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THE

Archives of Diagnosis

A QUARTERLY JOURNAL DEVOTED TO THE STUDY
AND THE PROGRESS OP DIAGNOSIS AND PROGNOSIS

FOITHDBD AND EDITEP BY

HE IN RICH STERN

New YORK

VoLUMli VIII
I9IS

Published by

REBMAN COMPANY
143 AND 145 West 36th Street
NEW YORK.N.Y.

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All Righti Reserved

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THE

ABGHIYES OF DIAGNOSIS

A QUARTERLY JOURNAL DEVOTED TO THE STUDY
AND THE PROGRESS OF DUGNOSIS AND PROGNOSIS

JANUARY, 1916

FOUMDBD AND BDITED BY

HEINRICH STERN, M.D., LL.D.

Haw r«rk

Pdblubbd by

REBMAN COMPANY

141, 148 AND 145 WEST 36th STREET

NEW YORK. N.Y.

COPVIIOHT ItIB BV REBKIH COHPANV. ALL RI0HT3 RasBBVED.

SuBSCKiPTiON Ohb Dollar A Ybar, Siholb Cofibs 60 Cbmtb. Forbiom 91. 60.

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VOLUME VIII
ContrSiutorS o( Apttial !3lrtfclet(

Abrabams, Robert

(New York)
BAKDLTJt, Sauuel Wvlus

(New York)
Beipeld, Akthuk F.

(Chicago)
Blatt, MtMtRis L.

(Chicago)
BuEBCER, Leo

(New York)
CoBNWALL, Edward E.

(Brooklyn-New York)
Deaveb, John B.

(Phibdelphia)
Geyser, Albert C

(New York)
GuTMAN, Jaci»

(Brooklyn-New York)
Hast, T. Stuabt

(New York)
Hays, Harold

(New York)
Kaktcw, T. L.

(Syracuse, N. Y.)

KlLDUFFE, RCWERT, JX.

(Chester, Pa.)
Lawhmin, Cecil C.

(Milwaukee)
Leyinson, Abrahaic

(Chicago)
Levy, I. H.

(Syracuse, N. Y.)

LlTTLB, GeORCE F.

(Brooklyn-New York)

LuDLUM, Walter D.
(Brooklyn-New York)

M ACID A, N At HAN

(New York)
Mettleb, L. Hasbison

((Thicago)
Peterkin, G. Sheabman

(Seattle, Wash.)
PiSKK, Godfbey R.

(New York)
Schott, Mobbis

(Qeveland)
SHEFnELD, Hebuan B.

(New York)

SiNCEB, GUSTAV

(Vienna, Austria)
Smithies, Frank

(Chicago)
Stephens, G. Arbour

(Swansea, England)
Stern, Arthur

(Elizabeth, N. J.)
Stern, Heinbich

(New York)
Tavu», J. Madison

(Philadelphia)
TiCE, Frederick

((Chicago)
Williams, B. G. R.

(Paris, III.)
Williams, Tom A.

(Washington, D. C.)
Wise, Fred

(New York)

9312

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jfiutti

PACING
PAGE

Tetaninn, 2 Illustrations 70

Cavernous Angioma of the Liver in a Baby Six Weeks Old.

Following page 72
Cavernous Angioma of the Liver in a Baby Six Weeks Old, 2 Illus-
trations Following page 72

Congeiutal Absence of All Abdominal Muscles, 2 Illustrations.

Followir^ page 72
The Pathology and Diagnosis of so-called Diabetic Gangrene, 2 Illns-

trationa 104

The Pathology and Diagnosis of so-called Diabetic Gangrene, 2 Illus-
trations Following page 105

Situs Viscerum Inversus Totalis, 2 Illustrations 252

Situs Viscerum Inversus Totalis, 2 Illustrations . . Following page 252

Situs Viscerum Inversus Totalis, 3 Illustrations . . Following page 352

Situs Viscerum Inversus Totalis, 2 Illustrations 3S3

A Case of Epilepsy Apparently of Intestinal Origin, 3 Illustrations . 360

A Case of Epilepsy Apparently of Intestinal Origin, 3 Illustrations 261

SUtutcBtioiW in Ztxt

Abnormalities

Abnormalities o:

Abnormalities

if Myocardial
if Myocardial
if Myocardial
if Myocardial
if Myocardial
if Myocardial
if Myocardial
if Myocardial
if Myocardial
if Myocardial
if Myocardial
if Myocardial
if Myocardial
if Myocardial
if Myocardial
)f Myocardial
if Myocardial
if Myocardial
if Myocardial
if Myocardial
if Myocardial
if Myocardial
if Myocardial
if Myocardial
if Myocardial
>f Myocardial

Function

2 Illustrations . .

Function

2 Illustrations . .

3 Illustrations . .

. . 23

Function

I Illustration . .

■ ■ ?S

Function

4 Illustrations . .

■ • S

Function

2 Illustrations . .

Function

2 Illustrations . .

Functior

I Illustration . .

1 Illustration . .

. . 124

Function

2 Illustrations . .

. . 211

2 Illustrations . .

. . 319

Function

3 Illustrations . .

. . 220

. . 223

Function

I Illustration . .

a Illustrations . .

. . 224

. . 225

2 Illustrations . .

. . 227

Function

2 Illustrations . .

„Google

vi Illustrations in Text

Abnormalities of Myocardial Function, 2 Illustrations zjo

Abnormalities of Myocardial Function, 2 Illustrations 341

Abnormalities of Myocardial Function, 1 Illustration 345

Abnormalities of Myocardial Function, i Illustration 346

Abnormalities of Myocardial Function, 3 Illustrations 347

Abnormalities of Myocardial Function, 3 Illustrations 348

Abnormalities of Myocardial Function, i Illustration 349

Abnormalities of Myocardial Function, 3 Illustrations 350

Abnormalities of Myocardial Function, 2 Illustrations 352

Abnormalities of Myocardial Function, 3 Illustrations 353

Genitourinary Conditions in Women, a Illustrations 369

Genitourinary Conditions in Women, i Illustration 370

Genitourinary Conditions in Women, i Illustration 371

Genitourinary Conditions in Women, I Illustration 372

Genitourinary Conditions in Women, I Illustration 373

Genitourinary Conditions in Women, i Illustration 374

Genitourinary Conditions in Women, I Illustration 375

Genitourinary Conditions in Women, 3 Illustrations 376

Genitourinary Conditions in Women, I Illustration 377

Genitourinary Conditions in Women, 4 Illustrations 378

Genitourinary Conditions in Women, 2 Illustrations 382

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INDEX OF SUBJECTS

FACE

Abderhalden method, diagnosis
of carcinoma by the 172

Abderhalden's protective fer-
ments in psychiatry 295

Abderhalden's serum reaction of
liver tissue in akoholisls 80

Abdominal angina, symptomatol-
ogy of 90

Abdominal muscles, congenital
absence of all 73

Abrahams' acromial auscultation
in the diagnosis of incipient
apical tuberculosis, a further
plea tor 158

Abscess, cases of lung 89

Acetone bodies, facts and fal-
lacies connected with the clini-
cal pathology of the 198

Achy ha gastrica, gastrogenons
diarrheas and the occurrence
of acbylia pancreatica 93

Achylia pancreatica in achylia
gastrica, gastrt^enous diar-
rheas and uie occurrence of 93

Acidosis 137

Acidosis, a clinical study of- a
case of 143

Acidosis in diabetes mellitus 393

Acrodermatitis chronica atrophi-
cans and diffuse idiopathic
atrophy of the skin, differential
diagnosis between 33

Acromion process, auscultation
at the 155

Actinomycosis 402

Aged, tuberculosis in the 173

Agglutination of the spirochaeta
pallida I7S

Agglutination test, the value of
uie, in persons inocubted with
typhoid vaccine 400

Albumin in the sputum in tuber-
culosis 85

Albuminuria in the tuberculous. . 174

Albuminuria, orthostatic-lordotic
and nephritic 276

Albumin reaction of sputum.,.. 84

Alcoholism and tuberculosis 83

PAG^

Alcoholists, Abderhalden's serum

reaction of liver tissue in.... 80
Aldehyde test for urobilinogen,

Ehrfich's 7^

Aleukia hemorrhagica 394

Alimentary tract, the carmin test
and the time of passage of in-

gesta through the 185

Alternation of the pulse 28s

Altitude, lymphocyte increase and 80

Analysis, gastric 287

Anemia and infection 85

Anemia in childhood, grave.... 1 70

Aneurism of sciatic artery 17&

Aneurism of the femoral artery,
remarkable reflex phenomenon

in an aSr

Angina, symptomato1<%y of ab-
dominal 9a

Angioma of the liver, cavernous,

in a baby six weeks old 7a

Aorta, secondary sounds over the 90
Appendicitis and acute appen-
dicular obstruction, acute 95

Appendicitis, differential diag-
nosis of chronic 185

Arsenic in the female organism,

occurrence of 393

Arteriosclerosis, blood and pulse

pressure in 90

Artery, aneurism of sciatic 179

Atherosclerosis, media calcifica-
tion and 287

Atrophy of the akin, differential
diagnosis between acroderma-
titis chronica atrophicans and

diffuse idiopathic 3j

Auscultation, Abrahams' acro-
mial, in the diagnosis of incipi-
ent apical tuberculosis 158

Auscultation at the acromion

process 155

Auscultation phenomenon over
larynx in croup and pseudo-
croup 177

Backache 100

Basedow's disease and female
genital oi^ns 81

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Index of Subjects

PAGE

Basedow's disease, theory of — 376

Biliary lithiasis 393

Bismuth pills 288

Bladder, diverticulum of the... 192

Blood and pulse pressure in
arteriosclerosis 90

Blood, cholesterin of the, in ob-
stetrical and gynecological cases 193

Blood, coagulation factors in
hemophilic i6g

Blood, determination of retention
nitrogen in, a method of test-
ing renal function 296

Blood, diagnostic value of uric
acid determinations in the 274

Blood of tuberculous patients,
tubercle bacilli in the 396

Blood reaction, dyspnea and its
relation to 178

Blood examination, diagnosis of
metastatic tumors of the bone-
marrow from the 395

Blood ,in the feces, improved
phenolphthalein reaction for
the demonstration of occult... ago

Blood serum, cholesterin content
of the human 275

Blood serum, pepstn in the 275

Blood sugar, comparative deter-
minations of, by polarization
and reduction i6g

Blood sugar determinations in
diabetics 275

Blood su^r, influence of muscu-
lar activity upon the 395

Blood, tubercle bacilli in the cir-
culating 280

Blood, uric acid content of in-
fantile 27s

Boas-Oppler bacillus 95

Bone metastases, skeletal cancer
or .^ 279

Book Reviews:
Backward baby, by Herman B.

Sheffield 19S

Diagnostic and therapeutic

technic, by Albert S. Morrow 198
Differential diagnosis. Vol. II,

by Richard C. Cabot 194

Diseases of the bronchi, lungs
and pleura, by Frederick T.

Lord 194

Diseases of the heart, by James
Mackenzie 197

PAGE

Book Reviews — Continued
Erkennung und Verhiitung des
Flecktyphus und Riickfall-
fiebers, by L. Brauer and

Juhus Moldovan 195

Infant-feeding, its principles
and practice, by F. L, Wach-

enheim 194

Infection and immunity, by

Charles E. Simon 199

Lehrbuch der spezifischen Di-
agnostik und Therapie der
Tuberkulose, by Bandelier

and Roepke 199

Medical ethnology, by Charles

E. Woodruff 197

Principles and practice of
tooth extraction and local
anesthesia of the maxillae,

by William J. Lederer 196

Text-book of the practice of
medicine, by Hobart Amory

Hare 200

Urinarjr analysis and diagnosis
by microscopical and chemi-
cal examination, by Louis

Heitimann ...' 198

Bowel, a plea for more frequent
examination of the lower, in

the diagnosis of disease 47

Bowels, dysentery -like affections

of the 9S

Bradycardia, permanent 286

Brain tumor, visual fields in.... 294

Calculi, ureteral 297

Cancer, diagnosis of colon 292

Cancer of the tongue, prognosis in 92
Carbon dioxid determinations,

alveolar 393

Carcinoma 278

Carcinoma, diagnosis of, by the

Abderhaiden method 172

Carcinoma, familial occurrence

of gastric 183

Cardiac weakness, clinical symp-
toms of beginning 91

Cardiovascular disease, the role

of syphilis in hypertensive 286

Cardiovascular insuRiciency on

thyroioxic basis 82

Carditis, heart block in acute

rheumatic 9t

Carmin test and the time of pas-
sage of ingesta through the ali-
mentary tract 18s

„Google

Index of Subjects

Castration, human hypophysis

after 278

Celb in the cerebrospinal fluid,

staining 393

Cells, the origin of local eosino-

^Phile 394

Cerebrospinal fever. 175

Cerebrospinal fluid, staining cells

in the 393

Cerebrospinal liquid, demonstra-
tion of meningococci in the... 401

Cerebrospinal meningitis 176

Chagas' disease, goiter, cretin-
ism and 403

Childhood, epistaxis in later 88

Childhood, frequency of tuber-
culosis in 280

Childhood, grave anemia in 170

Childhood, psychogenous anom-
alies of the gastric secretion in 93
Childhood, tuberculosis, a dis-
ease of 83

Children, night terrors in 190

Children, ovarian sarcomata in. 299
Children, Ront^en ra^ and pul-
monary conditions m 178

Children's urine, diastatic prop-
erty of 78

Cholelithiasis and pregnancy. . . . 300

Cholera 284

Cholesterin content of the human

blood serum 275

Cholesterin of the blood in ob-
stetrical and gynecological

cases, the total 193

Ciliary body in health and dis-
ease 278

Circulatory disturbances in the

newborn 300

Coagulation factors in hemophi-
lic blood 169

Cold, pathology of the 395

Colitis, ulcerative 185

Colon bacillus exaltations 5g

Colon cancer, diagnosis of 292

Complement- fixation in variola, 85, 86
Complement -fixation test in gon-
orrhea 398

Corpus luteum cysts, symptoma-
tology of 299

Creatin and creatinin excretion

in diabetes and nephritis 79

Cretinism, nervous 96

Croup and pseudo-croup, the aus-
cultation phenomenon over the
larynx in 177

Cysts, symptomatology of corpus
luteum 299

Dementia paralytica, spirochaeta
pallida in 295

Dementia praecox, physical man-
ifestations of 295

Dementia praecox, status lym-
phaticus in 99

Diabetes and nephritis, creatin
and creatinin excretion in.... 79

Diabetic constitution, heredity of
the 278

Diabetics, blood sugar determina-
tions in 27s

Diabetic gangrene, the pathology
and diagnosis of so-called.... loi

Diabetes mellitus, acidosis in..^ 393

Diabetes mellitus and disorders
of the glands of internal secre-
tions, pituitary gland in 39S

Diabetes, preliminary stages of. 60

Diaphragm, physical signs refer-
able to the 289

Diarrheas and the occurrence of
achylia pancreatica in adiylia
gastrica 93

Diarrhea, infantile 184

Diastatic property of children's

Diaio reaction, simplification of

the 86

Diphtheria bacilli in herpetic ves-
icles 176

Diphtheria, meningitis in 98

Diphtheria reaction, studies in

the Schick aoi

Diverticulum of the bladder.... 19a
Dohle's leukocyte inclusions.... 282
Ductus arteriosus, patency of the 286

Dysenteric rheumatoids 283

Dysentery-like affections of the

bowels 95

Dysentery, disturbantxs of the

internal secretion in 177

Dysentery. poMtive Gruber-Widal

reaction in 282

Dysentery, serodiagnosis of

larved cases of chronic 401

D>'spepsia. fatigue 288

I^spnea and its relation to blood

178

,y Google

Index of Subjecjs

PAGE

Dyssynergia cerebellaris progres-
siva 189

Ear complications in influenza.. 161
Ehrlich's aldehyde test for uro-
bilinogen 79

Electrocardiography 91

Enteric fever, tonicity of the ab-
dominal muscles in 87

Enterostasis, new theory of the

causation of 291

Eosinophile cells, the origin of

local 39*

Eosinophile sputum cells, espe-
cially in tuberculosis 84

Epilepsy and cerebral tumor .... 99

Epilepsy and pregnancy 300

Epilepsy, clinical stud^ of a case
of apparently intestinal origin. 358

Epistaxis in later childhood 88

Erysipelas, staphylococcic 86

Esophagitis dissecans superficialis 93

Fatigue dyspepsia 388

Fat indigestion 1S4

Fatty acids, volatile, in fresh and
spoiled milk, and the pathogen-
esis of digestive disturbances

in the nursling 93

Feces, urobilin test of urine and 394
Feeding cases, the diagnosis and
classification of difficult, after

the first year 150

Fibrillation, auricular 182

Fibrinolysis in chronic hepatic

insufficiency 96

Galactose and phenoltetra-
chlorphthalein as hepatic func-
tional tests 96

Gallop rhythm, production of. ... 91
Gall-stones, Rontgen diagnosis of 186
Gall-stone, ultimate results in

160 cases 97

Gangrene, the pathology and di-
agnosis of so-called diabetic. lOi

Gastric analysis 287

Gastric secretion in childhood,

psychogenous anomalies of the 93
Gastric symptoms, syphilis and, 289
Gastrocoloptosis in radiologic re-
spects 290

Gastrointestinal tract, lymphocy-
tosis, a sign of constitutional
disturbance in chronic affec-
tions of the 2go

PACE

Gastropaths, diagnostic value of
hyperesthesia of the solar

plexus and its relation to 43

Glands with an internal secretion,

mutual relations of some of the 172
Glycyl-trjfptophan reaction in

meningitis 97

Goiter, cretinism and Chagas'

disease 402

Goiter, prognosis in exophthal-
mic 277

Gold chlorid reaction, Lange.... yj
Gonococci, degeneration forms of 399
Gonorrhea, complement- hxation

test 398

Gout, tuberculosis and 174

Graves' disease and tuberculosis 397
Graves* disease in an infant nine

months old 17a

Graves' disease. Set also Base-

dov/s disease.
Gruber-Widal reaction in dysen-
tery, positive 282

Gruber reaction, simplilicatipn of 87
Gynecology, X-ray diagnosis in. 193

Headaches, gastric ite

Heart, contractility of the tSt

Heart and blood vessel disease

in the war 287

Heart block in acute rheumatic

carditis 91

Heart, hypertrophy of the right. 284
Heart in pregnancy, kidneys and Joo'
Heart, irregular action of the.. 285
Heart irregularities, transitory

complete 385

Heart sounds in the region of
normal pecuJiari-

. symptomless renal. . 297
Hemophilic blood, coagulation

factors in 169

Hemorrhages, leukocytosis in ab-
dominal 186

Hemorrhage of traumatic origin,

chronic subdural 97

Hemolysin reaction of Weil-
Kafka in psychiatric diagnosis 295

Hepatic functional tests 96

Hepatic insufficienqr, fibrinolysis

in chronic 96

Herpetic vesicles, diphtheria ba-
cilli in 176

Hibernation and the pituitary. ..278

„Google

Index of Subjects

PAGE

Hyperesthesia of the solar plexus
and its relation to gastropaths,
diagnostic value of 4a

Hypertension, dilatation of the
arch of the aorta in chronic
nephritis with 179

Hypoadrenia miscalled neuras-
thenia 335

Hypophysis after castration,
human 278

Icterus neonatorum, the produc-
tion of 300

Ileocecal valve in the Rontgen
picture, insufficiency of the. ... 95

Indigestion, fat 184

Indigestion in infancy, influence
of posture on 184

Idiocy, new symptoms in amau-
roOc family 296

Infancy, duodenal ulcers in 95

Infancy, influence of posture on
indigestion in 184

Infantilism, pancreatic 293

Infants, congenital syphilis in
prematurely-born 398

Infection and surgical recovery,
latent 177

Infection, anemia and 85

Influenza, the ear complications in iSi

Internal secretion, disturbances
of the, in dysentery 177

Internal secretion, rachitis and.. 81

Internal secretion, mutual rela-
of the, in their bearing upon
oral pathology 336

Internal secretions, mutual rela-
tions of some of the glands
with an 172

Inthrathoradc disease, diSer-
ential diagnosis between acute
abdominal and acute 178

Ketones of enterogenous forma-
tion 13a

Kidneys in relapsing fever, in-
volvement of 283

Kidneys and heart in pregnancy. 100

Labor pains, pituitary extract, its
value in distinguishing between
false and true 333

Lange gold chlorid reaction.... 97

Leukemia, acute myeloid (myelo-
blast) 344

Leukocyte inclusions, Dohle's. . 282

Leukoc^es and viscosity 169

PAGE

Leukocytosis in abdominal hem-
orrhages 186

Levulosuria, pseudo 171

Liperaia retinatis 171

Lithiasis, biliary 293

Ijyer, cavernous angioma of the,

in a baby six weeks old 73

Liver, tertiary syphilis of the... 186
Luetin test in late syphilitic dis-
ease of central nervous system 189

Luetin test in parasyphilis 28a

Lumbar lesions, new physical

Lung abscess, cases of 89

Lungs, latent syphilitic infection

of the 284

Lungs, percussion of the 88

Lungs, prognostic significance of
tuberculous cavities in the.... 280

Lungs, syphilis of the 88

Lymphocyte increase and altitude 80
Lymphocytosis, a sign of consti-
tutional disturbance in chronic
affections of the gastromtes-

tinal tract 290

Malaria, kala-azar and leprosy,

Wassermann reaction in 28a

Mammae, pathology of the secre-
tion of the 298

Meal, clinical use of water 288

Measles, multiple skin infarcts

^ after 283

Mediastinitis, diagnosis of 178

Mediastinum, primary new

growths of the 89

Meningitis and tuberculosis of

other organs, tuberculous 281

Meningitis, cerebrospinal 176

Meningitis, glycyltryptophan re-
action in 97

Meningitis in diphtheria ^

Meningitis, streptococcus 176

Meningococci in cerebrospinal

liquid, demonstration of 401

Metabolism, parenteral 79

Muscles, congenital absence of all

abdominal ya

Myocardial function, the diag-
nosis of abnormalities of, 5, 118,
-, ^ . . ^^' 339

Myxedema, partial 172

Neoplasms of the breast in
women, benign 298

„Google

Index of Subjects

PAGE

Nephritis, chronic, with hyper-
tension, dilatation of arch of

aorta in 179

Nephritis, creatin and (reatinin

excretion in, and diabetes 79

Nephritis in the nutritive dis-
orders of nurslings, acute. ... 78

Nephritis, syphilitic 190

Nephrotyphoid 401

Nervous system, luetin test in
late svpiiilitic disease of the

central 189

Nervous system, pharmacologic
tests in the diagnosis of dis-
turbances in the vegetative... 188
Nervous system, vegetative, and

abdominal diseases 294

Neurasthenia, hypoadrenia mis-
called 355

Neuritis complicating typhoid

fever, multiple 294

Newborn, circulatory disturb-
ances in the 300

Newborn, tuberculosis of the... 173

Night terrors in children igo

Ninhydrin reaction, examination
of tuberculous-meningeal spinal

fluid by means of the 39^

Nurslings, acute nephritis in the

nutritive disorders of 78

Nurslings and children, physiol-
ogy of the tendon reflexes in. . 187
Nurslings and older children, re-
nal function in 78

Nursling, the urinary secretion

in the 78

Nursling, volatile fatty acids in
fresh and spoiled milk, and the
pathogenesis of digestive dis-
turbances in the 93

Nutritive disorders of nurslings,

acute nephritis in the 78

Occlusion, intestinal 291

Oculo-cardiac reflex 187

Oral pathology, perversities of
the mternal secretions in their

bearing upon 336

Osteomyelitis, diagnosis of 87

Ovarian sarcomata in children.. 299

Pains, referred 290

Pancreatic disease 187

Pancreatic infantilism 293

Paralysis agitans 18S

Paralysis of the spinal accessory

PAGE

Parasyphilis, luetin test in 382

Paratyphoid fever 399

Pelvis, occult hemorrhage from

the renal 296

Pemphigus, positive Wassermann

reaction in I7S

Pepsin in the blood serum 37S

Percussion and the diagnosis of

apical tubercuIoMs 397

Percussion of the lungs 88

Pericarditis, rare forms of 363

Permanganate test for spinal

fluid 276

Pertussis 402

Phenolphthalein reaction, im-
proved, for the demonstration
of occult blood in the feces.. 290

Phosphaluria 170, 171

Phthisis, relationship of infan-
tile and adult 173

Phthisis, the thyroid in 277

Physical examinations, periodic. 164
Physi CO -dynamics, diagnosis from

the standpoint of 366

Physiology, pathological i

V. Pirquet test 84

Pituitary extract, its value in dis-
tinguishing between false and

true labor pains 33a

Pituitary gland in diabetes mel-
titus and disorders of (he
glands of internal secretions.. 395
Pituitary, hibernation and the... 278

Pneumonia, studies in 174

Polyarthritis, chronic progressive ^3

Polyposis, intestinal 186

Posture, influence of, on indi-
gestion in infancy 184

Pregnancy, cholelithiasis and — 300
Pregnancy, diagnosis and prog-
nosis of renal changes in 193

Pregnancy, epilepsy and 300

Pregnancy, experimental re-
search concemmg renal changes

in 99

Pregnancy, kidneys and heart in 100
Pregnancy, labor and puerperium,
toxicity of urine, serum and

milk during 299

Pro.'itate, hematogenous tuber-
culosis of the 297

Prostatic suppuration, internal

aspect of 297

Pruritus ani 96

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Index of Subjects

PACE

Pseudo-croup, broncho-pneu-
monic 284

Psychasthenia, analysis of a case

of 98

Psychiatry, Abderhalden's pro-
tective ferments in 295

Psychiatry diagnosis, hemolysin

reaction of Weil-Kafka in.... 293
Psychoanalysis, a word capable

of wide usefulness 74

Psychoses in old age, paranoid. 295
Psychoses, the diagnosis of the

borderland: a warning jag

Psychotic uremia and its mixed

forms 80

Pulsation, capillary 179

Pulse, alternation of the 283

Pulsus paradoxus 91

Pyelitis 191

IVelography, a new preparation

for 191

Pylorus, a new symptom of ulcer
at or about the duodenal por-
tion of the 360

Pylorus, tuberculous stenosis of

the 184

Rachitis and internal secretion. . 81

Raynaud's syndrome 277

Reflex, the oculo-cardiac 187

Reflexes, examination of the... 187
Reflexes in nurslings and chil-
dren; physiology of the tendon 187
Relapsing fever, involvement of

the kidneys in 383

Renal changes in pregnancy, ex-
perimental research concerning 99

Renal functional tests 190

Renal function, determination of
retention nitrogen in the blood,

a method of testing 296

Renal function in nurslings and

older children 78

Renal pelvis, occult hemorrhage

from the 296

Rheumatism, spasmodic symp-
toms in 401

Rheumatoids, dysenteric 283

Rontgen diagnosis in gynecology 193
Rontgen diagnosis of gall-stones 186
Rontgen ray and pulmonary con-
ditions in children 178

Rontgen ray, diagnosis of geni'
tourinary conditions in women

by means of the 368

Sarcoma, age incidence in 279

Sarcomata in children, ovarian.' ^99

Schick diphtheria reactionp
studies in the 3M

Schick toxin reaction 176

Sceletal cancer or bone metas-
tases 279

Serodiagnosis. See Abderhalden
and IVassermann reactions.

Serum reaction of liver tissue
in alcoholists, Abderhalden's.. 80

Situs viscerum inversus totalb. aso

Skin infarcts after measles, mul-
tiple 383

Spinal accessory nerve, paralysis

^of 189

Spmal fluid, permanganate test
for 27G

Spirochaeta pallida in dementia
paralytica 295

Spirochaeta pallida, agglutina-
tion of the 175

Spinal cord tumors 190

Spinal fluid, examination of lu-
be rculous-meningeal, by means
of the ninhydrin reaction 396

Sputum, albumin reaction of... 84

Sputum cells, eosinophile, espe-
cially in tuberculosis 84

Sputum in pulmonary tuberculo-
sis, albumin reaction of the... 174

Sputum, intracellular occurrence
of tubercle bacilli in the 279

Sputum in tuberculosis, albumin
in the 84, 85

Status lymphaticus in dementia
praecox 95

Stenosis of the pylorus, tubercu-

Sternum, normal peculiarities of
heart sounds in the region of

the 89

Stomach contents, tubercle bacilli

in 1S4

Stomach, syphilis of the 183

Streptococcus meningitis 176

Suppuration, internal aspect of

prostatic 297

Syphilis and gastric symptoms.. 289

Syphilis and tuberculosis 281

Syphilis, congenital 83

Syphilis, hereditary 82

Syphilis in prematurely-born in-
fants, congenital 3^

Syphilis of the liver, tertiary. . . i86

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Index of Subjects

PAGE

Syphilis of the lungs 88

Syphilis of the stomach 183

Syphilis, parenchymatous 189

Syphilis, splenic enlargement in

early 398

Syphilis, tests for 398

Syphilis, the role of, in hyper-
tensive cardiovascular disease. 286

Tachycardia, paroxysmal 181

Tendon reflexes in nurslings and
children, physiology of the... i^

Tetanism 70

Thrombo-angiitis obliterans, the
significance of thrombo-phle-

bitis in 301

Thrombo-phlebitis in thrombo-
angiitis obliterans, the signifi-
cance of 301

Thymus and thymus deaths,

hypertrophy of 277

Thyroid, acquired disease of the fc
Thyroid gland and female geni-
tals 81

Thyroid of phthisical patients... 277
Thyrotoxic basis, cardiovascular

insufficiency on 83

Tongue, prognosis in cancer of

the 92

Tonsillitis, pneumococcal 85

Tonsils, spirochetal ulceration of 399
Toxicity of urine, serum and
milk during pregnancy, tabor

and puerperium 299

Trichinosis, respiratory signs in. 402
Tubercle bacilli in the blood of

tuberculous patients 39^

Tubercle bacilli 191

Tubercle bacilli in stomach con-
tents 154

Tubercle badlli in the circulating

blood 380

Tubercle badlli in the sputum,

intracellular occurrence of 279

Tuberculosis, a disease of child-
hood 83

Tuberculosis, albumin in the spu-
tum in 84, 8s

Tuberculosis, albumin reaction

of the sputum in pulmonary., 174
Tuberculosis, albuminuria in the 174
Tuberculosis, alcoholism and... 83

Tuberculosis and gout 174

Tuberculosis, early diagnosis of
pulmonary 397

PACK

Tuberculosis, eostnophile sputum
cells, espedally in 84

Tuberculosis, Graves'disease and, 397

Tuberculosis in childhood, fre-
quency of 280

Tuberculosis, incipient apical, a
further plea for Abrahams'
acromial auscultation in the di-
agnosis of 158

Tuberculosis in the aged 173

Tuberculosis of school children,
pulmonary 83

Tuberculosis of the newborn... 173

Tuberculosis of the prostate,
hematogenous 297

Tuberculosis, percussion and the
diagnosis of apical 397

Tuberculosis, prognostic value of
sputum examinations in pul-
monary 174

Tuberculosis, prognostic value of
the temperature curve in pul-
monary 279

Tuberculosis, renal 191

Tuberculosis, subnormal temper-
ature in 83

Tuberculosis, syphilis and 281

Tuberculosis, testicular 192

Tuberculosis, the early diagnosis
of incipient pulmonary 67

Tuberculosis, the recognition of
the pretuberculous stage and
the early symptoms of 6a

Tuberculosis, tuberculous rheu-
matism and other forms of
larved 84

Tumor, epilepsy and cerebral, ., 99

Tumors of the bone-marrow, di-
agnosis of metastatic from the
blood examination 395

Tumors, spinal cord 190

Tumor, visual fields in brain... 294

Typhoid carriers, autopsies of
two 87

Typhoid diagnosis, vaccination
spleen tumefaction and 400

Typhoid fever, multiple neuritis
complicating 294

Typhoid fever, symptomatology
and diagnosis of 283

Typhoid vaccine, the value of the
agglutination test in persons
inoculated with 400

Typhoid without fever 400

„Google

Index of Subjects

PACE

Typhus fever, artificial hyper-
emia in the diagnosis of 40t

Typhus fever, number and forms
of white cells in 401

Ulcer, ^cate gastric and duodenal
perforating 94

Ulcer, a new symptom of, at or
about the duodenal portion of
the pylorus 3G0

Ulcer, a summary of the essen-
tial ^ints in the diagnosis of
gastric 147

Ulcer, familial occurrence of
gastric 183

Ulcer, perforated gastric 94

Ulcers in infancy, duodenal 95

Uremia and its mixed forms,
psychotic 80

Ureteral calculi 397

Uric add, calorimetric determi-
nation of urinary 170

Uric acid content of infantile
blood 275

Uric acid determinations in the
blood, diagnostic value of.... 274

Urinalysis and the general prac-
titioner 383

Urinary secretion in the nursling 76

Urine and feces, urobilin test of
the 394

Urme, diastabc property of chil-
dren's 78

PAGE

Urine, toxicihr of 274

Urine, tubercle bacilli in [91

Urinoid poisoning, symptoms of 274
Urobilin test of urine and feces. 394
Urobilinogen, Eh rlich's Aldehyde

test for 79

Uterus, prolapsus of the 298

Vaccination spleen, tumefaction

and typhoid diagnosis 400

Vagotonia 294

Variola, complement fixation

in 8s, 86

Vesiculitis, seminal 99

Vincent's angina 399

Viscosity, leukocytes and 169

Vision and ill-health, faulty 173

Wassermann reaction, a simple

substitute for isS

Wassermann reaction in malaria,

kala-aiar and leprosy 282

Wassermann reaction in pem-
phigus, positive 175

Wassermann reaction in relation

to diagnosis 281

Weil-Kafka hemolysin reaction

in psychiatric diagnosis 295

Widal reaction, simplification of 87
Women, benign neoplasms of the

breast in 298

Women, diagnosis of gentto-

urinary conditions in, by means

of the Rontgen ray 368

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„Google

Index of Authors

INDEX OF AUTHORS

Abhahaus, R., 155.
ACEL, J.. ^.
Adler, 309-
Albu, A^ 185.
Amann, J. A., 30a
Andwou), K. F., 83.
Asca. aMK

AUFUCHT, MS,

Austin, A. £., aSS.

Baexthlxik, K., 384.
Bahrvt, H., 93.
Bandelrk, 199.
Bandlei, S. W^ 333.
Barooft J., 178.
Babton, W. M., 172.
Beddakd. a. p., 393.
Beifeld, a. F^ 344.
Bebceix, p., 80.
BiscHOFP, 185.
BiTTOw A^ 93-
Blatt, M C, 901.
Blumu, G., 89.
Boas, L, 99a
BoLDT, H. J., 39S.
BoMDi. L, 99.
BoKDi, S., 90.
BooisTEiK, S. W., 383.
BoSLEE, A., 78.
b bam well, b., 993.
Bbaueb, L., 105.
buttmann, m. j., 93.
Bret, J., 384.
Brooks, H., 297.
BwwM, H. C, 398.
Brown, L., 191.
Brl-ce, a. N., 189.
Bruckner. £. L., 395.
Brugsch, T^ 389.
Bryan, K. C., 179.
BvERGES, L., 101, 301.
Burke, J^ 293.
bukbhah, e. a.. ss.

BuTLEK. E. M., 83.
Cabot, H., 192.

P.Tm.
'. t, 186.

Cabot, R. C, 1

CaU MIDGE. P. f

Carrall, W. '... __
Chancellor, P. S., 78.
Cheney, W. F.. 182.
Clark, J. G., 97.
Claytim, T, a., 394.
Cloptom, M. B., 87.
CocKF, C. H- 85.
CoHN, M., 279.
COLK, L. G., 18G.
OH.E, R., 174-
Collins, J., 19a
Cope, V. Z., 402.

COKIAT, I. H., 296.

Ohinwall, £. E., 3s8l
CoTTIN, 386.
Crohn. B. B., 187.

CULLEN, J. p., 173,

CusBiNG, H., 278, 394.

CVTRONBERG, S., 172.

Dally, J. F. H., 91.
Day, a. a., 184.
Deaver, J. B., I.
Dembicki, a., 79^
Denis, W., 274.
Deutsch, F., 401.
Dexteb, B 389.

DiETSCH, C, 401.

D'Onchia, F., 174.
Du Bois, P. L.. 176.
Dunn, C H., 184.
Dunn, H. P., 278.
Dunnes, 17a
DuRAND, G„ 29a

Edeluann, a., 394.
Edelsteik, F., 93.
EiCHHcntST. 296.
EiNBcatN, M,, 183.
Elliot, J. A., 3»».
Else, J. E.. 278.
Ely. L. W., 98.
Emerson. H., 99.
Engel, 78.

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XViii

Fahrenkamp, K., 285.
Falconer, A. W., 91.
Fee, F,, 04.
FiLDES, P., 395.
FiNDLEV, L., 83.
FiSEBEBG, M., 280,

Fleming, S., 176,
Flourney, H., 98.
FoLiN, O., 274.
FoNio, A., 169.
Foster, M., 175.
Fkank, E., 394,
Frank, F., 78.
Frankel, E., 401.

FftAZER, T., 84.

Fkoumer, v., 393.
Fry, H. J. B., 395-

Gault, H. M., 95.
George, A. W^i86.
Geraghty, J. T., 190, 297.
Gerney, H. M, 277.
Gerstly, J, R., 184.
Geyser, A. C., 6a.
Gilbert, M. A., 393.
Gildeueister, E., 284.
Gloves, E. G., 84. 397.
Goebel, 87.
GiWTscH, E., 278.
Gi»j>scheides, 400.
GooDPASTUKEj E. W., 96.
Gordon, G. S., 191.
Gradwohl, R. B. H., 281.
V. Graff, E., 81.
Grulee, C G.. 97, 173.
Griffith. T. W.. 286.
Gruber, G, B.. 283.
Gubergritz, M., 9t.
Gulbring, A., 1(19.
Gunson, E. B., 187.
Gutman, J., 47.

Halban, J., 299,
Hah u AN, L., 28a

Hare, H. A., 200.

Harms, F., 173.

Harper, J., 399.

Hart, T. S.. 9, 118, 307, 339.

Hartmak, F. a., 274.

Hartshorn, W. M., 178.

Hawes, J, B., 173.

Hays. H., 161.

Heaton, T., 287.

Heitzmann, L., 198.

Hess. A. F., 288.

Hesse, U.., 175.

Index of Authors

HevNEMANN, T., 300.
HiGCiNS, T. T., 299.
HtHMAN. p., 297.

HoBHOUSE, E., I7S.
HOHLWEG, H.. 296,
HoLiTscHER, 83-
Holmes, B., 295.
Host, H. P., 170.
Howard, C P„ 178.
Howard, H. A. H., 171
Huffuann, M,, igj.
Hunt, J. R., 189.

James, T, L., 80.
JaNowski. W., 90.
Jarno, L., 283.
Jeans, P. C. 82.
Johnston, M. R., 28a.
Jurgensen, E., 179.

Kabar, W. W., 173-
Kafka, V., 189. 396.
Kanior, J. L,, 154.
Kaufhann, J., 290.
Kehl, H,, 277,
Keith, A., 291.
Kennedy, A. M., 91.
Kessel, L.. 396.
KtLDUFFE, R., Jr., 3B3.
KoGoRE, A. R,, I79i
Kiss MEYER, A., 17s
Klaus, O., 172.
Klein, A., 85.
Koechun, E., 93.
KoLtscH. E., 299.
KoLMER, J. A., 176.
v. konschegc, a., 96.
Krans, R., 402.
KuLBS, 90.

Lackner, E., 276.
Lawhobn, C. C, 67.
Lam PERT, D. 79.
Landis, H. R. M., 284.
Lange, v., ^.
Laurit£en, M., 275.
Le Bdutillier, T„ 277.
Lederer, W. J., 196-
Lehmakn, G., 1 88.
Lemchen, B., 393.
Leschke, E., 8s, 95-
Levinson, A., 177, aoi, 276,
Levison, L. a., 186.
LEvnoN, M. B., 181.

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Index of Authors

LivY, I. H., 154.
U Wald, l. t., 184.
Uwis, p. A., 284.
Lewis, T., 178.

LlEFUANN, £., 275.

LiimiG, P., 2C^.
LrrTLE, G. F., 14a.
LosD, F. T., 194.

LOWENBEIH', 174.

LowY, J., 79.
LuDLUM, W. D., 13J.

LUNLIKSKI, W., 394.

LuNBi, A, 176.

Maase, C, 169.
Mackekkey, W. H„ 398.
Mackenzie, C, 178.
Mackenzie, T., 197.
Macnaity, a. S., 381.
Maggio, C., 403.
Macida, N., 15B.
Major, R. H., 97.
Marcbuse, E., 95.
Marek. R., 382.
Marks, H. E., 190.
Martini, £., 8a.
Mathieu, A., 391.
Matthes, M., 401.
Mayer, 174.
McAllister, V. J., 10a
McArdle, J. S.. 192,
McCaruson. R., 9&
McauRB, W. B., 7a
McOue. T., 186.
McIntosh, T
McQueen, f

MeLCHI(», E-, 1//.

Mettler, L. H., 399.
Meyer, C, 300.
Meyer, F., 40a

MlNOT, G. R., 403.

MnsA, G. C„ 383.
MoLDOFAN, Jt 195.

MoNCKEBBRC, J. G., 387.

Moody, A. M., 97.
Moore. R. P., 171.
V. MoRACZEwsKi. W., 395.
MoRCEtf STERN, K., 283,
MosiTZ, 91.
Morrow, A. S., 108.
MoSHAG, E. L., 176,
UosHES, E. M., 298.

Naish, a. E., 01.
Neal, J. B., 176.

TK, E., 177.

Newuah, D., 297.
Noble, E., 97,
NOHL, E., 84.
NofiDBURY, L. E. C, 06.
Norr, F. W., 189.
Novak, J., 81.

Ogiltie, C, 100.
OKiNTsceiTz, L., 173.
Osborne, O. T., 277.
Oswald, A., sTlS,
overend, w., 83.

Pancoast, H. K., 09,
Parsons- Smith, B., tSi.
Patrick, A, 87.
Pfanner. W., 184.
Peisek, H., 177.
Pei, p. K, 183.
Peubry, M. S., 393.
Petekkin, G. S., 368.
Petry, H., 88.
Photakis, B., 394.
PiSEK. G. R., 150.

PUTEK, 183.
PoSNER, C^ 101.

poulton, e. p., 393.
poynton, f. j., 401.
Pribrau, H.. 85.
Pribram, I. H., 275, 278.

Rackmann, F. M., 402.
Rall, i;6.
Rankin, G., 2S8.
Rehder, H., ^.
Reicre, a., 30S.
Reiche, F.. 86, 98.
Reiss, E., So, 400.
V. Reuss, a., 300,
Rhein, M., 86.
RisLEY, E. H., 279.
Robertson, M. £., 83.
Robertson, O. H., 79.
Robinson, H., 399.
R(«PK^ 190.
Roger, M. M., 274.
Rogers, J-, 82,
Romberg, E.. 2^.
rominger, e., 81.
Rosembusch, F., 403.
Rosin, 171.
Ross, D. M.. 282.
Ross, J. N. W., 89.
RossLE, R., 278.

ROTHMANN, 171.

V. ROZNOWSKI, J., 395,

Rubin, I, C, 193,

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Saxl, P, 275.
schikzingeb, 397.

ScHOLDEB, 276.
SCHHIVT, 82.

Schneider, A., 307.

Schneider, E.. 289.

SCHOONUAKEH, H., lE
SCHOTT, M., 4a.
SCHULTZE, F.. 283.

ScuDDER, C. L., 8g.

SiuMONDS, M., 297.

Simon, C. E., 199-

SiHGER. G., 283. 363.

SiOLi, F., 295-

SissoN. W. R.. 96.

Smith, C. H., 184.

Smith, W. H., 179-

Smithies. F„ 147-

Sprigcs, E. I., 393-

Stains, M. E., 8a

Steinmeier, y/., 281.

Stengel, A., 19a

Stephens. G. A., lafi.

Stern, A., ja.

Sterk, Heinrich, 118, 133, 338, 3G0.

Stetttner, E., 170.

Stoll. H. F., 286.

Stone, A. K., 83.

Stsauss, H., i8s, 401.

Strauss, O., 290.

SuRer, E., 284-

sutherland, w. d., 282.

V. Szab6ky, J., 174. 279-

Index of Authors

Thies, A., 294.
Thomas, B. A., 99.
Thomas, D. J., 176.
TicE, F., 350,
Trommer, E., iSS.
Trotter, W.,
Turner, W. t

Uhle, a. A., 398.

Vas, J., 187.

Veeder, B. S., 95, 2aa

Veith, 276-

Wachenhbim, F. L., 194-
Walker, C. B., 294.
Wegener, W., 93.
Weller, C, v.. 279.
weni1en8uro, 84.
Werner, P.. 299.
White, P. D., 285.

WlGDOROWlTSCH, ^7-

Wni, U. J., 398.
WiLKiE, D. P. D., 95.
Williams, B. G. R., 59.
Williams, T. A., 190, 355-
Wilson, C, 285.
WiNGBAVE, W., 399-
Wise, F.. 33.
Wolf, 193-
Wood, N. K.. 88.
Woodruff, C. E„ 197.
WObtzen, C. H., 187.

Young, E. N., 191.

Zabe, 193.

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Archives of Diagnosis

A QUARTERLY JOURNAL DEVOTED TO THE STUDY
AND THE PROGRESS OF DIAGNOSIS AND PROGNOSIS

JANUARY. 1916

l^petfal lartftlat

PATHOLOGICAL PHYSIOLOGY*

By JOHN B. DEAVER

Professor of the Practice of Surgery, University of Pennsylvania; Surgeon

in Chief. German Hospital,

Philadelphia

Pathology embraces both the structural and functional changes
caused by disease. The term pathological physiology is appropri-
ately applied to the pathology of function, but applied as a rule
in such manner that the student is prone to dissociate cause and
effect ; in other words, attention is too often paid to the symptoms
of disease to the exclusion of the disorders of physiology that give
rise to them. It will not be amiss, therefore, for us to consider
some of the broad general principles of the pathological physiology
of the digestive viscera contained within the abdominal cavity, with
a supplementary review of several phases of this interesting prob-
lem upon which recent discoveries have shed additional light.

Qinical symptoms arising from a diseased viscus merely confess
its physiological sins.

The fault in function may or may not be dependent upon a
gross pathological lesion, but in the event that such lesion does

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2 The Archives of Diagnosis

exist the disease in the vast majority of instances is a surgical one,
demands surgical treatment, and cannot be cured, except in the rar-
est instances, by other than surgical measures.

What I want particularly to impress upon you is the fact that
almost without exoeptioD pathological physicdogy of the abdominal
digestive organs denotes the presence of surgical pathology.

You must ncrt take from these remarks my denial that func-
tional disorders of the abdominal viscera occur in the absence of
structural changes. Indeed, the foremost problem that confronts
the abdominal surgeon is that of clinical differentiation between
medical and surgical diseases, for despite every effort it is often-
times impossible to determine the cause of a very obscure patho-
logical physiology.

How, then, can we justify the assertion that an alteration in
[unction of an abdominal oi^n continuing over a long period of
time is usually indicative of a surgical lesion? Why, you may ask,
will the surgeon assume the responsibility of advising operation
to the patient with abdominal symptoms so indefinite that accurate
diagnosis is impossible?

It is only by the conviction borne of long experience with the
pathological physiology of the living — by readjustment of the clin-
ical picture to conform with the finding at operations frequently
advised on mistaken diagnoses and finally by rational deductions
from discoveries accidentally made in the search for a cause of
persistent symptoms.

In certain conditions, such as duodenal ulcer, we have been
enabled in this manner to construct a clinical symptomatology char-
acteristic of the disease. In the case of other inflammatory or
neoplastic diseases of the abdominal digestive viscera that are not
associated with localizing signs, we have learned that the mere per-
sistence of functional changes usually denote the presence of a
surgical lesion.

You are well aware that the normal functional activities of the
digestive system demand a harmony of action in the secretory, ex-
cretory, absorptive and motor functions that will permit of the di-
gestion of food and excretion of waste products to proceed in the
entire absence of any conscious perception on the part of the
individual that these extremely complex processes are going on.

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Deaves : Pathological Physiology j

Both the cbcnikal and physical reactions in the digestitxi of food
are interdependent and under the ccHitrcd of a communal nerve
supply ; it is easily conceivable, therefore, that pathdogical physiol-
ogy of our digestive oF|;aBs will cause a dissociatitHi of function
among other members of the system. Regardless of the primary
seat of the disease, however, and despite, too, its nature, the
majority of chronic gastrointestinal disorders express themselves
primarily through the medium of gastric symptoms : the stomach ts
the mouthpiece of the abdominal digestive viscera. It is necessary,
therefore, to distinguish between symptom-complexes arising from
disease of the stomach itself and those dependent upon diseases of
the rdated abdominal digestive viscera. Medical teaching, as ex-
cnqtlified in the most modem books, implies that the recognition
of each deviation from the normal physiology is a simple matter,.
and the faith of the student in his ability to recognize each condi-
tion is shattered only when jHactical ^tperience has taught hitn:
the depths of this dclasMW. And then, instead of casting aside the
falsc friendship of dogmatic teaching and seeking for the truth
at the operation table, he has often become content to label every
gastric disorder dy^>epaia in one of its fifty-seven varieties.

As a result, prolonged and irrational efforts are made to alter
the course of a pathological physiology by means of drugs. This-
explains the [^evalence of inop^able cancer of the digestive tract ;
of irtBammatory lesions that produce crippling adhesions, which,
depute suigery's best efforts, condema the individual to chronic
itrralidism; this same disr^ard of the warning note of the living
pathc4ogical physiok^ in acute diseases explains the frightful
mOTbidity and mortality of acute appendicitis. It explains also why
intestinal obstruction cases are brought to the hospital days after
the onset of the condition, and, finally, to this cause must be at-
tributed the chronic inflammatory lesions of the biliary tract, with
bacterial invasion of the pancreas by way of its lymphatics, whereby
an essential part of this organ is destroyed. Let me repeat, all
abdconmal sjrmptoms are not indicative of surgical lesions, but I
firmly belkve that timely operation will only be advised by lAysi-
cians who are trained to look upon long-continued abdominal symp-
toms as an indication for swgical exploration. Text-books of the
future tmist be written on the basis of the living pathology re-

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4 The Abchives of Diagnosis

vealed at the operating table and not, as in the past, on the tenninal
pathology, as displayed on the mortuary slab.

The purely functional diseases of the gastrointestinal organs and
diseases of these viscera with a minor pathol<^cal basis, in other
words, medical conditions, are amenable to scientific dnig and
dietetic measures.

Let it be your practice, therefore, to advise the aseptic scalpel
to patients with the history of long-continued indigestion that has
failed to improve after one month's trial of proper medicinal treat-
ment. It is your duty to «nbrace the modernism of pathological
physiology, to demand a rational explanation for persistent ab-
dominal symptoms, and to ever remember that disorders of the
stomach are the verbal confession of surgical pathology somewhere
within the abdominal cavity.

At the outset of my remarks your attention was called to the
interdependence of the several functions of the gastrointestinal tract
and how any aberration in one function must necessarily influeoce
the others. It is obvious, however, that one or the other of these
functions is primarily influenced in each disease, and in the first
condition which we will consider, namely, acute intestinal obstruc-
tion, the initial change concerns the motor function of the gut tube-
Acute obstruction of the intestine is usually a rapidly fatal dis-
ease even in the absence of actual strangulation or gangrene of the
bowel, and it is inconceivable that any interference with the motor
power of the intestinal musculature could in itself quickly destroy
life. Heretofore the early death of these patients has been attrib*
uted to shock arising from injury to the splanchnic nerves at the
site of obstruction, and to peritonitis. In this conception of the
pathological physiology of the ileus, the motor function is pri-
marily deranged with secondary alteration in the protective func-
tion of the intestinal mucosa.

As a result of recent experimentation it has been found that
peritonitis has little influence in the fatal issue of ileus ; in fact, it
has been proved that animals will present the classical symptoms
of the disease when sterile cultures are obtainable from the peri-
toneal fluid, the peritoneal coat of the diseased bowel and from the
blood. It is evident that the pathological physiology of intestinal
obstruction entails a series of changes more complex than mere

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Deaver: Pathologicai. Physiology 5

interference with the motor and protective functions of the gut
walls. The additional factor concerns the secretory activity of
the intestinal mucosa, which has been found to secrete a virulent
toxin at the site of the obstruction. This toxic product of patho-
logical physiology is capable of producing the typical picture of
intestinal obstruction when administered to normal animals. In
toxic doses it causes a profound drop in blood pressure, general
collapse, lowered tfinperature and vomiting — in a word, the clinical
picture of intestinal obstruction.

The life of experimental animals can be prolonged by injection
of a normal saline solution, which fact merely confirms the evi-
dence already given that the fatal factor in the disease concerns
the pathological physiology of secretion of the intestinal mucosa,
since the saline solution for a time protects the nerve centers against
the toxin produced in the diseased bowel.

Bacterial invasion of the peritoneal cavity eventually takes place
and undoubtedly adds to the gravity of the condition, but the dan-
gerous initial factor in intestinal obstruction is the toxic product
of a pathological physiology. The clinical recognition of this, which
is now proved experimentally, has long been made. The late Dr.
Price was accustomed to speak of the poisons within the obstructed
gut and he advised and practised drainage of the intestine in all
cases of obstruction, whether mechanical in nature or due to the
paralysis often associated with peritonitis.

The first symptom of interference with motor function of the
intestine suggestive of obstruction should create in your minds the
picture of a pathological physiology that will soon create a lethal
poison, and with the early diagnosis of the condition the necessity
of dangerous operation will disappear.

Another abnormal physiological sequence of the abdominal di-
gestive organs begins with a primary disturbance of the secretory
and excretory functions of the liver. You will recall that the
normal physiology of the stomach and small intestine presupposes
the discharge of normal products of gastric digestion into a nor-
mal duodentun at regular intervals. In case the duodenum con-
tains fermented or putrid material, the gastric secretion becomes
changed and the discharge of chyme from the stomach is delayed,
with the result that putrefaction takes place within the stomach.

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6 The Archives of Diagnosis

The normality of duodenal physiology, in turn, depends in large
part upon the antiseptic properties of the bile, so that disturbances
of the biliary (unction become the frequent source of gastric dis-
orders.

The most frequent products of pathological physiology of the
liver are gall-stones, the chemical constituents of which are present
in normal bile and play an important role in intestinal digestion.
If, for any reason, the drainage of the bile duots becomes imper-
fect, if, in other words, the motor function of the biliary system be-
comes pathological, the bile salts are deposited in the form of gall-
stones. The motor insufhciency under these circumstances is only
relative, however, since it is dependent as a rule upon inflammatory
swelling of the lining mucosa. The clinical symptomatology of
gall-stones arises for the most part from the altered physiology
of the stomach, simply because nature has endowed this organ
with the power of expression of pathological physiology in any
upper abdominal organ. The remote effectrs of toxemia arising
from biliary disease is an alteration in the normal function of the
renal and cardio-vascular system. A long-continued action of re-
absorbed bile and toxins from the infected gall-ducts results in
myocardial and renal degeneration with the development of a patho-
logical physiology of these structures that soon becomes ir-
remediable. For this reason alone, and discounting the evil local
e£Eects of the disease, patients who present the symptoms of gall-
stone disease should be operated upon at once.

And now, just a word concerning the pathological physiology
of cancer of the stomach. This varies not alone in carcinoma of
different portions of the Stomach, but with the various clinical types
of the disease as well. The so-called acute cancers run a very rapid
course, and as a rule cause death in three months or less from
the time of appearance of the initial symptoms.

Cases of this kind give rise to characteristic symptoms, but are
not recognized sufficiently early for effective operative treatment.
The latent gastric cancers, especially those that involve areas other
than the pylorus, proceed often for many years, and eventually
cause death in absence of any prominent symptoms referable to
the stomach in the operable stage of the disease.
. The carcinomas commonly met with in the stomach like the

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Deaver: Pathouxiical Physiology ■ 7

preceding variety give rise to no characteristic pathological physiol-
ogy until the disease is far advanced, so that if you await the
onset of obstructive symptoms, hetnatemesis or the appearance of
a palpable mass in the epigastrium, the prognosis will be absolutely
hopeless. We do not expect a marked deviation from the normal
physiology of the stomach when carcinoma first attacks its walls,
since the constituent cells of the tumor are structurally identical
with the normal gastric epithelium, and, while they serve no normal
purpose, these abnormal cells do not alter the gastric physiology in .
the beginning of the disease.

The first evidence of cancer of the stomach is an indefinite iull-
ness or weight in the epigastrium after meals with loss of appe-
tite, a gradual loss in weight and strength that is usually progres-
sive in an individual who had previously enjoyed perfect health.
What is the pathological physiology underlying these symptoms?
It is primarily a motor insufficiency whereby the egress of food
from the stomach is retarded, with the result that fermentation
occurs and the clinical picture of chronic gastritis is produced.
With continued progress of the disease, the motor disturbance in-
creases, and promptly a change in the normal physiology of gastric-
secretion adds to the digestive difficulty.

The very first sign of disturbance with the motor power of the
stomach in an adult who has previously been free of gastric symp-
toms is an indication for surgical exploration of the upper ab-
domen, for if you procrastinate until the typical pathological physi-
ology presents itself, the malignant cells will have formed irremov-
able deposits in the adjacent lymph nodes. It is most conservative
to be most radical under these circumstances, and if you will learn
the lessons taught by the living pathological physiology at the op-
erating table your patients will show few deviations from the
normal until the scalpel exposes the offending organ to the light
of day.

Another phase of the pathological physiology of the abdominal
digestive viscera that is of particular interest concerns the absorp-
tive and protective functions of the large intestine. It has been
said that we eat with our small intestine and drink with the large
one. The absorption of fluids through the walls of the large bowel
is favored by an antiperistaltic action of the musculature of the

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8 The Archives of Diagnosis

proximal segments of the colon whereby the contents of this por-
tion of the intestinal tract are retained until the greater amount of
the liquid is taken up by the blood vessels. In infianunatory states
of the bowel walls this favors the migration of bacteria, nortnally
present in large numbers in the colon, and the products of local-
ized peritonitis are, therefore, frequently found as the remains of
an antecedent inflammation of the large gut.

Localized peritonitis of the upper abdomen other than that aris-
ing from gall-bladder disease is found in association with demon-
strable disease of the gastric or intestinal walls — usually ulcerative
in type, and one seldom hears of coi^enital membranes, therefore,
above the umbilical line. Lane's kink of the ileum, Jackson's mem-
brane surrounding the colon and similar abnormal peritoneal folds
are the products of an altered physiology of absorption of the
walls of the large gut that at one time permitted of the migration
of bacteria normally excluded from the peritoneal cavity.

These membranes which are the remains of an antecedent pathol'
ogy subsequently interfere with the motor function of the large
intestine, and the treatment of the stasis that follows is one of
the most difficult problems that confront the surgeon.

The attempt to restore the normal physiology of the large bowel
under conditions of stasis have met with slight success. The rea-
sons for surgical failure in this disease have a two-fold basis. In
the first plan of treatment, namely, that of excision of the large
bowel with anastomosis of the ileum to the sigmoid or similar
procedure with the cecum and rectum, the primary operative mor-
tality is so high that the procedure is unwarranted. Any method
which does not provide for exclusion of the large intestine fails
because the antiperistaltic action of its musculature fills the ex-
cluded gut with feces. Not only is the stasis that follows worse
than that prior to operation, but the impacted feces predispose the
walls of the excluded cul-de-sac to perforation. If anastomosis is
made between the ileum and sigmoid with bilateral exclusion of
the large gut, the latter becomes a veritable poison factory, and
unless an exit be provided for its contents the harmful results
of the absorbed toxins soon appear. If any exclusion operation
is attempted a mucous fistula should be made, either of the ascend-
:ing colon or of the splenic flexure of the colon. This step in the

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Hart: Abnormalities of Myocardial Function g

operation of the ileo-sigmoidostomy with bilateral exclusion of the
large intestines promises to be the best substitute for the opera-
tion of total resection of the large bowe!.

You have, no doubt, observed that the failure to find a satis-
factory treatment for intestinal stasis has a physiological basis —
the normal antiperistaltic action of the large intestine drives the
fecal material toward the ileocecal valve, while exclusion of the
gut both proximal and distal to the point of anastomosis is fol-
lowed by abnormalities in secretion and absorption in the excluded
gut of the same nature, but in greater degree than simple intestinal
stasis.

You have been given merely a glimpse of the pathological physiol-
ogy of several diseases of the abdominal digestive organs, but
enough I sincerely hope to stimulate the desire on the part of each
one of you to reduce every symptom of gastrointestinal disease
to its actual physiological and pathological cause. By following
this Golden Rule of practice the diseases that come under your
future observation will not be permitted to go on and on to incura-
bility because the symptoms are incomplete or otherwise fail to
conform with a clinical picture that is too often based on the
pathological physiology of terminal diseases.

THE DIAGNOSIS OF ABNORMALITIES OF MYOCARDIAL

FUNCTION

By T. STUART HART

Assistant Professor of Oinical Medidne, College of Physicians and

Surgeons, Columbia University; Visiting Physician,

Presbyterian Hospital

New York

III.

THE EXTRASYSTOLE

In the routine examination of the pulse our attention is frequent-
ly attracted by a form of irregularity which has the following char-
acters: the rhythm is for longer or shorter periods that of a normal
pulse, but at intervals this rhythm is interrupted by a pause during
which one may get the impression that one pulse beat has failed in

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lo The Archives of Diagkosis

its normal sequence ; it appears as if one pulse beat had been omitted
and the impression is often described as "a dropped beat" or as "an
intermittent pulse." When we come to verify our impressions by
more careful observation we may find that, during this pause in
which we at first thought a beat had been missed, we are able to
detect on delicate palpation, a small pulse wave which had at first
escaped our attention; this wave is usually much smaller than the
waves of the normal rhythm ; it occurs at a time which is a little
too early for the occurrence of a beat of the normal rhythm and is
followed by a pause which is somewhat greater than the inter-
val between the beats of the normal rhythm ; this pause is usu-
ally followed by a pulse wave which is a little larger and more
forcible than the waves of the normal. This irregularity is known
as an extrasystole. It is evidently the result of a ventricular con-
traction which has occurred too early and which is less forcible than
the normal rhythmic contractions of the heart; it is therefore also
known as premature contraction. On auscultating such a heart we
will detect a rhythmic series of normal sounds interrupted at inter-
vals by a group of sounds which are weaker and occur earlier than
those of the normal cycles ; this first and second sounds of the weak
group are followed by a silence which is considerably longer than
the normal diastolic period.

In some of the hearts of this group the extrasystolic contraction
will be represented by a single sound only, and no corresponding
wave even of an abortive character can be detected in the peripheral
arteries. These signs indicate that the premature beat was wanting
in force sufficient to open the aortic valve. The question of the
opening of the aortic valve depends on three factors ; (a) the energy
of the premature ventricular contraction; (b) the volume of the
blood in the ventricle at the moment ; and (c) the blood pressure
in the aorta. These factors depend in turn upon the time of the
occurrence of the extrasystole. If this comes early in diastole
the contractile power of the ventricle will have recovered to only
a moderate degree ; the volume of blood in the ventricle will then
be small and the aortic pressure will be near its highest point ; hence
it is hardly probable that the aortic valves will be opened and such a
premature contraction will be accompanied by the first heart sound
only ; the second sound, due to the closure of the aortic valve, will

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Hart: Abnormalities of Myocardial Functioh ii

be absent and there will be no corresponding pulse wave. If, how-
ever, the extrasystole comes later in the diastolic period, contrac-
tility win have more completely recovered; the volume of blood
which has passed into the ventricle will be greater and the aortic
pressure to be overcome much less ; hence the aortic valve will be
opened ; the second heart sound will be heard and the small extra-
systolic wave may be felt at the wrist,

PATHOLOGY AND ETIOLOGY .

In the sections on the physiology of the heart it was pointed out
that all portions of the musculature of the heart have the property
of excitability, that is that any muscle cell can respond to stimuli at
any time except during the "refractory period" which lasts for a
short time after the cell has been stimulated. Also that normally
stimuli are rhythmically originated at the "sinus node" and sweep
over the tissues of the heart in an orderly manner, exciting to
activity its chambers in a definite sequence.

If electrical stimuli of the proper strength be applied by means
of suitable electrodes to the wall of the heart of the experimental
animal (frog, turtle rabbit, dog, etc.), it will respond by a contrac-
tion, no matter what portion of the musculature is excited ; the ac-
tivity thus produced will spread downward in the direction taken
by physiological stimuli and also from the point of stimulation up-
ward toward the sinus node, i. e. in a direction the reverse of that
of physiological stimuli, and the chambers of the heart will contract
in the order in which the stimuli reach them. Contractions thus
excited from an abnormal focus are known as extrasystoles, and,
according to their point of origin, are known as auricular, ventric-
ular, etc.

If, in this manner, the heart is systematically studied by appl3dng
stimuli in the various ptiases of the cardiac ttyde while the heart is
beating rhythmically, it will be found that for a period beginnii^
just before and extending a short time after systole, the heart is not
excitable even by very powerful stimuli, i. e. the heart is in the "re-
fractory phase" because the molecules upon which the fundamental
properties of cardiac muscle depend have been decomposed into their
constituent ions. Now the extrasystole which has been experimen-
tally produced throws the heart muscle into the "refractory phase"

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12 The Archives of Diagnosis

so that the next physiological stimulus of the rhythmic series aris-
ing at the sinus node will reach the muscle cells lower down when
they are inexcitable, hence it will be ineffective in producing a
systole. The next systole will not occur until it is brought into being
by the next spontaneous stimulus which is formed at the sinus node
and which occurs exactly at the moment at which it would have
occurred had there been no extrasystole. This lengthened diastolic
period which follows the extrasystole is known as the "compensatory
pause." When the time consumed between the last normal heart
beat preceding the extrasystole and the normal beat following the
compensatory pause is exactly equal to the time occupied by two
beats of the normal rhythm, the long diastolic pause following the
extrasystole is known as a "complete compensatory pause f when
the interval between the last spontaneous systole and the post-com-
pensatory systole is less than the interval between two systoles of
the normal rhythm, the compensatory pause is called "ittcompletc."
A study of the compensatory pause in the mammalian heart re-
veals the following facts : (a) When the sinus node is stimulated
the extrasystole is not followed by a compensatory pause, (b)
When the auricle is stimulated the compensatory pause is usually
incomplete, (c) When the ventricle is stimulated the compensatory
pause is complete. These facts may be explained on the following
grounds : As soon as the stimulus material at the node is destroyed
by its direct stimulation, the construction of the material is immedi-
ately recommenced and reaches the explosive point at an interval
just equal to the period of the normal rhythm. When the auricle
is stimulated early in the diastolic period (see diagram A) the stim-
ulus is conveyed not only to the ventricle but also upward to the
node and will destroy the spontaneously forming stimulus material
at the node before it has reached the explosive point, hence the
interval between the last physiological stimulus and the post-extra-
systohc stimulus will be somewhat less than two cycles of the normal
rhythm. When the auricular stimulation occurs somewhat later
in diastole the retrograde stimulus may reach the node coincident
with the explosion of the rhythmically formed stimulus material,
hence in this instance the post-extrasystolic pause will be fully com-
pensatory. When the ventricle is stimulated (see diagram C) the
retrt^rade stimulus reaches the sinus node during its refractory

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Hart : Abnormalities of Myocardial Function

period just after its physiological stimulus and the post-extrasys-
tolic stimulus will exactly equal the period between two beats of the
normal rhythm and the post-extrasystolic pause will be fully com-
pensatory. This explanation indicates how extrasystoles arising
from different parts of the auricles may have compensatory pauses

I i i A i i 1 1

^^4-^^^-v^

1 1 1

till

1 I 1 1

'■. \\l\\\\t\

Diasrami to illuBtrate the imchaniim of the extnayttolc tUrting from Tiriou* parti
of the b«rt muKle. The arrows indicate the poiDts of oriiin and the directiong taken
by the atinmli. Dotted ■rrowi indicate the lime at which (be normal tlimului at the linu*
node ahould reach maturity if iti formation waa not interrupted hy the ejitramtole.

die normal brat and the eitraiyitole in maintaining an adequate circulation. Ai =: amicu-
tor ayitole. A-V = auricula-ventricular bundle. Va = ventricular ayitole.

either complete or incomplete. It may be stated, as a general rule,
that the nearer to the sinus node is the point of stimulation initiating
an extrasystole, and the earlier it occurs in diastole, the shorter will
be the post-extrasystolic pause; and, conversely, the farther from
the sinus node is the point of origin of the extrasystole and the later
it occurs the more nearly will the post-extrasystolic pause be com-
pensatory.

Electrocardiographic studies have further shown that the stimuli
originating extrasystoles may pass over the musculature of the heart

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14 The Archives of Diagnosis

by the normal paths (nomodrome extrasystole), or, since the stim-
uli may originate from some point far removed from the normal
path or may be shunted from this path by abnormal conditions of
the muscles which form an obstruction to their passage, they may
take an unusual course through the cardiac tissue (allodrome extrar
systoles). A discussion of these abnormal paths and their varie-
gated but characteristic electrocardiographic records will be left for
a later paragraph.

Extrasystoles have been produced experimentally in many ways
other than the employment of electrical stimuli. Mechanical irrita-
tion, heat, the application of irritating salts, obstruction of the great
veins (Stassen), clamping of the aorta (Hering), ligation of a
branch of the coronary artery (Lewis), the injection of digitalis
and atropin (Cushny), adrenalin (Kahn), muscarine and physo-
stigmine (Rothberger and Winterberg). Under proper conditions
extrasystoles have been produced in the isolated perfused heart and
in the mammalian heart in situ after all nervous connections have
been severed, hence it is probable that their cause is an increased
excitability of the muscle cells usually quite independent of nervous
influences, though Kraus and Nicolai have produced them by vagus
irritation.

The conditions of the experimental production of extrasystoles
have been set forth at some length since it is upon inferences from
these data that our conception of the patho1(^cal conditions under-
lying the extrasystole, as met with in man, is based. Very little
indeed is known of the histological changes associated with the pro-
duction of extrasystoles and there still remains here a field for care-
ful and exhaustive research. Oinically extrasystoles are found far
more frequently in those with slow hearts and often they may be
made to disappear by moderate exercise which quickens the heart
rate. The experimental evidence seems to indicate clearly that the
extrasystole occurs because some cardiac muscle cells become more
excitable than those of the sinus node and it is therefore on this
ground, easy to understand why an increase in excitability should
be more apparent during a slow rate, since in the faster rates
the excitability of the node is greater than in the slow rates ; under
such conditions the abnormal irritability of some portion of the
auricle or ventricle must be considerable to make itself evident.

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Hart: Abnormalities of Myocardial Function 15

It also seems fair to assume from the experimental evidence that
nutritional disturbance may play an important part in increasing the
excitability of heart muscle; an atheroma with a narrowing of the
coronary artery or one of its branches may be the pathological
counterpart of the ligation of the branches of the coronary which
has been shown by Lewis to regularly produce extrasystoles.

Numerous toxic agents are known to be associated with the pro-
duction of extrasystoles; they are quite common in many febrile
conditions, notably in acute rheumatic fevers. One of the very
common phenomena produced by the administration of large doses
of digitalis (at least to patients having damaged hearts) is the ap-
pearance of ventricular extrasystoles, on the withdrawal of this
drug they disappear. Nicotine is another of the cardiac poisons
which is clinically prominent as a cause of extrasystoles. The "to-
bacco heart" is one in which premature beats have become so
frequent as to make themselves uncomfortably evident. Excessive
tea drinkers are subject to this form of irregularity. Premature
beats are found in persons of all ages ; they are rare in the first dec-
ade of life and are most common after the age of 50. They are
considerably more common among men than among women.

Extrasystoles are probably very much more common than is gen-
erally supposed; it has been estimated that a majority of persons
reaching middle age have had extrasystoles at some period. They
are frequently met with in those who afford other signs of impair-
ment of the heart, such as valvular disease, myocardial degeneration
and the cardiac complications of nephritis, but premature contrac-
tions are also not uncommonly found in those whose hearts have
no discoverable abnormality other than this irr^ularity.

Premature contractions are exceedingly common in individuals
of the neurotic type; they may sometimes be induced by irritation
of the skin and in persons subject to this irregularity, merely plung-
ing the hands into cold water is sufHcient to develop it. They are
often associated with digestive disturbances, particularly when ac-
companied by flatulency. As has been mentioned exercise will fre-
<iuently cause the temporary disappearance of extrasystoles, but if
-carried to the point of fatigue the irregularity is prone to become
more evident than before. In those predisposed to them, suspen-
sion of respiration for a few seconds will sometimes induce these

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i6 The Archives of Diagnosis

premature contractions. When present in the upright position they
will often disappear as soon as the subject lies down, even though
this change in position is accompanied by a slight diminution in the
rate of the heart. Extrasystoles are quite common during convalcfr-
cence from infectious diseases.

IDENTIFICATION

Clinically, the starting point for establishing the presence of the
extrasystole is to determine whether the patient has a fundamentally
normal cardiac rhythm, which is broken on occasions more or less
frequently. When the interruptions occur at infrequent intervals, as-
is the case in the majority of these patients, the detection of the-
fundamental rhythm is comparatively easy. If one palpates the
radial artery there are long periods during which the pulse is per-
fectly reguUr, then occasionally this regular rhythm is broken by
a pause which is too long to fit the fundamental rhythm, or one
may detect a very small pulse wave followed by a pause longer than
that ordinarily separating the waves of the normal rhythm. When
one listens to the heart sounds they will be heard for long perioda
as a normal rhythmic series until this series is broken by the occur*
rence of one or two indistinct heart sounds which follow the last
normal sounds too early and which are in turn followed by a pause
longer than that occupied by the interval between the heart sounds-
of the periods of normal rhythm. The small premature waves de-
tected in the radial and the indistinct premature first (or first and
second) sounds heard over the precordium, each followed by a
more or less complete compensatory pause, are our usual common
evidences of the presence of extrasystoles. Whether one hears at
the time of the premature beat a first and second heart sound or only
a first heart sound depends, as has been pointed out in a preceding-
paragraph, on whether the extrasystolic contraction has, or has not
opened the aortic and pulmonary valves.

If murmurs are present during the periods of normal ^hythm^
they are much less distinct in the premature cycle and may be ab-
sent. The mitral systolic is the murmur which can most easily be-
detected in the extrasystolic cycle; the presystolic is more rarely
heard ; while aortic murmurs are absent or shortened in consonance-

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Hart: Abnormalities of Myocardial Function 17

with the action of the valve which may fail to open, or open only
for a brief period. I have recently seen a case presenting extra-
systoles in which no heart sounds could be heard, both first and sec-
ond sounds being replaced by loud harsh murmurs. At the time
of the extrasystole one could hear four murmurs following each
other at equally spaced intervals. The first and second of these
murmurs were louder and a little longer than the third and fourth;
the fourth murmur was followed by a considerable pause which was
succeeded by a repetition of the two murmurs which constituted the
auscultatory evidence of the ordinary rhythmic activity of the heart.

Another type of rhythm which is easily recognized as due to
extrasystotes is the so-called "bigeminus." Here the radial pulse
shows a rhythmic series composed of a large wave, a short pause, ,
a small wave and a long pause. This sequence is repeated again
and again. The repeated recurrence of two pulse waves followed
by a pause has given rise to the very expressive term "coupled
rhythm." It consists of a wave of the fundamental rhythm fol-
lowed by a premature beat and its compensatory pause. This
rhythm is one of the common manifestations of toxic doses of
digitalis. When an extrasystole occurs every third beat it gives
rise to a rhythm that was formerly described as the "pulsus
trigeminus."

When extrasystoles occur quite frequently and at very irregular
intervals it is sometimes more difficult to assure oneself, by the ordi-
nary physical signs, that the irregularity is due to premature con-
tractions, but careful observation will usually discover a fundamen-
tal rhythm, interrupted by beats which occur too early, are followed
by a pause and each time they appear give the impression of
"coupling."

Inspection of the jugular pulse is frequently an aid in making the
diagnosis of an extrasystole. The two venous waves which one
ordinarily sees during the fundamental rhythm are often replaced
at the time of the premature contraction by a single venous wave
larger than the others. This wave is due to the inability of the vein
to discharge its contents into the auricle at this moment, since the
pressure in the auricle is abnormally high, the ventricle being in
systole and the auriculoventricular valves being closed. This is, of
course, more in evidence when the origin of the extrasystole is in

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i8 The Abchives of Diagnosis

the ventricular wall and the auricle and ventricle contract simul-
taneously.

Whether an extrasystole is auricular or ventricular in origin can
only be definitely decided by graphic records and yet the trained
observer who has sharpened his powers of differentiation by corre-
lating his physical signs with the evidence of the graphic records,
can often, by noting the length of the compensatory pause and the
character of the heart sounds of the premature beat, quite correctly
assign a particular extrasystole to its proper category.

A graphic record of the radial or of the apex beat is often suffi-
cient evidence to establish the presence of the extrasystole. Such
a record (Figures 2, 3 and 4) shows a series of similar waves re-
, curring at equal intervals. This rhythm is more or less frequently
interrupted by a small wave which occurs too early to fit into the
fundamental rhythm. It is followed by a pause longer than that
between two beats of the fundamental rhythm, which in turn is
followed by a wave which is usually a little larger than the average
wave of the rhythmic series and which is the first of a new series
of rhythmic waves. In the case of an extrasystole which originates
in the ventricle the post-extrasystolic pause is fully compensatory
(see Figures 4 and 5), When the extrasystole has its origin higher
up in the cardiac tissues the pause is "incomplete" (Figures i, 2 and
3), the reason for this has been explained in a preceding paragraph
(page 12.)

THE POLYGRAM

Auricular Extrasystoles. The jugular tracing throws additional
li^t on the mechanism (Figures i and 2). Figure i shows a
rhythmic series of waves a c v, which is several times (at *) -inter-
rupted by a similar group which occur too early ; it is clear that the
auricle contracts too soon and is followed by a sequential contrac-
tion of the ventricle.

