remainder during the morning hours. They are more com-\\nmon in women than in men, and are readily excited by exhaustion or\\nnervous influence, as grief, emotion, or excitement of any kind. The\\nstools are fecal and watery, and contain some mucus. The mucus\\nusually coats the surface of the feces. The color of the feces is not\\nchanged. The patients usually suffer fom intestinal dyspepsia, or they\\nare subject to some gastric neurosis. They are not under weight, and\\nexcept for the inconvenience of the morning hours, could attend to the\\nordinary demands of life. They are more nervous than most people,\\nand are liable to attacks of hemicrania.\\nMembranous Diarrhcea. In a number of cases the discharge\\nfrom the bowels resembles membrane. The disease is also called\\nmembranous enteritis. The discharge contains much mucus, and may\\nbe quite watery. After the feces have been passed membrane is dis-\\ncharged. This may be in shreds or large masses, and may also be\\nlike a cast of the bowel. The patients are usually women who are\\nhysterical and have some menstrual disorder. Pain may precede the\\ndischarge, and continue until there is complete relief.\\nConstipation. Constipation may be due to a number of causes. It\\nmay be due to alteration or diminution in the secretions of the intesti-\\nnal tract, as is seen in all fevers, except when they are attended by\\nspecific intestinal catarrh, as in typhoid fever. Such diminution of\\nsecretion occurs in the summer, when there is more free perspiration\\nthan in other seasons, and is present in affections attended by excess\\nof perspiration, or exhaustive diuresis. Constipation, therefore, is a\\ncommon symptom of diabetes.\\nIn addition to alteration of the secretion, diminution in the sensi-\\nbility of the nerves may exist. This is the one chief cause of habitual\\nconstipation that is so prevalent. On account of carelessness the\\npatient loses the habit of having a regular movement of the bowel\\neach day, and in consequence the usual stimulus is removed. Consti-\\npation also occurs from weakness of the muscles.\\nThe three conditions diminution or alterations in the secretions,\\ndebility of the muscles, and impairment of the sensibility of the ner-", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0904.jp2"}, "905": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 823\\nvous mechanism are combined influences, on account of which consti-\\npation is so prevalent in persons of sedentary habits and in persons\\nliving upon improper diet. General diseases and local disorders which\\ninfluence either of the above elements cause constipation. Thus in\\nanaemia and chlorosis, in neurasthenia and hysteria, constipation is a\\ncommon condition. Its occurrence in fevers has been mentioned. In\\nthe convalescence from exhausting disease and prolonged confinement\\nto bed constipation is apt to ensue.\\nLocal Causes. Atony of the abdominal muscles or of the bowel\\nis the cause. Atony is most strikingly seen in peritonitis and typh-\\nlitis, in both of which a paretic state of the bowels develops. It is\\nseen in the aged and in cachexia along with atony of other muscles.\\nObstruction of the bowels, acute or chronic, usually causes constipation\\n(q. v.). If the obstruction is not complete, there may be diarrhoea on\\naccount of catarrhal inflammation. Constipation often occurs on ac-\\ncount of pain, particularly pain seated in the rectum. The pain is\\nsuch that the patient shrinks from an evacuation. Frequent postpone-\\nment soon causes constipation. The pain may be due to fissures, to\\nhemorrhoids, or to fistula. Constipation occurs also from local dis-\\neases in other portions of the body, influencing, in all probability, the\\nnervous mechanism by which peristaltic action is excited. In acute\\nand chronic disease of the brain and cord, as meningitis and myelitis,\\nconstipation is a usual attendant. It also occurs in tetanus. If the\\nbowel is deprived of fecal matter, evacuations cease constipation is,\\ntherefore, a common sign of stricture of the pylorus and of stricture or\\ncancer of the oesophagus.\\nSymptoms of Constipation. Constipation is characterized by diminu-\\ntion in the frequency of the bowel-movements. The frequency of the\\nmovements varies in health. Some persons are comfortable with an\\nevacuation taking place once a week, or at most every third or fourth\\nday. There are cases on record in which the evacuations took place\\nbut once a month. Cases of this class are usually due to muscular\\nparalysis of the bowels, with secondary dilatation. The accumulation\\nof feces is removed by a sharp attack of diarrhoea, attended by much\\npain. The diarrhoea sometimes continues for twenty-four hours. When\\nit sets in fever may be present until there is thorough evacuation.\\nLocal Symptoms. Usually the symptoms that attend constipation\\nare local, being due to the discomfort of the accumulation of feces.\\nThe local symptoms may be limited to the rectum or extend through-\\nout the abdomen. In the rectum there is a sensation as of the pres-\\nence of a mass, which may cause some pain. The abdomen is dis-\\ntended; there is considerable rumbling, and sometimes peristaltic\\nwaves are seen. The accumulation of the fecal mass in the bowels\\nmay set up tormina and tenesmus, and portions of the mass may be\\ndischarged from time to time. In other words, a diarrhoea may occur,\\nthe diarrhoea of constipation, or spurious diarrhoea. The stools are\\nsmall, composed of hard scybalous masses, generally coated with\\nmucus, and streaked with blood. The evacuation does not give relief,\\nand the desire for a movement may be more or less continuous.\\nOn examination in constipation with fecal accumulations the outline", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0905.jp2"}, "906": {"fulltext": "824 SPECIAL DIAGNOSIS.\\nof the colon may be marked out by palpation and percussion of the\\ndistended abdomen. In its course masses are felt varying in size from\\na marble to a base-ball, and in consistence they may be soft to the\\npalpating finger they are never indurated like a calcareous mass, as\\ngallstones or a mass due to malignant disease. (See Fecal Tumor.)\\nGeneral Symptoms. While in many instances the general symptoms\\nare of no consequence, in others the patients are nervous and may be\\nin more or less impaired health, on account of the secondary effects\\nupon the stomach. Digestion is impaired and the form of indigestion\\nis that which attends neurasthenia.\\nThe patients are of spare habit, usually of dark or muddy complex-\\nion. They may be depressed. There is inaptitude for mental exer-\\ntion they are more or less hypochondriacal. The tongue is constantly\\nfurred, the appetite variable there are weight and fulness after eating,\\nand generally some flatulency.\\nThe Secondary Effects of Constipation. The effects of constipation\\nupon the intestines are various and sometimes disastrous. They are\\ndilatation and ulceration. The former may become enormous, as in\\ncases reported by Formad and Osier. The dilatation may be so great\\nas to distend the entire abdomen. The ulceration may be localized to\\nthe rectum, or caecum, or extend throughout the entire large intestine.\\nOn palpation the course of the colon is tender, and fecal masses may\\nbe outlined that are painful, because of their pressure upon the ad-\\njacent ulcer. In the rectum the ulcer may be deep, and be followed\\nby peri-rectal abscess.\\nStercoral typhlitis. In the caecum the accumulation may cause a large\\nboggy swelling, extending in the course of the caecum, which is tender\\non pressure and dull on percussion.\\nFecal impaction, with secondary ulceration, is of frequent occurrence\\nin typhoid fever. This must be borne in mind, for often serious gen-\\neral and local symptoms arise because it is overlooked. Recently I\\nsaw a case with diarrhoea of constipation, with some fever, which per-\\nsisted for weeks after the usual course of typhoid fever. It was\\nthought the patient had tuberculosis, or that the typhoid process was\\nabnormally prolonged. Examination disclosed ulceration into the\\nvagina, and the feces were constantly discharged from this orifice. It\\nhad been thought that the discharges of feces were due to diarrhoea.\\nOf course, fever attended the process, and rendered the case all the\\nmore obscure.\\nIn this connection must be mentioned the constipation that occurs\\non account of lead-poisoning, and the exhibition of drugs, as opium, or\\nastringents. The constipation of lead-poisoning is usually attended\\nby colic, and the blue-line on the gums is seen, while wrist-drop or\\nother manifestations of lead may be present.\\nIntestinal Hemorrhage. The causes are general and local. The\\ngeneral causes are those that accompany hemorrhage in other localities.\\n(See Gastric Hemorrhage.) The local causes, when the hemorrhage is\\nsmall, are inflammation of the bowel traumatic injury to the bowel\\nfrom hernia, feces, and parasites, and foreign bodies swallowed, or from\\ncorrosive poison tumors of the bowel, as in cancer, invagination, and", "height": "4400", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0906.jp2"}, "907": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 825\\nulcers. When the hemorrhage is large the causes are the congestion\\nattending portal obstruction and liver disease, or disease of the heart\\nwith secondary obstruction aneurism of the superior mesenteric artery,\\nor aneurism rupturing into the intestine, and, occasionally, embolism\\nof the artery the ulceration from typhoid fever, from dysentery, and\\nfrom syphilis. It may occur in pyaemia and septicaemia, or the acute\\nexanthematous diseases.\\nThe symptoms may be those of hemorrhage alone collapse, pallor,\\nfailure of sight, tinnitus, vertigo, small pulse, and general restlessness.\\nThe hemorrhage must be copious under these circumstances, and is\\ndue (1) to an ulcer, as in typhoid fever (2) to portal obstruction (3)\\nto an aneurism (4) to purpura or haemophilia.\\nA second group of symptoms is connected with the appearance of\\nthe discharges from the bowels. The stools are bloody if the hemor-\\nrhage is low down, they are bright red and usually mixed with feces.\\nIf high up, they are tarry. The latter condition is known as melaena.\\n(See Feces.) The passage of the stools is preceded by colicky pains,\\nor there may be some rumbling. The diagnosis must be directed to-\\nward determining the cause of the hemorrhage, as well as its seat the\\nhistory, the associate diseases, or symptoms, aid in determining the\\ncause. Examination of the rectum may afford a clue to its origin.\\nThe Objective Symptoms.\\nThe Data Obtained by Observation. Physical Signs. (See\\nThe Abdomen.) Inspection. Local and general enlargements of the\\nabdomen have been discussed in the preceding pages. Movements of\\nthe intestines are seen in obstruction due to increased peristalsis. The\\nintestine above the point of obstruction may swell into a well-defined\\ntumor which becomes hard and dull, and tympanitic on percussion.\\nPalpation. Tenderness, peristalsis, peritoneal friction, the bubbling\\nof gas through a constriction of the bowel, and tumors, are recognized\\nby palpation. It is necessary often to place the patient on all-fours\\nor in a knee-chest position.\\nPercussion. The normal note is tympanitic. Local areas of dulness\\nmay be due to intestinal tumor. Light percussion should be employed.\\nA dull tympany indicates a solid mass surrounded by the distended\\nintestines. The outline of the large intestine can be ascertained by\\nfilling it with water.\\nThe Feces. General Considerations and Macroscopical\\nAppearances. The number of stools in health varies chiefly with\\nthe individual and the character of the food taken. After infancy,\\none passage in twenty-four hours is the rule, but it is natural for some\\npersons to have two or three, and for others to have but one passage\\nin two, three, or four days. Such a condition is termed constipation,\\nwhile pathological constipation is properly called obstipation. The\\nopposite condition is known as diarrhoea. The amount and character\\nof food and drink ingested influence the number of stools. Exercise\\nalso plays a role increased or diminished peristalsis, from whatever\\ncause, will induce diarrhoea or constipation, respectively. In disease", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0907.jp2"}, "908": {"fulltext": "826 SPECIAL DIAGNOSIS.\\nthe greatest extremes are met with from the non-passage of feces\\nfor days, as in obstruction, to an almost continuous discharge, as in\\nsome forms of intestinal inflammation. It is well to remember that\\ndiarrhoea may be the symptom of obstipation, as when impacted feces\\nin typhoid causes looseness of the bowels.\\nThe amount of feces varies with the quantity and nature of food. If\\nmost of the food is digested there will be but little left to form feces.\\nIn any disease that prevents the absorption of digested food or causes\\nan increase in the fluid contents of the intestine, as cholera, the amount\\nof feces will be increased. In health about 140 to 200 grammes are\\nvoided in twenty-four hours.\\nThe form and consistence of healthy stools vary somewhat. They\\nare commonly cylindrical and firm or mushy. When they remain long\\nin the intestinal canal, and the water is extracted, they become hard\\nand may form balls, or flattened masses known as scybala. These are\\nfrequently seen in convalescing typhoid patients. On the other hand,\\nthe feces may be without form, and are then liquid, either watery, as\\nin cholera, or purulent or bloody. Many diseases cause such a con-\\ndition.\\nThe odor of feces is sometimes more or less characteristic of certain\\nconditions. Thus the stools of nursing infants have a sour smell,\\nwhile in infantile diarrhoea, and when fermentation takes place, they\\nhave an odor of sebacic acid. When urine is mixed with the passage\\nthe odor will be ammoniacal with blood present it often has a stale\\nodor.\\nThe reaction is not constant. Thus in intestinal catarrh, with acid\\nfermentation, it will be acid, or in alkaline fermentation it will be\\nalkaline. The color of the stool varies too much to be of special diag-\\nnostic value. In health it is light to dark brown, due chiefly to the\\npresence of hydro-bilirubin, a product of decomposition of bile-pig-\\nment, which is never normally found unaltered in the feces. It is\\ninfluenced greatly by food and medicines. When certain berries, as\\nhuckleberries, are eaten, or certain medicines taken iron and bismuth\\nthey make the passages black. Calomel causes green stools, on\\naccount of the biliverdin discharged. Green stools may also receive\\ntheir color from the presence of a bacillus which produces a green dye.\\nSantonin, rhubarb, and senna cause yellow, and hsematoxylon red\\nstools. The last fact is important, as parents or nurses should always\\nbe warned to expect red passages when hsematoxylon is given.\\nThe feces may be red or reddish from the presence of unaltered\\nblood or black, when the blood has undergone changes the so-called\\ntarry stools are of this character. With a decrease in the amount\\nof bile the stools become less colored, and if the bile is cut off they\\nbecome clayey. This color may, in some cases, be due to the presence\\nof fat left undigested because of the lack of bile. On the other hand,\\nif from disorders of the stomach and intestine the contents pass through\\ntoo rapidly, the feces may contain unaltered bile, unchanged bile-pig-\\nment, giving a green or yellow color, and showing the bile-reaction.\\nThe constituents of feces that can be recognized by the naked eye are\\nnumerous. Seeds, stones, skins of fruit and berries, and the fibres of", "height": "4416", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0908.jp2"}, "909": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 827\\nvegetables are often seen in healthy stools. In the passages of chil-\\ndren and weak-minded individuals foreign substances of all descrip-\\ntions may be present. Foreign bodies and partially digested portions\\nof food may be mistaken for parasites. Portions of tumors from the\\ndigestive tract may appear in the feces.\\nIn certain diseases of the stomach and small intestine, and in those\\nwho eat very fast and do not properly masticate their food, undigested\\nand unchanged particles of food may be seen in the stools.\\nShreds of mucous membrane of varying size are passed with the\\nfeces. Von Jaksch saw such a shred 5 cm. long and 3 cm. broad in a\\ncase of cholelithiasis. Various sized pieces of membrane, consisting\\nof transformed mucus, are passed in membranous enteritis.\\nParticles resembling sago-grains, perhaps the result of over-indul-\\ngence in farinaceous food, have been met with.\\nGallstones in the feces have great clinical value. They may escape\\ndetection if not properly sought for. When suspected, each passage\\nshould be passed through a linen sieve, the fecal masses being softened\\nwith water. They may be found as small, crumbling masses, composed\\nchiefly of cholesterin (intrahepatic calculi), or as hard, irregular,\\nsmoothly worn, shining, many-sided, hard stones, sometimes as large\\nas an egg, usually the size of a pea. Enteroliths are occasionally seen.\\nThey are said to originate in the appendix.\\nBlood may be present in the feces in varying proportions and con-\\nditions. When found unaltered on the surface of scybalous masses, ijt\\nis from the rectum or large intestine, and probably the result of trau-\\nmatism. Hemorrhoids, if bleeding, may cause such an appearance, or\\nmay cause very free hemorrhage. Severe hemorrhage may come from\\nulceration of the rectum or colon, due to malignant disease or severe\\ninflammation. The blood may be intimately mixed with the feces,\\nand have its origin in the large intestine, but much more commonly it\\nindicates a source in the stomach or small intestine. Under such cir-\\ncumstances it is nearly always more or less changed by the intestinal\\njuices, and is brownish-red or black (the tarry stool mentioned above),\\nor has the appearance of coffee-grounds. The brighter the color of\\nthe blood the nearer is the source of hemorrhage to the anus. The\\nmore retarded the passage the greater the change while, if quickly\\nexpelled, blood from the small intestine may be passed unchanged, as\\nin the hemorrhage of typhoid fever. The microscope detects blood\\nwhen the naked eye fails to detect it. It is to be remembered that\\ncertain drugs, as already stated, may color the feces red, and simulate\\nblood.\\nMucus may be present in the passages in health, but when in any\\nmarked quantity there is a catarrh of the mucous membrane of the\\nintestines. When hard scybala are covered with mucus, or the mucus\\nis seen in shreds, the large intestine is the seat of a catarrh although\\nmucus may be mixed with thin stools, as in dysentery. Usually, how-\\never, when the mucus is finely divided and mixed with the feces, it\\ncomes from the small intestine. Mucous shreds have already been\\nmentioned. In cholera the particles of mucus look like boiled rice,\\nhence the term rice-water stool.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0909.jp2"}, "910": {"fulltext": "828\\nSPECIAL DIAGNOSIS.\\nFatty stools, to the naked eye, appear greasy or even clayey, when\\nthere is much fat, even though bile-pigment may be present.\\nPus may be present in large quantities from rupture of an abscess\\ninto the intestinal tract, or when there are ulcerations from various\\nconditions, producing pus in considerable quantities.\\nMickoscopical Examination of the Feces. Many animal\\nparasites are not microscopic, but it is convenient to consider them in\\nthe following paragraphs. A small portion of the solid feces to be\\nexamined is placed on a slide, moistened with a J per cent, salt solu-\\ntion, and a cover-slip applied or if liquid, various drops are to be\\nexamined. The different constituents found will vary with the food\\ntaken as well as with disease.\\nA. Constituents Deeived from Food. There may be portions\\nof digested or undigested food. In general it may be said that the\\npresence of large pieces of unchanged food, or many small particles of\\nundigested or only partially digested food, indicates defective digestion\\nin the stomach or small intestine. If unchanged bile is present, some\\nparticles will be colored yellow, another indication of disordered func-\\ntion.\\nFrom the food we may see muscle and elastic fibres, more or less,\\naccording to the quantity of meat eaten by the patient. The former\\nare recognized by their transverse striation the latter, by their double\\ncontour and curling ends. Fat may be present as fatty globules or\\nin the form of needles, fatty crystals. Much fatty food increases\\ntheir number, and they are seen plentifully in alcoholic poisoning,\\nin jaundice, in pancreatic diseases, tuberculosis of intestines, diseases\\nof the mesenteric glands, and enteritis. The crystals may be trans-\\nFlG. 197.\\nCollective view of the feces. (Eye-piece III., objective 8A, Reichert.) a. Muscle-fibres, b. Con-\\nnective tissue, c. Epithelium, d. White blood-corpuscles, e. Spiral cells, f-i. Various vegetable\\ncells, k. Triple phosphate crystals in a mass of various micro-organisms. I. Diatoms. (Von\\nJaksch.)\\nformed into fat-drops by the addition of acid and heat. When meat\\nis eaten freely, areolar tissue may be present, but its presence otherwise\\npoints to defective digestion. Various forms of vegetable cells are\\ncommonly seen, in which granules of starch may be contained, or the", "height": "4412", "width": "2608", "jp2-path": "practicaltreatis00muss_0_0910.jp2"}, "911": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 829\\nstarch particle may be free. Undigested milk occurs in the stools of\\nchildren and when diarrhoea prevails a substance, probably casein,\\nhas been described by Notlmagel as occurring in the feces of persons\\nwho have intestinal disturbances.\\nIn persons living on vegetables most of the above constituents will\\nbe absent, and in infants who partake only of milk, the derivatives of\\nmeat are absent, while there will be an excess of fatty crystals and fat-\\nglobules and coagulated products.\\nB. Constituents from the Alimentary Tract. Epithelium. In\\nevery normal stool will be found epithelium of the squamous variety.\\nOccasionally the columnar form is seen, and modified epithelial cells\\nare very common. In intestinal catarrh their number is greatly in-\\ncreased.\\nBed Blood-corpuscles. In the majority of blood-stained stools red\\nblood-cells are not found in their stead will be seen masses of free\\nblood-coloring matter and rhombic crystals of hseniatoidin. Red cells\\nare seen in dysenteries, in bloody stools in which the blood conies from\\nnear the anus, as in hemorrhoids, and when blood is discharged with\\nthe feces soon after the occurrence of the bleeding. If there is any\\ndoubt as to the presence of blood, when the corpuscle cannot be found,\\na true decision can be reached by examining for hamiin-crystals, ac-\\ncording to Teichmann s method. A portion of feces is dried and pow-\\ndered, placed on a slide with a grain of common salt, and covered by\\na cover-slip. A few drops of glacial acetic acid are directed beneath\\nthe slip, the slide is heated just to boiling, and if blood has been pres-\\nent, reddish-brown rhombic crystals of hsemin will soon be found.\\nLeucocytes. Leucocytes are frequently seen in healthy stools. When\\npus is present or discharged into the intestinal canal they are found in\\ngreat numbers, as in ulceration of the intestine and in abscess.\\nMolecular debris, or detritus, occurs in all feces as part of the waste-\\nproducts.\\nCrystals, i^a^-crystals are the most important. They have been\\nquite fully considered above. There seems to be little doubt that the\\ncrystalline needles found in the feces are salts and fatty acids, and not\\nty rosin.\\nChar cot-Ley den crystals, similar to those already described (see Spu-\\ntum), have occasionally been met with in the stools of typhoid fever\\npatients, in dysentery, intestinal tuberculosis, and ankylostomiasis.\\nJLazmato idin-cry stals occur as reddish-brown, hard, needle-shaped\\nbodies, usually in clusters, and free or enclosed in masses of mucin or\\na substance resembling it. They have been found in the feces of\\nbreast-fed infants, in cases of chronic intestinal catarrh, and, by Yon\\nJaksch, in the stools of a case of nephritis.\\nCrystals of various salts of calcium, of triple phosphate and cholesterin\\nwill often be recognized, but they have no diagnostic value. When\\nbismuth is being administered, black rhombic crystals of the sulphide\\nof bismuth will be recognized.\\nC. Parasites. (A) Animal and (B) vegetable parasites flourish in\\nthe intestinal tract, and the presence of some of these in the feces is\\nof the greatest clinical importance.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0911.jp2"}, "912": {"fulltext": "830\\nSPECIAL DIAGNOSIS.\\nA. Animal Parasites. Following Leuckart s classification, we\\nwill consider these parasites under the secondary heads\\nI. Protozoa. 1. Rhizopoda. This variety is made important be-\\ncause the amoeba dysenteric or amoeba coli belongs to it.\\n(a) Amoeba Dysenterioe. Amoeba Coli. This protozoon has been\\nfound so many times by various observers in different parts of the\\nworld that it can now be considered to be the causative factor of so-\\ncalled tropical dysentery. The subject has received special study in\\nour own country by Osier/ Stengel, 2 Dock, 3 and Councilman and\\nLafleur. 4 The work of Councilman and Lafleur is at the present time\\nthe best that has been published in any country and to it the reader\\nis particularly referred. The following notes are based on this book.\\nThe amoebae dysenteriae vary in size from 0.012 to 0.035 mm. They\\nare found most plentif ally in the small gelatinous masses often to be\\nseen in the feces. They vary in number in different cases, and in the\\nsame case at different times. The severer the lesions the more numer-\\nous are the amoebae. When not active they are round or oblong, and\\nhighly refractive. They contain one or more vacuoles of varying size.\\nOccasionally the division into an ectosarc and endosarc is easily made\\nout. When thus inactive they may be confounded with swollen con-\\nnective-tissue cells and compound granular bodies found in feces. The\\nactive amoebae have, however, a characteristic movement. This consists\\nof progression and of thrusting-out and retraction of pseudopodia. Their\\nactivity varies greatly. It is best seen when the body-heat is main-\\ntained. The stools should be passed into a clean and warm pan, and\\nexamined immediately, or kept warm until examined, and a warm\\nFig. 198.\\nAmoeba coli. (Hallopeau.\\nstage should be used with the microscope. The division into ectosarc\\nand endosarc is usually clear during activity. The ectosarc is com-\\nposed of a hyaline homogeneous mass, as are the pseudopodia, while the\\n1 Johns Hopkins Hospital Bulletin, May, 1890, vol. i., No. 5.\\nJ Phila. Med. News, 1890. 3 Texas Med. Journal, April, 1891.\\nJohns Hopkins Hospital Reports, vol. ii., Nos. 7, 8, 9.", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0912.jp2"}, "913": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 831\\nendosarc is made up, not of granular matter, but of a dense homo-\\ngeneous mass enclosing vacuoles and a nucleus. The vacuoles may\\nvary in size as well as in number. There may be one or two large\\nones, or the entire endosarc may appear as made up entirely of small\\nvacuoles. The nucleus is sometimes plainly seen as a small rounded\\nbody, but is more often difficult to distinguish from the vacuoles.\\nDried cover-slip preparations may be stained with the various aniline\\ndyes, but the results are not satisfactory.\\nThe amoebae will often be found to enclose bodies such as red blood-\\ncorpuscles, pus-cells, blood-coloring matter, bacilli and micrococci.\\nIn examining the feces for amoebse dysenterise the suggestion given\\nabove concerning the warm bed-pan and warm stage to the microscope,\\nand, above all, the immediate examination of the stool, should be ad-\\nhered to. The small gelatinous masses should be selected when present.\\nVarious magnifying powers should be used, including the y 1 oil-immer-\\nsion lens.\\n(6) Monadines, pear-shaped, with a long slender process, are seen\\nalive in only perfectly fresh stools. They are not found constantly in\\nany one disease.\\n2. Sporozoa. Under this head belongs the coccidium perforans of\\nLeuckart. They are short, elliptical bodies, which infest the intesti-\\nnal mucous membrane, and may damage it badly; they are often dis-\\ncharged in large numbers.\\n3. Infusoria, (a) Cercomonas Intestinalis. This is a pear-shaped\\nbody, nucleated, with eight tentacles of varying length. It is found\\nin the feces of persons suffering from various diseases, as cholera and\\ntyphoid fever, and probably of itself causes diarrhoea.\\n(6) Trichomonas intestinalis. Larger than the cercomonas, and cov-\\nered with cilise at the club end. It is not diagnostic and is not\\ncommon.\\n(c) Paramoecium coli. Larger than the preceding, 1 mm. long\\noval, covered everywhere with cilise may be found in diarrhoeic stools.\\nII. Vermes. These are much more generally known and are of\\nmuch more clinical value than the preceding.\\nThey have important clinical value, as the presence of some of them\\nin the intestinal canal gives rise to many untoward symptoms. They\\nwill be considered under (A) Platodes and (B) Annelides.\\nA. Platodes. 1. Tapeworm Cestodes. These parasites infest\\nthe small intestine only, to the walls of which they cling by the head.\\nThe head and neck are small the joints are flat and form long ribbons.\\nThe distal joints continually drop off and can easily be recognized in\\nthe stools by the naked eye, and the eggs by the use of the micro-\\nscope. The feces are best washed in water and broken up to obtain\\nthe eggs. As the lower joints are lost new ones take their place from\\nabove. The more important are as follows\\na. Taenia solium (Fig. 199) reaches a length of two to three metres.\\nThe head is the size of a pin-head. The neck is 2.5 cm. long, as thick\\nas a thread, and without joints. The segments forming the body are\\nshort and broad near the neck, but as they increase in size there is\\nmore growth in length than in width. The average dimensions are 9", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0913.jp2"}, "914": {"fulltext": "832 SPECIAL DIAGNOSIS.\\nto 10 mm. by 6 or 7 mm. The head appears dark, the body white.\\nThe joints are easily detected in the feces by the naked eye. Under\\nthe microscope the head is seen to be spheroidal, with four pigmented\\nsucking-disks surrounding at the base a rostellum, which is a crown\\nof hooks chitin hooks about twenty-four in number. In the ripe\\nsegments, or proglottides, is seen the longitudinal uterus with about\\ntwelve horizontal ramifications to a segment. The eggs are round or\\noval, 0.035 mm. long, with a thick, striated shell when ripe, and con-\\ntain hooklets.\\nFig. 199. Fig. 200.\\nOva of T. solium, a, with yolk, b, without\\nyolk, as in mature segments. The hard Drown\\nHead of T. solium. X 45. (Leuckart.) shell is indicated. (Leuckart.)\\nb. Tcenia mediocanellata, or saginata. This worm is four or five\\nmetres long. The head is slightly larger than that of the T. solium,\\nand more pigmented, and the segments are longer, fatter, and darker.\\nThe head is supplied with four powerful sucking-cups, but has no\\nrostellum or hooklets. The uterus in the ripe segment is much more\\nfinely branched than in the solium, and these segments have indepen-\\ndent movement. The eggs are very similar to those of the T. solium,\\nbut may be rather larger.\\nc. Tamia nana. In length the T. nana is only 10 to 15 mm., and\\n0.5 mm. in breadth. The round head is but 0.3 mm. in diameter.\\nThe segments are all short, and at the lower end of the body are four\\ntimes as wide as they are long. The head is found to have four round\\nsuckers at the base of a rostellum that can be inverted. At the base\\nof the rostellum are about twenty-two hooklets. The uterus is oblong\\nand filled with eggs. The eggs have a double membrane.\\nd. Tcenm cucumerina. This parasite is found to be 5 to 20 cm.\\nlong and about 2 mm. wide. The head is placed at the thinner end,\\nand under the microscope are to be seen some sixty hooklets regularly\\ndistributed about the rostellum, and four sucking-cups. The lower\\nsegments are decidedly larger than the upper 6 by 7 mm. When", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0914.jp2"}, "915": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 833\\nripe they become reddish, and contain cocoon-like bodies, in which\\nare six to twelve eggs.\\ne. Bothriocephalus latus. This is the largest of the worms, meas-\\nuring 7 or 8 metres. The head is somewhat drawn out, and on either\\nside is a long, narrow sucker. There are neither hooks nor rostellum.\\nThe proglottides are short near the head, but become square further\\ndown. The uterus appears as a rosette, peculiar to this worm. The\\neggs are oval, and measure 7 mm. by 0.045 mm., have a shell covering,\\nwith an opening like a lid at one end. Ripe segments are thrown off\\nin bunches, not singly.\\nIt will not be necessary to describe certain other varieties that are\\nrarely met with.\\n2. Trematodes, or flukes, a. Distoma hepaticum measures 28 mm.\\nby 10 mm., and is shaped like a leaf. A short head is situated at the\\nbroad end and has one sucker on the under surface is another sucker,\\nand between the two is the opening of the uterus, a highly convoluted\\narrangement. The eggs are brown, oval, about 0.12 mm. long, and\\nhave a lid at one end. It is not often seen.\\nb. Distoma lanceolatum. This round-shaped worm is about 8 mm.\\nlong and 3 mm. broad, and in other respects resembles the preceding.\\nThe eggs are more rounded and contain minute embryos. Like the\\nD. hepaticum, it is rarely seen.\\nc. Distoma crassum is the largest 4 to 8 cm. long. These flukes\\nare endemic in parts of Japan. In general these animals occupy the\\nbile-passages or upper part of the small intestine.\\nB. Annelides. 1. Round Worms Nematodes. A. Ascarides. a.\\nAscaris lumbricoides. This is the parasite usually referred to by the\\nterm round worm. It resembles the common earth-worm in shape\\nand color. The male worm is about 250 mm. long, and the female\\n400 mm. The head is made up of three prominent lips, and is sup-\\nplied with microscopical teeth. The vulva of the female is in the pos-\\nterior third of the body. The eggs are rounded, brownish, 0.06 mm.\\nin diameter, and covered, when fresh, by a rough albuminous coat over\\na hard shell. This worm has the small intestine for its habitat. It\\nmay pass with the stools or work its way into the stomach and be\\nvomited (the writer has had them thus vomited during the etherization\\nof a child of ten years). They have been the cause of jaundice by\\ncrawling into the ductus choledochus, and may infest the larger hepatic\\nducts. Enormous numbers may be present in the intestine at one\\ntime.\\nb. Oxyuris vermicularis. The thread- worm, or seat- worm, inhabits\\nthe large intestine, and is often present in the stool as a white, thread-\\nlike body the male 5 mm. and the female 10 mm. long They often\\nwander out of the anus and into the vagina. The head has a number\\nof small lips, and is covered with a thick skin. The female has one\\nvagina and two uteri. The eggs are unsymmetrical, have a laminated\\nshell and a diameter of about 4 mm.\\nB. Strongylides. Ankylostomum duodenale. This is a round worm,\\nreaching a length of 6 to 10 mm. in the male and 10 to 18 mm. in\\nthe female, and can, therefore, be seen easily, though the eggs are\\n53", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0915.jp2"}, "916": {"fulltext": "834 SPECIAL DIAGNOSIS.\\nmuch more frequently found in the stool than is the worm itself. With\\nthe eggs there may be present in the stools large numbers of Charcot-\\nLeyden crystals. The head is prominent, especially in the male. Four\\nhook-like teeth surround the mouth, and by these the animal attaches\\nitself to the intestinal wall. The tail of the male is expanded and that\\nof the female pointed. The vulva is in the posterior third. The eggs\\nare oval, about 0.05 mm. in diameter, and contain one to four cells\\nembryonic globules, which rapidly develop in a warm place outside\\nthe body, and may thus be recognized. The worm infests the small\\nintestine, especially the jejunum. It often causes serious symptoms\\nbloody stools and intense anaemia.\\nc. Trichotrachelides. a. Tricocephalus dispar. The whip- worm is\\n4 to 5 cm. in length, the female being longer than the male. It is\\nrecognized by the contrasting form of the anterior and posterior por-\\ntions. The former is thin and threadlike, the latter expanded and\\nbroad, and in the male curled up. The eggs are brownish, about 0.05\\nmm. long and half as broad, and have a button-like projection at either\\nend they are to be recognized in the stools, where large ones may be\\npresent. There may be only a few or thousands of the forms present\\nin the body. They live chiefly in the caecum and large intestine.\\nThey have been thought to cause beri-beri by some writers.\\nb. Trichina spiralis. It is the adult trichinae which exist in the\\nintestine and are found very infrequently in the feces. These produce\\nthe embryos, which become muscle trichinae. The adult male is 1.5\\nmm. long and the female twice that length. The former has two pro-\\njections from the hinder end, between which are four papillae. The\\nfemale has a tubular uterus and a tubular ovary in the posterior half\\nof the body.\\nD. Rhabdonema. Strongylides. Under rhabdonema intestinale\\nwe now include two small nematodes, which were termed anguillula\\nintestinal] s and A. stercoralis, and which are probably one and the\\nsame. They are found in the stools of cases of endemic diarrhoea of\\nhot countries. Usually the young embryos, which have developed in\\nthe intestinal canal, are dejected with the stools. These sexually\\nmature embryos are 0.8 to 1.2 mm long, male and female respectively.\\nThey are round and have a cone-shaped head. There are two jaws\\nand two teeth in each. The adult worm is about 2.2 mm. long and\\n0.04 mm. thick. The mouth has three lips. The vulva is at the be-\\nginning of the posterior third. The eggs might be easily confounded\\nwith those of the ankylostomum duodenale, but are somewhat more\\npointed, and larger. The rhabdonema infests the small intestine, and\\nis frequently found in connection with ankylostoma.\\nEchinococcus hooklets and portions of the striated cyst-wall have\\nbeen found in the feces. The rupture of a hydatid cyst into the in-\\ntestine may be discovered when the above structures are found, point-\\ning to a cyst in the abdominal cavity.\\nB. Vegetable Parasites. We find both (I) pathogenic and\\n(II) non-pathogenic vegetable parasites in the feces. The latter we\\nhave classed as (1) moulds, (2) yeasts, and (3) fission-fungi.\\n1. Moulds. The only mould found in the stools is the thrush", "height": "4416", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0916.jp2"}, "917": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 835\\nfungus, when children are the subjects of thrush in the mouth. It is\\nof very rare occurrence in the feces, and has no special clinical import.\\n2. Yeasts. In all feces, in health or disease, yeast fungi exist.\\nThey are most numerous in acid stools. They are round or ovoid, and\\nusually occur in groups. They stain dark broAvn with a solution of\\niodine and iodide of potash, while apparently similar cells become\\nviolet or blue with the same dye.\\n3. Fission-fungi. Bacteria are found in greatest numbers in the\\nfeces, chiefly as bacilli, micrococci, and spirilla. They may be grouped\\nas torulse or sarcinse. They present active movement, and may be\\nseparate or in colonies. The bacillus coli communis (B. termo) is the\\nmost frequent form met with, both in health and disease. It is not\\nyet determined what relations it holds to normal and abnormal condi-\\ntions, or what is the true relationship between it and certain other bac-\\nteria. B. subtilis is another bacterium found both in health and\\ndisease. As above stated, there are various organisms which stain\\nbrown Avith iodo-potassic-iodide solution, and others which become\\nblue with the same dye. Yon Jaksch has studied these latter closely.\\nThey take various forms, as long or short rods, and take different\\nshades of blue or violet. One of them is the Clostridium butyricum\\nof Nothnagel. It occurs as large round cells, like yeast fungi, and\\nstains like the tubercle bacilli with the Ziehl-Neelsen fluid. Von\\nJaksch finds these fungi in greater abundance in intestinal catarrh.\\nThey are present in both acid and alkaline stools.\\nBacillus coli communis has been found in the blood, various\\norgans, feces of cholera patients, in healthy feces, in the air, and in\\nputrefying infusions it can also be found in the peritoneal exudate\\nin most cases of peritonitis.\\n3forphology. A bacillus, 4 to 6// by 2 to Z/u, with rounded ends,\\nsometimes in cultures a short oval. Five or more flagella have been\\nobserved attached to the organism.\\nBiological Properties. Aerobic facultative anaerobic non-liquefy-\\ning slightly non-motile.\\nGrowth. On gelatin plates the colonies vary very much. The deep\\ncolonies are transparent, straw color to dark brown, or may be granu-\\nlar and opaque. The surface-colonies are large and spherical, centre\\ndark brown, edges transparent. In stab-cultures the surface-growth\\nis thin and dry. There is abundant growth along punctures, which\\nis white by reflected, but amber by transmitted light sometimes\\nmoss-like tufts are seen. On potato a soft, shining, brownish-yellow\\nlayer grows. Stains with anilines, but not by Gram s method. In-\\njected in guinea-pigs it produces fever, diarrhoea, and collapse. In-\\njected into the abdomen of rabbits it causes a typical peritonitis.\\nPathogenic Fungi. Spirillum Choler.e Asiatics. See page\\n338.\\nSpirillum Cholera Nostras. Morphology. Longer and thicker\\nthan the spirillum of Asiatic cholera central part thicker than ends.\\nStains as the true cholera spirillum.\\nBiological Properties. Culture. A thick, stocking-like funnel of\\nliquefaction instead of a fine, straight funnel. (See Fig. 87, page 340.)", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0917.jp2"}, "918": {"fulltext": "836 SPECIAL DIAGNOSIS.\\nTyphoid Fever Bacillus. This bacillus is present in the stools\\nof typhoid fever patients, but cannot be directly differentiated by\\nmicroscopic examination alone, either when stained or unstained. It\\nis necessary for its detection to make pure cultures according to bac-\\nteriological methods. The bacillus is about as long as the tubercle\\nbacillus, but much thicker, being one-third as thick as it is long.\\nThe ends are rounded. It is best stained by concentrated aqueous\\nsolutions of methylene-blue, the dried preparations on the cover-slip\\nbeing prepared as above. (See Plate III., Fig. 6, b and Typhoid\\nFever).\\nTubercle Bacillus. The bacillus of tuberculosis is frequently\\nfound in the feces of persons suffering from intestinal tuberculosis and\\noccasionally in the feces of cases of pulmonary tuberculosis, when\\nsputum has been swallowed. When tubercle bacilli are constantly\\nfound in the feces, and in large quantities, ifc points to the former\\ncondition almost to a certainty. They are detected by methods em-\\nployed in the examination of sputum.\\nBacilli op Booker. No less than nine bacilli have been described\\nby Booker. They have been found by him in cases of diarrhoea in\\nchildren. Seven of them resemble very closely the bacillus coli com-\\nmunis. Bacillus A is a bacillus with rounded ends, 3-4/z by 0.7 fi.\\nIt is aerobic and facultative anaerobic, liquefying, and motile. Colo-\\nnies on agar and potato are dirty brown. On gelatin they liquefy too\\nsoon to show characteristic form. The bacillus is found in the stools\\nof cholera infantum.\\nChemical Examination. The chemical examination of the feces\\nis of but slight clinical value. Mucin and albumin are normally pres-\\nent peptones in different diseases (Von Jaksch). Among the acids\\nto be found are bile-acids, volatile and fatty acids, formic, acetic,\\nbutyric, and propionic acids while phenol, indol, skatol, cholesterin,\\nand fats are always present, according to the same author. They will\\nnot aid in diagnosis.\\nThe normal coloring-matter of the feces is urobilin its presence is\\nshown by the proper tests. As before stated, bile-pigment never\\noccurs in the feces in health it is present when there is catarrh of the\\nsmall intestine. Blood-pigment is usually in the form of hasmatin.\\nAs might be expected, ptomaines have been obtained from the feces\\nof certain diseases caused by fungi.\\nDiseases Characterized by Pain and Flatulence.\\nIntestinal Indigestion. Intestinal indigestion is said to be due to\\nalterations in or diminution of the bile, the pancreatic, or the intestinal\\nsecretion. It is almost always attended by gastric indigestion, and\\nmay not readily be distinguished from it.\\nAcute Intestinal Indigestion. Acute intestinal indigestion is\\ndue to the irritation of food not properly digested in the stomach. It\\nis attended with colic, flatulency, and borborygmi. Some fever may\\ndevelop, and diarrhoea may ensue. In the mild forms the tongue is\\ncoated, there are loss of appetite and some general pains. There is", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0918.jp2"}, "919": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 837\\nepigastric distress or pain in the right upper quadrant. Flatulency\\nand constipation occur. The stools are often clay-colored 7 or may\\nnot be changed. Slight jaundice occurs, and there is an abundance of\\nlithates in the urine. Accompanying gastric indigestion modifies the\\nsymptoms slightly.\\nThe symptoms are more marked and pronounced in chronic intestinal\\nindigestion. The local symptoms are as follows Pain which begins\\nfrom two to six hours after eating. It may be complained of in the\\nregion of the liver or below the sternum. It is usually seated in the\\numbilical region. It is dull and continues two or three hours, or until\\nthe next meal is taken. There is some tenderness. With the pain\\nthere are tympanites, borborygmi, and a sense of fulness in the abdo-\\nmen the bowels are constipated, and the stools are hard and dry.\\nThe constipation alternates with diarrhoea, and undigested particles of\\nfood are passed. The appetite is not lost, but is variable. Hemor-\\nrhoids are often present.\\nThe general symptoms are marked, and are referred to the nervous\\nsystem and the condition of the blood. There are great depression and\\nhypochondriasis. The patients sleep badly, suffer from bad dreams and\\ntinnitus aurium there are spots before the eyes and more or less constant\\nheadache. They complain of pain in the back and limbs, and hyper-\\nesthesia and anaesthesia are present. There is inaptitude for mental\\nexertion. Frequently the patient has sudden attacks, apparently due\\nto toxins, as sudden fainting followed by collapse, or vertigo. During\\nthese attacks there are great palpitation and tachycardia. The ex-\\ntremities are cold, and there are cold sweats over the body. Inde-\\npendently of the attacks, the patient is subject to palpitation and some\\ndyspnoea. The urine is always high-colored, acid in reaction, and full\\nof urates and uric acid. Oxalate of lime may be present, and the\\nalbuminuria of uric acid occurs, due to the irritation. The patient\\nearly becomes anaemic, because of the auto-intoxication and poor\\nassimilation. There is some emaciation in some cases the emaciation\\nis rapid. The complexion is sallow. If there is an abundance of\\noxalates, the patient complains of weight and heaviness about the loins.\\nThe stools may contain fat, indicating probable pancreatic disease, if\\nfatty food has been ingested. On the other hand, with loss of appetite,\\nfurred tongue, frontal headache, and drowsiness, the stools may be\\nclay-colored and the bowels costive apparently the bile is at fault.\\nDiseases Characterized by Pain and Diarrhoea.\\nAcute Intestinal Catarrh. Cause. Exposure to cold or the direct\\nirritation of mechanical or chemical substances within the intestine.\\nIrritating food that is not digested, or that cannot be digested because\\nof the quantity spoiled meats and unripe fruit usually excite an\\nattack. Water saturated with impurities, or such as the individual is\\nnot accustomed to, may excite an attack. Strangers in a new locality\\nare frequently subject to a diarrhoea until accustomed to the drinking-\\nwater, which in the native does not excite catarrh. Toxic substances,\\nas poisons or drags, or toxic substances the result of putrefaction, as", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0919.jp2"}, "920": {"fulltext": "838 SPECIAL DIAGNOSIS.\\nptomaines, are frequent exciting causes. Extension of inflammation\\nfrom neighboring structures by infection, as in peritonitis, sets up a\\ncatarrh. Local diseases of the intestine, as ileus, intussusception, her-\\nnia, and ulcers of all forms, are attended by catarrh of the intestine.\\nIt also occurs in cachectic states of the system, as cancer, anaemia, and\\nBright s disease. In disease of the heart and bloodvessels, or of the\\nliver and spleen, where the disturbance of the circulation causes a con-\\ngestion, catarrhal inflammation occurs. It is of common occurrence\\nin the infectious diseases, and particularly in septicaemia and pyaemia.\\nSymptoms. Diarrhoea is the chief symptom, varying with the cause\\nand the extent of the catarrhal inflammation. The stools differ in fre-\\nquency and in color, as has been previously indicated in the various\\ntypes. They contain undigested matter sometimes worms. Colicky\\npains about the umbilicus, with borborygmi and frequent desire to go\\nto stool, attend each evacuation. The fever is of the remittent type,\\nand is attended with some prostration. The urine is scanty and high-\\ncolored. The symptoms vary somewhat with the location of the in-\\nflammation, although the exact locality cannot be distinctly defined.\\nThe symptoms of proctitis, pain with tormina and tenesmus, do, how-\\never, enable the localization to be made to that portion of the bowel.\\nThese are more common than in inflammation apparently limited to\\nthe small intestine, Avhile in colitis the violence of the rectal symptoms\\nstands between enteritis and proctitis.\\nThe diagnosis of acute intestinal catarrh is not difficult. It is more\\ndifficult to determine the actual cause. If the attack occurs suddenly\\nafter the eating of improper food, or the drinking of impure water, the\\nirritation is probably due to that cause, and may be determined by the\\nnature of the feces. If they contain undigested food, the diarrhoea is\\nprobably due to indigestion. Catarrh from cold usually follows ex-\\nposure, and is generally not very severe. To estimate the cause from\\npoison or drugs the condition of the rest of the intestinal tract must be\\ninvestigated and other symptoms of the effects of drugs must be in-\\nquired for. In arsenical poisoning there is always vomiting and the\\ndischarges are of a choleraic nature. Collapse rapidly ensues. The\\nother symptoms of arsenical poisoning must be inquired for and the\\nhistory of exposure, if possible, ascertained. The intestinal catarrh\\ndue to infectious diseases is attended by the symptoms due to the\\nrespective affections, each of which is usually readily recognized. It\\nmay be necessary to resort to a bacteriological examination of the feces.\\nThe intestinal catarrh which occurs on account of local disease of the\\nbowel, as hernia, stricture, etc., is preceded or attended by the local\\nsymptoms of these diseases. In like manner we judge of the nature\\nof the diarrhoea that occurs in the course of tuberculosis or syphilis,\\nand in the course of organic heart disease or of liver disease. In each\\ninstance the possible influence of morbid processes present in other\\nstructures must be very carefully estimated.\\nThe Varieties of Acute Intestinal Catarrh. Divisions\\nhave been made in accordance with the symptoms which distinguish\\nthe various localities of the intestine in which the inflammation is most\\nmarked.", "height": "4412", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0920.jp2"}, "921": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 839\\nCatarrh of the Duodenum. This partakes of the nature and has the\\nsymptoms of gastro-intestinal catarrh in a mild degree, and is charac-\\nterized by the occurrence of jaundice due to catarrhal inflammation of\\nthe biliary passages.\\nThe Small Intestine. Colicky pains and rumbling are experienced.\\nThere is usually gastritis at the same time. The feces are mixed with\\nmucus. Over the right lower quadrant there is tenderness on pressure.\\nCaecum. Pain in the right lower quadrant with tumor, dulness on\\npercussion, and tenderness are present. (See Typhlitis.)\\nColitis. The large intestine is most frequently affected. Pain and\\ntenderness occur along the course of the bowel. The evacuations\\ncontain mucus there is tenesmus. The association with gastro-\\nenteroptosis and with neurasthenia must be borne in mind.\\nThe Rectum. Proctitis gives rise frequently to small stools, tenes-\\nmus, pain in the left lower quadrant, with tenderness about the anus,\\nand spasms of the sphincter. There are considerable mucus and blood\\nin the passages.\\nCholera Infantum. This affection occurs in children during the\\nhot season. It is promoted by bad hygienic surroundings, and is due\\nto improper milk or food. At first there is catarrhal diarrhoea. This\\nmay continue for twenty-four hours, then vomiting and diarrhoea\\nensue. The stools are liquid and large in amount. At first they may\\ncontain milk-curds. The vomiting is excited by anything taken into\\nthe mouth, or by odors, or by movement of the little patient. The\\nwatery discharges are almost constant. They may be preceded by\\ngreenish or yellowish-green stools for twenty-four hours. Stools are\\nacid in reaction, and their odor is sour. At first there is colicky pain,\\nbut when the watery discharges begin there is only a little tenesmus.\\nThe stools irritate the skin and cause eczema. The rectum may be-\\ncome prolapsed. The abdomen is at first distended with gas, but soon\\nbecomes retracted.\\nIn a short time, twenty-four hours or even less, collapse ensues.\\nPrevious to the collapse the skin is hot and dry the patient is restless.\\nThe thirst is intense, the mouth dry. The body-temperature is 103\u00c2\u00b0 to\\n104\u00c2\u00b0. With collapse the extremities become cold, the skin cool. The\\naxillary temperature is lowered and the rectal temperature increased to\\n105\u00c2\u00b0 to 106\u00c2\u00b0. The restlessness continues, the fontanelles become de-\\npressed, the eyes sunken, the face pinched, the brows drawn. The urine\\ndiminishes in amount or may disappear entirely. Brain symptoms\\nensue. So-called hydrocephaloid symptoms follow rolling of the head,\\nstrabismus, turning in of the thumbs, and, later, convulsions. Stupor\\nfollowed by coma develops in the fatal cases. If the patient does not\\ndie in collapse, marasmus develops ulceration of the cornea may take\\nplace there are oedema and blood extravasation under the skin. The\\nchild emaciates and withers. On account of the weak heart and ex-\\nhaustion pulmonary atelectasis or bronchopneumonia may occur. The\\nage, the season, the presence of catarrh, with collapse and other symp-\\ntoms, render the diagnosis easy.\\nCholera Morbus. The attack is characterized by sudden vomiting,\\nfollowed in a short time by purging. The vomiting may be preceded", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0921.jp2"}, "922": {"fulltext": "840 SPECIAL DIAGNOSIS.\\nby pain, or both may occur at the same time. At first the pain is\\nseated in the epigastrium and subsequently about the navel. It is\\nvery severe and paroxysmal in character, compelling the patient to\\ndouble up if lying in bed. A cold perspiration breaks out on the fore-\\nhead, the extremities become cold, the face anxious the pulse becomes\\nrapid. At first the patient vomits undigested food, then watery,\\ngreenish-colored fluid. The latter is bitter. Purging sets in at once,\\nor within an hour. The bowel-movements follow an attack of pain.\\nThe first passage is fecal, and may contain undigested food the subse-\\nquent passages are watery and profuse. There are severe attacks of\\nburning and tenesmus the abdomen is tender around the navel and\\nin the epigastrium. After an evacuation there is slight relief, but soon\\nanother paroxysm of pain comes on. The vomiting is excessive, and\\nretching may be present in the intervals. Ice, or water, or anything\\ntaken into the stomach excites pain and causes the vomiting. The\\nattack subsides in twelve to twenty-four hours, and is followed by ex-\\nhaustion. In rare cases collapse ensues, and in others it is followed\\nby gastro-intestinal catarrh.\\nCholera Nostras. The symptoms are those of severe gastro-enter-\\nitis. There are sudden vomiting and diarrhoea. It usually begins in\\nthe night. The vomiting is not different from that of cholera morbus.\\nThe watery and brownish-colored stools become colorless and have the\\nappearance of rice-water. Pain attends the attack, rapid prostration\\nensues, the extremities become cold, and collapse takes place. With\\nthe collapse there are cramps in the legs. Other muscles of the body\\nmay become cramped. The disease occurs in epidemics during the hot\\nseason, and may be mistaken for cholera. It can be distinguished from\\nthe milder forms of cholera which precede the occurrence of the epi-\\ndemic only by the absence of the comma-bacillus. The bacillus of\\ncholera nostras is found in the stools. (See Feces.)\\nEntero-colitis. In entero-colitis the more intense inflammation\\nsucceeds a mild intestinal catarrh. There are increased languor, great\\nfretfulness, and fever. The early catarrh is attended by green acid\\nstools, with lumps of casein. The tongue is furred and moist at first. It\\nsoon becomes red and dry vomiting ensues. The stools are offensive\\nand increase in frequency, and, in addition to the appearance first indi-\\ncated, contain mucus and blood. Death may take place within the\\nfirst week, on account of exhaustion from the vomiting and diarrhoea.\\nIf the disease is protracted, it is attended by great wasting, symp-\\ntoms of hydrocephalus, skin eruptions, hypostatic pneumonia, and ex-\\ntremely weak, feeble circulation.\\nChronic Intestinal Catarrh. It usually follows an acute attack, or\\nmay be chronic from the start. It may follow gastric hyperacid-\\nity and dilatation of the stomach. It arises secondarily to portal con-\\ngestion in disease of the liver and in chronic disease of the heart or of\\nthe lungs. It occur in malaria and in the scorbutic cachexia.\\nThe symptom is diarrhoea alternating with constipation, or diarrhoea\\nalone. Stools may contain undigested food, or pus, mucus, and blood\\nin small amounts. Diarrhoea may be present in the morning only\\nunder these circumstances. If the feces are examined, the eggs of", "height": "4408", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0922.jp2"}, "923": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 841\\nparasites, or infusoria may be found. The local abdominal symp-\\ntoms of rumbling, flatulency, and tormina are present. There are\\nreflex symptoms of cardiac palpitation and dyspnoea (asthma). Rush\\nof blood to the head may occur. Often these symptoms are relieved\\nby the passage of flatus. Chronic catarrhal gastritis usually accom-\\npanies the intestinal catarrh. The general symptoms of anosmia y\\nemaciation, and neurasthenia are present. Hemorrhoids are common.\\nAmyloid Degeneration of the Intestines. The symptoms are\\nthose of diarrhoea, persistent but mild in character, associated with\\nsymptoms of amyloid disease in other organs. With enlargement of\\nthe liver and spleen changes in the urine due to amyloid disease are\\npresent. The occurrence of these symptoms in a patient with syphilis,\\nor especially in a child with bone disease or tuberculosis, points to the\\nnature of the case.\\nUlceration of the Intestines. Duodenal Ulcer. Ulcer of the\\nduodenum usually occurs in young subjects in whom there are symp-\\ntoms of chlorosis or anaemia. The causes are the same as those of\\ngastric ulcer. It may follow boils, erysipelas, or pemphigus, and\\ndiffers in one etiological respect from ulcer of the stomach, in that it\\noccurs more frequently in the male sex. The symptoms are obscure,\\nand may be wanting entirely, the patient probably complaining only\\nof intestinal indigestion. In other cases they are like those of gastric\\nulcer. In typical cases the symptoms are those of pain situated below\\nthe xiphoid or to the right of the median line in the region of the\\npylorus. The pain occurs after eating, and may be relieved by vomit-\\ning. There is localized tenderness on pressure. Hemorrhage may\\ntake place from the stomach, or blood be found in the stools alone. It\\ndiffers from gastric ulcer only in the possible difference in location of\\nthe pain, the occurrence of intestinal indigestion and hemorrhage, and\\nthe fact that the pain comes on one to two hours after eating.\\nDuodenal ulcer is diagnosticated by the occurrence of melsena, which\\nmay be excessive and cause syncope and vomiting with no blood in the\\nvomitus by pain, which may be in the right hypochondrium or be-\\ntween the navel and the right costal border by gastralgic attacks by\\ndyspepsia, with constipation.\\nGeneral Ulceration. Ulceration of the intestine may be due\\nto a specific infection, and hence be symptomatic of typhoid fever,\\nsyphilis, and tuberculosis. It is always present in the first mentioned,\\nand of frequent occurrence in the latter. Follicular ulceration occurs\\nin entero-colitis in children. Ulcers due to the pressure of feces occur\\nin typhlitis and chronic constipation. The sacculi of the colon become\\nfilled with scybalous masses, the pressure of which produces ulcers.\\nTenderness is experienced along the course of the colon, particularly\\non palpation of the fecal masses, which may be felt through the\\nabdominal wall. A chronic ulcerative colitis is the form that succeeds\\nthe diarrhoeas which occur during camp-life, or that are set up in com-\\nmunities where people are crowded and live under bad hygienic cir-\\ncumstances. It is the form that attends scurvy, and is frequently seen\\nin chronic Bright s disease. It may be succeeded by dilatation of the\\ncolon, by hypertrophy of the muscular walls, or by contraction of the", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0923.jp2"}, "924": {"fulltext": "842 SPECIAL DIAGNOSIS.\\nbowel. The persistent diarrhoea leads to profound emaciation, extreme\\nprostration, sallow complexion, with markedly impaired nutrition of\\nthe skin. Such forms of diarrhoea were seen during the late war, par-\\nticularly in soldiers held in captivity. The diarrhoea may first be of a\\nlienteric character, and later alternate with constipation. Stools con-\\ntain blood and mucus.\\nUlcers of the intestinal tract may occur from other causes, and diar-\\nrhoea may be the predominant symptom. They may be due to cancer\\nthe malignant nodules may ulcerate within the lumen of the bowel.\\nThe bowel may be perforated from the exterior, on account of suppura-\\ntion somewhere along its course, as in appendicitis, pancreatitis, or\\ntuberculous peritonitis.\\nSymptoms. The symptoms of intestinal ulcer are usually those of\\ndiarrhoea. Ulceration, however, may be present without any symp-\\ntoms whatsoever, particularly if the small intestine is affected. One\\nor two small ulcers, on the other hand, in the lower portion of the\\ncolon, may set up continuous diarrhoea. The stools are composed of\\nfeces, mucus, pus. shreds of tissue, and blood. If pus is discharged in\\nlarge amounts, an abscess has probably opened into the bowel. Mod-\\nerate discharge of pus usually follows ulcers in the colon. Pus may\\nbe present in cancer. Hemorrhage is of frequent occurrence, and is an\\nimportant diagnostic symptom, especially if profuse and occurring\\nwithout symptoms of obstruction, of gastric ulcer, or of hemorrhoids.\\nThe fragments of tissue found in the stools may point to the nature of\\nthe process. Large amounts attend the dysenteric process. The frag-\\nments may be composed of the mucosa, connective tissue, and the\\nmuscular coat. Pain occurs in many of the cases. It may be general\\nand colicky, or circumscribed in cases of ulcer of the colon. Perfora-\\ntion of the intestine is followed by localized or general peritonitis.\\nThe occurrence of the latter depends largely upon the situation and the\\nrapidity of the ulceration. If the perforation is in the posterior wall\\nof the colon, a circumscribed abscess may develop. When it is situ-\\nated in the upper zone the pus may accumulate underneath the dia-\\nphragm, or in the lesser peritoneal cavity. The signs of pyopneumo-\\nthorax subphrenicus occur when the latter accident takes place, as both\\npus and air accumulate in the abscess-cavity. In such instances the\\nulceration usually takes place at the splenic flexure. Perforation of\\nan ulcer of the caecum may simulate appendicitis.\\nTuberculosis of the Intestine. The disease is usually secondary\\nto chronic tuberculosis, but may be primary, especially in children.\\nThe symptoms are usually those of diarrhoea, and in the primary form\\nthis is associated with general emaciation, which advances rapidly, and\\nwith anaemia. Fever of the intermittent or remittent type is present.\\nThere is meteorism the abdomen is much distended, but eventually\\nbecomes contracted. The mesenteric glands can be made out along\\nthe spinal column, and the intestines may become bunched into a mass,\\nyielding a dull tympany on percussion in the centre of the abdomen.\\nThe diarrhoea is attended with colicky pains. The diagnosis is based\\nupon the rapid emaciation, irregular fever, enlargement of the mesen-\\nteric glands in a patient, usually a child, who had probably been ex-", "height": "4412", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0924.jp2"}, "925": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 843\\nposed to tuberculous infection. In one of my cases, the child, aged\\nfour years, ate of the same food, using the same utensils, as a brother,\\na young man of twenty-two years, dying of pulmonary tuberculosis.\\nThe child was constantly with the brother. The remainder of the family,\\neight in number, remained in perfect health, and were all of good\\nphysique. The elder brother became infected by association with\\ntuberculous subjects in improper quarters away from home.\\nIntestinal Obstruction.\\nIntestinal obstruction may be acute or chronic. Acute obstruction\\nmay set in in the course of chronic obstruction due to stricture of the\\nbowel, to occlusion due to external pressure, or to accumulations within\\nthe bowel.\\nCauses. Acute intestinal obstruction is due, first, to constriction by\\nbands or strangulation of the bowel through apertures second, to\\nvolvulus of the colon third, to acute intussusception.\\nIn the first instance the type of the obstruction is seen in strangu-\\nlated hernia, but similar strangulations occur in apertures within the\\nperitoneal cavity. Thus loops of the intestine are caught and con-\\nstricted in the duodeno-jejunal fossa, the so-called Treitz retro-\\nperitoneal hernia, or in the foramen of Winslow, also known as\\ninter-sigmoid hernia finally, diaphragmatic hernia, in which protru-\\nsions of the intestine through the diaphragm, along with other abdominal\\nviscera, may take place. The above-mentioned forms of hernia may\\nexist without symptoms, or may lead to constriction or twisting of the\\nloop of the intestine, with occurrence of acute obstruction. Moreover,\\nlacerations in the omentum may give rise to internal constrictions.\\nExternal constrictions, however, take place, most commonly in the\\nregions of hernias, on account of the gut being constricted by dense\\nfibrous adhesion or about the uterus or Fallopian tubes, which had\\npreviously been the seat of inflammation. The constricting bands\\nthat follow the local peritonitis may gradually occlude the gut, or be\\nin such position that the latter becomes twisted about it. In other\\nforms of peritonitis similar constricting bands may form, which are\\nliable to produce this accident. Disease about the vermiform ap-\\npendix, with secondary adhesions, has been observed to cause con-\\nstriction. A frequent form of intestinal obstruction is due to the\\ntangling of the intestines in the foetal remains of the omphalomesen-\\nteric duct, Meckel s diverticulum, which is situated a short distance\\nabove the ileo-csecal valve.\\nVolvulus is a form of acute obstruction due to twisting or knotting\\nof the intestine. The condition is not common. It occurs most fre-\\nquently at the sigmoid flexure of the colon. The mesentery of the\\nlatter is often congenitally narrowed, on account of which the colon is\\nunduly dragged upon, and, if filled with masses of feces, cannot restore\\nitself the twisting becomes permanent, and obstruction takes place.\\nPeristalsis is set up and other portions of the intestine wind about\\nthe pedicle of the loops, so as to form a regular knot. Abnormal\\nperistalsis, on account of diarrhoea, often precedes the appearance of", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0925.jp2"}, "926": {"fulltext": "844 SPECIAL DIAGNOSIS.\\nthe obstruction. External injury is said also to give rise to the forma-\\ntion of an obstruction.\\nIntussusception (Plate XXXIX. Fig. 1), as a cause of intestinal\\nobstruction, occurs most frequently in children, and is due to a portion\\nof the bowel being pushed into the lumen of that which lies next below\\nit. A circumscribed portion of the intestine may be paralyzed. In the\\nportion above, the peristaltic action continues and the energetic move-\\nments push it into the paralyzed part. Intussusception is found fre-\\nquently after death in the bodies of children dying from exhaustion.\\nIn such cases it occurs just before death. Intussusception also occurs\\nwhen intestinal polypi drag one portion of the bowel into the lower\\nportion. Large portions of the intestine may be involved. The inva-\\ngination usually takes place at the lower portion of the ileum, or into\\nthe caecum sometimes the invaginated portion may reach the rectum\\nand project externally. Intense inflammation and adhesion are set up.\\nThe internal portion becomes gangrenous, on account of constriction of\\nthe afferent vessels. This portion may slough and pass with the dejec-\\ntions, followed by spontaneous cure.\\nChronic intestinal obstruction may be due to occlusion by external\\npressure, or by the excessive accumulation of material within the\\nbowels, or to stricture. The various causes are specified below.\\nIntestinal obstruction, to view it from another stand-point, may be\\ndue to (a) disease outside of the intestines (6) to disease of the intes-\\ntinal walls (c) to accumulation within the intestine.\\nThe obstruction takes place under the same circumstances as ob-\\nstruction in other channels.\\nA. Diseases Outside of the Intestines. 1. Pressure of tumors, chiefly\\novarian tumors, uterine tumors, tumors of the omentum, and pelvic\\nabscess, or abscess about the caecum. The obstruction may be acute\\nor chronic. The symptoms of obstruction develop gradually, although\\nin some instances they may take place suddenly, especially if aided\\nby the accidental occurrence of fecal impaction.\\n2. Constricting bands, hernial openings, the remains of foetal struc-\\ntures, cause constriction of the intestine. In this class of cases there\\nis usually pain, and the history preceding the obstruction is that of\\nperitonitis, general or local, of old hernia, of appendicitis, of pyosal-\\npinx, or of inflammation about the gall-bladder and gall-ducts. The\\nonset may be acute or chronic. If the constriction is due to protrusion\\ninto hernial openings, the onset is usually sudden and without previous\\nsymptoms.\\n3. Peritonitis is a most common cause of acute intestinal obstruction.\\nIt may be due to overdistention by gas and paresis of the bowel, or to\\npressure by external exudation.\\n4. Knots and twists of the intestines, usually seated about the sig-\\nmoid flexure, causing volvulus, are a common cause of acute constriction.\\nB. Disease of the Intestinal Walls. 1. Invagination, or intussuscep-\\ntion. The attack is acute, although the affection may continue over a\\nlong period of time.\\n2. Cancer and other tumors of the intestine generally lead to stric-\\nture and chronic obstruction.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0926.jp2"}, "927": {"fulltext": "PLATE XXXIX.\\nFIG. 1.\\nT\\nPerUt v.\\nTumor K\\nInvagination of the Ileum.\\nFIG, 2.\\nTumorfk\\nCarcinoma of the Colon.", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0927.jp2"}, "928": {"fulltext": "", "height": "4412", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0928.jp2"}, "929": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 845\\n3. The healing of ulcers, which are syphilitic in the larger number\\nof cases, rarely tuberculous, will lead to stricture. The obstruction\\nbelongs to the chronic variety. It is seated, in the larger number of\\ninstances, in the rectum or sigmoid flexure of the colon.\\nC. Accumulations within the Intestines. 1. Feces. The obstruction\\ntakes place gradually, occurs in weak and debilitated people in the\\ncourse of constipation, especially the constipation of acute disease.\\n2. Accumulations of improper food or foreign materials. The seeds\\nof fruits or the husks of grain accumulate and cause obstruction.\\nMagnesia, iron, and other articles taken as medicines, from their accu-\\nmulation lead to obstruction of the intestine. In both of the above\\nmentioned varieties obstruction is chronic.\\n3. Impaction of gallstone within the intestine is followed by acute\\nobstruction.\\nThe Symptoms. When symptoms of intestinal obstruction occur\\nit is important to ascertain, in addition, first, the duration of the ob-\\nstruction and its mode of onset second, the possible cause of the ob-\\nstruction third, the seat of the obstruction.\\nThe Symptoms Common to Acute Obstruction. The symptoms of intes-\\ntinal obstruction depend upon the nature and the seat of the obstruction.\\nConstipation. The major symptom is stoppage of the intestinal contents.\\nWhen this takes place suddenly, and there is a local injury to the\\nbowel, the symptoms, both local and general, are severe and alarming.\\nWhen the constipation is complete there is no escape of flatus. Pain.\\nThe pain is at the seat of obstruction or about the umbilicus. It\\noccurs suddenly, and is intense and colicky or lancinating in character,\\nradiating from the point of obstruction. There is tenderness over the\\npainful part. The pain is due to the injury by the constricting agent\\nor to violent peristalsis. It may be relieved by pressure. When inter-\\nmittent, the obstruction is incomplete when constant, it is absolute.\\nTumor. In many instances a tumor can be outlined due to single loops\\nof intestine, thickened walls, or abnormal contents. This is particularly\\nthe case in the obstruction of invagination and the obstruction due to\\nvolvulus. Peristalsis. The obstruction further causes increased peri-\\nstalsis. This takes place above the point of constriction. Sometimes\\nthe movements of the intestine can be seen through the abdominal\\nwalls. The extent of the peristalsis is an indication of the site of the\\nobstruction. The higher the obstruction, the less the peristalsis.\\nMeteorism. The obstruction causes accumulation of gas above the\\npoint, giving rise to meteorism. If the obstruction is low down, the\\ndistention and meteorismus are general. If high up, as in the small\\nintestine, on account of constriction by Meckel s diverticulum or inter-\\nnal hernia, the meteorism is in the upper part of the abdomen, and\\nmay be limited in extent, or dilatation of the stomach alone may be\\npresent. Vomiting. Vomiting soon occurs in acute intestinal obstruc-\\ntion, due to decomposition of intestinal contents, to irritation of the\\nstomach by the intestinal contents, to a trauma of the peritoneum at\\nthe seat of the obstruction, or, finally, to the occurrence of peritonitis.\\nAt first the contents of the stomach are ejected, then watery fluid, bile\\ntinged or largely made up of bile, and later feculent matter. Although", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0929.jp2"}, "930": {"fulltext": "846 SPECIAL DIAGNOSIS.\\nof fecal odor, this is not true stercoraceous vomiting the latter occurs\\nlater in the course of the disease. It must not be forgotten that any ob-\\nstruction of the intestine may develop with extreme rapidity, so that\\nfecal vomiting may occur within two hours of the commencement of an\\nobstruction. It is recognized by the odor of the matter vomited and\\nby its color. It is a grave symptom, indicating complete obstruction\\nof the intestine. If the obstruction is high up, as in the jejunum,\\nfecal vomiting does not occur. The vomiting, however, is more per-\\nsistent in high obstruction. Eructations of gas are frequent. The\\ngeneral symptoms are those of extreme prostration or shock in its most\\npronounced form. The abdominal fades previously described develops\\nvery rapidly. The tongue is not changed at first, but soon becomes\\ndry and brown. In a few instances, as in invagination, there may be\\nfever, but in other cases usually at once, or very soon in its course, the\\ntemperature falls to normal or subnormal, or remains at this point if\\nit has not risen. The extremities are cold, the features pinched, the\\neyes sunken, the expression anxious. The pain causes the patient to\\ndouble up in bed. The pulse becomes rapid, weak, and thready in\\ncharacter. The respirations are proportionately hurried, but are also\\nmade more rapid and shallow by the tympany. The mind remains\\nclear until the supervention of peritonitis and septicaemia.\\nThe Symptoms Common to Chronic Obstruction. The symptoms are\\nthose of chronic constipation, with local symptoms due to the cause of\\nthe obstruction. The bowels are moved infrequently, and then in\\nsmall amounts. In obstruction due to stricture from cancer, or cica-\\ntricial closure, the feces are ribbon-shaped. Reference must again be\\nmade to the occurrence of so-called spurious diarrhoea, with or without\\nthe passage of small scybalous masses, on account of impaction of feces.\\nSome credence can be given to the oft-repeated expression of the pa-\\ntients that they have a sense of obstruction in the bowel and that they\\nexperience great relief when there is a free evacuation. In chronic\\nobstruction the general symptoms are those of inanition, with the ner-\\nvous train of symptoms that have been described in constipation\\nwhile the local symptoms depend upon the cause. When the local\\nsymptoms are due to the pressure of a tumor, or accumulation of pus\\nor fluid within the abdomen, there is a history of local disease, on ac-\\ncount of which the tumor developed such history is obtained in\\nfibroids or ovarian tumor, or in previous inflammation, which was fol-\\nlowed by the occurrence of a tumor about the locality of the inflam-\\nmation, as the pelvis or the appendix.\\nIf the obstruction is due to stricture from cancer of the intestine, the\\nsymptoms of that affection are present. A tumor can be made out at\\nsome situation in the course of the bowel. The symptoms are (1) the\\ncachexia, emaciation, and ansemia (2) pain (3) tumor (4) constipa-\\ntion with scybalous discharge (5) bloody discharge (6) mucous dis-\\ncharge. If the cancer is seated in the rectum, we find tormina and\\ntenesmus, and the discharge of blood and scybalous masses. Local\\nexamination reveals the presence of a malignant mass. Obstruction\\ndue to stricture from the healing of an ulcer is seated in the rectum or\\nsigmoid flexure of the colon. Pain and a sense of obstruction are", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0930.jp2"}, "931": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 847\\nreferred to that locality. A history of syphilis may be obtained, and\\nfrequently the rectal tube, or the finger, will detect the stricture. In\\nboth instances there is a history of imperfect, irregular action of the\\nbowels from time to time, with intervals of comparative comfort.\\nThese symptoms precede the constipation. When feces accumulate in\\nthe colon the larger accumulations take place in the sigmoid flexure\\nand in the caecum. Fecal tumors, described under Constipation, are\\nfelt through the abdominal walls. Obstruction from fecal accumula-\\ntion is preceded by a history of constipation (q. v.). The accumula-\\ntions can be easily discerned as a rule. It must not be forgotten that\\nchronic intestinal obstruction may at any time become acute.\\nChronic intestinal obstruction always occurs in adults. The onset is\\ngradual. The pain that attends obstruction of this form is intermit-\\ntent, and if there is fecal accumulation, it is not very prominent.\\nVomiting occurs late in the disease, is small in amount, and generally\\nis not a prominent factor. Obstruction to the passage of feces may be\\nconstant, or alternate with diarrhoea. In fecal accumulation it be-\\ncomes complete, although spurious diarrhoea may attend it. The dis-\\ncharges may be bloody, which points to cancer. Tenesmus is present\\nin stricture low down in the large bowel. Meteorism is not marked\\nwhen the obstruction is high up, as in acute obstruction. When the\\nobstruction is in the large intestine it may be extreme, and in fecal\\nobstruction gradually increases as the obstruction becomes more\\nmarked. Coils of intestine in peristaltic movement are seen only in\\ncases in which there is marked emaciation.\\nThe forms of chronic obstruction that are attended by tumor have\\nbeen mentioned.\\nThe Differential Diagnosis. It is essential in order to distin-\\nguish the form of acute obstruction to ascertain the nature of the ob-\\nstruction, and to determine, if possible, its site.\\nThe Nature of the Obstruction. Various factors must be\\nconsidered in order to estimate the cause of the obstruction.\\nThe Age. Obstruction from intussusception occurs early in life\\nfrom bands or through apertures, in adult life, usually prior to forty\\nyears of age from volvulus, between forty and sixty years. Obstruction\\ndue to a gallstone occurs during the middle or later period of life\\nalways after the fortieth year.\\nThe Previous History. In obstruction by bands of adhesion there\\nis a history of peritonitis, or, as Treves points out, previous attacks of\\nobstruction more or less marked. In volvulus the patient has been\\nsubject to constipation prior to the attack, and in intussusception there\\nhas been no previous history, unless polypus was present, causing drag-\\nging, colicky pains, and occasional discharge of blood.\\nThe Symptoms. The symptoms of the various forms of acute obstruc-\\ntion vary somewhat. Pain in strangulation, from bands or hernia, is\\nsevere and paroxysmal in character, attended by collapse. It occurs\\nearly in volvulus, though it is not so severe as in the former, and\\noccurs at long intervals, becoming constant with exacerbations. In\\nacute intussusception the pain occurs early, and is steady. It in-\\ncreases, and then may suddenly subside. At first it is paroxysmal,", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0931.jp2"}, "932": {"fulltext": "848 SPECIAL DIAGNOSIS.\\nattending discharge of blood and mucus from the bowels. Local ten-\\nderness in the first group of cases occurs late. In volvulus it occurs\\nearly, and may be noted over distended coils. In intussusception it is\\nusually common about a sausage-shaped tumor. Vomiting is marked\\nand occurs in strangulation, soon becomes feculent, and increases the\\nseverity of the paroxysms of pain. In jejunal obstruction it is ex-\\ncessive and non-feculent. In volvulus it does not come on so quickly,\\nbut is severe and constant when it takes place. The relaxation that\\nattends vomiting often affords relief to the obstruction. In intussus-\\nception it does not occur as early as in the other forms, and is not so\\nsevere. It becomes feculent in only a small number of cases. Con-\\nstipation is continuous in all cases except intussusception. In the\\nlatter there is some constipation, but it is not absolute diarrhoea is\\nnot uncommon, and discharge of blood in the stools occurs in 80 per\\ncent, of the cases, according to Treves. Prostration is severe in all\\ncases, although probably not so marked in volvulus. Because of its\\nclose proximity to the rectum tenesmus occurs m volvulus. It is of fre-\\nquent occurrence in intussusception, often beginning early in the attack.\\nThe Physical Signs. (Plate XXXIX. Figs. 1 and 2.) On palpa-\\ntion of the abdominal wall it is noted to be soft and flaccid in most of\\nthe cases, unless peritonitis has ensued. This occurs early in volvulus,\\nhence rigidity is marked. In a large number of cases a tumor can be\\nmade out only in intussusception. It is seated in the lower right\\nquadrant of the abdomen. Early in the attack it is oblong and of\\nsausage-shape. When peritonitis ensues it disappears, on account of the\\ntympany. A portion of the gut may protrude at the anus, or be felt\\non rectal examination. Meteorism occurs about the third day in a\\nstrangulation it occurs early, is very rapid and pronounced in volvu-\\nlus, and is absent in intussusception, unless constipation or peritonitis\\ntakes place. It is not marked in high obstruction.\\nThe Site of the Obstruction. The seat of obstruction is in a\\nmeasure indicated by (1) the location of the pain or abnormal sensa-\\ntions, (2) the character of the swelling, (3) the character of the stools,\\n(4) the degree of meteorism, (5) the results of a rectal examination, (6)\\nthe change in the urine, (7) the general condition. The patient is\\noften able to indicate the location of the obstruction fairly well by the\\nsensations of obstruction or fulness and by the great relief experienced\\nwhen a free evacuation of the bowels is naturally or artificially pro-\\nduced. On auscultation, when the bowel is irrigated, a murmur, like\\nthe deglutition-murmur, may be heard at the point of constriction of\\nthe gut. In obstruction high up there is but little meteorism, the\\ntumor is usually not detected, and pain is seated about the umbilicus\\nor the upper quadrants of the abdomen. Obstruction at the ileo-caecal\\nvalve may be indicated by a tumor in the lower right quadrant over\\nthe region of the valve or just above it. It is usually at this point\\nthat invagination takes place, and hence we may look for a tumor in\\nthis situation. (Plate XXXIX., Fig. 1.) On the other hand, in vol-\\nvulus of the colon, or stricture of the rectum, the obstruction, being\\nlow down, is attended by much meteorism and by pain in the left\\nlower quadrant of the abdomen. A tumor may be detected in this", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0932.jp2"}, "933": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 849\\nposition. The position of the obstruction is sometimes indicated by\\nthe seat of peristalsis. This may be seen to stop at a given point,\\nwhich usually indicates the position of the obstruction. The seat of\\nobstruction may be indicated by the number of coils of intestine that\\nare engaged in the peristaltic movement. The coils of intestine in front\\nof the tumor are dilated and hypertrophied. In active movement they\\ncause prominences which follow the course of the bowel. Wyllie has\\ncalled them patterns of abdominal tumidity. If the obstruction is\\nin the jejunum, peristalsis may not be observed. If the lower end of\\nthe large intestine is obstructed, the colon is prominent if the gut\\nabout the ileo-csecal valve, the region about and below the umbilicus is\\nprominent. The Urine. The position of the tumor, it is said, can be\\nascertained by changes in the urine. When the obstruction is in the\\nsmall intestine, indican is much increased from the decomposition of\\nalbuminous substances and products of putrefaction. In this location\\nthe urine may be suppressed. In stenosis of the large intestine indican\\nis not increased unless there is cancer. The value of the information\\nderived from the character of the stools and the results of rectal\\nexamination are obvious. Obstruction in the duodenum or jejunum is\\nfollowed by rapid collapse and anuria. In general, it may be said the\\nmore severe and rapid the symptoms the more likelihood that the\\nobstruction is in the small intestine.\\nIntussusception (Plate XXXIX., Fig. 1), or invagination, occurs\\nmost frequently in children prior to the tenth year. It is characterized\\nby severe colic and pain in the abdomen, first complained of about the\\nnavel. The severity increases in paroxysms, and only lessens if com-\\nplete strangulation has taken place. With the onset of the pain there\\nare one or two movements of the bowels, which contain mucus and\\nblood. After this there may be constipation, or the stools continue to\\nbe loose, and are as frequent as fifteen of twenty in a day. Sometimes\\nthey are quite bloody, and almost always there is some tenesmus. In\\na short time after the attack vomiting commences. It may be constant\\nor occur only after taking food. At first the abdomen is soft, but\\ntender on pressure. A sausage-like tumor can be felt on the right side\\nbelow the transverse umbilical line. On inspection of the rectum a\\nportion of the intestine may be seen, dark and gangrenous in appear-\\nance, or it may be felt by palpation. If there is much tenesmus, the\\nanus often remains open. In rare cases the bowel may slip back and\\nthe symptoms subside spontaneously. On the other hand, peritonitis\\nmay rapidly ensue, with high fever, followed by collapse and death.\\nDiagnosis. It must be distinguished from the enter o-colitis of child-\\nhood or the proctitis due to a polypus. In entero-colitis there is no\\ntumor, and the collapse and prostration do not occur so early and are\\nnot so rapid. There is greater likelihood of a number of the stools\\nbeing greenish, like spinach. In a polypus of the rectum the symp-\\ntoms are local. The child is worn out and restless, but great abdominal\\ntenderness, and the tumor, meteorism, vomiting, and collapse are absent.\\nThe rectum must be examined.\\nIntussusception must be distinguished from peritonitis, in which\\nsymptoms of stenosis of the bowel from ileus paralytica may be present.\\n54", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0933.jp2"}, "934": {"fulltext": "850 SPECIAL DIAGNOSIS.\\nThe history and sequence of events must be watched carefully. Often\\nthe commencement of the affection about hollow viscera which have pre-\\nviously been the seat of disease, or its onset with sudden perforation,\\nwill point to the nature of the affection. In peritonitis there is no\\nactive peristalsis there is general distention of the abdomen with\\ngeneral tenderness the urine is diminished, but does not contain in-\\ndican in excess. Collapse ensues rapidly. Signs of effusion within\\nthe abdomen may appear.\\nIt must be distinguished from embolism or thrombosis of the mesenteric\\nartery and infarction of the bowel. In the latter the symptoms take\\nplace suddenly. The patients have reached middle or late life, and have\\natheroma of the general arterial system. Sudden pain in the abdomen,\\nwith vomiting and symptoms of collapse, takes place. Moderate ob-\\nstruction occurs, with distention of the abdomen. After the pain diar-\\nrhoea with the passage of blood follows. The age and the absence of\\ntumor distinguish it from intussusception, the only intestinal condition\\nfor which it may be mistaken.\\nHernia and Constriction by Bands. Obstruction due to these con-\\nditions occurs in adults after the fortieth year of age, in both sexes.\\nIn stricture from pressure of bands there has usually been a history of\\nprevious attacks of peritonitis or of inflammation of the structures in\\nrelation to the peritoneum. Hence, a cholecystitis or appendicitis are\\noften found to precede the obstruction. The attacks begin suddenly,\\nand the symptoms may from the start be most pronounced. They are\\nthe typical symptoms of intestinal obstruction. The local tenderness,\\nhowever, may not be present as early as in other forms of obstruc-\\ntion. It is quite characteristic not to find a tumor or positive local\\ncause for the obstruction, and also not to have meteorismus. This is\\ndue to the fact that the obstruction is usually high up in the intestinal\\ntract.\\nVolvulus. Volvulus occurs most frequently in males. It occurs\\nlate in life, and is usually preceded by a history of constipation. Pre-\\nmonitory symptoms may have been present for a few days, but the\\nsymptoms of obstruction develop suddenly. They are the symptoms\\nof acute obstruction, but as the lesion is in the lower portion of the\\nbowel, meteorismus is present to a marked degree, and rectal symp-\\ntoms are found. Tenesmus is present in a small proportion of the\\ncases. Peritonitis is likely to set in early, with increase in the temper-\\nature, increased tenderness of the abdomen, and more pronounced\\nsymptoms of collapse.\\nDiagnosis of Intestinal Obstruction from Other Conditions. Intestinal\\nobstruction must be distinguished from peritonitis and appendicitis.\\nThis is sometimes very difficult. Careful attention must be paid to the\\nevolution of the case and the history of previous abdominal disease, or\\nof lesions on account of which, on the one hand, peritonitis may occur,\\nor, on the other, obstruction of the bowel. In peritonitis the attack\\nfollows disease in the uterine appendages, the vermiform appendix, or\\nthe gall-bladder, or perforation in some portion of the gastro-intestinal\\ntract. Fever usually attends the inflammation, with or without chill.\\nVomiting will probably occur at the onset, and then subside until the", "height": "4416", "width": "2608", "jp2-path": "practicaltreatis00muss_0_0934.jp2"}, "935": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 851\\nperitonitis becomes general. The first paroxysms of vomiting are appar-\\nently due to shock. The vomiting that occurs rarely becomes feculent.\\nAs the peritonitis advances the vomiting becomes passive a simple\\nconstant regurgitation of a large amount of fluid, greenish or grayish-\\nyellow, or watery, takes place. It pours into the mouth, and is simply\\ndischarged without the occurrence of retching. The abdomen is swollen\\nand tympanitic. The symptoms due to excessive tympany are more\\nmarked than in intestinal obstruction. As the diaphragm is interfered\\nwith, breathing is hurried. The abdomen is tender on pressure and is\\nthe seat of general pain. The general pain and tenderness, however,\\ncan usually be found to be more marked at the possible primary focus\\nof the disease. Further, on local examination, in these positions ful-\\nness or undue prominence or swelling may be observed. On palpation\\nover the point of origin there may be localized oedema. The symptoms\\nof collapse do not differ from those of intestinal obstruction in marked\\ndegree, although the peculiar appearance of the face and other nervous\\nfeatures occur more rapidly in peritonitis than in obstruction. It must\\nbe remembered that peritonitis in a large majority of cases attends ob-\\nstruction.\\nIn appendicitis the symptoms are somewhat like those of intestinal\\nobstruction. There may be constipation and vomiting. The former\\nis not pronounced, and can usually be relieved. Vomiting subsides\\nafter the first twenty-four hours, unless peritonitis supervenes it is\\nnever stercoraceous. The local physical signs are characteristic. In\\nappendicitis there is fixed tenderness on pressure at McBurney s point.\\nSome swelling can almost always be observed. On light or deep per-\\ncussion there is change in the note as compared with the other side.\\nFluctuation can often be detected in from two to four or five days.\\nBoth the tumor and fluctuation can be detected by bimanual examina-\\ntion of the abdomen and flank. Examination by the rectum may\\nreveal a tumor at the brim of the pelvis in the right side. Fever\\nattends the attack throughout. When peritonitis supervenes there is\\nrigidity of the entire abdomen, which at first was localized to the right\\nlower quadrant.\\nIntestinal obstruction must not be confounded with enteritis. In all\\nforms there is diarrhoea, in many vomiting. Pain of a colicky nature,\\nspreading from the neighborhood of the umbilicus, is marked when-\\never obstruction to the passage of feces or gas takes place. Vomiting\\nis not stercoraceous, and the general symptoms, collapse, etc., do not\\noccur. Acute hemorrhagic pancreatitis is also attended by symptoms\\nsimilar to those of intestinal obstruction. There is sudden severe pain\\nin the upper half of the abdomen, with vomiting and the rapid develop-\\nment of collapse there may be constipation the situation of the pain is\\nof some significance. Vomiting never becomes stercoraceous flatus can\\nusually be passed and the bowels opened by an enema. Meteoiismus does\\nnot take place, although the epigastrium is tympanitic. If the symp-\\ntoms are not so severe, there may be increased dulness, and possibly a\\ntumor on deep palpation in the left upper quadrant of the abdomen\\nalong the margins of the ribs, which should be dull on percussion, or,\\non account of its relation to the stomach, give a dull tympanitic note.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0935.jp2"}, "936": {"fulltext": "852 SPECIAL DIAGNOSIS.\\nThe symptoms of internal hemorrhage are present, pallor of the face\\nand extremities, syncope, and, in addition, prostration and other symp-\\ntoms of collapse.\\nCancer of the Intestines. (Plate XXXIX., Fig. 2.) Obstruc-\\ntion must not be confounded with carcinoma of the intestines. The\\ndisease usually occurs late in life, and is associated with progressive\\nemaciation and cachexia. There may not be any symptoms save general\\nfailure of health until the sudden occurrence of obstruction of the bowel.\\nThe symptoms vary with the position of the carcinoma and the direc-\\ntion of growth of the tumor. In some instances Avith the general symp-\\ntoms there may be irregular pain in the abdomen, with irregularity of\\nstools. The tumor may be detected if the small intestine is involved\\nIts detection is facilitated by having the patient get on the hands and\\nknees and palpating the abdomen in this position, and by clearing out\\nthe colon by a large enema. On auscultation the water may be heard\\nto enter the dilated colon beyond the tumor, the sound resembling the\\ndeglutition-murmur at the cardiac end of the stomach. If the tumor is\\nsituated in the lower colon, pain in the sacral region, resembling sciatica,\\nmay be complained of if the csecum or the sigmoid flexure is the seat\\nof disease, a tumor is usually detected. Wherever the situation, the\\ntumor found is tender, usually lying in the axis of the intestine\\nmovable if in the small intestine, fixed if in the csecum or the sigmoid\\nflexure. In the latter location the tumor may be felt per rectum. One\\nnotable characteristic is that it may be palpable some days and not be\\npresent at other times. The position and size may vary from day to\\nday, although it is always hard and knotty, not doughy. By means of\\nthe proctoscope, with the patient in the knee-chest position, as described\\nby Kelly, the presence of tumors of the descending colon will be dis-\\nclosed. Constipation is characteristic of most of the cases. It may\\nalternate with diarrhoea. Paralysis of the sphincter ani may take place,\\nwith incontinence. The stools are frequently ribbon-shaped, or they\\nmay pass in scybalous masses, and large or oftener small amounts of\\nblood, chiefly the latter, are passed with pus or mucus sometimes\\nmasses resembling cancer can be found in the stools. If the tumor is\\nin the rectum, there is great difficulty in defecation the act is attended\\nby pain. Later the pain becomes constant, and may radiate to the\\nhip or the genitalia. Sometimes this pain is the only symptom com-\\nplained of.\\nThe diagnostic symptoms are (1) The general symptoms of cancer.\\n(2) The tumor. (3) The occurrence of constipation which leads to\\ncomplete obstruction, or obstipation, alternating with diarrhoea. Blood\\nin the stools, with alteration in the shape of the feces, is significant. 1\\nDiseases of the Rectum.