Another case of auricular extrasystole is shown in Figure 2;
here the premature rontraction of the auricle occurs earlier in the
cycle than was the case in Figure i, so that the auricular premature
wave a' is superimposed on the v wave of the preceding group ; the
simultaneous contraction of the ventricle and the auricle causes an
unusual temporary stasis in the jugular vein, hence this large wave

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Hart: Abnormalities of Myocardial Fohction 19

(v a'), The extrasystole is followed by a compensatory pause which
is "incomplete."

The Nodal Extrasystole is illustrated (x Figure 3). In this in-
stance our conception is that the premature contraction starts at a
point in the tissues junctional between auricles and ventricles; from
this point the stimulus sweeps upward to the auricle and downward

icular extraavalole *t %. The compeiuator)' piuie u

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20 The Archives of Diagnosis

to the ventricle so that these chambers contract practically simultane-
ously, hence the waves a' and if of the'jugular coincide. The retro-
grade stimulation of the auricle has destroyed the usual stimulus
material accumulating at the normal pacemaker ; the building up of
stimulus material is, however, at once recommenced and this reaches

Fic. 3

Nodal cxtrasyitole Bt x. In Ibe juKulir tracing tbc a and i
occur (iniulMncously. The coRipcnHtory pauie ii incomplelc.

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Hart : Abnormalities of Myocardial Function 21

maturity in the normal time which is shown by the fact that the
time elapsing between the wave a' of the extrasystole and the suc-
ceeding a wave is exactly the interval of the normal rhythmic series.
Ventricular Extrasystoles are shown in Figure 4. The auricle,
as represented by the a waves of the jugular record, contracts rhyth-
mically, but occasionally {x) the ventricle contracts prematurely so

Jugubr

. A

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22 Tee Archives of Diagnosis

that at these times the auricle and ventricle contract simultaneously
and their activities are represented by a large wave (a'- c') in the
jugular tracing. The absence of the v wave in the extrasystolic
cycle which is quite evident in the records is due to the empty con-
dition of the ventricle at the time of the premature contraction. It
is to be noted that the post-extrasystolic pause is fully compensa-
tory. Figure 5 with its diagrammatic analysis shows a ventricular
extrasystole which occurs every third beat giving rise to the so-
called "pulsus trigeminus."

Mixed types of extrasystoles are not infrequently seen in a single
case. A tracing of such a patient is shown in Figure 6. Here one
may make out die following sequence : normal beat, auricular extra- '
systole, ventricular extrasystole. The analysis of the polygraph in
these cases is sometimes quite difficult. The analysis of the tracing
shown in Figure 6 was subsequently verified by electrocardiographic
records in which the analysis is much less difficult.

THE ELECTBOCARDIOGRAHS

As a rule the identification of the kind and point of origin of the
extrasystole is most accurately made by means of the electrocardi-
ographic record. The most distinctive features of extrasystoles are
that (i) they occur too eariy, and (2) they are followed by a pause
greater than the normal intersystolic pause.

To fix dearly the phenomena which the electrocardiogram dis-
closes, upon which we base conclusions as to the point of origin of
the extrasystole, let us recall just what the movements of the string
of the galvanometer represent. At any given moment the deflection
of the string indicates the algebraic stmi of the differences of elec-
trical potential of the heart as a whole. When the stimulus arises
at the sinus node (the normal pacemaker) and passes over the heart
in a sequential, orderly manner, a series of deflections occur which
we have learned to recognize (see Paper i) as the normal differ-
ences of electrical potential for successive instants of the cardiac
cycle. If now the stimulus arises from some point of the cardiac
musculature other than the "sintis node/' it is quite evident that the
impulse passing by abnormal paths and reaching portions of the
cardiac tissues at intervals quite at variance with the normal will
produce differences of electrical potential at successive moments of

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Hart : ABNORMALiTrEs of Myocardial Function 23

the cardiac cycle quite different from the normal. How great are
the variations in electrical potential which result from the extra-
systolic contractions may best be appreciated by a study of the
curves which are here reproduced.

Auricular Extrasysloles. When the focus from which the extra-
systole arises is at or near the sinus node the electrocardiographic
complexes are usually of the normal form. Such a record is shown
in Figure 7. It is composed of a series of complexes, each of which

Fig. 7

Auricular extroiyitole at x. Compenutory pause inconpletc P = auricular contTac-
tion. R T = vcutricuUr cantractioii. Biachial traciDg above.

is practically of the normal type. Each cycle is opened by a P wave,
which at its proper interval is followed by a normal ventricular com-
plex, QRST. In the center of the record the fundamental rhythm
is broken by a cycle (r) which, although normal in other respects,
occurs prematurely and is followed by a pause which is not quite
long enough to be completely compensatory. This premature con-
traction must have arisen at or near the sinus node, since the vari-
ous parts of the cardiac musculature have been stimulated by paths
and in a sequence which is the normal one.

e of the precedint ventricular

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34 The Archives of Diagnosis

The curve reproduced in Figure 8 shows an extrasystole which
has arisen high up in the auricle near the sinus. Here the extrasys-
tole has occurred so early that its F wave is superimposed on the T
■wave of the preceding cycle producing a wave which is equal to P
T. The pause following the extrasystole is incomplete.

It has been shown by Lewis* that if the auricle of an animal
is made to contract by applying artificial stimuli to various portions
of the auricular tissue, the resulting electrocardiographic records
will be greatly modified. When the point of stimulation is at or
near the sinus node the P wave is upward in direction and of a form
which we have come to regard as normal; as the point of stimula-
tion is made more and more remote from the sinus the P complexes
become irregular in form and may be directed downward or show
■ a diphasic variation. We are therefore led to infer that in the
human electrocardiogram an upward single P. wave represents an
auricular contraction originating at or near the sinus node ; a down-
ward directed P wave indicates an origin in the lower part of the
auricle ; a notched or diphasic P wave indicates an intermediate
point of auricular origin.

An extrasystole which arose in the lower part of the auricular
tissue is shown in Figure 9. The complexes of the ordinary rhythm

are normal in form except that the P waves are rather too broad
and have summits which are slightly flattened; the extrasystolic
cycle {x) is initiated by a P wave which is directed downward but
is followed by a ventricular complex which is normal in form, indi-
cating that the ventricular response to the premature auricular
•Heart. 1910. 11, p. 27-

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Hart: Abnormalities of Myocardial Function ^S

activity was the result of an impulse which passed down throUfi'^J
the A-V bundle and over the ventricular musculature by the norma/
paths in a perfectly orderly manner. It may be noted in passing
that the auricular complex which immediately follows the extrasys-
tole has a form somewhat different from the P waves of the suc-
ceeding normal cycles; this is not an unusual occurrence and sug-
gests that the auricle has not as yet entirely recovered its normal
function.

Figure lo displays a rhythm which was formerly known as the
"pulsus trigeminus." It consists of a series of two normal beats fol-

Radiil traeing above.

lowed by an auricular extrasystole. The impression produced on
the palpating finger by a pulse of this type is indicated by the radial
curve taken simultaneously with the electrocardiogram. All the
auricular (/*) complexes of this record show an unusual diphasic
form, suggesting that even those impulses which originated at the
sinus node have taken an abnormal path through the auricular
tissue. The P waves of the extrasystole {:r) are clearly reversed,
indicating an origin low down in the auricle.

The ventricular extrasystole presents in the electrocardiogram
(Figure li), a complex far removed from that of the normal ven-
tricular contraction. The abnormal point of origin and the conse-
quent abnormal path which the impulse follows usually produces a
much greater difference of electric potential than does the impulse
which descends from the auricle and follows the normal path.

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26 The Archives of Diagnosis

throi^h the A~V bundle and its branches. The auricle contracts at
regular intervals, so that often when an extrasystole occurs the
ventricular and auricular contractions are simultaneous. The little
wave representing auricular activity will then occur during the time

nul complM and extn^rslolic complex z.

of ventricular activity and is usually relatively so small that it is
submerged in the large waves of the ventricular complex. Figure
II shows an electrocardiogram taken from a patient by the cus-
tomary three leads. The first and last complexes of each lead are
the normal for this individual, between these are seen the extrasys-
toles. It is to be noted that the form of the extrasystolic waves
are very similar in leads II and III, but that these differ very ma-
terially from the extrasystole pictured in lead I. The similarity of
form of the extrasystolic complexes of leads II and III is usual. The
complex of lead I may be similar in form to that of lead II, but it
is usually quite different. The submerged auricular wave which
occurs during the extrasystole can be seen {only in lead II) as a
small notch (P) in the final dip of the extrasystolic complex.

Systematic studies of the electrical complexes obtained by stimu-
lating varous portions of the right and left ventricles both when the
branches of the bundle of His are intact and when one of the
branches has been cut, have shown that a comparison of the re-
cordsf taken by lead I and lead II will indicate the point from
which the extrasystole has its origin.

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Hakt : Abnokhauties of Myocardial Function

Lctd I Lead II

VentrkaUt exlmyMale ariiini I

Tnie 3. Ventricular extranitale Brialng from > point in tfac wall of the 1«ft ventricle

T™ J. Ventricuiar eitnuyitoie
It ine buc. Radia) tracing ■bove.

TyM 4. Ventrieulir extrtijritole iriiing frooi ■ point in the valt of the left nntrida

Type 4. Vei

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28 The Archives of Diagnosis

The prominent types are shown in Figures ra, 13, 14 and 15. The
direction of the principal deflection in leads I and II with the points
of origin of the extrasystoles may be tabulated as follows :

TYPE

DIRECTION OF PRINCIPLE
DEFLECTION

POINT OF ORIGIN OF

STIMULUS.

LEAD I.

LEAD IL

8
4

up
up
down
down

up
down

Right ventricle near base
a - ■• apex

Left ventricle near base
apex

A type of curve which is not infrequently met with is shown in
Figure 16, Two ventricular extrasystoles appear in this record.
Each is preceded by a P wave which occurs at its regular rhythmic
interval. At first sight one might regard this as an impulse which

Ventr[cul»r txlrasyslole at x. Thi Buticle conlrscts rhythmicaHy, aa shown bj" P waves.
P-R mlerval = 0.3 second. Tbe eitrasyslole does not originate in the auricle.

had its origin in the auricle and which was shunted off by an ab-
normal path through the ventricular wall. One notices, however,
that the length of the P-R interval of the normal complexes is unusu-
ally long (over o.z second), while the interval between P and the
onset of the extrasystolic complex is very brief (o.i second). It is
Therefore evident that insufficient time has elapsed between P and
the onset of the extrasystole to permit of the passage of the stimulus

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Hart: Abnormalities of Myocardial Function 29

from the auricle to the ventricle, and we must conclude that the
ventricle has contracted in response to a stimulus initiated indepen-
dently in its own wall.

A contrast to this case is shown in Figure 17. Here the ventric-
ular extrasystole (at x) occurs relatively early and the auricular
contraction P is seen as a step on the descending limb of the large
extrasystolic wave. The arterial tracing which accompanies this as

Fio. 17 Fig. tS

Exlrairetolic pauK Is fully compMiiaiary. niultancouity. Oriain of vcntriculac im-

pulw ia high up in tbe A-V bundle.

well as many of the preceding electrocardiograms shows the rela-
tively small wave which is produced in the arterial tree by the extra-
systole. This evident lack of efficiency of the premature contraction
in maintaining an adequate circulation is due to two factors (i) the
abnormal sequence of the stimulation of the muscle fibers of the
ventricle results in a contraction which is relatively incoordinated,
and the propelling power of the ventricles is less than under the
normal conditions ; (2) on account of the prematurity of its contrac-
tion the ventricle is less well filled with blood, hence a smaller
volume is expelled into the aorta.

The nodal extrasystole. The majority of extrasystoles which one
sees in the clinic have their origin in some portion of the ventricular
wall. Auricular premature contractions are far less frequent. A still
more rare form of extrasystole is shown in Figure 18. In this curve
the extrasystolic complex is only slightly changed from the ventri-
cular complex of the fundamental rhythm, the following pause is
fully compensatory and the presence of P in its normal rhythmic

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30 The Archives of Diagkosis

position following the principal wave of the extrasystole shows that
the rhythm of the auricle tuis not been disturbed. Since the ven-
tricular portion of the extrasystolic complex has a form not unlike
the ventricular complexes of the sequential rhj^hm and yet clearly
is not the result of auricular activity, we conclude that its point of
origin is at some point high up in the auriculo-ventricular bundle
and that its subsequent course through the ventricular wall follows
the normal channels. This is known as the nodal extrasystole.

The interpolated extrasystole is another rare form of premature
contraction. An extrasystole always ventricular in origin occurs
between two beats of the normal rhythm without otherwise disturb-
ing the orderly course of either the auricular or the ventricular
rhythm.

The extniritolci it(x) ariK from (be wall of the right ventricle oear

"Bigeininui." The exlruritoleB (x> ariie from ■ point in Ihc wall of the left ventricle

near Ihe base (Type 3>-

In Figures 19 and 20 are shown two types of "pulsus bigeminus,"
each due to an alternation of normal cardiac contractions and extra-
systoles; the extrasystoles of Figure 19 arise in the wall of the right
ventricle near the apex; the premature contractions of Figure 20
arise in a point in the left ventricular tissues near its base.

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Hart: Abnormalities of Myocardial Function 31

Extrasystoles of different points of origin frequently are met with
in the same patients on separate occasions and sometimes in dose
succession. Figure 21 shows auricular extrasystoles at a and ven-
tricular extrasystoles at x. The auricular extrasystoles have an in-

Fic. 21

' ni-icin. A = muricutir extrUTStole
Ltraiyatole* with complete compeai

Two types of ventricular fxlTUsystoles. X arisini from tbc right ventricle near tb*
buc. Y ari^Df from the left ventricle near the apex (Types i and »).

complete, the ventricular a complete compensatory pause. Figure 22
shows an alternation of ventricular extrasystoles (x) and normal
ventricular complexes. At the center of the record (y) the se-
quence is further disturbed by the occurrence of a ventricular extra-
systole from an entirely new point of origin.

THE CLINICAL SIGNIFICANCE

of the extrasystole is one of considerable importance. Most oE us
have followed the career of patients who have had occasional extra-
systoles for a number of years and often we can secure a history o^
the existence of this form of irregularity for many years, antedating

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32 The Archives of Diagnosis

our own observations, yet we rarely see a case of cardiac insuffi-
ciency which can reasonably be attributed to this irregularity
per se. The patient is often quite conscious of what they
often describe as a "thumping" in the precordial region, "fluttering
of the heart," or "palpitation." On examination a large number of
these sensations can be shown to be due to the presence of extra-
systoles. These sensations are often the occasion of considerable
alarm to the patient particularly when they are first discovered and
the physician who assures them that this irregularity in itself is of
very little significance and rarely is the forerunner of more serious
trouble does the patient a great service in removing his grounds for
anxiety.

When, however, we see cases which show extrasystoles at very
frequent intervals and particularly when the extrasystoles arise
from more than one focus our prognosis should be much more
guarded, such irregularities are evidences of more serious myocardial
defects. The rapid and persistent increase in the number and a
multiplication of the foci of origin of extrasystoles point to advanc-
ing myocardial changes and are often associated with symptoms in-
dicating cardiac insufficiency. Curiously enough some of the pa-
tients in whom I have discovered extrasystoles occurring constantly
and in great numbers were quite unconscious of cardiac irregular-
ities.

A more prolonged study of the different types of extrasystoles,
their points of origin and their frequency may eventually lead us to
modify our prognosis in accordance with such findings, but as yet
our facts do not warrant more positive statements. Our prognosis
ultimately rests on the extent of myocardial damage, and the extra-
systole is merely one of the symptoms which suggest that the de-
fective muscle is little or much affected.

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Wise : Acrodermatit:s Chronica Atrophicans 33

THE DIFFERENTIAL DIAGNOSIS BETWEEN ACRODER-
MATITIS CHRONICA ATROPHICANS AND DIFFUSE
IDIOPATHIC ATROPHY OF THE SKIN
(a clinical study)
By FRED WISE
Instructor in Dermatology and Sy philology, College of Physicians and
Sui^eons, Columbia University ; Chief of the Dermatological Clinic, Beth
Israel Hospital; Attending Dermatologist, Montefiore Home
New York
In view of the existing literature on the subject, to publish a
paper on acrodermatitis chronica atrophicans may seem a rather
fruitless undertaking. It is justified only by the fact that within
the last ten years, probably a dozen instances of this rare malady
have been encountered and exhibited before the dermatological
societies of New York City, and that the questions of diagnosis,
classification and nomenclature have frequently given rise to con-
siderable controversy and differences of opinion. The inference
should not be made, however, that with this paper the author hopes
or expects to put an end to the various contentions of the able and
well-informed clinicians, in whose eyes acrodermatitis atrophicans
and diffuse idiopathic atrophy of the skin is one and the same
clinical entity. Still, an attempt to differentiate the two disease-
processes from a purely clinical standpoint, may prove to be not
altogether futile.

Under the title acrodermatitis chronica atrophicans, Herxheimer
and Hartmann^, in 1902, first described a series of cases represent-
ing a certain clinical type of diffuse cutaneous atrophy. Before
this date, the same disease and other dermatoses resembling it, were
described under a great variety of titles, such as atrophia cutis
idiopathica, erythromelie, erythema paralyticum, etc. Buchwald', in
1883, was the first to publish a clear description of a case of this
kind. (For a full dissertation on the cutaneous atrophies, together
with a comprehensive index to the literature, the reader is referred
to the work of Finger and Oppenheim, "Die Hautatrophien,"
Vienna, 1910.)

Since the publication of Herxheimer and Hartmann's paper, a
great deal of work has been done in connection with the progres-

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34 The Archives of Diagnosis

sive idiopathic atrophies of the skin, more especially by German and
Austrian dermatologists. A perasal of the literature gives one the
impression that Herxheimer's efforts to demonstrate apparent clin-
ical differences between his acrodermatitis and the ordinary diffuse
cutaneous atrophies does not meet with universal approval. In
numerous comparatively recent case reports, Herxheimer's desig-
nation is either entirely ignored, or the reporter may tentatively
offer the suggestion that his case may represent an example of
acrodermatitis chronica atrophicans. Often he seems to be at a
loss to know under which title his case should be recorded. Even
Finger and Oppenheim only grudgingly admit the existence of a
clinical sub-variety of diffuse cutaneous atrophy, which Herxheimer
and Hartmann individualized by creating for it a new name. In fact,
these authors definitely state that they regard acrodermatitis
chronica atrophicans as being merely a variant of dermatitis atrophi-
cans maculosa, and not an individual species. Nevertheless, they
describe, in a very lucid and highly interesting fashion, two different
clinical entities in two separate and distinct chapters ; one dealing
with dermatitis atrophicans diffusa, the other with acrodermatitis
chronica atrophicans. Viewed in a critical light, they really con-
tradict themselves in denying the existence of the latter clinical
picture. For if it does not exist, why devote an entire chapter to
a dermatosis which obtains only in the minds of its originators?
Aside from this apparent inconsistency, the work of Finger and
Oppenheim is replete with the most valuable information relating
to the cutaneous atrophies, presenting the reader with an enormous
amount of original work on the subject, together with a compre-
hensive and painstaking compilation of the works of other ob-
servers. The superiority of their method of classification, together
with the excellence of their clinical depictions induces the writer to
borrow freely, in the succeeding paragraphs, from this work.

Finger and Oppenheim divide the subject of diffuse idiopathic
cutaneous atrophies in the following manner: Under the main
heading of Dermatitis atrophicans chronica progressiva idiopathica,
they include two sub-varieties: (l) Dermatitis atrophicans dif-
fusa; (2) Dermatitis atrophicans maculosa. Dermatitis atrophicans
diffusa is again subdivided into two varieties, namely: (i) Acro-
dermatitis chronica atrophicans; (2) Atrophia cutis idiopathica.

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Wise : Acrodermatitis Chronica Atrophicans 35

We are concerned here only with the last two types of cutaneous
atrophy ; for all other types, including also the atrophic end-stages
of diffuse scleroderma, present such radically dissimilar clinical ap-
pearances to the eye of the trained dermatologist, that they may
safely be eliminated from discussion.

In a previous paper, the writer* attempted to depict acrodermatitis
chronica atrophicans as a clinical entity, possessing a symptom-
complex peculiar to itself ; and to demonstrate the fact that the
symptomatol<^y, clinical appearance, course, evolution and termina-
tion of the malady differed, in some respects, from other forms of
diffuse atrophy of the skin, therefore entitling it to consideration
as a separate clinical entity. In this paper, an attempt will be
made to show wherein these differences lie ; and to accomplish this
purpose, a description of the two forms of cutaneous atrophy is
essential.

The dermatoses included under the caption of idiopathic cutane-
ous atrophy present a peculiar "flaccid" atrophy of the skin, to
which Jadassohn gave the name anetodermie ( Av£;'(f;;=flaccid).
Here the normal thickness of the skin is markedly diminished; it
appears to be redundant, flaccid, wrinkled and folded, showing a
decreased or altogether absent elasticity and is easily raised and
pinched between the fingers. Such a condition develops slowly and
advances insidiously, without any apparently preceding clinical or
histological integumentary changes, without apparent pre-existing
morbid alterations of the tissues, — not only of the skin, but of the
entire organism ; this total lack of etiological data is responsible for
the name "idiopathic" cutaneous atrophy.

Of the two main types of the affection, one implicates large areas
of the integument or even the entire skin, and is therefore called
dermatitis atrophicans diffusa or universalis ; the other involves only
small plaques — dermatitis atrophicans maculosa. The clinical dif-
ferentiation of the first type into two subdivisions depends upon the
localization of the beginning of the affection on the extremities, or,
upon the initial localization, on the trunk; hence the separation of
acrodermatitis atrophicans (acro=extremity) from the other forma
of dermatitis atrophicans, which may occur on any part of the body.
In typical acrodermatitis atrophicans, the inflammation, even macro-
scopically, may be ushered in not only by distinct swelling or edema.

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36 The Archives of Diagnosis

but also by distinct infiltrative lesions. In addition, the morbid
process in the latter type is almost always limited to the extrem-
ities, involvement of the trunk being rare.

Much as the different types of cutaneous atrophy resemble each
other from the clinical point of view, still more do they show their
resemblance to each other microscopically. The histopathological
alterations in sections derived from cases of acrodermatitis atrophi-
cans in its terminal stages, are, generally speaking, identical with
the microscopic appearances observed in cases of diffuse idiopathic
atrophy and dermatitis atrophicans maculosa. Such being the case,
the differential diagnosis of the various types rests upon clinical
grounds alone; the microscope merely confirms the clinical diag-
nosis of atrophy of the skin; it gives no hint as to which par-
ticular sub-type of atrophy we are dealing with,

ATROPHIA CUTIS DIFFUSA IDIOPATHICA
The disease usually begins by the appearance of plaques show-
ing variations in color from bright red to dark bluish-red. Two
types may be differentiated ; the plaques may be bright red, rather
sharply circumscribed, disappear completely under pressure and are
covered with thin, branny scales; or, they may be bluish-red, in-
distinctly outlined, cyanotic in appearance and without desquama-
tion. In the first type, the appearance is that of a mildly inflam-
matory erythema, while in the second, it resembles a passive
hyperemia. These plaques spread out and become confluent, their
coalescence being sometimes preceded by the formation of irr^ular-
network-hke stripes and bands; thus larger areas of the skin
become involved, while new plaques are forming in the vicinity,
or at distant portions of the integument. Shortly after these ap-
pearances, signs of anetodermia supervene, becoming apparent in
the flaccidity of the skin ; the thinning and wrinkling usually begin
in the central portions of the plaques, without manifesting any
marked changes in their original red color. The first change con-
sists of a fine wrinkling of the superficial layers, apparently affect-
ing only the epidermis in the beginning, leaving the appearance seen
after the regression of an acute edema. The clinical picture of a
fully developed atrophying dermatitis is rather constant and uni-
form, varying somewhat in respect to its localization. The skin

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Wise: Acrodermatitis Chronica Atsophicans 37

is dark red, bluish-red and brownish-red; from an intermingling
of pigmented and depigmented spots, it may assume a mottled,
multi-colored appearance.

The skin is markedly thinned and is so translucent that the
underlying veins, tendons and nerve-strands shine through distinctly
and appear prominently. Lifting a fold of skin, one has the im-
pression of having a piece of silk between the fingers ; large folds
of skin may be raised very readily, due to its loose attachment to
the underlying tissues ; allowing the fold to escape the fingers, the
skin very slowly assiunes its former position. Wrinkling and creas-
ing of the skin is marked, Pospelow comparing it to wrinkled
cigarette paper; others have compared it to the skin of a baked
apple.

In extensive cases, the larger folds show a disposition to follow
Langer's lines of cleavage. On the back, there is a linear configura-
tion following certain paths, beginning opposite the spine, diverg-
ing gradually downward and outward, then arching upward over
the lateral portions of the thorax, thence converging over the chest
wall with an upward trend. Around the mamnue, the folds of skin
assume a roughly circular disposition, while over the nates they
form flattened segments, extending from the outer and upper to
the lower and inner portions of the glutei, then bending upward
toward the crena ani. Around the elbows and knees the folds are
arranged in a roughly concentric manner, the arches increasing with
the distance from the articulation. Over the extensor surfaces of
the wrists and ankles the folds are arranged parallel with the
underlying tendons. In localities where the skin is normally loose
and easily folded, as on the back of the hands, on the knees and
elbows, the wrinkling and fold formation is most prominent ; also
where there is much subcutaneous fat, as over the buttocks and
mammx. The least amount of wrinkling usually takes place over
areas where the skin lies near the bone, as over the tibia and ulna,
and at the borders of the erythematous plaques which precede the
atrophic areas. The surface of the skin is exceedingly dry, free
of sweat and fat; the hair is sparse or may be entirely absent.
In some areas there is a fine, branny desquamation. The scales may
be firmly attached and lend to the skin a mother-of-pearl shimmer.
The knees and elbows are areas of predilection for the desquama-

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38 The Archives of Diagnosis

tion. The blood vessels of the skin appear in two shapes. The
subpapillary vessels fonn a fine, bluish-red network, in spots dis-
tinctly visible through the translucent integument ; such an appear-
ance is, however, somewhat unusual. The subcutaneous veins, es-
pecially those on the legs, form prominent, sinuous blue strands of
varying thickness, some raised considerably above the surface of
the thinned skin; others are not engoi^ed or dilated, but appearing
as broad blue bands gleaming beneath the skin. These veins form
a network most prominent in the atrophic areas ; in the erythematous
and infiltrated plaques they are absent.

Such is the clinical appearance of a typical case of atrophia cutis
idiopathica. Other cases show certain modifications of this picture.
In about a third of the reported cases the dorsal surface of the
feet, the anterior aspect of the legs, and sometimes also the fore-
arms, present a condition resembling scleroderma. Instead of the
reddish and bluish wrinkled skin commonly seen over these regions,
the integument is stiffened, appears to be tense, markedly yellow-
white, and can be folded only with difficulty. The borders are
usually indistinct; sometimes there is a peripheral zone of wrinkled,
reddish-brown skin, fusing with the adjacent normal skin. On
the leg this condition is usually seen over the lower third of the
tibia, anteriorly, extending to the anterior surface of the ankle and
fusing with the normal or atrophic skin over the dorsum of the
foot. The skin appears to be tense — an insufficient envelope for its
contents — causing a prominence of the underlying tendons which
appear as yellow and white strands. The integument is smooth, of
a waxy sheen, sometimes speckled with brown pigmented spots. The
veins, partly dilated, are prominent and distinctly visible, while the
circumference of the leg and foot may be diminished. These ap-
pearances are designated by the term "sclerodenna-like" ; they differ
from scleroderma chiefly with respect to the thinning and trans-
lucency which is characteristic of them.

These scleroderma-like areas occurring together with cutaneous
atrophy have formed the subject of considerable investigation by
several authors. The differentiation between atrophy of the skin
and the diffuse and circumscribed forms of scleroderma, the pos-
sible relations existing between the two, and the incidence of both
diseases appearing in the same symptom-complex, have been so

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Wise: Acrcwermatitis Chronica Atrophicans 39

thoroughly dealt with in an article by Rusch*, that further com*
ment here would seem superfluous.

ACRODERUATITIS CHRONICA ATROPHICANS

In the publication already referred to', the writer described in
detail a typical example of this malady occurring in a middle-aged
woman. He will, therefore, limit himself only to a brief descrip-
tion of the salient points characteristic of the condition.

The disease begins on the back of the hands or feet, or both, in
the shape of inflamed patches and edematous, soft, doughy infiltra*
tioQS. In the great majority of cases the skin of the fingers and
toes remain normal throughout the entire course of the disease.
The areas of predilection, in the banning, are the extensor sur-
faces of the forearms and legs. Itching is moderate or may be-
absent. The infiltrations are bluish-red in color, reminding one of
the nodules of erythema nodosum, without being as sharply cir-
cumscribed. These infiltrations must not be confounded with th&
bluish-red, prominent, hemispherical, hard, sharply circumscribed
tumors which appear in the neighborhood of the knees and elbows-
in the end-stages of acrodermatitis atrophicans; these occur only
in association with advanced atrophy of the skin. The primary soft,
doughy nodules mentioned above, in the course of weeks and
months, gradually assume a bluish and cyanotic appearance, be-
come flattened to the level of the surrounding skin, while the over-
lying epidermis becomes wrinkled into fine folds. As the infiltra-
tion recedes the wrinkling becomes more marked, the area is bluish-
red, transparent, thinned, gradually assuming the appearance already
described under diffuse cutaneous atrophy. The disease advances
upward, toward the groins and shoulders, by means of the peripheral
extension of the active border of the process, not by the fusing
or coalescence of scattered areas of inflammation or infiltration.
In other words, the disease progresses centripetally. On the lower
extremity, in the typical cases, the process advances upward to
within two or three inches of Poupart's ligament anteriorly, leav-
ing a triangular area on the inner and upper aspect of the thighs
free. Posteriorly and on the outer aspect of the thighs, as well
as over the buttocks, the process extends upward toward the trunk,
coming to a standstill at the crest of the ilium. The an^todermia.

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40 The Archives of Diagnosis

in the advanced cases, is most marked over the knees and buttocks.
In the final stages the appearance of the skin is similar to that
described under atrophia cutis idiopathica.

On the upper extremity the process advances to a short dis-
tance above the elbow joint. During the infiltrative or pre-atrophic
stage a characteristic phenomenon is the appearance of the so-called
"ulnar band." This consists of an infiltrated band of skin over-
lying the ulnar bone, extending from the wrist to the elbow. In
the course of months or even years this strip becomes thinned,
wrinkled, atrophic and translucent, its borders gradually merging
with the adjacent integument. In some cases the strip is quite
sharply marginated, so that the contrast between it and the sur-
rounding skin is quite obvious. An analogous strip less often
appears over the tibia. The ulnar band appears so consistently in
acrodermatitis chronica atrophicans that it may be regarded as a
characteristic symptom of this type of atrophy.

The above brief description applies to the ordinary types of acro-
dermatitis chronica atrophicans, of which the writer has seen a half-
dozen cases in the last ten years. Variations and modifications of
this clinical picture are described in the literature. A common
sequel to the process is the appearance of the hard, globular tumors
near the knees and elbows, mentioned above. According to Finger
and Oppenheim', these may also appear in atrophia cutis idiopathica,
but, according to others, with far less frequency. The sderoderma-
like alterations of the integument over the legs and forearms are
also common in acrodermatitis atrophicans. The translucency of
the skin, the an^todermia, the chronicity of the process, the absence
of subjective symptoms, the maintenance of the general health — are
points common to both forms of the disease. The chief points
upon which Herxheimer and Hartmann lay stress in their original
description of acrodermatitis atrophicans are:

1. The occurrence of a primary inflammation and infiltration pre-
ceding the atrophic process,

2. The be^nning of the disease on the backs of the hands and
^eet.

3. The slow and insidious centripetal progression, the disease
advancing by means of a gradual spreading of the active border.

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Wise: Acsoderuatitis Chronica Atrophicans

4. The limitation of the process to certain areas of predilectioa.

5. The presence of the ulnar (and tibial) band.

A comparison of the two types of atrophy in parallel columns
may bring out the di£Ferential points more dearly.

AcrodermotUis atrophicans Atrophia cutis diffusa idiopathica

Atrophy preceded 1^ inflamma-
tion, edema, infiltration.

Begins on the back of the hands
and feet, fingers and toes usu-
ally being free.

Advances centripetally, by the
gradual extension of the ac-
tive border of the process.

No clinical manifestations of in-
flammation and infiltration
precede atrophy.

May begin on any part of the
body.

Large areas are usually formed
by means of the coalescence
of previously scattered foci of
the disease.

No areas of predilection.

Process usually advances over
the trunk.

Usually seen on buttocks, back
and mammae.

Areas of predilection are the

upper and lower extremities.
Usually an "immune" triangular Not characteristic.

area below Poupart's ligament.
Process usually comes to a

standstill opposite the crest of

the ilium.
There is no configuration of skin

folds following the lines of

cleavage.
The presence of the ulnar (and Usually absent.

tibial) bands.

In conclusion, it may be said that those observers who still re-
gard the two types of cutaneous atrophy as one and the same
clinical entity have good reason to adhere to their opinions, the
question being a debatable one. To the writer it seems that the
two clinical pictures may well be separated ; their separation, how-
ever, being justified only by the sum total of their characteristics.

REFERENCES

I. Herxheimer and Hartmann. — Ueber Acrodermatitis Chronica Atrophicans.

Arch. f. Dermat. u. Syph., 1902, Ixi, pp. 57, 255.
a. Bachwald. — Ein Fall von idiopathischer difFuser Hautatrophie. Arch, f,

Dermat n. Syph., 1883.

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42 The Archives of Diagnosis

3. Wise.^Acrodermatitia Chronica Atrophicans; the Transition from Infiltra-

tion to Atrophy. Jour. Cutan. Dis., April, 1914, xxxii, No. 4. (With
clinical and histopathological photographs.)

4. Rusch. — Ueber idiopathische Hautatrophie und Slclerodermie. Dermat.

Zeitschr., 1906, xiii, p. 749.

5. Finger und Oppenheim. — Die Hautatrophien. F. Deufiche. Berlin, 1910.

DIAGNOSTIC VALUE OF HYPERESTHESIA OF THE

SOLAR PLEXUS AND ITS RELATION

TO GASTROPATHS

By MORRIS SCHOTT

Oeveland, Ohio

Like many objective and most subjective symptoms, hyperes-
thesia over the region of the solar plexus loses a greater part of
its diagnostic value if considered from the individual or monopa-
thological point of view, but considering the symptom from the
collective or multipathological side it becomes without question of
an important diagnostic importance. Just as thermometry in dis-
ease is of little value if considered without the other concomitant
objective and subjective symptoms in a given case, we may have
a parallelism in the importance of our aims in diagnosis tn hyperes-
thesia of the solar plexus.

In the normal state and in the healthy individual the physiolog-
ical functions of the stomach are performed unconsciously and
without sensation, only two conditions being necessary for con-
scious sensation, namely, hunger and distension of the stomach.
In the normal state the stomach is not impressed with tactile sen-
sation, a condition which gives us daily proof in the introduction
of the stomach tube — the passing of the tube is not felt after it
has passed the cardiac orifice. On the other hand, distension due
to fermentation, either by gas, aerophagia or a too large amount
of food at one time, will cause a very uncomfortable feeling, and
when a certain amount of overdistension obtains it will even cause
intense pain.

We see, then, that in the normal healthy individual there exists
no consciousness of the stomach.

It is different, however, whenever the equilibrium of the stomach

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ScHorr: Hyperesthesia of the Solar Plexus 43

functions is disturbed either directly or by reflex irritations due
to patho1<^cal conditions, affecting other abdominal organs and
innervated by the sympathetic system.

The semilunar or solar plexus is the largest and richest antasto-
motic ganglion of the sympathetic system, and pain-impressions are
no doubt due to the afferent and efferent sensory fibers having their
origin and their terminals in this location.

The physiological function and work of the stomach, like all
other normal functions of the visceral organs, being of an uncon-
scious nature, we must admit that all painful functions of the
stomach or other viscera must be considered to be of a pathological
nature. We are greatly indebted to Albert Mathieu for many of the
clearer points relating to localization of the epigastric point, as well
as the masterful classification of solar reflex hyperesthesia. Boas has
attributed the painful point in question to spasm or contraction of the
pylorus, others have claimed that the epigastric painful point was
created by pressure by the physician himself and due to suggesti-
bility of the patient, which no doubt is true in cases where the neu-
ropathic element predominates ; on the other hand, in the great ma-
jority of cases of dyspeptics the hyperesthetic point of the solar
plexus can be plainly demonstrated by pressure slightly to the right
of the median line and corresponding to the trunk of the celiac axis.
Mathieu observed some phthisical patients at the last stage of their
disease who were, as is the rule with such patients, also gastropaths.
He found the hypersensitive solar plexus point, marked the point
* with a nitrate of silver pencil, and at the autopsy ran a long
needle straight through from the- marked point, fixing it securely
in the vertebral column and in every instance penetrated the
same nervous plexus of the sympathetic. An attempt has been made
to measure the degree of hypersensitiveness and Boas has made use
of an esthisiometer registering the amount of pressure in grams ; the
instrument, however, is bulky and hardly adapted for general
use. Ch. Jean Roux invented a modihcation of the Boas instrument,
much smaller and giving the same results which registers a pres-
sure up to 5 kilograms. Boas claims that a pressure over the solar
plexus in the nonnal state can be carried to equal 10 kilograms be-
fore eliciting any sensation of pain, but I would not advise any such

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44 The Archives of Diagnosis

degree of pressure in any case, in fact I think the employment of
such force may be a dangerous proceeding in certain conditions.

Personally I use the common baby scale found in almost every
physician's obstetrical bag. For its employment I have devised a
simple extension on a pressure button with a hook at its extremity
on which I apply the scale and am able to raster the amount of
pressure by traction and reading the amount on the register. It is
simple and easily applied.

Considerit^ the amount of hyperesthesia in a given case, there are
several factors which may lead us into error. Foremost is the rigid-
ity of the abdominal wall, which especially in some neurotic types
of patients is at times very difficult to overcome, and requires the
physician's patience until complete relaxation is procured ; again we
meet with such extreme cases of hyperesthesia that the mere touch —
the slightest weight of the bedsheet or merely the atmospheric con-
tact — will cause contraction of the abdominal muscles.

The biliary vesicle either in acute or chronic lithiasis, distension
due to obstruction or simple inflammatory reaction, is also hyper-
esthetic, but the point of greater sensitiveness is located about three
fii^erbreadths to the right of the solar plexus point. Besides the
previous history of the patient will in most instances guide us in
our conclusions. On the other hand, biliary vesiculosis is often
associated with gastropathic conditions, and we can often draw a
dear line between the two painful points which I have called the
neutral gastro-hepatic and esthetic point. Registering the d^ee of
sensitiveness has often helped me in the diagnostic differentiation
between gastric and cysto-hepatic disease.

We will also have to differentiate a possible epigastric hernia ; in
order to produce the maximum degree of pain you request your
patient to strongly contract his rectus and other abdominal muscles
by flexing his trunk from the horizontal position when one can
sometimes even feel a small epigastric hernia. By this flexor trunk
movement the abdominal muscles become tense and rigid, forming
an effective protection of the sympathetic plexus and a previous
hyperesthetic solar plexus becomes hypoesthetic by abdominal pro-
tection.

In order to gain a better understanding of our cases we should

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Schott: Hyperesthesia of the Solar Plexus 45

divide them systematically, and put each case whenever possible
into its own class.

1. Temporary hyperesthesia during tardy gastric pains.

2. Permanent neuropathic hyperesthesia.

3. Secondary hyperesthesia.

4. Gastric pains without hyperesthesia of the solar plexus.

(i) Temporary hyperesthesia during tardy gastric pains is a well-
defined group frequently met with in our daily practice. The pain
usually appears from two to four hours after eating. Sometimes
the pain is provoked immediately after the ingestion of a small
amount of milk or even water. These patients do not usually suffer
when the stomach is empty or while fasting, but the classic char-
acteristic tardy pain appears at a varying period after alimentation.
Generally, we may ascribe such tardy pains to an organic lesion of
the stomach, associated with hyperchlorhydria. We usually meet with
such pains in acute as well as in chronic ulcer of the stomach, in
hyperacidity due to other causes or in alcoholic or mechanical gas-
tritis. Occasionally we meet with some cases where the hyperesthe-
sia persists even in the morning or while fasting, but there is always
a marked increase in the amount of hyperesthesia of the solar plexus
at the actual time of the active and tardy appearance of gastric pain.

{2) Permanent neuropathic hjrperesthesia. In neuropaths the re-
lation between the degree of immediate and tardy pain and the
solar plexus hyperesthesia reflexes is disturbed. Neuropaths insist
that there is, as a rule, no time in which they are free from pain ;
their hyperesthetic point is shifting from time to time, and the
greater sensitiveness has no relation to the time of ingestion. They
perceive their pains even in the morning when awakening. Pres-
sure over the solar plexus point will always elicit a pain that is
not dependent on any gastric or other abdominal disturbance. Due
to moral chaos or excitement, the pain may persist with appreciable
variation during several days or even months when a pressure of
200 to 500 grams may cause the most severe pain which no restric-
tion in diet will modify. At no time are these patients free from
pain when moderate pressure is applied over the solar plexus point,
and we must distinguish the actual pain due to true hyperesthesia
from neuropathic, hysterical or moral pain impressions.

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46 The Archives of Diagnosis

(3) Under the term of secondary hyperesthesia we may iitclude
such conditions which are caused by conditions other than direct
solar plexus sensory reflexes. Secondary solar hyperesthesias are
therefore expressions of conditions having their origin at a distant
part and respond to sympathetic nerve impulses. Amongst condi-
tions of this nature we may include the different ptoses of the ab-
dominal organs — gastric, hepatic, renal, intestinal (i) reflex irrita-
tions of an inflamed appendix, uterine and ovarian inflammatory con-
ditions, etc. Medicinal gastritis (gastrite medicamenteuze of the
French authors), a gastritis caused by drugs which irritate the
gastric mucous membrane, has hardly a place in this classification,
and I mention it only because the etiological factor is often over-
looked and neglected. The solar hyperesthesia which is directly
due to alcoholism must also be thought of. In my personal experi-
ence the hyperesthetic point due to alcoholic gastritis is, however,
more towards the central line of the hypogastrium, and, as a rule,
follows the line of greater curvature of the stomach.

(4) Gastric pains without hyperesthesia of the solar plexus. Al-
most invariably when we fail to elicit some degree of hyperesthesia
over the point of the solar plexus on pressure in gastropaths suffer-
ing with tardy or spasmodic pains, we may conclude that the patho-
logical and etiological factor is located elsewhere. Taking into
account even the extreme rigidity of the abdominal walls immedi-
ately following a perforation of an ulcer of the stomach or duode-
num, we can still differentiate a degree of hyperesthesia of the solar
plexus from the surrounding topographical locations, possibly due
to extreme irritation of the efferent fibers. Where the absence of
hyperesthesia over the solar plexus strikes us most forcibly during
the course of the most intensive tardy pains is in the crisis of tabes
dorsalis. During the course of the crisis of tabes, even when the
patient may suffer the most excruciating pain, a strong pressure
over the solar plexus point of 2 or 3 kilograms will show an almost
entire anesthesia. No doubt this absence of pressure pain over the
point of the solar plexus is due to lesions in the plexus or spinal
cord sympathetic fibers, and I believe that we have in the past not
insisted sufficiently on this deep-seated anesthesia in cases of gastric
spasmodic pains due to tabes dorsalis.

Conclusions. Reviewing what has been said in the preceding, we

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Gdtman : More Fbeqijent Examination of Lower Bowel 47

must admit that studying solar plexus reflexes, we can draw con-
clusions which may help us in many cases to clear up some diagnos-
tic difficulties. First of all we may conclude that an hyperesthetic
point over the region of the solar plexus in the dormant state of
tardy gastric pains suggests a pathological state of the gSstric walls,
a congestion of the mucosa, hyperacidity or ulcer of the stomach.
Neuropathic hyperesthesia, on the other hand, has a widely different
aspect, the production of the same not being constant, as is the case
in the preceding class, besides, in neuropathic hyperesthesia of the
solar plexus we usually detect the concomitant neuropathic elements.
The origin of hyperesthesia due to distant pathological conditions
can in most cases be traced by a careful and proper study and care-
ful examination of the abdominal and pelvic cavities. Finally the
absence of hyperesthesia of the solar plexus during the paroxysm
of gastric pains should lead us to consider the presence of a possi-
ble tabes dorsalis.

There is no question that the examination and production of the
solar plexus reflexes should be included in every careful diagnostic
investigation, especially since it is a simple method, and in the ab-
sence of an esthesiometer can be carried out by simple finger pres-
sure over a point of about one and a half fingerbreadths to the right
of the median line and directly over the location of the trunk of the
celiac axis.

A PLEA FOR MORE FREQUENT EXAMINATION OF THE
LOWER BOWEL IN THE DIAGNOSIS OF DISEASE.
By JACOB GUTMAN
Director, Pathological Laboratory, Jewish Maternity Hospital; Attending
Physician, St Mark's Hospital Clinic
Brooklyn, New York
A plea for a more thorough examination of every organ in the
diagnosis of pathological conditions seems unnecessary in these
days of scientific medicine, when accuracy is rigorously demanded
by the medical profession. However, certain unfortunate occur-
rences of recent memory impel me to make this very plea. During
the past two years my attention has repeatedly been called to a
number of cases where due to negligence or even culpable neglect

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48 The Archives of Diagnosis

to examine properly the lower bowel there has resulted the most
unfavorahle and quite unnecessary consequences. It seems inex-
cusable that the recto-anal region should receive so little attention.
Indeed the organs of this region are neglected not only by general
practitioners of medicine, but even by gastroenterologists, whose in-
terest they ought to particularly attract. Let me ask : Has any
important study of the physiological or pathological conditions of
the lower part of the intestinal tract appeared in print during recent
years?

That the rectum and the lower portion of the sigmoid flexure are
the seats of numerous disturbances is known even to the general
layman. Nor is the subject of proctology at all a new one, for
even centuries before the Christian era have rectal diseases been
known and pronounced a plague and a curse to suffering humani^.
The Bible, for instance, mentions these disorders in more than one
place. Why is it then that the rectum is neglected generally in the
examination of patients for diagnosis? Is the cause to be ascribed
to inefficient instruction upon tiiis subject given in medical colleges?
Or are the disturbances of the lower bowel considered too trivial
for serious attention ? Or is the cause perhaps to be found in the
modesty of the patient which interferes with frank investigations?
Is it perhaps the unpleasantness of the work which the physician
is willing to avoid, or is it a feeling of incompetency that obliges
him to shun these parts? Whatever the cause, the rectal dis-
turbances should receive thorough study and examination. No
diagnosis is complete unless these organs have been given careful
attention. It is a known fact, that carcinoma is a common habitant
of this part of the gastrointestinal tract. How often is such a malig-
nant growth in the lower bowel overlooked and allowed to remain
undetected until the resultant enlargement of the liver caused by
metastases of the cancer necessitates a thorough search for the pri-
mary growth? How often are patients having a positive basis in
pathological changes of the lower bowel with gastrointestinal dis-
turbances set down as neurasthenics and dyspeptics? We all know
how often diarrhea or constipation is ascribed to perfectly innocent
causes until an investigation of the lower bowel reveals the actual
etiological factor. How many individuals have suffered the loss of
comfort and health for long periods from causes located in the sig-

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GuTMAN : More Frequent Examination of Lower Bowel 49

moid and rectum which are not diagnosed? Such conditions are in-
tolerable. There are ways and means, numerous types of apparatus
and Laboratory methods affording as critical and exact an examina-
tion of the rectum and sigmoid as of any other part of the body. It
is possible to diagnose pathological conditions there as easily as
elsewhere.

A few illustrations, not the most striking ones, drawn from my
own experiences will point out the consequences following the
select of the lower bowel.

Case I, (Referred by Dr. A. L. Cardozo.) W. S., male, age 63
years, engineer, Scotch. His family or past history presented noth-
ing of interest. His habits — moderate beer drinker (occasionally
whiskey), inveterate smoker. As a young man — gonorrheal in-
fection. About 6 months previous to the examination the patient
began to feel uncomfortably in the lower part of his abdomen, first
more or less in the right iliac fossa, later entirely in the left. To
this the patient paid but little attention until the abdominal pain
became complicated with frequent bowel discharges. The latter
continued in spite of the frequent administration of various as-
trii^nts by his physician. The diarrheal evacuations soon became
more and more frequent, painful and expelled in a gush. Loss of
weight, weakness and abdominal distension soon followed.

When referred to me for examination, the patient appeared pale,
rather considerably emaciated, with emphysematous lungs, some-
what enlarged heart, sclerotic blood vessels, small liver, distended
abdomen tender upon palpation in its lower half. The anal orifice
was eroded and sensitive. The stools were very thin, dark colored,
fluid, ill-smelling and contained mucus and blood, microscopically
and chemically. The proctoscopic examination revealed in the
lowermost portion of the rectum several hemorrhoidal knots, some
ulcerated, others indurated, the mucosa appeared thickened, succu-
lent, congested and glistening. At about 30 cm. from the anus we
came across an encroachment upon the lumen of the bowel pro-
jecting from the right wall of the gut. This mass was fixed and of
such dimension as to occlude the passage of the intestine and to
make the further introduction of the instrument beyond the ob-
struction impossible. The mucous membrane covering the mass was
ulcerated and spread over with discharge. The diagnosis of a

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50 The Archives op Diagnosis

malignant tumor was made, and the case referred to Dr. Bt^rt
for advice as to the advisability of surgical treatment; but the case
was beyond sui^cat relief, as the disease had too far advanced and
the patient expired several weeks afterwards. This fatal temtina-
tion of the case might to a certain extent be ascribed to the delay
of an exact diagnosis caused by the tardiness of the patient to con-
sult his physician. An early proctoscopic examination would have
revealed the true condition, and proper surgical interference would
have changed the entire aspect of the case.

Case II. (Referred by Dr. J. Wheeler Smith.) M. C. McG., 52
years old, female, American. Family history as to occurrence of
neoplasms — negative. Married 22 years, i child, i miscarriage;
menopause at the age of 36. For the last 10 years patient was in-
clined toward constipation with occasional attacks of indigestion,
vertigo, irritability and nervousness. There never was any elevation
of temperature. The stools were generally hard, consisting of
small scybalous masses and of meager voltune; never bloody,
mucous or diarrheal. During the last few months the constipa-
tion became aggravated and the movements of the bowels were pre-
ceded by pain of a crampy character felt in the lower abdominal
fossa. The physical examination revealed a poorly nourished in-
dividual without particularly important pathological changes in the
lungs, heart or abdominal organs. Only the left lower abdomen
seemed tender to pressure, and an enteroptosis was more or less
evident. The administration of a bismuth enema disclosed con-
siderable information. The course of the fluid as seen with the
fluoroscopic apparatus was observed to fill the rectal ampulla, which
when distended was shown to be of normal dimensions ; it also filled
the sigmoid flexure without difficulty, but when the fluid attempted
to enter the adjoining portion of the descending colon there was a
decided interruption in the flow of the bismuth which continued un-
til the pressure under which the fluid was forced into the bowel was
considerably augmented by elevation of the irrigating vessel and
thus the resistance was overcome. The part of the bowel immediately
above the obstruction when filled was shown to be of larger diam-
eter than the rest of the bowels. Otherwise there were no other
difficulties encountered in the administration of the bismuth enema
until the whole length of the large bowels to the ileo-cecal valve was

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Gutman: Mose Frequent Exauination of Lower Bowel 51

filled. Because of the patient's age, the positive presence of an
obstruction of the bowels, the site of the constriction, the gradual
aggravation of the obstipation, the painful peristalsis accompanying
fecal expulsion, the run-down and more or less emaciated condition
of the patient — all these symptoms seem to have justified the as-
sumption of malignancy as the cause of the obstruction. The latter
condition was already established from the X-ray findings of the
case, but its character, ■whether malignant or benign, was- not
possible to be determined in this manner. The above numerated
symptoms, however, justified diagnosing the case as stricture of the
bowels secondary to a new growth. A proper romanoscopic exam-
ination would have solved Hie difficulty and would have enabled
a correct differentiation between malignancy and benignancy. Un-
fortunately owing to the social standing and nervous state of the
patient and the anxiety of the attending physician to avoid as much
as possible extraordinary manipulations or examinations, the em-
ployment of the sigmoidoscope had to be abandoned-

An abdominal operation upon this patient performed by Dr. Wil-
liam Francis Campbell disclosed in addition to a lower position of
the stomach and the displacement of the transverse colon into the
pelvis, a thick strong band of fibrous tissue, two inches broad, very
much resembling a Jacksonian membrane. This was found at the
junction of the sigmoid fiexure and the descending colon holding
the gut downwards and against the pelvic wall making it tense, im-
movable and causing a decided angulation and obstruction of its
lumen. The rest of the abdominal contents were, upon exploration,
found to be in a perfectly normal state. The patient made an un-
eventful recovery, with the disappearance of all her previous com-
plaints.

In this case, while a surgical operation was indicated in either
event, yet a careful proctoscopic examination of the lower bowel
would have excluded malignant tumor as a factor and would have
enhanced greatly the chances of an exact diagnosis.

Case III. (Referred by Dr. Ph. Oginz.) M. B., 24 years, male,
Russian. Mis history is unimportant with the exception perhaps
of a certain amount of gastrointestinal complaints and constipation.
Habits^ — perfectly good. Patient consulted his physician some few
months previous for frequency of his bowel movements, from five
to six daily. These were usually of a semisolid consistency, at times

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52 The Archives op Diackosis

more liquid, never bloody or painftil, but frequently mixed with
mucus. He also experienced considerable loss of weight and
gurgling sensations in the abdomen. A gastric analysis made by
his physician disclosed a total absence of digestive acids. Hence
the diarrheas were ascribed to the stomach condition and pro-
nounced as gastrc^nous. But the administration of hydrochloric
acid even in large doses for the relief of the achylia gastrica did
not seem to ameliorate his diarrheas. Upon examination, I found
the patient exhibited a number of symptoms typical of individuals
of the vagotonic type. His pupils were of different sizes, the left
eye deeper situated in the socket than the right, his face flushed,
his extremities cold and clammy, hyperhidrosis, dermographism,
poltakiuria, highly exaggerated reflexes, mucous cohtis and eosino-
philia.

In this case the diarrheas could have been properly accounted
for by the peculiar constitutional state of the patient and his achylia
gastrica, but a proctoscopic examination not neglected in this case
revealed conditions which have been Hie true cause of his intestinal
derangement, and which would not have been detected otherwise.
A number of very fine ulcerated separated areas situated high in
the sigmoid were thus detected. These were the cause of his diar-
rheas, as was shown by the disappearance of the patient's com-
plaints upon the cure of his ulcers by proper dieting, the adminis-
tration of hydrochloric acid in concentrated form and local appli-
cations.

Case IV, M. C, male, 40 years old, merchant, Russian. At the
age of 16 the patient had typhoid fever; otherwise his history has
no bearing upon his case. For the past six months the patient com-
plained of constipation and vague gastrointestinal irregularities.
These were ascribed by his attendant as due to gastric ulcer, and
the proper dietary and mineral oil to overcome the obstipation
were prescribed, but at a later period the patient began to suffer
cramps in the abdomen and frequent and very urging evacuations
of the bowels. These discharges were ill smelling, yellowish or
dark colored and of an oily consistency. Careful examination upon
consultation revealed nothing abnormal except a somewhat higher
blood pressure {160 mm. Hg.), and increased skin and periosteal
reflexes. His stomach contents after the usual test breakfast was

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GuTMAN ; More Frequent Examination of Lower Bowel 53

straw-colored, finely granular, 100 c.c. containing no blood or
lactic acid, but pepsin, lacferment, and microscopical ingredients in
normal amounts and appearances. The examination, macroscopic
and microscopic, of the feces proved the presence of a large amount
of pus and blood in addition to the normal varieties of food rests.
The sigmoidoscope revealed the real etiology of his complaints.
There were dry membranous hemorrhoidal loiots tn the lower part
of the rectum and at about 10 cm. from the anus the whole mucous
membrane encircling the gut at that position for about 3 inches
wide was rough, ulcerated, injected, and studded with numerous
papillary projections easily bleeding and quite sensitive to touch.
The surface of this ulcerated area was covered with a purulent
discharge. In this case, previously diagnosed as an ulcus ventriculi,
the application of the proctoscope facilitated the correct diagnosis
of the case and permitted the correction of an incorrect diagnosis.

I could cite from personal experience a number of similar in-
stances demonstrating the value of thorough investigation of the
lower bowel. These citations are not enumerated with the object
of unkind criticism, but rather to emphasize the consequences of
failure to examine the lower bowel properly. A brief description
of the manner in which such an examination should be conducted
seems therefore appropriate.

At 6rst we will review a few points of the anatomy of the organs
in question which are of practical interest The rectum begins at
the third sacral vertebra above and ends at the anus below. It is a
tubular organ, concave in form and lies closely and parallel to the
inner surface of the sacrum and coccyx. The rectum is practically
devoid of freedom of motion, especially in its lower portion, and
without peritoneal covering. Its length from sigmoid to anus is 11
to 13 cm. It may be divided into two distinct regions: (a) the
pars sphincterica, 4 cm. long, the lower and smaller, which is sur-
rounded by the external and internal sphincters and which plays
the more frequent role in the pathology of the organ, and (b) the
pars ampallaris, 7 to 9 cm. long, the upper and larger portion,
which is less frequently the seat of disturbances. When empty the
pars ampullaris presents the appearance of a tube collapsed with its
walls in opposition ; when distended however it appears as a spindle-
shaped affair measuring from 7 to 9 cm. in length, 4 to 6 cm. in

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54 The Archives of Diagnosis

width and with a capacity of 250 cubic cm. In appearance the
mucous membrane lining the rectum normally is perfectly smooth,
pink in color, moist and with a lustre; there are no prominent blood
vessels or mucus displayed upon its surface. In the upper, second
or larger portion of the rectum two, sometimes three folds of
mucous membrane project into the lumen of the gut. These are tfie
valves of Waldeyer or Houston, the lower often being known as
the plica coccygea, while the upper is called the plica sacralis.
Somewhat smaller and less conspicuous is the fold marking the
separation of the rectum from the sigmoid, the plica terminalis.

Adjoining the upper subdivision of the rectum is that part of the
sigmoid which permits inspection by the sigmoidoscope. It may
be well to make mention here that the entire length of the sigmoid
cannot be examined in this manner; only its lowermost section,
that extending from the plica terminalis upwards to the plica
labialis of the sigmoid, is accessible to direct inspection, but not
the segment beyond the last mentioned plica labialis. This circum-
stance arises from the fact that the gut, itself fixed, makes at that
point a sharp turn or an acute bend, thus preventing the introduction
of an instrument beyond this point. That portion of the sigmoid
flexure accessible to inspection is about 20 to 22 cm. long; its
mucous membrane appears to be thrown into numerous small folds,
the rugx flexurse, wrongly termed by some authors valves. In all
other respects the mucous membrane of this part of the sigmoid
flexure is of the same appearance as that of the rectum.

With this short review of anatomical data we may now proceed
with the description of the method of examination of the lower
bowel. There are two of these: (i) the palpation or digital
method and (2) the inspection or recto-romanoscopy. The digital
method is of distinct value and should never be neglected, but the
direct inspection method is the more important one. Numerous
details which escape detection otherwise can be appreciated by the
eye only. The color of the mucous membrane, its glossy appearance,
its moisture, minute hemorrhagic spots, smallest erosions, the
character of exudates, the presence of pseudo-membranes, the loca-
tion of discharges, etc. — all these and other characteristics can be
appreciated only by inspection and very rarely by palpation. Never-
theless, 3 digital examination helps in the determination of the con-
dition of the mucosa, its thickness, its smoothness or roughness,

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Gutman: More Frequent Exauination of Lower Bowel 55

any swellings or new growths, etc. To detect the latter it often-
times is necessary to change Hie position of the patient front
dorsal to the lateral, while keeping the examining finger in the
rectum, as the tumor may be situated within the posterior rectal
wall, and when so hidden it is inaccessible to palpation. However,
the changing of the position of the patient to the genu-pectoral
oftentimes causes the posterior wall and inclosed tumor to gravitate-
downwards and to become accessible to palpation.

The other method of examination, tlrat of direct inspection, is
accomplished by special instrxmients. Valve speculse are service-
able, but are of limited usefulness. The shortness of their blades
does not permit inspection of parts above the top of the instrument ;
furthennore, the blades obstruct the view of the mucosa ; the latter
often bulges between the blades giving the appearance of conges-
tion or the instrument stretches the bowel wall, making it appear
paler than it really is. Another bad feature of valve specuUe is-
that the tissues become caught between the blades when the latter
are being closed for the removal of the instrument, an occurrence-
which may cause considerable injury to the tissues and pain to the
patient.

Of the numerous recto-sigmoidoscopes in use I find the one most
serviceable and hence in personal use that of Schreiber as modihed
by Singer. This instrument seems to include all the good features-
of the others and is very solidly constructed mechanically.
Another very serviceable instrument is the colonoscope of
Heinrich Stern which is manufactured in the United States. Before
rectoscoping the patient to avoid fecal matter from obstructing the
view it is desirable to give the lower bowel a thorough cleansing.
This is done best by the administration several hours before the
examination of the common enema. It is important to administer
this treatment several hours previous to the examination ; otherwise
the peristalsis induced by instrumental manipulations may cause the
remaining liquid from the previously administered enema to de-
scend from its higher position in the bowel during the examination,
thus rendering observations unpleasant and even impossible. Never-
theless, there are occasions when it is desirable to study the natural
condition of the mucous membrane with its exudates, mucus, pus,
or other pathological products in the places of their several loca-
tions ; the cleansing is then contraindicated.

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56 The Archives of Diagnosis

As for other preparations none is required unless painful anal
fissures, inflamed hemorrhoids or nervousness of the individual
complicate the examination. Under these circumstances a 0,5 gram
anesthesin or other palliative suppository is placed into the rectum
before the examination. For the convenience of the examiner it
is advisable to place the patient upon a high examining table. It is
also necessary to put the patient in the genu-pectoral position, with
his legs well separated and perpendicular to the table; his chest
must rest flatly against the table and the spine bent well downward,
the back muscles being thoroughly relaxed. This position has a
great many advantages over the one formerly employed. Its value
is based upon the identical principle underlying the same position
when employed by gynecologists, namely the dilatation of the rectum
by atmospheric pressure. Gravity is another important and advan-
tageous factor of the genu-pectoral position. In this position the
viscera of the abdomen and pelvis fall forward and downward to-
ward the anterior wall and diaphragm, removing their pressure
against the rectum, thus permitting distention of the latter by the
tnrushing air when the organ is opened by the introduced instru-
ment. The view of the intestinal wall is then so complete that
with good illumination the whole mucosa may be studied quite
exactly. During the examination an assistant with his right arm
encircling the abdomen of the patient should stand to the right of
the latter in order to support this, while with his left hand the
assistant should help the examiner by separating the buttocks when
the instrument is beit^ introduced. The tube of the proctoscope
should be well anointed and by a slight screwing motion carefully
introduced into the pars sphincterica for a distance of 3 to 4 an.
The panelectroscope is then attached and its light directed toward
the lumen of the tube. The further insertion of the instrument is
conducted under the guidance of the eyesight.

Because of the tone and grip of the external and internal sphinc-
ters in the pars sphincterica, the introduction of the proctoscope in-
to the first portion of the rectum is attended by a certain amount of
resistance, but as soon as this part of the bowel is passed and the
next one, the ampullary, is entered the capaciousness of the latter is
immediately appreciated. There the instrument can be swung
around with perfect ease. While passing through this re^on we

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Gutman: More Frequent Examination of Lower Bowel 57

may encounter possible obstructions from the valves of Wal-
deyer. To overcome this we must so swing the end of the tube as
to glide it over the free extremity of the valves. At a distance of
10 to 13 cm, from the anus the termination of this upper portion
of the rectum is reached as evidenced by the appearance of the
plica terminalis. Passing that we land into the visible portion of
the sigmoid. Here again, because of the narrower width of the
sigmoid, the canal appears tight but further introduction is not re-
sisted as markedly as in the anal portion of the rectum.

It is needless to state that all these manipulations must be exe-
cuted most cautiously. The various curvatures and foldings of
the bowel should be carefully followed ; the patient is to suffer no
pain except perhaps a slight discomfort; injury to the delicate
mucous membranes should be avoided ; and under no circumstances
should force ever be employed. When obstruction is encountered
gentle manipulation only must be utilized to overcome the difficulty.
In this manner we are often able to examine the bowel to the
furthermost point of possible direct observation, the plica labialis.

When encountering bends of the walls of the gut, a pneumatic
attachment, consisting of a rubber bulb and window, devised and
tised for many years by Tuttle, may be employed to straighten or
separate these convolutions; but care must be taken, for reasons
sufficiently plain, not to stretch the gut too much. As a general
rule, this pneumatic attachment is not frequently required, but if
employed it must be used with caution.

The observations of the bowel conditions are made during the
introduction of the instrument as each portion of the mucous mem-
brane presents itself to view, in the lumen of the tube. If covered
by extraneous matter the membrane is carefully wiped clean with
long cotton applicators before inspection. For further corrobora-
tion it is advisable to repeat the observations during the withdrawal
of the proctoscope, especially of those places previously noted to
be of interest. It is necessary to watch the gradations of the tube
at all times so as to be informed as to what particular portion of
the bowel is under immediate observation and especially whenever
a point of interest is observed.

What is the normal appearance of the rectal mucosa and what
are the indications for recto-romanoscopy ? To answer the first

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S8 The Archives op Diagnosis

question : Normally, the mucous membrane of the rectum is per-
fectly smooth, velvety, somewhat shiny, of a rose color and not
bluish as when congested or when complicated with internal hem-
orrhoids. The mucosa is also always moist, but not succulent, is
free from mucus and reflects the light from the electroscope. In
pathological states the appearance of the mucosa is decidedly dif-
ferent from that just enumerated. In answer to the second ques-
tion, the indications for recto-romanoscopy, it may be said, that
jta hard and fast rules can be laid down as to 'the use of this
method of examination. It is advisable in every case of tenesmus,
rectal pain or discomfort, bloody evacuations, passage of mucus
and pus, etc., to take resort to this exact method of diagnosis, unless
such minor superficial affections as fissures, rhagades, piles, con-
dylomata, etc., may account for the symptoms and may be detected
by mere inspection of the parts. The enumerated symptoms usually
indicate some serious disturbance located within the lower bowel.

Another use of the procto-sigmoidoscope is the localization of
pathological processes. The determination of bleeding points in
cases of hemorrhage, the localization of ulcers and abscesses, the
identification of the seat of a stricture or stenosis, the detection of
polyps and neoplasms — all these constitute positive indications for
the use of the recto-sigmoidoscope. But not only is this method
of value in the establishment of positive diagnosis, it is also fre-
quently just as valuable for its negative evidences. By the recto-
romanoscope we are enabled to exclude positively the presence of
pathological conditions of the lower intestine when none are present
in spite of complaints by the patient about this region, as is not
uncommon among neurasthenics, hysterical and other individuals
of a neurotic disposition.

COLON BACILLUS EXALTATIONS

(observations and impressions)

By B. G. R. WILLIAMS

Paris, 111.

Some man has said that, "A colon bacillus is not a colon bacillus

when busy in some other portion of the anatomy than the colon,"

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Williams : Colon Bacillus Exaltations 59

an observation which I have come to believe correct, at least in
part. The colon bacillus of water polluted with sewage and other
colon bacilli found in nature as well as the resident of the large
bowel usually come up to certain morphological, "physiolc^cal"
and cultural standards ; but the colon bacillus of the abscess in-
variably fails in one or more of them. Has it yielded these in part
in the process of exaltation?

Before contrasting the several properties of the ordinary and
exalted types, it seems pertinent to sound a warning. Do not be
misled by the properties of a strain taken from pus and grown
upon artificial media. Very likely it is now but an ordinary type
and certainly is no longer pathogenic (or the human. The best
criterion is, of course, its activity in the tissues of the living human
organism, and careful observation of its properties there.

Motility. — The colon bacillus found in pus often shows about
the same degree of motility as the ordinary strains (we cannot
say "nonpathogenic," for these inoculated may cause pus forma-
tion ; I term them "ordinary" because they are not as yet suffi-
ciently exalted to cause trouble without inoculation). In other
words, motility is variable and may not be marked. It seems to
me, however, that the bacilli of the kidney infections are often
quite motile. At least the baciUurias of the Eberth and Escherich
types are not likely to be differentiated upon the property of motil-
ity alone. The colon bacillus is often very actively motile in the
freshly voided urine, whereas the typhoid bacillus may appear quite
at rest. Many men are being misled by the old advice that the
colon bacillus is nonmotile. This is more or less true with the
ordinary forms, but the exalted colon bacillus is not a colon
bacillus.

Form. — There is but little or no change of form in exaltation.
That thread formation, however, is rarely or never seen in the
colon rod of pus, is my observation. The exalted strain shows
more "individuality." In standing urines there appears to be a
distinct tendency to a^lutination before precipitation. In the
colon-typhoid group of bacilli increased motility and individuality
appear to be concomitants of exaltation.

Odor Producing. — The colon bacillus has been termed the B.
pyogenes foetidus because of the horrible fetors associated with

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6o The Archives of Diagnosis

certain anal abscesses. This term is misleading, it seems to me. A
foul smell is not present in the first of a series of these abscesses,
and a bad odor of tndol, amines and so on is likely to be of
favorable prognostic import, appearing in the last of the series and
su^ests attentuation rather than exaltation. The idea is seducmg
that the bacillus has been overpowered and is reverting to a prop-
erty of its ordinary strains. Moreover, the "permanently exalted"
types of this group of bacilli, as the typhoid and paratyphoid mem-
bers, are not associated with the liberation of offensive gases. In
colon pyelitis, the urine is rarely foul. Yet at autopsy when the
kidney is incised it is likely to loosen a very foul gas, showii^;
that at death the bacillus quickly reverted to the ordinary form,
and is, when exalted, a facultative saprophyte. In exaltation, there-
fore, the colon bacillus is likely to sacrifice its odor forming
properties.

Acid Producing. — On proper media the colon bacillus is dis-
tinctly an acid producer. In the test tube azolitmin added in small
quantities will be turned pink, than red. It has been suggested
that in the living hiunan being this bacillus gives rise to acid forma-
tion. The urines of colon pyelitis are invariably intensely acid.
Of course, the acids may be provided by the diseased human cells,
inasmuch as a high acidity is likewise noted in tuberculous kid-
ney. In living connective tissues, however, we have no data which
show that the colon bacillus elaborates acids. If so, these are
rapidly neutralized or removed, for the pus is alkaline or neutral.
While we are unable to positively state that this property is lost
by exaltation, such appears to be the case.

For various manifest reasons it is impossible to determine whether
or not other properties of the colon bacillus are lost by exaltation.
Cultural tests in other animals prove nothing as susceptibility,
hence degree and type of exaltation vary. Moreover, when re-
moved from the living human or upon the death of the latter, the
colon bacillus appears to revert easily to the ordinary type.

BOW IS EXALTATION EFFECTED?

We do not know how exaltation of the colon bacillus is effected.
We have two theories concerning the situs of exaltation. The older
is the ascending theory, urging that these infections are fecal inoc-

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Williams: Colon Bacillus Exaltations 6l

ulations, occurring when ordinary colon bacilli are passing or have
passed the anus. But it seems to me that the hematogenous is
the more plausible for the following reasons;

1st. Most bacteria at the anus are already attentuated or quite
dead notwithstanding their enormous numbers. It is not likely that
these would be easily exalted.

2d. Notwithstanding the frequency of statements to the contrary,
I am certain that true colon infections are not especially frequent
in the puerperium, and even if such were the case ascending in-
fection would not be proved. In my observation they are more
frequent in young women and even in babies (even where great
care is taken with the diapers). They are frequent in the school
teacher and shop girl forced to be on her feet for many hours,
where they often pass as "cystitis," and in young married women
especially where pregnancy is delayed. They are usually worse
at the catamenial periods, and may disappear with the next
pregnancy.

3d. We know that at least certain of these infections must be
hematogenous. Ascending infection cannot explain the perirenal
abscess or the pyelitis following skin abscesses.

4th. The colon infections do not appear to be strictly mucous
membrane infections, as a rule. The colon bacillus appendicitis
is more likely to be a perityphlitis than a catarrhal infection. The
"pyelitis" is probably an involvement of the interstitial tissue of
the renal medulla if my interpretation of sections is correct. More-
over, the perirectal and perirenal are the other usual ones, and these
are unquestionably connective tissue infections.

FALLACY OF VACCINES

If what has been stated above is true, the fallacy of vaccine
therapy will be noted at once. The exalted type changes imme-
diately to the ordinary type after removal from the living human
tissues or upon the death of the latter. Even as certain nonpatho-
genic properties are apparently regained so are other pathogenic
(immunity producing) properties lost, and bacterins (vaccines?)
produced from it vary in no way from those constantly present by
virtue of the residence of the colon bacillus in the bowel, as well
as his life's activities and death in that location.

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The Archives of Diagnosis

THE RECOGNITION OF THE PRETUBERCULOUS STAGE
AND THE EARLY SYMPTOMS OF TUBERCULOSIS

By albert C. GEYSER
Professor of Physical Therapeutics, Fardham University Medical School;

Late Qinical Instructor in Radiography and Radiotherapy, Cornell

University; Late Lecturer in Electrotherapy and Radiography,

New York Polyclinic School and Hospital

New York

"Prevention is better than cure." If this is true, it seems that
we ought to change our views as to the stereotyped text-book teach-
ings of ready-made diagnoses. As students we were drilled to
the observance of certain symptoms, and when these symptoms
were present we were dealing with a certain disease. In other
words, we were obliged to wait until the disease process was con-
firmed by its symptoms, then we made the diagnosis and started
in to treat the disease.

That may be the practice of medicine, it may even be the cure
of the disease, but it certainly is not prophylaxis. In order to
prevent disease we must recognize signs and symptoms which
herald the approach of the disease. Right here let me digress for
a moment from the theme. Prophylaxis in its widest sense can
never be realized until the present insurmountable wall that exists
between the medical profession and the public has been broken
down. How can we practice prophylaxis unless the public is edu-
cated and taken into our confidence? We must have the patients
come to us before they are suffering from the stereotyped text-
book symptoms. The tuberculous patient must not wait until the
cough will not yield to ready-made cough mixtures bought over
the drug counter. Neither must the physician wait until he can
detect consolidations and cavities and find the tubercle bacilli in
the sputum.

Doctor S. G. Ehrenreich, of the Montefiore Home for Con-
sumptives, recently examined 3,310 cases for the purpose of dis-
covering the time elapsed between the onset of the first symptoms
as noticed by the patient and the seeking of medical advice. His
investigation disclosed the following facts :

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Geyser : Recognition of the Pretuberculous Stage 63
duration of illness before medical advice was sought

Duration

Males

•emales

one month or less

100.

.. 5 per cent.

70.

.. 5 per cent.

one month to three

458.

..24 per cent.

308.

..23 per cent

three months to six

590.

..30 per cent.

470.

..34 per cent.

six months to one year

430.

. .22 per cent.

286.

..22 per cent.

one year to two years

244.

. . 13 per cent.

161.

. . 12 per cent

two years or more

108.

. . 6 per cent.

85-

.. 4 per cent

Fifty per cent, were sick at least six months before seeking
medical advice. Fifteen per cent, of all of these cases were ad-
vised by their physician that the lungs were not affected. Doctor
Ehrenreich then states, "I can safely say without any contradiction
that the physicians' neglect in not properly examining and diagnos-
ticating pulmonary tuberculosis is responsible for more than twenty
per cent, of all of our advanced cases."

I am quite sure that if the family physician explains to his
patients that it is a far greater achievement to prevent than even
to cure a disease, there will be a just and proper appreciation on
the part of his patients.

For the sake of convenience I shall arbitrarily divide tubercu-
losis pulmonalis into the pretuberculous and the early stages.

If we would practice prophylaxis in tuberculosis it must be
done in the pretuberculous stage. Before this is possible it is
essential that a certain few facts concerning this disease must be
appreciated.

There are certain tissues in the body that are invaded by the
tubercle bacilli in preference to all others. They are the apices
of the lungs, the ends of the long bones, articulations in general,
the glands and the skin. While all of these tissues differ ana-
tomically and physiologically, they have one thing in common, that
is physiological anemia.

To have a suitable soil for tuberculosis we must have anemia.
Having anemia we must have the bacillus tuberculosis taking up
its habitat there. Again, it is not the bacillus tuberculosis that kills
the patient, but a certain toxic material given off by the bacillus.
This toxic material causes further anemia whenever it comes into
contact with tissue cells, hence further spread of the disease. We

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64 The A&chives of Diagnosis

have three points to bear in mind, the anemia, the bacillus and the
toxic element. Since the existence of anemia prepares the cul-
ture medium and the toxines increase the same and eventually
overcome the individual, and as the bacillus is only the necessary
intermediary agent, it behooves us to recognize and prevent anemia,
to recognize and to overcome the manifestations of the toxic ele-
ments upon the system and at the same time to pay as little atten-
tion as possible to the bacillus tuberculosis.

Starting out upon these admitted premises let us look for the
earliest symptoms of the pretuberculous stage.

These symptoms are subjective and objective. The subjective
symptoms cause the patient to consult the doctor for nearly every
thing else except tuberculosis.

1st. General malaise and fatigue. The patient tires easily, his
appetite is capricious, he especially avoids fat and cream, nothing
seems to taste just right, he becomes irritable and moody, he thinks
that he needs a tonic or a stomachic, his hours of labor seem too
long, his work is becoming distasteful to him, he longs for a change,
he cannot stay at home because every one thinks him peevish. This
is the early irritable effect of anemia and toxemia.

2d. Upon awakening in the morning there seems to be an un-
usual amount of mucus present, he is obliged to clear his throat,
he hawks and expectorates, but he remembers having been in a
draft of fresh air and so "caught cold." He either partakes of the
family cough remedy or the drug^st "fixes up something." Cough
ever so slight must be accounted for.

3d. Loss of weight. For some reason the patient does not seem
to fill out, he remains lean, long and lanky; for his age he is
taller than his playmates, but his weight remains about ten or
more pounds below the normal.