\\nConsideration of rectal lesions belongs to the surgeon. It is proper,\\nhowever, to insist upon the very frequent deleterious effect of such\\nlesions in neurasthenic subjects. Indeed, the bleeding which attends\\n1 Musser: Carcinoma of the Descending Colon. Univ. Med. Mag., 1896.", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0936.jp2"}, "937": {"fulltext": "DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 853\\nhemorrhoids may be sufficient to lead to profound anaemia, upon which\\nneurasthenia may readily develop. The local suffering due to rectal\\nfissure, or prolapse, may aggravate any tendency to the state of neuras-\\nthenia, or aid materially, with other conditions, to fasten it more\\nfirmly upon the system. In cases of anaemia, of neurasthenia, of the\\ngastric neuroses, of debility, or prostration, the cause of which cannot\\nbe ascertained, the rectum should be examined. The appearance of\\nhemorrhoids and other rectal affections is described in works on surgery.\\nHemorrhoids, ulcers, fistula, and carcinoma are to be sought for in\\nabdominal affections.\\nInspection and palpation are necessary. The symptoms are those of\\nlocal pain, tenesmus, and frequently hemorrhage. The pain follows a\\nmovement of the bowels. There may be a feeling as of a foreign body\\nin the rectum, with some itching and burning about the anus. The\\npain may be so severe as to inhibit defecation. The timid subjects\\nwill not endure the act in consequence they suffer from vertigo, head-\\nache, tympanites, and symptoms of gastro-intestinal disorder. In\\nsome instances there is chronic catarrh of the rectum, with discharge\\nof small stools containing mucus or pus streaked with blood. Cases\\noccur in which hemorrhage is the only symptom, the constant recur-\\nrence of which leads to grave constitutional results. Hemorrhoids are\\nthe lesions for which the rectum is most frequently examined. They,\\nas well as other lesions, are of diagnostic significance in affections\\nbeyond the rectum. Thus in all forms of portal congestion internal\\nhemorrhoids are of constant occurrence, and when found in a toper\\nmay be one of the first indications of cirrhosis of the liver. Rectal\\nfissure is not of much diagnostic significance. The finding of a small\\ncancer, the symptoms of which may be those of hemorrhoids, may ex-\\nplain emaciation and the development of cachexia. Ulcer of the\\nrectum may be due to syphilis, cancer, or tuberculosis. A fistula is\\noften tuberculous. The rectum must be examined in cases of pyaemia,\\nparticularly of the portal variety, when jaundice, enlargement of the\\nliver, and hectic fever are present, for local rectal disease may cause\\npylephlebitis.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0937.jp2"}, "938": {"fulltext": "CHAPTEK VI.\\nDISEASES OF THE LIVER, SPLEEN, AND PANCREAS.\\nThe symptoms of disease of the liver are due to the morbid pro-\\ncesses, to disturbance of the functions of the hepatic cells, or to obstruc-\\ntion of the channels for the flow of blood and of bile. As these channels\\nextend beyond the glandular structure of the liver they may be affected\\nby disease outside of the organ. Hepatic symptoms may, therefore, be\\ndue to diseases other than those of the liver.\\nThe morbid process may, in time, cause alterations in function, ob-\\nstruction of channels, or physical alterations in the size and shape of\\nthe liver. But the channels may be obstructed and the size and shape\\nof the liver changed by disease outside of the liver.\\nSymptoms due to the Morbid Process. The morbid processes\\nare the congestions, the inflammations, the degenerations, the morbid\\ngrowths, and gross parasites.\\nIn congestion of the liver the symptoms are (1) the symptoms of the\\ncause, (2) enlargement of the organ from the increased amount of\\nblood, (3) functional disturbance from the same cause. The conges-\\ntion is not limited to the vessels in relation with the liver-cells, but\\ninvolves the vessels of the mucous membrane also, hence the latter\\nswell, obstruct the ducts, and produce jaundice in moderate degree.\\nThe inflammations are toxic and infectious. The symptoms are due\\nto the cause (intoxication or infection), to the degree of obstruction of\\nthe vessels and ducts, to the shape and size of the liver, and to the\\nalteration of its function. When the inflammation is diffused, as in\\nthe cirrhoses, the hepatic symptoms are more marked when local, as\\nin abscess, the infectious symptoms are in preponderance. If the\\nducts are the seat of infection, the bile channels are obstructed jaun-\\ndice arising if the vessels, ascites. In morbid growths of the liver\\nthe symptoms are those of malignant disease in general, to which are\\nadded symptoms due to change in the size of the liver, and, more fre-\\nquently than in inflammation, symptoms due to obstruction of the\\nchannels. The degenerations are so frequently secondary to and\\nmasked by the symptoms of their primary cause that, save in regard\\nto change of size, there are no hepatic symptoms worth mentioning.\\nSymptoms due to Functional Disturbance of the Liver.\\nThe functions of the liver are to secrete bile to destroy the haemoglobin\\nof the blood to destroy, modify or neutralize poisons entering, or to\\nmodify and render available for nutrition the peptones absorbed by, the\\nportal circulation the elaboration of glycogen. Bile is not secreted\\nwhen the liver-cells are destroyed, as in acute yellow atrophy. The\\nliver does not destroy the usual amount of haemoglobin. On the other\\nhand, haemoglobin may be so much in excess that the liver cannot", "height": "4408", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0938.jp2"}, "939": {"fulltext": "DISEASES OF LIVER, SPLEEN AND PANCREAS. 855\\ndestroy it jaundice then results. (See Hematogenous Jaundice.) Func-\\ntional disturbances of the liver are manifested clinically by symptoms\\ndue to the entrance into the circulation of imperfect products of diges-\\ntion, or poisons not destroyed by the liver.\\nLithcemia is a common toxic condition, and is believed to be due to\\nfunctional liver-disturbance. There is an excess of uric acid and\\nurates, or of other metabolic compounds in the blood. It may be a\\nconvenient term for the auto-intoxication which takes place in disease\\nof the gastro-intestinal tract. The symptoms are, first, symptoms of\\nexcess of lithic acid in the system second, the effects of the lithic\\nacid upon the nervous system. Lithsemia may be acute or chronic.\\nAcute Lith^mia Biliousness. When acute the local disturb-\\nances are furred tongue, a bitter taste in the mouth, anorexia, nausea,\\ndisgust at the sight of food, with possible morning vomiting. There\\nis some tenderness in the upper mid-abdomen, and, after eating, weight\\nand f nlness and distress in that region. Flatulency occurs. Symp-\\ntoms of intestinal dyspepsia may arise secondarily. Slight fever or\\nfeverishness may attend the attack. The skin is hot and burning or\\ncold perspirations may break out at irregular times, alternating with\\nflashes of heat. The bowels are constipated, the stools are clay-col-\\nored. The symptoms may be attended by slight obstruction to the\\nducts, causing a moderate degree of jaundice. In some instances the\\nliver is slightly enlarged. The urine is loaded with urates and uric\\nacid. It is scanty and high-colored, and there may be painful mictu-\\nrition. The nervous symptoms are usually those of depression, as head-\\nache, some dulness, or stupor the patient may be unusually drowsy.\\nThe headaches may be the most prominent feature of the attack. They\\nare frontal, attended by slight vertigo, flashes of light or spots before\\nthe eyes, and ringing in the ears.\\nThe same group of symptoms is seen in acute g astro-duodenal catarrh.\\nChronic Lith^mia. In chronic lithwmia the symptoms are varia-\\nble, and are characterized by disturbance of function in nearly all the\\norgans of the body. They have been classically described by Murchi-\\nson, Da Costa, and others, and while the theory is fairly satisfactory\\nto work upon for lines of treatment, the same group of symptoms may\\nbe met with in forms of chronic indigestion, particularly the forms in\\nwhich there is inability to digest sugars and starches. The symptoms\\nare attributed by some to chronic intestinal catarrh.\\nSymptoms. The patients are in ill health and subject to chronic\\nindigestion. They may be under weight or corpulent. The skin is\\nharsh and dry, its nutrition poor. It is subject to erythema or local\\ninflammations, as eczema, may arise. Irregular sweats occur, alter-\\nnating with intervals when the skin is hot and dry. The extremities\\nare cold and clammy, and tingling and numbness are often com-\\nplained of.\\nGastro-intestinal Symptoms. The symptoms are those of chronic\\nindigestion. There is constantly a furred tongue with local dyspeptic\\nsymptoms. The bowels are irregular or constipated sometimes\\nmucus is passed. Flatulency is excessive, both gastric and intestinal.\\nAn icteric tinge may be seen on account of a slight local catarrh of the", "height": "4416", "width": "2644", "jp2-path": "practicaltreatis00muss_0_0939.jp2"}, "940": {"fulltext": "856 SPECIAL DIAGNOSIS.\\nducts, or of hepatic congestion. It recurs at frequent periods, while a\\nsallow complexion is more or less constant.\\nRespiratory Symptoms. The patient is liable to attacks of catarrh\\nof the upper air-passages, and especially to pharyngitis. In lithsemic\\nstates tonsillitis is not uncommon. Chronic pharyngitis is present.\\nOn the other hand, some persons, particularly those over fifty years,\\nhave chronic bronchitis, and attacks of asthma are common. The\\nbronchitis cannot be distinguished from that due to other causes, except\\nby the fact that the subject is lithsemic. Emphysema of the lungs\\ndevelops on account of bronchitis and tissue degeneration.\\nCardiae Symptoms. Palpitation is a constant accompaniment of\\nmany forms of lithsemia in others there may be unduly rapid action\\nof the heart, or, during exacerbations, slowness of the heart s action.\\nIn the later stages pseudo-angina pectoris is of common occurrence.\\nIn the earlier stages pain about the heart or in the left side is fre-\\nquently complained of.\\nNervous Symptoms. Constant headache, worse in the morning, re-\\nlieved toward the end of the day. Some vertigo may be present.\\nDepression of spirits and inaptitude for mental exertion exist. The\\nmemory is dull, the faculties blunted. The patient is subject to back-\\nache, chiefly in the loins. Pain in the right shoulder is of frequent\\noccurrence. In addition, pains along the course of the nerves (neuritis),\\nand myalgias, are of common occurrence. The nerve-trunks may be\\ntender. There is tenderness in the sheaths of the muscles, or at the\\ninsertions of fasciae and tendons. Peripheral nerve-sensations are\\ncommon. Numbness and tingling are frequently complained of.\\nParsesthesise of all forms, variously distributed, are a source of annoy-\\nance. Local sensations of heat or burning alternate with areas of\\ncoldness. Tingling, pricking of needles, and other forms of pares-\\nthesia occur.\\nThe Urine. The urine is high-colored and contains an abundance\\nof uric acid and urates. The amount is scanty, the specific gravity\\nhigh. There may be albumin, small in amount, depending upon the\\nirritation of the urates in their passage through the kidneys. Cylin-\\ndroids are present casts are not common, although at times, when\\nthe uric acid is passed in excess, there may be a secondary nephritis,\\nwith albumin, blood, and casts. As an ultimate result of such condi-\\ntion we may have gallstones, or calculi in the kidneys and bladder.\\nLithsemic patients are subject to attacks of hepatic or renal colic.\\nAs part of the same process or an accompaniment we may have\\ngout or rheumatism. Acute inflammatory rheumatism (rheumatic fever)\\ndoes not belong to this category, but muscular rheumatism, subacute\\ninflammation of the joints with moderate fever, true gout, and gout\\nwith its modifications Avhen seated in the various joints, are the ultimate\\nresults of this process in the patient. Attacks of gout may occur in\\na patient who has not shown any symptoms of lithsemia, but those\\nwho have symptoms of lithsemia are more susceptible to causes which\\nproduce attacks of gout. The gouty and rheumatic manifestations are\\ndue to the deposition of uric acid and urates in tissues which are not\\nhighly vitalized, and in which, therefore, the circulation is sluggish.", "height": "4408", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0940.jp2"}, "941": {"fulltext": "DISEASES OF LIVER, SPLEEN AND PANCREAS. 857\\nLithsemia later assumes the gouty aspect. Tophi are seen in the\\nsituations natural to them. The appearance of the face is character-\\nistic, with capillary congestions and stases. The patients usually be-\\ncome more or less obese and are subject to attacks of glycosuria.\\nEarly in their life degenerations of vessels take place. The kidneys\\nare always under an excessive strain. A good deal of material is not\\ndischarged its effects upon peripheral vessels are such as to cause\\nvasomotor spasm and heightened tension, leading to low-grade inflam-\\nmations, with the development of atheroma. For the same reason\\nchronic interstitial nephritis is set up, and, because of heightened strain\\nin the vascular system, chronic sclerotic valvulitis.\\nFunctional symptoms from disorder of the liver are otherwise not\\nmarked, unless we include a group of cases in which sudden coma and\\nconvulsions take place, presumably because material has been absorbed\\nfrom the gastro-intestinal tract and enters the general circulation\\nthrough the temporary cessation of the function of the liver, the office\\nof which is to destroy the material. Such symptoms may arise in\\norganic disease of the liver, as cirrhosis.\\nSymptoms due to Obstruction of the Channels. (1) Obstruc-\\ntion of the bile-duets, either from disease or external pressure, causes\\njaundice, pain, and fever. The three symptoms may occur singly or\\ncombined. Jaundice may occur alone in obstruction by gallstones\\npain may occur with it or jaundice, pain, and fever may occur\\ntogether rarely, pain or fever may be present alone. Each symptom\\nwill be described later. (2) Obstruction of the blood-channels causes\\ncongestion of the liver, which may be active or passive, or portal ob-\\nstruction. The symptoms of each will be discussed suffice it to say\\nthat here again the symptoms are modified by the process. Thus in\\nportal obstruction from pressure the symptoms are quite different from\\nthose in portal obstruction due to suppurative inflammation of the vein.\\nCongestion of the Liver. In the congestions the liver is enlarged.\\nIf the hyperemia is active, painful distention may be complained of,\\nand the organ may be the seat of some tenderness. There may be, in\\naddition, weight and fulness in the liver-region. Active hyperemia\\nmay follow a chill or suppression of the menses, but more frequently\\noccurs after indiscretions of diet, the free use of alcohol, or stimulating\\nfood, followed by an attack of acute gastro-intestinal catarrh. It is\\nmore common in the tropics, and is due in that climate to suppression\\nof the perspiration. It is recognized by the occurrence of symptoms\\nof acute gastritis with enlargement, pain, and tenderness of the liver.\\nSlight jaundice may attend the attack.\\nPassive congestion is also attended by enlargement of the liver. The\\nenlargement may cause a sense of weight or fulness, but pain is not\\ncomplained of. The organ is not tender, the edges are smooth and\\nindurated. The liver may pulsate. This is detected by placing the\\nhand over the surface of the liver, when, with each impulse of the heart,\\nthe organ can be felt to expand. The symptoms of the cause of the\\npassive congestion combine with those just enumerated as due to en-\\nlargement of the organ. In addition we have symptoms due to obstruc-\\ntion of the flow of blood in the portal circuit.", "height": "4416", "width": "2644", "jp2-path": "practicaltreatis00muss_0_0941.jp2"}, "942": {"fulltext": "858 SPECIAL DIAGNOSIS.\\nPassive congestion occurs in organic heart disease after compensa-\\ntion has failed and the right heart is dilated. The organ rapidly be-\\ncomes congested because of its close proximity to this chamber. In\\nemphysema of the lungs, in fibroid phthisis, in intrathoracic tumors\\npressing upon the vena cava, mechanical congestion also takes place.\\nThe recognition of passive congestion is not difficult. The symptoms\\ndue to enlargement (see Objective Symptoms) and the symptoms due\\nto portal obstruction point to the true nature of the morbid process.\\nPortal Obstruction. Disease of the portal vein or occlusion of its\\nbranches in the liver, obstructs the flow of blood. The diseases of the\\nportal vein are thrombosis, and adhesive and suppurative inflammation.\\nObstruction of the terminal venous radicles in the liver is caused by\\ncirrhosis.\\nThrombosis of the portal vein attends cirrhosis of the liver, or may\\noccur secondarily to pressure upon the vein by a tumor. Disease of\\nthe pancreas was the cause of the pressure in a patient under my\\nobservation. As a result of thrombosis adhesive inflammation of the\\nvein takes place, with or without the establishment of a collateral cir-\\nculation to replace its function.\\nThe symptoms of disease of the trunk of the portal vein are the same\\nas those of obstruction of the terminal branches, and are known as the\\nsymptoms of portal congestion. (See below.) In one respect only do\\nthey differ. While we have ascites in both, in thrombosis of the\\nportal vein it occurs suddenly, and is characterized by rapid recurrence\\nafter tapping.\\nSuppurative inflammation of the portal vein is attended by symptoms\\nresembling pyaemia, and is also called portal pycemia. The inflamma-\\ntion is secondary, and depends upon inflammation in the portal area.\\nIt may follow appendicitis, infectious inflammation of the hemorrhoidal\\nveins, or of the veins anywhere in the gastro-intestinal tract. Pus is\\ncarried into the liver by the portal current. In consequence thereof,\\nmultiple hepatic abscesses arise. Three pathological affections are\\ntherefore seen (1) Suppuration in the portal area (2) inflammation\\nof the vein (3) multiple abscesses of the liver (for the symptoms of\\nwhich see Abscess).\\nOcclusion or overfilling of the branches in the liver occurs in passive\\ncongestion, and most typically in cirrhosis of the liver. The circula-\\ntion in the liver is interfered with the blood is thrown back into the\\nportal vein, and overfills the vessels of the portal area. As a result\\nwe have (1) congestion of the mucous membrane of the stomach and\\nbowels, with the symptoms of gastro-intestinal catarrh. (2) Dilatation\\nof the veins, chiefly the hemorrhoidal, giving rise to hemorrhoids. (3)\\nAscites. (4) Hemorrhages. The hemorrhages may occur in any part\\nof the gastro-intestinal tract. Hsematemesis and intestinal hemor-\\nrhage are seen singly or combined. The vomited blood may be small in\\namount, often with mucus. In some cases large, sometimes fatal, hemor-\\nrhages take place either from the mucous membrane of the stomach or\\nfrom the veins about the oesophagus, which often become varicosed in\\ncirrhosis. Hemorrhages from the intestine may be from enlarged\\nhemorrhoidal veins, from an intestinal ulcer, or from the intact mucous", "height": "4408", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0942.jp2"}, "943": {"fulltext": "DISEASES OF LIVER, SPLEEN AND PANCREAS. 859\\nmembrane. (5) Enlargement of the spleen. (6) Changes due to the\\ncollateral circulation. If complete collateral circulation is established,\\nthe above symptoms may not ensue. The collateral circulation may\\nbe through deep-seated or through superficial veins. If the latter,\\nthe external veins of the abdomen are enlarged. The epigastric and\\nmammary veins become prominent. The veins about the umbilicus\\nmay become so enlarged and prominent as to form a swelling, to\\nwhich the term caput Medusw has been applied. The venules along\\nthe line of attachment of the diaphragm in the lower thoracic zone\\nare overdistended. They may be the seat of pulsation. 1\\nIn consequence of the portal overfilling the enlarged terminal\\nbranches of the vein press upon contiguous structures, interfere with\\nthe circulation of blood in the major vascular system of the liver, and\\ninvite catarrh of the terminal ducts, with obstruction, and hence jaun-\\ndice. This is seen quite frequently in passive congestion of the liver,\\nrarely in cirrhosis.\\nSymptoms due to the Changes in Shape and Size. The liver\\nmay be enlarged, contracted, or irregular. (See Objective Symptoms.)\\nWhen the liver is contracted symptoms of portal obstruction usually\\noccur when enlarged they occur occasionally.\\nThe Data Obtained by Inquiry.\\nA knowledge of etiological factors is of aid in the diagnosis of\\nhepatic affections. In disease of the liver more than in any other\\norgan of the body we find the affection secondary to disease elsewhere.\\nMoreover, diseases of the liver are almost always associated with defi-\\nnite causes, the presence or absence of which is of great diagnostic sig-\\nnificance. In the study of hepatic disease we consider, therefore,\\namong etiological factors, the age, the sex, the habits of life, the\\nclimate, and the presence or absence of disease in other portions of the\\nbody. Primary liver disease is comparatively rare. Secondary liver\\ndisease, on the other hand, is of common occurrence. There are but\\nfew general diseases or states of the system that do not in some way\\ninfluence the liver. The above remarks refer to organic disease. Func-\\ntional disorders of the liver, as previously remarked, are so difficult\\nto separate from functional disorders of the stomach and intestines,\\nthat, practically, from an etiological and clinical stand-point, they go\\nhand-in-hand\\nThe Social History. The Age. Diseases of the liver usually\\noccur late in life, because the causes upon which they depend are oper-\\native only at that period. In a case, therefore, of ill health in a young\\nsubject, when the cause cannot well be determined, the liver is not so\\nlikely to be the seat of disease as in older subjects. Late in life we\\nhave gallstones with their multiple consequences, inflammation, cir-\\nrhosis, and cancer. We may, however, have the congestions and the\\ndegenerations in early life, although not so frequently.\\nThe Sex. The sex is not of much significance from a diagnostic\\nstand-point. Cancer may be more frequent in the female sex, because\\n1 Musser: Trans. Phil. Path. Soc, vol. xi. p. 20.", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0943.jp2"}, "944": {"fulltext": "860 SPECIAL DIAGNOSIS.\\ncancer of the uterus and other organs is more common. Cancer of\\nthe biliary passages is more frequent in females, because in that sex\\ngallstones, which are etiological factors in cancer, are more common.\\nCirrhosis, also, is said to be relatively more frequent in females.\\nThe Habits. It is always necessary to inquire into the habits. Alco-\\nholism points to cirrhosis the excessive use of stimulating foods to\\nhyperemia sedentary habits and the use of starches and fats to gall-\\nstones. The occupation has but little influence in the development of\\nhepatic disease. With regard to the climate, it may be said that in\\ntropical countries hyperemias and abscess of the liver are more fre-\\nquent.\\nThe Family History. But little avails in the study of the family\\nhistory for diagnosis, as most of the morbid processes are secondary\\nto disease elsewhere. This does not apply to biliary calculi, the\\nformation of which appears to be confined to members of special\\nfamilies.\\nPrevious Disease. It is absolutely essential to inquire into this\\nto establish a diagnosis, as liver disease is usually secondary. The\\noccurrence of heart disease or obstructive lung disease points to a con-\\ngestion infectious diseases to cirrhosis when that is not otherwise\\naccounted for dysentery to abscess ulceration or suppuration in the\\nportal area to multiple abscess syphilis to syphilitic diseases tuber-\\nculosis, suppurations, bone disease, and syphilis to amyloid disease\\npyaemia to multiple abscesses tuberculosis to fatty liver.\\nThe Subjective Symptoms.\\nThe subjective symptoms are such as belong to functional disorder\\nof the liver, conspicuous among which are gastro-intestinal symptoms\\nand toxaemia. (See Functional Disturbance and Lithsemia.)\\nPain is a frequent symptom of liver disease. When sudden in\\nonset, acute, and increased by pressure or movement, it is due to peri-\\nhepatitis. Acute paroxysmal pain below the ribs or in the epigastrium\\npoints to gallstones. It may be in the seventh or eighth interspace.\\nPain with distention occurs in congestion. Stabbing or darting pains\\nbelong to cancer. The pain of perihepatitis may attend abscess.\\nPain in the liver must not be confounded with pleurisy. In pneu-\\nmonia there is often congestion of the liver and perhaps perihepatitis.\\nThe associated pain has been mistaken for the pain of hepatic colic.\\nThe Data Obtained by Observation. The Objective Symptoms.\\nTopographical Anatomy. (See Plates XIII., XIV., and XXXV.)\\nThe right lobe of the liver is applied to the concavity formed by the\\nlower lobe of the right lung, being separated from it by the diaphragm.\\nThe thin lower edge of the right lung overlaps the liver at its upper\\npart, but the greater portion of the anterior surface of the right lobe of\\nthe liver is in contact with the ribs. The under surface of the liver\\nis in relation with the stomach, transverse colon, duodenum, right\\nkidney, and right suprarenal capsule. The highest part of its con-", "height": "4412", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0944.jp2"}, "945": {"fulltext": "DISEASES OF LIVER, SPLEEN AND PANCREAS, 861\\nvexity on the right side is about one inch below the nipple, or nearly\\non a level with the external and inferior angle of the pectoralis major.\\nPosteriorly the liver comes to the surface below the base of the right\\nlung, about the level of the tenth dorsal spine. (Holden.)\\nA needle thrust into the right side, between the sixth and seventh\\nribs, would traverse the lung, and then go through the diaphragm at\\nits central attachment, into the liver. The lower border of the liver\\nextends in the median line, one-third of the distance from the tip of\\nthe xiphoid cartilage to the umbilicus. In the right mammary line it\\nextends to the lower border of the ribs and in the mid-axillary line\\nto the tenth rib. The upper border is opposite the upper border of\\nthe sixth rib in the mammary line, and extends horizontally in the\\naxilla to the ninth rib behind.\\nThe attachments of the liver permit of a certain amount of move-\\nment. Hence, the liver can be depressed by deep inspiration, emphy-\\nsema of the lungs, or right pleural effusion. If the patient lie upon\\nhis left side, the left lobe of the liver rises higher and the right ex-\\ntends lower, and vice versa if the patient lie upon the right side, the\\nliver turning upon the suspensory ligament as an axis. (Gerhardt.)\\nInspection. Inspection is not of very great assistance in the diag-\\nnosis of diseases of the liver. Frequently there is a swelling or tumor\\nin the right upper quadrant, which may or may not be produced by\\nan enlargement of the liver, but which should direct attention to that\\norgan. The lower right zone of the thorax may also be distinctly\\nprominent. Such a swelling may be observed in amyloid disease,\\nhydatid tumor, cancer, abscess, and, less frequently, in fatty liver.\\nIn amyloid and fatty livers the projection in the right upper quadrant,\\nwhich may extend to the left beyond the median line, presents a\\nsmooth surface, whereas in hydatid tumor there is frequently a rounded\\nprojection at some part of the prominent area, and, in cancer, several\\nnodules may be large enough to cause slight rounded projections, which\\nthe eye is more apt to detect after the sense of touch has first directed\\nattention to their presence.\\nEnlargement and occasionally pulsation of the superficial abdominal\\nveins are accompaniments of cirrhosis.\\nJaundice. The Symptoms. The color of the skin and of the mucous\\nmembranes in jaundice has been described. (See page 121.) In\\naddition to the yellow discoloration we find 1. Irritations of the\\nskin. Pruritus is common and intense, and may cause great dis-\\ntress. An attack of jaundice may be preceded by general itching.\\nIt occurs in all forms, but is more marked in obstructive jaundice\\nof long duration. Scratch-marks are seen on the surface of the skin,\\nand erythematous eruptions and boils frequently occur. Xanthelasma\\nis a peculiar affection occurring on the tongue, on the skin of the\\neyelids, and about the ears. (See page 92.) 2. Discoloration of the\\nsecretions. All the secretions of the body are changed in color, as\\npreviously described. 3. Bite absent in the feces. The stools are ashy\\nor gray in color. 4. Slowness of the pidse. The heart s action falls to\\n40 or 30 to the minute, or even lower. 5. Hemorrhages. In the later", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0945.jp2"}, "946": {"fulltext": "862 SPECIAL DIAGNOSIS.\\nstages of all forms of jaundice hemorrhages are of common occurrence.\\nIn acute malignant jaundice they are seen underneath the skin, and\\ncome from the mucous membranes. 6. Cerebral symptoms. Irrita-\\nbility and depression of spirits are marked. As the disease advances\\nthe mind grows sluggish the patient is dull, and sleeping most of the\\ntime. Gradually the symptoms of the typhoid state develop. In the\\nacute febrile forms coma and convulsions are of common occurrence.\\nIn the affection known as acute yellow atrophy the cerebral symptoms\\nare marked, and occur soon after the onset of the disease. Within\\nthe first twenty-four hours there may be convulsions, with delirium\\nin the intervals, and subsequently coma.\\nCauses. Jaundice is of two varieties, the hepatogenous and the\\nhematogenous.\\nHepatogenous Jaundice. Jaundice is hepatogenous when there\\nis obstruction of the ducts. The obstruction may take place in the\\nlarge ducts or in the smaller terminal ducts. The obstruction may be\\ndue to disease outside of the ducts to disease of the ducts, or to ob-\\nstruction within the ducts.\\n1. Jaundice from disease outside of the ducts. External pressure.\\nExternal pressure by tumors of the stomach, kidney, pancreas, or\\nomentum by tumors of the liver itself, or enlarged glands in the\\nfissure of the liver by accumulated feces in the colon by an abdom-\\ninal aneurism and by the pregnant uterus, in rare instances, may cause\\njaundice. Jaundice due to disease outside of the duets is gradual in\\nonset, varies in degree with the amount of pressure, and becomes\\nchronic, except in pregnancy and from fecal accumulation it may\\ncause death, or persist until such termination results from the primary\\ndisease. It is recognized by the absence of pain the presence of dis-\\nease in other localities, indicated by its peculiar symptoms and signs\\nthe absence of a history of gallstones and, finally, by the patient s\\nage. Its nature must be inferred from the symptoms and physical\\nsigns of disease in neighboring structures. If the jaundice is due to\\nenlargement of the lymphatic glands, its nature may be inferred from\\nthe presence of primary carcinoma in other organs of the body, or from\\nthe condition of the lymphatic glands in other parts. If they are the\\nseat of malignant disease, it can usually be recognized. Cancer of the\\nliver must be excluded by its symptoms enlargement with jaundice,\\nwith moderate fever, rapid emaciation, and short duration of the dis-\\nease. In the large majority of cases this form of jaundice is due to\\ndisease of the pancreas, particularly carcinoma.\\n2. Jaundice from disease of the ducts themselves. Catarrhal in-\\nflammation, suppurative inflammation, or adhesive inflammation of the\\nducts and cancer or other tumors of the duct cause jaundice.\\nJaundice due to disease of the ducts presents various features. The\\nmost common form is that due to catarrhal inflammation of the ducts.\\nThe jaundice comes on suddenly, at least within forty-eight hours after\\nthe onset of the symptoms there is no pain, but it is attended by\\nvomiting and other symptoms of mild gastritis, and is usually accom-\\npanied by itching. It follows indiscretions in diet, and occurs in\\nyoung subjects. A definite cause for the gastritis can usually be found.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0946.jp2"}, "947": {"fulltext": "DISEASES OF LIVER, SPLEEN AND PANCREAS. 863\\nThe diagnosis is based upon the age, the association of the jaundice\\nwith gastritis, for which a definite cause can often be assigned the\\nabsence of organic heart disease, or any lesion within the body, on\\naccount of which jaundice might arise the moderate degree of jaun-\\ndice, the absence of emaciation and symptoms of portal obstruction,\\nthe occurrence of moderate enlargement without pain. It must not be\\nforgotten that jaundice due to obstruction from gallstones, or to press-\\nure from tumors outside of the duct, is characterized in its onset by\\nsymptoms similar to those just mentioned. It is often necessary to\\nwait before giving an opinion a history of previous attacks of jaun-\\ndice and the age of the patient, over forty years, also lead to caution\\nin the diagnosis.\\nIf the jaundice is due to suppurative inflammation of the duds, cho-\\nlangitis, the infection is usually associated with a previous history of\\ngallstones. It must not be forgotten, however, that other lesions, which\\ncause jaundice, may invite an infectious inflammation of the ducts also,\\nsuch as obstruction by external pressure. The course of the jaundice\\nis chronic. Fever and other symptoms of an infection attend it. In\\nadhesive inflammation there is a history of trauma from gallstones, and\\nthe affection is chronic. In eaneer of the gall-ducts the advent of jaun-\\ndice is slow, the course protracted the symptoms are the symptoms\\nof carcinoma, to which are often added the physical signs of an en-\\nlarged gall-bladder. (See Diseases of the Gall-ducts.)\\n3. Jaundice from obstruction within the ducts. Foreign bodies\\nwithin the ducts, as inspissated mucus, gallstones, or parasites, such as\\nround worms or hydatid cysts, are the common causes of the occlusion\\nof the ducts which may cause jaundice.\\nForeign bodies within the duets cause jaundice by direct obstruction,\\nor by the catarrhal inflammation which their presence excites. The\\nsymptoms occur suddenly in the former instance, gradually in the\\nlatter. The characteristic symptoms of gallstones precede the jaundice.\\nThe patient is usually a woman past forty years, with habits of life\\nwhich predispose to the formation of calculi. Colicky pains occurring\\nin paroxysms, intermittent jaundice varying in intensity, and an inter-\\nmittent fever, point to this form of obstruction.\\nJaundice due to lowering of the blood-pressure in the liver, so that\\nthe tension between the bile-ducts and the blood-passages is altered,\\noccurs suddenly, is light in degree, and is not attended by marked\\nsymptoms it is due usually to shock or emotions.\\nHematogenous Jaundice. Jaundice is hcematogenous or non-\\nobstructive when (1) the function of the liver-cells has been suppressed,\\nas in acute yellow atrophy of the liver (2) when blood-destruction\\nis in excess of the capacity of the liver to remove the product of\\ndestruction the urobilin, as in certain forms of malaria, in perni-\\ncious anaemia, in certain fevers, and other toxaemias. The onset of\\nthe jaundice is rapid, the general symptoms are more pronounced, par-\\nticularly the cerebral symptoms. They occur simultaneously with the\\njaundice. They are infectious, as in acute yellow atrophy of the liver\\nand in Weil s disease. The toxic forms of haematogenous jaundice are\\nnot severe the discoloration of the skin is light yellow, and may not", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0947.jp2"}, "948": {"fulltext": "864 SPECIAL DIAGNOSIS.\\neven be observed by the patient, nor cause pronounced symptoms.\\nThe blood is destroyed rapidly in these cases, and, as it cannot be\\ndisposed of by the liver, spleen, or kidneys, the transformed haemo-\\nglobin is deposited in the tissues. In this class of cases the urine\\ncontains but little bile-pigment, but there is a large amount of urobilin\\nand indican. The stools are not clay-colored.\\nMalignant or Infectious Jaundice. Acute Yellow Atrophy of the\\nLiver. Acute diffuse inflammation of the liver, with necrosis of the\\ncells, characterized by jaundice and cholsemia. Many of the cases\\noccur during pregnancy. It is most common prior to the thirtieth\\nyear. It is said to follow fright. The symptoms are local and gen-\\neral. Jaundice is at first noticed after an attack of gastroduodenal\\ncatarrh. It is light, occasionally extends over the entire body, and is\\nnot usually attended by itching. After a continuance of these mild\\nsymptoms for from two days to two weeks, the patient complains of\\nheadache delirium sets in with stupor and convulsions. The headache\\nis attended with vomiting. Fever of moderate degree begins at the same\\ntime, although in some cases it is absent.\\nAlthough the jaundice is not intense, the effects upon the blood are\\nearly seen hemorrhages underneath the skin and from the mucous\\nmembrane take place. In pregnant women abortion follows, the hem-\\norrhage from which may be very excessive. The stupor and delirium\\nare followed by coma, and death takes place in the first week or coma\\nmay be preceded by the typhoid state, and the disease lasts longer\\nthan a week. The urine is bile-stained, and contains albumin and.\\ncasts. It diminishes in amount, and is soon passed involuntarily.\\nLencin and tyrosin are always present. The latter may be seen in the\\nsediment, although it is more marked when a few drops are evaporated\\non a cover-glass. The bowels are loose and the stools involuntary and\\nclay colored.\\nOn examination the liver is found to be diminished in size this\\nmay not be appreciated by percussion in the anterior region, but in the\\naxillary region the width is reduced one to two inches. There may\\nbe some tenderness over the liver and over the ducts.\\nDiagnosis. The data upon which a diagnosis is based are the age,\\nsex, pregnancy, the rapidity of onset of cerebral symptoms following\\njaundice, diminution in the size of the liver, with leucin and tyrosin\\nin the urine. It must be distinguished from the jaundice of hyper-\\ntrophic cirrhosis of the liver, which at times becomes malignant. Some\\nobservers have thought that acute yellow atrophy may supervene upon\\nthis form of cirrhosis, thereby causing malignant jaundice but there\\nis more fever than in atrophy, while leucin and tyrosin are not found\\nin the urine. It must not be forgotten that all cases of jaundice may\\nterminate suddenly with delirium, followed by coma, or by the develop-\\nment of the typhoid state.\\nIn phospl torus-poisoning the hemorrhages, the jaundice, and diminu-\\ntion in the size of the liver are the same as in acute yellow atrophy.\\nGastric symptoms are more marked, and leucin and tyrosin are not\\npresent in the urine.", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_0948.jp2"}, "949": {"fulltext": "DISEASES OF LIVER, SPLEEN AND PANCREAS. 865\\nWeil s Disease. This infection, in which jaundice is the chief\\nsymptom, is considered in the chapter on Infectious Diseases.\\nYellow Fever. The account of the jaundice attending this infec-\\ntion is found in the chapter on Infectious Diseases.\\nInfantile Jaundice. Jaundice in infants is due to two causes\\nFirst, congenital obliteration of the ducts and, second, catarrhal in-\\nflammation. It must not be confounded with the yellow discoloration\\nof the skin, due to the excess of coloring-matter in the blood, which is\\nnot disposed of by the liver.\\nIn congenital obliteration of the gall-ducts jaundice rapidly ensues\\nand deepens to an intense degree hemorrhages occur, the child be-\\ncomes stupid or comatose, may have convulsions, and death takes place\\nin coma. There is rapid emaciation, and the liver and spleen are en-\\nlarged. The child may live many months.\\nSimple catarrhal jaundice in infants is associated with moderate\\ngastric disorder. The jaundice is light the conjunctiva? alone may\\nbe discolored. In infants malignant or infectious jaundice may be\\ndue to inflammation of the portal veins, secondary to umbilical phleb-\\nitis. The jaundice develops after suppurative inflammation about the\\numbilicus, and is attended by fever. There may be some tenderness over\\nthe liver frequently peritonitis develops at the same time. Pysemic\\nsymptoms may set in, and pus may be found in other situations. If\\ndeath does not ensue early the jaundice becomes more pronounced and\\ncauses cutaneous and mucous hemorrhages. Convulsions and coma\\nare apt to supervene before death. Jaundice in infants also occurs in\\ninterstitial hepatitis of syphilitic origin. The evidences of hereditary\\nsyphilis are seen in the skin and mucous membranes. The liver is\\nenlarged, and there may be tenderness from perihepatitis.\\nFever. Hepatic Fever. The occurrence of fever may be of diag-\\nnostic importance in distinguishing the various forms of obstructive\\njaundice. Fever occurs frequently in jaundice but is significant in cer-\\ntain forms only. In catarrhal jaundice it is present for three or four\\ndays only, disappearing as the severe gastric symptoms subside. It is\\nprobably toxic. In hepatic colic, with jaundice, it is transitory and\\nassociated with chills and sweats. In jaundice from obstruction it\\noccurs when an infectious cholangitis, primary or secondary, arises.\\nA peculiar type known as intermittent hepatic fever (see page 202) is\\noften seen. The intermittent fever is associated with gallstones in the\\nfollowing groups First, with each paroxysm of hepatic colic moder-\\nate fever and jaundice are present. The latter becomes more intense\\nafter each paroxysm, but disappears in a short time. The paroxysmal\\nattacks may recur at intervals for years. Second, the hepatic colic is\\nattended by distinct ague-like paroxysms of chill, fever, and sweat,\\nafter each of which the jaundice, which continues to the end, is more\\nintense. Third, hepatic colic and gastric disturbance occur with fever,\\nbut without jaundice. The symptoms occur in distinct paroxysms.\\nGallstones are probably the cause in all these conditions, leading in\\nsome cases to chronic obstruction of the duct without infection.\\nIf an infectious cholangitis, with or without gallstones, is present, the\\nsymptoms are somewhat different, although the fever is of the same\\n55", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0949.jp2"}, "950": {"fulltext": "SQ6 SPECIAL DIAGNOSIS.\\ntype. Thus (1) there is more tenderness in the hepatic region, with\\nenlargement of the gall-bladder (2) the paroxysms are more frequent\\n(3) jaundice is not so intense and not influenced by paroxysms (4)\\nthe patient is ill in the intervals, and there is wasting. There are no\\nperiods of improvement locally or in the general condition. The most\\nimportant point in cases of gallstone is the subsidence of all symptoms\\nbetween the paroxysm of fever.\\nIntermitting fever of this character must be distinguished from\\nmalaria. The history of gallstones, with pain in the region of the\\nliver, and the negative appearance of the blood, are sufficient to estab-\\nlish the diagnosis.\\nHepatic fever also occurs in cancer when the neoplasms grow rapidly,\\nin certain forms of cirrhosis, and in obstruction from other causes than\\ngallstones. It is particularly common in suppurative inflammation of\\nhydatid cysts, or after they rupture and discharge into the biliary\\nvessels. Without previous knowledge of the hydatid cyst the diagno-\\nsis is almost impossible, save that the pain is less when the obstruction\\nis due to this cause than in obstruction from the passage of gallstones.\\nPalpation. By palpation the lower border of the liver can be de-\\ntermined in thin subjects, or in those in whom the liver is greatly\\nenlarged. It may be difficult to determine the border when the abdo-\\nmen is distended on account of flatulency. Careful palpation must be\\nmade with the tips of the fingers, pressing them firmly inward along\\nthe margin of the ribs, at the same time securing relaxation of the\\nabdominal muscles by having the patient take a full breath, and\\nhaving the legs drawn up and the shoulders elevated. The pressure\\nshould be made in the intervals following the act of inspiration. By\\ncare and patience the fingers can be pushed deeply inward and be\\nmade to feel the border of the liver, even in health. Care must be\\ntaken not to cause contraction of the right rectus muscle, for if this\\ntakes place the indurated mass may simulate tumor or enlargement of\\nthe liver. The left lobe of the liver, below the ensiform cartilage,\\nextends half-way to the umbilicus. Here it is most accessible to pal-\\npation. By palpation we also determine the size of the gall-bladder\\nand the degree of movement of the liver in respiration. On full in-\\nspiration the liver descends, and during the act of expiration rises\\nagain. This movability is of service in distinguishing the liver from\\nother organs that are fixed within the abdomen.\\nIn amyloid disease the lower edge is smooth, rounded, the tissue\\ndense and unyielding to pressure, and the anterior surface perfectly\\nsmooth, as a rule but when the liver is also cirrhotic or syphilitic the\\nsurface may be irregular and fissured. 1\\nThe fatty liver has also a rounded smooth border, but its tissue is not so\\ndense and resistant, except when cirrhosis coexists. Its surface is smooth.\\nIn single abscess the liver is enlarged, but not uniformly, and not\\ninvariably. If the abscess is located in the right lobe, and nearer the\\nanterior than the posterior surface, palpation may be able to detect not\\nonly enlargement, but also deep-seated obscure fluctuation, surrounded\\n1 See Mu^ser Amyloid Disease of Liver, Penna. State Medical Journal, 1899.", "height": "4416", "width": "2640", "jp2-path": "practicaltreatis00muss_0_0950.jp2"}, "951": {"fulltext": "DISEASES OF LIVER, SPLEEN AND PANCREAS. 867\\nby a zone of hard tissue. The tumor is round, smooth, tense, tender,\\nand painful.\\nIn multiple abscesses the liver is enlarged uniformly, and usually\\nnone of the abscesses are large enough to be felt as a distinct promi-\\nnence. The liver is tender and painful.\\nIn hydatid tumor the degree of enlargement depends very much\\nupon the situation of the cyst, upon its stage of development, and upon\\nthe activity of the echinococci. Sometimes the cyst is so small that\\nits existence remains unsuspected at other times the enlargement is\\nso great as to fill the abdominal cavity. As in abscess, the possibility\\nof detecting the tense, globular, fluctuating, painless tumor character-\\nistic of the disease depends upon its situation. If it is on the anterior\\nsurface or lower border, it is easily detected, especially if the tumor is\\nat all large but if it projects from the posterior surface or from the\\nupper or lateral borders, detection is difficult, and may be impossible.\\nIn congestion of the liver the enlargement is not so great as in ab-\\nscess, nor are pain and tenderness so pronounced. Moreover, the\\nenlargement is usually not permanent. The lower border, if it pro-\\njects below the edge of the ribs, is smooth.\\nIn hypertrophic cirrhosis the enlargement is moderate, the surface\\nsmooth, or but slightly roughened, denser than normal, and somewhat\\ntender.\\nIn cancer the enlargement resembles that of single abscess and\\nhydatid tumor in that it is irregular. But, unlike hydatid tumor, the\\nirregularities are due to knobs or bosses which project from the sur-\\nface of the liver, are usually entirely free from any fluctuation, and are\\ntender on palpation. There may be a single large mass, or a number\\nof knobs or nodules. The part projecting below the ribs may be free\\nfrom any nodules.\\nPalpation of the liver may discover a friction from perihepatitis, and\\npain or tenderness from that cause, or from cancer or abscess. Pidsa-\\ntion of the liver may be a transmitted impulse from the abdominal\\naorta or a venous pulse, such as occurs also in the jugulars, from tri-\\ncuspid regurgitation.\\nFloating liver is diagnosticated by feeling in the lower, most fre-\\nquently the right portion of the belly, a large tumor, which may, how-\\never, easily be confounded with tumors of other organs. It can be\\ndistinguished as liver (1) By recognizing the notch (2) by the pres-\\nence of a tympanitic note in the proper region of the liver, as loops of\\nintestine lie between the diaphragm and liver (3) by the excessive\\nmovability of the tumor and (4) by the fact that it is possible to re-\\nplace the liver (5) by its size and consistency. It occurs almost\\nexclusively in women, possibly as the result of a congenital lengthen-\\ning of the suspensory ligament, although more likely from relaxed\\nabdominal walls. It may be confounded with ovarian cyst, appendi-\\ncitis with tumor, and movable right kidney with hydronephrosis.\\nConstriction of the liver from tight lacing (Schnurleber) occurs chiefly\\nin women. Tight corsets, and, still more, tight waist-straps or bands,\\nsqueeze the liver downward, especially the right lobe, so that it can be\\npalpated. In more pronounced cases a furrow, often palpable, is pro-", "height": "4396", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0951.jp2"}, "952": {"fulltext": "868 SPECIAL DIAGNOSIS.\\nduced, and, below this, a constricted lobe which may extend as far\\ndown as the anterior superior spine of the ilium and cany the gall-\\nbladder with it. In other instances, the right lobe is elongated, ex-\\ntending even to the crest of the ilium. 1\\nLobes so depressed are usually thin and easily movable, and can be\\ngrasped with the hand and moved to and fro. If the lobe does not\\nreach so far downward, it is more rounded and blunt in shape. It is\\nnot always easy to demonstrate its connection with the liver, because\\ncoils of intestine lying over the liver in the furrow make palpation diffi-\\ncult, and cause a tympanitic note between the liver-dulness and the\\ndulness of the constricted lobe.\\nConfusion with tumors of other kinds can be avoided usually by\\ndeep palpation or percussion.\\nGall-bladder. When the gall-bladder has a certain degree of\\nfulness, it may, according to Gerhardt, be not only felt in healthy\\npersons, if the stomach and bowel are empty, as a smooth, round, fluc-\\ntuating tumor at the lower border of the liver, but be even visible and\\nbe outlined by percussion. If a line is drawn from the right acromion\\nprocess to the umbilicus, it will bisect the gall-bladder at a point where\\nit passes over the margin of the ribs. The fundus is situated below\\nthe edge of the liver, at about the ninth costal cartilage, just outside\\nthe edge of the right rectus muscle. Palpation is easy when, owing\\nto closure of the cystic duct, the gall-bladder is distended with bile or\\nwith inflammatory exudate, or enlarged by thickening of its walls or\\nby an accumulation of gallstones. A pear-shaped tumor is then felt\\nwhich, if not adherent to the border of the liver, is movable with it.\\nIn simple stasis, hydrops vesica? fellese, and purulent inflammation\\nthe tumor is tense and elastic in inflammatory or carcinomatous\\nthickening of the wall, dense and irregular. Calculi can often be recog-\\nnized by the form or hardness or by the sound made by rubbing them\\ntogether.\\nAspiration. We are warranted in determining the nature of an\\nobscure enlargement of the liver or of the gall-bladder by aspiration.\\nIn abscess, pus in hydatid disease, the characteristic fluid, may be\\nwithdrawn.\\nIn a case of local enlargement the apex of the swelling should be\\naspirated. If aspiration is performed near the upper border, the\\nneedle should be thrust downward if near the lower border, upward.\\nThe left lobe should be aspirated with care, in order that the stomach\\nbe not pierced. (See Aspiration in Diagnosis.)\\nAuscultation. By auscultation we may detect a friction-sound in\\nperihepatitis a grating or rubbing when the gall-bladder contains cal-\\nculi if it is palpated a continuous murmur in tricuspid regurgitation.\\nPercussion. The Size and Shape of the Liver. (See Plate\\nXVL, Fig. 1.) Diminution in size can only be recognized by per-\\ncussion. The normal extent of hepatic dulness is diminished. This\\n1 Musser Transactions Philadelphia Pathological Society, vol. x.", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0952.jp2"}, "953": {"fulltext": "DISEASES OF LIVER, SPLEEN AND PANCREAS. 869\\nis usually more marked in the anterior and lateral regions. The\\ndiminution is due to simple or acute yellow atrophy of the liver or\\ncirrhosis. It must not be confounded with the apparent diminution\\nthat takes place in emphysema, or that which occurs from distention\\nof the bowels with flatus, as in peritonitis. Absence of hepatic dulness\\nmay occur when there is gas in the peritoneal cavity. When there is\\nconsiderable distention of the intestines by gas, the anterior and lateral\\nhepatic areas may be tympanitic.\\nEnlargement of the liver is determined by inspection, palpation, and\\npercussion. By percussion the size of the liver is accurately made out.\\nAny marked increase of hepatic dulness beyond the normal limits (see\\np. 861) usually means increase in size of the liver. Both superficial\\nand deep percussion most be performed. Palpatory percussion is of\\ngreat advantage.\\nThe upper border is determined by percussing from a point above\\nthe liver-area toward the liver anteriorly from the third interspace\\ndownward, laterally from the fourth, and posteriorly from the angle of\\nthe scapula. In health the upper border of the liver is found at the\\nfifth interspace in the axilla, at the sixth and in the back, at the\\nninth interspace. Thence downward hepatic dulness should continue\\nto the margin of the ribs. It falls short of this position by at least\\nan inch in the aged, and in deep-chested persons it may not be more\\nthan two inches in width in front. The width of the liver-dulness in\\nthe right mid-clavicular line is about four inches, in the mid-axillary\\nline six inches, and in the mid-scapular line three inches.\\nExtent and direction of enlargement. The entire liver may be en-\\nlarged and of normal shape, or its outline may be irregular again, the\\nenlargement may be limited to one lobe. Hence, the area of dulness\\nmay be increased in all directions, or the increase may be above or\\nbelow the normal limit, if the normal shape is preserved. By percus-\\nsion it may be found that the enlargement is regular from increase in\\nsize upward or downward, or increase in the area of dulness in both\\ndirections. On the other hand, if the enlargement is irregular, the\\nliver-dulness may begin higher in the anterior region than in the axil-\\nlary region, or may extend beyond the margin of the ribs in a limited\\narea. When the enlargement is limited to the left lobe it is revealed\\nby increase in the dulness from the xiphoid cartilage downward as far\\nas the umbilicus. The entire middle region to the navel may be filled\\nup by the enlarged liver.\\nUniform enlargement of the liver is due to congestion, hypertrophic cir-\\nrhosis, fatty degeneration, amyloid disease, leukaemia, cancer, and some-\\ntimes to hydatid disease and abscess. Enlargement of one lobe of the liver\\nis due to hydatid disease, to abscess, or to cancer, in nearly all cases.\\nEither the right or the left lobe may be the seat of such enlargement.\\nEnlargement in one direction is due also to the three conditions just\\nindicated. Although in abscess or hydatid disease enlargement down-\\nward is the more common one, it may be directly upward, the lower\\nborder of the liver occupying the normal position. When enlargement\\nof the liver extends upward it is due to a cyst, or an abscess in the\\nconvex surface of the right lobe.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0953.jp2"}, "954": {"fulltext": "870 SPECIAL DIAGNOSIS.\\nIrregularity in the shape of the liver-dulness occurs in cancer, in\\nabscess, and hydatid disease. Notwithstanding the apparent irregu-\\nlarity, enlargements of the liver conform to its usual outline, with but\\nmoderate variations, and always occupy the normal site of the organ.\\nDiagnosis. Enlargement of the liver must be distinguished from\\nenlargement of organs in contiguity with the liver, and from structures\\nusually containing air, which have become solid or non-resonant. The\\nenlargement must, therefore, be distinguished from pleural effusion,\\nfrom disease of the lungs which causes dulness on percussion, or from\\ndisease of the abdominal organs causing increased dulness near the\\nhepatic region. Hence, in renal tumors, in tumors of the large intes-\\ntine or stomach, in ovarian tumors, in tumors due to accumulation of\\nfeces, the physical signs on percussion may simulate enlargement of\\nthe liver.\\nSimulated Enlargement. It is well to bear in mind the conditions\\nwhich simulate enlargement of the liver. Of these we have\\n1. Congenital malformation the liver may be of abnormal shape,\\non account of which the area of dulness will be increased in a particu-\\nlar direction. It may be quadrangular or rounded. The liver may\\nbe found in the right pleural sac in congenital diaphragmatic hernia.\\nThe increase of dulness upward will simulate enlargement of the liver.\\nCongenital malformations may be suspected in the absence of any\\nsymptoms of hepatic disease, or of conditions which may cause other\\nforms of spurious enlargement. Moreover, the increased dulness will\\nhave existed from early life.\\n2. In rhachitis, on account of the malformation of the chest, the\\nposition of the liver may be such that its area will be increased. For\\nthe same reason the liver may be felt below the margin of the ribs.\\n3. Disease of the spinal column causes dislocation, on account of\\nwhich the liver may apparently be increased in size.\\n4. Enlargement of the liver must be distinguished from pleural\\neffusions. This is sometimes difficult. The symptoms of the pulmo-\\nnary affection must be considered. The general conditions which\\ncause hydrothorax must be borne in mind. The difficulty in distin-\\nguishing the two arises because the dulness of each is continuous. In\\npleural effusion, however, there is uniform bulging of the affected side.\\nThe liver is not movable, the chest-expansion is lessened. The upper\\nborder of dulness of the fluid may be movable if the effusion is not\\nlarge, while the line of dulness is S-shaped that is, high behind and\\nhigh in front. If the effusion is large, the upper limit of dulness is\\nhorizontal. The upper limit of dulness in the pleural effusion changes\\nits position in many instances. In enlargement of the liver the lower\\nribs are often everted, but in pleural effusion a depression may be seen\\nbetween the lower margin of the ribs and the upper surface of the\\nliver, if the latter is dislocated by pressure of the fluid. Sometimes\\nenlargements of the liver give rise to secondaiy pleural effusion, so\\nthat too often, after finding pleural effusion, the size of the liver is not\\nestimated.\\n5. Pericardial effusion and dilated heart are said to simulate enlarge-\\nment of the liver. The history of the case, the origin and mode of", "height": "4416", "width": "2656", "jp2-path": "practicaltreatis00muss_0_0954.jp2"}, "955": {"fulltext": "DISEASES OF LIVER, SPLEEN AND PANCREAS. 871\\ndevelopment of the symptoms, the physical signs of cardiac disease,\\npoint to its true nature.\\n6. Enlargement of the liver may be due apparently to subdiaphrag-\\nmatic abscess. The history of the case is generally essential to a diag-\\nnosis. The accumulation between the liver and diaphragm causes the\\nlatter to be pushed downward. It is very difficult to distinguish the\\nspurious from the false enlargement in these instances. Aspiration\\nmay help in the diagnosis.\\n7. Abnormal Condition of the Abdominal Parietes. Increased ten-\\nsion or spasm of the recti muscles, giving rise to phantom tumors of\\nthe abdomen, simulate enlargement of the liver. They occur in young\\ngirls, and are associated with gastro-intestinal catarrh and symptoms\\nof hysteria. Ansesthesia must often be employed to disperse the\\nswelling.\\n8. Tight Lacing. This may displace the liver upward or downward,\\naccording to the direction of the pressure. It may also, by exerting\\nlateral compression, bring more of the liver into contact with the ante-\\nrior abdominal wall. And finally, if the constriction has been by a\\nstrap or tight cord, a portion of the liver may be more or less detached\\nand appear as a movable tumor.\\n9. Some enlargements of the abdominal contents cause spurious en-\\nlargement of the liver. In the same way increased abdominal pressure\\n(ascites, tympanites, etc.) causes the liver to rise higher than normal.\\na. The accumulation of feces in the colon. This causes continuance\\nof liver-dulness downward, on account of which it may be thought\\nthat the patient has liver disease. A purgative must be given.\\nb. An ovarian cyst.\\nc. The presence of ascites. Exclusion of the latter is sometimes\\ndifficult, because the ascites may be loculated and situated in the hepatic\\nregion. It may give rise to symptoms of hepatic enlargement. Prob-\\nably aspiration alone can establish the diagnosis. Ordinary ascites\\nshould be easily distinguished by the physical signs and the result of\\nexploratory puncture.\\nd. Tumors of the omentum, chiefly tuberculous, may occupy such\\nrelation to the liver as to increase the dulness downward. The history,\\nthe occurrence of the omental tumor, with symptoms of tuberculosis,\\nmay aid in determining the true condition.\\ne. In tumors of the kidney, which simulate enlarged liver, it is\\nfound that the edge of the liver cannot well be felt, but Murchison\\nthinks the fingers can usually be inserted between the ribs and the\\nupper part of the renal tumor. The renal tumor, however, is not\\nfixed. It is rounded on every side it has the shape of a kidney.\\nIt may be associated with changes in the urine.\\nEnlargements of the liver must be distinguished from pancreatic\\ncyst, or effusion in the lesser peritoneal cavity. This can usually be\\naccomplished with ease, except in hydatid disease of the left lobe near\\nthe suspensory ligament. In effusion in the lesser peritoneal cavity\\nthe tumor occupies the left upper quadrant, and may extend as low as\\nthe transverse umbilical line. It causes dislocation of the heart, so\\nthat the apex is as high as the third interspace, and beyond the mid-", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0955.jp2"}, "956": {"fulltext": "872 SPECIAL DIAGNOSIS.\\nclavicular line. It is accompanied by an increase in the dulness pos-\\nteriorly, so that the upper limit may extend to the angle of the left\\nscapula. Puncture may furnish the necessary information.\\nThe presence or absence of pain may sometimes furnish a clue to\\nthe nature of the enlargement of the liver. Murchison considers this\\na reliable distinction. Painless enlargements of the liver are due to\\npassive congestion, to hydatid disease, to fatty and amyloid disease of\\nthe liver. Painful enlargements of the liver are seen in abscess, cancer,\\nand syphilitic disease, with perihepatitis.\\nIn children the lower border of the liver is normally lower than in\\nadults, because the liver is itself proportionately larger. For the same\\nreason the upper border is at a higher level.\\nEnlargement of the Liver. Enlargement of the liver occurs\\nin the congestions the acute inflammations, except acute yellow atrophy\\nthe chronic inflammations, except cirrhosis the degenerations, the\\nmorbid growths, and in hydatid disease. The physical signs have been\\nconsidered seriatim in the pages immediately preceding. It must be\\nremembered that the disease may occur without great changes in the\\nsize of the liver. The congestions have been considered in the previous\\npages.\\nThe remaining diseases of the liver will be considered in accordance\\nwith their pathological classification. After the congestions, we have\\nthe inflammations, then the morbid growths, then the degenerations,\\nand, finally, hydatid disease.\\nAbscess of the Liver.\\nTwo forms are seen tropical abscess, so-called, in which one or two\\nabscesses are found and multiple abscesses, found throughout the\\nliver-structure. The single or solitary abscess usually occurs in the\\ncourse of dysentery, and, in all probability, in the amoebic form only.\\nA single abscess may also be due to traumatism, particularly in chil-\\ndren. Multiple abscesses occur secondarily to inflammation somewhere\\nin the portal area. Inflammation and abscess about the rectum, in-\\nflammation of the appendix, ulceration anywhere in the gastrointesti-\\nnal tract may be followed by multiple hepatic abscesses. The abscesses,\\nhowever, do not occur directly by means of emboli, as in the case of\\namoebic abscess, but after inflammation of the portal vein or suppura-\\ntive pylephlebitis. Multiple abscesses of the liver also follow obstruc-\\ntion and infectious inflammation of the biliary passages {suppurative\\ncholangitis).\\nTropical abscess or amoebic abscess varies in its clinical course. In\\na typical case the clinical picture is that of the general symptoms of\\nsuppuration setting in in the course of, or soon after, an exacerbation\\nof amoebic dysentery, with local symptoms referred to the liver.\\nSymptoms. The general symptoms are those of intermittent fever,\\nparoxysms of which may occur daily or only every second day, attended\\nby chill, fever, and sweat. The fever may be remittent or continuous.\\nThe complexion in tropical abscess of the liver is peculiar, as all\\nwriters upon tropical disease agree. The skin is sallow, 1 he complex-", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0956.jp2"}, "957": {"fulltext": "", "height": "4396", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0957.jp2"}, "958": {"fulltext": "PLATE XL.\\nOedema J\u00c2\u00a7\\nTender- fj\\nness 1\\nAbscess of the Livei\\nfiq. 2.\\nr\\n,i\\nM^v Mft^JI\\nHypertrophic Cirrhosis of the Liver with Enlargement\\nof the Spleen.", "height": "4408", "width": "2624", "jp2-path": "practicaltreatis00muss_0_0958.jp2"}, "959": {"fulltext": "DISEASES OF LIVER, SPLEEN AND PANCREAS.\\n873\\nion muddy, the face pale. Through this a slightly icteroid tint may\\nbe seen, and the conjunctivae are bile-tinged. Distinct jaundice is rare.\\nThe local symptoms. Pain in the region of the liver this may be\\nreferred to the region of the right or left lobe. It may be seated in\\nthe fifth or sixth interspaces anteriorly, or behind at the ninth and\\ntenth ribs. There may be pain in the right shoulder. The pain may\\nbe paroxysmal, or it may be intense and persistent.\\nThe patient complains of weight and fulness in the region of the\\nliver the enlargement causes some dyspnoea, and may cause cough\\nand some vomiting.\\nFig. 201.\\no_ M E M E M\\nE M E M E M E\\nM E t\\n/I E M\\nM IE M E M\\nE M E M E\\nM E\\nM E\\n\u00e2\u0080\u009e\u00e2\u0080\u009e_o\\nt\\n4\\nIO4\\n|i|\\n7TT T\\n41 I\\n_\\nT/-n\u00c2\u00b0\\n7\\n-1-\\nII r\\nT\\n4t\\nu 1t\\n_l~\\nL4 31\\n4\\nI\\nn\\n4-\\n-J\\nr _\\n101I- i. H\\n4\\n--3\\nT_ D\\n4 -7\\nTk-J\\nt-\\n4 t-\\nv4\\nIff\\n^_iz\\nt- U4\\nit\\nr-\\nII\\nt tt:\\nt- tt\\nT -t\\n-ft t\\nC +7\\nTon t- II\\n-t\\n4.\\nJ-V-- t\\n4 3\u00c2\u00a3\\n100 f- +f-\\nf\\nt4 tt\\n4\\nt\\nr\\np 4- it\\nt t\\nI\\nX\\n-f\\n99 :i :f\\ni\\ni\\nt\\n_-\u00c2\u00a3\\n-J -i\\nt\\nJ t\\n\u00e2\u0080\u009eo\\nI\\n98\\nt 4\\nt\\nt\\nIntermittent fever in abscess of the liver.\\nPhysical Examination. (Plate XL., Fig. 1.) The liver is enlarged.\\nThe enlargement may be uniform if the abscess is central, the entire\\norgan takes part in the swelling on the other hand, it may be an\\nenlargement upward in the anterior, the axillary, or the posterior region.\\nIf the convex surface of the right lobe of the liver is affected, the en-\\nlargement is usually upward. If the lower portion of the right lobe is\\naffected, enlargement extends downward, and the lobe of the liver can\\nreadily be detected on palpation. The mass may extend outward from\\nthe liver-edge. At first it is hard ultimately it softens and may fluctu-\\nate. If the abscess is limited to the left lobe of the liver, and is situ-\\nated about the suspensory ligament, the enlargement may be seen\\nbelow the xiphoid cartilage. It may extend to the umbilicus and\\nproject forward. Sometimes it may be so large as to cause eversion of\\nthe ribs of each side, and render the entire epigastrium unusually", "height": "4416", "width": "2640", "jp2-path": "practicaltreatis00muss_0_0959.jp2"}, "960": {"fulltext": "874 SPECIAL DIAGNOSIS.\\nprominent. The surface may become reddened. Over the tumor\\nthere is tenderness on palpation, and there may be, as in other situa-\\ntions, fluctuation. (Edema of the surface is frequently seen.\\nThe irregular enlargement above mentioned is made out by percus-\\nsion. The enlargement may be difficult to ascertain, on account of\\nsecondary pleural effusion, or secondary pleural inflammation, with the\\ndevelopment of a hepato-pulmonary fistula, causing dulness posteriorly.\\nIf the case has been seen from the first, a friction-sound may be heard,\\nfollowed by the physical signs of effusion.\\nThe appetite is lost, and nausea at the sight of food is pronounced.\\nThe condition of the bowels may vary with the state of the intestinal\\ntract at the time of the hepatic complication. The dysenteric symp-\\ntoms may subside entirely or they may continue. Often there is only\\nconstipation, with the passage of mucus and hardened feces. In an\\nobscure case the study of the stools should be made. The detection\\nof amoebae in the mucus or in the feces may point to the true conclusion.\\nAtypical cases are characterized by the absence of general symptoms,\\nor the absence of local signs. Fever may be absent entirely, exhaus-\\ntion alone being present, which could probably be ascribed to the pre-\\nvious dysentery. Pronounced anaemia due to the dysentery may be\\nassociated, and even be the most marked symptom, as well as inflam-\\nmation of the joints, or neuritis. In a case under my care the only\\nsymptom for a long time, with the exception of anaemia and loss of\\nappetite, was severe pain in the sixth interspace. In other instances\\nthere are no liver-symptoms whatsoever. General symptoms of infec-\\ntion, or an irregular, or even a continued fever, the cause of which\\ncannot be ascertained, may alone be present. In one of my cases\\nthere was moderate continued fever, with loss of appetite and dyspeptic\\nsymptoms. There was no diarrhoea. No cause could be given for\\nthe fever, although it was noted that there was slight enlargement of\\nthe liver. The patient slipped out of the ward and went down to the\\nyard to smoke on his return he was seized with an intestinal hemor-\\nrhage which could not be checked and which resulted fatally. At the\\nautopsy a large abscess of the liver was found, and there was ulceration\\nof the rectum from which the intestinal hemorrhage took place.\\nThe diagnosis is usually not difficult in the typical cases. Under\\nall circumstances attention must be paid to the facts bearing upon the\\netiology and the association of general and local symptoms. If the\\ngeneral symptoms of suppuration are present, malarial abscess may be\\nmistaken for an intermittent fever. The result of an examination of\\nthe blood and of treatment by quinine Avould establish a diagnosis of\\nmalarial fever. It is difficult sometimes to determine whether the\\nabscess is in the abdominal wall or in the liver proper, or whether it\\nis situated beneath the diaphragm. If the liver is movable with respi-\\nration, the two former conditions may be excluded. An abscess in the\\nabdominal wall is not influenced by respiration, and in subdiaphrag-\\nmatic abscess the movement is impaired. Suppuration of a hydatid cyst\\ncannot be distinguished unless it has been known beforehand that a\\nsimple hydatid was present in the liver. Under such circumstances,\\nif suppuration occurs, it is likely to be confined to the cyst. Abscess", "height": "4408", "width": "2624", "jp2-path": "practicaltreatis00muss_0_0960.jp2"}, "961": {"fulltext": "DISEASES OF LIVER, SPLEEN AND PANCREAS. 875\\nof the liver must be distinguished from gallstones, attended by inter-\\nmitting fever without suppuration. While the distinction is difficult\\nin many cases, yet the history of the case, the association of jaundice\\nwhich deepens after each paroxysm, and the good general nutrition of\\nthe patient point to gallstones. Abscess of the liver is of shorter dura-\\ntion than cholelithiasis, and its primary cause can usually be ascer-\\ntained by examination of the rectum or the discovery of suppuration\\nin other parts of the body.\\nExploratory puncture must be employed in many cases, and it can\\nusually be done with safety. Puncture must be made over the region\\nin which the enlargement is greatest, or at which the swelling is most\\nprominent. In abscess secondary to dysentery a brownish-colored\\npus will be withdrawn, resembling anchovy sauce. It may be of a\\npeculiar odor, and, on examination, amoebse common to this form of\\ndysentery may be found. If there is no point of election, the needle\\nmay be introduced in the lowest interspace in the anterior axillary, or\\nthe seventh interspace in the mid-axillary line. A fairly large-sized\\naspirator should be used. Suppuration may be present, and yet not\\nbe reached by aspiration.\\nSuppueative Pylephlebitis. Abscess of the liver may be due\\nto pycemia. It may be a part of general pyamiia, or of portal pyaemia.\\nParasites and foreign bodies, as well as gallstones, may excite an ab-\\nscess. The echinococcus cyst may suppurate, or round-worms may\\npenetrate to the liver and cause suppuration.\\nThe symptoms of suppurative pylephlebitis and of pymnic abscess are\\ngeneral and local. Jaundice is more common than in solitary abscess,\\nand there are greater pain and tenderness over the liver, which is uni-\\nformly enlarged and tender. With the enlargement of the liver and\\njaundice we have the symptoms of pysemia. They are not peculiar.\\nSometimes the fever is distinctly intermitting, or it may be irregular\\nand septic in character.\\nThe symptoms of solitary abscess of the liver, as has been previously\\nstated, may be obscure, and attention be called to the liver only when\\nsymptoms arise due to a rupture into the neighboring organs. If per-\\nforation takes place into the peritoneum, it is not likely that the cause\\ncan be established during life. The perforation frequently extends\\nthrough the diaphragm to the pleura, and then to the lung. An em-\\npyema may be set up, the true source of which may not be ascertained\\nunless the pus is examined. The physical signs are those of empyema\\ndulness or diminished resonance, absence of fremitus and vocal reso-\\nnance, diminished breath-sounds, and impaired movement, together\\nwith symptoms of cough and dyspnoea. When the lung is infected\\nthe physical signs may resemble those of consolidation. We find dul-\\nness, bronchial breathing, and increased tactile fremitus. A harassing,\\nconvulsive cough occurs, and, sooner or later, expectoration of a red-\\ndish-brown, brickdust-colored material which resembles anchovy sauce.\\nThis characteristic expectoration is decisive. It contains amoebse, and,\\nin addition to blood-pigment and corpuscles, orange-red crystals of\\nhsematoidin, cholesterin-plates, and leucin and ty rosin. When the\\nabscess perforates into the stomach or bowel the discharge from either", "height": "4416", "width": "2640", "jp2-path": "practicaltreatis00muss_0_0961.jp2"}, "962": {"fulltext": "876 SPECIAL DIAGNOSIS.\\ncavity may be of the above-mentioned nature. Perforation into the\\npericardium is usually followed by immediate death.\\nCirrhosis of the Liver.\\nA diffuse interstitial inflammation of the liver, frequently with atro-\\nphy of the organ, is caused, in the large majority of cases, by irritants\\nwhich enter the portal circulation through the stomach. Of the irri-\\ntants alcohol is the most common, and particularly the stronger liquors,\\nas gin and whiskey. Other irritants, as spices used to excess, may\\nlikewise cause the diffuse inflammation. Cirrhosis of the liver may,\\nhowever, be a sequel to the infectious diseases, notably scarlatina, and\\nmay be incited by malaria. The infectious forms of cirrhosis usually\\nlead to atrophy of the liver.\\nAnother form is due to obstruction of the bile-ducts, with secondary\\novergrowth of the connective tissue. It is known as hypertrophic or\\nbiliary cirrhosis. In addition, cirrhosis of the liver may arise in the\\ncourse of syphilis the histological characteristics are different from\\nthose of true cirrhosis. A secondary cirrhosis of the liver arises in\\nthe course of passive congestion of that organ, producing the so-called\\nnutmeg-liver.\\nCirrhosis of the liver of the atrophic form, due to alcohol, presents\\nvarious clinical features. In the first place, it may exist without\\ncausing any symptoms whatever during life. It may be found after\\ndeath from other causes, or it may not present symptoms until an acci-\\ndent occurs in the course of the disease, as hemorrhage from some por-\\ntion of the collateral circulation. In both cases the symptoms are\\nabsent because the collateral circulation is complete. If this is incom-\\nplete, however, grave symptoms, local and general, ensue.\\nBefore detailing them it may be well to state that the occurrence of\\none symptom, which we have termed accidental, may lead to the infer-\\nence that cirrhosis of the liver is present, particularly if the patient\\nhas been an alcoholic. This symptom is hemorrhage. It may be of\\nthe stomach, causing death at once or after repeated hemorrhages it\\nmay also take place from the intestine.\\nThe Symptoms of Cirrhosis. The symptoms are general, due to in-\\nterference with the nutrition of the patient and local, their extent\\ndepending upon the degree of obstruction to the portal circulation.\\nGeneral symptoms rarely occur unless the local symptoms are present,\\nas the latter cause malnutrition and mal-assimilation from interference\\nwith the gastro-intestinal digestion.\\nThe symptoms have been divided into those of the first stage, or\\nstage of enlargement, and those of the second stage, or contraction.\\nThe so-called first stage is not always observed.\\nDuring the first stage the symptoms are those of gastritis, with en-\\nlargement of the liver. The gastric symptoms are morning retching\\nor vomiting, with discharge of mucus, associated with other symptoms\\nof gastric catarrh, as loss of appetite, nausea, tenderness in the epigas-\\ntrium, eructations, and constipation, with loss of flesh and strength.\\nThe liver is enlarged, but the outline is regular.", "height": "4412", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0962.jp2"}, "963": {"fulltext": "", "height": "4392", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0963.jp2"}, "964": {"fulltext": "PLATE XLI.\\nV\\nCirrhosis of the Liver with Ascites.", "height": "4324", "width": "2708", "jp2-path": "practicaltreatis00muss_0_0964.jp2"}, "965": {"fulltext": "DISEASES OF LIVER, SPLEEN AND PANCREAS. 877\\nDuring the second stage more severe symptoms arise, due to obstruc-\\ntion of the portal capillaries. The abdomen becomes distended and\\na sensation of weight and pressure is complained of. On examination\\nascites is detected. This may be enormous, causing monstrous disten-\\ntion, with pouting of the umbilicus. The spleen is found to be en-\\nlarged, extending over twice or three times the normal area of per-\\ncussion. If ascites does not interfere, the edge of the spleen can be\\nreadily made out The portal obstruction causes secondary gastro-\\nintestinal catarrh, if it was not already present, on account of the alco-\\nholism. Although constipation is usually present, there may be per-\\nsistent diarrhoea, usually lienteric and occurring in the morning only.\\nHemorrhages may take place from the gastro-intestinal tract at any\\ntime, either from the stomach or the intestine. Not infrequently they\\noccur from the oesophagus, due to varicosity of the veins at the junc-\\ntion of the oesophagus and the cardiac end of the stomach. Hemor-\\nrhoids are always present and may bleed at each stool. Jaundice is\\nnot the rule, and, if present, is usually light and due to the duodenal\\ncatarrh. The skin has a yellowish tinge or only a grayish earthen\\ncolor.\\nPhysical Examination. (Plate XL., Fig. 2, and Plate XLI.) This\\nmay be rendered difficult before paracentesis is performed by the exten-\\nsive ascites. The enlarged liver of the first stage will be found to have\\nundergone contraction, although diminution in the area of dulness is\\nnot by any means as absolutely confirmative of contraction as the oppo-\\nsite condition is of hypertrophy. Percussion should be performed seve-\\nral times, because the distended intestinal coils may affect the results.\\nWith the distention of the abdomen enlargement of the superficial\\nveins is also observed. This may be very pronounced, particularly\\nabout the umbilicus. The enlarged, swollen mass of veins in this situ-\\nation has been called, from its appearance, the caput Medusm.\\nThe general symptoms of cirrhosis, and particularly the symptoms\\nof the later stages, are striking and diagnostic. The nutrition is much\\nimpaired. The patient, who, in the large majority of cases, had been\\ncorpulent, becomes emaciated. The skin changes in color and becomes\\nof an earthy-gray or dirty sallow hue. The capillary venules of the\\nface are dilated the distended capillaries on the nose are distinct.\\nLater, ecchymoses may occur in the skin, and hemorrhages take place\\nfrom the mucous membrane and into the retina. Debility ensues\\noedema of the ankles is almost sure to occur, and sometimes general\\nanasarca may take place. It is extremely rare to have fever unless\\ncomplications occur. The pulse is small and becomes more rapid than\\nnormal the heart-sounds grow weaker. The skin may be the seat of\\neruptions, and chronic skin diseases of various kinds develop.\\nThe urine throughout the disease presents no characteristics as\\nascites develops, it becomes scanty and dark, and loaded with urates\\nand uric acid. In rare instances it may contain sugar, and, if the uric\\nacid is in excess, albumin.\\nCollateral Circulation. The collateral circulation that develops in\\norder that the portal blood may reach the right heart takes place in\\nvarious ways. First, communication may be formed between the veins", "height": "4416", "width": "2644", "jp2-path": "practicaltreatis00muss_0_0965.jp2"}, "966": {"fulltext": "878 SPECIAL DIAGNOSIS.\\nof the mesentery and those of the posterior abdominal walls second\\nbetween the coronary veins of the stomach and the veins of Glisson s\\ncapsule and the phrenic veins third, between the hemorrhoidal and\\nthe inferior mesenteric veins fourth, between enlarged veins occupy-\\ning the position of the obliterated umbilical vein in the ligamentum\\nteres, and the epigastric and mammary vein.\\nIn the study of a case of cirrhosis of the liver a judgment as to its\\nnature may be, in a measure, confirmed by the presence of other phe-\\nnomena due to the same cause. Very frequently we have, at the same\\ntime, cirrhosis of the kidneys and sclerosis of the arteries, with second-\\nary atheroma, both of which have led to hypertrophy of the heart.\\nStriimpell refers to the association of cirrhosis and chronic tubercular\\nperitonitis. He thinks the former is the primary lesion which predis-\\nposes to the development of the latter. The course of the disease is\\nprolonged.\\nThe duration cannot be determined accurately, as the onset is usually\\ninsidious. After the ascites appears the duration may vary from six\\nto eighteen months. Of course, this depends largely upon the com-\\npleteness of the compensatory circulation. Death usually occurs from\\nintercurrent disease or progressive exhaustion. In not a few cases\\ncerebral symptoms occur. In addition to the cirrhotic cachexia, the\\nsudden occurrence of coma and convulsions, preceded by delirium,\\nmay ensue the cause of this is not fully known. It must be borne\\nin mind that the occurrence of these symptoms in an alcoholic subject\\nmay be due to a cirrhosis, the presence of which had not been sus-\\npected during life.\\nDiagnosis. The diagnosis is usually not difficult if the complete\\npicture of the case is presented. It cannot be established positively\\nwithout definite knowledge of the cause. If the patient comes under\\nobservation after ascites has developed, the diagnosis is more difficult.\\nIt must, in the majority of cases, be based upon exclusion of heart,\\nlung, and kidney disease. A history of alcoholism and the presence\\nof other symptoms of liver disease point to the hepatic origin of ascites.\\nAscites may be due to other causes within the abdomen, notably chronic\\nperitonitis, exclusion of which is sometimes difficult. The general ten-\\nderness, the less marked distention of the abdomen, and the absence\\nof enlargement of the spleen point to peritonitis. The fatty cirrhotic\\nliver may present symptoms similar to those of the atrophic form,\\nexcept that it is enlarged.\\nHypertrophic cirrhosis, or so-called biliary cirrhosis, presents a\\nsomewhat different picture. In the first place, the cause is different.\\nThere is a history of gallstones, or obstruction of the duct from other\\ncauses. The liver is uniformly enlarged, and the surface is smooth\\nand strikingly indurated. There are weakness and loss of appetite.\\nJaundice ensues very early, or may be the first symptom. It increases\\nand persists throughout the course of the disease. Ascites is very slight\\nor absent altogether. The enlargement and jaundice may continue for\\nmonths or even years without the development of grave symptoms.\\nFever may, however, set in at any time, being in all probability due\\nto the biliary obstruction. It is continuous the temperature rises", "height": "4400", "width": "2708", "jp2-path": "practicaltreatis00muss_0_0966.jp2"}, "967": {"fulltext": "DISEASES OF LIVER, SPLEEN AND PANCREAS. 879\\nto from 102\u00c2\u00b0 to 104\u00c2\u00b0 the tongue becomes dry and brown, the pulse\\nrapid. All the symptoms of febrile jaundice ensue. The patient may\\nbe seized with convulsions in the course of the disease, followed by\\ncoma and death. Most authorities state that the enlargement persists\\nthroughout the course of the disease, but some observers say that after\\na long period of enlargement, with jaundice, contraction of the liver\\ntakes place, with symptoms of portal obstruction. Then the spleen\\nmay become enlarged and ascites take place, while the symptoms of\\ndigestive disturbances become more prominent. There may be ner-\\nvous symptoms, due to acute, diffuse necrosis (acute yellow atrophy),\\nsetting in in the course of the disease.\\nThe diagnosis is often difficult. Gradual and persistent jaundice\\nwithout cause, continuing for a long time, associated with persistent\\nenlargement of the liver without symptoms of portal obstruction in\\nthe non-alcoholic subject, points pretty certainly to hypertrophic cir-\\nrhosis of the liver.\\nSyphilitic Disease of the Liver.\\nSyphilitic disease of the liver may result in cirrhosis, or in the\\ndevelopment of gummata. Syphilitic cirrhosis presents the same symp-\\ntoms as the alcoholic form. The history, the marked irregularity on\\nthe surface of the liver, and the existence of syphilis elsewhere may\\nlead to a diagnosis of the true condition.\\nIn congenital syphilitic disease of the liver the inflammation is\\ndiffuse the liver is enlarged and hard the surface is smooth there\\nare usually syphilitic lesions in other organs the patient presents\\nsyphilitic eruptions, and has the well-known wizened appearance that\\nbelongs to this affection.\\nSyphilitic gummata in the liver may exist without presenting any\\nsymptoms whatsoever, or they may reveal their presence by pain and a\\nlocalized swelling and discomfort, which call the patient s attention to\\nthe region, particularly if his general health is reduced at the same\\ntime. Tumors are situated in the left lobe, in the median line, or\\nalong the margin of the ribs. The pain is usually localized in this\\nregion, but may extend more or less over the entire liver, particularly\\nif there is general perihepatitis along with other evidences of syphilis\\nthe latter are not always present, however. If the temperature is\\ntaken frequently, a moderate febrile range will be observed. It may\\nnot rise above 100 J\u00c2\u00b0, but in the absence of other causes it is a valu-\\nable diagnostic symptom. 1 In other instances the gummata may grow\\nin such situation as to interfere with the portal circulation, or press\\nupon the gall-ducts. The latter is very rare. If the gummata are\\nfelt, they appear as enlarged bosses which give the sensation of flat-\\ntened hemispheres. Sometimes several separate elevations can be\\nmade out on the surface of the enlarged organ. To determine the\\nexact nature of the lesion is often very difficult. The symptoms may\\nconclusively point to hepatic disease. Knowledge of the presence of\\n1 The Diagnostic Importance of Fever in Late Syphilis. Musser: University\\nMedical Magazine, October, 1892.", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_0967.jp2"}, "968": {"fulltext": "880 SPECIAL DIAGNOSIS.\\nsyphilis aids in the diagnosis. If without a syphilitic history there\\nare scars in the throat, nodes on the bones, or other signs of syphilis,\\nthe diagnosis will be tolerably certain. Severe pain is more promi-\\nnent in syphilis than in cirrhosis, and the nodules of syphilis are very\\ndifferent from the granular surface of cirrhosis.\\nThe Fatty Liver.\\nThe symptoms of fatty liver are not marked. The physical sign is\\na uniform enlargement extending in all directions. On palpation the\\nedges can be felt they are rounded and smooth. They are soft at\\nfirst, but later become indurated. Fatty liver may be followed by\\ncirrhosis after a period of alcoholism. The general symptoms are\\nthose of the primary disease. Fatty liver occurs in gouty subjects,\\nbut is notably present in wasting diseases, in tuberculosis, in chronic\\nhip-joint disease, and in amyloid disease of the liver.\\nFatty liver sometimes follows the congestion of the liver which is\\npresent in the course of organic heart disease. It is not a true fatty\\nliver, but a fatty cirrhosis. There is increased fatty degeneration with\\nan overgrowth of connective tissue. This form is associated with heart\\nand kidney disease. On palpation the edges of the liver are indurated.\\nThe liver may undergo diminution in size later, and the symptoms of\\ncirrhosis ensue.\\nAmyloid Disease of the Liver.\\nEnlargement of the liver without pain is often due to amyloid dis-\\nease. Similar disease is found in other organs, and there is present,\\nto point to the nature of the enlargement, syphilis, bone disease, pro-\\nlonged suppuration, or tuberculosis. In amyloid disease the pallor of\\nthe patient is great the face may be swollen, and the ankles slightly\\noedematous. The spleen is enlarged, the urine albuminous and abun-\\ndant, but of moderate specific gravity. A history of syphilis is an\\nimportant point in establishing the diagnosis. Fatty liver can readily\\nbe distinguished from amyloid disease by palpation. In the latter the\\nsurface is smooth, but very much indurated.\\nCancer of the Liver.\\nThe etiological factors upon which the diagnosis of cancer is based\\nare the age of the patient most frequently between the fortieth and\\nsixtieth year the female sex, in a measure and heredity. The dis-\\nease is nearly always secondary to cancer in some other situation\\nconsequently, in cases in which symptoms point to cancer of the liver,\\nsearch must he made for the primary lesion elsewhere. The most fre-\\nquent seat is the rectum, the uterus, the stomach, the remainder of the\\ngastro-intestinal tract, the eye. The eye has been removed for obscure\\ndisease, and symptoms of carcinoma of the liver have subsequently de-\\nveloped. The nature of the hepatic symptoms was obscure during life,\\nbut at the post-mortem examination melanotic sarcoma was found\\nthe primary lesion undoubtedly had been in the eye. Further etio-\\nlogical influences that may bear upon the diagnosis are (1) The occur-", "height": "4408", "width": "2624", "jp2-path": "practicaltreatis00muss_0_0968.jp2"}, "969": {"fulltext": "", "height": "4396", "width": "2600", "jp2-path": "practicaltreatis00muss_0_0969.jp2"}, "970": {"fulltext": "PLATE XLII,\\nFIG. 1.\\n-^TU\\n/K\\nv\\nyv\\\\ 7\\nK x v fl\\nCarcinoma of the Gall Bladder with Involvement of the Live:\\nt\\nEnlargement of the Gall Bladder.", "height": "4392", "width": "2708", "jp2-path": "practicaltreatis00muss_0_0970.jp2"}, "971": {"fulltext": "DISEASES OF LIVER, SPLEEN AND PANCREAS. 881\\nrence of gallstones, which act as the exciting cause in the development\\nof primary cancer of the ducts, thence spreading to the liver (2) the\\noccurrence of trauma.\\nThe symptoms of cancer of the liver may be due to (1) increase in\\nthe size of the liver (2) to pressure of the growths upon the ducts or\\nterminal portal vessels and (3) to the general effects of carcinoma\\nupon the system the cachexia.\\nPhysical Signs. (Plate XXXVIIL, Fig. 2, Plate XL., Fig. 2, and\\nPlate XLIL, Fig. 1.) The liver is enlarged and its surface irregular.\\nThe organ can be made out, by palpation, extending below the margin\\nof the ribs. The edges are irregular, and, on the surface, bosses can\\nbe distinctly felt. In rare cases one or two masses only may be pres-\\nent, growing out of the substance of the left lobe of the liver, causing\\na large tumor below the sternum. The nodules are usually hard, but\\nsometimes may be soft and even fluctuate. After emaciation becomes\\nmarked the nodules can be seen as well as felt near the surface of the\\nskin, and their number distinctly made out. The abdomen is dis-\\ntended.\\nThe liver is movable with inspiration. Progressive enlargement can\\nbe noted while under observation. The enlargement can be well de-\\nfined by percussion, and, while the surface is irregular, the general\\nshape of the dulness corresponds to that of the liver. The increased\\nsize and inflammation of the capsule cause a sensation of weight in the\\nhepatic region and pain which may be intermitting in character. The\\nnodules may be tender on palpation. The superficial veins are enlarged.\\nIn not every instance do we find enlargement. In some cases the\\ncancer is associated with cirrhosis of the liver, or may itself be of a\\nnodular type, and in the course of the disease undergo shrinkage. The\\nliver is then normal or diminished in size, as indicated by percussion.\\nThe symptoms that attend cancer are 1. Jaundice, which is not\\nvery deep unless the common duct is affected. 2. Ascites, Avhich is\\nalways present in the atrophic forms, but may be absent when the\\nliver is enlarged. 3. The general symptoms are those of rapid emacia-\\ntion, prostration, and, in some instances, moderate fever. Fever\\nattends the rapidly-growing cases. It is usually continuous, but may\\nbe intermittent, especially if there is suppuration or suppurative in-\\nflammation of the ducts. It is a well-known fact that gallstones are\\nof common occurrence in patients suffering from cancer in any location\\nwhatever. The symptoms of biliary calculus or of obstruction may\\nattend those of secondary cancer of the liver, and the stone has an\\netiological significance.\\nIn many instances secondary cancer of the liver may be present\\nwithout symptoms to attract attention to this organ during life. If\\ncancer in certain other regions has continued for the usual period of\\ntime, it is almost certain that at the autopsy cancer of the liver will be\\nfound to be present.\\nDiagnosis. The diagnosis of cancer of the liver is not difficult when\\nthe changes in the liver can be made out on palpation and percussion.\\nIn rare instances, in which the liver is smooth, it may be mistaken for\\nfatty or amyloid liver. A definite cause can usually be assigned for\\n56", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0971.jp2"}, "972": {"fulltext": "882 SPECIAL DIAGNOSIS.\\nthe latter, while the occurrence of jaundice, the rapid increase in size\\nof the liver, and the general symptoms of the cancerous cachexia indi-\\ncate cancer of the liver. The syphilitic liver with irregular gummata\\nmay cause serious doubt the history of the case and other signs of\\nsyphilis aid in the diagnosis. Locally the condition may exactly sim-\\nulate carcinoma. The jaundice, however, is not so frequent in occur-\\nrence, or so deep in syphilitic gummata the cachexia does not ensue,\\nbut the therapeutic test may be essential in order to make a diagnosis.\\nIn hypertrophic cirrhosis of the liver the jaundice is deep and the\\nliver enlarged but there is little wasting or anaemia. The surface of\\nthe liver is smooth there are certainly no bosses, and the organ is\\npainless. Ascites is more common in cirrhosis the patient is usually\\naffected earlier in life than in cancer.\\nIn a large growing cancer one or two of the nodules may suppurate\\nand simulate abscess of the liver. Abscess follows a definite cause\\nusually, and occurs in middle life cancer is secondary to disease in\\nother organs and occurs usually in late life. The results of aspiration\\ndiffer in each. Moreover, a history of dysentery, the occurrence of\\npain, of profound anaemia, of pronounced hectic fever with irregular\\nenlargement of the liver, but without jaundice or cachexia, point to\\nabscess.\\nCancer of the liver may be simulated by cancer of organs in close\\nproximity to the liver, as the pancreas, the pyloric end of the stomach,\\nor the colon. In addition to the usual symptoms of pyloric cancer, it\\nwill be found that jaundice occurs late. Cancer of the pyloric end is\\nnot movable with respiration unless it becomes adherent to the liver.\\nCancer of the omentum and colon are not modified by respiration. The\\npercussion-note over them is different they frequently extend beyond\\nthe liver-confines and are associated with symptoms of obstruction of\\nthe bowels. Fecal accumulation in the transverse colon must not be\\nmistaken for cancer of the liver. The large masses adjacent to the\\nliver may closely simulate cancerous nodules. In doubtful cases the\\ncolon should be emptied. Cancer of the liver and hydatid disease\\nmust not be confounded. The tumor in hydatid disease is usually\\nsingle it is large, and may fluctuate or yield the hydatid fremitus. It\\ncauses irregular enlargement of the liver, when the tumor presents\\nin the epigastrium or along the margin of the ribs. It is painless.\\nAspiration yields the characteristic hydatid fluid.\\nCancer of the bile-ducts cannot always be distinguished from cancer\\nof the liver. Jaundice early in the course of the disease, in a person\\nwho has had gallstones, followed by enlargement of the liver and gall-\\nbladder, in the absence of primary disease elsewhere, suggests cancer\\nof the gall-bladder or ducts. This is more or less confirmed if the\\nsmooth and painless gall-bladder becomes hard, irregular, and tender\\non pressure. Cancer of the pancreas also presents difficulties a tumor\\nin the mid-costal region, however, with vomiting and the early devel-\\nopment of jaundice, before the liver has become enlarged or nodular,\\nand associated with other characteristic symptoms, such as intestinal\\ndyspepsia and fatty stools, points to the pancreas as the primary seat\\nof the disease.", "height": "4416", "width": "2708", "jp2-path": "practicaltreatis00muss_0_0972.jp2"}, "973": {"fulltext": "DISEASES OF LIVER, SPLEEN AND PANCREAS. 883\\nHydatid Disease of the Liver.\\nHydatid disease is comparatively rare in this country, but, in my\\nown experience at least, it is undoubtedly increasing in frequency.\\nWithout any increase in the opportunities for observation, I have\\nseen seven cases within the last two years, compared to the same\\nnumber during the five previous years. The disease occurs in people\\nwho live with dogs. It may occur at any age, but is most common\\nin adult life. It is very rare before the fifth year.\\nThe symptoms are local, depending upon the size of the tumor.\\nSmall cysts may be present without any disturbance. Large and\\ngrowing cysts cause signs of tumor, with great increase in the size of\\nthe liver. The physical signs depend upon the situation of the tumor.\\nIt may be found in the median line above the umbilicus, causing a\\ndistinct prominence, tense and firm, which sometimes yields fluctua-\\ntion. Quite often the tumor grows at the suspensory ligament, pushing\\nthe diaphragm upward, dislocating the heart, and causing an increased\\narea of dulness in the left upper quadrant. In this position it may\\nsimulate a pancreatic cyst or effusion in the lesser peritoneal cavity.