4th. The complexion is "perfect," the skin is white, does not tan,
but bums in the summer. If it happens to be a girl the complexion
does not require "making up," especially late in the afternoon ; the
eyelashes are long and abundant, the pupil frequently dilated and
the eye bright, the hair growth almost luxuriant, but each hair is
thin and dry, giving it that much desired fluffy appearance. The
fii^ernails are long and shapely with a bluish white background.

5th. Small pulmonary hemorrhages or sanguinous expectorations

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Geysek: Recognition of the Pretuberculous Stage 65

especially occurriag in women with a tendency to lessening of the
menstrual flow must be construed as significant.

6th. Rapid pulse. As soon as the system begins to absorb the
toxic products of the tubercle bacillus there ensues a reaction on
the part of the system to overcome this toxemia. The result is
a quickened pulse rate. A daily pulse rate of eighty-flve or more
without other discoverable causes becomes suspicious.

7th. Increased temperature. Hand in hand with the increased
circulation we have the increased temperature. It is far better to
be guided by the daily variations between the minimum and the
maximum than by the temperature per se. The normal tempera-
ture differs with each individual, but if the daily variation exceeds
one and six-tenths degrees F. it should arouse our suspicion. The
daily variation in a tuberculous subject amounts to from two to
three and a half degrees F.

8th. Progressive loss of weight. A patient with incipient tubercu-
losis giving the two previous symptoms of necessity is subject to
hyperoxydation, hence the systematic loss of weight. This loss of
weight is entirely out of proportion to the food intake or manner
of labor performed. Such patients abhor fats, they not only fail
to assimilate it, but they actually eliminate it.

Fat is free in the circulation, the absorbents are taking the fat
from the various deposits into the circulation for the purpose of
aiding oxydation or the production of body heat. Free fat can be
demonstrated in the blood in most cases.

9th. Litten's phenomenon. With even the slightest tuberculous
infection of the lungs, the diaphragm upon the affected side does
not make its full excursion during inspiration or expiration. In
a good light, a shade or wave-like motion can plainly be seen to
lag behind its fellow of the opposite side. From a physiological
viewpoint the reason for this is obvious.

loth. Supraclavicular retraction. As soon as tubercles have
formed or are forming in the upper part of the lung, inflammatory
adhesions develop. As a result of this the supraclavicular fossa on
the affected side is markedly influenced upon deep inspiration and
«xpiration. The difference between the two fossae is very notice-
able.

These are some of the early clinical signs of pulmonary tubercu-

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66 The Ahchives of Diagnosis

losis. Whenever a majority ot these are present, the case should
be considered as in the pretuberculous stage, if the patient shows
the minority of these symptoms then laboratory aid must be sought.

ist. The tuberculin reaction. Whether this responds to the
cutaneous, the subcutaneous or conjunctival tests is immaterial.
Reaction means that there is or recently has been a tuberculous
process somewhere in that patient. As to flie choice of these
methods too much value must not be placed on either of them ; in
Muller's medical clinic at Munich the ophthalmic test is entirely
forbidden as not only useless, but also dangerous.

The von Pirquet reaction. V. I. Glintschikoff studied 148 cases
and showed that in tuberculosis the intensity of the reaction is in
inverse relation to the severity of the disease. As the disease
progresses the reaction becomes weaker, often disappearing in the
last stages. In other words, the system is no longer able to respond
or react when the cells have been completely placed under the effect
of toxines from the tubercle bacilli.

The subcutaneous method is contraindicated in the presence of
fever, hemorrhage, definite physical signs or the bacilli in the
sputum. By either method a positive reaction can have but very
little diagnostic value as far as early clinical tuberculosis is con-
cerned. At its best it can only be confirmatory with other pre-
existing symptoms.

If the process is latent and the local lesion cannot be determined
such a patient should be considered as tuberculous, but he should
not undertake any special therapeutics. Hygiene and prophylaxis
are his saf^uard. Nature seems to be overcoming his disease and
we have not yet been able to improve upon the "vis medicatrix
naturae."

2d. The presence of the bacilli in the sputum. Tubercle bacilli
never appear in the sputum unless softening of the focus has takes
place. It is, of course, prima facia evidence of infection. If the
greater majority of the early clinical symptoms are absent, but
the laboratory findings present upon repeated examinations, such
a patient should be considered as being in the first stages of the
disease. When a majority of the clinical symptoms are present
plus the laboratory findings, the family history good, the physical
condition at par and the hygienic environment suitable, such a

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I-AWHORN : Incipient Pulmonasy Tuberculosis ^"J

patient should be considered as in the early second stage. When
all of the pretuberculous clinical manifestations are present plus
laboratory findings the patient is in the late second stage.

It matters little as to time, whether these conditions have been
present for one month or several years. Some patients never get
to the first stage, others live for years in the second stage, while
still others succumb to the third stage a few weeks after the onset.

The recoveries under modem methods (physical and diathermic
treatment) are ninety per cent, and over in the pretuberculous stage,
eighty-five per cent, in the first stage, and, as Doctor Van Rensselaer
of the Albany tuberculosis camp has shown in his presidential ad-
dress last May, sixty-nine per cent, in all but the very last stages.

It may be true that some of the cases diagnosed as in the pre-
tuberculous stage would never develop the real disease. When we
reflect upon the fact that every child before the age of twelve
years has been infected, that ninety-five per cent, of all cases com-
ing to autopsy show signs of healed tuberculous lesions, that one
out of every eight persons dies of tuberculosis, it is safer to run
the risk of treating an occasional or even quite a number of such
cases and restoring them to health clinically, than to run the risk
of letting a single one escape and develop the disease beyond human
aid.

In tuberculosis as in cancer when the diagnosis is so positive
that it can be made by the laity, it is apt to be too late for efficient
therapeutics.

THE EARLY DIAGNOSIS OF INCIPIENT PULMONARY
TUBERCULOSIS.

By CECIL C LAWHORN
Physician in Charge, North Side Children's Tuberculosis CUnic
Milwaukee, Wis.
Tuberculosis in some form has been found to be present in 90
per cent, of children up to 15 years of age. Calmette says that 90
per cent, of children from 5 to 15 years of age, and from 91 to 97
per cent, of young people above that age are affected with some
form of tuberculosis. Von Pirquet states that 90 per cent, are in-
fected in the first year of life.

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68 The Archives of Diagnosis

In Fishberg's series of 692 children under 15 years of age, ex-
amined medically and by the von Pirquet test, belot^ng to 317 fa-
jnilies where one or both parents were tuberctdous and had applied
. for relief to the United Hebrew Charities of New York in March,
April and May, 1913, 67,23 per cent., or 465, were found to be
tuberculous.

Comby reported 638 cases in 1675 necropsies upon children 15
years old or less from the combined hospital statistics in Farts.
Between the lOth and the 15th year of the series, 71.23 per cent,
were tuberculous.

Leroux, of Paris, says that from his radiograms, it is evinced
that the base or middle part of the lung is in the majority of cases
the primary seat of inoculation in infants and young children, but
that in children over 10 years of age and in adults it is the apex
which is usually involved.

By radiography carried on for two years it is possible to show
the evolution of glandulo-pulmonary tuberculosis in three stages : a.
Pulmonary infection of some part of the lung and unilateral aden-
opathy, b. Tracheo-bronchial adenopathy more or less latent, c.
Reinfection of the apex and evolution of chronic pulmonary disease.

A diagnosis of incipient active pulmonary tuberculosis envolve-
ment is greatly to be desired and from the recent light thrown upon
childhood infection, the examining physician should suspect
phthisis in every child or adult presented for examination who may
have any suspicion of lung disease or have symptoms of anemia,
malnutrition, poor sleep, gastric disturbances, diarrhea, tachycardia,
pains in chest or abdomen, lassitude, loss of weight, and !n children
a failure to gain weight, hoarseness, fever and tracheo-bronchial
adenopathy as evidenced by d'Espine's sign, positive tuberculin skin
reactions and radiography.

A. F. Beifeld in a recent article in the Archives of Diagnosis for
October, 1914, "An aid in the early diagnosis of pulmonary con-
sumption," mentions the apical percussion methods of Goldscheider
and Kronig, the muscular spasm phenomenon of Pottenger, acromial
lagging, pupillary inequalities, myoidema and acromion ausculta-
tion recommended by Abrahams and Magida. The latter method
in the diagnosis of incipient tuberculosis which has had such wide
publicity of late, I have found of no value owing to the inability of

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Lawhorn: Incipient Pulmonarv Tuberculosis 69

the examiner to determine the pathol<^cal from the physiological
signs present in probably normal individuaJs.

To bring out the fine diagnostic moist riles on auscultation, Bei-
■ feld mentions further the well known deep inspiration, sharp
coughing, a deep inspiration after the patient has counted as long
as possible in a single breath, administration of potassium iodide,
etc In addition he describes a new method, "The whispered voice
method." The patient is instructed to whisper in an emphatic man-
ner in a single breath, "One, two, three," several times following
which he is to inspire deeply. (The latter he does spontaneously.)

I am able to verify this method as being quite effective, having
used the same since 1910, when I observed the phenomenon by acci-
dent in testing whispered pectoriloquy in the Tuberculosis Qinic
of the Presbyterian Hospital in New York. In addition to and in
conjunction with this I go further. I instruct the patient to cotmt
repeatedly in whispers "One, two, three," six or more times, in the
same outgoing breath and then to cough also in the same breath,
taking care not to inspire at all before the cough, then to inspire
deeply, immediately after the cough. The patient will always spon-
taneously take a deep inspiration after the cough.

If the fine rales sought for are constantly present and not dissi-
pated on coughing followed by deep inspirations or are elicited
regularly after the continued whispering, coughing and inspiration
combined, the conclusion of a positive diagnosis is justified.

The diagnostic factor is that if the fine moist riles are transitory
or disappear by this or any of the auscultatory methods, the con-
dition is not of a tuberculous nature as is exemplified in a bron-
chitis, where upon the first examination more or less suspicious
rales are discovered, but upon repeated deep inspirations or cough-
ing they disappear temporarily or permanently, while in pulmonary
tuberculosis the opposite is true.

An experience of several years has strengthened my belief in the
correctness of my observations. I have found the methods valuable
and effective in the examination of children who will not breathe
satisfactorily, in adults who cannot or will not breathe in the way
desired, and in very muscular men whose normal muscle sounds
interfere with the respiratory sounds. I remember the case of a
young German, 21 years old, a seaman. He was very robust, had

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70 The Archives of Diagnosis

large, powerful muscles, and was a picture of health, but had a
suspicious cough. When instructed to breathe deeply, the muscle-
sounds completely overshadowed the respiratory sounds ; on account
of the great muscular development percussion was also unsatisfac-
tory. The whisper and cough method was used, which permitted
the rales to be heard, a positive diagnosis was made and a month or
two later a positive sputum was obtained.

The presence of the fine rales, whether at apices or elsewhere, in
patients suspected to have pulmonary tuberculosis (when non-tu-
berculous conditions which may account for them can he excluded)
afford the earliest positive signs of pulmonary tuberculosis.

In an endeavor to explain the phenomenon brought out by the
whispering method, I think that the strain of continued whispering
in a single outgoing breath causes by reflex action an overproduc-
tion of moisture, especially in the finer bronchioles and alveoli ; then
by complete collapse of the walls of the alveoli due to the cough and
immediately followed by deep inspirations, the consequent separa-
tion of the moist, agglutinated, diseased walls of the air sacks, and
the air rushing through the moist bronchioles, these two factors
produce the rales, whereas in a simple bronchitis the excessive mois-
ture and pathology is only in the bronchioles and bronchi, forced
breathing clears these air passages and the rales disappear, but in
incipient phthisis the rales are brought out more distinctly and re-
main permanently.

By HERMAN B. SHEFFIELD
New York
The two-months-old baby was entirely normal at birth. He
weighed eight pounds and thrived nicely the first two weeks of his
life while nursed by his mother. Owing to financial distress, how-
ever, the mother was soon compelled to work out by the day and
to entrust the care of her baby to her old mother, who fed it on
a milk mixture of her own design. The baby soon began to fail,
and accordingly the feeding underwent almost daily changes to
siiit the good judgment of the numerous neighbors who owned
sturdy babies. Finding, finally, that all the well-intentioned sug-

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Sheffield: Tetanism 71

gestions proved of no avail, the mother concluded to try a doctor.
When the baby came under my observation at the hospital he
weighed four and a half pounds. He was the very image of a
marasmic baby. He had a voracious appetite, but almost invariably
vomited after feeding. The stools were frequent, green and filled
with undigested particles of food. He suffered from colic espe-
cially soon after feeding, was restless, cried and whined pitifully,
and slept poorly. The anterior fontanelle, the eyes and cheeks were
sunken, the nose and chin were pointed, the abdomen was retracted,
the skin wrinkled, in some places hanging in folds, and adding to
this the earthy pallor and senile expression of his face, the poor
creature was a sight dreadful to behold. As a further addition
to his misery he was suffering from a symptom-complex which a
few years ago* I ventured to describe as tetanism. This is a
peculiar form of continued muscular hypertonicity occasionally ob-
served in very young infants with markedly lowered vitality, be it
as a result of prematurity, syphilis or chronic gastroenteritis. The
onset of the spasticity is fairly rapid, and in severe cases, when
fully established, the posture assumed by the patient is pathog-
nomonic (see Fig. i). The head is moderately retracted, the facial
muscles are contracted, the jaws are firmly set together, the fore-
arms are flexed upon the arms and the hands are tightly clinched,
so as to form firmly closed fists. As a rule, the legs are bent
angularly and the feet either overlap each other or are arched.
The muscular contractures relax off and on (see Fig. H), more
especially during profound sleep, but never subside entirely. The
hypertonicity increases on handling the baby, but it never interferes
with feeding. With improvement of the general health of the baby,
the contractures gradually disappear.

As can be noted from the accompanying illustrations tetanism is
a typical clinical picture easily to be differentiated from similar
spasmodic affections. On the first examination of the patient we
may suspect either tetany, tetanus or eclampsia, but on careful
analysis of the symptomatology of these affections, the erroneous
impression can readily be dispelled. Tetanism differs from tetany
by its more gradual development and almost continuous persistence
for several months ; any kind of handling of the baby increases its

*Arch. of Pediatrics, Aug., 1910.

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yx The Archives of Diagnosis

muscular hypertonicity, while in tetany the attacks may be brought
about or aggravated only by pressure upon large trunks of nerves
or arteries (Trousseau's phenomenon), electric excitability (Erb's
phenomenon), or irritation of the facial nerve (Chvostek's sign).
Tetanus is an acute disease, preceded by an infection, as a rule
accompanied by difficult d^lutition and respiratory embarrassment
and usually ending fatally within a week. Eclampsia infantum oc*
curs in attacks and is associated with loss of consciousness. In the
same manner we can promptly exclude so-called meningismus;
moreover, none of these spasmodic affections of infancy ever give
rise to the characteristic contractures of the extremities just de-
scribed and illustrated.

I. CAVERNOUS ANGIOMA OF THE LIVER IN A BABY

SIX WEEKS OLD

II. CONGENITAL ABSENCE OF ALL ABDOMINAL

MUSCLES

By ARTHUR STERN

Attending Physician to the Children's Wards, St Elizabeth Hospital and the

Eliiabeth General Hospital

EUiabeth. N. J.

Case I. Muriel M. Six weeks old, was sent into my service

at the Elizabeth General Hospital through the kindness of Dr.

Horace Livengood.

The mother, who is twenty-five years old, had three children of
whom the first died, the second lives and is healthy, and this was
bom after a pregnancy during which the mother was anemic and
suffered from varicose veins.

The child was nursed for two weeks and then put on artificial
food. On Oct. 22d, the mother brought the child to Dr. Liven-
good's office saying that for the past few weeks the stomach of the
baby had been growing larger and the rest of the baby thinner.
There was very little digestive disturbance, no vomiting and occa-
sionally a green, lumpy stool. The child, after examination by Dr.
Livengood, who found a large tumor in the abdomen, was then
sent into my service at the hospital.

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The Archivks of Diagnosis

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Stern: Angioma of the Liver 73

The examination showed a greatly distended abdomen with a
large, bard tumor coming from under both ribs and extending
deep into the pelvis, and in the right lower side an indentation
could be made out. The X-ray picture, after a small bismuth meal,
showed the stomach to be normal and a dense mass in the
abdomen.

The child stayed at the hospital only a few days and was then
taken home, where it died Oct. 31st.

Dr. Livengood was able to perform a partial abdominal autopsy
and found the tumor to be the liver. A part of it was removed
and examined by Dr. J. H. P. Conover, pathologist to the hospital,
who pronounced the tumor to be a cavernous angioma. There
was very little liver tissue present, but large cavernous cavities
lined with endothelial cells.

Liver tumors of this nature are exceedingly rare, and I have
been able to discover only five cases reported in the literature.

Hippel, Philipp, Yamagiwa, and Nakamura have described tu-
mors of mesoentodermal and mesoectodermal character of the liver.

In these five observed cases, entodermal adenomatous and even
carcinomatous (Yamagiwa) formations were found intersected with
myxomatous, fibrous, cartilaginous and even osseous formations.

The description of these rare cases is found in the Handbook of
the Pathological Anatomy of the Infantile Age of Bruening and
Schwalbe.

Case II. Baby N., male, was bom as the third child of a family,
where mother and father are healthy and also the first two children.

I saw the child immediately after birth. The abdomen formed
a lai^e bag, and with each respiration some of the abdominal con-
tents were aspirated into the thorax. As far as I could feel, there
was no diaphragm present and the abdominal wall was almost trans-
parent, but contained large pulsating blood vessels. These vessels
ran mostly into the tunbilicus, but communicated with each other
and pulsated. Immediately after birth the child passed free blood
instead of urine and kept on bleeding until it died, forty-eight hours
after birth. An autopsy was not permitted.

Apparently this case belongs into the large group of "Monstra
per defectum." The interesting feature is the communication of

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74 The Archives of Diagnosis

the blood vessels with the uropoetic system and the metaplasia of
the abdominal wall with a highly vascular tissue.

RETESENCES

Bruening un<i Schwalbe. — Handbuch d. allgemeinen Pathologie u. d. patho-
logischen Anatomic des Kindesalters.

Bimbaum. — Klintk d. Missbildungen u. kongenttalen Erkrankungen. Ber-
lin, 1909.

Von Hippel. — Ueber ein enormes kavemdses Angiocn. Miinchener med,
Wochenschr., 1903.

Philipp. — Zwei intereswnte Falle von bosartigen Neubildungen bei kleinen
Kindern. Jahrbuch f. Kinderheilkunde, Vol. LXVHl. p. 369.

"PSYCHOANALYSIS" A WORD CAPABLE OF WIDE

USEFULNESS

By J. MADISON TAYLOR

Professor of Non- Pharmaceutic Therapeutics, Medical Department,

Temple University

Philadelphia

Psychoanalysis is a term full of meaning, signifying the process
of unravelling subversions of consciousness and serving as the first
step toward setting thera in order.

Language suffers strange parodies while acting as vehicle of
thoughts and purposes for, sects dominated by vagaries of belief or
feeling. The word "Psychoanalysis" has become thus burdened
with hidden, unsavory wholly unfair mismeanings. It probably
cannot be expurgated, but its essential meaning can, and should be
restored and properly applied.

The Freudians have set the world astir by re-enacting a sort of
Phallic revival ; a reversal to earlier concepts of hysteria. "Psycho-
analysis" is now nearly as familiar as "Urinalysis," it could be made
to become nearly as useful.

All who assume responsibility in ministering to psychopathies
make, and long have made, use of psychological analysis in search-
ing into the intricacies of mental perturbations. Psychogenesis of
clouding of the consciousness was well known in ancient days, and
good means were then employed to disencumber and free the suf-
ferer from its effects. The clouds come from diverse sources and

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Taylok ; "Psychoanalysis" 75

avenues, chiefly sickness of the feeling tones ; disharmonies between
creature and environment. A life history has ceased to flow alot^
normal channels ; the subject has become quagmired, has wandered
into strange ways ; in short got lost ; less from not knowing how to
find the way than by misinterpretation of landmarks by reason of
morbid pre-occupation and a growing terror of harmless objects;
to frantic anxieties to get somewhere, forgetting that it would be
easy enough if only primary laws of progression were observed.

A life history is thus turned aside from the even tenor of its way ;
then a guide is needed to follow after, to pick up the trail, interpret
the divagations, hunt up the wanderer, reassure him and put his feet
upon the right road and keep them there tilt power is regained to
start afresh and work out life problems with confidence and aware-
ness of one's powers.

The Freudian guide would have us believe that all such wander-
ings in the maze are due to sexual shock received during earliest
glimmerings of adolescent development. He would insist that
"libido" is a force which dominates each and every phase of human
purposes, existence, faith and act.

Where, we may well ask, do the organic, toxic and other acquired
causes and their conditions come in ; not to mention the underlying
developmental hypoplastic factors so common?

It is customary for any one ministering to a disordered mind to
make systematic search into all the mental chambers, open and shut,
patent or secret, leaving nothing undisclosed.

That process may be called a Psyckoanamnesis (a contribution
to picturesque verbiage). Thereupon we proceed to group the cor-
related findings together with due regard to perspective and values
by Psycho-syHthesis (another offering to descriptiveness), and are
in a position to enter upon the task of Psychoanalysis.

Next in order is to fonn expert judgments, opinions on the sig-
nificances of data obtained, and to reach conclusions on their nature
and bearings, reaching a Psycho-diagnosis or the better term contrib-
uted by Boris Sidis, Psychognosis.

Now we are in a position to formulate procedures for rescuing
the distressed or confused person from effects of personal errors,
of act, of ideation, of emotivation, of hurtful self-estimates of his
or her own mischievous or disabling fancies or faulty evaluations

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y6 The Archives of Diagnosis

of somatic possessions ; thereupon proceeding to rehabilitate the
dissociated elements of consciousness and apply the now popular
and widely discussed measure known as Psychotherapy. This may
seem a circuitous route to follow ; it is well fortified by high sound-
ing words.

Few or no advances in clinical medicine are so useful as the
changing of a disorderly mind into an orderly efficient mind. It is
not a modern discovery that the mind (or psyche which conveys a
larger significance) is frequently affected so seriously as to resemble
"madness" or insanity. The earlier observers recognized and appre-
ciated the condition; some of them made illuminating observations
and recommendations, helpful to us modems, provided we interpret
them aright. Moreover they supply dear vision as to the prevalence
then, precisely as now, of mixed instances of somatic and psychic
disorder.

Most, if not all, human ailments are complicated by personal
misinterpretations of somatic derangements and diseases.

In determining means for complete and permanent relief or cure,
the wise practitioner never omits to keep the factor of mind control
in the foreground of his purpose.

This is true not only of protracted disabilities, but likewise of
acute states. External stimulations, especially when excessive,
amounting to cell irritation, or sensory disturbances, involve also
anxieties about unknown possibilities. Fear effects are thus often
transferred from, or to, those in the domestic or industrial circle.
These anxieties may disturb mental equipoise to a degree not imme-
diately apparent, nor determinable by commonly known means, yet
elements of disaster are there, growing insidiously, or passing quick-
ly, as may be decreed.

A group of morbid mental conditions is constantly presenting to
every experienced practitioner where the word in season, spoken
with wisdom, tact and force, limits disabilities effectively no matter
what vagaries of medication or "rational procedures" have been,
or shall also be, employed.

Many an obscure medical man, moreover, is the best of counsel-
lors, the volume of whose practice is by no means an index of the
efficacy of his treatment. So unobtrusively yet radically does he
make well there is no room for graphic demonstrations by pandering

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Tavlor : "Psychoanalysis" fj

to human weaknesses and vanities which enable a bolder one to
appear a wonder worker, as shown by crowded offices and bewil-
deringly impressive methods. These last by their mass and glitter
cause poor fools to stand amazed at his "business" and pray to be
numbered among his wealthy and numerous clients.

These honest, capable clinicians often possess unappreciated gifts ;
sympathetic, broad, analytical minds, fortified by sincere desires to
help those who are heavy laden, to lift up the weakhearted, to set
the feet of the confused and discouraged on the right road to effi-
ciency.

In brief, they employ psychoanamnesis, psychoanalysis, psycho-
synthesis, psychodiagnosis, and psychotherapy, unwittingly, yet
effectively.

The followers of Freud contribute to the elucidation of vexing
problems while engaged in a form of special pleading which closely
resembles verbigei^tion in a contracted mental field. They give the
impression of being sustained by strange waves of feeling, wishes
and belief, rather than by a strictly scientitic endeavor.

The enthusiastic admirers and devoted followers of Freud (with
modesty all their own) claim that there is no other single factor in
mental life so dominating as sex ; no other that has associated with
it such tremendous emotional values, which so predominate over
even the instincts of self-preservation; that it is to quote Ernest
Jones, "the great fundamental, highly emotionally valued instinct,
which spreads out and touches every part in the psychic life, and
which is manifested quite as universally in the activities and insti-
tutions of the social system."

We are besought by these gentlemen to accept their opinions unre-
servedly, exhibiting faith that they have vouchsafed to them special
advices from some unerring source of power.

They show, however, an undue eagerness to demonstrate the uni-
versality of their postulate that "libido" is paramount which savors
of a suspicion that it is not wholly provable.

One good thing they have done, pven us a good word in psycho-
analysis provided we put this word where it belongs, and not where
they would keep it.

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The Archives of Diagnosis

fko^tM of Bfagiuufic mtt ^siuntaE

GENERAL METHODS OF EXAMINATION— SYSTEMIC

AFFECTIONS— DISORDERS OF GENERAL

METABOLISM

The Raul Function in Nnnlingi and Older Children— A. Bosleb, Zeitschr.

f. Kinderheilkunde, Vol. XI, 1914. Nos. 5 and 6.

Older children with renal disease had no markedly different renal
activity than children with healthy kidneys. In some of the
nurslings with healthy kidneys the soditmi chlorid retention was
remarkably high. This was probably the result of sodium chlorid
hunger. Mill.

The Urinary Secretion in the Nnrtlint— Ehgel, Deutsche med. Wochenschr.,

Nov. 12, 11J14.

A properly nourished nursling imbibing about 800 cc. liquid per
day micturates on the average 25 times during the 24 hours. When
ingesting from 1200 to 1600 cc. of liquid daily, an occurrence which
is quite frequent, the number of micturitions may be increased to
60 or even 70 during the 24 hours. Generally speaking, the evacu-
ation of the bladder ceases during sleep. During the day and when
the muscular and nervous systems are most active, the urinations
are most frequent. Most micturitions discharge from 10 to 20 cc;
the largest amounts are generally voided during the night, from 50
to 60 cc, and exceptionally from 70 to 90 cc. Mill.

Diattatic Property of Children'e Urine— W. B. McClure and P. S. Chan-
cellor, Zeitschr. f. Kinderheilkunde, Vol. XI, Nos. 5 and 6, 1914,
The diastatic quality of the urine of children increases with the
age of the children. It is possible that rachitis and chorea contribute
toward augmentation of the diastatic property. Mill.

Acute Nephritis in the Nutritive Disorders of Nurslings— F. Frank,

Archiv f. Kinderheilkunde, Vol. LXIII, Nos. 3 and 4-

Conclusions derived from the observation and study of 22 per-
taining cases. Acute nephritis does not occur frequently in the
nursing period of infants. Acute nephritis in the nursling is mostly
exudative in character and presents frequently a hemorrhagic ten-
dency. This must be ascribed to the abnormally great permeability
of the blood vessels during the first year of hfe. Etiologically, all
types of infection and especially nutritive disturbances play a
marked role. Mill.

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Progress of Diagnosis and Prognosis 79

Pirenteral Hetabolitm— A. Deubicki and J. Lowv, Deutsches Archiv f. kita

Mediiin, Vol. CXVI. Nos. 5 and 6.

The parenteral metabolism is in part dependent upon the numer-
ous fermentative processes, which are the expression of the func-
tion of the most varying organ-cells. The leukocytes are among
the most important of these cell forms. Apart from phagocytosis,
antitoxic, oxidative, reducing, and fat and albumin splitting proper-
ties must be ascribed to the leukocytes. After the period of diges-
tion an increase in leukocytes can be demonstrated. Such increase
is, however, denied by some authors. Authors noted in 134 cases
an increase of leukocytes after digestion in 53 cases, a decrease in
49, and no change in 32 cases. Leukocytosis existed in 23 cases
of diminished, and l6 cases of unchanged serum-concentration.

Western.
Ehrlich's Aldthyit Test for Urobilinogen—O. H. Robertson, Cat. State

Jour. Med., Feb., 1915.

A positive test is of very little value on account of the fact that it
appears in such a relatively large number of conditions having no
apparent relation to liver function. One negative test does not rule
out the possibility of a positive test appearing later on. A persis-
tently negative test is of more value than a positive, but in view of
the lack of clinical data, it cannot be said to exclude a pathological
liver condition. Sachs.

Creatin and Creatinin Excretion in Diabetes and Nephriti>— D. Laupert,

Zeitschr. f. Win. MedUin, Vol. LXXX, Nos. 5 and 6.

Author made his investigations with the aid of the Authenrieth-
Miiller method. Healthy persons who ingested neither meat nor
bouillon excreted between 0.9 and 2.4 grams creatinin per day.
Most individuals excreted between 1.2 and 1.5 gram creatinin.
Creatin could be but rarely demonstrated; when it occurred it was
present in traces only. In diabetes, creatinin was either eliminated
in less than normal amounts, or in amounts which approached the
lowest normal limit. The amount of creatinin in all the diabetic
cases generally was below i gram. In some of the graver cases, i
gram or a trifle more was found in a few instances. In 5 cases of
nephritis a diminution of the excreted creatinin was ascertained.
This was the case when diuresis was not diminished and the renal
function was but slightly lowered. Creatin was present in minute
amounts in one case of marked renal insufficiency. In two cases of
diabetes with synchronous renal sclerosis creatinin was excreted in
particularly small amounts. There is a parallelism between the
creatin excretion and acidosis in instances of grave diabetes. Thus,
it is possible that the creatin excretion is also the result of the inter-
mediary metabolism, i. e. that creatin is the lower, creatinin the

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8o The Archives of Diagnosis

higher product of metabolism. The creatinin excretion may be em-
ployed in functional renal diagnosis. Western.
Abderhaldm'i Serum Reaction of Liver Tiiaue in Alcoholiati — E. Martini,

Deutsche med. Wochenscbr., Dec lo, 1914.

In 9 alcoholists, the serum reacted distinctly positive with liver
tissue 7 times. Of these, 4 had demonstrable hepatic enlargement
It is possible that the serum reaction may facilitate the early recc^-
nition of alcoholic liver affections. Mill,

Psychotic Uremia and its Mixed Fomu— E. Reiss, Zeit$chr. f. klin. Medidn,

Vol. LXXX, Nos. 5 and 6.

The psychotic type of uremia is characterized by conditions of
marked confusion, by illusions and hallucinations, and deep coma.
These conditions are often of a very transitory nature, disappear
and reappear, frequently a few times during the day. The affection
need not be accompanied by a pronounced disturbance of the ex-
ternal renal secretion. In two of author's cases typical sclerosis of
the cerebral arteries was found at the necropsy. The mixed types of
this form of uremia may present manifestations that occur in any
of the groups of uremia; often their manifestations are not
characteristic. In the asthenic type of uremia there is a more or
less complete obstruction of the renal passage, resulting in aug-
mentation of the retention nitrogen. In convulsive as well as in
psychotic uremia such renal disturbance cannot be demonstrated.
The substances giving rise to the latter types of uremia are not re-
tained in the body by reason of the diminished excretory ability of
the kidneys. Concerning the place of their production and their
nature we possess as yet no information. The psychotic form of
uremia is more or less connected with the sclerosis of the cerebral
arteries that has been demonstrated in many of the pertaining cases.
Still, the clinical picture of psychotic uremia is by no means identical
with that of sclerosis of the cerebral arteries and should be dif-
ferentiated from it. Western,
Lymphocyte Increase and Altitude— M. E. Stains and T. L. James, Arch.

Int. Med., Sept, 1914-

At an elevation of 6000 feet there is an increase of the larger
lymphocytes of at least 20 or 30 per cent, in both man and monkey.
The total white blood cells per cubic millimeter are approximately
the same at sea level and at an altitude of 6,000 feet, namely about
7500. The red corpuscles increase by 22 per cent, at an altitude of
6000 feet, Sachs,

Preliminary Stages of Diabetes — P. Bebgell, Deutsche med. Wochenschr.,

Dec. 17, 1914-

Author advances the following conclusions: The dissolving
property of the human urine for cupric hydrate — Cu(OH)2 — is not

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Prockess of Diagnosis and Prognosis 8i

caused by a small content of glucose. The reduction property of
normal urine is likewise not due to glucose nor to uric acid per se.
The urine of persons with normal carbohydrate metabolism, diluted
to a specific gravity of 1012, exhibits a slight copper dissolving
quali^ when small amounts of carbohydrates are ingested, and the
specific gravity of the urine does not exceed 1020, The copper dis-
solving propcTty of the urine is occasionally much augmented in
children. In relatives of diabetics it is increased in two-thirds of
the cases, A certain percentage of these cases, especially those with
the most pronounced reactions, should be looked upon as being in
the preliminary stages of diabetes. The copper dissolving property
of the urine seems to be dependent upon aldoses and ketoses that
possess a lower molecular weight than glucose. The increased cop-
per dissolving property disappears when the carbohydrates are
withdrawn. When more carbohydrates and glucose are ingested,
the reaction becomes stronger, and, in the preliminary stages of
diabetes, traces of glucose will make their appearance. Those with
a hereditary tendency of a marked copper dissolving quality of the
urine are to be treated like individuals with mild diabetes. Mill.
Rachitis and Internal Secretion— E. Romingeb, Zeitschr. f. Kinderheilkunde,

Vol. XI, Nos. 5 and 6, 1914.

Author approached the question whether or not it be possible to
demonstrate in rachitis a disturbance of the glands with an internal
secretion. For this purpose he employed the dialyzation method of
Abderhalden. As regards the thyroid, thymus, ovaries and testicles
he obtained absolutely negative results. Mill.

Basedow's Disease and Female Genital Ortans— E. v. GiArp and J. Novak,

Archiv f. Gynakologie. Vol CII, No. i.

Kesults of the examination of 36 women. Basedow's disease is
not rarely associated with anatomical and functional changes of the
genitals. There are cases, however, in which the genital area is not
at all affected by the presence of the disease. Genital changes may
ensue primarily, and may even in a measure compensate for Base-
dow's disease. However, genital disturbances may occur as a result
of an autochthonous Basedow's disease. Mill.

Thyroid Gland and Female Genitals— E. v. Gsapf, Archiv f. Gynakologie,

Vol CII, No. I.

Enlargement of the thyroid gland during pregnancy is mostly
due to the enlargement of an already existing struma. Among all
the cases there are only from 9 to 15 per cent, which have ensued
without a previously altered gland. Parturition causes frequently,
however not invariably, a further enlargement of the thyroid. This
is again reduced after parturition. Alimentary glycosuria is very

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82 The Archives of Diagnosis

much intensified in pregnant women with struma. This leaves no
doubt that the thyroid exerts a special influence in this regard. On
the other hand, albuminuria occurs more often when no enlarge-
ment of the gland has ensued. Ingestion of ovarian preparations
was without effect upon the thyroid gland. The assumption, ac-
cording to which struma and myoma are often associated, is an
erroneous one. Mill.

Cardiovascular Iniufficiencjr on Thrrotozic Basis— Sch mutt, Verein
deutsch. Aente, Prag, Miinchencr med. Wochenschr., Nov. 24, 1914.
Demonstration of a case of cardiovascular insufficiency on the
basis of a thyrotoxicosis. There existed a swelling of the upper
extremities, the chest, back, abdomen and thighs, ascites and bilat-
eral hydrothorax, and some edema of the calves. The right eyelid
was abnormally opened, and Graefe's symptom was distinctly posi-
tive. Other symptoms on the part of the sympathicus were not
present. The thyroid gland vras not enlarged. Five years ago
similar symptoms existed and the thyroid was enlarged. After 6
months these symptoms subsided. For the following 2j^ years
the condition was perfectly normal. Mill.

Acquired Diaeaie of the Tb3rroid— J. Rogers, Annals Surg., Sept., 1914.

Partial thyroidectomy is to be especially avoided in patients who
have not completed or who have just completed their growth and
development. Cases of symmetrically enlarged thyroids seem
peculiarly prone to relapse even after a considerable period. Opera-
tion is to be avoided in subjects of the very nervous type. Patients
with marked exophthalmus of long duration bear any operation
badly and can seldom be more than moderately improved. Of 62
patients who applied for relief after one or more partial thyroi-
dectomies, only the minority had failed to show any benefit, and a
considerable part of this minority stated that they were worse than
before the operation. Sachs.

INFECTIOUS DISEASES
Hereditary Syphilla— P. C. Jeans and E. M. Butler, Am. Jour, Dis. Child.,

Nov., 1914.

Authors found that 33 per cent, of the syphilitic children over
one year had permanent disabling damage. Eighteen per cent, of
such children had long-continued disabling damage. There is about
5 times as much feeble-mi ndedness in syphilitic families as in non-
syphilitic families. The mortality for artificially- fed syphilitic in-
fants, is five tinges as high as for breast fed syphilitic infants,
not including deaths due to intestinal disturbances. Sachs.

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Progress of Diagnosis and Prognosis 83

Coagenlttl Syphilis— L. Findley and M. E. Robektson, Glasgow Med. Jour.,

Dec, 191 4.

A condition of chronic eczema situated at the angles of the
mouth and invading the mucous membranes of the lips is often of a
syphilitic nature. Congenital heart disease is not infrequently found
in patients suffering with congenital syphilis, as is evidenced by a
positive Wassermann reaction. About 45 per cent, of cases of
spastic diplegia and 60 per cent, of mental defectives also seem to
be the subjects of congenital syphilis as is show.n by a positive
Wassermann reaction. Sachs.

, Klinik

Under the present conditions, the majority of cases of tubercu-
losis, date back to an infection in childhood. Such early acquired tu-
berculosis, if it is benign in nature, gives rise to a certain degree of
ininiunity which later explains the rather benign course of tubercu-
losis at a more advanced age'. The source of infection in tuber-
culosis without symptoms must be ascribed to tuberculous individ-
uals, frequently, however, the infection is caused by tuberculous
milk. Fry.

Pulmonary Pfathiiu of School Children— W. ChTBEND, Brit. Med. Jour.,

Dec 12, 1914.

The coexistence of an intermittent sudden cou^ in the absence
of cases of pertussis ; wasting, pallor, and tiredness ; a subfebrile
temperature, rising occasionally to 100 deg. F. ; the presence of
capillary veins and a growth of hair over the upper thoracic spines ;
and the absence of any obvious disease, should lead to a careful
examination of the case for pulmonary tuberculosis and enlarged
bronchial glands. Sachs.

— HoLiTScBER, Beitrage z. Klinik d. Tuberku-

Results of the study of 2720 pertaining cases of international
origin. The number of alcoholics among the young tuberculous is
decidedly less than would correspond to the average population.
On the other hand, among tlie tuberculous of more advanced age a
surprisingly large percentage of alcoholics is encountered. Fry.

Subnomial Temperature in Tuberculosis— A. K. Stone, Bost. Med. and

Surg. Jour.. Dec. 31, 1914.

In pulmonary' tuberculosis, usually succeeding the active febrile
stage, there is a period in which the temperature is subnormal, that
is, it does not rise above 98.6 degrees F. This period of subnormal
temperature may last for weeks. Author is of the opinion that the

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84 The Archives of Diagnosis

persistent subnormal temperature is an indication that the case is on
the whole progressing favorably. Sachs.

Tnbcrcnlous Rheumatiain and other FomM of Larved Taberciilou»—
E. NoHL, Beitrage z. Klinik d. Tuberfculose, Vol XXIX, No. 2.
Author mentions among the larved forms of tuberculosis, (i)
inactive-latent tuberculosis, which in the absence of clinical symp-
toms may be recognized by the employment of specific diagnostic
means; (2) active-latent tuberculosis, representing a genuine tuber-
culous affection of an organ, bat appearing under different symp-
toms; (3) tuberculous intoxication. Fby.

Von Pirquet Teit— T. Fkazbr, Med. Rec, Jan, 9, 1913.

A positive Von Pirquet reaction is less frequent in children than
it was once thought to be, the high percentage of reactions obtained
being due to the application of the test to. the infected children of
the poorer classes. Therefore a positive reaction is of greater signifi-
cance than it is commonly supposed to be. While there is an in-
creasing percentage of reactions with years, and a corresponding
decrease in the value of the reaction, the view usually held that the
reaction has significance only during the first two or three years of
life is not borne out by recent figures. We should be suspicious of a
reaction occurring up to the age of ten. A negative reaction, nega-
tive on repetition of the test, is valuable evidence of the absence of
tuberculosis, unless the child is suffering with advanced or acute
disease, especially measles. Sachs.

Eoiinophile Sputum CcUb, eapeciaUy in Tuberculons— Wendenburc,

Beitrage z. Klinik i. Tuberkulose. Vol. XXIX, No. I.

Local eosinophilia may be caused by a chronic inflammatory ir-
ritation which effects proliferation, transmigration and emigration
of the capillary endothelia of the vicinity. In chronic tuberculosis,
a peribronchioiytic inflammation induces a suppurative discharge in
the bronchial tubes without the presence of bacilli in the expectora-
tion. A suppurative sputum, the suppurative character of which
cannot be explained by the presence of specific microorganisms,
may with reasonable certainty be characterized as tuberculous when
the eosinophiles are present to the extent of 5 per cent, or more.

Fry.
Albumin Reaction of Sputum — E. G. Glover, Brit. Jour. Tuberculosis,

Oct., 19 1 4.

Author made 210 quantitative examinations for albumin. The
sputum of tuberculous patients contains on the average a laiger
amount of albumin than that of the non-tuberculous, but a larger
amount is sometimes found in the sputum of the non-tuberculous

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Pkogkess of Diagnosis and Prognosis 85

than in the tuberculous. Injury to the epithelium of any part o£
the respiratory or buccal tract may give rise to the presence o£
albumin in the sputum. This reaction is therefore, not of much
material assistance in the diagnosis of doubtful cases of pulmonary
tuberculosis. Sachs.

Albomin in the Sputum in Tuberculoua — C. H. Cocke, Am. Jour. Med.

Sci., Nor, 1914-

Author concludes that all cases of pulmonary tuberculosis show-
ing bacilli give a positive albumin reaction in the sputum. Fre-
quently albumin will be found in incipient tuberculosis before
bacilli are present, but its presence is variable and cannot be relied
upon as a definite means of diagnosis in incipient cases. The
heavier the albumin content, the greater the activity of the tuber-
culous process. Fibrosing or proliferating forms of tuberculosis
fail to show an albumin reaction in the sputum, also cases cured for
two years or more will not show it. When physical signs and the
tuberculin reaction fail to show activity, the presence of albumin
in the sputum may do so. Sachs,

AnenUa and Infection— H. Pubrau, Deutsches Archiv f. klin. Medizin,

Vol. CXVI, Nos. 5 and 6. -

Report of the case of a woman, 39 years old, who was affected
with genital hemorrhages for one year when a blood-picture re-
sembling that of myelotic leukemia developed. After an mtervening
pneumonic infection the blood-picture b«:aine soon normal again.

Western.
Pneumococcal TonuUitit— E. Leschkb, Munchener med. Wochenschr.,

Dec 39, 1914-

Among the various forms of tonsillitis, those caused by a pneu-
mococcal infection play a specific part. They are characterized
clinically by their stubborn persistence and marked disturbance of
the general health, which is the case even when the local condition
is seemingly very mild. Bacteriologically, this type of tonsillitis
presents the diplococcus lanceolatus as the predominating patho-
genic microorganism. The clinical picture of the affection is either
that of follicular tonsillitis with plugs or gray-yellowish to gray-
greenish exudate, or it is that of pneimiococcal influenza, or final^,
that of septic pneumococcal tonsillitis, respectively pneumococcemia.

Mill.
Complement-Kzation in Variola— A. Klbik, Munchener med. Wochenschr.,

Nov. 24, 1914.

There is no doubt that in the serum of smallpox patients anti-
bodies can be demonstrated by means of the complement-fixation
reaction. The complement-fixation test in variola differs from

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86 The Archives of Diagnosis

serum reaction in syphilis ; contrary to the latter it is specific, i, e.
there is a genuine antigen-antibody reaction in which in all proba-
bility the etiological factors of variola are themselves the antigen.
At the present time the only available antigen seems to be the
material from the small-pox pustules. AH other antigens are un-
reliable and should therefore not be employed. In order to obtain a
greater constancy of this antigen, author recommends the employ-
ment of pustule crusts. Mill.

Complement Fixation in Variola— A. v. Kohschbgc, Munchener med.
Wochenschr., Jan. 5. I9I5-
Author, who has experimentally approached the subject of com-

filement fixation in vanola, advances the following conclusions: (i)
n the serum of patients affected with variola specific antibodies
are present; {2) only such antigens effect complement deviation
which are undoubtedly the instigators of variola. Mill.

Staphylococcic Erysipelas— F. Reiche, Zentralblatt f. innere Medizin, 1914.

No. 44.

There are some cases of erysipelas which are caused by staphylo-
cocci. Author reports the clinical history of a case of erysipelas
which was typical in every respect, but in which the staphylococcus
albus alone was found. The onset of the infection ensued through
a superficial lesion on the bridge of the nose. The case terminated
iethally. In the heart blood the staphylococcus albus was also dem-
onstrated. In erysipelas due to staphylococcus infection, staphylo-
coccemia with very severe pyemic manifestations occurs frequently.

Western.
Simplification of the Diazo Reaction — H. Rhein, Feldarztliche Beilage,

Munchener med. Wochenachr., D«. 8, 1914.

The impossibility of having the reagents for the Ehrlich diazo
reaction always on hand, especially when treating soldiers in a field
hospital, prompted author to make use of Weiss' test. The latter
is based upon the same principle as the diazo reaction, i. e. the
oxidation of urochromogen. The test is performed as follows : The
urine in the test tube is diluted until it loses its color, ordinarily,
the addition of twice or three times its bulk of water suffices. From
3 to 10 drops of a solution of potassium permanganate (i:iooo)
are added to' the diluted urine. In case the reaction is positive, a
distinct gold-yellow coloration will ensue. When negative, either
no coloration at all will occur, or but a light brown hue will appear.
• — Author has employed this test in about roo cases of typhoid fever.
It always corresponded to Ehrlich's diazo reaction. In about 10
per cent, of the latter in which the color of the foam was not dis-
tinct, Weiss' test showed a positive diazo reaction. The method is

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Progress of Diagnosis and Prognosis 87

so simple that author uses it exclusively during daylight. In the
presence of artificial light Ehrlich's reaction is more distinct. A
further simplification of this test is the direct addition of a small
erain of potassium permanganate to the diluted urine. If the di-
luted urine is at once shaken after the permanganate has been
added, a positive reaction will immediately denote itself by a beauti-
ful gold-yellow coloration. In case the test is negative a brownish
suspension will ensue after a few seconds. Mill.

Simplification of Gruber't (Vndal's) Reaction— L. v. Liebebuann and

J. AcEL, Deutsche med. Wochenschr., Dec 10, 1914.

It is not necessary to prepare scrum from the blood or to place
this into bouillon or physiological sodium chlorid solution, and to re-
move the blood cells by centrifugation. The test may he materially
simplified by collecting the blood in distilled water (2 drops of
blood from the tip of the finger in i cc. distilled water), and, after
the immediately ensuing of complete hemolysis, to employ the
colored, clear blood solution for the agglutination test. Mill.

Tonicity of the Abdominal HusdeB in Enteric Fever— A. Patrick, Quart

Jour. Med. (London), Oct., 1914.

Author describes a condition of the abdominal muscles which was
first noted by Gardner, It is a slight superficial resistance over a
part or the whole of the anterior abdominal wall, with increased
superficial resistance in the right hypochondrium. It is recognized
by light pressure with fingers. When deeper pressure is made, the
resistance is overcome, and it is not recognized as long as this
pressure is kept up. When the fingers are run lightly over the
surface of the abdomen in these cases, the sensation resembles that
produced by running the fingers lightly over soft dough. It is
quite different from the deep resistance which is found in cases of
general peritonitis, where increase of pressure is met with by in-
crease of resistance. Sachs.

Autopaiea of Two Typhoid Carrier! — Gofsel, Zeitschr. f. Hygiene u. In-

fektionskrankheiten, Vol. LXXVIII, No. 3. 1914.

The necropsy of two chronic typhoid bacilli carriers showed
typhoid bacilli in the bile of both. The bacUli were also demon-
strated in gall-stones found in one of the cases. Mill,

DiaEDOsifl of Osteomyelitis— M. B. Cloftom, Surg., Gynecol, and Obstet.,

Jan., 1915.

Emphasis is laid on the fact that the earliest symptom of osteo-
myelitis is pain in the shaft of the long bone (usually near the
end), accompanying septic symptoms. In a few cases of profound
sepsis, the pain-sense is lost. Swelling of the shaft near the joint.

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88 The Archives of Diagnosis

frequently at the epiphyseal line, occurs early. In septic arthritis,
there is usually less pain and several joints arc involved. Tuber-
culosis is a chronic infection and involves the epiphysis. In the
later stage of acute osteomyelitis, the Rontgen ray is of great value.

Sachs.

RESPIRATORY AND CIRCULATORY ORGANS.
BpiiUxis in Later Childhood— H. Petry, Berliner klin. Wochenschr., Dec 7,

1914.

Local inspection of the nose is imperative whenever there ensues
epistaxis in children. This is also necessary when no fever is pres-
ent. Although in most of the instances nothing but a simple ul-
ceration of the septum will thus be revealed, occasionally a chronic
nasal diphtheria may be encountered. This is particularly the case
in the nursling. In sepsis and affections resembling it as well as
in all infectious diseases, the diagnosis "septic epistaxis" is not

Eermissible without a scrutinizing examination of the nose,
[emorrbage due to a simple ulcer of the septum may aggravate the
course of the disease and thus call forth the clinical picture of grave
septic infection. Mill.

Percuasioa of the Lungt— N. K. Wood, Med. Press (Lond.), Dec. 23, 1914.
The present methods of percussion are of little value, because,
far from having any universal standard of dulness, there is not in
most instances, even an individual standard. Upward percussion
is an absolute essential of correct work. The old method of down-
ward percussion should be discarded, and no longer taught to medi-
cal students. Wood adopts the following standard which he says is
definite and easily learned. This standard can be readily acquired
by the ear, and by the musical sense of both hands, measured by
the force of the plexor blow and the resistance under the plexi-
meter. Normal resonance is F to F sharp below middle C ; i-line
dulness or impaired resonance is A below middle C to middle C ;
2-line dulness or deiinite dulness is £ flat to F above middle C;
3-line dulness or very marked dulness is B flat below immediate
C; 4-line dulness or flatness is E to F above intermediate C.

Sachs.
Sjrphilis of the Lungs— E. A. Burrham, Boston Med. and Surg. Jour.,
Sept. 10, 1914.

In its early stages, syphilis produces pulmonary conditions like
bronchitis and bronchopneumonia, but it most frequently affects the
lungs in the tertiary stage, when its lesions produce physical signs
which are identical with those of pulmonary tuberculosis. The
patient with pulmonary syphilis does not appear to be so ill as one

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Progress of Diagnosis and Prognosis 89

with a tuberculous infection of the same extent. Hemoptysis i&
more frequent in tuberculosis, the temperature curve is more vari-
able than in syphilis, while the latter condition does not produce so
rapid a loss of flesh and strength. The absence of bacilli in the
sputum together with the presence of any of the stigmata of
syphilis, and es[)ecially with a positive Wassermann reaction should
make a diagnosis certain. Sachs.

Cues of Lime Abtceu— C L. Scudder, Bost. Med. and Surg. Jour., Oct. I,
1914.
Lung abscess may follow an embolism after an ordinary surgicat

X ration. Sudden severe pain in the chest, associated with a rise
temperature and pulmonary signs following surgical operations-
should suggest the possible beginning of a lung abscess. Manjr
intraabdominal infections are associated directly with an infection
through the diaphragm of the diaphragmatic pleura, and then of
the lung with lung abscess. The Rontgen ray is of great value ia
the diagnosis of this condition. Sachs.

Primaiy New Orowths of the Hediastmum— J. N. W. Ross, Edinburgh

Med. Joar., Dec, 1914-

Malignant disease of the mediastinum is not so rare as is generally-
supposed, whereas innocent tumors of the mediastinum are ex-
ceedingly rare in England. It is essentially a disease of early
middle life, but it may occur at any age. It seems to be increasing;
in frequency. The disease is twice as common in males as in fe-
males. A definite tuberculous history is often present in these cases.
The anterior mediastinum is the common seat of origin and lympho-
sarcoma is the commonest form of malignant disease. Carcinoma
of the mediastinum is more frequent in females than in males.
The lungs are practically always affected sooner or later, and
pulmonary symptoms are generally present. Extra-thoracic me-
tastases occur frequently. Hemoptysis though moderately common
is rarely severe. A pleural effusion is often present and it is fre-
quently hemorrhagic, but a hemorrhagic effusion is not pathogno-
monic of malignant disease of the mediastinum. Sachs.
Normal Peculiarities of Heart Sounds in the Region of the Stemimi —

G. Bluues, Arch. Int. Med., Oct., 1914-

Author describes the normal cardiac sound underneath the ster-
num as a superficial scratching sound. It occurs at all ages after
infancy. It is heard throughout both systole and diastole and is
of brief duration. The sound appears to be superficial, strongly
suggests a friction rub, but does not resemble an endocardial mur-
mur. It is uninfluenced by respiration. It is usually heard best at
the lower end of the sternum opposite the flfth and sixth costal

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90 The Archives of Diagnosis

cartilage, a little to the left of the medium line. This sound is a
physiological phenomenon, and the author is confident that it will be
an occasional source of error. Sachs.'

Secondarr Sounds over the Aorta— KClbs, Zeitschr. f. klin. Mediiin, Vol

LXXX, Nos. s and 6.

Report of 31 observations of systolic sounds which were localized
in the second intercostal space. The character of these sounds
was uneven, scraping and rough. In 12 instances accentuation of
the second aortic sound and extension of the aorta in the Rontgen
shadow were found ; enlargement of the heart toward the left was
demonstrated in 17 cases. Blood pressure was above 160 mm, Hg.
in 7 cases, between 140 and 160 mm. Hg, in 13 cases, and below
140 mm, Hg. in 11 cases. Subjective symptoms occurred in but
10 cases; in 5 cases angina pectoris was present. In 16 cases the
sounds were of an adventitious secondary nature, and were met
with in a purely accidental manner. Polyarthritis and syphilis could
be excluded in 17 of the cases, Artherosclerosis plays probably
the principal part in the production of these secondary sounds. Ac-
cording to the clinical manifestations, a typical stenosis of the aorta
did not exist in any of these cases. The sound is always more or
less adventitious and must be caused by a roughened aortic wall
or by changes of tension in the vessel. Western.

Blood and Pulie PreMore in Arterioscleroda— W, Janowski, Zeitschr. f.

Win. Mediiin, Vol, LXXX, Nos. 5 and 6,

In 24 out of 200 cases of arteriosclerosis the blood pressure was
increased. In 88 cases the blood pressure varied between 120 and
160 mm, Hg., in 51 cases between 180 and 200 mm. Hg. ; in 6
cases the pressure was above 200 mm. Hg. Of 62 sclerotics who
had survived myocardiac decompensation, 42 exhibited normal
blood pressure; only 4 had a pressure between 140 and 160 mm.
Hg. The low pressure is caused by the far-advanced heart affec-
tion. Pulse pressure of 2i of 42 patients thus affected was between
30 and 40 mm. Hg. Of 18 patients with increased blood pressure
who had had cardiac decompensation, but 3 presented a lower pulse
pressure than 60 mm. Hg. In 50 cases of arteriosclerosis with
renal involvement myocarditis existed positively in 4 cases. In
these the blood pressure varied between 128 and 144 mm, Hg., the
pulse pressure between 48 and go mm. Hg. In the other cases the
blood pressure was considerably increased, in 29 above 180 mm, Hg.
The pulse pressure in 75 per* cent, of patients of this group was
between 70 and 135 mm.Hg. The cases of arteriosclerosis associ-
ated with nephritis showed the highest blood pressure. In 7 cases
of acute nephritis the blood pressure was between 130 and 185 mm.
Hg. In 16 cases of chronic nephritis the blood pressure and pulse
pressure were normal; in 84 they were increased. Western.

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Progress of Diagnosis and Prognosis 91

Electro-Cardiograpb;— J. F. H. Daily, West London Med. Jour., Oct., 1914.
Author is of the opinion that one of the chief fields of utility of
the electro-cardiograph in practice is the ease with which one can
pick out and classify the functional disorders which are oft-times
a source of such great discomfort to the patient, and thus we are
able to state with much greater confidence an opinion as to pr(^-
nosis. Many of the hearts condemned in former years because of
symptoms which cause anxiety and pain, when treated as a result
of the knowledge gained from this and other modem cardiac re-
search, will prove to have still many years of useful activity.

Sachs.
Heart-Block in Acute Rheumatic Carditis— A. E. Naish and A. M. Ken-
nedy, Lancet, Nov. 28, 1914.

Two cases of acute rheumatic carditis in children are reported by
authors in which heart-block occurred. Both cases were associated
with similar histological changes in the cardiac musculature.

Sachs.
PnltoB Paradoxui — A. W. Falconer and J. M. McQueen, Quart. Jour. Med.
(London), Oct., 1914.

Authors State that in addition to the ordinary sinus arrhythmia, at
least two entirely different conditions have been included under the
term pulsus paradoxus : ( i ) Cases presenting complete obliteration
of the pulse during deep inspiration, and due in their opinion to
oval deformation of the subclavian artery in the subclavian triangle;
(2) Cases occurring in a great variety of conditions, in which the
one common factor is an embarrassment of the circulation, and in
which the normal inspiratory diminution of the blood pressure is a
sufficient explanation. Sachs.

Production of Gallop-Rhythm— M. Gubergbitz, Deutsches Archiv f. klin.

Mediiin. Vol. CXVI, Noa. 5 and 6.

Gallop-rhythm is observed in various forms of myocardial weak-
ness, especially in interstitial nephritis and in certain infectious
diseases. It is mostly associated with hypertension. When gallop-
rhythm is associated with low blood pressure, the prognosis is less
favorable. The mechanism of the production of the various forms
of gallop-rhythm (presystolic and protodiastolic gallop) is an en-
tirely different one as is evinced by the electrocardiogram.

Western.
Clinical Symptoms of BeEinning Cardiac Weakness— Moritz, Munchener

med. Wochensehr., Jan. 5, 191S.

A clinically important form of dyspnea is the nocturnal cardiac
asthma. The patients may be troubled for a long period, occa-
sionally almost every night, with transitory dyspnea which rouse

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92 The Archives of Diagnosis

them out of sleep and compel tbem to sit up. During the day no
especially marked dtfUculties may arise. It is even possible that the
patient is able to take a comparatively long walk. Frequently the
nightly attacks of dyspnea and oppression are associated with a
good deal of irritation to cough. This cough may once in a while
remove a somewhat tenaceous sputum. As soon as this expectora-
tion has taken place the patient will breathe easier. Such cases
may be mistaken for instances of bronchial asthma. It is rather
suspicious when during a nocturnal cough seizure an abundant,
thin and foamy expectoration is eliminated. When this is the case,
then one is most always confronted with a mild attack of pulmonary
edema. A form of cardiac asthma that is by no means rare is the
frightened startling with a sense of oppression at the moment of
falling asleep. The patient, though extremely sleepy, may be kept
from falling asleep by this phenomenon, which is apt to recur fre-
quently. These -nocturnal symptoms occur comparatively often in
patients with high blood pressure. Many of these, as is well known,
have contracted kidney. During the day, the pulse, as far as fulness
and frequency are concerned, may be within normal limits.

Mill,
Symptomatologr of Abdominal Angina— M. J. Breiikann, Zentralblatt f.

innere Uedizin, 1914, No. 46.

Abdominal angina is caused by sclerosis of the abdominal blood
vessels or by vascular spasm. It has the same etiology as athero-
sclerosis in general. Among the sjonptoms are, painful meteorism
due to intestinal paresis; pains, often very violent in character;
epigastric pulsation ; pallor ; vertigo ; syncope, and pressure sensi-
tiveness of the aorta. The symptoms occur periodically. The
diagnosis must necessarily exclude other diseases of the abdominal
organs. The prognosis is unfavorable, as a general rule, as the
symptoms are often an expression of the beginning of the end.

Western.

ALIMENTARY TRACT
Frognoaia in Cancer of the Tongue— W. Trotter, Lancet. Oct. 24, 1914.

A favorable prognosis as to the danger of an operation for cancer
of the tongue can always be given in cases of edentulous patients.
If a man develops cancer of the mouth or pharynx, the posses*
sion of natural teeth is a misfortune almost as great as the ma-
lignant disease itself. The precocious development of early diffuse
invasion seems particularly liable to occur in strong, healthy, well-
nourished subjects of florid appearance and comparative early age.
A glandular enlargement in which the glands are ill-defined and
rather soft so that they are not always distinctly palpable offer a
very bad prognosis. Sachs,

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PSOGKESS OF DlaGNOSIS AND pKOGNOSIS 93

Esophagids Disiecans Supcrficialis — E. Koechlim, Korrespondeniblatt f.

Schweizer Aerite, No. 35, 1914.

The patient was a woman, 35 years old. She was affected with
the rare disease described as esophagitis dissecans superiicialis. The
woman recovered after vomiting membranes of which one was 25
cm. long. Mill.

Volatile Fatty Acida in Fresh and SpoUed . Hilk, and the PathogeneBis of
Digestive Distttrbances in the NuTBling— H. Bahrdt and F. Edelstein,
Zeitscbr. f. Kinderheilkunde, Vol. XI. Nos. 5 and 6, 1914.
Author made some experiments with fresh milk which was kept
at room temperature for 2 days and with milk that had been im-
pregnated with pure cultures of various bacteria and had also been
left standing for some time. In neither of the specimens of milk
could an amount of volatile fatty acids be demonstrated that was
sufhciently large to give cause to digestive disturbances, especially
to summer diarrheas. Mill.

Psycbosenous Anomalies of the Gastric Secretion in Childhood—

W. Weoekee, Archiv f. Kinderheilkunde, Vol. LXIII, Nos. 5 and 6.

Among 80 children with disturbances of the stomach, 19 pre-
sented pathological composition of the gastric juice, that is, 2 had
hyperacidity and 17 pronounced anachlorhydrJa. Such disturbances
occur comparatively frequently in older children. A neuropathic
constitution ts most always underlying such secretory anomalies.
The children affected with these secretory disturbances are mostly
more or less undernourished, are pale and exhibit some degree of
vasomotor paresis ; their conjunctival and tracheal reflexes are
either missing or markedly diminished ; the deep reflexes are in-
creased and there is a mechanical overexcitability of the peripheral
nerves and positive Rosenbach phenomenon. Occasionally a rela-
tionship with the exudative diathesis seems to exist. The prognosis
of these nervous disturbances in childhood is favorable.

Mill.
Gastrosenous Diarrheas and the Occurrence of Achylia PancreaUca in

Achjrlia Gastrica— A. BrTTow, Deutsche med. Wochenschr., Nov. 5, IQ14.

Severe creatorrhea and mild steatorrhea ensue frequently in
diarrheas due to achylia gastrica. The amount of trypsin in the
stools and the stomach is nevertheless normal in many of these
cases. The abnormal state of the feces does not prove the presence
of a functional achylia pancreatica. The latter ensues infrequently ;
the diminution of trypsin in achylia occurs somewhat oftener. The
unequal utilization of the ingesta in achylia is the consequence of
increased peristalsis and insufficient gastric digestion. The examina-
tion by means of the Rontgen rays showed in these diarrheas a

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94 The Archives of Diagnosis

moderately increased evacuation of the stomach and small intestine,
and more rapid emptying of the colon. The latter phenomenon is
frequently the result of a catarrhal condition that has ensued on the
basis of a chemical or bacterial alteration. Mill.

Perforated Gastric Ulcer— A CoUectiTe Report, Edinburgh Med. Jour.,

Dec, 1914.

In the vast majority of cases the patient suffered with indigestion
of a severe type for a long period before perforation occurred.
Hematemesis was much more common in women than in men. No
information could be elicited in the records of gastric perforations
to indicate that the occurrence of perforation is heralded by any
characteristic symptoms. In severe cases, the indigestion baa been
distinctly worse than usual for some days before. In practically
every case the initial symptom was agonizing pain in the epigas-
trium coming on with great suddenness and seventy. In the great
majority of cases the pain was situated in the epigastrium and, as
a rule, towards the left of the middle line. Vomiting is a much
more common symptom in perforation of the stomach than in
duodenal perforation. In most cases the main tenderness was over
the epigastric and left hypochondriac regions, and this was found
to correspond fairly accurately with the site of the perforation.
By the time the patient comes under observation, general muscular
rigidity is as a rule present. Diminution or loss of liver dulness
was recognized in 127 of the 175 cases in which it was noted.

Sachs.

Acute Gastric and Duodenal Perforating Ulcer — F. Fee, Lancet-Clinic, Jan.

16, 1915,

Acute gastric and duodenal ulcer must be differentiated in the
early stages from acute thoracic lesions, but no great difficulty
should exist here if we remember to make a complete physical ex-
amination of the patient, when pleurisy or pneumonia will be re-
vealed by the usual signs. Perforation of the gall-bladder is one of
the most difficult conditions to differentiate, for the symptoms and
signs may be almost identical. In such cases one must rely upon
the previous history. Acute pancreatitis in a patient with a very
thick abdominal wall may present many difficulties in differential
diagnosis. In the?e cases the pain is of a different character, and
is not limited to the right side as in duodenal perforation. Vomit-
ing is more frequent. The pulse in early perforation is not in-
creased in frequency, but is weak, rapid and thready in acute pan-
creatitis. In ordinary cases the swollen gland can be easily palpated.
The characteristic rapid, jerky respiration also is absent in acute
pancreatitis. Sachs,

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Progress of Diagnosis and Prognosis 95

B<Ma>Oppler Bacilln*— H. M. Gault and C. C. lus, Jour. Path, and BacL

(London), Oct, 1914.

A comparison of the Boas-Oppler bacillus with the Bacillus
Bulgaricus tends to prove that it is identical with the latter organism
and not an organism sui generis. Authors believe that in cases of
cancer of the stomach it is the absence of hydrochloric acid that
allows of the growth of the organism, and that the lactic acid is
formed as a result of the activity of this bacillus. Sachs.

Duodenal Ulcen in Infancy— B. S. Veedeb, Am. Jour. Med. Sci., Nov., 1914.

Author reports 5 cases of duodenal ulcer in infants. In 4 of the
cases a clinical diagnosis was made which was later confirmed in
3 instances at autopsy, and in one case the lesion was found post-
mortem. In the fourth case the infant recovered. All the infants
were under 6 months of age and marasmic. In none of the cases
had there been an acute gastrointestinal disturbance. Vomiting was
present in all the cases. The presence of gross hemorrhage from
the bowel is the only definite symptom pointing to a duodenal
ulcer, and hence when this symptom, which may be looked upon as
a complication, is absent, the diagnosis cannot be made. It is
necessary to exclude ulcerative lesions of the lower intestine, anal
fissure, etc. Sachs.

DTsenteiy-like Affectiont of th« Bowels— E. Leschke, Deutsche med.

Wochenschr., Dec 3, 1914,

Observations in 8 cases (soldiers). There are intestinal affec-
tions with bloody and slimy discharges which exactly resemble
genuine bacillary dysentery, but which, etiologically, differ very
much from it. They are caused by other enterogenous infections
or by parasites, or by enterogenous intoxications ; they may also be
due to parenteral infections, as through the tonsils, or to mechanical
damage of the intestinal wall. Anaphylactic enteritis may also
resemble dysentery. Mill.

losoSciencjr of the Ileocecal Valve in the RSntgen Picture— £. Marcusb,

Berliner klin, Wochenschr., Dec. 21, 1914.

The insufficiency of the ileocecal valve as determined by the
rontgenogram is an interesting incidental discovery which does not
permit of any diagnostic conclusions. Mill.

Acute Appendicitis and Acute Appendicular Obstruction— D. P. D. Wu.kie,

Brit. Med. Jour., Dec. s, iQM-

Two acute pathological processes are met with in the vermiform
appendix, t. e., acute appendicitis and acute appendicular obstruc-
tion. Clinically, acute appendicitis is distinguished by the signs
of inflammation, there being from the onset a rise in temperature

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96 The Archives of Diagnosis

and pulse. Acute appendicular obstruction gives rise to vomiting,
colicky pain and abdominal tenderness, but at the onset to no ap-
preciable rise in pulse or temperature. The change occurring in
an appendix, the lumen of which is completely obstructed, depends
on the presence or absence of fecal matter within its lumen.

Sachs.
Pruritis Ani— L. E. C. Norcbuky, Practitioner (London), Nov., 1914.

A thorough investigation of the rectum and pelvic colon by means
of the sigmoidoscope should be carried out in every case of pruritus
ani in which an external examination or an examination of the
anal canal does not reveal a satisfactory cause. Pruritus ani may
be caused by an irritating discharge from simple or malignant
growths in the bowel, from certain forms of colitis or proctitis;
granular proctitis or the hypertrophic catarrhal variety. Sachs.

FJbrinolyus in Clirotuc Hepatic Insoffiden;— E. W. Goodpastuke, Johns
Hopkins Hospital Bull., Nov., 1914.

Specimens of blood from 4 cases of atrophic hM)atic cirrhosis
have possessed the property of completely digesting their clot with-
in a few hours, at body temperature. Normal blood will not digest
its clot for days or weeks. Dissolution of clot in the blood of cirr-
hosis cases is due to an enzyme. Its activity is destroyed by heat;
inhibited by normal serum ; and diminished in old plasma. Fibrino-
gen content of the blood of each case has been below normal. Hydre-
mia was a constant feature. One case exhibited a low phenolte-
trachlorphthalein output. Digestion of clots in vivo explains in part
the hemmorrhagic tendency present in these patients. Western.

Hepatic Functional Tests (Galactose and Phenoltetrachlorphthalein)—

W. R. SiESoN, Arch. Int. Med., Dee. 15, 1914.

Forty grams of galactose are given by mouth at 6 A. M. in 200
or 300 c.c. of tea. The usual breakfast is given one hour later.
The urine is collected for a period of 6 hours after the ingestion of
the galactose, at 2 hour intervals, and tested for sugar. In the
majority of cases of normal individuals, less than one gram is ex-
creted. Patients with icterus catarrhalis have an intolerance to
galactose. The galactose test may be used in differentiating icterus
catarrhalis from other hepatic conditions showing biliary stasis. It
is rarely positive in cases of cirrhosis of the liver showing no evi-
dence of biliary stasis. Phenoltetrachlorphthalein when given sub-
cutaneously to a patient escapes only in the bile and the feces are
tested for it. The normal output is about 35 per cent. Further
studies must be undertaken before any definite conclusions can be
drawn concerning the value of this test. It offers a means of
diagnosing certain cases of cirrhosis of the hver and of neoplasms

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PfiOGREss OF Diagnosis and Prognosis 97

of this origin. (See Archives of Diagnosis, Vol. VI, p. 394, and
Vol. VII, p. 193.) Sachs.

Ultimate Reaulta in 160 Gall-Stone Cbbm— J. G. Clark, Am. Jour. Med.

Sd., Nov., 1914.

The worst results occur among the combined cases in which there
are manifest symptoms due to biliary changes. The ratio of cures
is in direct proportion to the severity of the symptoms. The weight
of evidence most emphatically favors the early removal of gall-
stones whether they produce symptoms or not. Sachs.

NERVOUS SYSTEM

Lange Gold Chlorid Reaction— C. G. Grulee and A. M. Moomr, Am. Jour.

Dis. Child.. Jan., 1915.

In the cases of congenital syphilis included in this report, the
cerebrospinal fluid reacted to the colloidal gold solution always
in lower dilutions, and with a marked degree of regularity,
strongest in the dilutions of 1 140 and 1 :8o. There is a small group
of cases of congenital syphilis in which the reaction is similar to
that of paretic dementia. The reaction as obtained in congenital
syphilis is most nearly approached by those conditions which show
a slight inflammation of the meninges or brain, and are not likely to
be confused clinically with syphihs. The reaction in tuberculous
meningitis is found to be most intense in the dilutions of i :i6o and
1 :32o. It is evident that the Lange gold chlorid reaction is of
value only as an aid in diagnosis. Sachs.

Chronic Subdural Hemorrhage of Traumatic Origin— W. Trottes, BriL

Jour. Surg., Oct., 1914.

Internal hemorrhagic pachymeningitis is a term which should be
discarded in favor of some such term as chronic subdural hemor-
rhage. Apart from certain cases occuring in diseases which have
a strong tendency to spontaneous hemorrhage, and possibly in-
cluding them, hemorrhagic pachymeningitis is almost if not quite
invariably a true traumatic hemorrhage coming from veins in
their course between the brain and dural sinus. This condition
should be dealt with surgically, with the expectation of a successful
immediate and remote result, if the treatment is carried out early.
It constitutes a clinical type of disease well marked and characteris-
tic. Sachs.
'Qlycyl-TTyptophan Reaction in Henin^ti>— R. H. Major and E. Noble, .

Arch. Int Med., Sept, 1914.

The glycyl-tryptophan test is a valuable addition to our diagnostic
measures in meningitis. Meningitis is consistently present in cases
in which the peptolytic index is higher than one. Sachs.

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The AncHnfES of Diagnosis

I in DiphtherU— F. Reicre, Zeitschr. f. Kinderheilkunde, Nos. $

and 6, 1914.

The association of diphtheria with meningitis of most varying
bacterial origin is very rare. In 8000 cases of diphtheria the com-
bination ensued but 8 times. The cases which recovered presented
the clinical picture of serious meningitis. Mill.

New Pbydcal Sign in Lumbar Leuoni— L. W. Ely, Am. Jour. Orthop.

Surg., Oct., 1914.

When lesions, either traumatic or inflammatory, of the lumbar
spine are present, author states that if the patient be laid on his
face and his knee flexed, his pelvis on the side of the lesion will
rise from the table. By means of this sign lumbar lesions may be
differentiated from those of the sacroiliac joint. Sachs.

Nervous CretiniBm— R. McCauuson, Brit Jour. Children's Dis., Dec., 1914.
Author is well aware of the objections to the use of the term
"nervous cretinism," but in so distinguishing these cases by a dis-
tinctive title, he hopes to focus attention on a condition which de-
pends on congenital hypothyroidism. The symptoms are, in brief,
a combination of congenital myxedema with congenital cerebral
diplegia, in all their varying grades. The signs of derangement of
the central nervous system may vary from the slightest degrees of
paraplegia to the most intense grades of spasticity, athetosis, fits,
and idiocy. Such extreme examples of this type of cretinism may
be indistinguishable from cases of cerebral diplagia, and it is only
by the recognition of the scanty myxedematous signs of the malady,
and by the application of the therapeutic test of thyroid medication
that their true nature can be appreciated. Sachs.

Analysis of a Case of Psycbastfaenia— H. Flournov, Johns Hopkins Hos-
pital Bull.. Nov.. 191 4.

Report of a case of psychasthenia with the following striking
points: The sudden onset of an obsessive fear that the patient
would kill his child, then that he would kill himself, against which
the patient fought in vain for 7 months. The disappearance of the
obsession as soon as the patient saw that it could be connected with
previous difficulties. The persistence of an uneasy feeling towards
the children, without fear, arising at times when the patient is de-
pressed or crossed. The whole trouble is closely related to a sus-
picious state of mind, a fact which the patient had to realize. His
prospect of avoiding a relapse of the obsessive fears depends greatly
on the extent to which he will be able to assume a new mental
attitude towards his wife. (The case report should be studied in the
original.) Western.

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Progress of Diagnosis and Prognosis gg

Status Ljmphaticus in Dementia Prucox — H. Euerson, Arch. Int. Med.,

Dec, 1914-

Status lymphaticus in males is characterized by decided scantiness
of the hair on chin and upper Up, scanty axillary and sternal hair,
scanty or feminine distribution of pubic hair, a slender thorax,
rounded contour of upper arms and thighs, with an arching of the'
latter, hypoplastic external genitals, particularly if associated with
cryptorchidism • and a delicate velvety skin. The diagnosis is
further confirmed if we find hyperplasia of the l3rmph tissue of
nose, throat, and tongue and an -increase in the palpable cervical
and axillary lymph nodes. The incidence of status lymphaticus in
cases of acute alienation in the first three decades is higher than
among alcoholics and narcotic drug habitues, in whom there is an
incidence of 22 per cent. Sachs.

EpUepar and Cerebral Tumor— W. A. Tusneb, Brit Med. Jour., Dec. 5, 1914.

Tumors involving the cortex and subcortical white matter of a
cerebral hemisphere may give rise to seizures having features
characteristic of idiopathic epilepsy. These attacks may precede
the onset of the symptoms and signs of intracranial tumor by many
years and render the diagnosis of the true cause of the attack well-
nigh impossible. The existence of certain signs, however, favors the
presence of an organic lesion ; such are a well-defined local warning,
the presence of some degree of post-convulsive hemiplegia, ine-
quality of the deep reflexes on the two sides, unilateral abolition or
impairment of the abdominal reflexes, and above all the develop-
ment of an extensor plantar response. It is, therefore, important in
all cases of epilepsy to examine the reflexes, and the optic discs
from time to time. Sachs.

URINARY ORGANS— MALE GENITALIA
Seminal VeoicoUtii— B. A. Thouas and H. K. Pancoast, Annals Surg.,

Sept., 191 4.

Seminal vesiculitis is more prevalent than it is supposed to be.
It has a manifold symptomatology, often expressing itself remote
from the urinary tract. The disease is analogous to pustubes in the
female. Sachs.

FEMALE ORGANS OF GENERATION— PREGNANCY-
PARTURITION— I NFANTS
Experimental Research concemins Renal Changes in Pregtiancy— J. and

5. BoNDi, Archiv t. Gynakologie, Vol. CII, No. i.

The kidney of the pregnant animal is more sensitive to poisons
than that of the non-pregnant. Epithelial poisons like uranitmi

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100 The Archives of Diagnosis

and chromium show especially marked alterations, while arsenic
and cantharidin, causing vascular poisoning, give rise to but slight
changes. The sensitiveness of the kidney of the gravid animal
seems, therefore, to be limited to the epithelium of the urinary
tubules, and especially to the convoluted tubules. Mill,

The Kidneya and Heart in Pregnancy— V. J. McAluster, Med. Press

(London), Nov. 25, 1914.