\\nIf the tumor is in the right lobe, the enlargement of the liver may be\\nupward or downward. The upper border of liver-dulness may begin\\ntwo or three interspaces higher than normal posteriorly or in the axil-\\nlary region. If the cysts are superficial, when palpated with the fingers\\nof the left hand and percussed with the right, a vibration or trembling\\nmovement is felt, which may continue for a certain time. It is known\\nas the hydatid fremitus. It is not always present. The enlargement\\nis painless. Local sensations of weight and dragging may be complained\\nof. If suppuration sets in, there may be a good deal of pain.\\nThe general symptoms are negative the nutrition does not suffer\\nunless the enlarged mass interferes, by its pressure, with physiological\\nacts of digestion and assimilation. If suppuration sets in, the general\\nsymptoms of abscess of the liver arise. Jaundice is more common than\\nin tropical abscess. The abscess may perforate into one of the adjacent\\nhollow viscera, or into the pleura and bronchi. It may perforate exter-\\nnally. It may perforate into the pericardium or vena cava, and cause\\ndeath. If perforation takes place in the biliary passages, obstructive\\njaundice arises, with secondary suppurative cholangitis. When the\\ncysts rupture, or if they are aspirated, an eruption of urticaria may\\nbreak out. This is not of diagnostic significance, except that it may\\npoint to rupture of the cyst.\\nDiagnosis. The diagnosis is not difficult. The occurrence of irregu-\\nlar, painless enlargement of the liver without general symptoms is sig-\\nnificant. If fluctuation is detected, or the fremitus, a more positive\\nconclusion can be reached. When suppuration takes place the symptoms\\nare like those of abscess of the liver. Hydatid disease is to be distin-\\nguished from syphilitic hepatitis, in which the enlargement is hard and\\nirregular, and does not fluctuate. Sometimes the symptoms resemble\\ncancer, but the age of the patient, the presence of jaundice, and the\\nextreme emaciation and cachexia indicate that affection rather than\\nhydatid disease. Enlargement of the gall-bladder containing a mucoid", "height": "4416", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0973.jp2"}, "974": {"fulltext": "884\\nSPECIAL DIAGNOSIS.\\nfluid, in which fluctuation can be detected, may simulate hydatid dis-\\nease. The enlargement, however, may be preceded by conditions which\\ncause obstruction of the cystic duct. The gall-bladder is movable. In\\nsome instances there may be resonance between it and the liver. It is\\nusually of a pyriform or oblong shape. In hydronephrosis the symptoms\\nHuman echinococci. (From Finlayson, after Davatne.)\\nA, a group of echinococci, still adhering to the germinal membrane by their pedicles. X 40.\\nB, an echinococcus with head invaginated in the body. X 107.\\nC, the same compressed, showing the suckers and hooks of the retracted head.\\nD, echinococcus with head protruded.\\nE, crown of hooks, showing the two circles. X 350.\\nof a localized cyst are present. It does not move with respiration, as in\\nhydatid disease it is attended by symptoms of renal disease explora-\\ntory puncture is sometimes necessary to establish a diagnosis. A hydatid\\ncyst is frequently confounded with pleural effusion of the right side, for\\nthere may be all the physical signs of effusion at the right base. The\\nFig. 203.\\nf J\\nHooks from taenia echinococcus. X 350.\\ndistinction can be made by the character of the line of dulness. In\\nhydatid cyst, as Frerichs points out, it is a curved line, the greatest\\nheight of which is found in the scapular region. It is not difficult\\nusually to distinguish hydatid cyst from other forms of painless enlarge-\\nment. In fatty and amyloid disease the enlargement is uniform. Both", "height": "4416", "width": "2584", "jp2-path": "practicaltreatis00muss_0_0974.jp2"}, "975": {"fulltext": "DISEASES OF LIVER, SPLEEN AND PANCREAS. 885\\noccur more commonly in individuals of previous ill health, whereas\\nhydatid disease occurs in healthy individuals.\\nAn absolute diagnosis of hydatid disease is based upon the results of\\nexploratory puncture. When this is made over a tumor, or the centre\\nof dulness, if it is due to hydatid disease, a clear fluid, slightly opales-\\ncent, is withdrawn. The fluid is of a specific gravity of 1005 to 1009\\nit is of neutral reaction, does not contain albumin, but contains chlorides\\nand sometimes traces of sugar. Hooklets may be found in the clear\\nfluid.\\nDiseases of the Gall-ducts.\\nPain and jaundice are symptoms of disease of the biliary passages.\\nPain may be constant or paroxysmal. If it occurs in mild degree, with\\ntenderness and with jaundice, it is probably due to catarrh of the biliary\\npassages. If severe, and in paroxysms with or without jaundice, it is\\ndue to gallstones.\\nInflammation of the Bile-ducts. This is due to inflammation and\\nobstruction of the terminal portions of the common bile-duct. But few\\nwords are necessary, as it has been referred to frequently in speaking\\nof jaundice. The symptoms are those of moderate jaundice, occurring\\ncoincidently with or following in a few days upon an attack of acute\\ngastritis. The disease may occur in epidemic form.\\nGallstones. Gallstones form in the biliary passages, and may remain\\nthere without creating symptoms, or they may, by the efforts to pass\\nthem, cause attacks of pain called hepatic or biliary colic, after which\\nthe stone may pass into the intestinal tract without further hepatic\\nsymptoms. It may become impacted in the biliary canal and set up\\ncatarrhal or suppurative inflammation, which in turn may be followed\\nby stricture. Gallstones usually form or at least show signs of their\\npresence after the age of forty years, most frequently in women and\\nin people who have led a sedentary life and partaken of rich and indi-\\ngestible food. Individuals in different generations of the same family\\nmay be predisposed to them.\\nHepatic Colic. The passage of gallstones may be attended by a\\nslight amount of pain only, which, unless in the right upper quadrant,\\nwould pass for an attack of simple indigestion. In the large majority\\nof cases the pain is severe. The attack may be preceded by biliousness\\nor indigestion for twenty-four hours, and moderate pains or a sense of\\nweight and fulness in the liver. It frequently follows the taking of\\nfood. Ringing in the ears, disturbance of vision, or undue flushings\\nare said to precede it in some instances.\\nThe attack may be sudden. The patient is seized with pain along\\nthe margin of the ribs of the right side, or there may be pain above\\nthe ribs, over the liver, and in the right shoulder at the same time.\\nFrom the hepatic region it extends to the median line. Very fre-\\nquently the pain begins and continues in the epigastrium. It may be\\nmost pronounced in this locality from the first. The pain is intense\\nand paroxysmal. The patient is doubled up in agony. It causes more\\nor less collapse. The pulse increases. Vomiting usually occurs at the\\nsame time, consisting first of the contents of the stomach, and then of a", "height": "4416", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0975.jp2"}, "976": {"fulltext": "886 SPECIAL DIAGNOSIS.\\nyellowish, bile-stained fluid. The vomiting may be extreme, so that\\nthe patient is tormented by the pain, the retching, and vomiting. The\\nattack sometimes disappears as suddenly as it occurred, or wears off\\ngradually. When most severe, symptoms of shock follow. The bowels\\nare not disturbed during the attack. The urine may become suppressed\\nit is usually high-colored, and after the attack may contain bile.\\nAt the time of the attack there is considerable tenderness below the\\nxiphoid cartilage and in the hepatic region. The tenderness is more\\nmarked on deep pressure in the gall-bladder region and to the right of\\nthe mid-clavicular line, at the margin of the ribs. The epigastrium\\nmay be slightly swollen. The tenderness persists after the attack,\\nand the stomach may be weak or irritable for some time pain, how-\\never, usually disappears at once. The attack may recur frequently until\\nthe stone has been passed, so that in twenty-four hours the patient may\\nhave a dozen or more paroxysms. After the attacks have subsided\\nlight jaundice may supervene, which usually does not continue more\\nthan a Aveek at the furthest, during which there are also symptoms of\\nmild gastritis. (See Intestinal Colic.)\\nIn some instances a chill precedes or immediately follows the pain,\\nafter which the temperature rises. After the paroxysm subsides the\\nfever disappears rapidly, being followed by profuse perspiration. If\\nthe gallstones have set up catarrhal inflammation, moderate fever may\\ncontinue for a few days. (See Fever in Obstruction.)\\nDaring any paroxysm of hepatic colic it is desirable to determine\\nwhether or not a gallstone has been passed. This can only be done\\nby placing the feces in a sieve and pouring water upon them until they\\ndissolve. Instead of gallstones, dark-colored granular bile, which has\\nbecome inspissated, is sometimes seen in the movements. Bile in this\\nform gives rise to as much pain, according to Harley, as true biliary\\nconcretions. If the stone is not passed, it may fall back into the gall-\\nbladder and cause no further symptoms for a time, or become impacted\\nin the ducts. The impaction may be such that no obstruction is caused\\nby its position, the bile being forced through or around it or complete\\nobstruction may take place. (See Jaundice.)\\nObstruction of the Common Duct by Gallstones, (a) In addition to\\njaundice paroxysms of chill, fever, and sweat occur, with catarrhal\\ninflammation of the biliary passages. (1) The paroxysms resemble\\nintermittent fever (2) the jaundice may continue for years and deepen\\nafter each paroxysm (3) hepatic colic may occur with the paroxysm\\n(4) the health fails but slightly. The paroxysms may occur daily or\\nonly once a week, or they may be tertian and quartan in type. The\\npain is referred to other situations than the gall-bladder or the epigas-\\ntrium. It is often relieved by vomiting or by certain positions of the\\nbody. The jaundice may be intermittent or remittent. On account\\nof the obstruction in this situation the liver becomes enlarged. It is\\nfirm and smooth on palpation. The enlargement, as determined by\\npercussion, is uniform. The gall-bladder is not enlarged. Fenger s\\nthorough studies show that the intermittent phenomena are due to ball-\\nvalve action of a single stone. He also points out that emaciation is of\\ncommon occurrence, (b) Gallstones may cause suppurative inflammation", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0976.jp2"}, "977": {"fulltext": "DISEASES OF LIVER, SPLEEN AND PANCREAS. 887\\nof the biliary ducts, just as suppuration of the gall-bladder may ensue.\\nThe symptoms, both general and local, are pronounced. The fever may\\nbe intermittent, but is more likely to be remittent jaundice is present,\\nbut it is constant in its intensity. The local signs of enlargement and\\ntenderness are made out. The patients die of exhaustion or septicaemia.\\nSometimes the gall-bladder ruptures into the stomach or colon, and\\ntemporary abeyance of the symptoms may result.\\nThe Accidents of Gallstones. While these effects of the presence of\\nstones in the biliary passages may rightly be considered as accidents,\\nnevertheless their occurrence is so common as to be part and parcel of\\nthe history of gallstones. As accidents, we have most commonly the\\noccurrence of localized peritonitis, which leads to dislocation of the gall-\\nbladder, constriction of the duodenum, with secondary dilatation of the\\nstomach we also have the formation of biliary fistula, with passage of\\nthe gallstone into the contiguous organs or channels. The stone may\\nulcerate into the gall-bladder from one of the ducts, may perforate the\\nportal vein, or may perforate into the abdominal cavity the most fre-\\nquent accident. Perforation also takes place into the duodenum, into\\nthe colon, and, rarely, into the stomach. Such perforation can only\\nbe inferred from its secondary effects (1) An attack of gallstones\\n(2) local inflammation with fever (3) the occurrence of peritonitis, or\\nthe discharge of pus by the bowels, or by vomiting. That it is due to\\ngallstones is proved in those rare instances in which the stone is passed\\nper rectum. Often it may be impacted in the intestinal canal, causing\\nsymptoms of acute obstruction, or in the rectum, causing local tormina\\nand tenesmus. The perforation, however, occurs in other directions.\\nSometimes fistulous connection is formed between the gall-bladder and\\nthe urinary passages, calculi and pus being discharged in the urine. In\\nother instances fistulse between the bile-passages and the lungs are\\nformed. The bile is coughed up and expectorated, sometimes with small\\ncalculi. In the most common form ulceration proceeds toward the sur-\\nface, with formation of cutaneous fistula. After the fistula has opened\\nexternally gallstones in large numbers may be passed. If not, the\\ncause of the fistula must be determined by the history and the results\\nof investigation by probe, due attention being given to the condition of\\nother organs.\\nEnlargement of the Gall-bladder. (Plate XLIL, Fig. 2.) Enlarge-\\nment of the gall-bladder may be due to obstruction in the cystic duct.\\nThe liver is not secondarily affected. The enlargement is noted at the\\nedge of the liver in the usual situation, and may gradually increase to\\nan enormous extent, so that it has been mistaken for an ovarian cyst.\\nThe gall-bladder is often quite movable, and on account of its location\\nand movability, as well as its long shape, has been mistaken for a float-\\ning or movable kidney. If the gall-bladder is not too large, it can be\\nfelt as a rounded or pyriform mass when the hand is placed along the\\nmargin of the liver, becoming more marked when the patient takes a\\nfull breath. The. enlargement is not attended by any other symptoms\\nexcept mechanical ones, unless the contents of the gall-bladder are\\npurulent. In obstruction with simple enlargement the fluid of the gall-\\nbladder, should aspiration be performed, is thin, of a mucoid nature,", "height": "4416", "width": "2644", "jp2-path": "practicaltreatis00muss_0_0977.jp2"}, "978": {"fulltext": "888 SPECIAL DIAGNOSIS.\\nand alkaline in reaction. It may contain cholesterin-plates, and some-\\ntimes blood. It must be distinguished from the fluid of a hydatid cyst.\\nSimple enlargement of the gall-bladder must be distinguished from\\nenlargements due to inflammation. (1) Acute phlegmonous inflamma-\\ntion of the gall-bladder may take place, attended by localized pain and\\ntenderness, by high temperature, extreme prostration, and the rapid\\ndevelopment of the typhoid state. Peritonitis rapidly ensues. It can-\\nnot be distinguished from other forms of acute inflammation in the same\\nregion, unless there was (a) a history of gallstones (b) tumor of the\\ngall-bladder before the attack developed. (2) Suppurative inflammation\\nof the gall-bladder may occur from gallstones and in infectious diseases.\\nThe colon bacillus, the diplococcus of pneumonia, and the typhoid bacil-\\nlus give rise to infectious inflammation of the gall-bladder. The enlarge-\\nment takes place suddenly and may increase, the tumor becoming tender\\nand painful on palpation. The direction of growth is toward the umbil-\\nicus. The general symptoms are those of suppuration. Hectic fever\\nor markedly remittent fever occurs, and, unless surgical relief is given,\\nperitonitis ensues from infection or from rupture. This complication\\nmay be suspected from the occurrence of collapse and increase of the\\nlocal symptoms.\\nEither of the above forms of cholecystitis is attended by pain in the\\nregion of the gall-bladder or in the epigastrium or even as low down as\\nthe region of the appendix. The pain is severe and paroxysmal. The\\nsymptoms of bacterial infection, of which vomiting and fever are the\\nmost prominent, rapidly follow. The symptoms simulate appendicitis,\\nintestinal obstruction, and pancreatitis.\\nEnlargement, or tumors of the gall-bladder, usually due to cystic\\nobstruction, as previously mentioned, may be mistaken for floating\\nkidney, for tumor of the pylorus and for ovarian cyst.\\nTumors of the gall-bladder from any of the above-mentioned causes\\nare recognized by their position and shape, and by the character of the\\ntumor. The joosition varies. The usual site is in the gall-bladder\\nregion, but it may extend as low as the groin, or may be so large as to\\ndistend the ribs and fill almost the entire abdominal cavity. If, how-\\never, the case has been under observation from the beginning, the tumor\\nmust have been found originally in the gall-bladder region. This region\\ncorresponds to the point of intersection of the border of the ribs by\\na line drawn from the acromion process of the right shoulder to the\\numbilicus, or in the direction of the foramen of Winslow. The tumor\\ngrows from this point toward the umbilicus in nearly all the cases. It\\ncan be recognized by its shape, which is pyriform, globular, or conical.\\nThe character of the tumor varies. It is usually tender and firm, but\\nelastic on pressure, and movable. Fluctuation may often be detected.\\nThe septic gall-bladder is symmetrical and resistant to the touch. If\\nthe enlarged gall-bladder contains calculi, they may be felt as small,\\nhard masses, which cause a grating sensation, to be transmitted to the\\nfinger. On aspiration, if the cystic duct is obstructed, the mucoid\\nfluid previously mentioned, or pus, is withdrawn. If the common duct\\nis obstructed, bile will pass through the trocar.\\nThe enlargement must be distinguished from tumors of the liver,", "height": "4412", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0978.jp2"}, "979": {"fulltext": "DISEASES OF LIVER, SPLEEN AND PANCREAS. 889\\nstomach, duodenum, pancreas, or lymphatic glands. Tumors of the\\nliver are usually due to carcinoma. They are multiple, associated with\\nenlargement of the liver, with jaundice, ascites, enlargement of the\\nspleen, and emaciation. Tumors of the stomach, duodenum, and pan-\\ncreas are in a different position, and are attended by functional disturb-\\nance of the respective organs from which they spring. An abscess of\\nthe liver, if purulent, may simulate enlargement of the gall-bladder.\\nIf the abscess can be palpated, an area of induration is first felt, fol-\\nlowed afterward by softening and fluctuation of the swelling. In judg-\\ning of the true nature of the tumor we must bear in mind the causes of\\nabscess. In hydatid disease the tumor develops slowly it is painless\\nit may yield fremitus, and, if movable, the course is slow and not\\nattended by general symptoms. Multilocular hydatid disease can rarely\\nbe distinguished save by the difference in position of the tumor. It is\\nnodulated, hard, and tender, but is associated with jaundice, ascites,\\noedema of the legs, enlarged spleen, and great emaciation and prostra-\\ntion, with rapid decline. A syphilitic gumma in the liver may occupy\\nthe region of the gall-bladder. It can usually be made out as continu-\\nous with the liver-structure. It is tender and painful, but irregular\\nother signs of syphilis, or a history of the infection and of symptoms\\nof a primary and secondary period, will aid in the distinction of the\\ndisease.\\nFloating Kidney. The gall-bladder is larger and fixed at one end,\\nwhereas the entire kidney is movable. The gall-bladder may -fluctuate,\\nand is associated with symptoms of hepatic disease. On the other\\nhand, the well-known symptoms of floating kidney, the shape of the\\ntumor, the sensation of nausea induced by palpation, point to the renal\\norigin of the mass. Tumors of the kidney must be distinguished, such\\nas sarcoma, hydronephrosis, and pyonephrosis. 1. There may be\\nchanges in the urine. 2. In renal tumors the intestine is in front of\\nsome portion of them, or a zone of resonance is found between the\\nliver-dulness and the tumor. 3. Renal tumors are fixed. They may,\\nas in hydronephrosis, come and go, preceded by attacks of renal colic\\nand attended by anuria. From ovarian or uterine tumors the diagnosis\\nmust be made by examination of the genital organs, although with the\\nformer there is often difficulty.\\nEnlargement of the gall-bladder on account of calculous obstruction\\nmust be distinguished from enlargement due to cancer of that organ.\\nThis is often difficult and cannot be done without having the patient\\nunder observation for a long period of time. Cancer of the gall-bladder\\nis usually primary. It may begin in the gall-ducts. In the larger\\nnumber of cases it occurs in patients who have had gallstones. It is\\nfound most frequently in females, and after the fiftieth year. Tight-\\nlacing or pressure around the abdomen may predispose to it. The\\nsymptoms are pain, jaundice, emaciation, cachexia, and the presence\\nof a tumor. The pain is localized and lancinating in character. Jaun-\\ndice occurs in 70 per cent, of the cases, and gradually increases in inten-\\nsity. The tumor is situated in the gall-bladder region, to the right of\\nthe umbilicus. It is hard or firm, painful, and the seat of tenderness.\\nThe tumor is fixed. Sometimes the disease is found in the cystic duct,", "height": "4416", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0979.jp2"}, "980": {"fulltext": "890 SPECIAL DIAGNOSIS.\\nand then the gall-bladder is enlarged. As the history of gallstones is\\nof frequent occurrence in both instances, it is impossible to distinguish\\nthe two forms of obstruction causing enlargement, save that in carcinoma\\nthe emaciation and cachexia may point to the true nature of the case.\\nIn tumor of the gall-bladder due to cancer the secondary effects on the\\nliver are usually more marked than in tumor from other causes. The\\nliver enlarges and its surface becomes irregular or nodular. 1\\nDiseases of the Spleen.\\nTopography of Spleen. (Plate XXXV.) The spleen lies in the\\nleft upper quadrant beneath, and in contact with the diaphragm above,\\nand below with the tail of the pancreas, cardiac end of the stomach,\\nand suprarenal capsule. It extends transversely between the upper\\nborder of the ninth rib and the lower border of the eleventh rib, and\\nfrom the middle axillary line posteriorly toward the spine.\\nPalpation. An enlarged spleen usually retains the normal shape.\\nThe direction of the enlargement is downward and inward. It is access-\\nible to palpation in proportion to the degree of enlargement and of\\nrelaxation of the abdominal walls. It is movable with respiration.\\nIt cannot be said to be enlarged unless the edge is palpable at the end\\nof deep inspiration, notwithstanding there may be increased dulness in\\nthe lower axillary region. When moderately enlarged, the smooth,\\nblunt, rounded anterior surface and sharp edge of the spleen can be\\nfelt at the margin of the ribs, in deep inspiration when the enlarge-\\nment is great, as in leukcemia, the organ can be grasped with both\\nhands, and its hilus clearly mapped out. The same thing can be done\\nin the rare instances of floating spleen, but here a knee-chest position\\nwill favor successful palpation. The posterior border of an enlarged\\nspleen can usually be made out by passing the hand backward over the\\nresisting organ. At its posterior border a non-resisting space can be\\ndetected between the border and the mass of lumbar muscle. In chil-\\ndren it is always easy to define this border. Xo such space exists in\\nrenal enlargements. The existence of this space and the direction of\\nenlargement of the spleen are due to the costo-colic fold of peritoneum\\n(Jenner). In splenic leukaemia the spleen may be larger after a meal,\\nyield a creaking fremitus on palpation, a murmur on auscultation, and\\nmay even pulsate. The spleen may also lessen in size after diarrhoea\\nor free hemorrhage. As it lies entirely behind the ribs, it does not, of\\ncourse, admit of palpation when the size is normal.\\nPercussion. (Plate XVI., Fig. 2.) Being a solid body it gives\\na dull sound on percussion, contrasting with pulmonary resonance\\nabove, intestinal tympany below, and stomach tympany anteriorly.\\nPosteriorly and below its dulness merges into that of the lumbar region\\nand kidney. The upper posterior portion is hidden behind the dia-\\nphragm and overlapping lung, and hence is not accessible to percussion.\\nPractically, therefore, the normal splenic dulness extends between the\\nninth and eleventh ribs, in the middle and posterior axillary lines, the\\nspleen being there in contact with the ribs.\\n1 Musser: Trans. Assoc. Amer. Physicians, vol. iv., 1889.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0980.jp2"}, "981": {"fulltext": "DISEASES OF LIVER, SPLEEN AND PANCREAS. 891\\nIn percussion of the spleen the patient should lie on his right side.\\nBeginning from above downward we percuss gently until pulmonary\\nresonance is succeeded by dulness then anteriorly, proceeding toward\\nthe axilla, until stomach tympany yields to dulness. In the same\\nway, percussing from below upward, the line is reached where intestinal\\ntympany gives way to dulness.\\nSplenic dulness may be encroached upon by the stomach or colon\\ndistended with gas, or its dulness may appear increased through disten-\\ntion of the stomach and colon with solid matter, or by a left pleural\\neffusion, or left basal pneumonia. The spleen may also be pressed\\nupward by ascites or by a large abdominal tumor, so that its normal\\ndulness is much lessened.\\nIf the ligament which holds it in place becomes relaxed, the spleen\\nmay become floating. According to Stint-zing, a floating spleen is\\nincreased in density, is generally enlarged, and is recognized by its\\nform (notch, etc.), by being movable to and fro, and by the absence of\\nsplenic dulness in the normal position, and its reappearance when the\\nspleen is replaced.\\nEnlargement of the Spleen. Enlargement of the spleen may be\\nacute or chronic. Acute enlargement occurs in certain infectious dis-\\neases, particularly typhoid fever, typhus, smallpox, relapsing fever,\\nscarlet fever, diphtheria, epidemic cerebro-spinal meningitis, the mala-\\nrial fevers and meningitis, and in diseases with blood-poisoning, as\\nsepticaemia, puerperal fever, and erysipelas.\\nA rare cause of enlargement is acute splenitis. Generally, it is the\\nresult of emboli lodged in the spleen and starting from an endocarditis.\\nThe area of splenic dulness extends rapidly, and there is local pain\\nand tenderness on pressure, increased by coughing and deep inspira-\\ntion other symptoms are fever, nausea and vomiting, and occasionally\\ndelirium. If, as frequently happens in splenitis, emboli lodge in the\\nkidneys also, the urine will be albuminous and bloody. If suppura-\\ntion ensues, the fever becomes hectic, and the spleen continues to\\nincrease in size. Splenic abscess may, however, remain latent until\\nrupture occurs.\\nChronic enlargement of the spleen occurs as hypertrophy and as the\\nresult of amyloid disease, leukaemia and pseudoleukemia, chronic mala-\\nrial poisoning (ague-cake), syphilis, hydatid tumor, and cancer. En-\\nlargement is greatest in leukaemia and in ague-cake. The spleen in\\nwell-marked cases of these affections may reach to the umbilicus and\\neven beyond, filling up the hypogastrium and extending to the right\\niliac region, measuring thirteen or fourteen inches in length and half\\nas much in breadth, and proportionately increased in thickness.\\nPrimary splenic enlargement may occur (1) without local or general\\nsymptoms (2) anaemia, profuse hemorrhages, and brown pigmentation\\nof the skin may be present with the enlargement. Hemorrhages are\\nusually limited to the gastro-intestinal tract. The anaemia is of a chlo-\\nritic type, and there is no change in the leucocytes. (3) Enlargement\\nmay be associated with cirrhosis of the liver and jaundice, with gastro-\\nintestinal hemorrhages and with ascites. This affection is commonly\\nknown as Banti s disease. The blood changes are almost a counterpart", "height": "4416", "width": "2648", "jp2-path": "practicaltreatis00muss_0_0981.jp2"}, "982": {"fulltext": "892 SPECIAL DIAGNOSIS.\\nof those in progressive pernicious anaemia. It may be confounded with\\nchronic inflammation of the peritoneum, giving rise to ascites and\\nassociated with mediastinal pericarditis.\\nDiagnosis of Enlargement of the Spleen. (Plate XLIIL,\\nFigs. 1 and 2.) Enlargement of the spleen can be distinguished from\\nenlargement of the left kidney by the greater movability of the spleen.\\n1 The spleen does not extend as far back toward the spine as the kidney,\\nso that the fingers can be thrust behind its posterior border, and, if the\\nother hand grasps the anterior edge, the organ can be moved backward\\nand forward. Splenic dulness extends to the ninth rib or higher.\\nKidney-dulness has no thoracic area, but reaches to the spine (lumbar).\\n2. Again, the spleen is more movable with respiration than the kidney\\nis. 3. The spleen falls further toward the median line, when the patient\\nis in the knee-chest position, than does the kidney. 4. An enlarged\\nkidney has the colon in front of it, and hence its dulness is obscured by\\nthe tympany of the bowel. 5. The shape of an enlarged kidney is more\\nglobular than that of the spleen. The anterior surface of the latter is\\nsmooth and rounded, but at its junction with the flat posterior surface\\nthere is a sharp edge. 6. Pain in renal disease often shoots down the\\nureters and into the testicles. In diseases of the spleen the pain is\\ngenerally localized to the splenic region, and may shoot into the left\\nshoulder. 7. Result of examination of the urine will often make clear\\nthat the disease is renal, or, by its negative result, will point to the\\nsplenic origin of the tumor.\\nIt is sometimes difficult to demonstrate enlargement of the spleen\\nwhen the liver, and particularly the left lobe, are enlarged. Careful\\npalpation reveals the edge of the spleen, which descends further than\\nthe liver in full inspiration. Having found the anterior edge, pressure\\nwith the other hand posteriorly will bring the spleen forward, which\\nwould not occur if the suspected enlargement was the left lobe of the\\nliver.\\nThe diagnosis of splenic leukcemia (Plate XLIV., Fig. 1) rests princi-\\npally upon the blood-condition, particularly upon the existence of a\\nmarked increase of white blood-cells. Red cells are decreased, and\\naltered forms are present. In addition to characteristic blood-changes\\nthere is a great disposition to hemorrhages dropsies and priapism are\\ncommon and, in later stages, fever, diarrhoea, great weakness, and\\ngrave complications, such as pneumonia. Hemorrhage in splenic leu-\\nkaemia occurs from the nose, bowel, stomach, gums, or kidney. It may\\nalso be subcutaneous, intermuscular, cerebral, or retinal.\\nRegarding the diagnosis of splenic hypertrophy (ague-cake) in chronic\\nmalarial affections, Osier says The history of malarial cachexia, the\\nabsence of lymphatic enlargement, and the blood-condition will usually\\nbe sufficient for the purpose of a diagnosis. Great increase in the\\nwhite blood-corpuscles is not often seen in the chronic splenic tumor of\\nmalaria indeed, they may be much diminished in number. Toward\\nthe end in very chronic cases the clinical picture may be very similar\\nthe large abdomen, possibly ascites, dropsy of the feet, and irregular\\nfever may resemble closely splenic leukaemia, and the absence of an\\nincrease in the colorless corpuscles may be the only marked difference.", "height": "4408", "width": "2624", "jp2-path": "practicaltreatis00muss_0_0982.jp2"}, "983": {"fulltext": "PLATE XLII\\nFIG. 1,\\nFIG. 2.\\nEnlargement of the Spleen.\\nTumor of the Left Kidney.", "height": "4336", "width": "2612", "jp2-path": "practicaltreatis00muss_0_0983.jp2"}, "984": {"fulltext": "", "height": "4408", "width": "2588", "jp2-path": "practicaltreatis00muss_0_0984.jp2"}, "985": {"fulltext": "PLATE XLIV\\nFIG. 1.\\n\u00e2\u0080\u0094LI\\nMf\\nMJ\\nLeukaemia Enlarged Liver and Spleen.\\nFIG\\n2.\\ns.\\nIB ^^^|r\u00c2\u00bb\\n,/f\\n.\\\\^NN_\\nflN^\\n4fl^\\n^x c\\n1\\n\\\\j\\nCyst of the Pancreas.", "height": "4336", "width": "2688", "jp2-path": "practicaltreatis00muss_0_0985.jp2"}, "986": {"fulltext": "", "height": "4408", "width": "2640", "jp2-path": "practicaltreatis00muss_0_0986.jp2"}, "987": {"fulltext": "DISEASES OF LIVER, SPLEEN AND PANCREAS. 893\\nAmyloid spleen, with enlargement of the organ, occurs in conditions\\nof prolonged suppuration, especially when the bones are involved, and\\nin chronic phthisis and syphilis. The spleen is enlarged, hard, and\\npainless. The enlargement is rarely great enough to produce distress\\non that account, and it is so commonly associated with a similar condi-\\ntion of the liver and kidneys, if not of other organs, that any constitu-\\ntional symptoms produced by the spleen are apt to be masked by those\\nproduced by other organs.\\nHydatid tumor of the spleen rarely causes any symptoms except\\nwhen it becomes very large then it may give rise to discomfort and a\\ndragging pain in the left hypochondrium. But hydatid tumors of the\\nspleen are only exceptionally very large when large enough to admit\\nof palpation, and when the tumor is situated anteriorly or projects from\\nthe lower border or from beneath the organ, the detection of fluctuation,\\nthe withdrawal of the characteristic fluid by aspiration, and possibly\\nthe hydatid fremitus, will establish the diagnosis, when taken in con-\\nnection with the gradual development of the tumor and exposure to\\npossible infection. In the absence of physical signs of a cyst the nature\\nof the tumor can only be suspected from the habits of the patient or\\nhis place of residence. Suppuration of the sac may be brought about\\nby injury or rupture into the adjacent cavities, with grave if not fatal\\nresults.\\nInherited syphilis and chronic syphilis are accompanied by enlarge-\\nment of the spleen. They cause a chronic interstitial inflammation.\\nThe enlargement is not very great, and does not present characteristic\\nfeatures.\\nMalignant tumors of the spleen are very rarely primary. The diag-\\nnosis must be made by noting malignant disease elsewhere, the very\\nrapid enlargement of the spleen, with possibly nodules scattered over\\nits surface, and the presence of cachexia and the usual constitutional\\nsigns of a malignant disease.\\nIn young children enlargement of the spleen is not uncommon. It is\\nfound associated most frequently with rickets, syphilis, and malarial\\npoisoning, and has been attributed to each of these diseases. In the\\nLondon Lancet, April 30, 1892, Dr. J. W. Carr analyzes thirty cases,\\nand comes to the conclusion that the enlargement of the spleen is due\\nto splenic anosmia, the essential cause being unknown. Rickets, syph-\\nilis, and ague are found as passing causes only, since the disease is\\nfound in some cases where these causes can be excluded. According to\\nthis author, the disease is extremely rare in children older than two\\nand one-half years. The spleen is more readily palpated in children\\nthan in adults. It is also more movable, and hence by bimanual pal-\\npation it can be more easily brought forward to the median line.\\nDiseases of the Pancreas.\\nJust as the functional activity of the pancreas is separated with diffi-\\nculty from that of other functionally related organs, so the aberration\\nof such activity is discerned with the greatest difficulty. As the physi-\\nology and pathology are blended so the symptoms are intermingled.", "height": "4416", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0987.jp2"}, "988": {"fulltext": "894 SPECIAL DIAGNOSIS.\\nThe pancreatic secretion aids in intestinal digestion, particularly in\\nemulsifying fats, hence symptoms due to disturbance of this function\\nare looked for, and it is, in a measure, true of all cases of pancreatic\\ndisease that there is some intestinal indigestion. For the purpose of\\ndetermining whether the function of digestion of fats has been modified\\nthe patient with suspected pancreatic disease is given fats in some form,\\nand the stools are watched. If fat is passed in the stool in the amount\\ntaken by the mouth, without being broken up, or emulsified, it is held\\nas proof that disease of the pancreas is present. While fatty stools may\\nbe indicative of pancreatic disease, the absence of fat in the stools, in\\npatients who are fed upon it, cannot be considered to exclude disease\\nof this organ, for, notwithstanding its absence in a large number of\\ninstances in which the experiment was tried, the pancreas was found\\nto be the seat of grave disease. Sugar has been observed in the urine\\nin many cases in which the pancreas was the seat of the disease. In\\nfact, glycosuria has been attributed to pancreatic disease in cases of\\ngrave diabetes. This symptom, however, is not constant in pancreatic\\nlesions. Three classes of symptoms intestinal indigestion, fatty stools,\\nand glycosuria are, therefore, not diagnostic of pancreatic disease, but\\nonly afford presumptive evidence of its presence.\\nTumor of the Pancreas. The most striking symptoms of disease of\\nthe pancreas, apart from those due to the morbid process, as suppura-\\ntion or cancer, are those due to a tumor pressing upon surrounding\\nstructures. It may press upon the gall-duct, causing jaundice. From\\nits situation in the epigastric region it may resemble an aneurism, or a\\ntumor of the pylorus or of the transverse colon. Tumors of the pan-\\ncreas are usually due to cancer. This is usually of the scirrhous variety,\\nand generally primary. The enlargement cannot be distinctly made\\nout unless the patient is very much emaciated. When it has advanced\\nconsiderably it may simulate aneurism, but is distinguished by the\\ndifference in the character of the pulsation. In aneurism the pulsation\\nis distensile, in disease of the pancreas it is an up-and-down movement\\nthe hand is lifted with each pulsation of the aorta. Tumor of the\\npylorus is excluded largely because of the more superficial position of\\nthe mass, because of its association with pyloric obstruction, and with less\\nfrequent jaundice than occurs in disease of the pancreas. A pyloric tumor\\nis more movable and may change position after the stomach is inflated\\nby gas or distended by fluid. Examination with the patient on the\\nhands and knees may aid in the distinction between the two. In a\\ntumor of the transverse colon its nearness to the surface and its mova-\\nbility, its association with more or less constipation, and the occurrence\\nof intestinal hemorrhage, are of diagnostic significance.\\nThe general symptoms of the cancerous cachexia the occur-\\nrence of intestinal indigestion, or of fatty stools the gradual onset of\\njaundice the occurrence of deep-seated epigastric pain an immovable\\ntumor, with glycosuria, make a symptom-group very characteristic of\\ncancer of the pancreas.\\nWhen the patient is on a milk-diet an examination of the feces will\\nshow that an excess of the ingested fat is lost in short, that there is\\ndeficient pancreatic digestion with lessened absorption of fat.", "height": "4412", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0988.jp2"}, "989": {"fulltext": "DISEASES OF LIVER, SPLEEN AND PANCREAS. 895\\nHemorrhage. We owe to F. W. Draper and Prince our knowl-\\nedge of hemorrhage into the pancreas. Since they have published the\\nresults of their labors the affection has been frequently recognized.\\nThe attack comes on suddenly in perfect health, and usually terminates\\nlife in a short period. Nothing in the occupation or conduct of the\\npatient at the time is known to favor the development of the hemor-\\nrhage. He is seized with severe pain, which is localized in the upper\\npart of the abdomen. It increases in severity, and may intermit like\\ncolic. Nausea and vomiting take place almost at the same time. The\\nvomiting becomes obstinate. Extreme depression rapidly sets in and\\nthe patient becomes anxious and restless. Collapse ensues in a short\\ntime. The extremities become cold and the forehead is covered with\\nsweat. The pulse increases in frequency, and rapidly diminishes in\\nstrength. It soon becomes imperceptible. The pain and vomiting\\ncall attention to the upper abdomen. It is tender on pressure the\\ntenderness may extend throughout the entire upper half of the abdo-\\nmen. Tympanites may develop. There is constipation in many cases.\\nThe temperature remains normal, or becomes subnormal. The pain,\\nthe vomiting, the anxious and restless state continue without relief.\\nFrom the above group of symptoms it can readily be seen that the\\ndiagnosis is obscure. The disease can be taken for perforation of the\\nstomach by ulcer, although the vomiting may not be so persistent and\\nfrequent. Intestinal obstruction in the upper portion of the tract\\npresents allied symptoms. The hemorrhagic symptoms, however, are\\nmore pronounced in pancreatic hemorrhage. Pallor of the face is sure\\nto ensue. The vomiting is not fecal in character. Constipation can\\nbe relieved. It is, however, difficult, and in many cases impossible,\\nto establish a diagnosis. The rapidity of development of the symptoms\\nis of importance. The pain and collapse may be due to rupture of an\\naneurism of the aorta.\\nAcute Hemorrhagic Pancreatitis. For our knowledge of this\\ndisease we are indebted to Fitz. He collated the facts from the litera-\\nture, and, adding the results of his own valuable observations, has\\nenabled us to recognize this affection during life. It usually occurs\\nafter the middle period of life, although it may occur in early child-\\nhood, the youngest patient known to the writer being eight months of\\nage. It is more common in males in those addicted to alcohol, and\\nin. fat subjects. The patient has often been the subject of attacks of\\nindigestion or of epigastric pain or of biliary colic. A blow on the\\nabdomen or injury in the lumbar region appears to have been the\\nexciting cause in a number of cases.\\nThe attack develops suddenly, resembling somewhat hemorrhage of\\nthe pancreas. There is violent pain which is at first complained of in\\nthe upper abdomen, although it is sometimes general. Nausea and\\nvomiting are present in all the cases, constipation in most of them.\\nThe abdomen is frequently the seat of tympanitic distention. In\\nmany instances an obscure tumor can be made out in the lower epi-\\ngastric region. Collapse-symptoms supervene, although fever may\\noccur, the temperature rising to 102\u00c2\u00b0. The cases terminate by the\\nfourth day, even earlier in some cases. The pain and collapse are", "height": "4416", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0989.jp2"}, "990": {"fulltext": "896\\nSPECIAL DIAGNOSIS.\\nprobably due to pressure of the effused blood upon the coeliac plexus.\\nThe fever is due to a colon-bacillus infection. Violent delirium resem-\\nbling acute mania and not unlike that seen in atropine-poisoning, occurs\\nin some instances. Symptoms of localized peritonitis arise, and if the\\npatient lives the tumor increases to a considerable size.\\nFig. 204.\\nTumor of the pancreas.\\nThe symptoms resemble acute intestinal obstruction, an irritant poison,\\nor perforation of the gastro-intestinal or biliary tract. In several in-\\nstances laparotomy has been performed for the relief of supposed\\nobstruction. The intense pain in the epigastrium, with violent vomit-\\ning and distention of the upper abdomen, without a possible cause for\\nobstruction, are favorable to acute pancreatitis. The difficulty of diag-\\nnosis, however, is so great that resort to laparotomy is justifiable, in\\norder to determine exactly the nature of the condition. In a most\\ninteresting case reported by W. S. Thayer, the diagnosis of acute\\npancreatitis (confirmed by laparotomy) was based upon the history of\\nprevious attacks of pancreatic pain, with fever, vomiting, and collapse,\\noccurring in an adult, who was over-fat and an alcoholic the exclusion\\nof disease in other organs and the absence of a history of gallstones or\\ngastric ulcer or abscess from other causes the occurrence of pain the\\npresence of a deep-seated tumor which gave indistinct signs of fluctua-\\ntion, which was not movable with respiration, and the dulness of which\\nwas not continuous with or of the same character as that of adjacent", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0990.jp2"}, "991": {"fulltext": "DISEASES OF LIVER, SPLEEN AND PANCREAS. 897\\nsolid organs. Epigastric tympany was also a point in favor of pancre-\\natic disease. The accompanying figure indicates the site of the tamor\\nin Dr. Thayer s case.\\nSuppurative Pancreatitis. Fitz has found that this affection\\noccurs in adults under forty years, more frequently in males. Symp-\\ntoms continue during several weeks, and mav persist for a year. Pain\\nin the epigastrium is complained of, associated with irregular vomiting,\\nthe latter persisting in spite of care as to feeding. Fever is irregular\\nin type, and exhaustion ensues. Jaundice, fatty diarrhoea, and gly-\\ncosuria have been met with in some cases. In a case under my observa-\\ntion obstruction of the portal vein took place, with ascites. The latter\\nwas large, and recurred rapidly after tapping. In this patient pain\\nand gastric disturbance were absent. There was no fever. Emacia-\\ntion, constipation, and a tumor above the umbilicus were present; the\\nemaciation was extreme. The tumor was ill-defined, painless, appar-\\nently superficial. Many other symptoms of pancreatic disease pointed\\nout by Roberts were present. Apathy and despondency were marked\\nbronzing of the face was also present. The patient was a middle-aged\\nman, forty- two years old, addicted to the use of alcohol. He was\\nthought to have cirrhosis of the liver. As happened in this case, the\\npus may accumulate in the duodeno-jejunal fossa and fill up the cavity\\nof the lesser peritoneum, with more pronounced symptoms of tumor\\nthan occur in similar fluid accumulations in the above-mentioned cavity.\\nGangrenous Pancreatitis. This may follow later upon hemor-\\nrhages into the pancreas. The symptoms are extremely obscure. Symp-\\ntoms of collapse may occur, following pain, which is of longer duration\\nthan in the acute form, or vomiting, which is not so persistent. A\\npatient of mine, upward of sixty years old, suffering from dyspepsia,\\nvomited blood in the course of an illness which was characterized by\\nloss of flesh and weakness. The anaemia became very profound after\\nthe gastric hemorrhage, and exhaustion was extreme. There was no\\nmarked tumor, but only resistance in the region below the xiphoid.\\nThere were dulness and tubular breathing at the base of the left lung.\\nFever was absent. Death ensued from exhaustion. A small, flat car-\\ncinoma was found in the pyloric end of the stomach, but there was no\\nperforation. Gangrenous pancreatitis, with signs of an ante-mortem\\nhemorrhage, was found. The accumulation took place behind the\\nstomach and colon, but in front of the kidney its outer wall was\\nbounded by the spleen. It was circumscribed above by the diaphragm.\\nPleuritis and small pulmonary abscesses at the base of the left lung\\nwere found.\\nIn some instances the pancreas has sloughed into the bowel, and in\\ntwo such cases recovery took place after its discharge from the rectum.\\nChronic pancreatitis is not recognized during life, although its possible\\npresence must be considered in all cases of diabetes, and in jaundice\\nnot otherwise explained.\\nCyst of the Pancreas. (Plate XLIV., Fig. 2.) Cysts of the\\npancreas follow impaction of calculi in the pancreatic duct sometimes\\nthe biliary calculi obstruct the orifice. The symptoms are those of\\ntumor in the upper abdomen which occupies the median position, or is\\n57", "height": "4416", "width": "2604", "jp2-path": "practicaltreatis00muss_0_0991.jp2"}, "992": {"fulltext": "898 SPECIAL DIAGNOSIS.\\nchiefly on the left side in the upper quadrant. It may fill the abdominal\\ncavity and simulate ovarian tumor. It usually develops slowly, but\\ncases of rapid onset have been described. Fatty diarrhoea is not present.\\nThere is a sense of weight and fulness in the epigastrium. The cysts\\nare not really true cysts, but accumulations of pancreatic fluid in the\\nlesser peritoneal cavity.\\nThe signs are those of tumor to the left of the median line, encroach-\\ning upon the left lobe of the liver above, and extending almost to the\\ntransverse umbilical line. Korte, in a series of sixteen cases, observed\\nthat the greatest prominence of the mass was below the navel. The\\ntumor is smooth, and may fluctuate it is not hard and tabulated. On\\naccount of its presence the diaphragm may be arched so that the heart\\nis dislocated upward to the left the apex is found in the third inter-\\nspace. It also causes increased dulness behind on the left side, the\\nupper border approaching the angle of the scapula. Exploratory punc-\\nture in either instance determines the nature of the fluid, and may deter-\\nmine the diagnosis. Boas does not think the chemical character of the\\nfluid is sufficient to establish a diagnosis. (See Examination of Cyst\\nFluid, page 367.)\\nSenn has pointed out that in cysts of the pancreas the complexion is\\npeculiar it is described as an unhealthy yellow, dirty, or earthy hue.\\nThe writer also considers that, in the diagnosis of pancreatic cyst, the\\nhistory of the case, the location of the tumor, and its relation to other\\norgans are to be considered. The disease occurs in adults, and usually\\nfollows traumatism. A blow in the epigastrium is a prominent ex-\\nciting cause. In some instances it occurs after an attack of so-called\\nbiliary colic or colicky pains in the upper abdomen, with vomiting,\\nbut without jaundice a condition characteristic of calculus in the\\npancreatic ducts. The growth of the tumor in some cases is unusually\\nrapid a point in favor of its pancreatic origin. It may attain an\\nenormous size, as previously mentioned.\\nIn contrast to cancer, pain is absent. Fatty stools are absent. Pre-\\nvious gastro-intestinal derangement may be ascertained upon inquiry.\\nDiabetes, in this as well as other affections of the pancreas, may be\\npresent. The cyst is always found at first in the region occupied by\\nthe pancreas, depending somewhat upon the portion of the pancreas\\nfrom which it originated. It may be below the right lobe of the liver,\\nbelow the xiphoid, or in the left upper quadrant. In the great majority\\nof cases it occupies the last situation. It displaces the stomach forward\\nand to the right, the transverse colon downward, the diaphragm and\\nthe contents of the chest upward. The cyst may be movable in respi-\\nration.\\nDiagnosis. It must be distinguished from cancer of the pancreas or\\nadjacent organs, aneurism, hydatid cyst of the liver, the spleen, or the\\nperitoneum, affections of the retroperitoneal glands, hydronephrosis,\\ncystic disease of the suprarenal capsule, circumscribed peritonitis with\\nexudation, ascites, cystic disease of the ovary. Pain is an important\\nsymptom of disease of the pancreas in its more acute manifestations\\nit must be distinguished from the pain of intestinal obstruction and the\\npain of perforative peritonitis. The pain is always localized in the", "height": "4416", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0992.jp2"}, "993": {"fulltext": "DISEASES OF LIVER, SPLEEN AND PANCREAS.\\nregion below the xiphoid, or, in general, is confined to the upper half\\nof the abdomen. It exactly simulates the pain of the affections just\\ndescribed. This resemblance is more pronounced because of the asso-\\nciation of vomiting and collapse in obstruction and perforative perito-\\nnitis. Pain, although not so intense, but of a colicky nature, attended\\nby diarrhoea or constipation, in some instances with intestinal hemor-\\nrhage, may be due to calculous disease of the pancreas. Frequently\\nthis form of pain can be recognized if other symptoms of pancreatic\\ndisease, such as glycosuria, steatorrhea, and intestinal indigestion, are\\npresent.", "height": "4416", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0993.jp2"}, "994": {"fulltext": "CHAPTER VII.\\nDISEASES OF THE KIDNEYS.\\nThe kidneys are affected by disease from several sources. First,\\nthe great vascular supply is subject to the alteration which takes place\\nin any large arterial area, either from direct hyperemia, through the\\ninfluence of the vasomotor nerves (see Hyperemia), or from passive\\nhyperemia or congestion through the central organ of the circulation.\\nSecond, the bloodvessels are the seat of thrombosis and embolism, particu-\\nlarly the latter, causing renal infarction. Third, infectious material, as\\nmicro-organisms or toxins, is carried to the kidney, and, in passing\\nthrough the structure, gives rise to inflammation either of an infective\\nor of an irritative character. Similarly, poisons that are ingested, and\\nthe products of metabolism, which, if modified in character or in-\\ncreased in amount, excite irritation and lead to inflammatory changes.\\nBut the kidney is open to attack from sources lower down in the\\nurinary tract. Through the bladder and ureter infection may extend\\nupward, causing the consecutive inflammatory processes which are often\\nseen after disease of the urethra, bladder, or ureter. The kidney is at\\nthe apex of a system of tubes or channels. Any alteration of them,\\nwhether mechanical or functional, has a secondary effect upon the kid-\\nney. Obstruction of the ureter, or obstruction in the conduits beyond,\\nleads to consecutive hypertrophy, inflammation, and atrophy. (See\\nMorbid Processes.) If the urine is abnormal, one of these three\\ncausal conditions obviously may be present.\\nThe morbid processes which may take place in the kidney are such\\nas are common to all organs congestion, inflammation, degeneration,\\nand morbid growths. The symptoms that attend the morbid processes\\nare such as accompany similar processes elsewhere. The general symp-\\ntoms of the morbid processes are not marked except in the case of\\ninfectious inflammation or of morbid growths, as carcinoma. There are\\nfever and emaciation. Fever occurs in acute nephritis, perinephritic\\nabscess, suppurative and tuberculous nephritis, pyelitis, and, with twists\\nof the ureter, in floating kidney. Emaciation occurs in chronic, suppu-\\nrative, and tuberculous nephritis and carcinoma. Other general symp-\\ntoms in renal disease are due to the interference with the function of\\nthe organ which usually results. Pain is the only local symptom due\\nto the morbid process a swelling the only physical sign.\\nThe symptoms of renal disease are also due to the functional or ana-\\ntomical alteration of the kidney. But the structure is so closely inter-\\nwoven with the function that morbid changes in one imply morbid\\nchanges in the other. As the anatomical alterations are usually beyond\\nthe pale of physical investigation, we find that functional symptoms\\nalone are apparent. Hence, we look for changes in the urine, which is", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_0994.jp2"}, "995": {"fulltext": "DISEASES OF THE KIDNEYS. 901\\nthe product of renal function, and for symptoms resulting from abey-\\nance or cessation of the function. Rarely we have enlargements due to\\ntumor, as cancer or abscess, or to obstruction of the channels, causing\\nhydronephrosis, or to parasitic disease.\\nThe symptoms due to the alteration of function are 1 Urcemia.\\n2. Cardio-vascular symptoms. 3. Ancemia. 4. Dropsy. 5. Altera-\\ntions of the urine. 6. Alterations in micturition. The symptoms of\\nrenal disease are, therefore, both subjective and objective.\\nThe urine is not simply an index of the condition of the kidneys.\\nIt varies, within the bounds of health, in color, quantity, and quality.\\nFood, exercise, and other conditions modify the secretion. It can\\nreadily be seen, therefore, that any general disease and many local dis-\\neases cause alterations in the character of the urine. Any abnormal\\nurine, therefore, may be symptomatic of renal disease or of disease\\nbeyond the point at which the urine passes out of the body. Usually\\nabnormal changes in the urine, due to the general condition, do not\\ngive rise to local renal symptoms or to abnormal renal function. The\\nexception is seen when an excess of uric acid, or of urates, or of oxalates\\nis passed. They may give rise to local pain and may set up sufficient\\nirritation to cause albuminuria.\\nClassification. The best classification of diseases of the kidneys is\\nthat based upon the propositions of Delafield, who, in a paper entitled\\nOn the Diseases of the Kidneys Popularly Called Bright s Disease/ 1\\nsubmitted a classification dependent upon the nature of the morbid pro-\\ncess. The morbid processes included congestions, degenerations, and\\ninflammations of the renal structure. In addition to these affections\\nwe must also include in the nosology of renal disease tumors (cancer,\\nabscess, and hydronephrosis), and anomalies of growth or position\\n(floating kidney, horseshoe kidney), affections due to invasion of the\\nkidney by parasites, and affections due to obstruction of the tubes\\nthrough which the offices of the kidney are carried on (renal calculus,\\nhydronephrosis, and pyonephrosis).\\nThe Data Obtained by Inquiry. The Subjective Symptoms.\\nThe subjective symptoms are due to morbid processes within the\\nkidney or to alterations of its function. The class of nervous symp-\\ntoms which belong to uraemia are subjective in character, as are also the\\nsymptoms of movable kidney.\\nPain. Pain, in the kidneys is referred to the loins. It is complained\\nof as a dull aching, sometimes increased by movement, often attended\\nby a sense of weight or pressure. Pain of this character extends over\\nthe entire lumbar region and is due to disease of both kidneys, as in\\nacute nephritis. It is bilateral. We have also unilateral renal pain,\\nreferred to one kidney. The pain may be seated in the region of the\\nkidney behind, opposite the two lower dorsal and two upper lumbar\\nvertebral spines, or deep-seated in the abdomen, to the right or left of\\n1 Trans. Amer. Physicians, vol. vi., 1891, p. 124.", "height": "4416", "width": "2636", "jp2-path": "practicaltreatis00muss_0_0995.jp2"}, "996": {"fulltext": "902 SPECIAL DIAGNOSIS.\\nthe spinal column below the level of the umbilicus. It is not generally\\nmistaken for pain due to other causes, as myalgia, or disease of the\\nvertebrae. If rnyalgic, it may follow exposure to cold and be associ-\\nated with pain in other muscles. Neuralgia of the kidneys no doubt\\noccurs. It may be due to malaria, lead-poisoning, gout, or anaemia.\\nIt partakes of the character of neuralgia elsewhere. It must not be\\nforgotten that in a case of disease of one kidney the pain is frequently\\nreferred to its healthy fellow.\\nUnilateral pain may be constant or paroxysmal. Constant pain is\\nusually due to organic disease of the kidney, as carcinoma or tubercu-\\nlosis. (See Palpation.) It may, however, be due to the impaction of a\\ncalculus in the pelvis of the kidney. It may also be due to a displaced\\nor movable kidney. In tumors the pain may follow the course of the\\nsciatic nerve, simulating sciatica. In pyelitis and hydronephrosis the\\npain is of a tearing character, whereas in movable kidney it is variable.\\nParoxysmal and lancinating pain, the paroxysms occurring at long\\nintervals, is usually due to renal calculus, or to the presence of a foreign\\nsubstance, as blood, in the pelvis of the kidney. The pain is seated\\nnot only in the regions just indicated, but extends along the ureter,\\nfrom the loin to the front of the abdomen. It may persist for some\\ntime, at a point on either side of the umbilicus above or below it, or at\\na point on the surface of the abdomen opposite the brim of the pelvis.\\nThence the pain extends into the bladder, either above the pubis (the\\nhypogastric region), or into the testicle, or down the inside of the thigh.\\nIt may be in the loin and at the end of the penis at the same time, or\\nlancinate along the whole urinary tract. In rare cases the pain is in\\nthe kidney of the healthy side. The pain of renal colic is always asso-\\nciated with frequency of micturition, with or without pain during the\\npassage of the urine. The character of the urine often points to the\\ncause of the pain. The urine is usually bloody, and at first scanty\\nwhen the obstruction is removed, it becomes copious. It sometimes\\ncontains pus. Between the paroxysms the urine may contain blood,\\npus, and pelvic epithelium. Renal pain or colic located in front of\\nthe abdomen must not be confounded with the pain of hepatic or intes-\\ntinal colic. The pain is usually lower than in hepatic colic, extends\\nalong the course of the ureter, and is attended by symptoms referable\\nto the urinary and not to the hepatic system.\\nNephrolithiasis (Renal Calculus).\\nRenal calculi vary in size from sand, through gravel/ 7 to stones.\\nThe latter may be from the size of a cherry to one large enough to fill\\nthe pelvis of the kidney. They consist usually of uric acid, and are\\nhard, brownish-red or blackish, crystalline, and the larger ones are\\narranged in distinct layers. More rarely we have calculi of calcium\\noxalate, extremely hard and nodular. Some stones have alternate\\nlayers of the two salts others consist of phosphates, but usually the\\ninside is of uric acid or calcium oxalate, the phosphates having been\\ndeposited after the urine became alkaline. Very rare forms are of\\ncystin, xanthin, indigo, etc.", "height": "4416", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0996.jp2"}, "997": {"fulltext": "DISEASES OF THE KIDNEYS. 903\\nA consideration of the frequency of the affection and some etiological\\ndata aid in the diagnosis. It is not a common affection. I have had\\ntwenty-nine cases in private practice and eleven in hospital practice.\\nThirteen cases only have been treated in the Presbyterian Hospital in\\ntwenty-five years, during which time over 8000 cases of all kinds were\\ntreated. 1 It is a disease of the middle and upper classes. This is par-\\nticularly true of uric-acid calculous disease. It is not a disease of the\\nold or the very young, in my experience. The youngest subject was\\ntwenty-five years of age the oldest sixty-nine. The ages ranged from\\nthirty-five to fifty-five. Twelve of my private patients were of the\\nfemale sex, seventeen of the male sex. There does not seem to be much\\ndifference of frequency in the two sexes. Most authorities, however,\\nhold to the preponderance in women, the ratio being as 3 to 1. Seden-\\ntary occupation and an in-door life are predisposing.\\nSymptoms. Symptoms may be wanting or they may be divided into\\nthree classes\\n(a) Calculi may remain in the pelvis of the kidney, and not cause\\nany renal symptoms. They may cause gastric disturbance or catarrh\\nof the bladder or renal pelvis. There may be occasional pain in the\\nlumbar region, the cause of which is unsuspected.\\n(6) They may excite pain, hematuria, and frequent micturition.\\n(c) They may attempt to pass from the pelvis of the kidney into the\\nureter. They then cause renal colic, the symptoms of which have been\\ndescribed above. In the intervals of the attacks of colic the patient\\nmay be free from symptoms.\\nThe symptoms ascribed to the presence of a calculus in the pelvis\\nof the kidney are pain, intermittent hematuria, pyuria, pyelitis, renal\\nintermitting fever, acute orchitis, frequent micturition, and renal colic.\\nPain. Pain of the affected organ is the most constant symptom,\\nand this pain is increased by movement, by jolting, and by pressure.\\nIndeed, pain induced by pressure is of as great significance as sponta-\\nneous pain. It frequently is persistent, and even continues in any\\nposition assumed by the patient.\\nPain in the region of the kidney occurs from renal hyperemia, neph-\\nritis, pyelitis, tumors, and malignant disease, or from myalgia of rheu-\\nmatic or other causation. Indeed, we have seen renal pain and hema-\\nturia in a case of commencing appendicitis. The pain of renal calculus\\n(not renal colic) comes and goes, and is more commonly intermitting\\nand paroxysmal. Very frequently, however, it is constant and local-\\nized, either in the region over the kidney, or anteriorly in the region\\nmentioned. In my experience it comes on during the day, and particu-\\nlarly the after part of the day, and not, as Jacobson would have us\\nbelieve, at night. That it may occur spontaneously is not so much\\na peculiarity of renal calculus as that it can be excited by pressure,\\nmovement, etc.\\nPain is of more diagnostic significance in renal calculus than in any\\nother renal affection. Every attribute that has been applied to pain\\nbelongs to the pain of renal calculus. Its very vagaries render its\\n1 J. H. Musser: Kenal Calculus, Philadelphia Medical Journal, 1898.", "height": "4416", "width": "2640", "jp2-path": "practicaltreatis00muss_0_0997.jp2"}, "998": {"fulltext": "904 SPECIAL DIAGNOSIS.\\npresence one of the most valuable signs of renal calculus. Its behavior,\\nhowever, is often like the flitting nerve-aches of hysteria, and we must\\nsee to it that this counterfeit is not passed upon us. Urinary phenomena\\ndo not serve for the distinction other neurotic manifestations or the\\nstigmata of hysteria aid in the diagnosis. The pain may be aggravated\\nby the function of menstruation and even bear close relationship to it.\\nHematuria. Hemorrhage from the kidney is the classical symp-\\ntom of stone. It is the most constant and positive symptom of renal\\ncalculus. Prior to the use of the centrifugal machine, blood no doubt\\nescaped the eye of the observer when in small amounts, partly because\\nit was destroyed as the urine advanced in decomposition during the\\nperiod it was set aside for the deposition of its solid elements, and\\npartly because the fewness of corpuscles rendered them difficult to find.\\nExcluding all causes outside of the kidney i. e., of vesical and ureteral\\norigin renal hematuria may be due to congestion and inflammation,\\nto infarctions, to new-growths, to tuberculosis, to renal calculus, and to\\nparasites. The fevers and infections, and scurvy, purpura, leukaemia,\\nand haemophilia are responsible for a number of cases. In six years\\n2923 samples of the urine of 1997 persons were critically examined\\nin my laboratory. Blood was present in 364 cases detected by micro-\\nscopic examination alone.\\nThe hsematuria resulted from congestions or hypersemias (pregnancy,\\ngoitre, heart-disease, the fevers, infections, and jaundice) in fifty-six\\ncases. In forty-two cases the hsematuria occurred in the course of\\nacute and chronic Bright s disease, and in nineteen more in arterio-\\ncapillary fibrosis, being either of renal or cardiac origin. Gastric dis-\\norders, rheumatism in many forms, gout, neurasthenia, and anaemia\\naccount for eighty-one of the cases, conditions always associated with\\nthe copious discharge of urinary salts, Avhich are irritating. Vesical\\ndisease accounts for seventeen cases, renal calculus for twenty-eight,\\nand in twenty the diagnosis was not noted at the time and is forgotten.\\nAll the cases of renal calculus had hsematuria. It is not an inter-\\nmittent phenomena alone, but one that is constantly persistent.\\nIt is necessary to eliminate all sources of urethral, vesical, and ureteral\\nhemorrhage before coming to a conclusion that the hemorrhage is of\\nrenal origin. Cystoscopy must be resorted to, of course, and possibly\\nin the right hands, ureteral catheterization. If the hemorrhage is free\\nthe time of its passage in the act of urination must be determined. The\\nreaction of the urine must be borne in mind. It is true, catheterization\\nalone can avail to pronounce from which kidney the hemorrhage comes.\\nBlood-cylinders are rare, if present at all, in renal calculus. They\\ndenote hemorrhage from the renal substance.\\nIn a person of middle life with uric or oxalic acid tendencies, by\\nvirtue of heredity, occupation and habits, in whom no cause for the\\nhemorrhage can exist in the urethra, bladder, or ureter, the chances\\nare that it is of pelvic origin, due to the irritation of gravel or of urine\\ndensely loaded with salts.\\nKlemperer has recently called attention to hsematuria from healthy\\n1 Deutsche med. Wochenschrift, March 4, 1897.", "height": "4404", "width": "2640", "jp2-path": "practicaltreatis00muss_0_0998.jp2"}, "999": {"fulltext": "DISEASES OF THE KIDNEYS. 905\\nkidneys, as the result of overexertion, in one case from horseback\\nriding, in another from the bicycle. He also reports four cases of\\nhaemophilia and a group due to an angioneurosis. Hyaline casts were\\nnot present, although blood-cylindroids were. General symptoms of\\nneurasthenia support the diagnosis in the angioneurotic cases.\\nPyuria. Pus in the urine is looked upon by all authorities as\\nalmost essential to the diagnosis of renal calculus, but in my experience\\nthis product of inflammation is usually absent. Of the twenty-eight\\ncases which I examined, in fifteen there was no pus in six a few cells\\nor a very small quantity was found (four, womb cause obvious) in\\none it was noted as considerable (old gonorrhoea and syphilis, four\\nexaminations) in one a small quantity (male, cause assignable) in\\none it was small in amount, twice only in some fifty examinations\\nin one it was abundant and due to genito-urinary infection as well as\\npyelitis. Pyuria is not present unless an accidental infection has taken\\nplace from the lower tract.\\nAlbumin. In twenty-one patients albumin was found. It was in\\nlarge excess in three, due to coexisting Bright s disease. As a trace it\\nis of frequent occurrence and does not imply a coexisting nephritis.\\nCasts. Casts are present in the urine in nearly all cases of renal\\ncalculus. Sedimentation must be used. They are hyaline not abun-\\ndant long and narrow. Their persistence without other kinds, with\\nor without albumin, is diagnostic of renal irritation, and with other\\nsigns points quite unfailingly to calculus.\\nThe specific gravity of the urine is an aid in the diagnosis. Its\\npersistence above the normal is both a comfort and a sign. It enables\\none to exclude renal cirrhosis and aids to eliminate hysteria or a renal\\nneurosis.\\nFrequent micturition is not in my experience an indication of\\nstone in the kidney, save when attempts are made for its passage,\\nalthough spoken of as a symptom of value by most authorities.\\nParoxysmal renal fever, allied to hepatic fever in its expres-\\nsion, rarely occurs, but when present may be due to calculus. It may\\nalso be due to absorption of retained products, if the kidney is floating\\nand becomes twisted. It may be due to pyelitis.\\nDuration of symptoms and family history are also valuable\\ndata.\\nDiagnosis. Middle life is a predisposing factor, and persistent\\nhematuria is symptomatic, but pyuria rarely so, while albuminuria and\\nhyaline casts in urine of high specific gravity are prominent elements\\nof the symptom-complex upon which a diagnosis is made.\\nThe diagnosis can be established by the symptom-complex of pain,\\nlocal tenderness, persistent hoematuria, albuminuria, and easts (the cardiac,\\nvascular, and nephritic origin of which is excluded), by the phenomena\\nof renal colic and by passage of fragments of stone.\\nIf the hemorrhage persists after prolonged rest, it is more likely of\\ncancerous or tuberculous origin.\\nThe differential diagnosis must be made from appendicitis, movable\\nand twisted kidney, biliary colic, and other affections simulating these.\\nCatheterization and exploration by the ureter are required in many", "height": "4416", "width": "2628", "jp2-path": "practicaltreatis00muss_0_0999.jp2"}, "1000": {"fulltext": "906 SPECIAL DIAGNOSIS.\\ncases. Hollander believes we can in a large number of cases make a\\ndiagnosis without the aid of catheterization, and fears the danger of\\ninfection from below.\\nKelly, very skilfully after ureteral catheterization, aspirates the\\nureters and thereby brings down fragments of calculi. He also explores\\nthe ureters with hard-rubber bougies tipped with wax. He can deter-\\nmine the presence of calculi by the markings on the tips of the bougie.\\nFrequency of Micturition. There are four causes of frequent\\nmicturition (1) Disease of the kidneys, the ureters, or the bladder\\n(2) an increase in the amount of urine, as in diabetes (3) concentra-\\ntion of the urine, as in fevers, gout, or acute nephritis (4) a reflex or\\npure neurosis.\\nIncreased frequency of micturition occurs in almost all organic affec-\\ntions of the geni to-urinary system. It is seen in all forms of congestion\\nand inflammation of the kidneys. In some forms of nephritis the\\nincreased frequency may be due to increase in the amount of urine as\\nwell as to increased sensitiveness of the organs. In chronic nephritis\\nit may not be noticed, save that the patient is called upon to pass\\nurine at night, arousing him from sleep for this purpose. Disease of\\nthe ureter and disease of the bladder are also associated with this\\ntroublesome symptom. It occurs in its most aggravated and charac-\\nteristic form in renal calculus, or when any foreign substance is\\nlocated in the ureter or bladder. The frequency amounts to six, eight,\\nor even a dozen times in an hour. It is often associated with tenes-\\nmus, the patient having a constant desire to urinate, but passing small\\namounts. This form of tenesmus is more frequent when the bladder\\nor urethra is the seat of disease, and in renal calculus.\\nThe Data Obtained by Observation The Objective Symptoms.\\nThe data obtained by observation are secured 1. By physical exam-\\nination of the kidney. 2. By an examination of the urine. 3. By\\ncatheterization of the ureters. 4. By a skiagraphic examination. The\\nexamination of any person who is sick is not complete without an\\nexamination of the kidney and of the urine. The third and fourth\\nmethods of examination are not necessary unless the subjective symp-\\ntoms indicate their necessity, or general symptoms are not otherwise\\nexplained.\\nTopography of the Kidneys. (Plate XIII., Fig. 2.) The kid-\\nneys are situated in the right and left lumbar regions respectively, the\\nleft being a little higher than the right. They extend from the eleventh\\nrib, or twelfth dorsal vertebra, to the third dorsal vertebra. The left\\nkidney is in contact above with the spleen, and the right with the liver.\\nPalpation and Percussion. The kidneys are enveloped in more\\nor less abundant fat their distance from the anterior surface of the\\nabdomen renders them inaccessible to percussion from that direction,\\nand the thick dorsal and lumbar tissues, coupled with the relation of\\nthe kidneys with the organs, spleen, and liver, which give a dull note\\non percussion, make it difficult to outline the kidneys from behind.\\nPalpation of the normal kidney is difficult. It can only be bimanual.", "height": "4416", "width": "2660", "jp2-path": "practicaltreatis00muss_0_1000.jp2"}, "1001": {"fulltext": "DISEASES OF THE KIDNEYS. 907\\nPlace the fingers of one hand below the last rib outside of the lumbar\\nmuscles erector spina? and apply the other below the ribs in front.\\nFirm, persistent pressure with the abdominal muscles relaxed, especially\\nin thin subjects, will often enable the normal kidney to be felt.\\nPalpation of the kidney becomes easy when it is either enlarged or\\ndisplaced. In the case of an enlarged kidney the patient should lie\\nupon his back or be slightly turned to the opposite side one hand is\\nplaced beneath the kidney and pressed upward, while the other is pressed\\nfirmly and steadily from above, or laterally toward the kidney. In this\\nmanner the kidney can be grasped between the two hands, its size esti-\\nmated, and its physical characteristics as regards hardness, softness,\\nfluctuation, and mobility determined. Enlargements are also detected\\nby palpation of the abdomen. (See Palpation of the Abdomen.) The\\nfact that the tumor moves a little with respiration aids in its detection\\nand if it is unusually movable the edge of the hand can be slipped\\nabove its upper end, by turning edgewise that border of the hand\\nwhich is adjacent to the ribs. A renal tumor is usually two or three\\ninches to either side of the median line, a little above the transverse\\numbilical line.\\nA very favorable position for palpating movable kidneys is that\\nassumed by standing and leaning forward over a chair, with the trunk\\nsupported by the hands resting on the seat of the chair. In this\\nposition the abdominal muscles are relaxed and the kidneys fall for-\\nward.\\nIn the diagnosis of renal tumors, in general, it should be borne in\\nmind that they are slightly movable with respiration unless adherent,\\nas in malignant disease, abscess, and cysts. Unless too large they pre-\\nserve their reniform shape, and press in front of them the ascending or\\ndescending colon, whereas ovarian tumors lie in front of it. The posi-\\ntion of the colon should, therefore, always be ascertained, and to this\\nend it may be necessary to innate it.\\nPercussion. The best results are obtained by having the patient\\nlie face downward, and placing a cushion under the belly, so as to make\\nthe lumbar regions a little more prominent. Strong percussion is\\nrequired, and an artificial plessor and pleximeter are to be preferred.\\nPercussion should be conducted with a view to marking the angle\\nwhich the liver-dulness and splenic dulness make with that of the kid-\\nney on the right and left sides respectively. The kidneys extend below\\nthe lower lines of liver and splenic dulness, and laterally for a width not\\ngreater than four inches. The difficulties in the way of outlining the\\nkidneys by percussion are greatly increased in persons with much flesh,\\nor when the abdominal walls are waterlogged, as they become in ascites,\\nand it is practically impossible, under such circumstances, to be sure of\\nthe boundaries of the kidneys. The colon must be emptied to yield\\ntrustworthy results.\\nMovable Kidney.\\nMovable kidney is usually seen in women after the age of forty years,\\nwho have done physical work or have had many children. Adult\\nmales and single women do not escape. Its occurrence is frequently", "height": "4416", "width": "2636", "jp2-path": "practicaltreatis00muss_0_1001.jp2"}, "1002": {"fulltext": "908 SPECIAL DIAGNOSIS.\\npreceded by a history of unusual lifting or strain, followed by tearing\\nor dragging sensations in the abdomen. Pain may continue for\\nseveral weeks after the injury, and then subside and the occurrence\\nbe forgotten, or subjective sensations may continue. In other in-\\nstances the movable kidney is a part of a general visceral displace-\\nment. Gastroptosis and gastro-enteroptosis can usually be made out in\\nsuch cases.\\nThe symptoms that arise are due to the local dragging or pulling of\\nthe kidney on its bloodvessels and nerves, or to reflex symptoms, or to\\npressure upon adjacent organs.\\nThe pain that attends movable kidney is usually referred to the\\nright or left of the median line sometimes to the hypogastrium It\\nmay be constant, dull, and aching in character. Paroxysms may arise\\nin the course of the constant pain, or a paroxysm alone may take place.\\nThe paroxysms continue for three or four days, during which time\\nother subjective symptoms are more pronounced. The attacks are\\nknown as DietVs crises. Nausea may attend the paroxysms, or be more\\nor less constant. Sometimes vomiting takes place. The great pain is\\nassociated with swelling and tenderness of the kidney. The pain,\\nvomiting, and local tenderness may simulate peritonitis.\\nIn addition to pain a dragging sensation is experienced the patient\\nmay be aware of the presence of a tumor or lump in the abdomen, and\\nalso of its movability. The reflex symptoms are chiefly referable to\\nthe nervous system. Emotional disturbance is observed when the\\norgan is displaced. Hysteria may be present. Palpitation of the heart\\nis a common reflex symptom. There are often depression of spirits\\nand hypochondriasis. Jaundice may occur from pressure, and the intes-\\ntine may be occluded.\\nThe urinary symptoms are of interest. When the local pain and\\nother symptoms are more pronounced the urine may be scanty. In\\none case it was reduced to sixteen ounces in twenty-four hours. At\\nthe same time that the urine is scanty hydronephrosis will develop. It\\nwill be referred to again. As the kidney slips back into its bed the\\ntwisting of the ureter is relieved, and copious discharges of urine take\\nplace.\\nObjective Symptoms. (Plate XL V., Fig. 1.) The abdominal walls\\nare usually relaxed, and may or may not contain a large amount of fat.\\nMovable kidney is best detected by palpation. The patient should stand\\nwith the body bent forward and the hands resting on a chair, as de-\\nscribed above. The organ is recognized by its rounded borders, its\\nbean shape, its movability, the detection of the hilus and perhaps of the\\npulsation of vessels in it, and by the fact that it can be replaced. Pal-\\npation causes a sickening feeling, analogous to that experienced when\\na testicle is compressed, but less in degree. Percussion will, however,\\ndemonstrate that a body, supposed from palpation to be the kidney, is a\\nsolid organ. The tumor can be found to the right or left of the median\\nline, freely movable and changing its position with that of the patient.\\nIf the tumor is situated on the right side, it may be in close proximity\\nto the liver, or be felt opposite the umbilicus, or often in the iliac region.\\nWhen near the liver, by careful palpation the fingers can be introduced", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1002.jp2"}, "1003": {"fulltext": "PLATE XLV.\\nFIG. 1.\\nMovable Kidney.\\nFIG. 2.\\n\u00e2\u0096\u00a0v.\\n\\\\Sk\\nMf\\nSarcoma of the Right Kidney.", "height": "4392", "width": "2652", "jp2-path": "practicaltreatis00muss_0_1003.jp2"}, "1004": {"fulltext": "", "height": "4404", "width": "2588", "jp2-path": "practicaltreatis00muss_0_1004.jp2"}, "1005": {"fulltext": "DISEASES OF THE KIDNEYS. 909\\nbetween the border of the liver and the mass. Usually it does not\\nmove with respiration, but sometimes it is found to do so. On the\\nleft side it may be as high up as the margin of the ribs. It is gener-\\nally felt in the mid-clavicular line, a little above the level of the umbil-\\nicus.\\nIn a case recently under the writer s care the woman, aged fifty-five\\nyears, would experience pain in the abdomen about once a month, to\\nthe right of and above the umbilicus. At times nausea and vomiting\\naccompanied the attacks, at other times marked depression or hysteria.\\nAnuria always occurred and continued for a variable time, not longer\\nthan five days. With one of the paroxysms a tumor was found in the\\nregion of the gall-bladder, movable with respiration, but distinctly\\ndefined from the liver by placing the fingers between the lobe and\\nkidney. It moved with each change of position of the patient, and at\\nfirst the hilus could be distinctly felt. As the pain continued the\\nanuria persisted, and a marked change in the tumor was observable.\\nIt gradually increased in size, and a portion of it fluctuated it was\\nround and partook of the character of a cyst. The fluctuation was de-\\ntected by placing the hand on the tumor in front and pressing firmly\\ntoward the other hand placed in the loin above the pelvis. After sev-\\neral days a copious discharge of urine took place and the swelling\\nsubsided.\\nMovable kidney may be confounded with tumor of the gall-bladder,\\ntumor of the pylorus, and with tumors in the pelvis. It is not likely\\nto be confounded with an omental tumor, carcinoma, or tuberculosis,\\nbecause the phenomena of these processes are not present and ascites\\ndoes not occur, nor is there rise of temperature, as in many cases of\\ntuberculosis. As pointed out by Henry Morris, tumor of the gall-\\nbladder and movable kidney are frequently of conjoint occurrence.\\nMovable kidney is distinguished by the absence of previous history or\\nof symptoms or signs indicating disease of the gall-ducts. If jaundice\\nis present, it is not so intense as in tumors of the gall-bladder. While\\nthe gall-bladder is movable, it is not so distinctly so as movable kidney.\\nThe gall-bladder moves in an arc of a circle, the centre of which is at\\nthe edge of the right lobe of the liver. It can be pushed further to\\nthe left than to the right, but never downward as a movable kidney.\\nMoreover, the gall-bladder is always palpable, the movable kidney\\ncannot always be felt. The gall-bladder, if it contain calculi, is very\\nhard compared to the kidney. Anuria does not occur.\\nThe kidney tends to spring back to its place in the loin the gall-\\nbladder to the anterior part of the abdomen. Even if the gall-bladder\\nis enlarged, the kidney can be felt by bimanual palpation while the\\nopposite does not obtain. In cancer of the pylorus the emaciation and\\nanaemia are more pronounced than in movable kidney. The vomit-\\ning, usually characteristic in that affection, and the physical signs of\\ndilated stomach, can be made out. Tumors of the pelvic organs are\\ndetermined by examination according to the usual methods.\\nHorseshoe Kidxey. There are usually no symptoms. The kid-\\nney can sometimes be felt through the abdomen if its walls are relaxed,\\nor by bimanual examination.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1005.jp2"}, "1006": {"fulltext": "910 SPECIAL DIAGNOSIS.\\nEnlargement. Renal Tumor.\\nEnlargements of the kidney may be detected by percussion the width\\nof the kidney is increased, and the percussion-dulness therefore extends\\nfurther to the right or left, according as the right or left kidney is\\naffected. As the causes which produce enlargements of the kidney\\nsufficiently great to be detected by percussion do not, with rare excep-\\ntions, involve both kidneys at the same time, comparison of the two\\nsides is of great value in the diagnosis.\\nRenal tumors rarely bulge in the lumbar region, although there is\\na sensation of increased resistance in this area. The mass is never\\nnotched, is usually smooth, and often takes the shape of the kidney if\\nthat organ is involved in its entirety. Otherwise the outline is not\\nreniform. The bowel is usually in front of the mass, although in\\ntumors of the right kidney the csecum and colon may be pushed to the\\ninner side, and of the left kidney the colon may be pressed outward.\\nThe diseases of the kidney attended by enlargement are malignant\\ntumors, cystic kidney, hydronephrosis and pyonephrosis, abscess, and peri-\\nnephritic abscess.\\nSarcoma and Carcinoma of the Kidney.\\nEither disease may be primary or secondary. Sarcoma may be con-\\ngenital. The tumor may occur at any age, but is relatively common\\nin young children. Twenty-five out of sixty-seven cases collected by\\nDr. William Roberts occurred in children under ten years of age. In\\nolder persons it is often preceded by calculus. Symptoms: In some\\ninstances there are no symptoms during life. In others the disease\\nmay advance considerably before it presents any signs. If symptoms\\nare complained of they are usually limited to pain, the occurrence of\\nhematuria, or the development of a tumor. The pain is dull and seated\\nin the lumbar region. It may be neuralgic in character; and, indeed,\\nthere may be a true sciatica with paresis of the leg from pressure of the\\ntumor. The tumor (Plate XLV., Fig. 2) is firm its surface is smooth\\nor nodulated. It may be felt in the loins, and in front, above the um-\\nbilicus, a few inches to the right or left of the median line the descend-\\ning colon lies in front of the tumor. The latter may grow with great\\nrapidity and attain enormous size, filling the abdominal cavity and giving\\nrise to pressure-symptoms in surrounding organs. The growth occurs\\nmore often anteriorly and downward toward the pubis, because there is\\nless resistance in these directions. As rapidly growing cancers are soft,\\nthe tumor frequently exhibits a certain degree of elasticity, which may\\nbe mistaken for fluctuation. It is immovable either by the hands or\\nwith respiration.\\nOn percussion the resistance is increased and the note is dull, except\\nin front, where the colon, which has been pushed forward, gives a tym-\\npanitic note. If the colon should be flattened out between the tumor\\nand the abdominal wall, it may be felt as a band stretching across the\\ntumor, with dullness on percussion. In such a case inflation of the\\ncolon will be of great assistance in the diagnosis. Rare physical signs", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1006.jp2"}, "1007": {"fulltext": "DISEASES OF THE KIDNEYS. 911\\nare pulsation and a blowing murmur. The hcematuria may be con-\\nstant or intermittent. The clots of blood may cause renal colic.\\nThe general symptoms are those of carcinoma. A marked rapidity\\nof the pulse has been noted in several cases. In girls a premature\\ndevelopment of hair on the pubes and in the axilla? and pigmentation\\nof the skin have been observed.\\nHemorrhage is an early symptom, and in the absence of nephritis or\\ncystitis should always suggest tumor. It may occur early and may\\nbe intermittent or persistent. In some instances it occurs but once,\\nusually it is frequent. When excessive, the growth is never innocent.\\nPain is not of much value, and may be absent until perinephritis occurs.\\nSymptomatic varicocele may occur. The examination of the urine, save\\nthat it discloses the presence of blood, is negative. In this sense it is of\\nvalue. Pus occurs if there is secondary infection or if calculi precede\\nthe growth. Rarely fragments of carcinoma are said to be detected.\\nIn order to determine the kidney affected separate urine should be\\nobtained from each organ.\\nThe tumor must be distinguished from tumors of the lymphatic\\nglands, of the liver, of the spleen, and of the ovary. It must not be\\nconfounded with psoas abscesses and perinephritic abscesses, which\\ncause a tumor in the lumbar region.\\nCystic Kidneys.\\n1. Congenital. The kidney consists of a small mass of cysts filled\\nwith clear fluid. It may interfere with the birth of the child on account\\nof its large size.\\n2. Acquired. The cause is trauma and obstruction of the ureter, the\\npresence of which is determined by catheterization. The symptoms\\nare those of a fluctuating renal tumor. The urine may be normal or\\nhcematuria may be present.\\nHydronephrosis.\\nCauses. It may be congenital. Obstruction of ureter by stone\\npressure of tumor twist, as in movable kidney exudates.\\nSymptoms. In addition to the symptoms of the causal condition we\\nhave, upon the development of hydronephrosis, the presence of a tumor,\\narising in the region of the kidney and extending toward the middle\\nline. Sometimes fluctuation can be detected often it cannot. Varia-\\ntions in size of the tumor may occur with changes in amount of urine\\npassed. Puncture, and the finding of a fluid with elements of urine in\\nit, are valuable means of diagnosis but if the hydronephrosis is old,\\nthis fails, as the fluid loses its urinary character, and cannot, for instance,\\nbe distinguished from that of an ovarian cyst. When on one side the\\nurine may be normal when on both sides it is diminished anuria and\\nuraemia may occur. If pyelitis is present, pyuria is observed.\\nIntermittent hydronephrosis is associated with movable kidney, hence\\nit is more frequent in women. It is characterized by the development\\nof a renal tumor with variable frequency, and with pain, nausea, and\\nvomiting. At the same time the urine is scanty. In a few hours or", "height": "4416", "width": "2628", "jp2-path": "practicaltreatis00muss_0_1007.jp2"}, "1008": {"fulltext": "912 SPECIAL DIAGNOSIS.\\ndays there is an increase in the amount of urine with subsidence of the\\ntumor.\\nPain may or may not be present. Gastric symptoms are very com-\\nmon. Either constipation or diarrhoea is seen. Hypertrophy of the\\nleft ventricle may occur, as in chronic nephritis.\\nHydronephrosis consists in a dilatation of the kidney pelvis with\\nurine, which is prevented from escaping by obstruction of the ureter,\\neither by the pressure of a tumor, or by disease of the bladder or ureter\\nitself. In time the kidney atrophies from the pressure and a large cyst\\nforms. The tumor has the physical characteristics of pyonephrosis, but\\nthe history is different, and if there is any discharge, it is free from\\npus. As in pyonephrosis, the tumor may become small, following a\\ncopious discharge in this case of urine or may even wholly disap-\\npear, if the obstruction is removed. This sign is pathognomonic.\\nIf obstruction continue to be absolute, the diagnosis must be made\\nby the detection of a fluctuating renal tumor, the absence of fever and\\nsigns of suppuration, and by the result of exploratory puncture. The\\nurine is usually free from pathological changes.\\nIt may be confounded with ascites, if very large, but hydronephrosis\\nis rarely bilateral, and the fluid in it does not change its level upon\\nchange of position of the patient, as is the case with ascites. The\\nhistory of the two conditions will be different.\\nAn ovarian cyst can usually be traced into the pelvis it does not\\ncarry the colon in front of it, and hence is dull, even on superficial\\npercussion, and it leaves the loins resonant.\\nPyelitis. Pyonephrosis.\\nPyelitis is rarely primary usually secondary. Severe infectious dis-\\neases (typhus, variola, diphtheria, pyaemia) toxic substances ingested\\n(cantharides, etc.) chronic nephritis inflammation of the bladder or\\nureter strictures of the ureter or urethra hypertrophy of the pros-\\ntate spinal palsies of the bladder calculus parasites blood-clots,\\nare the antecedent causal factors infection the active cause.\\nSymptoms. The Urine. Pus in the urine with pelvic epithelium\\nalthough it is not safe to base a diagnosis on the presence of the latter\\ncasts of the canals opening into the pelvis are more characteristic\\nepithelial casts, and casts containing micro-organisms. The urine is\\noften increased, acid, and contains pus and albumin, rarely blood.\\nPyuria may be the only renal sign. In all forms of pyuria above the\\nbladder Kelly withdraws the pus by catheterization and suction. He\\nallows the catheters to remain from ten minutes to four or five hours,\\nin order to estimate,the functional power of each kidney. Of course,\\nthe pus is studied microscopically and bacteriologically. Pain in the\\nregion of the kidney, often severe, is complained of, although it may\\nbe absent. When present, it is often of a tearing character. Tumor.\\nA tumor is often present. It is most prominent in the loin or in the\\nabdomen. In the latter the mass can be felt two inches to either side of\\nthe umbilicus, usually above the transverse line.\\nPyelitis differs from abscess of the kidney. The latter may be the", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1008.jp2"}, "1009": {"fulltext": "DISEASES OF THE KIDNEYS. 913\\nresult of a local infection from the pelvis of the kidney or may be\\npysernic.\\nIn abscess of the kidney there is some fulness in the loin of the\\naffected side. The kidney is felt to be enlarged, and is tender and\\npainful. A tumor may be detected anteriorly. The diagnosis is based\\non a study of the cause (acute nephritis, pyaemia, impacted calculus\\nin the ureter, erysipelas), or the detection of blood and pus in\\nthe urine, which is scanty, and on the constitutional symptoms. The\\nprogress of the case is usually acute. If the abscess is tubercular,\\ntubercle bacilli can be detected in the purulent sediment of the urine,\\nand there will be other foci of tuberculosis Avith a corresponding clini-\\ncal history.\\nWhen the pus is confined by an occluded ureter, the pelvis is over-\\ndistended. In pyonephrosis the tumor is tense, smooth, and globular.\\nFluctuation may be detected. Tenderness is usually absent the course\\nis slow and does not affect the general health so much as abscess. The\\npus may be discharged copiously from time to time, and the tumor be\\ntherefore diminished in size. The urine may be occasionally almost\\nclear. Pyonephrosis arises secondarily to pyelitis, and often after the\\nlatter has lasted some time.\\nFever is irregular, remitting, or septic. The fever and pyuria may\\nbe the only symptoms. If the bladder is healthy, its symptoms fail to\\naid in diagnosis.\\nPerinephritic Abscess.\\nIt occurs as a primary disease in apparently healthy individuals, or\\nafter infectious diseases.\\nPerinephritis arises usually from extension of inflammation and sup-\\npuration from the kidney, but may be the result of strain, exposure to\\ncold, or injury. Perinephritis may also be pysemic, and occur after\\ninfectious fevers, and in actinomycosis.\\nSymptoms. The secondary forms have symptoms of the primary\\ndisease, and, later, swelling and pain in the renal region.\\nPrimary form. Chills and fever, pain, difficulty in defecation. The\\ngeneral condition suffers. Finally, in all cases, there is the formation\\nof a swelling in the lumbar region, at first hard then oedema of the\\nskin follows, and fluctuation is detected. The abscess may descend\\nand point above Poupart s ligament. It may press upward and cause\\ndyspnoea. Great tenderness and pain in the region of the swelling may\\narise, and the pain may radiate to the leg. Irregular septic fever and\\nchills appear. The urine is not generally changed unless some com-\\nmunication with the pelvis or ureter has formed. The patient lies on\\nhis back, turned toward the affected side. The knee and hip of this\\nside are flexed and the thigh rotated outward. The affection may simu-\\nlate coxitis and appendicitis.\\nThe swelling of a perinephritic abscess appears in the lumbar region\\nof the side affected. It is rounded in form and doughy (Da Costa).\\nLike other kidney tumors, it is not affected by respiration. The usual\\nsigns of confined suppuration exist, and pulmonary or pleural compli-\\ncations may occur. As the abscess progresses, the local signs of suppu-\\n58", "height": "4404", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1009.jp2"}, "1010": {"fulltext": "914 SPECIAL DIAGNOSIS.\\nration become more marked, the skin reddens, and pus may be discharged\\nexternally.\\nThe most marked subjective symptom is pain, which may amount\\nto agony, and is paroxysmal soreness from restricted motion of the\\npsoas muscle is apt to be complained of.\\nA tumor was present in the loins in sixty-five out of seventy-one\\ncases analyzed by Fenwick, but did not generally manifest itself until\\nthe inflammation had made considerable progress. There is dulness on\\npercussion even in the early stage, and, later, fluctuation. The general\\nsymptoms are vomiting, constipation, fever, and sometimes rigors. It\\nis more common in males than in females (sixty-one males to thirty-\\nnine females in Fenwick s cases).\\nHydatid Cyst.\\nA hydatid cyst of the kidney presents the usual physical signs of such\\ncysts. A fremitus may be detected, or small cysts may be found in the\\nurine.\\nIt is comparatively rare. Usually there are no symptoms until a\\ntumor is felt. Then pain gradually develops. The cyst may open into\\nthe pelvis of the kidney, and cysts or scolices be discharged, with colic.\\nPyelitis and cystitis may also develop.\\nEchinococcus cyst may inflame and lead to general pysemia. Punc-\\nture of the discovered tumor is otherwise the only means of diagnosis.\\nIt must be differentiated from hydronephrosis and ovarian tumors.\\nPuncture is necessary.\\nExamination of the Urine.\\n1. Inspection. The urine in health is a clear yellow or amber-\\ncolored fluid, having a specific gravity of about 1020, and generally acid\\nin reaction. It contains normally about forty-five parts in the thousand\\nof solid matter, the principal part of which is urea twenty-one and a\\nhalf parts. The other solids are uric acid and its salts certain extrac-\\ntives creatin, creatinin, ammonia, hippuric acid, xanthin, hypoxanthin.\\nsarcin, pigment, etc. and chlorides, phosphates, sulphates, with their\\nbases, soda, potash, lime, and magnesia.\\nThe volume of urine passed in twenty-four hours is usually from forty\\nto fifty ounces, but it may fall to thirty ounces or rise to seventy with-\\nout the existence of disease. Women are believed to pass from five to\\nten ounces less than men. The volume is diminished when the skin\\nis acting freely, as in warm weather, and when the bowels are loose\\nand, on the other hand, cold, constipation, and nervous excitement, espe-\\ncially if it induce anxiety and fear, all tend to increase the quantity\\nsecreted.\\nColor. The color of the urine is due largely but not wholly to\\nurobilin, which is formed from the hsematin of the blood. The color\\ndeepens when the urine is concentrated, which occurs after a hearty\\nmeal, or exercise, especially in warm weather and it becomes paler\\nwhen a large quantity is passed. The color is frequently changed in", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1010.jp2"}, "1011": {"fulltext": "DISEASES OF THE KIDNEYS. 915\\ndisease. In fevers the urine, soon after being passed, is apt to become\\nturbid from the precipitation of urates, and the color varies from white,\\nespecially in children, to yellow, brown, or pink. When the precipi-\\ntate settles the supernatant urine may be high-colored and clear, or\\nslightly opaque from some suspended matter.\\nThe admixture of pus and chyle gives the urine a milky color. The\\nurine may also be yellowish-white and turbid from phosphates, semen,\\nsarcinae, and bacteria.\\nThe urine is red, reddish-brown, or smoky in acute nephritis, the\\ncolor being due to blood. It is bloody in haematuria, cancer of the\\nkidneys and bladder, and in injuries of the genito-urinary apparatus.\\nThe urine is very red and clear when concentrated and containing a\\nlarge amount of urates. The red color of the urine may be due to\\nhaemoglobin, constituting hemoglobinuria, or to excess of urobilin, as\\nin scurvy and pernicious anaemia. Haemoglobinuria occurs as the result\\nof the action of certain poisons, such as chlorate of potash in infectious\\ndiseases, such as scarlet fever and in malarial fevers also in a pecu-\\nliar disease known as paroxysmal haemoglobinuria.\\nAgain, a golden-red discoloration of the urine is common in jaundice\\nfrequently the upper layers have a greenish tinge by reflected light.\\nFinally, a red color is produced by the internal administration of\\nlogwood and fuchsin.\\nA yellow color, when opaque, may be due to suspended phosphates\\nand urates. Urine is sometimes golden yellow or of a saffron color in\\njaundice, and from the effects of santonin, picric acid, and rhubarb\\ntaken internally. A yellow or yellowish-white turbidity may be due\\nalso to a mixture of pus and phosphates, and sometimes to semen, sar-\\ncinae, and bacteria. The urine usually becomes more or less opaque\\nand yellow when it has undergone alkaline fermentation. Such a\\nchange occurs normally within a longer or shorter time after the urine\\nhas been passed. It is promoted by heat and exposure to air, and\\nretarded by cold and exclusion from air. If possible, the urine should\\nbe examined before this fermentation has occurred. Pathologically, in\\ncases of cystitis, the urine when passed is already in alkaline fermen-\\ntation.\\nThe urine is sometimes chocolate-brown when it contains blood and\\nthe blood has been acted upon by the urine, producing methaemoglobin.\\nBrown, greenish-brown, or black urine may result from contained bile-\\nsalts from indican from carbolic acid, creosote, and tar used inter-\\nnally and externally from the internal use of senna, and in cases\\nwhere there are melanotic tumors. Senator injected melanin into\\nhuman beings and obtained in four cases only a large indicanuria.\\nUrine is pale usually in proportion as it is copious in quantity. It\\nis paler in those who are using milk or vegetable diet than in those\\nwho eat meats. Under the influence of nervous excitement, especially\\nanxiety and the dread of an approaching ordeal, such as an examina-\\ntion, an abnormal quantity of very pale urine is secreted.\\nPathologically, pale urine is characteristic of diabetes, chronic Bright s\\ndisease, and polyuria. Such urine is also secreted in hysterical attacks,\\nat the crises of febrile diseases, and in anaemic conditions.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1011.jp2"}, "1012": {"fulltext": "916 SPECIAL DIAGNOSIS.\\nThe Quantity. The volume may be increased, diminished, or\\nunchanged in disease. It is increased principally in three diseases\\ndiabetes mellitus, diabetes insipidus, and in the middle period of chronic\\nBright s disease, especially the interstitial form. In diabetes mellitus\\nit sometimes exceeds thirty-two pints. It may be increased also in\\nhypertrophy of the left ventricle, which induces greater pressure in the\\nrenal arteries as well as in the whole arterial system and also in cystic\\ndegeneration, and in double hydronephrosis.\\nDiabetes Insipidus. This form of diabetes differs from the sacchar-\\nine in that the urine is normal, but of low specific gravity. The\\ndisease may come on suddenly after mental emotion, or develop grad-\\nually. The amount of urine may range from ten to forty pints. The\\nurine is of low specific gravity from 1001 to 1005. It is pale and\\nwatery. The solid constituents are not reduced. Urea is sometimes\\nincreased, but abnormal constituents are very rare. The passage of\\nlarge amounts of urine induces thirst, but otherwise the symptoms do\\nnot tally with the symptoms of diabetes mellitus. The patients are\\nusually well nourished.\\nThe disease is usually secondary to some organic disease of the brain,\\nor of the abdomen, as tubercular peritonitis, abdominal tumors, or\\naneurisms. It usually occurs in males, and is often hereditary. It is\\nmost common in young people. Traumatism, meningitis, affections of\\nthe brain involving the sixth nerve, tumors of the brain or of the\\nmedulla, are causal factors. It may follow fright, a protracted debauch,\\nor perturbation of the nervous system from other causes.\\nThe diagnosis is not difficult. It must be distinguished from the\\npolyuria that is seen in chronic interstitial nephritis, and in amyloid\\ndisease. In hysteria, polyuria is common, although transitory. The\\npresence of the stigmata and other hysterical manifestations lead to the\\ndiagnosis in hysteria.\\nThe urine is diminished in acute nephritis and in the final stages of\\nchronic nephritis sometimes, also, it is diminished in the middle\\nperiod of chronic nephritis, but usually it is here increased. All dis-\\neases which directly or indirectly impair the force of the circulation\\nlessen the secretion of the urine. Hence, the quantity is diminished in\\ndiseases of the heart-muscle and in valvular diseases not fully com-\\npensated in emphysema and in chronic bronchitis. It is lessened also\\nin cirrhosis of the liver. In febrile diseases the urine is scanty and\\nhigh-colored, and sometimes it is almost suppressed (anuria).\\nThe urine is sometimes suppressed in acute nephritis, such as follows\\nscarlet fever, and in the final stages of all the organic affections of the\\nkidneys \u00e2\u0080\u0094chronic nephritis, hydronephrosis and pyonephrosis, etc. It\\nmay result (1) from the destruction of the secreting tissue of the kidney\\nor interference with its nervous or vascular supply, or (2) from mechan-\\nical obstruction to the outflow of urine. To the first class belong the\\ncases of suppression occurring in acnte and chronic nephritis, and the\\nsuppression from shock and collapse, whether occurring in the stage of\\ncollapse of yellow fever, cholera, and other grave febrile diseases, or\\nfrom serious internal injuries.\\nSuch suppression sometimes follows slight operations on the urethra", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1012.jp2"}, "1013": {"fulltext": "DISEASES OF THE KIDNEYS. 917\\n(urethral fever) or results from the internal administration of drugs\\nthe excretion of which occasions violent irritation of the kidney\\ncantharides, turpentine, and even the inhalation of ether. Clinically,\\nsuppression not due to obstruction is distinguished from the obstructive\\nform by the character of the urine, which is usually not entirely sup-\\npressed, and by the more rapid course of the disease. The urine,\\naccording to Roberts, is either concentrated or it contains albumin,\\nblood, and casts. Death or recovery results within a day or two. In\\nthe obstructive form, on the other hand, the urine which escapes past\\nthe obstacle is pale, watery, and devoid of albumin and casts.\\nObstructive suppression is the result of the plugging of the ureter by\\na calculus, when the opposite kidney is either absent or incapable of\\nsecreting. It also results from the occlusion of the ureters by morbid\\ngrowths, especially at the vesical orifices, from lateral pressure upon\\nthe ureters, or from some interference with or malformation of the\\nureters or renal arteries.\\nAcute transient obstructive suppression occurs sometimes in persons\\nwith enlarged prostates, or old strictures, who have drunk too freely of\\nalcoholic beverages, and, perhaps, have wound up a debauch by sexual\\nintercourse.\\nThe Density of the Ukine. The average density of normal\\nurine is about 1020. It may fall to 1015 or rise to 1025, depending\\nupon the quantity of fluid and food taken, the condition of the atmos-\\nphere, especially as regards temperature, and upon mental influences\\nusually of an emotional character. The specific gravity of the urine\\nis tested by a urinometer graduated for degrees of density between\\n1000 and 1040. Only a reliable instrument should be used. As the\\ndensity of the urine passed at different times during the day varies\\ngreatly, the urine for the whole twenty-four hours should be saved\\nand a specimen of this tested.\\nThe method of taking the specific gravity is very simple. A test-\\ntube or graduate, having a diameter of about one and a quarter inch\\nand a length of six or seven inches, is filled with urine to such a point\\nthat the lowest part of the urinometer when inserted floats clear of the\\nbottom of the tube. The instrument must also float free of the sides\\nof the tube. The specific gravity should then be read off from below\\nthat is to say, by holding the tube up so that the level of the fluid is a\\nlittle above that of the eye. Most urinometers are graduated for 60\u00c2\u00b0,\\nbut in ordinary examinations it is not necessary to have the urine ex-\\nactly at this temperature it should, however, be allowed to cool after it\\nhas been passed, otherwise the specific gravity will appear to be too low.\\nIn disease the specific gravity varies more widely than in health it\\nmay fall to 1000 or 1005 in diabetes insipidus and chronic Bright s\\ndisease, and rise to 1060 or even higher in diabetes mellitus. As a\\nrule, to which the urine in diabetes mellitus is the principal exception,\\nthe color is an index of the density, pale urine being of low density\\nand high-colored urine of high density.\\nThe density is increased when the urine is scanty in amount, whether\\nas the result of fever, acute nephritis, large consumption of solid food,\\nexercise, or free sweating. In all such cases the specific gravity rarely", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1013.jp2"}, "1014": {"fulltext": "918 SPECIAL DIAGNOSIS.\\nrises above 1035, and usually not above 1028 or 1030. AVhen the\\nspecific gravity rises above 1035, and the urine is pale in color, the\\npresence of sugar is to be suspected and when it rises above 1040\\nsugar is almost certainly present.\\nThe specific gravity is lowered by drinking copiously, by the effect\\nof external cold, by a diet of vegetables and milk, and, in general, by\\nthe same causes that make the urine copious. Usually, but not always,\\na urine containing a large amount of albumin is of low density.\\nPathologically, a low specific gravity is encountered in diabetes in-\\nsipidus, in which it may fall nearly or quite to 1000 generally in the\\nmiddle or quiescent period of chronic Bright s disease in the crisis of\\nfevers in obstructive suppression in hysterical attacks, and in hydro-\\nnephrosis.\\nSpecific Gravity as an Index of the Amount of Solids. If the last two\\nfigures of the specific gravity be doubled, the sum will represent the\\namount of solid matter in 1000 grains of urine. This is Trapp s\\nmethod the estimate is only rough, but it is useful. Of course, the\\nurine for twenty-four hours must be used.\\nThe Re action The reaction of healthy urine is usually acid, but\\nit may be neutral or slightly alkaline about two hours after a meal of\\nmixed food. The acidity is tested with litmus-paper the blue paper\\nis turned purple or red by an acid, and the red paper is turned blue by\\nan alkali. Violet paper is to be preferred, as it is suitable for showing\\nboth reactions, an alkali turning it blue and an acid red.\\nThe acidity of the urine is increased in gout, lithiasis, acute rheuma-\\ntism, diabetes, chronic Bright/ s disease, and as the result of the admin-\\nistration of vegetable or mineral acids.\\nThe urine is all: aline as the result of alkaline fermentation in the\\nbladder in cystitis from the presence of much blood or pus from\\nprolonged immersion of the body in a cold bath in debilitating dis-\\neases and in some cases of nervous dyspepsia, and as the result of the\\ninternal administration of alkalies.\\nUrinary Sediments. A white, flocculent sediment, composed of\\nepithelium and mucus, occurs normally in most urines after they have\\nstood for some hours.\\nA dense sediment, varying in color from that of brown sugar to pink\\nor red, consists of amorphous urates. It dissolves upon the appli-\\ncation of heat. A sediment usually resembling red pepper, but some-\\ntimes of a brown color, consists of uric acid. It can be proved to be\\nuric acid by the murexid test. The suspected material is placed in a\\ncrucible or evaporating dish with a few drops of nitric acid. As heat is\\napplied the uric acid or amorphous urate dissolves with effervescence.\\nHeat is now kept up until the material is evaporated to dryness it is\\nthen allowed to cool. If it is now touched with a glass rod, dipped in\\nstrong ammonia, a characteristic blue or violet color is produced. Uric\\nacid is not usually so abundant as the sediment of amorphous urates\\nit sinks more rapidly, and is deposited from acid, high-colored urines.\\nA yellowish or whitish sediment may consist of urate of sodium.\\nA white sediment usually consists of phosphates, associated with\\nwhich we sometimes fi nd a white sediment consisting of urate of ammo-.", "height": "4416", "width": "2676", "jp2-path": "practicaltreatis00muss_0_1014.jp2"}, "1015": {"fulltext": "DISEASES OF THE KIDNEYS. 919\\nnium, with or without pus. Such urines are alkaline. A white sedi-\\nment may be due to uric acid, especially in children.\\nA yellowish-white sediment may consist of pus, with or without\\nmucus. If the urine is acid, the sediment is loose and free to move\\nbut when the urine is alkaline the sediment consists of a viscid, coherent\\nmass, which can be drawn out into tough, stringy filaments.\\nA chocolate-brown sediment, occurring in a reddish, smoky urine,\\nconsists of blood from the kidneys. Clots of blood come from the\\nureters, bladder, or urethra.\\nOdor. The odor of normal urine is sometimes spoken of as aromatic,\\nbut generally it is sufficiently characteristic to be best described as\\nurinous. When the urine is concentrated the odor is intensified, and\\nmay become unpleasantly strong, like the urine of the horse.\\nCertain articles of food, such as garlic and asparagus, give the urine\\ncharacteristic odors. Turpentine, both when taken internally and in-\\nhaled, gives to it the odor of violets. The odors of copaiba and of cubebs\\ncan easily be detected in the urine of patients who are taking these drugs.\\nIn marked cystitis the natural urinous odor becomes more pungent,\\nand is blended with a strong ammoniacal odor. When much pus is\\npresent, and the urine has stood awhile, a putrid odor is developed.\\nIn diabetes mellitus the urine has a sweetish, hay-like odor. In\\ndiabetic coma the odor is sometimes that of chloroform, due to the\\npresence of acetone and diacetic acid in the urine. This odor, however,\\nis more likely to be detected in the breath.\\n2. Chemical Examination of the Urine. Examination of the urine\\nby the unaided senses, which has been dwelt upon thus far, is simply\\npreliminary to an examination by chemical methods and by instruments\\nof precision, particularly the microscope.\\nUrea. Urea is freely soluble in water, and hence never appears as\\na sediment. It is the most important final product of nitrogenous dis-\\nintegration in the body, and is an index of the eliminative power of the\\nkidneys. Usually the density of the urine increases in proportion to\\nthe amount of urea contained in it. The average daily amount of urea\\nexcreted by an adult man between the ages of twenty and forty years\\nis about 500 grains. The urea, like the total volume of the urine, is\\nsubject to variations within the limits of health. It is increased after a\\nmeal, especially if the latter be rich in nitrogenous food after copious\\ningestion of liquids, and by a close atmosphere. On the other hand,\\nfasting, free perspiration, a loose condition of the bowels, and a vege-\\ntable or milk diet diminish the quantity of urea. Again, the quantity\\nvaries with the age of the person. According to Ralfe, at five years\\nthe amount daily is 180 grains at 12, 320 at 21, 535 and at 40\\nyears, 555 grains.\\nA large man will excrete absolutely more than a small man, and a\\nlarge, muscular man will excrete relatively more than a fat man of the\\nsame height.\\nThe excretion of urea is increased in fever and inflammatory dis-\\neases in diabetes mellitus and insipidus in malaria, pernicious anseinia,\\nand after a crisis in pneumonia. It is increased also by certain bever-", "height": "4416", "width": "2628", "jp2-path": "practicaltreatis00muss_0_1015.jp2"}, "1016": {"fulltext": "920 SPECIAL DIAGNOSIS.\\nages, as coffee, and by many drugs, especially those which act as hepatic\\nstimulants.\\nIt is diminished in all forms of nephritis, especially when uraemia\\nresults in acute gout and chronic rheumatism in disease accompanied\\nby emaciation and cachexia and in leprosy, pemphigus, melancholia,\\nimbecility, catalepsy, hysteria, and cholera (Saundby).\\nEstimation of Urea. For the methods employed in the exact quan-\\ntitative estimation of urea the student is referred to special works on\\nthe urine.\\nFor ordinary clinical purposes the apparatus devised by Professor\\nCharles Doremus, and known as his ureometer, gives sufficiently accu-\\nrate results. The principle upon which it is based is that urea when\\nbrought in contact with sodium hypobromite is decomposed, and free\\nnitrogen is eliminated. The nitrogen evolved is the measure of the urea\\ncontained in the urine. The instruments are graduated so that each\\ndivision of the scale represents one grain of urea per fluidounce of urine.\\nThe hypobromite solution is prepared by dissolving 100 grammes of\\nsodium hydroxide in 250 c.c. of water, cooling the solution, and then\\nadding 25 c.c. of bromine.\\nIt is better, however, to freshly prepare the hypobromite solution\\nfor each examination. This can readily be done by having a solution\\nof sodium hydroxide containing six ounces to a pint of water. It\\nshould be kept tightly corked with a rubber or paraffined stopper.\\nThe sodium hydroxide solution is poured into the long tube of the\\nureometer to the mark then one-tenth of its volume of bromine is\\nintroduced by means of a pipette, and sufficient water added to fill the\\nlong arm and the bend of the tube. The hypobromite solution should\\nfill the tube completely, and any bubbles rising to the top of the tube\\nshould be removed before the introduction of the urine. The pipette\\nis then filled with the urine up to the 1 c.c. mark, any urine adhering\\nto its surface being carefully wiped off. The pipette is introduced care-\\nfully, so as not to compress the bulb until the point extends as high up\\nas possible beyond the bend. The bulb is now compressed slowly until\\n1 c.c. of urine has been introduced. Decomposition of the urea occurs\\nand bubbles of nitrogen rise to the surface of the long arm of the tube\\nwhen bubbles of gas cease to be evolved the volume of nitrogen gas is\\nread off, and according to the graduations on the tube considered as so\\nmany grains of urea per fluidounce of urine, or as so many milligrammes\\nof urea in 1 c.c. of urine, according to whether it is graduated in the\\nEnglish or the metric system.\\nThe Chlorides. The presence or absence of chlorides is sometimes\\nof diagnostic value. They are increased when absorption of exudations\\nor transudations is going on, and in malarial fevers, diabetes insipidus,\\nand Bright s disease. They are diminished or absent in pneumonia\\nduring its progressive stage, and in fevers. The chlorine of the chlo-\\nrides can be detected and roughly estimated by an 8 or 10 per cent,\\nsolution of argentic nitrate. A few drops of nitric acid are first added\\nto the urine, to prevent the silver from precipitating phosphoric acid.\\nA single drop of the silver solution mentioned will precipitate the\\nchlorine of the chlorides in a thick white lump, which falls to the bot-", "height": "4412", "width": "2688", "jp2-path": "practicaltreatis00muss_0_1016.jp2"}, "1017": {"fulltext": "DISEASES OF THE KIDNEYS. 921\\ntorn of the test-tube, provided the amount present is normal. If, on\\nthe other hand, the quantity is diminished to one-tenth per cent, or\\nless, it will not be precipitated in a lump or lumps, but a white cloudi-\\nness is produced which renders the whole solution opaque. If no pre-\\ncipitation or cloudiness occurs, the chlorides are absent.\\nSerum-albumin. Albumin is of common occurrence, but cannot\\never be looked upon as a normal constituent of the urine, though its\\npresence by no means indicates disease of the kidneys. The ordinary\\nform is serum-albumin, but other proteids, as globulin, mucin, pep-\\ntone, albumose, fibrin, and also haemoglobin methsemoglobin, are found\\nat times. The most trustworthy tests for ordinary albumin (serum-\\nalbumin) are boiling, with the addition of nitric or acetic acid over-\\nlaying cold nitric acid with urine (Heller s test) the picric acid, the\\npotassium ferrocyanide, and the potassium-mercuric-iodide (Tanret s)\\ntests. The author believes that many of the recent tests, such as sodium\\ntungstate, acidulated brine, magnesium nitrate, phenic-acetic acid, and\\ntrichlor-acetic acid, are too sensitive and precipitate other substances\\nin the urine, and, therefore, are not reliable for clinical work.\\nSerum globulin responds to all the following tests for serum-albumin.\\nIts differentiation is not difficult, but usually unnecessary. (See note\\non page 937.)\\nBoiling and Nitric Acid Test. A narrow, long test-tube is filled two-\\nthirds full of urine and the upper third boiled thoroughly, and then a\\nfew drops of nitric acid are added. Any albumin present will be coag-\\nulated and appear as a white cloud, contrasting strongly with the clear\\nunboiled urine beneath it. When the albumin is moderate or even\\nsmall in amount it can be detected without difficulty by simply holding\\nthe test-tube up to the light. When there is only a faint trace present\\nit will be overlooked unless the tube be examined against a dark sur-\\nface in such a way that the light falls upon it from above, in front,\\nand preferably a little to one side. A cloud may escape detection when\\nlooked for by artificial light, but may be distinct by daylight. Serum-\\nglobulin is also precipitated by this test. But serum-globulin is not\\noften present by itself, and its significance is not yet understood. It\\nmay be detected in any urine, as Roberts points out, by diluting the\\nurine with pure water, the urine then becoming more or less milky.\\nIt may be removed from urine by saturating the latter with magnesium\\nsulphate and filtering off the precipitated globulin. The presence of\\nserum-globulin in no way interferes with the test for serum -albumin.\\nIf the urine is opaque from amorphous urates, it is unnecessary to\\nfilter them out heat much below boiling will dissolve them, the pre-\\ncipitation of albumin occurring later at a higher temperature.\\nIf the urine is alkaline or faintly acid, phosphates will produce a\\ncloud upon heating the urine but they are instantly dissolved upon\\nthe addition of a few drops of nitric or acetic acid.\\nMucin produces an opalescence upon heating with an organic acid,\\nbut Saundby declares that it coagulates not in flocculi, as is the case\\nwith albumin, but in the form of tiny filaments.\\nBoiling and Acetic Acid Test. This is preferred by many to the\\npreceding test. It is performed in a similar manner. Acetic acid is,", "height": "4416", "width": "2628", "jp2-path": "practicaltreatis00muss_0_1017.jp2"}, "1018": {"fulltext": "922 SPECIAL DIAGNOSIS.\\nhowever, not reliable for acidulation it precipitates the mucin which\\nis often found in healthy urine, forming a white cloud which is apt\\nto be mistaken for albumin this is especially true in urines of high\\nspecific gravity containing uric acid, urates, or oxalates.\\nThe Nitric Acid (Heller s) Test This test, while not so delicate as\\nthe acetic acid test, is very simple and accurate in its results. Cold\\nnitric acid is poured into a test-tube to the depth of about an inch.\\nThe tube is then inclined to an angle of about 45 degrees, and urine\\nallowed to flow gently down upon the acid by trickling along the side\\nof the tube from a pipette or glass tube. At the point of contact of\\nthe acid and urine a zone of white, coagulated albumin forms. The\\ntest can also be made as follows Into a short, broad test-tube several\\ncubic centimetres of urine are poured nitric acid is introduced with\\na pipette provided with a rubber bulb by passing the pipette through\\nthe urine to the bottom of the tube and gently pressing the rubber\\nbulb care must be taken to withdraw the pipette as the last portion\\nof acid is expelled, so that no air-bubbles will break up the point of\\ncontact of the urine and acid. The thickness of the white zone is\\ngenerally an index of the amount of albumin present. If there is\\nbarely a trace of albumin, half an hour may be required to develop\\nany opalescence.\\nA cloud of urates is sometimes produced and obscures the test. This\\ncloud does not, however, begin at the point of contact and extend\\nupward, but at the upper level of the urine and extends downward,\\nand is dissipated by heat.\\nPatients who are taking copaiba or cubebs pass a urine which gives\\na white zone at the point of contact with cold nitric acid, but heat\\ndiminishes the opacity, and the precipitate is soluble in alcohol the\\nodor of the drugs in the urine assists in the detection of their presence.\\nThe Picric Acid Test. This is an extremely delicate test for albumin.\\nA saturated solution of picric acid is allowed to flow down upon and\\nslightly mix with the upper layers of the urine, which half fills a good-\\nsized test-tube. At the point of contact an opaque white zone of coagu-\\nlated albumin is formed. If no white zone appears, albumin is almost\\ncertainly absent. Hence, the picric acid test is a valuable negative\\ntest. But, unfortunately, a white zone is formed by peptone, mucin,\\nand various alkaloids, particularly quinine. The white zone produced\\nby the presence of the substances just named disappears upon the appli-\\ncation of heat, whereas an opalescence due to albumin becomes diffused\\nthroughout the whole urine.\\nThe Potassium Ferrocyanide Test. This test is highly recommended\\nas simple, rapid, and accurate by Purdy, who performs it as follows\\nInto a test-tube are poured fifteen to thirty drops of acetic acid, and\\nthen two or three times that amount of potassium ferrocyanide solution\\n(1 to 20) is added, and the two thoroughly mixed by shaking the tube.\\nThe urine is now added to the depth of two-thirds of the test-tube. If\\nany albumin is present, it will be precipitated throughout the whole\\nvolume of urine in the form of a milk-like flocculent cloud, more or\\nless according to the amount of albumin present. By this method all\\nmodifications of albumin, acid or alkaline, are precipitated and the", "height": "4416", "width": "2628", "jp2-path": "practicaltreatis00muss_0_1018.jp2"}, "1019": {"fulltext": "DISEASES OF THE KIDNEYS. 923\\nprecipitation of mucin is avoided. It gives no reaction with phosphates,\\nurates, peptones, vegetable alkaloids, or the acids found in the urine\\nafter the ingestion of copaiba, etc. This test may also be performed\\nas follows An ordinary test-tube is half filled with urine and a\\ndrachm or two of the potassium ferrocyanide solution (1 to 20) are\\nadded. After thoroughly mingling the reagent and the urine a few\\ndrops of acetic acid are added. If albumin is present, it will plainly\\ncome into view. This test, therefore, depends upon the production of\\na cloudiness or milkiness throughout the entire mixture in the tube.\\nTo some eyes the albumin is not so readily perceived as in those tests\\nwhich depend upon the formation of a distinct line at the point of contact.\\nThe Potassium-mer curio Iodide Test (Tanrefs). The solution is made\\nas follows Potassium iodide, 3.32 grammes bichloride of mercury,\\n1.35 grammes; acetic acid, 20 c.c. distilled water about 30 c.c. (the\\npotassium iodide and the bichloride of mercury should be dissolved\\nseparately in the water and the solution mixed, to which the acetic acid\\nis added and the whole made up to 60 c.c. with distilled water). As\\nthus prepared the test is applied by the contact-method by overlaying\\nthe reagent with urine. This test responds to all modifications of albu-\\nmin, also to peptones and proteoses, as well as to the vegetable alkaloids\\nand acids found in the urine after the ingestion of copaiba, etc. All\\nreactions except those occurring with albumin, mucin, and the acids\\nfound in the urine after the ingestion of copaiba, etc., disappear with\\nheat. It is a very good and delicate control-test for albumin. The\\nsolution, however, is of a yellowish hue, quite similar to the color of\\nurines of low specific gravity. This sometimes renders the line of\\ncontact difficult to perceive.\\nIt is well to follow a routine method in testing for albumin first,\\nby boiling and the addition of nitric acid, and then the contact (Hel-\\nler s) test if there is doubt, either the potassium ferrocyanide or picric\\nacid test finally, Tanret s solution will reveal minute quantities of\\nalbumin, and may be used as a confirmatory test.\\nIn all the tests for albumin mentioned a clear urine is necessary,\\nespecially when the amount of albumin is very small. This can be\\nobtained by filtration when the opacity is due to pus, blood, mucus,\\nand uric acid and, more effectively, by the addition of a small quan-\\ntity of sodium hydroxide, warming slightly, and filtering. If the\\nfiltrate is not clear, a few drops of magnesium fluid (sulphate of mag-\\nnesium, pure ammonium chloride, and pure liquor ammonise, of each 2\\ndrachms distilled water, 2 ounces), as recommended by Hoffmann and\\nUltzmann, may be added, and the urine again warmed and filtered.\\nResume of Tests for Albumin.\\n1. The heat test.\\nA. Method Albumin is precipitated on boiling.\\nB. Exception 1. In alkaline urines albumin may be overlooked\\nfrom the formation of soluble potassium and magnesium compounds.\\nWhen patients are taking alkaline salts the test may be fallacious.\\n2. An excess of acid may also interfere with the test.\\n3. Feebly alkaline or neutral urines produce a precipitate of earthy\\nphosphates, but it is instantly soluble in a small quantity of acid.", "height": "4416", "width": "2640", "jp2-path": "practicaltreatis00muss_0_1019.jp2"}, "1020": {"fulltext": "924 SPECIAL DIAGNOSIS.\\n4. Patients on a vegetable diet pass urine containing carbonates which\\nprecipitate with heat. The addition of an acid causes great evolution\\nof gas.\\nII. The heat and acetic acid test.\\nMethod Determine the reaction of the urine. If alkaline, make\\nfaintly acid with acetic acid then boil and add a little more acetic\\nacid. If there is no precipitate, boil again. The acetic acid precipitates\\nnucleo-proteids, which are excluded by the methods above described.\\nIII. The heat and nitric acid test.\\nA. Method Bring the urine to the boiling-point and add nitric\\nacid, drop by drop, shaking the mixture between each addition. A\\nsmall precipitate is thrown down even if a very small amount of albu-\\nmin is present. The nitric acid should not exceed more than one-tenth\\nof the volume of urine examined. The urine must not be heated after\\nthe addition of the acid.\\nB. Exceptions 1. In concentrated urines, uric acid or its salts\\nmay precipitate. Distinguish from albumin by filtering off the pre-\\ncipitate and testing it by the biuret reaction, or dilute the urine with\\nan equal volume of water when uric acid will not precipitate.\\n2. Resin acids in turpentine, benzoin, cubebs, and other balsams, if\\npresent in the urine, are precipitated by nitric acid. Distinguish from\\nalbumin by adding one or two volumes of alcohol when the solution is\\ncool. The precipitate of resin acids is dissolved.\\n3. In urines containing biliverdin a precipitate is formed. Distin-\\nguish from albumin by adding alcohol, which dissolves biliverdin.\\nIV. Cold nitric acid test.\\nA. Method Pour the urine gently on the nitric acid. The albumin\\ncoagulates in the presence of an excess of strong nitric acid. A ring\\nappears at the surface of contact if albumin is present. A second ring\\nmay be seen y 1 to 1 cm. above the junction, due to nucleo-proteids.\\nDistinguish from albumin by repeating the test with urine diluted\\nwith two or three volumes of water. The albumin rin^ diminishes\\nand the nucleo-proteid ring is unchanged or increased. A haze due to\\nnucleo-proteid may form, and also continue after dilution.\\nB. Exceptions 1. In concentrated urines a secondary ring due to\\nuric acid may form above the junction. It is soluble on gently heating,\\nand does not form when the urine has been diluted.\\n2. In highly concentrated urine a precipitate of nitrate of urea may\\nfall. Distinguish by its crystalline nature.\\n3. Resin acids cause a precipitate of uniform cloudiness. Distinguish\\nby solubility in alcohol.\\n4. In highly colored urines the urinary pigments form a colored\\nring at the plane of contact, and in bilious urines the play of colors,\\nas in Gmelin-Malin-Heintz s test for bile, is seen.\\n5. The urine of patients taking alkaline iodides gives a dense brown\\nring of iodine. Distinguish by adding a few c.c. of chloroform and\\nmixing them. A violet tinge is imparted to the liquid.\\n6. Albumoses are precipitated, as well as all forms of albumin. Dis-\\ntinguish by the previously mentioned tests. Peptone and vegetable\\nalkaloids are not precipitated.", "height": "4400", "width": "2600", "jp2-path": "practicaltreatis00muss_0_1020.jp2"}, "1021": {"fulltext": "DISEASES OE THE KIDNEYS. 925\\nV. The potassium ferrocyanide and acetic acid test.\\nA. Method It is best performed as a ring test. The urine should\\nbe carefully run into a mixture of twenty or thirty drops of acetic acid\\nand sixty or ninety drops of saturated solution of potassium ferrocyanide.\\nA white ring forms at the junction if albumin is present. With small\\namounts of albumin the ring takes some minutes to form.\\nB. Exceptions 1. Albumoses are precipitated. They are soluble\\nin excess of acetic acid. They disappear on heating and reappear on\\ncooling.\\n2. Resin acids give a precipitate ivhich is soluble in alcohol.\\n3. Phosphates, urates, alkaloids, and peptones are not precipitated.\\nVI. Roberts brine test.\\nSaturated sodium hydrate solution with 5 per cent, hydrochloric acid.\\nIt does not darken the urine nor precipitate uric acid.\\nA. Method Use the ring test, which shows albumin and albumoses.\\nB. Exceptions Resin acids precipitate. Distinguish by dissolving\\nin alcohol.\\nVII. The salt and acetic acid test.\\nThe acetic acid is substituted for HC1, and a large excess of salt\\nsolution used.\\nA. Method The salt solution is first added to the urine and\\nthoroughly mixed. Acetic acid is then poured in. Nucleo-proteids\\nare not precipitated. (All other forms of albumin are precipitated.)\\nSalt and vinegar may be used, and the mixture heated in a metal spoon.\\nB. Exceptions 1. Albumoses form and disappear on heating, to\\nreappear on cooling.\\n2. If albumoses and albumin appear together, boil for a short time\\nand filter the hot fluid through a warm filter. The clear filtrate becomes\\nturbid from albumoses as it cools.\\n3. Resin acids and uric acid are precipitated, the latter only in con-\\ncentrated urines, and after standing. Distinguish by the usual tests.\\nV. and VI. do not generally precipitate nucleo-proteids. With\\nVII., if equal parts of urine and salt solution are used with a few\\ndrops of acetic acid, nucleo-proteids are not precipitated. The solution\\nmust be boiled when test VII. is employed.\\nVIII. Salicylsulphonic acid.\\nAll forms of albumin are precipitated. The precipitate becomes\\nflocculent on heating. If the urine is alkaline more of the reagent is\\nneeded than if acid. Phosphates, urates, bile, alkaloids, and drugs do\\nnot give a reaction.\\nA. Method After adding the solution to the urine heat and allow T\\nto stand.\\nB. Exceptions Albumoses are precipitated, but disappear on heat-\\ning and reappear on cooling.\\nIX. Trichloracetic acid.\\nExceptions 1. Precipitates uric acid when in excess. Distinguish\\nby heating, which dissolves the acid, or dilute the urine before applying\\nthe test.\\n2. Nucleo-proteids give an opalescence. Albumoses are not pre-\\ncipitated.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1021.jp2"}, "1022": {"fulltext": "926\\nSPECIAL DIAGNOSIS.\\nFig. 205.\\nX. Picric acid.\\nA. Method A saturated solution of picric acid must be used alone,\\nin combination with HC1, or with acetic acid. Value doubtful.\\nB. Exceptions Uric acid, creatinin, nucleo-proteids, alkaloids, potas-\\nsium salts, and albumoses are precipitated.\\nXI. Millard s reagent.\\nValue doubtful. Precipitates albumoses, nucleo-proteids, alkaloids,\\nand resin acids. Distinguish by usual tests.\\nXII. Tanret s reagent.\\nVery delicate. Precipitates all forms of albumin, albumoses, nucleo-\\nproteids, peptones, alkaloids, and resin acids. Distinguish by usual\\ntests.\\nXIII. Spiegler s reagent.\\nDelicate. Precipitates albumin, albumoses, and nucleo-\\nproteids, but not peptones.\\nXIV. Acetic acid.\\nMethod Filter the urine and add acetic acid to a\\nportion, pouring the two in the tube held against a black\\nbackground. Albumin and nucleo-proteids are precipi-\\ntated. Distinguish by diluting the filtered urine with two\\nor three volumes of distilled water, then add acetic acid,\\nand compare the precipitate with that in an undiluted\\nspecimen. A nucleo-proteid precipitate will increase in\\nintensity. An albumin precipitate will diminish or re-\\nmain unchanged.\\nSalicylsulphonic acid is the most delicate test. An\\nobjection to it is the fact that it precipitates nucleo-\\nproteids. Control the test by Heller s cold nitric acid\\ntest, from which the nucleo-proteids are removed, as\\nabove described.\\nThe quantitative estimation of albumin is of some im-\\nportance. The most direct method is by coagulating the\\nalbumin by boiling, collecting it upon a weighed filter,\\nwashing with water and finally with alcohol, drying and\\nweighing it. Such a process, however, consumes too much\\ntime for clinical purposes, and it is not faultless. An\\napproximate estimation may be made by boiling the urine\\nin a test-tube, adding several drops of nitric acid, allowing\\nthe albumin to settle, and then comparing the depth of\\nalbumin with the height of the column of urine. In this\\nway we may speak of urine furnishing one-tenth or one-\\nquarter of its bulk of coagulated albumin.\\nEsbach has invented an albuminimeter (Fig. 205) which\\ngives good results. The solution used to precipitate the\\nalbumin consists of 10 grammes of picric acid and 20\\ngrammes of citric acid, chemically pure and dry, dissolved\\nin 900 c.c. of hot water and after cooling, diluting the\\nsolution to 1000 c.c. The urine is diluted with a definite\\namount of water if it contains too much albumin. The albuminimeter\\nis filled to the mark U with urine, and from that mark to R with the\\nrl\\nEs bach s\\nalbuminimeter.", "height": "4416", "width": "2580", "jp2-path": "practicaltreatis00muss_0_1022.jp2"}, "1023": {"fulltext": "DISEASES OF THE KIDNEYS. 927\\nreagent. The tube is then corked with a rubber stopper, turned upside\\ndown ten times, so as to mix the urine intimately with the reagent, and\\nthen allowed to stand undisturbed for twenty-four hours. At the end\\nof this time the depth of the sediment of coagulated albumin is ascer-\\ntained by observing where the top of the sediment comes in contact\\nwith a mark on the scale on the tube. Each mark corresponds to one-\\ntenth per cent, of albumin.\\nThis estimation, as already stated, is not absolutely accurate. Never-\\ntheless, if used systematically, and always in the same way, relative\\nvalues will be obtained, and these are the most important in watching\\nthe progress of a case, as they give positive information regarding an\\nincrease or diminution of the amount of albumin in the urine. It\\nscarcely need be said that the urine tested must be a portion of the\\nwhole twenty-four hours urine.\\nThe estimation of the amount of albumin is also readily made with\\nthe centrifugal machine to 10 c.c. of the albuminous urine are added\\n3.5 c.c. of potassium ferrocyanide solution (1 to 10) and 1.5 c.c. of\\nacetic acid the mixture is then revolved in the machine about three\\nminutes, and the amount of precipitate read off.\\nAlbuminuria. Albuminuria is not indicative of disease of any one\\norgan, nor does it point to any general pathological condition. It\\noccurs as follows\\n1 In diseases of the kidney acute and chronic Bright s disease, amy-\\nloid disease, tuberculosis, cancer, abscess, and calculus.\\n2. In disturbances of the circulation diseases of the heart and chronic\\npulmonary diseases, as emphysema obstruction of the renal arteries or\\nveins, cirrhosis of the liver, peritonitis, pregnancy, abdominal tumors\\nin passive congestions due to great weakness in anaemia and Graves\\ndisease.\\n3. In febrile and inflammatory diseases in the eruptive and infec-\\ntious fevers, and in rheumatism, diphtheria, pneumonia, and gout.\\n4. In blood diseases purpura, leucocythsemia, and scurvy.\\n5. From the poisonous action of drugs lead, turpentine, and others.\\n6. In nervous disorders concussion of the brain and cerebral hemor-\\nrhage, epilepsy, tetanus, and delirium tremens as Pye-Smith remarks,\\nit is doubtful whether albuminuria is caused by the nervous diseases.\\n7. Local extra-renal affections pyelitis, cystitis, gonorrhoea, and\\nleucorrhoea.\\n8. Functional. In young persons, particularly of the male sex, there\\noccurs occasionally slight albuminuria after exercise, a special diet, or\\na cold bath. Albumin may be found after rising in the morning, or\\nearly after dinner, or toward evening. On account of its occurring\\nonly at certain times it has been called cyclical or intermittent,\\nand because there is no evident disease present, it is occasionally spoken\\nof as physiological albuminuria.\\nGoodhart examined the urine of 1500 individuals and noted albumin\\nin 272, or in 20 per cent. In 39 cases the albuminuria could not posi-\\ntively be said to be due to disease of the kidney. Of these 39, 26 were\\nmales and 13 females. In 32 of the 39 cases it was temporary, and in\\nmost of them it had disappeared within forty-eight hours, or sooner.", "height": "4416", "width": "2636", "jp2-path": "practicaltreatis00muss_0_1023.jp2"}, "1024": {"fulltext": "928 SPECIAL DIAGNOSIS.\\nIn 2 cases there were oxalates in the urine in 1 hsemoglobinuria in 8\\nleucorrhoeal discharges and discharges from other parts of the genital\\npassages (see division 7) and in 17 a markedly neurotic temperament.\\nThese last he thinks the most typical cases of intermittent albuminuria\\non the whole, he regards the condition as less common than has been\\nsupposed.\\nOne variety of functional albuminuria is apparently due to the irri-\\ntation of the kidney produced by the excretion of oxalates and uric acid.\\nThe urine is of increased density, 1028, 1030 or higher, and contains\\nuric acid or oxalate of lime, or both, and cylindroids. Tube-casts are\\nvery uncommon. The albuminuria usually disappears under proper\\ndiet. This condition is sometimes called morbus Da Costse.\\nIt is conceded that there may be albuminuria of renal origin without\\nrenal disease, but the diagnosis must be by exclusion, and can be reached\\nsafely only after extended observation. The most important elements\\nin the diagnosis are the age of the patient, unimpaired general health,\\na specific gravity of the urine normal or above normal, the fact that\\nthe albuminuria is influenced by diet and exercise, and that it tends to\\ndisappear under suitable regimen. The prognosis is favorable.\\nMucin. Xucleo-albumin, or nucleo-proteid, is nucleic acid and\\nchondro-sulphuric acid combined with a proteid. Sometimes, patho-\\nlogically, tauro-cholic acid enters into the combination. This is not\\ntrue mucus, but urinary mucus. It is present in the urine in health,\\nbeing especially abundant in women from the admixture of the vaginal\\nsecretion, and in excess in inflammatory conditions of the urinary tract.\\nIt is distinguished from albumin by the fact that it gives a precipitate\\nupon the addition of vegetable acids, as acetic or citric. The precipi-\\ntate is increased by removing the salts of the urine by dialysis, or by\\ndilution of the urine, with two or three volumes of distilled water,\\ndiminishing thereby the relative proportion of salts to mucus. It is\\nprecipitated by dilute mineral acids, but is soluble in concentrated\\nmineral acids or dilute alkalies.\\nAccording to Roberts, the best method for the detection of mucin is\\nby means of a saturated solution of citric acid, employed in the same\\nmanner as the contact-method of applying the nitric acid test for albu-\\nmin. A small quantity of the urine is first put in a test-tube, and citric\\nacid allowed to trickle down the sides of the tube until it forms a dis-\\ntinct layer below the column of urine. If mucin is present there will\\ngradually appear an opalescent zone immediately above the layer of\\nacid. Acetic acid, mixed with one-third of its volume of glycerin,\\nanswers admirably as a test for mucin. Sometimes, when mucin is\\nvery abundant, the addition of an excess of acetic acid produces a\\nmarked milkiness in the urine, which is not discharged by boiling the\\nliquid.\\nBlood. Urine containing blood is usually red in color or reddish-\\nbrown and opaque, but it may be chocolate-brown if the blood is present\\nin large quantity and has been acted upon by the urine. Such urine\\nnecessarily contains albumin.\\nBlood occurs in the urine from (1) diseases of the kidney and urinary\\npassages, among which are Bright s disease, acute congestion of the", "height": "4416", "width": "2628", "jp2-path": "practicaltreatis00muss_0_1024.jp2"}, "1025": {"fulltext": "DISEASES OF THE KIDNEYS. 929\\nkidney, renal calculus, cancer, tuberculosis from ureteritis, cystitis, and\\nurethritis, and from injuries (2) from general diseases, such as the\\neruptive and intermittent fevers, scurvy, purpura, peliosis rheumatica,\\nleucocythaemia, cholera (3) from adjacent organs, as in menstruation\\nand hemorrhage from the uterus (4) from the toxic action of drugs\\ncantharides, turpentine, and other violent irritants of the kidney (5)\\nvicariously occasionally menstruation fails to occur and hematuria\\nreplaces it. The same is true of bleeding from piles. Latour has\\nreported a case of asthma which subsided suddenly upon the appear-\\nance of hematuria.\\nThe chemical tests for blood are the same as those for its coloring-\\nmatter, and will be referred to under Haemoglobin.\\nHaemoglobin. Haemoglobin is, of course, present whenever blood\\nis, but sometimes it occurs independently of hematuria. Thus, it is\\nfound in grave infectious diseases, as the result of toxic action of drugs,\\nsuch as carbolic acid, and in an independent disease known as parox-\\nysmal haemoglobinuria. A suitable test consists in adding one or two\\ndrops of freshly prepared tincture of guaiac to about one drachm of\\nurine, then shaking the mixture and adding several drops of a solution\\nof hydrogen peroxide. If blood-coloring matter be present, a beautiful\\nblue coloration will be produced.\\nThe same test answers for methaemogiobin and haematin.\\nParoxysmal Hcemoglobinuria. The urine contains blood, or only\\nthe coloring-matter of the blood is present. Haemoglobinuria is more\\nfrequent in adult males it may be excited by a cold bath, or exposure\\nto cold, or by exertion. It is sometimes associated with Raynaud s\\ndisease. The attacks come on suddenly, often preceded by chills.\\nSometimes fever accompanies the disease. Vomiting and diarrhoea\\noccur with haemoglobinuria. Pain in the loins is sometimes com-\\nplained of. The paroxysm may last a day or two, or two or three\\nparoxysms may occur in the course of twenty-four hours.\\nAlbumose (Proteoses, propeptone or Meissner s peptone). Formerly\\nthe reactions which we know now determine the presence of the albu-\\nmoses were thought to indicate the presence of peptone. The latter\\nsubstance is extremely rare. Recent chemical investigations show\\nthat that which was called peptonuria is truly albumosuria. Albu-\\nmose has been found in the urine in osteomalacia and diseases of the\\nmedulla of bone and in myxoedema. When persistent it is in all proba-\\nbility due to multiple tumors of the bones or to myxoedema. The\\nalbumosuria may be considered as primary. Transitory albumosuria\\nis found in pneumonia, deep-seated suppuration, meningitis, and in der-\\nmatitis, intestinal ulcer, measles, scarlatina, and mental diseases. Its\\nfrequent occurrence renders its presence of not much diagnostic value.\\nAccording to von Jaksch, its presence may indicate that a suppurative\\nprocess exists. In the diagnosis of epidemic cerebro-spinal from tuber-\\ncular meningitis transitory albumosuria speaks for the former if no\\nulcerative tuberculous process exists elsewhere. Urine containing it\\ndoes not respond, at first, to the heat and nitric-acid test, but on cooling\\na precipitate forms which responds to the biuret test. (In this test the\\nurine is first treated with about one-half its volume of sodium hydrox-\\n59", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1025.jp2"}, "1026": {"fulltext": "930 SPECIAL DIAGNOSIS.\\nicle solution, and then a 1 per cent, solution of cupric sulphate is added,\\ndrop by drop. If albumose is present, the resulting cupric hydroxide\\nis dissolved, and the fluid becomes of a violet-red color.) The proba-\\nbility of the presence of albumose is strengthened if a turbidity occurs\\nwith the acetic acid and potassium ferrocyanide test (acetic acid, specific\\ngravity 1064, to which a few drops of a 10 per cent, solution of potas-\\nsium ferrocyanide have been added), and also with the biuret test,\\napplied directly to the urine itself. Albumin also responds to this test.\\nThe best test for albumoses is that of Hofmeister, modified by Sal-\\nkowski. Twenty to fifty c.c. of urine are acidified with acetic acid and\\nthen added to an equal quantity of a saturated solution of common salt,\\nboiled and filtered. In this manner the urine is freed from albumin\\nthe albumin remaining as a filtrate while the albumose is re-dissolved.\\nThe filtered fluid containing the albumose is placed in a beaker and\\na few drops of HC1 added. A solution of phosphotungstic acid is\\nadded and the precipitate consolidated by heat into a coherent mass.\\nThen pour off the supernatant fluid wash the precipitate with water\\nand dissolve in a solution of soda (sp. gr. 1.16), which is added, drop\\nby drop, until dissolved. If the solution is blue it is to be gently\\nheated, to decolorize. A few drops of a 1 per cent, solution of sul-\\nphate of copper is added to the soda solution. If a red or violet color,\\nthe biuret reaction results, albumose is present.\\nThe late Dr. N. A. Randolph suggested the following test, which is\\ngiven by Tyson To 5 c.c. of urine, which must be cold and faintly\\nacid, add two drops of a saturated solution of potassium iodide and\\nthen three or four drops of Millon s reagent. If albumoses or bile-\\nacids are present, a yellow precipitate falls. If the yellow precipitate\\ndoes not respond to the test for bile-acids, it is due to albumose.\\nSugar (Glucose). Next to albumin, sugar is the most important\\nabnormal constituent of the urine. It is not present in normal urines\\nin quantities that can be detected by ordinary clinical methods. The\\nbest tests for its detection are Fehling s test and the fermentation test.\\nFehling s Test. Fehling s solution is prepared by dissolving 34.652\\ngrammes of pure crystallized cupric sulphate in about 200 c.c. of water.\\nAbout 173 grammes of sodic potassium tartrate (Rochelle salt) are dis-\\nsolved in about 480 c.c. of sodium hydroxide solution of 1.14 specific\\ngravity. The cupric sulphate solution is added slowly to the sodic\\npotassium tartrate solution, stirring constantly until all of the cupric\\nsulphate solution has been added. The bluish-white precipitate of\\ncupric hydroxide which first forms will, on stirring the liquid, be\\ncompletely dissolved. The blue liquid is then diluted with water to\\nexactly 1000 c.c. One c.c. of this solution will be reduced by 0.005\\nof a gramme of glucose. Fehling s solution is prone to decomposition,\\nand as much as possible, to avoid the occurrence of decomposition, it is\\nbest to keep the cupric sulphate and sodic potassium tartrate solutions\\nin separate bottles closed with rubber stoppers. To accomplish this,\\nthe 34.652 grammes of cupric sulphate are dissolved in water and\\ndiluted to 500 c.c, and the sodic potassium tartrate is dissolved in\\nwater and diluted to 500 c.c, and the two solutions preserved in sepa-\\nrate bottles closed with rubber stoppers. The solution, prepared in", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1026.jp2"}, "1027": {"fulltext": "DISEASES OF THE KIDNEYS. 931\\nthis manner, is made ready for use by mixing one volume of the cupric\\nsulphate solution with an equal volume of the sodic potassium tartrate\\nsolution. The resulting liquid will be Fehling s solution, and 1 c.c. of\\nit will be equal to 0.005 of a gramme of glucose.\\nCertain precautions are necessary in the application of this test.\\n1. Any albumin present must be removed by boiling and filtration.\\n2. The Fehling solution, diluted with 4 to 5 volumes of water, must\\nbe boiled first and the urine added to it the urine must not be boiled\\nfirst and the Fehling solution added to it. Boiling the reagent first is\\na test of its stability if a precipitate occurs, the solution is unfit for use.\\nAs Wormley correctly says, a precipitate is more likely to occur when\\nthe Fehling solution has been diluted with four or five times its volume\\nof water than on boiling the undiluted solution. 3. Prolonged boiling\\nis to be avoided. The solution is to be heated to the boiling-point\\nand the urine then added if no precipitate indicating sugar occurs\\nuntil urine is added almost equal in volume to that of the reagent, the\\nmixture should be again heated to the boiling-point and then set aside.\\n4. AYhen the earthy phosphates are abundant, it is well to get rid of\\nthem by adding a small quantity of sodium hydroxide and filtering\\nbefore applying the sugar test. 5. Changes in color may occur from\\nthe presence of urea, uric acid, and extractives. These changes can\\nbe obviated, when necessary, by the method proposed by Seegen, who\\nrecommends repeated filtering through animal charcoal until the urine\\nis rendered colorless. Fehling s test is then applied to the filtered urine.\\nThe method of applying Fehling s test is as follows Fehling s solu-\\ntion is poured to the depth of about one-quarter of an inch into a test-\\ntube, and diluted with four or five times its volume of water, and heated\\nuntil it begins to boil then one or two drops of the suspected urine are\\nadded. If it be ordinary diabetic urine, the mixture, after an interval\\nof a few seconds, will suddenly turn to an intense opaque yellow or\\nreddish-brown color, and in a short time an abundant yellow or reddish-\\nbrown precipitate falls to the bottom. If, however, the quantity of\\nsugar present be small, the suspected urine is added more freely, but\\nnot beyond a volume equal to that of the diluted Fehling s solution\\nemployed. In this latter case it is necessary to raise the mixture once\\nmore to the boiling-point. It is then allowed to cool slowly. If no\\ncuprous oxide has been thrown down when the liquid has become cold,\\nthen the urine may be pronounced sugar-free.\\nSir William Roberts has recently point( d out the value of repeated\\nfiltration through animal charcoal of urine which reacts doubtfully to\\nthe test for sugar by this filtration the urates, uric acid, and other\\nnormal constituents of the urine, which have more or less power of\\nreducing Fehling s solution, are removed, while the sugar passes\\nthrough and is found in undiminished quantity in the filtrate.\\nThe test is made as follows A test-tube is charged with Fehling s\\nsolution to the depth of about one-quarter of an inch, diluted with four\\nor five times its volume of water, and brought to the boiling-point the\\nurine, filtered through charcoal, is added to the depth of about two\\ninches, and the two fluids mixed. The flame of a lamp is then applied\\nto the upper half of the column of liquid, and this is boiled for a couple", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1027.jp2"}, "1028": {"fulltext": "932 SPECIAL DIAGNOSIS.\\nof seconds. If sugar is present, the upper half loses its blue color and\\nassumes a yellowish tinge, and the earthy phosphates which are thrown\\nclown in light flakes by the alkali of the test are tinted more or less of\\na gold color by the precipitation on them of the cuprous oxide.\\nThe Fermentation Test. This is based upon the fact that sugar by\\nfermentation with yeast breaks up into alcohol and carbon dioxide.\\nIt is a reliable but not a very delicate test for sugar.\\nA piece of yeast-cake the size of a pea is added to a test-tube full of\\nurine. The open end of the tube is inverted under water in a saucer\\nor beaker. If sugar is present in amounts larger than two and a half\\ngrains to the ounce, bubbles of carbon dioxide collect at the upper part\\nof the tube after standing twelve hours in a temperature of about 90\u00c2\u00b0 P.\\nThe Phenyl-hydrazin Test. Von Jaksch believes this test to be a very\\naccurate one. About two grains of phenyl-hydrazin hydrochloride and\\nabout three grains of sodium acetate are put into a test-tube half -full of\\nwater. The contents of the tube are heated and the tube filled with the\\nsuspected urine. The tube is kept for fifteen or twenty minutes in\\nboiling water, and then put in a vessel of cold water. When a large\\namount of sugar is present a deposit of yellow, needle-like crystals is\\nvisible to the naked eye but when only a small amount is present, the\\nsediment must be examined under the microscope. The crystals appear\\nsingly, or in sheaves and fine radii. Yellow plates and brown balls do\\nnot indicate sugar. (Plate XLVI.)\\nQuantitative estimation of sugar can be made with Fehling s solution\\nby using a burette and measured quantities of urine and reagent.\\nWormley recommends a method which answers very well for office-\\nuse One cubic centimetre of Fehling s solution is diluted in a large\\ntest-tube with four cubic centimetres of distilled water, and boiled.\\nOne-tenth of a cubic centimetre of the suspected urine is then added\\nfrom a graduated pipette. Heat is then applied, the precipitate watched,\\nand then another one-tenth cubic centimetre added, and heat again\\napplied. The addition of one-tenth of a cubic centimetre, followed by\\nheat, is continued, until it is found, after proper subsidence, that all\\nthe color is removed from the diluted Fehling s solution. If in doing\\nthis one cubic centimetre of urine has been added, it will have contained\\njust 0.5 per cent, of sugar. If more than one cubic centimetre, it will\\nhave contained less than 0.5 per cent. If exactly two cubic centimetres\\nare used, it will have contained exactly 0.25 per cent. If one-tenth of\\na cubic centimetre has been used, the urine will have contained 5 per\\ncent, of sugar. If the quantity of sugar in the urine is large, the urine\\nshould first be diluted with a measured volume of water, allowance\\nbeing made for this in the estimation.\\nWhen the quantity of sugar is relatively large fermentation is the\\nsimplest and most trustworthy method. Roberts has shown that\\nsaccharine urine loses by fermentation one degree in density for every\\ngrain of sugar contained in an ounce of urine. For example, if the\\nurine before fermentation had a specific gravity of 1040, and after fer-\\nmentation a specific gravity of 1010, then the urine contained 30 grains\\nof sugar to the ounce. In the application of this method, about four\\nounces of diabetic urine are put in a twelve-ounce bottle, and a piece", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1028.jp2"}, "1029": {"fulltext": "PLATE XLVJ\\n.A v\\nCrystals of Phenyl-glueosazone.\\n(Oc. 4, Obj. D.) Drawn by J. D. Z. Chase.", "height": "4396", "width": "2660", "jp2-path": "practicaltreatis00muss_0_1029.jp2"}, "1030": {"fulltext": "", "height": "4404", "width": "2588", "jp2-path": "practicaltreatis00muss_0_1030.jp2"}, "1031": {"fulltext": "DISEASES OF THE KIDNEYS. 933\\nof Vienna yeast, about the size of a pea, is broken up and then added\\nto it. This bottle is closed with a perforated cork to allow the C0 2\\nto escape, and stood aside in a warm place to ferment. Beside it is\\nplaced a tightly corked four-ounce bottle filled with the same urine,\\nbut without any yeast. In about twenty-four hours the fermentation\\nwill have ceased. The specific gravity of the fermented urine is then\\ntaken and also that of the unchanged urine. Every degree of loss in\\ndensity represents one grain of sugar per ounce of urine.\\nDiabetes Mellitus. The occurrence of any of the following condi-\\ntions should lead to an examination of the urine for sugar, and an esti-\\nmation of the quantity of urine passed in twenty-four hours, apart from\\nthe routine examination, which should be made in every case of chronic\\ndisease or of obscure acute disease 1. Muscular weakness without\\ncause. The weakness is progressive and rapidly advances to an ex-\\ntreme degree. 2. Emaciation. In young subjects this is rapid in\\ncases of diabetes. In older patients it is not so striking, particularly\\nif the gouty diathesis is present. 3. Thirst. This is a symptom\\nwhich is of common occurrence in diabetes, and is most distressing.\\nIf the amount of fluids taken be compared with the amount of urine\\nexcreted, it will be found that the two bear a definite ratio. The thirst\\nis greater immediately after meals, although the patient does not neces-\\nsarily have indigestion. 4. Hunger. Excess of appetite, boulimia or\\npolyphagia, also occurs in diabetes. The amount of food that is taken\\nis sometimes enormous, and the ravenous way it is devoured is revolt-\\ning. 5. Loss of sexual power.\\nThe five symptoms just mentioned, with increased frequency in\\nmicturition, are the common symptoms of diabetes mellitus. They\\nmay develop gradually. In rare instances the onset is sudden. The\\noccurrence of these symptoms should lead at once to an examination of\\nthe renal secretion.\\nThree special characteristics of the urine are observed. A. The\\namount is increased, so that from six to ten pints, or even as much as\\nthirty to forty pints, are passed in twenty-four hours. B. The specific\\ngravity ranges from 1025 to 1015, and may even be higher. C. The\\npresence of sugar. The sugar is detected by the ordinary tests. (See\\nExamination of Urine.) In addition the urine is usually of pale color,\\nof a sweetish odor and acid reaction.\\nIn addition to thirst and increased appetite, some gastro-intestinal\\nsymptoms may be of diagnostic importance. Of these, first, the appear-\\nance of the tongue is characteristic. It is dry, red, and glazed. The\\ndryness is increased because of the scanty flow of saliva. The gums\\nare swollen and spongy, and marginal gingivitis and stomatitis are often\\npresent. There are no marked dyspeptic symptoms. Constipation is of\\ncommon occurrence.\\nIn diabetes other secretions diminish.. Perspirations do not occur,\\nexcept in inflammatory complications. The skin is harsh and dry. As\\nthe disease progresses the heart s action becomes weak and the pulse\\nfrequent, with lowered tension. The temperature of the body is usually\\nbelow normal.\\nDiabetes may occur at any age, but is most frequent in adult life.", "height": "4416", "width": "2580", "jp2-path": "practicaltreatis00muss_0_1031.jp2"}, "1032": {"fulltext": "934 SPECIAL DIAGNOSIS.\\nIn young adults the symptoms are more pronounced, and the duration\\nshorter. In patients past middle life the disease may continue for a num-\\nber of years without marked interference with the health and nutrition.\\nWhile the symptoms just mentioned should lead to an examination\\nof the urine, diabetes mellitus may not be suspected by any of the usual\\nobjective or subjective symptoms. It may happen that none of these\\nsymptoms is sufficiently marked, and that only by routine examination\\nof the urine, or by the occurrence of affections known to be associated\\nwith sugar in the urine, is the disease discovered.\\nOf the complications which should lead to the suspicion of sugar in\\nthe urine the following are the most important\\n1. Cutaneous Complications. Boils and carbuncles should always\\nlead to an examination of the urine. Pruritus and chronic eczema\\nmay have diabetes in the background. Gangrene of the extremities,\\nchiefly of the feet and legs, and gangrene in other situations, is of com-\\nmon occurrence in the course of diabetes.\\n2. Lung-complications. Tuberculosis, both of the chronic and the\\nacute pneumonic type, is frequently associated with diabetes. Lobar\\npneumonia is apt to occur. In all cases of pneumonia the urine should\\nbe examined for sugar. Its presence would modify the prognosis of an\\notherwise moderate case. Gangrene is likely to ensue in the acute and\\nchronic lung affections. Gangrene of the lung in the course of diabetes\\nmay be latent, and recognized only by the odor and the character of the\\nexpectoration, or it may run an acute febrile course.\\n3. Nervous Symptoms. Diabetic coma may develop in the course of\\nthe disease. In young subjects, particularly, the occurrence of coma\\nshould lead to a suspicion of diabetes. Such coma may occur before\\nthe disease has been recognized. The coma may follow an attack of\\nfainting and prostration, with stupor, which deepens into complete\\nunconsciousness. It may be preceded by nausea and vomiting or by\\nthe lung-complications previously mentioned. This form of coma is\\nusually preceded by extreme dyspnoea, by agitation, pain in the head,\\nand some delirium. The pulse becomes rapid and feeble, and coma\\ndevelops gradually. For this form of coma the term acetonaimia is\\nused. The breath is of a peculiar sweetish odor, due to acetone, and\\nthis compound is detected in the urine. Coma may occur without any\\npremonitory symptoms whatsoever, the patient reeling for a short time,\\nand complaining of pain in the head as if intoxicated.\\nPeripheral neuritis should always lead to an examination of the\\nurine. It may be limited to one group of nerves, or may be more or\\nless general, with symptoms like those of locomotor ataxia, as the light-\\nning-pains, abolition of reflexes and loss of power in the extensor\\nmuscles. Diabetic patients are also subject to neuralgia, and to periph-\\neral hypersesthesia and paresthesia, probably due to neuritis. The\\nneuritis may be so extreme as to lead to paraplegia.\\n4. Eye-symptoms. A curious symptom of diabetes is the occurrence\\nof cataract. This may develop at any age, and is often rapid in its\\ncourse. Cataract or alterations of vision should always demand an\\nexamination of the urine. Diabetic retinitis is sometimes present.\\nAtrophy of the optic nerves, or muscular insufficiencies, may take", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1032.jp2"}, "1033": {"fulltext": "DISEASES OF THE KIDNEYS. 935\\nplace, the latter causing the pronounced symptoms of eye-strain.\\nRinging in the ears, deafness, the occurrence of acute otitis, are\\nphenomena which arise in the course of diabetes.\\nDiagnosis. Sugar in the urine occurs temporarily when there is\\nan excess of saccharine diet, or when there is functional disorder of the\\nliver. The sugar is small in amount, and the glycosuria is transient.\\nThe diagnosis of true diabetes is not difficult, although the disease may\\nbe overlooked unless the habit, previously insisted upon, of constant\\nurinary examinations is fully developed.\\nIndican. An excess of indican in the urine is known as indicanuria.\\nThe substance is detected by several methods. Jaffe s test Equal\\nvolumes of hydrochloric acid and urine are mixed. By means of a\\nglass pipette a solution of sodium hypochlorite is dropped into the fluid.\\nAn indigo-blue color is produced if indican be present. The hypochlo-\\nrite must not be added in excess. A quantitative determination is\\nmade by the colorimetric process of Salkowski. A rough analysis is\\nfirst made, to determine the quantity of calcium hypochlorite, which\\ncauses the greatest amount of indigo to unite with it. If the urine\\ncontains much indican, a small portion, as 2.5 to 5 c.c, is diluted with\\nwater to 10 c.c. If there is but little indican, 10 c.c. of the urine are\\nused without dilution. An equal quantity of hydrochloric acid is\\nadded. To this the amount of hypochlorite solution with which, in\\nthe first test, indigo combined in the greatest amount is added. Then\\nthe liquid is neutralized with sodium hydroxide, then enough sodium\\ncarbonate is added to make it alkaline. The indigo-blue is thus pre-\\ncipitated and collected on a filter. The precipitate is repeatedly washed\\nwith water until the alkaline reaction disappears. The filtrate is dried\\nand extracted by heating with chloroform, until the latter no longer\\nassumes a blue color. The chloroform extract is increased to a round\\nnumber of c.c. by the addition of chloroform, and placed in a vessel\\nwith parallel sides. The intensity of its color is compared with a\\nfreshly prepared chloroform solution of indigo blue of known strength.\\nTo one or other of these chloroform is added until the tint of both is\\nthe same. The quantity of indigo-blue derived from the urine is deter-\\nmined, and its percentage calculated from the intensity of color and\\nstrength of the solution of indigo of known strength. Five to twenty\\nmilligrammes of indigo-blue are passed in twenty-four hours in health.\\nIndican is increased by animal diet an increase which, under other\\ncircumstances, is pathological. Its presence is a sign of intestinal\\nputrefaction. It may accompany a decomposition of albumin in cavi-\\nties. It is present in empyema and in puerperal peritonitis. By\\ndetection of its presence in these diseases cavities due to pus may be\\ndistinguished from those due to other causes. Indican is increased in\\nacute diarrhoea and in intestinal tuberculosis. Von Jaksch states that\\nlarge quantities of indican in the urine imply that abundant albuminous\\nputrefaction or putrid suppuration is in progress in the system. It must\\nnot be forgotten that indicanuria will often arise in simple constipation.\\nBile -pigments and Bile-acids. Bile-pigment or bilirubin occurs\\nin the urine in cases of hepatogenic and hematogenic jaundice and in\\nportal thrombosis.", "height": "4416", "width": "2628", "jp2-path": "practicaltreatis00muss_0_1033.jp2"}, "1034": {"fulltext": "936 SPECIAL DIAGNOSIS.\\nGmelin s test and its modifications are the ones usually employed.\\nA small quantity of nitric acid, to which some nitrous acid has been\\nadded, is put into a test-tube and then gently overlaid with urine. If\\nbile-pigment is present, a series of colors appear at the junction of the\\ntwo fluids green, blue, violet, and yellow. A green color (biliverdin)\\nmust be present to prove the existence of bile-pigment.\\nThe same test may be applied by placing a few drops of the acid\\nupon one side of a plate and the urine on the other, and then allowing\\nthe two to run together. The play of colors takes place, as before, at\\nthe line of junction of the acids and urine.\\nRosenbach s modification is an improvement. About 200 c.c. of urine\\nare allowed to flow through pure white filter-paper, and then a drop of\\nnitric acid is placed upon the paper saturated with the urine. The\\ncolors appear as before described.\\nA very simple test consists in allowing a few drops of the acid to\\nfall into a test-tube full of urine. If bile-pigment is present, a\\ngreen color appears at the line of junction of the two fluids. This\\ntest may fail, however, if only small quantities of bile-pigment are\\npresent.\\nThe tests for bile-acids are either too elaborate or too unsatisfactory\\nfor clinical use.\\nPus. Pus is found in the urine whenever there is suppuration or\\na catarrhal condition of the genito-urinary tract. Hence, it occurs in\\nabscess of the kidney, pyonephrosis, pyelitis, tuberculosis, cystitis, gonor-\\nrhoea, leucorrhoea, etc. It is relatively common in women, from a\\ncatarrhal condition of the vulva and vaginal mucous membrane, and\\nis, therefore, of less significance than in men. Urine containing much\\npus is slightly albuminous but frequently pus-cells are found in urine\\nwhich gives no reaction for albumin.\\nThe chemical test for pus is its conversion into a tenacious (gelat-\\ninous), glairy mass by boiling with caustic potash.\\nAcetonuria. An excess of acetone occurs in the following diseases\\n(1) In diabetes (2) in cancer independent of starvation (3) in starva-\\ntion (4) in certain psychoses (5) in auto-intoxications (6) in derange-\\nment of digestion (7) in fevers. In diabetes acetone indicates an\\nadvanced stage of the disease. Lieben s test for acetone is as follows\\nTo several c.c. of urine a few drops of iodo-potassium iodide solution\\nand sodium hydroxide are added. If acetone is in excess, the precipi-\\ntation of iodoform takes plaoe, which may be recognized by its odor.\\nDiaceturia. Diacetic acid is found in the urine in diabetes, in fevers,\\nand in auto-intoxications. It is common with children in fever. It\\nis of grave significance when in the urine of adults. Coma usually\\nfollows its occurrence in the urine in fevers and in diabetes. Test A\\nconcentrated solution of ferric chloride is cautiously added to the urine.\\nIf a precipitate be formed, it should be removed by filtration and more\\nferric chloride added to the filtrate. If diacetic acid be present, the\\nliquid will become claret-red in color.\\nHaematoporphyrinuria. This is a rare constituent of the urine\\nderived from the blood. It is said to be a form of hsematin freed from\\niron. Nakarai thinks that the occurrence of hsematoporphyrinuria is", "height": "4416", "width": "2580", "jp2-path": "practicaltreatis00muss_0_1034.jp2"}, "1035": {"fulltext": "DISEASES OF THE KIDNEYS. 937\\nconstant in lead-poisoning, and occurs with some degree of frequency\\nin intestinal hemorrhage.\\nAlkaptonuria. The substance in the urine which has been identi-\\nfied as alkapton is also known as pyrocatechin (Ebstein and Muller,\\nVirchow s Archiv, Bd. lxv. s. 394), protocatechinic acid (Smith, Dub-\\nlin Journ. Med. 8c, 1882, vol. i. p. 465), urrhodinic acid (Kirk, British\\nMedical Journal, London, 1886, vol. ii. p. 1017), glycosuric acid (Mar-\\nshall, Medical News, Philadelphia, 1887, p. 35), uroleucinic and uro-\\nxanthinic acids (Kirk, British Medical Journal, London, 1888, vol. ii.\\np. 232), and homogentisinic acid (Baumann and Wolkow, Ztschr. f.\\nphysiol. Chem., Strassburg, Bd. xv. s. 228). It reduces copper, as\\ndoes glucose, and its occurrence is of interest, because the presence of\\nthe substance has led to the diagnosis of glycosuria in many instances,\\nin consequence of which persons have been refused life insurance.\\nThe urine containing this substance deepens in color on exposure to\\nair. It is of a peculiar aromatic odor, and reduces cupric salts rapidly.\\nThere is, however, no reaction to the fermentation test, to Bottger s\\nbismuth test, or to phenylhydrazin, and no deviation of the rays of\\npolarized light. The urine does not contain bile-pigment. It is of\\nnormal specific gravity, and becomes very dark on the addition of an\\nalkali or of a temporarily bluish-green color with perchloride of iron.\\nAmmonia nitrite of silver is instantaneously reduced when added to\\nthe urine with a deposit of metallic silver.\\nAlkaptonuria is usually congenital. Several members of the same\\nfamily will have it. No symptoms attend the condition.\\nNote. Serum-globulin is converted into a coagulated proteid when\\nheat is applied or concentrated nitric acid added to a solution. Globu-\\nlin is soluble in dilute salt solutions. If urine, rich in globulin, is\\nadded, drop by drop, to a large volume of distilled water, the globulin\\nis precipitated as the percentage of salt is reduced by dilution. Globu-\\nlin is also precipitated by dialysis. If a portion of urine containing\\nglobulin is saturated with magnesium sulphate or half saturated with\\nammonium sulphate, globulin is precipitated.\\nHills describes the method as follows 25-50 cubic centimetres\\nof the urine are made neutral or slightly alkaline with ammonium\\nhydroxide, and the precipitated phosphates removed by filtration. An\\nequal volume of a saturated solution of ammonium sulphate is then\\nadded, the mixture shaken, and allowed to stand for some time, and\\nfinally filtered. The precipitate is washed with a half-saturated solu-\\ntion of ammonium sulphate for the removal of the last traces of albu-\\nmin and the filtrate and precipitate tested for albumin and globulin\\nrespectively, as previously described. The formation of a precipitate\\nupon the addition of either magnesium or ammonium sulphate is not\\nin itself evidence of the presence of globulin/\\nMicroscopical Examination of the Urine. Microscopical examina-\\ntion of the urine is chiefly concerned with the sediments, and these are\\nconveniently divided into the organized and unorganized.\\n1 Boston Medical and Surgical Journal, 1899, vol. cxli No. 6.", "height": "4416", "width": "2636", "jp2-path": "practicaltreatis00muss_0_1035.jp2"}, "1036": {"fulltext": "938\\nSPECIAL DIAGNOSIS.\\nThe organized deposits in the urine are blood, pus, mucus, epithelium,\\ncasts, spermatozoa, micro-organisms, cancerous and tuberculous matter,\\nentozoa.\\nThe unorganized deposits are uric acid and its compounds, oxalate and\\ncarbonate of lime, phosphates, leucin and ty rosin, cystin and cholesterin.\\nNormal urine forms a slight sediment, consisting of epithelium from\\ndifferent parts of the genito-urinary tract, principally from the bladder\\nin males, and from the vagina and bladder in females. There are also\\nsome crystals of the different urinary salts, sometimes mucus and a few\\nwhite blood-cells, and, if the urine has stood a while, especially if alka-\\nline, more or fewer bacteria. It may accidentally contain extraneous\\nmatter, derived from the vessel which contains it or from the air. (Fig.\\n206.)\\nFig. 206.\\nExtraneous matters found in urine: a, cotton-fibres; b, flax-fibres; c, hairs; d, air-bubbles!\\ne, oil-globules wheat-starch g, potato-starch h, rice-starch granules; i, i, i, vegetable tissue\\nk, muscular tissue I, feathers.\\nThe centrifugal machine has now become an important adjunct to\\nthe rapid and accurate microscopical examination of the urine. There", "height": "4416", "width": "2584", "jp2-path": "practicaltreatis00muss_0_1036.jp2"}, "1037": {"fulltext": "DISEASES OF THE KIDNEYS. 939\\nare now numerous varieties to be secured at the instrument-stores, some\\nof which are devised solely for urinary examination, while others have\\nadditional apparatus for examination of the blood and sputum. The\\nmajority of them are revolved by hand. Electricity can be readily\\napplied to any of them and labor be saved by such a device. The\\nadvantages of centrifugal force over the older gravity method employed\\nin microscopical examination are marked. Some few of them can be\\nbriefly outlined\\n1. Centrifugalization secures complete, rapid, and concentrated sedi-\\nmentation. It is, therefore, best suited to microscopical diagnosis.\\n2. Casts or other organic material, if present, can be studied care-\\nfully before they are macerated or partially destroyed by bacteria or\\nchanged by the deposition of amorphous or crystalline material. This\\nis a most important aid to correct diagnosis.\\n3. Crystals, if present at the time of urination, can be discovered and\\ndifferentiated from those that normally crystallize out after some hours.\\n4. Certain bodies, hyaline casts, for instance, because of their rather\\nlight specific gravity, do not settle on the simple standing of the urine,\\nand thus escape detection. These with all other substances are thrown\\ndown with the centrifugal machine.\\n5. Bacteria are discovered with greater ease, especially the tubercle\\nbacillus.\\nThe method commonly used for the examination of the urinary sedi-\\nment is as follows The urine for examination (the chemical analysis\\nhaving previously been made) is decanted until there remains but a\\nsmall amount in the bottle, which amount contains any sediment\\nalready formed, and heavier organic materials. This is then poured\\ninto one of the tubes of the centrifugal machine to within one-half\\ninch of the top if but one specimen of urine is to be examined, fill\\nboth tubes with the same urine. If there is not sufficient urine to do\\nthis, fill the remaining tube or tubes with water. It is well to mark\\nthe external metal shields of the tubes with a figure, say 1 and 2, or a\\nand b, so that the urines, if different specimens, may not become con-\\nfused.\\nThe tubes are then rapidly revolved for three minutes, then removed\\nfrom the machine and a few drops of the sediment withdrawn with a\\npipette and placed upon the slide for examination under the microscope.\\nIt is necessary to remember that care must be exercised in removing\\nthis sediment from the tube. The straight glass pipette without a\\npointed end seems to give the best results in securing the sediment.\\nThe finger is placed upon one end, the pipette inserted to the bottom\\nof the tube and the finger is then elevated just enough to secure a few\\ndrops of the sediment that has been cast down by centrifugalization.\\nIf the urine contains but the normal mucous cloud, a very small whitish\\nsediment or cloud is found at the bottom of the tube. If oxalate of\\nlime is present, a small filmy whitish sediment is seen. The sediment\\nof amorphous urates is pinkish, fawn, or salmon color. Uric acid\\nappears as a brick-dust sediment. Pus produces a heavy yellowish\\nsediment phosphates a heavy white sediment, which is sometimes\\nyellowish-white from admixture with leucocytes. Blood in small", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_1037.jp2"}, "1038": {"fulltext": "940\\nSPECIAL DIAGNOSIS.\\nquantities produces a rather characteristic brownish deposit. Large\\namounts of blood appear as reddish coagulae at the bottom of the tube.\\nWith some of the centrifugal machines the various urinary salts and\\nthe amount of albumin present can readily be estimated. Such instru-\\nments are provided Ayith graduated tubes, in which the urine and the\\nnecessary reagents are put and the resulting precipitate rapidly cast\\ndown.\\nFig. 207.\\nCellular elements from the urine. 1, squamous epithelium 2, red blood-corpuscles 3, poly-\\nnuclear leucocytes 4, transitional cells 5, epithelium from the kidneys 6, epithelium from the\\nbladder 7, micrococcus aurese 8, yeast-fungi.\\nIn this manner Purdy estimates the chlorides, sulphates, and phos-\\nphates, and also the amount of albumin most satisfactorily. It is ques-\\ntionable, however, whether the estimation of the salts is accurate.\\nOrganized Sediments. Blood. If the blood comes from the kid-\\nney, it is usually intimately mixed with the urine, which remains of a\\nred or reddish-brown color, and contains possibly tube-casts and renal\\nepithelium. The blood-cells appear singly, have frequently lost their\\nhaemoglobin, and hence look like pale-yellow disks. (See Fig. 207.)\\nSometimes blood coagulates in the ureters, and long, cylindrical\\nplugs are passed, causing symptoms resembling those of renal colic.\\nWhen blood comes from the bladder or neck of the bladder (fissure)\\nthere are symptoms of frequent micturition, of acute pain and tenes-\\nmus, and the blood is not intimately mixed with the urine. When\\nfrom the neck of the bladder, it often occurs in a few r drops at the end\\nof micturition, accompanied with great pain and a sense of faintness.\\nIntermittent hematuria, according to Von Jaksch, points directly to\\ncalculus or tumor of the bladder.\\nBlood-cells, when unaltered, are unmistakable, on account of their\\nwell-known biconcave appearance. When they haye lost their color-\\ning-matter they appear as circular, very pale disks, with extremely\\nfaint outline and feeble refractive power. Absence of a nucleus serves", "height": "4412", "width": "2576", "jp2-path": "practicaltreatis00muss_0_1038.jp2"}, "1039": {"fulltext": "DISEASES OF THE KIDNEYS. 941\\nto distinguish thern from yeast-spores, and the latter, moreover, are\\noften oval in shape. They are less likely to be confounded with the\\novoid and circular shapes of oxalate of lime crystals, because the latter\\nare not common, and can be seen usually in their more common forms\\nas octahedra and dumb-bells in the same urine.\\nPus. The sources of pus in the urine have been referred to already.\\nThe pus-corpuscle is an opaque, spherical, granular cell, usually some-\\nwhat larger than are blood-cells. In dilute urine, or urine to which\\nwater has been added, it swells sometimes to twice its original size.\\nAt the same time, it becomes less granular, and two, three, or four\\nnuclei may appear. In concentrated urines the pus-cell is small. The\\naddition of acetic acid also causes it to swell, and brings out the nuclei\\nmore distinctly and rapidly. Sometimes the pus-cells are discrete,\\nsometimes in dense clumps, and sometimes nothing but a dense mass\\nof pus-cells appear in the field of the microscope.\\nIt cannot be decided from microscopic examination whether a cell\\nis a pus-corpuscle, a mucus-corpuscle, a white blood-cell, or an inflam-\\nmatory leucocyte. It must be a matter of inference from the general\\ncharacters of the urine. If red blood-cells are also present, the proba-\\nbility of finding white blood-cells is increased, but pus-cells are not\\nnecessarily excluded. So, too, if much mucus be present in the urine,\\nthe doubtful cell may be a mucus-corpuscle. Some clue to the source\\nof the pus can be obtained from the urine itself. Urine containing pus\\nfrom the kidney is usually acid, whereas in cystitis it is alkaline, and\\nalmost always contains phosphates, mucus, and abundant bacteria.\\nAgain, pus from the kidney, or kidney pelvis, is apt to vary greatly in\\namounts, or be discharged intermittently and the urine, when filtered\\nfree from pus-cells, is usually still albuminous. Renal epithelium and\\ncasts may also be found.\\nCasts. Casts are the most important of the urinary deposits. They\\nvary greatly in number and size. Sometimes in acute nephritis they\\nform a considerable part of the sediment, but usually they have to be\\nsought for carefully and patiently. A few words as to the method of\\nexamining for them may not be superfluous.\\nSedimentation by the centrifugal machine is now much in vogue. If\\nthe centrifugal machine cannot be employed, proceed as follows\\nSix or eight ounces of the urine to be examined should be allowed\\nto settle in a bottle as soon after being passed as possible. The bottle\\nshould be tightly corked, because urine exposed to the air decomposes\\nvery quickly it should be sent to the person who is to examine it as\\nsoon after being passed as possible, in order that an examination may\\nbe made before fermentative changes spoil it for trustworthy analysis.\\nAfter standing twelve, or preferably twenty-four hours, nearly all of the\\nsolid matter will have collected at the bottom of the bottle. The super-\\nnatant clear fluid can nOw be poured off, and the lower portion of the\\nurine and the sediment poured into a conical subsiding-glass. If the\\nurine is febrile, there may be by this time a large deposit of amorphous\\nurates, which will obscure the search for casts they may be dissolved\\nby gentle heating without destroying the casts, and the clear urine\\nagain allowed to settle for a few hours. So, too, if phosphates are", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_1039.jp2"}, "1040": {"fulltext": "942\\nSPECIAL DIAGNOSIS.\\nabundant, they should be gotten rid of by gentle heating and acidula-\\ntion with two or three drops of dilute acetic acid.\\nAfter the urine in the conical subsiding-glass, which will not now\\namount to more than an ounce or two, has stood for a few hours, any\\ncasts that may be present will have fallen into the bottom. If the\\nurine is very concentrated (1030 or more), epithelium, blood, and casts\\nwill be suspended longer hence, it may be well to dilute the urine\\nbefore allowing it to settle.\\nA glass tube, with an internal diameter of about one-eighth of an\\ninch, and with one end drawn out fine, is the most convenient thing\\nfor collecting the sediment. The ordinary glass pipette, with a rubber\\nsuction-bulb at one end, commonly known as a medicine-dropper,\\nsometimes answers admirably. If the common glass tube is used, the\\nforefinger of the right hand should be placed over the open upper end,\\nand the fine lower end passed down to the bottom of the glass. The\\nfinger is then removed sufficiently to permit a few drops to be sucked\\nin. The same thing is attained if the finger is entirely removed as soon\\nas the point on the tube reaches the bottom of the conical glass but\\nin that case more than the lowest layers of the sediment or urine are\\nsucked up, and hence all but a few drops should be allowed to flow out\\nwhen the tube is removed from the urine. In this way the drops pre-\\nserved for microscopical examination will contain the sediment from\\nthe very bottom of the glass. In this sediment, in pale urines free\\nfrom much urates, phosphates, and pus, the casts will be found, if any\\nare present in the urine. It is most important to examine the bottom\\nlayers of the sediment when the latter is scanty, or when phosphates\\nor urates have begun to precipitate after the urine has been standing\\nsome time. If the urine is already cloudy with phosphates, urates, or\\npus, when it is put aside to settle, any casts that may be present will be\\ncarried down with the heavier sediment, and will be found intimately\\nmixed with it, or even on top of the other sediment.\\nFig. 208.\\nEpithelial and hyaline casts.\\nThe few drops preserved for microscopical examination are now depos-\\nited on several slides, without a cover-glass, and examined carefully\\nfor casts under a power of 50 to 60 diameters. Casts may be numerous,", "height": "4400", "width": "2520", "jp2-path": "practicaltreatis00muss_0_1040.jp2"}, "1041": {"fulltext": "DISEASES OF THE KIDNEYS.\\n943\\nso that nearly every field contains one dozen or more, or they may be\\nvery few, not more than one or two being found on a slide. The best\\nroutine method for microscopical examination is as follows place a\\nfew drops of the urinary sediment upon the slide spread the drops in\\nHyaline casts and cylindroids in hypostatic congestion of kidney. Low power.\\na thin layer use no cover-glass examine with the low power a diam-\\neter of 50 with a small amount of light the whole slide can be care-\\nfully searched in three minutes, and casts discovered can be minutely\\nFig. 210.\\nHyaline casts from a case of acute nephritis. 1, plain hyaline cast 2, granular deposit on hyaline\\ncast; 3, cellular deposit (blood and epithelium).\\nstudied with the higher power. When but few casts are present, several\\nslides can be rapidly examined with the low power, and an accurate\\nestimation of the number made.", "height": "4416", "width": "2604", "jp2-path": "practicaltreatis00muss_0_1041.jp2"}, "1042": {"fulltext": "944\\nSPECIAL DIAGNOSIS.\\nAll the pipettes used in examining urine must be kept clean. They\\nshould be allowed to stand in water which is frequently changed, and\\ncarefully rinsed in running water before being used.\\nTube-casts usually indicate acute or chronic nephritis but they are\\nsometimes found in cases of renal calculi in icterus, usually without\\nalbuminuria in diabetes, and sometimes in secondary congestion of\\nthe kidney.\\nFig. 211.\\nGranular casts.\\nSeveral varieties of casts are found. 1. Hyaline casts, as their name\\nimplies, are clear, translucent bodies, which refract light so slightly that\\nthey are easily overlooked. They have well-defined margins, the ends\\nbeing frequently rounded they are rarely very long, and are straight,\\nor but slightly bent. They are rarely equally translucent throughout at\\nsome part more or less granulation will generally be found. They\\nvary in diameter from that of a white blood-cell to six or eight times\\nas large. They can be stained, and so rendered more distinct, by\\nallowing a drop of gentian-violet solution to flow in under the edge of\\nthe cover-glass. (Figs. 209 and 210.) 2. Granular casts are hyaline\\ncasts which appear granular either from some deposit on their surface\\nor from a granular change of the cast itself. When the granulation\\ndoes not interfere with the translucency the casts are described as\\npale or slightly granular and when they become very dark, so as\\nto resemble closely a blood-cast, they are called dark or opaque\\ngranular casts. (Plate XLVIL, Fig. 1, 1 and Figs. 210, 211.) 3.\\nWaxy casts appear to the eye to be more solid in structure than the\\nhyaline casts they also appear more cylindrical in form, are more or\\nless yellow in color, and are apt to be larger than hyaline casts. (Plate\\nXLVIL, Fig. 1, 2.) 4. Fatty casts are hyaline or faintly granular\\ncasts on which are deposited, in spots, minute oil-drops. They are\\nsometimes called oil-casts if the oil-drops are very abundant. (Fig.\\n212.) 5. Ill o i sts are either made up of a mass of blood-cells pressed\\ntogether into a cylindrical shape, or, more frequently, a hyaline cast is", "height": "4408", "width": "2628", "jp2-path": "practicaltreatis00muss_0_1042.jp2"}, "1043": {"fulltext": "PLATE XLVII\\n2\\n1. Hyaline Casts with Granular Matter and Epithelial Cells\\ndeposited upon them. 2. Amyloid (waxy) Cast.\\n(Oc. 4. ob. D.) Drawn by J. D. Z. Chase.\\nu\\nFIG. 2.\\nr A\\n1\\nBlood-easts from Case of Acute Nephritis.\\n(Oc. 4. ob. D.) Drawn by J. D. Z. Chase.", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_1043.jp2"}, "1044": {"fulltext": "", "height": "4400", "width": "2552", "jp2-path": "practicaltreatis00muss_0_1044.jp2"}, "1045": {"fulltext": "DISEASES OF THE KIDNEYS.\\n945\\nstudded with blood-cells. (Plate XLVIL, Fig. 2.) 6. Epithelial casts\\nsometimes seem to be composed entirely of epithelial cells closely packed\\ntogether. Such casts are relatively rare, and very beautiful. Ordi-\\nnarily, just as in the case of blood-casts, an epithelial cast consists of\\nFig. 212.\\nFatty casts from a case of chronic parenchymatous nephritis.\\na hyaline cast more or less covered with renal epithelium. (Plate\\nXLVIL, Fig. 1, 1; and Fig. 208.) 7. Dr. George Johnson has\\ndescribed casts composed of j9 its-corpuscles. In two cases in which\\nthey were found in the urine the patients were found at the autopsy to\\nFig. 213.\\nCylindroids.\\nhave multiple abscesses of the kidney. 8. Cylindroids are very common.\\nIn general appearance they resemble hyaline casts but they are apt to\\nbe much longer, bent, twisted or split, and to have, on close examina-\\n60", "height": "4432", "width": "2628", "jp2-path": "practicaltreatis00muss_0_1045.jp2"}, "1046": {"fulltext": "946\\nSPECIAL DIAGNOSIS.\\ntion, a striated or finely ribbed appearance. Moreover, the diameter\\nof the cast frequently varies greatly at different points sometimes it\\nappears constricted in several places, and in other cases one end tapers\\noff into a thread. Often cylinclroids consist of fine, narrow, ribbon-like\\nthreads. (Figs. 209 and 213.)\\nSpermatozoa. Spermatozoa are easily recognized by their tadpole\\nshape and by the vibratile motion of their long, delicate tails. They\\nFig. 214.\\nHuman semen, a, spermatozoa b, cylindrical epithelium c, bodies enclosing lecithin gran-\\nules d, squamous epithelium from the urethra d testicle-cells e, amyloid corpuscles sper-\\nmatic crystals g, hyaline globules. (Von Jaksch.)\\nare found in the urine of both sexes after sexual intercourse. (Figs.\\n214 and 215.)\\nMany continent men have occasionally nocturnal emissions, accom-\\npanied by erections and erotic sensations. These cannot be looked\\nupon as abnormal, and they are compatible with robust health. There\\nare other persons, neurotic, anaemic, and generally constipated in habit,\\nwho have emissions at night two or three times a week, of which they\\nare unconscious until they wake and find themselves wet. Semen may\\nalso be lost during micturition and defecation, especially when much\\nstraining is required. Such a condition (spermatorrhoea) is abnormal.\\nIt is due to general nervous and muscular relaxation, associated with\\nnervous dyspepsia and anaemia, and aggravated by sedentary life, con-\\nstipation, and the reading of salacious literature or the cultivation of\\nerotic thoughts. In young men, it sometimes follows habits of mastur-\\nbation, which have been broken up but have left behind a hypersesthetic\\ncondition of the prostatic portion of the urethra, with or without dila-\\ntation of the orifices of the ejaculatory ducts or a stricture of gonor-\\nrhoea! origin may be its cause. Students and overworked and over-\\nstrained business and professional men are the ones most frequently\\naffected.\\nHowever caused, the condition is apt to beget a most distressing state\\nof despondency, in which the patient imagines all possible ills, and is\\nLiable to drift into a hysterical, melancholic, even suicidal frame of\\nmind, and so falls a victim to quacks.\\nEpithelium. Epithelium from the kidney, bladder, and genito-\\nurinary passages occurs in the urine. Epithelial deposits in male urine\\nare very scanty, unless there is some disease of the kidney or bladder,", "height": "4400", "width": "2552", "jp2-path": "practicaltreatis00muss_0_1046.jp2"}, "1047": {"fulltext": "DISEASES OF THE KIDNEYS. 947\\nor a catarrhal condition of the prostatic urethra, such as is left from\\nan old gonorrhoea. On the other hand, considerable epithelium may\\nbe normally present in the urine of Avomen, being derived principally\\nfrom the vagina and bladder.\\nVaginal epithelium consists of large, flat pavement-cells, and is\\nreadily distinguished.\\nFig. 215.\\nSpermatozoa from urine.\\nThe type of epithelium of the kidney, kidney pelvis, ureter, and\\nbladder is the same, and it is not possible to distinguish with certainty\\nthe cells which come from each. If the cells are scanty, Von Jaksch\\nthinks they come from the ureter. He has found them in moderate\\nquantities and superimposed upon one another.\\nRenal cells closely resemble the oval polygonal cells from the deeper\\nlayers of the bladder, but they have a relatively larger nucleus. (See\\nFig.^ 207.)\\nLipuria. Oil is found in the urine in fatty degeneration of the\\nkidney and its epithelium, and occasionally in the urine of those who\\nare taking cod-liver oil, and in calculous disease of the pancreas.\\nTyson suggests that it may come from cystic cheesy degeneration of the\\nkidney.\\nIt is also found in chronic nephritis, in phosphorus-poisoning, and in\\ndiabetes mellitus, as well as in chyluria. The urine is turbid, but\\nclears when agitated with ether. The fat may be separated by a sedi-\\nmentator, and can be recognized by its refractive properties.\\nStaining for Fat. Reecler recommends Soudan Three for staining\\nhuman secretions and excretions, to determine the presence of fat.\\nLarge fat-droplets take a bright red, and small droplets a yellow or\\norange color. Fat can thus be demonstrated in the blood in lipjeroia,\\nlipuria, and chyluria. By this method fat can be demonstrated in the\\nstomach-contents and in the feces of adults with jaundice. A saturated\\nsolution of Soudan Three in 96 per cent, alcohol is employed. Equal", "height": "4432", "width": "2596", "jp2-path": "practicaltreatis00muss_0_1047.jp2"}, "1048": {"fulltext": "948 SPECIAL DIAGNOSIS.\\nparts of this solution and 96 per cent, alcohol are added to the urine.