Heart lesions or kidney lesions complicating pregnancy seldom
prove fatal. Occurring together, their association with pregnancy
IS usually extremely serious in its consequences. Pregnancy deter-
mines an increased cardiac activity and the heart slowly hyper-
trophies to withstand the sudden strain of parturition. Experience
shows that the gravest cardiac lesions in this connection are those
affecting the cardiac musculature. Where the kidneys are diseased,
the behavior of the blood pressure is of great importance. An
elevated blood pressure increases greatly the work of the heart.

Sachs.
Backache— C Ogiltib, N. Y. Med. Jour., Dec 5, 1914-

Backache is often caused by a postural deformity which pro-
duces a muscular strain. Weak feet are a frequent cause of this
postural deformity. Sacroiliac joint strain is dso responsible for
a number of cases. Myalgia is often of an infectious origin.

Sachs.

THE EDITOR HAS RECEIVED A NUMBER OP RECENT PUBLICATIONS
WHICH WILL BE REVIEWED, AS FAR AS SPACE PEBMITS, IN THE
APRIL ISSUE OF THE ARCHIVES OF DIAGNOSIS.

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THE

ARCHIVES OF DIAGNOSIS

A QUARTERLY JOURNAL DEVOTED TO THE STUDY
AND THE PROGRESS OF DIAGNOSIS AND PROGNOSIS

APRIL, 1915

FOUNDBD AND EDITED BY

HEINRICH STERN, M.D., LL.D.
Hiw York

PUBLIIHKD BT

REBMAN COMPANY

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Archives of Diagnosis

A QUARTERLY JOURNAL DEVOTED TO THE STUDV
AND THE PROGRESS OF DIAGNOSIS AND PROGNOSIS

i^petial Ztrticletf

THE PATHOLOGY AND DIAGNOSIS OF SO-CALLED
DIABETIC GANGRENE
By LEO BUERGER
Associate Attending Surgeon and Associate in Surgical Pathology, Mt. Sinai
Hospital; Visiting Surgeon, Har Moriah Hospital; Instructor in
Qinical Surgery, Columbia University
New York
The widespread impression that the vasomotor affections of the
extremities are related in some way It) the gangrene of organic vas-
cular disease, has convinced us that neither the pathological nor the
clinical aspect of these maladies is clparly understood. In an ex-
tensive pathological investigation of the vascular lesions in forty-
iive amputated lower extremities taken from cases of thrombo-
angiitis obliterans,* and of some thirty amputated lower extremi-
ties obtained from cases of arteriosclerotic and diabetic gangrene,
a large number of pathologic data were acquired which have en-
abled us to crystallize and classify our conceptions as to the lesions
that attend the different types of gangrene of the extremities. In
our series, there was also material obtained from the upper ex-
tremities, including an arm amputated for thrombo-angiitis ob-
literans, and several fingers ; and besides this, two gangrenous limbs
•Studies made in the Department of Surgical Pathology, Mt Sinai Hospital.

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102 The Archives of Diagkosis

in which it could be clearly demonstrated that gangrene can occur
without any organic arterial disease.

The chnical material at our disposal was still larger, including
some two hundred and fifty cases of thrombo-angiitis obliterans and
many cases of gangrene of the neurogenic or vasomotor type (Ray-
naud's disease, chronic acro-asphyxia, etc.), cases of atherosclerotic,
so-called diabetic gangrene, and thrombotic and embolic gangrene
due to other causes.

Both our pathological and clinical material, therefore, was ade-
quate to allow us to come to very definite conclusions regarding the
arterial changes that lead to so-called diabetic gangrene. Current
conceptions are so hazy as to the causation of diabetic gangrene,
that it may not be amiss to give here a brief outline of the pathologi-
cal lesions that have been found responsible for this condition. We
may anticipate by saying that diabetic gangrene is, in truth, a
process of mortification directly referable to extensive arterial dis-
ease, the arteries of the affected extremities being intensely athero-
sclerotic, often occluded over a large part of their course, usually by
obturating atheromatous and calcific masses, less commonly by vir-
tue of secondary thrombosis.

For an elucidation of the pathology and diagnosis of diabetic gan-
grene, we will give a brief summary of the usual lesions encountered
in the vessels in these cases, will compare them with the lesions of
arteriosclerotic or senile gangrene, and finally give a resume of the
pathology of the vessels in thrombo-angiitis obliterans, since this is
the largest class of cases which may offer difficulties in diagnosis.
As for the clinical diagnosis, this shall be discussed by giving a sum-
mary of some of the more important clinical types of diabetic gan-
grene, and by differentiating these from thrombo-angiitis obliterans,
embolic and thrombotic gangrene, arteriosclerotic gangrene, and gan-
grene due to vasomotor disturbances.

For purposes of differential diagnosis, we have found the follow-
ing classification of the vasomotor and trophic disturbances of the
lower extremities of particular value. We distinguish trophic dis-
turbances and gangrene according to whether the vessels of the af-
fected region show no organic abnormalities, or as to whether dis-
tinct, degenerative, inflammatory or occlusive lesions occur. Thus,
we have, first, a neurogenic variety including Raynaud's disease.

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Buerger: Diagnosis of So-Called Diabetic Gangrene 103

scleroderma, multiple circumscribed gangrene, erythromelalgia, scle-
rodactyly and acro-asphyxia or acre-cyanosis ; and, second the group
in which the arteries show organic lesions either thrombo-angiitis
obliterans, arteriosclerosis, and rare lesions of endarteritis and em-
bolic or thrombotic occlusion.

THE PATHOLOGY OF SO-CALLED DIABETIC GANGRENE

A Study of the condition of the arteries and veins in limbs ampu-
tated for so-called diabetic gangrene, reveals the fact that in each
and every instance we are dealing, not with a gangrenous process
due to the diabetes per se, but a mortifying process dependent upon
extensive arterial disease. If we dissect out the larger vessels, in-
cluding the femoral, popliteal, posterior tibial, peroneal, anterior
tibial and plantars with their larger branches, we soon learn this
fact, that there is an extensive and intense athero- or arteriosclero-
tic process. In some cases there is marked occlusion due to the
heaping up of atheromatous and calcific material, or to a combina-
tion of this process and secondary thrombosis, or a moderate degree
of atherosclerosis with obturating thrombosis. These cases may be
grouped under the caption "intense, obturating, atherosclerotic pro-
cess." In another series of cases, we find tliat, although very few
of the vessels are completely closed, the atherosclerotic process is
very extensive and intense, making the vascular walls rigid, or pro-
ducing a dilatation or pouching of the walls of many vessels. Both
of these lesions will have as their sequence impaired nutrition of
the parts, by virtue of the loss of elasticity in the arterial walls.
This type may be grouped under the caption "atherosclerosis with
slight or no occlusion."

Common to both types, however, is the fact that the larger veins
do not share in the atherosclerotic process, although they may at
times seem to have suffered a moderate degree of endarteritis or
thickening of the intima. In short, characteristic for so-called dia-
betic gangrene is the presence of the typical lesions of athero- or
arteriosclerosis. These differ in no way from the lesions of the
arteries in arteriosclerotic or senile gangrene, and justify the con-
clusion that in diabetic gangrene we are dealing with an athero-
sclerotic or ateriosclerotic process.

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104 The Archives of Diagnosis

The arterial lesions may be summed up as follows: Extensive
degeneration of the arterial walls, intense atherosclerosis, calcifica-
tion, sometimes bone formation, often occlusion of a large part of a
vessel's course, the arteries being converted into rigid pipe stems;
at other times, less pronounced atherosclerosis with dilatation of
the vessel walls in places, and in still other cases a combination of
intense atherosclerosis with thrombosis. A reference to Fig. i*
will show the nature of the occlusive process in some of the cases
of diabetic and arteriosclerotic gangrene. The elastic tissue stains
show a proliferation and heaping up of the elastic layers or lamellae,
and that the remnant of the lumen may be occluded by organized
clot. Another type of lesion not depicted here, is that in which
marked calcification of the vessel walls takes place, sometimes at-
tended with bone formation.

The following abstract from some of my notes on the pathology
of the vessels in amputated legs of cases of so-called diabetic gan-
grene will illustrate in detail the type of lesions that are found.

P. A., April I, 1909 (diabetic gangrene) : Right leg ablated at
the knee joint; one ulcer situated at the outer border of the foot,
corresponding to the head of the fifth metatarsal; it is about the
size of a dime, covered with slu^sh, necrotic granulations ; a sec-
ond ulcer, slightly larger, more superficial, found at the head of the
first metatarsal, at the inner border of the foot.

Popliteal artery is atheromatous at the point of ablation, possibly
thickened but not occluded.

Posterior tibial is almost completely closed by atheromatous
plaques. Its middle third is almost completely closed by degenerate
atheromatous masses; the lower third shows similar lesions.

External plantar is almost completely closed by atheroma.

Peroneal — in its upper part it is almost completely closed by a
series of atheromatous plaques; throughout the remainder of its
course, there are yellowish, rounded atheromatous plaques and dif-
fuse atheroma.

Anterior tibial is practically closed by the atheromatous process
and calcification throughout its entire extent.

•PhoK

thologist,

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Buerger: Diagnosis of So-Called Diabetic Gangrene 105

Dorsalis pedis is open, but markedly atheromatous. The veins
are all open ; the external and internal saphenous are normal.

Thefe is no periarteritis.

Summary: — ^A case of ulceration and beginning gangrene in a
diabetic; extensive atherosclerosis with occlusion of many of the
arteries, the veins being open. In short, this case is a typical exam-
ple of the variety in which the atherosclerotic process is occlusive
in nature.

As an example of somewhat less marked atherosclerosis, associ-
ated, however, with obtiterative thrombosis, we have the following
case:

R. A. "diabetic gangrene."

Right leg: ablation 65^ inches above joint. The dorsum of bie
toe and adjacent surface of first metatarsal bone are the seat of be-
ginning tpngrene that has extended almost to the head of the meta-
tarsal bone. This area is covered with a brownish green discolored
skin beneath which lies a pool of fluid ; when this necrotic material
is wiped away, the tendon sheath of extensor muscles of toe and
underlying hone are exposed. The necrotic material has insinuated
itself beneath and around the extensor tendons of the second and
third toes, downward as far as the base of these toes, and upward
as far as the head of corresponding metatarsal bones. The epider-
mis covering the sole is easily stripped off over the anterior three
quarters of the foot, exposing an irregularly quadrilateral gangre-
nous patch about the center of the foot. The appearance of this
patch is like that described as occurring on the dorsum. It ex-
tends upward between the plantar fascia and muscle groups, appar-
ently coming into contact with the first and second metatarsal bones
and communicating with the gangrenous area on the dorsum.

Femoral artery is sclerotic and brittle. At one point near the
lower end of femoral artery, there is a large ulceration of the intima
about 3x7 mm. Just below this there is another ulceration with
some undermining of the intima by extravasation of blood. The ves-
sel itself is patent. The femoral vein is only slightly thickened and
is patent.

Popliteal artery is patent throughout. Its wall is much thickened
and somewhat calcareous, especially in the upper part, where there
is an encircling band of calcareous material about 2 mm. in breadth.

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io6 The Archives of Diagnosis

The intima is smooth, but there is diffuse atheroma, this being espe-
cially marked about the orifices of smaller branches. The accom-
panying vein is only slightly thickened and is open throughout.

Posterior tibial, at its origin, and for a distance of about II cm.
is patent ; from this point on, there is an obliterating thrombosis
of the vessel. The occluded portion is contracted. The vessel, as
a whole, presents only a moderate degree of sclerosis, this being
more marked from the point of thrombosis down.

Peroneal artery, at its origin, and for a distance of about 4 cm.,
presents a similar picture to the posterior tibial. In the rest of its
course there is complete obliteration by an old, white, organized
thrombus. The accompanying veins do not show as much thicken-
ing as posterior tibial, and are patent.

Internal saphenous vein shows marked thickening of wall, so
that the vessel can be rolled beneath finger like a cord ; it is, however,
open throughout.

Anterior tibial shows a process similar to that involving the fe-
moral though less extensive. Toward the lower end there is con-
siderable narrowing of vessel as a whole, but the lumen is unim-
paired.

Summary: — Gangrene associated with arteriosclerosis and athe-
roma of the femoral vessel ; extensive obliterative thrombosis and
atheroma of the posterior tibial and peroneal arteries with thicken-
ing of the internal saphenous vein.

Another instance of extensive arterial disease is seen in the fol-
lowing case :

A. B. "diabetic gangrene." Specimen — leg amputated at lower
third of thigh.

Popliteal open ; well developed calcific plaques.

Posterior tibial — atheromatous and calcified plaques which almost
completely close the vessel.

External plantar — closed by atheromatous masses, also internal
plantar.

Anterior tibial — pipe stem ; partly open throughout ; lower part
of anterior tibial and dorsalis pedis practically closed by calcific
atheroma.

Summary : — Evidently a case in which extensive calcification and

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Buerger: Diagnosis of So-Called Diabetic Gangrene 107

atheroma have almost completely closed the larger portion of the
distal vessels.

ARTERIOSCLEROTIC GANGRENE

In this group we include a presenile and senile variety, the
lesions being identical. In both there is well advanced atherosclero-
sis, which is in no way distinguishable from the vascular lesions asso-
ciated with diabetic gangrene. In the presenile group that occurs
in men of forty to fifty-five years of age, the calcific, degenerative
process may be less advanced, but in the senile group of arterio-
sclerotic gangrene, we find exactly the same lesions that occur in
the gangrene of diabetics. Characteristic of both the diabetic and
arteriosclerotic groups is the involvement of the larger arteries, pri-
marily by an affection that involves the wall of the vessel, secon-
darily by a lesion of occlusion, usually due to the production of
degenerative atheromatous and calcific masses, more rarely by the
presence of obturating, organized thrombi.

THROMBOTIC GANGRENE

There is another group of cases which occurs very frequently in
patients after the age of fifty. Although the arteriosclerotic process
is but moderately pronounced, an occlusive thrombosis suddenly
develops, usually in the peripheral vessels such as the dorsalis pedis,
plantars, anterior tibial and distal portion of the posterior tibial.
In these cases we see mild or moderate lesions of atherosclerosis
with a superimposed complete occlusion by what we term a "bland
thrombus." Fig. 2 was taken from such a case in which amputa-
tion revealed only a very slight degree of atherosclerosis and a
recent thrombosis of the distal vessels, the dorsalis pedis and pos-
terior tibial.

THROMBO-ANGITTIS OBLITERANS

The name, thrombo-angiitis obliterans, was proposed in 1908* for
that interesting group of cases of presenile gangrene previously de-
scribed under the name, endarteritis obliterans. Pathological studies
of some forty-five amputated lower extremities and of some twenty-
five superficial veins affected by that stage of the disease known as
"migrating phlebitis," have shown, that we are dealing here with

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io8 The Archives of Diagnosis

an acute inflammatory process involving the superficial veins, the
deeper arteries or deep veins, followed by complete occlusion through
the formation of red, obturating thrombi; and that a stage of heal-
ing follows through organization of the clot and resorption of the
products of the acute inflammatory process.

The early or acute stage of the disease can be best studied in the
superficial veins when these are the seat of the inflammatory
thrombophlebitis. These lesions, as they are found in the exsected
veins, are infiltration of the wall of the vessel with polynuclear leu-
kocytes and occlusive thrombi (Fig. 3) with the formation of pu-
rulent or miliary foci of pus. Organization or healing then takes
place, the purulent foci becoming changed into characteristic foci
that closely resemble miliary tubercles. Later on, the exudative
products in the vessel wall become absorbed, vascularization of the
clot takes place, new vessels appear in the media, and the clot dis-
appears, becoming canalized and vascularized. Finally, in the healed
stage of the disease, the media of the vessel wall presents nothing
remarkable, but the presence of new-formed vessels ; the adventitia
is thickened ; a certain amount of periarteritis develops ; the arteries
and veins being firmly adherent to each other, and the lumen of the
affected vessel is closed completely, the organized clot containing
new-formed vessels or vascular spaces. These may give the occluded
vessel the appearance that had been regarded for so many years as
an obliterating endarteritic process.

When an artery and its venae comites are afTected, various stages
of the process may be found in the different vessels in the same
sheath. Thus, in the posterior tibial depicted in Fig. 4, the artery
is in the old or "healed" stage of the disease; so also is one of the
veins. Another vein is in the acute and inflammatory stage, and
still another vein is in an intermediate or healing stage where miliary
foci are in evidence.

In short, we have here a specific entity in all probability of
an inflammatory nature, leading to extensive occlusion of most of
the arteries and often many of the veins of the lower extremities.

When the lesions of this disease are known, they cannot be mis-
taken either for endarteritis or for the atherosclerotic or arterio-
sclerotic processes that belong to the diabetic, senile and the pre-
senile atherosclerotic cases.

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Buerger : Diagnosis of So-Called Diabetic Gangreme 109

embolic and thrombotic gangrene
This may occur either in cases in which the vessels are absolutely
normal, or, somewhat more frequently, in cases in which an athero-
sclerotic process is present. As a complication and sequela of cer-
tain infectious diseases, embolic and thrombotic gangrene is not un-
common. We have seen a number of cases after severe pneumonia.
One of the favorite sites for embolic or thrombotic processes is the
popliteal artery, although an extensive thrombosis following em-
bolism may occur in the femoral or even higher up. Both diabetic
cases and cases not at all afflicted with this disease may be taken with
sudden occlusion of arteries or veins.

In brief, therefore, an extensive atherosclerotic process is the
usual pathological lesion not only in so-called diabetic gangrene, but
also in the gangrene of senile cases, of the "arteriosclerotic" cases,
of many cases of presenile arteriosclerosis, and in some of the cases
of arteriosclerosis associated with thrombosis. In thrombo-angiitis
obliterans, however, we have a distinct entity, not at all related to
these diseases of the vessels previously described, in all probability
of inflammatory nature, the inciting organism, if any be present,
being unknown. As for the embolic gangrene, this may or may not
be associated with disease of the vessel wall.

Regarding the pathology of the cases which we group as vaso-
motor or neurogenic, including Raynaud's disease, erythromelalgia
and chronic acro-asphyxia, our own investigations have shown defi-
nitely that gangrene in such cases is not dependent upon organic
vascular disease, both the arteries and veins remaining patent,'

The cases of diabetes in which trophic disorders or gangrene of
the lower extremities develop, do not vary greatly from the senile
or advanced arteriosclerotic cases, except that the complicating af-
fection "diabetes" may augment the mortality, may influence the
advent of coma, and may increase the tendency to phlegmon forma-
tion. Considerable diversity in the onset of the disease, manifold
variations in the types of trophic disturbances and gangrene will
be noted if a large series be collected for study. So too, in the occur-
rence of complications will variations occur.
The following is a history often obtained in these cases :
For months or years there has been some trouble in walking, such
as pain in the calf, in the instep or in the ball of the foot on walking:

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no The Archives of Diagnosis

that is, intermittent claudication. Sooner or later, paresthesiae,
burning sensation or pain will develop somewhere in the foot, usually
at the site of impending gangrene. A dry patch of skin, an abrasion
or a bleb will appear very frequently over the outer or inner border
of the foot, near the head of the corresponding metatarsal bones,
and will be transformed into a chronic ulcer or into a patch of dry
gangrene. In other cases, a perforating ulcer will develop; and in
still others, the process will take on a more fulminating type, gan-
grene of the moist type rapidly developing.

In any of these cases, when gangrene or trophic ulcers have made
their appearance, secondary lymphangitis or phlegmon formation
may rapidly take place.

A more protracted course is taken by those cases in which an
ulcer of limited extent persists for weeks or months, may even heal,
or give way to the formation of another ulcer in another portion
of the foot, the latter lesion either terminating favorably, or more
commonly leading to gangrene or infection.

The following extracts from the histories of some of my cases will
illustrate some of the types encountered:

Rapidly developing wet gangrene.

I. Z., Aug. 8, 1914, female, age 54, was perfectly well until seven
years ago when she complained of pruritus vaginae ; sugar was found
in the urine. Two months ago, after the removal of a callus on the
sole of the left foot, a painful, indolent ulcer developed; this re-
fused to heal. Recently there developed spontaneously a number of
large blebs on the dorsum of the foot and over the toes.

Physical examination, Aug. 1 1, 1914. A perforating ulcer is pres-
ent on the plantar aspect of the left foot. Over the dorsum of the
same foot and just behind the middle toe, there are large blebs
apparently filled with sanguineus fluid. The dorsum of the foot
presents a peculiar bluish-red mottled discoloration, and when the
blebs are opened, bloody fluid is obtained. The foot is markedly
cold.

The right foot also shows a bleb over the tip of the big toe and
extending over the plantar aspect.

Aug. 14. The ecchymotic area on the dorsum of the left foot is
apparently extending ; the second toe is cyanotic and cold.

Diagnosis : Impending wet gangrene.

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Buerger: Diagnosis of So-Called Diabetic Gangrene hi

In short, we have here a case, in which, superimposed upon a
typically slowly developing, perforating ulcer, there supervened evi-
dences of extensive wet gangrene. Interesting and characteristic for
this type of gangrene are: Separation of the epidermis, the extra-
vasation of bloody serum under the epidermis, cyanotic discolora-
tion of the foot, coldness of the foot, coupled with the absence of
pulsation in the larger vessels, including the dorsalis pedis, posterior
tibial and popliteal.

More common are those cases in which the mortifying process is
slow in developing, being attended sooner or later by an inflamma-
tory or phlegmonous process.

H. G., male, age 62, Feb. 22, 1907. For about five years he
has been drinking large quantites of water, and has to void fre-
quently in large amounts. For three of four weeks he has had
trouble with the big toe of the right foot, there being almost con-
stant pain. The whole toe became black shortly after the develop-
ment of a small, dried, blackish spot at the tip of the toe.

Physical examination : The right foot is somewhat swollen and
reddened up to the ankle. The big toe shows the typical evidences
of dry gangrene, extending up to the metatarso-phalangeal articu<
lation, where there is an irregular line of demarcation. There are
two small ulcerations of the dorsum of the toe which discharge a
small amount of serous material. The pulses in the dorsalis pedis,
posterior tibial and popliteal arteries are absent.

Pathological examination of the amputated limb shows gangrene
of the big toe and purulent infiltration of the cellular tissues on the
dorsum of the foot. Another phlegmon involves the plantar aspect
in the region of the ball of the great toe. There is an extensive and
intense arteriosclerosis.

In addition to the cases in which we either have rapidly develop-
ing gangrene or more slowly progressing dry gangrene with or with-
out phlegmonous infiltration, there are other types in which merely
a trophic ulcer is present or ulcers of small extent, that may or may
not heal. A multitude of combinations can be expected, if we see
a large amount of material. Characteristic, however, are these facts,
that initiated by a period of intermittent claudication ; or without any
prodromal symptoms ; or, following some trauma such as cutting
a nail or a corn; or, after local infection; or, apparently without

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112 The Archives op Diagnosis

cause, evidences of trophic disturbances make their appearance.
These may manifest themselves in the form of a superficial ulcer,
a perforating ulcer, or in the development of an area of dry or
wet gangrene.

DIFFERENTIAL DIAGNOSIS

When we are confronted with cases of trophic disturbance or
gangrene of the lower extremities, we will find that, for purposes
of diagnosis as well as prognosis, a routine examination made ac-
cording to a plan adopted by us some seven years ago will be of
some value. Our scheme of physical diagnosis includes an exam-
ination of the following points: First, general appearance of the
limb, including an investigation of the presence of trophic disorders
or gangrene ; second, appearance of the limb in the dependent posi-
tion (presence of chronic erythromelia) ; third, presence or absence
of ischemia or blanching in the elevated position; fourth, estima-
tion of the angle of circulatory sufficiency; fifth, pulsation in the
palpable vessels : iliac, femoral, popliteal, posterior tibial, anterior
tibial and dorsalts pedis; sixth, the occurrence of an induced or re-
actionary rubor or erythromelia.

First, The general appearance of the limb: In distinct contrast
to the cases of thrombo-angiitis obliterans, the arteriosclerotic or
elderly diabetic patient will show evidence of malnutrition of the
limbs. The foot, as a rule, looks withered and shows evidence of
some atrophy. The normal irregularities of contour produced by
the extensor tendons and bony prominences, will be present, except
if a complication such as infection or bilateral edema is present.
In thrombo-angiitis obliterans there is a tendency to obliteration of
these markings. There may be distinct pallor, even in the horizon-
tal position. It is an evidence of poor circulation. Fissures,, ulcers,
perforating ulcers, gangrene, bullae, ecchymoses, impaired nail
growth and gangrenous areas may be present.

Second, on depressing the foot, when there is no inflammation
present, a red flush of the foot will be noted. This is a condition of
rubor or erythromelia, as I have elsewhere termed it. It is brought
about by a compensatory dilatation of the superficial capillaries, and
is most characteristic of thrombo-angiitis obliterans. /( may be also

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Buerger: Diagnosis op So-Called Diabetic Gangrene 113

present in the arteriosclerotic and diabetic cases. It seems to be an
effort on the part of nature to make up for the impairment of cir-
culation by virtue of dilatation of the superficial capillaries.

Third, when the limbs are elevated, blanching usually sets in
rapidly, when mechanical interference with the circulation is at hand.
The extent of the blanching and the rapidity with which it appears
are both valuable aids in the estimation of the amount of arterial
disease.

Fourth, the angle of circulatory sufficiency*: In the diabetic or
arteriosclerotic cases, the estimation of this angle is not of as great
importance as in the cases of Hirombo-angiitis obliterans. By ele-
vation to the vertical we establish a blanched condition o£ the limb.
If we then gradually depress the limb, about 30° at a time, we will
note the point at which the circulation will return. If this be at the
horizontal, we call "the angle of circulatory sufficiency" 90°. Nor-
mally, the angle should be 180°, that is, color should still be present
when the leg is held perpendicular to the horizontal. The greater
the impairment of the circulation, the more will we have to depress
the limb before the evidence of arterial return will manifest itself
in the integument. Thus, below the horizontal, the angle will be
less than 90°.

In many cases of arterial disease, the estimation of this angle is
a valuable adjuvant, not only in the recognition of the amount of
occlusive disturbance, but also in prognosis.

Fifth, absence of pulsation as an indication of arterial occlusion:
The femoral, popliteal, posterior tibial, dorsalis pedis and posterior
tibial must be palpated in every instance. Absence of pulsation
is, as a rule, an indication of occulsion at the point palpated.

Sixth, reactionary hyperemia, reactionary erythromelia : By this
term, we mean an induced rubor that can b^ elicited in the foot
when it is allowed to hang down, after a preliminary period of ele-
vation to the vertical. It is a physiological phenomenon, that ische-
mia of a limb artificially produced by an Esmarch or Martin ban-
dage, will be followed by sudden dilatation of the capillaries of the
peripheral parts, when the circulation is allowed to return. We
have made use of this well-known manifestation in the examination

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1 14 The Archives of Diagnosis

of cases, in which impaired circulation due to arterial occlusion is
suspected. Particularly in cases of thrombo-angiitis obliterans, have
we found it applicable, but also in other cases of organic vascular
disease. Thus, in early cases of arteriosclerosis, as well as in
thrombo-angiitis obliterans, we may find that, after preliminary ele-
vation, and consequent depression of the limb to the dependent posi-
tion, a very striking and intense rubor appears. This is prac-
tically diagnostic of arterial occlusion, because it seems to indicate
that blanching has been produced. In early cases, it is especially
valuable, for it may be present long before the chronic condition
of "erythromelia" or rubor in the dependent position develops.

In short, for all cases of suspected arterial occlusion, a routine
examination, whichhas for its purpose the production of objective
evidences of the effects of arterial occlusion, and which includes
the palpation of the arteries themselves, is of extreme importance
in diagnosis.

Having diagnosticated, then, the presence of mechanical inter-
ference with the circulation, by the demonstration of the signs and
sjmiptoms discussed, we must make a differential diagnosis in all
cases between the neurogenic vasomotor and trophic diseases that
may be attended with gangrene, and those affections that depend
upon organic arterial disease. In a discussion of the subject of dia-
betic gangrene, the vasomotor cases need but slight mention, for the
differential diagnosis is not difficult. For our purposes it is more
important to distinguish that large group of cases which we have
termed thrombo-angiitis obliterans, from the arteriosclerotic gan-
grene, for, diabetic gangrene is but a subdivision of the athero-
sclerotic or arteriosclerotic type.

If we pass in review the characteristic features of thrombo-angi-
itis obliterans, which I have discussed in detail elsewhere,' we
could summarize these as follows : The disease occurs, as a rule, in
young men between the ages of twenty and thirty, although the
symptoms may not appear until as late as forty or fifty, or even at a
later age. More than 99 per cent, of the cases seem to occur in
Polish, Galician, Russian and Austrian Jews, females being prac-
tically never afflicted. One of the first symptoms is pain in the foot
or in the ankle, more commonly in the calf on walking, or a feeling
of tiredness that leads the patient to take frequent rests, and often

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Buerger: Diagnosis of So-Called Diabetic Gangrene 115

su^^sts to him to seek the advice of an orthopedist. After a pro-
dromal period of weeks or months and sometimes years, in which
the symptom of intermittent claudication may be the most promi-
nent, there develops either spontaneously, or after the cutting of a
nail, callous or after injury, some evidence of trophic disorder. At
the tip of one of the toes, or at the outer border of the foot under
a nail, or in the web between the toes, a dry patch of skin which soon
blackens into an area of gangrene may develop, or a hemorrhagic
bleb appears and is followed by the development of an ulcer ; or a
painful fissure is produced. This is the second stage of the disease,
which may be regarded as that of trophic disorders and impending
gangrene. About this time, or even sooner, a peculiar reddish blush
of the foot takes place which is intense in the dependent position,
and disappears upon elevation of the limb. We have termed this
condition of rubor erytkromelia. Because of its constancy and in-
tensity it is characteristic for this disease, although also associated
with arterial occlusion due to other causes, such as atherosclerosis.
About this time, there develops intense pain, either in the region of
the ulcer or gangrenous patch or throughout the leg. The pain may
become so intense at night, that sleep is impossible, the patients
being robbed of sleep for days and weeks at a time. From this point
on, the disease may take a varied course. Trophic disorders may
last for weeks, months, or even years without making much progress,
may heal spontaneously, or give way to dry gangrene, amputation
being the issue. Sooner or later, however, in most of the cases, gan-
grene of one limb becomes either so extensive or the pain becomes
BO excruciating, that the extremity cannot be saved.

In short, after a prodromal period of indefinite pain or intermit-
tent claudication, there develop symptoms of trophic disorder and
manifestations referable to impaired circulation, leading finally to
gangrene and amputation.

Another characteristic feature of the disease (to which I called
attention in 1909') is the occurrence of a characteristic migrating
phlebitis involving the superficial veins of either the lower or upper
extremities, preferably seeking the territory of the internal and ex-
ternal saphenous. Extending over a period of weeks, months, or
even years, we see the appearance of painful nodosities and of
elongated, inflamed cords in the skin, manifestations which indicate

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Ii6 The Archives of Diagnosis

the involvement of superficial venules or larger veins with the dis-
ease, thrombo-angiitis obliterans. The exsection of such veins fol-
lowed by careful histological examination has revealed to us that
there is a specific morphological picture characteristic for thrombo-
angiitis obliterans, which can be demonstrated not only in the super-
ficial veins, but also in the deep vessels of the amputated limbs.
This specific picture, not discoverable in any otfier thrombotic dis-
ease, is preceded by an acute inflammatory stage (Fig, 3) which
would lead us to assume that we are dealing here with a disease of
infectious origin.

Although the recognition of the disease, thrombo-angiitis oblit-
erans, will rarely be difficult in the young, the older patients may
present difficulties in differentiation from arteriosclerotic disease.
The diagnosis of thrombo-angiitis obliterans must depend upon (l)
the racial (Hebrew) and sex (male) predilection; (2) the early in-
volvement of the lower extremities; (3) the early symptoms of
pain or intermittent claudication; (4) the presence of migrating
phlebitis; (5) evidences of pulseless vessels; (6) the presence of
blanching of the extremity in the elevated position ; ( 7) the existence
of rubor in the dependent position ; (8) the relation of the hyperemic
phenomena to posture; (9) the absence of simultaneous, symmetri-
cal involvement; and (lo), the slow, progressive chronic course ter-
minating in gangrene.

In the arteriosclerotic (diabetic) gangrene the general appearance
of the limb will be different. The foot will have a somewhat atro-
phic appearance, except in the stage of infection. The gangrenous
process advances more rapidly, is more frequently of the moist type,
more often associated with phlegmon formation and extensive
sloughing, more frequently preceded by a perforating ulcer. The
erythromeha, if present, is less marked, less distinct; there is no
migrating phlebitis, and there are distinct evidences of arteriosclero-
sis, often recognizable in the condition of the dorsalis pedis or other
vessels. Purely vasomotor symptoms are rarely present. When the
arteriosclerotic gangrene occurs in patients between forty-five and
fifty-five years of age, a differential diagnosis from thrombo-angiitis
becomes difficult and often impossible. For, in certain instances,
thrombo-angiitis obliterans may have existed without symptoms since
early adult age, and may have become spontaneously cured, the

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Buerger : Diagnosis of So-Called Diabetic Gangrene 117

clinical effects of the obturation of the arteries having been com-
pletely compensated by the establishment of adequate collaterals.
In such cases, gangrene may occur later in life, not because of the
former thrombo-angiitis obUterans, but because of the subsequently
engrafted arteriosclerotic disease. Pathological studies of ampu-
tated limbs have definitely shown that such a combination can occur.

A differential diagnosis from the true vasomotor conditions will
be rarely an arduous task. It will suffice to take Raynaud's disease
as an example and point out its chief characteristics.

In Raynaud's disease we will note the following features: A
sudden onset of the first stage of local syncope or regionary ischemia
involving usually the fingers, more rarely the toes, and occasionally
the margins of the ears or the tip of the nose with coldness and
blanching; associated sensory phenomena, paresthesia, and pain; a
comparatively short duration of the vasomotor and sensory mani-
festations, their intermittent character with return to normal be-
tween the attacks; the symptoms of local asphyxia attended with
local depression of temperature and swelling of the parts involved ;
the disappearance of the asphyxia with substitution of reactive
hyperemia and a third stage of dry gangrene. Characteristic for
this disease as well as for the cases of scleroderma and sclerodactyly
is the striking atrophy of the ends of the distal phalanges. The
changes in the bones can be well demonstrated by Rontgen-ray ex-
amination, atrophy and disappearance of large portions of end-
phalanges being distinctive and diagnostic features. In our own ex-
perience the alterations in the bones could be detected early in the
disease, probably developing simultaneously with the other trophic
disturbances.

CONCLUSION

For purposes of clinical diagnosis, prognosis and for a correct
understanding of the pathology of the various conditions compli-
cated with gangrene of the lower extremities, it is expedient to
classify the cases into two large groups: those in which the trophic
lesions depend upon organic disease of arteries or veins, and those
in which the nutrient vessels are intact. Pathological studies have
led us to the opinion that one large group of cases— designated as
thrombo-angiitis obliterans — must be separated from a second large
group — athero- or arteriosclerotic disease, — because the pathological

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ri8 The Archives of Diagnosis

lesions are distinctive in each group. In the latter group belong
the cases of so-called diabetic gangrene, as well as the "senile" and
some of the presenile cases. From the clinical standpoint, a classi-
fication in which vasomotor cases, including Raynaud's disease, ery-
thromelalgia, etc., are recognized as being independent of organic
arterial disease, and in which thrombo-angiitis and arteriosclerotic
gangrene are conceded to be distinct entities associated with charac-
teristic and extensive vascular disease, will give the best opportunity
for correct diagnosis.

REFERENCES

Oct., igo8.

2. Buerger -Op penheimer. — "Gangrene Without Organic Vascular Disease,"

Med. Rec, Dec, 1914.

3. Buerf^er. — "Veins in Thrombo-angiitis Obliterans," Jour. Am. Med. Ass.,

April 24, 1909.

Buerger. — "Recent Studies in the Pathology of Thrombo-angiitis Ob-
literans," Jour. Med. Research, Vol. XXXI, No. 2. Nov., 1914.

Buerger. — "Is Thrombo-angiitis Obliterans an Infectious Disease?" Surg.,
Gynec and Obst., Nov.. 1914.

Buerger. — "Concerning Vasomotor and Trophic Disturbances of the Upper
Extremities; With Particular Reference to Thrombo-angiitis Obliterans,"
Am. Jour. Med. Sci., No. 2, Feb.. igi5.

4. Buerger. — "The Association of Migrating Thrombophlebitis with Thrombo-

angiitis Obliterans," Internal. Oin., Vol. Ill, 19th Series.

THE DIAGNOSIS OF ABNORMALITIES OF MYOCARDIAL

FUNCTION

By T. STUART HART

Assistant Professor of Chnical Medicine, College of Physicians and Surgeons,

Columbia University ; Visiting Physician, Presbyterian Hospital

New York

IV. TACHYCARDIA — THE ACCELERATED HEART.

A heart rate of abnormal rapidity is one of the most frequent phe-
nomenon observed by the physician. For purposes of the present
discussion one may classify all such cases in two groups :

I. ACCELERATED HEARTS.
II. PAROXYSMAL TACHYCARDIA.

The main clinical feature which distinguishes these groups is the
manner in which the transition from the normal to the abnormal

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Hart: Abnormalities of Myocardial Function 119

rate is accomplished. In the case of the accelerated heart the transi-
tion from the slow to the rapid and from the rapid to the slow rate
is gradual ; in a very brief period- the heart cycle may hecome so
shortened that the rate per minute is increased 50 per cent., and yet,
as observed by palpation or auscultation, the length of any two suc-
cessive cycles is so nearly identical that neither the finger nor the
ear is able to detect the minute differences which go to make up the
change.

In the paroxysmal tachycardia the onset and the offset of the
change in rate is abrupt and the observer and even the patient is
usually able to detect the sudden^ transition without difficulty.

THE ACCELERATED HEART

ETIOLOGY AND PATHOLOGY

It has already been pointed out that the rate of the normal heart
is not fixed, but varies with the needs of the body at any particular
moment. This rate adjustment is brought about through the regula-
tory mechanism of the extra cardial nerves. In the conditions now
to be considered the underlying factors are many and complicated,
but we may recognize three important elements which individually
or in association may produce an abnormal acceleration of the heart:

(A) The outside demands on the heart may be excessive.

A full discussion of the demands on the heart which originate
outside of the cardio-regulatory nervous mechanism and the cardiac
tissues themselves, the nature of such demands and their modus
operandi, important and interesting as they are, would lead us out-
side of the limits which we have set in these papers devoted to the
subject of myocardial function. However, this outside call for in-
creased cardiac activity must never be lost sight of in analyzing the
response of the cardiac tissues to these demands. A simple illustra-
tion of the response of the heart to increased demand is seen in the
effect of work. As a general rule it may be stated that the response
to physical exertion of an individual with a good myocardium is
shown in an increased blood pressure. One with a defective myocar-
dium shows an abnormal acceleration of the heart rate. With a
normal heart muscle under efficient regulation and a normal vaso-
motor tone, moderate exercise causes an increase of cardiac rate.

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120 The Archives of'Diaghosis

but with rest the rate should return to its usual level in the space of
a very few minutes. That the demands of exercise produce an in-
trinsic physiological effect on the myocardium is evidenced by the
fact that the normal electrocardiogram constantly shows under suCh
stress definite though small changes ; in addition to the shortening of
the diastolic period (T-P) there is an increase in the size of waves
P and T and a deepening of S.

(B) The extracardial nerves may be at fault in their regulatory
capacity.

It is quite evident in certain accelerated hearts that the fine nervous
adjustments are unbalanced. The activity of the vagi are depressed
or there is an excessive activity of the accelerators, such a lack of
balance mainly affects the heart through its pacemaker, the sinus
node. This is probably the mechanism of the rapid changes of rate
in emotional conditions, the so-called "labile pulse" of neurasthenics
and the more persistent rate increase in certain organic lesions of the
central nervous system and of the peripheral nerves supplying the
heart.

(C) The heart muscle may be defective and responds to normal
outside demands with abnormal acceleration. The direct application
of heat to the myocardium is known to increase the cardiac activity.
Bacterial and chemical toxins set free in many of the infectious dis-
eases are recognized as efficient agents in causing functional or
organic changes of the myocardium, which are the basis of a response
in rate out of proportion to the stress.

While we can sometimes designate one of these particular factors,
excessive outside demands, defective nerve regulation or myocardial
damage, as the cause of the increased heart rate, the problem is usu-
ally more complicated. No doubt frequehtly two or all of these ele-
ments play a part. In the present state of our knowledge we are
often at a loss in deciding which link in the chain is at fault, and, if
more than one, their relative importance.

Fever is nearly always accompanied by an acceleration of heart
rate, and so uniform is this phenomenon that the well known Lieber-
meister's rule of an increase of 8 pulse beats for each d^ree of tem-
perature above the normal is found approximately accurate, albeit,
with many exceptions. Whether this is brought about by the in-
creased temperature of the blood passing through the heart, or by the

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Hart: Abnormalities of Myocardial Function 121

chemical action of associated toxins on the regulatory nervous
mechanism, or on the cells of the cardiac muscle, is undecided.

The increased heart rate of shock is undoubtedly due to local or
general vaso-motor disturbance with its reflex demands on the heart
to maintain an adequate blood pressure. A similar explanation
seems probable for Graves' disease, and the excessive administration
of thyroid extract in which the evidence points to the damaging effect
of toxins on the vaso-motor apparatus, rather than the heart muscle.
The "labile pulse," wide pulse pressure, flushing, local sweating and
tremors characteristic of this disease suggest that the toxins chiefly
attack the sympathetic nervous system, possibly incidentally produc-
ing a hypertonus of the accelerator nerves, and probably act on the
heart muscle only in an indirect manner. Pregnancy probably has
only a reflex effect on cardiac activity.

Exhausting diseases (tuberculosis, etc.) and convalescence -from
•wasting diseases (typhoid, etc.), nearly always show some degree of
increase pulse rate. Each one of these conditions, febrile or afe-
brile, with toxic and nutritional disturbances may affect the outside
demands on the heart, the functional balance of the extracardial
nerves, or the cardiac muscle, and in each instance the effort should
be made to determine and apportion the relative responsibility of
each of these factors in the acceleration of the heart. The severe
anemias, high grades of chlorosis, marked secondary anemias (as
in malignant disease), and the primary pernicious forms are in-
variably associated with an increase in heart rate. In the extreme
grades of anemia the cardiac muscle shows an advanced degree of
degeneration with fatty infiltration and hemorrhages,^ so that we
have little hesitancy in ascribing tiie altered heart activity to the
direct toxic or nutritional effect on the myocardium.

In valvular disease the mechanical defect must be considered. The
volume output is unusual and the normal bodily calls for blood are
met by an increased heart rate. In the majority of these cases, how-
ever, the disease which was the agent in distorting the valves has
also injured the myocardium and this, in association with the change
in cardiac tone resulting from dilatation and hypertrophy, are impor-
tant influences in modifying heart rate. Changes in the myocardium
are produced by acute rheumatic fever and other infectious diseases
I. Lazarus. — "Pernicious Anemia," Nothnagel's Practice, Phila., 1906, p. 383.

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122 The Archives of Diagnosis

with a resulting acceleration of heart rate. These changes may be
chemical with no demonstrable histological abnormality, or there may
be fatty degeneration and £brous replacement, so that we meet with
many degrees of functional impairment.

MECHANISM

The main link in the mechanism through which the increased rate
of the "accelerated heart" is produced is the "sinus node," the nor-
mal pacemaker of the heart. Here the fundamental properties of
"stimulus formation" or "excitation" or both, become heightened.
This change may be intrinsic, that is to say, the chemical processes
of the muscle cells of the node are so changed that they form and
explode stimulus material more rapidly, or the change may be
brought about by the modifying impulses showered on the node by
the extracardial nerves. The sinus node is particularly influenced by
impulses brought to it by the right vagus and the right accelerator.*

The distinguishing feature of the "accelerated heart" is that the ■
sinus node retains its function as the pacemaker of the heart. This
is shown by the graphic records which indicate that the impulse for-
mation arises at the normal point and spreads through the auricle, the
bundle of His and the ventricle in a normal orderly fashion. There
are several facts, however, which indicate that, in these "accelerated
hearts" other portions of the musculature may have their properties
of "stimulus formation," "excitability," and perhaps also "conduc-
tion "heightened. It is known that the fibers of the left vagus and
of the left sympathetic are in the main distributed to portions of the
heart below the sinus node,' and experimental evidence indicates that
cutting the left vagus and stimulating the left sympathetic have a
considerable effect in increasing the heart rate. Again in certain
"accelerated hearts" it may be seen that systole, which in the normal
heart has a very constant length, is shortened. This is only con-
ceivable on the ground that one or more of the fundamental proper-
ties of cardiac muscle mentioned above are quantitatively changed.

The principal change from the normal in the cardiac cycle of the
accelerated heart is a shortening of the diastolic period. From this
it follows that the rest period of the heart is curtailed and the time

2, Robinson and Draper.— Jour. Exp. Med., igil, XIV, p. 227.

3. Gohn and Lewis.— Jour. Exp. Med., 1913, XVIII. p. 739-

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Hart: Abnormalities of Myocardial Function 123

allowed for the recovery of the property of "contractility" is con-
siderably less than in the heart working at the normal rate, hence the
contractile power is less. Furthermore there is less opportunity for
the heart to receive its normal quota of blood, hence the volume out-
put is smaller. It follows as a result of these two factors that the
pulse is smaller in volume and of diminished force.

identification

Little need be said of the clinical recognition of the "accelerated

heart ;" the pulse may be counted either by palpation at the wrist or

perhaps more accurately by auscultation at the apex. If one is pres-

D.Z SkoiuI

Fig. I

AcMlcfaUd he»n. Rate uj. Patient snffiring from rtwuinstic myocardiiii,

ent during the change from a slow to a faster rate this is best detected
by counting the pulse in 10 second intervals, omitting every other 10
seconds. Neither the finger nor the ear can detect the small differ-
ences in the lengths of the successive diastolic periods, but the varia-
tions in length of the cycles separated by considerable periods is
easily made out. The volume output of the heart is usually some-
what diminished with the acceleration of the rate and the consequent
diminution in the peripheral arterial wave may be quite evident.
The polygram of the accelerated heart conforms to the normal

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124 The Archives of Diagnosis

except that the diastolic period is shortened. This is at times so
marked that the a wave may be superimposed on the preceding v
wave. The jugular tracings (Figures i and 2) show a normal se-
quence of waves, a, c, v. Figure l is a record of a girl, 15 years of
age, suffering from rheumatic myocarditis and adherent pericardium.
The rate at the time the record was taken was 145 and the rapidity
was in part due to excitement, as her pulse at rest was commonly 120.
The slightest physical exertion at this time would send her pulse to
160, suggesting a marked instability of the sinus node.

In Figure 2 is shown a tracing of a case of Graves' disease; the
rate is 138, It is evident from the jugular tracing that the normal

pacemaker is in control and that the rapid rate depends upon the
shortening of the diastolic period.

Electrocardiograms of accelerated hearts are presented in Figures
3 and 4. Figure 3, from a case of Graves' disease, shows a short
diastolic period, but the sequence of waves is normal. Figure 4 was
obtained from a case of cerebral hemorrhage, a few hours before
death. The diagnosis was confirmed by autopsy and it seems clearly
a case in which the nervous regulatory mechanism is at fault. The
P and T waves in this record overlap. Careful measurement sug-

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Hart: Abnormalities of Myocardial Functiok 125

gests that the earlier of the two peaks represents the auricular con-
traction which occurs before the preceding ventricular systole is com-
pleted. This curve simulates quite closely the records obtained ex-

perimentally during the stimulation of the right sympathetic gan-
glion by Rothberger and Winterberg.*

THE CLINICAL SIGNIFICANCE AND PROGNOSIS

of the accelerated heart depend on the underlying condition and to
determine this, the responsibility of excessive outside demands, lack
of balance between the elements of the nerve regulatory mechanism
4. Archiv f. d. ges. Physiol.. 1910, CXXXV, p. 557, Fig. 18. d.

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126 The Archives of Diagnosis

and defects of the myocardium, must be correctly apportioned. In
general one may say that excessive outside demands and unbalanced
nerve control acting on a heart with its myocardium intact, arc usu-
ally more readily corrected, and hence of less serious import to the
patient than when the heart acceleration depends upon an intrinsic
defect of the myocardium. But even a normal myocardium may be
worn out by the excessive activity induced by extracardial condi-
tions, and a defective myocardium properly handled may recover
full functional efficiency. The tests by which we may gage the
integrity of the heart muscle and its reserve force will be discussed
in a later paper.

A SIMPLE SUBSTITUTE FOR THE WASSERMANN

REACTION

Bv G. ARBOUR STEPHENS

Hon. Physician, Royal Cambrian Institute for the Deaf ; Fellow of the

Medical Society of London ; Late Lecturer on Biology.

Swansea Technical College

Swansea. England

Under the heading of "Distilled Water Versus Salvarsan in the
Treatment of Syphilis," in the British Medical Journal for April 5,
1913, I tried to show that excellent results can be obtained in the
treatment of syphilis by the subcutaneous injection of distilled
water, and as it is unattended by any danger, therefore, on account
of its ease of application, such a treatment ought to appeal to the
general practitioner.

Since I published that article I have had a large number of
other cases which have responded with the same readiness and
with the same result. Distilled water, like salvarsan, must be used
in conjunction with the internal administration of mercury, which
I always administer in the form of colloidal mercury, and especially
that made by Merck of Darmstadt.

In the Practitioner for September, 1910, and The Dublin Jour-
nal of Medical Science for June, 191 1, I gave the results of some
of my work on colloids and surface tension, and as the result

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Stephens: Substitute for Wassermann Reaction 127

of that work I determined to try the effects of distilled water in
syphilis, and, fortunately, with good results.

Following up such a successful issue of a treatment arrived at
on theoretical considerations, I decided to compare the response
from a surface tension point of view of healthy and syphilitic blood
to various solutions.

Amongst these solutions was ammonium chlorid, which has the
unusual effect of raising the surface tension. In all these experi-
ments it is very important to have all the reagents pure and the
glasses clean, otherwise any impurity will negative the rise that
ought to take place.

The best solution of ammonium chlorid to use is one of about
12 per cent., and the way to carry out the test is as follows:

Clean the lobule of the ear with petrol, prick it and draw off
a sufficiency of blood in a hemocytometer pipette, ttiat is, up to
the half mark, and fill i^ to the remainder of the pipette with a
12 per cent, solution of pure ammonium chlorid in distilled water.

The blood and solution should be thoroughly mixed, and at once
examined under the microscope. Any delay is dangerous, for
evaporation takes place, and the ammonium chlorid crystallizes out
very readily and spoils the test.

Examined in this way, the red corpuscles show a marked change,
for in healthy blood the darker center tends to contract or crinkle
up into an irregular mass, whereas in syphilitic blood the darker
center tends to expand in some cases out toward the circumference
of the corpuscle.

The advantage of this test is its simplicity, enabling it to be
carried out by any medical man, and it only takes three minutes
to perform, whereas the Wassermann is complicated and expensive
and requires a practitioner specialized in the work.

There are, of course, gradations in the results from complete
contraction to the point when doubt arises, a point that is frequently
arrived at even with the Wassermann.

In this connection I would mention an interesting case which
I saw fourteen days ago for the first time.

The man, aged 23 years, had just got over an attack of gon-
orrhea, but felt unable to follow his occupation on account of dis-
inclination for work and depression. I examined his blood, which

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128 The Archives of Diagnosis

seemed to me to be satisfactory, and I gave him a good nerve tonic,
but without any benefit. I again tested his blood with the am-
monium chlorid, but this time the resuh was marked and I forth-
with injected lo c.c. of distilled water under his skin, and ordered
him 30 minims of colloidal mercury. He returned in three days
for a second injection, when his appearance had altogether changed,
and his depression had disappeared. So much did he feel better
that he was arranging to go back to London on the following day.
I usually inject 10 c.c. of distilled water twice a week for six
weeks and then give a rest.

FACTS AND FALLACIES CONNECTED WITH THE
CLINICAL PATHOLOGY OF THE ACETONE BODIES
By HEINRICH STERN
New York
While in many instances of acidosis B-oxybutyric acid is encoun-
tered in undue amounts, this is by no means the only low fatty acid
that contributes toward the acid intoxication. The other members
of this series, proprionic, valeric, capric, enanthylic, caprylic, pelar-
gonic and capric acids are probably as important in the production
of acidosis as are the members of the butyric acid group themselves.
Furthermore, besides acetone (C,H,0), the ketone yielded by acetic
or aceto-acetic acid, the ketones formed from the successive mem-
bers of the fatty acid series, differing from one another by twice
CHj, undoubtedly participate in the production, or are concomitants
of the clinical pictures that are erroneously ascribed to the acetone
bodies or their direct progenitors. Such ketones are proprione
(CjHiaO) yielded by proprionic acid, butyrone (C,H,,0) from
butyric acid, and valerone (CeH,gO), a product of valeric acid. The
close chemical relationship of the successive members of the fatty
gcid series and that of their respective ketones, and the facts that they
are, to the greater part, volatile liquids which are readily intermisci-
ble and are subject to the same chemical reactions, give strength to
the assumption that one member of the series of fatty acids or ke-
tones may preponderate in a given case, but that it is hardly probable
that these single members are present to the exclusion of all the

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Stern : Clinical Pathology of the Acetone Bodies 129

others. Originating in the organism from practically the same source
or sources and being affected by the identical chemical influences, it
is obvious why more than one of the lower fatty acids and more than
one of their ketones are apt to occur at a time, and why the phe-
nomena of acidosis, which are by no means invariable and uniform,
must of necessity be the result of the conjoint activity, or be the
concomitants of various fatty acids and various ketones.

It is probably true that there is no case of general acidosis in which
acetone or its immediate forerunner, diacetic acid, cannot tbe demon-
strated in the urine; this, however, is no conclusive proof that other
ketones or their corresponding fatty acids are not found associated
with the former. It is simply the readiness with which acetone and
diacetic acid are detected in the urine that has given them a clin-
ical prominence which, in reality, they do not deserve. Were the
other ketones and fatty acids as easy of demonstration, the acetone
bodies and their direct progenitors would not be exclusively held
responsible as the materia peccans or be considered the main patho-
Ic^cal product in acidosis.

While the occurrence of acetonuria may, therefore, furnish con-
vincing evidence of an imminent or already established acidosis, it
is in itself no proof that other members of the low fatty acid series
have not participated in establishing this abnormal state.

Although acetone and other ketones appear very promptly in the
urine, the amount in which they occur therein is no direct or un-
failing indication of the intensity of the degree of acidosis. This
is particularly the case in infants and young children, in whom the
very volatile ketones leave the body principally through the medium
of the expired air. As a rule, long before the ketones can be demon-
strated in the urinary secretion, they have manifested their presence
in the air exhaled by the little patient. Of course, the same series
of ketones is also contained in the air from the lungs expelled
by adult patients with acidosis, but here these substances occur in
infinitely smaller amounts, their greater part being excreted by the
kidneys. A certain quantity of these volatile bodies, especially in
the very young, is also apt to escape through the mouth as one of
the terminals of the digestive tract. In this case, it is very likely
that they have derived from the alimentary canal where they
were producd. The best, and probably the only positive, manner

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130 The Archives of Diagnosis

to determine the presence of ketones in the expired air is by means
of well-trained olfactories. This olfactory testing, at any rate, is
the only clinical method that is at our disposal. The ketones cannot
alone be recognized by the use of olfaction, but their amounts be
roughly estimated by constructing an olfactometer for a given case.*

We find it in the text-books generally that the breath in acidosis
is sweetish, fruit-like. As far as this pertains to the adult, this
is certainly true in a certain proportion of the cases. .In children,
on the other hand, in whom the far greater part of the patholog-
ically increased volatile acids and ketones leave the body by the
expired air, this has always a distinct, and occasionally a pene-
trating, odor of impure rancidity. This odor, to be sure, is far
from being sweetish, and is certainly not resembling that emanat-
ing from fruit or chloroform, A whiff of it, once conveyed to
the olfactory center, will always linger in the memory. This odor
may be likened to that of a mixture composed of about sixty per
cent, of butyric acid, thirty per cent, of valeric acid and ten per
cent, of acetic acid. The proportions, however, are not definite, and
the odor varies within certain limits. In some cases, particularly
when diabetes is present, the odor is not seldom extraordinarily
vile. I must confess that the ketone-laden breath almost overpow-
ered me in a few instances, and in the case of a four-year-old diabetic
girl the odor was so strong and lasting that it still could be noted
in my office hours after she had left. Blessed are diose who, being
compelled to be about such little patients, are not endowed with a
keen sense and appreciation of smell.

This rancid odor is by no means to be ascribed to that caused
by the souring of milk in the stomach. In the first instance, the
odor is solely communicated by the expired air in the preponderat-
ing majority of the cases ; secondly, it has very little in common
with the odor of curdled milk; thirdly, it endures and cannot be

•It is a pity that so many undertake the study of medicine without at-
tempting to uniformly train and develop all their five senses. The most neg-
lected of the senses, as far as their employment in clinical medicine is con-
cerned, is that of olfaction. The average individual, from whom the physi-
cian makes no exception, relegates the important function of smelling to
the dog. deeming himself superior to that what he is wont to call "a dog's
trait." The sense of smell, however, will detect the presence of infinitesimal
amounts of substances which are not at all shown by either the microscope or
the test tube reaction.

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Stern : Clinical Pathology of the Acetone Bodies 131

modified by medicaments introduced by mouth or rectum, and,
fourthly, it is present when the stomach is entirely empty, when
the httle patient had not ingested milk for days and, also, when
there is total abstinence from food.

It seems that only when the pathologic excess of the volatile
acids and the ketones is very great a certain proportion of them
find their way into the urine. When, therefore, the urine of in-
fants and young children exhibits acetone or its progenitors, the
case cannot a priori be counted among the milder ones. Under
such circumstances, one always has to deal with a certain degree
of intoxication. In adult individuals where most of these patho-
logic amounts of fatty acids and their intermediary substances are
eliminated from the economy through the medium of the urine, a
ketonuria is invariably of a far less pathologic significance as one
of similar intensity-degree in infants. Thus, it may happen that
the milder degrees of acid intoxication in children, those cases not
manifesting themselves by pathologic amounts of the acetone bodies
in the urine, are either entirely overlooked or regarded as some-
thing else.

The ketones may also be removed by way of the bowels. In
this case they may be excreted with the feces- or they may be ex-
pelled with the intestinal gases. In all cases in which acetone was
found in the feces themselves, the urine also contained large amounts
of this substance. The occurrence of acetone in the feces seems
to point to its local, its enterogenous, production.*

It has already been stated that the ketones, on account of their
great volatility, are readily absorbed. If their absorption through
the lacteals does not ensue, either a catarrhal affection accompanied
by diarrhea is interfering with it, or the acetone substances are
not yielded until the residual ingesta containing the lower fatty
acids have reached the large bowel. It is my clinical conviction
that a structurally or functionally diseased cecum, hindering the

'Acetone in the stools may be detected in the following manner: The fresh
feces are first well diluted with water, acidified with acetic acid, and then
distilled. The destillate (10 c.c.) is treated with a solution of iodine in
ammonium iodide; this results in the formation of iodoform and a black
precipitate of nitrogen iodide. The latter gradually disappears on standing,
thus rendering visible the iodoform. This test is reliable, as it excludes dis-
turbing factors and sources of error like alcohol and aldehyde.

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132 The Archives of Diagnosis

free absorption of water, is the frequent scat of the formation
and retention of enterogenous ketones.

The observation that the ketones may be expelled with the in-
testinal gases was made by me. Their presence can clinically only
be demonstrated by the sense of smell. A decided ketone odor in
the intestinal gases I have noted in three diabetic children, aged
five, nine and ten years, respectively. The expired air and the
urine of these patients contained large amounts of acetone and
its associated substances.

In other cases, the intestinal gases also contain ketones. However,
their presence is not as readily discernible, as they are admixed
with the other gases of fermentation and putrefaction. One can-
not err often by maintaining that the butyric-valeric odor of the
flatus in the presence of ketone expiration and ketonuria is occa-
sioned by the occurrence of the same ketones in the intestines.

While it is likely that the ketones expelled with the flatus are of
enterogenous production, one cannot entirely dismiss the thought
that they may possibly be the consequence of metabolic disturbances
beyond the intestinal wall. The large quantities of acetone bodies
in the expired air and the urinfe of many patients would point to
this. At the same time, it must not be lost sight of the possibility
that many cases of enterogenous acetone production do not concur
with an acetonuria, that the ketones may leave the body at the
termini of the alimentary canal, and that the entire pathologic process
may be confined within the latter. The badly smelling flatus and
stools in such cases may, and often are, caused by the low fatty
acids and their products of decomposition.

KETONES OF ENTEROGENOUS FORMATION
By HEINRICH STERN
New York
For clinical purposes I have subdivided the cases of acid intoxi-
cation into accidental and catabolic types. The former comprise all
the instances in which the ketonuria is of supposedly intestinal
origin, the latter those in which the ketones are assumed to be the
direct or mediate result of incomplete or perverse processes beyond
the stage of anabolism.

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Stern : Ketones of Enterogenous Formation 133

Since the publication of my book on the autotoxicoses,* in which
the pertaining theories and data were discussed at greater length,
very little of import has been added to our knowledge concerning
the ketones and acidosis. This is especially true as regards the acci-
dental or intestinal acetonuria. As to the clinical side of this ques-
tion, it seems almost that the pediatrists are considering it their
exclusive domain. They report case after case, accusing a sup-
posed acidosis as the causative factor of the trouble, but forget or
are unable to furnish positive proof thereof.

Moreover, the clinicians are not at all certain whether an acute
acid intoxication, to which the various non- diabetic symptom-
complexes in children are ascribed, is of enterogenous or catabolic
production. Some even go so far as to deny the possibility of the
intestinal origin and the localized activity of the materia peccans,
but apply just the same remedies, they claim with success, which
do not exert any influence at all beyond the intestinal wall..

Of course, it is clinically not always discernible where the in-
testinal production of the ketones ends and their catabolic forma*
tion begins. Moreover, it is quite feasible that certain instances
of ketonemia may be due to an association of intestinally and
catabolically developed substances.

A differential diagnosis may sometimes be entertained on the
basis of the following points :

Inlestittal Acidosis. Catabolic Acidosis.

Age. Mostly in infants and Most frequent after

young children. middle life.

Mode of on- Frequently by some form Gradual,
set. of gastrointestinal de-

rangement.

Duration. More or less transient, but Mostly lasting like its

tending to recurrence. substrate.
Ceasing with the under-
lying disorder.

Chicago,

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134 1'iiE Archives of Diagnosis

Intestinal Acidosis. Calabotic Acidosis.

Significance. Perverse disintegration and Alkali deficit in tissues;

excretion of fatty sub- (anomalous) disinte-

stances in alimentary gration of body fat.
tract.

Body 1

:ight. No, or no marked, inHw Gradual loss,
ence.

Alkali ther- Not producing any
apy. provement.

- Exerts little or no inilu-

Second- Headache, languor, depres- Peculiar dyspnea, apha<
a r y p h e- sion, vertigo, vomiting, sia, stupor, fatal coma,
nomena. epileptiform states.

Acetonemia of intestinal origin is by some considered to be an
affection sui generis. Whether such an acetonemia is the cause,
or the concomitant or the effect of a certain symptom-complex
with which the pediatrist is confronted, is a question that must be
decided in each and every instance. Personally, I believe that this
acetonemia may sometimes be the etiological factor, at other times
an associate phenomenon of a syndrome, and still at other times
the result of the pathologic process underlying the entire dis-
turbance.

By intestinal acetonemia, which, with less justification, but for
convenience sake, may also be called intestinal acidosis, I under-
stand a condition in which ketones and allied bodies in a preformed
state have, on account of a deficiency on the part of the liver,
found their way into the general blood stream. These ketones,
their associates and progenitors arc rather innocuous in themselves.
They are elaborated in the intestines and may act therein as local
irritants. In small amounts they are probably of physiologic oc-
currence, and the presence of traces of acetone in the urine may
be and has been considered a normal phenomenon. It is their over-
production in the intestine with which we have to deal at this
moment. The ketones are very readily absorbed from the alimentary

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Stern : Ketones of Enterogenous Formation 135

tract. In case comparatively large amounts of these substances are
quickly taken up and carried to the portal circulation, the autoprotec-
tioti of the organism against enterogenous substances, be they
poisonous or excessive in quantity, may fail. The absolutely healthy
oi^nism is equipped to dispose of these products by various means,
no matter whether they are the result of normal or pathologic
processes.

First. — Some enterogenous substances — prior to absorption —
leave the body in the gaseous form at the distal ends of the ali-
mentary canal, others are excreted with the feces.

Second. — A niunber of intestinal substances are converted into
innocuous material, in which form they are either transmitted to
the circulation or are excreted with the feces.

Third, — The normally functionating liver prevents from enter-
ing the general circulation or transforms into innocuous compounds
such enterogenous (toxic) material which has traversed the in-
testinal mucosa and found its way into the portal circulation.

Fourth. — The antibodies circulating in the blood may cause at-
tenuation or inactivity of the toxic matters conveyed to the blood.

The last mentioned autoprotective means of the organism is with-
out effect as far as the ketones are concerned. On the hand of
the other three possible modes of autoprotection, it is clearly evinced
that in the last instance no intestinal substance can enter the gen-
eral circulation when the liver function is efficient and faultless.

The first autoprotective eventuality, namely, that an enterogenous
substance may leave the body in a gaseous form at the distal ends
of the alimentary tract, or may be excreted with the feces, cer-
tainly seems to apply to the incompletely or improperly converted
fatty acid products. The ketones, particularly in infants and young
children, may be exhaled by the mouth and may be expelled to-
gether with the intestinal gases or the feces. When contained in
the expired air, the ketones are probably of catabolic origin in
the majority of the cases ; when the odor of the combined ketones
comes from the mouth while the patient holds his breath, these
may have been derived from the alimentary canal, and this is
doubtlessly the case when the ketones are contained in the flatus
or the feces alone. By the direct expulsion of these substances from

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136 The Archives of Diagnosis

the gastrointestinal tract the body protects itself against their pos-
sible local and general influences.

The second autoprotective measure, according to which certain
intestinal substances are converted into harmless material, in which
form they are either transmitted to the circulation or are excreted
with the feces, is also of importance as regards the great bulk of
low fatty acids that are evolved during normal digestion, or which
are rapidly produced when certain nutriments are ingested or dur-
ing certain pathologic processes implicating especially the gastro-
intestinal apparatus.

The fatty acids of low molecular weight are normally, to some
extent, transformed into gases like COj,N,CH„ and H; the re-
maining acids, neutralized by fixed and volatile alkali, are absorbed,
after which they undergo oxidation.

Very little of a definite nature is known of the pathology of
the low fatty acids that are produced enterogcnously. These acids,
though neutralizable, are neither emulsifiable nor saponifiable.
About their fate in the organism, in case they should not have
been rendered absorbable, we possess but very meager and vague
data. We know that the volatile fatty acids are always present
in the stools of infants with pronounced acid reaction, but the
fecal acidity is never of such high degree as to account for the
total low fatty acids that are generated in the alimentary tube of
a milk-fed baby. (Besides, a certain proportion of the fecal acid-
ity is undoubtedly caused by the intestinal micro-organisms whose
number and activity are often pathologically increased in many of
the alimentary disturbances of infantile life.) Moreover, it stands
to reason that but a certain proportion of these acids, when keton-
ized, leave the body, partly in a gaseous form and partly combined
with the feces. There is, hence, nothing left but to assume that
while in the pertaining cases the low fatty acids remain in the
bowel, where they combine with fixed and volatile alkali as long
as there is a supply of these, and where they are split up in
various ways, the volatile ketones, one of their disintegration
products, for reason of their free and rapid diffusion, are in a
measure enabled to enter the portal circulation. It is here, now,
that the third and most important autoprotective reaction, that due
to a well functioning liver, should be displayed, for this, be it

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LuDLUM : Acidosis 137

on account of a special property or on account of the mere presence
of glycogen within its cells, accelerates the breaking down of the
ketone bodies.

The liver, failing in its ketone-splitting function, can no longer
prevent the transitory flooding of the blood stream with ketone
substances. The alkali supply of the tissues and blood, so it ap-
pears, has nothing, or but very little, to do with the neutralization
or disintegration of the ketone substances that already existed
before they were transmitted to the blood current.

ACIDOSIS

By WALTER D. LUDLUM

Assistant Pediatrician, Kings County Hospital ; Attending Physician, Kingston

Avenue and Seaside Hospitals

Brooklyn— New York

Acidosis is a condition showing itself to be of great and con-
stantly more obvious, if not greater, importance, and yet the word
has been used variously and has not a distinct and universally
known significance; therefore, a definition is in order; the fol-
lowing seems fair:

Acidosis is a condition demonstrated by the presence of acetone
in excess and diacetic acid in the urine, thus su^esting their pre-
existence in the blood and tissues. At the present time, it is not
even known, so far as I know, whether these and allied substances
are responsible for the symptoms seen or are mere indices and
concomitants of the actual causes. At least, it can be said that
these two substances and Beta-oxybutyric acid are present in such
states of acidosis and are our easiest index to its occurrence.

What is the source of these bodies? Beta-oxybutyric acid is
CH,— CHOH— CH,— COOH.

This oxidizes readily to: Diacetic acid, which is CH, — CO—
CH»— COOH.

And this, in its turn, to : Acetone, which is CH, — CO — CH,,

Diacetic acid is made up of two molecules of acetic acid by
dehydration, thus: CH,— CO— |OH— H| — H,C— COOH.

One might, and, indeed, must, go far more deeply into the chem-
istry to have a reasonable understanding of this subject, but this

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138 The Archives or Diagnosis

is too abstruse for hasty and oral presentation and the above will
suffice for our present purpose.

These acetone bodies, as they are often conveniently termed, may
be formed from any of the three types of food materials: from
the carbohydrates they seem not to come as a pathological fact;
from the proteid materials, by way of the amino-acids, they may
be and, probably, sometimes are, but their main source is appar-
ently the fatty acids.

Acetone is a normal constituent of the urine, but in minute
quantity and as an indication of acidosis it is present in excess;
oxybutyric acid is an intermediate product in the catabolism of the
fatty acids, while diacetic acid is an irregular and adventitious
product. Whatever the real cause of acidosis, the presence of these
bodies in the urine would at least indicate an inadequate oxida-
tion of, usually, the fatty acids, by reason of a deficient supply of
alkali. The condition occurs usually where there is an insufficient
supply of carbohydrate or inabihty to utilize it, and this means
a great variety of conditions such as malignant growths, starva-
tion, post-operative, etc., but in children chiefly cyclic vomiting and
other recurrent disorders.

If we accept as a definition of acidosis the mere presence of
these bodies in the urine, it is interesting to note how often this
takes place with apparently entire unimportance; it would be in-
teresting to have frequent investigations made to learn how often
they are found and what, if any, are the regular associations of
their presence. One report of this kind I read with great inter-
est, by Frew, in The Lancet. Summarized, it is as follows:

The urine of 662 unselected cases was examined ; of these, 408
cases, or 61.6 per cent., showed acetone at some time; of these, 2
cases were diabetic coma; 150 (22.5 per cent.) were gastroenteric;
256 (38.5 per cent.) unaccounted for under ordinary headings.

The most constant time for the occurrence of the acetone was
36 hours after admission, and it was always gone by the fourth
day.

The system of the body affected by the disease seemed to have
no influence, whether gastroenteric, pulmonary, etc., nor did the
particular disease, except that in typhoid it was very low, only
15.3 per cent.

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LxmLUH : Acidosis 139

The age incidence was interesting; acetone was found in chil-
dren under two years in 47 per cent,; over two years in 68 per
cent.; under one year of age it was found in 41 per cent, of the
cases. The maximum was between three and four years, namely,
84 per cent.

Of II breast-fed babies put on cow's milk, all developed acetone,
which cleared up in three days, while of 38 under one year bottle-
fed only 6 (15 per cent.) did.

He called attention to the following observations: That ace-
tonuria occurred after admission ; that it was more frequent in
children over 2 years with a change of diet in the direction of
simplicity, arid that it was not affected by the disease suffered.

He drew the following conclusions : That acetonuria is common
in childhood ; that it is due to carbohydrate starvation, usually
caused by failure of digestion, not by lack of supply; that this loss
of digestive capacity may be due merely to change of diet; that
it is more easily caused the younger the child ; that three days are
required for the acconunodation of digestion ; that disease has little
effect.

This paper was not designed to be a detailed presentation of the
theory of acidosis, but merely to emphasize it as a subject of prac-
tical importance and to intimate again, perhaps, that often that
is found which is sought. This practical part may occupy small
space as compared with this introduction, intended only to lead up
to it.

I shall not give detailed histories of cases, but merely use some
as illustrations of the points which seem to me of interest and
importance.

A girl of four, typical cyclic vomiting, nothing unusual in the
attacks, diagnosis long made, attacks occurring irregularly, but at
intervals generally between six and twelve weeks; child always
thin, never a hearty appetite, -attacks moderately severe, lasting
about three days with vomiting very frequent. For four weeks a
fairly close regimen had been carried out; then she went out of
town and an attack promptly followed. What was the cause?
Change and excitement? At least, it is to be observed that at-
tacks are frequently thus precipitated. On strict diet and other

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I40 The Archives of Diagnosis

treatment she has Had only one mild attack in six months, but
she does not grow fat, not even decently.

A baby of ten months, nursed four months, fed since mostly
on malt soup mixtures by one of the most eminent pediatrists;
growth slow, weighing i6)4 pounds from a birth weight of 8
pounds. Home from the country a week, no change in fonnula
or the milk. Patient has been vomiting two days, bowels were
mildly disturbed the day before being first seen, but were per-
fectly good tfiat day; temperature, loi deg. F. ; presumptive diag-
nosis, indigestion. Vomiting continues when on barley water only,
not very frequent and violent, but enough; bowels good. Acetone
and diacetic acid were found; diagnosis: recurrent or acidemic
vomiting. The return to normal diet was very slow.

A girl of four years, sick two days with a little fever and a
mild sore throat, but with persistent vomiting for thirty-six hours ;
no history of a previous attack of such vomiting. Examination
shows a definite follicular tonsillitis, clean tongue, temperature of
loi deg. F., no other abnormality on direct physical examination.
I suggested to the attending physician that, if it were not for the
tonsillitis, I should call it cyclic or acidemic vomiting; acetone and
diacetic acid were found, alkaline treatment instituted and the
condition subsided in twelve hours.

A boy of four years, under my own care from birth ; practically
always well and well nourished. One attack, a year ago, of bron-
chitis with little fever and an abnormal amount of vomiting. Six
weeks ago bronchitis with persistent vomiting all the first day;
bronchitis severe, diffuse, moist, but after two days taking on a
mildly asthmatic character, scarcely any fever. Now another at-
tack of bronchitis coming on very suddenly, from being nearly well
he is prostrated in a couple of hours, looks seriously sick, tempera-
ture only loo deg. F., diffuse rales over one lung, few in the other,
in the "full" lung they are moist, some of the other are asthmatic.
Acetone and diacetic acid are present ; main treatment is alkaline.

When we find recurring attacks of any condition in a child
from two to ten years of age, less often below or above those ages,
especially if it be recurrent vomiting or bronchitis, and particularly if
the latter has an asthmatic character, it would be worth while to
look for acetone and diacetic acid.

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LTn>LUM : Acidosis 141

If we find persistent vomiting even without a history of previous
similar attacks, without adequate cause, with normal temperature
or slight elevation, with prostration disproportionate to the other
symptoms, even if there be present some definite lesion as tonsillitis
or bronchitis, an acidosis may be suspected and sought.

Neither from observation nor reading have I been strongly im-
pressed with the idea that acidosis was an infection toxicosis, though
this is suggested by several. It seems, without question, a metabolic
disorder due to inherent predisposition brought out by diet un-
suited to that predisposed capacity, with perhaps — or occasionally —
an incidental disease.

On this basis the treatment is as follows : With all due regard
to the fact that all kinds of food may be the origin of these
acetone bodies, they seem to come usually from fat, especially but-
ter-fat; occasionally from proteid. Sugar seems to facilitate their
formation, while starch inhibits it. Therefore, a diet from which
eream is eliminated, meat is greatly reduced and sugar reduced to
a minimum, serves to prevent the condition. The chief difficulty
with this is that so little is left, and I confess to the trouble I find
in keeping these youngsters fattened. Having cut his fare to this
minimum diet, one should carefully try out increases and endeavor
to learn the specific capacity of the individual case.

Medicinally, the treatment Ues in alkaline medication; bicarbon-
ate of soda typically or sodium or potassium citrate with at times
salicylates. These measures seem to work. It is almost superflu-
ous to mention the virtues of fresh air, baths, rest and exercise
properly adjusted with emphasis on the rest, climate and all hy-
gienic measures ; lack of excitement and undue activity is important.

Not to speak of them as conclusions, we might make the fol-
lowing suggestions :

That acidosis, or acetonemia, is a common condition in childhood.

That the transient presence of acetone in the urine is often
unimportant, but yet definitely significant ; at other times it is both
important and significant.

That acidosis occurs in childhood most often in conditions with
a tendency to recurrence.

That it will be instructive and interesting to watch for it and
find as fully as possible its associations and significance.

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142 The Archives of Diagnosis

A CLINICAL STUDY OF A CASE OF ACIDOSIS

By GEORGE F. LITTLE

Assistant Oinical Professor of Pediatrics, Long Island College Hospital;

Pediatrician, Kings County Hospital; Consulting Pediatrician,

Mercy Hospital, Hempstead. Long Island, and the

Brooklyn Children's Aid Society

Brooklyn — New York

This child has been under my constant care and supervision since
birth, and an excellent opportunity has thereby been afforded for
the study of the manifestations of acidosis.

Boy — four years and nine months of age.