\\nIn urinary sediments the fat-droplets in casts stain a scarlet red.\\nChyluria. This is a more or less milky condition of the urine, due\\nto the presence of fat, which probably gains entrance to some part of\\nthe urinary tract by rupture of the lymphatic vessels. A case has been\\nreported by Saundby, in which a young unmarried girl, being pregnant,\\ncompressed her abdomen so much, in order to conceal her condition,\\nthat oedema of the legs, thigh, vulva, and lower parts of the abdomen\\nresulted. After her confinement the urine became milky, and remained\\nso for many days. It contained fatty matters and cholesterin, but no\\nalbumin or sugar.\\nFat and albumin appear at the same time in some diseases. They\\nrecur at long intervals. Red and white blood-corpuscles are also found\\nin small amounts. The urine coagulates on standing, or gelatinizes.\\nParasitic chyluria is due to the filaria sanguinis hominis, whose\\nembryos obstruct the lymphatics. The latter may be found in the\\nurine.\\nEntozoa. The most common is the echinococcus or hydatid. When\\nthis infects the kidney or urinary vessels, hooklets and even cysts have\\nbeen passed in the urine. The disease is, of course, extremely rare in\\nthis country.\\nThe filaria sanguinis hominis, which causes parasitic chyluria, is occa-\\nsionally found in the urine. (See Filaria.)\\nThe Bilharzia hwmatobia sometimes lodges in the urinary tract and\\ncauses hematuria. It is peculiar to Egypt.\\nDistoma Haematobium. Common in Egypt and Abyssinia. Eggs\\ncollect in great masses in the urinary passages, and lead to inflamma-\\ntion, ulcers, stenosis, etc. Eggs found in the urine alone make the\\ndiagnosis possible.\\nStrongylus Gigas. Very rare. Symptoms of pyelitis. (The parasite\\nis of the size of an earth-worm.)\\nIntestinal worms may creep into the bladder through fistulous or\\nother openings, and be discharged through the urethra.\\nMicro-organisms. Normal urine contains no micro-organisms at the\\ntime it is voided. As the result of exposure to air, however, they may\\ndevelop in great abundance. The non-pathogenic organisms found are\\nclassed as mould-fungi (hyphomycetes), yeast-fungi (blastomycetes), and\\nfission-fungi (schizomycetes).\\nMould-fungi, according to Yon Jaksch, are rarely found in foul\\nnormal urine. Yeast-fungi are also rare in normal urine. Fission-\\nfungi are found in urine undergoing ammoniacal decomposition.\\nSarcinse, usually smaller than those of the stomach, are occasionally\\nmet with especially, according to Roberts, where there is some dis-\\norder of the urinary organs, renal pains, painful micturition, cystitis, etc.\\nUnder the name baderiuria, Roberts and others have described cases\\nin which the urine contained bacteria at the time of being voided. He\\nmakes four groups (1) Cases in which the presence of bacteria is asso-\\nciated with incipient putrefactive changes in the urine (2) cases associ-\\nated with ammoniacal fermentation of the urine (3) cases in which\\ncommon forms of bacteria are present without decomposition of the", "height": "4412", "width": "2628", "jp2-path": "practicaltreatis00muss_0_1048.jp2"}, "1049": {"fulltext": "", "height": "4388", "width": "2588", "jp2-path": "practicaltreatis00muss_0_1049.jp2"}, "1050": {"fulltext": "PLATE XLVIII.\\nJ?\\nUric Acid.\\nA. Common forms. B. Amorphous urates.\\n(Ob. D. and A.. Oc. 4.) Drawn by J. D. Z. Chase.\\nFIO. 2.\\nf\\nw\\n45\\nr-\\n#V^\\nCombination of Uric Acid and Calcium Oxalate.\\n(Oc. 4, Ob. D.) Drawn by J. D. Z. Chase.", "height": "4416", "width": "2604", "jp2-path": "practicaltreatis00muss_0_1050.jp2"}, "1051": {"fulltext": "DISEASES OF THE KIDNEYS. 949\\nurine and (4) cases in which micrococcus-chains are voided in the\\nurine.\\nThe pathogenic organisms which are more or less closely associated\\nwith infectious diseases, septic processes, and tuberculosis are found\\nat times in the urine, and can be demonstrated by the proper staining-\\nmethods.\\nFig. 216.\\nVy\\nVibriones in urine. (Roberts.)\\nDock has given an admirable account of the occurrence of the tri-\\nchomonas in the genito-urinary passages. This parasite belongs to the\\nflagellate infusoria. The prominent symptoms caused in Dock s case\\nwere painful, difficult, and frequent urination, followed by hsematuria.\\nThe urine contained pus, epithelium of all kinds, and a number of bodies\\nslightly larger than pus-corpuscles of a peculiar amyloid appearance\\nthe trichomouades.\\nMorbid Growths. The urine very rarely contains the elements of\\nmorbid growths. Von Jaksch says he never has found them in any\\nway reliable in the case of tumors of the kidney. The detection of\\ncancer-cells or pigmented cells, such as occur in melanotic cancers,\\nmay confirm the diagnosis if the clinical symptoms point to cancer.\\nTumor-elements are most likely to be found in ulcerating tumor of the\\nbladder.\\nUnorganized Sediments. Uric Acid. Uric acid is present in small\\nquantities (eight to ten grains a day) in normal urine. It is increased\\nin febrile and wasting diseases, such as phthisis in diseases of the\\nliver and spleen (leukaemia), and in malarial fever, diabetes, scurvy,\\nrhachitis, and following an attack of gout. Excessive use of milk is\\nsaid to increase it. Its excretion is also increased by certain drugs\\ncolchicum, corrosive sublimate, salicylic acid, and euonymin.\\nIt is diminished in anaemia, chlorosis, and during a paroxysm of gout\\nin chronic nephritis by certain drugs large doses of quinine (Ranke),\\ncaffein, sodium chloride and sodium carbonate, lithia, and iodide of\\npotash. (Plate XLYIIL, Figs. 1 and 2.)\\nAccording to Roberts, a deposit of uric acid occurring some twelve\\nto twenty-four hours after the urine has been passed has no patholog-\\nical significance. If the deposit occurs within three or four hours after\\nthe urine has been passed, it is certainly not natural. It is frequently\\nobserved in convalescence from febrile complaints, especially articular\\nrheumatism also in the middle periods of chronic Bright s disease, in\\nchorea, in certain types of diabetes, and in enlargement of the spleen.\\nIf, however, the uric acid is precipitated before the urine cools, or im-\\nmediately afterward, it is probable that the same precipitation may occur\\nwithin some part of the urinary passages, and so form a calculus.", "height": "4432", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1051.jp2"}, "1052": {"fulltext": "950\\nSPECIAL DIAGNOSIS.\\nUrates. Amorphous urates appear under the microscope as opaque\\ngranular particles, which dissolve upon heating, and respond to the\\nmurexid test. The deposit is more or less dense, and is sometimes\\narranged so as to resemble granular casts.\\nFig. 217.\\nSodium urate.\\na a. From a gouty concretion, b b. Arti-\\nficially prepared by adding liq. sodse to the\\namorphous urate deposit. (Roberts.)\\nAmmonium urate spontaneously\\ndeposited.\\na. Spheres and globular masses, b.\\nDumb-bells, crosses, rosettes. (Rob-\\nerts.)\\nSodium urate appears as spherules or globules, from which project\\nshort spines, either straight or curved. It occurs most frequently in\\nconcentrated acid urines, such as are passed by children with acute\\nfebrile diseases. (Fig. 217.)\\nFig. 218.\\nAmmonium urate.\\nAMMONIUM URATE resembles sodium urate. It is frequently asso-\\ncm\\\\ with phosphatic deposits, and is precipitated from alkaline\\nmines. Sometimes it appears in the shape of dumb-bells. (Figs. 217\\nand 218.) _\\nPhosphates. Phosphates appear in the urine as ammonio-magne-\\nsium phosphate and as the crystalline and amorphous phosphate of lime.", "height": "4408", "width": "2628", "jp2-path": "practicaltreatis00muss_0_1052.jp2"}, "1053": {"fulltext": "DISEASES OF THE KIDNEYS.\\n951\\nThey are precipitated in alkaline or faintly acid urines, which produce\\na cloud upon being heated the cloud is distinguished from albumin,\\nas already pointed out, by the fact that it disappears when the urine is\\nFig. 219.\\nTriple phosphates.\\nacidulated with acetic or nitric acid. Ammonio-magnesium phosphate\\nis easily recognized by its rhombic prisms coffin-lid shape. Other\\nshapes are ^produced by modification of the primary one, chiefly by\\nbevelling of the edges and hollowing out of the sides. These crystals\\nFig. 220.\\nCalcium phosphate crystals.\\nare usually large, and are frequently found, together with amorphous\\nphosphates, bladder epithelium, and pus, in cases of cystitis.\\nAmorphous phosphate of lime consists of fine granular particles much\\nresembling amorphous urates, but distinguished from them by not dis-", "height": "4432", "width": "2580", "jp2-path": "practicaltreatis00muss_0_1053.jp2"}, "1054": {"fulltext": "952 SPECIAL DIAGNOSIS.\\nappearing upon the application of heat, but instantly dissolving when\\nthe urine is acidulated.\\nCrystalline phosphate of lime is a not infrequent deposit. It is\\nfound as narrow-wedged crystals, occasionally grouped together in the\\nform of stars, sheaves, or bundles, with their apices at a common\\ncentre.\\nAccording to Roberts, this deposit, in quantity, is an accompaniment\\nof some grave disorder. He has found the stellar phosphates in cancer\\nof the pylorus, once in phthisis, and more than once in patients ex-\\nhausted by obstinate rheumatism. It may, however, occur in health,\\nwhen the urine is rich in lime and its acidity greatly reduced.\\nIn one or two cases of renal colic the writer has observed numerous\\nshining particles, which, upon microscopical examination, have been\\nshown to be an opalescent film, covered with small, sharp phosphatic\\n(probably calcium) crystals. (Fig. 221.)\\nFig. 221.\\nOpalescent film in a case of renal colic.\\nOxalate of Lime. Oxalate of lime occurs in the form of small octa-\\nhedral crystals, or, more rarely, as dumb-bells, and in the form of ovals\\nor disks. It is precipitated almost always from acid urines. (Plate\\nVI., Fig. 2 and Fig. 222.)\\nOxaluria. According to Beneke, oxaluria has its proximate cause in\\nan impeded metamorphosis, an insufficient activity of that stage which\\nchanges oxalic acid into carbonic acid.\\nWhen oxalates are constantly found in the urine a condition of pro-\\nfound hypochondriasis is found to exist, but it has no necessary relation\\nto the oxaluria. An increase of oxalates in the urine is found in dia-\\nbetes, especially when there is diminution in the amount of sugar. It\\nis in excess in certain forms of indigestion. Its constant passage may\\nbe attended by pains in the back and loins. Flatulent and nervous\\ndyspepsia usually accompany the increase, and neurasthenia also may\\nbe present.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1054.jp2"}, "1055": {"fulltext": "DISEASES OF THE KIDNEYS.\\n953\\nCystin. Cystin occurs in the form of hexagonal prisms, either as\\nirregular masses or superimposed one upon another, so as to form\\ntruncated pyramids. It is a very rare sediment, but appears to be\\nmost common in children and young male adults. Several members\\nof the same family have been known to pass it. Its chief clinical sig-\\nnificance arises from the fact that rarely it is the basis of calculi.\\nFig. 222\\nCalcium oxalate.\\nLeucin and Tyrosin. Leucin and tyrosin are generally described\\ntogether, though the former is not spontaneously deposited from urine.\\nIt appears in the form of spheres, which refract light strongly and have\\na radiating arrangement. (Fig- 223.)\\nFig. 223.\\nCrystals of leucin (different forms). (Crystals of creatinin chloride of zinc resemble the leucin\\ncrystals depicted at a.) The crystals figured toward the right consist of comparatively impure\\nleucin. (From Charles Chemistry.)\\nTyrosin has been found as a sediment, of a light greenish-yellow color,\\nin typhoid fever and acute yellow atrophy of the liver. It appears in\\nthe form of tolerably long, needle-like crystals, or as bundles and\\nsheaves. Frerichs attaches great importance to leucin and tyrosin in\\nthe diagnosis of acute yellow atrophy of the liver. (Fig. 224.)", "height": "4432", "width": "2588", "jp2-path": "practicaltreatis00muss_0_1055.jp2"}, "1056": {"fulltext": "954\\nSPECIAL DIAGNOSIS.\\nCholesterin. This occurs at times in fatty degeneration of the kid-\\nneys, jaundice, chyluria, diabetes, and, according to Pohl, in the urine of\\nepileptics treated with bromide of potash. (Fig. 225.)\\nFig. 224.\\nTyrosin crystals.\\nMelanuria. Melanin is held in solution or suspended in small gran-\\nules. The urine is dark in color, and blackens intensely when sulphuric\\nacid or tincture of chloride of iron is added to it. A concentrated solu-\\ntion of perchloride of iron serves to detect the presence of the substance.\\nFig. 225.\\nCrystals of cholesterin.\\nA few drops added to the urine turn it gray. If a few drops more are\\nadded, the phosphates are precipitated along with the coloring-matter.\\nBoth are dissolved by an excess of the iron solution. Melanin is usually\\nfound in cases of melanotic carcinoma.", "height": "4396", "width": "2608", "jp2-path": "practicaltreatis00muss_0_1056.jp2"}, "1057": {"fulltext": "DISEASES OF THE KIDNEYS. 955\\nCatheterization and Exploration of the Ureters.\\nExamination of the bladder, the ureters, and the pelvis of the kidney\\nhas been wonderfully advanced by the genius of Howard Kelly. The\\nfollowing instruments are required for the examination of the bladder\\nFemale catheter urethral calibrator a series of urethral dilators a\\nseries of specula with obturators common head-mirror and a lamp,\\nArgand burner or electric light long, delicate mouse-toothed forceps\\nsuction-apparatus for completely emptying the bladder ureteral\\nsearcher ureteral catheter with a handle small bran-bags for ele-\\nvating the pelvis.\\nThe procedure is as follows Empty the bladder measure the meatus\\nurinarius externus dilate the urethra to twelve or fifteen millimetres\\ninsert speculum of diameter of last dilator and remove obturator\\nelevate the hips of the patient about a foot above the level of the\\ntable; inspect with light; remove residual urine by suction or with\\ncotton and mouse-toothed forceps.\\nFor anaesthesia, a pledget of cotton saturated with a 5 per cent, solu-\\ntion of cocaine may be introduced seven minutes before dilatation. On\\nremoval of the obturator the bladder becomes distended with air. The\\nbladder is viewed by turning the speculum, and each ureteral orifice is\\nbrought into view by turning the speculum thirty degrees to one side\\nor the other. Kelly says The orifice appears as a dimple or a little\\npit, or, in inflammatory cases, as a round hole in a cushioned eminence\\nat other times as a with the point directed outward again, it may\\nbe scarcely visible even to a trained eye, appearing as a fine crack in\\nthe mucosa, and occasionally is so obscure as to be recognized only by\\nthe jet of urine as it escapes, or by a slight difference in the color of\\nthe mucous membrane at that point. In rare cases it has the form of\\na truncated cone with gently sloping sides this appearance is most apt\\nto be developed in the knee-breast position. The bladder mucosa is\\nusually of a slightly deeper rose color around the ureter, and in the\\npresence of an inflammatory process it even appears deeply injected.\\nCatheterization of the Ureters. The catheters are sterilized they are\\nstiffened with a wire stylet. The orifice is exposed, and then the outer\\nend of the catheter being held over the shoulder by an assistant, the\\nconical end is introduced and pushed up the ureter, while at the same\\ntime the stylet is being removed. The speculum is removed and again\\nintroduced beside the first catheter. The remaining ureter is then cath-\\neterized both are properly designated and allowed to drain into test-\\ntubes plugged with sterilized cotton and fixed in a block of wood. By\\ncatheterization, aspiration, and exploration of the ureters with a bougie,\\nthe source of pysemia anywhere from the urethral orifice to the renal\\npelvis can be found renal calculi diagnosticated strictures of the\\nureter located hydronephrosis distinguished from soft malignant\\ngrowths and the functional value of each kidney determined.\\nKelly suggests the following guide to the ureteral orifice A. point\\nis marked on the cystoscope 5 J cm. from the vesical end, and from this\\npoint two diverging lines are drawn toward the handle with an angle\\nof sixty degrees between them. The speculum is introduced up to the", "height": "4432", "width": "2588", "jp2-path": "practicaltreatis00muss_0_1057.jp2"}, "1058": {"fulltext": "956 SPECIAL DIAGNOSIS.\\npoint of the V, and turned to the right or left until one side of the\\nY is in line with the axis of the body then by elevating the endo-\\nscope until it touches the floor of the bladder the ureteral orifice will\\nusually be found within the area covered by the orifice of the speculum.\\nBy means of a searcher, or sound, the suspected orifice is further ex-\\namined.\\nObjective Symptoms due to Impairment of the Function\\nof the Kidney.\\nUraemia. Under symptoms due to impairment of the functions of\\nthe kidney belong the various manifestations of ursemia. Diseased\\nkidneys do not eliminate the products of tissue-waste, which are poison-\\nous materials. The toxic matter is retained within the blood, and\\nproduces toxaemia, which may be acute or chronic. In acute urcemia\\nthe manifestations develop suddenly and continue but a short period\\nof time, with alarmingly active symptoms until death or recovery. In\\nchronic urcemia the onset is gradual. The manifestations may be lim-\\nited to one or two conditions, as headache or morning nausea, or they\\nmay include the more pronounced symptoms of ursemia.\\nNervous Symptoms. 1. Headache. The pain is situated in the\\noccipital region, and may extend down the neck. It is severe and of\\na bursting character. It may be associated with giddiness. In both\\nacute and chronic nephritis it is often the first manifestation. It may\\nbe associated with eye-symptoms. It may be present on waking, and\\ncontinue only through the morning hours. In acute ursemia it persists\\nthroughout the attack. Numbness and tingling of the fingers are often\\ncomplained of at the same time.\\n2. Delirium. The delirium may be mild. This is usually the case\\nin the typhoid state or if a subnormal temperature prevails. It is\\nsometimes attended by delusions. There is often subsultus, and pick-\\ning at the bedclothing. The delirium may amount to true mania, and\\nthe patient may exhibit other maniacal symptoms. On the other\\nhand, the patient may be noisy, restless, and sleepless. Melancholia\\nand delusional insanity may develop after the violent nervous symptoms\\nof ursemia pass off.\\n3. Convulsions. A convulsion may be the first indication of disease\\nof the kidneys, or it may succeed a few days of persistent headache,\\nor follow an attack of ursemic vomiting. The convulsion resembles\\nepilepsy, and hence is known as an epileptiform convulsion. If the\\nspasms recur in rapid succession, the interval is occupied by delirium\\nor coma. If they are infrequent, the patient s mind may be clear in\\nthe intervals. Sometimes a focal or Jacksonian epilepsy occurs instead\\nof the true epileptiform convulsion. The temperature is usually elevated.\\nIn worn-out subjects, or those who have had exhaustive diarrhoea, or\\nare debilitated from other causes, the temperature may be subnormal.\\nA temporary blindness often follows the convulsion (urcemic amaurosis).\\nUraemic deafness may occur.\\n4. Coma. After the convulsion the mind may be restored, or the\\npatient may lapse into stupor, followed by complete coma. Coma may", "height": "4416", "width": "2580", "jp2-path": "practicaltreatis00muss_0_1058.jp2"}, "1059": {"fulltext": "DISEASES OF THE KIDNEYS. 957\\ndevelop without convulsions, or immediately succeed a general convul-\\nsion. Headache or eye-symptoms may precede the coma. In some\\ninstances the patient lapses into a typhoid state, in which the tongue is\\nheavily furred and the breath very offensive. Unless the coma is pro-\\nfound there is usually some twitching of the muscles of the hands and\\nface.\\n5. Local palsies. Dercum was among the first to call attention to the\\noccurrence of uraeniic monoplegia or hemiplegia. The cases resemble\\ncentral cerebral disease. The nature of the palsy is inferred from the\\nresults of the examination of the urine and the condition of the heart\\nand arteries. Palsy develops suddenly, or may occur after a convul-\\nsion.\\n6. Cramps in the muscles of the calves, particularly at night, are of\\ncommon occurrence, and should always lead to an examination of the\\nurine.\\n7. Pruritus, local or general, is another nervous symptom which may\\nbe of uraemic origin.\\n8. Pain in the upper abdomen, particularly in the median line, is a\\nfrequent precursor of more severe uraemic symptoms. It is of uraemic\\norigin itself. It may be seated in either of the upper quadrants, and\\nthence extend to the lower portion of the abdomen.\\nUremic Dyspncea. Modifications of the breathing often accom-\\npany symptoms of uraemia. The dyspnoea may be constant. It may\\noccur in paroxysms, or both types may alternate. A common type in\\nthe uraemia of chronic nephritis is the Cheyne-Stokes breathing.\\nParoxysmal dyspnoea usually occurs at night, and resembles asthma\\nin every respect. Cheyne-Stokes breathing continues, even through\\nthe period of coma, although not necessarily associated with it. (See\\npage 456.)\\nIn addition to uraeruic dyspnoea, the occurrence of inflammatory\\npulmonary complications may be the first indication that the condition\\nof the urine should be inquired into. Bronchitis, pneumonia, and\\npleurisy are common complications.\\nGastrointestinal Symptoms of Ujrjemia. Several forms are\\nseen. 1. Loss of appetite is common. It is attended with absolute\\ndistaste for food after a small portion is taken. 2. Nausea, which\\nmay be continuous, or more frequently limited to the early morning.\\n3. Vomiting may be paroxysmal, occurring chiefly in the early morn-\\ning, or it may be sudden in onset, uncontrollable, and continue until\\nnervous symptoms of uraemia develop. Urea is found in the vomit.\\nThe matter ejected is profuse, of a low specific gravity, and at first\\nacid in reaction. If chronic, it may become alkaline. The odor is\\noften sufficient to cause its recognition. 4. Constipation is generally\\nthe rule in the course of chronic Bright s disease. 5. Diarrhoea. One\\nof the manifestations of uraemia is the occurrence of sudden, profuse\\nserous purging. This may be so extreme as to cause collapse, or may\\nusher in coma and convulsions. 6. Hiccough, although a muscular\\naffection, is usually associated with gastric disturbances.\\nLatent uraemia was first recognized by Sir William Roberts. It is\\nseen in its most characteristic form in calculus suppression. The", "height": "4432", "width": "2588", "jp2-path": "practicaltreatis00muss_0_1059.jp2"}, "1060": {"fulltext": "958 SPECIAL DIAGNOSIS.\\npatient for several days will have subnormal temperature, myosis,\\noccasional vomiting, and toward the end twitching of the voluntary\\nmuscles and slight drowsiness. After the end of five or ten days\\ncoma, convulsions, or dyspnoea ensue.\\nCardiovascular Symptoms of Nephritis. The symptoms are\\nthe effects of the retention of morbid products. First, the heart and\\nbloodvessels. The poison which is not excreted circulates throughout\\nthe system. One of its effects is irritation of the vasomotor nerves of\\nthe bloodvessels. Excitation of these nerves causes peripheral con-\\ntraction of the smaller vessels. At once the flow of blood is obstructed,\\nso that, on account of the contraction, hypertrophy of the heart rapidly\\nensues. The first prominent symptom, therefore, is due to changes in\\nthe heart-muscle.\\nHypertrophy of the Heart. The most pronounced change is hyper-\\ntrophy. The persistent spasm of the peripheral vessels causes in-\\ncreased arterial tension. The blood-pressure is raised and causes\\nincreased accentuation of the aortic second sound. High tension in\\nthe artery is recognized by the peculiar character of the pulse and by\\nmeans of the sphygmograph.\\nDilatation of the Heart. Unfortunately, hypertrophy of the heart\\ncannot always be kept up. If it fails, we then have a second con-\\ndition of the heart which is frequently found in renal inflamma-\\ntions it is dilatation. The state of the coronary arteries predisposes\\nto this condition of the heart-muscle. The previously mentioned\\narterial tension favors the development of chronic endarteritis with\\ngeneral atheroma. The coronary arteries take part in this process.\\nThe endarteritis hinders cardiac nutrition, dilatation of the heart-\\nmuscle follows, and later comes the development of two other condi-\\ntions, atrophy and myocarditis.\\nHere may be mentioned other relations of the heart and kidneys\\na. TTe have renal disease following forms of cardiac disease. In dila-\\ntation of the heart passive congestion of the particular organ takes\\nplace. The kidney very quickly becomes the seat of such congestion.\\nIn the course of simple dilatation, or of valvular heart-disease, the\\nsecondary dilatation, passive congestion, and chronic inflammation\\ndevelop slowly. Embolism may also occur, b. Renal disease and\\ncardiac disease may develop at the same time from a common cause,\\nas alcoholism, gout, or endarteritis.\\nIn addition to high arterial tension and accentuation of the aortic\\nsecond sound, the objective symptoms of atheroma of the aorta and\\narteries are present with the chronic inflammations of the kidney.\\nThese vascular changes need not be again rehearsed. (See Endarteritis.)\\nIt is important, however, to bear in mind that they frequently occur\\ntogether, and also that in all instances of arterial disease the condition\\nof the urine must be inquired into. It need not be said that symptoms\\nI in- to rupture of the bloodvessels, particularly in the brain, or to an-\\neurism, necessarily may be present in the course of renal inflammation.\\nGastrointestinal Symptoms. Fermentative dyspepsia, gastralgia,\\nchronic gastritis, enteritis, and ulcerative colitis are of common occur-\\nrence.", "height": "4412", "width": "2592", "jp2-path": "practicaltreatis00muss_0_1060.jp2"}, "1061": {"fulltext": "DISEASES OF THE KIDNEYS. 959\\nHemorrhages. The arteries are very liable to rupture, causing\\nepistaxis, retinal hemorrhage, hemorrhages from the bowels and lungs,\\nand hemorrhages underneath the skin. Frequent hemorrhages in large\\namounts from any portion of the body should call attention to the\\ncondition of the urine.\\nOphthalmoscopic Changes. The eye-ground should always be\\nexamined indeed, the patient himself by his complaints often directs\\nattention only to the eye, the examination of which discloses the pres-\\nence of an albuminuric retinitis. The changes may occur in the acute\\nor chronic forms of nephritis, although they are more common in the\\nlatter. 1. A diffuse, slight opacity and swelling of the retina, due to\\noedema. 2. White spots or patches of various sizes, for the most part the\\nresult of degenerative processes. 3. Hemorrhages. 4. Inflammation\\nof the intraocular end of the optic nerve. 5. Atrophy of the retina and\\nnerve may sometimes result from and succeed the inflammatory changes.\\nThese changes may affect one eye only (Gowers). It must not be for-\\ngotten that temporary blindness may occur independently of retinitis.\\nDropsy. Dropsy may occur in all forms of nephritis. It is most\\ncommon in acute varieties, but it is also present in chronic diffuse neph-\\nritis with exudation. Renal dropsy usually begins in the face. It may\\ndevelop suddenly in acute forms. In the marked forms, oedema of the\\neyelids may continue for a long time. All varieties may be found, from\\nlocal oedema to extreme anasarca. The serous cavities are also filled.\\nThe oedema is usually associated with a diminished amount of urine.\\nIts improvement is attended by increased diuresis. Dropsy, in chronic\\ndisease, is usually due to dilatation of the heart. (See page 100).\\nThe Cutaneous Symptoms, and Appearance of the Face.\\nIn mflammatory affections of the kidney, the appearance of the skin\\nand expression of the face are often characteristic, and point at once to\\nan examination of the urine. The face is pallid, and of an ivory white-\\nness. In the chronic form the pallor gives way to an ashen-gray or\\nsallow complexion. In chronic nephritis the skin becomes dry and\\nharsh, and, rarely, is covered with a powdery substance, giving it the\\nappearance of frost on the skin. The powdery substance is due to urea.\\nPetechke. In the later stages of chronic inflammatory affections\\nhemorrhages under the skin and in the mucous membrane are seen.\\nAnaemia. Anaemia is a frequent symptom in all forms of nephritis\\nit is usually marked. It is associated with the peculiar pallor just\\ndescribed, and attended by all the other usual symptoms.\\nGeneral Symptoms. The cause of renal disease, as far as symp-\\ntoms pointing to the kidneys are concerned, is often latent. Instead\\nof renal symptoms, a generally depraved state of the system may be\\nseen, with emaciation and weakness. Lassitude without cause demands\\nan examination of the urine.\\nDiabetic Coma. Acetonsemia is a toxaemia which develops in the\\nterminal stages of diabetes. It is due to an accumulation of acetone\\nin the blood. It is also called diabetic coma. It develops acutely. A\\nsudden onset is attended by sharp pain in the stomach with nausea, and\\nfrequently vomiting. At the same time there is severe dyspnoea. The\\nbreathing is irregular and of a panting character, with inspiratory and", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1061.jp2"}, "1062": {"fulltext": "960 SPECIAL DIAGNOSIS.\\nexpiratory dyspnoea. There may or may not be cyanosis. The patient\\nis obliged to sit up in bed on account of the air-hunger. Restlessness\\nbegins at once. Delirium develops within the first hour. In a few\\nhours coma sets in. The temperature is subnormal the pulse is irreg-\\nular, and soon becomes weak and thready. The odor of acetone is\\ndetected on the breath.\\nCongestion of the Kidney.\\nCongestions of the kidney are acute and chronic, and depend upon\\nchanges in the circulation, whereby blood accumulates in the kidney.\\nAcute congestion of the kidney is caused by the action of irritant\\npoisons it follows surgical operations, particularly if prolonged, and\\nmay follow extirpation of one kidney. Diseased kidneys are apt to\\nbecome the seat of active congestion.\\nSymptoms. The urine is diminished in amount, or may be suppressed\\nentirely. Only a small amount is passed at frequent intervals, or it can\\nbe secured by the catheter alone. Albumin is present in considerable\\namount, and blood and epithelial casts are numerous. Death may take\\nplace, with symptoms of urseinia.\\nChronic Congestion of the Kidney. It is also called passive conges-\\ntion. This form of congestion is usually a part of general venous stasis,\\ndue to disease of the heart or lungs, as valvular disease of the heart,\\nwith secondary dilatation or pulmonary emphysema. It is quite com-\\nmon.\\nSymptoms. The urine is diminished in amount dark in color of\\nhigh specific gravity, ranging from 1020 to 1030. Uric acid and\\nurates are increased. Urea to the amount of from 10 to 12 grains to\\nthe ounce is passed in twenty-four hours. At first there is no further\\nchange, but, subsequently, albumin appears in small amounts in an\\nintermittent manner. Later, it is constant and increased in amount.\\nHyaline casts are found in the urine, and a few red blood-cells.\\nThe condition is recognized by its association with congestion in other\\norgans by the diminution in the amount of urine, its high specific\\ngravity, and excess of uric acid and urates. This form of congestion\\nis serious, because it leads to chronic nephritis. The latter is recog-\\nnized by the usual changes in the urine.\\nInflammations of the Kidney.\\nThe inflammations of the kidney are divided in accordance with the\\nactivity of the process and the degree of exudation or cell-proliferation\\nthat attends the inflammation. We, therefore, have the following\\nvarieties\\nAcute exudative nephritis (acute Bright s disease).\\nAcute productive or diffuse nephritis (acute Bright s disease).\\nChronic productive or diffuse nephritis with exudation (chronic\\ntubular nephritis).\\nChronic productive or diffuse nephritis without exudation (chronic\\ni 1 1 1 rstitial nephritis).\\nSuppurative nephritis.", "height": "4412", "width": "2580", "jp2-path": "practicaltreatis00muss_0_1062.jp2"}, "1063": {"fulltext": "DISEASES OF THE KIDNEYS. 961\\nTubercular nephritis.\\nAcute Exudative Nephritis or Glomerulonephritis. In\\nthis form of nephritis there are congestion, exudation of plasma, trans-\\nudation of red and white blood-cells, and changes in the epithelium.\\nCauses. It may occur without definite cause, save exposure to cold,\\nand at times even without such history. It occurs in most of the infec-\\ntious diseases. It is of common occurrence after scarlet fever, and in\\nthe course of pregnancy and in septicaemia. It occurs in diphtheria,\\nerysipelas, and pneumonia frequently. It is the expression of a pecu-\\nliar type of typhoid fever. It may complicate dysentery and acute\\ntuberculosis. It forms one of the modes of termination of diabetes.\\nSymptoms. The course of the disease may be mild, presenting only\\nchanges in the urine, or there may be, in addition to decided changes\\nin the character of the urine, local and general symptoms.\\nIn mild cases the urine is diminished in amount micturition is fre-\\nquent the color of the urine is increased, and the specific gravity is\\nusually high. A small amount of albumin is found, and a few epithe-\\nlial and blood-casts, and sometimes blood. At the termination of the\\ndisease the casts are hyaline.\\nIn severe cases the disease is ushered in by chill, attended and fol-\\nlowed by pain in the loins, with, fever, headache, and much restlessness.\\nThe urine may be passed more frequently than usual, but in small\\namounts or micturition may diminish in frequency or cease entirely.\\nExamination of the urine reveals the characteristic changes. The\\nquantity of the urine is lessened the specific gravity is normal or\\nincreased. There is a large amount of albumin, and an abundance\\nof hyaline, granular, epithelial, and blood-casts. Free white and red\\nblood-cells, and epithelium from the pelvis and tubules are found.\\nThe fever continues the pain in the loins is sometimes very severe,\\nand may be taken for lumbago, unless an examination of the urine is\\nmade. Within the first forty-eight hours the characteristic symptoms\\nthat follow the chill and that attend the urinary changes are headache,\\nsleeplessness, more or less stupor, muscular twitchings, or general convul-\\nsions. Eye-symptoms may be present. Instead of cerebral symptoms,\\ndyspnoea may be marked. With both, nausea and vomiting are of\\ncommon occurrence. The heart s action is increased in force and fre-\\nquency. The left ventricle rapidly becomes hypertrophiecl. The aortic\\nsecond sound is accentuated. The pulse is hard and exhibits the char-\\nacteristic features of high tension. From the onset of the first symptom,\\nor within the first week, two other striking phenomena arise. They are,\\nfirst, the occurrence of dropsy second, the occurrence of ancemia.\\nDropsy or oedema is one of the most constant symptoms. It appears\\nfirst in the face, especially the eyelids. It may be limited to this region.\\nIt is worse in the morning. From the face, in bad cases, it extends to\\nthe lower extremities and to the scrotum, and thence all over the body.\\nAnasarca is the name applied to the general dropsy the connective\\ntissue is infiltrated with serum. It is recognized by the pallor of the\\nswollen surface the pitting on pressure the absence of heat and of\\npain. (See page 148.)\\nEffusion may take place into the serous cavities, either the pleura,\\n61", "height": "4432", "width": "2588", "jp2-path": "practicaltreatis00muss_0_1063.jp2"}, "1064": {"fulltext": "962 SPECIAL DIAGNOSIS.\\npericardium, or peritoneum, causing the symptoms due to effusion-\\nIn some instances there is oedema of the mucous membranes, as the\\nconjunctiva, the soft palate, and the glottis.\\nDyspnoea may be a pronounced symptom, due either to uraemia\\n(ursemic asthma) or oedema of the glottis, effusions into the pleura, or\\nto bronchitis. If dilatation of the heart occurs, dyspnoea may arise,\\ndue to that or to the secondary oedema of the lungs.\\nWith or without the occurrence of nausea or vomiting there is always\\nloss of appetite, and usually constipation.\\nThe fever is usually moderate and irregular in type. Prostration is\\ncommon often there is emaciation. Symptoms of xiramiia may occur\\nat any time.\\nExudative nephritis with excessive pus formation is of sudden onset,\\ncharacterized by high fever and extreme prostration. There is rapid\\nemaciation and the early development of the typhoid state. This is\\npreceded by delirium, headache, and stupor, with great restlessness.\\nThere is but little, if any, dropsy. Large numbers of red and white\\nblood-cells and the usual casts are found in the urine. There is not so\\nmuch diminution in the urine as is usually seen. The disease may\\narise without apparent cause, or complicate scarlet fever or diphtheria.\\nThis form is very fatal, and resembles acute meningitis, from which\\nit is diagnosticated by the change in the urine.\\nAcute Productive or Diffuse Nephritis. In this form there\\nis an overgrowth of connective tissue, and excessive growth of the\\ncapsule-cells in the glomeruli, in addition to the lesions of the first\\nform. The whole kidney is not necessarily affected, but only portions\\nat a time. Symptoms The onset is sudden. The subjective symptoms\\npreviously described are present in a marked degree. Nervous symp-\\ntoms (uraemia) are most pronounced. Dropsy develops rapidly and to\\nan extreme degree. There is rapid development of anaemia and loss of\\nflesh. The remaining symptoms tally with those of the first affection.\\nThe urine is scanty, bloody, and of high specific gravity. The micro-\\nscopical appearances are like those of acute exudative nephritis. If\\nconvalescence is established, the urine becomes more abundant, with a\\ncorresponding fall in the specific gravity. The albumin and casts may\\nappear for a time, but eventually disappear.\\nDiagnosis. The diagnosis of acute nephritis of either form is based\\nupon the examination of the urine. Etiological associations are of\\nvalue. The more pronounced cases follow scarlet fever and pregnancy.\\nIn the latter condition it usually advances slowly. There may be\\nno symptoms until the occurrence of uraemia. In some instances the\\ndisease resembles typhoid fever. In cases in which the onset is sud-\\nden, with early uraemic symptoms, it must not be mistaken for epilepsy,\\ndelirium, or mania.\\nChronic Productive or Diffuse Nephritis with Exudation.\\nIn chronic inflammations the formation of new tissue always takes\\nplace. They are divided, therefore, into exudative and non-exudative\\ninflammations. The exudation is from the vessels. Causes This form\\nusually follows acute productive nephritis and chronic congestions or\\ndegenerations of the kidney. It develops in the course of syphilis,", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1064.jp2"}, "1065": {"fulltext": "DISEASES OF THE KIDNEYS. 963\\ntuberculosis, endocarditis, disease of the bones, and prolonged suppura-\\ntion. Frequent exposure to cold and wet, a residence in damp dwell-\\nings, and the alcoholic habit are causal conditions. It usually occurs\\nin middle life, more frequently in men. When it occurs as a primary\\ndisease it is usually found in young adults. Symptoms The disease\\ndevelops slowly. General symptoms may first be observed. Dropsy\\nmay develop at first and continue throughout the disease, or recur at\\nlong intervals. The appearance of the patient is striking. The skin\\nis of a peculiar pallor and is pasty in appearance. The sclerotics are\\nvery white. The anaemia which gives rise to the pallor is profound,\\nand often closely resembles that of pernicious anaemia. The anaemia\\nis due to diminution in the haemoglobin and reduction in the number\\nof red blood-cells.\\nHeadache and sleeplessness are common symptoms. Pronounced acute\\nuraemia does not often occur. Chronic urcemia may prove fatal by the\\npatient lapsing into a typhoid state, in which delirium alternates with\\nstupor.\\nThe urine is variable in quantity and character. It must not be for-\\ngotten that the course of the disease and the urinary symptoms are often\\nquite variable in chronic nephritis. The urine may be normal in amount,\\nbut during the exacerbations it is scanty or suppressed. The specific\\ngravity and the amount of urea lessen. In the most rapid cases it\\nvaries between 1012 and 1020. In chronic cases it falls as low as 1005\\nand even 1001. In the later stages the amount of the urine and the\\nspecific gravity may both be increased. Albumin is present in large\\namounts. When the disease is most active, and the dropsy at its\\nheight, the quantity of albumin is very large. In the quiescent period\\nof the disease the amount is lessened. Casts are abundant, both epithe-\\nlial, fatty, and granular red blood-cells are often found.\\nRetinitis albuminuria is frequently developed in the course of the\\ndisease.\\nDyspnoea is a common symptom. The dyspnoea may be due to any\\none of the many causes previously described which produce this symp-\\ntom in the course of nephritis. It is frequently limited to sudden\\nattacks which develop in the night or early morning. There is often\\nsome bronchial catarrh.\\nNausea and vomiting are common symptoms. The appetite is lost.\\nHypertrophy of the left ventricle takes place in all cases, except in\\nthose who had been previously weakened by other disease. The right\\nventricle is often hypertrophied also. The second aortic sound is\\naccentuated, and the pulse is of high tension. Symptoms, such as\\nheadache and vertigo, arise on account of the profound anaemia.\\nThe disease is characterized in its course by remissions and exacerba-\\ntions. During the exacerbations any one of the prominent symptoms\\nthat occur in renal inflammations may be present. (Edema is the one\\nsymptom which occurs most frequently, and is likely to continue the\\nlongest. The disease lasts from three months to three years, and may\\npass into the second variety of chronic inflammation.\\nCourse of the Disease. Delafield has well outlined the course. The\\nconstant symptoms are anaemia, dropsy, and albuminuria. 1. The", "height": "4432", "width": "2596", "jp2-path": "practicaltreatis00muss_0_1065.jp2"}, "1066": {"fulltext": "964 SPECIAL DIAGNOSIS.\\nsymptoms may be continuous and progressive in severity, death taking\\nplace at the end of one or two years, on account of dropsy or uraemia.\\n2. The symptoms may continue for several months, and the patient\\nfinally improve. Recurrent attacks take place, the symptoms being\\nmore severe with each attack. In the intervals of the attacks there is\\na small amount of albumin in the urine. 3. The patient may appar-\\nently recover, but the urine continues to be of low specific gravity, and\\ncontains some albumin. A fatal attack of uraemia, or an apoplexy, or\\nthe onset of an acute disease may cause an exacerbation of the renal\\nsymptoms. 4. The symptoms may persist in a mild degree for years,\\nthe patient at the same time feeling comparatively well. 5. Spasmodic\\ndyspnoea may be the first and only symptom for a long time.\\nChroxic Productive or Diffuse Nephritis without Exuda-\\ntion. This is the form of nephritis which is also called interstitial\\nnephritis, granular kidney, or cirrhosis of the kidney.\\nThe kidneys are diminished in size, the capsules are adherent, and\\nthe surface roughened. There is an overgrowth of connective tissue\\nwith atrophy of the epithelium and of the tubules, and dilatation of\\nsome of the tubes, forming cysts.\\nCauses. This form of nephritis follows chronic congestion of the\\nkidney, and is also caused by alcohol, lead, gout, syphilis, malaria, and\\nby chronic endarteritis. The latter condition, as well as cirrhosis of\\nthe liver and pulmonary emphysema, frequently develops hand-in-hand\\nwith the nephritis. This form of nephritis is notably prevalent in\\nseveral generations of different families, so that an hereditary history\\nis often readily obtained.\\nSymptoms. The onset of the disease usually occurs late in life,\\nalthough well-defined cases may occur as early as the twenty-fifth\\nyear. The progress at first is very insidious, and the disease may have\\nadvanced to an extreme stage without the occurrence of a single symp-\\ntom. Death, indeed, may be due to other causes or a person in\\napparently perfect health may suddenly manifest symptoms of uraemia,\\nor may develop apoplexy or some other usual accompaniment of inter-\\nstitial nephritis.\\nThe urine is increased in amount, clear in color, and of low specific\\ngravity. The albumin is small in amount, or may be absent. Repeated\\nexaminations extending over a considerable period of time may dis-\\nclose its presence. Hyaline casts are present in small numbers. In\\nsome cases it may be necessary to examine a dozen or fifteen slides\\nbefore they are found. Sometimes there are a few red blood-cells.\\nRarely the urine is bloody at irregular periods in the course of the\\ndisease, or actual hematuria may take place. With the exception of\\nthe state of the urine, the only symptom present may be the loss of\\nflesh and strength. At the same time the skin becomes dry and harsh.\\nCEdema, however, is not usually present unless there is dilatation of\\nthe heart. Special symptoms are due to uraemia, to changes in the\\nheart and arteries, and to neuroretinitis.\\nThe Heart. The left ventricle hypertrophies. The aortic second\\nsound is accentuated. The pulse is of high tension. The arteries\\nbecome more prominent, and present all the signs of endarteritis. In", "height": "4412", "width": "2556", "jp2-path": "practicaltreatis00muss_0_1066.jp2"}, "1067": {"fulltext": "DISEASES OF THE KIDNEYS. 965\\nthe later stages, as nutrition fails, dilatation of the heart takes place,\\nwith regurgitation at the mitral valve, and the development of a train\\nof symptoms due to these changes. Among others we find general\\nmalaise, palpitation of the heart, dyspnoea, oedema, and visceral conges-\\ntions.\\nUrcemie Symptoms. These symptoms may occur at any time in the\\ncourse of the disease. Headache is most common and constant. It\\nmay occur early in the morning only, or continue throughout the day.\\nIt may be continuous and cause sleeplessness. General neuralgic pains\\nmay be present instead of severe headache. Muscular twitchings or\\ngeneral convulsions may be other pronounced symptoms, or, instead,\\ndelirium, mild or violent, stupor, and coma may come on. These\\nsymptoms occur suddenly or develop very gradually. In acute uraemia\\nwith the above-mentioned cerebral symptoms there is peripheral spasm\\nof the arteries, causing high arterial tension, and there is elevation of\\nthe temperature. The fever may rise to 103\u00c2\u00b0 or 104\u00c2\u00b0, but is usually\\nabout 102\u00c2\u00b0, and is irregularly continuous. After the patient lapses\\ninto deep coma, if the attack is fatal, the tension of the pulse is lost,\\nand it is increased in frequency and diminished in strength. In chronic\\nuraemia the cerebral symptoms develop gradually. The temperature is\\nlikely to be subnormal, particularly if diarrhoea or other debilitating\\ninfluence is coincident. The pulse is rapid and feeble.\\nPulmonary symptoms due to uraemia are quite common. They may\\nbe the first expression of uraemia. This is seen in all forms of nephritis.\\nThe most marked symptom is dyspnoea, which is spasmodic and of\\nshort duration. The attacks may occur frequently, and are usually\\nincreased by exertion and aggravated by a recumbent posture. The\\nshortness of breath may occur in the early morning hours, or may con-\\ntinue throughout the clay.\\nPulmonary symptoms, other than those of uraemia, may be due to an\\nintercurrent bronchitis, pneumonia, or pleurisy. Chronic bronchitis or\\noedema of the lungs may be present, on account of dilatation of the right\\nheart. The chief pulmonary symptoms that point to these conditions\\nare dyspnoea and cough.\\nSpasmodic dyspnoea is the first and sometimes the only symptom for\\na long time. Later the renal symptoms become pronounced, pointing\\nto the true nature of the disease.\\nGastro-intestinal Symptoms. Catarrhal gastritis almost always com-\\nplicates nephritis. In addition, gastric symptoms due to uraemia, and\\nhence to deficient action of the kidney, ensue. The most common is\\nthe occurrence of morning nausea or of morning vomiting the occur-\\nrence of spasmodic vomiting at irregular periods, or the occurrence of\\nviolent, acute vomiting, which is followed in two or three days by other\\nsymptoms of uraemia. The patients are usually constipated. When\\nthe disease is complicated with cirrhosis of the liver, intestinal catarrh\\nis common, and intestinal ulceration with consequent diarrhoea is fre-\\nquently found. The onset of uraemia may be characterized by violent\\nand profuse serous purging, which of itself may cause collapse and death.\\nNeuroretinitis is a frequent complication of nephritis, and may\\nadvance more rapidly than other complications, so that dimness of", "height": "4432", "width": "2632", "jp2-path": "practicaltreatis00muss_0_1067.jp2"}, "1068": {"fulltext": "966 SPECIAL DIAGNOSIS.\\nvision, blindness, or other eye-symptoms may cause the patient to\\nconsult an oculist before attention is called to the condition of the\\nkidneys. The occurrence of this complication points at once to the\\nnecessity of an examination of the urine.\\nIt is common, in the course of an interstitial nephritis, to have acci-\\ndents due to the condition of the arteries that accompanies this disease.\\nOn account of the atheroma, aided by the hypertrophied heart, rupture\\nof the vessels frequently takes place. Apoplexy is, therefore, of com-\\nmon occurrence, and hemorrhage into other organs sometimes occurs.\\nThe renal disease is often not suspected until after the patient has\\nhad an attack of apoplexy. The course of this form of nephritis is\\nvaried very much by the occurrence of complications, notably em-\\nphysema, endocarditis, or cirrhosis of the liver.\\nCatarrhs. There is always a tendency to chronic inflammations of\\nthe mucous membranes, and to acute inflammations of serous mem-\\nbranes in the course of chronic diffuse nephritis. It is necessary,\\ntherefore, when local inflammations of this character are present, to\\nmake thorough and repeated examinations of the urine, especially in\\na patient over forty years of age, with a history of one of the causal\\nfactors previously mentioned.\\nCourse of the Disease. Several clinical forms of interstitial nephritis\\nare observed. In the latent form the disease may have advanced to\\nan extreme degree without any symptoms of renal disease during life,\\ndeath taking place from an intercurrent disease or accident. On the\\nother hand, palpitation of the heart may be the only symptom com-\\nplained of, and the observer finds a hard pulse, general atheroma, and\\nhypertrophy of the left ventricle with accentuation of the second sound.\\nApart from this the patient may enjoy very good health. The danger\\nlies in the occurrence of pneumonia or inflammation of a serous mem-\\nbrane. Often the local inflammatory symptoms are slight or masked\\nby the symptoms of renal disease, which develop rapidly.\\nIn another group of cases some special symptom only may be com-\\nplained of. In some instances it may be gastric catarrh, in some eye-\\nsymptoms alone may be present, while in others hemicrania or other\\nforms of headache are observed. With the headache there is usually\\nvomiting. Again, we may have constant neuralgia or persistent muscu-\\nlar rheumatism as the only symptom. Nose-bleed is a symptom which\\nmay be the only indication of chronic nephritis, particularly if the\\nepistaxis occurs frequently.\\nIn other cases the course is not latent, but characterized by a series\\nof attacks at varying intervals.\\nDuring the attacks the symptoms resemble the acute form of neph-\\nritis, with acute uraemia, the occurrence of dyspnoea and loss of appetite,\\nnausea and vomiting. The tension of the arteries is higher at the\\ntime of the attacks. The urine contains albumin, and is of low specific\\ngravity during the time of the attack during the interval the albumin\\nis found at irregular times.\\nSuppurative Nephritis (Abscess of Kidney). Infectious matter\\nis conveyed to the kidney either Ihrough the blood, as in pyaemia and\\nulcerative endocarditis (rarely dysentery and actinomycosis), or by the", "height": "4416", "width": "2556", "jp2-path": "practicaltreatis00muss_0_1068.jp2"}, "1069": {"fulltext": "DISEASES OF THE KIDNEYS. 967\\nureters, as when it follows pyelitis or cystitis. A wound may infect the\\nkidney directly.\\nSymptoms. The symptoms are those of primary disease, and the\\naffection is usually only recognized post-mortem. Or the symptoms\\nare merely those of suppuration. Pas is seen in the urine only on\\nrupture of the abscess into the pelvis of the kidney.\\nTubercular Nephritis. Fever, emaciation, anaemia, and pros-\\ntration characterize the course of the disease. Tuberculosis is usually\\nfound elsewhere. There may be no other symptoms. Sometimes\\nhydronephrosis is present. A tumor is often present. It may be in\\nthe loins, or may be in front, above, and a few inches to the right\\nor left of the umbilicus. The urine is normal or contains pus and\\ndetritus or even bacilli. The finding of the latter is necessary often\\nto establish a diagnosis. In all instances of pyuria renal tuberculosis\\nshould be suspected. Catheterization of the ureters may disclose the\\norgan affected. The urine should then be centrifugalized and the\\nsediment examined for bacilli, and, as Reynolds points out, a portion\\ninoculated in guinea-pigs. The tuberculin test may be employed.\\nThe testicles and bladder should be carefully examined for primary\\ntuberculosis.\\nTuberculosis of the kidney presents symptoms like those of pyelitis,\\nrenal calculus, or a new growth. It is almost impossible to distinguish\\nany one of the four until an interval has elapsed. In all cases the\\npatient suffers from dull pain, sometimes with a bearing-down sensa-\\ntion. Hematuria occurs, and the patient is liable to attacks of renal\\ncolic. These symptoms may continue until a tumor can be made out.\\nEven before this pain will be elicited on palpation, which may extend\\nall along the urinary tract. With the occurrence of the tumor the\\ngeneral symptoms of tuberculosis arise. Further diagnosis is based\\nupon the results of the urinary examination.\\nThe Degenerations.\\nDegeneration may be either acute or chronic. The process is always\\nsecondary, due to the action of inorganic poisons, as arsenic or phos-\\nphorus, or the poison of infectious disease, or is produced as the effect\\nof chronic disease of the organs, or by disturbance of the circulation.\\nIn acute degeneration of the kidneys the urine is unchanged, or its\\nquantity is diminished. It contains a little albumin, or the albumin is\\npresent in large amount, with casts and blood-corpuscles.\\nThere may be no symptoms except changes in the urine, or symptoms\\nof uraemia may develop at once. Dropsy and hypertrophy of the heart\\ndo not occur.\\nChronic degenerations in the kidneys follow chronic congestion, or\\nare produced by alcoholism or syphilis. They occur in the course of\\npulmonary phthisis, and of chronic suppuration they may develop in\\nthe course of gout or malarial cachexia. Symptoms In the simpler\\nforms there may be no clinical symptoms whatsoever. In others\\nthere is loss of flesh and strength, the development of anaemia, and, in\\nrare instances, the development of the typhoid state.", "height": "4432", "width": "2628", "jp2-path": "practicaltreatis00muss_0_1069.jp2"}, "1070": {"fulltext": "968 SPECIAL DIAGNOSIS.\\nThe changes in the urine vary. It may be abundant, scanty, or\\nsuppressed. The specific gravity is not changed, but albumin and\\ncasts are found.\\nAmyloid degeneration of the kidney is associated with similar degen-\\neration in other organs. It occurs in the course of phthisis, of chronic\\nsuppurations, of syphilis, of chronic dysentery, and is thought to occur\\nin the malarial cachexia, or with gout. Symptoms The degeneration\\nmay be present without clinical symptoms. If symptoms arise, they\\nare due to the anaemia and cachexia that attend the primary disease,\\nand to the involvement of the other organs in the same process, as the\\nliver, spleen, and intestines. Pnrdy says dyspepsia is prominent and\\ndiarrhoeal attacks are common. The liver and spleen become enlarged\\nduring the course of the disease in the majority of cases. (Edema may\\nbe present, although it is more frequently absent. Uraemia is of rare\\noccurrence. In the uncomplicated degenerations there is no hypertrophy\\nof the left ventricle, and albuminuric retinitis is a rare complication.\\nThe Urine. It may be diminished, normal, or increased, usually the\\nlatter it varies from time to time in the same case, depending upon\\ncomplicating symptoms, as diarrhoea, which causes diminished amount\\nof urine. It is usually very pale. The specific gravity is not constant.\\nIt ranges from 1008 to 1014. Albumin is constantly present, and usu-\\nally in considerable amount. Hyaline casts and white blood-cells are\\nalways found. When other casts are present nephritis probably com-\\nplicates the condition. The chief distinctive feature of the casts is their\\nlarge size and hyaline character.\\nThe diagnosis of amyloid disease is based upon the presence of the\\ncause changes in the urine and signs of similar disease in other organs.", "height": "4416", "width": "2520", "jp2-path": "practicaltreatis00muss_0_1070.jp2"}, "1071": {"fulltext": "CHAPTER VIII.\\nDISEASES OF THE NERVOUS SYSTEM.\\nThe Data Obtained by Inquiry.\\nThe Social History. This includes a knowledge of the patient s\\noccupation, whether he or she is married or not, the conditions under\\nwhich he may live, as, for example, in cases of great wealth, there is\\nperhaps more tendency or at least more opportunity to dissipation in\\nconditions of poverty the patient may have been insufficiently nourished,\\nor have suffered from continual anxiety. The most important factor is\\nprobably the occupation. Occupations, from a clinical stand-point, may\\nbe divided into those that require mental exertion, those that require\\nphysical exertion, and those that expose the workmen to the possibility\\nof Various forms of intoxication.\\nThe Family History. This is perhaps of more importance in\\nconnection with nervous diseases than in connection with those of any\\nother system. By neurotic heredity we mean the fact that in certain\\nfamilies a tendency to the development of various forms of nervous\\ndisease exists, which may be manifested, however, only in certain mem-\\nbers of a given generation. Various terms are employed, to indicate\\nthe nature of the inheritance. Direct inheritance means that the child\\nsuffers from exactly the same disease as its parent. If both parents\\nhave the same disease, the child is likely to have it more severely, and\\nthis is spoken of as cumulative inheritance. By indirect inheritance is\\nmeant the condition in which collateral ancestry and not the parents\\nhave had the disease. Both the parents of the child may appear to be\\nhealthy, and the grandparents have suffered from the same disease, and\\nthis is called atavistic inheritance. By similar inheritance is meant the\\noccurrence in the offspring of a disease similar to that from which the\\nparents have suffered. Examples of such diseases are Huntington s\\nchorea, Goldflam s periodic paralysis, etc. By dissimilar inheritance is\\nmeant the development in the offspring of a form of nervous disease\\ndiffering from that which existed in the parents, as an epileptic child\\nborn of parents suffering from neurasthenia, hysteria, or insanity. The\\nindications of neurotic heredity are manifold. Inquiries must be made\\nin regard to cases of insanity, to cases of epilepsy, to instances of suicide,\\nto peculiarities of character, to criminal tendencies, to addiction to the\\nuse of drugs, such as alcohol or opium to congenital deformities, or to\\ncongenital diseases, such as deaf-mutism, etc. Charcot has called atten-\\ntion to the fact that certain of the so-called rheumatic manifestations\\nmay occur in the antecedents of a patient suffering from nervous disease.\\nThe History of Previous Diseases. This is of considerable im-\\nportance. The infectious diseases are sometimes followed by peripheral", "height": "4416", "width": "2636", "jp2-path": "practicaltreatis00muss_0_1071.jp2"}, "1072": {"fulltext": "970 SPECIAL DIAGNOSIS.\\nneuritis or lesions in the central nervous system, or they may produce\\nan early tendency to arterio-sclerosis. It is of importance to know\\nwhether the fetal existence of the patient was normal, and, if possible,\\nto obtain data concerning the condition of the mother during this period.\\nInquiry should be made regarding the nature of the birth the existence\\nof infantile spasms, at what age they occurred, when. they ceased, if at\\nall, and if there was any suspected reason for their development. It\\nshould be noted when the child first walked, when it first was able to\\ntalk, the rapidity of its intellectual development and progress at school,\\nwhether the character was normal, if there were night terrors or noc-\\nturnal enuresis. In boys the physician should endeavor to discover if\\nthere is any history of severe injury, particularly to the head, whether\\nthe boy had the opportunity for free exercise or was restricted in this\\nrespect if his habits were good if he smoked early if he was over-\\nworked at school or obliged to work hard during early adolescence.\\nIn the case of females the physician should inquire at what period\\npuberty occurred, and whether there has been any difficulty with men-\\nstruation. The existence of luetic infection is often difficult to eluci-\\ndate. Occasionally it Avill be admitted, but more frequently it is neces-\\nsary to discover the fact by indirect questioning.\\nThe History of the Disease Itself. As in other conditions,\\nthe patient should be questioned regarding the duration of the disease,\\nits earliest manifestations, whether exacerbations and remissions have\\noccurred, and the nature of its course. It is important to inquire for\\nslight symptoms that are usually overlooked by the patient, such as\\nthe ocular disturbances, ptosis, paralysis of the external rectus in loco-\\nmotor ataxia, a tendency to extravagance in paresis, the manifestations\\nof nocturnal epilepsy, etc.\\nThe Subjective Symptoms. The data obtained by inquiry in-\\nclude the subjective sensations of the patient. These are chiefly of\\ntwo kinds pain and paresthesia. In addition, the patients sometimes\\ncomplain of a general feeling of restlessness, of irritability, of inability\\nto think consecutively, or various other forms of indefinite general and\\nintellectual disturbance. Pain is, however, such an important symptom\\nin general disease that it has been discussed in the section upon Gen-\\neral Diagnosis.\\nPARiESTHESi^E maybe defined as subjective sensations, either resem-\\nbling those normally occurring as a result of excessive stimulation of\\nthe sensory nerves, or of a peculiar nature. They are exceedingly\\nvarious in their character, and may be sharply localized or indefinitely\\ndistributed. To them belong chiefly itching, tingling, formication,\\nnumbness, subjective sensation of heat or of cold, of moisture, of\\npressure, or of tearing or rending. Sometimes the paresthesia? are\\nvery slight in character, and may escape the notice of the patient until\\nhis attention has been directed to them in some cases they become so\\nsevere as to cause intense suffering and temporary helplessness. They\\nusually indicate some functional or organic disturbance of a nerve-\\ntrunk, and are, therefore, as a rule, limited to the distribution of some\\nparticular nerve. The functional forms, however, may be produced\\nby external conditions, such as pressure upon the bloodvessels leading", "height": "4408", "width": "2544", "jp2-path": "practicaltreatis00muss_0_1072.jp2"}, "1073": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM. 971\\nto a local anaemia, exposure to cold, to heat, and the like. A peculiar\\ntype of this condition is known as meralgia paraesthetica, and is char-\\nacterized by paresthesia in the distribution of the external cutaneous\\nnerve of the thigh. In this disease, and occasionally in other forms of\\nparesthesia, the subjective symptoms are associated with objective\\ndisturbances of sensation.\\nThe Data Obtained by Observation.\\nThese include nearly all the important symptoms of nervous disease,\\nand are, therefore, of paramount importance. They are disturbance of\\nsensation, of motion, of reflex action, of appearance and of contour,\\ndisturbances of the special senses, of the functional activity of the\\nvarious organs of the body, and alteration of the condition of nutrition.\\nSensation. New varieties of sensation appear to be discovered every\\nyear, and it is therefore tedious and sometimes impossible to analyze all\\nthat have been already described. Sensations may be described as those\\nwhich are relatively simple that is, involving but a single variety of\\nperception, and those that are complex.\\nSimple Sensations. Tactile sensation, or the sense of touch, is\\nusually spoken of as sesthesia. It is the ability to know when some\\nexternal object has come in contact with the skin. Hyperesthesia is an\\nincreased sensitiveness to contact and hypcesthesia, decreased sensitive-\\nness anesthesia, total loss of the ability to perceive objects touching\\nthe skin. No satisfactory instrument for the measurement of the touch\\nsense has as yet been devised. In general, it may be tested either\\ndirectly with the end of some hard, blunt object, or, when still acute,\\nwith a camel s-hair brush or cotton point. The patient should close\\nhis eyes, or, what is better, permit them to be bandaged, and should\\nthen be instructed to indicate by some word or motion the moment\\ncontact takes place. The investigator must be careful not to use force,\\nand the instrument employed should not be so sharp nor so rough as to\\nproduce pain. From time to time the patient should be asked whether\\nhe were touched when contact has not been made, although some move-\\nment indicating the approach of the instrument to the skin has been\\nperformed. Frequently in prolonged examinations the attention becomes\\nfatigued, and the patient no longer recognizes whether he is touched\\nor not, and answers at random. Hyperesthesia may occur in a variety\\nof conditions. Its most common cause is functional exaltation or irri-\\ntability of the nerves, which may occur in neuralgia or neuritis. It also\\noccurs in organic disease of the cord, and is then limited to the area of\\ndistribution of the spinal segment just above the destructive lesion.\\nThis is spoken of as the zone of hyperesthesia. It is also occasionally\\npresent in f unctional conditions, such as neurasthenia and hysteria, and\\nmay be merely the result of some local irritation of the skin. The\\ndegree of tactile perception varies considerably in different persons.\\nHypcesthesia may occur in a variety of conditions in neuralgia, in\\npartial lesions of the spinal cord, particularly disease of the posterior\\ncolumns, and rarely in central lesions of various kinds, particularly\\nthose occurring in the parietal lobe, in the end of the posterior limb of", "height": "4416", "width": "2636", "jp2-path": "practicaltreatis00muss_0_1073.jp2"}, "1074": {"fulltext": "972 SPECIAL DIAGNOSIS.\\nthe internal capsule, and in the pons. It also occurs in functional\\nnervous conditions, and is quite common among the insane. Ances-\\nthesia results from solutions of continuity of the sensory nerves, from\\ndestructive lesions of the cord, or from central lesions. It is also the\\ncommonest form of hysterical stigma. Organic anaesthesia may be dis-\\ntinguished from functional anaesthesia by its distribution. If caused\\nby nerve injury, it will exist in the region supplied by that particular\\nnerve. If caused by disease of the spinal cord, the area of anaesthesia\\nwill be segmental in type that is, bounded by two nearly horizontal\\nlines passing about the body. In unilateral lesions of the spinal cord\\nthe anaesthesia is limited to the opposite side of the body. In central\\ndisease the anaesthesia is commonly unilateral, and corresponds to the\\nparalyzed side, if paralysis is present. If due to a lesion of the cortex,\\nhowever, it may be limited to one extremity, where it is usually asso-\\nciated with paralysis.\\nPain sense, or algesia, is the ability to perceive pain of any kind.\\nVarious instruments have been devised for testing its intensity.\\nAmong the best is that suggested by Kulbin, consisting of a needle\\nwhich is thrust into the skin for varying distances the amount of press-\\nure required and the degree of penetration being indicated on a scale.\\nEven this, however, is far from accurate, and for clinical purposes it\\nis sufficient to use a needle or pinch a small fold of skin between the\\nfinger-nails. In case of very pronounced disturbance of the pain-sense\\nit is sometimes possible to use the actual cautery or to thrust a needle\\nentirely through a thick fold of the skin. A faradic current is also\\nfrequently employed, and to a certain extent is accurate, if data can be\\nobtained by comparing the healthy with the diseased side of the body.\\nAs, however, it appears that there is a special form of sensation for the\\ninduced current, its results cannot be relied upon implicitly. Hyper-\\nalgesia, is increased susceptibility to painful impressions, so that the\\nlightest contact may cause exquisite agony. It occurs in inflammation\\nand in those conditions associated with hyperesthesia. A variety of\\nhyperalgesia is tenderness that is, pain elicited by simple pressure.\\nIt is most frequently associated with local inflammation, and occurs\\nalong the course of the nerves in neuritis and neuralgia. Hypalgesia,\\nor decreased susceptibility of pain, occurs as a result of partial lesion\\nof the nerves, or of the central portion of the spinal cord, and, occa-\\nsionally, as a result of focal lesions in the brain. It is also very com-\\nmon among idiots, immediately after epileptic attacks, and in cases of\\nhysteria. Hypalgesia may also be acquired as a result of constant\\nexposure to a mild form of irritation, as, for example, in those accus-\\ntomed to going bare-footed. Analgesia is an exceedingly important\\nsymptom. It results from total destruction of the nerve from disease\\nof the central gray matter of the spinal cord, such as occurs in trans-\\nverse myelitis, syringomyelia in tumors of the cord and from focal\\ndisease of the brain, particularly if situated in the parietal lobe, and\\nthe posterior limb of the internal capsule. It also occurs in a great\\nvariety of functional conditions, and may be general in the form of\\ninsanity known as primary stupor. It is a very common lesion in\\nhysteria, and in this disease the area of distribution may assume the", "height": "4408", "width": "2544", "jp2-path": "practicaltreatis00muss_0_1074.jp2"}, "1075": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM. 973\\nmost curious forms, being limited to one-half of the body, or tracing\\ngeometrical figures on various parts of the skin. It may also be pro-\\nduced by hypnotic suggestion. Organic analgesia is frequently associ-\\nated with trophic changes, either as a result of the inability of the part\\nto defend itself against irritation, or as a result of the intimate associa-\\ntion of the sensory and trophic nerve-fibres.\\nVisceral pain may be elicited by strong pressure upon the testicles,\\novaries, or breasts, or a violent blow upon the abdomen. It is usually\\ncharacterized by intense prostration and nausea. Visceral analgesia\\noccurs in some cases of locomotor ataxia and occasionally in hysteria.\\nThe heat sense, or thermocesthesia, enables us to recognize the differ-\\nence in temperature between various bodies. It is usually tested by\\nfilling two test-tubes, one with hot and one with cold water, and apply-\\ning them in irregular alternation to the region under investigation.\\nThe difference in temperature between the two tubes is a rough test\\nof the delicacy of the sense. In health a difference of 1\u00c2\u00b0 C can be\\nrecognized upon the more sensitive portions of the body (the ante-\\nrior surface of the forearms, the skin of the face, and the chest). A\\nrougher test is the use of metal and wooden objects. The former con-\\nduct heat more rapidly from the surface, and therefore give rise to a\\nsensation of cold. The heat-sense is rather complicated, and is not yet\\nthoroughly understood. There seem to be special points upon the skin\\nwhere the nerves for heat and cold terminate. (Goldscheider.) There\\nmay be loss of perception for cold objects, while the perception for hot\\nobjects remains unimpaired, or the reverse may be present. Sometimes\\nthe patient calls all objects warm and at other times he calls them cold.\\nHyperthermocesthesia is practically of no value as a clinical sign, for our\\nmethods of testing the delicacy of the sense are at present imperfect,\\nand hypothermowsthesia is also difficult to detect, and probably belongs\\nto the category of conditions in which one of the sensations is more or\\nless impaired. Thermoanesthesia, or complete loss of the heat-sense,\\nis very important clinically. It occurs in neuritis or destructive lesions\\nof the nerve, and in central disease of the spinal cord, such as transverse\\nor pressure myelitis, tumor, and especially in syringomyelia. As a\\nresult of being most frequently associated with cord disease, the thermo-\\nansesthetic area is usually segmental. The heat-sense may, in connection\\nwith other forms of sensation, be diminished in functional nervous\\ndisease.\\nThe above three forms of simple sensation are those usually regarded\\nas of the greatest clinical importance. They may be equally affected,\\nor one or two may be preserved and the others diminished or lost.\\nThe latter condition is known as dissociation of sensation. It occurs\\nin neuritis, but is exceedingly rare. It also occurs in various forms of\\nmyelitis, particularly pressure myelitis. It is the most characteristic\\nsymptom, and for a long time was considered pathognomonic of syringo-\\nmyelia. In this form of dissociation tactile sense is preserved, and the\\ntemperature and pain senses are lost. When the tactile sense is lost, and\\nthe pain sense still present, the condition is termed ancesthesia dolorosa.\\nSimple sensations of perhaps less clinical importance than the fore-\\ngoing are trichocesthesia, or the consciousness that a cutaneous hair has", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_1075.jp2"}, "1076": {"fulltext": "974 SPECIAL DIAGNOSIS.\\nbeen touched. This is really the sensation perceived when tactile sense\\nis tested with the cotton point the latter is felt very well upon the\\nforearm, on the back of the hand, and not on the palm, where sen-\\nsation is distinctly more acute. Von Bechterew calls attention particu-\\nlarly to the fact that trichosesthesia and tactile sense are not equally\\ndelicate in various parts of the body. The former is most readily\\ntested by touching the individual hairs with a small needle or cotton\\npoint. More elaborate apparatus of no particular value has, however,\\nbeen devised.\\nThe Sensation of Locality. When any part of the surface of the body\\nis touched we can, under normal conditions, tell the location of the\\npoint of contact. This varies, however, consideraoly in various parts\\nof the body, being more accurate on the lips and less on the skin of\\nthe back between the shoulder blades, where an error of from 6 cm.\\nto 7 cm. is still within the normal limits. It may be very much dis-\\nturbed without any loss of the delicacy of the touch sense. It may be\\ntested by making contact with the finger or any blunt object. Another\\nmethod formerly much used by clinicians, and still employed by psy-\\nchologists, is the use of the ossthesiometer, an instrument consisting\\nessentially of two points that can be placed at a measured distance\\nfrom each other. It has been found that in normal persons these can\\nbe detected as two points at the tip of the tongue when separated only\\n1 mm. but may still be felt as one on the back when separated as much\\nas 65 mm. This method is extremely inaccurate, for the reason that\\nit is difficult to apply the points with the same degree of force. More-\\nover, experiments have shown that the skin readily becomes educated\\nand able to discriminate points much closer together than is normal\\nfor the, part that is being tested.\\nAUochiria. This is a general term applied to the false localization of\\nsensory stimuli. In some cases the sensation may be felt not at the\\npoint where it was applied, but at exactly the corresponding point on\\nthe opposite side of the body. This occurs particularly in hysteria.\\nIn organic disease of the spinal cord mistakes of localization are not\\nuncommon thus, in hypaesthesia of the arm, irritation at the hand\\nmay be referred to the shoulder, and the same is true of the lower\\nextremity.\\nWhen there exists a hypsesthesia it is of course difficult for the\\npatient to localize as accurately as is possible when sensation is normal.\\nThe Electro-cutaneous Sense. This is really the degree of resistance\\nto the irritation of the induced current. It varies considerably in\\ndifferent individuals, and in the same individual under different con-\\nditions and in different parts of the body. It is perhaps most delicate\\non the skin of the face, and least delicate on the back and the outer\\nsurface of the thighs. It is curiously affected in certain nervous dis-\\neases thus, in the periodic paralysis of Goldflam it is almost completely\\nabolished during the attack. In meralgia paraesthetica it is also, as a\\nrule, greatly diminished. In all cases of muscular degeneration the\\nelectric current is better supported than when the muscles react. It\\nis also greatly diminished when there is oedema of the skin or much\\nsubcutaneous fat. It sometimes persists, however, when tactile anaes-", "height": "4408", "width": "2592", "jp2-path": "practicaltreatis00muss_0_1076.jp2"}, "1077": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM. 975\\nthesia is present. In tetany it is greatly exaggerated (Erb s sign), and\\nthis constitutes one of the cardinal symptoms of the disease, and it is\\nalso increased in some of the functional nervous conditions. It is best\\ntested by using a simple faradic battery, employing as the electrode\\nfor contact either the wire brush or the naked wire. No satisfactory\\nsystem of measurement has as yet been devised, but it is of advantage\\nto use invariably the same battery, and to note the position of the inner\\ncoil with reference to the outer one.\\nPressure Sense. The clinical significance of this has not yet been\\ndetermined. It is certain, however, that it undergoes considerable\\nvariation as the result of various pathological changes. It may be\\ntested roughly by making various degrees of pressure with the finger\\nor a blunt object upon the surface of the skin, the limb being so placed\\nthat it is impossible for the patient to make muscular resistance. It\\nmay be tested more accurately by using a series of little blocks that\\ncan be piled one on top of the other, or by filling a vessel more or less\\ncompletely with shot or mercury.\\nFunctional Modifications of the Various Forms of Sensa-\\ntion. Delayed Sensation. The perception of the various forms of\\nstimulation that are appreciated in consciousness as sensations may\\nbe delayed for some time after the stimulus has been applied. This\\nis spoken of as delayed sensation, and the interval may, in extreme\\ncases, be several seconds. It is not known where this delay takes\\nplace, whether in the sensory bodies of the skin, or in the nerves, or in\\nthe central nervous system. This symptom is manifested particularly\\nin tabes dorsalis, but may occur in functional nervous disease and in\\nvarious forms of organic central disease. It has also been noted in\\nperipheral neuritis. The delay can occur for one sensation alone, as\\nthe pain sense, even when tactile sense is normal.\\nComplex Sensations. These are probably very numerous, but\\nonly two have been so carefully studied that they are valuable for\\nclinical purposes. These are the so-called position or muscular sense,\\nand the stereognostic sense. By the position or muscular sense we mean\\nthe ability to perceive and recognize the position of the limbs or of the\\nbody that is, whether, for example, the joints are in a state of flexion\\nor extension, supination, pronation, or rotation whether the spine is\\nbent or erect, and the position of the head with reference to the trunk.\\nIt probably depends upon the complex co-ordination of the perceptions\\nreceived from the muscles, joints, periosteum, tendons, and skin. It\\nmay be tested in a variety of ways. The patient should be instructed\\nto close his eyes or have them bandaged the finger is carefully grasped\\non either side and flexed or extended. After each movement the patient\\nindicates its direction. After the fingers have been tested the same\\nprocess is employed for the wrist, elbow, and shoulder. Similar methods\\nmay be used for the feet, and the head may be rotated to the right or\\nthe left, bent forward, laterally, or backward. Another method is to\\ntake one arm, bend it into some particular position, and instruct the\\npatient to imitate the position with the other arm the same thing being\\ndone with the legs or the patient may be instructed to describe the\\nposition in which his arm has been placed, without attempting an imi-", "height": "4432", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1077.jp2"}, "1078": {"fulltext": "976 SPECIAL DIAGNOSIS.\\ntation. This sense is lost when for any reason there is total anaesthesia\\nof the part, and may disappear as an isolated symptom in case of disease\\nof the posterior columns or in the ataxia due to central lesions. By\\nthe stereognostie sense we mean the ability to recognize the shape,\\nconsistency, surface, and nature of any object placed in the hand or\\nbrought in contact with the skin of any part of the body. This sen-\\nsation is most readily tested by directing the patient to keep the eyes\\nfirmly closed; then to select a number of small objects, such as a\\npencil, match-safe, coin, key, etc., and place them in his hand and\\ndirect him to name them or describe them. This sense depends upon\\na variety of perceptions. The size of the object is recognized by a\\ncombination of the locality and muscle senses the nature of its surface\\nby the tactile sense its consistency chiefly by the pressure sense, per-\\nhaps aided by the pain-sense its nature that is, whether of metal,\\nwood, or any other substance largely by the temperature sense. The\\nstereognostie sense is always abolished when tactile sense is absent.\\nOccasionally in hysteria the patient may declare himself unable to\\nperceive touch when the stereognostie sense is intact, but this is an\\nexception. It may, however, be lost when tactile sense is still preserved,\\nespecially if the locality sense and the muscle sense have been greatly\\nimpaired. When due to organic causes its absence usually indicates a\\nlesion in the parietal lobe or in the projection fibres coming from this\\nregion. It occurs frequently in hemiplegia, in cerebral monoplegia,\\nand occasionally in peripheral palsy, involving two forms of sensation.\\nIt has also been observed as a transient symptom after brain shock\\nwithout disturbance of any other sense.\\nDisturbance of Motility. These may be grouped under a number\\nof heads. First, loss of power, which may be either partial, paresis\\nor complete, paralysis. Second, impairment of movement, inco-ordina-\\ntion, or ataxia. Third, closely allied to this, tremor. Fourth, excessive\\nmuscular movement, spasm, or convulsions.\\nParalysis. This is a loss of power in the muscles. It may be\\ntrue, in which the loss of power is due to some disease of the muscle\\nitself or the nervous influence controlling it or false, when it is due\\nmerely to an inhibition of the muscular function produced by a disease\\nof the muscle or joint that causes pain upon movement. Paralysis is\\nclassified, according to the part affected, into monoplegia, when one\\nextremity is involved hemiplegia, when half the body is involved\\nparaplegia, when two symmetrical extremities are involved para-\\nplegia cruralis, if the legs are affected paraplegia brachialis, if the\\narms are affected (this term is usually restricted clinically to paralysis\\nof both legs) diplegia, when two extremities are affected without\\ninvolvement of the trunk. Clinically, this is sometimes restricted,\\nalthough incorrectly, to paralysis of both arms (diplegia brachialis) or\\nof both sides of the face {diplegia facialis). Crossed paralysis is a term\\napplied to paralysis of one side of the face and the opposite side of the\\nbody. Local paralysis is the term used when only small groups of\\nmuscles are affected. Multiple paralyses is employed when several\\nparts of the body are involved at the same time. Paralysis is also\\nclassified, according to the cause, into cerebral paralysis, spinal parol-", "height": "4416", "width": "2536", "jp2-path": "practicaltreatis00muss_0_1078.jp2"}, "1079": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM. 977\\nysis, neural paralysis, and muscular or myopathic paralysis. Paralysis\\nis also classified, according to the type, into spastic paralysis, in which\\nthe muscle tone is increased and the reflexes are exaggerated, and con-\\ntractures are either present or likely to ensue, and flaccid paralysis, in\\nwhich the muscle tone is diminished, in which there is no resistance to\\npassive movement, and the reflexes are abolished. Spastic paralysis is\\nusually due to some lesion in the central motor neuron that is, between\\nthe motor cortex and the terminations of the fibres of the pyramidal\\ntracts in the anterior cornua of the spinal cord. The lesion, therefore,\\nmay be situated in the cortex, the corona radiata, the internal capsule,\\nthe pons, the pyramids of the medulla, and the lateral columns of the\\ncord. Spastic paralysis must not be confused with the contractures\\nthat ensue after degeneration of the muscles, as in infantile palsy,\\nneuritis, etc. In these cases the limbs are in a state of permanent\\nflexion. The resistance to extension and to passive movement is not\\ndue to increased muscular tone, but to an actual shortening of the\\nmuscle and its tendons, which can only be overcome by rupture of one\\nor the other. Flaccid paralysis may be produced by cerebral lesions,\\nbut is more commonly due to lesions of the peripheral motor neurons\\nthat is, from the anterior cornua of the cord to the muscle itself.\\nIt may, therefore, be produced by destruction of the ganglion cells, by\\ninjury to the anterior roots, or the peripheral nerves, or disease of the\\nmuscle. Flaccid paralysis frequently occurs as the result of functional\\nconditions for example, it is the type of paralysis that is usually\\nobserved in hysteria. As the trophic centres influencing the muscle\\nare either cut off or destroyed, atrophy of the latter usually takes place\\n(atrophic paralysis), which is characterized by decrease in bulk, altera-\\ntion of the electrical reactions, and fibrillary twitchings. Monoplegia,\\nor paralysis of one limb, may be caused by small lesions in the cerebral\\ncortex or the corona radiata. It is rarely produced by lesions of the\\ninternal capsule, where the fibres are placed closely together, or of\\nthe spinal cord, unless the gray matter of the latter is involved. It\\noccurs in circumscribed forms of infantile paralysis, in lesions of the\\nperipheral nerves, particularly the roots of the plexuses, but rarely in\\ndisease of the muscles alone, the lesions in this case being more widely\\ndistributed. Monoplegia also occurs in hysteria and in the pseudo-\\nparalysis due to localized disease of the muscles or joints. Hemiplegia\\nis commonly due to a lesion of the opposite side of the central convolu-\\ntions. This lesion may either be extensive and destroy the motor por-\\ntion of the cortex or corona radiata, or more circumscribed, involving\\nthe internal capsule, the crura, the pons, or the medulla. Spinal lesions,\\nalso, if unilateral, which is rare, and situated above the fourth cervical\\nsegment, may produce paralysis of the same side of the body. Vide\\nBrown-Sequard s syndrome.) In hemiplegia due to lesion of the cere-\\nbrum, the muscles of the trunk, and those supplied by the upper\\nbranch of the facial nerve commonly escape. The lower half of the\\nface, the arm and leg, and the side of the body opposite the affected\\nhemisphere are paralyzed. If due to lesion of the pons below the\\ndecussation of the facial fibres that is, in the posterior half the arm\\nand leg of the opposite side and the lower half of the face on the\\n62", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1079.jp2"}, "1080": {"fulltext": "978 SPECIAL DIAGNOSIS.\\nsame side are paralyzed {crossed paralysis, pontine palsy). Lesions of\\nthe medulla ordinarily, in addition to the motor tracts, involve other\\nimportant nuclei and tracts. Spinal hemiplegia is characterized by\\nthe absence of facial involvement. Hysterical hemiplegia can only be\\nrecognized in some cases by the discovery of the other stigmata of that\\ndisease. The form of paralysis in organic hemiplegia is ordinarily\\nspastic, and usually in the coarse of time pronounced contractures\\noccur. Paraplegia cruralis is usually produced by a lesion of the spinal\\ncord. If this lesion is situated above the lumbar portion of the cord,\\nthe type of paralysis is spastic if in the lumbar or sacral region, or\\ninvolving the cauda equina, there is often abolition of the reflexes and\\nflaccidity of some of the muscles. Paraplegia, therefore, occurs in trans-\\nverse or pressure myelitis, in tumor of the spinal cord, in hemorrhage\\ninto the spinal cord, and as a result of traumatism. It is occasionally\\nproduced by multiple neuritis of the legs, particularly that form known\\nas Landry s paralysis, or in alcoholic neuritis, by bilateral cerebral\\nlesions, and occasionally as a functional condition. Paraplegia brachi-\\nalis is a rare condition occurring chiefly as the result of a localized\\nmeningitis in the cervical enlargement, particularly pachymeningitis\\nhypertrophica cervicalis. As the result of the destruction of the ante-\\nrior roots there is atrophy and degeneration of the muscles, and the\\nparalysis is flaccid. It may also occur in syringomyelia, and more\\nrarely as a result of traumatic injury to both sides of the brachial\\nplexus. Diplegia facialis is almost invariably the result of bilateral\\nfacial palsy that is, either neuritis or an injury to the facial nerve\\nafter it leaves the medulla. The paralysis is, therefore, flaccid in\\ntype, characterized by the loss of the normal folds, and the inability to\\nclose the eyes and drooping of the corner of the mouth.\\nMultiple palsies are usually due to some general condition affecting\\nthe peripheral neurons thus, in multiple infantile palsy the anterior\\ncornua of the gray matter of the spinal cord are involved in various\\nsituations. The paralysis is usually flaccid and incomplete that is,\\ncertain groups of muscles escape. In polyneuritis due to intoxication\\nor infection there may be paralysis either of certain groups of muscles,\\nparticularly the extensors, or of the entire limb. This occurs most\\nfrequently in poisoning by lead, arsenic, and alcohol, or in infectious\\ndiseases, as beri-beri and diphtheria. The paralysis is nearly always\\nflaccid there is muscular atrophy, and the reactions of degeneration\\nultimately appear. Local palsies are usually due also to lesions of the\\nperipheral neurons. Occasionally, however, a very small lesion in the\\ncortex will produce this condition. They are commonly the result of\\nsome trauma injuring a single nerve-trunk. The paralysis is, of course,\\nflaccid, and the reactions of degeneration are present.\\nA congenital absence of complete atrophy of the muscle gives rise\\nto myopathic paralysis. In either case the diagnosis must usually be\\nmade by careful anatomical examination, as in the course of a very\\nshort time the patient learns to compensate the defect of the individual\\nmuscle by the excessive action of others in its neighborhood. The\\nmuscles most frequently affected by congenital absence are the pec-\\ntorals, although many others also may be involved. Total atrophy", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1080.jp2"}, "1081": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM. 979\\noccurs in various myopathies, but with extreme slowness. In a special\\ntype of muscular atrophy (type of Duchenne-Aran) atrophy occurs in in-\\ndividual muscles or in small groups, and compensation is usually acquired\\nfor a considerable time until the progress of the disease renders it no\\nlonger possible.\\nParesis is a term used to indicate partial loss of power in the volun-\\ntary muscles. In addition to the causes given for paralysis, it may be\\nproduced by exhaustion. Paresis is of two kinds that in which the\\nmuscle is unable to exert its normal force at any time, and that in\\nwhich the muscle may exert its normal force for a brief period and\\nthen rapidly becomes exhausted and insufficient. In the former there\\nis some deformity, such as foot-drop or wrist-drop. In the latter the\\nsymptoms do not appear until some effort has been made. Paresis\\nmay also be temporary, as after fatigue stationary, as in cases of\\ninjury to the central nervous system or progressive, as in the myop-\\nathies. In the latter condition the muscles waste and lose their\\npower, but reactions of degeneration do not occur, and there are no\\nfibrillary twitchings. Ultimately, the condition may go on to absolute\\nparalysis. The power of the muscle may be tested very accurately by\\nmeans of the dynamometer. This consists of a steel spring with a\\nstaff on one side and a sliding index on the other. The patient com-\\npresses the spring in the palm of the hand, and the amount of pressure\\nis indicated in pounds or kilogrammes upon the index. By various\\nmechanical devices the dynamometer may also be employed for the\\nother muscles of the body. Care should be taken when it is used that\\nthe patient is not permitted to throw his weight against it. In using\\nthe instrument it is chiefly important to regard not so much the abso-\\nlute power as the difference between the two sides, the degree of mus-\\ncular force normally present varying very greatly in different indi-\\nviduals. Clinically, it is often sufficient to have the patient squeeze\\nthe physician s hand first with one hand and then with the other even\\nmoderate differences being readily detected by this means. The patient\\nmay also be instructed to resist passive movements, such as the exten-\\nsion of the flexed arm the flexion of the extended arm the lateral\\nmovement of the head the opening of the eyelids, or the various\\nmovements of the lower extremities.\\nIntermittent claudication is a term applied to indicate the occurrence\\nof transient, partial, or complete paresis or lameness. Sometimes the\\npatient will suddenly be unable to continue locomotion, and fall to the\\nground at others, one limb will become weak, causing a pronounced\\nlimp and necessitating the aid of a crutch while in other instances\\nthere is simply discomfort upon continued locomotion. This symptom\\noccurs in various forms of functional nervous diseases thus the peri-\\nodic paralysis of Goldflam, meralgia paraesthetica, and as an idiopathic\\ncondition in diabetes and arterio-sclerosis.\\nDisturbances of movement, characterized by excessive or perverted\\nmuscular activity, consist of ataxia, tremor, and spasm. By ataxia\\nis meant the inability to co-ordinate perfectly that is, to give each\\nmuscle its due share in the performance of any action. As a result\\nthe movements are irregular and imperfect. Various types of ataxia", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1081.jp2"}, "1082": {"fulltext": "980 SPECIAL DIAGNOSIS.\\nhave been distinguished Spinal ataxia, in which the disturbances of\\nmotion are more pronounced when the eyes are closed, and which is due\\nto disease of the posterior columns cerebellar ataxia, in which the dis-\\nturbances are equally severe when the eyes are opened or closed, but\\ndisappear when the patient lies down cerebral ataxia, in which there\\nis loss of muscular sense and marked persistent inco-ordination of\\nmovement, occurs as a result of injury to the parietal lobe pseudo-\\nataxia, due to the weakness of certain groups of muscles, so that they\\ndo not properly oppose the action of other groups. Finally, there is\\na form of ataxia apparently due to anaesthesia of the skin and loss of\\nthe muscular sense, in which the patient is able to perform movements\\nperfectly as long as he can watch the part with the eye, but as soon\\nas the eyes are closed the ataxia appears Ataxia may be tested in a\\nvariety of ways. Ataxia of the upper extremities may be recognized\\nby directing the patient to touch the tip of the nose with the tip of\\nthe forefinger, or to extend the arms and bring the tips of the\\nforefingers together with a rapid motion. In health, after one or\\ntwo trials, either of these movements can be done perfectly. When\\nataxia is present they are carried out awkwardly, and the forefingers\\nare only brought in contact with each other or the tip of the nose after\\nseveral irregular coarse oscillations. The ataxia of the legs may be\\ntested by requesting the patient, lying upon his back, to touch some\\nobject held above his feet with one of the toes, or to bring the heel of\\none foot against the knee of the other. When the patient is erect the\\nataxia may be tested by getting him to place the feet together, when\\nthere may be some SAvaying that is usually very markedly increased\\nwhen the eyes are closed. If the ataxia is very slight it may be neces-\\nsary to get the patient to stand on one foot with the eyes closed, or\\nto attempt to step backward under the same conditions. Under these\\ncircumstances a considerable swaying occurs that is more pronounced\\nthan the swaying noticed in a normal person attempting to perform\\nthe same movements. If the ataxia is at all pronounced it produces a\\ncharacteristic disturbance in the gait. (See Ataxic Gait.) Ataxia of\\nthe head is difficult to detect. Some observers contend that a peculiar\\nform of grimacing, whenever the patient attempts to move the lips or\\nthe eyes, or whenever the muscles of the face express some emotion, is\\nan ataxic condition due to overaction.\\nTremor. This is a disturbance of motion characterized by an oscilla-\\ntion of the part or parts involved. Tremor may be of various kinds.\\nIt may be fine or coarse, constant or irregular. It may disappear\\nupon voluntary effort or only be apparent when motion is attempted\\n{intention tremor). It may be the result of paralysis, paralytic tremor\\nof poisoning, toxic tremor of some functional nervous disease, as the\\nhysterical tremor or spasm of the muscle, spasmodic tremor or it may\\noccur as a family peculiarity without any discoverable cause, hereditary\\nor idiopathic tremor. Tremors are also classified as rapid, in which the\\nmovements occur more than five times per second and slow, in which\\nthe oscillations may occur at intervals of several seconds. Nearly all\\nforms of tremor are increased by placing the muscles upon a stretch.