Past History. — Grandparents n^^tive. Parents alive and well.
No inherited disease or dyscrasia. Prolonged labor, some sixty
hours before sufficient dilatation was secured to permit rotation
by forceps from an occiput posterior position. Owing to shock,
breast milk was insufficient during the first ten days, then failed.
Through nutrition difficulties, in intensely hot weather, the infant
showed a considerable degree of malnutrition, but was brought to
normal condition in the first three months.

There have been no illnesses of note, except pertussis. Surround-
ings, as to care, diet and hygiene, have been ideal. The bowels have
been regular.

Present Condition. — Robust health. Height, three feet, eight and
a quarter inches. Weight, fifty pounds, two ounces. Some two
and a half inches and nine pounds above the average for boys at
five years. The child is active and muscular, with an unusually
bright mentality ; he is of nervous temperament.

History of Acidosis. — At about two years of age, there was an
attack of uncontrollable vomiting, with rise of temperature, lasting
some six hours. At the end of twenty-four hours, nourishment
was retained, and the little patient was as well as ever in three days.
At the inception of this illness, dietary errors were probed for, but
could not be found. There had been two previous attacks of sim-
ilar nature, at intervals approximating two months, without dis-
coverable etiological factors. The so-called cyclic, recurrent or
periodic vomiting was, therefore, suspected and a specimen of urine
was secured in the first day of this second recurrence. There was
a showing of diacetic acid and acetone.

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Little: Clinical Study of a Case of Acidosis 143

For the succeeding two years there were vomiting attacks, in
cyclic form, the intervals approximating two months, except that
frequency was increased during pertussis, which lasted through the
summer of 1913. Beginning with the summer season of last year,
the periodic disturbance has become more frequent, in spite of
treatment; intermissions for some time being about three weeks,
and once but two weeks. Recently the attacks are seen four to
five weeks apart. With this change in frequency there has been
a change in symptomatology in most of the recurrences.

Character of the Usual Attacks. — Until the later period just
mentioned, the prodromal symptom was nausea. This was shown,
in younger days, by partial refusal of food at one meal, entire re-
fusal at the next, if offered. The little patient would state that he
"felt sick in his throat." Later, with increasing powers of ob-
servation, the hand would be placed over the epigastric region to
locate the place of sickness. After a somewhat varying time —
more often ten or twelve hours after the first sign of nausea —
active and uncontrollable vomiting supervened; this manifestation
lasting around six hours. The stomach was emptied in the hrst couple
of efforts, but, for perhaps two hours, further efforts at emesis
were made at intervals of about ten minutes, productive only of
small quantities of bile-like fluid. Periods of rest, in the succeed-
ing few hours, gradually lengthened — fifteen, twenty, thirty min-
utes — with cessation of vomiting in the average time limit men-
tioned. Nourishment, commenced in very small quantities, could
usually be retained about twenty-four hburs after the initial nausea.
Fever was regularly present, mainly during the first day — loi
d^. to 104 deg. F. The patient was normal again in activities
around three days from the beginning of the illness — except that
the appearance showed, and the scales proved, a loss of weight of
several pounds. This was generally regained in a week. Preceding
an attack the bowels have usually been somewhat loose for a day.
After the acute symptoms there is constipation for several days.

It is interesting to note that, in all the past history, the prodromal
nausea has invariably been followed by active vomiting, except that
in the last three months there have been two occasions where the
nausea has been followed only by slight malaise, for a day or two,
where the major attack, in other words, seem to have aborted.

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144 1'h£ Archives of Diagnosis

A Change in the Picture. — That the symptoms preceding stom-
ach involvement may, in some cases, be of a respiratory type is
recognized — coryza or asthmatic manifestations appearii^. I have
not, however, met with a case, in practice, or in literature, where
the development of these symptoms has been so alarming as in
two or three of the recent attacks in the child under discussion.

Early in the summer of 1914 there was the onset of what was
apparently an ordinary cold — rhinitis one day, bronchitis the next
The patient was restless and feverish during the third night, with
some acceleration of respiration. In the morning the general pic-
ture gave an opportunity for figuring that the bronchitis had rather
suddenly invaded the small tubes and probably had reached the
alveoli. The temperature was 103 deg. F., the pulse 140, respira-
tions 55, shallow, labored, irregular. Cyanosis showed on the
face and under the finger nails. There was marked dyspnea, with
recession of the chest wall, above the clavicles, on inspiration. The
physical signs were indefinite. Active measures of treatment were
instituted for relief of congestion — full catharsis, steam inhalations
every two hours, mustard jackets, covering the whole thorax, every
six hours.

The condition maintained, practically unchanged, throughout the
day and early evening; there was then a change for the better, the
respirations falling to 35 within an hour, with increase in depth
and regularity. Vomiting set in for the usual period. The child
was convalescing in the morning, with the respiratory tract in
normal condition. The urine showed acetone.

An attack, of similar nature to the above, showed itself several
weeks later, but was somewhat milder in its manifestations. Early
in October, a recurrence of the same type supervened with symp-
toms, on the part of the respiratory tract, more alarming than
those first noted. Following a coryza and a laryngitis, the boy for
thirty-six hours presented the picture of an overwhelming pneu-
monia. Temperature 104-104. 5 deg. F., respiration averaging 60 —
urgent dyspnea and cyanosis. Dr. Thomas R. French and Dr.
Elias H. Bartley saw the case with me ; both admitted the picture
to be one of pneumonia, rather than of asthma, although the nu-
merous rales of all kinds in the chest were more indicative to Dr.

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Little ; Clinical Study of a Case of Acidosis 145

Bartley of the latter condition. At the end of the period spoken of,
the respiratory symptoms cleared up, practically within an hour,
and a period of vomiting supervened.

A month later, the child showed a coryza, followed by a laryngitis
and then by a frank asthma, of mild type, and of only a few hours'
duration — followed again by the vomiting.

Attacks since this time have been preceded by the coryza and
laryngitis, but have been free from other respiratory symptoms —
except that the most recent recurrence assumed the old type, with
absence of any respiratory involvement. It is notable that, while
intervals have been lessened of late, the severity of the gastric crisis
has been modified, there perhaps being only some half dozen vomit-
ing spells, extending over a period still approximating six hours.

Treatment During Attacks. — At the first suspicion of onset, I
have given one and a half to two grains of calomel, followed in
a few hours by a tablespoonful of the milk of magnesia — this latter
has often been refused on account of increased nausea, and if forced
would not be retained. In the recent periods, where nausea has
been preceded for a couple of days by respiratory involvement, it
is possible to push alkalis. Twenty grains of sodium bicarbonate,
Squibb, are given, well diluted, at hourly intervals. As it is natu-
rally inadvisable to alkalinize the gastric juice during stomach diges-
tion, perhaps half a dozen of these doses can be exhibited in a day.

The little patient is given ice-water, or preferably seltzer, in small
quantities, but very frequently, during the vomiting, for thirst is
pressing and even though the liquid be not long retained, it serves
in a measure to wash out the stomach and makes emesis easier.
When the seltzer is not objected to, a little soda is added. Small
pieces of ice in the mouth are grateful ; in younger years the ice was
wrapped in a piece of gauze, the distal ends held by the nurse. In
several of the sharp and more prolonged attacks, soda solution, one
drachm in four ounces of water, has been placed high in the rectum,
at four-hour intervals. Hypodermoclysis has not been found neces-
sary.

When emesis ceases, and it is found that a tablespoonful of water
is several times retained, an equal quantity of skimmed milk is
offered — this has been peptonized by the warm process for ten min-

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146 The Archives of Diagnosis

utes and is given ice-cold at half hour intervals. Toleration being
shown by a few feedings, the quantity is doubled for several occa-
sions, then for several more two ounces an hour are offered — fol-
lowed by four ounces at two-hour intervals. Zwieback, or a
cracker, light cereal gruels, a little vanilla ice cream, soft egg and
toast are added to the diet, as indicated, in the next couple of days,
and in the order mentioned. One-third to one-half of the cream is
added to the skim milk on the second day and peptonization some-
what reduced. Cold peptonization suffices on the third day, with
two-thirds, or full, cream. Return to full diet is customary on
the fourth day, sometimes a little earlier in mild attacks.

Interval Treatment. — Fats and sugars, in the diet of the boy, have
been reduced as much as is consonant with physical demands for
sustenance and growth. Regularity of the bowels is insisted upon—
if a day passes without a movement, an enema is given at bedtime,
or a glycerin suppository inserted — a laxative by mouth is ex-
hibited at the same time; milk of magnesia, a tablespoon ful, or
phenolphthalein, grains one and one half. This latter drug is put
up, by one of the manufacturers, in chocolate tablets, of this
strength. These may be divided for younger children and crushed
— ^the older child eats them with avidity.

As for medication, sodium bicarbonate is given twice a day in
ten-grain doses. The taste of this, in solution, is likely to be ob-
jected to at first, but the distaste is soon overcome. The drug
may be given in seltzer or vichy, which entirely disguises the flavor,
A few days' intermission is allowed now and then. The solution
is given between meals.

In accordance with a suggestion of Kerley,* sodium salicylate,
from ol. gaultheria, was alternated, for several months, with the
bicarbonate. Four grains of the former drug was given twice a
day, in solution, with a little peppermint water added, for a period
of five days. The alkali following for ten days. In this case, no
beneficial results were noted.

All general hygienic measures for the maintenance of good physi-
cal condition are faithfully observed.

•Practice of Pediatrics.

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SuiTHiEs: Diagnosis of Gastric Ulcer 14;

A SUMMARY OF THE ESSENTIAL POINTS IN THE

DIAGNOSIS OF GASTRIC ULCER

By FRANK SMITHIES

Chicago, 111.

I. FACTS DETERMINED PROM HISTORY

(a) Frequently dietetic or hygienic irregularities. Males are
more frequently affected than are females.

(b) History of recurring acute infections (la grippe — tonsilHtis,
exanthemata, etc.). Seasonal relation of distress not uncommon,
exacerbations occurring in tall or spring.

(c) Association with disease of appendix or gall-bladder (with
which ulcer, especially in subjects below 30 years of age, is often
confused).

(d) Periodicity of complaint; occurs in from 75 to 85 per cent.
of instances until complications set in. Between "spells" or "at-
tacks" of indigestion, so called, there is generally good gastric
health. Weight is not infrequently lost during attacks, and rapidly
gained when such cease.

(e) Epigastric distress; present in more than 95 per cent, of in-
stances. Varies in severity from discomfort to severe, gnawing
or cramp-like pains. Discomfort has point of maximum location,
subjectively, in practically 3 out of 4 cases. Pain has usually
reached its height within four hours following meals. Pain comes
on sooner post cibo in ulcers located near the cardia than where
such are well toward the pylorus.

(f) Food relief of distress occurs in four out of five instances
of peptic ulcer of the uncomplicated type. Relief of pain fre-
quently bears relation to amount of food taken, i.e., a large meal
gives longer relief than a small one. Pain is also relieved by
vomiting, the taking of alkalies, by rest, diet and opiates.

(g) Vomiting occurs in more than two-thirds of instances ;
vomitus usually comes on at the height of gastric distress and
when acidity is highest. Vomitus of food that has lain in the
stomach longer than six hours ("delayed vomit") increases as com-
plications (stenoses or perforation) develop. Pyrosis, water-brash,
eructations and sour belching are common on ordinary diet.

(h) Hemorrhage (hematemesis or melena) occurs in from 30

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148 The Archives of Diagnosis

to 40 per cent- of instances. While hematemesis is more frequent
than melena, yet melena alone may occur wholly irrespective of
the location of the gastric ulcer. Severe hemorrhage is accom-
panied by sign of shock and collapse.

n. FACTS ELICITED UPON PHYSICAL EXAUINATION

(a) Patient usually well nourished without toxic or cachectic
appearance, imless pyloric stenosis or "hour glass" contraction has
occurred.

(b) Area of epigastric tenderness in region of pyloric half of
stomach. This is usually in the mid-epigastrium, but not neces-
sarily so. The area is most frequently definitely local where acute
or chronic perforation has taken place, A tender ridge may some-
times be palpated where a large chronic ulcer exists.

(c) Dilated, splashy stomach occurs where marked pyloric spasm
exists or stenosis has taken place. If this is excessive, visible
peristalsis (and rarely "reverse" peristalsis) may be noted.

III. FACTS ELICITED BY LABORATORY EXAMINATION

(a) Test meal — motility interfered with in more than 50 per
cent, of instances. Gastric acidity increased as regards free hydro-
chloric acid in the majority of non-stenosing ulcers. In stenosing
ulcers, with dilatation of the stomach, while free hydrochloric acid-
ity may not be much above normal, the total acidity is increased
in greater ratio. Blood may or may not be present in gastric
extracts (macroscopically or by chemical test). Lactic acid is a
rare finding. Pepsin and rennin are frequently increased.

Microscopically where gastric dilatation has occurred, fermenta-
tive changes are proved by the finding of great numbers of bud-
ding yeasts and of sarcinae (large and small types), together with
remnants of retained food.

(b) Stool — may show nothing pathologic. Recent hemorrhages
generally result in the passage of "tarry" stools for several suc-
ceeding days. Perforation of an ulcer to the pancreas not infre-
quently results in pancreatic inefficiency with passage of stools
containing undigested food or ferment abnormalities.

During periods of the ulcer's activity, if the patient is kept
upon meat-free or milk diet for several days, at the end of such
time the stool may be shown, by chemical tests (benzidin or

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Smithies: Dlacnosis of Gastric Ulcer 149

guaiac), to contain blood. Progressive ulcers or ulcers undei^;D-
ing cancerous change generally show blood constantly in the stools
by chemic tests,

(c) X-ray findings. In many instances of uncomplicated ulcer
no facts are returned after most careful examination by both fluoro-
scopic or plate methods. Complicated ulcers (stenosing, calloused,
hour-glass-producing, perforating, etc.) are recc^nizable in nearly
three out of four instances by the combined screen and plate
methods.

A dependable clinical technic is as follows:

Empty the gastrointestinal canal by the administration of 2 ounces
of castor oil in beer or malt extract.

Give a "Motor opaque meal," consisting of 2 to 4 ounces of
barium sulphate (pure) or of bismuth subcarbonate in 6 to 8
ounces of cream of wheat, oatmeal, wheatena, or the like, at 4 a.m.

Six hours following examine, by means of the fluoroscopic screen,
to locate the position of the motor meal. The presence of the
opaque mixture in the stomach usually indicates anatomic inter-
ference with the onward progress of the food or furnishes evi-
dences of gastric atony. Plates may be made at this time for
purposes of recording the position of the motor meal.

A second meal, for purposes of studying gastroduodenal contour
and activity, is next given. This consists of 2 to 4 ounces of barium
sulphate or of bismuth subcarbonate in 16 to 24 ounces of butter-
milk, fermillac or potato purie.

While the patient is taking this second meal the stomach is ob-
served by means of the fluoroscope. Palpation is carried on and
ttie patient examined in various positions. If suspicious contrac-
tures, peristaltic waves or other abnormalities appear, the patient
should be reexamined on several successive days, before and after
the administration of such antispasmodics as atropin (gr. 1/50 hypo-
dermically) or tr, belladonna (gtt. xv every 3 hours for a day).
This procedure aids in demonstrating the constancy or the tran-
sience of a local sign. Plates (frequently taken with the patient in
different positions) may be next made for purposes of leisure
study or for permanent record of positive or negative results.

When present, briefly, the X-ray findings in gastric ulcer are:

L Positive signs. The "niche" or "accessory cavity" indicating
calloused, penetrating ulcer.

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150 The Archives of Diagnosis

II. Corroborative signs, (a) "Incisura," i.e., local evidence of
halting of peristaltic rhythm by spastic contraction of circular muscle
fibers in the vicinity of an ulcer. Best brought out on screen ex-
amination during or after palpation.

(b) "Hour-glass" stomach (bi-loculation). This may be perma-
nent (callous ulcer, perforation, adhesion) or transient (local
spasm, with or without ulcer), and should always be proved by
repeated examination, with and without an antispasmodic (atropin,
belladonna).

(c) Gastric residue — this may vary in amount. Its constant
demonstration after six hours means atony or stenosis. Intermit-
tently it may result from extra gastric or gastric pathology caus-
ing pyloric spasm, (cholecystitis, appendicitis, etc.)

(d) Fixation of all or part of the stomach (perforation, adhe-
sion, fistula.)

(e) Area of tenderness to palpation usually localized at some
part of the stomach shadow. Should always be checked by re-
peated examination before and after an antispasmodic.

(f) Alterations in gastric peristalsis, e.g., exa^erated peristalsis,
intermittent, frequently associated with spasmodic closure and re-
laxation of the pylorus. Antiperistalsis may be seen on rare
occasions.

THE DIAGNOSIS AND CLASSIFICATION OF DIFFICULT
FEEDING CASES AFTER THE FIRST YEAR

By GODFREY R. PISEK

Professor of Pediatrics, New York Post-Graduate Medical School and Hos-
pital; Professor of Pediatrics, University of Vermont
College of Medicine
New York

Numerous and worthy articles have been written with the object
of making the subject of infant feeding simpler, and describing how
to deal with those pathological infants known as "difficult feeding
cases" ; but comparatively little has been said regarding the diagnosis
and management of patients in the early years of life who, although
free from distinct constitutional diseases, suffer from marked mal-
nutrition.

These children are brought to the physician because they are not

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Pisek: Difficult Feeding Cases 151

as robust as their neighbor's child of the same age; because they
tire easily, because they are under-size, thin and pale. The mother
complains that the child is extremely diflicult to feed, capricious, or
that the food "seems to do the child no good."

On examination they are found to be as a type, mentally well de-
veloped but physically much below the average ; the musculature is
flabby, the chest long and the thoracic capacity much diminished, the
spinal muscles are relaxed, producing a poor posture. They are in-
variably anemic owing to poor oxygenation and constipation. They
prefer to play alone and shun the active amusements of other chil-
dren. The mother further relates that she has tried to force the child
to eat and grow fat, but has not succeeded. Her physician has pre-
scribed "tonics" but without success.

The family physician is just as capable as the pediatrist (to whom
they are so often sent) to care for this type of child. How this may
be done will be indicated in this paper, the object of which is to call
to your attention a neglected field of practice in which recovery is
dependent upon the conversion of food elements into blood and
healthy tissue, and in which stress is laid upon practical hygiene
rather than upon the use of drugs. Particularly must we make this
plea for the child who has a right to begin his life work with a
healthy mind in a healthy body.

The laity are beginning to appreciate that it is- wise economy to
correct minor ills by periodical examinations and systematic feeding
regulations, rather than to await the occurrence of serious illness.
Fortunately, these cases of late malnutrition are less frequently seen
than the atrophic or marasmic artificially- fed babies in infancy; but
when they do occur they often need more study and detailed manage-
ment to attain success than the infants.

In infancy our difficulties mainly arise when we attempt to sub-
stitute artificial food for the human product, and when the attempt
is made to fit the baby to the food, instead of adapting it to the
delicate developing digestive system.

At a later period, when the teeth have erupted and the child has
progressed to the point of taking semi-solid foods, there may occur
as a result of faulty feeding, malnutrition, or even such profound
changes as to put the child's life in jeopardy unless by skilled dietetic
management the vital spark is fanned into life.

The analysis of our case records enables us to group the cases
under the following captions : Those that have been difficult feeding

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152 The Archives of Diagnosis

cases in infancy, and are still sufferers from nutritional disturbances
which prevent them from assimilating foods ordinarily found in a
dietary suitable to their age.

Those that have been fed on an unbalanced ration made up mostly
of carbohydrates.

Those with an inherent intolerance for proteins or fats.

Another type is the child that has made fairly normal progress in
infancy, but who later in childhood remains stationary or slowly
loses weight and vitality. Here the condition often results from in-
sidious dietetic errors. They are said to have idiosyncrasies to
certain articles of food, which prove to be not so much idiosyncrasies
of the child as of the mother; or the whims and fancies of the child
are unduly considered until the dietary is extremely limited. They
are said to have a poor appetite and, therefore, this jaded appetite
is stimulated by misguided, misdirected efforts at meal time of story
telling or amusements. Such cases mainly appear among the neuro-
pathic children of the well-to-do, and among the city dwellers where
outdoor exercise is restricted, but whose access to improper foods is
proportionately great. Even among the poor coming to our hos-
pitals the cause is very rarely due to insufficient food, but it is due
to a poor quality of food, poorly selected, and still more important
poorly prepared.

A close study of the antecedent feeding history, the present dietary
and an intimate knowledge of the daily life is essential for proper
future management.

The physician must inquire not only as to what the child is offered
in his dietary, but what is the child actually getting. This is best
reached by recording the likes and dislikes of the particular child and
the average amounts taken.

Physical examination will disclose the loss of weight, the poorly
developed body, flabby masculature, enfeebled heart and blood, dry
skin and toneless abdomen, of this victim of malnutrition.

The weight should be considered in relation to the birth weight
and the highest weight ever attained.

Examinations of the stools and of the urine are to be made not
only once but on repeated occasions so that the measure of digestion
may be obtained, and in order that we may determine what constitu-
ents of the diet were not used up. As pointed out by the writer in a

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PiSEK: Difficult Feeding Cases 153

previous communication there is no intricate or complicated process
necessary for a practical examination of the stools to determine
suitable treatment.

The children under consideration will show no evidences in the
stools or urine of disease conditions, but they will exhibit marked
changes in their ability to assimilate the various food constituents.
It may be well here to review some of these characteristics. In this
we will also follow the lead of Morse and Talbot, who have made
extensive studies of the child's stools. Grossly we may find large
undigested food masses ; the result of imperfect food mastication or
of food so well comminuted, that the child bolted it wi^out the need
of chewing.

A simple test with litmus paper will give some evidence of the
mal-assimilation of the proteins or the fats. In the former instance
of protein putrefaction, a marked alkaline reaction is obtained, be-
sides the distinct putrefactive odor ; while on the other hand an acid
reaction appears in fat and starch disturbances, accompanied by a
butyric odor if the fats are at fault, or a sour lactic acid odor if it is
the carbohydrates that are causing the trouble.

With the microscope we may further determine by finding an
excess of fatty acids and soaps that the digestion is normal, but that
assimilation is abnormal.

Fortunately, we are also able to elicit much information regarding
the development of the intestinal tract by means of the X-rays;
serial rontgenograms have paved the way to a closer understanding
of the pathological conditions which obtain in many of the cases of
marked malnutrition.

A dilated stomach with or without a sluggish atonic intestinal tract
is found in many of these children, the condition usually being pro-
portionate to the degree of malnutrition present.

It is not our purpose to discuss the treatment here. Suffice it to
say, that the diagnosis once made and the type determined, the cure
is dependent upon a knowledge of the principles of nutrition and the
preparation of foods coupled with a thorough study of each case
individually. Resourcefulness and a knowledge of the preparation
of food is imperative. Food must be supplied that is agreeable,
easily digested, and that still contains the elements essential for
growth and development.

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154 The Archives of Diagnosis

TUBERCLE BACILLI IN STOMACH CONTENTS

Bv I. H. LEVY AND J. L. KANTOR

Syracuse, N. Y.

Recently, while examining the gastric contents of a tuberculous
patient, one of us was struck by the resemblance of the extracted
material to tuberculous sputum. A smear revealed the presence
of tubercle bacilli. Since that time we have succeeded in demon-
strating the organisms in this fashion in two other cases.

As the bacilli in the stomach come from swallowed sputum, it
would seem best, for obvious reasons, to aspirate early in the morn-
ing, while the patient is fasting, and as soon as possible after
arising. On the other hand, the ready demonstration of the or-
ganisms in the presence of food (as in one of our cases) would
suggest the value of examining any available specimen of gastric
contents in tuberculous suspects. There should be no difficulty
in obtaining some contents for examination in every case, provided
an aspirating device is used. Our own technic is to use a short
tube with glass connecting-piece and an Ewald bulb. The bacilli
are easily and beautifully stained by the ordinary Ziehl-Neelsen
procedure. We have been able to show experimentally that the
staining qualities of the organisms are not affected by HCl-pepsin
digestion for periods corresponding to the retention of substances
in the stomach, and that the bacilli can be demonstrated after even
a month's digestion in vitro, provided the staining time is appro-
priately lengthened {15 minutes steaming, one-half hour in cold).
We have occasionally seen a large, plump, acid-fast cocco-bacillus
in the stomach contents — possibly similar to the organism de-
scribed by Smithies* — but this bears no resemblance whatever to
the bacillus of tuberculosis, and should cause no confusion in
diagnosis.

It is not, of course, in ordinary cases of pulmonary tuberculosis
that the method herein described can lay claim to any practical
value as a diagnostic measure. Nevertheless, there seems to be
a fairly important group of conditions in which expectorated sputum
is unavailable and where such a method should be of service. Th«
following applications suggest themselves : { l ) In tuberculosis of
infants and young children, where this method should give results

♦Smithies.— Am. Jour. Med. Sci., Feb., 1915, CXLIX, p. 193.

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Abrahams: Auscultation at the Acromion 155

at least as good as the throat-tickling procedure now generally
advocated; (2) in incipient stages of tuberculosis, where expectora-
tion is absent, and where it is inconstant; (3) in cases of miliary
tuberculosis to supplement the search for the bacilli in the urine
and stools; (4) in all unconscious states, and in tuberculous
meningitis to supplement the search in cerebrospinal fluid; (5) in
tuberculosis in the insane.

SUMMARY AND CONCLUSIONS

1. We have been able to demonstrate tubercle bacilli in the stom-
ach contents of three patients suffering from pulmonary tubercu-
losis.

2. We believe that where expectorated sputum is unavailable (as
in the group of conditions mentioned above) a certain number of
positive diagnoses of puhnonary tuberculosis can be made with the
aid of the stomach tube, as already described.

3. We believe that an early positive diagnosis of pulmonary
tuberculosis can be made more frequently by the gastroenterologist,
should he adopt the custom of searching the fasting contents for
tubercle bacilli in all cases suspected of suffering from the dyspepsia
of phthisis.

AUSCULTATION AT THE ACROMION PROCESS

(memorandum AND REJOINDER)

By ROBERT ABRAHAMS
Adjunct Professor of Medidne, New York Post-Graduate Medical School
and Hospital; Consulting Physician. Manhattan State Hospital
and Home of Daughters of Jacob
New York
Since the publication of my paper on the subject of "Auscultation
at the Acromion Process, its Significance in Apical Disease" (Ar-
chives of Diagnosis, April, 1913) I had the extreme satisfaction to
learn of the indorsement of my views by many workers in the field
of pulmonary tuberculosis. I also had occasion to demonstrate this
special form of auscultation to hundreds of physicians, from all cor-
ners of the country, who come to the New York Post-Graduate
Medical School to brush up the old and ring in the new ol things
medical. And while there were some who catne to scoff, eventually

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IS6 The Archives of Diagnosis

all remained to pray. The ease with which, even the uninitiated,
acquire the art of auscultating the acromion ends of the clavicles is
one of the best arguments in favor of its practice.

Yet once in a while a voice or an echo is heard in opposition to
this method. In order to satisfy the honest opposition, a short re-
view of the subject is necessary.

The trouble with those who find fault with the method is that they
lay stress exclusively on the modified and amplified respiratory
sounds which are heard over the acromion processes. As a matter
of fact, auscultation at the ends of the clavicles will bring out moist,
dry and musical rales which are not obtained by direct examination
of the apices. Friction sounds are extremely rare over the apices
in the early stages of tuberculous infiltration, but are comparatively
frequently heard over the acromion processes. A little practice will
enable one to exclude muscle sound. Strong coughing and forced
breathing may bring out mucous rales over the ends of the clavicles,
but will not over the apices. Now, those gentlemen who honored
me with their adverse criticisms have utterly failed to mention these
immensely superior signs of early tuberculosis involving the upper
parts of the lungs.

Perhaps it may be well to place the normal auscultatory sounds
of the apices in parallel columns ;

RIGHT APEX LEFT APEX

1 broncho-vesicular breathing. i vesicular breathing.

2 clear, well-defined spoken 2 ill-defined spoken voice.

voice.

3 clear and distinct whisper 3 muffled and indistinct whisper

sound. sound.

Now whoever approaches the acromion process should think of
these physiological differences between the two apices. He should al-
so bear in mind the difference between vesicular breathing and
broncho-vesicular breathing, namely, in the first, inspiration is heard
from the beginning to the end, while expiration is only half or a third
of inspiration; in the second, both inspiration and expiration are of

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Abrahams: Auscultation at the Acromion 157

the same duration. In health, these qualities of the respiratory mur-
murs of the respective apices are preserved and continued over the
acromion processes, with the very important addition that they are
amplified, one or two degrees. An exception is often found in the left
acromion process, where the expiratory sound is more pronounced
than the inspiratory.

The spoken voice and the whispered sound are equally modified
and amplified to a degree which would be classed abnormal when
heard over the apices.

Now what happens in disease of the apices? Auscultation over
the left acromion elicits marked broncho-vesicular breathing; louder
spoken-voice and very pronounced whispered sound.

Auscultation over the right apex yields almost tubular breathit^
with distinctly prolonged expiratory sound and unquestionable whis-
pered pectoriloquy.

While these auscultatory phenomena are unmistakably appre-
hended over the acromions, one may at the same time hear very little
auscultatory changes by direct auscultation of the apices. And herein
is the crux and significance of auscultation of the acromion processes
in early tuberculosis of the apices.

But our good friend and careful investigator, Dr. Joseph H.
Barach, says that "between the prominent findings at the acromion
in the normal and the findings in the slightly or moderately diseased,
I believe no one can differentiate with certainty and accuracy." (Ar-
chives OF Diagnosis, July, 1914.) This statement is based upon
an "I beheve."

No one values the work that Dr. Barach did, of which I only
learned lately, in his study of the sound conducting properties of the
bones of the thorax more than I, yet I venture to tell him and others
that the slavery of statistics is not conducive to the mastery of clinical
facts. Live clinical impressions, gathered for years at large clinics
where patients are carefully watched and results scrupulously noted,
have in them a potential and manifest energy that the dry-as-dust sta-
tistics may never hope to possess.

We are told that "50 young men," who submitted to acromion
auscultation, had chests "beyond a doubt perfectly healthy," yet they
showed an amplified breathing at the acromion processes. If they
did, "beyond a doubt" a good many of them had had tuberculosis of

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158 The Archives of Diagnosis

the apices, which show and will continue to show auscultatory
changes in the acromions and perhaps in the apices. For I convinced
myself and others, that just as auscultation at the acromions may
indicate active, so it may indicate passive, or healed, tuberculosis.

I have subjected quite a' number of patients in whom acromion
more than apical auscultation pointed to an early lesion to X-ray ex-
amination ; in some the result was negative yet eventually showed
unmistakable signs of tuberculosis ; in others there were marked
infiltrations, and the wonder was that so few auscultatory signs were
obtained by direct examination of the apex, and in still others, by
far the largest number, there was hyperemia or congestion of the
apex, or as the radiographer would say, "the apex looked cloudy,"
but no ocular evidence of infiltration. For such cases, the incipient-
ly incipient as it were, auscultation at the acromion processes is a
great boon, a great help, a veritable discovery.

A FURTHER PLEA FOR ABRAHAMS' ACROMIAL
AUSCULTATION IN THE DIAGNOSIS OF IN-
CIPIENT APICAL TUBERCULOSIS
By NATHAN MAGIDA
Oinical Assistant in the New York Post-Graduate Medical School and Hospital
New York

I am glad to find -new cause for bringing this subject once
more before the profession. Dr. Joseph H. Barach, in the Ar-
chives OF DiAGHosis for June, 1914, contributed an article in
which he reviewed my paper on "Acromial Breathing as an Aid in
the Diagnosis of Incipient Apical Tuberculosis," which appeared
in the New York Medical Journal of December 27, 1913, and his
conclusions seem to be that we were too hasty in considering this
sign of great value as represented therein.

Before I go any further, I beg to accord to Dr. Barach all
credit due him for his work on "Bone Conduction of Soimd." I
must confess that when I wrote my article I had no knowledge of his
study on the subject.

In the present paper, besides maintaining our position in this
matter, I wish also to give somewhat fuller details in reference
to the use of this sign.

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Magida: Abrahams' Acromial Auscultation 159

It seems to me that Dr. Barach did not consider the matter at
hand from our point of view, his contention being that "Acromial
Breathing" may be elicited in normal cases; that is, the sounds
heard over the apices are more dearly perceptible over the acromial
ends of the clavicle. This is true, and is exactly the principle upon
which we are worlcing. But, neither Dr. Abrahams, in his orig-
inal article, which appeared in the Archives of Diagnosis of April,
1913, nor I claim to make positive diagnoses of incipient apical
tuberculosis whenever we get amplified auscultatory signs at the
ends of the clavicles. What we do claim for "Acromial Breath-
ing," however, is that it is an aid — and a valuable aid — in the diag-
nosis of incipient apical tuberculosis. This has been proved re-
peatedly to ourselves and also to many physicians taking courses
in physical diagnosis under Dr. Abrahams at the Post-Graduate
Hospital.

There is, to my mind, no one sign which can be put down as
positively diagnostic of early tuberculosis. For this reason it does
not seem to me amiss to be familiar with, and use, as many signs
as possible in attempting to make a diagnosis of this disease in its
very early stages. As I stated in my article, this sign is constant
in incipient apical cases, and that is the reason for our ardent en-
thusiasm in the matter. Still, even though we constantly find it
in these cases, that does not mean to imply that we base our diag-
nosis on this sign only. Hence, if, in examining a case, we find,
for example, a change in percussion, and, on listening over the
acromion end of the corresponding clavicle, auscultatory signs are
marked, ample, exaggerated, though no such changes are apparent
by direct examination of the apex, we think that we are justified in
making a diagnosis of incipient tuberculosis. The only difference,
of course, in examining the right apex is that we have to take
into account the normal auscultatory differences between the right
and left apices.

In further proof of the value of this sign in early cases, I wish
to offer the results which we have obtained in a series of X-rays
taken after we had made a diagnosis of incipient apical tubercu-
losis by, or with the aid of Abrahams' method. All these cases had
so very few signs and symptoms that an appeal to the X-ray was
deemed of value as a trial. It must also be kept in mind that the

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i6o The Archives of Diagnosis

changes in incipient apical tuberculosis are usually too slight to show
tangible diagnostic signs on the radiographic field. Stilt, out of 15
cases, 8 were returned as positive, 3 doubtful, and 4 negative. The
following are instances of the findings in positive cases :

1. "The pulmonic fields are of even size, but unevenly illuminated,
there being a clouding of the entire left pulmonic field below the
clavicle, and of the right above the clavicle. There are numerous
small miliary deposits at the right apex, while the vascular mark-
ings of the left upper lobe are seen with unusual distinctness, and
there are evidences of miliary deposits which are confluent in the
left upper lobe. These findings indicate pulmonary tuberculosis
in the first stage." Direct auscultation unsatisfactory.

2. "A radiographic examination of the chest discloses the pres-
ence of a diffuse tuberculous infiltration of both lungs. Both apices
are clouded, and the left chest discloses more extensive lesions than
the right." Acromion auscultation was most pathognomonic.

3. "A radiographic examination of the chest shows a diffused
miliary tuberculosis of both lungs with partial infiltration of the
right apex, wherein are visible numerous calcific foci. The hilum
shadows are large. There is evidence of some dilatation of the
bronchi at the root." Acromion auscultation told the tale.

4. "A radiographic examination of the chest shows evidence of
infiltration of the left apex. The distribution of the lesion is peri-
vascular." Acromion breathing and whispered sound suggested the
diagnosis.

I hope that the above will clearly outline our position in this
matter and that we shall no longer give the impression of mak-
ing this one sign a positive one of tuberculosis by itself. All that
we wish to claim for it, is that it is a very good aid — and helps to
obtain signs which could not be obtained otherwise.

While on the subject, I should like again to bring out the points
to be observed in order to get the full value of this method. The
following has, no doubt, been pointed out by the other gentlemen
who have written on this subject, but I do not think that it would
be out of the way to review them:

I. The bell of the stethoscope used should not be of too large
a circumference, as most of these patients are rather thin in the
acromial region.

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Hays: Ear Complications in Influenza i6i

2. If the bell does not fit snugly over the acromion process so
that all external sounds are excluded, the skin of the surrounding
area should be pinched up on either side of the bell.

3. The patient should be instructed to breathe deeply and not
ncMsily.

4. Examination of the nose should always be made before ex-
amining the acromion process, in fact, before examining the apices,
because patients with nasal obstructions of any kind give exag-
gerated breathing sounds over the apices which are much more
marked over the acromion processes.

5. The heart should always be examined before the apices, as
mitral disease usually gives a certain amount of congestion in this
region somewhat resembling incipient tuberculosis.

6. Most important of all, the apices should always be examined
before the acromion processes, as this method is really a com-
parative one and its full value cannot be appreciated unless the
examiner knows the normal sounds elicited over the apices.

I beg to thank Dr. Seth I. Hirsch, of the Post-Graduate X-ray
T.aboratory, for the radioscopic information.

THE EAR COMPLICATIONS IN INFLUENZA
By HAROLD HAYS
Assistant Otological Surgeon, New York Eye and Ear Infirmary; Assistant
Laryngologist and Otologist, City Hospital, etc.
New York
During epidemics of influenza and during the seasonal period of
the year when influenzal infections are more prevalent, ear com-
plications are frequently seen. These are usually secondary to in-
fluenzal infections of the nose and throat, which often result in
severe inflammatory reactions of the accessory sinuses of the nose
at the same time.

It is seldom, however, that the infection in the ear is caused
directly by the influenza bacillus. In the majority of instances,
the ear condition arises from a general lowering of the resistance,
which allows secondary infecting organisms to penetrate through
the already infected mucous membranes of the eustachian tube.
These organisms, in the order of their inipQy*j^nce, *^^ *^^ strep-

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i62 The Archives of Diagnosis

tococcus mucosus capsulatus, the pneumococcus, the streptococcus
pyogenes, the staphylococcus pyc^enes aureus, and more rarely the
bacillus coli communis, the bacillus proteus, and the Friedlander
bacillus. Whether the influenza bacillus is really present in the
ear infection, or whether it is merely overgrown by the other or-
ganisms, it is hard to say. The influenza bacillus is extremely diffi-
cult to grow except on blood media, and it is possible, therefore,
that it may be present many times, but not discovered.

The ear complications of an influenza may be extremely severe,
depending upon the virulence of the organisms and the resistance
of the patient. In the majority of instances, the patient suffers
from a dulness in the ears, perhaps with sharp shooting pains. The
drum appears normal, but examination with the pharyngoscope
shows a very intensely congested eustachian tube which completely
closes off the middle ear. We thus have what is called an acute
tubal catarrh, which, if taken in time, will resolve very nicely and
result in no complications. The dulness in the ear is caused by a
rarefaction of the contained air within the middle ear cavity.

The treatment of the eustachian tubal orifice at the time when
the inflammatory condition is confined to these parts is extremely
important; and it is possible in many instances to retard the in-
flammation, thus preventing an infection in the middle ear itself,
by timely and proper attention to such parts. Inflation of the
middle ear through a highly inflamed tube, the mouth of which
contains many virulent organisms, is pernicious and unwarrantable.
In such cases it is wiser to treat the cause of the condition and
the inflamed mucosa of the nasopharynx rather than attempting to
force a moderate amount of infected air into a part that is well
closed off by Nature. Once the infection has been retarded, cau-
tious inflation of the middle ear is necessary ; and, fortunately, al-
most all such cases arc cured even when the middle ear symptoms
are ignored for weeks.

In some instances the infection creeps up these congested tubes,
causing an acute otitis media with or without fluid. As I have
just stated, this may be caused by untimely inflation. The ear
drum becomes intensely engorged, but resolves in a great many
cases when proper medication is given to the tube and when the
ear itself is irrigated with hot saline solution. If f^uid is deter-

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Hays: Ear Complicatioks in Influenza 163

mined in a sufficient amount to give pain and deafness, a para-
centesis must be performed. This fluid, as a rule, is light and
straw colored, seldom pus, but usually contains infecting organisms.
The patient is often reheved after incision, but the fluid may
change into pus within the course of forty-eight hours, and the
ear needs careful watching. The change from serum into pus is
frequently due to a reinfection of the middle ear from extraneous
organisms in the external canal which, unfortunately, cannot be
sterilized sufficiently to keep such infection from taking place.
Many times there is a congestion of the mastoid cells with dis-
tinct tenderness particularly over the antrum and tip of the
mastoid. This does not indicate the presence of an acute mas-
toiditis, but is merely an extension of the inflammation by conti-
guity. If a proper incision is made in the drum and the ear
condition resolves, the inflammatory reaction in the mastoid cells
resolves, too. Very often deafness persists for a considerable length
of time, even after the discharge has ceased and all acute symp-
toms have disappeared. This is due mainly ta a thickening of
the drum and to adhesions of the ossicles consequent upon a serous
effusion. Careful attention to this matter usually results in a com-
plete subsidence of the symptoms.

When a purulent discharge takes place and the tenderness over
the mastoid process increases in extent, we have an indication that
some of the infection has found no outlet in the small honey-
combed cells. If the discharge continues to be copious, if there
is a great deal of pain with radiating headache, if there is tender-
ness on deep or superficial pressure which extends posteriorly be-
hind the sinus, indications are present that a mastoiditis has de-
veloped which needs operation. However, many cases are seen with
extreme tenderness over the mastoid where no operation is nec-
essary. The writer recalls six cases of otitis media developing in
one family, at the time of an epidemic of influenza. Three of the
patients had marked symptoms of mastoiditis. One was operated
upon. The other two refused operation and got well, although
every indication was present that resolution would not take place
without operative interference.

The X-ray picture of the mastoid is frequently of great help in
borderline cases. One should not trust to an X-ray picture with-

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164 The Aschives of Diagnosis

out corroborative clinical evidence, of course, but it certainly
makes assurance doubly sure. If a culture has been taken and
the involving organism has been found to be other than the strep-
tococcus capsulatus, one need not be alarmed; for the other bac-
teria, as a rule, do not give serious complications. When com-
plications do occur, such complications demand immediate atten-
tion ; for one may see develop a sinus thrombosis, a brain abscess,
or acute meningitis — any one of which may result gravely.

PERIODIC PHYSICAL EXAMINATIONS

By J. MADISON TAYLOR

Associate Professor of N on- Pharmaceutic Therapeutics, Medical Department

of Temple University

Philadelphia

Occasional, or periodic examinations in one's later years are im-
perative; in early middle hfe essential; in early adulthood of the
utmost importance.

They constitute the chief economic index of inherent resources;
likewise they reveal where retrenchments must be made. No origi-
nal capacities, no specialized faculties, no courageous self confidence,
nor commendable efforts to keep well, can suffice to guard against
the onset of insidious disease.

Nor is it a mark of valor to disregard powers of the enemy. We
walk amid perils. We avoid many, 'tis true, but how pathetic is the
episode of a robust, splendid citizen, falling suddenly by the way-
side, involving disaster to many others ; also important allied interests
either suffer or are jeopardized by his collapse ! The spectacle recurs
constantly. Only rarely need it be.

Reasonable precautions will usually sufRce to prevent such ca-
tastrophes. Especially is this true by foretelling and forestalling
the approach of physical and also mental decrepitude.

Indeed, to become a derelict is almost worse than sudden death ;
which last, after all, may be regarded as a desirable form of exit.

Ramifications of correlated interests must always be considered
No one lives unto himself alone.

There are duties to one's household, one's company or one's claa
which are as binding as duty to one's future state.

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• Taylor: Periodic Physical Examinations 165

For the citizen, father, partner who values sustained efficiency,
who wishes to learn how much of time or opportunity remains and
would conserve these to the uttermost, there is one best means avail-
able, viz.: periodic careful evaluations of physical and mental assets.

By means of periodic examinations it can be determined whether
one actually is the man he believes himself to be. If not, he should
learn and trim his sails anew. Knowing precisely on what he ma;
count, he may then revise methods to his lasting advantage.

If he has overstrained his physiologic credit, a change in course of
living may readily lead to better things.

Definite retrogressions, even beginnings of what would inevitably
result in decrepitude, can usually be delimited, or checked when
taken in time. Nor is this candid seeking to learn what one hopes
may not be, yet really is, in some form or degree, to be construed as
timidity, or over-apprehension. On the contrary it is the mark o!
admirable judgment, and commendable prevision.

Biologic calculations have adduced evidence (however much con-
crete provings are needed) to the effect that man's possible years are
near about 160 provided conduct could be made to accord with
growth forces and survival values.

World thought runs now much toward euthenics ; the science of
inherent resources interpreted in the light of idealized environment
and conformity in conduct to physiologic requirements. Among the
fields of personal investigation easily the first are possibilities of dis-
integrations in the cycle of structures immediately concerned in the
maintenance of life, vegetative existence, breathing, digestion, circu-
lation, elimination of waste matters and the like. This oftentimes
constitutes rescue work, saving leaks heretofore undetected which
may, and will, progress to irreparable losses.

Next in order of economic importance are the organs and struc-
tures of precision which should be conserved whereby proficiency
is maintained, the even tenor of advance so desirable in one's career
and pleasures. The eyes are usually reckoned the primal considera-
tion ; in some it may be the ear, in others the hand ; in all the neuro-
muscular mechanisms.

We must not omit mention of the teeth, which are not only of
exceeding use, but when seriously impaired, especially when wrongly
assumed to be properly conserved, are not seldom causes of far

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l66 The Archives of Diagnosis ■

reaching disorder, of mental and physical catastrophes. One may
reply that, nowadays, everyone is aware of the need for thorough
investigation of the eyes.

Do not be misled. I have heard persons high in the scale of lead-
ership boast that their eyes were so good as to need no help from
medical experts ; and for years they had avoided them. Let it be
dearly understood that this is a grave blunder. There is no such
critical index of aging, of loss of precious proficiencies, as advanc-
ing deterioration in the eyes. Since the great discovery of struc-
tural errors in the make-up of eyes, and how these may be corrected
by the simple device of accurately fitted glasses, the age of individ-
ual usefulness has been almost doubled. Moreover, that terror which
can make the boldest blanch, the onset of blindness in its various
manifestations, causes and degrees, can only be determined by
frankly seeking and submitting to expert tests. Take cataract for
one illustration. The early use of suitable glasses alone may rescue
an eye so threatened from destruction.

There follow many items of conservation (too long to present
here) which bear upon both efficiency and survival. Habit forma-
tion is a great power for good and for evil, A heedless disposition,
reckless tastes, pursuing lines of least resistance, haphazard adapta-
tions, offer large fields for reaccounting and compulsory revision.

We need not take up here the obvious and much discussed ques-
tions of wrong habits of eating and drinking, of smoking and the
like sybaritic trends. Less known, yet of equal significance are static
errors due to domination of bad postural and motor habits.

Consider for a moment the body from the standpoint of a working
machine devised to remain in commission, if rightly conserved, for
at least three score years and ten.

This same body to do its perfect work must not only contain a
set of sound organs whereby it shall perform serenely its appointed
course, but there is also framework, thews, sinews, bones, a beauti-
fully devised and perfected skeltal structure constituting an efliicient
container and ground work for these noble organs, and their bio-
chemical complexities.

Man stands erect, the one and only animal which does. While
he has evolved through untold ages, as the one erect, plantigrade
mammal, whose component parts have adjusted themselves to ever

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Taylor: Periodic Physical Examinations id"]

varying exigencies, reaching relative perfection, yet none the less
certain penalties threaten the individual who omits to so revise con-
duct as to keep all this complex mechanism in order.

Man's upright posture while endowing him with definite kinds and
degrees of preeminence places him also in some grave forms of dis-
advantage.*

This detriment is not so obvious if normal attitudes are main-
tained, but becomes forceful and hurtful when unnatural attitudes,
amoimting to deformities, are persisted in ; and that too in spite of
all the amazing endurance of occupational distortions. These in-
duce anomalous compressions on tubular structures, angulations,
kinks, adhesions and other positions of visceral disadvantage. Not
seldom postural regulation alone is capable of restoring health.

An examination to be efficacious should include a careful estima-
tion of the motor mechanisms beginning with the joints, flexures,
tendons, their capabilities of movement, range, and the like. Closely
associated is flexibility of the muscles, pliancy of structures con-
cerned in the transmission and transformation of force. Many of
the tendinous insertions will be found painful on pressure, effects
of fibromyositis, producing limitations of movement which can and
should be cured before permanent disabilities ensue. Capacity for
movements in the thorax is highly significant. Impairments here
niake for obstructions to the excursus of the lungs, impediments to
free action of the heart and great vessels, the very center of oxida-
tion and oxygenation.

So also of the external abdominal muscles which should fully sup*
port the great vegetative and reproductive organs in order to render
their action complete and harmonious. Undue relaxations here (un-
fortunately too common as middle age approaches) make for stag-
nation in the circulation, the splanchnic vessels in particular, in-
ducing a form of neurasthenia most distressing and disabling.

Few remedial measures can accomplish more for general better-
ment than judicious training of these abdominal muscles, including
also the diaphragm and lifting power of the thoracic and shoulder
girdle group.

The erector spinae muscles need to be in good tone to maintain

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i68 The Archives of Diagnosis

normal erectness, the uplift of the whole torso, sustaining thoracic
competence and also interrelationships of the abdominal viscera.
Hence it is obvious that scnitinization of the entire gross muscula-
ture is essential in determining degrees of organic competence. Elas-
ticity is readily impaired as age creeps on. Undue compression on
vital structures is hurtful in a thousand directions and advances
insidiously interfering with ebb and flow of fluids, retarding elimina-
tion, holding back destructive waste products, encouraging cellular
disintegration in organs whose action is essential to life itself. Ob-
viously periodic examinations are gravely needed for every one
entirely independent of any consciousness of disability.

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Progress of Diagnosis and Progkosis 169

^togreM a( BiagiuuffK avib ^rognoiffif

GENERAL METHODS OF EXAMINATION— SYSTEMIC

AFFECTIONS— DISORDERS OF GENERAL

METABOLISM

Compvative Detenniiuttiotis of Blood-Sugar bjr Polarization and Reduc-
tion— C Maase and H. Tacbau, Zeitschr. £. klin. Medizin, Vol. LXXXI,
Nos. I and a.

Comparative determinations of the blood-sugar by means of
polarization and the reduction methods of Bertrand and Tachau
gave identical results when the sugar content of the blood was
normal or increased. In but one case the results were discrepant.
In this case the sugar content determined polariscopically was de-
cidedly greater than when determined by the reduction methods.
This was probably due to the presence of a carbohydrate more
markedly rotating, but weaker reducing than dextrose. After the
ingestion of 100 grams levulosc reduction showed decidedly higher
values as polarization. Western.

Copulation Pactora in Hemophilic Blood— A. Fonio, Mitteilungen a. d.

Grenzgebieten d. Medizin u. Chirurgie, Vol. XXVIII, No. 2.

The exact study of a case of hereditary hemophilia showed that
the blood platelets were insufficient, but not decreased, that throm-
bogen was normal in its behavior, that thrombin was contained in
the serum in large amounts, but that its activity was insufficient,
and that fibrinogen was present in normal quantity. These factors
tend to demonstrate that in hemophilia there is an insufhciency of
the organs presiding over the organs generating the platelets. The
characteristic phenomena of hemophilia may be explained on the
hand of the insufficient function of the blood platelets. Mill.

Leukocytes and VitcoMty — A. Gulbring, Beitrage z. Klinik d. Tuberkulose,
VoL XXX, No. I.

The viscosity of the blood is solely dependent upon the number of
polynuclear leukocytes. The number of lymphocytes is without
influence upon the viscosity. The greater the number of the poly-
nuclear leukocytes the higher will be the viscosity of the blood.

Fry.

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170 The Archives of Diagnosis

Colorimetric Detenniiiatioii of Urinary Uric Acid— H. F, Host, Zeitschr.

f. kUn. Medizin, Vol. LXXXI, No*, i and 2.

Author found the following modiBcation of Riegler's method the
most trustworthy of all the colorimetric tests for uric acid in the
urine. Into test tube bearing the mark 20 cc. at the proper place,
2 cc. urine is placed. To this 0.6 gram ammonium chlorid is added.
The mixture is then heated to about 40 deg. C, after which it is
set aside for not less than half an hour. Then it is filtered through
a small filter. A solution of ammonium sulphate (20 per cent.) for
"Nachspiilung" is then used 4 or 5 times. The ammonium urate
on the filter is then brought into solution by means of boiling di-
sodium phosphate (15 cc. of a 5 per cent, solution) which is filtered
into the first test tube. A solution of phosphomolybdic acid (4 cc. of a
90 per cent, solution) is then added to the filtrate and the test tube
filled to the mark 20 cc. with the disodium phosphate solution. The
mixture is then heated to the boiling point, and when cooled off
compared with the standard solution in the colorimeter. The stand-
ard fluid is composed of 2 cc. uric acid solution with 2 milligrams
uric acid, 4 cc. phosphomolybdic acid and 14 cc. disodium phosphate
solution. Western.

Grave Anemia in Childhood — E. Stettner, Jahrbuch f. Kinderheilkunde,

Vol. LXXX, No. 5.

Report of the hematologic examination of 3 cases of splenic
anemia. Anemias in childhood often originate from increased dis-
integration of blood following infections. The prognosis is entirely
dependent upon the degree of the affection. Therapeutic measures
may be of great assistance. Mill,

Phoaphaturia — Dunhek, Berliner vereinigte arztl. Gesellsch., Miinchener med.

Wochenschr., Feb. 2, 1915.

Author differentiates rigidly between the precipitation of am-
monium phosphate (coffin -shaped crystals), the result of urea de-
composition in bacteriuria, and genuine phosphaturia in which the
phosphates are precipitated as salts of lime. When there exists a
normal ratio of phosphoric acid and calcium the soluble double
acid salts is formed. If there is an excess of calcium or
a deficiency of phosphoric acid the insoluble simple acid salt is
produced. Genuine phosphaturia is therefore divided into two
groups: subacid phosphaturia (diminution of phosphoric acid) and
calciuria. Genuine phosphaturia, a constitutional affection, must
also be differentiated from alimentary phosphaturia. The decrease
of acidity may be caused by acid impoverishment in the presence of
increased hydrochloric acid excretion in the stomach. In the ma-
jority of the cases a direct influence of the nervous system upon the
composition of the urine must be assumed. This explanation is

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Progress of Diagnosis and Prognosis 171

more plausible than the one which assumes a primary blood alka-
lescence which has as yet not been demonstrated. In calciuria the
excretion of lime is augmented. The amount of CaO excreted in
one day never exceeds 0.4 or 0.5 gram. The kidney excretes but
10 per cent, of the ingested lime. Increased ingestion of lime is not
followed by an increased excretion of lime via the urinary system.
Colitis does not stand at the foundation of phosphaturia and the
kidneys do not exert vicarious function in respect to Ca excretion.
Calciuria may exist without colitis. Phosphaturia is a partial mani-
festation of neurasthenia. The therapy must be directed against
this affection. Phosphoric acid in 5 per cent, dilution, of which 20
drops is to be given three times a day, will be found of use in
calciuria. Mill.

Pfaospbatum — Rothmann, Berliner vereinigte ar«1. Gesellsch., Munchener
med. Wochenschr., Feb. a, I9IS-

There is no parallelism between neurasthenia and phosphaturia.
Patients with phosphaturia, on the other hand, frequently show
urticaria, eczema and vasomotoric disturbances. Mill.

PhcMphaturia— Rosin, Berliner vereinigte arztl. Gesellsch., Munchener med.
Wochenschr., Feb. 2, 1915.

Phosphaturia is not a disturbance of metabolism, but a nervous
excretory disturbance of the kidneys. Mill.

pBendo-LeTulosuria— P. J. Camuidgl and H. A. H. Howard, Lancet, Feb.

17, 1915-

Although true levulosuria or fructosuria may be met with, it is
apparently a rare condition and in the majority of cases, it seems
probable that the term is a misnomer, and that the levorotatory
reducing substance that occurs in the urine is in reality the ketonic
acid, isoglucuronic acid, authors have described. This is differenti-
ated from levulose by Borchardt's test, by being precipitated from an
acid solution by saturation with lead acetate, and the melting point
of the parabromphenylosazone. Sachs.

Lipemia R«tiiuUa— R. F. Mooke, Lancet, Feb. 30, 1915.

Ltpemia retinalis occurs in cases of diabetes in young people who
are usually bordering on coma. This condition is of grave prog-
nostic significance. It implies a high grade of lipemia, such as prob-
ably only occurs in diabetes. The ophthalmic picture is so striking
that it should not be mistaken for any other condition. The opacity
of the plasma is most likely the cause of the conspicuous change in
color and appearance of the retinal vessels. Sachs.

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1^2 The Archives of [)iagnosi5

Partial UyxedMiu — W. M. Baiton, Jour. A.M. A., Mar. 30, 1915.

The chief clinical types of thyroid insufficiency which appear to
be recognized at present come under six categories: (i) Growii^
boys and girls, suffering either from general mental backwardness
or persistent nocturnal enuresis; (2) Certain backward children
between 2 and 5 years of age, showing various symptoms of which
the two most familiar are slowness in learning to talk and delay in
learning to walk; (3) Certain infants, who without being true
cretins, present symptoms of amentia or idiocy; (5) Certain stout,
sterile women of the child bearing age; (5) Certain females at or
about the menopause who have rapidly become too stout; (6) Suf-
ferers from certain nervous affections, which closely resemble and
are frequently called neurasthenia and tic douloureux. Saths.

Cases of Basedow disease are very rare in childhood. No case
was ever described in a child 9 months old. The child exhibited the
following symptoms of the disease: Pulse frequency 144, exoph-
thalmus, distinct Grafe and Stellwag's phenomena and enlargement
of the thyroid gland. All these symptoms had vanished after one
year. Mill.

Uutual Rdationt of tome of the Glandi with an Internal Secretioii—
L. OKiNTSCHnz, Archiv f. Gynakologie, Vol. CII, No, a.
It is as yet impossible to draw any conclusions concerning the
antagonism or synergysm of the glands with an internal secretion.
Author's personal researches concerned the effect of the removal of
the ovaries upon the thyroid, adrenals, hypophysis and uterus. Be-
sides, observations were made as regards the influence of sub-
cutaneous administration of the products of some of the glands
(ovary, placenta, etc.) upon castrated animals. According to
author, the corpus luteum is a gland with a negative internal func-
tion, i.e., a function neutralizing the toxic substances circulating in
the organism. Mill.

DiagnoBia of Carcinonta b7 the Abderhalden Method — S. Cvtbonbebg,
Mitteitungen a. d. Grenzgebieten d. Medizin u. Chinirgie, Vol. XXVIII,
No. 2.

Report of 97 cases and detailed test protocols. Of 35 undoubted
carcinoma cases 33 reacted positively. According to author the un-
derlying principle of the method is absolutely correct, but the value
of the reaction is limited on account of certain sources of error.

Mill.

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Progress ok Diagnosis ahd Prognosis 173

Fatdtjr Vinon and lU-Healtb— W. W. Kabab, Med. Press (London), Feb. 10,
1915.

In endeavoring to relieve functional troubles, always keep in mind
the etiological factor of the eye. Because a patient wears glasses
does not necessarily mean that they are correct. As a matter of
fact, not more than 25 per cent, of all glasses worn are in hailing
distance of correctness. In case glasses do not relieve the symptoms,
and you still have reason to suspect the eye, use the atropin test by
instilling a one per cent, solution once a day for 10 days in both of
the patient's eyes. This will in most cases paralyze the accommoda-
tion, stop the eye-strain, and in the latter case give immediate relief.

Sachs.

INFECTIOUS DISEASES

ReUtiotiship of Infantile and Adult PhthisiB— J. P. Cuixen, Practitioner

(London), April, 1915.

Adult and infantile phthisis are one and the same disease, the
difference in the symptoms and signs are explicable on anatomical
peculiarities. The affection in childhood may remain limited to the
lymphatic paths. In many cases a diagnosis can only be made by
means of radiography. Wrongly diagnosed or diagnosed too late,
the parenchyma of the lung becomes affected. In childhood local
symptoms are indefinite and general symptoms are more marked.
In both adult and infantile tuberculosis, the path of infection is
identical, in both it is at first pulmonary, and the point of entry is
in the vicinity of the terminal bronchiole. Sachs.

Tuberculosis of the Newborn — C. G. Grulee and F. Habus, Am. Jour. Dis.

Child., April, 1915.

The newborn infant is affected clinically by the same infections
in a much different way from the older infant. In the diagnosis of
tuberculosis of the newborn, the combination of enlargement of the
spleen, high irregular temperature and enlargement of the liver, to-
gether with tuberculosis in the mother, is suggestive. Little can be
expected from the ordinary tests. In the newborn the von Pirquet
test has proved negative almost without exception. A blood culture
or the injection of blood into animals may be tried, but they offer
many difficulties. Therefore it can be seen that it is very difficult to
arrive at a diagnosis of tuberculosis in the newburn even though its
presence be suspected. Sachs.

Tabercolosis in the Aged — J. B. Hawes, znd, Am. Jour. Med. Sci., May,

191 S.

The diagnosis of senile tuberculosis is often very difficult.
Asthma, emphysema, and chronic bronchitis may so mask the tuber-

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174 '^BB Archives of Diagnosis

ai]ou3 process in the lungs as to render its detection very hard.
Constitutional symptoms may be lacking. Tuberculin tests are of
no value. Rontgen ray examination is often of great service. Re-
peated and frequent sputum examinations are essential in these
cases. Such examinations should be made at frequent intervals in
every case of chronic lung trouble in elderly persons. Sachs.

Albamin Reactioii of the Sputum in Pulmonary Tuberculous — Lowenbeiit,

Zeitachr. f. Toberkulose. Vol. XXIII, No. 2.

In the differential diagnosis between uncomplicated chronic bron-
chitis and tuberculosis an albumin content of i per mille and more
positively points to tuberculosis. An amount of albumin below I
per mille does not exclude tuberculosis. An albumin content of i
per mille and more in chronic emphysema and bronchitis indicates
that a tuberculosis is also present. Together with the other methods
of examination the quantitative albumin determination furnishes
valuable data as regards the prognosis. In general, the increase or
decrease of the albumin content is of greater import than the abso-
lute amount of the same. The alteration of the albumin content is
often of greater import as is the increase or decrease of the tubercle
bacilli. Fry.

Prognostic Value of Sputum Examinationa in Pulmonary Tuberculosis —

7. Szab6ky, Zeitschr. f. Tuberkulose, Vol. XXIII, No. 4.

The albumin content of the sputum of tuberculous patients per-
mits of prognostic conclusions. The larger the amount of albumin
in the sputum the more unfavorable is the outlook in a case of
tuberculosis. When the albumin content of the sputum is i per
mille, or more, the course of the affection is always a more violent
one. Fry.

Albuminuria in the Tuberculous— F. D'Onghia, BeitraKc z. Klinik d.

Tuberkulose, Vol. XXIX, No. 3.

In 50 young persons affected with tuberculosis albuminuria was
found in 28 cases. Fry.

Tuberculosis and Gout— Mayek, Zeitschr. f. Tuberkulose, Vol. XXIII,

No. 3-

In many cases there exists an interrelation between tuberculosis
and gout. Examination of the purin metabolism will reveal interest-
ing data. Hemorrhages as equivalents of gouty attacks may even
supervene. Fry,

Studies in Pneumonia — R. Cole, Johns Hopkins Hospital Bull., May, 1915-
It has so far been impossible to detect by chemical or biological
means the presence of poisons, either in the media in which
pneumococci have been cultivated or in the body fluids of animals

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Progress of Diagnosis and Prognosis 173

dying from infection with these organisms. Lately considerable
stress has been laid on the importance of bacterial anaphylatoxins,
as described by Friedberger, in producing the symptoms of infec-
tion. The anaphylatoxin theory assumes that the intoxication is
due to split products of the bacterial protein. According to Fried-
berger the ferment causing the splitting is supposed to be present
in the serum, but the demonstration by Neufeld and Dold, and also
by Rosenow, that autolyzed bacteria, in the absence of serum, are
toxic has required that the theory be modified so as to presuppose
that the ferments are present in the bacterial bodies. Author has
been able, however, to show that the bacteria simply dissolved in
dilute solution of bile, or even brought into solution by freezing and
grinding, are also toxic. Author concludes that the evidence is still
very inconclusive, that any of the reactions is of significance so far
as intoxication in lobar pneumonia is concerned. Experimental evi-
dence indicates that the symptoms are due to the action of the living
bacteria, rather than to the action of substances contained within
the dead bacterial cells. Western,

Agglntinatioii of the Spirochieu Pallida— A. Kissuever, Deutsche med.

Wochenschr., March 18, 1915.

Serum of syphilitics agglutinates the spirochaeta pallida in a
specific manner. The reaction is not constaht in syphilis, but may
be demonstrated in all its stages. The relation of the agglutination
to the treatment is not as yet determined. Mill.

Podtive WaBsermaim Reaction in Pemphicua— M. Hesse, Wiener klin.

Wochenschr., Jan. 21, 191S-

Of II cases of pemphigus (vulgaris, vegetans, herpetiformis) g
showed a positive Wassermann reaction. This reaction is, there-
fore, rather characteristic of pemphigus. Mill.
Cerebrotpinal Fever— E. Hobhouse, Brit. Med. Jour., March 6, 1915.

The diagnosis of cerebrospinal fever should not be influenced by
the absence of any one or two supposedly essential symptoms ; all
are uncertain. But the combination of either rash, or vomiting, or
squint, or rigidity of limbs, and opisthotonos, with a clinical picture
otherwise resembling influenza, is very strongly suggestive of the
graver disease. Sachs.

Cerebroapinal Fever— M. Foster, Brit Med. Jour., March 27, 1915.

Retraction of the head has been present in every case save one
— that of a man found unconscious in bed. In 4 out of 19 cases, a
definite rash appeared. It consisted of discrete papules about the
size of number one shot, which did not dissappear on pressure and
varied in color from scarlet to mulberry. In the author's cases,
there was only slight evidence of any affection of the cranial nerves.

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176 The Archives of Diagnosis

The mental condition presented every gradation from profound
coma with inability to swallow, through violent noisy delirium, to
a mere condition of mental hebetude. Vomiting has always been
present except in fulminating cases. Rigidity of the muscles of the
limbs has not been a marked feature. The sphincters have been
affected in a considerable proportion of the cases. Sachs.

Cerebrospinal HcninKitic— A. Luhdi, D. J. Thomas and S. Fleming, Brit.
Med. Jour., March 20, 1915.

The disease is much more widespread than is usually recognized.
Authors say that the disease probably gives fair warning of its onset
by catarrhal symptoms, and often goes no further. In its second
stage it may run a long non-malignant course, giving plenty of time
to arouse suspicion, and if correctly diagnosed would probably be
cured by suitable treatment. During an epidemic, routine examina-
tion of all throats is very important. Sachs.
Streptococcus Hcningitis— P. L. Do Bois and J. B. Neal, Arch Pediat.,
Jan., igij.

During the past four years authors have seen 18 cases of strepto-
coccic meningitis, of which only one recovered. Five of the cases
were due to the streptococcus mucosus capsulatus, the rest to the
streptococcus pyogenes group. Of 11 cases, 5 gave a history of
middle-ear disease or mastoid ; 2 of scarlet fever, middle-ear disease
and mastoid ; one of operation on the nose ; 2 of trauma of the head ;
one of whooping-cough. Sachs.

Schick Toxin Reaction— J. A. Kolmer and E. L. Moshag, Am. Jour. Dis.

Child., March, 1915.

The reaction consists in the appearance, after the intracutaneous
injection of a certain amount of diphtheria toxin, of an area of
erythema with a brownish tinge, measuring 0.5 to 2 cm. in diameter,
and accompanied by slight edematous infiltration of the underlying
tissues. It appears in from 24 to 48 hours after the injection. This
reaction is a reliable and valuable method for detecting susceptibJli^
to diphtheria. Persons reacting negatively have an amount of anti-
toxin in their system which is probably sufficient to protect them
against infection. Persons reacting weakly or strongly positive may
be regarded as susceptible to diphtheria. About 40 to 50 per cent,
of children from one to 15 years old react positively to the toxin
test; this means that the preliminary use of the toxin test will
eliminate the necessity of administering prophylactic doses of anti-
toxin to about 50 per cent, of the children. Sachs.
Diphtheria Bacilli in Herpetic Veuclea— Rau.. Munchener med.

Wochenschr., March 23, 1915.

Diphtheria bacilli are not rarely encountered in herpetic vesicles in

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Progkess of Diagnosis and Prognosis 177

patients affected by diphtheria. No prognostic significance can be
attached to this finding. Herpetic lesions carrying the diphtheria
bacilli are probably never the transmitter of the infection. Mill.
Diatnrbances of the Internal Secretion in Dyunterr — H. Peiseb, Deutsche
med. Wochcnschr., Jan, 21, 1915.

The disturbances of the internal secretion in dysentery observed
by author concern especially the function of the thyroid-adrenal
group. Disturbances of the pancreas-parathyroid group are nnich
less in evidence. Many manifestations point to an increased tonus
of the sympatheticus, others to an increased vagus irritation. These
observations may also explain the good effects of preparations of
belladonna in cases in which the opiates give no result whatever.
Exophthalmos and a peculiar brightness of the eyes in the course
or after recovery from dysentery seem to point to hyperthyrosis.
The thyroid in these cases is frequently enkrged, but the thymus
seems to be hypoplastic. A marked intolerance for carbohydrates
is found in dysentery. Mill.

Latent Infection and Surgical Recovery— E. Melchiok, Berliner klin.
Wochcnschr., Feb. I, 191 5.

The conception "recovery" is often quite an inadequate one. Gen-
erally speaking, a phlegmon, an osteomyelitis or a lymphadenitis
is considered to be cured when the tangible clinical symptoms have
disappeared. Such disappearance of the clinical manifestations,
however, does not always correspond to a recovery in the bacterio-
logic sense. It may be but a latency, a semi -immunity, which may
already contain the etiologic factor of a recurrence or of a
metastasis. Mill.

RESPIRATORY AND CIRCULATORY ORGANS
The Auscultation Phenomenon over the Larynx in Croup and Pseudo-

Cronp — A. Levinson. Miinchener med, Wocbenschr., Feb. 2, 1915.

The auscultation over the normal larynx of the child evinces in
the inspiration period a dragging sound; when expiring the sound
is somewhat lengthened. In the presence of pseudo-croup an im-
pure, limited sound is heard during inspiration by auscultating di-
rectly over the thyroid cartilage. During expiration the sound is
lengthened and dragging. Auscultating the suprasternal fossa
moist medium rales are heard during expiration and inspiration,
while over the lungs normal vesicular breathing is present. In the
presence of croup the inspiration is an open vowel, deep and harsh.
Expiration is much longer than inspiration and resembles a V. In
case an advanced stenosis is present rales are not audible. Only
when a bronchitis has supervened rales may be heard over the
larynx, but the breathing always remains deep and dry. Mill.

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178 The Archives of Diagnosis

Dyipnea ud ita SeUtion to Blood Reaction— T. Lewis and J. Barcropt,

Quart. Jour. Med. (London), Jan., 1915.

Authors report 4 new cases in which the symptom-complex, previ-
ously described by them, was present. This complex is associated
with reduced alkalinity of the blood and occurs in elderly subjects.
It comprises a continuous dyspnea, often intensified for short
periods, especially at night; good or bad blood aeration as judged
by the absence of cyanosis, or such cyanosis as would seem com-
patible with simple cardiac dyspnea, and by examination of the
alveolar air ; Cheyne- Stokes breathing, with or without full apneic
periods, and with an increase of pulse-rate (80-100) per minute;
and lastly a subnormal temperature. This symptom-complex, asso-
ciated as it is with cardiac enlargement, general arterial disease, and
fibrosis of the kidney, may be, and frequently is combined with any
of those symptoms spoken of at the present time as uremic. This
association is not necessary, but is superadded to the symptom-com-
plex. The complex is of extremely frequent occurrence. Sachs.

Differential Diagnoaia Between Acute Abdominal and Acute Intrathoracic

Dlaeaae— C. Mackenzie, Lancet, April 17, 1915-

Severe abdominal pain, often accompanied by vomiting, rigidity
of the muscles, and even local tenderness, may exist without any
lesion of an abdominal viscus. It is advisable in every doubtful
case to examine the thoracic viscera before submitting a patient to
laparotomy. In all cases the pulse- respiratory quotient can be
analyzed and considered with the temperature. If attention is paid
to this quotient, many cases of pneumonia will not be treated by
abdominal section. Reliance cannot be placed on the quotient or
temperature where pleurisy or pericarditis are considered, and as
in the past, so in the future will mistakes occasionally occur. A
rectal examination should be made in all suspected acute abdominal
conditions since tenderness is usually elicited, and actual swelling
often found. Sachs.

Diagnoaia of Hediaatinilis— C. P. Howard. Johns Hopkins Hospital Bull.,

May, 1915.

The following conclusions are offered : Tuberculosis plays a very
important part in the etiology of chronic mediastinitis. One or
more of the pressure phenomena of mediastinal tumor and aortic
aneurysm may be present in this condition. Perez' mediastinal fric-
tion may prove of diagnostic value. Western.

RSntgen Ray and Pulmonary Conditiona in Children — W. M. Hartshorn,

Am. Jour. Dis. Child., May, 1915-

The Rontgen ray is of distince value in the diagnosis of diseases
of the respiratory tract. In pneumonia a shadow may appear over

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Progress of Diagnosis and Prognosis 179

the suspected area several days before the development of definite
physical signs. It is of value in determining the progress of lung
involvement. Rontgenograms may be taken on successive days as
long as there are signs of active advancement of the process. The
rontgen ray offers material assistance in differential diagnosis,
tuberculosis, abcess of the lung, lobar and bronchopneumonia.
Through the obliteration of the costal-phrenic angle, the rontgen
ray indicates the presence of an exudate. Sachs.

Report of observations of a number of cases with capillary pulsa-
tion. Most cases were associated with arteriosclerosis. This has
frequently ensued as a consequence of syphilis. The pronounced
capillary pulse is a symptom of the much increased work of the left
ventricle and the arterial circulation. Whenever the capillary pulse
is met with, it points to disturbances necessitating a careful control
of all the factors connected with blood movement and blood dis-
tribution. Western.

Dilatation of the Arch of the Aorta in Chronic Ncpbritii with Hjperten-
Bion — W. H. SuiTH and A. R. Kilgore, Am. Jour. Med. Sci., April, igi5.
Authors conclude that dilatation of the arch under the age of fifty
years in non-syphilitic conditions is rather frequent, especially in
chronic nephritis with hypertension. The dilatation may be quite
marked, particularly in the younger patients.

Western.
Aneurism of the Sciatic Arter; — R. C. Bkyan, AnnaU Surg.. Oct.. igi^

It has been noted that both spontaneous and traumatic aneurism
of the sciatic artery occur more frequently in the male than in the
female in proportion of two to one. Most of the patients are be-
tween 20 and 40 years of age in the laboring class and apparently
otherwise healthy. It has also been established that aneurism of
the sciatic artery occurs more often on the left side than on the right.
D'Antona emphasizes the following : A line between the top of the
great trochanter and posterior inferior spine of the ilium is a distinct
landmark and separates gluteal aneurism which lies above, from
sciatic aneurism which hes below this line. He also calls attention
to the location of the bruit in reference to this line. D'Antbna fur-
ther states that a differential diagnosis between aneurism of the
gluteal and sciatic artery is at all times difficult and in most instances
unpossible. Fischer says that aneurism of the gluteal lies high, as
a rule, above the tuber ischii and to its inner margin, while tfiat of
the sciatic is deep, and at, or below, the level of the tuber ischii.
Fischer also calls attention to the fact that with marked pulsation

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i8o The Archives of Diagnosis

of the tumor along the posterior border of the femur, increased
thickness of the deep femoral and low pulse of the cruralis, one
should bear in mind a possible ischiatico- popliteal aneurism.
D'Antona lays particular emphasis on an early neuralgia, in cases
of aneurism of the sciatic artery, on account of its normal anatomical
relationship to the larger sciatic nerve. This obtained markedly in
author's case and appears to be a strong diagnostic symptom for
aneurism of the sciatic artery. He also refers to the hard edema
which goes along with sciatic aneurism and which is produced by a
vasomotor paralysis or vasodilating excitation which is not noted
in the gluteal aneurism. Traumatic aneurisms, following stabs, gun-
shot wounds, or a fall, may be diffuse, circumscribed or varicose and
are more rare than the spontaneous aneurism, whose history Is nega-
tive to any injury but, in a certain percentage of cases, goes on to
the formation of anastomotic aneurism. Fischer states that the dif-
ferential diagnosis between aneurism of the gluteal artery, abscesses,
cysts, and cancer, is always difficult and in some cases impossible.
Diagnosis of aneurism of the sciatic artery must be based mainly
on the complex of pulsations, bruits with aneurismal character, and
sciatic pains which can be brought out in this region. Differential
diagnosis should consider abscesses, hygroma, sciatic hernia, gumma,
cancer (markschwamme) and pulsating sarcoma. Abscesses: In
this region abscesses may be deep-seated, arising in the sciatic space
by retroperitoneal involvement and extruded downward through the
notch from above, or, more rarely, by way of the bowel. The recto-
vesical fascia, however, would appear to be a sufficient barrier
against the escape of suppuration from the ischiorectal space to this
locality. The superficial phlegmons and cellulitis are to be recog-
nized by local evidences with constitutional reaction. Rectal ex-
amination in both instances should be carried out. Bufsk: Various
authors describe 31 bursae about the hip-joint. Those which may be
justifiably confounded with sciatic aneurism are: i. The bursa of
the gluteus maximus, which is located between this muscle tendon
and the great trochanter; inflammation of this bursa is not uncom-
mon, and gives rise to a doughy tumor behind the great trochanter
with eversion and abduction of the thigh in contrast to the flexion
and inversion of aneurism. 2, The bursa over the tuber ischii which
is small, rarely involved, and points internal toward the anal margin
along the lower fold of the buttocks. 3. The bursa of the gluteus
medius developed in the tendon of that muscle as it runs over the
upper and outer margin of the great trochanter. Inflammation here
may be noted anterior and external to the trochanter. Sciatic hernia :
Garre gives two forms of sciatic hernia, the hernia suprapyriformis
and the hernia infrapyriformis. In both the intestine protrudes
beneath the gluteus maximus and is deeply buried. Most sciatic
herniae occur in women past middle life. Beside the intermittent

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Progress of Diagnosis and Prognosis i8i

pain which goes hand in hand with all varieties of hernia, in this in-
stance there is a tumor below the gluteus maximus which is reducible
with subsidence of the pain. Not infrequently these hernias point
inward to the anal margin and even to the coccyx. Gumma : Should
always be suspected and a thorough investigation instituted.
Malignant growths of any type may arise in this region, as nearly
every form of tissue is represented here. Of the many varieties,

[lulsating sarcoma offers the greatest obstacle to differential diagnosis,
n myelogenous sarcoma, pulsations and bruits are not infrequently
present. True aneurism of bone, however, is extremely rare. Klebs
reports no such case. Vibrating or pulsating sarcomata are due to
great vascularity and cystic degeneration. The prognosis of aneu-
rism of the sciatic artery is extremely profound. Spontaneous cure
is not to be expected in any case. Very rarely does aneurism of this
artery remain stationary. It may lor a year or so, but fatal
hemorrhage will result some time, and sudden rupture may cause
death following a gradual asthenia. D'Antona has collected the
figures of the mortality following ligation of the hypogastric artery
and found it to be 40 per cent. The mortahty of the cases in this
series, surgical and medical, was 32 per cent. Sachs.