\\nTremor can usually be recognized by simple inspection. In some cases", "height": "4400", "width": "2596", "jp2-path": "practicaltreatis00muss_0_1082.jp2"}, "1083": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM. 981\\nit is necessary to use peculiar methods of detecting it. Ordinarily it is\\nsufficient, in order to detect tremor of the fingers, to get the patient to\\nextend them forcibly and keep them in that position. If the tremor,\\nhowever, is exceedingly fine, its effect may be exaggerated by attaching\\nlong, light rods to the fingers, such as straws. This procedure is often\\nexceedingly useful in cases of tremor of the head or the feet. Tremors\\nmay be recorded by attaching to the part affected rods whose ends are\\nfurnished with a pencil or stylet which writes upon a moving roll of\\npaper. If a chronograph marks off seconds or fractions of a second\\nat the same time, it is possible to measure very accurately the rate of\\noscillation. A more convenient method consists in allowing the patient\\nto put the trembling part, for example, the hand, upon a small drum\\nwhich conveys each movement to an oscillatory stylet that marks upon\\na piece of smoked glass or paper. Seconds should be marked at the\\nsame time. Persistent fine tremor occurs particularly in paralysis\\nagitans. In this the movements in the fingers are those of flexion\\nand extension and of opposition in the thumb, and it has, therefore,\\nbeen spoken of as the pill-rotter s tremor. It also occurs not infre-\\nquently in exophthalmic goitre and as hereditary or idiopathic tremor.\\nIrregular tremors occur as a manifestation of ataxia, often with cere-\\nbral lesions (the paralytic tremor), and after intoxications, as alcohol\\nand tobacco. The hysterical tremor may be either irregular or regular.\\nIts character is largely influenced by surrounding circumstances thus\\nif the hysterical patient be in the hospital Avard and have an oppor-\\ntunity of seeing a case of paralysis agitans, the tremor peculiar to that\\ncondition is often closely reproduced. Ordinarily, however, the hys-\\nterical tremor, being the result of voluntary and variable effort, is\\nirregular. Intention tremor occurs particularly in multiple sclerosis.\\nIn this condition no tremor is observed while the parts are at rest, but\\nas soon as voluntary motion is attempted a violent tremor ensues, and\\ncontinues until the effort ceases. Such a tremor can be particularly\\nwell elicited by asking the patient to convey a glass of water to his\\nmouth. The movements become more and more violent as the lips are\\napproached, and frequently more or less of the water is spilled. It may\\nalso be tested by asking the patient to touch with the forefinger some\\nobject. It will be observed, as the finger approaches, that the oscilla-\\ntions become more vigorous and wider. Intention tremor may, of\\ncourse, be present in other parts of the body. Generalized tremors\\nare spoken of as convulsions or convulsive movements (g. v.).\\nMuscular Spasm. By this is meant a condition in which the\\nmuscle is involuntarily but forcibly contracted, either persistently\\n(tonic or tetanic spasm) or rhythmically (clonic spasm). Tonic spasms\\nare characterized by the vigorous contraction of the muscle, which\\nbecomes hard and painful. If only one group of muscles is affected,\\nas, for example, the calf, the joint controlled by this group is placed in\\nthe position normally assumed when they are active. If all the muscles\\nof the limb or even antagonistic groups are affected, the flexors usually\\novercome the extensors. This, however, is not invariably the case.\\nWhen all the muscles of the body are involved, the powerful muscles\\nof the back usually arch the spinal column, and there is a more or less", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1083.jp2"}, "1084": {"fulltext": "982 SPECIAL DIAGNOSIS.\\nsevere opisthotonos. Tonic spasms can usually be diagnosticated by\\nsimple inspection. They occur particularly in tetanus, strychnine-\\npoisoning, and hysteria, and in these conditions may often be produced\\nby peripheral irritation. Localized spasms in the upper extremities\\nmay occur as a result of disease of the cord above the cervical enlarge-\\nment, or of the brain, producing a spastic condition of the muscles.\\nThis is rare. A more common type is the peculiar form of spasm\\nseen in tetany, consisting in the closure of the fingers and the opposi-\\ntion of the thumb, giving rise to the so-called obstetrical hand. Spasms\\nin certain individual muscles of the hand or arm occur in the occupation\\nneuroses. Spasms of the lower extremities are also occasioned by the\\nvarious conditions giving rise to spasticity of the muscles. An idio-\\npathic form of spasm not infrequently occurs in the calf muscles, par-\\nticularly on awakening. It appears to be of no clinical significance.\\nHysterical spasms are of various types. The tonic forms may affect a\\nsingle limb or even a single group of muscles, and may persist for long\\nperiods of time, giving rise either to extension or persistent flexion of\\nthe limb. In the latter case shortening may ultimately ensue and\\ncause persistence of the deformity. General hysterical spasms usually\\ncan be recognized by the fact that the patient assumes some extraor-\\ndinary posture, as opisthotonos, pleurosthotonos, and emprosthotonos.\\nThese spasms are often precipitated by pressure upon some sensitive\\npoint (hysterogenic zone, ovaria), and may sometimes be abolished\\nby pressing upon the same or a corresponding portion of the body. A\\npeculiar form of localized tonic spasm is that occurring in the masseters,\\nknown as trismus. The myotonic reaction is frequently spoken of as a\\nform of tetanic spasm. It consists of a sudden, persistent contraction\\nof the muscle or groups of muscles with which some voluntary move-\\nment has been attempted. It occurs, as far as is known, only in Thorn-\\nsen s disease. Clonic spasms are of various types. They may affect a\\nsingle extremity, half the body, or, in rare cases, the whole body. The\\nmovements are usually rhythmical, and vary greatly in different cases.\\nThe most frequent causes of clonic spasms are the injuries to the brain.\\nFocal irritation in the motor region will produce at first a spasm in the\\npart innervated by that area. If the irritation is sufficiently strong, or\\nacts for a sufficiently long time, its influence will extend to the adjacent\\nareas in the cortex, and a general unilateral or bilateral convulsion will\\nensue. This is the so-called epileptiform attack. If the local spasm\\nis distinct and precedes by some time the development of the general\\ntwitching, it is spoken of as focal, or Jacksonian epilepsy. As a result\\nof the violent irritation in the brain, unconsciousness usually ensues,\\nbut not invariably. Clonic convulsions may possibly be of local origin,\\nalthough this is exceedingly doubtful. Ankle clonus, however, and\\npatellar clonus bear a certain resemblance to this symptom of disease.\\nA localized form of clonic spasm, due to peripheral irritation in all\\nlikelihood, is facial tic, characterized by occasional or successive light-\\nning-like contractions of the muscles of the face. Functional con-\\nvulsions, particularly those occurring in hysterical patients, are very\\nfrequently clonic in character. Often there will be a preliminary\\ntetanic spasm, followed in a short time by the development of clonic", "height": "4412", "width": "2544", "jp2-path": "practicaltreatis00muss_0_1084.jp2"}, "1085": {"fulltext": "DTSEASES OF THE NERVOUS SYSTEM. 983\\nmovements. These assume various forms, the commonest being per-\\nhaps beating with the limbs, throwing of the head from side to side,\\nand lateral or antero-posterior movements of the body. The attitudes\\nand movements express fear, threat, ecstasy, eroticism, or other emo-\\ntional states.\\nAllied to the clonic spasms, but bearing also close affinity to tremors,\\nare the irregular movements that occur in chorea and athetosis, i The\\ntypical movement of chorea is an irregular innervation of groups of\\nmuscles that appears to be voluntary in character, but that is not under\\nthe control of the patient, is much more rapid, as a rule, than a volun-\\ntary movement, and recurs at very frequent intervals. Choreic move-\\nments may be mild, or so severe that they produce irregular contortions\\nof the body, causing the patient to throw himself or herself from side\\nto side, and often producing severe bodily injuries and even death by\\nexhaustion. Athetosis is a name given to a peculiar, slow, irregularly\\nrhythmical movement of the extremities, generally spoken of as worm-\\nlike in character. It is ordinarily most marked in the fingers. In\\nmovement these are gradually extended until they form almost a right\\nangle with the back of the hand, and then slowly flexed and extended\\nagain, each finger moving more or less independently of the others.\\nAt the same time there is movement at the wrist- joint, the elbow, and\\nsometimes of the trunk. The limbs may be affected, giving rise to a\\ncurious, staggering gait in which the patient seems ever to be about to\\nlose his equilibrium, but maintains it almost by a miracle. Frequently\\nthe muscles of the face are involved, giving rise to curious, irregular\\ngrimaces and more or less disturbance of speech or dysarthria. The\\nmovements are usually continuous. Athetosis is a very common sequel\\nto cerebral lesions occurring in early childhood.\\nThe term convulsion is used to designate general spasm with loss of\\nconsciousness. It is often employed, however, to indicate general clonic\\nspasm of the whole body, even if consciousness be still present. This\\nuse is undesirable, and should be avoided. General convulsions inva-\\nriably indicate some disturbance in the brain. If this is organic, it\\nmay be either some chronic disease with occasional exacerbation of\\ncortical irritation, or some acute injury or some disease, such as men-\\ningitis. If it is some functional disturbance, it may be hysteria or\\nepilepsy. (The latter is, of course, usually due to organic lesions.)\\nThe term muscular tone means that condition of the voluntary\\nmuscles of the body by which they are maintained in a state of tension\\nsufficient to enable them to respond promptly to nervous innervation.\\nMuscular tone varies slightly under normal conditions. It is less in\\nprofound fatigue, and when the attention is distracted by external\\nobjects it is more marked when the patient concentrates his attention\\nupon the part being tested. It is invariably diminished after lesions\\nof the peripheral motor neuron, in cases of profound cachexia, in coma,\\nand during anaesthesia. It is also generally decreased in lesions of the\\nposterior columns of the spinal cord. It is increased in lesions of the\\ncentral motor neuron without involvement of the peripheral neuron, in\\nneurasthenia, hysteria, and in conditions affecting the brain as a whole,\\nsuch as meningitis, brain tumor, etc. It must be remembered that", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1085.jp2"}, "1086": {"fulltext": "984 SPECIAL DIAGNOSIS.\\nflaccid paralysis does not necessarily imply diminished muscle tone\\nthus in the early stages of hemiplegia the muscles are completely\\nrelaxed, but, nevertheless, the reflexes are usually increased. There\\nare two methods of testing this quality First, passive movements\\nsecond, the tendon reflexes. In the former the limb to be tested is\\ngrasped firmly, and, if flexed, is suddenly but not too forcibly ex-\\ntended, or, if extended, is flexed. If the muscle tone is normal there\\nmay be a transient, involuntary resistance at first, but this disappears\\nvery soon, and then the limb may be moved in any position with com-\\nparatively slight effort. Any of the joints may be tested independently\\nin this manner. It is important to inform the patient what is to be\\ndone and what is to be tested. In children, in the ignorant, and in the\\ninsane it is often almost impossible to overcome the tendency to volun-\\ntary resistance, which is usually increased by the anxiety produced by\\nthe examination. Occasionally it is necessary to take some measures\\nto distract the attention, such as giving the patient a sum in arithmetic\\nto perform, requesting him to look at the ceiling or some particular\\nobject, or engaging him in conversation. Increase of the muscle tone\\nis determined by increased resistance to passive movements. This may\\nbe so great that it is almost impossible to bend the limb at any of the\\njoints, or so slight that it is difficult to discriminate it from the normal\\ncondition.\\nThe exaggerated forms are usually spoken of as spasticity of the\\nmuscles, and when associated with paretic or paralytic conditions the\\nterm spastic paralysis is employed. Diminution of the muscle-tone is\\nusually difficult to detect by passive movements alone. When it is\\nentirely lost the limb is spoken of as flail-like. The joints seem to\\nhave no tendency to remain in one position. If the limb is shaken,\\nwith every movement they pass from extension to flexion, or vice versa.\\nUnder these circumstances the passive movements are entirely unre-\\nsisted, the only effort necessary being that required to overcome the\\nweight of the limb itself.\\nThe Texdox Reflexes. These were first described by Westphal\\nin connection with the reflexes of the knee. They consist essentially\\nof a rapid twitch or succession of twitches in the muscle when the\\ntendon by which it is attached to some bony part is struck a sharp\\nblow. There is some difference of opinion regarding the true nature\\nof the stimulus required to produce them. According to Gowers, it is\\na simple extension of the muscle, and he, therefore, uses the term myo-\\ntatic phenomenon. Sternberg, on the other hand, believes that he has\\nshown that they are the result of vibrations in the tendon, which are\\ncommunicated by it to the muscle. Others contend that they are pure\\nreflexes produced by the mechanical action of the blow upon the nerve-\\nfibres in the tendon itself. It is certain, at any rate, that more factors\\nare required than the mere tone of the muscle, and that afferent im-\\npulses to the spinal cord and efferent impulses from it are necessary to\\nthe development of the reflex and that it is furthermore profoundly\\ninfluenced by higher centres that usually have an inhibitory action\\n(upper reflex arc). The question is complicated by the fact that in\\ncertain cases the reflexes may be elicited by tapping the bony parts, such", "height": "4408", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1086.jp2"}, "1087": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM. 985\\nas the periosteal reflexes by irritating the skin overlying the muscles,\\nas the cutaneous reflexes or by tapping upon the fascia or the belly\\nof the muscle itself. In general, it may be said that all conditions pro-\\nducing increased muscular tone produce exaggeration of the reflexes,\\nand that all conditions diminishing muscular tone diminish the reflexes.\\nIn marked contradiction to this, however, are the facts that attention to\\nthe reflex, being tested, vvill diminish or abolish it completely, whereas\\ndistraction of the attention, which ordinarily diminishes muscular tone,\\nincreases the force of the reflex. Moreover, in certain forms of pro-\\nfound coma, where the muscle tone appears to be at a minimum, the\\nreflexes appear to be often greatly exaggerated. Thus, in uraemia and\\ndiabetic coma, I have been able on several occasions to detect exaggera-\\ntion of the reflexes when the limbs were flail-like in their relaxation.\\nThe individual reflexes of the head are practically limited to the chin-\\njerk. This is elicited by having the patient open his mouth slightly,\\nthen a flat object, such as a tongue depressor, or the handle of a spoon, is\\nplaced upon the teeth of the lower jaw and sharply tapped with the\\nfinger or hammer. Under normal circumstances there will be a slight\\nupward jerk of the chin. It may also be elicited with less discomfort\\nto the patient by placing the finger beneath the lower lip and upon the\\nmental prominence and striking it sharply with the hammer. This does\\nnot always result in a reflex under normal conditions, but is quite satis-\\nfactory for the purpose of testing pathological exaggeration. The chin-\\njerk is nearly always increased in neurasthenia and hysteria, and is\\nsometimes present in profound coma. In the conditions of general\\nspasticity that are occasionally met with in severe infectious disease it\\nis also usually exaggerated. Its absence does not appear to be of any\\npathological significance. Allied to the tendon or peritoneal reflexes\\nis the phenomena known as Chvostetis sign. This occurs only in tetany,\\nand consists of a sudden lightning-like twitching of the muscles of the\\nface, particularly the elevators of the angles of the lip and the muscles\\nof the eyelids. It is elicited by striking the skin below the zygomatic\\narch just in front of the ear with the hammer. It was formerly sup-\\nposed that this was due to mechanical irritation of the trunk of the\\nfacial nerve, but the same phenomenon can also be elicited by striking\\nover the malar bone or in the region of the infra-orbital foramen. No\\ntendon reflexes have as yet been discovered for the muscles of the\\ntrunk.\\nIn the arms the most important are the bicipital, tricipital, and\\nthe supinator reflexes. The bicipital reflex is best obtained by allow-\\ning the patient to rest the perfectly relaxed arm upon some support,\\nfor example, the arm of the investigator in a semi-flexed position.\\nThe finger or thumb is then placed upon the tendon of the biceps, and\\nstruck a sharp blow with the hammer or the finger, as in percussing.\\nIn nearly all normal cases a slight twitching or distinct contraction of\\nthe biceps can be obtained in this manner. Sometimes it is possible,\\nby resting the arm upon a support, to see the tendon distinctly and to\\nstrike it directly, but this is usually much less satisfactory. The tri-\\ncipital reflex is readily obtained by holding the arm semi-flexel and\\nrelaxed, and then striking just above the olecranon process of the ulna.", "height": "4432", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1087.jp2"}, "1088": {"fulltext": "986 SPECIAL DIAGNOSIS.\\nThe supinator reflex is obtained by striking the radius just above the\\nstyloid process. These reflexes are particularly distinct in hemiplegia,\\nupon the paralyzed side. They also occur in the general conditions\\nabove mentioned. Their absence is of no pathological significance, as\\nit is often impossible to obtain them in normal individuals. In addi-\\ntion a reflex may be obtained by striking the bodies of the extensor\\nmuscles of the forearm, giving rise to extension of the fingers. A\\nform of wrist clonus occasionally occurs that may be elicited by sud-\\ndenly flexing the wrist-joint either dorsally or ventrally, and holding\\nit in the cramped position. The hypothenar reflex is the contraction\\nproduced in the palmaris brevis by pressure upon the pisiform bone.\\nIt does not appear to be dependent upon any diseased condition. Tap-\\nping upon the bodies of the muscles sometimes gives rise to a sharp\\ncontraction. This is particularly observed in connection with the\\nshoulder muscles (Striimpell) and pectoral muscles. An important\\nreflex, the abdominal reflex, is elicited by drawing the end of a blunt\\nobject obliquely across the skin of the abdomen downward and out-\\nward or upward and inward, the object being to make it cross the line\\nof the intercostal nerves as nearly as possible at a right angle. This\\nproduces contraction in the muscles innervated by these nerves, and\\nis due to the stimulation of their cutaneous distribution. It may be\\nexaggerated in functional nervous conditions, and is diminished in\\ncases of hemiplegia and anaesthesia on the anaesthetic sides. Its absence\\nat some particular point occasionally serves as an additional factor in\\nthe localization of lesions of the spinal cord. Various reflexes, prob-\\nably periosteal or fascial in nature, may be produced by tapping upon\\nthe spinous processes of the ilium. As far as is known, they are not\\nof any clinical value.\\nThe reflexes of the lower extremities are the most important of\\nall. The first discovered, the knee-jerk, is invariably present in health,\\nand by its delicacy and constancy is the most valuable reflex for clin-\\nical purposes. It may be elicited in a variety of ways. Perhaps\\nthe best method is to have the patient lie upon his back then placing\\none hand under the knee it should be lifted several inches from the\\nsurface of the bed or table until the leg and thigh form an obtuse\\nangle of about 120\u00c2\u00b0. Then with the finger, the side of the hand,\\nthe edge of the stethoscope, or the percussion hammer 1 it is struck a\\nsharp blow. The patellar tendon should be struck between the lower\\nedge of the patella and the tuberculum of the tibia. The stroke should\\nbe delivered with moderate force, and, according to the practice of most\\nclinicians, a single blow is sufficient, but sometimes the reflex is more\\ncertainly elicited if several strokes are given in quick succession. The\\nmost obvious and vigorous contraction occurs in the quadriceps of the\\nsame side, causing the leg to be tipped upward suddenly and giving\\nrise to the name knee-jerk. In addition, the adductors of the same side\\nnearly always contract slightly, and occasionally the flexor muscles\\n1 There are various forms of these one with a heavy metal head and short, wooden\\nhandle, the end of the metal head being covered with leather another, composed of a\\nwedge-shaped piece of rubber set in a light metal handle the latter is probably the\\nbetter.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1088.jp2"}, "1089": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM. 987\\nthat is, the biceps, the semi-tendinosus, and the semi-membranosus\\nalso contract. Frequently the adductors of the opposite side contract\\nvery slightly in health, and sometimes quite vigorously in diseased\\nconditions (crossed-reflex). Other methods of obtaining this reflex are\\nto allow the patient to sit on a low chair with the leg extended forward,\\nuntil it forms a blunt angle with the thigh, with the heel resting upon\\nthe ground. The patellar tendon is then struck as before. Clinically\\nit is usually sufficient when the patient is sitting in an ordinary chair\\nto have one leg thrown over the other, and hanging loosely and freely.\\nOccasionally it is difficult, on account of extreme relaxation of the\\nmuscles, to stretch the tendon sufficiently to obtain the reflex by this\\nmethod, and Gowers suggests that under these circumstances the legs\\nshould be completely flexed upon the thighs. It is often difficult to\\ndiscover the tendon, either on account of deformity of the joint or\\nbecause of an excess of fat tissue. In one case that I have observed,\\nin which extensive arthropathies existed, the knee-jerk was present,\\nbut obtained with great difficulty, on account of the distortion of the\\nparts. The patellar tendon reflex, therefore, is a multiple muscular\\nreflex, producing phenomena of the opposite side, the so-called bilateral\\nreflex. .It is said to be invariably present in health, but its intensity\\nvaries considerably, and in some apparently healthy persons without\\nany evidence of disease of the spinal cord it is extremely difficult to\\nelicit. Under these circumstances it is necessary to use various pro-\\ncedures in order to make it evident. These consist either in requesting\\nthe patient to look at the ceiling, in order to distract the attention, or\\nto perform some violent muscular effort, such as an attempt to pull the\\nhands apart when they are clasped together, to squeeze the dynamom-\\neter, etc. Under these circumstances the knee-jerk, if obtained, is\\nspoken of as reinforced. It is always important to have the muscles\\ncompletely relaxed, and to prevail upon the patient not to think of\\nwhat is being done. The knee-jerk is sometimes rendered more pro-\\nnounced by emotion, and sometimes inhibited, as, for example, by\\nfright. The arc of the knee-jerk is situated in the first lumbar seg-\\nment of the cord, but probably occasionally deviates slightly from this\\nposition, being either higher or lower. The knee-jerk is, therefore,\\ninvariably increased in any disease of the pyramidal tracts above this\\npoint. It is diminished in disease of the efferent or afferent fibres.\\nIts absence in tabes dorsalis was noted early, and has long been con-\\nsidered evidence of disease of the posterior columns. Closely allied to\\nthe knee-jerk in its clinical significance and mode of occurrence is the\\npatellar reflex. This is elicited usually by placing the finger transversely\\nabove the patellar, pushing the bone forcibly down, and then striking\\nthe finger with the hammer. Ordinarily a distinct, pronounced con-\\ntraction of the quadriceps alone is produced. In order to elicit this\\nreflex the leg must be extended and relaxed. Patellar clonus occasion-\\nally occurs, and is obtained by placing the thumb and forefinger on the\\nupper edge of the patella and pushing it forcibly downward and keep-\\ning it in that situation. If clonus occurs it will be characterized by a\\nseries of rapid contractions of the quadriceps, resulting in a vertical\\noscillation of the patella. It occurs in disease of the spinal cord, and", "height": "4428", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1089.jp2"}, "1090": {"fulltext": "988 SPECIAL DIAGNOSIS.\\nnot infrequently in conditions of increased tonicity in general infectious\\ndiseases. 1\\nIn general it ma} 7 be said that the mechanical effort is dependent\\nupon the condition of the nutrition of the quadriceps and the amount\\nof interference of the opposing muscles. Exaggeration of the knee-\\njerk is characterized by a more vigorous effort or more extensive con-\\ntraction of the surrounding muscles. The latter, indeed, may, by the\\ninvolvement of the flexors, diminish the excursion of the leg. Some-\\ntimes in cases of profound emaciation, as in cachexia, although the\\nknee-jerk is increased and the muscle apparently contracts vigorously,\\nits power is so greatly diminished that it is unable to move the leg.\\nElaborate mechanisms, therefore, that have been devised for meas-\\nuring the knee-jerk do measure in fact only the amount of movement\\nof the foot, and are practically worthless. They consist essentially of\\nan arc of a circle whose radius is approximately equal to the length of\\nthe leg. Either a pencil or a small readily movable index is placed\\nagaiust the foot, and the knee-jerk is measured by the number of de-\\ngrees marked off on the scale. It is manifest that comparisons are\\nonly valuable when the blow is of exactly the same force, and then\\nonly when the experiments are performed upon the same individual\\nwithin a limited period of time. In order to obtain a constant force\\nof blow various instruments have been devised, the simplest being\\nweights dropped through a paper cylinder upon the patellar tendon,\\nand the more complicated having springs for their motive power.\\nTendon reflexes may also be obtained by tapping upon the hamstring\\ntendons. They are of no particular value. Tapping upon the inner\\ncondyle of the tibia often produces contraction of the adductor muscles,\\nbut this is not, as a rule, as pronounced as the contraction produced by\\nthe percussion upon the patellar tendon. Next in importance to the\\npatellar reflex is the Achillis tendon reflex, which consists of the contrac-\\ntion of the gastrocnemius and soleus muscles when the Achillis tendon\\nis struck. It is most readily elicited by lifting the entire leg from the\\nbed or table, and holding it by the ball of the foot, which is gently\\npressed upward. The tendon is thus moderately stretched, and may\\nbe struck directly. In nearly all healthy individuals this reflex is\\npresent, but is absent in some, and its absence is apparently of no clin-\\nical significance. Exaggeration may be indicated in moderate cases by\\nthe more forcible extension of the foot. In more pronounced cases it\\ngives rise to a peculiar and characteristic phenomenon, known as ankle\\nclonus. This may be elicited by tapping the tendon once vigorously or\\nseveral times in succession when the leg is held in the manner described,\\nbut is more readily produced by slightly flexing the leg and thigh, then\\ngrasping the ball of the foot firmly, flexing it dorsally with considerable\\nforce, and holding it in that position. When ankle clonus exists there\\nwill be violent vibratory oscillations of the foot, as long as the pressure\\nupon the sole is continued, that vary from two to three up to five or\\n1 Dr. Mills has devised an ingenious instrument, consisting of a metal ring with a\\ncurved handle, by which the patella may be drawn downward and the jerk or clonus\\nmore certainly elicited.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1090.jp2"}, "1091": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM. 989\\nten movements per second. There is usually a rhythmical increase and\\ndecrease in the rapidity, without absolute cessation at any time. Occa-\\nsionally, in very mild cases, the clonus after a few movements becomes\\nweaker, and rapidly disappears. Ankle clonus is supposed to indicate\\nthe existence of a lesion above the second lumbar segment of the spinal\\ncord that seriously interferes with the function of the pyramidal tract.\\nFor a long time there has been doubt as to whether it occurs in func-\\ntional disease, but it seems now to be established that it does. Its\\noccurrence in functional conditions is, however, of such extreme rarity\\nthat when it is present organic disease should always be suspected. It\\nis most characteristic in spastic paraplegia, either due to transverse\\nmyelitis, to lateral sclerosis, or to syringomyelia. It also occurs after\\nlesions in the motor regions of the brain. It can sometimes be elicited\\nby supporting the weight of the leg upon the toe. Under these circum-\\nstances it develops spontaneously in organic conditions, and sometimes\\nin fatigue, cold, or exhaustion. It may also be produced in normal\\npersons who continue for a sufficient length of time voluntary oscilla-\\ntory movements of the foot supported in this manner. A pseudo-ankle\\nclonus has been described as characterized by a few irregular oscilla-\\ntions that soon cease. It occurs in functional disease and occasionally\\namong malingerers. Tapping upon the tendon of the great toe occa-\\nsionally produces a slight contraction of that member. The other\\nreflexes of the lower extremities are front tap, dorsal extension of the\\ntoes upon percussion of the anterior surface of the tibia, and the toe\\nreflex that is, slight flexion of the toes when the skin of the sole is\\nirritated. This, according to Babinsky, is replaced by a dorsal flexion\\nof the toes when the pyramidal columns are involved, and disappears\\nin tabes dorsalis. The plantar reflex properly belongs to the group of\\ncutaneous reflexes. It is characterized by the involuntary withdrawal\\nof the foot when the sole is irritated. It is of course absent in cases\\nof anaesthesia, and is greatly exaggerated in functional nervous condi-\\ntions, occasionally giving rise to a peculiar general tremor of the leg or\\neven of the whole body. It is best elicited by drawing a blunt object\\n(pencil, handle of a stethoscope) across the surface of the foot.\\nAllied to the reflexes is the so-called paradoxical contraction of West-\\nphal. This consists in a persistent spasm of the muscle when its two\\nattachments are suddenly brought closer together. It is most fre-\\nquently observed in the peroneal muscles of the leg, and may be elicited\\nby suddenly flexing the foot dorsally. It occurs most frequently in\\nvarious functional conditions, and has also been observed in paralysis\\nagitans.\\n!Next to the functional conditions of the muscles, which is indicated\\nby the degree of motility that they possess, we are interested in the\\nstate of their nutrition. It may be suspected that this is impaired\\nwhen fibrillary contractions or atrophy are present.\\nAtrophy of the muscles may usually be detected by simple inspection.\\nIf only certain groups are involved, the latter will appear more or less\\ndistorted. It is always, however, important to measure the injured\\nlimb and compare it with the sound side if the affection is unilateral.\\nWhen due to general conditions, such as the muscular dystrophies or", "height": "4416", "width": "2632", "jp2-path": "practicaltreatis00muss_0_1091.jp2"}, "1092": {"fulltext": "990\\nSPECIAL DIAGNOSIS.\\npolyneuritis, it is sometimes more difficult to be certain of its existence.\\nA general atrophy of the muscular system also occurs in cachectic\\nstates, such as the cachexia of carcinoma. Fibrillary twitchings occur\\nThey are characterized\\nin muscles undergoing degenerative changes.\\nFig. 226.\\nM. occipit.\\nM. retrah. auric.\\nN. auricul. post.\\nM. splenitis\\nN. accessorius\\nM. sternocleidom.\\nM. cucullaris\\nN. axillaris (M. deltoid.)\\nN. thoracic, long. (M. serr.\\nant. maj.\\nPlexus brach.\\nM. temporal.\\nM. frontal.\\nM. corrugator super-\\n[cilii.\\nM. orbicul. palp.\\nNasal muscles.\\njM. levat. lab. sup.\\nM. zygomaticus.\\nM. orbic. oris.\\nM. masseter. [talis.\\nM. levator menti (men-\\nM. depressor lab. inf.\\n(quadr. menti).\\nM. depressor ang. oris\\n(triangul. menti).\\nN. hypoglossus.\\nPlatjsma\\nM. sternohyoideus.\\nM. oniohyoideus.\\nN. phrenicus.\\nM. sternothyreoideus.\\nErb s point (M. del-\\ntoid., biceps, brach.\\nint. supinator long.\\nN. thoracic ant. (M.\\npect. maj.).\\nMotor points for the head and neck. (Sahli.)\\nby the sudden, spasmodic contraction of individual fibres in the mass\\nof the muscle itself, giving rise to a curious trembling of the overlying\\nskin and a peculiar sensation to the palpating hand, as if minute waves\\nwere passing through the muscular substance. They often occur spon-\\ntaneously, and in degenerating muscles may be elicited by slight median-", "height": "4408", "width": "2640", "jp2-path": "practicaltreatis00muss_0_1092.jp2"}, "1093": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM. 991\\nical stimuli, such as cold, percussion, or shock. Fibrillary twitchings\\nmay also occur in healthy muscles that have either been chilled (tremor\\nor shivering) or subjected to severe fatigue.\\nThe most reliable method of diagnosis is by an electrical examina-\\ntion. For this purpose we use two types of apparatus. The galvanic\\ncurrent is produced by the galvanic battery, consisting of a number of\\ncells, each containing an electro-positive and electro-negative element\\nand filled with battery fluid. Long wires are attached to the battery,\\nthrough which the current flows when they are brought in contact or\\nthe circuit closed, and ceases when they are kept apart or the circuit\\nopened. The free end of the wire toward which the current flows\\nfrom the cell is called the anode, and the free end from which the\\ncurrent passes to the cell, the cathode then, if any substance is intro-\\nduced between these ends of the wire, closing the circuit, the current\\npasses through it from the anode or positive pole to the cathode or\\nnegative pole. It is customary to introduce into the circuit for meas-\\nuring the amount of electricity employed a galvanometer, which is\\ngraduated in milliamperes. 1 As it is important to employ a definite\\nnumber of milliamperes, the apparatus is also provided with a rheostat,\\nwhich renders it possible by the introduction of a greater or less degree\\nof resistance to regulate the amount of electricity passing through the\\nbody. The free ends of the wire are, for medical purposes, supplied\\nwith electrodes. These consist essentially of metal disks or plates\\nto which the wire is attached, provided with a wooden or hard rubber\\nnon-conducting handle. As the resistance normally offered by the\\nskin is greatly reduced if it be moistened, the ends of the electrodes\\nare covered with cotton or gauze and moistened by immersion in either\\nplain or salt water. The area of the cross-section of the electrode may\\nvary considerably. Ordinarily, it is customary to have one very large\\nelectrode, from 50 to 100 square centimetres in area, and one exactly\\n3 square centimetres in area. (Stintzing 7 s standard electrode.) In\\naddition, for therapeutic purposes, it is customary to have for the\\ngalvanic and faradic apparatus a wire brush and various special elec-\\ntrodes for application to the more inaccessible portions of the body.\\nIf a muscle or nerve is to be investigated the large electrode is thor-\\noughly moistened and placed over the back or the sternum. It is\\nnot advisable to place it over the neck nor to allow the patient to hold\\nit in the hand. The current is so arranged that this large electrode is\\nat first the anode and the small electrode the cathode. The cathode\\nis now placed over the muscle or the nerve to be stimulated, locating\\nit, if possible, exactly over the most sensitive (electrically) point. This\\nis most readily determined by comparison with the figures on pages 990\\net seq. The circuit should be open and the rheostat so placed that the\\nminimum amount of current flows through the body. The circuit is\\n1 One milliampere equals 0.001 of an ampere. The ampere is the unit adopted for\\nthe measure of the amount of current. It is determined by dividing the unit of\\nelectromotive force, one volt\u00e2\u0080\u0094 that is, 0.9 of the amount of current liberated by a\\nfreshly filled Daniell cell, divided by 1 ohm that is, the amount of current required\\nto overcome a unit of standard resistance, or a column of mercury 1.06 metres in\\nlength and 1 square millimetre in cross-section.", "height": "4432", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1093.jp2"}, "1094": {"fulltext": "992\\nSPECIAL DIAGNOSIS.\\nnow rapidly opened and closed, while the cathode is kept in position\\nand the rheostat gradually moved around until the current is strong\\nenough to produce a slight twitching of the muscle. This will first\\noccur at the making of the circuit, and is spoken of as cathodal closing\\ncontraction, or CCC. The current should now be slightly increased,\\nand by means of a switch the small electrode converted into the anode\\nand the other into the cathode. It will soon be observed that a con-\\ntraction takes place both at opening and closing the current. This is\\nspoken of as the anodal closing contraction, or ACC, and the anodal\\nopening contraction, or AOC. If the small electrode be again made\\nFig. 227.\\nRectus abdominis.\\nIntercostal nerves.\\nSerratus magnus.\\nLatissimus dorsi.\\nIntercostal nerves.\\nTransversus\\nabdominis.\\nDiagram of the motor points of the trunk. (From Von Ziemssen.)\\nthe cathode, it will be found that there is a vigorous contraction when\\nthe current is closed, but none when it is opened. Finally, if the cur-\\nrent is made still stronger, it will be found that the closure of the\\ncurrent produces at the cathode no longer a simple lightning-like con-\\ntraction, but a prolonged cramp of the muscle, spoken of as cathodal\\nclosing tetanus, or CCTe. The contraction produced by both opening\\nand closing the current at the anode is now much stronger than before,\\nand there will probably appear a slight contraction at the opening of\\nthe cathode, the cathodal opening contraction, or COC that is to say,\\nwith gradual, increasing current the order of contraction is as follows\\nin a normal muscle cathodal closing contraction, anodal closing con-\\ntraction, anodal opening contraction, cathodal closing tetanus, cathodal", "height": "4416", "width": "2556", "jp2-path": "practicaltreatis00muss_0_1094.jp2"}, "1095": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM.\\n993\\nopening contraction. Under ordinary circumstances the healthy muscle\\ncontracts suddenly and relaxes almost immediately. Various modi-\\nfications of these phenomena occur in diseased conditions, and there are\\nconsiderable quantitative changes between the different muscles in\\nhealth. Thus, in the muscles of the face contraction is always more\\n2 4\\nDiagram of the motor points of the arm, under side\\n1. Musculocutaneous nerve. 2. Musculocutaneous nerve,\\ntriceps. 6. Median nerve. 8. Brachialis anticus. 10. Ulnar nerve\\nnerve to the pronator teres.\\n(From Von Ziemssen.)\\n3 Biceps. 4. Internal nerve of\\n12. Branch of median\\nrapid than in those of the thigh, and can be elicited with much weaker\\ncurrents. In disease we recognize three types of alteration First,\\nquantitative changes second, quantitative qualitative changes third,\\npure qualitative changes. Before discussing these it is necessary to\\ndescribe the faradic apparatus. This consists essentially of a coil of\\nwire through which flows an electric current, that forms the core for a\\nMotor points of the arm, outer side. (From Von Ziemssen.)\\n1. External head of triceps. 2. Musculo-spiral nerve. 3. Brachialis anticus. 4. Supinator\\nlongus. 5. Extensor carpi radialis longior. 6. Extensor carpi radialis brevior.\\nsecond coil not attached to it. If, now, the current passing through\\nthe inner or primary coil is interrupted, there will be generated, at each\\nopening of the current, a current in the outer or secondary coil, going\\nin the opposite direction, and, at each closure, a current going in the\\nsame direction. This is usually the stronger, and, if the interruptions\\n63", "height": "4428", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1095.jp2"}, "1096": {"fulltext": "994\\nSPECIAL DIAGNOSIS.\\nare sufficiently rapid, dominates the reversed current. The ends of the\\nsecondary coil are attached to the electrodes. The strength of the cur-\\nrent is altered by moving the inner coil away from the secondary coil.\\nFig. 230.\\nFig. 231.\\nMotor points of forearm, inner surface. Motor points of forearm, outer surface.\\n(From Von Zi ems sen.)\\nFig. 230.\u00e2\u0080\u0094 1. Flexor carpi radialis. 2. Branch of the median nerve for the pronator teres. 3.\\nFlexor profundus digitorum. 4. Palmaris longus. 5. Flexor sublimis digitorum. 6. Flexor\\ncarpi ulnaris. 7. Flexor longus pollicis. 8. Flexor sublimis digitorum (middle and ring fingers).\\n9. Median nerve. 10. Ulnar nerve. 11. Abductor pollicis. 12. Flexor sublimis digitorum (index\\nand little finger). 13. Opponens pollicis. 14. Deep branch of ulnar nerve. 15. Flexor brevis\\npollicis. 1G. Palmaris brevis. 17. Adductor pollicis. 18. Adductor minimi digiti. 19. Lumbri-\\ncalis (first). 20. Flexor brevis minimi digiti. 22. Opponens minimi digiti. 24. Lumbricales\\n(second, third, and fourth).\\nFig. 231.\u00e2\u0080\u0094 1. Extensor carpi ulnaris. 2. Supinator longus. 3. Extensor minimi digiti. 4. Ex-\\ntensor carpi radialis longior. 5. Extensor indicis. 6. Extensor carpi radialis brevior. 7. Extensor\\nsecundi internodii pollicis. 8. Extensor communis digitorum. 9. Abductor minimi digiti. 10.\\nExtensor indicis. 11. Dorsal interosseus (fourth). 12. Extensor indicis and extensor ossis meta-\\ncarpi pollicis. 14. Extensor ossis metacarpi pollicis. 16. Extensor primi internodii pollicis. 18.\\nFlexor longns pollicis. 20. Dorsal interossei.", "height": "4416", "width": "2572", "jp2-path": "practicaltreatis00muss_0_1096.jp2"}, "1097": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM.\\n995\\nThis is spoken of as the distance between the coils, and is measured in\\ninches or centimetres. It is manifest that this method for measuring\\nis not absolute, but its value must be determined for each particular\\nmachine. This can only be done by the physiological test that is,\\nmeasuring the force required to produce contractions in some muscles\\nand then comparing it with the known value for this muscle obtained by\\na standard machine, and obtaining in this way the ratio. The current\\nFig. 232.\\nFig. 233.\\nMotor points of thigh, anterior surface. Posterior surface.\\n(From Von Ziemssen.)\\nFig. 232.\u00e2\u0080\u0094 1. Tensor vaginae femoris (branch of superior gluteal nerve). 2. Anterior crural nerve.\\n3. Tensor vaginae femoris (branch of crural nerve). 4. Obturator nerve. 5. Rectus femoris. 6. Sar-\\ntorius. 7. Vastus externus. 8. Adductor longus. 9. Vastus externus. 10. Branch of crural nerve\\nto quadriceps extensor cruris. 12. Crureus. 14. Branch of crural nerve to vastus externus.\\nFig. 233.\u00e2\u0080\u0094 1. Adductor magnus. 2. Inferior gluteal nerve for gluteus maximus. 3. Semi-tendin-\\nosus. 4. Great sciatic nerve. 5. Semi-membranosus. 6. Long head of biceps. 7. Gastrocnemius\\n(internal head). 8. Short head of biceps. 10. Posterior tibial nerve. 12. Peroneal nerve. 14. Gas-\\ntrocnemius (external head). 16. Soleus.\\nis, of course, increased Jwhen the secondary coil is directly over the\\nprimary one and diminished when the primary coil is withdrawn. As\\nthe current in the secondary coil is oscillatory that is, going first in\\none direction and then in the other it is not theoretically possible to\\nspeak of an anode and a cathode. Practically, however, the current\\ngoing in the same direction as that of the primary coil is the stronger,\\nand a difference does exist between the two ends of the wire, which are", "height": "4432", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1097.jp2"}, "1098": {"fulltext": "996\\nSPECIAL DIAGNOSIS.\\nusually spoken of, therefore, as cathode and anode. A contraction pro-\\nduced by the faradic stream is always tetanic in health, as there are a\\nseries of stimulations constantly passing through the muscle.\\nFig. 234.\\nFig. 235.\\nMotor points of the leg, outer side. Inner side.\\n(From Von Ziemssen.)\\nFig. 234.\u00e2\u0080\u0094 1. Peroneal nerve. 2. Peroneus longus. 3. Gastrocnemius (external head). 4. Tibi-\\nalis anticus. 5. Soleus. 6. Extensor longus pollicis. 7. Extensor communis digitorum longus.\\n8. Branch of peroneal nerve for extensor brevis digitorum. 9. Peroneal brevis. 10. Dorsal inter-\\nossei. 11. Soleus. 13. Flexor longus pollicis. 15. Extensor brevis digitorum. 17. Abductor\\nminimi digiti.\\nFig. 235.\u00e2\u0080\u0094 1. Gastrocnemius (internal head). 2. Soleus. 3. Flexor communis digitorum longus.\\n4. Posterior tibial nerve. 5. Abductor pollicis.\\nAlterations in the Reactions of the Muscles and Nerves\\nto Electricity. Reactions of Degeneration. Quantitative\\nalterations consist in increase or decrease of the susceptibility of the\\nmuscles or nerves to electrical action. They may be determined in\\ncase the lesion is unilateral by comparison with the normal side of the\\nbody in case the lesion is bilateral, only by comparison with a stand-\\nard table, such as has been furnished by Stintzing. If the deviation", "height": "4412", "width": "2572", "jp2-path": "practicaltreatis00muss_0_1098.jp2"}, "1099": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM.\\n997\\nfrom the normal is slight, the error has very likely been produced by\\nvariation or alteration in the resistance of the skin. Quantitative\\nincrease in the electrical reaction occurs chiefly in tetany, for which\\ndisease it is almost pathognomonic, and has been spoken of as Erb s\\nsign. It occurs also occasionally in the early stages of hemiplegia, in\\nparalysis of the facial nerve, and has been noted in certain cases of\\ntabes dorsalis. Diminished electrical irritability occurs in all the forms\\nof idiopathic muscular dystrophy. It also occurs in those forms of\\natrophy due to lesion of the central motor neuron without involve-\\nment of the peripheral motor neuron. It also occurs in those atrophies\\nsecondary to disease of the joints and loss of functional activity on the\\npart of the muscle. Diminished reaction may occur in hysteria and\\nprofound neurasthenia, and has been observed in some cases of loco-\\nmotor ataxia, and even in some cases of progressive spinal muscular\\natrophy of exceedingly slow course. It also occurs in certain nervous\\ndiseases whose nature is not yet understood, as in Goldflam s periodic\\nparalysis, although it is to be noted that there are other alterations in\\nthe electrical reactions in this disease. The quantitative qualitative reac-\\ntion consists, first, of a diminution of the reaction of the muscle or the\\nnerve to the faradic current, and its diminution or exaggeration to the\\ngalvanic current, with distinct alteration of the order in which the\\nvarious forms of galvanic irritation produce contractions. Cohn dis-\\ncriminates three types of this form of degeneration First, the complete\\nreaction, mild in character, and terminating in recovery second, the\\ncomplete reaction, severe and incurable and, third, a partial reaction.\\nHe gives the following table illustrating the various stages of these three\\nforms\\nTotal Beaction of Degeneration.\\nModerate Form.\\nIndirect stimulation (nerve).\\nDirect stimulation (muscle).\\nF.\\nG.\\nF.\\nG.\\n1st stage, 1-8 days.\\nDiminished.\\nDiminished.\\nDiminished.\\nDiminished.\\n2d stage, 2-15 weeks.\\nLost.\\nLost.\\nLost.\\nIncreased, con-\\ntraction slow.\\nAOC CCC.\\n3d stage, 6-30 weeks.\\nReturning.\\nReturning.\\nReturning.\\nDiminishing\\ncontraction\\nmore rapid.\\nAOC or\\nCCC.\\n4th stage, later.\\nSubnormal.\\nSubnormal.\\nSubnormal.\\nSubnormal, no\\nqualitative\\nchanges\\nProgressive\\nIncurable Form.\\n1st and 2d stages.\\nAs first and second stages above.\\n3d stage, after 6 weeks.\\nLost.\\nLost.\\nLost.\\nDiminished\\nor lost.\\nAOOCCC.\\n1 By direct stimulation is meant the application of the electrode to the muscle itself-\\nBy indirect stimulation is meant the application of the electrode to the motor nerve-\\ntrunk. The latter term is employed because irritation of the nerve can only be detected\\nby the activity of the muscle, and the stimulation of the latter is, of course, in this\\nmode of application, indirect.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1099.jp2"}, "1100": {"fulltext": "998\\nSPECIAL DIAGNOSIS.\\nPartial, Reaction of Degeneration.\\nIndirect stimulation (nerve). Direct stimulation (muscle).\\n1st stage, 1-S days.\\n2d stage, 2-5 weeks.\\n3d stage, 6-12 weeks.\\n3d stage, 6 weeks.\\nNormal or\\ndiminished.\\nNormal or\\ndiminished.\\nG.\\nNormal or\\ndiminished.\\nNormal or\\ndiminished.\\nNormal or\\ndiminished.\\nNormal or\\ndiminished.\\nAll normal or progressive form.\\nDiminished Diminished Diminished\\nor lost. or lost. or lost.\\nG.\\nNormal or\\ndiminished.\\nIncreased, con-\\ntraction slow.\\nAOCXCCC.\\nDiminished\\nor lost.\\nContraction\\nstill slow.\\nAOC CCC.\\nThe following points in these tables need explanation. The faradic\\nreaction is similar to that which occurs in the normal muscle, but\\nrequires a much stronger current to produce it. The galvanic reaction\\nof the nerve is similar to that obtained under normal conditions, except-\\ning that a stronger current is required. The contraction is lightning-\\nlike and disappears instantly. The direct galvanic stimulation of the\\nmuscle, however, produces a worm-like contraction very different from\\nthat observed in the normal muscle, and is ascribed to the direct stimu-\\nlation of the muscle itself and not to the stimulation of thet erminations\\nof the motor nerves. This often occurs with a much weaker current\\nthan is normally required to produce contraction in the muscle. It\\nAvill also be observed that the cathodal closing contraction is no longer\\nthe first to appear, but it is replaced by the anodal opening contraction,\\nand this is followed by the anodal closing contraction, cathodal closing\\ncontraction occurring only with relatively strong currents. If regen-\\neration occurs muscular contractions occur in response to weaker faradic\\ncurrents, and by direct galvanic stimulation they become more light-\\nning-like in character. Gradually the cathodal closing contraction\\nappears in response to weaker currents, and finally occurs before the\\nanodal opening contraction. If recovery does not take place, direct\\ngalvanic stimulation requires stronger and stronger currents, and there\\nis no increase in the rapidity of the contraction. The cathodal closing\\ncontraction disappears, and finally only the anodal contraction remains,\\nwhich is exceedingly slow and worm-like. When the muscle-tissue has\\nbeen completely replaced by connective tissue all reactions naturally\\ncease. The partial reaction of degeneration is very similar to the mild,\\ncomplete form. Recovery, however, occurs, as a rule, very rapidly.\\nThe reaction of degeneration may be used for determining the prog-\\nnosis of the case. When after the sixth week the muscle does not\\nrespond as readily as before to direct galvanic stimulation, and the\\ncathodal closing contraction becomes equal to or greater than the anodal\\nopening contraction, the prognosis is exceedingly favorable. Particu-\\nlarly the increased rapidity of the contraction is of great significance.\\nIf, on the other hand, after from six to twelve weeks no change has\\noccurred and the anodal still precedes cathodal contraction, and both\\narc worm-like in character, the prognosis is doubtful. Months, how-\\never, may elapse before the muscle gradually begins to regain its normal", "height": "4416", "width": "2564", "jp2-path": "practicaltreatis00muss_0_1100.jp2"}, "1101": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM. 999\\ncharacter. The voluntary contractions of the muscle, as a rule, persist\\nafter the reaction of degeneration has become manifest, unless, of course,\\nthere has been total destruction of the peripheral motor neurons. Often\\nin cases of peripheral neuritis it Avill be observed that the reaction of\\ndegeneration is present in muscles that are apparently healthy, but\\nwhich, when the process is progressive, subsequently atrophy. When\\nregeneration occurs voluntary motion will have been almost completely\\nrestored long before the muscle has become entirely normal, and it\\nmay often reappear before any improvement can be detected in the\\nelectrical reactions. In testing these reactions the following points are\\nto be noted First, the reaction of the nerve to faradic and galvanic\\nelectricity second, the reaction of the muscle itself. It is particularly\\nimportant to be certain that only the muscle under investigation is\\naffected by the electrical current. Sometimes it will be impossible to\\naccomplish this, but ordinarily it can be done sufficiently well to enable\\nus to secure positive results. It must be remembered, however, that\\nthe reactions of degeneration often occur in the muscles of limbs that\\nhave been injured, or are found in limbs in which some of the groups\\nof muscles have already undergone atrophy, and thus altered the ana-\\ntomical relations. Under these circumstances mistakes are very likely\\nto arise. Sometimes valuable information can be obtained by stimu-\\nlating a nerve-trunk and observing whether all the muscles innervated\\nshow normal or impaired contractility. Quantitative and qualitative\\nreactions of degeneration occur primarily as a result of disease of the\\nperipheral motor neuron. They are, therefore, found in all diseases of\\nthe spinal cord that affect the anterior cornua or the motor roots, and\\nin all diseases of the medulla that affect the motor nuclei or their roots\\ntherefore, in acute and chronic antero-poliomyelitis, progressive spinal\\nmuscular atrophy, in bulbar palsy, in transverse myelitis, syringo-\\nmyelia, tumor of the cord, and as a result of chronic forms of menin-\\ngitis, or disease of the vertebral columns pressing upon the roots.\\nThey are also found in all forms of peripheral neuritis, either the\\ntoxic, the infectious, or the traumatic, and in all cases of solution of\\ncontinuity of the nerves. They occasionally occur in the so-called\\nidiopathic muscular dystrophies, but in these they are exceptional.\\nThey are also fouud in a few cases after cerebral lesions.\\nAtypical Types of the Reaction of Degeneration. Only two of these\\nare important. First, the myotonic reaction, consists of the persistence\\nof the muscular contraction after the electric stimulus has been removed.\\nThis occurs either with the faradic or the galvanic current, but the order\\nof contraction to the various forms of stimulation of the latter is not\\naltered. This reaction is pathognomonic of Thomsen s disease myo-\\ntonia congenita. It is more likely to occur as a result of stimulation\\nof the muscle itself than of stimulation of the nerve. Second, the\\nmyesthenic reaction is characterized by the rapid exhaustion o\u00c2\u00a3 the\\nmuscle or the nerve, so that relaxation may take place while the faradic\\ncurrent is still being employed, and if the muscle is stimulated succes-\\nsively several times, it loses its power to contract or requires a stronger\\ncurrent. It occurs in periodic family paralysis. Remak and Marino\\nhave described a peculiar form of reaction which they name the neuro-", "height": "4416", "width": "2628", "jp2-path": "practicaltreatis00muss_0_1101.jp2"}, "1102": {"fulltext": "1000 SPECIAL DIAGNOSIS.\\ntonic reaction. It consists of the persistence of the contraction only\\nafter stimulation of the nerve.\\nDisturbances of Speech. These may be divided into two groups\\naphasia, the disturbance of the central nervous mechanism controlling\\nspeech, writing, and mimicry and anarthria, the disturbance of the\\nperipheral motor mechanism of speech.\\nBy aphasia is meant the loss or impairment of the ability to under-\\nstand spoken, written, or mimic language, and to express thoughts\\nby the same means. It is ordinarily divided into two forms motor\\naphasia, or the inability to innervate the motor apparatus for speech,\\nwhile the sensory or perceptive functions are intact and sensory\\naphasia, or the inability to recall or understand words, although the\\nability to produce sound is preserved. A variety of other forms, how-\\never, have in the course of time come to be recognized. Oppenheim\\nrecognizes the following five varieties (1) Motor aphasia. This consists\\nof the loss of power to speak, with persistence of the understanding of\\nspoken, written, and mimic speech. This is the first form of aphasia in\\nwhich it was possible to locate with accuracy the portion of the brain\\ninvolved. The lesion is cortical or subcortical, and involves the foot of\\nthe third frontal convolution on the left side. The symptoms are\\nvariable according to the extent and destructiveness of the lesion. (2)\\nSensory aphasia. The perception of sound as such is preserved, but there\\nis inability to recognize the significance of words, although spontaneous\\nand occasionally voluntary speech is preserved. The lesion is usually\\nfound in the auditory centre that is, the first temporal convolution\\non the left side. The symptoms may be variable, alexia being often\\npresent. (3) Pure alexia, or word blindness. In this, although sight\\nis preserved and objects may be recognized, the ability to understand\\nwritten or printed language is lost. Spoken speech is still understood,\\nvoluntary speech and writing possible, and occasionally written words\\nmay be read if the patient is permitted to trace the letters with a pencil\\nor the finger, recognizing each one as it is formed. The lesion is\\nusually found in the left occipital lobe on the external surface, but\\nsometimes involves the gyrus angularis. (4) Pure agraphia, or the\\nloss of power to write, all the other qualities remaining normal. Lesions\\nhave been found in the left upper parietal lobe. (5) Optic aphasia.\\nIn this objects may be seen and recognized, but it is impossible for the\\npatient to find the proper name for them. If the objects are recog-\\nnized by some other sense, as, for example, hearing or touch, the name\\nmay be recollected instantly. The lesion is usually found at the junc-\\ntion of the first temporo-sphenoidal and the occipital lobes. This form\\nis frequently a symptom in otitic abscess. Loss of the stereognostic\\nsense may also be regarded in some respects as an aphatic manifestation.\\nIn order to explain aphasia, it has been customary, since the time\\nof Wernicke, to employ the diagram given in Fig. 236. In this the\\ntriangle, A C M, represents the intra-cerebral paths and centres for\\nthe mechanism of speech, and the lines Aa and Mm the peripheral\\napparatus. In this diagram A represents the centre for auditory per-\\nception M the centre for the emission of motor impulses and Cthe\\nconcept centre, in which the intellect analyzes the impressions received", "height": "4412", "width": "2552", "jp2-path": "practicaltreatis00muss_0_1102.jp2"}, "1103": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM.\\n1001\\nand from which the directing influence for the choice of language is\\ntransmitted to the motor centre. Act represents the auditory nerve\\nMm, the motor nerves to the pharynx, tongue, and lips. Auditory\\nimpressions may, therefore, be transmitted along Aa to A, thence\\ndirectly to M, and thence to the larynx. This is the mechanism sup-\\nposed to be involved in ordinary mechanical speech that is to say,\\nthe mechanical repetition of spoken words. The auditory impressions\\nmay, however, pass from A to C, there be analyzed or understood, and\\nthen transmitted to M, either in the same or altered form. This con-\\nstitutes the intelligent repetition of spoken speech. If the alteration\\nof form is considerable, or if, without immediate auditory impressions,\\nimpulses are transmitted from C to M, voluntary or intelligent speech\\nis said to occur. Although this diagram probably does not accurately\\nrepresent the conditions existing in the brain, it has been found that\\nthe varieties of aphasia that can be theoretically deduced from it cor-\\nrespond more or less closely to those that may be recognized in actual\\npractice. These varieties are as follows Destruction of the motor\\ncentre, M, gives rise to the so-called cortical motor aphasia with the\\nfollowing symptoms Loss of (1) voluntary speech (2) repetition\\n(3) reading aloud (4) voluntary writing (5) writing from dictation.\\nThere are preserved (1) the understanding of speech (2) the under-\\nstanding of writing (3) the ability to copy writing. Destruction of\\nthe auditory centre, A, gives rise to cortical sensory aphasia. There\\nare lost (1) the understanding of speech (2) the understanding of\\nwriting (3) the ability to repeat speech (4) the ability to write from\\ndictation (5) the ability to read aloud. There are preserved (1) vol-\\nuntary speech (2) voluntary writing (3) the ability to copy writing.\\nA lesion in C would give rise to cortical apperceptive aphasia. The\\nsymptoms of this form would differ very slightly from those due to\\ninterruption of the tracts supplying it. The centre is probably com-\\nplex and its parts are widely distributed. The speech disturbances of\\ngeneral paresis are possibly due to its partial destruction. Lesions of\\nthe various tracts of fibres connecting the different centres with each\\nother or with the periphery also produce symptoms. Lesions between\\nA and M produce the symptom known as paraphasia. (1) Voluntary", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1103.jp2"}, "1104": {"fulltext": "1002 SPECIAL DIAGNOSIS.\\nspeech (2) repetition of speech (3) the understanding of spoken and\\nwritten language and (4) the ability to copy writing are all preserved.\\nThe only symptom, therefore, of this condition is the misuse or false\\npronunciation of words. Thus, objects may be misnamed, one word\\nused in place of another, different syllables of the words misplaced\\n(literal paraphasia), or the words jumbled in a sentence (verbal par-\\naphasia). There is usually also paragraphia that is, a similar dis-\\nturbance of written language paralexia, manifest when the patient\\nattempts to read aloud, and sometimes the symptom known as agram-\\nmatism that is, the misuse of cases, moods, or tenses. Paraphasia,\\nhowever, occurs also in certain general diseases of the brain, and is\\npractically always present if the intrinsic tracts concerned in speech\\nare disturbed. Interruption of the tract uniting C and M causes trans-\\ncortical motor aphasia. There are lost (1) voluntary speech and (2)\\nvoluntary writing. There are preserved (1) the understanding of speech\\n(2) the understanding of writing (3) the ability to copy (4) the ability\\nto repeat words (5) the ability to write from dictation (6) the ability\\nto read aloud. The most characteristic symptom is the inability of the\\npatient to remember words, although he is able to repeat them fluently.\\nThe interruption between A and C gives rise to transcortical sensory\\naphasia. There are lost (1) the understanding of speech (2) the under-\\nstanding of writing. There are preserved (1) voluntary speech (2)\\nvoluntary writing (3) the repetition of speech (4) reading aloud\\n(5) writing from dictation. Both voluntary speech and writing are\\nusually affected by the paraphasia common to the interruption of the\\nintrinsic tracts. It differs from the preceding form particularly in the\\nfact that words spoken upon repetition or written from dictation are\\nnot in the least understood by the patient. In this form communica-\\ntion with the patient, even by gestures, is often impossible. Finally,\\nlesions may occur in the tracts uniting the centres concerned in speech\\nwith the periphery. Lesions in the tract Mm give rise to subcortical\\nmotor aphasia. There are lost (1) voluntary speech-; (2) repetition of\\nspeech (3) the ability to read aloud. There are preserved (1) the under-\\nstanding of speech (2) the understanding of writing (3) the ability\\nto copy (4) voluntary writing and (6) writing from dictation. This\\nis, of course, the purest form of motor aphasia. Interruption of the\\ntract Aa gives rise to subcortical sensory aphasia. There are lost (1)\\nunderstanding of speech (2) the repetition of speech (3) the ability\\nto write from dictation. There are preserved (1) voluntary speech\\n(2) voluntary writing (3) understanding of writing (4) reading aloud\\nand (5) copying.\\nThis theoretical classification with groupings of symptoms is sus-\\nceptible to modification in actual pathology by a variety of conditions.\\nThe most important modification is that produced by the existence of\\npossible lesions of other centres concerned in speech. Thus, the share\\ntaken by the visual receptive and apperceptive centres is of great\\nimportance in all persons who have been taught to read. They are\\nnecessarily concerned also in the production of writing. It is not,\\nhowever, possible to represent them by a diagram as we have repre-\\nsented auditory and motor speech, for it appears that impulses from", "height": "4416", "width": "2560", "jp2-path": "practicaltreatis00muss_0_1104.jp2"}, "1105": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM.\\n1003\\nthe visual centres must pass through the receptive centre for speech,\\nor A, before being transferred to the arm centre or the speech centres.\\nThe same is true for tactile impressions. These are of importance\\nchiefly in blind persons who have been taught to read with their\\nfingers, in whom, indeed, they may equal in importance the role of\\nthe visual centres in normal persons. Various complicated diagrams\\nhave been devised for the purpose of exhibiting the influence of all\\nthese centres upon speech, and Mills has introduced an additional\\nnaming centre, situated in the third temporal convolution, in which\\nFig. 237.\\nL.P.O.C.\\nR.P.O.C.\\nR.P.A..C.\\nL.P.A.C.\\nA, auditory centre (centre for word-hearing) V, visual centre (centre for word-seeing) N,\\nnaming centre (centre where percepts are given in name) B, motor speech centre in Broca s\\nconvolution (regarded by Broadbent as a propositionizing centre) an utterance centre\u00e2\u0080\u0094 motor\\ncentre\u00e2\u0080\u0094 is also required to complete the motor side of the speech process, if the view is accepted\\nG, graphic centre; R. Oc, primary cortical visual centre in the right occipital lobe; L. Oc,\\nprimary cortical visual centre in the left occipital lobe; R. P. O. O, optic centres at the base\\nof the brain, right side; L. P. O. C, optic centres at the base of the brain, left side; R T.,\\nprimary cortical auditory centres in the right temporal lobe L. T primary cortical auditory\\ncentres in the left temporal lobe R. P. A. C, auditory centres at the base of the brain, right side\\nL P. A. C, auditory centres at the base of the brain, left side.\\nperceptions are given the names that properly belong to them. His\\ndiagram is one of the most satisfactory of all the more complicated\\ndiagrams representing the speech function (see Fig. 237), but, unfortu-\\nnately, it is not yet possible to deduce from it theoretically the symptoms\\nthat actually occur. Another source of error is the fact that lesions\\nmay be only partially destructive, or may be so large as to involve two\\nor more tracts or centres at the same time. Under these circumstances\\nthe symptoms become very complex, and it is often impossible to deter-\\nmine the extent of the physiological disturbance that has been pro-\\nduced. Usually, however, the localization of these lesions is not dim-", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1105.jp2"}, "1106": {"fulltext": "1004 SPECIAL DIAGNOSIS.\\ncult, on account of the predominance of certain characteristic localizing\\nsymptoms.\\nIt will be obvious from this description that it is necessary in each\\ncase of aphasia to test a variety of functions. These can best be\\nexamined as follows 1. Voluntary speech. If the patient is able\\nto answer questions intelligently or makes spontaneous intelligent\\nremarks to the physician, voluntary speech is preserved. Voluntary\\nspeech may, however, exist and the remarks of the patient be never-\\ntheless unintelligible when there is an extreme degree of paraphasia.\\n2. The ability to repeat words. This may be tested by merely saying\\na word or several words and getting the patient to repeat them.\\nMechanical speech, whose centre is supposed to be located in the\\nspeech area of the right hemisphere, may also be tested by request-\\ning the patient to repeat some well-known series such, for example, as\\nthe names of the days of the week, the alphabet, the numbers, or the\\nmonths. Sometimes familiar songs may be remembered and spoken\\nwhen it is absolutely impossible for the patient to make an intelligent\\nanswer. Under striking emotional conditions epithets or oaths may\\nalso be employed. The ability to repeat words may sometimes be\\npresent when it is impossible to determine it on account of the exist-\\nence of transcortical sensory aphasia. Under these circumstances it is\\nimpossible to make the patient understand what he is expected to do.\\n3. Reading aloud. It must not be forgotten that in some cases this\\nsymptom is masked by defects of vision. If possible, the eyes should\\nalways be examined and the patient be given his glasses if he has been\\nin the habit of using them. It is advantageous to use large type, such\\nas the headlines of newspapers. 4. Voluntary writing. This symptom\\nmay be masked by the existence of right hemiplegia and inability to\\nwrite Avith the left hand. 5. Writing from dictation. As in the repe-\\ntition of speech, this symptom may be masked by the inability of the\\npatient to understand what he is expected to do. 6. Copying. Errors\\nof vision should again be excluded as well as paralysis and other motor\\ndisturbances of the arm. 7. The understanding of speech. This is\\nperhaps one of the most difficult of all aphatic symptoms to determine.\\nThe patient is usually requested to perform some simple action, such\\nas putting out the tongue, touching the ear with the hand, etc. This\\nmay be perfectly performed, but more complex commands or long\\nstatements may not be understood. It is supposed that this is per-\\nhaps due to incompleteness of the lesion, or to a general disturbance of\\nintellect, such as must occur in any case of aphasia, in a more or less\\npronounced degree. It is, therefore, important to attempt if possible\\nto converse with the patient, getting him to reply by gestures, or writ-\\ning, according to his ability, and gradually to employ more and more\\ncomplex statements. In cases of marked paraphasia the improper use\\nof words in the replies may lead to the belief that the patient does not\\nunderstand what is said to him, when, as a matter of fact, word per-\\nception is perfect. 8. Understanding of writing. This is subject to\\nthe same errors as the understanding of speech, and, in addition, the\\npossibility of visual defect. 9. The existence of paraphasia. This, of\\ncourse, can only be detected when either voluntary speech or the ability", "height": "4416", "width": "2556", "jp2-path": "practicaltreatis00muss_0_1106.jp2"}, "1107": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM.\\n1005\\nto repeat words is present. Under these circumstances it may be recog-\\nnized when it is only slight in degree by getting the patient to repeat\\nwords of many syllables, such as incomprehensibility/ or sentences\\nof several words. Disturbances of writing, apart from disturbances of\\nspeech, may also occur. These may be better understood by a considera-\\ntion of Fig. 238, in which the writing centres are added to the speech\\ncentres. It will be seen from this that there may be destruction of W,\\nor agraphia. There are lost (1) voluntary writing (2) copying and\\nthere is preserved the ability to read. Destruction of V, or cortical\\nalexia. This is characterized by the loss of (1) the recognition of writ-\\nten words (2) voluntary writing. Speech may be intact. Destruction\\nof W V, or conduction agraphia. There is lost (1) voluntary writing\\n(2) voluntary copying. There is preserved ability to read that is to\\nsay, it corresponds exactly to the preceding form. Under such circum-\\nstances paragraphia may exist in this type. Transcortical agraphia.\\nThere is lost voluntary writing. There is preserved (1) mechanical\\ncopying; and (2) reading. Transcortical alexia. There is lost the\\nability to read. There is -preserved (1) voluntary writing (2) copy-\\ning. Finally, there may be interruption of the tracts to the periphery,\\ngiving rise to subcortical agraphia. There are lost (1) voluntary\\nwriting (2) copying. There is preserved reading. Paragraphia\\nnever occurs in this form. Subcortical alexia. There are lost reading\\nand copying. There is preserved voluntary writing. All of these\\nforms may coexist with the various types of aphasia. In testing the\\npatient for alexia the following symptoms should be examined (1)\\nVoluntary writing (see above) (2) writing from dictation (see above)\\n(3) copying and (4) the recognition of letters either spoken or written.\\nIn testing patients for voluntary writing with the left hand, it must be\\nremembered that many aphasics give mirror writing. The following\\nterms are also used in connection with aphasia aphrasia, the inability", "height": "4416", "width": "2652", "jp2-path": "practicaltreatis00muss_0_1107.jp2"}, "1108": {"fulltext": "1006 SPECIAL DIAGNOSIS.\\nto form sentences with words dysphasia, the imperfect formation of\\nsentences apraxia, the total loss of speech.\\nBy anarthria is meant a disturbance in the peripheral motor\\nmechanism of speech, as a result of disease of the nuclei in the medulla\\nor of the peripheral nerves arising from them. This may vary in\\ndegree from complete aphonia, or loss of power to make sounds and\\nwords, which occurs in bulbar paralysis, or the aphonia of laryngeal\\nparalysis, in which whispering speech is still preserved, to merely the\\nimperfect pronunciation of certain consonants, as a result of local paral-\\nysis or paresis of the lips or tongue. Anarthria may be permanent or\\ntemporary, or, in cases of slight paresis, recurrent, giving rise to inter-\\nmittent claudication of speech. It is best tested by directing the patient\\nto repeat letters of the alphabet, to count, or to repeat words with long\\nsyllables and difficult consonants, as artillery/ extraordinarily,\\netc. Allied to anarthria, but perhaps the result of certain functional\\ndisturbance, are stuttering and stammering. In the former, if the patient\\nattempts to speak, there is inhibition of motion for a longer or shorter\\ninterval, and then the word may be pronounced with explosive violence,\\nand the following words of the sentence spoken normally. In stam-\\nmering there is frequently repetition of the first two or three consonants\\nof the word, particularly if these happen to be labials. Stuttering\\nand stammering are sometimes associated with defective intelligence.\\nFinally, there are a series of disturbances of speech in which intellec-\\ntual derangement is apparently the chief factor. These may perhaps\\nbe forms of aphasia due to partial destruction of the concept centre or\\ncentres. Among them may be mentioned the inability or unwillingness\\nto speak, that occurs in the mutism of the insane a tendency to exces-\\nsive speech, logorrhoea the omission of syllables, particularly character-\\nistic of general paresis difficult words, such as those mentioned above,\\nbeing pronounced imperfectly, as arlry for artillery, or even less\\naccurately. Scanning speech, in which the words are separated by\\nconsiderable intervals, and are spoken with a peculiar drawl and a\\ndescending cadence. It is particularly characteristic of multiple scle-\\nrosis, but may occasionally occur in general paresis. Other forms are\\nexplosive, or staccato speech, and a peculiar, slow, drawling utterance,\\noccasionally termed bradylalia, that occurs in certain states of mental\\ndepression. Echolalia occurs almost exclusively in imbeciles, and is\\ncharacterized by the repetition of all sounds heard.\\nDisorders of nutrition, or trophic changes, are lesions pro-\\nduced in tissues as a result of defective or altered innervation. They\\nmay be classified clinically into superficial trophic changes affecting\\nthe skin and its appendages, etc., and deep trophic changes affecting\\nthe muscles and joints. Among the superficial trophic changes of the\\nmild form may be included vasomotor disturbances. In a strict sense\\nflushing and the dead finger of Raynaud s disease are trophic altera-\\ntions, but it is not certain what parts of the central nervous system are\\ninvolved in order to bring them about. More severe are the various\\neruptive disorders that occur, particularly a herpetic eruption along\\nthe course of the nerve {herpes zoster). This occurs chiefly along the\\nintercostal nerves, but may also occur along the other nerves of the", "height": "4416", "width": "2568", "jp2-path": "practicaltreatis00muss_0_1108.jp2"}, "1109": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM. 1007\\nbody, such as those of the face. It is characterized by the appearance\\nof numerous vesicles surrounded by a congested zone and limited\\nstrictly to the distribution of the nerve or nerves involved. It occurs\\nin neuralgias, in chronic neuritis, and in some cases as a result of an\\ninjury to the ganglion of the posterior spinal root. Among the milder\\ntrophic disturbances are the graying or falling out of the hair in the\\ndistribution of some particular nerve and the alterations in the nails.\\nThe latter are characterized by an increased brittleness, the formation\\nof longitudinal ridges, and an excessive slowness of growth, which may\\nbe best detected by staining the nail at its root with nitric acid and\\ncomparing the amount of growth with that observed in a normal nail.\\nThese trophic disturbances in the nail occur in general cachectic states,\\nbut they are usually slight. They are more pronounced in lesions of\\nthe peripheral nerves supplying the fingers and toes, and also occur in\\ndestructive lesions of the spinal cord in the lumbar or cervical enlarge-\\nment, such as syringomyelia and pachymeningitis cervicalis hyper-\\ntrophica. More severe lesions are those due to the combination of\\ndefective resistance and secondary infection. These are chiefly the\\nforms of panaritis observed in syringomyelia and characterized by the\\nformation of an abscess at the root of the nail, which breaks down,\\nleaving a chronic ulcer that heals very slowly, usually with the loss of\\nthe nail. In leprosy, in either the nodular or neural forms, and in\\nMorvan s disease, somewhat similar changes also occur. Atrophy of\\nthe subcutaneous tissue with loss of elasticity of the skin is also a\\ncharacteristic form of trophic disturbance. The part is shrunken, the\\nfinger-tips become pointed, the skin is dry and glossy or glazed, and\\nthe cutaneous bloodvessels, especially the veins, are distended. This\\noccurs in destructive lesions of the peripheral nerves, and particularly\\nin myelitis or destructive lesions of the spinal cord. An analogous change\\nsometimes occurs in the teeth. These either become carious very rapidly\\nand are destroyed, or become loosened in their sockets and fall out pain-\\nlessly. The latter symptom is characteristic of the early stage of tabes\\ndorsalis. There is also a tendency to the formation of chronic ulcers in\\nthe affected parts as a result of trifling injuries. Finally, severe lesions\\nof the central nervous system may give rise to gangrene. This is\\ncharacterized by the rapid destruction of the skin and underlying\\nparts in regions subjected to the most trifling injuries, such as pressure.\\nThe part first becomes red, then a slight abrasion is formed upon the\\nsurface, followed by ulceration and the conversion of the surrounding\\ntissue into a gangrenous mass, black and offensive. The usual situa-\\ntion is upon the back, just over the sacrum or to either side of it. It\\nis called bed-sore, or decubitus. Bed-sores may also appear upon the\\nhips, the knees, the heels, the shoulders, or, hi fact, almost any part of\\nthe body. They are ordinarily the result of myelitis, in which they\\nprogress rapidly, and are more extensive than in any other condition.\\nThey may also occur, however, in cases of profound cachexia or ex-\\nhaustion, and as a result of prolonged unconsciousness and of lack of\\nattention in mental disease. Gangrene of the skin may also occur in\\nhysteria. The mechanism of this is not clearly understood, but it is\\nsupposed to be due to vasomotor disturbances. Other severe cutaneous", "height": "4416", "width": "2652", "jp2-path": "practicaltreatis00muss_0_1109.jp2"}, "1110": {"fulltext": "1008 SPECIAL DIAGNOSIS.\\nlesions are the deep ulcerations that occur in various parts of the body,\\nparticularly the feet (mat perforante). These have been noted in tabes\\ndorsalis, in syringomyelia, and also in hysteria. Finally, destructive\\nlesions of the extremities with loss of the fingers may occur in Raynaud s\\ndisease, in syringomyelia, and in leprosy. Trophic lesions of the deeper\\nparts involve the joints and the muscles. Trophic lesions of the joints, or\\narthropathies, are characterized by the enlargement of the joint involved,\\nusually the knee, proliferation of the bone, relaxation of the ligament,\\nso that the mobility of the joint is much greater than normal, and, for\\nexample, in the knee, there may be considerable lateral motion as well\\nas flexion and extension. The joint surfaces become rough and give\\nrise to a grating upon palpation. Curiously enough, aside from the\\nundue mobility, the function of the joint remains relatively good, and\\nthe patient is often able to walk upon a knee that bends laterally almost\\nto a right angle. There is usually little pain. These arthropathies\\nmay also assume the atrophic instead of the hypertrophic form the\\narthrite seche of the French. In this case the ends of the long bones\\natrophy and luxation commonly occurs. The frequency with which\\nthe different joints are affected is, according to Growers, as follows\\nKnee, 45 hip, 20 shoulder, 1 1 tarsus, 8 elbow, 5 ankle, 4. In\\naddition, the fingers and the ends of the ribs may show these altera-\\ntions.\\nAlteration of the contour of the body occurs, as a whole, in various\\nnervous diseases. In acromegaly the bones of the feet, hands, and face\\nare greatly enlarged there is usually slight kyphosis, and the soft parts\\nbecome thickened, the whole appearance being extremely characteristic.\\nIn myxoedema the subcutaneous tissues are thickened, giving the subject\\nthe appearance of enormous obesity. In the various forms of amyotro-\\nphy, particularly the spinal type, the patient becomes extremely ema-\\nciated alteration of the shape of the head occurs in hydrocephalus, the\\nenlargement being globular, and the face, by contrast, very small in\\nmicrocephaly the cranium is greatly reduced in size, and the face appears\\nmore prominent and rather of an animal type. Occasionally, in the\\nvarious chronic lesions associated with idiocy and epilepsy, there may\\nbe marked asymmetry of the skull. Sometimes an intracranial tumor\\nwill also produce a local distortion. Alterations in the expression or\\nappearance of the face are produced by exophthalmic goitre, which is\\nreadily recognized, on account of the marked prominence of the eyes\\nand the swelling of the neck. In facial tic the lightning-like contrac-\\ntions of the muscles on one side of the face, occurring at more or less\\nfrequent intervals, are extremely characteristic. In facial paralysis in\\nthe early stage the absence of folds on one side of the face, the droop-\\ning corner of the mouth, and partially opened eyelid are typical of\\nthe condition. In the later stage contractures may occur, causing the\\nmouth to be drawn up and the eye to be kept partially closed with\\naccentuation of the normal folds of the skin. Mimic paralysis that\\nis, failure of one side of the face or of both sides to assume an expres-\\nsion in accordance with the language or the feelings of the patient\\noccurs in lesions of the optic thalamus, and perhaps as a result of par-\\ntial injury to the facial nerve. Stolidity of expression that is, immo-", "height": "4404", "width": "2596", "jp2-path": "practicaltreatis00muss_0_1110.jp2"}, "1111": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM. 1009\\nbility of the facial muscles occurs in paralysis agitans. Finally, in\\nvarious mental diseases the expression of the features may more or less\\nclosely indicate the type. Thus the mournful countenance of the mel-\\nancholic, the excited, eager aspect of the maniac, or the furtive, anxious\\nexpression of the paranoiac, have all been described. It must not be\\nforgotten, however, that temporary emotional states may give rise to\\nthe same manifestations. The Mongolian type of the features that\\nis, slightly oblique eyes and high cheek bones seems to be character-\\nistic of a certain form of idiocy. The reason for its occurrence is\\nnot known. Alterations in the posture of the body occur in a great\\nvariety of diseases. The spinal column may be permanently bent and\\nankylosed in rhyzomyelic spondylosis. This may also be associated\\nwith ankylosis of the large joints. The position and gait in every\\ncase are quite characteristic. Angular deformity of the spine occurs\\nin Pott s disease. Lateral curvature frequently occurs in the various\\nforms of muscular dystrophy and in Friedreich s ataxia. The pres-\\nence of a large, fluctuating tumor at the base of the spinal column over\\nthe lumbar or sacral region is indicative of spina bifida, the lesion\\nbeing, of course, congenital, and in this case there is often an extensive\\ngrowth of hair upon the skin covering the tumor.\\nChanges in the Extremities. Various alterations in the contour of the\\narms are produced by muscular atrophy. The most characteristic is\\nthe flattening of the shoulder-joint that occurs as a result of the wast-\\ning of the deltoid and the peculiar appearance of the hand produced\\nby the wasting of the thenar and hypothenar muscles. In the latter\\nthe thumb assumes a position parallel to the fingers, which is only\\ncharacteristic, however, when it involves the metacarpal bone as well\\nas the phalanges (ape-hand). The position of the hand is affected in\\nparalysis of the extensors, giving rise to wrist-drop in injury to the\\nradial and to the ulnar nerves. If the latter is involved the interossei\\nmuscles are paralyzed, so that the proximal phalanges can no longer\\nbe flexed, and the extensors gradually pull them backward until they\\nare perpendicular to the dorsum of the hand (main en griffe). Enlarge-\\nment of the hands, as a whole, occurs in acromegaly and in pulmonary\\nosteoarthropathy. Mutilation of the fingers is frequently characteristic\\nof syringomyelia, Morvan s disease, Raynaud s disease, and leprosy.\\n(See Trophic Changes.) The alterations produced by muscular disease\\nin the lower extremities are analogous to those that occur in the upper\\nextremities. In addition, however, there is a peculiar alteration pro-\\nduced by pseudo-hypertrophic muscular atrophy, in which the limbs\\nappear to be of Herculean development. Enlargement of the feet, as\\na whole, occurs in the same conditions as does enlargement of the\\nhands. Deformities of the feet are much more common as a result of\\ncontractures following anterior poliomyelitis, which gives rise to the\\nvarious types of club-foot. Certain nervous diseases frequently cause\\ndeformity of the knee and hip-joints, particularly syringomyelia,\\nwhich gives rise to a form of dry arthritis of the hip and tabes dor-\\nsalis, producing the tabetic arthropathies. (See Trophic Lesions.)\\nMental Disturbances. These are of most varied kinds. They\\nmay be divided into disturbance of consciousness and disturbance of\\n64", "height": "4416", "width": "2660", "jp2-path": "practicaltreatis00muss_0_1111.jp2"}, "1112": {"fulltext": "1010 SPECIAL DIAGNOSIS.\\nintellection. Disturbances of consciousness may be of various degrees.\\nThe mildest form is called apathy. The patient lies quietly, makes no\\nvoluntary attempt to commence a conversation, shows no interest in his\\nsurroundings, and only answers if spoken to. A more severe state may\\nbe spoken of as lethargy or stupor. The term coma implies that it is\\nimpossible to arouse the patient by any means, and at the same time the\\ncondition resembles more or less closely actual sleep. The reflexes are\\nusually preserved, and there is a certain degree of perception to painful\\nimpulses, manifested by the withdrawal of the part irritated. Uncon-\\nsciousness is, of course, a condition that cannot be sharply differentiated\\nfrom this. The term is ordinarily applied to conditions that do not\\nresemble natural sleep. The patient may lie quietly, but the breathing\\nis stertorous the eyes may be opeu all the muscles may be relaxed\\nor various types of spasm may be present. These conditions occur in\\nthe intoxications, infections, poisonings, and as a result of severe injury\\nto the head. A peculiar type of coma, known as coma vigil, is charac-\\nterized by complete relaxation of the patient, whose eyes, nevertheless,\\nremain open and appear to observe that which transpires around the\\nbed. The mildest form of disturbance of intellect consists in impair-\\nment of memory, or amnesia. This may be restricted to the memory\\nof certain things only, as the names of certain classes of objects or cer-\\ntain groups of words. It may also be restricted to loss of memory for\\ncertain definite periods of time, which may occur as a result of severe\\ninjury or disease during or about this period. If the memory is lost\\nfor the period preceding the traumatism, the condition is spoken of\\nas antero-active amnesia if for the period following, retro-active am-\\nnesia. Memory is commonly impaired in old age, and often as a result\\nof chronic cerebral disease, particularly in paralytic dementia. General\\nimpairment of the intellect is spoken of as imbecility or idiocy. In its\\nmilder forms imbecility consists in diminution of the reasoning powers,\\nso that the patient is unable to form accurate judgments. In its severer\\ngrades, and particularly in the more pronounced forms of idiocy, intel-\\nlectual activity may appear to be absolutely abolished, life being merely\\na mechanical process not under control of the reason. Both conditions\\nare usually associated with alterations in the substance of the brain,\\neither in the form of hydrocephalus or of the various scleroses associ-\\nated with epilepsy. Exaltation of the intellectual functions associated\\nwith excitement, and more or less violence is usually spoken of as delir-\\nium. This may be severe or mild. It is characterized by a tendency to\\ntalk or to be noisy, and by great restlessness. Delirium occurs in many\\nof the acute infectious diseases, particularly in meningitis. Among the\\ncommoner symptoms of intellectual disorder usually grouped under\\nthe term insanity are exaltation, or mania, depression, or melancholia,\\nand delusional states, or paranoia. By mania, is meant excessive intel-\\nlectual activity, characterized by a tendency to be noisy, to be active,\\nfondness for singing, shouting, swearing, or punning. There is usually,\\nalso, in the acute forms a rapid loss of weight and decrease in the physical\\npowers, while the patient believes himself to be in the most admirable\\nand exceptional condition. Mania occurs as a nervous disease and as\\nthe result of inflammations of the brain-substance in acute delirium.", "height": "4412", "width": "2552", "jp2-path": "practicaltreatis00muss_0_1112.jp2"}, "1113": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM. 1011\\nIt occurs in the exacerbations of general paresis and in diseased states\\nof unknown etiology that are denominated by the term itself. In\\nmelancholia the expression of the patient is mournful, he is commonly\\nquiet, sits with his head cast down, refuses to speak, to eat, or to take\\nany interest in what goes on about him. Often he weeps or groans\\nconstantly, and when persuaded to talk, expresses an acute sense of his\\nmanifold sins and the hopelessness of salvation, or will complain of\\nmisfortunes that have not befallen him. Melancholia occasionally\\noccurs in general paresis, particularly in patients whose vitality has\\nbeen exhausted by excesses. It also occurs as one of the varieties of\\ninsanity. The term paranoia is used by different authors in very dif-\\nferent senses. In general, it may be said that the majority imply by\\nit the existence of delusions or false ideas that have, among themselves,\\na certain logical sequence, or, as the term is, are organized. Thus a\\nparanoiac may believe that he is being persecuted by a certain person,\\nand be able to give reasons why his persecutor should torment him.\\nIt must not be forgotten that occasionally these delusions may be true\\nin fact, although none the less symptoms of the mental condition.\\nWhen there is merely a false idea it is spoken of as a delusion. If\\nthe person complains of certain physical impressions, such as non-exist-\\nent sounds, visions, odors, or tastes, the term hallucination is generally\\nemployed.\\nLocalization of Lesions of the Nervous System. In a diag-\\nnosis of diseases of the nervous system, particularly those that are the\\nresult of focal lesions, it is usually far more important to determine the\\nsituation of the lesions than the nature of the pathological process.\\nThe nervous system may be regarded physiologically as a collection of\\nneurons. By neuron is meant a nerve-cell and all its processes to their\\nultimate ramifications. The processes are of two kinds the so-called\\nprotoplasmic processes, which are relatively short, thick, and branched,\\nand appear to resemble in many respects the protoplasm of the nerve-\\ncell itself and the axis-cylinder, a long, slender process that in its\\ncourse gives off at regular intervals still more slender branches, the\\ncollaterals, and at its termination usually breaks up into a small tuft of\\nfibres that surround some other ganglion cell. An exception to the\\nlatter rule is formed by the axis-cylinders of the motor cells that run\\nto the muscles, and end in tufts of fibres distributed to peculiar\\nterminations in the muscle-fibres. The axis-cylinders, at a certain\\ndistance from the nerve-cell, usually become surrounded by myelin\\nsheaths, and constitute the nerve-fibres which make up the greater bulk\\nof the central nervous system (the white substance), and practically all of\\nthe peripheral nervous system. Neurons with similar functions are usu-\\nally grouped together, the aggregation of the cells forming a nucleus, and\\nof the fibres a bundle or system. The gray matter is largely composed\\nof these groups of ganglion cells or nuclei. Physiology has shown, al-\\nthough not absolutely conclusively, that the axis-cylinders convey im-\\npulses from the cell, and the protoplasmic processes cpnvey impulses or\\nnutriment to the cell. In the cell itself these impulses are modified or\\naltered in some as yet unknown manner. At present the course and\\nfunctions of comparatively few of the groups of neurons are known.", "height": "4416", "width": "2664", "jp2-path": "practicaltreatis00muss_0_1113.jp2"}, "1114": {"fulltext": "1012 SPECIAL DIAGNOSIS.\\nThose that have been most accurately studied may be divided into the\\nsensory neurons, conveying impulses from the peripheral nervous sys-\\ntem, and the motor neurons, conveying impulses from the central\\nnervous system to the muscles. The sensory neurons commence in the\\nvarious sensory corpuscles, in the skin, and organs. They pass through\\nthe peripheral nervous system to the posterior roots of the spinal cord,\\nand here they enter the cells in the ganglia of the posterior roots.\\nFrom these cells a fibre emerges that for a short distance is continuous\\nwith the entering fibre, and then leaves it and continues along the pos-\\nterior root of the spinal cord. Here it divides into two branches, an\\nascending and a descending branch. Of the function of the latter\\nnothing certain is known. Some of the ascending branches pass into\\nthe lateral posterior column (Burdach), and at a higher level into the\\nmedian posterior column (Goll). Those entering the cord in the upper\\ndorsal and cervical regions, however, do not pass into the median poste-\\nrior column, but continue in the lateral posterior column to a nucleus in\\nthe medulla. Both columns end respectively in the nucleus cuneatus\\nand the nucleus gracilis. These two nuclei may be looked upon as indi-\\ncating the termination of the peripheral sensory neurons. These two\\ngroups of fibres probably convey only touch and muscular sensations.\\nThe fibres conveying pain and temperature sensations apparently pass\\nup the cord through the central gray matter, but their central termi-\\nnation is not yet definitely known. From the ganglion cells in the\\ntwo nuclei in the medulla, axis-cylinders arise that pass toward the\\nbrain and form a mass of fibres known as the filet. In the medulla\\nthese are situated on either side of the median line, lying between\\nthe olivary bodies. They continue to occupy the central regions of\\nthe pons in its posterior part, but anteriorly they gradually spread out\\nuntil they form a narrow band, placed horizontally, just below the\\ngray matter surrounding the aqueduct of Sylvius. They then enter\\nthe tegmentum of the cms, and the majority lose themselves in the\\nventral nucleus of the optic thalamus. They constitute the second\\nchain of sensory neurons. It is probable that from the optic thal-\\namus, and from the other nuclei in which perhaps fibres of the filet\\nterminate, other axis-cylinders arise which pass through the corona\\nradiata to the sensory areas in the cortex. These sensory areas will\\nbe discussed in connection with the cortical localization.\\nDestructive lesions in the peripheral sensory nerves produce total\\nanaesthesia of the part supplied. Partial lesions may produce partial\\nanaesthesia or even dissociation of sensation. Irritative lesions of the\\nperipheral nerves produce severe pain, usually referred to the part sup-\\nplied by the nerve, and there are also sensitive points or general tender-\\nness over the nerve trunk. Certain forms of irritative lesion produce\\npartial alteration of sensation, which is usually spoken of as pares-\\nthesia (q. v.). Trophic changes in the skin often occur. Lesions of\\nthe posterior roots also produce total anaesthesia. If the lesion is on\\nthe peripheral side of the ganglion there are in addition trophic changes\\nin the part supplied. If the lesion lies between the ganglion and the\\nspinal cord, the anaesthesia is total, but trophic changes do not occur.\\nLesion of the ganglion itself usually produces anaesthesia and atrophic", "height": "4408", "width": "2596", "jp2-path": "practicaltreatis00muss_0_1114.jp2"}, "1115": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM.\\n1013\\nchanges, if complete if partial, the symptoms are variable. In some\\ncases herpes zoster along the course of the nerve has been observed.\\nIrritative lesions of the posterior roots produce fulgurant pains in the\\nlimbs, or a feeling of constriction in the trunk. They may also be the\\ncause of visceral crises. Destructive lesions of the posterior columns\\nof the spinal cord produce more or less tactile anaesthesia and loss of\\nthe muscle sense. As a result of the latter there is ataxia. Lesions of\\neither of the two central sensory neurons produce various forms of anaes-\\nthesia, depending upon their extent. According to our knowledge of\\nFig. 239.\\nDiagram to show the relative positions of the several motor tracts in their course from the cortex\\nto the cms.\\nThe section through the convolutions is vertical that through the internal capsules, I C, hori-\\nzontal; that through the crus is again vertical. CN, caudate nucleus; O TH, optic thalamus;\\nL2 and L3, the middle and outer parts of the lenticular nucleus f a I, face, arm, and leg fibres.\\nThe words in italics indicate the corresponding cortical centres. (Gowers.)