Contractility of the Heart— M. B. Levitok, Jour. A.M.A„ May 8, 1915.

The contractility of the heart muscle varies within wide limits,
depending on the pathological process. This can be fairly well es-
timated clinically and is a valuable differential and prognostic sign.
The findings on auscultation and percussion vary after exercise.
The heart muscle may react in three ways: (a) In functional and
early lesions, the heart boundaries may on exercise return immedi-
ately to normal, bruits disappear and normal tones at once replace
them; (b) In moderately severe cardiac (and particularly car-
diorenal) cases, the boundaries may return to normal not immedi-
ately but after rest in bed ; (3) The heart remains permanently en-
larged and inelastic, not only after the exercise test, but even on
prolonged rest in bed. Sachs.

Paroxysmal Tachycardia— B. Paksoks- Smith, Practitioner (London), April,
1915.

Too much weight must not be attached to the presence of mur-
murs in cardiac cases. A loud murmur may be produced by an in-
significant lesion, and a soft murmur, heard only with difficulty, may
possibly speak for gross and advanced disease. A heart, whose
muscle suffers no loss of tone at the end of an ordinary day's work,
is in a highly satisfactory state of compensation, whatever the lesion
present. Our most valuable and reliable method of estimating car-
diac tonus is by means of X-ray examinations, before and after
exertion ; for we know that a dilatation follows any appreciable loss

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i82 The Archives of Diagnosis

of tone, and that a heart whose tonic properties are up to the
normal standard, not only fails to dilate, but may, even diminish in
size on physical exercise, assuming the latter to be short of actual
strain. In any case of paroxysmal tachycardia, the following clin-
ical varieties must be thought of: (i) Paroxysmal tachycardia of
exophthalmic goitre; (2) associated with emotional states; (3) con-
sequent on dyspepsia; {4) of auricular fibrillation; (5) of auricular
flutter, and (6) dependent upon a transposition of the site of the
origin of the heart's contraction. Sachs.

Auricular Fibrillation— H. Schoonuakeb, Med, Rec, March 27, 1915.

Auricular fibrillation is the common cause of cardiac arrhythmia
characterized by complete irregularity. Auricular fibrillation is of
frequent occurrence, especially in mitral stenosis and in the senile
heart. Auricular fibrillation should be recognized without the aid
of recording instruments. An arrhythmia in which there is no
regularity, no sequence, with the heart rate above 100, being unin-
fluenced by treatment, together with the positive or ventricular
venous pulse, as seen in the neck is almost surely due to auricular
fibrillation. Sachs.

ALIMENTARY TRACT
Gaitric Headaches — W. F. Cheney, Am. Jour. Med. Sci., May, igi5-

It is diflicult to understand how disorder of the stomach can pro-
duce violent pain in the head, and no adequate scientific explana-
tion for it can really be given ; but it is equally difficult to explain
in another case how constipation causes headache, and why the pain
disappears promptly after the lower bowel is emptied. The head-
aches due to gastric disease are usually periodic. They repeat them-
selves throughout months or years. They may occur but once in a
month, or once or several times in a week. Over certain periods
they may become practically constant, though worse or better at
certain times in the day. Rut the most common story is of sudden,
unexpected attacks of pain in the head, coming after days or weeks
of good health. Such headaches are of variable duration, but rarely
last over 24 hours. The patient weakens with the pain in the morn-
ing, and it grows more intense as the day goes on ; or it may come
on in the evening, persist during the night, and pass off after the
patient rises. These headaches may be so severe and prostrating as
to incapacitate the sufferer for any kind of work while they last.
Sometimes nausea and vomiting accompany the pain, giving rise to
the popular term "sick headache," In other cases there may be no
disturbance whatever of the stomach to make the digestive organs
even suspected. Following the attack there may prevail a soreness
over the scalp at the site of the previous pain and a feeling of

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Pkogress of Diagnosis and Prognosis 183

mental uncleamess and confusion. The site of the pain is not suf-
ficient to determine a gastric origin. Perhaps the most common
type is hemicrania, one-sided pain, though not always of the same
type. The pain is described as boring in character, through one
eye or temple ; or it may be the entire half of the head, even back
to the base and the nape of the neck, that aches and throbs ; while
the opposite side is entirely free from discomfort and as clear as
ever. But this one-sided headache is caused frequently by alimen-
tary toxicosis ; it is the characteristic type of the paroxysm known
as migraine, and it sometimes occurs as a manifestation of uremia.
Whether there is complaint of indigestion or not, a test meal and
gastric analysis will be needed to reveal the cause of the headaches.
The most frequent disturbance in such cases is one of motility;
myasthenia or atony due to weakness of the muscular wall. The
significant feature is the delay of food in the stomach, Hyper-
chlorhydria may be present in some of the cases. In the diagnosis
of gastric headaches the history makes us only suspect, the gastric
analysis makes us reasonably certain, but only after elimination of
all other possible causes can this one be accepted as the basis of
therapy. Western.

Familial Occurrence of Gastric Ulcer^PuTEK, Archiv. f. Verdauungs-

krankheiten, Vol. XX, Nos. 3 and 4-

Author diagnosed the presence of gastric ulcer in a number of
members of one family. He opines that this occurrence is not an
accidental one, as the entire family exhibited neuropathic phenom-
ena. Besides local influences a pathogenetic influence of the nervous
system must be accepted as of etiologic import ; the familial occur-
rence of gastric ulcer is, therefore, not accidental. Western.
Familial Occnrrence of Gaitric Carcinoma— P. K. Pel, Berliner klin.

Wochenschr., March 22, igis.

Of 7 children of healthy parents, 5 died of gastric carcinoma.
Predisposing conditions could not be found. The remaining 2
children are still alive. Mill.

Syphilis of the Stomach— M. Einhork, Med. Rec., March 13, igi5.

There is no absolute sign distinctive of gastric carcinoma (except-
ing microscopic tissue section) which may not be encountered in a
gummatous tumor of the stomach. The absence of a positive Was-
sermann reaction does not positively militate against lues ; nor does
its presence indicate that the gastric affection is a syphihtic one. A
vigorous antiluetic treatment carried out over an extended period of
time (two or four weeks or more) gives us the desired information
with regard to the differential diagnosis. If there is general im-
provement and with it a perceptible decrease or disappearance of
the tumor, then we are entitled to make a diagnosis of gastric

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i84 The Archives of Diagnosis

syphilis. Patients with distinct syphilis frequently suffer from
other organic lesions of the stomach which are entirely independent
of the co-existing general lues. Sachs.

Tuberculous Stenous of the Pylorus — W. Ppakmes, Mitteilungen a. d.

GreiKgebieten d. Mediiin u. Chirurgie. Vol. XXVIII, No. i.

Report of a case in which besides an apical affection there existed
a stenosis of the first portion of the duodenum. The operation
showed the presence of a tuberculous ulcer in the pylorus. This
was removed, after which progressive improvement ensued.

Mill.
Pat Indigeition— C. H. Dunn, Am. Jour. Dis. Child., March, 1915.

Fat tolerance is diagnosed in those cases in which the giving in
the food of a moderate amount of fat is followed by the appearance
in the stools of free fat or excessive soap, or in which an increase
in the amount of fat given in the food produces immediately sym-
toms of indigestion and nutritional disturbance. There is no con-
stant or typical appearance of the dejecta in these cases. Tubercu-
lous babies are especially prone to fat intolerance. Sachs.

Infiomce of Posture on Indigestion in Infancy— C. H. Smith and L. T.
Le Wau>, Am. Jour. Dis. Child., April, 1915.

Rontgenography has shown the fallacy of the old idea that the
stomach in infancy is vertical in position. The shape of the stom-
ach depends on the amount of food and gas present, pressure from
the outside, posture, etc. Authors conclude that air is swallowed
with the food by many if not by all infants. The erect posture
favors eructation of this air ; the horizontal posture prevents it. The
horizontal posture by preventing eructation is an important cause
of vomiting, colic, indigestion and disturbed sleep. This is a very
thorough and practical paper, and is profusely illustrated. Sachs.

Infantile Diarrhea— A. A. Day and J. R. Gerstiy, Am. Jour. Dis. Child.,

March, 191 5-

Twenty-two cases of severe diarrhea studied by the authors divide
themselves into three groups: (i) food disturbances; (2) infectious
diarrheas, and (3) parenteral infections. By the latter is meant
such cases of diarrheas as occur secondary to infections outside of
the intestinal tract, as a bronchitis, an otitis media, or a choryza.
But 2 of these 22 cases could be classified definitely as belonging to
the group of food disturbances. These two showed the picture of
alimentary intoxication described so clearly by Finkelstein — a rise
in temperature, a sharp drop in weight, watery, green stools, per-
haps even bloody, skin of a pale muddy color, fixed staring eyes,
tireless deep breathing, an enlarged liver, leukocytosis and glyco-

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Prockess of Diagnosis and Prognosis 185

suria. In two cases the gas bacillus was found. The greatest num-
ber of these cases were associated with foci of infection in other
parts of the body, that is, the parenteral infection group. This cor-
responds with the observations of Finkelstein that the parenteral
infections are by all means the most important factor in the pro-
duction of food disturbances. Sachs.

The Carmin Test and the Time for the PasMse of Ingeita through the
A]imentu7 Tract— H. Stkauss, Archiv f. Verdauungskrankheiten, Vol. XX,
No a. 3 and 4.

It is true that the X-ray examination gives more complete evi-
dence concerning the condition of the gastrointestinal canal than
the carmin test. As regards the length of time a certain food re-
mains in the alimentary tract, however, the carmin test which 13 so
readily applicable gives just as reliable evidence as the X-ray ex-
amination. At any rate, the carmin test deserves a more frequent
employment in the clinical study of the cases. Western.

Differential Diagnosii of Chronic Appendicitis— Bischoit, Monatsschr. f.

Geburtshilfe u. Gynakologie, Vol. XL, No. 3.

In 37 cases of uncertain diagnosis author employed the method of
Bastedo. In 23 of these cases the method furnished positive results,
and there was an appendiceal change in every one of them when
operated upon. In 14 of the cases the method proved negative, and
at operation no appendiceal manifestations were noted. Mill.

Ulcerative Colitia — A. Albu, Mitteilungen a. d. Grenzgebieten d. Medizin u.

Chinirgie, Vol. XXVIII, No. 2.

A report of 23 cases observed by author. Of these 2 were acute,
the rest chronic. One of the acute cases recovered ; the other died.
Of the chronic cases 6 recovered under exclusive medical treat-
ment ; 12, among which 3 cases were operated upon, did not recover,
and 3 cases died. Ulcerative colitis is an independent, infectious
disease of the intestine. Etiologically, it is probably the conse-
quence of an infection due to the aliments. The ulcers, which are
present in nearly every case, have the size of a pinhead, are super-
ficial and occur in little groups. They occur most frequently in the
region of the sigmoid flexure. Generally, they do not leave any
visible scars. Clinically, the affection starts in most cases in a lin-
gering manner, and manifests itself by tenesmus, watery and bloody,
and slimy stools often containing pus and necrotic pieces of tissue.
Constipation is frequently present. The X-ray will not reveal a
typical disease picture.

Mill.

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i86 The Archives of DiAGNOsts

InUstinal Polyposii — W. C. Cauall, Surg. Gynecol, and Obstet, April,
191 5-
Intestinal polyposis is a comparatively rare disease. It occurs
especially in the young and middle-aged. In the majority of cases
the growths are found in the large intestine and in the rectum. The
growths often cause obstruction and intussusception. The symp-
toms usually vary with the position, size and nimiber of the
polypi. Rectal polypi are usually easy to discover with a procto-
scope. Regardless of the location of the growths, they usually
produce hemorrhage sooner or later. Diarrhea may become very
profuse at times, rectal tenesmus may be present, and vague abdom-
inal symptoms, as colic and obstruction also occur. Of 52 cases
reported by Doering, only one patient was perfectly well after four
years. Sachs.

LeukocTtOBia in Abdominal Hemorrhagei — L. A. Levison, Jour. A.M.A.,
April 17, 1915.

Leukocytosis should not be relied on as a differential point when
the clinical signs demand the differentiation of appendicitis or other
inflammatory trouble in the abdomen and an intra-abdominal hem-
orrhage. Leukocytosis from the latter condition is to be distin-
guished from the post-hemorrhagic leukocytosis which follows any
severe bleeding. Leukocytosis from intra-abdominal hemorrhage
comes on within 24 hours and lasts until the second day.

Sachs.

RSntgen Diagnoais of GaU-Stonei — L. G. Cole and A. W. Georce, Bost.
Med. and Surg. Jour., March 4, 1915.

Experience has shown that gall-stones may be detected about
twice as frequently as formerly by: (a) Special technic for making
the rontgen plates; (b) careful study of the rontgen plates by vari-
ous methods; (c) thorough intimacy with the ron^nographic ap-
pearance of gall-stones. A positive diagnosis can be made in so
many cases that the negative diagnosis has become of considerable
significance. If there is no direct evidence of gall-stones, the stom-
ach, cap, duodenum, and colon should be examined for adhesions
from an accompanying cholecystitis. Sachs.

Tertiary Syphilis of the Liver — T. McCrae, Johns Hopkins Hospital Bull.,

May, 1915--

The left lobe of the liver is often involved to a much greater ex-
tent relatively than the right lobe. This should always suggest the
consideration of syphilis. A history of ascites which subsided
spontaneously or disappeared after tapping to reappear sometime
later should excite suspicion. The importance of examining the
patient immediately after tapping also deserves emphasis. It may
be possible only at that time to have an opportunity of palpating

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Progress of Diagnosis and Prognosis 187

the liver in a satisfactory way. After iodid is taken a remarkable
feature is the rapidity with which the temperature falls to normal.
In the majority of the cases this occurs within z days, and it rarely
takes longer than 5 days. Western.

Pancreatic DtMase— B. B. Crohn, Arch. Int. Med., April 15, 1915.

The quantitative examination of duodenal ferments is the most
rational and accurate method of studying the external secretion of
the pancreas. Diminution of such enzyme activity of the pancreas
is a reliable sign of organic disease of the gland. Occasionally,
though rarely, a diminution of ferments occurs as a symptom of
organic disease elsewhere in the body. Roughly, the diminution of
ferments is directly proportional to the extent of organic destruc-
tion which has taken place. The absorption of fat and nitrogen
from the intestine is independent of the condition of the external
secretion or even of its presence. Absorption may be poor with a
healthy gland, or good with a gland of which only a fragment
survives the disease. The functional activity of the gland deter-
mines the degree of absorption. Duodenal ferment tests give the
index of the organic condition of the gland. Absorption tests gfve
the index of the functional activity of the pancreas. Sachs,

NERVOUS SYSTEM

Examination of the Reflexes— C. H. Wuktzen, Deutsche Zeitschr. f. Nerven-

heilkunde, Vol. LIII, Nos. 1 and 2.

Examination of 2,000 cases demonstrated the extraordinary con-
stancy of the common skin and tendon reflexes. Patellar and
plantar reflexes were always present, the tendon Achilles reflex was
absent in 3.5 per mille. Abdominal reflexes could not be elicited in
I.61 per cent, and cremasteric reflexes in 2 per mille of the cases.

Western.

Phyiiolofcr of the Tendon Reflexes in Nurslings and Cliildren— J. Vas,

Jahrbuch f. Kinderheilkunde, Vol. LXXX, No. +

The tendon Achilles and patellar reflexes are the same in nurs-
lings and children as in adults. In the few cases in which these
reflexes cannot be obtained in healthy nurslings below six months
of age, it is always the fault of external causes, as the technic of
examination, the restlessness of the child, etc. Mill.

The Oculo-Cardiac Reflex~E. B. Gunson, Brit. Jour. Children's Dis., April;

1915-

The oculo-cardiac reflex is a reflex change in the rate of the
heart associated in some cases with a change in rhythm, following
ocular compression. The path of the reflex is considered to be

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i88 The Archives of Diagnosis

along the fifth cranial nerve, the medulla, and the vagus, or sym*
pathetic. The reflex is positive when slowing of the pulse occurs
and negative when either no slowing or actual quickening results.
Persons exhibiting the former state are described as vagotonics,
those exhibiting the latter as sympatheticotonics. The reflex is posi-
tive on normal persons. The reflex is positive in about 92 per cent,
of children convalescing from diphtheria and scarlet fever. In cases
of so-called "cardiac paralysis' the reflex was negative and re-
mained 50 until death. In cases which recovered, the reflex became
positive when the heart returned to the normal state. Sachs.

Pharmacologic Teata in the Diagnoaia of Diaturbancca in the VcgetatiTe
Nervoua Sratem— G. Lebhamm, Zeitschr. f. klin. Medizin, Vol. LXXXI,
Nos. I and 2.

Examinations of 100 cases of manifold nature characterized by
symptoms of disturbances in the vegetative nervous system. It was
learned that the reaction to pilocarpin does not invariably corre-
spond to the clinical diagnosis ; frequently, the degree of this reaction
does not go hand in hand with the clinical symptoms. Tests with
atropin showed identical behavior. A positive atropin reaction
by no means always corresponds to a positive pilocarpin reaction.
There is no definite antagonism between the reaction to adrenalin
on the one side and to pilocarpin and atropin on the other. Of 22
adrenalin-sensitive persons 21 showed a distinct pilocarpin reaction,
while when there existed pilocarpin-sensitiveness a marked adren-
alin reaction was hardly ever noted. The antagonism between vago-
tonia and sympathicotomy does not exist. Adolescents are more
susceptible to pilocarpin and adrenalin ; senile persons are suscep-
tible to atropin. It is of therapeutic import that atropin is frequently
of no avail in vagotonia, but that it improves the condition in cer-
tain instances, so that its administration should be tried. If im-
provement ensues the drug should be continued for a protracted
period. Adrenalin, which is often useful in pronounced acute car-
diac insufliciency, must be employed with caution on account of
its frequent disagreeable secondary effects. Western.

Paraljrsia Agitana — E. Tbohueb, Deutsche Zeitschr. f. Mervenheilkunde,
Vol. LIII, Nos. I and 2.

Author adds some as yet unobserved symptoms to the syndrome
of paralysis agitans. He bases his observations upon a study of 40
pertaining cases. The new symptoms are: a preliminary stage
often lasting for years and neurasthenoid in character, intention
tremor, incongruence of tremor and rigorj certain trophic disturb-
ances, abasia, Babinski phenomenon, epileptoid attacks, and peculiar
psychoses in the course of the disease. Western,

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Progress of Diagnosis and Prognosis 189

Faralyus of the Spinal Acceuory Nerv«— A. N. Bruce, Rev. Neurol, and
Psych., Feb., 1915.

Paralysis of the spinal accessory from injury to the nerve during
the removal of tuberculous glands from the neck is well known.
The results, as a rule, become visible immediately after the opera-
tion. Author reports 2 cases in which the injury to the nerve was
not evident until after 10 and 14 years respectively. The feeling of
weakness in the shoulder joint has only been recently noticed.

Sachs.
Pue&chTtnatout SjrpbUis— F. W. Noir, Brit. Med. Jour., Jan. 30, 1915.

It is rare to find an error in the diagnosis of general paralysis
when in combination with the history and clinical signs and sym[>-
toms, the cerebrospinal fluid has been examined. Increase of globu-
lin and phagocytosis do not of themselves prove the syphilitic char-
acter of a disease of the central nervous system. A positive Was-
sermann reaction in the cerebrospinal fluid was only found in cases
of general paralysis, tabes, and syphilitic disease of the central
nervous system. Sachs.

Laetin Test in LAte Syphilitic DiacMc of the Central NervooB System—
V. Kafka, Berliner klin. Wochenschr,, Jan. 4. 1915.

The luetin test, employed in 139 cases, gave positive reactions in
62 per cent, of latent general syphilitis, in 72 per cent, of congenital
syphilis, in 52 per cent, of general paralysis, in 90 per cent, of
cerebral syphilis and 100 per cent, of tabes. The luetin reaction is
hardly ever positive in the first or second stage of lues. On the
other hand, in the tertiary stage it yields positive results in almost
every case. Mill.

Dyssynergia Cerebellaria ProEreBuva — J. R. Hunt, Brain (London), Vol.

XXXVII, Part II.

There exists a chronic progressive form of cerebellar tremor, the
most striking and characteristic symptom of which is a generalized
volitional tremor, which begins locally and gradually progresses. In
its advanced stage, the disorder of motility is comparable in severity
and violence with that of Huntington's chorea, or the generalized
athetosis. There is, however, this difference, that in a position of
rest and muscular relaxation, the tremor movements cease. An
analysis of the motor disorder shows a marked disturbance of the
ability properly to control and regulate coordinated movements.
This is shown by the presence of hypermetria, dysmetria, adiadoko-
kinesis, dyssynergia, hypotonia, and intermittent asthenia. All of
these symptoms, including the volitional tremor, coincide with the
classical symptomatology which results from a loss of the cerebellar
control over voluntary movements. The disorder is therefore re-

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19° The Archives of Diagnosis

garded as of cerebellar origin. The local onset, gradual progression,
and chronic course indicate a progressive degeneration of certain
special structures of the cerebellar mechanism presiding over the
control and regulation of muscle movements. Sachs.

Spinal Cord Tumors— J. Coluns and H. E. Makks, Am. Jour. Med. Sei.,

Jan., 1915.

Pain and other classical data are valuable, but not essential phe-
nomena in the early diagnosis of spinal cord tumors. The essential
element in the diagnosis is the determination of a gradually pro-
gressive motor and sensory spinal paralysis, the upper pole of
which, despite increase in cross-section intensity, varies slightly, if
at all. In every case of so-called transverse myelitis, the possibility
of cord tumor should be considered. The diagnosis of myelitis of
unknown origin is made far too often; exploratory laminectomy is
not done often enough. Painless advancing tumors are not atypical.

Sachs.
Night TeiTora in Children— T. A. Williaus, Med. Press (London).

April 14, 1915.

Author relates a number of cases of night terrors in children
which illustrate the great sociol<^cal importance of conditions
purely psychological. Impaired efficiency from psychological causes
is quite common in children. When a nervousness of this origin
shows itself, a proper analysis of the child's mind is the first step
towards its removal. Sachs.

URINARY ORGANS— MALE GENITALIA
Renal Functional Teats — J. T. Gekachtv, Johns Hopkins Hospital BulL,

May, 1915-

Functional studies reveal only the excretory capacity of the kid-
ney. By themselves they do not make the diagnosis or settle the
prognosis. The value of any of these excretory tests is purely em-
pirical, because of lack of sound physiological information dealing
with the ultimate physics and chemistry of the excretion of any sub-
stance by any part of the kidney, the tubes or glomeruli. They in-
dicate only the functional value of the kidney at the time at which
the test is performed, but cannot of themselves indicate what the
renal function will be to-morrow or next week. This latter informa-
tion is to be derived from the knowledge of the underlying pathologi-
cal process which is producing the reduced function. Western.
Syphilitic Nephrida — A. Stengel and J. H. Austin, Am. Jour. Med. Sci.,

Jan., 1915.

There is evidence to suggest that there exists a parenchymatous
type of nephritis due to syphilis, characterized by an abundant a!bu-

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Progress of Diagnosis and Prognosis 191

minuria, with many hyaline, granular, and occasionally epithelial
casts, with a tendency to produce edema of renal distribution, asso-
ciated, as a rule, with moderate reduction of phthalein output and
exhibiting an almost constant tendency to the presence of doubly
refractile lipoid globules, varying in size from an erythrocyte, to
globules three or four times this diameter. These globules some-
times float free in the urine, but many times are a constituent of a
compound granular cell or possibly of an epithelial cast. On the
other hand, similar lipoid globules may be found in severe acute -or
chronic parenchymatous nephritis of other etiology, but in only a
minority of the cases. Sachs.

Tubercle Bacilli in Urine — L. Brown, Jour. A.M.A., Mar. 13, 1913-

No staining method differentiates absolutely tubercle bacilli from
smegma bacilli, but cultural methods itiay aid greatly. Animal in-
oculations with the production of tuberculosis is an absolute test,
hut of value only when positive. The same care about the collection
of urine should be exercised as about the collection of sputum.
Tubercle bacilli can be excreted through apparently normal kid-
neys. Radiography may aid in the quick detection of caseous foci
when the urine contains no tubercle bacilli. Tubercle bacilli occur
in the urine in genital tuberculosis usually late in the disease and
are consequently of little aid in the diagnosis of the condition.

Sachs.

Renal Tnberculoiift--G. 5. Gordon, Surg. Gynecol, and Obstet., Feb., 1915.
Renal tuberculosis gives no local symptoms in a large percentage
of the cases. Hematuria or symptoms of its spread to the bladder
may be the first manifestations of its presence. Gonococci, staphylo-
cocci, or other pathologic microorganisms in the urine in no way
exclude the concurrent presence of tubercle bacilli. Author thinks
that renal tuberculosis predisposes the urinary tract to other in-
fections. Sachs.

Pyelitis— C. Posner, Berliner klin. Wochenschr., Jan. 18, 1915.

Author is not willing to determine whether pyelitides are of cystic
or hematogenous or lymphi^enous origin. Both eventualities are
possible, but the metastatic development appears to be the most
frequent. Mill.

A New Preparation for Pyelography— E. N. Young, Bost. Med. and Surg.
Jour., April 15, 191 5.

Collargol is an absorbable kidney poison when used in the renal
pelvis. The emulsion of argentide as prepared by Mr. Godsoe, the
pharmacist at the Massachusetts General Hospital, is a clear non-

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192 The Archives of Diagnosis

absorbable opaque fluid, which can be used with the minimum of
danger to the patient and maximum satisfaction to the surgeon.
Silver iodid itself cannot be used for this preparation, but an accu-
rately made saturated solution will do vety well. Since the latter is
somewhat difficult to make, and if not correctly made, may be irri-
tating, author has simplified the formula by using a saturated solu-
tion already on the market. Godsoe prepares the emulsion as fol-
lows : Quince seed 100 grains, water 8 ounces, macerate for 24 hours
widi frequent agitation. Do not crush the seed. Strain through
cloth. Add 2 per cent, boric acid solution up to 20 ounces. It is
important to extract with water and not with boric acid solution,
as boric acid solution does not make a good mucilage. Enough of
this mucilage is added to I2J/4 c.c. of argentide to make 50 c.c. and
vigorously shaken for two minutes. The resulting emulsion lasts
several weeks and is a thin clear fluid, flowing freely through a
ureter catheter, Sachs,

Diverticulum of the Bladder — H. Cabot, Bost. Med. and Surg. Jour.,
March 11, 1915.

Author reports ten cases of diverticulum of the bladder. The
average age of onset of the symptoms was 37 years. Author is of
the opinion that these sacculations are of congenital origin. They
may and do exist for years without causing symptoms which, when
they appear, depend upon the advent of infection. They occur most
commonly in the neighborhood of the ureteral orifices, and may
sooner or later by pressure upon the ureter produce ureteral dilata-
tion, hydronephrosis, and extensive destruction of the kidney.
Those cases which have been discovered early and removed have
been followed by complete cure. Sachs.

Testicular TobercoloBis— J. S. McAkdli;, Practitioner (London), April, 1915,
The external secretion of the testicle is not the only one which
renders the gland of importance to the well-being of the subject,
for while in the lower animals emasculation has few, if any, ill
effects, in man it produces a profound mental depression, at times
of an alarming nature. Mental weakness and even mania have fol-
lowed in the track of castration. The affections which most stimu-
late tuberculosis of the testicle are syphilis of that organ and
gonorrheal epididymitis. The differential diagnosis is rarely diffi-
cult, for in tuberculosis the epididymis is the primary center, in
syphilis the testicle proper is the point of deposition of the infective
material. In tuberculosis, the testicular substance is usually en-
crouched upon only by pressure. Sachs.

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Prcx»ess of Diagnosis and Prognosis 193

FEMALE ORGANS OF GENERATION — PREGNANCY —
PARTURITION— INFANTS

X>Ra7 DiacnostB in Gsmecology— I. C. Ri»in, Surg. Gynecol, and Obstet.,
April, 1915,

Author employs the X-ray in gynecological diagnosis in conjunc-
tion with intra-uterine collargol injections. A 10 per cent, collargol
solution is essential for a satisfactory X-ray picture. Under mild
pressure (i.e., about 3 m.m. of mercury) the injection is not at-
tended by pain. It is not desirable to inject more than 5 c.c. of the
solution in the average case. The cases should be selected. One
should make sure that there is no active infection of the uterus or
the tubes. Post-abortive conditions with fever are contraindications.
There are no bad sequels, the menstrual cycle is not disturbed, and
the method is safe as far as peritonitis is concerned. The method
is of aid (a) in the diagnosis of the patency or the occlusion of the
tubes ; (b) in differentiating intra-uterine from extra-uterine tumors
as intra-hgamentous cysts and myoma; (c) in certain malformations
of the uterus and possibly also of the tubes; (d) in determining
whether a single or bilateral salpingectomy has been done on a
patient that had previously been operated; (e) in studying true
flexions of the uterus and mal -developments. Sachs.

Diagnosit and Prognosis of Renal Changes in Pregnancy— Wolp and Zade,
Monatsschr. f. Gefaurtshilfe u. Gynakologie, Vol. XL, No. 5-
The various forms of renal disturbances occurring during preg-
nancy cannot be clearly differentiated at the present day. A chronic
nephritis may develop from a nephritis during the puerperium.
Albuminuric retinitis may also be observed in uncomplicated neph-
ropathy and eclampsia. In chronic nephritis and synchronous preg-
nancy the occurrence of albuminuric retinitis has not the bad prog-
nostic significance as in the absence of pregnancy. It may entirely
disappear after labor. Mill.

The Total Ctaotestcrin of the Blood in Obstetrical and Gynecological
Caset— M. Hoffmann, Zentralblatt i. Gynakologie, 1915, Nos. 2 and 3.
The cholesterin content of the blood increases during pregnancy
by about 0.06 per cent., reaches its maximum during the last month
and declines to the normal amount after 8 to 10 days from the time
of delivery. In eclampsia especially high values appear to occur.
The cholesterin curve is apparently not influenced by menstruation.
It is markedly increased in narcoses and declines in the presence
of malignant growths, especially when there is synchronous a
or cachexia.

rMsLL.

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The Archives of Diagnosis

3EUcent ^bluationtf

JMo iknU

DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. By Fkdesick
T. Lord, M.D., Visiting Physician, Massachusetts General Hospital ; Visit-
ing Physician, Channing Home (for Consumptives) ; Instructor in Ginical
Medicine, Harvard Medical School, Illustrated with 93 Engravings and
3 Colored Plates. Philadelphia and New York, Lea and Febiger, 1915.
A man possessed of the vast clinical experience of Dr. Lord
should have overcome his natural timidity and presented to us in
the very first instance the results of his own work and observation.
Instead of doing this, he has chosen to publish a very diligent retro-
spect on the diseases of the respiratory organs which is based
almost exclusively upon the literary production of others. It is
really a pity that the author kept himself so much in the back-
ground. However, it must be frankly stated that his work is the
only complete and up-to-date book on the subject which has recently
been published in the United States. H. S.

INFANT-FEEDING. Its Principles and Practice. By F. L. Wachenheiu,
M.D., Attending Pediatrist, Sydenham Hospital and Mount Sinai Dispen-
sary, New York City. Philadelphia and New York, Lea and Febiger, 1915.
This is an unusually lucid recapitulation of nearly all that has
been published on the question of infant-feeding during the past
ten years. Although the author advances no theory of his own —
and this is hardly necessary in view of the fact that we can do very
well without a dozen or two that have been solely advanced for the
promulgation of the greater glory of the respective originators — he
has succeeded in presenting the subject matter in a novel, and at
the same time, concise manner. The little book cannot fail to
make numerous friends among those who are brought in frequent
contact with healthy and diseased babies. H. S.

DIFFERENTIAL DIAGNOSIS. Volume 11. Presented through an Ana-
lysis of 317 Cases. By Ricbakd C. Cabot. M.D.. Assistant Professor of
Clinical Medicine, Harvard University Medical School, Boston; Chief of
the West Medical Service at the Massachusetts General Hospital. Pro-
fusely Illustrated. Philadelphia and London, W. B. Saunders Company,
191S.
Dr.|ep|ni continues his scheme to teach what he considers "Dif-

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Recent Publications 195

ferential Diagnosis" by means of the analysis of case histories. The
method, originated by the author, in order to be of real benefit to
the reader, demands extraordinary memory on the latter's part.
Besides, it is rather too elementary and does not convey any mode
of procedure in the diagnosis of cases with which the modem clini-
cian had not become acquainted in his college days. H. S.

THE BACKWARD BABY. A Treatise on Idiwr and the Allied Mentol
Deficiencies in Infancy and Early Giildhood. Awarded the Alvarenga Prize
of the College of Physicians of Philadelphia. By Herman B. SHEFnELo,
M.D., Author of Modern Diagnosis and Treatment of Diseases of Children,
etc Mew York, Rebman Company.

This well written and illustrated prize-essay is a careful
study of mental deficiencies in infants in contradistinction from
that in older children. Stress is put on environment as a predomi-
nating cause of mental backwardness, and the author maintains
that, while the Darwinian theory of heredity holds good for normal
racial characteristics, it is not applicable to abnormal mental and
physical states. In the early detection of mental deficiencies in in-
fancy the author suggests a number of valuable mental tests, and
describes a peculiar attitude — status idiolicus — assumed by these
children which is pathognomonic of their condition. Under the
heading of "moramentia" the diverse forms of delayed mentality
from sense deprivation, etc., are fully gone into, and a new "incen-
tive" method of training is outlined which is based upon using food
as a bait, as it were, to induce mental defectives to learn to help
themselves, and the like. Special attention is given to organotherapy
and surgery in the management of idiocy and cognate mental degen-
eracies. H. S.

DIE ERKENNUNG UND VERHUETUNG DES FLECKTYPHUS UND
RUECKFALLFIEBERS. Von Generaloherarzt Prof. Dr. L. Beauer, Ep-
pendorf. Beralender innerer Kliniber bei der Armeeabteilung Woyrsch.
Nebst Vorschritlen lur BEKAEMPFUNG DER LAEUSEPLAGE BEI
DER TRUPPE, Von K. u. K. Regimentsarit Dr. Jinjus Moldovan, Prases
der Salubritatskom mission der 2. osterr.-ungar. Arniee, Mit 4 farbigen, I
schwarzen und I Kurventafel sowie 5 Abbildungen im Text. Wurzburg,
Verlag von Curt Kabitzsch, 1915.

Of all medical publications that were prompted by the present
war this brochure on typhus fever is without doubt the most in-
teresting one which has reached the reviewer's table.

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196 The Archives of Diagnosis

In Germany and Austria typhus exanthematicus is of very rare
occurrence. In times of peace sporadic cases of the disease may be
encountered in the main centers of traffic in the Russo-Polish
frontier districts. The infection, on the other hand, is endemic
in the Balkan countries, in Southern Russia and in Poland, in-
cluding Warsaw.

Typhus fever is said to hardly ever occur in the Summer; it
is, however, quite frequent in the latter part of the Winter and
in the Spring. Under the influence of unsanitary conditions ex-
tensive epidemics may then suddenly arise.

The causative agent of spotted fever is as yet unknown. The
Wassermann reaction is generally negative in this disease. Salvar-
san is therapeutically ine^ective. For this reason it is unlikely that
any of the species of spirochetes is etiologically responsible for the
affection.

The virus is probably attached to the leukocytes and not to the
red blood cells. The free blood serum and the spinal fluid are
apparently not infectious.

The transmission of typhus fever may occur in two ways, viz.,
by the bite of pediculus vestimenti, the clothes louse, and that of
pediculus capitis, the common or head louse. Lice are true trans-
mitting agents; they become active infective agents only five or six
days after they have taken up the infected blood. The virus is
still demonstrable in the second generation of the lice. It has not
been positively shown that bed-bugs or fleas may transmit the
disease.

Lice do not inhabitate straw for any length of time. They also
never deposit their eggs in the straw. It is a mistake to believe that
the infected straw on which soldiers have been resting is one of
the main sources of the spread of the lice. The contagion takes
place from man to man or through the agency of infected woolen
underwear. H. S.

THE PRINCIPLES AND PRACTICE OF TOOTH EXTRACTION AND
LOCAL ANESTHESIA OF THE MAXILLA. By William J. Lkdereb,
D.D.S., Dental Consultant to the German Hospital in the City o( New York.

This little volume of 258 pages will prove not only of interest to
dentists, but really ought to find its way into the library of the
medical man. It is a short but full description of all types of tooth
extractions, ranging from simple cases to those types proving
surgical operations. The author describes each class of cases, giv-
ing his technic of procedure. The second half of the book treats

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Recent Publications 197

on local anesthesia, especially "nerve blocking" as applied to the
Jaws, a feature which should interest every surgeon, as this type
of anesthesia replaces narcosis in almost all jaw operations. The
volume is rich in exceptionally good illustrations.

S. E. F.

MEDICAL ETHNOLOGY. By Chas. E. Woodruff, A.M., M.D.. Author of
"The Effects of Tropical Light on White Men" and "Expansion of Races;"
Associate Editor. "American Medicine" ; Lieutenant- Colonel. U. S. Army,
Retired ; Member American Therapeutic Association, etc. New York, Reb-
man Company, 1915-

The author makes the following introductory remarks: "Medical
ethnology deals with the different morbidity and mortality rates
of the different physical types of people living in the same locality.
Demography treats of the changes in a population as a whole, its
increases and decreases through births, deaths and migrations.
Medical ethnology is then a branch of demography, and explains
why certain changes of type take place. These changes have been
known for a very long time, indeed ever since ethnography has
been a science, but it is only recently that their causes have been
discovered and the matter found to be of great therapeutic and
hygienic importance."

It is, indeed, a great undertaking for a physician to tackle a prob-
lem that can only be mastered by the most advanced and profound
of biologists, and while Dr. Woodruff's attempt is certainly a very
courageous and creditable one, it must necessarily lack the great
guiding principle, the common denominator which a physician, edu-
cated in the era of medical casuistry, will hardly ever find in the
domains that are not particularly his own.

The book, however, imparts a great deal of interesting and
valuable information not only to the practitioner of medicine, but
also to the lawyer, the theologian and the educated public in
general. H, S.

St^ Cbttiontf

DISEASES OF THE HEART. By James Mackenzie, M.D., F.R.C.P.,
LL.D., etc., Physician to the London Hospital (in Charge of the Cardiac
Department) ; Consulting Physician to the Victoria Hospital, Burnley.
Third Edition; Second Impression. London, Oxford Medical Publications,
Henry Frowde, Hodder and Stoughton, 1 91 4.

The first edition of this work marked a distinct era in the proper
appreciation and the rational treatment of the diseases of the heart.

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igS The Archives of Diagnosis

Mackenzie is indeed the founder of modem clinical cardiology.
The present edition records all the advances pertaining to the sub-
ject that have been made since the past four or five years. Progress
in clinical cardiology has chiefly taken place in three directions.
First, as far as a succinct differentiation of disease-signs is con-
cerned ; second, as to the relation of heart symptoms to eventual
heart failure, and, third, as to the scientific foundation of cardiac
therapy. The present edition abounds in common sense, and though
the subject in its modem aspects is naturally a complicated one,
especially for the older men in medicine, the masterly fashion in
which it is treated and the classical, simple language employed by
the author will overcome the intrinsic difficulties which interfere
with a ready understanding, and render the perusal of this im-
portant work a veritable pleasure. H. S.

URINARY ANALYSIS AND DIAGNOSIS BY MICROSCOPICAL AND
CHEMICAL EXAMINATION. By Louis Heitzmann, M.D., New York.
Third Revised and Enlarged Edition. With 131 Illustrations, Mostly Otig-
inal. New York. William Wood and Company, 1915.

Instead of the third, the present edition of "Heitzmann" should
be the fifteenth. The comparatively slow sale of this, the most im-
portant work on urinary microscopy in existence, demonstrates
clearly that the average practitioner of medicine has not as yet
awaked to the necessity of a more refined examination of the
urine. This, I am sure, does not pertain to the readers of the
Archives of Diagnosis who know Dr. Heitzmann's theories and
interpretations from his articles and illustrations that have appeared
in its columns. There can t>e no doubt that the future belongs
to the urinary microscopy as taught by Heitzmann. H, S.

DIAGNOSTIC AND THERAPEUTIC TECHNIC. A Manual of Practical
Procedures Employed in Diagnosis and Treatment. By Ai.bebt S. Moibow,
A.B., M.D., Qinical Professor of Surgery in the New York Polyclinic;
Attending Surgeon to the Workhouse Hospital, and to the Central and
Neurological Hospitals. With 860 Illustrations, Mostly Original. Second
Edition, Thoroughly Revised. Philadelphia and London, W. B. Saundert
Company, 1915.

On the advent of the first edition of this book we were glad to be
able to recommend it to our readers (Archives of Diagnosis, 1911,
p. 212). The present edition contains about 60 more pages and 45
additional illustrations. The author has given undue prominence

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Recent Publications 199

to some of the devices of his medical friends and associates, while
he has omitted to give mention to certain diagnostic and therapeutic
technic procedures that should have been included in a book of
such broad scope. H. S.

LEHRBUCH DER SPEZIFISCHEN DIAGNOSTIK UND THERAPIE
DER TUBERKULOSE. Fiir Aente und Studierende. Von Dr. Bandelier,
Chefarzt des Sanatorium! Schwarzwaldheim in Schomberg bei Wildbad und
Prof, Dr. Roepke, Chefarzt der Eisenbahnheihtatte Stadiwald in Mel-
sungen bei Kassel. Achte Auflage. Mit einem Vorwort von. Wirkl. Geh,
Rat Prof. Dr. R. Koch, Exzellenz. Mit 25 Temperaturkurven auf 7 Litho-
graphischen Tafein, 2 Farb. Lith. Tafeln und 6 Textabbildungen. Wurzburg,
Verlag von Curt Kabitzsch, 1915.

The fact that this work on specific diagnosis and treatment of
tuberculosis has appeared in its eighth edition is in itself sufficient
proof of its value and popularity. It certainly needs no recom-
mendation on our part.

Among the last sentences of the book are the following : Tuber-
culin must become an integral part of ihe armamentarium of every
physician, must become Ihe alpha and omega of our diagnostics,
prophylaxis and therapeutics of tuberculosis. Only then it will ac-
complish that for which it was designed, viz., to assist in the ex-
termination of tuberculosis." H. S.

INFECTION AND IMMUNITY. A Text-Book of Immunology and Se-
rology. For Students and Practitioners, By Charles E. Simon. B.A.,
M.D., Professor of Oinical Pathology and Experimental Medicine at the
College of Physicians and Surgeons ; Pathologist to the Union Protestant
Infirmary and the Hospital for the Women of Maryland ; Clinical Patholo-
gist to die Mercy Hospital of Baltimore, Maryland. Third Edition, Re-
vised and Enlarged. Illustrated. Philadelphia and New York. Lea and
Febiger, 1915.

When we reviewed the second edition of this work we said that
the author has clarified a complex subject in an admirable manner.
This is also the case in the present edition, which, in some respects,
even surpasses the former. The section on the Wassermann reac-
tion, for instance, has been almost entirely rewritten. The theory
and technic of Abderhalden's protective (defensive) ferments have
been dwelled upon in sufhcient detail, and other recently advanced
factors pertaining to infection and immunity have found due con-
sideration.

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200 The Archives of Diagnosis

The subject-matter, as set forth, is readily grasped by any prac-
tictioner who is not entirely fossilized.

We congratulate Dr. Simon not only upon his excellent work,
but also upon his moral courage in "respectfully dedicating" it at
this time to the atrocious, heinous Teutons "Paul Ehrlich, the
Grandmaster of Experimental Medicine and the German Men of
Medical Science." H. S.

A TEXT-BOOK OF THE PRACTICE OF MEDICINE. For Students and
Practitioners. By Hobast Amoky Hake, B.Sc, M.D., Professor of Thera-
peutics, Materia M^dica, and Diagnosis in the Jefferson Medical College of
Philadelphia; Physician to the Jetferson Medical College Hospital; One
Time Qinical Professor of Diseases of Children in the University of Penn-
sylvania, etc Third Edition, Revised and Enlarged. Illustrated with 142
Engravings and 16 Plates in Colors and Monochrome. Philadelphia and
New York, Lea and Febiger, 1915.

It is always a pleasure to consult one of Dr. Hare's books. His
style is classical in its simplicity, and I doubt very much that there
is another medical author in this country whose writings can com-
pare with those of the Philadelphia clinician as far as succinctness,
straightforwardness and lucidness are concerned.

The third edition of this Practice of Medicine is a beautiful vol-
ume which is entirely brought up to date. It serves the purpose
for which it is intended very well. H. S.

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THE

ARCHIVES OF DIAGNOSIS

A QUARTERLY JOURNAL DEVOTED TO THE STUDY
AKD THE ntOGRESS OF DUGNOSIS AKD PROGNOSIS

JULY, 1915

rOUNDBD AND EDITED BY

HEINRICH STERN, M.D., LL.D.

REBMAN COMPANY

M. 148 AMD 140 WEST 86tb STREET
NEW YORK, N.V.

T IMS By BBBHAH COHPANT. AU. ItlOHTt BSSERVBD.

BaUT*d u 8*ooad-ClMi Mattar, Fabnarr e, 1108, M tli* Pott-OBo* at M«v York, H. T.
UadM Um am oCCoostwi <rf Uweh S, ISfll

SUBBCRIPTIOH OHB DOLLAR A YSAR. SlNQLI CoPISS 60 CBNTB. PoKBIOH $1.50.

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„Google

THE

Archives of Diagnosis

A QUARTERLY JOURNAL DEVOTED TO THE STUDY
AND THE PROGRESS OF DIAGNOSIS AND PROGNOSIS

Vol. Vin JULY, 1916 No. 3

l^pcttal iSlctfcluC

STUDIES IN THE SCHICK DIPHTHERIA REACTION
Ry ABRAHAM LEVINSON

MORRIS L. BLATT
Chicago

Von Pirquet's discovery of the cutaneous tuberculin reaction, in
1907, paved the way for the investigation of specific skin reactions
in infectious diseases. Since that time we have had many contribu-
tions in this direction. Noguchi (*) described his luetin test for
the detection of syphilis; Irons (-) obtained a cutaneous reaction
with a glycerin extract of gonococcus in persons suffering from
gonorrhea; Oaypole (^) obtained a reaction in persons affected
with a streptothrix group of organisms.

One of the most important skin reactions described recently is
one obtained in the absence of sufficient diphtheria antitoxin in the
blood. B. Schick, the discoverer of the test, found (*) that diph-
theria toxin in minimal lethal doses, when injected intracutaneously,
will produce a specific reaction which can in turn be influenced by
the injection of diphtheria antitoxin. We are already in posses-
sion of many data regarding this test. There still remains, how-
ever, quite a fruitful field for investigation. We undertook a series
of tests in our hospital and dispensary cases, with the following
problems in mind:

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202 The Archives of Diagnosis

1. What percentage of individuals possess natural immunity, the
ages at which immunity is most common, and what is the effect
of sex on natural immunity.

We were especially interested in noting the applicability of the
test in dispensary practice where patients are not under constant
observation as they are in the hospital, the result of this test in
turn to be of service in indicating its usefulness in private
practice.

2. Whether a disease other than diphtheria has any suppressing
effect on the Schick reaction.

3. Whether a v. Pirquet test done simultaneously with the Schick
has any influence on the Schick reaction.

4. Whether tuberculin treatment has a counteracting effect on
the Schick,

5. What effect vaccination has on the Schick.

6. How different members of the same family react to the Schick.
Before presenting our findings and observations, we shall give

a brief resume of the test in general.

PRINCIPLE

It has been a matter of common observation among physicians
that some individuals do not contract diphtheria even though ex-
posed to it. Romer (") has described a biologic test for the deter-
mination of the amount of antitoxin in the blood. He found that
intracutaneous injections of toxin and of human serum into a
guinea pig resulted in necrosis if the serum did not contain suffi-
cient antitoxin, but was neutralized if it did. Schick found that
the intracutaneous test when applied to human beings gave the
same information as to the presence or absence of antitoxin in the
blood.

Ill making the test on a guinea pig that weighed 250 grams,
Schick u.sed 1/50 of a- lethal dose of toxin. For instance, if the
lethal dose for the guinea pig was 0.005, ^-^ ^-^^ **f ^ toxin 1/1,000
dilution was used. Some patients to whom the test was applied
reacted positively, others negatively. In testing the blood of those
who showed a negative reaction to this toxin injection, by the Romer
method, Schick and numerous other observers found that the blood
contained at least 0.03 unit of antibodies or antitoxin pro cmm. A

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Levinson and Blatt: Schick Diphtheria Reaction 203

positive reaction, on the contrary, showed that the blood contained
less than 0.03 unit of antitoxin pro cmm., the amount required to
produce an immunity to the toxin injection. It was also found that
a larger dose of antitoxin will suppress the toxin reaction much
sooner than a smaller dose, and that some individuals require less
antitoxin than others to bring about this result. From a series
of experiments along this line, Schick concluded that the principle
of antitoxin reaction in man is the same as -that in the guinea pig,
that first the toxin in the tissues is paralyzed and then the toxin
in the blood.

The technic of different workers on the Schick reaction varies
slightly, especially in the amount of diluted toxin administered.
Park {"), for instance, dilutes the toxin so that 1/50 of the lethal
dose is contained in 0.2 c.c. of the solution. Since we, however,
adopted the method used by Schick, we shall give a description
of his technic,

A strong diphtheria toxin is taken, and the minimal lethal dose
for a guinea pig weighing 250 grams is determined by injecting a
series of guinea pigs. The dilutions are then made with sterile
normal salt solution until o.i c.c, of the solution equals 1/50 of
the minimal lethal dose. The toxin should be kept in a cool place,
to prevent spoiling. It is also best to keep the mixture in a dark
bottle, as hght seems to have a deleterious effect upon it. A rub-
ber cap through which the needle may be inserted before using is
preferable to a cork, as with each opening of the bottle there
is danger of contamination.

A syringe divided into i/io c.c. graduations can be used. More
accurate results, however, may be obtained from the use of the
tuberculin syringe, which is graduated into 100 parts. The needle
is of great importance in this work. It should be very thin and
have a short point, so that when introduced into the skin the point
may easily be covered over by the skin, thus preventing the fluid
from running out around the point. The injection with a needle
of this description, besides causing less pain than the injection with
a large needle, also greatly decreases the possibihty of trauma, a
matter that usually presents difficulty in ascertaining the reactions.

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204 The Archives of Diagnosis

The best- place for injection is in the scapular or intrascapular
region. The needle is inserted intracutaneously, the skin about
the region of injection being held between the thumb and the index
finger. If the injection has been made correctly, the skin about
the area of injection will show a whitened appearance with defi-
nite indentations. Some workers use the arm as a place of in-
jection. Our experience, however, makes us favor the back as
the region of injection, for the reason that the skin there being less
sensitive the danger of traumatic reaction is much less than it would
be in the arm or forearm.

Reaction, as a rule, occurs in about twenty-four hours after in-
jection, although some reactions may occur as early as twelve hours
and others as late as seventy-two hours after injection. A positive
reaction is manifested by an area of erythema and induration, which
usually becomes more marked the following day and persists for
five or six days. The reaction seen in twenty-four hours presents
an erythema of from 0.5 cm. to i cm. long, and from 0.2 to 0.8
cm. wide, with some induration. The twenty-four hours following,
the erythema shows an increase in strength and diameter. The third
twenty-four hours, the erythema takes on a brownish tinge, be-
coming darker with each succeeding day until its disappearance,
leaving a brownish discoloration at the place of reaction, or result-
ing in a superficial cracking of the skin over the spot of injection
with a subsequent desquamation in eight or nine days.

The extent of the reaction is of course a matter of great im-
portance to the worker. It involves the determination of the re-
action as to its positive or negative character, often a puzzling
question to answer. A reaction that clearly shows the findings
described above can easily be characterized as positive, just as one
that shows merely the point of injection can be put down as neg-
ative. There are cases, however, that show a slight reaction, i.e.,
a faint erythema, and in these the question arises as to whether
the reaction is positive or negative. Schick has used as control
on the opposite side a toxin-antitoxin mixture, consisting of a solu-
tion of toxin with an excess of antitoxin, to make sure that the
positive reaction, on the other side, if it does occur, is due to
the toxin. We, however, found that besides the difficulty in get-
ting toxin-antitoxin, the result may be misleading, as the antitoxin

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Levinson and Blatt : Schick Diphtheria Reaction 205

may, and, in fact, does at times give a serum reaction. We,
therefore, prefer as a control on the other side a normal salt in-
jection, which we have found quite satisfactory. Moreover, the
control can usually be omitted, the toxin test alone being sufficient.
We took the following as our standard of characterization :

Positive Reaction
Erythema and induration, at least 0.5 x 0,2 cm.

Negative Reaction
Needle track, redness or induration.

Small papule at point of injection, showing no increase sub-
sequently.

Erythema without induration, disappearing without leaving trace
in 24 hours.

FINDINGS

We diluted a strong diphtheria toxin with 19 parts of normal
salt (i to 20) and this solution we diluted further with 28.5
parts of normal salt solution; o.i c.c, of this solution was, there-
fore, equivalent to 1/5,900 c.c. of the toxin (1x20x28.5x10).
All other steps in our technic corresponded to the technic of Schick
described above.

We tested 208 children. Of this number 60 were normal, 55
were afflicted with diseases other than diphtheria or tuberculosis,
86 were tuberculous or suspects on whom a v. Pirquet was done,
6 had been vaccinated a few days before the Schick test was ap-
plied, and one was a case of diphtheritic paralysis.

Series I consisting of 60 normal children between the ages of 7
months and 9 years gave 47 or 78.13 per cent, negative and 13 or
21 2/3 per cent, positive.

Sex played no role whatever in the result of the reaction. Age,
on the other hand, did. All the children under one year of age
showed a negative reaction, the susceptibility increasing with ad-
vance of age.

In series II out of 55 children afflicted with diseases other than
diphtheria and tuberculosis, 34, or 61.8 per cent., showed a negative
reaction to the Schick test.

Here also, as in the case of normal children, sex exerted no

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2o6 The ARcnrvES of Diagnosis

influence. Age was a factor, all children under 6 months reading
negatively.

The disease seemingly plays no role in increasing the suscepti-
bility of the Schick reaction. The higher percentage of positives
in this series (38 per cent., as compared to 21 per cent, -in nor-
mal cases) may be accounted for by the greater number of older
children examined.

In series III 33 children, suspects of tuberculosis, received the
Schick simultaneous with the v. Pirquet test. They seemed to
have no influence upon each other, some children giving a posi-
tive Schick and a negative v. Pirquet, and vice versa.

In series IV out of 38 children that received tubercuhn treatment,
16 were positive. The result, however, bore no relation to the re-
action obtained -from the tuberculin treatment.

CONCLUSIONS

1. The Schick reaction is valuable in dispensary, as well as in
private practice.

2. One should wait at least twenty-four hours before deciding
whether a Schick reaction is positive or negative. The examina-
tion should be repeated the following twenty-four hours, and if
possible also several days later. This, of course, diminishes some-
what the value of the Schick test as a diagnostic measure in urgent
cases of diphtheria.

3. While a positive Schick reaction does not necessarily mean
that the disease in question is diphtheria, antitoxin should be given
in all cases showing a positive Schick reaction upon exposure to
diphtheria.

4. Our scries of cases showed a percentage of negative Schick
reactions ranging from 61 per cent, to 78 per cent. This would
seem to indicate that a very high percentage of children possess
natural imnninity to diphtheria. The administration of antitoxin
can, therefore, be eliminated in a great many cases if the Schick
test is apphed.

5. TJie Schick reaction, as a rule, is negative in children under
six mouths of age, frequently also in children under twelve months.
Susceptibility, however, increases with increase of age.

6. Sex exerts very little influence on the Schick test.

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Hart : Abnokmalities of Myocardial Function 207

7. Diseases other than diphtheria have no effect on the Schick
reaction.

8. Tuberculin tests, as well as tuberculin treatment, exert no in-
fluence on the Schick test.

We wish to acknowledge our indebtedness to Dr. George Weaver
of the Durand Hospital, who supplied us with the diphtheria toxin
needed for our work.

We also wish to express our thanks to the medical staff and
nurses of the Sarah Morris (Michael Reese) Hospital, the Jewish
Aid Dispensary and the Bethlehem Nursery, for the assistance
rendered us in making our tests.

1. Ncffuehi. — "A CittaiHOus Reaelion in Syiihilis." Jour. Experini. Med. Vol

XIV. No. 6, igii.

2. Irons.-— Jcur. liifLTtioiis Dis.. July, 1912.

3. Claypole —'■Human Slreptothriehosis and Its Differentiation from Tuber-

culosis." Arch, inter Med.. igi4. XIV, 104.

4. Seliielc, B. — "Spciifische Therapic der Diphtheric." Centralblatt f. BakteiJo-

logie. Referate 57-

5. Romer. — "Ueber den Gehalt des Blutes an Diphtheric Antitoxin be! ge-

sunden Erwachsencn, Rekonvaleszenten und Bazillentragern," Deutsche
Med. Wochensdir., March 2, 1914, p. 542-

6. Park, M. — "The Schick Reaction and Its Practical Application," Arch.

Pediat., July, 1914.
(Editor's Note).— The tables accompanying this article were omitted for
technical reasons.

THE DIAGNOSIS OF ABNORMALITIES OF MYO-
CARDIAL FUNCTION
By T. STUART HART

Assistant Professor of Clinical Medicine, College of Physicians and Surgeons,

Columbia University ; Visiting Physician, Presbyterian Hospital

New York

V. PAROXYSMAL TACHYCARDIA

Acceleration of the heart rate, which has been discussed in the
last paper, is exceedingly common and is important as a symptom
associated with many conditions. Paroxysmal tachycardia, vvhich
we are now to examine, is relatively rare, and is associated with

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2o8 The Archives of Diagnosis

phenomena so distinct and definite that the syndrome deserves con-
sideration as a clinical entity.

This group is particularly characterized by the suddenness of
the change in the rate of the heart. The acceleration in rate occurs
as a paroxysm whose onset is abrupt and whose termination is
equally sudden. The change in rate, both of the onset and off-
set of the attack, occurs in a period of time less than that occu-
pied by one normal cardiac cycle. The duration of the paroxysms
are extremely variable. They may last for only a few beats or
may continue for minutes, hours or days. The longest attack which
has come under my notice was continued for 28 days. This varia-
bility is the rule not only comparing different cases, but also in
the successive attacks of a single individual. The relative time
consumed by the paroxysms and the intervals of slow rate is very
variable, but in nearly all instances the slow periods exceed the
paroxysmal periods by a considerable margin.

MECHANISM

An analysis of the paroxysms shows that it is composed of a
series of contractions having their origin in some part of the cardiac
musculature other than the sinus node; in other words, a rapid
succession of extra systoles; in some point of the heart wall ex-
citability is raised to such a point that for a period stimuli are
set free at an abnormally rapid rate, and, in accordance with the
law that the most excitable portion of the heart sets the rate for
the less excitable portions, this excessively irritable point usurps
the function of the pace-maker, and for the time the normal pace-
maker, the sinus node, is buried in the flood of stimuli arising from
this new point of origin. Usually all of the contractions of a
given paroxysm arise from a single point and spread over the heart
muscle by the same path. This is shown by the similarity of the
waves obtained in graphic records. For the most part, the con-
tractions are rhythmic, hence their rate is to a degree a measure
of the rate of stimulus formation and the excitability of the irri-
table point.

During the period of slowing, the sinus node regains its ascend-
ency and sets the pace. If one studies carefully the periods of
slow rate, one will almost invariably discover isolated extra sys-

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Hart ; Abnormalities of Myocardial Function 209

toles occurring more or less frequently. These are usually o( the
same type as those which go to make up the beats of the parox-
ysm, and are often of material assistance in determining the par-
ticular point in the heart in which the extra systoles of the
paroxysms have their origin. It is conceivable that any portion of
the heart muscle may be capable, under suitable conditions, of
assuming the role of pace-maker for a limited period of time. We
are certainly able to define paroxysms which have their origin in
the wall of the auricle, in the region of the auriculo-ventricular node
and in the right and left ventricles. Most of the paroxysms have
an auricular origin. Ventricular paroxysmal tachycardias are com-
paratively rare.

When the point of origin is in the auricle, the ventricle usually
responds promptly and in the usual manner to each auricular im-
pulse. At times, however, the electrocardiographic records sug-
gest that the stimulus has taken a path through the ventricle wall,
somewhat removed from the normal, or again the exciting effects
of the frequent stimuli may be seen in a depression of the bundle
contractility, as evidenced by an abnormally long period between
the auricular and ventricular contractions.

It has been shown by Erlanger* that stimuli may pass over the
conducting system of the heart in a direction opposite to the nor-
mal. We have evidence that this occurs in paroxysms of ven-
tricular origin, and that the auricular contraction is a response to
stimuli reaching it from the ventricle.

EXPERIMENTAL PRODUCTION

In a previous paper it has been pointed out that single extra
systoles may be produced experimentally by applying mechanical
or electrical stimuli to various portions of the cardiac musculature.
If a properly spaced series of such stimuli are applied to the wall
of the heart, a tachycardia will instantly result, composed of a
succession of extra systoles. During such an artificial paroxysm,
the activity of the normal pace-maker is submerged by the stimuli
set free from the new focus. When the artificial stimuli are with-
drawn the tachycardia terminates abruptly. The normal pace-
maker immediately regains its ascendency and the normal rhythm

lArch. Int. Med., 1913, VoL XI, p. 362.

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2IO The Archives of Diagnosis

is resumed. Such paroxysms may be induced by stimulation of
either the auricle or the ventricle. When the ventricle is thus
excited, the stimuli are transmitted upward to the auricle, a direc-
tion the reverse of the normal, and the contractions follow instead
of precede the ventricular contractions. These retrograde stimuli
pass the bundle of His with less velocity than those which pass
over the heart in the normal direction, hence a part of them may
be blocked and the auricle may fail to respond to each ventricular
contraction. Tachycardias have been experimentally produced by
the administration of aconitin (Ciishny), muscarine (Rothberger
and Winterberg), by an abrupt increase of the blood pressure
(Hering), and by ligature of the coronary arteries (Lewis) ; a
production of attacks of tachycardia by ligation of the coronaries
particularly elicits our interest, since it more nearly approximates
conditions which we may encounter clinically. Lewis' found that
obstruction of the blood flow in the right coronary was usually,
and that of the descending branch of the left coronary was in-
variably, followed by isolated ventricular extra systoles, as the nu-
trition of that portion of the ventricular wall supplied by these
vessels became progressively impaired, extra systoles appeared at
shorter and shorter intervals, until finally there was established a
rapid series of rhythmically recurring extra systoles, constituting
a true paroxysmal tachycardia. Under these conditions the stimuli
became retrograde and the auricular followed the ventricular con-
traction. The extra systoles were rhythmical and graphic records
showed that in a given case all the extra systoles had a single point
of origin. In dogs rates between 300 and 420 per minute were
obtained. The phenomenon occurred both when the vagi were
intact and when they were sectioned, showing that the disturbance
had its origin in the wall of the heart and could not be as-
cribed to altered central innervation. When the ligature was
removed and the circulation became re-established, the paroxysm
abruptly ceased and the sinus node resumed its function of pace-
maker.

The diagrams, figures i and 2 indicate the mechanism of the
paroxysmal attacks. Figure l represents a focus of abnormal irri*
tability situated in the wall of the auricle. The impulses are set

^Hcart, 190^10, Vol. I, p. 98.

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Hart: Abnormalities of Myocardial Function 211

free so rapidly that the stimulus material forming at the sinus node
is destroyed before reaching maturity. As soon, however, as the
abnormal irritability of the auricular wall is lost, the accumulation
of stimulus material at the sinus node continues for the normal
period and thus the node resumes its role of pace-maker. Figure

t i j I i J i A

"I TTTTTTTm I I T

iiUuL

^ff=^F?

T T t T t t T r T

""\s;

rbyibmic acTits o;

Ihc diwci

on ukrn

.(ion were nol nilerrupled hy llie extrasyslole. The thicki
ntneular s);sto1c indicate the relative eifcct of the notin:

2 represents an abnormal focus in the ventricular wall, which, for
a short period becomes the pace-maker of the whole heart. Here
the ventricular impulses become retrograde, that is, they passed up-
ward over the A-V bundle and stimulated the auricle from below.
These impulses are frequently blocked, as is indicated in the dia-
gram, in which the auricle responds only to every other ventricular
impulse.

It might be supposed from this review of the mechanism of these
disturbances that paroxysmal tachycardias would be frequent se-
quelae of single extra systoles. This is not the case. Isolated extra

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212 The Archives of Diagnosis

systoles are extremely common. Probably most individuals reach-
ing the age of 50 have had extra systoles at one time or another,
but attacks of true tachycardia are comparatively rare. On the
other hand, it may be said that probably every true paroxysm is
preceded by isolated extra systoles.

PATHOLOGV

Little is known of the histolc^cal changes which may form the
anatomical basis of paroxysmal tachycardia. In my own series only
two cases have had a fatal termination, and in neither of these
was a post mortem permitted. In the literature several autopsies
have been reported and these have all shown more or less ex-
cessive myocardial change — sclerosis, fibrosis, atrophy, and arterial
degeneration, particularly of the coronaries. One does not feel that
we have as yet evidence of any definite pathological lesion which
is characteristic. Experimental evidence suggests that the cause
may be found in the intracellular chemical change induced by vari-
ations in the blood supply in the heart, which may or may not
show degeneration of the myocardium.

In no one of my series of 26 cases of paroxysmal tachycardia
have I been able to obtain a history of a similar condition in an
ancestor or in any immediate relative. My youngest case was a
boy who had his first attack when 10 years of age; the oldest a
man of 69, whose paroxysms had annoyed him for 2 years. One
patient, a man of 44, has suffered from attacks over 3 period of
20 years. The distribution by decades of the time of onset in
my series is as follows:

Decade 10-20 20-30 30-40 40-50 50-60 60-70

Number of Cases 4 7 4 4 5 2

Among the 26 cases which I have observed, 19 were males and 7
females. The following tabulation indicates that the syndrome oc-
curs about twice as often in men as in 1

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Hart

Total

Hart : Abnormalities of Myocardial Funct:on

Hoffmann* Lewis*

Men 6 J8

Women 4 J i

An analysis of my cases presents the following factors, which
may have a bearing direct or indirect on the condition of the myo-
cardium. Alcohol was used to excess by 4; tobacco by 2 of the
men. Severe gastrointestinal disturbance had preceded the attacks
for several years in 3 of the women; nearly all had a history of
one or more of the infectious diseases of childhood; in one case
the onset of tachycardia followed 6 months after a severe infec-
tion of the middle ear; in another yellow fever antedated the at-
tacks by 2 years. There had been frank attacks of acute articular
rheumatism, followed by endocarditis with valvular defects, in 4
cases ; a syphilitic infection was demonstrable in 4 cases, 3 of which
showed evidence of myocardial damage other than the attacks of
tachycardia. Several of the series had taken considerable doses
of digitalis ; in one a physician whose arrhythmia had been
wrongly diagnosed as complete irregularity and auricular fibrilla-
tion had taken very large doses, and it seems to me that this was
undoubtedly an important agent in increasing the irritability of
the heart muscles. The attacks in the youngest patient of my
series, a boy of ten, immediately followed a race in which he par-
ticipated, at which time the physician who saw him found evidence
of acute dilatation. A case of mild Graves' disease, in which the
pulse averaged 100, has shown on several occasions paroxysms
lasting only a few minutes in which the rate was between 160 and
170. Valvular defects were present in 9 of my patients; the
mitral valve was involved in 7, of which 4 were cases of well-
marked stenosis; one patient had an aortic insufficiency and one
had defects of both the aortic and mitral valves; 15 cases showed
various degrees of cardiac enlargement. In many cases the irri-
tability of the heart muscle seems to require a very small excit-
ing factor to induce an attack. The patient will usually ascribe
the onset to flatulence, some emotional disturbance or unusual

'Die Electrocardiographic, Wiesbaden, 1914.
'Ginical E)isorders of Ihe Heart Beat, London, igi3.

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214 The Archives of Diagnosis

physical exertion ; any one of these is probably an efficient cause
to call forth an attack in a myocardium suitably damaged.

SYMPTOMS

The symptoms associated with paroxysmal tachycardia are of
great variety, and show great differences from individual to indi-
vidual. This is doubtless in a large measure due to the extent of
damage present in the myocardium and the abihty of the heart
to meet the tax thus exacted. The patient is practically always
conscious of the abrupt onset and termination of the attacks. They
usually describe the attacks as beginning with one or two "thumps"
or "throbs" in the precordial region, followed by a sensation of flut-
tering in the chest, which is terminated by another "thump" or
"flop," and the attack is over. The amount of anxiety is always
greater in the early attacks; as the patient becomes more or less
accustomed to the paroxysm he is less alarmed, and a momentary
pause in his activities may be the only evidence to show that he
knows the attack is on. This absence of alarm I have noticed
particularly in young adults who have had attacks for a number
of years, but whose hearts show no anatomical abnormality and
functional disturbance characterized only by the attacks of extra
systoles at more or less infrequent intervals.

One of my patients, whose attacks have continued for several
days, was quite unconcerned even when his heart was beating at
170. He rarely voluntarily assumed a recumbent position on ac-
count of the attacks and it was difficult to convince him that rest
at these times was important.

In those who have an associated valvular lesion, and in those
with evidence of marked arterial changes, a greater discomfort and
attendant anxiety are closely associated with the symptoms re-
ferrable to the cardiac insufficiency which is induced by, or the
precordial pain which accompanies, the attack.

At the onset patients often complain of palpitation in the chest
and a swelhng and pulsation of the vessels of the neck. Often
they have eructations of gas, nausea and vomiting. There may
be a "gone," sinking feeling, and, if the attack is prolonged, sweat-
ing, coldness, great lassitude and an intolerable feeling of weak-
ness. They may have a sensation of palpitation or of bounding in

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Hart: Abnormalities of Myocardial Function 215

the chest, shortness of breath or a sensation of suffocation. In one
case under my o.bservation attacks were invariably accompanied by
a watery dtarrhcea; in another by frequent micturition.

In the prolonged attacks, increase of the cardiac dulness to the
left can sometimes be made out and the symptoms of circulatory em-
barrassment terminate the picture. The veins are not properly
emptied, but are engorged, and there is pronounced cyanosis. The
liver may be increased in size and become tender to palpation. There
may be edema of the extremities ; there may be cough with profuse
thin, or blood-streaked, expectoration, with the physical signs of
pulmonary congestion.

The paroxysms are often attended with headache and dizziness,
more rarely with momentary or prolonged periods of unconscious-
ness, which may be explained on the basis of cerebral anemia. Pain
is sometimes prominent. Sometimes this is accompanied by the
feeling of oppression and of constriction of the chest, which accom-
panies the attacks, in nearly all patients to a greater or less degree.
The pain is usually precordial, and is sometimes sharp, suggest-
ing a real angina, and may radiate into the arms and back and
sometimes one can detect areas of hyperesthesia over the chest and
arms, following the distribution of one or more of the upper
thoracic and lower cervical nerves. Some patients complain of
numbness and tingling of the extremities.

A progressive cardiac insufficiency may terminate in general
anasarca, pulmonary edema, collapse and occasional death. As a
rule, however, the signs of cardiac insufficiency are very moderate,
and even when present to an extreme degree clear up with great
rapidity, following the abrupt ending of the rapid heart action. The
absence of alarm, the facial change of expression from one of
anxiety to complete calm; the abrupt change from dyspnea to quiet
breathing; the sudden cessation of pain; the subsidence of en-
gorged veins of the neck coincident with the termination of the
paroxysm present some of the most remarkable and agreeable clin-
ical phenomena with which we are familiar.

The signs of pulmonary congestion and edema of the extremi-
ties may require a period of days for their subsidence, the rapidity
depending to a considerable degree on the functional efficiency of
the heart when it has resumed its normal rate.

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2i6 The Archives of Diagnosis

As illustrating the character of severe attacks terminating fatally,
one case which I had the opportunity to obscn^e closely for a period
of months, may be descrit>ed.

A man, 55 years of age, who had a leutic infection 20 years
earlier, had a heart moderately enlarged to the left and a faint
systolic murmur at the apex. Between the attacks his pulse was
about 70 with many extra systoles. At all times there was evi-
dence of a moderate degree of cardiac insufficiency, A descrip-
tion of the attacks, obtained from the patient, was as follows:

"The exact cause of these attacks of syncope and tachycardia,
which come as often as twenty times in one day and have been ab-
sent as long as 26 days, cannot be determined. Many times he
has been wakened from his sleep by dizziness to become uncon-
scious and have a typical attack. Again, a slight exertion, as walk-
ing, going up stairs or straining to pass water, may be followed by
an attack, but these same exertions, or even more severe ones at
another time, may have no harmful effect. The attack comes on
suddenly with dizziness, grayness before the eyes and a buzzing in
the head like an organ. There are no premonitary symptoms. Un-
consciousness follows rapidly, and when he comes to his heart is
lieating very rapidly, 200 to 250 to the minute. There is a chok-
ing sensation, as if a ball were in the throat, and he is shaking all
over. There is never any pain over the heart or down the arm.
At times he has been struck down as if by electricity without warn-
ing, again he has simply had dizziness and grayness, without losing
consciousness. The tachycardia lasts a varying length of time,
sometimes for only ten minutes, at other times all day. During its
continuance he has great gastric disturbance, with frequent vomit-
ing. He cannot forecast the end of the attacks until it is at an
end. Then^ at times, a violent regular beating of the heart is suc-
ceeded by two or three irregular beats, as if something shook the
heart, and this is immediately followed by two or three tremendous
throbs of the heart with each of which there is a feeling as if
fresh air were forced into his throat and head and the attack stops
suddenly as it began."

His paroxysms of tachycardia continued for 5 years, becoming
gradually more frequent, and he finally died during an attack.

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Hart: Abnormalities of Myocardial Function 217

identificatiok

The conditions other than paroxysmal tachycardia which afford
a heart rate of over 160 are extremely rare. During the paroxysm
the pulse is exceedingly small, often irregular in force and fre-
quently cannot be detected at the wrist. Under these conditions
our examination should at once be directed to the precordial region.
The apex beat may be imperceptible to the touch or, when palpable,
may give the impression of complete irregularity. The heart sounds
may be indistinct and have a fetal character; often they are sharp
and distinct ; as a rule, they are perfectly rhythmic, but so rapid
that the rate can be only approximately estimated ; this is best ac-
complished by counting short (5 seconds) periods. If one is for-
tunate enough to be making observations at the beginning or at
the termination of the attack, the change in rate is readily detected.
The transitions are usually accompanied by one or two large forcible
beats, with loud sounds and unusually large pulse waves. The
change in rate is quite abrupt. In the absence of such an observa-
tion the patient will frequently establish the diagnosis by his de-
scription of the sudden onset and termination of the attacks. Valvu-
lar murmurs, if present during the slow rate, sometimes cannot be
detected during the paroxysm. In some cases a heart without mur-
murs during the slow period will develop a loud systolic murmur
during the paroxysms.

During the slow periods extra systoles followed by pauses, more
or less fully compensatory, can usually be detected ; sometimes they
are very frequent, more often only occasional. Single extra sys-
toles are quite common between paroxysms which are of short
duration and which follow one another at brief intervals.

During the paroxysms the veins of the neck are prominent, dis-
tended, hard and pulsate with great rapidity. Often two pulsations
of the jugular may be seen to correspond to each systole of the
heart.

In most instances the attacks are not affected by the position as-
sumed by the patient and continue whether he sits up or lies down
without change in rate.

When seen only between the attacks the diagnosis rests largely
on the history, but the patient's description of the attacks is usually

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2i8 The Archives of Diagnosis

so clear that there is little difficulty in classifying the abnormal
activity.

The cases which present the most obscure diagnostic problems are
those with very frequent short paroxysms separated by equally
short periods of slow rate broken by frequently occurring extra
systoles. These are often wrongly classified as complete irregu-
larity due to auricular fibrillation. They may usually be assigned
to their correct category by means of a careful and prolonged study
of the ordinary physical signs. Their status may be absolutely
settled by graphic records.

The polygram brings out clearly some features of the paroxysms
which are observed with great difficulty by the ordinary means of
eliciting physical signs.

In figures 3 and 4 are shown brachial and jugular tracings taken
from a woman 35 years of age. Figure 3 shows the usual condi-
tion of her pulse; the rate is 82; the arterial pulse is of good size
and well sustained ; the jugular pulse shows a normal sequence of
waves a, c and v; the a-c interval is normal (less than 0.2 second).
Figure 4 is a record taken during her second paroxysm, which
lasted 2 days without interruption. At the time the tracing was
secured the attack has been under way for 24 hours. The heart
at this time was beating rhythmically at a rate of 182 per minute.
The small volume of the brachial pulse is in great contrast to that
of the slow periods. The venous curve shows, in place of the well-
defined waves of the slow heart rate, one large wave and one small
notch to each cycle. The interpretation is that the auricle and the
ventricle are contracting simultaneously, so that the veins are un-
able to empty into the right auricle in the normal manner. The
large jugular waves, much greater than the jugular waves of the
normal period, are due to a summation of the a and c waves. It
will also be seen that during the paroxysm the a-c interval is con-
siderably prolonged (over 0.3 second), indicating that there is a
delay in the conduction of the stimulus from the auricle to the
ventricle. This is not an uncommon feature in tachycardias, the
excessive functional demand on the slender A-V bundle leading to
its partial exhaustion.