\\nthis subject, destructive lesions, such as hemorrhage or aneurism in the\\nposterior portion of the posterior limb or the internal capsule, or destruc-\\ntive lesions of the optic thalamus, are usually associated with hemian-\\nesthesia on the opposite side of the body. At times, tactile sense is\\npreserved and only the pain sense lost. As a rule, however, all forms\\nof sensation are more or less affected.\\nThe motor neurons consist of two groups, the central and peripheral\\nneurons. The central motor neurons commence in the motor portion\\nof the cortex. They then pass through the corona radiata to the inter-\\nnal capsule, where they form a large band of fibres occupying the knee", "height": "4416", "width": "2652", "jp2-path": "practicaltreatis00muss_0_1115.jp2"}, "1116": {"fulltext": "1014\\nSPECIAL DIAGNOSIS.\\nand the anterior two-thirds of the posterior limb. (See Fig. 239.)\\nThe fibres for the face occupy the knee and anterior third of this por-\\ntion. Next come the fibres for the arm, then those for the leg, and,\\nfinally, the fibres for the trunk. From the internal capsule the fibres\\npass into the crura cerebri, where they lie beneath the substantia nigra,\\noccupying about the middle of each eras. The fibres for the face and\\ncranial nerves lie internal to those for the extremities and trunk.\\nFrom here they pass to the ventral portion of the pons, where they are\\nbroken up into small bundles by the association of fibres of the two\\ncerebellar hemispheres. These reunite and form the pyramids in the\\nanterior portion of the medulla, which decussate in the first cervical\\nsegment and pass down the cord as the lateral pyramidal columns.\\n(See Fig. 240.) A few of the other fibres, however, do not decussate\\nFig. 240.\\nwmmmmrn.\\nROOT.\\nDiagram showing the different tracts of the cord. (Goweks.)\\nat this time, but pass downward in the direct pyramidal columns, which\\ndecussate through the anterior commissure of the cord at lower levels.\\nThe fibres for the cranial nerves decussate, as a rule, in the neighbor-\\nhood of the nuclei for these nerves, and by this means we are able to\\nlocate with considerable accuracy the situation of lesions in the pons\\nand medulla. The fibres for the oculomotor nerves decussate in the\\ntegmentum and the nuclei around the aqueduct of Sylvius. The fibres\\nfor the facial decussate in the anterior portion of the pons. From this\\npoint downward fibres are continually crossing the median raphe to\\nthe nuclei of the various motor cranial nerves until the main decussa-\\ntion that is, in the first cervical segment. It follows, therefore, that\\nif a lesion occurs in such a position that it affects the fibres of one of\\nthe cranial nerves after they have crossed the median line, at the same\\ntime involving the undecussated fibres of the pyramids, we will have\\nthe syndrome known as a crossed paralysis that is, the muscles sup-\\nplied by the affected cranial nerves will be paralyzed on the same side", "height": "4416", "width": "2564", "jp2-path": "practicaltreatis00muss_0_1116.jp2"}, "1117": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM. 1015\\nas the lesion, and the rest of the body on the opposite side. (See\\nLesions of the Cranial Nerves.) The peripheral motor neurons com-\\nmence in the cells of the anterior cornna of the spinal cord, passing out\\nthrough the anterior roots, and reach the muscles through the periph-\\neral nerves.\\nThe functions of these two neurons are apparently not identical.\\nThe central motor neurons convey impulses from the cortex to the\\ncells of the anterior cornua, by which the latter are stimulated to pro-\\nduce muscular movement. At the same time they seem to possess an\\ninhibitory influence by means of some form of constant activity, so\\nthat while they are intact the reflexes are restrained, and the muscles\\ndo not become spastic. Upon the nutrition of the muscles they appar-\\nently have no influence whatever, or at least act only indirectly by\\ncausing paralysis. The peripheral motor neurons control directly mus-\\ncular activity. By their continuous action they maintain muscle tonus,\\nand when unrestrained by the influence of the upper neurons produce a\\ncondition of spasticity. While they and the sensory neurons forming\\nthe arc are intact, reflex action persists. They also control in some\\nmysterious way the nutritional changes in the muscles. Destructive\\nlesions of the lower neurons that is, of the peripheral nerves involving\\nthe motor fibres of the anterior root and of the ganglion cells in the\\ncornua cause paralysis and degenerative changes in the muscles. Irri-\\ntative lesions cause spasms these are usually tonic in character, and\\neither momentary (as in facial tic) or more rarely persistent (tetanic).\\nThe muscle tonus is lost, and, therefore, the paralysis is flaccid in char-\\nacter and the reflexes are abolished. Destructive lesions in the central\\nmotor neurons, on the other hand, produce paralysis of the muscles.\\nbut their nutrition is not impaired, their muscle tonus is increased\\nuntil they become spastic, and the reflexes are exaggerated. Irritative\\nlesions of the central nervous neurons produce, as a rule, clonic spasms.\\nThese may be limited to the part irritated, as occurs in some form of\\ncentral softening in the motor region, or become generalized. (See\\nConvulsions).\\nCortical Localization. The origins of the motor neurons and the\\nterminations of the sensory neurons are, as will be seen from this descrip-\\ntion, in the cortex of the brain. It is, therefore, of considerable im-\\nportance to be able to locate the portions of the cortex that have to\\ndo with these functions. As a result of experimental work and of the\\nrepeated examination of pathological specimens, a considerable amount\\nof knowledge has been acquired upon this subject. The motor regions,\\nindeed, are marked out with accuracy, and some of the regions for the\\nreception of impulses from the organs of special sense are also certainly\\nknown. The cortex of the brain has been divided into various regions\\nthat are referred to certain fissures that are quite constant in position.\\nThe most important of these is the fissure of Sylvius. It separates\\nthe temporo sphenoidal lobe below from the frontal and parietal lobes\\nabove. Around its posterior extremity there winds the convolution\\nknown as the gyrus angularis. Next is the Rolandic fissure, passing\\nfrom the superior longitudinal fissure to the fissure of Sylvius, with\\nwhich it forms an acute angle. It separates the frontal from the pari-", "height": "4416", "width": "2628", "jp2-path": "practicaltreatis00muss_0_1117.jp2"}, "1118": {"fulltext": "1016\\nSPECIAL DIAGNOSIS.\\netal lobe, and lies in the midst of the motor region of the cortex. In\\nfront of it is the ascending frontal convolution, and behind the ascend-\\ning parietal convolution. These two contain nearly all the motor\\ncentres. The third prominent fissure is the occipito-parietal. It is\\nFig. 241.\\nMl T o\\nCortical centres and areas of representation on the lateral aspect of the hemicerebrum. (Mills.)\\nCortical centres and areas of representation on the mesial aspect of the hemicerebrum. (Mills.)", "height": "4408", "width": "2568", "jp2-path": "practicaltreatis00muss_0_1118.jp2"}, "1119": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM. 1017\\nbest defined on the median surface of the brain, but can be traced for a\\nshort distance on the convex surface. It separates the parietal from\\nthe occipital lobe. On the median surface it unites at an acute angle\\nwith the calcarine fissure, the two enclosing between them the trian-\\ngular convolution that is known as the cuneus. (See Fig. 241 and Fig.\\n242.) The motor centres are so arranged that those for the face are\\nin the lowest portion of the motor region, those for the arms just above\\nthem, those for the legs around these, and those for the trunk in the\\nposterior termination of the ascending parietal convolution, along the\\nmargin of the superior longitudinal fissure. These centres do not repre-\\nsent particular muscles, but particular forms of movement, involving\\nfrequently the simultaneous contraction of several muscular groups.\\nIt is not known how sharp their limitations are, but it is supposed that\\nthe central portion of the focus is most exclusively devoted to its func-\\ntion, while at the periphery this fades gradually into the surrounding\\ncentres. The motor region for speech was first discovered by Broca, in\\n1861. It occupies the posterior portion of the third frontal convolu-\\ntion and the lower part of the ascending frontal convolution. The\\ntermination of the sensory neurous is not yet conclusively determined.\\nIt seems likely that some of them terminate in the motor region, and\\nothers in the upper portion of the parietal lobe. It is probable that\\ndifferent forms of sensation are represented by different areas upon\\nthe cortex, but at present our knowledge of this subject is uncertain.\\nThe stereognostic sense appears to be situated in the parietal lobe\\nthat is, lesions in this locality will cause its loss without disturbance\\nof tactile sensation. As it has been shown that this sense is largely\\ndependent upon muscular and localization senses, it is likely that the\\nfibres concerning these terminate in the parietal lobe. It is to be noted\\nthat although it is the general rule that fibres from one hemisphere\\nultimately pass to the opposite side of the body, this is by no means\\ninvariably the case. Certain muscles, such as those of the trunk, appar-\\nently are innervated from both sides of the brain that is, bilaterally\\nso that if one centre is destroyed the other assumes its functions,\\nand no paralysis ensues. It also appears possible, in certain instances,\\nfor the centre of one hemisphere gradually to learn to perform the\\nfunctions of the centre of the other hemisphere when the latter has\\nbeen destroyed. This is seen most clearly in cases of the destruction\\nof the speech centre on the left side, when, if the patient is still young,\\nthe speech centre on the right side may assume all its duties.\\nThe Centres for Reception of Special Senses. The cuneus of the\\nmedian surface of the occipital lobe appears to receive directly the\\nfibres from the optic tract. When it is destroyed there is bilateral\\ncontralateral hemianopsia. The pupillary reflexes are, however, pre-\\nserved, so that light impulses must exert some activity at a point in\\nthe chain of neurons between this and the eye, probably in the anterior\\nquadrigeminal bodies. The centre for audition is situated in the teni-\\nporo-sphenoidal convolution. Destructive lesions produce deafness in\\nthe ear of the opposite side, or at least impairment of hearing, which,\\nas a rule, rapidly disappears. The centres for smell and taste have\\nbeen placed respectively in the uncinate and fornicate convolutions.", "height": "4416", "width": "2656", "jp2-path": "practicaltreatis00muss_0_1119.jp2"}, "1120": {"fulltext": "1018 SPECIAL DIAGNOSIS.\\nThe evidence for these localizations is very strong, but is not yet abso-\\nlutely conclusive. It is doubtful whether irritative lesions in any of\\nthe centres for special sense are responsible for hallucinations.\\nThe functions of the frontal lobes are not well known. It has been\\nsupposed that they are the seat of intelligence, but there has never\\nbeen adequate proof of this belief. Lesions of the frontal lobes may,\\ntherefore, exist without giving rise to any symptoms that lead to a sus-\\npicion of their presence. On the other hand, the patients may exhibit\\nvarious intellectual disturbances, but, on the whole, none that are char-\\nacteristic, and perhaps these symptoms do not occur more frequently as\\na result of disease of this part than when some other part of the brain\\nhas been affected. It has been claimed that there is a certain degree\\nof intellectual impairment that the patient, while not insane or even\\neccentric, becomes incapable of exercising the same degree of judgment\\nand comprehension that he formerly possessed. It has been claimed, also,\\nthat a peculiar form of insanity, characterized by progressive dementia\\nassociated with a manifestation of self-contentedness, occurs only in\\nlesions of this part, and it has been given the term moria. The pro-\\nduction of a tendency to make puns has also been described to lesions\\nin this region. It does not always occur, but, on the other hand, it\\nmay occur as an early manifestation of insanity without gross lesion\\nor in connection with the lesions of other parts of the brain. The\\nmost important symptoms, of course, are those due to the involvement\\nof the adjacent motor centres. The one most frequently affected is the\\nspeech centre in the third frontal gyri, and as a result aphasia is a com-\\nmon associated symptom, particularly if the lesion is situated in the left\\nhemisphere. The other motor centres may, however, be involved and\\nproduce characteristic symptoms.\\nThe functions of the basal ganglia of the brain are as yet insufficiently\\nknown to enable us to diagnose lesions situated in them with certainty.\\nLesions in the lenticular nucleus may be entirely latent. In some cases\\nthey appear to have produced sensory disturbances, but even this is\\ndoubtful. Ordinarily, the only symptoms they produce are those\\nresulting from pressure upon the surrounding parts, such as the inter-\\nnal capsule. The optic thalamus appears to receive fibres from many\\nparts of the cortex. Its relation to the fillet has already been men-\\ntioned, and lesions in this region frequently produce sensory disturb-\\nances. The pulvinar appears to be one of the three basal ganglia asso-\\nciated with the optic tract, and when it is destroyed there is usually\\nbilateral contralateral hemianopsia. There is some doubt, however,\\nwhether this is not due to the involvement of the neighboring struc-\\ntures, either the fibres of the optic tract passing just beneath it or of\\nthe geniculate bodies. Nothnagel and v. Bechterew have called atten-\\ntion to the fact that certain localized movements on the part of the\\nmuscles of the face, particularly those concerned in the expression of\\nthe emotions, are more or less completely abolished by destruction of\\nthe optic thalami. The existence of this mimic paralysis has. in a few\\ncases, led to the correct diagnosis of thalamic lesion. The anterior\\ncorpora quadrigemina apparently form one of the intermediate stations\\nfor the optic tract, the fibres from the nerve ending in them, and new", "height": "4416", "width": "2560", "jp2-path": "practicaltreatis00muss_0_1120.jp2"}, "1121": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM.\\n1019\\nneurons commencing that possibly form the fibres of the optic radiation\\nThey are apparently the situations in which the arch of the pupillary\\nreflex is completed. The internal geniculate ganglia and the posterior\\ncorpora quaclrigemina appear to be associated with hearing.\\nLesions in the pons and medulla produce, as a rule, characteristic\\nsymptoms that make it possible to locate them with considerable accu-\\nracy. This is due to the fact that the nuclei of the cranial nerves are\\nsituated in these two portions of the brain, and also that they form the\\ngreat source of communication between the cerebrum and the spinal\\ncord, containing both motor and sensory fibres. (See Fig. 243.) The\\nnucleus of the oculomotor nerve is found surrounding the anterior\\nportion of the aqueduct of Sylvius, just beneath the anterior corpora\\nquadrigernina. Numerous groups of cells have been separated which\\nare supposed to belong each to a different muscle. Destructive lesions\\ncause partial or complete ophthalmoplegia, according to the extent of\\nthe lesion. There is, therefore, abolition of the pupillary reflex. Just\\nFig. 24c\\nRelative location of the nuclei of the different cranial nerves. (Edinger.)\\nbehind it, and beneath the posterior corpora, is a small group of cells\\nfor the pathetic nerve. The nucleus of the trigeminus is situated in\\nthe anterior portion of the pons, just to the outer side of the fillet, the\\nmotor group of cells lying inside the sensory group. The Gasserian\\nganglion receives the peripheral branches of this nerve and corresponds\\nto the spinal ganglia. In addition the nerve receives a bundle of fibres\\nfrom the lower portion of the medulla. Disturbances of the nucleus\\nproduce anaesthesia on the same side of the face, involving the conjunc-\\ntiva and the mucous membrane of the mouth. There is loss of taste in\\nthe anterior two-thirds of the tongue, and there is some disturbance of\\nsmell in the nostril on the same side. At the same time the pterygoid\\nmuscles are paralyzed and mastication is imperfect. Irritative lesions\\ncause tic douloureux. This may also be the result of disease of the\\nganglion. The nucleus of the abdueens lies in the posterior portion of\\nthe pons, just beneath the floor of the fourth ventricle. Destructive\\nlesions cause internal strabismus. The nucleus of the facial nerve is", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1121.jp2"}, "1122": {"fulltext": "1020 SPECIAL DIAGNOSIS.\\nfound in the posterior portion of the pons, lying slightly behind and to\\nthe median side of the nuclei for the trigeminus. The fibres from this\\nnerve pass out first forward, then downward and backward, and arise\\nfrom the lateral surface of the medulla at its anterior extremity, pass-\\ning forward over the pontine cerebellar tubercles. Destructive lesions\\ncause paralysis of the same side of the face, usually involving the upper\\nbranch. (See Hemiplegia.) Irritative lesions cause facial tic. The\\nnucleus of the acusticus is found in the anterior portion of the medulla\\noblongata, just beneath the floor of the fourth ventricle, lying just above\\nthe superior olivary body. Lesions produce nerve or mental deafness\\non the same side. The nuclei of the vagus and the glosso-pharyngeal\\nnerves are apparently in the jugular and petrosal ganglia that is to\\nsay, they are sensory nerves, and correspond to the sensory fibres enter-\\ning the spinal cord. From these ganglia fibres pass into the medulla\\noblongata at its lateral aspect, and end in a nucleus in the floor of the\\nfourth ventricle. The motor nucleus of the vagus is supposed to be\\nthe nucleus ambiguus, situated just posteriorly to the olive in the poste-\\nrior portion of the floor of the fourth ventricle. Close to the median\\nline is the hypoglossal nucleus. Its destruction produces paralysis and\\ndegenerative atrophy of the corresponding side of the tongue.\\nThe functions of the pons are merely those of the centres and tracts\\nit contains, and therefore the symptoms are dependent upon the situ-\\nation and greater or less amount of destruction that the lesions produce.\\nOn account of the decussation of the central fibres for the facial nerve\\nin this region, crossed paralysis is usually considered pathognomonic of\\npontine disease. The functions of the medulla are also largely dependent\\nupon the nuclei and tracts it contains. As it contains the centres for\\nthe pneumogastric and some of the centres or tracts of fibres for respi-\\nration, lesions in it are ordinarily followed very promptly by death.\\nLesions of the restiform bodies that is, the lower portion of the medul-\\nlary peduncle to the cerebellum are frequently associated with nystag-\\nmus, and may cause the symptoms of cerebellar ataxia. As the medulla\\ncontains the nuclei of the motor nerves to the pharynx, larynx and\\nmouth, paralysis of the muscles in this region is spoken of as bulbar\\npalsy.\\nThe cerebellum is supposed to be concerned in co-ordination and\\nthe maintenance of the equilibrium. The hemispheres may, however,\\nbe extensively diseased without giving rise to any symptoms. If the\\nmiddle lobe is affected the characteristic manifestations are disturbance\\nof equilibrium and inco-ordination. The gait resembles that of a\\ndrunken man, nystagmus is frequent, especially in cases of tumor.\\nGiddiness and vomiting sometimes occur, but are, however, of no\\nlocalizing value. The knee-jerk is often absent, but sometimes in-\\ncreased and sometimes variable. If the pyramidal tracts are pressed\\nupon it is always increased, and there is then weakness in the extremi-\\nties. As a result of pressure there may be paralysis of the cranial\\nnerves, difficulty in articulation, and occasionally epileptiform convul-\\nsions. If the medullary peduncle is affected by an irritative lesion,\\nquite characteristic symptoms result. These are forced movements\\nthat is to say, the patient may have an irresistible tendency to fall", "height": "4412", "width": "2568", "jp2-path": "practicaltreatis00muss_0_1122.jp2"}, "1123": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM. 1021\\ntoward or lie upon one side. There are no symptoms diagnostic of\\ndisease of the superior or middle peduncles. Disease of one side of\\nthe pons may cause symptoms similar to those of cerebellar trouble.\\nLocalization of Spinal Lesions. The spinal cord may be re-\\ngarded in two ways First, as the pathway between the peripheral\\nnervous system and the brain, containing the tracts running from the\\nbrain to the motor nerves, and from the sensory nerves to the brain\\nsecond, as a number of groups of ganglion cells arranged in horizontal\\nlayers or segments. These segments are usually classified according\\nto the nerve-roots that spring from them. There are, therefore, eight\\ncervical, twelve dorsal, five lumbar, and five sacral segments of the\\ncord. The white matter of the spinal cord is divided into two regions\\nthe antero-lateral part, extending from the median fissure to the poste-\\nrior horns, and the posterior part, lying between the posterior horns.\\nThe antero-lateral part contains the motor fibres or pyramidal tracts,\\nwhose functions have already been described. In addition, there are\\ncertain fibres that pass downward whose functions are not certainly\\nknown. The gray matter of the cord is divided into the anterior and\\nthe posterior horns. It is composed of nerve-cells and nerve-fibres.\\nThe nerve-cells in the anterior horns form a large group, which send\\ntheir axis-cylinders into the anterior roots, and comprise the peripheral\\nmotor neurons. In the posterior horns, in the dorsal region, there is a\\ngroup of cells on the inner side known as the column of Clarke, which\\napparently have something to do with equilibration. Other cells, whose\\nfunctions are not definitely known, are also found in the posterior\\ncornua. The gray matter also contains a large number of nerve-fibres,\\nsome of which pass transversely and apparently are concerned in reflex\\naction others ascend, and convey to the brain the sensations of pain,\\nheat and cold. Each segment of the cord innervates and receives sen-\\nsory impressions from an approximately corresponding segment of the\\nbody, and contains the lower reflex arcs. The motor and reflex func-\\ntions of the various segments are shown in the table and the sensory\\nfunctions in Fig. 244 and Fig. 245.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1123.jp2"}, "1124": {"fulltext": "1022\\nSPECIAL DIAGNOSIS.\\nTable of Motor and Reflex Functions of the Segment of the\\nSpjnal Cord. Modified from Gowers and Muller.\\nSegments.\\nC.\\nMotor innervation.\\n1 Small rotators of head\\n2 J Depressors of hyoid\\n3 1 Diaphragm\\n4 J Platysma\\nScaleni.\\nLev. ang. scapulas.\\nCucullaris.\\n5 1 Deltoid\\nBiceps\\nI Coraco brachialis\\nSupinator longus\\nSpinati\\nSerratus major\\n6 J Pectoral major (clav.) Pronators\\nTriceps\\n7 Flexors of wrist and\\nfingers\\nI Pectoralis (costal)\\nSubscapularis\\nI Latissimus dorsi\\n8 J Teres major\\nj Extensors of wrist\\nJ and fingers\\nD.\\n1\\n2]\\n3\\n4\\n6 Intercostal muscles\\n1 Muscles of hand\\nI I\\nExtensors of thumb\\n9\\n10 J\\n11\\n12\\nAbdominal muscles\\nErectors of spine\\nQuadratus lumborum J\\nlleo psoas\\nCremaster\\nSartorius\\nPectineus\\nAdductors\\nQuadriceps\\nGracilis r^\\nObturator Gluteal\\nAdductors J\\nFlexors of knee\\nJ 1\\nReflex centres.\\nI\\nJ J\\nDilatation of the pupil,\\nsensory part.\\nScapular.\\nTendon reflexes of the\\nmuscles of the arms.\\nDilatation of pupil,\\nmotor part.\\nI 1\\nEpigastric.\\nAbdominal.\\nCremasteric.\\nKnee-jerk.\\nI 1\\nGluteal reflex.\\nSJ\\nExternal rotators of thigh\\nExtensors of foot\\nTibialis anticus\\nPeroneal muscles\\nPerineal and anal muscles\\nAchillis tendon reflex.\\nPlantar reflex.\\nCentres for the bladder\\nand rectum.", "height": "4412", "width": "2560", "jp2-path": "practicaltreatis00muss_0_1124.jp2"}, "1125": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM.\\nFig. 244. Fig. 245.\\n1023\\n(From Oppenheim.\\n(From Oppenheim.)\\nGeneral Symptomatology of Lesions of the Brain. Lesions\\nof the brain may be irritative or destructive. The former, if affecting\\nthe motor tract, produce clonic spasms. If destructive, they produce\\nparalysis without atrophy, and cause increase in the muscle-tone by\\nthe removal of the influence of the superior arc and exaggeration of\\nthe reflexes. All these changes occur in the muscles of the opposite\\nside of the body. Irritative lesions are most likely to be extra-cerebral\\nthat is, pressing upon the cortex. Lesions in the brain-substance are\\nusually destructive, and, therefore, cause paralysis. As motor fibres\\nare distributed over a considerable area of the cortex, lesions in this\\nregion, if circumscribed, are likely to cause monoplegia. If involving\\nthe area for the face, the upper branch of the facial nerve, which is\\ninnervated from both sides, is rarely involved. Aphasia only occurs\\nif the left side is destroved. Lesions in the corona radiata near the", "height": "4416", "width": "2660", "jp2-path": "practicaltreatis00muss_0_1125.jp2"}, "1126": {"fulltext": "1024 SPECIAL DIAGNOSIS.\\ncortex usually cause monoplegia if near the internal capsule, hemi-\\nplegia is more common. Lesions in the internal capsule almost invari-\\nably cause hemiplegia. If the knee and anterior portion of the posterior\\nlimb are involved, hemiplegia without sensory changes results. If\\nthey also affect the posterior third of the posterior limb, sensory dis-\\nturbances are present, and there is likely to be hemianopsia. Lesions\\nin the anterior portion of the anterior limb produce no recognizable\\nsymptoms, and are termed latent. General disturbances of the brain may\\nbe caused by increase of the intracranial pressure. This may be brought\\nabout by growths, traumatism, oedema, or inflammation. There is usually\\nheadache, delirium or coma, and vomiting. If the process is of slow\\ndevelopment, a certain amount of adaptation may occur, and only the\\nheadache and vomiting may be present. The former is occasionally\\nsharply localized. In addition, if the pressure be long continued, there\\nis oedema of the optic nerve. (See Disorders of the Special Senses.)\\nGeneral Symptoms of Disease of the Spinal Cord. These\\ndepend upon the segment of the cord and upon the nerve-tracts in-\\nvolved. Lesions are spoken of as transverse if they involve the whole\\ncord, unilateral if they involve but one side, and focal if they involve\\nonly a circumscribed portion. Transverse lesions may be produced by\\ninflammation, by pressure either by a tumor or as a result of deformity\\nof the vertebral column (Pott s disease). Transverse lesions above\\nthe fifth cervical segment usually cause death by paralysis of the\\ndiaphragm. If the patient survive there is paralysis of all four\\nextremities and total anaesthesia of the body. There is also paralysis\\nof the bladder and rectum and abolition of the cutaneous reflexes, and,\\nin* the majority of cases, of the tendon reflexes. Transverse lesions\\nbetween the fifth cervical and the first dorsal segments produce atrophy\\nand degeneration of certain muscles of the arm, according to their\\nsituation. There is spastic paralysis of the legs and total anaesthesia\\nof the body as far up as the part that transmits sensation to the lowest\\nintact segment. There is paralysis of the bladder and rectum, aboli-\\ntion of the reflexes whose arcs are found in the segments involved, and\\nsometimes exaggeration of all the tendon reflexes that are completed in\\nthe lower segments. The cutaneous reflexes are abolished. Lesions of\\nthe dorsal region produce spastic paraplegia and paralysis of the bladder\\nand rectum. The arms escape entirely, and respiration is not disturbed.\\nThe anaesthesia extends up to the segment involved. Lesions in the\\nlumbar region produce atrophy and degeneration of certain groups of\\nmuscles in the legs, with paralysis and disturbances of sensation, dis-\\ntributed according to their extent. The situation of a lesion may be\\nroughly determined by a study of the reflexes. If the lesion involve\\nthe segments concerned in any of these, they are, of course, abolished.\\nIf the lesion is above them, they are sometimes exaggerated if below\\nthem, they are ordinarily not involved. Lesions of the conus termin-\\nalis and the cauda, as they involve the large number of nerve-roots,\\nproduce a complexity of symptoms. There are irregular areas of\\nanaesthesia corresponding to the posterior roots involved, and atrophy\\nand degeneration of the muscles supplied by the anterior roots. The\\nbladder and rectum usually are affected.", "height": "4408", "width": "2584", "jp2-path": "practicaltreatis00muss_0_1126.jp2"}, "1127": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM. 1025\\nUnilateral Lesion of the Spinal Cord (the syndrome of Brown-Sequard).\\nThis produces paralysis of the same side and anaesthesia of the oppo-\\nsite side, both symptoms extending as far upward as the region sup-\\nplied by the segment that has been affected. Disturbance of sensation\\nis not total. There is tactile anaesthesia, analgesia, and loss of tem-\\nperature-sense on the side opposite the lesion, but persistence of the\\nmuscular sense, which, however, is diminished or lost on the same side\\nas the lesion. Disturbance of motion is complete. Atrophy and de-\\ngeneration occur in the muscles supplied by the involved segment\\nbelow this there is spastic paralysis, with increase in the reflexes.\\nAbove the paralytic area there is a zone of hyperesthesia that has\\nnever been satisfactorily explained. The commonest cause of unilat-\\neral lesion is traumatism, particularly bullet and stab Avounds. Occa-\\nsionally the symptoms develop in the early stages of syringomyelia or\\nas a result of tumor or hemorrhage of the spinal cord. Focal lesions\\nin the spinal cord produce various symptoms, according to their situa-\\ntion. Inflammations involving the gray matter are commonly spoken\\nof as poliomyelitis. They usually attack the anterior cornua and in-\\nvolve only the peripheral motor neuron that is, they produce paralysis,\\natrophy, and degeneration of the muscles. Inflammatory lesions in the\\nwhite matter are spoken of as leukomyelitis. They produce symptoms\\naccording to the tracts they involve.\\nThe Cranial Nerves. The olfactory, optic, oculomotor, pathetic,\\nabducens, auditory, and glosso-pharyngeal have already been described\\nin connection with the special senses. The trigeminal nerve takes its\\norigin from the centres in the pons and medulla already described.\\nDestructive lesions of the motor portion cause paralysis of the ptery-\\ngoid muscles. If they are unilateral it is impossible for the patient\\nto move the mouth toward the opposite side when the lower jaw is pro-\\ntruded. It is to be assumed that atrophy and degeneration of these\\nmuscles occur, but their electrical examination is practically impossible.\\nIrritative lesions produce cramp known as trismus. This is, of course,\\nusually due to central disease. The sensory portion of the trigeminus\\nsupplies the skin of the face and the mucous membranes of the cavities\\nof the head. The distribution of the three branches is shown in Fig.\\n246. Irritative lesions produce tic douloureux destructive lesions,\\nanaesthesia in the distribution of the part affected. The facial nerve\\narises from the nuclei in the posterior portion of the pons. These are\\nprobably double, each supplying a separate branch of the nerve, and\\nthe superior nucleus is innervated from both sides of the cerebrum. It\\nis the motor nerve for the muscles of the face, and supplies the tem-\\nporal, masseter, the orbicularis palpebrarum, the muscles of the lower\\npart of the face, the muscles of the palate, and the platysma myoides.\\nUnilateral destructive lesions produce paralysis of the muscles of the\\nface (BelPs palsy). This can be recognized by the disappearance of\\nthe folds, drooping of the corner of the mouth, and the inability to\\nclose the eye. In addition there may be loss of taste and hyperacusis\\nin the ear on the same side. Occasionally there is deviation of the\\ntongue, the palate is oblique, and the uvula is pulled toward the sound\\n65", "height": "4416", "width": "2664", "jp2-path": "practicaltreatis00muss_0_1127.jp2"}, "1128": {"fulltext": "1026 SPECIAL DIAGNOSIS.\\nside. If the peripheral portion of the nerve is involved, usually both\\nthe upper and lower branches are affected, and the paralysis is general.\\nIf the lesion is central the upper branch commonly escapes, or, at least,\\ninstead of being paralyzed, is only paretic. Moreover, in central lesions\\nlying above the pons the opposite side of the bod} r is paralyzed. Secre-\\ntion of saliva on the same side is diminished or abolished. This may\\nbe tested on the sublingual glands by raising the tip of the tongue,\\ncarefully drying the sublingual space and getting the patient to inhale\\nsome pungent substance, such as acetic acid or musk. The saliva will\\nimmediately appear on the sound side, but will fail to appear on the\\nother. In facial paralysis it is impossible for the patient to masticate\\non the diseased side, because the food collects between the cheek and\\nthe gums. It is also impossible for him to whistle. Saliva freely\\ndribbles from the drooping corner of the mouth, and as it is impossible\\nto contract the orbicularis palpebrarum the eye remains open even in\\nsleep (lagophthalmus), and the corneal reflex is abolished or imperfect.\\nWhen the patient attempts to close the eye the ball rolls upward and\\noutward. In addition, the palatine reflex also disappears. In facial\\nparalysis of long standing contractures may occur. In all cases the\\nmuscles show either partial or complete reactions of degeneration. Irri-\\ntative lesions of the facial nerve cause spasm of the facial muscles,\\nusually spoken of as facial tic. The vagus nerve supplies motor fibres\\nto the larynx, sensory fibres to the lungs, and inhibitory fibres, prob-\\nably sensory in nature, to the heart. It also probably sends sensory\\nfibres to the gastro-intestinal tract. Destructive lesions of the vagus\\nproduce, if unilateral, unilateral paralysis of the vocal cords, interference\\nwith deglutition, and transient tachycardia. The laryngeal changes\\nare most characteristic. (See Chapter I., Part II.) Irritative lesions\\nproduce spasm of the glottis, with dyspnoea or aphonia. The spinal\\naccessory nerve is the motor nerve for the trapezius and part of the\\nsternocleidomastoid. Destructive lesions of this nerve are the chief\\ncause of torticollis. The hypoglossal nerve is the motor nerve for the\\ntongue, and is, therefore, concerned in chewing, swallowing, and speak-\\ning. Unilateral destructive lesions produce paralysis of one-half of the\\ntongue, which is protruded toward the paralyzed side, with atrophy and\\ndegeneration of the muscle. Fibrillary twitchings are usually present.\\nThe functional disturbance, however, is slight, and the patient may\\ncomplain of no discomfort. Bilateral paralysis produces, however, very\\nsevere symptoms. The tongue lies flaccid in the mouth, it is impossible\\nto protrude it, or even to move it from side to side. Mastication is\\nimpossible and swallowing exceedingly difficult. Speech is at first seri-\\nously affected, but, as a rule, the patient in time learns to compensate\\nthe lingual palsy. Paralysis of the tongue as a result of central lesion\\nalmost never occurs.\\nGeneral Diagnosis of Nervous Diseases. It is necessary to\\nstudy the patient according to some fixed plan, otherwise its com-\\nplexity and the numerous investigations that it is necessary to make\\nrender a thorough examination almost impossible. It is true, of course,\\nthat in actual clinical practice diseases will be met whose clinical symp-\\ntoms are so characteristic that the diagnosis can be made almost by", "height": "4416", "width": "2560", "jp2-path": "practicaltreatis00muss_0_1128.jp2"}, "1129": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM. 1027\\ninspection alone, and a prolonged examination will only be useful for\\nthe purpose of excluding or detecting possible complications. On the\\nother hand, certain cases will occur that almost defy diagnosis, on account\\nof the multiplicity and contradictory character of the symptoms. In gen-\\neral it may be said that, aside from the history and the subjective symp-\\ntoms, the physician will meet with four groups of signs disturbance\\nof sensation, disturbances of motility, atrophic and degenerative lesions,\\nand disturbances of intelligence. These should be taken up in the fol-\\nlowing order 1. Disturbance of intellect. Tt is often possible to detect\\nthis, when it exists, by simple conversation with the patient. It may\\nbe indicated by the history, or, on the other hand, the history and the\\nbehavior of the patient may exclude it altogether. 2. Disturbances of\\nmotion. It is well to study first the more patent alterations. Thus the\\npatient should be told to move the arms and legs, in order to detect\\nparalysis he should be requested to walk, in order to study the gait\\nhe should be directed to perform some fine, co-ordinated movement, in\\norder to detect possible ataxia and to put the muscles in a state of\\ntension, in order to exaggerate a possible tremor. Following this the\\nindividual movements should be carefully examined. It must be\\nremembered that, whether the lesion is in the central or peripheral\\nnervous system, disturbance of motility is manifested only in the\\nmuscles themselves, and the investigations, therefore, should commence\\nwith these that is to say, it is not desirable to test the motor functions\\nof each particular nerve, but rather of each particular group of muscles,\\nand to deduce from the changes found in them the nerve or segment\\ninvolved. I he following table from Sahli gives a classification of the\\nmuscles of the extremities, according to their functions, with their\\nnerve-supply\\nTable of the Voluntary Muscles Grouped According to their\\nFunctions, with their Nervous Supply. (From Sahli.)\\nUpper Extremity.\\nA. Movements of the shoulder-blade.\\n1 Elevators of the shoulder.\\nMiddle part of the cucullaris (N. accessorius).\\nEhomboidei (N. dors, scapul., 5th cervical nerve).\\nLevator scapulae (2d and 3d cerv. nerv. and N. dors. scap.\\nUpper portion of the pectoral major (Nn. thorac. ant., 5th and 6th cerv.\\nnerves).\\n2. Depressors of the shoulder.\\nPectoralis minor (Nn. thorac. anterior).\\nLower portion of the latissimus dorsi (N. subscapularis).\\nLower portion of the pectoralis major (N. thorac. ant.).\\n3. Adduction of the shoulder.\\nLower portion of the cucullaris (N. accessor.\\nUpper portion of the latissimus dorsi (N. subscapulars)\\n4. Abduction of the shoulder.\\nUpper third of the pectoral, major (N. thor. ant.).\\nSerratus anticus major (N. thorac. longus, 6th, 7th, 8th cerv. nerv.).", "height": "4416", "width": "2664", "jp2-path": "practicaltreatis00muss_0_1129.jp2"}, "1130": {"fulltext": "1028 SPECIAL DIAGNOSIS\\nB. Movements of the shoulder-joint.\\n1 Elevators of the arm.\\n(a) Laterally, deltoid (N. axillaris).\\nVertically, serratus anticus major (N. thorac. longus).\\n(6) Anteriorly, anterior portion of the deltoid (N. axillaris).\\nCoracobrachialis (N. musculocutaneous).\\nBiceps (N. musculocutaneous).\\n(c) Posterior portion of the deltoid (N. axillaris).\\n2. Adduction of the arm.\\nPectoralis major (N. thorac. anticus, 5th and 6th cerv. n.\\nLatissimus dorsi and teres major (N. subscapulars\\nInfraspinatus (N. suprascapular, fith and 6th cerv. n.).\\nTeres minor (N. axillaris).\\nThese muscles also depress the arm.\\n3. Internal rotation.\\nSubscapulars (Nn. subscapulars).\\n4. External rotation.\\nInfraspinatus (N. suprascapularis).\\nTeres minor (N. axillaris).\\nC. Movements of the elbow.\\n1. Flexion.\\nBiceps (N. musculocutan.\\nBrachialis (N. musculocutan.\\nSupinator longus (N. radialis).\\n2. Extension.\\nTriceps (N. radialis).\\n3. Supination.\\nSupinator brevis (Kradialis)\\nSupinator longus J v\\n4. Pronation.\\nPronator quadratus 1 (Nmedianus)-\\nPronator teres I v\\nSupinator longus (N. radialis).\\nD. Movements of the wrist-joint.\\n1. Flexion.\\nFlex, carpi radialis (N. medianis).\\nFlex, carpi ulnaris i\\nPalmaris longus J\\n2. Extension.\\nExtensor radialis longus and brevis ,*r y\\nExtensor ulnaris J\\n3. Abduction.\\nEXLTngufand brevis} K medianis and K radiaUs\\n4. Adduction.\\nExtensor ulnaris and flexor carpi ulnaris (Nn. radial, and ulnar).\\nE. Movements of the fingers.\\n1. Flexion.\\nFlexor digitor. sublim.; flexion of the 2d phalanx (N. median).\\nFlexor digitor. prof.; flexion of the terminal phalanx (Nn. median, ulnar).\\nInterossei and lumbrical muscles, flexion of the proximal phalanx (Nn.\\nulnaris, median.", "height": "4412", "width": "2568", "jp2-path": "practicaltreatis00muss_0_1130.jp2"}, "1131": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM. 1029\\n2. Extension.\\nExtensor dig. comm. (N. radialis).\\nInterossei and lumbrical muscles (N. ulnar, N. median).\\nF. Movements of the thumb.\\n1. Flexion.\\nFlexor pollicis longus and brevis (N. median).\\n2. Extension.\\nExtensor pollicis longus and brevis (N. radialis).\\n3. Abduction.\\nAbductor pollicis long. (N. radialis).\\nAbductor pollicis brev. (N. median).\\n4. Adduction.\\nAdductor pollicis (N. ulnaris).\\n5. Opposition.\\nOpponens pollicis I (N mediant\\nAdductor pollicis brev. UN mecllan\\nG. Movements of the eittle finger.\\n1. Flexion.\\nFlexor communis digitorum profundus and sublimis (N. median and N.\\nFlexor brevis minimi digiti (N. ulnaris). ulnaris).\\n2. Extension.\\nExtensor minimi digiti proprius (N. radial.\\n3. Abduction.\\nAbductor minimi digiti (N. ulnaris).\\n4. Opposition.\\nOpponens minimi digiti (N. ulnaris).\\nLower Extremity.\\nA. Movements of the hip- joint.\\n1. Elevation of thigh,\\nIliopsoas (N. plexus lumbalis).\\nKectus femoris _ pnrftli -x\\nSartorius P cruralls\\n2. Depression of thigh.\\nGlutseus maximus (Nn. glut. inf. and ischiadicus).\\nFlexors of the knee (N. ischiadicus).\\n3. Internal flexion.\\nGlutseus med. and minim. (N. glut, super.).\\n4. External rotation.\\nQuadratus femoris XT N\\nObturator int. and Gemelli is ^iadicus).\\nObturator ext. CN. obturat.\\nPyriformis (Plex. ischiad.\\nIliopsoas (Plex. lumbal.).\\nGlutaeus max. (N. glutaeus inf.\\n5. Adduction.\\nAdductores (N. obturator).\\nPectineus (N. crural and obturat.\\nGracilis (N. obturator).\\n6. Abduction.\\nGlutseus med. and min. (N. glut. sup.", "height": "4416", "width": "2652", "jp2-path": "practicaltreatis00muss_0_1131.jp2"}, "1132": {"fulltext": "1030 SPECIAL DIAGNOSIS.\\nB. Movements of the knee-joint.\\n1. Flexion.\\nSartorius (N. cruralis).\\nGracilis (N. obturat.).\\nSemitendinosus\\nSemimembranosus mN. ischiad.\\nBiceps. J\\nPopliteus (N. tibial, N. ischiad.).\\n2. Extension.\\nQuadriceps (N. cruralis).\\nC. Movements of the ankle-joint.\\n1. Dorsal flexion.\\nTibial antic. 1 v\\nExtensor commun. dig. long. N P eron P rof\\n2. Plantar flexion.\\nGastrocnemius! AT u x\\nSoleus [(N. tibial).\\nPerineus long. (N. peron. superficial).\\n3. Adduction.\\nTibial postic (N. tibial).\\nTibial ant. (N. peron. prof.\\n4. Abduction.\\nPeroneus long.\\nPeroneus brevis V (N. peron. prof.).\\nComm. dig. long J\\n5. Elevation of the inner side of the foot.\\nTibial ant. (N peron prof.\\nTibial post. (N. tibial).\\n6. Elevation of the outer side of foot.\\nD. Movements of the toes.\\n1. Flexion.\\nFlexor comm. digit, long, and brev. 1,-m- +;K: a i\\\\\\nInterrossei and lumbricales J\\n2. Extension.\\nExtensor comm. digit, long, and brev. (N. peron. prof.).\\n3. Adduction.\\nInterossei plantares (N. tibial).\\n4. Abduction.\\nInterossei dorsales (N. tibial).\\nE. Movements of the great toe.\\n1. Flexion.\\nFlexor hallucis long, and brev. (N. tibial).\\n2. Extension.\\nExtensor hallucis long, and brev. (N. peron. prof.).\\n3. Adduction.\\nAdductor hallucis (N. tibial).\\n4. Abduction.\\nAbductor hallucis (N. tibial).", "height": "4416", "width": "2568", "jp2-path": "practicaltreatis00muss_0_1132.jp2"}, "1133": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM.\\n1031\\nF. Movements of the smaee toe.\\n1. Flexion.\\nFlexor minimi digit. (N. tibial).\\n2. Abduction.\\nAbductor minimi digit. (N. tibial).\\n3. Opposition.\\nOpponens minimi digit. (N. tibial).\\nEach movement should be tested by requesting the patient to per-\\nform it first unimpeded, and then against resistance. (For functions\\nof motor cranial nerves, see page 1025.) 3. Sensory disturbances. As\\nin testing the motor disturbances, there is first obtained a rapid orien-\\ntation of the sensory condition of the patient. For this purpose it is\\ncustomary to touch with the finger or a blunt object both sides of the\\nFig. 246.\\nCutaneous nerves of the head and face.\\nVi, V\u00c2\u00bb V s first, second, and third branches of the trigeminus; S 0, supra-orbital I, lachrymal\\nst, supratrochlear it, infratrochlear e, ethmoidal sm, malar at, auriculo-temporal b, buc\\ncinator to, mental am, auricularis magnus oma and omi, occipitalis major and minor.\\nface, the arms, the legs, and both sides of the body. If the patient\\ndeclares that there is no difference in the sensory perceptions, tactile\\nanaesthesia may be temporarily excluded. The same regions are tested\\nfor pain and temperature-sense, and it is often desirable to test the\\nmuscle-sense at the same time, although this properly belongs to dis-\\nturbances of motility. It is often possible, in testing sensation, to decide\\nwhether the lesion is peripheral or central by its distribution. If it\\naffects the spinal cord it will be segmental in type. (See Fig. 244 and\\nFig. 245.) If it affects the peripheral nerves, the area or areas will\\ncorrespond to the cutaneous distribution of the nerve or nerves involved.\\n(See Fig. 246 et seq.) 4. The cutaneous trophic changes occur", "height": "4416", "width": "2648", "jp2-path": "practicaltreatis00muss_0_1133.jp2"}, "1134": {"fulltext": "1032\\nSPECIAL DIAGNOSIS.\\nparticularly in the form of panaritis of glossy skin or of bed-sores.\\nTrophic changes in the joints occur especially in the knee, shoulder, and\\nhip. Trophic changes in the muscles may occur in any part of the body.\\nThey are, of course, nearly always associated with distinct paralysis.\\nHaving obtained a rough idea of the condition of the patient, it is then\\nFig. 247.\\nCutaneous nerves of the anterior surface of the trunk. (Sahli.)\\nnecessary to make a more minute examination. 1. The various func-\\ntions should be carefully studied, particularly those of the cerebral\\nnerves. These should be taken up in order and all their functions\\ntested. 2. It is important to note the reflexes, especially those\\nof the eye, and the tendon and cutaneous reflexes of the body and", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1134.jp2"}, "1135": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM.\\n1033\\nextremities. 3. The position, station, and gait. 4. The disturbances\\nof speech. 5. The condition of the individual muscles and nerves of\\nFig. 248.\\n1 W \\\\Ni(nfeicosto-\\nf\\ncut:\\nN.rculial.\\nCutaneous nerves of the anterior surface of the arm. (Sahli.)\\nthe body. The diagnosis must then be made by the study of the symp-\\ntoms elicited. It should be, if possible, both topical and pathological,\\nalthough it is not always possible to make the latter.\\nSPECIAL DIAGNOSIS OF DISEASES OF THE NERVOUS\\nSYSTEM.\\nThe semeiological classification of nervous diseases presents many\\ndifficulties. Many of the diseases that are closely analogous in their", "height": "4428", "width": "2652", "jp2-path": "practicaltreatis00muss_0_1135.jp2"}, "1136": {"fulltext": "1034\\nSPECIAL DIAGNOSIS.\\nsymptoms are widely different in their pathology or etiology, and\\nmany diseases present such variations in their symptom-complex that\\nat one period they could properly be placed in one group and at\\nanother period elsewhere. In general, it may be said, however, that\\nthe diseases of the peripheral motor neurons differ so widely from\\nthose of the central motor neurons that they can be classified as two\\nseparate groups, and in a third group would come the diseases of the\\nsensory neurons. Combinations of these three groups, producing on\\ntheir part rather clearly marked complexes of symptoms, may then be\\ndescribed, and finally the general and local diseases of the brain and\\nFig. 249.\\nMedianus\\nDistribution of the cutaneous nerves in the hand.\\ncord. An entirely separate group, characterized by peculiar symptoms,\\nare the so-called functional nervous diseases, or the neuroses. It must\\nbe admitted, however, that this group, as a result of more accurate\\nmethods of investigation, is growing rapidly smaller.\\nDiseases of the Peripheral Motor Neurons and the Muscles.\\nDiseases Characterized by Pure Motor Disturbance.\\nProgressive Muscular Atrophy. Two forms are recognized the\\nscapulo-humoral type of Erb and the facio-scapulo-humoral type\\nof Dejerine-Landouzy. In the former the disease commences in the\\nmuscles of the shoulder, especially the pectorals and the latissimus\\ndorsi. Next the adjacent muscles are involved, followed by the\\nmuscles of the arms, thighs, and finally the muscles of the calf.\\nThere is gradual loss of power corresponding to the atrophy of the\\nmuscles, but reactions of degeneration do not occur. As a result of the", "height": "4416", "width": "2572", "jp2-path": "practicaltreatis00muss_0_1136.jp2"}, "1137": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM.\\n1035\\nwasting, peculiar alterations occur in the configuration of the body\\nthat is, the shoulder-blades become prominent, lordosis occurs, and, as\\na result of the weakness of the glutei, it may be necessary for the\\nFig. 250.\\nN. cut. brach. ext. (From\\nthe N. musculocuta-\\nneus).\\nN median.\\nCutaneous nerves of the posterior surface of the arm. (Sahli.)\\npatient to arise, as in the following form, by climbing up his legs.\\nThe gait, as a result of the atrophy of the cpadriceps, is waddling in\\ncharacter. The disease usually presents itself about puberty.\\nIn the latter type the symptoms are essentially the same, excepting\\nthat the first muscles to undergo atrophy are those of the eyelids and", "height": "4416", "width": "2648", "jp2-path": "practicaltreatis00muss_0_1137.jp2"}, "1138": {"fulltext": "1036\\nSPECIAL DIAGNOSIS.\\nmouth. This form usually commences about the third or fourth year\\nof life.\\nPseudo-hypertropliic Muscular Paralysis. The disease usually com-\\nmences in the muscles of the calves. These become greatly enlarged,\\nhard, and there is great loss of power. Other muscles of the legs are\\nN. peroneus\\nN. peroneus superf.\\nFig. 251.\\nW .J*\\nN. pud. coram, (pi. sacr.)\\nN. cut. fern. post. (pi. (sacr.)\\nN. obturator, (pi. lumb.)\\nN. peroneus prof.\\nN. plant, int.\\nN. cut. dorsi pedis ext.\\nN. plant, ext.\\nCutaneous nerves of the anterior surface of the leg. (Sahli.\\nnext involved then those of the back, and perhaps the arms. Not all\\nthe muscles that undergo atrophy show a preliminary hypertrophy.\\nThe electrical reactions remain normal, and the loss of power is due\\nmerely to the atrophy of the true muscle substance. The gait is\\nwaddling, and the patient is unable to arise from the ground, except\\nby getting upon the hands and knees and then gradually climbing up", "height": "4416", "width": "2576", "jp2-path": "practicaltreatis00muss_0_1138.jp2"}, "1139": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM.\\n1037\\nhis legs. There is usually lordosis or scoliosis, and occasionally con-\\ntractures occur, leading to formation of club-foot. In all these three\\nforms of disease the course is slowly progressive.\\nFig. 252.\\n\\\\Iumb.e^sacnJ\\nN. obturatorius\\nN. saphenus rnaj\\nN. cut. fern. lat. (pi. lumb.)\\nN. communicans tibial et\\nperoneus.\\nN. peroneus supernV.\\nN. cut. dorsi pedis ext.\\nN. plant, ext.\\nCutaneous nerves of the posterior surface of the leg. (Sahli.\\nDiseases Characterized by Motor Disturbance, with Degen-\\nerative Changes in the Muscles.\\nProgressive Muscular Atrophy Consecutive to Disease of the Nerves.\\n(The Charcot-Marie-Hoffmann type the peroneal type of Gowers.)\\nThe first muscles affected are those of the feet and hands, usually in\\nthe former, the peronei, the extensors of the toes, and the small muscles", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1139.jp2"}, "1140": {"fulltext": "1038 SPECIAL DIAGNOSIS.\\nof the foot in the latter, the interossei and the muscles of the thenar\\nand the hypothenar eminences. The affected muscles show distinct\\nfibrillary twitchings and usually the characteristic reactions of degenera-\\ntion to the electrical current. These reactions of degeneration are also\\npresent in the nerves. There is usually a coarse, irregular tremor, and\\nthe atrophy of some of the muscles with contractures of others give rise\\nto various deformities, such as the ape-hand, the main en griffe, or, if\\nthe foot is first affected, to foot-drop. Later the foot assumes a posi-\\ntion of equino valgus or varus. In this disease there is sometimes\\ninvolvement of the sensory fibres, and the patients may complain of\\nslight paresthesia or even of pain. Hypsesthesia is also occasionally\\npresent. In a form of this disease described by Dejerine under the\\ntitle of Infantile Hypertrophic and Progressive Interstitial Neuritis,\\nthere are, in addition to the above changes, the symptoms of locomotor\\nataxia that is, Komberg s symptom lancinating pains, atactic gait,\\nand even disturbance of the pupillary reflexes. The nerve-trunks\\nbecome enlarged and can be felt beneath the skin.\\nProgressive Spinal Muscular Atrophy. (Type of Duchenne-Aran.)\\nThe disease commences usually in the muscles of the hand, particularly\\nin those of the thenar eminences, giving rise to the formation of the\\nape-hand. The interosseous spaces become deeper, the fingers become\\ngradually weakened, and ultimately become fixed in a semi-flexed con-\\ndition incomplete main en griffe. The muscles show fibrillary twitch-\\ning and give the reactions of degeneration to the electrical current.\\nUsually the process is bilateral. As the disease progresses it next\\ninvolves the muscles of the shoulder, especially the deltoids, and later\\nthe muscles of the upper arm, and then of the forearm. Finally, the\\nmuscles of the back become involved, and even the lower extremities.\\nSensory disturbances are never present. The emaciation is extreme,\\nbut total paralysis occurs only very late in the disease.\\nAcute Anterior Poliomyelitis. This is really an infectious disease,\\ncommencing with chills and fever and characterized by the rapid ap-\\npearance of flaccid paralysis in one or more limbs. The onset is usually\\nsudden, and the paralysis may occur before the development of the\\ngeneral symptoms. The legs are more frequently involved than the\\narms the muscles are usually affected in functionally similar groups,\\nsuch, for example, as the flexors of the upper arm, and then very rapidly\\nbegin to undergo contractures. These produce deformities, particularly\\nvarious forms of club-foot, scoliosis or lordosis, and contractures of\\nthe hand. The disease usually occurs in children, and the affected\\nextremity does not grow as rapidly as the other. Occasionally adults\\nare attacked. Sensory disturbances are absent, the reflexes are abol-\\nished, and the electrical reactions are those of degeneration. In the\\nvery early stage pains, usually radiating from some point in the back,\\nhave been noted in a few instances. Ordinarily, the paralysis is more\\nextensive at first than later that is to say, many of the muscles\\ninvolved recover completely.\\nChronic Anterior Poliomyelitis. This is characterized by the slow\\ndevelopment of paralysis in one or more groups of muscles or extremi-\\nties of the body. The flexors are more likely to be attacked than the", "height": "4416", "width": "2568", "jp2-path": "practicaltreatis00muss_0_1140.jp2"}, "1141": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM. 1039\\nextensors. The muscles show fibrillary twitchings and the reactions\\nof degeneration, and the paralysis is usually flaccid. The process is\\nusually self -limited, but bulbar symptoms may appear and cause death.\\nThe disease resembles closely progressive spinal muscular atrophy.\\nPeriodic Paralysis. This is a disease characterized by the occur-\\nrence from time to time of paralysis of all four extremities. The\\nparalysis is usually flaccid in type, occurs without pain, and is associ-\\nated with extraordinary increase in the electrical resistance of the skin.\\nThe disease usually occurs in several members of the same family, the\\nparoxysms lasting three or four days.\\nDiseases Characterized by Disturbance of Motion Occurring\\nwithout Reference to any Definite Portion of the Cere-\\nbral Nervous System.\\nChorea (Sydenham s chorea) is characterized by irregular twitching\\nmovements affecting various groups of muscles in the body that are\\nusually functionally associated, so that the movements appear to be the\\nresult of voluntary innervation. These movements may be generally\\ndistributed, or more pronounced on one side than the other, or may\\neven occur only in one part of the body. They may involve the muscles\\nof the face, the arm, the leg, or the muscles of the trunk, particularly\\nthe diaphragm, giving rise to an irregular, jerking inspiration. They\\nmay vary in severity from slight, almost imperceptible contractions to\\nsevere, general convulsive movements in which the violence is so great\\nthat bruises or even fractures may occur. As a rule, the affected limbs\\nare slightly weaker, and in some cases this paralysis is very pronounced\\n(paralytic chorea). The mind is usually clear, but there may be some\\nirritability of temper. In a few cases with violent movements there is\\npronounced insomnia and violent delirium (chorea insaniens). Speech\\nmay be affected either as a result of choreic movements of the lips or on\\naccount of psychic disturbance. Associated symptoms are the presence\\nof a heart murmur, irregularity of cardiac action, rheumatic pains in\\nthe limbs, which usually disappear as the movements become more\\npronounced and, occasionally in the violent form, fever.\\nHuntington s chorea is characterized by the development, between the\\nages of twenty and forty, of choreiform movements of moderate degree,\\nassociated with gradually progressive dementia. The disease is strictly\\nhereditary, occurring only in the offspring of those who have suffered\\nfrom it. The twitchings resemble those of chorea, but are rarely vio-\\nlent, and often associated with a slight rigidity. The first mental\\nsymptom is usually loss of memory. Later, the patient may have\\ndelusions of grandeur or severe melancholia. Usually life is prolonged\\nto an advanced age, the mental symptoms gradually passing into the\\ntype of severe senile dementia. A curious condition is the tendency\\nof the patient to avoid society.\\nChorea Electrica. There are various varieties of this condition one\\noccurring in children, characterized by lightning-like contractions of\\ngroups of muscles, sometimes those of the trunk or those of the ex-\\ntremities another, Dubinins disease, which appears to be an infectious", "height": "4416", "width": "2652", "jp2-path": "practicaltreatis00muss_0_1141.jp2"}, "1142": {"fulltext": "1040 SPECIAL DIAGNOSIS.\\nprocess, commences with violent pains in the head, neck, and back, slight\\nfever, and general convulsions. Muscular contractions occur, usually\\ninvolving all the muscles of the body that are characterized by their fre-\\nquent recurrence and brief duration. Death is the usual termination.\\nParamyoclonus Multiplex. This is a disease, probably hysterical in\\nnature, characterized by lightning-like contractions in groups of muscles,\\nwhich do not, however, produce movement that would in any way\\nresemble co-ordinated action. Often the patient from time to time\\nemits a peculiar sound resembling a grunt, probably the result of\\ndiaphragmatic involvement. The electrical reactions are normal, and\\nthe reflexes are sometimes slightly increased.\\nHabit spasm is characterized by the repetition of some peculiar,\\nunnecessary movement, such as shrugging the shoulders, winking the\\neye, rubbing the elbow against the side, etc. Emotional disturbances\\nor the presence of bystanders always increase the symptoms.\\nSaltatoric spasm (jumper s disease, latah) is a hysterical manifesta-\\ntion in which the patient, whenever he or she attempts to stand, is\\ncompelled to rise on the toes or even to spring from the ground.\\nOften after such movements the patient falls. The spasm disappears\\nif the patient lies down, but may be produced by pressure upon the\\nsoles of the feet.\\nGeneral Tic (Ifaladie de Gilles de la Tourette maladie der tics con-\\nvulsifs). This is a psychical condition characterized by curious move-\\nments of the limbs and grimaces and the utterance of words, that have\\nno relation to the evironment, that may be profane or obscene (copro-\\nlalia), or the imitations of sounds heard (echolalia). The patient becomes\\nmore or less melancholy, and may even be violently insane.\\nParalysis Agitans. This is characterized by a peculiar, fine tremor\\nof the extremities, rigidity of the muscles, disturbance of gait, and\\ngradually progressive paresis. The first symptom noted is usually a\\nslight impairment of agility. As the disease commences in advanced\\nlife, this is not regarded with suspicion but later the immobility of\\nthe muscles of the face and the complete loss of facial expression sug-\\ngests the nature of the case. It will now be found that the patient\\nwill have difficulty in rolling over, if lying down, and that there is dif-\\nficulty in commencing to walk and afterward a tendency to take quick\\nsteps (festination). The patient, if studied, will be seen to have from\\ntime to time a slight movement forward or backward, which, if stand-\\ning or walking, may cause him to fall in one direction or the other\\n(propulsion, retropulsion). Speech is also involved, difficulty in articu-\\nlation being characterized at first by slight halting and then the rapid\\nutterance of the words. The tremor of the hands is spoken of as pill-\\nroller s tremor (q. v.). Tremor of the head is a nodding movement to\\nand fro. There may also be irregular movements of the toes or legs.\\nThe tremor is diminished or abolished temporarily by voluntary move-\\nment and disappears during sleep.\\nTetany is probably an infectious disease characterized by cramp of\\nthe muscles of the arms and the persistence of peculiar nervous and\\nmental alterations. The attack usually commences with paresthesia or\\npain in the limbs then the muscles controlling the fingers become stiff.", "height": "4416", "width": "2576", "jp2-path": "practicaltreatis00muss_0_1142.jp2"}, "1143": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM. 1041\\nThe flexors gradually contract and draw the fingers and thumb together,\\nthe so-called obstetrical hand. This cramp is tonic in character, and\\nmay last for several minutes or ev T en for many hours. It is often asso-\\nciated with intense pain During the interval it may be reproduced\\nby prolonged, severe pressure upon the nerve-trunks, particularly the\\nmedian nerve (Trousseau s sign). The muscles show marked irrita-\\nbility to mechanical stimuli, particularly those of the face, and twitch-\\ning may be caused by tapping upon the trunk of the facial nerve, upon\\nthe malar bone, or over the infraorbital foramen (Chvostek s sign).\\nThe muscles show extreme electrical irritability, contract to very weak\\ncurrents, and in some cases AOTe and COTe have been obtained\\n(Erb s sign). Finally, the patient is extremely sensitive to the induced\\ncurrent (Hoffmann s sign). During the attack, and even during the\\ninterval, there is sometimes slight oedema of the face, hands, and feet,\\nand the latter have a tendency to assume a partial equino-varus posi-\\ntion. Often there is slight fever.\\nOccupation Neuroses. These are characterized by the development\\nof pain in the limb employed when the attempt is made to perform\\nsome habitual movement. It is most common as a result of writing.\\nThe patient notices at first that he becomes more readily fatigued than\\nusual, and there may be dull pains in the joints or in the palm of the\\nhand. The painful sensations may then extend up the arm, often as\\nfar as the shoulder. They are rarely severe, but by their persistent,\\ndull character are extremely annoying. The motor symptoms are\\ncharacterized by a tonic spasm of the muscles employed in grasping\\nthe pen, so that it is held too tightly, and often there is difficulty in\\nholding it properly. From time to time the spasmodic condition may\\nincrease and cause inaccurate strokes. The writing is usually heavy and\\noften quite illegible. The muscles apparently never degenerate. The\\nelectrical reactions are normal or only slightly altered. If the patient\\nlearns to write with the left hand, the symptoms of the disease usually\\ndevelop in it after a short time. Similar symptoms occur in piano-\\nplayers, violin-players, dairy-maids, telegraphists, and various other\\npersons who are obliged to perform the same movement for long periods.\\nThomsen s Disease. This is characterized by the occurrence of tonic\\nspasm as the result of voluntary innervation of the muscles. The\\npatient, upon attempting to make a movement, finds the part rigidly\\nfixed for a longer or shorter interval of time. The spasm then relaxes,\\nthe movement can be performed, and does not recur while the muscles\\nare kept active. There are occasionally cramp-like pains in the mus-\\ncles and a peculiar alteration in the electrical reactions. (See Myotonic\\nReaction.) The disease is chronic, but subject to exacerbations, partic-\\nularly as a result of exposure to cold, previous excessive exercise, or\\nemotional disturbance.\\nDiseases of the Sensory Neuron, with Disturbances of\\nSensation.\\nThese are generally included under the term neuralgia. Neuralgia\\nis a condition characterized by pain of a dull, burning, or shooting\\n66", "height": "4416", "width": "2684", "jp2-path": "practicaltreatis00muss_0_1143.jp2"}, "1144": {"fulltext": "1042 SPECIAL DIAGNOSIS.\\ncharacter that occurs in the distribution of some particular sensory\\nnerve or nerves. The pain may be remittent or intermittent. It is\\nexaggerated, as a rule, by external irritation or emotional disturbance.\\nThe nerve-trunk is often tender, not only during the attack, but also\\nduring the interval. Associated symptoms are often present. The\\nmost common are the vasomotor disturbances, the area of distribution\\nof the affected side showing persistent or paroxysmal flushing or occa-\\nsionally pallor. Secretion of sweat is sometimes increased, and there\\nmay be exaggeration of the activity of glands supplied by the nerve.\\nOccasionally there is marked oedema of the skin, and sometimes a\\nherpetic eruption. Very rarely in neuralgia there is local graying of\\nthe hair. Motor symptoms may also occur. These consist of spas-\\nmodic twitching that may be associated with exacerbations of the pain.\\nNeuralgias due to various general conditions sometimes have a charac-\\nteristic localization. Thus in diabetes, sciatica occurs in malaria,\\nsupra-orbital neuralgia in neurasthenia, occipital neuralgia.\\nSpecial Forms. Neuralgia of the Trigeminal Nerve (tic douloureux).\\nThis usually occurs in only one branch of the nerve, and is commonly\\nunilateral. The pain is paroxysmal and very severe, and is often\\nreferred by the patient to some supposed source of peripheral irritation,\\nas disease of the nose, carious teeth, etc. It is usually associated with\\nincrease in the secretion of various glands, such as the tear glands, the\\nsalivary glands, the nasal mucous membrane, etc. Trophic changes\\nare not uncommon. These may vary from herpetic eruptions and\\ngraying of the hair to atrophy of the soft parts and even of the bones\\nof the face. Occasionally trophic alterations of the cornea also appear.\\nOccipital Neuralgia. This involves the occipitalis major nerve, but\\noccasionally the auricularis magnus and the nerves of the neck are also\\naffected. The pain is distributed over the occipital region of the head,\\nand is usually bilateral. The point of greatest tenderness is over the\\ncervical vertebrae, usually slightly to one side of the spinous processes.\\nBrachial neuralgia is characterized by pain distributed in the arm of\\nthe affected side. This may be either persistent or paroxysmal. If\\nthe latter, parsesthesise in the hand or arm are frequent during the\\nintervals. The points of tenderness are found where the nerves pass\\nover the bones or just behind the clavicle. Occasionally trophic changes\\nare observed.\\nIntercostal neuralgia is characterized by pain distributed along the\\ncourse of the intercostal nerves. There are three characteristic tender\\npoints one next to the spinal column, one in the axillary line, and\\none over the sternum or rectus abdominus. There are usually trophic\\ndisturbances in the skin over the affected nerve, characterized by red-\\ndening or especially by a herpetic eruption (herpes zoster).\\nLumbar neuralgia is characterized by pain radiating from the lumbar\\nto the gluteal region. Occasionally the anterior surfaces of the thighs\\nare also involved. The sensitive points are found over the lumbar\\nvertebrae along the edge of the crest of the ilium and over the linea alba.\\nCrural neuralgia is characterized by pains radiating from the front\\nof the thigh into the feet. Paresthesia? are frequently present during\\nthe intervals of the attacks.", "height": "4416", "width": "2568", "jp2-path": "practicaltreatis00muss_0_1144.jp2"}, "1145": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM. 1043\\nSciatica is characterized by pain in the posterior surface of the thigh,\\noften radiating to the feet. It is an exceedingly common form, usually\\nparoxysmal in character, the attacks being preceded by paresthesias.\\nThe pain is increased by any movement tending to stretch the nerve,\\nand as a result the patient walks with a peculiar gait, the thigh of the\\naffected side being held fixed and parallel to the body. This some-\\ntimes results in a slight curvature of the spine. The nerve is often\\nsensitive through its entire length. The special points of tenderness\\nare found near the posterior superior spine of the ilium, at the lower\\nedge of the gluteus maximus, just outside the tuber ischii, and in the\\ncavity of the knee-joint. The reflexes are usually slightly exaggerated.\\nThere is sometimes slight weakness of the muscles and occasionally\\nfibrillary twitchings.\\nOther forms of neuralgia are mastodynia, or irritable breast neuralgia\\nof the phrenic nerve, characterized by deep pain in the thorax and slight\\ndyspnoea coccygodynia and various neuralgia-like pains in the viscera.\\nDiseases somewhat similar to neuralgia are meralgia paresthetica,\\ncharacterized by tingling, burning, or tearing in the area of the distri-\\nbution of the external cutaneous nerve of the thigh, usually unequally\\nbilateral, and made worse by prolonged exercise, either walking or\\nstanding. Frequently there is a tender point just below the anterior\\nsuperior spine of the ilium. Sensory disturbances in the form of\\nhypsesthesia, hypalgesia, and diminished electro-cutaneous sensibility\\nare very common.\\nAchroparcesthesice are characterized by tingling or pain in the extremi-\\nties. The affected members are usually tender, and there is hyperes-\\nthesia. Occasionally vasomotor disturbances are present. An allied\\ncondition is the symptom known as tender toes that occurs in the course\\nof typhoid fever.\\nDiseases of the Sensory Neuron Characterized by Disturb-\\nance of Motion, Sensation, and Trophic Disorders.\\nTabes Dorsalis. This is characterized by ataxia, particularly of the\\nlower extremities, lancinating pains in the legs, loss of the knee-jerk,\\nand the Argyll-Robertson pupil. It is divided into three stages the\\npreatactic, the atactic, and paralytic. The symptoms of the preatactic\\nstage frequently commence with disturbance in the nerves affecting\\nthe eyeball. There may be paresis of the abducens, giving rise to\\ndiplopia of the levator palpebral, giving rise to ptosis or sluggish or\\nabsent reaction to light on the part of the pupil, while the reaction of\\naccommodation still persists (Argyll-Robertson pupil). The symptoms in\\nthe nerves of the lower extremities are particularly the lancinating pains\\nthat are felt in the posterior portion of the thigh. These come on from\\ntime to time, and the patient feels as if he has been stabbed. They are\\nmore frequent in damp weather, and are frequently confused with rheu-\\nmatism. The knee-jerk is absent, and the patient may note that it is a\\nlittle bit more difficult to walk in the dark. The station in the early stage\\nis usually only slightly affected. There is a sense of constriction about\\nthe body (girdle pain), and sometimes hypsesthesia of the lower extremi-", "height": "4416", "width": "2668", "jp2-path": "practicaltreatis00muss_0_1145.jp2"}, "1146": {"fulltext": "1044 SPECIAL DIAGNOSIS.\\nties that may be associated with a slight hyperalgesia in the zone just\\nabove it. The patients may also remark that they have slight difficulty\\nin urination and some diminution of sexual potency. The second\\nstage, or the stage of ataxia, is characterized by the symptoms of the\\npreceding stage, all of which are now pronounced. In addition the\\npatient exhibits inco-ordination of movement, especially in the lower\\nlimbs. Station is so impaired that it is usually impossible for him\\nto stand alone with the eyes closed and the feet together. Walk-\\ning in the dark is difficult and usually associated with frequent falls.\\nIn the daylight, with the aid of the eyes, the patient can usually\\nwalk quite well, but lifts the feet higher than usual from the ground,\\nand separates them widely. (See Ataxic Gait.) The inco-ordination is\\nmanifested by the difficulty with which the patients perform certain\\nmovements, such as touching some object with the tip of the linger as,\\nfor example, the nose, ear\u00e2\u0080\u0094 or in bringing the heel of one foot against\\nthe knee of the other. There is diminished muscle-tone, and, of course,\\nabsolute loss of tendon reflexes, even when reinforced. There are\\nparesthesia?, especially in the lower extremities analgesia in the same\\nsituation, or sometimes delay in the conduction of pain. Micturition is\\nsometimes difficult at others there is incontinence, but insufficiency\\nof the sphincter ani rarely occurs. Impotence is complete. The\\nArgyll-Robertson pupil is present there is usually myosis, nyctalopia,\\nand occasionally atrophy of the optic nerve. In the latter condition\\nit has been noted that when blindness has fully developed the ataxia\\nbecomes less pronounced or may disappear completely. The visceral\\ncrises are characterized by attacks of intense pain involving usually\\nthe stomach or sometimes affecting the larynx or heart or other viscera.\\nThe laryngeal crises are often accompanied by distressing cough and\\ndyspnoea. Trophic changes occur, of which the most common are the\\narthropathies. These involve particularly the knee, hip, and shoulder-\\njoints. In addition, the patient may have painless falling out of the\\nteeth or rapid softening of them. In certain cases a chronic ulcer\\ndevelops on the sole of the foot, which usually progresses until it has\\nproduced perforation (mat perforante). In the paralytic stage of ataxia\\nthe loss of muscle-tone has reached such an exreme degree that loco-\\nmotion is impossible. The patients by this time have usually developed\\ncystitis, and death occurs either as a result of exhaustion or of general\\nsepticaemia.\\nThe Cervical Type of Tabes Dorsalis. This is characterized by\\nthe development of the symptoms chiefly in the arms. The lightning\\npains are found in the upper extremities, there is loss of the bicipital\\nand tricipital reflexes, and the girdle sensation is usually felt in the\\nupper part of the thorax. The ocular symptoms are the same. The\\nvisceral crises are likely to affect the larynx. In this form ataxia in\\nthe legs, Romberg s symptom, and the absence of the knee-jerk may\\nnot be present until late in the disease.\\nFriedreich s Ataxia. This is characterized by inco-ordination, loss\\nof knee-jerk, weakness, irregular speech, and slight deformities. The\\ndisease commences in youth, and is usually hereditary in character.\\nThe first symptom is inco-ordination of the lower limbs. This gradu-", "height": "4408", "width": "2596", "jp2-path": "practicaltreatis00muss_0_1146.jp2"}, "1147": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM. 1045\\nally becomes more severe, the muscles grow weaker, the flexors more\\nso than the extensors, often giving rise in time to pes equino-varus.\\nThe muscles of the back also grow weaker, giving rise to scoliosis the\\nknee-jerks are absent, the pupillary reflexes remain normal, and intelli-\\ngence is unaffected. The speech is peculiar, some of the syllables being\\npronounced readily and others slowly, with a drawl. The gait becomes\\nmarkedly ataxic, the patients keeping the legs widely separated. In\\ntime the paresis and inco-ordination become so severe that walking\\nis impossible. The disease is progressive and usually affects several\\nmembers of the same family.\\nThe cerebellar type of hereditary ataxia differs from the foregoing by\\nthe fact that the knee-jerks are exaggerated, and there is occasionally\\nabsence of the pupillary reflex to light.\\nDiseases of the Peripheral Motor and the Sensory Neuron.\\nThese are all characterized by disturbances of motion and sensation,\\nusually associated with more or less severe trophic changes.\\nNeuritis. Inflammation of the nerves is characterized by pain local-\\nized in the nerve affected, tenderness, and perhaps paresis or paralysis\\nof certain groups of muscles. The pain is made more severe if the\\nlimb is held in such a position that the nerve is stretched. As it is a\\ntrue inflammatory condition, there are usually constitutional disturb-\\nances, such as fever, malaise, etc. Often the disease is progressive,\\nextending from the peripheral to the more central nerve-trunks. This\\nis spoken of as ascending neuritis. Along the course of the nerve there\\nare often vasomotor and secretory disturbances, or the lesions may be\\nmore severe, such as atrophy of the skin, with glossiness, or trophic\\nFig. 253-.\\nV\\n-4T\\nIs d\\nAlcoholic neuritis. Foot-drop and wrist-drop.\\nchanges in the nails. Multiple neuritis is characterized by the appear-\\nance of the symptoms of the disease in a number of nerves at the same\\ntime. The nerves of the limbs are far more frequently affected than\\nthose of the trunk. The symptoms are modified by the cause. In\\nalcoholic polyneuritis there are usually slight paresthesias of the limbs,\\nwith marked paresis of the muscles, particularly the extensors, giving\\nrise to foot-drop and wrist-drop. (See Fig. 253.) The disease usually\\naffects all four extremities. In lead-poisoning the disease is sometimes\\nunilateral, is usually restricted to the arms, and the sensory disturb-", "height": "4416", "width": "2660", "jp2-path": "practicaltreatis00muss_0_1147.jp2"}, "1148": {"fulltext": "1046 SPECIAL DIAGNOSIS.\\nances are very slight or absent. There is paralysis of the extensor\\nmuscles of the arm, which in severe cases goes on to muscular degen-\\neration. Neuritis may also be produced by arsenic. Diphtheritic poly-\\nneuritis is usually characterized by paralysis of the muscles of the\\npalate, but occasionally the muscles of the limbs are also involved.\\nIn certain of the chronic forms of polyneuritis, instead of loss of power,\\nthere is marked loss of co-ordination. This is spoken of as the ataxic\\nvariety.\\nBeri-beri, or kakke, is an infectious disease characterized by the symp-\\ntoms of a peripheral multiple and symmetrical neuritis. The patients\\nusually present general symptoms, as fever and chills, and then com-\\nplain of a sense of weakness or heaviness in the legs, paresthesia?, and\\ndiminution of tactile sensation. The electrical examination of the\\nmuscles of the legs usually shows the reactions of degeneration. Later,\\nthe muscles undergo further degeneration and become paralyzed. There\\nis oedema of the skin, and the anaesthesia becomes more pronounced.\\nOccasionally pain-sense is preserved, giving rise to anaesthesia dolorosa.\\nThe paralysis becomes more extensive, and the patient may die as a\\nresult of the involvement of the respiratory muscles.\\nMultiple neuromata sometimes occur very extensively upon the nerves\\nof the skin, at times producing symptoms of multiple pressure upon the\\nnerves that is, paresthesia?, paralyses, or loss of sensation. At other\\ntimes they produce no symptoms whatever, and can only be recognized\\nby inspection.\\nDiseases of the Spinal Cord Involving the Central Motor\\nNeurons.\\nPrimary spastic paraplegia is characterized by weakness of the legs\\nwithout muscular degeneration and with increased reflexes. The dis-\\nease was formerly supposed to be the result of the involvement of the\\nlateral columns of the cord. The first symptoms are weakness or a\\nfeeling of heaviness in the legs then spontaneous cramps appi ar.\\nThe reflexes are greatly exaggerated, and the muscle tone is so in-\\ncreased, particularly in the extensors of the thigh or knee and foot, that\\nthe patient walks with the leg partially extended, dragging the toe\\nalong the ground the arms are rarely involved. The electrical reac-\\ntions of the muscles are normal. The sphincters are very rarely in-\\nvolved, and sensation is usually unimpaired. If cramps are frequent,\\nhowever, the muscles may be sore. In children the adductors become\\nstronger than the abductors, and a peculiar, crossed-legged gait is there-\\nby produced.\\nAmyotrophic Lateral Sclerosis. This is characterized by a spastic\\nparaplegia, with exaggeration of the reflexes and degeneration of the\\nmuscles. The symptoms consist of weakness in the legs, which at the\\nsame time become stiff. The muscles rapidly atrophy there are fibril-\\nlary twitchings and reactions of degeneration. The arms are usually\\ninvolved first, the degeneration commencing in the muscles of the hands\\nand giving rise ultimately to the production of various deformities, such", "height": "4416", "width": "2568", "jp2-path": "practicaltreatis00muss_0_1148.jp2"}, "1149": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM. 1047\\nas the claw-hand. The tendon reflexes are greatly exaggerated there\\nare patellar clonus and ankle clonus. The muscles are greatly weakened,\\nbut remain rigid until late in the course of the disease. The sphincters\\nare rarely involved, the pupillary reflexes are normal, and there are\\nno sensory disturbances. Bulbar symptoms that is, paralysis of the\\nlarynx, pharynx, and palate occur, giving rise to dysphagia, alteration\\nin speech, and frequently causing an inspiration pneumonia.\\nMultiple Sclerosis. This is a condition that involves the sensory and\\nmotor tracts in the spinal cord and occasionally in the brain. The\\ncharacteristic symptoms are intention tremor, nystagmus, and scan-\\nning speech. The patient usually has weakness of the legs, with some\\ntremor and exaggeration of the reflexes. In the arms the same con-\\nditions are present, and in the attempt to grasp any object a violent\\ntremor is developed, which continues until the movement has been\\naccomplished. Various areas of anaesthesia are also present, depending\\nlargely upon the localization of the lesions. There is usually persistent\\nnystagmus, lateral in character the speech is slow and drawling, and\\nthe patient has a tendency to laugh or weep without provocation. In\\na large proportion of the cases there is more or less complete atrophy\\nof the optic nerve. Less frequent symptoms are vertigo, occurring in\\nparoxysmal attacks, diminution of intelligence, and occasionally dis-\\nturbances of the function of the bladder, and in a few cases atrophy\\nand degeneration of the muscles. The disease is usually chronic, but\\nfrom time to time there are exacerbations. It appears to be frequently\\nassociated with hysterical manifestations. In some cases bulbar symp-\\ntoms appear early and rapidly lead to death.\\nHypertrophic Cervical Pachymeningitis. This is characterized by pain\\nin both arms, followed by muscular degeneration commencing in the\\nhands. Later, there may be spastic paraplegia of the legs, with anaes-\\nthesia of the body below the affected segment. Occasionally this\\ndisease, which is usually due to tuberculous meningitis, may occur in\\nother portions of the spinal cord, giving rise, therefore, to various\\nsymptoms.\\nAcute spinal meningitis is characterized by intense pain in the back,\\nradiating into the legs rigidity of the spinal column, with opisthot-\\nonos intense hyperesthesia of the skin of the body, and, if the dis-\\nease lasts long enough, paralyses. Kernig s symptom that is, the\\ninability to extend the flexed leg as a result of flexor cramp is said\\nto occur only in this condition and in cerebral spinal meningitis. The\\ntdche spinale occurs also in other conditions.\\nSyphilitic spinal meningitis produces a great variety of symptoms.\\nThere are, however, pains due to pressure upon the posterior roots,\\ngirdle pains of the body, and occasionally paralysis of the muscles of\\nthe extremities, with atrophy and degeneration. Often, also, the spinal\\ncord is involved, giving rise to the symptoms of pressure or transverse\\nmyelitis (q. v.) or Brown-Sequard s syndrome (q. v.). The sensory symp-\\ntoms, aside from the pains, consist of hyperesthesia, hypaesthesia, or\\nanaesthesia. The tendon reflexes of the lower extremities may be lost\\nand reappear, and this by some is supposed to be pathognomonic of the\\ndisease.", "height": "4416", "width": "2668", "jp2-path": "practicaltreatis00muss_0_1149.jp2"}, "1150": {"fulltext": "1048 SPECIAL DIAGNOSIS.\\nDiseases Characterized by the Syndrome of Transverse\\nInterruption of the Spinal Cord.\\nPotfs Disease (caries of the vertebrae). This is characterized by an\\nangular deformity of the spine, spastic paraplegia, and various disturb-\\nances of sensation in the body below the level of the lesion. In the\\nearlier stage the only symptoms may be pain in the back, usually radi-\\nating around toward the ventral surface. There may be no deformity,\\nbut sudden pressure upon the head, jarring of the spine by coming\\ndown heavily upon the heels, and pressure over the tender point in the\\nback may elicit sharp pains. In this stage there are usually slight\\nexaggeration of the reflexes and perhaps a slight Aveakness of the legs.\\nLater, the angular deformity becomes apparent, usually in the form of\\na sharp projection in the dorsal portion of the spinal column, but it\\nmay appear also in the cervical and lumbar region. The weakness of\\nthe lower extremities becomes more pronounced, and may give rise to an\\nactual paraplegia. The pains are usually severe, radiate around the\\ntrunk, and sometimes affect other portions of the body. Sensation\\nmay be slightly impaired. There may be distinct dissociation below\\nthe lesion that is, loss of temperature and pain senses, with preserva-\\ntion of tactile sense or there may be total anaesthesia. As in myelitis,\\nbed-sores or other trophic changes of the skin are very likely to develop,\\nand the patients suffer severely in general nutrition. In the earlier\\nstages, and more particularly in the stage of recovery, after the de-\\nformity has become stationary, ataxia may exist. The reflexes are\\nsometimes greatly exaggerated, and there is often ankle clonus. When\\nthe paraplegia has become complete all the reflexes are usually abolished.\\nGirdle sensation is also very common. The course is very variable. At\\ntimes the destruction of the body of the vertebra is rapid, and the symp-\\ntoms develop acutely. At others it occurs very slowly, and the symp-\\ntoms, even after years duration, may be exceedingly slight. Caries of\\nthe upper cervical vertebrae produce pains that involve the neck and\\nthe occipital region of the head. The position of the head is peculiar\\nit is drawn slightly forward and carried very rigidly, and the chin is\\nelevated. These patients may sometimes die suddenly as a result of\\npressure by the odontoid process on the medulla.\\nTumors of the Membranes. The symptoms of this condition are ex-\\ntremely variable, according to the location, nature, and extent of the\\ngrowth. Occasionally deformities occur as a result of pressure upon\\nthe arches of the vertebrae. Paraplegia usually develops, sometimes\\nvery suddenly, sometimes gradually. There is usually exaggeration of\\nthe reflexes and ankle clonus but this in time may disappear, or may\\nnever occur if the tumor is situated in the lumbar region. When the\\nposterior roots are pressed upon there are root pains and the girdle sen-\\nsation. Sensory disturbances are more or less complete according to the\\ndegree of destruction that has occurred in the spinal cord. Dissociation\\nof sensation rarely occurs, but anaesthesia is very common. After com-\\nplete destruction of the spinal cord at any point trophic changes occur.\\nChronic Internal Meningitis. This is usually characterized by pain\\nthat radiates into various portions of the body, particularly the limbs,", "height": "4408", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1150.jp2"}, "1151": {"fulltext": "DISEASES OF THE NEB VOUS SYSTEM. 1049\\nand by more or less hyperesthesia. The motor symptoms con-\\nsist of tremors, spasms, and occasionally, when the anterior roots are\\ninvolved, paralyses, with muscular degeneration. In the milder forms\\nthe only motor symptoms may be inco-ordination of movement. Her-\\npetic eruptions along the course of the nerves arising from the\\ninvolved posterior roots are quite common.\\nAcute Myelitis. There are a number of varieties of this condition,\\nthe most common and typical being transverse myelitis. It is an\\nacute inflammatory disease associated with constitutional disturbance\\nthat is, chills, fever, and malaise, and is occasionally ushered in with a\\nconvulsion. The symptoms are those of transverse lesion of the spinal\\ncord. Ordinarily the dorsal part is affected and there are, therefore,\\nin the earlier stages weakness and paresthesias of the legs, and perhaps\\na girdle sensation and hyperesthesia over the spine, the zone sup-\\nplied by the involved segment. In the course of a few days or hours the\\nweakness of the legs increases until there is complete paraplegia. The\\ntone of the muscles is enormously exaggerated, the knee-jerks are in-\\ncreased, and there is both patellar and ankle clonus and often Sinkler s\\ntoe-jerk. The limbs are usually spastic and kept in a position of ex-\\ntension. From time to time the muscles give violent twitches. There\\nis complete anesthesia up to the horizontal line surrounding the trunk,\\nat Attach point there is girdle sensation, and above it there is a zone of\\nhyperesthesia. The muscles supplied by the affected segment atrophy\\nand give reactions of degenerations. Those in the region below main-\\ntain their nutrition for a considerable time. There is difficulty in\\nmicturition, usually paralysis of the bladder, and finally overflow from\\nretention. The urine becomes alkaline, cystitis develops very rapidly,\\nand is often followed by extensive sloughing of the surrounding parts.\\nBed-sores occur early and extend deeply. Trophic lesions also occur\\nin the legs, the skin becomes thin and glazed, and the toe-nails are\\nbrittle. Even arthropathies have occasionally been observed. After\\nthe acute stage has passed more or less improvement may occur, charac-\\nterized by gradual return of power in the legs and partial recovery of\\nsensation.\\nAcute Focal Myelitis. This gives rise to only part of the symptoms\\ndescribed above, depending upon the tracts involved by the process\\nand the various nuclei that have been destroyed. There is, therefore,\\nusually a monoplegia, associated with exaggeration of the reflexes and\\nirregular areas of anesthesia, or, if the focus be in the arm or the leg\\ncentre, diminution or loss of the reflexes and degeneration of the muscles.\\nDisseminated myelitis gives rise to a complicated group of symptoms,\\naccording to the number, situation, and extent of the lesions. It\\nresembles perhaps most closely transverse myelitis (q. v.).\\nChronic myelitis is distinguished from the acute form by the more\\ngradual development of the symptoms. The patient first notices weak-\\nness of the legs, perhaps characterized from time to time by complete\\ntransient loss of power {giving way of the legs). If the reflexes are\\nexamined at this time, they will be found slightly exaggerated later\\nthey become very markedly increased, and ankle clonus develops. The\\npatient also complains, in the early stages, of paresthesie in the limbs", "height": "4416", "width": "2660", "jp2-path": "practicaltreatis00muss_0_1151.jp2"}, "1152": {"fulltext": "1050 SPECIAL DIAGNOSIS.\\nthat may involve the arms as well as the legs, and sometimes the trunk.\\nA girdle sensation is also frequently present. Finally, muscular atro-\\nphies occur, and even severe trophic disturbances the picture ulti-\\nmately resembling that of acute myelitis.\\nPressure upon the spinal cord may be produced either by injury to\\nthe vertebral column or by growths in or hemorrhages into the mem-\\nbranes. The symptoms are those of transverse lesion. If due to tumor,\\nthey develop very slowly if due to traumatism, as a rule, very rapidly.\\nThere is weakness or paralysis of the legs, with increase of the muscle-\\ntone and exaggeration of the reflexes. Ankle clonus is almost invariably\\npresent. The pains are usually due to pressure upon the posterior roots,\\nand are paroxysmal and lightning-like in character. Girdle sensation\\nis also present. The muscles supplied by the segments of the cord\\ninvolved undergo degenerative atrophy.\\nLandry s Paralysis. This is characterized by progressive paralysis\\nof the legs, arms, and muscles of the throat, leading ultimately to\\ndeath. The first symptoms noted are weakness of the legs, which may\\ninvolve both, or at first only one. This gradually ascends, and at the\\nsame time the patient notices paresthetic sensations. There are, how-\\never, few or no objective sensory disturbances excepting occasionally\\na slight hyperesthesia. The reflexes are lost, the muscles are without\\ntone, and the paralysis is, therefore, flaccid. Electrical changes do not\\noccur, or only in very chronic cases. The paralysis gradually ascends,\\ninvolving the muscles of the abdomen, the thorax, and arms. When\\nthe thorax is involved the patient usually has rapid respiration, and\\ncomplains of dyspnoea. Later there are symptoms of bulbar involve-\\nment, difficulty in deglutition, and interference with speech. The\\ndiaphragm becomes paralyzed, and the patients die as a result of\\nexhaustion. The intelligence remains normal throughout the disease\\nthere is never loss of consciousness and there is no disturbance of the\\nfunction of the bladder or rectum. Fever does not occur.\\nHemorrhage into the Cord (spinal apoplexy). This is characterized\\nby the sudden interruption of the functions of the cord at a certain\\nlevel. There is usually, at the time the hemorrhage occurs, severe\\npain, then rapidly developing paralysis of the legs, which may be\\nflaccid if the lumbar region is involved, or spastic if the lesion is\\nhigher up. Heniatoniyelia into the cervical region may cause paralysis\\nof the arms, but death usually occurs suddenly. The sensory dis-\\nturbances are irregular in character. At times there is dissociation of\\nsensation, more frequently complete anesthesia up to the level of the\\nhemorrhage. The patient has no fever, consciousness is not disturbed,\\nbut there is interference with the functions of the bladder and rectum.\\nOccasionally the hemorrhage involves particularly one side of the cord\\nor only one-half of the gray matter, producing the syndrome of Brown-\\nSequard (q. v.). The diagnosis can frequently be made from the subse-\\nquent course of the case. If death does not occur, rapid improvement\\nis usually the rule. The sphincters regain their functions, power\\nreturns in the limbs, and ultimately the patient may recover com-\\npletely. In some cases, however, the recovery, although pronounced,\\nis only partial.", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1152.jp2"}, "1153": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM. 1051\\nSyringomyelia (cavity in the spinal cord). This is characterized by a\\ngroup of symptoms whose occurrence together is almost pathognomonic.\\nFirst, dissociation of sensation pain and temperature senses are lost\\ntactile and muscle senses are retained. Second, degenerative atrophy\\nof the muscles, associated with fibrillary twitchings and alteration of\\nthe electrical reactions. Third, trophic lesions which may involve the\\nskin, particularly that of the fingers or the joints. The disease appears\\nto develop with extreme slowness. The earliest symptoms may be the\\noccurrence of painless whitlows that is, inflammation around the\\nfinger-nail, with perhaps the ultimate destruction of the nail itself.\\nThese may recur in one finger after another for several years and\\nwithout the presence of any other symptoms, excepting perhaps a\\nslight disturbance of sensation in the fingers. Later, muscular atro-\\nphies appear. These involve particularly the muscles of the shoulder\\nor the hand. In the latter situation they may give rise to the appear-\\nance that occurs in progressive spinal muscular atrophy. At the same\\ntime the sensory disturbances become more pronounced, gradually\\nascending the arm and perhaps involving the trunk. The upper\\nborder forms a horizontal line about the body that is, the alterations\\nare segmental in type. The trophic changes may then assume a more\\nsevere form, giving rise to deep, painless ulcerations in the fingers, and\\nperhaps loss of the terminal phalanges. For a long time the symp-\\ntoms may remain almost exclusively unilateral, and it is rare for the\\ntwo sides to be equally affected. The motor symptoms, aside from the\\nweakness resulting from the muscular atrophy, consist of weakness of\\nthe legs with exaggeration of the reflexes that is, spastic paraparesis.\\nAt times the lower portion of the cord is particularly affected, and then\\nthe sensory and trophic changes are found in the legs. Station may\\nbe slightly altered in the latter stages of the disease, but this is by no\\nmeans a characteristic symptom. Ultimately the patient develops scoli-\\nosis, trophic changes affect other parts than the hands, giving rise to\\narthropathies, or to a form of dry arthritis with absorption of the bone.\\nThere may be vasomotor disturbances, and in some cases inequality of\\nthe pupils. The intellect is undisturbed. The patients ordinarily die\\nas a result of exhaustion or pulmonary involvement, but occasionally\\nin the latter stages of the disease bulbar symptoms occur.\\nMorvan s Disease. This is characterized by the appearance of painless\\nwhitlows in the fingers, sometimes associated with deep ulcerations of the\\nsoft parts. There are usually sensory disturbances similar to those\\nfound in syringomyelia, with the addition of tactile anaesthesia, but\\nmuscular atrophy rarely exists. The disease is exceedingly chronic.\\nIt is possibly only a variety of syringomyelia.\\nTraumatism of the Spinal Cord. This may either produce destruc-\\ntion, partial or complete, of the tissue of the cord itself, giving rise to\\nthe syndrome of transverse interruption, or else give rise to a group\\nof indefinite motor, sensory, and mental disturbances that have been\\ngrouped under the term traumatic neuroses. (See Hysteria.) The\\nsymptoms, the result of organic lesion, may come on gradually or\\nimmediately. They are similar to those produced by pressure upon\\nthe cord.", "height": "4416", "width": "2676", "jp2-path": "practicaltreatis00muss_0_1153.jp2"}, "1154": {"fulltext": "1052 SPECIAL DIAGNOSIS.\\nDiseases of the Brain Characterized by General Symptoms and\\nSensory and Motor Disturbances.