In these two figures the respiratory curve is brought out in the
venous tracing. That in this case the dyspnea was not very marked

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Hart: Abnormalities of Myocardial Function 219

is evidenced by the facts that the breathing was 24 during the
slow rate and only 30 during the attack, and that the excursion is
not very much greater during the paroxysm.

Fig, 4

Auricular Uchycirdia. Raw j&i. Respiratory rjte 30. Foe record of (he ume >
'een alUcks Ke ^S"". 3- Compare in the two recordi the volumes of the arte

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220 The Archives or Diagnosis

Tracings from another case of auricular tachycardia are shown
in figures 5 and 6, As in the preceding case, the contrasts between
the cardiac rates (72 and 174) and the arterial pulse volumes of
the two periods are shown in the brachial tracings. During the

:lc and Ihe ventncLc. Each on
ir a c *avc d( b cycle juit con

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Hart : Abnormalities of Myocardial Functigii 221

paroxysm (figure 6) only one large wave appears in the jugular
to each cardiac cycle.

The slow period (figure 5) is interrupted at one point (X) by
an extra systole with an incomplete compensatory pause, hence we
may conclude that it probably had its origin in the auricular wall.
It is a series of such extra systoles which constitute the paroxysm.

Figure 7 was taken from a man of 36 during a prolonged parox-
ysm. The ventricular rate is 158 and is perfectly rhythmic. The
jugular tracing shows the great venous congestion and the very
large waves which are due to simultaneous contractions of auricle
and ventricle ; conduction is delayed. The exact point in the auricle
which has become the temporary pace-maker for the whole heart
cannot be definitely settled from the polygraphic record. The
respiratory curve upon which the large jugular waves are super-
imposed show that, in spite of the prolonged attack, the breathing
is not greatly accelerated ; at this time it was 22 to the minute, but
quite irregular.

A rare tracing from a case of ventricular tachycardia is repro-
duced in figure 8: The brachial shows at A the usual rate for
this patient between attacks (92 per minute). At X isolated extra
systoles, each with a complete compensatory pause, occur; the
premature beats are so weak that they make practically no impres-
sion on the brachial pressure. At B are shown two short paroxysms
of tachycardia, indicating the manner of the abrupt onset and termi-
nation of the attacks. The a-c interval of the "normal" rhythm of
this patient was always longer than that of a normal heart, meas-
uring nearly 0.3 second.

During the paroxysm the auricle contracted in response to the
"retrograde stimulus" from the ventricle ; this cannot be conclusively
made out in the polygram, but is substantiated by electrocardio-
graphic records (see figure 21), The irregularity of this putse is
so extreme that it might easily have been mistaken for a case of
"complete irregularity" and auricular fibrillation, had no graphic
records been secured.

The electrocardiogram gives us information in regard to parox-
ysmal tachycardia which we can obtain by no other method.
Through this agency we have discovered the real mechanism of the
attacks. The knowledge acquired in this way tends to emphasize

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The Archives of Diagnosis

Si
3S.

as-

li
h

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Hart : Abnormalities of Myocardial Function 223

the importance of the muscle cell changes and to minimize the role
played by the extra cardial nerves in inducing this change in cardiac
activity. These graphic records convince us that a new point in
the heart wall has become the temporary pace-maker of the heart.
The proof is most clearly demonstrated, if we study the records of
such a case as is shown in figure 21, where the evidence is com-
plete in a single curve. This is from a case of ventricular parox-
ysmal tachycardia, a condition of extreme rarity, hence it will be
better to first direct our attention to the more common forms,
namely, tachycardias of auricular origin.

Such a case is illustrated in figure lO, which was taken durir^
a paroxysm in which the heart rate was 167, Figure 9 was se-
cured from the same patient a few hours after the cessation of the
attack. This record shows a perfectly normal curve for a heart
with a rate of 80. Both records were taken by lead II (right arm
and left foot). If we should superimpose the ventricular portion
(beginning of R to the end of T) of the cycles shown in figure 9
on one of the cycles of figure 10, we would find that they corre-
spond in every particular, except that the summit of the T wave
shows constantly a deep notch. If we compare the records further,
we note that in figure 10 there is no wave which corresponds to
the well-marked P wave of figure 9. Careful measurement shows
that the notch in the T wave (figure 10) occurs at exactly the time
at which a P wave of the normal rhythm should precede the R
wave, hence we conclude that the positive P wave of the normal
rhythm is replaced by a negative wave notching the T wave of
the paroxysm.

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234 ^"^ Archives of Diagnosis

In studying the auricular extra systole, it was shown that when
the premature beat started from a point in the auricle at some
distance from the sinus node, the P wave of the electrocardiogram
was distorted in form, or even completely reversed in direction.

Taten durini a paroxysm, rate 167- "Lai H. Same patient as fiaure 9
inversion of P, ifliich notchu the aummil of T. Auricular uchycardia. The pa
of the heart it in the lowtr pan of ihe auriik.

Same patient » fisure ti. Rale 76 between attack*. Taken by lead II. P it tlifthllr
notched, otherwise the curve is normal.

hence in the records under consideration we are led to conclude
that the paroxysm shown in figure lo is composed of a series of
extra systoles having their origin at a point in the auricular wall
considerably removed from the site of the normal pace-maker.

Figure II, taken by lead 11, shows a normal electrocardiogram,
except for a slight notching of the P wave. Figure I2 was taken
from the same patient during an attack which lasted for one hour,
during which the heart rate was 174. Here the ventricular por-

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Hart: Abnormalities of Myocardial Function 225

tions of the two records are almost identical, except that the waves
of the paroxysm are a trifle smaller than those of the slow rate.
During the paroxysm no F wave can be definitely located; in this
case it was probably so small that it caused no distortion of the
relatively large T wave.

Fic. 12

I, kad II. From »

Slow pcnod, ume case as fipire I4- Kate ;s. Lead III. P is notched, R and T

bave a davmward diieclion.

Electrocardiograms of another case of auricular paroxysmal
tachycardia are shown in figures 13 and 14; both records were taken
by lead III (left arm and left leg).

When figure 13 was taken the heart rate was 75 per minute. This
record shows several abnormal features; the P wave is slightly
notched and R is directed downward (the latter feature is quite

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226 The Archives of Diagnosis

usual in hypertrophy of the left ventricle), T is also directed down-
ward. During the paroxysm (figure 14), the rate is 168. R is still
directed downward and is increased in amplitude, suggesting a dila-
tation of the left ventricle. The slow wave between the R waves
is an algebraic sum of the waves P and T of the new rhythm.

The next case, illustrated in figures 15 and 16, shows some in-
teresting features, during the slow period {rate 76 per minute),
the P wave is unusually broad. R is slightly notched and the
rhythm is broken by an extra systole, which is plainly of ventricu-
lar origin. The paroxysm (rate 188) is composed of R waves fol-
lowed by a depression, which in all probability are reversed P waves,

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Hart: Abnormalities of Myocardial Function 227

having their point of origin in the lower part of the auricle, pos-
sibly near the A-V node. The P-R interval is prolonged, measuring
over 0.2 second, exhibiting the delay in conduction which is not
an uncommon feature of these cases. In this instance the com-
plexes of the paroxysm probably represent extra systoles of auricu-
lar origin and do not conform to the type of the isolated extra sys-
tole which interrupts the slow rhythm (figure 15).

Fig. I?

low down )n the auriclt if tvidencea by the ib/up; chanKe in iht dirttiron'i>"lh° P wave.

Figures 17, 18 and 19 depict the mode of transition from the
slow to the rapid and from the rapid to the slow rate in different
cases.

The onset of a paroxysm can be seen in figure 17 and the dis-
location of the pace-maker from the sinus node to a point low
down in the auricle is indicated by the change in forms of the P

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228 The Archives of Diagnosis

wave from a positive to a ne^tive deflection. In the first cycle
of the paroxysm the reversed P wave falls at the apex of the T
wave, but subsequently notches the earlier portions of this part
of the ventricular complex.

The offset of a paroxysm is shown in figure i8. The bizarre
complexes which intervene between the paroxysm and the slow
rhythm probably represent extra systoles of unusual types, and
are doubtless the kind of cardiac activity which give the patient
the subjective sensation of "throbs" or "thumps" at the time of the
transition.

Another transition from a heart beat of i6o to one of 70 is
shown in figure ig. The curve is somewhat distorted by the move-
ments of the patient produced by the sensations experienced at the
time of the termination of his attack.

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Hart; Abnormalities of Myocardial Functiok 229

The most convincing evidence of the nature of the mechanism
in paroxysmal tachycardia is brought to view when we are fortu-
nate enough to secure in a single record periods of stow rates in-
terrupted by single extra systoles, continued into periods of tachy-
cardia. Such records are shown in figures 20 and 21.

A short paroxysm of tachycardia (rate 168), changing to a slow
rate (86) broken by extra systoles, is shown in figure 20. The
patient, from whom this curve was taken, was a physician, 65 years
of age, in whom the diagnosis of "complete irregularity," due to
auricular fibrillation, had been repeatedly made. The correct diag-
nosis was hardly possible until electrocardiographic records were
secured. The slow rate is interrupted by auricular extra systoles
(X,) and another type of extra systole (X,) which has its origin
in the ventricular wall. The auricular premature beats have their
origin high up in the auricle, since the P wave of the extra systole
is a positive wave, as is shown by the waves which are clearly
the sum of T and P. The paroxysm is composed of both kinds
of extra systoles, but the auricular type predominates, which is
also the case in the period of slower cardiac activity

The electrocardiogram of a case of ventricular tachycardia' is
shown in figure 21. Tachycardias of this type are extremely un-
usual. The bizarre forms of the complexes of his slow rate (80)
are seen in the short diastolic (P-T) interval, the broad P wave,
the long P-R interval and the unusual form of the R waves. These
features alone suggest serious myocardial damage. From time to
time there appear isolated ventricular extra systoles (X). The
paroxysm (rate 200) is composed of complexes similar in form
to those of the isolated extra systoles. Between the large waves
of the paroxysmal period are seen small waves (P) which occur
with every other cycle. These undoubtedly represent auricular con-
tractions due to retrograde stimuli arising in the ventricle. It ap-
pears that every other impulse, from the ventricle is blocked. This
record conforms in many particulars to the curves obtained experi-
mentally after tying one of the coronary arteries, hence a tentative
diagnosis may be made of partial coronary obstruction. The pa-
tient is still alive (3 years after the record was taken), hence the
diagnosis has not been verified.
'A complete record of this case will be found in Heart, 1912. Vol. IV, p. 128.

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The Archives of Diagnosis

1 H

Si
.'.I

ill

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Hart: Abnormalities of Myocardial Function 231

clinical significance and prognosis

There is little doubt that every subject of paroxysmal tachycardia
has a defect of the myocardium that must be seriously considered.
The prognosis is most difficult. Some patients over a period of
many years have attacks which incommode them but little and the
attacks become less severe, less alarming, and in some instances
disappear altogether. Some have only a few attacks before the
fatal termination.

I have never seen a case that was fatal until a number of at-
tacks had occurred, nor have I found such a case reported in the
literature.

The condition of the heart in the intervals between attacks is
important as an aid in determining the seriousness in the individual
case. If at these times the heart shows no abnormality other than
occasional extra systoles, one can be reasonably sure that there is
no imminent danger. If, however, marked valvular defects are
present, if there is evidence of an old inflammation of the peri-
cardium, if there is a general arteriosclerosis, if extra systoles con-
stantly occur at very frequent intervals, and if the heart is embar-
rassed in maintaining an adequate circulation in the periods of
slow rate, the paroxysms will rightly be viewed with much appre-
hension. The paroxysm is very exhausting to the heart. If the
myocardial damage is made evident by the attacks only, the heart
will probably successfully carry this stress; if, however, other evi-
dences of myocardial damage exist, the strain of the paroxysm is
a far more serious matter. The patients who do particularly well
are young subjects with no evidence of cardiac abnormality be-
tween attacks. Middle-aged and elderly individuals sooner or later
invariably develop other evidences of myocardial insufficiency and,
while they may have many and frequent attacks of tachycardia
without serious manifestations, the ultimate outlook is less
favorable.

The frequency and duration of the individual attacks do not
seem to be very important factors in determining the prognosis.
Much more important is the severity of the attacks as estimated
by the degree of circulatory embarrassment, cardiac dilatation, the
congestion of lungs and liver and edema of the extremities. At-
tacks associated with unconsciousness should be viewed with gravity.

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232 The Archives of Diagnosis

With a history of a moderate number of attacks over a number
of years in a young adult, with intervening periods of normal heart
action, one may usually give a good pr<^;nosis. When the patient
is more advanced in years and has paroxysms of increasing fre-
quency and severity, and intermediate periods characterized by signs
of cardiac insufficiency, the outcome of any particular attack is
doubtful, the prognosis for the future is not good.

PITUITARY EXTRACT— ITS VALUE IN DISTINGUISH-
ING BETWEEN FALSE AND TRUE LABOR PAINS
By SAMUEL WVLLIS BANDLER

Adjunct Professor ot Gynecology, New York Post-Graduate Medical

School and Hospital

New York

Just why labor occurs on the two hundred and eightieth day
is not generally known, except that it is a characteristic of the
human species. What the elements are, or whence they come
which produce labor pains and the expulsion of the fetus, can only
be suspected on the theory that the action of pituitary extract in
increasing labor pains points to the hypophysis as the source of
the secretion which produces this phenomenon.

One of the greatest aids in labor is the use of pituitary extract
given by the hypodermatic method. All that this secretion does,
if given in not too large doses, is to increase the labor pains, not
alone subjectively but objectively, that is, the labor pains are made
effectual, the contractions of the uterus do excellent work. This
holds good in the first stage as well as in the second stage of
labor. In fact, with the regular use of small doses of pituitary
extract in the second stage of labor, with the head well molded
through the brim, with the cervix dilated, the use of forceps is
diminished almost to nullity.

Pituitary extract, when given before labor pains come on, that
is, before the patient is in labor, has no effect whatsoever. It
does, as in Caesarean section, contract the uterus, which is of
great value, after the fetus is expelled. It does in other cases,
such as abortion or miscarriage, have a slow etTect in contract-

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Bandler: Pituitary Extract 233

ing the uterus, but, in the pregnant woman, unless she is in labor,
it has absolutely no effect whatsoever in bringing on rhythmical
labor pains.

These facts suggested the use of pituitary extract by the hypo-
dermic needle as a diagnostic procedure; in other words, patients
often, at or about the expected time, or even a month before, have
what are known as suggestive pains. Very often these are only
what the text-books call "false pains."

The obstetrician is in doubt as to whether the patient is going
into labor. These pains may come, last for a few minutes or an
hour or two, and then stop for a day or a week, come on again,
and in that way keep the physician on the anxious seat.

Knowing the effect of pituitary extract when the patient is
actually in labor, I tried the use of this drug in these cases where
we were in doubt, with the idea of determining whether the pa-
tient's pains were real or false, and to my agreeable surprise it
has proved to be of the greatest value in several instances.

Before reciting any individual cases, I may say that if the pa-
tient have pains of this indefinite sort, and a third of an ampoule
of pituitary extract be given by needle, if in half an hour another
third of an ampoule be given by needle, and if in another half-hour
a third of an ampoule be given, and then no regular rhythmic pains
come on, the patient is not in labor.

On the other hand, one is surprised to find how often this treat-
ment brings on regular rhythmic labor pains, and the patient goes
on through her labor as she would have done under ordinary
circumstances, even if no preliminary pains of lesser or greater
character had taken place.

Let me instance the case of a patient who went a week over
her expected labor period. She had had, on two occasions, pains
every ten or fifteen minutes lasting for an hour or two. These
pains would then cease.

I determined, on the occurrence of the next so-called irregular
pains, to try the use of pituitary extract. When the pains came
on every ten or fifteen minutes, the nurse notified me, and when
I reached the house after the lapse of an hour and a half all these
pains had stopped. I then administered a third of an ampoule
of pituitary extract, in half an hour I gave another third, in an-

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234 The Archives of Diagnosis

other half hour another third. The patient went on into regular
labor and in six hours was, under chloroform, delivered. This
was a primipara.

Another patient, who had had one child, was warned by me
to inform me of the first pains she had or of any flow of liquor
amnii, or of any signs of blood. She notihed me at seven-thirty
in the evening that on the toilet she had noticed a slight stain
of blood. I immediately went to the house and found the pa-
tient fully dressed ready to go out. I said I shall try and see
if you are in labor or not. I gave her a third of an ampoule
of pituitary extract and in ten minutes the pains came on reg-
ularly. She was undressed and put to bed, in half an hour she
received a second ampoule, in a half hour a third of an ampoule.
Two hours after I entered the house her baby was born, A
patient pregnant for the second time, complained during the last
week of irregular pains, lasting for an hour or two on several
occasions. I finally told her that she must notify me when the
next pains occurred. On a Sunday morning, at seven o'clock, the
nurse rang me up and told me that the patient was again having
the so-called irregular pains. I reached the house at nine o'clock,
gave her a third of an ampoule, after half an hour another third
of an ampoule. She went on into regular rhythmic pains, the
pituitrin was repeated on several occasions, and four hours after
I reached the house her baby was bom under chloroform anes-
thesia.

The next is a case of a patient who had had two children, the
second one being born in a rather rapid time. I warned her to
let me know of the approach of labor pains immediately as they
occurred. She rang me up early in the morning. (She lived an
hour by automobile from my office.) I immediately went to the
house, and when I reached there the patient was almost ready to
go to sleep. Through the experience gained from the other cases,
I determined to find out whether the patient was or was not in
labor. Again, I gave this patient a third of an ampoule of
pituitary extract and pains came on. In half an hour I gave her
another third of an ampoule, in a third half-hour another third
of an ampoule, and in three hours this patient too was delivered
under chloroform. Had no pituitrin been given, no one knows

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Bandler: Pituitary Extract 235

how many hours we might have been waiting for the regular onset
of labor pains.

Let me instance the case of another patient who was to be con-
fined in the month of December, about the twentieth. She was
very large, I thought because of a great deal of liquor amnii ; Hie
patient herself, for some reason or other, felt that a mistake had
been made in our calculations. On November the twenty-fifth, on
a Sunday morning, she notified me that she was having regular
pains at intervals of fifteen minutes. She lived very near the
hospital, so I told her to go there and send for her nurse.

When I reached there, the uterus did show every fifteen min-
utes fairly firm contractions. I gave her a third of an ampoule of
pituitary extract, repeated the same every half hour for six doses.
The pains continued for a while at intervals of fifteen to five
minutes, and then completely stopped. The patient went to sleep.
That very afternoon I sent her home and told her she was not in
labor. Just four weeks afterward she had the same sort of pains.
I was sent for and gave her the pituitary extract in the same man-
ner. She went into a regular labor, and in three hours she was
delivered of her infant.

As a final case, let me note a patient who, again like the previ-
ous one, was extremely large. I thought because of a great deal
of liquor amnii. The patient herself expected the possibility of
twins, or the possibility that a mistake of a month had been made
in our calculations.

On two occasions, one exactly four weeks before the time at
which I had fixed the labor, another a week after, the patient
notified me that pains were coming on every fifteen minutes with
a sense of pressure on the bladder. The first time I gave her
five doses of a third of an ampoule of pituitary extract and the
pains completely died away. On the second occasion, I did the
same, staying there five hours, giving her six doses of pituitary
extract a third of an ampoule each, and again for the second time
the pains died down. In each instance I had no hesitation in leav-
ing the patient immediately after the effect of the pituitary ex-
tract showed that no labor was going on. When in this last case
the labor is to occur I do not know, as the time which I have
fixed has not yet been reached.

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236 The Archives of Diagnosis

All these factors, aside from theoretical considerations, show me
that in pituitary extract we have a very valuable drug from the
standpoint of diagnosis.

I might summarize by saying that any patient who has irr^ular
labor pains, or what are known as "false pains," or thinks she
is in labor, who has any symptoms resembling the symptoms she
experienced in any of her previous labors, who does not respontf
to frequent doses of pituitary extract, who does not go into labor
after a few such doses have been given hypodermatically, is not
at that time in labor.

Of course, this does not aid us in fixing the exact time at which
the real labor pains will come on, but it shows us that that par-
ticular time is not the time when we are supposed to stand by and
await, for hours, the birth of an infant

PERVERSITIES OF THE INTERNAL SECRETIONS IN

THEIR BEARING UPON ORAL PATHOLOGY

Bv HEINRICH STERN

New York

Experimental and clinical proof is not wanting that some of
the internal secretions contribute toward the proper development
of structures and contents of the buccal cavity, and that certain
perversities of these secretions are liable to announce themselves
by mal development or anomalies of the textures of the mouth, es-
pecially its bony framework and the teeth.

The definitely known effects of the internal secretions upon the
normal development of the bony structures of the mouth are not
many, but the demonstrable influences of the pathology of the in-
ternal secretions upon the oral structures are considerably less. It
should, furthermore, be remembered that animal experimentation
can never exactly reflect a certain disease condition in the human
organism, and that it may even lead to quite deceptive results and
misinterpretations. ' With this proviso in mind, the following
cursory review of the known effects of the internal secretions upon
the anatomy and pathology of the jaws and teeth should be
interpreted.

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Stern : Internal Secretions and Oral Pathology 237

The principal glands in question are the thyroid, the parathyroids,
the thymus, the pituitary, the ovaries and the testicles.

THYROID GLAND

In endemic goitre and myxedema, disturt>ances of thyroid func-
tion, the osseous growth is more or less interfered with. In per-
sons thus affected, the teeth are poorly developed, and the erup-
tion of the permanent teeth is retarded as the epithelium covering
the surface of the dental groove and the dental papilla, the two
elements from which the dental textures are derived, are under-
developed.

parathyroid glandules

The parathyroid secretion is supposed to exert a detoxicating
activity. Others ascribe to the parathyroids a certain regulatory
influence of calcium metabolism. As far as alterations of the den-
tal structures after removal of the parathyroids are concerned, our
knowledge is wholly obtained from observations made on animals
deprived of these organs. In the incisors of parathyrodectomized
rats, alterations in the enamel and dentin, due to calcium deficiency,
were demonstrated. The pathological changes consisted in enamel
lacunae and the deposition therein of exposed dentin.

thymus gland
There is little doubt that the thymus gland exerts certain effects
upon the development of the teeth and jaws. In animals whose
thymus has been removed, there is a weaker development of the
skull, dentition is retarded, and there is marked textural deficiency
of the teeth. There is also ample clinical evidence that an insuffi-
ciency of the thymus gland has its bearings upon dentition in a
pathological sense.

pituitary gland
Pituitary oversecretion induces changes in the bony framework
of the oral cavity, particularly the inferior maxilla and the zygoma.
Diminished function of the hypophysis, on the other hand, inhibits
osseous growth, retards dentition, and prevents proper structural
development of the teeth.

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238 The Ahchives of Diagmosis

sexual glands
Nothing seems to have been published concerning a direct influ-
ence of the internal secretions of the ovaries and testicles on the
development of the human teeth. We know, however, that the
teeth of castrated animals, especially those of the males, are more
or less underdeveloped. This is especially evident in the male hog-
It would be mere speculation to adduce an influence of any of
the other glands with an internal secretion (including the adrenals)
upon the growth and further development of the jaws and teeth.
Such influences, of course, may exist. Yet there is no proof thereof.
A single coincidence does not establish a fact any more than one
swallow will make a summer.

Some of the secretions of the glands aforementioned may be
correlated in their function and may exert positive influences; other
secretions may also operate unitedly, but may yield negative, neu-
trali::ing, detoxicating effects. The normal activity of the one set
of glands is just as essential to the organism as that of the other.
Still, definite conclusions as to the synergism and the antagonism
of the various internal secretions, in particular of the few which
are supposed to preside over the growth and development of the
osseous structures and the teeth, cannot be drawn at this early date.
Ferdinand Blum, one of the first investigators of thyroid func-
tion, maintained, and I believe still maintains, that thyroid activ-
ity is wholly or in the main one of detoxication. His contention
is practically disproved, and it is the consensus of opinion of most
experimenters and clinicians that it is a positive influence which
is yielded by the secretion of the thyroid gland. Substantially the
reverse has taken place in the view held as regards the quality
of the effect of the internal secretion of the ovary. While it was
generally understood that the ovary was a gland with a positive
internal secretion, Okintschitz has very recently demonstrated
(Archiv f. Gynakologie, Vol. CII, No. 2) that the corpus luteum
gives off a negative internal secretion, one which neutralizes the
toxic substances circulating in the organism. In accordance with
Okintschitz's findings, the influence of the internal secretion of the
ovary upon the growth and development of the teeth and the bony
framework of the buccal cavity is entirely negative in nature; it
is in no way or manner directly concerned in the upbuild of the

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Stern: IhfTERNAL Secretions and Oral Pathology 239

osseous structures, including the teeth, and it is only of import in
the neutrahzation of certain toxic elements which may interfere
with the function of the glands presiding over calcium metabolism.

Besides the organs that are known to exhibit an internal secre-
tion, there are undoubtedly many others possessing the same qual-
ity, in which, however, this has as yet not been demonstrated.
This also pertains in all probability to some of the organs whose
internal secretions directly or indirectly contribute toward the de-
velopment and maintenance of the manifold structures in the buccal
cavity. Moreover, the physiological activity of certain of the or-
gans furnishing an internal secretion is of different intensity in the
various phases of life. It is not so long ago, for instance, that
the opinion was held that the thymus gland was completely vestigial
in the adult. While the deterioration of this gland is by no means
so consummate in mature age as was once supposed, there cannot
be any doubt that the import of the thymus to the infant below
two years of age is greater than to the older child, inasmuch as
this organ does no longer increase after that age and that it
actually decreases in size after puberty. In conformity with the
larger volume of the gland stands also its physiological activity.

The activity of a certain gland with an internal secretion may
in a sense become a vicarious one. That is, the deficient function
of one or more glands may be compensated for by a correlated
force issued by another gland. It stands to reason that this per-
tains primarily to the glands yielding secretions of similar qual-
ity, i.e., secretions that would normally display synergistic activity.

Again, at different ages the activity of one or the other of the
glands predominates. As far as the subject under consideration
is concerned, we have seen that at a very early age it is the func-
tion of the thymus which prevails. A few years before puberty,
thyroid activity, if not at its height, is very intense, and presumably
extends its influence to the oral cavity and its contents, and after
puberty it is the sexual glands which slowly ascend to their high-
est attainable degree of physiological development. While the activ-
ity of the secretions of these glands differs widely, that is, while one
of these secretions can never fully replace the other, the predomi-
nance of each of them at the proper period of life is a physiological
phenomenon.

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240 The Archives of Diagnosis

The aevelopment of the osseous structures of the organism, neces-
sarily preceding that of the higher specialized tissues, demands the
full activity of the thymus and all the glands with correlated func-
tion. The more specialized textures pre-eminently require for their
growth and proficiency the synergistic secretions of the thyroid and
other glands. When maturity is reached, direct thyroid activity,
though essential, should normally become reduced in intensity,
while, for the time being, the function of the sexual glands are
more or less displayed. This explanation, I know, is based on
rather a teleological reasoning, but I believe that it assists in the
understanding of the argument.

Glancing over the brief resume of the facts concerning the in-
fluence of the glands with an internal secretion upon the struc-
tures of and in the buccal cavity, it appears as if nothing were
known about their effect on structures other than osseous or dental.
This, however, is not the case, as there are at least two affections
of the soft tissues of the oral and contiguous cavities which may
be the results of deficient thyroid activity.

One of the soft tissue involvements is evidenced by edematous
swellings of the visible mucous membranes of the tongue, uvula
and nose. Sir Felix Semon states that the laryngologist is occa-
sionally consulted on account of stoppage of the nose, accumulation
of mucus in the posterior nasal cavity and the throat, a feeling
as if the tongue were too large for the mouth, on account of
retarded articulation in speaking and the leathery, dull sound of
the voice, and that a more minute examination will often demon-
strate the myxedematous nature of the various disturbances.

The other manifestation of the influence of an internal secre-
tion upon non-osseous structures of the mouth is noticeable in the
gums. It is also due to thyroid deficiency. I was the first to de-
scribe this phenomenon as a possible symptom of hypothyrosis.
(Further Experiences with Thyroid Modification and Therapy,
Am. Med., March, 1912.)

My observation consists simply in the fact that in a certain pro-
portion of gingiz'al lesions these are a part manifestation of myx-
edema or minor degrees of hypothyrosis, and that these lesions dis-
appear together with the other phenomena of thyroid insufficiency
on the introduction of thyroid therapy.

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Stern : Internal Secretions and Oral Pathology 241

The possible etiologic connection between deficient or perverse
thyroid function and Fauchard's or Riggs' disease was observed
by me as far back as 1902, when, on the occasion of a series of
lectures on the disorders of catabolism to post-graduates in medi-
cine, I maintained that, besides local causes and the usually assigned
systemic affections as diabetes, gout, rhachitis, leukemia, arterio-
sclerosis, etc., a hypothyrosis may stand at the foundation of the
gingival process, I have held this view ever since, no matter to
what fanciful causes others have tried to fasten inflammations of
the gingivae. The discovery of the ameba buccalis even could not
prompt me to change my views in respect to the possible hypo-
thyrotoxic origin of a certain number of instances of gingivitis.

(That amebse can be demonstrated in almost every mouth at al-
most any time, and this in spite of scrupulous cleanliness, is known
for a number of years, but that they are pathogenic and cause
gingival disease or pyorrhea has not been proved to my satisfac-
tion. Neither is there a scintilla of proof that the hypodermatic
administration of emetine, or the local use of this drug or its
mother substance, ipecac, can per se cure these affections.)

Of course, there are local conditions which favor the production
of the gingival process, or aggravate it in case it is already existent ;
and there are systemic affections, especially syphilis, which may
be accompanied by Riggs' disease. Many cases of syphilis, how-
ever, do not exhibit a gingival lesion, and it is an open question
whether, when it has ensued, it is of syphilitic or mercurial origin.
Again, I am convinced that many instances generally spoken of
as Riggs' disease of syphilitic causation, in reality are not cases
of this affection at all, but the end-results of mercurial stomatitis.

The alleviation of one of the constitutional diseases, as for in-
stance the suppression of hyperglycemia, is hardly ever followed
by a prompt and well-marked improvement of the gingival condi-
tion. When, on the other hand, the affection of the gum tissues
is of hypothyroid origin, it disappears, as a rule, synchronously
with the other hypothyroid manifestations. While, therefore, a
causal relationship between the constitutional and local disease ts
by no means a certainty, the dependence of the gingivitis upon the
thyroid deficiency is definitely established.

There are, hence, anomalies of the gingiva which are part and

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242 The Archives of Diagnosis

parcel of a hypothyrotoxicosis. If this yields to the exhibition of
thyroid, the gingival phenomenon will also accede to it. (In a
majority of the pertaining cases it is, nevertheless, essential that
the teeth and gums he kept in as healthy a condition as possible,
that the tartar be removed and local treatment instituted when the
circumstances call for it. At the same time, reliance must not solely
be placed upon the removal of possible local irritants or defects.)

In the article already mentioned, I quoted from the records of
52 cases of hypothyroidism which were under my continued ob-
servation for from two months to nearly two years. Of these 52
cases, 28 showed no gingival symptoms at all; in lo cases there
existed mild affections of the gums (not of a pyorrheal nature,
and unaccompanied by atrophy, etc.), while in the remaining 14
cases there had ensued more or less pronounced gingival manifes-
tations. Though these 14 cases had received more or less local care
at the hands of dentists, the results therefrom were, generally
speaking, indifferent. The administration of from 15 to 45 centi-
grams (3 to 9 grains) of thyroid for from six to fourteen weeks
was followed by a complete cure of the gingival process — for the
time being — in 3 instances, a distinct improvement in 5 others,
and a slight improvement in an additional 2 instances. The re-
maining 4 cases were not ameliorated at all after from three to
four months' administration of the drug. One case of the last
group, however, became markedly better when a second attempt
at thyroid compensation was undertaken some time later. The
fact that out of 14 cases of hyperthyrosis with gingival symp-
toms ID were beneficially influenced, shows conclusively that these
manifestations were due to an insufficient thyroid secretion, and
that thyroid therapy furnished the compensating factor.

Since reporting my observations three years ago, I have seen
a very large number of persons in a hypothyroid state. In a cer-
tain proportion of the cases, it was the pathological condition of
the gums which prompted me to search for other possible mani-
festations of hypothyroidism. Gingival disease of manifold type
and degree was encountered by me in fully twenty-five per cent.
of all the instances of deficient thyroid activity. These gingival
affections seemed not to be of hypothyroid origin in about three
or four per cent, of the cases, that is, no improvement of the local

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Stebn : Internal Secretions and Oral Pathology 243

pathological state ensued with or after the abatement of the other
hypothyroid phenomena.

Specifically, the gum affections in hypothyroidism that responded
to thyroid therapy could be differentiated as slight localized red-
dening, simple gingivitis with or without pericementitis, marginal
gingivitis, spongy gums, lacerated gums, deeply seated gingivitis
and pyorrhea alveolaris. The teeth were more or less loosened in
a goodly proportion of the cases.

The majority of the gingival affections were found between the
thirtieth and fiftieth year of life. There were about three times
more women than men affected with disease of the gums. The
preponderating number of women had either never been pregnant
or had not borne children for a long time. The hypothyroid state
varied from languor, the falling out of hair and a fleeting edema
to adiposis dolorosa, or completely developed myxedema.

In all instances of hypothyrosis, thyroid administration must be
continued for protracted periods. When improvement has super-
vened, the medication may be entirely stopped or the dosage and
the frequency of its exhibition may be diminished for some time.
It stands to reason that the gingival process may again manifest
itself together with a recrudescent hypothyroid state. For this
reason we can only speak of a cure of hypothyroid gingivitis in
the same sense as we speak of a cure of the hypothyrotoxicosis
itself.

In hypothyrotoxicosis it is especially the peripheral organs that
are most affected. Denutritional and degenerative changes take
place more readily in peripheral than deeper seated or central parts,
for the reason that the terminal arterioles and their nerve supply
are prone to be affected by even comparatively slight untoward in-
fluences. The smooth and vascular mucous membrane covering the
gums is a component part of the internal integument. Together
with the fibrous tissue which is intimately connected to the alveolar
periosteum, it forms a peripheral structure that is readily sus-
ceptible to systemic influences of almost every kind. Denutrition,
disease and structural degeneration will be the natural and ultimate
result.

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244 The Archives of Diagnosis

ACUTE MYELOID (MYELOBLAST) LEUKEMIA

By ARTHUR F. BEIFELD

Instructor in Medicine, Northwestern University Medical School

Chicago

The development of our present knowledge of the leukemias took
place in several well-defined stages. Virchow, m 1845, placed the
condition upon a firm pathologic basis by differentiating it from
pyemia. Ebstein' (1889) and Fraeiikel* (1895) recognized and
defined, clinically and hematologically, respectively, an acute
leukemia. At first, all acute leukemias were looked upon as lym-
phatic; in fact, as recently as 1907, Naegeli' regarded only eleven
cases in the literature as unambiguously myeloid. In the past dec-
ade many cases have been shown beyond question to be myeloid,
by means, particularly, of careful histologic studies and modem
staining methods; the case of Schultze* stands out as one of the
first proved instances of an acute myeloid leukemia. Opinion, to-
day, seems to inchne toward the position that the myeloid is much
more frequent than the lymphatic (Turk,' Ziegler and Jochmann,'
Jochmann and Bluhdom').

The recognition of an acute leukemia, disregarding for a moment
the type, is not difficult. The acute forms are unquestionably com-
moner than the chronic; in the absence of histologic examinations
and hematologic studies, however, they pass under the diagnosis
of morbus maculosus (Werlhof), scorbutus, ulcerative angina, sep-
sis, pernicious and other high-grade anemias.

More difficult is the differentiation of the types of acute leukemia.
Clinically they parallel one another closely. The bete noire is the
presence in the blood in both forms, often predominatingly, of large
mononuclear cells, with more or less basophilic cytoplasm, and with-
out granules. To determine whether these cells are of lymphatic
or myeloid origin, in the particular case, may be impossible, de-
spite the employment of refined morphologic, chemical and biologic
criteria. In certain cases the autopsy is necessary for a final opinion
(case of Herz,* which the writer saw) ; in others the diagnosis can
be made with a fair degree of certainty from the blood picture;
while, in a small proportion, the intra vitam diagnosis is unusually
clear. The following case belongs to the latter category :

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Beifeld: Acute Myeloid Leukemia 245

K. C, Russian, twenty years old, a laborer by occupation, en-
tered the Cook County Hospital November 16, 1914. Important
light is thrown upon the possible duration of the case by the fact
that he had passed the inspection of the immigration authorities
eight months before. Except for vague abdominal symptoms (con-
stipation) he had always been well up to the onset of the present
illness, four months before. At first he had experienced cramp-
like abdominal pains, had lost his appetite, and was troubled with
headache and vertigo. Gradually his condition became worse, until
two weeks ago increasing weakness forced him to go to bed. The
last fortnight had been marked by great loss of strength, swelling
of the feet, dizziness, constant headache, dyspnea, constipation, ab-
dominal pain and vomiting, repeated epistaxis and bloody stools.

He admitted the moderate use of beer and whiskey and denied
venereal infection.

The young man was extremely anemic — integument, mucous
membranes, lobes of the ear — the skin presenting a rather lemon-
yellow tint. His general nutrition was good. The physical exam-
ination revealed little : clotted blood in the nasal passages and naso-
pharynx; no ulcerative lesions in the mouth, about the teeth, on
the tonsils, or in the pharynx; a systolic murmur over the entire
precordium, soft in character, with nortnal heart borders; a spleen,
slightly enlarged on percussion, the edge of which could readily
be palpated on deep inspiration; a just palpable liver edge; a few
small, discrete, not tender lymph nodes in the left cervical chain and
in the left axillary, left epitrochlear and both inguinal groups ;
tenderness over the cranium, sternum, tibias and femurs; and a
number of quarter-size deep hemorrhages over the tibial surfaces
of both extremities.

There was observed, in addition, bilateral retinal hemorrhages,
an irregular low-grade temperature, and a blood pressure of 112 mm.
systolic and 60 mm. diastolic.

The condition of the patient remained practically unchanged, ex-
cept for progressive weakness and lethargy, until his death on No-
vember 28th, twelve days after admission.

The enumeration of the erythrocytes and leukocytes and the esti-
mations of the hemoglobin (Dare) are shown in tabular form
below;

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246 The Archives of Diagnosis

ii/,i8 11/21 11/21 11/23 11/24 11/26 11/27

Erythrocytes 952000 ?68ooo 776000 670000 592000 672000 648000

Leukocytes 24850 40000 46900 41650 45000 71200 82400

Hemoglobin 12% 16% 14% 13% 13% 11% u%

The high-grade and progressive anemia evident from the fore-
going is not uncommon in the acute leukemias, which as a rule
affect the erythropoetic system far more vigorously than do the
chronic forms. Not infrequent, further, is a high-color index,
in this case averaging slightly greater than one. The good state of
nutrition, the pallor, the marked oligocythemia, and the high-color
index suggest pernicious anemia, but the leukocytic increase — for-
eign to P. A., except as a terminal septic episode — and the (jual-
itative study of the white cells, particularly the presence of myelo-
blasts and their derivatives, speak against the Biermer type of
anemia.

The submyelemic value — 24850 — present on admission, answers
one of the clinical criteria of an acute leukemia, namely, that a
case must be under observation at a time when leukemic values
have not developed, thus eliminating the possibility of an acute
exacerbation of a chronic form, or the influence of a terminal sep-
tic event. The increase in the course of ten days to a more nearly
leukemic value — 82400 — points also to the existence of a frankly
acute case and its development under observation.

The leukocytes were distributed as follows:'

Normo-

Polynuclea

Turk's

Irrita-

blasts
pen 00

Myel,

Premydo-

Myelo

N'eutro-

Lympho-

tion

cells

blasts

cytes

cylcs

philes

cytes

Forms

counted

First

Count .

..62JS%

9-9X

0.5%

21.1%

5.8%

0.1%

than 6

Second

Count .

..56.7

10.7

2.0

23.6

7.0

0.0

Third

Count .

■ -570

21.0

1.6

14-4

5-8

0.2

The first and second enumeration, it will be noted, show no ap-
preciable difference. The last count, made from blood taken shortly
before death, differs strikingly, in two particulars, from the fore-
going ones. In the last count the premyelocytes — cells with myelo-
cytic nucleus and beginning granulation — have doubled in percentage

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Beifeld: Acute Myeloid Leukemia 247

as compared with the first two examinations, and this it will be
observed is at the expense of the polynuclear neutrophiles. In other
words, if, in each count, premyelocytes and polynuclear neutrophiles
are added, tfie total is practically the same in all three.

This variation tn the final count might be attributed to func-
tional (chemical) variations in the cells themselves, with a result-
ing greater affinity of the granules for the stains, were it not for
the fact already emphasized that the increase in granular mononu-
clears is at the expense of the polymorphonuclears. A more rea-
sonable explanation for the variation, then, would be that as death
approached the myeloid tissue became more exhausted, producing
in jilace of mature cells, their forerunners, the premyelocytes. In
keeping with this theory is the gradual diminution of nucleated red
cells.

Ihat the case under consideration is one of acute leukemia can-
not be doubted in view of the course, the hemorrhagic diathesis,
the development under observation of a leukemic from a subleu-
kemic state, the high-grade anemia and the predominance of large
cells. Points speaking for the myeloid origin of the case are these:

1. The striking atypicalness of the white cells, suggestive always
of myeloid upheaval. Pertinent details of the blood picture will
be considered below.

2. The unusually marked evidence of transition from undifferen-
tiated mother cells to cells of the myelocytic row. This is particu-
larly well shown in the last differential count, in which 21 per cent,
of the cells counted represent transitions from the non-granular
to the granular condition. Apart from histologic studies of the
tissues involved, this is unquestionably the most satisfactory means
of separating the two types of acute leukemia .Naegeli, Tiirk). In
the lymphatic form, the large mononuclear undifferentiated cells
show their lymphoblastic origin in that the cells about them are
maturer, or ripe, lymphocytes, and myelocytes are few ; while, in tiie
myeloid type, apparently similar large cells are seen to have as de-
scendants granular forms, that is, premyelocytes and myelocytes.

3. The Winkler oxydase reaction. Recourse has also been taken
to chemical means to differentiate the acute leukemias. Based upon
the hypotliesis that cells of myeloid origin contain an oxidizing
ferment -oxydase, which cells of lymphatic origin do not, several

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248 The Archives of Diagnosis

tests have been fomiulatetl for the recognition of this ferment. The
most satisfactory of these seems to be the indophenol reaction of
Winkler," the application of which to the leukemias was made by
Schultze." The reagents, a i per cent, aqueous solution of alpha
naphthol (to which an equal weight of sod. carbonate has been added
to promote solution), and a i per cent, aqueous solution of dimethyl-
phenylendiamin, if brought together in the presence of oxygen, pro-
duce a blue pigment, the exact composition of which is uncertam.
Frozen sections from fresh tissues or from organs which have stood
for months in formalin, and blood-smears hardened in formalin or
alcohol, if treated successively with the two reagents, present blue
granules, usually fine, sometimes coarse as a result of coalescence,
corresponding to the oxydases present in the cell (not to the granules
of the Ehrlich school). This color phenomenon is transient, fading
in several hours. Previous heating of a specimen destroys the fer-
ment; alcohol causes the color to disappear, though it can be re-
stored by renewed application of the reagents.

The indophenol reaction, in our case, was exquisitely positive.
Nearly every cell showed itself to be of the myeloid system by
the appearance of numerous blue granules. As a control, use was
made of a blood-smear from a case of acute lymphatic leukemia
recently under observation ; only here and there did a cell show the
oxydase granules (polynudears).

4. Morphologic differentiation of myeloblast and lymphoblast.
Oftentimes the usual criteria available here are of no value. Mye-
loblasts are, on the average, larger than lymphoblasts. In our case,
as will be detailed later, are many micromyeloblasts, thus obscuring
the value of size standard. No special stains were employed to
demonstrate the number of nucleoli or Schridde's perinuclear zone.
Speaking directly, however, for myeloblast as against lymphoblast
are the delicacy of the nuclear chromatin — ^without the thickenings
seen in lymphocytic cells — the presence in many cells of one or
more deep clefts (Rieder type) and the tendency of the nucleus in
many of the small and medium-sized cells completely to fill the cell
body (Pappenheim)".

Of the foregoing features, that which speaks directly and un-
equivocally for the myeloid nature of this leukemia is the unusually
clear evidence that the descendants of the large mononuclear un-

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Eeiff-ld: Acute Myeloid Leukemia 249

granulated cells are cells of the myelocytic type. Concerning the
value of this manifestation hematologists are generally agreed,
whereas in the case of other criteria of difference— morphology,
oxydase reaction, etc. — there is a considerable variation of opinion.

It seems worth while to enter somewhat in detail into the morpho-
logic characteristics of certain of the white cells. The predominant
type — the myeloblast — appears in many forms, this in itself speak-
ing for a tumultous myeloid activity. Most numerous is the familiar
type, usually considerably larger than the myelocyte, with lepto-
ehromatic nucleus, several nucleoli, a considerable cytoplasm of
various degrees of basophilic intensity, containing no granules, and
often showing one or more vacuoles in the cytoplasm. There is,
further, a considerable percentage of cells about the size of the
myelocyte, with a nucleus identical with that of the myeloblast and
the most slender of cytoplasmic zones or none at all. These cells
often present a deep cleft, or several clefts, which may divide the
nucleus into two parts. These medium-sized cells, but more par-
ticularly another cell also numerically high, roughly the size of a
normal lymphocyte, surest very strongly the lymphocytic character.
A considerable discussion has been engendered as to the origin of
these cells. We have seen fit to class them as meso- and micro-
rayeloblasts on the basis of criteria set up by Pappenheim, namely,
the nuclear character — delicate chromatin as compared with the
cruder structure of the lymphatic cells — which present chromatin
knobs or heaps — the absence of protoplasmic zones, this being par-
ticularly significant in the case of the meso-myetoblasts, and the
deep clefts already described, also significant of myeloid origin,
especially in cells of medium size. Finally, in scnne of the cells in
which the protoplasm is somewhat more abundant, granules, usually
few in number, can be found. (Lydtin" and others describe cases
of acute micromyeloblastic leukemia.)

The polynuclear neutrophiles in all specimens are atypical in
point of size — nearly all are large — and in the absence, in the
majority, of granules. To this latter feature Naegeli" calls atten-
tion in the second edition of his book.

No basophilic or eosinophilic cells are present. This is the rule
in the acute form of myeloid leukemia. Nor can any cell be defi-
nitely identified as a normal large mononuclear (transitional') .

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250 The Archives of Diagnosis

A few of the cells contain scattered granules suggestive of azur
granules (Wright stain). There are rarely more than five or six of
these granules in a cell, often only one or two. Some are three
or four times the size of the usual eosinophilic granule. All possess
a vivid, almost cherry-red color not at all su^estive of eosinophilic
granules. Azur granules are generally believed to occur only in
cells of the lymphocytic types — and then in more mature cells —
and often only with special stains. Pappenheim calls these bodies
myeloid azurophilic granules. Naegeli, however, vigorously dis-
putes this interpretation and classifies the granules as unripe neutro'
phi lie.

As to the red cells, there is little to be said. Normoblasts are
present in every preparation, diminishing in number toward the
last. A moderate anisocytosis, with a tendency toward the small
cell, is present. There is also slight potkilocytosis.

The blood platelets are considerably diminished.

KZFERENCES

1. Ebstein.— Deutsches Archiv, f, klin. Mediiin, Vol. XLIV. p. 343.

2. Fraenkel.— Deutsche med. Wochenschr., 189S, Vol. XXXI, p. 639.

3. Naegeli.— Blutkrankheiten, Leipiig, 1908, p. 358 et seq.

4. SchulWe— Ziegler's Beilrige, 1906, VoL XXXIX, p. 252,

5. Turk. — Personal Communication.

6. Ziegier and Jochtnann. — Deutsche med. Wochenschr., 1907, No, 19.

7. Jochmann and Bliihdorn.— Fol. Haematol ogica, Vol. XII, p. 181.

8. Hen. — Die Acute Leukamie, Leipzig and Wien, 191 1. p. 53.

9. Winkler. — Fol. Haematologica, Vol. IV, 1907, p. 323 and Vol. V, 1908, p. I?.

10. Schultze. — Miinchener med. Wochenschr., 1909, p. 167.

11. Pappenheim. — Atlas der mensch. Blutzellen, I9ii-i2. Supplement Proto-

type 61, p. 78 et seq.

12. Lydtin.— Fol. Haematol ogica, Vol, XV, p. 316.

13. Naegeli, — Blutkrankheilen, 2d edit,, Leipzig. 1913.

SITUS VISCERUM INVERSUS TOTALIS
Bv FREDERICK TICE

Transposition of the internal organs, either complete or partial,
has long since ceased to be a curiosity, but it still maintains much
interest for the embryologist, the pathologist, and more especially
for the surgeon and internist.

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TrcE: Situs Viscerum Inversus Totalis 251

Petnis Servius, 1643, is given the credit of recording the first
case. Grueber, in 1863, was able to collect 78 cases, while A. Pic,
up to 1895, collected a sum total of 195. Pollack and Jewell, in
1910, found that during the preceding fifteen years 128 articles on
this condition were published, and from which they were able to
analyze 78 cases. Since 1910 up to the present year 161 additional
cases have appeared in the literature.

At first the condition was most frequently determined in the
autopsy or dissecting room ; later, by the surgeon or internist, while
the marked increase during recent years is to be attributed to more
accurate clinical methods and especially to the assistance of the
Rontgen rays.

During the past few years four cases with complete transposition
have come under my observation. Two of these were reported some
time ago, but will be included, as more satisfactory skiagrams have
since been obtained.

Case I. The following abstract is taken from the original report:

(a) Clinical History: W. C, male child, eight years old. Has
always been well until about two months ago, when he complained
of headache, slight chills, nose bleed and loss of appetite, and his
mother thought he had a fever. After a few days, as his condi-
tion did not improve, he was placed in bed and was first seen at
this time. Suspecting, from the history, a possible typhoid, the ab-
domen was examined. Several typical rose spots were present, and
the left hypochondrium examined for the confirmatory palpable
spleen, which could not be detected. It was at this time, before the
systematic routine examination, that my attention was directed to
the right-sided portion of the heart.

.Thinking that other organs as well as the heart might be mis-
placed led to the discovery that the liver was on the left, and the
spleen on the right side. At the time of the first examination,
during the typhoid, the spleen was easily palpable two fingers below
the right costal arch. After a mild course of about three weeks'
duration, patient made a complete recovery.

(b) Physical Examination: General physical condition is good.
Head and neck are negative.

Chest. — (i) Heart: Inspection and palpation reveal the apex
beat in the right fifth intercostal space about one inch inside of the

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252 The Archives of Diagnosis

nipple line. Cardiac outline by percussion shows the base to be
at the upper border of the third right costal cartilage and rib,
extending about one inch to' the right of the sternum. The left
border is at the left border of the sternum. The right border from
the right end of the base line to apex beat. Auscultation is nega-
tive, except that maximum intensity of tones corroborate location
of apex as previously indicated. (2) Lungs: Negative, except
normal pulmonary signs are present where cardiac findings should
be and such are present to the right of the sternum. Traube's space
is absent on the left, but present on the right.

Abdomen. — (i) Liver; Percussion determines hver dulness,
which is located on the left side, with gastric tympany on the right.
(2) Spleen: Dulness on the right side — not palpable.

Extremities. — Patient is right-handed, but uses left almost as
much.

Genitourinary Organs, — Right testicle is more dependent than
left. To assist in the more accurate location of the heart, liver
and spleen, a rontgenogram was made.

Believing that the stomach is also transposed, the patient was
given one ounce of bismuth subnitrate and a second rontgenogram
was made. The most interesting feature consists in the possible
mistaken conclusions to which the condition might lead. Some of
these are the following:

1. With an obliteration of Traube's space, dulness in the lower
left chest and the heart displaced to the right, the diagnosis of a
left-sided encysted pleurisy with an effusion is quite possible.

2. Dextrocardia, congenital or acquired, could be diagnosed if the
other conditions were not determined.

3. The impossibility of palpating the spleen in the usual location
in those conditions in which it is enlarged, might cast doubt on
the probable diagnosis as first occurred in this case.

4. In a case of cholelithiasis, the pain would be located on the
left side. This condition, associated with jaundice and absence
of the hepatic dulness in the normal location, might indicate the
existence of an acute yellow atrophy of the liver, which diagnosis
was actually made in one recorded case.

5. As other organs are transposed, it is reasonable to conclude

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The Archives of Diagnosis

-2 S S

is ^'^

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The Archives of Diagnosis

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The Archives of Diagnosis

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The Akciiives of Diagnosis

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Tice: Situs Viscerum Inversus Totalis 253

that the appendix is on the opposite side. This being true, in a
, case of appendicitis the findings would be on the left.

Case 2. Elva J. Otis, female, fifty years old. Admitted to the
County Hospital, Chicago, August 18, 1911.

Present Complaint. — Paroxysmal attacks of severe stabbing pain,
coming on shortly after eating. Between paroxysms pain is con-
stantly present, but of dull, aching character. Pain begins in epi-
gastrium, radiates to left costal border, but is especially referred
to left shoulder and back. With paroxysms patient vomits large
quantity of greenish material. Vomitus has never contained blood.

Past History. — Peritonitis about twenty-five years ago. Operated
and drained for many months. Ventral hernia occurred, was oper-
ated and resulted in fecal fistula, which was operated on and fol-
lowed by return of ventral hernia. Has had pneumonia and pleur-
isy, but does not know which side was involved.

Personal History. — Uses alcohol in moderation. Denies specific
infections. For past twenty-five years has used large quantities
of morphin.

Physical Examination. — Chest : Lungs negative, except for bron-
chitis ; normal resonance in cardiac area to left of sternum. Traube's
space dull. Cardiac dulness to right of sternum with apex beat
in fifth right interspace, about two inches from the right sternal
border. Soft systolic murmur at apex.

Abdomen. — Ventral Hernia: Hepatic dulness to left of median
line and lower border palpable about one inch below costal arch.
Spleen not palpable.

Patient was discharged September 2, 191 1, on the clinical diag-
nosis of morphinism and transposition of viscera. This patient was
again admitted to the hospital December 10, 191 1, with practically
the same history and physical findings, except she was deeply
jaundiced. Receiving-room diagnosis was cholelithiasis and sple-
nomegaly. Patient was operated December 15. Median incision
was made. Abdominal organs completely transposed. Liver en-
larged and cirrhotic. Gall-bladder much distended, but contained
no stones. One large calculus impacted in common duct, which
was incised and stone removed. Gall-bladder was also drained.
Patient died about twenty-three hours after operation.

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254 "^^^ AsCHivES OF Diagnosis

Autopsy Report. — Confirmed clinical Endings of complete trans-
position of internal organs.

Case 3. Chas. Schuppel, male, forty-three years old..

This case was reported by Dr. Chadbourne and probably by sev-
eral others since that time. During the past several years he has
been admitted to the County Hospital every few months on various
complaints. Once he had a traumatic injury to his left hip, while
on another occasion he presented the symptoms of appendicitis in
the left lower quadrant of abdomen. He practically lives in one
hospital or another and goes from clinic to clinic exhibiting him-
self for a compensation. He is a typical "dispensary floater" or
"medical freak." His skiagrams will only be given as a supple-
ment to the previous report

Case 4. P. Schoenbrun, male, thirty-four years old. (Referred
by Dr. F. Chauvet, April, 1915.)

Patient was always well until about one month ago, when he
suffered from slight pains and discomfort in the right lower chest.
The first physician consulted informed him that he had a pleurisy.
Later another physician detached the heart to the right and found
the liver and spleen transposed. Fluoroscopic examination con-
firmed the physical findings and also no evidence of a pleurisy. It
is more than probable that the discomfort in the right side was
due to some cardiac disturbance from overindulgence in coffee or
tobacco. A skiagram of the chest was made and arrangements
completed for gastrointestinal ones, but the patient has failed to
return.

Achelis. — Deutsche med. Wochenschr., 1911, V. 37, p. 527.-

AhlberK.— Allm. Sv«n. Laksrtiden (Stockholm), 1906, V. 3, p. 333.

Allen.— BriL Med. Jour., 1910, V. i, p. 987.

Baldenweck. — Tribune Med. (Paris), 1904, No. 35, V. 36, p. 502.

Barbo.— Berliner klin. Wochenschr., 1900, No- 26.

Barjon.— Bull. Soc. des Hop. de Lyon, 1911, V. 10, p. 184.

Becker.— Deutsche MilitararztL Zeitschrift. (Berlin), 1908, V. 37. p. 432.

Ben da.— Berliner med. Gesells., 25 Jan, 190S-

Berliner.- Deutsche med. Wochenschr., 1903, V. 29, Beilage, p. 39 (35)-

Billington.— Southern Med. Jour., 1910, V. 3. P- 300.

Birtch,— Calif. State Jour. Med., 1912, V. 10, p. 483-

Blodgett.— Boston Med. and Surg. Jour., 1896, V, 13+ P- 3I3-

Bodon.— Zentralblatt fur Gynakol., 1897, No, ao, p. 592.

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Tice: Situs Viscerum Inversus Totalis 255

BoUad.^our. Am. Med. Ass., 1908, V. 50, p. 1123.

Bommes.— Fortschr. a. d. Geb. d. Rontgenstrahlen, igoS, V. la, p. 384.

Botticher.— Deutsche med, Wochenschr., 1899 (Vercin's Beil. No, 9, p. 56).

Boyd,— Glasgow Med. Jour., 1895, V, 44, p, 89, also p. 305.

Brix.—M finch ener med. Wochenschr., 1913, V, 60, p. 2790,

Burgerhout.— Neder. Tijd. V, Geneesk., 191a, V, I, p, 1494,

Burghart.— Deutsche med. Wochenschr., 1897, V, 23, p. 606.

Capitan.— Comptes. Rend. Soc. de Biol. (Paris), iScff, 10 s., V. 4, p, S34.

Carlyll. — Guy's Hospl. Gazette (London), 1910, V. 24, p. 186.

Carpenter.— Proc Roy. Soc. of Med. (London), (Sect Div. of Chil.), p. 323,

1908-9, V. 2.
Carpenter.— Proc. Roy. Soc of Med. (London).
Casati. — Lancet (London), 1903, V, i, p. 406-

Caton.— Jour, Anat. and Physiol, (London), 1896, 1897, V. 31, p. 446,
Ceresole.— Bull. Soc de Radiol. M*d. (Paris), 1911, V. 3, p. 257.
Chatterji.— Indian Med. Record (Calcutta), 1897, V, 12, p. 94,
Christoffer sen .—Norsk Magazin F. Laegevid, 1904, No, 8,
aement.— Lyon Med, 1895, V. 80, p. 383.
Cominotti.— Rw, bluet, di Soc. Med (Venice), 1899, V. 30, p. 19.
Conti.— Gati. d. osped. (Milan), 1897, V. 18. p, 458,
Cooke,— Brit. Med. Jonr^ 1902, V. i, p, 332.
Cova.— Gail. d. osped, (Milan), i8(A V, 19. p. 66,
Crawford,- Jour, Am. Med. Ass., 189S, V. 25, p. 323.
Craier.— University Med. Mag., No. 8, 1899.
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Fabre. — Dauphine Med. (Gwenoble), 1912, V. 36, p. 143.
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Fischler. — Miinchener med. Wochenschr, 1903, V. 50, p, 1706,
Flesch.- Zentralblatt f. innere Med., V. 29, 1908, p. 338.
Fraker.— Columbus Med. Jour, 1896, V. 16, p. 40a
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p, 300) ■
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2S6 The Archives of Diagnosis

Guillemin.— Revue MM. de L'Est. (Nancy), 1912, V. 44, p. 593.

Guthrie.— Proc. Roy. Soc. of Med. (London), V. 5, 1911-3 (Sec. Dij. of

Chil.), p. ISO.
Habermann.— Munchener med. Wochcnschr., 1904, V. 51, p. IJ48.
HartUnd.— Lancet (London), V. i, 1904, p. 1017.
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Hebblethwaite.— Brit. Med. Jour., 1907. V. z, p. 1597.
Heidemann.— Berliner klin. Wochcnschr., 1897, V. 34, p. 60a
Heinie.— Jahrbuch f. KJnderheitkunde, 1898, V. 48, p. lit.
Hertz. — Archives of the Roentgen Ray, 1913-14, V. 18, p. 325.
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Horder. — St Bartholomew's Hosp. Reports (London), 1903, V. 41, p. ill.
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liar. — Bull. d. Soc. Med. Ch. di Pisa., 1909, V. 33, p. 402.
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Jeanne. — Normandie Med., 1903, V. 18, p. loi.
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Jordon.— Brit. Med. Jour., 1911, V. 2, p. 1355.
Kaminer. — ^Verein. f. innere Med. (Berlin), 20 Nov., 1905.
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Karashima. — (Monograph) Munich, igi2, 42 pp.

Karsner. — Proc. Pathol. Soc of Philadelphia, 1910, n. 5., V. 13, p. 225.
Kaul.— Indian Lancet (Calcutta), 1898, V. XI. p. 8.
Kirvull.— St. Petersburgcr med. Wochcnschr., 191 1, V. 36, p. 6.
Kissling.— Deutsche med. Wochcnschr., 1902 (Verein's Beil., No. 32, p. 250).
Kitaj.— Verein Deulscher Aente in Prag., 19 Nov., 1904.
Klingmuller.— Aeritliche Praxis (Berlin), 1905, V. 18, p. 253.
Roller.— Virchow's Archiv. CLVI, Heft, i, 1899.
Koster.^Medizin. Gesellschaft in Leipzig, 31 Jan., 1905.
Krokiewiez.— Virchow's Archiv., 1913, V. air, p. 429.
Krumbe in .—Deutsche Miliiararztl. Zeit., 1901, p. 228.
Lamari— Gazz. d' ospedali (Milan), 1903, V. 24, p. 656.
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Little and Helmhoh.— Bull. Johns Hopkins' HospL, V. 16, p. 249, 1905.
Lowenthal,— Lancet (London), 1909, V. I, p. 461.
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TicE: Situs Viscervm Inversus Totalis 257

Lagnan. — Compt Rend. Soc. de Bio!, (Paris), 1903. V. S4> P- 1460.

Manson. — Brit. Med. Jour., 1912, V. 2, p. 77a.

Masbrenien.— Bull. Sot d' Obstct. (Paris), 1898, p. 106.

Mathiea.— Bull Med. (Paris), 1899, V. 13, P- 26.

Meyer.— Hosp, Tidende (Copenhagen), 1907, V. IS, P- 857-

Minovici.— Arch, de Sci. Med. (Bucarcst), 1898, V. 3, p. 34i-

Mohr. — Munchener med. Wochenschr., 1912, V, 59, P- 387.

Monselise. — Gaiz. degli. ispedali (Milan), 1910, V. 31, p. 1595-

Monteverdi. — Pediatria (Naples), 1897, V. 5, p. 134.

Montat— Lyon Med., 1903, V. 100, p. 1043.

Morel. — Bull. Soc. Med. d. Hop. (Paris), 1904, 3 s., V. 21, p. 921.

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Napier. — Glasgow Med. Jour., 1906, V. 66, p. 135.

Oeri.— Frankf. Zeit. f. Pathologic, 1909, V. 3, p. 393.

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Palamountain.^our. Am. Med. Ass., 1915, V. 64, p. 1986.

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Plate.— Deutsche med. Wochenschr., 1898 (Herein Beil., No. 30, p. 220).

Podevin.— Bull. Soc. Med. des Hop. (Paris), 1913, n. s., V. 35, p. Z15.

Pokrovski.~-Russki Vrach. (St. Petersburg), 1906, V. 5, p. 1365.

Pollock and Jewell.— Med. Record, 1910, V. 77, p. 152.

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Posselt.— Deutsches Arch. f. Aim. Med., 1895, V. 56, p. 202.

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258 The Archives of Diagnosis

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CLINICAL STUDY OF A CASE OF EPILEPSY APPAR-
ENTLY OF INTESTINAL ORIGIN
By EDWARD E CORNWAIX
Attending Physician, Williamsburg and Norwegian Hospitals; Consulting
Physician, Bethany Deaconess Hospital
Brooklyn— New York
The patient whose case is described in this paper was referred
to the writer by Dr. A. C. Brush. He is a man twenty-one years
old. No member of either his father's or mother's families was
ever known to have had epilepsy, and his family history, as far
as could be ascertained, was generally good. Concerning his per-
sonal history previous to the beginning of the present illness, the
following facts were learned: He had cholera infantum in his
second summer, whooping cough at hve, measles at fifteen, and
influenza at eighteen. Between fifteen and eighteen he grew very
rapidly, increasing eight inches in height and forty-four pounds
in weight during that period. He suffered from constipation as
far back as his memory carries, and as far back as 1907 the con-
stipation was so severe that he would sometimes go without a

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Cornwall: Epilrpsy of Intestinal Origin 259

movement of the bowels for as long as a week. He also suffered
from headaches. At eighteen he entered Columbia University in
the electrical engineering course. He stood well in his classes, but
took no interest in athletics or outside amusements, and spent most
of his spare time in the study of wireless telegraphy. The only
formal exercises which he took were those in the gymnasium work
required by the university. In connection with this required gym-
nasium work, he noticed that running often produced s. sharp pain
in the right upper quadrant of his abdomen, or a sensation as if
he had "a heavy weight or lump there, which bumped up and down,
especially down." His general health he considered to be good
until the present illness began.

January 7, 1913, he ate boiled cabbage at his evening meal, and
later in the evening fruit cake. During the night following he was
distressed by a pain in the pit of his stomach, and in the morn-
ing, when he attempted to get up, felt so uncomfortable that he
was constrained to remain in bed. About an hour after his at-
tempt to get up, he was found unconscious, with set eyes, breath-
ii^ sterterously. Twenty minutes later he revived, got rid of con-
siderable gas from his stomach, and was relieved of his abdominal
distress. This attack was diagnosticated as acute indigestion.

February 13, 1913, his college examinations took place, about
which he worried, although he passed them creditably. At dinner
that night he ate creamed cabbage. The following morning he
awoke without special bad feelings, so he said afterward, but at
9 A.M. he was found unconscious, with saliva dribbling from his
mouth, and a purplish face. Later small red spots appeared on
his cheeks immediately under the eyelids, which faded out in a
day or two. After this attack he was forbidden to return to col-
lege by his attending physician, and was put on a diet in which
starch was restricted.

In March, 191 3, he had an attack of scarlatina of moderate
severity, from which he made a good recovery.

July 26, 191 3, he went as wireless operator on a steamship sail-
ing to Panama. On this trip he was much troubled witfi indiges-
tion and constipation.

August 14, 1913, he returned from Panama, and immediately on
arriving at his home lay down for a nap. A little later he was

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26o The Archives of Diagnosis

found unconscious, with hands and feet moving convulsively.
After inhalation of ammonia from a strong solution, he promptly
revived.

September 28, 1913, at about 8 a.u., he was heard to breathe
sterterously, and was found unconscious, with eyes set and tongue
bitten. He revived promptly after inhalation of the ammonia
solution.

October 26, 1913, after visiting away from home and eating
strange food, including "chicken" salad probably made from veal,
he was observed, at 6 a.u., while still apparently asleep, to be
moving his legs in a convulsive manner and to be dribbling bloody
saliva. He could not be aroused at first, but ten minutes after
inhaling ammonia smelling salts he recovered consciousness and
belched gas from his stomach ; his right eye was blood shot.

Attacks similar to those above described occurred on the fol-
lowing dates: November 27, 1913, January 9, January 27, Janu-
ary 31, February 24, March 3, March 18, April 2, April 23, May
ID, May 23, and May 28, 1914.

At the time of these attacks and for short periods before and
after, he suffered from coated tongue, bad taste in the mouth, foul
breath, belching of gas from the stomach, intestinal flatulence, giv-
ing off of offensive gases from the bowels (which had a "chemical
laboratory smell") and constipation. He also suffered from these
symptoms, though in less degree, off and on between the attacks.
He usually had no remembrance of events occurring during the
first half-hour after the attacks, and for a day or two after the
attacks his recollection of events which occurred during the day
or two preceding them was imperfect. He was usually drowsy for
a short time after the attacks, but less so after the later than the
earlier ones. It was noticed in the period between the middle of
April and the end of May, 1914, that he often moaned in his sleep
and twitched with his hands and feet.

May 30, 1914, two days after the occurrence of the attack last
mentioned, he first came under the writer's observation. Physical
examination made on that date showed : General appearance good ;
height, 5 feet iij/^ inches; weight, 154 pounds; lungs, negative;
heart apparently normal in size, no murmurs heard, action slightly
irregular; area of liver dulness slightly increased; spleen, negative;

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The ARCiirvEs of DiAtiNosis

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CoRNWAt.i.: Epilepsy of Intestinal Origin 261

transverse colon seems to dip down on the right side, cecum and
ascending colon seem moderately dilated; blood pressure, 115 mm.
Hg. systolic, 55 mm. Hg. diastolic. Examination of urine, June 12,
1914, showed: Quantity in 24 hours, 1914 c.c. ; acid; specific
gravity, 1,016; no albumin, glucose or casts found; indican, a
trace; urea, 1.2 per cent; many crystals of triple phosphates in
sediment.

The plan of treatment laid out for this patient was as follows:

He was kept out of college until February 3, 1915, but allowed
to amuse himself with the wireless telegraphic outfit which he had
rigged up on his house, and encouraged to take exercise in the
open air.

He was put on a non-putrefactive, laxative diet, arranged to
supply daily about 75 grams of protein and fuel of the value of
about 2,500 calories. The articles in his dietetic prescription were :
Milk and preparations of milk, including lactacidized milk, cream
cheese, cottage cheese, American cheese, cream and butter; cereal
preparations, including bread, rusk, zwieback, maccaroni, boiled
rice, bran biscuits and raw wheat bran; potato, carrot, and speci-
fied green vegetables, the latter in good quantity; specified fruits,
of the kinds containing citric and malic acids, in good quantity;
milk soups made with milk and specified vegetables; olive oil;
levulose.

Certain exercises were prescribed for him, to be performed be-
fore going to bed. These exercises were given for the purpose
of improving peristalsis, strengthening the abdominal muscles, and
restoring as far as possible to their original position his displaced
viscera. They included the exercises known by the names of
"pumping," "rotation," "scissors," and "bicycle."

He was given cathartics of the vegetable class as needed, and
also Russian oil.

He was given rhubarb and soda mixture in dram doses three
times a day, and sodium bromid in ten-grain doses three times a
day.

This plan of treatment, as regards the diet and exercises, has
been steadily kept up to the present time, June 7, 1915. The
sodium bromid was discontinued after one month. The Russian
oil was discontinued after about three months, as the patient did

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262 The Archives of Diagnosis

not think it had much effect on his bowel movements. The rhu-
barb and soda mixture was taken intermittently. The cathartics
were kept up, in varying doses, until the end of May, 19151 when
it was found that the bowels moved satisfactorily without them,
while raw bran was included in the diet.

Seven days after beginning this treatment, that is, on June ^,
1914, the patient had a convulsive attack similar to those previously
described, except that the symptoms were less pronounced and the
tongue was not bitten.

It was not until nearly six and a half months later that another
attack occurred, which followed the patient's first attempt to smoke
tobacco (as a celebration of his coming of age). At i a.u. De-
cember 18, 1914, shortly after going to bed, he had a slight at-
tack, which lasted less than two minutes, in which his tongue was
not bitten, and from which he recovered promptly and completely.
There was no loss of memory of things that happened shortly be-
fore the attack. About half an hour after recovering he had a
regular movement of the bowels.

He resumed his interrupted course at Columbia University on
February 3, 1915, returning every night to his home, which was in
Flatbush. He was not allowed to take part in the r^ular gymnastic
exercises required by the college.

February 24, 1915, at 6.30 p.m., while sitting at a table writ-
ing, he suddenly fell oflf his chair, unconscious, but did not bite
his tongue. He recovered in about one minute, apparently com-
pletely. Just before the attack he remembers that he started to
write the letter C, but he wrote the letter L instead. About fif-
teen minutes after recovering he answered a call on the telephone,
and spoke rationally, but he was not able later to recollect what
the conversation was about, although he remembers clearly some-
thing which happened about three minutes after the attack; and
he appeared perfectly normal to those who observed him immedi-
ately after the attack. That night red spots, a little larger than
a pin head, appeared on his arms and legs, around his left eye
and over the left end of his upper lip, which were faint the fol-
lowing morning and disappeared before the next night. Immedi-
ately after this attack and during the entire evening, he had a
feeling in his head "like what one has in a stuffy room."

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Cornwall: Epilepsy of Intestinal Origin 263

After returning to college he did not get as much sleep as
formerly, averaging only about six and a half hours daily.

April 12, 1915, he had an attack similar to the last one described,
but no red spots appeared. This attack occurred while sitting at
a table studying. Immediately after coming out of it he talked in-
coherently about his studies for a few minutes. He recovered com-
pletely in less than half an hour. There were no premonitory symp-
toms. On the day of this attack he had been irritated and excited
by a controversy with one of his instructors, and also had a slight
coryza.

May II, 1915, he had another light attack similar to the last
three in general character, being of short duration, and not at-
tended with biting of the tongue. This attack, like the last two,
occurred while he was sitting at a table studying.

In the latter part of May, 1915, he passed his college exam-
inations with credit.

Physical examination on May 23, 1915, showed him to be in
good general condition. Weight, 159J4 pounds, which was 5j4
pounds more than when he began the present treatment. Pres-
sure over the ascending colon produced a sensation "as if some-
thing were drawn tightly over it," especially over the upper half.

X-ray examinations were made of this case by Dr. Charles East-
mond on June i, 2 and 3, 1915. His report is as follows:

"Seven hours after a bismuth meal:

"The stomach is entirely empty. There is a large residue in the
terminal ileum, which is considerably dilated as a whole, but there
are no local points of constriction, nor is the dilatation greater in
one part than in another. The bismuth has progressed to the
hepatic flexure.

"After twelve hours:

"The ileum is entirely empty. The bismuth is distributed through-
out the ascending, transverse and descending colons. The first
portion of the transverse colon lies in contact with the ascending
colon, but the incisures are sharp. The colon at this time presents
no other abnormalities, except that the transverse portion is ex-
cessively long, so that even in the prone position it descends into
the pelvis. With the patient standing at this time the hepatic
flexure is at a point about one and a half inches above the iliac

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264 The Archives of Diagnosis

crest, and the spleenic flexure only about three and a half or four
inches above the iliac crest. The transverse colon in this position
lies well down in the pelvis.

"After about thirty hours:

"The cecum, ascending colon and first half of the transverse
colon have emptied fairly well. The bismuth now fills the colon
right down to the rectum. The transverse colon still appears to be
very long and descends well down into the pelvis.

"The patient was ordered a cathartic and asked to return.

"After a bismuth enema had been administered :

"The enema has passed the ileo-cecal valve so that the last por-
tion of the ileum can be distinctly seen ; it comes up from below the
tip of the cecum, against which it seems to rest, and lies mostly
against the cecum until it enters it. The entire colon is distinctly
outlined, and in both the prone and erect positions the colon presents
practically no abnormalities except for the excessively long trans-
verse colon mentioned previously and the abnormal descensus of
the colon into the pelvis."

Of the facts observed or elicited in the study of this case, the
following, perhaps, are among the more significant :

1. Facts in the family and personal history previous to the on-
set of the convulsive seizures:

The family history was negative. In the patient's previous per-
sonal history constipation appears prominently, with gastric and
intestinal flatulence and discharge of foul gases from the bowel.
There was a peculiar sensation experienced in the upper ri^t
quadrant of the abdomen, brought on by running, described as a
"feeling as of a lump bumping up and down," which was some-
times accompanied by pain. For some months before the convulsive
attacks appeared, the patient devoted himself closely to study and
neglected ordinary amusements, social diversions and out-of-door
exercise.

2. Physical findings:

The most significant physical findings are those revealed by the
X-ray examinations, which showed a coloptosis, with the trans-
verse colon in the pelvis; the ascending colon extending one and
a half inches above the iliac crest, and the descending colon ex-
tending three or four inches above the iliac crest ; notable dilata-

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Cornwall: Epilepsv of Intestinal Okigin 265

tion of the terminal portion of the ileum, and insufficiency of the
ilio-cecal valve; but no distinct obstruction anywhere in the course
of the gut, and no particular stasis except in the terminal portion
of the ileum.

3. Facts observed in connection with the bowels:

The constipation showed a tendency to persist unless relieved by
laxatives. Russian oil did not prove of much value. Moderate
doses of laxative drugs of a vegetable character, in connection
with a diet which included cellulose and other organic laxative
substances, were sufficient to produce satisfactory movements once
or twice a day ; and at the end of the year the diet alone was suffi-
cient. Coated tongue, bad taste in the mouth, foul breath, belch-
ing of gas from the stomach, discharge of offensive gases from
the bowel were common symptoms during the period before com-
ing under the writer's observation in which the attacks occurred,
and were particularly prominent shortly before and after'the in-
cidence of the attacks; but they were much less prominent, and,
indeed, almost unnoticeable during the period while under the
writer's observation and treatment. During this last period dis-
charge of gases from the intestines was occasionally noticed, but
the gases no longer had the "chemical laboratory smell," but had
an odor like that "from a flatulent horse." The stools during
this last period, while on the diet prescribed by the writer, were
notably smaller in size than formerly.

4. The convulsive seizures;

The convulsive seizures resembled, in general, those commonly
observed in epilepsy, but they showed considerable variation in
character, intensity, duration, and the occurrence of premonitory
and subsequent symptoms. They occurred six times during the
year 1913, and eleven times between January i, 1914, and June i,
1914. Their rate of occurrence was about once a month during
the first year, except for five months following an attack of scar-
let fever; and a little more than twice a month during the first
five months of the second year, at the end of which period the
patient came first under the writer's observation. After being put
on a course of treatment which was aimed chiefly at relieving con-
stipation and intestinal putrefaction, the attacks diminished greatly
in frequency. One attack occurred seven days after beginning the

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266 The Archives op Diagnosis

treatment, and then there was freedom from the attacks for more
than six months. During the remainder of the period of a little
over a year, while under this treatment, four attacks occurred,
which were milder and less typically epileptic in character than the
former ones. Three of these four attacks occurred while the pa-
tient was occupied with his college work, and was getting an in-
sufHcient amount of sleep; and they took place while he was sit-
ting at a table studying, instead of when lying down, as before.