\\nDiseases Characterized by Mental, Motor, Sensory, and\\nSometimes Trophic Disorders.\\nExternal pachymeningitis is a rare condition, usually secondary to\\ntraumatism or abscess, characterized by fever, headache, often sharply\\nlocalized, and convulsions. Frequently the symptoms are masked.\\nIf there is much thickening of the membrane, evidence of focal dis-\\nease in the form of paralyses or convulsions may be present. Hcema-\\ntoma of the dura mater is a condition usually occurring in cases of\\nchronic disease. There may be slight fever and headache without\\nother symptoms. In some cases, however, the onset is sudden and\\napoplectiform in type. The patients develop hemiplegia, unconscious-\\nness, and occasionally unilateral convulsions.\\nInternal or Leptomeningitis. The symptoms vary according to the\\nnature of the process, its localization, and extent. The patient may\\nfor a few days preceding an attack complain of malaise and headache,\\nthen there is often a chill followed by fever, convulsions, and delirium.\\nThe headache becomes more intense, and frequently there is vomiting,\\nsometimes without associated nausea. The headache is usually severe,\\nand often localized to the frontal or occipital regions occasionally,\\nhowever, it is more general. From time to time there are acute exacer-\\nbations, causing the patient to cry out the hydrocephalic cry. The\\nskin is hypersesthetic all the sensory nerves have their functions\\nincreased there is photophobia and inability to tolerate noises. Fre-\\nquently there is paresis of the vasomotors of the skin, so that localized\\ncutaneous irritation, such as may be produced by drawing the end of\\na blunt object across the surface, gives rise to a persistent red mark\\n(tdche cerebrate). The patient usually lies with the head drawn far back\\nand the muscles of the neck tense and rigid. This, however, occurs\\nonly when the cervical portion of the spinal cord is also involved. It\\nis an exceedingly important and an almost pathognomonic symptom.\\nAny attempt to straighten the head causes intense pain. Examination\\nof the eye-grounds usually shows intense congestion and more or less\\nperineuritis. Sometimes there is very distinct choked disk. The\\npupils are often unequal, and strabismus and even nystagmus fre-\\nquently occur. Paralysis of any of the cranial nerves indicates that\\nthe process is chiefly localized at the base, as in tuberculous meningitis.\\nParalysis of the oculomotor or some of its branches is exceedingly com-\\nmon. The facial nerve may also be paretic. The tendon reflexes are\\nusually somewhat exaggerated, muscular tone is increased, and occa-\\nsionally there is distinct monoplegia or hemiplegia. Fever, headache,\\nand delirium usually persist throughout the course of the disease and\\nthe former is often very high. The different forms of meningitis are\\noften difficult to discriminate. By means of Quincke s lumbar puncture\\nit is sometimes possible to make a bacteriological diagnosis from the fluid\\nwithdrawn. Meningitis due to certain pyogenic micro-organisms, such as\\nthe pneumococcus, staphylococcus, etc., may be suspected when the", "height": "4412", "width": "2592", "jp2-path": "practicaltreatis00muss_0_1154.jp2"}, "1155": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM. 1053\\nfever is high there is marked retraction of the head, indicating spinal\\ninvolvement, and the course is steadily progressive to death. Some\\nother disease may often be associated with the meningitic symptoms,\\nor it may have occurred previously, as pneumonia, typhoid fever, etc.\\nEpidemic cerebro-spinal meningitis may simulate the symptoms of\\npurulent meningitis exactly. In some cases, however, the course is\\nmore prolonged, and even wdien the termination is fatal there is apt to\\nbe a remission of longer or shorter duration. Tuberculous meningitis\\nis usually characterized by the presence of paralyses of some of the\\ncranial nerves, particularly those of the eye muscles, and the absence\\nof symptoms of spinal involvement. This disease may run an exceed-\\ningly slow course, and the diagnosis is often for a time impossible.\\nKernig s sign is said to be pathognomonic of meningitis. It consists\\nof the inability of the patient to straighten the leg when the thigh\\nhas been flexed upon the abdomen and the leg upon the thigh.\\nCerebral Hemorrhage (apoplexy). This is characterized by a great\\nvariety of symptoms, depending largely upon the location of the lesion.\\nThey may be divided into those of the attack and those that are perma-\\nnent. The symptoms of the attack consist of prodromata that is, head-\\nache, tendency to vertigo, a sense of fulness in the head, roaring in the\\nears, and perhaps some thickness of speech. These may pass off without\\nan attack or may lead directly to it. The attack itself is usually char-\\nacterized by the sudden occurrence of complete unconsciousness. The\\npatient falls to the ground, and there is at first a temporary pallor.\\nThis is succeeded by flushing of the face, which may become almost\\npurple. The pulse is full and bounding and with difficulty compress-\\nible. The breathing is stertorous, the eyes are partially opened the\\npupils are usually contracted and often unequal. Often there may be\\nvomiting, or involuntary micturition or defecation. The limbs remain\\ncompletely paralyzed, or in some cases there are unilateral convulsions.\\nIf, as is commonly the case, the hemorrhage has involved the motor\\ntract, there is complete flaccid paralysis of one side, with, however,\\nincreased reflexes. If death does not occur in the course of the first\\ntwenty-four hours, the patient usually begins to shoAv signs of con-\\nsciousness, and may be aroused from his comatose condition by sharp\\nquestioning. The patient then ma} r go into a still more deeply coma-\\ntose condition, with rise of temperature, followed by death, or there\\nmay be no further indications of hemorrhage, and recovery may set in.\\nAs a rule, in those cases in which the prognosis is favorable no rise of\\ntemperature occurs. It may now be found that the patient has hemian-\\nopsia, usually the visual fields on the same side of the lesion being\\nblinded. Conjugate deviation may or may not have existed from the\\nfirst, the patient ordinarily looking toward the sound side. If the\\nspeech centre has been involved, there is absolute aphasia but even\\nwhen it is not directly affected partial aphasia is very common. The\\nhemiplegic limbs remain paralyzed the others regain their power. It\\nis now necessary to determine the extent of the damage and to locate\\nas nearly as possible the situation of the lesion. Complete hemiplegia\\nmay involve the lower branch of the facial, the arm, and the leg. The\\nupper branch of the facial and the muscles of the trunk commonly", "height": "4416", "width": "2648", "jp2-path": "practicaltreatis00muss_0_1155.jp2"}, "1156": {"fulltext": "1054 SPECIAL DIAGNOSIS.\\nescape, although the former may show slight paresis. Sensory disturb-\\nances may or may not be present. There is sometimes loss of all forms\\nof sensation and sometimes disturbance of only the tactile or the mus-\\ncular sense. Occasionally when tactile sense is preserved there may\\nbe loss of the stereognostic sense. Complete hemiplegia with disturb-\\nance of sensation almost invariably indicates destruction of the internal\\ncapsule upon the opposite side. Motor disturbances in the form of clonic\\nconvulsions may also occur in the paralyzed limbs, and occasionally,\\nprobably as the result of a double lesion, in the limbs of the sound\\nside. They are commonly the result of cortical lesion, irritating in\\ncharacter, either infarction, or else some growth pressing upon and\\ninvolving the cortex. As the case progresses there is usually more\\nor less return of motor power and almost complete return of sensation.\\nThis may, however, be exceedingly gradual, several weeks elapsing be-\\nfore the sensory disturbances have entirely disappeared. The muscles\\nthat remain permanently paralyzed gradually atrophy, but nearly always\\ngive normal qualitative electrical reactions until the muscular substance\\ndisappears, leaving contracted fibrous tissue. The muscles themselves\\nmay show early contractions, the flexors ordinarily overcoming the\\nextensors. Repeated attacks of apoplexy are by no means uncommon,\\nand the double lesions thus produced may give rise to very complex\\nsymptom-groups. (See, also, Cerebral Localization and Aphasia.)\\nCerebral Embolism and Thrombosis. This is a condition characterized\\nby symptoms very similar to those of cerebral hemorrhage. Prodromal\\nsymptoms, in the form of headache, vertigo, weakness, and malaise, are\\noften present. At times there also may be slight impairment of speech,\\nor the patient may be dull and apathetic. The attack usually comes\\non more gradually than hemorrhage, although this is not invariably\\nthe case. In some instances consciousness is not entirely lost, and as\\na result the hemiplegia may develop before the coma. When uncon-\\nsciousness does occur there is usually less congestion of the face and\\nnot such marked evidence of increased arterial tension as we find in\\nhemorrhage. Among the other general symptoms may be mentioned\\nconvulsions, vomiting, and occasionally delirium. The permanent\\nsymptoms resemble exactly those produced by hemorrhage, but\\nrecovery is usually more rapid and more complete than in the former\\ncondition. Apoplexy occurring in children differs from that occurring\\nin adults only by the fact that the initial symptoms are more severe, and\\nthe convulsions are frequent and may be repeated. The permanent\\nsymptoms differ slightly, inasmuch as aphasia rarely persists. The\\nparalysis may be partial, and may in some instances be replaced by\\nathetoid movements. Sensation is rarely impaired.\\nBulbar paralysis is a disease of the peripheral motor neurons arising\\nin the medulla. It is characterized by the degeneration of the muscles\\nof the lips, tongue, and pharynx. The course is slowly progressive.\\nThe earliest symptom is dysarthria, then difficulty in swallowing,\\nchewing, and phonation. The face becomes expressionless, the mouth\\nremains open, saliva dribbles from it, and occasionally the eyelids are\\ninvolved and the eye remains open (logophthalmus). The cardiac\\naction and respiration may be rapid. Death usually occurs as a result", "height": "4416", "width": "2576", "jp2-path": "practicaltreatis00muss_0_1156.jp2"}, "1157": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM. 1055\\nof inspiration pneumonia, or exhaustion. In the variety known as\\nasthenic bulbar paralysis there may be long remissions or even per-\\nmanent recovery.\\nEncephalitis. This is a condition that rarely can be diagnosed during\\nlife. It may be suspected, however, if, in the course of some other\\nacute infectious disease, the patient develops intense headache, severe\\ndelirium, and perhaps local palsies. There may be general exaggera-\\ntion of all the reflexes, with ankle clonus, and usually hyperesthesia of\\nthe skin, and exaltation of the special senses. Examination of the\\neye-grounds usually fails to reveal optic neuritis.\\nAbscess of the Brain. This is a local disease, giving rise to local\\nand general symptoms. General disturbances are chiefly fever, chills,\\nleukocytosis, headache, and delirium. The symptoms of focal dis-\\nease depend, of course, upon the location of the abscess. The com-\\nmonest seat is in the temporo-sphenoidal lobe, as a result of infection\\nfollowing ear disease. This often gives rise to mind-blindness or\\namnesia. Sometimes there are no general symptoms if the abscess is\\nlocated in the blind regions of the brain. The focal symptoms may\\nnot be manifest until rupture has occurred. This often gives rise to\\nan epileptiform attack.\\nTumors of the Brain. Like the preceding lesion, these give rise to\\ntwo groups of symptoms general, which are merely those of increased\\nintracranial pressure or local, due to the involvement of centre and\\ntracts. The general symptoms of brain tumor are (1) headache. This\\nis usually very severe, of a boring character, and subject to exacer-\\nbations (2) vomiting. This is paroxysmal, and often occurs without\\nnausea (3) papillitis. It usually occurs early, is intense, and often\\nleads rapidly to blindness. The local symptoms are, of course, numer-\\nous. Tumors in the frontal lobe give rise to none, or at most to some\\ndisturbance of intelligence and perhaps a tendency to make puns.\\nTumors in the motor region may cause irritative or destructive changes\\nin the tissue. Irritation is manifested by local spasms, which may or\\nmay not be succeeded by general convulsions (Jacksonian epilepsy).\\nParalytic lesions are those of monoplegia or hemiplegia. Tumors in\\nthe parietal lobes may cause interference with the muscle sense or\\nsome disturbance of vision or speech centres, according to their situa-\\ntion. Tumors in the occipital lobes usually cause mind-blindness\\nthat is, inability to recognize objects, and preservation of the pupillary\\nreflexes. Tumors in the different fossa of the skull often give rise to\\nsymptoms dependent upon pressure upon the cranial nerves. In the\\nanterior fossa there may be loss of the power to smell upon one side.\\nIn the middle fossa the nerves chiefly affected are the optic, giving\\nrise to unilateral blindness, or, if the tumor involve the chiasm, to\\nbitemporal hemianopsia the oculomotor nerves, the abducens and\\nthe pathetic, giving rise to more or less complete ophthalmoplegia.\\nTumors in the posterior fossa commonly involve the facial and\\nauditory nerve, and it is said that facial paralysis with nerve-deafness\\non the same side is characteristic of tumor in this situation. The\\nhypoglossal nerve may also be involved. Tumors may, of course,\\ngrow slowly, rapidly, or cease to increase in size, and the symptoms", "height": "4416", "width": "2660", "jp2-path": "practicaltreatis00muss_0_1157.jp2"}, "1158": {"fulltext": "1056 SPECIAL DIAGNOSIS.\\nshow a corresponding rate of development. In rapidly growing\\ntumors apoplectiform attacks are frequent, but a certain amount of\\ncompensation occurs, and remissions are not uncommon. In slowly\\ngrowing tumors the symptoms may remain apparently stationary for\\nlong periods. Tumors are sometimes entirely latent, and are simply\\ndiscovered accidentally at the autopsy.\\nSclerosis of the Brain. This is usually a diffuse or a multiple lesion\\nthat gives rise to a great variety of symptoms, more or less indefinite\\nin character. Ordinarily the lesion is congenital, or develops shortly\\nafter birth. The patient remains an imbecile or an idiot, and soon\\ndevelops epileptic convulsions. If the sclerosis is more pronounced\\non one side than the other there is usually a tendency to fall toward\\nthe opposite side. There may be arrest in development in these limbs,\\nand more or less muscular paralysis. Occasionally, apparently as a\\nresult of foetal thrombosis or embolism, the sclerosis may be limited\\nto one portion of the brain or even to one hemisphere. In this case\\nthere is always arrest in the growth of the opposite side of the body.\\nHydrocephalus (chronic infantile form). This is characterized by an\\nextraordinary alteration in the contour of the head, which becomes\\ngreatly enlarged and globular in shape, while the face remains small\\nand infantile in appearance. The symptoms are sometimes exceedingly\\npronounced at other times entirely absent. Persons with a moderate\\ndegree of hydrocephalus have displayed through life a normal intelli-\\ngence. In other cases the head is heavy and the muscles of the neck\\nunable to support it. The child is an imbecile or an idiot, and epileptic\\nconvulsions are very common. Occasionally ocular symptoms may be\\npresent. These consist of ptosis, strabismus, or nystagmus, and some-\\ntimes of atrophy of the optic nerve, and blindness.\\nAcute Delirium. This is a disease characterized by prodromata and\\na stage of excitation, and usually terminates in death. The prodromata\\nconsist of disturbances of the general health, loss of appetite, and in-\\nsomnia. The patient is restless, anxious, and may show diminution of\\nintelligence, and become more or less violent. He then rapidly\\npasses into the stage of excitation, is restless, noisy, and frequently\\nhomicidal, shouting disconnected words or sentences, singing or shriek-\\ning. Sometimes there are delusions of persecution, and he attempts to\\nescape. In addition, there are the symptoms of the so-called typhoid\\nstate, high fever, profound prostration, dry tongue, and rapid and weak\\npulse. The patient refuses all food, is continually active, and emaciates\\nvery rapidly. Among the objective symptoms are increase of the\\nreflexes, narrowing of the pupils, and hyperesthesia, with more or less\\nhypalgesia. From this stage the patient passes into a state of collapse,\\nlies in a condition of muttering delirium, with carphology, and usually\\ndies from exhaustion.\\nGeneral paralysis of the insane is a form of progressive dementia\\ncharacterized by delusions of grandeur or states of depression associ-\\nated with exacerbations of maniacal character. There are, in addition,\\nweakness and tremors of the muscles of the face, paresis of the extremi-\\nties, the Argyll-Robertson pupil, and peculiar disturbances of speech.\\nIt is usual to recognize three stages. The prodromal stage, character-", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_1158.jp2"}, "1159": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM. 1057\\nized by irritability or sometimes by depression diminution or loss of\\nthe moral sense impaired judgment, particularly in business affairs\\nand a tendency to extravagance and dissipation. Frequently symptoms\\nassociated with degeneration, such as intolerance for alcohol, intense\\negotism, etc., appear. The sexual function in this stage is often greatly\\nincreased. Memory fails and the intellectual capacity is considerably\\ndiminished. There are often slight disturbances of speech, and some-\\ntimes paralytic pupils. Frequently there is insomnia and occasional\\nattacks of migraine. In the second stage, which usually develops\\ngradually, the attacks of migraine are replaced by apoplectic or epileptic\\nattacks or by distinct maniacal conditions memory is greatly impaired,\\nthe intellect is considerably disturbed, the patient becoming unable to\\ndo easy mathematical problems, to comprehend his environment, or\\nto sustain a simple conversation. Usually there are delusions of gran-\\ndeur, the patient believing himself rich, beautiful, successful, intelligent,\\nand reiterating constantly his advantages, although from time to time\\nthere will be states of depression and partial recognition of the failure\\nof power. In other cases, however, particularly chronic alcoholics,\\nthere is distinct melancholia the patient is hypochondriacal, or may\\nhave delusions of persecution, or a sense of misfortune. The disturb-\\nances of speech are characteristic the most common is the omission\\nof syllables. This may best be tested by asking the patient to repeat\\ncertain words, particularly those containing a number of r s and l s, as\\nthird riding artillery brigade, truly rural, etc. There is marked\\ntremor of the lips and of the tongue, producing a sort of ataxia in the\\nspeech, with the disturbance of the formation of nearly all the sounds.\\nThe pupillary changes are similar to those described in the prodromal\\nstage, but usually are more pronounced. The extremities are weak,\\nand often exhibit distinct tremors. Finally, the patient becomes com-\\npletely demented, usually lies quietly and placidly in bed, or occasion-\\nally mutters unintelligible sounds. Sensation, either as a result of\\nimpaired perception or because of degenerative changes in the periph-\\neral nervous system or the spinal cord, becomes greatly impaired,\\nparticularly the pain-sense. The patient is unable to stand, and has\\ninvoluntary or rather unperceived micturition and defecation, and fre-\\nquently develops bed-sores or cystitis. A curious and quite common\\nsymptom is the gnashing of the teeth, which in some cases is almost\\npersistent. Death usually occurs from exhaustion. Among the less fre-\\nquent symptoms are a curious unsteadiness of gait, exaggeration of the\\nreflexes, rapid diminution in weight, particularly in the last two stages.\\nEpilepsy. This is a condition characterized by attacks of clonic\\nconvulsions, associated with loss of consciousness and usually some\\nimpairment of intelligence. In the characteristic epileptic fit we can\\nusually distinguish three stages the prodroma, the attack, and the\\npostepileptic stage. In the prodromal stage aura? are frequently\\npresent. These may be of the most varying character. A patient\\nmay either have a curious sensation in the epigastrium, paresthesia\\nin a limb, and the subjective sensation of movement, or disturbance of\\nthe special senses, particularly an unpleasant odor or a whirring sound.\\nSometimes the sensations are painful or distressing, as a sense of con-\\n67", "height": "4416", "width": "2664", "jp2-path": "practicaltreatis00muss_0_1159.jp2"}, "1160": {"fulltext": "1058 SPECIAL DIAGNOSIS.\\nstriction about the throat. At other times there is giddiness, vertigo,\\nor nausea, or the recurrence of some particular idea. Occasionally the\\naurse consist of some imperative movement, such as whirling about,\\nrunning, or jumping. At the commencement of the attack there is\\nusually a cry the epileptic cry. Ordinarily this is a curious sort of\\ngasping, due to the forcible contraction of the thorax and partial closure\\nof the glottis. In some cases, however, it may be a loud shriek. The\\npatient then falls to the ground, and the convulsive movements com-\\nmence. These are rarely of equal vigor on both sides the head and\\neyes show conjugate deviation the face is bluish and pallid the mouth\\nis filled with frothy fluid, which is often blood-stained, on account of\\nbiting the tongue the limbs may be extended or flexed in tonic con-\\ntraction. This is soon replaced by a violent to-and-fro tremor. The\\npatient is completely unconscious, and may, in falling, cause himself\\nserious injury. There is no conjunctival reflex, the pupils are widely\\ndilated frequently the urine is passed during the attack, and there is\\noccasionally profuse sweating. Toward the end the convulsions become\\nless frequent. Respiration is re-established at first irregular, then gradu-\\nally it becomes more aud more steady. The cyanosis disappears, and\\nthe patient usually passes into a profound sleep. This may last several\\nhours, and he then awakes, feeling dull and fatigued, but otherwise\\nnormal. At other times, immediately after the attack, there is vomit-\\ning or nausea, and sometimes a feeling of excessive hunger. He may\\nbecome maniacal, usually with homicidal mania, or the postepileptic\\nstage may be manifested by nothing more serious than some imperative\\nmovement, such as running or shouting. The convulsive stage may be\\nreplaced by purely sensory phenomena, without .complete loss of con-\\nsciousness, or there may be merely a fine tremor, or the patient may\\nsimply run or be otherwise violent, while wholly unconscious.\\nPetit Mai. In this condition the loss of consciousness is so transitory\\nand the motor symptoms are so slight that its nature often escapes\\ndetection. The patient, if talking, will suddenly stop for a moment\\nthere is a peculiar rigidity of the expression and perhaps slight sway-\\ning. This will disappear almost immediately, and the patient will\\nresume the conversation. Sometimes after these attacks there will be\\na feeling of drowsiness for a short period. Aurse may be present in the\\nform of giddiness or twitching of the limb. The attack may also occa-\\nsionally be ushered in with a scream or a peculiar gasping expiration.\\nImmediately after the attack automatic movements may be performed.\\nAttacks of petit mal often occur during sleep, and the only symptoms\\nthen that point to the existence of the disease are a feeling of heaviness\\nin the morning, perhaps a sore and bitten tongue, and nocturnal enuresis.\\nFocal epilepsy (Jacksonian epilepsy). This form resembles general\\nepilepsy, with the difference that the motor or the sensory disturbances\\nalways commence in the same part of the body, and from this part\\ngradually extend until they become general. Thus, the thumb may\\nfirst be affected, showing a tonic and then a clonic spasm then the\\nhand, the arm, the whole of that side, or both sides or the disturbance\\nmay commence in the foot. The disease almost invariably indicates\\nthe existence of a focal lesion in the brain.", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_1160.jp2"}, "1161": {"fulltext": "DISEASES OF THE NEEVOUS SYSTEM. 1059\\nGeneral Symptoms in Epilepsy. Epileptics are usually dull, apathetic,\\nhaving a tendency to excess in eating. An excess of indican is often\\npresent in the urine. Often there is distinct mental impairment, or,\\nwhen the disease occurs early in life, there may be congenital imbe-\\ncility or idiocy. The temper of epileptics is usually irritable, and they\\nare likely to commit acts of violence.\\nMigraine (hemicrania). This is a disease characterized by parox-\\nysmal attacks of headache associated with nausea and vomiting, and\\nfrequently with disturbances of the special senses. The attacks are\\nusually followed by prolonged sleep. The headache is peculiar, in that\\nit commences slowly as a dull but severe pain that gradually increases\\nin intensity, with occasional exacerbations or throbbing, and is limited\\nto one side of the head. Occasionally, however, it is bilateral, but is\\nthen usually unequal. At the same time the patient experiences a\\nsensation of intense nausea that may be followed by vomiting. The\\nspecial senses are affected in various ways. There may be photophobia,\\nhvperacusis, and occasionally the appearance of peculiar scotomata,\\nwhich commence as a bright spot that spreads, the outer edge being of\\nan irregular, jagged character, and finally disappears at the periphery\\nof the field of vision. New lines constantly form at the centre, and\\nfollow those first appearing. Sometimes the patient complains of dim-\\nness of vision, and this may affect only part of the visual field. Occa-\\nsionally there is temporary aphasia, particularly if the pain occurs in\\nthe left side of the head. In addition, the patients may observe vaso-\\nmotor symptoms, paresthesia, or occasionally stiffness or spasms in the\\nlimb. The paroxysm usually terminates in sleep, which may be pro-\\nlonged, and when the patient awakens all symptoms have disappeared.\\nSometimes there is a severe attack of polyuria.\\nMeniere y s Disease. This is characterized by attacks of vertigo, asso-\\nciated with nausea. The attack usually begins with tinnitus, then\\nintense vertigo, which may come on so suddenly that the patient falls\\nto the ground, or else he is obliged to lie down, and remain in this\\nposition until the attack is over.\\nHysteria is a disease due to disturbance of the self-control, producing\\na curious complex of symptoms that appear to be the result of imitation\\nor of a desire to attract attention or sympathy, associated with certain\\ndisturbances of the special senses and of sensation. The psychical symp-\\ntoms are a certain tendency to self-consciousness, so that the patient is\\nanxious to describe his or her sufferings to surrounding persons is in\\nthe habit of performing ludicrous or startling acts for the purpose of\\nattracting attention is emotional, weeping or laughing readily, and\\nis often irritable and suspicious. Among the sensory symptoms are\\nareas of tactile anaesthesia or analgesia. These may involve exactly\\none -half of the body, including the accessible mucous membranes, or\\nthey may be symmetrical in distribution on both sides of the median\\nline, and often form geometrical figures. These are not the result\\napparently of simulation on the part of the patient, because they remain\\nunchanged for a number of days. Tenderness that is, hyperalgesia\\nmay be present over the ovaries and the spine. The areas of anaes-\\nthesia may be transferred from one part of the body to the other,", "height": "4416", "width": "2672", "jp2-path": "practicaltreatis00muss_0_1161.jp2"}, "1162": {"fulltext": "1060 SPECIAL DIAGNOSIS.\\neither spontaneously or as a result of suggestion. The latter is most\\neffectual when the transfer is made by means of a magnet or metals.\\nThe special senses may have their function exalted, so that the\\npatients have an extraordinary acuteness of smell or hearing, or find\\nit difficult to endure strong lights.\\nDepression of the function of the special senses is perhaps more\\ncommon, particularly loss of the sense of smell and taste. Hysterical\\ndeafness is exceedingly rare. Hysterical blindness not infrequently\\noccurs, is characterized by widely dilated pupils, that usually react\\nto light, and, of course, by normal eye-grounds. The hysterical stigmata\\nassociated with the eye are of great importance, partly on account of\\ntheir peculiarities, partly on account of their persistence. The most fre-\\nquent is simple contraction of the formed field. This, however, occurs in\\nother conditions, and is, therefore, not as characteristic as contraction of\\nthe formed field with inversion of the color field that is to say, a red\\nobject will be seen further from the central visual point than a blue one.\\nMonocular diplopia, in the absence of structural defect in the eyeball, is\\npathognomonic of hysteria. In rare cases three images may be perceived.\\nThe motor symptoms are paresis, or occasionally complete paralysis.\\nThe commonest form of this is hysterical aphonia, in which the patients\\nare unable to contract the vocal cords for the purpose of producing\\nsound, but may be perfectly able to cough or perform any other func-\\ntion with them. In these cases speech usually returns suddenly under\\nthe influence of a strong emotion or suggestion. The paralysis in other\\nparts of the body occurs in imitation of some form of organic disease.\\nThus there may be paraplegia, hemiplegia, or monoplegia. Loss of\\npower is rarely complete, and occasionally patients move the limbs\\nwhen they believe themselves unobserved. The electrical reactions\\nremain normal, although the degree of resistance in the skin may be\\ngreatly increased. The reflexes are exaggerated, especially those due\\nto cutaneous irritations, such as the plantar reflex, but ankle clonus\\ndoes not occur. The gait may be staggering, imitating cerebellar\\nataxia or the ataxia due to intoxication sometimes there are tremors,\\ncoarse and irregular, and rarely constant. In some cases of hysteria\\nactual contractures of the muscles occur, indicating the existence of\\ntrophic disorders. Spasmodic contractions sometimes occur in the\\nmuscles of the abdomen, giving rise to an apparent or hysterical\\nabdominal tumor. Actual trophic changes may also occur in hys-\\nterical patients, but these are rare in this country. There may be\\nhemorrhages into or from the skin, particularly from the forehead,\\npalms of the hands, and the soles of the feet (stigmata of the passion),\\nor there may be localized areas of gangrene in the skin.\\nThe attack (crise hysterique) may be divided into the prodromal period\\nand the convulsive. The aurse consist of a variety of sensory disturb-\\nances, of which the most common is the sensation of a ball rising in\\nthe throat (globus hystericus). The patient may also have a sensation\\nof heat or cold, or moisture of the skin, or various painful impressions.\\nOccasionally the tenderness over the ovary is greatly increased (ovaria),\\nand the attack may be precipitated by pressure in this region. It is\\nimpossible to describe all the movements that occur in the grande crise.", "height": "4396", "width": "2592", "jp2-path": "practicaltreatis00muss_0_1162.jp2"}, "1163": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM. 1061\\nThe convulsion may be tonic or clonic. The patient may assume the\\nmost extraordinary positions. Among the most characteristic is opis-\\nthotonos, in which the heels and the back of the head rest upon the\\nfloor or bed, while the body forms an arch or the patient may assume\\nattitudes that suggest or are characteristic of mirth, sorrow, fear, pas-\\nsion, etc. Consciousness is rarely entirely lost, although there may be\\nsubsequently total amnesia for the period of the attack, and, no matter\\nhow violent the movements of the patient, injury to any part never\\noccurs. Gradually the movements become less violent, the patient be-\\ncomes quiet, and consciousness returns. During the attack the pupils\\nare usually dilated, the reflexes may be increased, and respirations are\\ncommonly extremely rapid, in one case that I observed they reached\\n100 per minute. Occasionally the attack may be cut short by pressure\\nupon one of the hysterogenic zones. After the attack the patient may\\nbe perfectly normal. At times there may be persistent, curious, per-\\nverse tendencies, such as unwillingness to eat, or, at least, a simulation\\nof fasting.\\nNeurasthenia is a disease characterized by an exceedingly complex\\nsymptomatology. The symptoms may be divided into the general and\\nspecial groups the former including those common to all forms of\\nneurasthenia, the latter those associated particularly with subjective\\nand objective functional disturbance of the various organs. The mental\\nsymptoms are various. The patients are usually querulous, depressed,\\nand hypochondriacal. They are very irritable, but incapable of\\nprolonged emotional exaltation. They find difficulty in concentrat-\\ning their attention, particularly upon those subjects with which they\\nhave previously been familiar. Memory is impaired and the intellec-\\ntual capacities apparently diminished. It must be remembered, how-\\never, that careful testing of the memory or judgment rarely shows\\nthat it is seriously affected. An important symptom is the insomnia.\\nThis may be of all varieties, but ordinarily the patient, after sleeping\\nin the early part of the night, Avill awaken and be unable to sleep again\\nfor some hours. The statements by the patients in regard to this symp-\\ntom are very unreliable. Frequently they complain of unpleasant or\\nfrightful dreams when they actually have slept. Among the sensory\\nsymptoms the most important is headache. This is of a peculiar but\\nalmost typical form. The patient complains of a heavy, dull feeling,\\nas if wearing some heavy object, the usual simile being a lead helmet.\\nOccasionally the pain is localized sometimes to the occipital region\\nand sometimes to a circumscribed area, the latter usually the result of\\nsuggestion. Another symptom that is very common is pain in the\\nback. This is usually felt in the neck or the lumbar and sacral region\\nit is of a dull, persistent character, and may be associated with points of\\ntenderness over the spine. Occasionally there are disturbances of the\\nspecial senses. The patient may complain of inability to see sharply,\\nor there may be muscse volitantes. At other times he will fail to hear\\ndistinctly or may complain of roaring or tinnitus. Actual diminution\\nof the visual power or of the sense of hearing does not occur. The\\npatients may complain, however, of paresthesias in the limbs and of\\nvarious symptoms usually the result of suggestion. Sensation is other-", "height": "4416", "width": "2656", "jp2-path": "practicaltreatis00muss_0_1163.jp2"}, "1164": {"fulltext": "1062 SPECIAL DIAGNOSIS.\\nwise normal. There is usually a general decrease in muscular power.\\nSometimes this may be preserved for short periods of activity, but\\nfatigue, as a rule, comes on very rapidly. At other times it is impos-\\nsible for the patient to exert the amount of force that would be normal\\nfor his muscular development. Occasionally this weakness is localized\\nto one limb or side of the body. When the patient is directed to hold\\na limb rigid or to extend the fingers forcibly a fine tremor of the\\nextremities occurs. This may be persistent or readily exhausted in\\naddition, fibrillary twitchings of the muscles not infrequently occur.\\nThe tendon reflexes are generally exaggerated. Ankle clonus, however,\\nexcepting the form spoken of as pseudoclonus, is exceedingly un-\\ncommon. Absence of the knee-jerk does not occur in neurasthenia.\\nThe cutaneous reflexes are sometimes greatly exaggerated, sometimes\\ndepressed. Vasomotor symptoms are very common. The patient\\nflushes easily, and there is often dermographia he complains of palpi-\\ntation and occasionally of irregularity of the heart s action. Often\\nperspiration is produced by slight exertion.\\nIn addition to these symptoms, the neurasthenic may complain of\\nvarious local disorders of the nervous system he usually suspects that\\nhe has locomotor ataxia, and he will probably have learned the symp-\\ntoms of this condition sufficiently well to imitate them more or less\\naccurately, or he may believe himself suffering from general paresis or\\nbrain tumor, or any other condition with which he may be familiar.\\nFrom general paresis the diagnosis is sometimes quite difficult unless the\\nArgyll-Robertson pupil, which never occurs in neurasthenia, is present.\\nAnother common form is gastro-intestinal neurasthenia. The patient\\nmay complain of excessive acidity, and, in fact, vomit from time to\\ntime masses of acid material, or there may be difficulty with digestion\\nand hypochlorhydria or anacidity. Constipation is an exceedingly fre-\\nquent symptom. From time to time the patient may also evacuate\\nlarge quantities of mucus, and sometimes there may be persistent\\nmucous diarrhoea. This is one of the most intractable forms of the\\ndisease. Finally, the patient may be a sexual neurasthenic and be-\\nlieve himself to be suffering from organic or functional disease of the\\ngenital organs. To this variety is usually, but I believe incorrectly,\\nreckoned the various types of sexual perversion. The degree of neu-\\nrasthenia is spoken of as mild or severe, according as the symptoms\\nare slight or pronounced.", "height": "4412", "width": "2596", "jp2-path": "practicaltreatis00muss_0_1164.jp2"}, "1165": {"fulltext": "INDEX.\\nA BASIA, 74\\nlV Abdomen, aspiration of, 358\\ncolor of, 727\\nenlargement of, general, 729\\nlocal, 733\\ninspection of, 727\\nmarkings on, 727\\npalpation and percussion of, 735\\nretraction of, 735\\nshape of, 729\\ntopography of, 725\\nAbscess of brain, 1055\\nfecal, 743\\nof kidney, 966\\npelvic, 744\\npericecal, 743\\nperinephritic, 913\\nin precordial region, 584\\nretropharyngeal, 717\\nsubdiaphragmatic, 753, 764\\nAcetonemia, 958\\nAcetonuria, 936\\nAchromia of red corpuscles, 375\\nAcroparesthesia, 1043\\nAcne, 143\\nAcromegalia, 169\\nActinomyces, 352\\nin sputum, 536\\nActinomycosis, 350\\nof mouth, 694\\npulmonic type of, 351\\nAddison s disease, 124\\nAdenoid vegetations in nasopharynx, 714\\nAdherent pericardium, 648\\nJEgophony, 513\\nin pleurisy, 571\\nJEsthesiometer, 974\\nAge in the etiology of disease, 24\\nAgue, dumb, 285\\nAlbumin in urine, tests for, 921\\nquantitative estimation of, 926\\nAlbuminuria, 927\\nin renal calculus, 905\\nAlbumosuria, 929\\nAlexia, 1000\\nAlkaptonuria, 937\\nAllochiria, 974\\nAlveolar cells in sputum, 523\\nAmaurosis, uremic, 966\\nAmnesia, 1010\\nAmoeba dysenterie or coli, 344\\nin feces, 830\\nin pus, 363\\nin sputum, 528\\nAmoebic dysentery, 342\\nAmyloid degeneration of kidney, 968\\nAnemia, 389, 401\\nblood in, 394\\nclassification of, 390\\nfrom disease, 391\\nfever in, 209\\nin gastric disease, 794\\nfrom hemorrhage, 391\\nlocal, 402\\nfrom malnutrition, 392\\nmurmurs in, arterial, 641\\ncardiac, 637\\nvenous, 641\\nin nephritis, 959\\nneuralgia in, 48\\nparasitic, 391\\npernicious or idiopathic, 393\\nin phthisis, 558\\nsplenic enlargement in, 392\\nsymptoms of, 370\\ntoxic, 390\\nAnesthesia, 972\\ndolorosa, 973\\nAnalgesia, 972\\nAnarthria, 1006\\nAnasarca, 153\\nAneurism, 674\\nof heart, 656\\nthoracic, 674\\ndiagnosis of, 681\\nhemorrhage in, 467\\npain in, 584\\nphysical signs of, 678\\nsphygmogram in, 612\\nAngina Ludovici, 706, 717\\npectoris, 585\\nin aortic regurgitation, 657\\narterial tension in, 606\\nin coronary artery disease, 654\\nAngle of Ludwig, 472\\nAnkle clonus, 988\\nAnkylostomum duodenale, 838\\nAnorexia, 772, 799\\nAnosmia, 419\\nAnthracosis, 327\\nAnthrax, 277\\nbacillus of, 278\\ndistinguished from carbuncle, 279\\nintestinal form of, 277\\nwool- sorter s type of, 278\\nAntrum, abscess of, 429\\nAorta, aneurism of, 674. See also Aneu-\\nrism.", "height": "4416", "width": "2664", "jp2-path": "practicaltreatis00muss_0_1165.jp2"}, "1166": {"fulltext": "1064\\nINDEX.\\nAorta, atheroma of, murmurs in, 637\\npain in, 584\\npulsation of, 596\\nAortic area, 632\\nobstruction, 659\\ndistinguished from atheroma of\\naorta, 639\\nthrill in, 603\\nregurgitation, 657\\npresystolic murmur in, 665\\npulsation in, distinguished from\\naneurism, 683\\npulse in, 639\\nsphygmogram in, 612\\nthrill in, 603\\nApex-beat. See Heart, impulse of.\\nAphasia, 1000\\nAphonia, hysterical, 1060\\nin pericardial effusion, 645\\nApoplexy, 1053\\nrelation of arterio-sclerosis to, 673\\nAppendicitis, 738\\nabscess formation in, 741\\ncatarrhal, 738\\ndecubitus in, 69\\ndistinguished from acute intestinal\\nobstruction, 851\\nfrom hip-joint disease, 742\\nfrom perinephritic abscess, 743\\nfrom typhoid fever, 302, 740\\ngangrenous, 742\\npain in, 818\\npalpation in, 737\\nperforating, 741\\ndistinguished from acute tubercu-\\nlous peritonitis, 743, 755\\nrecurrent, 740\\ntuberculous, 755\\nAppetite, alteration of, 772, 799\\nApraxia, 1006\\nAprosexia, 715\\nArcus senilis, 96\\nArgyria, 126\\nArrhythmia, 587\\nin auto-intoxication, 203, 211\\nArsenic-poisoning, 216\\nArteries, murmurs in, in arterial sclerosis,\\n673\\npalpation of, 605\\npulsation of, visible, 596\\nin aortic regurgitation, 658\\nsclerosis of, 672\\ntension of, 606\\nArterio-capillary fibrosis, 672\\npulsation of arteries in, 598\\nArthritis, gonorrheal, 178\\nrheumatoid, 185\\nhand in, 113\\ntuberculous, 178\\nAscaris lumbricoides, 833\\nsymptoms of, 815\\nAscites, 729\\ncharacter of fluid in, 730\\ndistinguished from enlargement of\\nliver, 871\\nfrom hydronephrosis, 912\\nAspiration, technique of, 357\\nAstasia, 74\\nAsthma, 459\\ncauses of, 460\\ndecubitus in, 69\\nin nasal disease, 420\\nsputum of, 524\\nAtavism, 29\\nAtaxia, 979\\nAtelectasis, 548\\nAtheroma of arteries, 672\\nmurmurs in, 641\\nAthetosis, 983\\nAuscultation of chest, 502\\nsounds in health, 503, 505\\nof voice, 512\\nAuto-intoxication, 760\\nBACELLTS sign of empyema, 572\\nBacilli of Booker, 836\\nBacillus of anthrax, 278\\nof cholera, 338\\ncoli communis, 363, 835\\nof diphtheria, 333\\ngeneral characteristics of, 221\\nof influenza, 536\\nof leprosy, 349\\nmallei, 336\\nmucous capsulatus, 535\\nof pertussis, 536\\nsmegmse, 532\\nin gangrene of lung, 530\\nof syphilis, 363\\nof tetanus, 353\\nof tuberculosis, 530, 836\\nof typhoid fever, 298\\nof yellow fever, 305\\nBackache, 57\\nin infectious fevers, 201\\nBacteria, general characteristics of, 220\\nBacteriological diagnosis, 229\\nmethods, 230\\napparatus, 231\\ncollection of material, 232\\ncover-slip preparations, 244\\nculture media, 242\\nexamination of blood, 232\\nhanging-drop preparations, 241\\nidentification of organisms, 245\\ninoculation of animals, 244\\nplate culture, 243\\nsmear culture, 244\\nstaining, 240\\nof capsule, 535\\nof tubercle bacillus, 532\\nsterilization, 231\\nBacteriuria, 948\\nBamberger s sign of pericardial effusion,\\n648\\nBaruch s sign of typhoid fever, 301\\nBelching, 802\\nBell tympany in chest, 412\\nBeri-beri, 1046\\noedema in, 152, 153\\nBile in urine, test for, 936", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_1166.jp2"}, "1167": {"fulltext": "INDEX.\\n1065\\nBile-ducts, cancer of, distinguished from\\nhepatic cancer, 882\\ninflammation of, 885\\nobstruction of by gallstones, 886\\nBiliousness, 855\\nbad taste in, 764\\nBlack tongue, 696\\nBlasts, 375\\nBlepharospasm, 92\\nBlood, alkalinity of, 386\\nbacteriological examination of, 232\\ncolor index of, 385\\ncounting the corpuscles of, 376\\ncover-slip preparations of, 372\\nin gastric contents, test for, 782\\nhaemoglobin of, 384\\nleucocytes of, 379\\nparasites in, 388\\nphysical appearance of, 371\\npigment in, 386\\npressure of, 414\\nred corpuscles of, 375\\nnumber of, 379\\nserum as culture media, 242\\nspecific gravity of, 387\\nstaining of, 373\\nin stools, 820\\nin urine, 928, 940\\nBoils in diabetes, 934\\nBones, the, 169\\nin osteitis deformans, 170\\nin rickets, 172\\nBothriocephalus latus, 833\\nsymptoms of, 814\\nBoulimia, 772\\nBradycardia, 609\\nin jaundice, 861\\nin typhus fever, 249\\nBradylalia, 1006\\nBrain, abscess of, 1055\\ngeneral symptoms of disease of, 1024\\nsclerosis of, 1056\\ntumors of, 1055\\nchoked disk in, 100\\nBrawny induration, 157\\nBreath, fetor of, 687, 708 _\\nBreathing. See also Respiration.\\namphoric, 508\\nbronchial, 503, 507\\nin pleural effusion, 571\\nbroncho-vesicular, 504, 509\\ncavernous, 508\\njerking inspiration in, 506\\nprolonged expiration in, 506\\ntubular, 508\\nvesicular, 503\\nexaggerated, 505\\nfeeble or absent, 505\\nBroadbent s sign of adherent pericardium,\\n596\\nrone\\nBronchiectasis, 566\\ndistinguished from phthisis, 567\\nBronchitis, acute, 542\\ndiagnosis of, 543\\ncapillary, 545\\nBronchitis, chronic, 544\\nfibrinous coagula in, 524\\nlithsemic, 856\\nplastic, 546\\nputrid, 547\\nBronchophony, 513\\nBronchorrhoea, 545\\nBronzing of skin, 124\\nBrown-Sequard s syndrome, 1025\\nBulbar paralysis, 1054, 1056\\nCAECUM, abscess about, 743\\ninflammation of, 742\\nCachexia, cancerous, 412\\nin gastric cancer, 810\\nmalarial, 289\\nvarieties of, 67\\nCalculus, biliary, 885\\nrenal, 902\\nCancer. See Carcinoma.\\nCantering rhythm of heart, 627\\nCapillary pulse, 598, 659\\nCaput Medusse, 728, 877\\nCarbuncle in diabetes, 934\\ndistinguished from anthrax, 279\\nCarcinoma, cachexia of, 412\\nfascies of, 81\\ngastric, 808\\npain in, 771\\nsupraclavicular glands in, 159\\ngeneral symptoms of, 411\\nof larynx, 441\\nof lung, 567\\nhaemoptysis in, 467\\nof oesophagus, 722\\nof peritoneum, 754\\nof skin, 158\\nCardialgia, 770\\nCardio-hepatic triangle, 615, 646\\nCarreau, 736, 758\\nCase-records, 22, 536\\nCasts in urine, 941\\nin renal calculus, 905\\nwithout nephritis, 944\\nCataract, 99\\nCatarrh, nasal, 427. See also Rhinitis.\\nsuffocative, 545\\nCatarrhe sec, 544\\nCavities, pulmonary, 514\\nbronchophony in, 413\\ndistinguished from pneumotho-\\nrax, 578\\nphysical signs of, 514\\nCercomonas intestinalis, 831\\nCerebellar gait, 73\\nCerebellum, symptoms of affections of,\\n1020\\nCerebral localization, 1011\\nbasal centres, 1018\\ncortical, 1015\\nmedullary, 1019\\nhemorrhage, 1053\\nthrombosis and embolism, 1054\\nCerebro-spinal fever. See Meningitis.\\nChalicosis, 551", "height": "4416", "width": "2668", "jp2-path": "practicaltreatis00muss_0_1167.jp2"}, "1168": {"fulltext": "1066\\nINDEX.\\nCharcot-Leyden crystals in nasal discharge,\\n426\\nin sputum, 526, 546\\nChest in adenoid disease, 715\\nangles of, 471\\nauscultation of, 502\\nbarrel-shaped, 477\\nbilateral diminution in size of, 480\\nenlargement of, 477\\nin chronic interstitial pneumonia, 550\\npleural effusion, 576\\ncounting the ribs of, 472\\ndeficient expansion of, 487\\ndeformities of, 483\\nfluoroscopic examination of, 488\\nfluctuation in, 492\\ninspection of, 473\\nlocal changes in size and shape of, 485\\nmensuration of, 515\\nmovements of, 476\\nin disease, 486\\npalpation of, 490\\npercussion of, 492\\nphthisical, 480\\nregions and landmarks of, 471\\nrespiratory capacity of, 516\\nrhachitic, 172, 480\\nshape of normal, 475\\ntopographical anatomy of, 472\\ntransverse groove in, 483\\nunilateral changes in shape of, 583\\nCheyne-Stokes respiration, 487\\nChickenpox, 253\\nChills, 191\\nmalarial, 280\\nChin-jerk, 985\\nChlorosis, 392\\nChoked disk, 100\\nCholangitis, 862, 885\\nCholecystitis, 888\\nCholera, Asiatic, 336\\ndiagnosis of, 338\\nspirillum of, 338\\nfascies in, 81, 337\\ninfantum, 839\\nbacilli of Booker in, 836\\nmorbus, 839\\nnostras, 840\\nspirillum of, 835\\nCholesterin crystals in pus, 363\\nin sputum, 327\\nin urine, 954\\nCholuria, 935\\nChorea, 1039\\nas a sequel to rheumatism, 181\\nin heart disease, 589\\nmovements in, 983\\nChoroiditis, 100\\nChvostek s sign of tetany, 985, 1041\\nChyluria, 948\\nClaudication, intermittent, 979\\nClonic spasms, 982\\nClonus, ankle, 988\\npatellar, 987\\nwrist, 986\\nClubbed fingers in thoracic aneurism, 677\\nCoin test in pneumothorax, 577\\nColic, hepatic, 817, 885\\nintestinal, 816\\nlead, 817\\nrenal, 817, 902\\nuterine, 562\\nColitis, chronic ulcerative, 841\\nCollapse, 65\\nColon, dilatation of, 732, 824\\nColor index of blood, 385\\nComa, diabetic, 958\\nin heart disease, 589\\nurasmic, 956\\nComma bacillus, 338\\nCongestion. See Hyperemia, 402.\\nConjunctiva, the, 96\\nConstipation, 822\\nConsumption. See Tuberculosis, pulmon-\\nary, 555.\\ngalloping, 552\\nConvulsions, 983\\nin heart disease, 589\\nursemic, 956\\nCoprolalia, 1040\\nCor bovinum, 657\\nCornea in general diagnosis, 96\\nCoronary arteries, disease of, 653\\nCorrigan s pulse, 658\\nCoryza, acute, 427\\nsyphilitic, 429\\nCostal angle in rickets, 481\\nCough in aneurism of aorta, 676\\nin bronchiectasis, 566\\nin capillary bronchitis, 546\\ncharacteristics of, 465\\nin chronic bronchitis, 544\\ndry, 465\\nin gastric disease, 773\\nin heart disease, 588\\nlaryngeal, 435\\nin mediastinal disease, 684\\nmoist, 465\\nin nasal disease, 420\\nnervous, 436\\nin pertussis, 466\\nin phthisis, 560\\nin pleurisy, 575\\nof puberty, 465\\nin pulmonary affections, 464\\nreflex and central, 464\\nCoxalgia distinguished from appendicitis,\\n743\\nCracked-pot sound, 501\\nin pneumothorax, 577\\nCramps in uraemia, 957\\nCranial nerves, location of nuclei of, 1020\\nsymptoms of affections of, 1025\\nCraniotabes, 87\\nCranium, auscultation and percussion of, 87\\nCrepitation, 510\\nCretins, facial appearance of, 82\\nCrises of pain, 44\\nin tabes dorsalis, 45, 800\\nCroup, diagnosis of, 442, 443\\nCulture media, 242\\nCurschman s spirals, 525, 546", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1168.jp2"}, "1169": {"fulltext": "INDEX.\\n1067\\nCyanosis, 122\\nin capillary bronchitis, 546\\nin emphysema, 664\\nCylindroids, 945\\nCyrtometer, 515\\nCysticercus of skin, 158\\nCystin in urine, 953\\nCysts, hydatid, 366\\nof kidney, 367\\novarian, 367\\npancreatic, 367\\nDEAF-MUTISM, hysterical, 109\\nDeafness in adenoid disease, 714\\nhysterical, 109\\nin nasal affections, 420\\nnervous, 108\\nDecubitus, 68\\n(abed-sore), 409, 1007\\nDegeneration, fatty, amyloid, etc., 410\\nDelirium, 1010\\nacute, 1056\\nin uraemia, 956\\nDelusions, 1011\\nDengue, 267\\nDental arch in thumb-sucking, 687\\nDermatitis distinguished from erysipelas,\\n311\\nDiabetes insipidus, 916\\nmellitus, 933\\nacetonemia in, 958\\nasthma in, 461\\nbronzing in, 126\\nneuralgia in, 48\\nDiaceturia, 936\\nDiagnosis, bacteriological, 229\\nconditions rendering it impossible, 19\\ndata upon which based, 18\\nDiaphragm, movements of, 476\\nparalysis of, 461\\nphenomenon of Litten, 477\\nDiarrhoea, catarrhal, 819\\nchronic, 822\\nin gastric disease, 773\\nmembranous, 822\\nnervous, 821\\nstools in, 820\\nuraemic, 957, 965\\nDiatheses, varieties of, 66\\nDiazo-reaction in typhoid fever, 294\\nDietl s crises, 908\\nDiphtheria, 330\\nbacillus of, 333\\ndiagnosis of, 333\\ndistinguished from scarlet fever, 260\\nfrom tonsillitis, 713\\nfalse membrane in, 332\\nheart in, 333\\nlaryngeal stenosis in, 332\\nsequelae of, 333\\nuraemia in, 332\\nDiplococcus intracellularis meningitidis,\\n329\\npneumoniae. See Micrococcus Lanceo-\\nlatus.\\nDiplophonia, 433\\nDiplopia, 94\\nDipping in abdominal palpation, 730\\nDistoma hepaticum, 833\\nDropsy. See (Edema.\\novarian, 745\\nDrowsiness in dyspepsia, 773\\nDulness on percussion, 496\\nDuodenal catarrh, 839\\nulcer, 841\\nDupuytren s contraction, 115\\nDysentery, amoeba of, 344\\namoebic or tropical, 342\\ncatarrhal, 341\\ndiphtheritic and gangrenous, 345\\nDyspepsia, atonic, 803\\nflatulent, 804\\nin heart disease, 589\\nnervous, 803\\nreflex, 805\\nDysphagia, 435\\nin aneurism of aorta, 720\\nin disease of larynx, 430\\nof pharynx, 708\\nof oesophagus, 721\\nfrom foreign body in oesophagus, 722\\nmediastinal tumor, 720\\nfrom paralysis of oesophagus, 724\\nin pericardial effusion, 645\\nfrom pressure on oesophagus, 720\\nDysphasia, 1006\\nDysphonia, 432\\nDyspnoea in adenoid disease, 716\\nin aortic aneurism, 677\\nin asthma, 459\\nin capillary bronchitis, 545\\ncauses of, 456\\ndyspeptic, 463\\nin emphysema, 564\\nexpiratory, 435, 464\\nin gastric disease, 773\\nin heart disease, 588\\ninspiratory, 434\\nin laryngeal disease, 433\\nin mediastinal tumor, 684\\nin nephritis, 962\\nin obstruction of trachea or bronchi,\\n456 _\\nin pericardial effusion, 645\\nin pharyngeal disease, 708\\nin phthisis, 560\\nrate of respiration in, 463\\nin retropharyngeal abscesses, 717\\nuraemic, 957, 965 _\\nDystrophies of connective tissue, 156\\nmuscular, 163\\nEAR-cough, 465\\ndischarge from, 107\\nhaematoma of, 107\\ntophi in, 107\\nEcholalia, 1006\\nEczema distinguished from chickenpox,\\n255\\nElastic fibres in sputum, 523", "height": "4416", "width": "2664", "jp2-path": "practicaltreatis00muss_0_1169.jp2"}, "1170": {"fulltext": "1068\\nINDEX.\\nElectrical diagnosis, 991\\nElephantiasis, 162\\nEmbolism, in aortic obstruction, 659\\nin arterio-sclerosis, 403\\ncapillary, 404\\nfat and air,* 404\\nin malignant endocarditis, 651\\nof mesenteric arteries, 815\\npulmonary, 541\\nEmbryocardia, 627\\nin dilatation, 672\\nEmphysema, 564\\natrophic, 566\\nbarrel-shaped chest in, 479\\nbreath-sounds in, 505\\ndistinguished from pneumothorax, 578\\ninterlobular, 566\\nphysical signs of, 565\\nsubcutaneous, 155, 719\\nEmprosthotonos, 70\\nEmpyema, 572\\nnecessitatis, 572\\npulsating, 574\\ndistinguished from aneurism, 683\\nEncephalitis, 1055\\nEndocarditis, 650\\nchronic, 653\\nmalignant, 651\\nfrom pneumococcus infection, 318\\nin rheumatic fever, 180\\nin septicaemia, 227\\nsimple, 650\\nEnophthalmos, 92\\nEnteralgia, 816\\nEnteritis, membranous, 822\\nEntero-colitis, 840\\nEnteroptosis, 748\\nEnuresis in adenoid disease, 715\\nEosinophilia, 382\\nEphemeral fever, 212\\nEpiglottis, inflammation of, 435\\nEpilepsy, 1058\\nfocal or Jacksonian, 982, 1059\\nEpistaxis, 426\\nErgotism, 215\\nEructations, 802\\nEruption in measles, 261\\nin pharynx, 709\\nin scarlet fever, 259\\nin syphilis, 269\\nin typhoid fever, 296\\nin typhus fever, 248\\nin varicella, 254\\nin variola, 251\\nErysipelas, 309\\nErythema, 135\\nof infectious diseases, 139\\nmedicinal, 139\\nmultiforme, 137\\nnodosum, 138\\nnon-contagious, causes of, 136\\nErythromelalgia, 115\\nExophthalmic goitre, 88\\npulse in, 608\\nExophthalmos, 92\\nExploratory puncture. See Aspiration.\\nExudations, 360\\nchylous, 365\\nhemorrhagic, 364\\npurulent, 360\\nseropurulent, 364\\nserous, 365\\nEye, affections of muscles of, 92\\nin scurvy, 188\\nEyelids, oedema of, 91\\nFACE in acromegalia, 169\\nin adenoid disease, 82, 714\\nin erysipelas, 310\\nhemiatrophy of, 83\\nin hereditary syphilis, 82\\nin hydrocephalus, 82\\nin nervous diseases, 82\\nin osteitis deformans, 170\\nin peritonitis, 751\\nin scurvy, 188\\nin tetanus, 352\\nin uraemia, 959\\nin yellow fever, 304\\nFamily relations in the etiology of disease,\\n26,27\\nFarcy, 335. See also Glanders.\\nFascies of various diseases, 81\\nFat in stools in pancreatic disease, 894\\nin urine, 947\\nFauces, examination of, 708\\nFecal abscess, 743\\nimpaction, 737, 824\\nepigastric pulsation in, 597\\nFeces, 825\\nbacteria in, 835\\nblood in, 827,829\\nchemical examination of, 836\\ngallstone in, 827\\nmicroscopical examination of, 828\\nprotozoa in, 830\\nvermes in, 831\\nFeigned disease, detection of, 33. See also\\nPain, Simulated.\\nFestination, 1040\\nFever, arterial, tension in, 199\\naseptic, 209\\nataxic state in, 200\\nin auto-intoxication, 211\\nin carcinoma, 228\\ncerebral symptoms in, 199\\ncerebro-spinal, 326\\nclinical causes of, 203\\ncourse and stages of, 196, 204\\ndaily range of, 198\\ndefervescence of, mode of, 197, 204\\neruptive, 247\\nglandular, 265\\nhepatic intermitting, 206\\ninfluence of age on, 204\\nintermittent, 280\\nin phthisis, 558\\nin intoxication, 209\\nmalarial, 279\\nMalta, 305\\nmiliary, 272", "height": "4416", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1170.jp2"}, "1171": {"fulltext": "INDEX.\\n1069\\nFever, in morphinism, 212\\nonset, mode of, 197\\npathology of, 191\\nin phthisis, 558\\npulse-rate in, 199, 211\\nin reaction from apoplexy, 202\\nrecrudescence of, 198\\nrelapsing, 274\\nrenal, paroxysmal, 905\\nrespiration in, 199, 211\\nrheumatic, 178\\nscarlet, 255\\nin septicemia, 210\\nsimple continued, 212\\nsudden fall of, 205\\nonset of, 204\\nin sunstroke, 211\\nin suppuration, 408\\nsymptoms of, 198\\nin syphilis, 206, 229\\ntongue in, 701\\nin trichinosis, 354\\nin tuberculosis, 205\\ntypes of, 195\\ntyphoid, 289\\nin typhoid fever, 204\\ntyphoid state in, 199\\ntyphus, 247\\nurinary intermitting, 206\\nyellow, 303\\nFibrinous coagula in sputum, 524\\nFibroid change in tissues, 411\\ntumors of uterus, 745\\nFilaria sanguinis hominis, 388\\nin urine, 948\\nFits, 64\\nFlagellse, staining of, 158\\nFlat-foot, pain in, 54\\nFlatulency, 769\\nin diarrhoea, 821\\nFlint, murmur of, 658\\nFluctuation in abdomen, 730\\nFontanelles, 87\\nFoot-and-mouth disease, 273\\nFreckles in rheumatoid arthritis, 126\\nFremitus, friction, 491\\nhydatid, 883\\nperitonea], 754\\nvocal, 490\\nFriction fremitus, 491\\nin pericarditis, 643\\nsound, 511\\ndistinguished from pleural fric-\\ntion, 642\\nfrom rales, 510\\nfrom vascular murmur, 642\\nmediastinal, 650\\nin pericarditis, 629, 641\\npleural, 511\\nFriedreich s ataxia, 1044\\nrespiratory change of sound, 515\\nFunnel- breast, 483\\nG\\nAIT in disease, 70\\nGall-bladder, aspiration of, 868\\nGall-bladder, cancer of, 889\\nenlargement of, 887\\npalpation of, 868\\ntumors of, 888\\ndiagnosis of, 889\\ndistinguished from movable kid-\\nney, 909\\nGallstones, 885\\naccidents resulting from, 887\\ncolic due to, 817\\nobstruction of common duct by, 886\\nGangrene, 409\\nof lung, 563\\nhemoptysis in, 467\\nfrom trophic disturbance, 1007\\nGastralgia, 770,771, 779\\nneurasthenic, 800\\nGastrectasis, 807\\nGastric crises, 769\\nacute, 791\\npain in, 771\\nchronic, 805\\ndistinguished from ulcer and can-\\ncer, 811\\nmycotic and diphtheritic, 796\\nphlegmonous, 796\\ntoxic, 796\\nGastrodiaphany, 774\\nGastrodynia, 770\\nGastroxynsis, 802\\nGerhardt s change of sound, 515\\nGirdle pain, 55\\nGlanders, 335\\nbacillus of, 336\\ndiagnosis of, 336\\nmallein test for, 336\\nGlands, lymphatic, enlargement of, 159\\nGlandular fever, 265\\nGlenard s disease, 748\\nGlobulin in urine, 937\\nGlobus hystericus, 769, 1061\\nGlossitis, 696\\ndissecting, 698\\nGlycosuria, 933,^ 935\\nin pancreatic disease, 894\\nGoitre, exophthalmic, 88\\nGonococcus, 363\\nin blood, 308\\nGonorrhceal septicaemia, 307\\nGout, 183\\nacute articular, 184\\nblood in, 184\\nchronic, 184\\ngastric symptoms in, 762\\nhand in, 114\\nrelation to lithsemia, 856\\nretrocedent, 184\\nteeth in, 691\\nGram s stain, 241\\nGums in cachexia, 690\\nin lead-poisoning, 691\\nin scurvy, 189, 691\\nHABIT spasm, 1040\\nHabits in etiology of disease, 25", "height": "4416", "width": "2660", "jp2-path": "practicaltreatis00muss_0_1171.jp2"}, "1172": {"fulltext": "1070\\nINDEX.\\nHaematemesis, 792\\ndistinguished from haemoptysis, 793\\nin gastric ulcer, 812\\ncancer, 810\\nin hepatic cirrhosis, 676\\nHematocele, pelvic, 744\\nHaematoidin crystals, 364\\nin pus, 527\\nHaematokrit, 378\\nHaematoporphyrinuria, 936\\nHematuria, 928, 940\\nmalarial, 288\\nfrom overexertion, 904\\nin renal calculus, 904\\ncancer, 911\\nHaemocytometer, 376\\nHaemoglobin, 384\\nHsemoglobinometers, 384\\nHaemaglobinuria, 929\\nHsemopericardium, 648\\nHaemophilia, 129\\ndiagnosis of, 130\\nHaemoptysis, 468, 521. See also Hemor-\\nrhage, pulmonary.\\nHemothorax, 593\\nHair in diagnosis, 85\\nHallucinations, 1011\\nHands in acromegaly, 170\\ndeformities of, 110, 113\\nswelling of, 113\\nHanging-drop, method of making, 241\\nHarrison s groove, 172\\nHay-fever, 420, 547\\nHead in rickets, 173\\nHeadache, anaemic, 42\\ncharacter of pain in, 52\\nchronic, causes of, 52\\nin indigestion, 770\\nin infectious fevers, 201\\nin inflammation of frontal bones, 49\\nlithaemic, 770, 856\\nocular, 51\\nin syphilis, 52\\nin uraemia, 956\\nHearing impaired by drugs, 108\\ntests for, 107\\nHeart, aneurism of, 656\\narea of absolute dulness, 614\\nchange in, 615\\ngraphic record of, 619\\nin pericardial effusion,\\n646\\nof deep dulness, 616\\narrhythmia of, 587\\nauscultation of, 619\\ndilatation of, 670\\nacute, 671\\narea of dulness in, 616\\nvalve, shock in, 603\\ndisease of, etiological factors in, 582\\nbradycardia in, 609\\ncough in, 588\\ndropsy in, 588\\ndyspeptic symptoms in, 589\\ndyspnoea in, 588\\ngeneral pathology of, 580\\nHeart, disease of, haemoptysis in, 467, 588\\ninspection in, 592\\nkidneys in, 589\\nnervous symptoms in, 588\\npain in, 583, 585\\npraecordia in, 592\\nretraction of interspaces in, 595\\nin emphysema, 565\\nfatty overgrowth of, 656\\nhypertrophy of, 667\\narea of dulness in, 616\\ndiagnosis of, 670\\nimpulse in, 593, 602\\nepigastric, 597\\nphysical signs of, 668\\nin valvular disease, 657\\nimpulse of, 592\\nabsence of, 594\\nadditional, 595\\narea of, 595\\nchanges in position of, in health,\\n593\\nin dilatation, 671\\ndisplacement of, 593\\npalpation of, 601\\nstrength of, 602\\ninflammation of muscles of. See Myo-\\ncarditis,\\nirregular, in pericardial effusion, 645\\nirritable, 587\\nmurmurs. See Murmurs,\\nneuroses of, 581\\npalpitation of, 586\\npercussion of, 614\\npleximetric, 617\\nrepercussion of, 618\\nphysiology of, 591\\nin pleural effusion, 571\\nright side of, hypertrophy of, 669, 670\\nrupture of, 656\\nsounds, aortic accentuated, 625\\ndiminished, 626\\nmitral, diminished, 626\\nnormal, 620\\ndiastolic, 623\\ndifferentiation of, 623\\nsystolic, 621\\ntransmission of, 623\\npulmonary, accentuated, 625\\ndiminished, 626\\nreduplication of, 627\\nfalse, 629\\nsystolic, accentuation of, 624\\ntopography of, 590\\nvalves of, position of, 591\\nvalvular disease of, chronic, 656\\neffects on heart and pulse, 639\\ngastric symptoms in, 761\\nweakness of, sphygmogram in, 612\\nHeat exhaustion, 212\\nHeberden s nodes, 114\\nHemianopsia, 102\\nHemiplegia, 977\\nHemorrhage, 405\\nin central nervous disease, 131\\ncerebral, 1053", "height": "4408", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1172.jp2"}, "1173": {"fulltext": "INDEX.\\n1071\\nHemorrhage, gastric, 792\\ndistinguished from pulmonary\\nhemorrhage, 469\\ngastro-intestinal, in portal congestion,\\n858\\ninternal, symptoms of, 406\\nintestinal, 824\\nin duodenal ulcer, 841\\nfrom mucous membrane of mouth, 687\\nfrom oesophagus, 719\\nfrom pharynx, 709\\npulmonary, 466\\nin capillary bronchitis, 546\\ncharacter of blood in, 468\\nin chronic interstitial pneumonia,\\n551\\ndistinguished from other forms,\\n469,793\\nin heart disease, 588\\nin infarction of lung, 542\\nin phthisis, 553, 560\\nsymptoms of, 468\\nin scurvy, 189\\nin thoracic aneurism, 677\\ninto skin, 126\\nin anaemia, 127\\nin fever, 127\\nin jaundice, 862\\nin septicaemia, 227\\ntoxic, 131\\nin uraemia, 959\\nHemorrhoids, 853\\nHepatic colic, 885\\nfever, 864\\nHepato-pulmonary abscess from dysentery,\\n346\\nHeredity, transmission of nervous diseases\\nby, 961\\npulmonary diseases by, 455\\nHernia as a cause of intestinal obstruction,\\n859\\nHerpes labialis, 138\\nzoster, 187, 1006\\nHiccough in gastric diseases, 773\\nHippocratic fascies, 81\\nHippus, 97\\nHodgkin s disease, 160, 399\\nHutchinson s teeth, 270, 691\\nHydatid cyst of liver, 883\\nof lung, 568\\nHydrocephalus, 1056\\nphysiognomy of, 86\\nHydronephrosis, 911\\ndistinguished from hydatid cyst of\\nliver, 884\\nHydropericardium, 648\\nHydrophobia, 273\\nHydrothorax, 573\\nHypaesthesia, 971\\nHypalgesia, 972\\nHyperacidity, gastric, 801\\nHyperaemia, active, 401\\npassive or venous, 402\\nHyperaesthesia, 971\\nof stomach, 798\\nHyperalgesia, 972\\nHyperorexia, 799\\nHyperpyrexia, 194\\nHyperthermoaesthesia, 973\\nHysteria, 1059\\ndetection of, 89\\njoint in, 189\\npseudo-angina in, 586\\nHysterical mimicry of disease, 33\\n[DIOCY, 1010\\nL Impetigo, 255\\nImpulse of heart, 592. See Heart, im-\\npulse of.\\nIndicanuria, 935\\nin empyema, 573\\nin gastric cancer, 810\\nin intestinal obstruction, 849\\nIndigestion, gastric, 797\\nintestinal, 836\\nInfarction, 404\\nof lung, 467\\nInfections, classification of, 219\\netiology of, 218\\nfever in, 203\\nhistory in diagnosis of, 246\\npulse in, 608\\nterminal, 228\\nInflammation, 407\\nof mucous membrane, 408\\nof serous membrane, 408\\nInfluenza, 323\\nbacillus of, 536\\ndiagnosis of, 325\\nophthalmic neuralgia in, 48\\nInheritance in the etiology of disease, 27\\nInoculation of animals, 244\\nIntermittent fever. See Malarial Fever,\\n280.\\nIntestines, amyloid degeneration of, 841\\ncancer of, 852\\ncatarrh of, acute, 837\\nchronic, 840\\ndisease of, physical signs in, 825\\nobstruction of, acute, causes of, 843\\nsymptoms of, 846\\nchronic, causes of, 844\\nsymptoms of, 846\\ndiagnosis of, 847, 850\\nparasites in, 814\\ntuberculosis of, 842\\nulceration of, 841\\nIntoxication, alcoholic, 214\\nfever in, 209\\nby food, 213\\nby grain, 214\\nby lead, 215\\nIntussusception, 744, 844, 849\\nIritis, 97\\nJAUNDICE, 121\\nO acute febrile, 271\\nbradycardia in, 609\\ncatarrhal, 862, 866\\nin cholelithiasis, 88(", "height": "4416", "width": "2732", "jp2-path": "practicaltreatis00muss_0_1173.jp2"}, "1174": {"fulltext": "1072\\nINDEX.\\nJaundice, in congestion of liver, 859\\nfever in, 864\\nhematogenous, 863\\nhepatogenous, 862\\ninfantile, 865\\nmalignant, 864\\nsymptoms of, 861\\nJoints, crepitus in, 177\\nenlargement of, 176\\nfluctuation in, 177\\nhysterical, 189\\nmovability of, 177\\npain in, 176\\npathological processes in, 177\\nposition assumed, 177\\nin rheumatic fever, 179\\nin tabes dorsalis, 189\\ntrophic lesions of, 1008\\ntuberculosis of, 178\\nKERNIG S sign of cerebro -spinal fever,\\n330, 1053\\nKidney, abscess of, 913\\ncongestion of, 960\\ncystic, 911, 967\\ndegeneration of, 967\\nenlargement of, 910\\ndistinguished from enlarged spleen,\\n892\\ngranular, 964\\nin heart disease, 589\\nhorseshoe, 909\\nhydatid cyst of, 914\\ninflammations of. See Nephritis,\\nmovable, 907\\ndistinguished from tumor of gall-\\nm bladder, 889\\npain in disease of, 901\\npalpation of, 906\\npercussion of, 907\\nsarcoma and carcinoma of, 910\\ntopography of, 906\\nKnee-jerk, 986\\nKoch s postulates, 218\\nKoplik s sign of measles, 261\\nAGOPHTHALMOS, 92, 1026, 1054\\n-Li Landry s paralysis. 1050\\nLaryngismus stridulus, 434\\nin rickets, 174\\nLaryngitis, acute, 441\\nwith stenosis, 442\\nchronic, 432\\nmembranous and diphtheritic, 443\\nspasmodic, 443\\nsubmucous, 445\\nLaryngoscopy, 437\\nLarynx, color of mucous membrane in, 439\\ncough in disease of, 435\\ndysphagia in disease of, 435\\ndyspnoea in disease of, 433\\nforeign bodies in, distinguished from\\nwhooping-cough, 445\\nhemorrhage from, 436\\nLarynx, inco-ordination of muscles of, 436\\nlupus of, 440\\noedema of, 443\\ndistinguished from membranous\\nlaryngitis, 444\\npain in, 431\\nparaesthesia, hyperaesthesia, and anaes-\\nthesia of, 432\\nparalysis of muscles of, 445\\nperichondritis of, 431\\nsyphilis of, 439, 440, 448\\ntuberculosis of, 439, 440, 447\\ndistinguished from syphilis, 448\\ntumors of, 440, 447\\nLathy rism, 215\\nLead- poisoning, 215\\ncolic in, 817\\nLeprosy, 349\\nin mouth, 694\\norganism of, 349\\nLeptomeningitis, 1052\\nLeptothrix buccalis, 690\\nin sputum, 529\\nLeucin in urine, 953\\nLeucocythaemia, 396\\nacute, 399\\nblood in, 397\\nlymphatic form of, 399\\nspleen in, 892\\nsplenomedullary form of, 396\\nLeucocytosis, 381\\nabsence of, in typhoid fever, 299\\nin infectious disease, 238\\nin pneumonia, 315\\nLeucopenia, 382\\nLeukaemia. See Leucocythaemia, 396\\nLinea albican tes, 728\\nLipaemia, 386\\nLipomata, peritoneal, 733\\nLips in diagnosis, 85\\nLipuria, 947\\nLithaemia, 855\\nneuralgia in, 48\\nLiver, abscess of, 346, 872\\ndiagnosis of, 874\\ndistinguished from cancer, 882\\nacute yellow atrophy of, 864\\namyloid disease of, 866, 880\\narterial pulsation of, 604\\nauscultation of, 868\\ncancer of, 880\\npalpation in, 867\\ncirrhosis of, atrophic, 876\\ncollateral circulation in, 877\\ngastric symptoms in, 762\\nhypertrophic, 878\\ndistinguished from cancer,\\n882\\nsyphilitic, 879\\ncongestion of, 857\\nconstriction of, from lacing, 867\\ndiminution in size of, 869\\nenlargement of, 869\\nconditions with which confounded,\\n870\\netiological factors in disease of, 859", "height": "4408", "width": "2592", "jp2-path": "practicaltreatis00muss_0_1174.jp2"}, "1175": {"fulltext": "INDEX.\\n1073\\nLiver, fatty, 866, 880\\nfloating, 867\\nfunctional disturbances of, 855\\nhydatid disease of, 883\\ntumor in, 867\\npain in, 873\\npalpation of, 866\\nsyphilis of, 879\\ntopographical anatomy of, 860\\nLocalization of lesions of nervous system,\\n1011\\nLocomotor ataxia. See Tabes dorsalis,\\n1043\\nLogorrhcea, 1006\\nLud wig s angina, 717\\nLumbago, 167\\nLumbar puncture, 359\\nin cerebro spinal fever, 328\\nLung or lungs, abscess of, 563\\nboundaries of, in disease, 498\\ncollapse of, 548\\ncongestion of, 540\\ncough in diseases of, 464\\ndiminution of air space in, 458\\nembolism and thrombosis of, 541\\ngangrene of, 521, 563\\ngeneral svmptomatologv of disease of,\\n452\\nhistory in disease of, 455\\nhydatid disease of, 568\\nneuroses of, 540\\noedema of, 540\\npercussion sounds in disease of, 498\\nrelationship of. to heart, 453\\nsize of, in phthisis, 561\\ntopographical anatomy of, 473\\ntuberculosis of, 552. See Tuberculosis,\\npulmonary.\\ntumors of, 567\\nLupus of larynx, 440\\nLymphadenoma, 399\\nLymphangitis, 161\\nin septicaemia, 227\\nLymphatic glands in leucocythaemia, 399\\nLymphatism, 162\\nLymphocytosis, 382\\nLymphosarcoma, 158, 160\\nMACROGLOSSIA, 700\\nMain en griffe, 1009\\nMalarial cachexia. 239\\nneuralgia in, 48\\nspleen in, 892\\nfever, 279\\ndiagnosis of, 283\\nintermittent, 285\\nirregular forms of, 285\\npernicious, 287\\nPlasmodia of, 282\\nremittent, 287\\nMallein test for glanders, 336\\nMalta fever, 305\\nMania, 1010\\nMcBurney s point, 739\\nMeasles, 260\\nMeasles, distinguished from scarlet fever,\\n259\\nMeat-poisoning, 213\\nMediastinal friction, 650\\ntumors, 684\\nMediastinitis, 683\\nMediastino-pericarditis, ^indurative, 650\\nj Medicinal rashes, 139\\nI Melaena, 825\\nMelanaemia, 386\\nMelancholia, 1011\\nMelanuria, 954\\nMeniere s disease, 108, 1059\\nstation in, 74\\nMeningitis, 1052\\nchronic internal spinal, 1048\\nepidemic cerebro-spinal, 326, 1047\\ncomplications and sequelae of, 328\\ndistinguished from typhoid fever,\\n302\\nKernig s sign of, 330\\nlumbar puncture in, 328\\norganism of, 329\\nsymptoms of, 327\\ntemperature in, 326\\nfrom pneumococcus infection, 318\\nsyphilitic, 1047\\nMensuration of chest, 515, 517\\nMental disturbances, 1010\\nMeralgia paraesthetica, 1043\\nMerycismus, 803\\nMetallic tinkling in chest, 512\\nin pneumothorax, 578\\nMetatarsalgia, 54\\nMicrococci, general characteristics of, 220\\nMicrococcus lanceolatus, 363, 534\\nMicturition, frequent, 906\\nMigraine, 49, 1059\\nvTiliaria, 140\\nMiliary fever, 272\\nMilk-poisoning, 214\\nsickness, 273\\nMitral area, 632\\ninsufficiency, 660\\nbroken compensation in, 661\\nphysical signs of, 662\\nstenosis, 663\\nphysical signs of, 664\\npulmonary second sound in, 626\\nthrill in, 603\\nMonoplegia, 979\\nMorphinism, 212\\nMorphcea, 157\\nMorton s painful affection of foot, 54\\nMor van s disease, 1051\\nMotor points of muscles, 994\\nMountain fever, identity with typhoid, 303\\nMouth-breathing, 417, 426\\ncolor of mucous membrane of, 687\\ndryness of, 686\\nhemorrhage into mucous membrane\\nof, 687\\nMumps, 84, 265\\nMurmurs of anaemia, 637\\nin aortic aneurism, 680\\narea, 633, 634", "height": "4416", "width": "2740", "jp2-path": "practicaltreatis00muss_0_1175.jp2"}, "1176": {"fulltext": "1074\\nINDEX.\\nMurmurs in aortic obstruction, 659\\nregurgitation, 658\\narterial, 640\\ndouble, 641\\nfrom pressure, 641\\ncardio-muscular, 638\\n-respiratory, 638\\ncharacter of, 635\\ncombined, 640, 667\\ndisappearance of, 637\\nof Flint, 658\\ninfluence of pressure on, 638\\nloudness of, 636\\nat mitral area, 633, 634\\nof mitral insufficiency, 662\\nstenosis, 664\\nposition of maximum intensity of, 631\\npresystolic, 664, 665\\nat pulmonary area, 634\\nin relative incompetency, 637\\ntime of, 632\\ntransmission of, 635\\nin tricuspid stenosis, 666\\nat tricuspid area, 633, 634\\nvascular, 629\\nMuscular atrophy, 164, 989\\ndiagnosis of, 164\\nperoneal type of, 164\\nprogressive, 1034\\nconsecutive to disease of\\nnerves, 1037\\nspinal, 1038\\ntable of, 165\\nhypertrophy, 166\\nossification, 167\\nparalysis, pseudo-hypertrophic, 1036\\ntone, 983\\nMuscles, extra-ocular, actions of, 92\\naffections of, 93\\ndisturbed balance of, 95\\nfunctional classification of, 1027\\nlack of tone in, 78\\nMyalgia, 167\\ndistinguished from neuralgia, 45\\noccipital and frontal, 47\\nMydriasis, 98\\nMyelitis, acute, 1049\\nchronic, 1049\\ndisseminated, 1049\\nMyelocytes, 383\\nMyocarditis, 654\\nMyoidema, 163\\nMyosis, 98\\nMyositis, 166\\nMyotonia congenita, 166\\nMyotonic reaction, 999\\nMyxoedema, 154\\nNAILS in diagnosis, 116\\ndisturbed nutrition of, 1007\\nNasal discharge, a portent of uraemia, 418\\nNasopharynx, adenoid vegetations in, 714\\nNausea in gastric disease, 764\\nin headache, 52\\nursemic, 957\\nI Necrosis of tissue, 409\\nI Nephritis, acute exudative or glomerulo,\\n961\\nwith pus formation, 962\\nproductive, 962\\nchronic productive, 962\\nwithout exudation, 964\\nerythema in, 140\\ngastric symptoms in, 762\\ninterstitial, 964\\nretinitis in, 100\\nsuppurative, 966\\ntubercular, 967\\nNephrolithiasis, 902\\ncolic in, 817\\nNervousness, 34\\nNeuralgia, 1041\\ncauses of, 53\\ncharacter of pain in, 47\\ndistinguished from myalgia, 45\\nintercostal, distinguished from pleu-\\nrisy, 470, 576\\nfrom local irritation, 47\\nmalarial, 285\\npoints of tenderness in, 45\\nreflex from eye, teeth, or tongue, 48\\nsecondary, 49\\nsymptoms of, 52\\nfrom systemic conditions, 48\\ntrigeminal, 47\\nNeurasthenia, 1061\\nNeurasthenic gastralgia, 800\\nNeuritis, 1047\\nof optic nerve, 100\\nNeuromata multiple, 1046\\nNeurons, motor, lesions of, 1013\\nsensory, lesions of, 1012\\nNeuroses, gastric, 797\\nof lungs and bronchi, 540\\nof occupation, 1041\\nreflex, 420\\nNeusser s granules, 383\\nNight-blindness, 189\\nrestlessness in adenoid disease, 716\\nsweats of phthisis, 559\\nNigrities, 696\\nNodes on bone, 175\\nNose, 426\\nappearance of mucous membrane of,\\n423\\nauxiliary cavities of, disease of, 429\\ndeformity of, 421\\nexamination of, 421\\nobstruction of, 420\\npolypi in, 424\\nrelation of disease of, to asthma, 420\\nulceration in, 424\\nNucleo-albumin in urine, 928\\nNyctalopia, 189\\nNystagmus, 95\\nOBJECTIVE symptoms, methods of ob-\\nserving, 60\\nObstipation, 822, 825\\nOccipital neuralgia, 1042", "height": "4416", "width": "2604", "jp2-path": "practicaltreatis00muss_0_1176.jp2"}, "1177": {"fulltext": "INDEX.\\n1075\\nOccupation in etiology of disease, 26\\nneuroses of, 1041\\n(Edema, angio- neurotic, 153\\nof arms and thorax, 151\\ndiagnosis of, 150\\nof feet, 151\\ngeneral, 153\\nin heart disease, 588\\ninflammatory, 150\\nlocal, 150\\nsignificance of, 152\\nof lungs, 540\\nmode of recognition of, 149\\nin nephritis, 961\\npathology of, 148\\nin trichinosis, 151, 354\\nin uraemia, 959\\nOesophagitis, 721\\n(Esophagus, abscess of, 721\\ncarcinoma of, 722\\ndilatation of, 723\\nexamination of, 719\\nforeign body. in, 722\\nobstruction of, 720\\nspasm of, 723\\nstricture of, 721\\nOidium albicans, 690\\nin sputum, 529\\nOligochromsemia, 585\\nOligocythemia, 379, 395\\nOphthalmoplegia, 105\\nOphthalmoscopy, 99\\nOpisthotonos, 70\\nOpium habit, 212\\nOptic atrophy in tabes dorsalis, 101\\nOsteitis deformans, 170\\nOsteo-arthropathy, pulmonary, bones in,\\n171\\nOsteomalacia, 174\\nOsteomyelitis, 175\\nOvarian cysts, 367\\ndiagnosis of, 745\\nOxaluria, 952\\nOxyuris vermicularis, 833\\nsymptoms of, 815\\nOzsena, 425\\nin glanders, 335\\nPACHYMENINGITIS, external cere-\\nI bral, 1052\\nhypertrophic cervical, 1047\\nPain in abdomen, 726\\nin appendicitis, 739, 818\\nin arms, 54\\ncharacter of onset of, 41\\nin chest in phthisis, 360\\ncrises of, 44\\ndeep seated, 44\\ndefinition of, 36\\nin diarrhoea, 821\\nduration of, 41\\nin epigastrium, 584, 770\\nin relapsing fever, 275\\nin uraemia, 957\\nestimation of, 38\\nPain, etiology of, 37\\nin extra-uterine pregnancy, 817\\nin foot in flat-foot, 54\\nin gastric disease, 771, 775, 818\\nulcer, 812\\ngeneral, 43\\nin rickets, 173\\ngirdle, 55\\nin heel in gout, 54\\nindicating location of disease, 43\\nnature of disease, 42\\ninframammary, 56\\nintermittent or remittent, 41\\nin intestinal obstruction, 818\\nin joints, 176\\nkinds of, 42\\nin larynx, 431\\nin legs, 53, 54\\nin cerebral hemorrhage, 54\\nin loins, 57\\nmeasurement of, 40\\nmodes of expression of, 37\\nin mouth, 686\\nmuscular in trichinosis, 354\\nin nasal disease, 419\\nin oesophagus, 718\\nin otitis media, 49\\nin pancreatic disease, 818\\nparoxysmal, 42\\nin pericarditis, 643\\nperiodic, 42\\nperipheral of central origin, 36, 44,\\n54\\nin peritonitis, 750, 818\\nin pharynx, 707\\nin pleurisy, 469, 569, 575\\nin prsecordia, 583\\nin rectum, 817\\nreferred, 43, 44\\nin scalp, 46\\nsense, 973\\nin shock, 40\\nsimulated, 39. See also Feigned dis-\\nease.\\nin spine, 55, 56\\nin and behind sternum, 55, 175\\nsuperficial, 43\\nsympathetic, 43\\nin thoracic aneurism, 676\\nin vertebral disease, 819\\nvisceral, 973\\nPalpitation of heart, 586\\nin gastric disease, 773\\nin lithsemia, 856\\nPalsies, local and multiple, 978\\nPancreas, cancer of, 894\\ndistinguished from hepatic can-\\ncer, 882\\ncysts of, 898\\ndistinguished from enlarged liver,\\n871\\nfluid in, 367\\ndiseases of, 893\\nhemorrhage into, 895\\ntumors of, 746, 894\\nPancreatitis, acute hemorrhagic, 895", "height": "4416", "width": "2732", "jp2-path": "practicaltreatis00muss_0_1177.jp2"}, "1178": {"fulltext": "1076\\nINDEX.\\nPancreatitis, acute hemorrhagic, distin-\\nguished from acute intestinal ob-\\nstruction, 851\\ngangrenous, 897\\nsuppurative, 897\\nPapillitis, 100\\nPapilloma of larynx, 440\\nParadoxical contraction of Westphal, 989\\nParesthesia, 970\\nParalysis, 976\\nagitans, 1040\\nbulbar, 1054, 1056\\ncrossed, 1014\\ndiphtheritic, 333\\nLandry s, 1050\\nlocal, in uraemia, 957\\nmyopathic, 978\\nof orbital nerves, 106\\nperiodic, 1039\\npseudo-hypertrophic muscular, 1036\\ngait in, 72\\nstation in, 74\\nParamyoclonus multiplex, 166, 1040\\nParanoia, 1011\\nParaphasia, 1001\\nParaplegia, 978\\nhysterical, gait in, 72\\nprimary spastic, 1046\\ngait in, 71, 72\\nfrom Pott s disease, 1048\\nParasites, anaemia due to, 391\\nin intestines, 814\\nin mouth, 693\\nin sputum, 528\\nParesis, 979\\ngeneral, of the insane, 1057\\nParosmia, 419\\nParotitis, epidemic, 84\\nsymptomatic, 718\\nPectoriloquy, 413\\nPeliosis rheumatica, 129\\nPellagra, 215\\nPercussion, 492\\nauscultatory, 497\\nof chest, amphoric sound in, 501\\ncracked-pot sound in, 501\\ndulness in, 500\\nhyper-resonance, 498\\nimpaired resonance, 499\\nnormal sounds in, 494\\ntympany in, 499\\nrespiratory, 497\\nsuperficial and deep, 497\\nPericardial friction sound, 603, 629\\ndistinguished from pleural, 630\\nPericarditis, 641\\nacute fibrinous, 641\\nadhesive, 648\\nwith effusion, 644\\nimpulse in, 593\\npain in, 584\\nphysical signs of, 645\\nfrom pneumococcus infection, 318\\nPericardium, aspiration of, 358\\nPerinephritic abscess, 913\\nPeriostitis, 175\\nPeristalsis, visible, 729, 774\\nPeritonitis, 750\\nchronic, 754\\ndiagnosis of, 752\\nin dysentery, 347\\nhysterical, 753\\nlocalized, 753\\ntuberculous, 755\\nPerspiration in crisis of pneumonia, 145\\ndiminished, 146\\nincreased, 145\\nlocal, 146\\nin miliary fever, 272\\nin phthisis, 559\\nin rheumatic fever, 145, 180\\nin rickets, 173\\nin tuberculosis, 145\\nPertussis, 265\\nbacillus of, 536\\ncough in, 466\\nPetit mal, 1058\\nPhantom tumor, 734, 1061\\nPharyngitis, acute, 716\\nchronic, 717\\nlithsemic, 856\\nphlegmonous, 717\\nrheumatic, 717\\nPharynx, adenoids of, 714\\nanaesthesia of, 710\\ncolor of mucous membrane of, 709\\nexamination of, 708\\npseudomembrane on, 710\\nspasm of, 708\\nulcers in, 709\\nPhlebitis in septicaemia, 227\\nPhlegmasia alba dolens, 403\\nPhosphates in urine, 950\\nPhosphorus-poisoning, 865\\nPhotophobia, 92\\nPhrenic nerve, paralysis of, 461\\nPhthisis. See Tuberculosis, pulmonary,\\n555.\\nPhysical signs, pictoric record of, 536\\nPica, 772\\nPigeon-breast, 715\\nPigmentation of skin, 124\\nPlague, bubonic, 347\\nbacillus of, 348\\nPlasmodia of malaria, 282\\nstaining of, 284\\nPlate cultures, 243\\nPlethora, 401\\nPleural friction sound, distinguished from\\npericardia], 630\\nPleurisy acute, 569\\ndistinguished from intercostal neu-\\nralgia, 470, 576\\nfrom pleurodynia, 469, 576\\nfrom pneumonia, 575\\nphysical signs of, 570\\nchronic, 576\\nwith thickening, 576\\ncough in, 465\\ndiaphragmatic, 574\\netiology of, 569\\nwith effusion, 570", "height": "4416", "width": "2600", "jp2-path": "practicaltreatis00muss_0_1178.jp2"}, "1179": {"fulltext": "INDEX.\\n1077\\nPleurisy, with effusion, aegophony in, 513\\naspiration of, 358\\ncharacter of fluid in, 365\\ndistinguished from consolidation,\\n575\\nfrom enlarged liver, 870\\nfrom hydatid cyst of liver,\\n^884\\nheart in, 571\\nshape and size of chest in, 484\\nmovements of chest in, 487, 488\\npain in, 469\\nfrom pneumococcus infection, 318\\ntuberculous, 574\\nPleurodynia, 167\\ndistinguished from pleurisy, 469, 488,\\n576\\nPlumbism, 215\\nPneumatosis, 802\\nPneumococcus, 363\\nsepticaemia due to, 318\\nPneumokoniosis, 550\\nPneumonia-broncho-, 549\\ndistinguished from collapse of\\nlung, 549\\nphysical signs of, 549\\ntuberculous, 550\\nbronchophony in, 513\\nchronic interstitial, 550\\ncrepitant rales in, 510\\ncroupous or lobar, 311\\nbacteriological diagnosis of, 318\\ncentral variety, 311\\ncerebral symptoms in, 314\\nchlorides in urine in, 315\\ncritical sweats in, 145\\ndiagnosis of, 317\\ndistinguished from collapse of\\nlung, 548\\nin drunkards, 317\\nduration and course of, 316\\nheart and pulse in, 314\\nmassive, 315\\norganism of, 534\\nphysical signs of, 315\\nrespiration in, 312\\nsputum in, 312\\nvarieties of, 316\\nin infants, 317\\nmovements of chest in, 487\\npulmonary second sound in, 625\\nsputum of, 521\\nPneumopericardium, 648\\nPneumoperitoneum, 751\\nPneumothorax, 577\\ndiagnosis of, 578\\ndistinguished from emphysema, 566\\nPoikilocytosis, 375\\nPoisoning. See Intoxication, 209\\nPoliomyelitis, anterior, 1038\\nPolyphagia, 803\\nPolypi, nasal, 424\\nPons, lesions of, 1019\\nPortal vein, obstruction of, 858\\npyaemia, 858\\nPott s disease, paraplegia in, 1048\\nPraecordia, prominence of, 592\\nPrevious disease, bearing of, on diagnosis,\\n29\\nPregnancy, pigmentation in, 125\\nvomiting in, 767\\nPressure, sense of, 975\\nProctitis, 839\\nPruritus, 134\\nin jaundice, 861\\nin uraemia, 957\\nPtosis, 91\\nPtyalism, 694\\nPulmonary disease. See Lung.\\nvalve disease, 666\\narea, 632\\nPulsation of arteries, 587, 596\\na subjective symptom, 590\\nepigastric, 596, 728\\nof veins, 599\\nPulse in aortic aneurism, 681\\ncapillary, 598, 659\\nCorrigan s, 658\\nin fever, 199\\nfrequency of, 604, 608\\nhigh tension, sphygmogram in, 613\\nirregular, sphygmogram in, 614\\nlow tension, sphygmogram in, 613\\nmethod of taking, 604\\nin peritonitis, 752\\nin rheumatoid arthritis, 186\\nrhythm of, 607\\ntension of, 606\\nin fever\\nvenous, 600\\nvolume of, 606\\nPulsus paradoxus in adherent pericarditis,\\n649\\nin pericardial effusion, 645\\nPuncture, exploratory, 357\\nPupillary reflex, 97\\nPurpura, 128\\nPus, bacteria of, 240, 360\\nchemical examination of, 364\\nphysical characteristics of, 360\\nstaining of, 240\\ntubercular, 362\\nin urine, 936, 941\\nPyaemia, 224\\nPyelitis, 912\\nPylephlebitis, suppurative, 875\\nPylorus, stenosis of, 808\\nPyonephrosis, 912\\nPyopneumothorax, 577\\nsubphrenicus, 578, 747\\nPyorrhoea alveolaris, 691\\nPyrosis, 772, 802\\nPyuria, 936\\nabsence of in renal calculus, 905\\nRHACHITIS. See Eickets, 172\\nRales, 509\\ndistinguished from friction sound,\\n510\\nRanula, 697, 700\\nEashes, medicinal, 139", "height": "4416", "width": "2740", "jp2-path": "practicaltreatis00muss_0_1179.jp2"}, "1180": {"fulltext": "1078\\nINDEX.\\nKay fungus, 351\\nRaynaud s disease, 115, 1006\\nEeactions of degeneration, 996\\natypical, 999\\nRecords of cases, 21\\nRectum, diseases of, 852\\nReflex, abdominal, 986\\npatellar, 987\\nplantar, 989\\nreinforcement of, 987\\ntendo-Achillis, 988\\ntendon, 985\\nRegions of chest, 471\\nRegurgitation of food, 772\\nin disease of oesophagus, 723\\nReichman s disease, 801\\nRelapsing fever, 274\\nserum diagnosis in, 276\\nspirillum of, 275\\nRenal calculus, 902\\ncolic, 902\\nResidence in etiology of disease, 26\\nResistance to finger in percussion, 496\\nResonance, pulmonary, 494\\nRespiration, Cheyne-Stokes, 487\\nin fever, 199\\nrate of, 476, 486\\nratio of inspiration to expiration, 486\\ntypes of, 476\\nRestlessness, 70\\nRetinitis, 100\\nalbuminuric, 959, 965\\nRetraction of interspaces in adherent peri-\\ncardium, 649\\nRetroperitoneal sarcoma, 754\\nRetropharyngeal abscess, 717\\nRhabdenoma intestinale, 834\\nRheumatic fever, 178\\ncomplications and sequelae of, 181\\ndiagnosis of, 181\\nendo- and pericarditis in, 180\\ntemperature in, 180\\nRheumatism, acute articular. See Rheu-\\nmatic fever,\\nchronic articular, 183\\ngastric symptoms of, 762\\ngonorrhoeal, 178\\nhand in, 113, 114\\nmuscular, 167\\nrelation of, to lithsemia, 856\\nsubacute articular, 182\\nsubcutaneous nodules in, 158\\nRheumatoid arthritis, 185\\ndiagnosis of, 187\\nfingers in, 114\\npulse in, 186, 608\\nRhinitis, atrophic, 425\\ncaseous, 425\\nchronic hypertrophic, 424, 428\\nidiopathic, 420\\nsicca, 429\\nsimple acute, 427\\nsyphilitic, 429\\nRhinoscopy, 421\\nRickets, 172\\ndiagnosis of, 174\\nRickets, fontanelles in, 87\\nshape of chest in, 480\\nsweating of head in, 146\\nRigidity of abdomen in peritonitis, 751\\nRoseola, 139\\nRotheln, 264\\nRubella, 264\\ndistinguished from scarlet fever, 259\\nRumination, 803\\nO ALIVA, 687\\nO in disease, 689\\nSalivation, 687\\nSaltatoric spasm, 1040\\nSarcina, 220\\nin gastric contents, 784\\nin urine, 948\\nSarcoma, retroperitoneal, 754\\nof skin, 157\\nScalp, pain in, 46\\nScanning speech, 1006\\nScaphoid abdomen, 735\\nScarlet fever, 255\\ncomplications and sequela? of, 258\\ndiagnosis of, 258\\npulse in, 608\\ntongue in, 701\\nvarieties of, 257\\nScars, significance of, in diagnosis, 146\\nSciatica, 53, 1043\\nScleroderma, 157\\nSclerosis, amyotrophic lateral, 1046\\nmultiple or insular, 1047\\ngait in, 71\\nScotoma, 102\\nScurvy, 188\\ngums in, 691\\nhemorrhage in, 128\\n-rickets, 189\\nSeitz s sign of cavity, 515\\nSensation, 971\\ndelayed, 975\\ndissociation of, 973\\nof locality, 974\\nmuscular, 975\\nof pain from induced current, 975\\nof pressure, 975\\nstereognostic, 976\\ntactile, 971\\nof temperature, 973\\nSepticemia, 225\\nfever in, 210\\nSeptico-pysemia, 334\\nSerum diagnosis, 233\\ndilution and time limit in, 236\\nthe appearance of the reaction, 236\\nin relapsing fever, 276\\nin typhoid fever, 235, 299\\nvalue of, 237\\nwith dried blood, 236\\nwith fluid serum or blood, 234\\nSex in etiology of disease, 25\\nShell-fish poisoning, 214\\nShock, 65\\neffect of, on pain, 39, 40", "height": "4416", "width": "2596", "jp2-path": "practicaltreatis00muss_0_1180.jp2"}, "1181": {"fulltext": "INDEX.\\n1079\\nShock from hemorrhage, 406\\nShortness of breath, 462. See Dyspnoea.\\nSiderosis, 551\\nSkin, color of, 119\\nhemorrhage into, 126\\nlesions of, artificial, 41\\nclassification of, 132\\ngeneral diagnosis of, 141\\nsyphilitic, 142\\ntraumatic, 141\\nulcerative, 144\\nmalignant nodules under, 157\\nnutrition of, 144\\npigmentation of, 125\\nSkodaic resonance, 499\\nin pleural effusion, 570\\nin pneumonia, 315\\nSmallpox. See Variola, 250\\nSmell, disturbance of sense of, 419\\nSpasm, habit, 1040\\nmuscular, 981\\nsaltatoric, 1040\\nSpeech, disturbances of, 1000\\nSpermatozoa in urine, 946\\nSphygmograph, 609\\nSpinal cord, general symptoms of disease\\nof, 1024\\nhemorrhage into, 1050\\npressure on, symptoms of, 1050\\ntraumatism of, 1051\\ntumor of membranes of. 1 048\\nlocalization, 1021\\nSpirilla, general characteristics of, 222\\nSpirillum of cholera Asiatica, 338\\nnostras, 835\\nof relapsing fever, 275\\nSpirometry, 516\\nSpleen, amyloid, 893\\ndiseases of, 890\\nenlargement of, 891\\nin cirrhosis of liver, 877\\nin Hodgkin s disease, 161\\nin infants, 893\\nin leucocythsemia, 396\\nin malaria, 289\\nin pneumonia, 314\\nin simple anaemia, 392\\nfloating, 890\\nhydatid cyst of, 893\\nmalignant tumors of, 893\\npalpation of, 890\\npercussion of, 890\\npuncture of, 360\\nsyphilis of, 893\\ntopography of, 890\\nSplenitis, acute, 891\\nSpores of bacilli, 221\\nSputum, 519\\nin bronchiectasis, 566\\nin bronchitis, capillary, 546\\nplastic, 546\\nchemistry of, 536\\nin gangrene of lung, 563\\nfrom larynx, 441\\nin liver abscess, 529\\nin lobar pneumonia, 312\\nSputum, method of collecting, 519\\nmicrococcus lanceolatus in, 534\\nmicroscopic examination of, 522\\nin phthisis, 561\\nphysical characteristics of, 520\\ntubercle bacilli in, 530\\nStaining of bacteria, 240\\nStaphylococci, 361, 362\\nStation in disease, 74\\nStelwag s sign, 89\\nSterilization in bacteriology, 231\\nStethoscope, 502\\nStiff neck in oesophagitis, 719\\nStigmata of the passion, 1061\\nStokes- A dams syndrome in myocarditis,\\n589, 655\\nStomach, absorptive power of, 790\\nanaesthesia of, 803\\natony of, 803\\nauscultation of, 778\\nauscultatory percussion of, 777\\ncarcinoma of, 808\\ndistinguished from ulcer and\\nchronic gastritis, 811\\ngastric contents in, 810\\ncirrhosis of, 806\\ncatarrh of. See Gastritis,\\ncontents, acetic acid in, 788\\nalcohol in, test for, 788\\nanacidity of, 791\\nbile in, 782\\nblood in, 782\\nbutyric acid in, 788\\ncarbohydrates in, 789\\nchemical examination of, 784\\nclinical value of examination of,\\n791\\nfree acid in, test for, 784\\nhydrochloric acid in test for, 785\\nhyperacidity of, 791\\nlactic acid in, significance of, 792\\ntest for, 787\\nmethod of securing, 779\\nmicroscopical examination of, 783\\nmucus in, 782\\npepsinogen in, 789\\nrennin in, 789\\nsyntonin in, 789\\ntotal acidity of, 784\\ncough, 465\\ndigestive power of, 789\\ndilatation of, 777, 807\\ndiminution in size of, 777\\ngeneral condition in disease of, 793\\nhistory in disease of, 763\\nhyperacidity and hyperemia of, 801\\ninspection of, 774\\ninternal exploration of, 775\\nmotor power of, 790\\nneuroses of, 797\\nnervous mechanism of, 760\\nin other diseases, 761\\npalpation of, 775\\npercussion of, 776\\nposition of, 776\\nrelaxation of orifices of, 803", "height": "4412", "width": "2736", "jp2-path": "practicaltreatis00muss_0_1181.jp2"}, "1182": {"fulltext": "1080\\nINDEX.\\nStomach, tumor of, 775\\nulcer of, 811\\nStomatitis, 692\\naphthous, 693\\ncatarrhal, 693\\ngangrenous, 694\\nmaterna, 693\\nmercurial, 694\\nparasitic, 693\\nulcerative, 693\\nStools in amoebic dysentery, 343\\nin catarrhal dysentery, 345\\nin cholera, 337\\nin diarrhoea, 820\\nStreptococcus pyogenes, 362\\nStrongylus, symptoms of, 815\\nStuttering and stammering, 1006\\nSubdiaphragmatic abscess, 746\\nSublingual ulcer, 695\\nSuccussion, Hippocratic, 512\\nin pneumothorax 577\\nsplash in stomach, 778\\nSudamina, 140\\nSugar in urine, 931\\nSulphocyanide of potassium in saliva, 689\\nSunstroke, 211\\nfever in, 203\\nSuppuration, symptoms of, 408\\nSuprarenal capsules, disease of, 734\\nSweat. See Perspiration.\\nSymptoms, evolution of, 31\\nobjective, definition of, 17\\nsubjective, definition of, 17\\nvaluation of, 32\\nSyncope, 64\\nSynovitis, 178\\nSyphilis, acquired, 269\\ncaries of frontal bone in, 87\\ncoryza in, 429\\neffect of mercury on haemoglobin in,\\n271\\nfever in, 206, 229\\nheadache in, 49, 592\\nhereditary, 270\\nof larynx, 439, 448\\nof liver, 879\\nlymphatic glands in, 159\\nnasal ulceration in, 424\\nneuralgia in, 48\\nof pharynx, 709\\nskin lesions in, 142\\nteeth in, 691\\nSyringomyelia, 1050\\nTABES dorsalis, 1043\\ncervical type of, 1044\\ngait in, 70\\njoints in, 189\\npain in, 55\\npulse in, 608\\nmesenterica, 748\\nTache cerebral, 1052\\nTachycardia, 608\\nin exophthalmic goitre, 89\\nTaenia, 831\\nTaenia, symptoms of, 814\\nTeeth, 691\\nHutchinson s, 27]\\nin rickets, 172\\ntime of eruption of, 692\\nTeething, 692\\nTemperature. See also Fever.\\ndanger limit of, 194\\ndetermination of, 192\\ninfluence of age and sex on, 208\\nnormal variation in, 194\\npathological variations in, 194\\nsense of, 973\\nsubnormal, 201\\nwhen to take, 193\\nTendon reflexes, 985\\nTenesmus, 42\\nin diarrhoea, 821\\nTension in arteries, 606\\nTetanus, 352\\nbacillus of, 353\\nTetany, 1040\\nin dilatation of stomach, 807\\nin rickets, 174\\nThermoanesthesia, 973\\nThirst in gastric disease, 764\\nThomsen s disease, 166, 1041\\nThorax. See Chest.\\nThrill in aortic aneurism, 679\\nobstruction, 659\\ncardiac, 603\\nin mitral stenosis, 664\\nin tricuspid stenosis, 666\\nThroat in scarlet fever, 256\\nThrombosis^ 403\\nin arterio-capillary fibrosis, 673\\ncerebral, 1054\\nThrush, 690\\nThumb-sucking, effect on dental arch, 687\\nThyroid gland, enlargement of, 88\\nTic douloureux, 47, 53, 1042\\nfacial, 982\\ngeneral, 1040\\nTinea, 143\\nTinnitus aurium, 107\\nTongue, 695\\natrophy of, 700\\ncoating of, 700\\ncysts of, 700\\ndiagnostic significance of, 704\\ndiscoloration of, 695\\ndryness of, 704\\nfurrows in, 697\\ngeographical, 700\\nhypertrophy of, 700\\nmovements of, in disease, 706\\nin prognosis and treatment, 705\\nof scarlet fever, 257\\nulcers of, 698\\nwhite patches on, 699\\nTonsillitis, acute, 711\\nchronic, 714\\ndistinguished from diphtheria, 713\\nfollicular, 712\\nsuppurative, 712\\nTonsils, the, 710", "height": "4412", "width": "2616", "jp2-path": "practicaltreatis00muss_0_1182.jp2"}, "1183": {"fulltext": "INDEX.\\n1081\\nTonsils, foreign body in, 714\\nleptothrix in, 711\\npseudomembraue on, 711\\nulcers of, 711\\nTooth-cough, 465\\nTophi in gout, 184\\nTormina ventriculi, 803\\nTorticollis, 168 _\\nToxaemia, fever in, 203\\nToxins and toxalbumins, 221\\nTrachea, obstruction of, 457\\nTracheal tugging in aneurism, 88, 681\\nTransudations, 365\\nTraube s semilunar space, 776\\nTremor, 980\\nin exophthalmic goitre, 90\\nTrichina spiralis, 354, 834\\nTrichinosis, 354\\neosinophilia in, 356\\nface in, 84\\noedema in, 151\\nTrichoaesthesia, 973\\nTrichomonas in genito-urinary tract, 949\\nTrichterbrust, 483, 715\\nTricocephalus dispar, 834\\nTricuspid area, 632\\nregurgitation, 665\\nvenous pulse in, 600\\nstenosis, 666\\nTrismus neonatorum, 353\\nTrophic disturbances, 1006\\nTrousseau s sign of tetany, 1041\\nTubercle bacillus, 530\\nTuberculin test, 321\\nin tubercular adenitis, 161\\nTuberculosis, 319\\nacute miliary, 322\\ndistinguished from typhoid fever,\\n302, 555\\npulmonary type of, 554\\nbacillus of, 530\\ncervical glands in, 1 59\\nfever in, 205\\nhereditary tendency to, 320\\nof intestine, 842\\nof kidney, 967\\nof pharynx, 709\\npulmonary, acute, 552\\ndistinguished from pneumo-\\nnia, 554\\nchronic, 555\\ndiagnosis of, 319\\nexcursion of diaphragm in,\\n477\\nfever in, 558\\ngastric symptoms in, 761\\nhaemoptysis in, 467, 560\\ninspiratory capacity in, 518\\nmodes of invasion in, 556\\nmovements of chest in, 488\\npain in chest in, 560\\nphysical signs of, 561\\nsputum in, 561\\nsweats in, 559\\nof tongue, 699\\nTuberculous peritonitis, 755\\nTuberculous peritonitis, acute, distin-\\nguished from perforating ap\\npendicitis, 743\\ndiagnosis of, 758\\ntumors in, 757\\nTwitching, fibrillary muscular, 989\\nTympany, a percussion sound, 495\\nTympanites in peritonitis, 732, 751\\nTyphlitis, 742\\nstercoral, 824\\nTyphoid fever, 289\\nabsence of leucocytosis in, 299\\nbacillus of, 298, 300\\nBaruch s sign of, 301\\ncomplications and sequelae of, 298\\ndiagnosis of, 301\\ndistinguished from appendicitis,\\n740\\nfrom malignant endocarditis,\\n652\\nfrom typhus fever, 249\\neruption in, 296\\nheart-sounds in, 294\\nincubation of, 289\\nnervous symptoms of, 294\\npulse in, 291\\nspleen in, 290\\ntemperature in, 290\\ntongue in, 702\\nurine in, 294\\nvarieties of, 297\\nWidal reaction in 233. See\\nSerum diagnosis,\\nwithout fever, 229\\nwithout intestinal lesions, 298\\nstate, 199\\nTyphus fever, 247\\nTyrosin crystals, in sputum, 528\\nin urine, 953\\nULCER in mouth, 694\\nof skin, diagnosis of, 144\\nof stomach, 811\\nsublingual, 695\\nof tongue, 698\\ntrophic, 1008\\nUmbilicus in tuberculous peritonitis, 728,\\n755\\nUnconsciousness, 64\\nUraemia, 956, 965\\nasthma in, 461\\ncardio-vascular symptoms of, 958\\ndropsy in, 959\\ndyspnoea in, 957, 965\\ngastro-intestinal symptoms in, 965,\\n977\\nhemorrhage in, 959\\nlatent, 95\u00c2\u00bb\\nnervous symptoms in, 956, 965\\nretinal changes in, 959, 965\\ntemperature in, 956, 965\\nUrates in urine, 950\\nUrea, estimation of, 920\\nUreters, catheterization of, 955\\nUric acid in blood, test for, 386", "height": "4416", "width": "2732", "jp2-path": "practicaltreatis00muss_0_1183.jp2"}, "1184": {"fulltext": "1082\\nINDEX.\\nUric acid diathesis, 184. See Gout.\\nNeusser s granules in, 383\\nin urine, 949\\nUrine, acetone in, 936\\nalbumin in, causes of, 927\\nquantitative estimation of, 926\\ntests for, 921\\nalbumose in, 929\\nalkapton in, 937\\nbacteria in, 948\\nbile-pigments and bile-acids in, 935\\nblood in, 92S, 940\\ncancer cells in, 949\\ncasts in, 941\\ncentrifugation of, 938\\nchemical examination of, 919\\nchlorides in, 920\\nin gastric cancer, 794\\nin pneumonia, 315\\ncholesterin in, 954\\ncolor of, 914\\ncylindroids in, 945\\ncystin in, 953\\ndiacetic acid in, 936\\nentozoa in, 948\\nepithelium in, 946\\nextraneous matter in, 938\\nfat and chyle in, 947\\nin gastric disease, 794\\nglobulin in, 937\\nindican in, 935\\nleucin and tyrosin in, 953\\nin lithsemia, 856\\nmelanin in, 954\\nin nephritis, acute exudative, 961\\nproductive, 962\\nchronic productive, 963, 964\\nnucleo-albumin in, 928\\nodor of, 919\\noxalates in, 952\\nphosphates in, 950\\npus in, 936, 941\\nreaction of, 918\\nin rheumatic fever, 180\\nsediments in, 918\\nsolids in, estimated from specific grav-\\nity, 918\\nspecific gravity of, 917\\nspermatozoa in, 946\\nsugar in, test for, 936\\nquantitative estimation of, 932\\nsuppression of, 916\\nurates in, 950\\nurea in, 919\\nquantitative estimation of, 920\\nuric acid in, 949\\nvolume of, 914, 916\\nUrticaria, 138\\nUvula, 710\\nVALLE1X, points of,\\nValve-shock, 602\\nVaricella, 253\\n45\\nVariola, 250\\nvarieties of, 252\\nVarioloid, 252\\nVasomotor changes in hysterical joints, 190\\nmechanism, 415\\nsymptoms in migraine, 50\\nin neuralgia, 53\\nVeins, diastolic collapse of, 601\\nin adherent pericarditis, 649\\ndistention of, 598\\nmurmurs in, 641\\npulsation of, 599\\nthrombosis of, 614\\nVenous hum, 641\\npulse, 600\\nVertebral canal, aspiration of, 359\\nVertigo in dyspeptic headache, 52\\nparalyzing, 109\\nVision, field of, 101\\nVocal resonance, 513\\nVoice in adenoid disease, 715\\nin central nervous disease, 449\\nVolvulus, 843\\nVomiting, 764\\ncerebral, 768\\ncyclic, 768\\nin gastric cancer, 767, 809\\nulcer, 767, 812\\nin gastritis, 766\\nin migraine, 50\\nin peritonitis, 751, 768\\nin phthisis, 561\\nof pregnancy, 767\\nreflex, 767\\nin toxaemia, 768\\nursemic, 768, 957, 965\\nVon Graefe s sign, 89\\nWATERBRASH, 872\\nWeight of body in disease, 76\\nWeil s disease, 271\\nWernicke s sign, 104\\nWhooping-cough, 265\\nWidal reaction, 233. See Serum diagnosis.\\nWilliams tracheal tone, 514\\nWintrich s change of note over cavity, 414\\nin pneumothorax, 577\\nWool-sorter s disease, 278\\nWord-blindness and word-deafness, 1000\\nWrist-drop, 113\\nWriter s cramp, 1041\\nXANTHELASMA, 695\\nXerostoma, 686\\nX-ray examination of chest, 488\\nof stomach, 775\\nYELLOW fever, 303\\nI bacillus of, 305 p\\ngeneral diagnosis of, 305\\nserum diagnosis of, 305", "height": "4416", "width": "2604", "jp2-path": "practicaltreatis00muss_0_1184.jp2"}, "1185": {"fulltext": "", "height": "4404", "width": "2720", "jp2-path": "practicaltreatis00muss_0_1185.jp2"}, "1186": {"fulltext": "", "height": "4396", "width": "2656", "jp2-path": "practicaltreatis00muss_0_1186.jp2"}, "1187": {"fulltext": "", "height": "4412", "width": "2660", "jp2-path": "practicaltreatis00muss_0_1187.jp2"}, "1188": {"fulltext": "", "height": "4380", "width": "2588", "jp2-path": "practicaltreatis00muss_0_1188.jp2"}, "1189": {"fulltext": "", "height": "4356", "width": "2464", "jp2-path": "practicaltreatis00muss_0_1189.jp2"}, "1190": {"fulltext": "Q^\\nA/0", "height": "4373", "width": "2620", "jp2-path": "practicaltreatis00muss_0_1190.jp2"}, "1191": {"fulltext": "", "height": "4340", "width": "2420", "jp2-path": "practicaltreatis00muss_0_1191.jp2"}, "1192": {"fulltext": "X X\u00c2\u00bb X*\\nX\\nSSSSSi\\nIli \u00c2\u00a7li^\\n\u00c2\u00a3\u00c2\u00a7\u00c2\u00a7\u00c2\u00bb\u00c2\u00ab3K iK\\nx X-, xt- X\\n*:-X X X x\\nX X X -X\\\\ X XXXX\\n-X gfi XX\\niiuiuniiJUiu \u00e2\u0096\u00a0il^HMBIM 1\\n-X-XXXX-X\\nx xx x-x xx:", "height": "4585", "width": "2941", "jp2-path": "practicaltreatis00muss_0_1192.jp2"}}