The study of this case, as far as it has been carried, does not
yield a definite answer to the diagnostic and prognostic questions
which naturally arise, viz., whether the convulsive seizures are
due to an intrinsic and incurable derangement of the nervous sys-
tem, or whether they are due essentially and chiefly to a cause out-
side the nervous system which is removable. The facts observed,
however, surest the possibility of a toxic-exciting or mechanical
cause of intestinal origin, and they also suggest what seems to be
the most promising line of treatment.

DIAGNOSIS FROM THE STANDPOINT OF PHYSICO-
DYNAMICS
By J. MADISON TAYLOR
Associate Professor of Non- Pharmaceutic Therapeutics, Medical
Department, Temple University
Philadelphia
I
Any clinical problem deserves to be approached from at least
two or three angles. Human infirmities are not only of great com-
plexity, but greater ui^ency. That factor which is most urgent
needs iirst rec<^ition and first aid. A position of advantage being
obtained by affording relief to the obvious errors, we may then
profitably proceed to search out every avenue of causation and
phenomenal formation.

It is not always to the patient's best welfare to select for par-
ticular treatment that one feature which, in the opinion of the
clinician, seems especially interesting; nor the only one which hts
degree of learning or his taste or experience induces him to select

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Taylor : Physicodykamic Diagnosis 267

as his point of departure. Hence, the hope may be expressed that
clinical teachings of the future shall include more of a perspective,
more practical transvatuations of grouped phenomena, also their
correlation and just apportionment of blame. In the survey certain
significant facts demand inclusion which are too often subordinated.

Any one of us can recall instances where we happened to note
clearly the one point constituting a key to the situation which had
escaped the attention of many able predecessors.

The personal equation, we say. Yes, it is inevitable that some .
consciousnesses are able to perceive one kind, others yet another
kind or form of origin or determinant of action. The fact is if
we can leam to simplify our means of approach by new and prom-
ising directions, they are worth considering.

A sick human being is something other than a living body afflicted
with a damaged organ, or disease processes or effects. To relieve
the malady, it is seldom enough to define just what, where and
how the major phenomena are and are manifested, and to admin-
ister suitable counsel or medication.

The mind, always a dominant factor, is contained in, and con-
ditioned by, an essentially mechano-physical organism.

The sick body is an aggregation of biochemical forces which have
become perverted and require particularized regulation. It is also
a human mechanism out of gear.

A multitude of physico-dynamic factors likewise co-exist demand-
ing recognition and adjustment. The term physico-dynamics seems
a good one to describe that department of bio-dynamics which has
to do with physics, the laws of matter and energy.'

The laws of physical science are universal and apply equally to

'The term physics is a poor one, so is physical or physiologic, since all
are based on physics or growth forces. Hence, it is by no means easy to
get a word which will convey the idea of what is meant when we wish to
differentiate between the forces or phenomena described in the science of
physics as contrasted with the more vitalized processes of active growth
energies or physiology. It is worse when we would attempt a concept of
physical phenomena. In despair of better orthography, the term physico-
dynamic has been selected to meet the need of the forces which are to be
connoted as residing in the science of physics.

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268 The Archives of Diagnosis

living organisms and to so-called inanimate objects. Maladies
should always be estimated from the effects they produce on (i)
the mechanisms of the individual, and (2) his or her personal
peculiarities, which differ in kind and degree from others, as well
as from causes and abnormal effects common to others.

Any clinician would be wise to read over, once in a while, an
elementary book on physics. The mind will thus become re-
familiarized with properties of matter, energy, motion, velocity,
gravity, statics, etc., helpful in understanding biologic principles.'

Lord Macaulay urged every one to read Euclid once a month
to aid in keeping the mental processes systematic and sequential.
We might with equal emphasis recommend reading over a primer
on physics.'

Physics deals with molecular changes of matter. Mechanics deals
with the laws of energy and motion. Psychology deals with the
facts of consciousness; with classification and generalization of
mental phenomena. Geometry deals with spatial facts. Chemistry
deals with atomic combinations and mutations ; different forms of
matter. Physiology deals with proces.ses going to make the
equihbrium of organic life. Sociology deals with processes of
social life, etc. Biology deals with the properties of matter and
energy of living matter. The lines of demarkation between them
are not defined; they interact.

The era of "expectant treatment" is not so large a credit to
medical progress as at first we were led to believe. To be sure,
inherent force, making for growth and repair, can be relied upon
to a certain point; then skill, experience, shrewd observation and
I sense must fill in the outline. This outline must have as

iDr. John C. Draper's book on "Medical Physics" (Lea Bros., 1885) is a
mine of information.

^Two courses of action should arise in the adviser's consciousness in times
of need. One is to act promptly guided by inferential interpretations, and
to supply such imperative help needed as previous experience suggests, a
hit-or-miss, rule of thumb, rough and ready method, e.g., to fix a watch we
may listen to it, note disorders in action, may proceed to oil it, move its
hands, shake it, and perhaps it will go. The second and more certain
way is to secure precise information as to abnormal conditions and remedy
them. In the matter of the watch, e.g., to open it, and, after carefully in-
specting its mechanism, to repair precisely what is found to be amiss.

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Taylor: Physicodynamic Diagnosis 269

3 basis certain scientific factors and principles as are involved in
the problem,

III

In making diagnoses from the physico-dynamic standpoint, it
is desirable to acquire a somewhat different method of securing,
as well as interpreting, findings; to use the familiar forms of in-
spection, palpation, etc., but to look and feel for other conditions
than those commonly sought for. For example, a multitude of
abnormalities will be revealed by expert palpation, tactile awareness,
resistance or relaxation, densities, spasm, vague sensitiveness, al-
terned local static relationships, etc., etc.

Among the factors to be reckoned with are :

1. Anomalies of development, especially minor departures from
the norm. These by faulty habitudes, disease processes, errors in
conduct, accident and the like fortuitous happenings, may become
emphasized or exaggerated and impair organic competence.

2. Anomalies of structure induced by neglect of right methods
of hving, especially those bearing on faulty mechanics, errors in
action, movement, posture, inducing disorders of mobility, ehs-
ticity, pliancy, tone, rhythm; also direct and bye effects of over-
effort, exhaustion, of disuse or misuse by neglect of normal exer-
cise or excitation.

3. Abnormalities of structure arising from disordered or dis-
eased states, and of traumata, etc.; (a) static efifects of errors in
metabolism, minor infectious processes, injury, upon gross struc-
tures and finer cell aggregations, also on regulative mechanisms,
ductless glands, sense organs, nerves, brain, and the like; (b) re-
sistance effects, spasm, rigidities, densities ; (c) sensory effects.
Over-excitation on sensori motor mechanisms, negative anesthesia
or positive hyperesthesia, pain direct or indirect, immediate or re-
mote or reflex complicated effects.

4. Reflexes, their phenomena and effects in solving clinical prob-
lems ; reflexology, reflexodiagnosis ; referred pains, origin and mani-
festation ; aberrancies of reflex phenomena.

IV
In employing physico-dynamic" diagnosis, it is desirable to be-
come particularly adept in familiar forms of investigation, which

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270 The Archives of Diacnosis

are ordinarily used perfunctorily, or only to reveal a limited group
of tindings.

Inspection: One should be so familiar with normal gross anat-
omy, posture, attitude, proportion, etc., as to observe at a glance
departures from norm, anomalies in conformation and to appraise
causative factors, among which are effects of local relaxation,
spasm, contracture, rigidity, displacement, imbalance and the like
mechanistic phenomena ; also to become aware of normal or ad-
missible variants.

Palpation: Using this term in its widest, most liberal interpre-
tation of tactile perception or apperception, the "feel" of struc-
tures, superficial and deep ; estimating degrees and kinds of tissue-
tension, spasm or relaxation, capabilities of action, mobility pas-
sive and active; of adhesions, densities, rigidities; of resistances
or counteractions, also relaxations ; of sensitiveness, normal and
abnormal ; of dryness or moistness ; of local temperature changes,
and the like; above all, an instinctive quality not definable, but
rather an awareness of something amiss in the substance or fabric,
and what it probably indicates to be learned through tactile per-
ceptions.

Diagnostic Manipulation or Handling: While seizing and test-
ing tissues or parts by larger motions than touch on surfaces may
be regarded as part of "Palpation," I submit that it is worth sep-
arate and careful consideration. By this imitation of, and indeed
improvement on, the methods of the surgeon, a different group
of phenomena are evaluated than the relatively crude seizings and
fingerings they ordinarily employ. The internist can thereby de-
termine the significance of a multitude of phenomena entirely within
his domain.

Some observations thus made are exact and some safely inferen-
tial. To be sure, the internist does make use of some, a few,
similar explorations, but by no means habitually, nor does he learn
as much thereby as he might to advantage. It is this diagnostic
measure I would direct attention and hope to show its value.

For example, much will be revealed by imitating the surgeor.
by seizing the limbs, moving them about, determining degrees and
directions of resistance, limitations of mobility, pliancy caused by

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Taylor: Physicodynamic Diagnosis 271

various agencies among which are effects of metabolic disorders,
gout, rheumatism, fibromyositis, etc.

Especially is this of use in searching for latent forms and de-
grees of that widely prevalent and, to my mind, unappreciated
group of disorders known as fibromyositis. These are sometimes
painful, latently tender, at others non-sensitive or only sensitive
occasionally, or only by cunning palpation, and hence particularized
definition, yet are at all times more or less disabling.

Conditions revealed by these three avenues of approach will be
found often of targe significance as bearing on circulation not
alone of the major, but especially of minor (lymphatic) cycle. As
to the major circulation, so large a subject, we can here merely
allude to some points which need special emphasis in this connec-
tion, e.g., vagus tone, sympathetic, vasomotor tone, and tone in the
autonomic distribution.

In particular, attention should be focussed on lymphatic per-
meability, or stasis, and its bearing on nutrition of vital organs,
nerves, nerve-sheaths, muscles and muscle-sheaths, attachments,
fibrous structures, and the like.

The disorder presenting is to be estimated from observed ef-
fects, now existing in the individual, in the light of personal pe-
culiarities (inherent or acquired), which may differ in kind and
degree from others, as well as from causes differing in effects on
others.

In short, a study is to be made of what kind of human mechan-
ism is affected with the disorder; how he or she reacts to the
mechanistic group of causal factors; rather than the more usual
method of merely determining the clinical phenomena presenting,
and applying remedies presumably capable of modifying the con-
dition found.

Moreover, there are vague, unclear, morbid, often painful, states
to be reckoned with in many diseases which complicate the plainer
manifestations, but are too often regarded as inevitable and bound
to disappear as the disease processes yield to natural powers for
repair.

It is my purpose to present reasons for believing that many

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272 The Archives of Diagkosis

of these contributory factors can and should be discovered, defined
and delimited, with the result of modifying the distressing or ul-
timately damaging effects otherwise ignored.

Physiologists have given us a mass of information which it is
our duty to interpret and use. Among the items of available
knowledge of which clinicians do not make adequate use is
physiologic physics.^

The laws of physical science are universal and apply equally to
living organisms and so-called inanimate things.

Clinicians have contributed much to this department, notably
since the advent of the Rontgen ray.

Surgeons, especially by laying bare secrets of bodily makeup, are
enabled to see, touch, and thus know a vast amount of mechanistic
facts found in normal and abnormal states, as well as changes
wrought by disease. These opportunities are becoming utilized in-
creasingly by internists, and the time will soon come when the
findings will be presented in systematized form to the great ad-
vantage of the general practitioner, and especially to the patient.

One element of common sense consists in determining the na-
ture, peculiarities and abnormahties of the individual mechanism;
whether, and if so where, it has undergone changes in shape, tone,
balance; whether some parts are too loose or too tense; whether
the fountains of force are rightly supplied, transmitted, trans-
formed, or interfered with; too rigid or too mobile or in other
respects out of adjustment.

When so complex a mechanism as the human body is out of
gear in one particular, it is a truism that other parts share in the
disharmony, and that less obvious derangements become efBcient
factors in distress, disability, or even grave peril. When the or-

iJhe lairo physicists of the seventeenth century (in Italy), as Abratns
remarks, were enthusiasts in a most important domain of medicine. They
sought to explain the functions of the body, and the effects of remedial
agencies through static and hydraulic laws. Though long neglected, these
principles must be reckoned with to-day, or our duty to an invalid is not
fully discharged. Some legendary notions still obtain exhibiting the prim-
itive hope for "specifics," for "panaceas," and other mythogenic expectations
of effecting cures.

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Taylor: Physicodynamic Diagnosis 273

ganism is thus in disequilibrium there is need for a master work-
man to readjust and redirect autoprotective forces.

Rontgenotherapy and surgery have brought us a long step for-
ward in knowledge of function and of obscure disorders, especially
of mechanistic or static derangements. Surgery has shed much
light by direct touch and sight, where heretofore only inferences
could be made.

These new and practical opportunities of learning things as they
actually are have already revolutionized observation, carried knowl-
edge to a point unbelievable a few years back. Not yet have in-
ternists availed themselves of these priceless visualizations direct
and mental, as they soon will do. The most thorough laboratory
(biochemical) researches can only reveal abnormalities within a
limited domain.

VII

Admitting all that these liberalizing sources of awareness can
supply, there yet remains a number of significant collateral con-
ditions requiring elucidation. Any one who will take the trouble
to survey the abundant sources of diagnosis by expert observation,
by vision, touch, handling of structures, and at the same time hold-
ing in mind his primary knowledge of physics, will greatly increase
his powers and usefulness for relief and cure.

Doubtless most, if not all, who study medicine have been grounded
in the principles of physics, the essential properties of matter, and
can call them to mind. The special applicability of these forces
has been demonstrated in teachings of biology, in physiology and
anatomy.

To judge from personal experience in teaching students of medi-
cine, both under- and post-graduates, the impressions received from
these studies fluctuate and often become practically effaced. To
cite my own case, an exceptionally good grounding in physics had
faded sadly when occasions arose to utilize my knowledge of physics
in forming dear concepts of primitive or essential forces as mani-
fested in physiologic and anatomic problems. It is fair to assume
few keep them clearly in the foreground of consciousness during
the solution of daily recurring fields of inquiry.

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The Archives of Diagnosis

^coffceKK of Bfagnotfftf anb ^^gnoKitf

GENERAL METHODS OF EXAMINATION— SYSTEMIC
AFFECTIONS— DISORDERS OF GENERAL
METABOLISM
Toxicity of Urine— M. H. Roger, Presse med., May 31, 1915.

In his analyses of urine Bouchard succeeded in dissociating the
effect of seven different substances, to which are added four discov-
ered later. We know at present : a diuretic substance, urea ; a nar-
cotic substance, a sialogenous substance, two substances inducing
convulsions, a myotic substance, a hypothermic and a hyperthennic
substance, a cardiac poison; a hypotensive and a hypertensive sub-
stance, these latter discovered by Abelous and Bardier. Urine emit-
ted by day is narcotic ; that emitted by night is convulsivant, accord-
ing to Bouchard, which leads him to maintain the toxic effect of
sleep. ZiUMER.

SjrmptomB of Urinod PoisoninK— F. A. Hartman, Arch. Int. Med., July,

1915-

Urinod is prepared from the destitutes of acid-treated urines. It
is a neutral malodorous oil, boiling at 108 degrees C, with 28 mm.
pressure. It is a cyclic ketone with the empirical formula C»HgO.
The symptoms produced by urinod are nausea, headache, loss of ap-
petite, heaviness of the stomach after eating, twitching, irritability,
mental dulness, physical weariness, drowsiness, dyspnea, convul-
sions and a state of nonirritabihty. Urinod appears to be one of the
most toxic substances in the urine. Cases are cited in which there
have been indications of urinod retention in the body. The symp-
toms of urinod poisoning resemble the nervous symptoms of uremia.
Urinod retention, therefore, might partly account for these nervous
symptoms. Sachs.

Diagnostic Value of Uric Acid Determinations in the Blood— O. Foun

and W. Denis, Arch. Int. Med., July, 191S.

In gout the blood is almost invariably high in uric acid, while the
other waste products represented in the nonprotein nitrogen of the
blood are usually within normal limits. In arthritis also the blood
is not infrequently abnormally high in uric acid, but most such cases
have abnormally high nonprotein nitrogen as well. Neither qualita-
tive nor quantitative determinations of the uric acid in the blood can
be depended on in the differential diagnosis in doubtful cases of gout

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Progress of Diagnosis and Prognosis 275

or arthritis. The patient must be put on a purin free diet and uric
acid determinations must be accompanied by determinations of the
nonprotein nitrogen (or urea). Sachs.

Uric Acid Content of Infantile Blood— E. Liefmanh, Zeitschr. f. Kinder-

heilkunde, Vol. XII, Nos. 4 and 5, 1915.

The uric acid content of the blood of the nursling fluctuates be-
tween 1.3 and 1,7 mg, in every 100 c.c. of blood. When on a diet
rich in purins it increases rapidly. After withdrawal of the purins
the uric acid content declines slowly. The uric acid content is also
augmented in fasting, febrile and systemically diseased children.
Nurslings with exudative diathesis exhibit no special increase of
uric acid in the blood. For this reason, it appears, that there exists
no connection between the exudative and the urtc acid diathesis.

Mill,
The Choleateria Content of the Human Blood Scrum— I. H. Probau,

Zentralblatt f. inncre Medixin, Na 21, igiS.

In most cases of nephritis the cholesterin in the serum is much
increased. In polycythemia this is also the case. A case of diabetic
coma showed an increased amount of cholesterin in the blood serum.
The cholesterin content of the serum warrants certain conclusions
in the pathogenesis of various diseases. Western.

Pepsin in the Blood Serum— P. Saxl, Wiener itied. Wochenschr., March 8,

191S.

Author succeeded in bringing about casein digestion by the blood
serum. He did this with the sera of 20 healthy or slightly diseased
individuals. This casein digestion is apparently due to peptic ac-
tivity. Mill.

Blood Sugar Determinations in Diabetics and Their Clinical Import —

M. Lauritzen, Ugeskrift f. Lager, No. 6, 1915,

The blood sugar determinations were made according to the
method of Ivar Bang. The determinations were made with the
blood of 100 diabetic patients. Author believes that these determi-
nations are of great value in the differential diagnosis, (i) Whether
the case is one of diabetes with or without hyperglycemia; (2) in
the forming of a prognosis in the cases in which acetonuria and
diaceturia permit of no orientation as regards an unfavorable prog-
nosis, and (3) to control the results of the therapeutic endeavors.
While, formerly, the aglycosuria seemed sufficient proof of the suc-
cess of the instituted treatment, one can now determine the diet
which does not give rise to hyperglycemia after the meals. Such
a diet is to be kept by the diabetic patient as longs as it is possible.
Hyperglycemia, it must be known, destroys the tolerance for
starches in diabetes. Tessen.

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2/6 The Archives of Diagnosis

Pernianganate Test for Spinal Fluid— E. Lackner and A. Levinson, Arch.

Pediat., July, .I<H5.

The test is a modification of the Kubel-Thieraann method, but in
the following form was first employed by Mayerhofer. The method
is as follows : One ex. of the spinal fluid is measured in an accurately
graduated pipet and introduced into an Erlenmeyer fiask ; 50 c.c. dis-
tilled water and 10 c.c. of diluted fl^SO^ are added and the mix-
ture is brought to a boil ; 10 c.c. of a decinormal permanganate solu-
tion is then introduced into the flask and the solution is boiled for
exactly 10 minutes. At the end of the time 10 c.c. of decinormal
oxalic acid is put into the flask, whereupon the red or yellowish-red
color turns white. Titration is carried on drop by drop from a
buret containing permanganate solution until the color of the solu-
tion in the receptable turns red and remains so for a number of
minutes. The number of c.c. of permanganate required to produce
the end reaction is then read off and the figure is taken as the per-
manganate index. In doing this one must, however, make certain
that 10 c.c. of N/10 permanganate equals 10 c.c. N/io oxalic acrd.
It is also necessary to ascertain how much permanganate is required
to oxidize the water and the H^SO,, and this amount should be sub-
tracted from the number of c.c. of permanganate required to oxidize
the spinal fluid solution. For example, if 4 c.c. of N/10 permangan-
ate was required for the spinal fluid and 0.5 c.c. permanganate for
water and H^SO,, the 0.5 c.c. should be subtracted from the whole
number, leaving the reduction index only 3.5. The spinal fluid in
normal cases, or even in meningismus has little organic substance.
As a result the permanganate index is low, while the organic sub-
stances in the spinal fluid of meningitis are increased, and therefore
the permanganate index is higher. In tuberculous meningitis the
first portion of the fluid contains more organic substances than the
second, the second more than the third, each portion being about 10
c.c. in amount. In meningismus the reverse is true, the consequent
portions containing a greater amount of organic substances than the
preceding. These findings are hence of diagnostic value, Sachs.
Orthostatic-Lordotic and Nephritic Albuminnria—Sc holder and Vehh,

Archiv f. Orthopadie, Mechanotherapie u. Unfallchirurgie, Vol. XII, No. 4.

This is-a review of Jehle's work. The article does not bring any-
thing new. Mill.
Theory of Basedow's Disease— A. Oswald, Miinchener med. Wochenschr.,

July 6, 1915.

Author is not of the opinion of Mobius, according to which the
entire syndrome of Basedow's disease is primarily dependent upon
a disease of the thyroid gland. He believes that an important
genetic factor of the syndrome, probably the most important, is sit-
uated in the nervous system. Author does by no means deny the

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Progress of Diagnosis and Prognosis 277

participation of internal secretory activity in the genesis of the
Basedow symptom-complex, and he even is of the opinion that the
thyroid gland plays the most important role in this regard. How-
ever, he furnishes sufficient evidence that the most important of all
the genetic factors is due to the state of the nervous system. The
article must be read in the original. Mill.

The Thyroid of Phthiaical Patients— H. Kehl, Virchow's Archiv, Vol.

CCXVI, Nos. I to 3.

Anatomical examinations of the thyroid gland of individuals who
had died of tuberculosis. Of 50 thyroids 2 showed tuberculosis.
Lymphatic tissue was not found in any of the glands. Typical
Basedow changes were also not encountered in any of the glands.
Increase of connective tissue, however, was noted. Mill.

PrognosiB in Exophthalmic Goitre— H. M. Gerney, Brit. Med. Jour.,

May 29, igi5.

From an investigation of 93 cases of exophthalmic goitre author
states that the death rate is 25 per cent, in cases beginning between
10 and 15 years of age, and increases gradually to 44 per cent, in
cases beginning after 45 years. In cases coming into the hospital
who have been ill under one year, the death rate was 35 per cent.,
between i and 2 years 75 per cent. The rate falls after the fourth
year, as after that length of time the disease may be regarded as
chronic and the symptoms are always less acute. Early develop-
ment of very acute symptoms, such as diarrhea and tachycardia, add
to the gravity of the prognosis. Sachs.

Rajmaud'B Syndrome— O. T. Osbobne, Am. Jour. Med. Sci., August, 1915.

A very readable article that brings nothing new. Author em-
phasizes that the syndrome may appear in a very mild form ; that
women are attacked much more frequently than men ; that the com-
monest age is from 15 to 30, though no age is exempt; that fre-
quently uterine and ovarian disturbances are encountered; that the
worst attacks sometimes occur periodically, with a more or less close
relationship to the menstrual period; and that some of the well-
known symptoms of a disturbed thyroid secretion are often present,
probably more frequently on the side of hypothyroidism than hyper-
thyroidism. Sachs.
Hypertrophy of Thymus and Thymus Deaths — T. Le Boutillier, Arch.

Pediatr., May, 191S-

A careful examination of the chest in the region of the thymus
should be made in all children who are examined in order to deter-
mine if there be an enlargement of this gland. Especially is this
so in cases of slight or marked dyspnea or cyanosis which cannot
be traced to any other cause. These cases should be rontgeno-
graphed. Tracheostenosis, resulting therefrom, is a positive condi-

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278 The Archives of Diagnosis

tion and, in certain cases, death is caused by it. Enlarged thymus
is sometimes associated with goitre. Sachs.

Hibernation and the Pituituy— H. Gushing and E. Gortsch, Jour. Ex-
periment Med., July, 1915.

A train of symptoms, coupled with retardation of tissue
metabolism and with inactivity of the reproductive glands, not only
accompanies states of experimentally induced hypophysial defi-
ciency, but is equally characteristic of clinical states of hypopitui-
tarism. The most notable of these symptoms are a tendency in the
chronic cases towards an unusual deposition of fat, a lowering of
body temperature, slowing of the pulse and respiration, fall in blood-
pressure, and often a pronounced somnolence. These symptoms
bear a marked resemblance to the physiological phenomena accom-
panying the state of hibernation, which have hitherto been unsatis-
factorily ascribed solely to extracorporeal factors ; namely, a sea-
sonal deprivation of food and low temperature. Hibernation may
be ascribed to a seasonal physiological wave of pluriglandular in-
activity and the essential role may perhaps be ascribed to the pitui-
tary body. Sachs.
Human HypophTBis after Castration— R. Rossle, Virchow's Archiv, Vol.

CCXVI, Nos. I to 3.

Castration may lead to an enlargement and the histological altera-
tion of the anterior lobe of the hypophysis. There is found a multi-
tude of eosinophiles, heterotopia of eosinophiles and small numbers
or absence of basophile epithelia. These histologic characteristics
are, however, neither constant nor absolutely specific of the hypophy-
sis of castrates. SIill.
Heredity of the Diabetic Constitution— I. H. Pribram, Zentralblatt f.

innere Medizin, No. zi, 1915.

Pedigree of a family the father of which is an offspring of a
gouty, the mother of which comes of a diabetic family. The three
oldest children have diabetes. The disease appeared in the fourth
decennary of life. The younger brothers and sisters, of whom there
are six, are still free from glucose. The third generation is not as
yet diabetic. Western.

Ciliary Body in Health and Disease— H. P. Dunn, Lancet, May 29, 1913.

Author states that hypothyroidism is sometimes the cause of irido-
cyclitis. This form of irido-cyclitis readily responds to thyroid med-
ication. Sachs.
Carcinoma— J. E. Else, Northwest Med., July, 1915.

Any epithehal cell may under certain conditions develop cancer
cells. In at least a portion of the cancer group there is a contagious
element and the process can be and is transmitted from one person
to another. Infective organisms play a part in the etiology of some

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Progress of Diagnosis and Frogkosis 279

cases, but whether they have a specific action or merely furnish the
necessary chronic stimulus to cause malignant proliferation of epi-
thelial cells, is not known. Trauma, chemical irritation and chronic
irritation of all other types are of etiologic importance. Western.
Skeletal Cancer or Bone Hetastaset— E. H. Risley, Boston Med. and

Surg. Jour., April 22, 1915,

Metastases are more common after cancer of the breast than any
other organ. The prostate and thyroid are next in frequency as a
source of metastases. The liability of a bone to cancerous invasion
increases with its proximity to the site of the primary focus. Thus
the sternum and ribs are affected about equally and more frequently
than any other bones. Pain is the only characteristic symptom.
Visible or palpable tumor is rare, while spontaneous fracture is quite
common. Any fracture of a long bone occurring as a result of a
trivial injury should immediately suggest the possibility of bone
metastases and should lead to careful search for the primary new
growth. In all cases of painful paraplegia a neoplasm should be
suspected. Sachs.

Age Incidence in Sarcoma— C. V. Weller, Arch. Int. Med., April, 191S.

Sarcoma occurs most frequently at the age period of 48 to 52.
The age distribution of sarcoma in males and females is nearly the
same. The sarcoma incidence in youth is somewhat higher than
the carcinoma incidence, nevertheless there is throughout life a
marked parallelism between the age incidence curve for the two
types of malignancy, and for more than twenty there is a practicable
coincidence in the age distribution. Sachs.

INFECTIOUS DISEASES
Prognostic Value of the Temperature Curve in Pulmonar? Tuberculosis

—J. SZABOKY, Zeitsehr. t. Tuberkulose, Vol XXIII, No 6.

The more uniform the temperature in pulmonary tuberculosis
(low amplitude) the more favorable is the prognosis, provided that
the low amplitude is not due to low minima alone. High amplitude
is indicative of an unfavorable prognosis, even when the tempera-
ture in toto is not too high. The temperature elevation occurring
in patients (that had been afebrile or became afebrile by treatment)
after the performance of a certain amount of work is only of bad
prognostic significance when it persists after a protracted period of
rest. Fry,

Intracellular Occurrence of Tubercle Bacilli in the Sputum— M. Cohk,

Beitrage i. Klirik d. Tuberkulose. Vol. XXXI, No. I.

Examination of the freshly raised sputum in 81 cases of patients
with pulmonary tuberculosis. The preparation was stained with a
concentrated Assmann-Jenner stain. Author studied the behavior

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28o The Archives of Diagnosis

of the phagocytes toward the tubercle bacilli. Among 8i cases, 8
(lo per cent.) showed marked phagocytosis. Of these 5 occurred
in the 30 cases that died later on ; 2 occurred in the 29 cases with a
dubious prognosis, and i among the 1 1 cases with a good prognosis.
The sputa with marked phagocytosis were mostly rich in bacteria.
The intracellular location of the tubercle bacilli does not admit of
any conclusions in regard to the course of pulmonary tuberculosis.
Lymphocytes do not occur frequently in the sputum of tuberculous
patients. Fry.

Tubercle Bacilli in the Circulating Blood— C R. Austiuan and L.
Hauuak, Johns Hopkins Hospital Bull, Aug., 1915,
In pulmonary tuberculosis authors were unable to demonstrate
the presence of tubercle bacilli in the blood in a single instance not-
withstanding the fact that many of the patients when examined were
in the last stages of the disease. In animals, when the disease re-
mains localized in the lungs, tubercle bacilli are not found in the
. circulating blood. When the disease becomes generalized, as it does
in the late stages of pulmonary infection and very soon after over-
whelming intravenous injections, circulating tubercle baciUi are fre-
quently demonstrable. The evidence presented points strongly
against the mobilization of tubercle bacilli by the injection of tuber-
culin. A larger number of positive results was revealed by the
method of animal inoculation than by the microscopical examination
of the sediment obtained by treating blood according to the acetic-
acid-antiformin method. Western.

Frequency of Tuberculgsis in Childhood— B. S. Veeder and M. R.
JoHMSTON, Am. Jour. Dis, Child., June, 1915.

A study of the tuberculin tests in 1,332 hospital children in St.
Louis shows that the percentage of positive reactions reaches a maxi-
mum of 44 per cent, at the age period of 10 to 14 years, including
cases with clinical tuberculosis. These figures are much lower than
the usual "90 per cent." figure for the incidence of infection with the
tubercle bacillus in children by their fourteenth year, which has
gained such widespread publicity and which is based on the figures
of Hamburger of Vienna. No conclusions as to the extent of infec-
tion can be drawn from the statistics of any one city or class of
children, and the statement that 90 per cent, or more of individuals
are infected by puberity is an extreme exaggeration of the actual
conditions which exist. Sachs.

Prognostic Significance of Tuberculous Cavities in the Lungs— -M. Fish-
berg, N. Y. Med. Jour., June 26, 1915.

In very acute forms of tuberculosis, cavitation is exceedingly rare.
The prognosis is gloomy with or without locahzed destruction of
pulmonary tissues. In aduUs such cases are rare, but in infants
rapid cavity formation is seen at times, and the termination is almost

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Progress of Diagnosis and Prognosis 281

invariably fatal. In subacute forms of phthisis in which excava-
tions are apt to form very rapidly, the prognosis is unfavorable, un-
less the cavity is rather small. In chronic phthisis, excavations even
when extensive are compatible with a long and efRcient life. On
the whole cavities are an indication of chronicity of the tuberculous
process in the lungs. Sachs.

TuberculouB HenUiKitiB and TuberculoNB of other Orgaiu — W, Stein-

MEiER, Virchow's Archiv, Vol. CCXVI, Nos. I to 3.

A statistical study. Children are particularly prone to tuberculous
meningitis. In nearly 45 per cent, of the cases the tuberculous men-
ingitis was a part phenomenon of a generalized tuberculosis. In
more than 7 per cent, of the cases there was a combination with
urc^enital tuberculosis. Mill.

Syphilis and Tuberculous — A. 5. Macnalty, Practitioner (London), June,

1915-

Syphilitic affections of the lungs or glands may simulate tubercu-
losis of the lungs or glands. Syphilis of the lungs is stated by many
authorities to be a disease of great rarity, while others advance the
opinion that it occurs more frequently than has been supposed, but
that it has been confounded with tuberculosis. The possibility of
error is augmented by the fact that syphilis and tuberculosis may
occur at the same time in the same subject. Sachs.

WasBcnnann Reaction in Relation to Diagnosis— R. B. H. Gradwobl,

Southern Med. Jour,, June, 191S.

In the recognition of a latent case of syphilis, an obscure case, a
tertiary case, the case that has had syphilis a long time ago, etc., the
Wassermann reaction will often make the diagnosis where all else
fails. Cases are legion that have gone the rounds and have been
treated for everything but syphilis. Some there are that deny ever
having had syphilis, denying either a primary sore or a secondary
skin manifestation. Some lie and others don't know. Some are late
congenital cases that naturally know nothing of their parents' in-
fection. Possibly the most monumental sin that besets the profes-
sion to-day is its readiness to accept any statement from any pa-
tient regarding the history of a past syphilitic infection in so far
as it has any bearing on the inclusion or exclusion of syphilis in ex-
plaining a present obscure disease. We are too prone to ask a pa-
tient whether he ever had syphilis, and on being told "no" to accept
this as final proof that he cannot possibly now have the disease.
We are also too much inclined to regard the patient's respectability
as offering a bar to the existence of syphilis. We are too prone to
think of syphilis as the last explanation instead of the first in seek-
ing the cause of something obscure. Some of us are overawed
by the apparent or real chastity of our patients, particularly of the
female sex. Sex, age, social position, marital status, nothing should

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282 The Archives of Diagnosis

stand in our way in investigation of disease. And there should be
no hesitation once the diagnosis is made in telling the patient the
real nature of his disease. It is in this class of patients that the
Wassermann looms up as the great hope of diagnosis. The blood
serum examination usually sufRces to pin down the existence of a
stomach or liver or heart or lung syphilis.
Luctin Te« in PmBTphilis— D. M. Ross, Jour. Mental Sci., April, 1915.

The luetin reaction is a valuable addition to our diagnostic tests
for syphilis. It is easily carried out by the clinician, is absolutely
specific for the disease, and is occasionally positive in cases in which
the Wassermann reaction is negative. Much states that when it
is a question of ascertaining if the patient has ever been infected
with syphilis, the luetin test is the more instructive, but when it is
desired to know if tbe disease is still active, the Wassermann is the
more helpful. Sachs.

WaMemuim Reaction in Halvia, Kala-Asar and Leprosy— W. D. Sutho-

LAND and G. C. Mitka. Indian Jour. Med. Research, April, IQIS-

Chronic malaria does not affect the Wassermann at all. One must
wait a week until the patient's peripheral blood has been clear of
parasites before having the blood tested. In 38 cases of kala-azar
the Wassermann reaction was positive in 10, but only 2 of these
cases gave a more than slightly positive reaction. In 34 undoubted
cases of leprosy, 14 were of the anesthetic form; of these 4 gave
a positive Wassermann reaction. Of the remaining 20 cases, 7 gave
a positive reaction, Sachs.

Ddhle's Leukocyte Inclusions— H. Rehdeb, Deutschcs Archiv f. klin.

Mediiin, Vol. CXVII. Nos. i and 2.

Typical leukocyte inclusions (trypochetes), as originally described
by Dohle, are only found in scarlet fever and, with very few ex-
ceptions, in no other diseases. Atypical inclusions, on the other
hand, occur in almost all febrile affections. The true nature of these
bodies is not as yet definitely known. It is not known if these in-
clusion substances are spirochetes or protozoa, either of which may
be a possible causative agent of scarlet. The atypical leukocyte in-
clusions are probably only protoplasm particles. Western.
Positive Gruber-Wid«l Reaction in Dysentery— R. Mabek, Wiener klin.

Wochenschr., May 20, 1915.

Author noted a positive Gruber-Widal reaction in a number of
cases which seemed to be dysenteric colitis in a clinical sense. In
many cases it is not possible to obtain a bacteriological and serologi-
cal diagnosis of dysentery. It may be surmised that some of the
causative factors of dysentery are closely related, morphologically
and biologically, to the typhoid bacilli. It is noteworthy that in some
cases after preventive vaccination for typhoid the dysentery, ag-

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Progress of Diagnosis and Prognosis 283

glutination, which became negative, is again rendered active. At
any rate, a positive Gruber-Widal reaction is no longer a positive
proof for the existence of typhoid fever if the clinical course of the
disease does not point to this infection. Mill.

DyKnteric Rheiunatoida — G. Sincer, Wiener med. Wochenschr., Feb. 8,

1915-

Among 600 cases of dysentery, author has met polyarthritic rheu-
matoids in 7 instances. These rheumatoids must be considered to be
of metastatic origin ; on account of their septic character they are
related with the acute rheumatic polyarthritis. Mill.

STmptomatoIofy ind DupiOBi* of Typhoid Fever— F, Schultze, Deutsche

med. Wochenschr., June 17. i9iS-

Typhoid fever may be ushered in with chills. These, however,
are of rare occurrence. The violent pains in the head and neck
must be due in certain cases to the presence of encephalomyelomen-
ingitis. Herpes may occasionally be noted in the beginning of
typhoid fever. Author has had typhoid fever 42^^ years ago, but
still shows a positive Gruber-Widal reaction. Mill.

Involvement of the Kidneys in Relapsing Fever— L. Jarno, Wiener klin.

Wochenschr., April 22, 1915.

Examinations of 170 cases. It was found that, as a rule, small
amounts of albumin were already present on the iirst day of the
first attack. On the second day the albumin content was increased
to 0.5 to 1.5 per mille. The albumin continued in the urine until
defervescence ensued. The sediment contained large numbers of
granular casts, which disappeared together with the albumin. The
second attack runs mostly a similar course. In later attacks the al-
buminuria and cylindruria are less marked. A permanent renal in-
jury was noted in but one of the cases. In two instances hemor-
rhagic nephritis had been present. Mill.
Multiple Skin Infarcts after Heaslet— K MoBCEKsmtN and G. B. Gruber,

Zeitschr. f. Kinderheilkunde, Vol. XTI, Nos. 2 and 3.

After a case of measles there appeared skin infarcts and necroses
on one side of the body. They were not due to embolism, but to lo-
calized thromboses of a number of arterial regions. Mill,

Chronic ProKressive Polyarthritis— S. W. Boosstein, Med. Rec., June 19,

191S.

This paper is a report of 105 cases of chronic progressive poly-
arthritis. Author concludes that the disease has no relation at all
to rheumatism. The predominating etiological factor is distinctly
an infection, either in the joint itself or at a distant point. The
disease is not dangerous to life and is usually self-limited. Sachs.

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284 The Archives of Diagnosis

Cholera— E. Gildemeister and K. Baeetrlein, Miinchener med. Wochenschr.,

May 25, 1915.

Some of the conclusions reached by authors are as follows : Chol-
era vibrions die within a short time in a large portion of the cholera
discharges. The vibrions, however, may remain viable in a not in-
considerable number of stools for a number of weeks, occasionally
longer than 30 days. In the intestinal discharges of healthy germ-
carriers cholera vibrions may also retain their viability for some
weeks. Mill.

RESPIRATORY AND CIRCULATORY ORGANS
Broncho-Pneumonic Pseudo Croup — E. Su.ver, Jahrbuch f, Kinderheil-

kunde, Vol. LXXX, No. 6.

The diagnosis of broncho-pneumonic pseudo croup is based upon
the following characteristics: (i) Appearance of the initial catarrh
(tracheitis and bronchitis) ; {2) absence of pseudo membranes in
the nose, trachea, tonsils, larynx, etc.; (3) clinical symptoms of
broncho-pneumonia together with laryngeal phenomena; (4) bac-
teriological examination. In dubious cases diphtheria antitoxin is
recommended. Mill.

Latent Syphilitic Infection of the Lungs— H. R. M. Landis and P. A.

Lewis, Am. Jour. Med. Sci.. August, 1915.

The diagnosis of latent syphilitic infection of the lungs must be
made by exclusion. Thus if the symptoms and physical signs are
those characteristic of tuberculosis and the sputum does not contain
tubercle bacilli, or the progress of the case differs from that usually
encountered in tuberculosis, the possibility of some other exciting
cause should be thought of. Not only should the sputum be exam-
ined for organisms other than the tubercle bacillus, but in addition
a Wassermann test should be made in every doubtful case. Sachs.
Hypertrophy of the Right Heart— J. Bret, Progres med., June 27, 1914.

In all cases of hypertrophy of the right ventricle, it is not the le-
sions of the pulmonary parenchyma so much as the lesions of the
vessels that play the pathogenic role. They are, in fact, the athero-
matous lesions of the pulmonary artery, as described by Giroux,
which is accompanied by more marked hypertrophy of the right
ventricle, and sometimes less marked atheroma of the pulmonary
artery is associated with mitral contraction. The clinical symptoms
are: marked cyanosis, dyspnea, drowsy torpor, hepatic hypertrophy,
albuminuria, acceleration or slowing of the cardiac rhythm, without
arrhythmia, systolic pressure of no or 120 mm. Ilg. (Riva-Rocci),
diastohc pressure 90 to 95, polyglobulia and increased viscosity.
These symptoms comprise the primary asphyxial syndrome.

ZlUMER.

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Progress of Diagnosis and Prognosis 285

IiretnUr Action oE the Heart— C. Wilsok, Brit Med. Jour., June 5, 1915.
Definite heart -block is always serious and the patient should be
kept well within his limits, as his life is insecure. The young patient
exhibiting sinus arrhythmia should not be debarred from any oc-
cupation or recreation suited to the general physique, nor should any
treatment be prescribed except on other grounds- When there is
no direct evidence of cardiac mischief, the irregularity due to extra
systoles may be absolutely ignored. Where heart disease exists, pa-
tients showing this form of arrhythmia may be reassured and en-
couraged to exercise their activities to the extent of comfort. They
need not live in fear of sudden death. Auricular fibrillation is very
common in damaged hearts. A majority of the cases of heart fail-
ure exhibiting dropsy are associated with this condition. It can
often be diagnosed from simply feeling the pulse. An absolute ir-
regularity which persists is in itself sufficient. In heart-block sinus
arrhythmia and extra systole, exertion or any influence which quick-
ens the pulse tends to reduce or perhaps abolish the irregularity,
while in fibrillation precisely the opposite effect is produced. Pulsus
altemans often occurs only as a terminal phenomenon, and as such
it has, when recognized, a grave prognostic significance. Paroxysmal
tachycardia is sometimes fatal, but more often passes and leaves the
patient but little worse until the next attack occurs. Auricular flut-
ter is generally associated with sclerotic changes of advancing years.
Ability to differentiate the rhythms will restore far more patients
to activity than it will condemn. Sachs.

TraoBitory Complete Cardiac Irregularities— K. Fabbenkamp, Deutsche!

Archiv f. klin. Meditin, VoL CXVII, Nos, I and 2,

There are marked cardiac irregularities which are transitory, last-
ing generally but a few hours, in which the nerve influence is often
clearly noticeable. This nerve influence consists in an increased
vagus irritability. These arrhythmias appear not always in the
frame of the same clinical picture. The symptom-complex is apt to
change in the same patient. It is clinically of importance that extra
systolic arrhythmia be differentiated from perpetual arrhythmia.

Western.

Alternation of the Pulse— P. D. White, Am. Jour. Med. Sci., July, t9i5-

True alternation of the radial pulse has been found in 71 of 300
cardiac and cardiorenal patients examined with the sphygmograph
by the writer at the Massachusetts General Hospital. It has oc-
curred as commonly as auricular fibrillation. The relationship of the
degree of alternation to prognosis was as one would anticipate : the
greater the degree, the shorter the life after the pulse discovery.

Sachs.

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286 The Archives of Diagnosis

Pernunent Bradrcudia— Cottin, Archives Maladies du Coeur. dcs Vaisseaux

et du Sang, June, 1915.

Chronic slowness of pulse, due to auriculo-ventricular dissocia-
tion, is not always the result of a lesion of the bundle of His, as
has long since been demonstrated. The hitherto accepted notions
that paroxysmal occurrence of attacks of bradycardia were invaria-
bly of nervous origin, and that auriculo-ventricular dissociation,
combined with a lesion of the bundle of His, was the cause of per-
manent bradycardia, have been modified by the recent researches of
Rathery and Lian, who have demonstrated in the Paris hospitals two
cases of permanent bradycardia of nervous origin. Still more re-
cently Souques and Routier have published observations of three
cases of Adams-Stokes disease, also of nervous origin. Zimmer.
Patency of the Ductiu Arterionis— T. W. GkiKFiTH, Quart. Jour. Med.

(London), April, 1915.

Two examples of the patency of the ductus arteriosus occurred
in patients in whom the affection was recognized during life. One
of these succumbed to an infective endocarditis, and the diagnosis
was verified on the post-mortem table. In the other the condition
was probably associated with some further anomaly of the great
vessels, and with a developmental error which gave rise to cyanosis,
for this is a symptom which is not often met with in uncomplicated
cases of patency of the arterial duct. In the first case there was
heard at the inner end of the second left intercostal space a loud
systolic bruit, followed by a very loud diastolic bruit, which was
audible a considerable distance outwards along the second space and
was not transmitted along the left edge of the sternum. These two
sounds produced as it were one continuous bruit with systolic and
diastolic increments. Sachs.

The Role of Syphilis in Hypertenaive Cardiovaacular Diaease— H. F.

Stoll, Am. Jour. Med. Sci., August, 1Q15.

The results of author's investigation is summarized thus: Syphilis
is the underlying or basic factor in a much higher percentage of
hypertensive cases than has hitherto been realized. Of 50 individ-
uals studied 90 per cent, either gave a positive Wassermann or luetin
test, or were known to have had lues, or had children with hered-
itary syphilis. Nineteen were from cardiovascular families. In 17
of them either one or both tests were |K)sitive. One of the two with
negative reactions is surely specific. This strongly suggests the ex-
istence of what might be termed "familial cardiovascular syphilis,"
It would seem that hypertensive disease is one of the most com-
mon — possibly the most frequent — of the so-called "late" manifesta-
tions of hereditary syphilis. Apoplexy and sudden cardiac death
occurring in middle life are almost always due to syphilis, and it
cannot be considered a negligible factor even in the aged. The re-

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Progress of Diagnosis and Prognosis 287

maining parent and the children of individuals dying a cardio-
vascular-renal death in middle life should be tested for syphilis, as
they are infected in a high percentage of the cases. Sachs.

Cmrdiac and Vascular Diseases in the War— E. Rombebg, Kfiinchener med.

Wochenschr., May i8, igiS.

Persons with sclerotic, not normally functionating arteries are,
comparatively, more frequently affected with cardiac insufficiency
than individuals with normal blood vessels. However, exhausted
and reconvalescent individuals or those with latent fever who are
troubled with cardiac disorders, even those exhibiting accidental
sounds, must not necessarily be affected with heart disea.se. Exami-
nation of heart and pulse often do not suffice to form a definite
opinion about the condition of the heart. In order to come to a
definite understanding, it is always essential that the condition and
behavior of all the other organs that stand in connection with the
circulation, and the previous medical history of the individual be
taken into due consideration. Mill.

Media Calcification and Atherosclerosis — J. G. Monckeberc, Virchow's

Archiv, Vol. CCXVI, Nos. I to 3.

Calcification of the media and atherosclerosis should be differen-
tiated between. Neither the degree nor the extent of a peripheral
calcification of the media justifies, without additional reasons, the
assumption of an atherosclerosis of the central vessels. Both proc-
esses may, however, be found associated. Mill.
A Remarkable Reflex Phenomenon in an Aneurism of the Femoral

Artery — WiGDOROwrrscH, Deutsche med. Wochenschr., June 17, 19IS.

Pressure upon the femoral artery beneath Poupart's ligament in
an injured leg caused a dechne of pulse- frequency from 72 to from
42 to 45 pulsations per minute. The pulse-frequency was not dimin-
ished in the healthy limb. Mill.

ALIMENTARY TRACT
Gastric AnalyMa— T. Heaton, Brit. Med. Jour., April 24, 1915.

The interpretation of the figures obtained by gastric analysis after
a test meal is by reason of the number of factors involved a matter
of great complexity. A means of standardizing results is afforded
by adding to the meal a fixed proportion of some inert substance,
such as urea, whose proportion can be estimated subsequently in the
gastric content. It is then possible to arrive by calculation at an
approximation of the actxial composition of the secreted gastric juice,
as opposed to those of the mixture of this with the remnants of the
fluid of the meal. By this method it is possible also to eliminate the
disturbing influences of an abnormally rapid or an abnormally slow
rate of emptying of the stomach into the duodenum. The condi-

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z88 The Archives of Diagnosis

tions of hyperacidity and hypoacidity can be differentiated from
those respectively of hypersecretion and hyposecretion. Sachs.
Clinical Use of W»ter Mwl-A. E Austin, Bost. MeA and Surg. Jour.,

June lo, 1915.

The patient is given, on the evening before he is examined, a meal
of meat, potato, bread, butter, rice and raisins, and the next morn-
ing, on a fasting stomach, 350 c.c. of water is administered. Twenty
minutes later, the extreme limit at which the water normally leaves
the stomach,. it is removed. The water meal has the advantage of
readily allowing one to see whether or not there is any residue left
from the Riegel meal. Lactic acid, blood and bile are also much
more readily detected in the absence of a mass of partly digested
food. The water meal is especially convenient for dispensary pa-
tients. Sachs.
Bismuth Pills in Fluoroscopic Examiiution of the Infant's Stomach—

A. F. Hess, Am. Jour. Dis. Chili, June, 1915.

Author used keratin coated bismuth pills having definite circum-
ferences. His purpose was to furnish a simple means of gauging
the size of the pylorus and of judging whether this sphincter was
normally patent or not. By fluoroscopy it was found that under
normal conditions objects do not leave the stomach in direct ratio
to their size ; that, in fact, larger objects are apt to be propelled into
the intestine more quickly than smaller ones. Thus it is possible that
food which has been insufficiently masticated may remain in the
stomach for a shorter period rather than for a longer period than
food that has been thoroughly comminuted. Probably this is fre-
quently the case. The pills were delayed in their passage through
the pylorus when the infant was placed on the left side, and were
hastened in their passage by placing the infant on the right side.
In cases of pylorospasm there was a retardation in the passage of
the pills from the stomach into the intestine. The degree of this
delay varied in accordance with the degree of obstruction. Sachs.
FatipM Dyspepsia — G. Rankin, Brit Med. Jour., June 19, 1915.

Fatigue dyspepsia is characterized in every case by an irritability
or exhausted state of the nervous system, the result of over strain.
It is met with almost exclusively in those whose labors are intellec-
tual or originative. Every case is accompanied by the landmarks
of the neurasthenic state. The appetite is not necessarily seriously
impaired, but the patient becomes suspicious of one thing after an-
other in his daily dietary, and cuts it out of his menu in the hope
that he will thereby find relief to the miserable discomfort which
he comes to realize will inevitably succeed each meal.' This discom-
fort comes on 2 to 4 hours after the taking of food, and declares
itself by a gnawing and burning sensation in the stomach, followed
by a feeling of oppressive distension, with a commanding desire to

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Progress of Diagnosis and Prognosis 289

find relief in constantly repeated eructations or even active vomiting.
The taking of more food gives him immediate though temporary im-
munity from his trouble. He adopts the plan of having certain food
at his bedside in order to secure such comfort. Sachs.

STphilis and GaBtric Symptoms— T, Bsucsca and E. Schneider, Berliner

klin. Wochensehr., June 7, igiS-

Besides the formation of gummata, the following phenomena are
characteristic of syphilis: (i) The fact that gastric ulcer is mostly
associated with diminished HCi secretion in tertiary syphilis; (2)
the frequent achylia in lues, which in all probabihty is due to a
chronic gastritis; (3) sensory irritation phenomena, (2) root-
neuritic zones of the middle dorsal segments, which certainly do not
stand in relation to the stomach, but are thought to be stomach dis-
eases by the patients; (b) sensory irritation phenomena, probably
due to the vagus; (4) motor irritation phenomena outside of typi-
cal zones; (5) states of supersecretion, on the other hand, seem not
to be characteristic of syphilis. The combination of violent pain and
supersecretion, however, is not rare, and points to gastric ulcer
without any connection with syphilis. Mill.

Physical Signs Referable to the Diaphragm— R. I>exie>, Am. Jour, tied,

Sd., August, 1915.

Inflammation or irritation of the pleural or peritoneal surface of
the diaphragm does not give rise to local symptoms. The pain re-
sulting from such processes is referred upward along the phrenic
nerves to the third or fourth cervical segments or downward along
the sixth or twelfth intercostals into the lower dorsal segments.
The pain is usually accompanied by tenderness and hyperesthesia or
hyperalgesia of the skin. The recognition and interpretation of these
signs may be of considerable imjiortance in differential diagnosis be-
tween intrathoracic or intraperitoneal disease, in the absence of any
signs in the lungs. When a part or the whole of the diaphragm is
forced downward the contraction of the diaphragm exerts a more
powerful inward pull along the line of its attachments. This is espe-
cially marked when the anterior portion of the diaphragm is de-
pressed. This will result in a lessening of the outward excursion of
the subcostal angle, or an actual retraction along the line of dia-
phragmatic attachment. Conversely any condition which lifts the
diaphragm upward lessens the strength of the inward pull of the
contracting diaphragm, with the result that the normal outward
movement of the costal margins will be increased. The presence
of a retraction or of an abnormal outward flaring of the subcostal
angle will often be of aid in the explanation of obscure diseases of
the viscera which lie immediately above or immediately below the
diaphragm, especially in pericardial effusion or in subphrenic abscess.

Sachs.

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290 The Archives of Diagnosis

GutrocoloptouB in Radiologic Respects— O. Stbauss, Deutsche med.

Wochenschr., June 17, 1915.

The article represents a review of the book of Rovsing on this
question. This book offers nothing new concerning the clinical pic-
ture of gastrocoloptosis. A surgical interference is not advocated
unless continued observations show the superiority of this mode of
treatment. In uncomplicated instances of gastroptosis the X-ray ex-
amination determines the diagnosis. Mill,
Lyinphocytoiis, a Sisn of Coiutitutioiul Disturbance in Clironic Affec-
tions of the Gastrointestinal Tract— J. K.vupmann, Mitteilutigen a. d.

Grenzgebieteii d. Medizin u. Chinirgie, Vol. XXVIII, No. 3.

In 60 per cent, of chronic diseases of the alimentary tract (140
cases) lymphocytosis was noted. This lymphocytosis may be an ex-
pression of an abnormal constitution (status hypoplasticus). Au-
thor believes that a constitutional anomaly may form the basis on
which functional ahmentary disturbances may develop. This, he
continues, occurs mostly through a disorder of an internal secretion
to which patients of this class are particularly predisposed. Mill.
Improved Phenolphthalein Reaction for the Demonstration of Occult

Blood in the Feces — J. Boas, Deutsche med. Wochenschr., May 13, 1915.

Author describes his "Phenolphthalein ring test." The feces are
extracted by glacial acetic acid-alcohol (5 drops glacial acetic acid to
15 to 20 grams alcohol). The phenolphthalein reagent (15 drops)
is placed into a test tube ; to this is added 5 to 6 drops of hydrogen
peroxid (,"1 per cent.) and 2 c.c. absolute alcohol. The mixture is
then well shaken. The fecal extract is then filtered through a fun-
nel into the test tube in such a manner that the filtrate flows slowly
down the side of the tube into the reagent. In the presence of blood
coloring matter a ring, light or dark red, is formed. Mill.

Referred Pains — G. Durano, Progres medical, July 25, igiS-

From an exhaustive study of the semeiologic value of referred
pains, author has formed the conclusion that, while referred pains
are not, as some authors have asserted, "almost pathognomonic of a
lesion of the pylorus," and do not, of themselves, indicate a definite
and localized disease of the pylorus and duodenum, arising from
whatever cause, they are of incontestable value in diagnosis, but
merely as a signal of alarm. Examination of the patient alone
should ascertain the cause of the pyloric affection and therapeutic
treatment may aid in estabhshing a diagnosis in difficult cases. Au-
thor does not admit that the syndrome of "referred pains" abso-
lutely indicates pyloric contraction from a lesion oE the gastric
mucous membrane, but considers that functional pyloric disturbances
are due to a multiplicity of causes. Innervation of the sphincter
may result from various disturbances, whether of peripheral, cen-
tral, or reflex origin, and all these causes should be taken into con-

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Pkocress of Diagnosis and Prognosis 291

sideration as etiologic factors of the pyloric cramp, and of the
syndrome of referred pains, which are its expression. As a fact, re-
ferred pains of gastroduodenal origin are present in the great ma-
jority of cases, the attack occurring at regular hours, and it is this,
rather than their topography and irradiation, that gives them a noso-
logic individuality. In practice, pain in the gall-bladder and pan-
creas, which is much rarer, may be confounded with "referred
pains" in diagnosis. But although cholelithiasis and pancreatic lithi-
asis, or pancreatitis, may frequently give rise to the syndrome of
inveterate "referred pains," confusion in diagnosis need not occur
if the primordial or accessory symptoms of the patient be carefully
studied. Zimmer.

New Theory of the Causation of EnteroBtasis— A. Keith, West London

Med. Jour., July, IQIS-

In passing along the alimentary tract food is propelled through a
series of zones or segments, each furnished with its own pacemaker
and its own rhythmical contractions. Irregularities may occur in the
nodal and conducting system of the alimentary tract — irregularities
of the same kind which are known to occur in the heart. When such
irregularities or blocks do occur, we find them at the points where
one rhythmical zone or area passes into the succeeding zone, as at
the junction of the esophagus and stomach, at the gastroduodenal
junction, where the duodenal zone passes into the jejunal and where
the jejuno-iliac passes into the ileo-colic. In order to have an or-
derly propulsion of food along the whole length of the alimentary
canal, those various rhythmical zones must be closely coordinated
in their action. Bayliss and Starling observed that distension of
the duodenum inhibited the action of flie ileum. Thus one can un-
derstand how stasis in the great bowel may be followed by ileal
stasis, duodenal or gastric stasis, or how a disturbance of the con-
ductivity or excitability of any of the rhythmical zones may ulti-
mately give rise to stasis in all. Sachs.
Intestinal Occlusion — A. Mathieu, Archives Maladies de I'Appar. Digest.

et de la Nutrition, June, 1914.

In incomplete stenosis of the pylorus, during paroxysms of pain,
a considerable amount of fluid accumulates in the stomach; this is
due to glandular hypersecretion and peristaltic contractions, visible
to the naked eye, and still more apparent under radioscopic examina-
tion, showing the strenuous efforts made by the muscular pouch to
overcome the obstacle. It appears that at the time of the painful
pyloric cramp there occurs considerable hypersecretion and exag-
gerated peristalsis, and sometimes even a nti -peristaltic contractions.
Frequently there is abundant vomiting of a liquid which, should the
pyloric lesion be of an ulcerating character, contains an increased
amount of hydrochloric acid, which is the chemical characteristic of

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2Q2 The Archives of Diagnosis

gastric hypersecretion. In incomplete stenosis toward the hepatic
angle of the colon, there frequently appears a syndrome analogous to
that named after Bouveret, of Lyons, in which there are also
paroxysms of pain, with dilatation of the cecum, which may be per-
ceived outwardly. The dilated cecal pouch also frequently betrays
peristaltic contraction occurring synchronously with the paroxysm
of pain, and examination shows the presence of a greater or less
amount of fluid in the dilated cecum. This syndroma is to the cecum
what the pyloric attack with hypersecretion is to the stomach. It
has a physio- pathologic analogy to Kocnig's syndrome, which deals,
however, only with the small intestine. Should the stenosis aflfect
the initial portion of the jejunum, it may be difllicult to distinguish
between intestinal dilatation and dilatation of the stomach from
pyloric stenosis. As washing out the stomach leaves below a second,
dilated and pulsating pouch, it was extremely difficult to make a
diagnosis between stenosis of the jejunum and gastric biloculation,
before radioscopy came into use. Identical reaction occurs when
the stenosis is much lower down, near the end of the ileum. There
is present also painful colic, dilatation and distension of the intes-
tinal flexures, the peristaltic contractions of which are apparent at
the moment of the colic, and there may be a considerable accumula-
tion of hypersecretion fluid and of stasis in these dilated flexures,
which may be returned or driven back into the stomach by the anti-
peristaltic contractions. The abundant vomiting which occurs in
stoppage of the small intestines also occurs in stenosis of the colon
when the ileocecal valve is forced. Author considers that abdominal
clapotage and false ascites is of great symptomatic value in the diag-
nosis. It is often impossible for some time to decide whether it is a
case of intestinal stoppage or marked gastric dilatation from pyloric
stenosis. Ziumer.

Diagnoais of Colon Cancer— J. Burke, N. Y. State Jour. Med., July, 1915.
In cases of unexplained loss of weight and diminished muscular
strength, with secondary anemia in any adult above forty years,
particularly if gastrointestinal symptoms are present, cancer of the
colon should be carefully considered. Where a tumor is present
in any of the four corners of the abdomen colon cancer must be
thought of. When peritoneal friction sounds are heard over the
tumor it speaks positively for its intraperitoneal origin. In sudden
profuse hemorrhage from the bowel the colon should be diligently
investigated for cancer, particularly the sigmoid flexure. When an
adult complains of colicky pains in the abdomen, particularly when
accompanied by disturbances of bowel function, colon cancer should
be thought of as the probable cause. In cases of suspected acute ap-
pendicitis in elderly people, cancer of the cecum must not be lost
sight of in our diagnostic deliberations. In all cases where there is

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Progress of Diagnosis and Prognosis

293

the slightest suspicion of colonic derangement the X-ray should never
be omitted in the examination. In all cases of suspected cancer of
the bowel, X-ray examination should always be made. The X-ray
is the greatest aid modern science gives us in the differential diag-
nosis of colon cancer. Western.
Pancreatic Infantilinn— B. Brauweu., Edinburgh Med. Jour., May, 1Q15.

Pancreatic infantilism is characterized by arrested bodily and sex-
ual development; there is no mental defect or deformity or struc-
tural defect of the bones; there is no visceral derangement or dis-
ease except chronic diarrhea, flatulent distension of the abdomen
and defective or arrested pancreatic secretion. The latter is prob-
ably due to a chronic pancreatitis. In some cases the condition of
diarrhea and infantilism is cured by the administration of pancreatic
extract, Sachs.

Biliary Lithiasu— M. A. Gilbekt, Jour. Med. Frang., April 15, 1914.

Gall-stones may make their way through the biliary ducts and
reach the intestines, or, on the other hand, finding it impossible to
pass through the ducts, may fall back into the gall-bladder. The first
proceeding induces the ordinary hepatic colic, with expulsion of the
gall-stones ; the second causes gall-bladder colic, without expulsion
of the gall-stones. Both forms of colic occur about 3 to 4 hours
after a meal, and present an analogous clinical picture. In some
cases they may be distinguished from one another by a biliary tumor
or swelling, indicating the occlusion of the gall-bladder; this may
disappear rapidly when the attack subsides, or may, in exceptional
cases, last a week. Certain negative symptoms should never be
overlooked, such as the absence of icterus, hepatalgia and hepato-
megaly, and the absence of bihary concretions tn the stools should be
specially noted. The attack is usually sudden, sometimes continu-
ous, sometimes paroxysmal, and may last from a few hours to sev-
eral days, or even weeks. It is generally less painful, but lasts
longer than ordinary hepatic colic with expulsion. In a lithiatic pa-
tient gall-bladder colic may alternate with ordinary colic, but usually
one form prevails. The intervals vary, but are usually shorter than
in the case of expulsive colic. A course of cholagogic treatment
may induce veritable liver complaint. In some instances, gall-
bladder colic may recur all through the life of a patient. The at-
tacks generally cease at a given time because the stones become im-
movable in the gall-bladder; sometimes one or two attacks of colic,
with expulsion of the gall-stones, will rid the bladder of them, but
there are apt to be complications. A stone may be imprisoned in the
bladder, forming a permanent gall cyst, which often turns into
cholecystitis. Then, after biliary and perbiliary phlegmons, the gall-
stone may penetrate into the most abnormal passages. The diag-
nosis is often very difficult if the malady is recent, and there is no

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294 The Archives of Diagnosis

cholecystitis. One thinks of poisoning, of gastric pain, of a gas-
tric attack due to tabes. If there is a cholecystitis, the diagnosis is
localized in the biliary passages, and only as the attack develops, and
as one discovers gall-stones in the stools, can one determine whether
or not it is an expulsive attack. Recent cases are, of course, less
readily diagnosed. Zimmer,

NERVOUS SYSTEM
Vagotonia— W. Lublinski, Berliner klin. Woehenschr.. May 7, 1915.

The clinical picture of vagotonia consists of contracted pupil, sali-
vation, sweating, acrocyanosis, pronounced dermographia, bradycar-
dia and respiratory arrhythmia, cramps in the upper tracts and the
abdominal organs, probably also in the vesical sphincters. Atropin
influences the vagotonia by reducing the irritability of the vagus
terminals. Mill.

Vegetative Ncrvoiw SyBtem and Abdominal Discatea— A. Thies, Mitteil-

ungen a. d. Grenzgebieten d. Medizin u. Chirurgie, Vol. XXVIII, No. 3.

On the hand of a large number of clinical cases author again
confirms the fact that abdominal affections may give rise to symp-
toms of the vegetative nervous system. The examination which in-
cludes phenomena on the part of the eyelids and pupils (contraction,
dilatation) shows a certain regularity of the eye phenomena in ac-
cordance with the localization of the abdominal disease. After dis-
appearance of the abdominal symptoms those of the eyes are dimin-
ished or disappear altogether. Mill.
Multiple Neuritis compIicatinK Typhoid Fever— T. A. Claytor, Am. Jour.

Med. Sci., May, 1915.

Author collected 25 cases of multiple neuritis complicating or fol-
lowing typhoid fever, which with his own case make a series of 26.
Symptoms of the condition were recognized in 14 instances during
the course of the fever, while 12 cases were recognized after the
fever had subsided. Pain was present 17 times, absent 9 times.
Paralysis was noted 25 times ; in i case it was not mentioned. The
duration of the condition varied from 3 to 14 months. Unqualified
recovery took place in 1 1 cases, improvement in 7, death in 2, and
the result was not given in 6 cases. Sachs.

Visual Fields in Brain Tumor- H. Cusrin'g and C. B. Walker, Brain,

Vol. XXXVII.

In a series of 454 cases classified as tumor of the brain, there have
been loi in which the lesion was of hypophysial or para hypophysial
origin, and in 8r of these cases, chiasmal involvement lead to defor-
mation of the fields of vision. These deformations tended at the
time of admission to be bitemporal in 26 cases, homonymous in 12,
were unclassified in 8 cases, and in the remaining 35 showed blind-

ly GoOgIc

Pbogress of Diagnosis and Prognosis 295

ness in one or both eyes, making it difficult to tell in which groups
bitemporal or homonymous — they belonged. Detailed perimetry
with small test objects of serial sizes, particular attention being paid
to the shading off of the upper temporal peripheries and to the pres-
ence of relative paracentcral scomata in the same quadrant, is ad-
vocated for patients with pituitary disease in order that stages of
hemianopsia antecedent to those usually recognized may be detected.

Sachs.
Abderhald«i's Protective Ferments in Paychiatry— F. Sioli, Archiv f.

Psychiatric u. Nervcnkrankheiten, Vol. LV, No. I.

The results obtained by Abderhalden's method in psychiatry are
not sufficiently univocal that they can be employed in the diagnosis,
prognosis or pathogenetic basis. Again, the method is subject to
many sources of error. Before the method finds chnical application
it has to be thoroughly tested. Western.

Hemolysin Reaction of Weil-Kafka in Psychiatric DiagnoBta — E. L.

Bruckner, Archiv f. Psychiatric u. Nervcnkrankheiten, Vol. LV, No. 1.

As a rule, the reaction is positive in progressive paralysis. In
paralysis, suspected for clinical reasons, the reaction is a valuable
adjuvant of the clinical diagnosis. Western.

Physical HanifestationB of Dementia Precox — B. Holues, Lancct-Qinic,

July :?, 19:5.

The morphologic microscopic picture of the testicle in dementia
precox is conclusive of a progressive destructive process or affection
involving especially the seminiferous tubules, but also modifying the
appearance of the chromaffin cells or the cells of Leydig. The brain
in dementia precox is hydrocephalic, and the brain weight is too
great both for the size of the skull and the size and weight of the
body. Catatonia is a condition of wet brain, and if we interpret
Nissl's last thesis correctly it would not be irrational to treat it by
compression. Western.

Spirochaeta Pallida in Dementia Paralytica— J. McIhtosh and P. Fildes,

Brain, Vol. XXXVII.

The brains of 7 cases of dementia paralytica were examined and
in 6 of these spirochetes were found by the dark ground method,
although when sections were cut, the organisms were only detected
in 3. The spirochetes were always confined to the gray matter; in
one case only was a single specimen seen in the meninges. Sachs.
Paranoid Psychoses in Old Age — Seelert, Archiv f. Psychiatric u. Nervcn-
krankheiten, Vol. LV, No. 1.

Report of 12 pertaining cases on the basis of which a description
of paranoid psychoses of old age is given. On account of their
symptomatology and course these psychoses represent a special
group. The one symptom common to all these psychoses is the pres-

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296 The Archives of Diagnosis

ence of delusions. The patients believe themselves to be wronged,
molested and persecuted ; they are suspicious and distrustful. Mis-
interpretation of their observations and experiences, especially mis-
constructions of disease processes of body and mind, play an im-
portant part. The frequent paroxysmal pains and annoyances, as
dizziness, ringing in the ears, fear, sense of heat, headache, sleep-
lessness, etc., probably ensue upon an organic substrate. These
symptoms, the age of the patient and their frequent concurrence
with cardiac and vascular disturbances, point to the existence of
arteriosclerotic changes. All these phenomena are explained by the
patients to be the consequence of molestations on the part of their
entourage, and are thought by them to be due to poisoning with
vapors, spoiled food, medicaments, etc. The anamnesis evinces that
these patients were always more or less excitable and easily affected
psychically, that they were always prone to misinterpret or miscon-
strue, and that these traits were always noticeable in the character
and temperament of the patients. Later on in life these characteris-
tics become more pronounced and then constitute the psychosis. It
is, therefore, probable that the paranoid psychoses of old age are an
individual reaction form of an endogenous, slowly progressive or-
ganic process. , , Western.
Neir Symptoms in Amaurotic Family Idiocy— I. H. Cobiat, Bost Med.

and Surg. Jour., July I, 1915.

Author has noted in some cases of amaurotic family idiocy the
following new symptoms, which are not as a rule included in the
classical description of the disease: Hydrocephalus; bulbar symp-
toms — drooling of saliva, choking spells, difficulty in swallowing,
and attacks of apnea; nystagmus, hypotonia, and abnormal reflex
phenomena. Increased reflex action to sound and touch are among
the most interesting phenomena of this disease. Sachs.

URINARY ORGANS— MALE GENITALIA
Deteraunation of Retention Nitrogen in the Blood, m Method for TeatiiiK

Renal Function — H. Hohlweg, Mitteilungfn a. d. Grenzgebieten d. Medizin

u. airurgie, Vol. XXVHI, No. 3.

In monolateral afl'ection of the kidneys the retention nitrogen in
the blood is never increased. This is also the case when the individ-
ual possesses but one kidney which is sound. When, however, the
renal affection is bilateral, or when the single kidney present is af-
fected, the retention nitrogen is always increased. Mill.
Occult Hemorrhase from the Renal Pelvis— Eichhorst, ZentratbUtt f.

innere Medizin, No. 12, 1915.

The demonstration of cells of blood pigment (large round cells
with blood pigment) in the urinary sediment is of great significance

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Progress of Diagnosis and Prognosis 297

in the diagnosis of calculi in the pelvis. These cells are derived from
colorless blood corpuscles. Western.

SymptomlesB R«nal Hetnatum— D. Newma^i, Brit Jour. Surg., April, 1915.
The absence of symptoms and of physical signs beyond the pres-
ence of blood in the urine is characteristic of small tumors in the
pelvis or in the medullary substance of the kidney. It may be pres-
ent for a long period in such cases before pain or any other symp-
tom is complained of. Aneurism, occupying the pelvis and rupturing
into it, may cause hematuria and the bleeding may persist for months
before any other symptoms develop. The hemorrhage may be fatal
before other signs show themselves ; but usually the bleeding is small
in amount and gradually increases. In a few cases of renal calculus
blood may appear in the urine unattended hy subjective evidence of
disease. Symptomless hematuria in tuberculosis is a more com-
mon occurrence than is generally suspected. It is met with in young
persons or in children. Sachs.

Ureteral Calculi— J. T. Geraghtv and F. Hinuak, Surg. Gynecol, and

Obstet, May, 1915.

Except in rare instances, the symptoms of ureteral calculi are not
diagnostic and are insufficient to definitely determine either its pres-
ence or position. In the most expert hands a surprisingly large per-
centage of calculi may not be determined by rontgenography. By
means of coUargol ureterograms a calculus will occasionally be de-
tected which was not revealed by the simple rontgenogram. The
employment of the waxed-tipped catheter is hy far the most accu-
rate method for the detection of ureteral calculi, and this method
should be in more general use. In 6 out of 36 cases, it has located
a stone in which repeated rontgenograms were uniformly negative.

Sachs.
Internal Aipcct of Prostatic Suppuration— H. Brooks, &{ed. Rec, July 17,

1915.

General symptoms of a very striking and confusing character may
develop in cases of prostatic suppuration. Prostration is the most
impressive of these general manifestations of the disease. Mental
depression, temperature elevation, profuse and drenching perspira-
tion, slow pulse and a hypoleukocytosis may lead one to suspect the
presence of typhoid fever. Rectal examination of the prostate will
decide the diagnosis, but it must be remembered that prostatic sup-
puration may exist without any localizing symptoms. Sachs.
Hematogenous Tuberculosis of the Prostate— M. Simmonds, Virchow's

Archiv, Vol. CCXVI, Nos. I to 3.

In II per cent, of the cases of tuberculosis of the prostate the dis-
ease appeared to be hematogenous. The affection may appear in two
forms, (l) as an excretion (Ausscheidungs) tuberculosis, (2) as

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298 The Archives of Diagnosis

an interstitial, metastatic tuberculosis. The first form preponderates
greatly. Mill.

FEMALE ORGANS OF GENERATION— PREGNANCY-
PARTURITION— INFANTS
PathotoK7 of the Secretion of the Hunmae— P. Ijndig, Zeitschr. f. G«-

burtshilfe u. Gynakolc^e, Vol LXXVI, No. 3.

A non- physiological secretion of the mamniK is much more fre-
quent than is generally assumed. Author found repeatedly colos-
trum and colostrum-like secretion in tuberculous nulliparis, in old
patients with carcinoma, etc. It is possibly the destruction process
as such which, by permitting an influx of protein decomposition
products into the blood current, stimulates the activity of the
mammae. Reflex stimulation within the endocrinal glands may be
a causative factor of the pathologic secretion of the mammK.

Mill.
Benign NeopUnns of the Breut in Women— E. M. Mosher, Woman's

Med. Jour., July, 191S.

In instances of benign neoplasms of the breast the patient may be
a subject of hypothyroidism. In cases of this kind the thyroid
activity should be investigated by administering thyroid extract. In
other instances of benign growths the gastrointestinal canal should
be carefully examined. The influence of enteroptosis and intestinal
stasis upon the production of breast neoplasms should never be
minimized. Western.

Prolapsus of the Uterus— H. J. Boun, Am. Jour. Obstet. and Dis. of Women

and Children, 1915, No. 6.

Speaking on the relation of the other pelvic organs in instances
of uterine prolapse, author says the following: When one does a
vaginal hysterectomy or any other surgical intervention which neces-
sitates separation of the bladder from the cervix, it miist be obvious
that, in cases of marked prolapsus the bladder too must be displaced,
since the connective tissue between the bladder and the cervix —
save in very exceptional instances — is quite firm, and therefore does
not readily give way itself. Therefore.it follows that the bladder
descends with the cervix, and in this way forms a cystocele. Conse-
quently it follows that, in marked instances of this kind, we may
have residual urine after the act of voluntary micturition has been
completed. But it is not only the bladder which descends. In
marked instances the urethra also becomes dislocated at its bladder
end, A similar dislocation takes place of the anterior rectal wall
forming a rectocele, which has, however, as the underlying cause
an injury of the soft parts during parturition. Whether the adnexx
become displaced in injuries accompanying uterine descent depends
upon the position of the uterine body. If there be but a moderate

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Progress of Diagnosis and Prognosis 299

descent of the uterine body and principally an elongation of the
cervix, the adnexse are not likely to become displaced downward at
all; but, necessarily, if the uterine body also descends markedly, the
adnexse (tubes and ovaries) must likewise follow the body to a
greater or less extent. In instances of very marked uterine prolapse
with descent of the entire vagina, the entire pelvic floor becomes so
relaxed that it is evident that it can offer no support for the pelvic
organs. Sachs.

SjTiiptoiiutolosy of Corpus Lutenm Cysts — J. Halbak, Zentralblatt f.
. Gynakologie, No. 24, 1915.

Report of 9 cases, of which 2 were complicated by gravidity. Oc-
casionally cysts are developed from the corpus luteum. These cysts
possess the property of the corpus luteum to inhibit menstruation.
For this reason amenorrhea exists in the presence of corpus luteum
cysts. This property is of import in the diagnosis. An exact diag-
nosis is essential in the pertaining cases, as cysts of this character
may disappear spontaneously and do not need to be operated upon.
Alternating cysts, i. e., alternating formation of cysts in both ovaries,
disappearing spontaneously, must be considered to be corpus luteum
cysts. These cysts are thin-walled and burst readily, even when the
bimanual examination is made with the greatest of care. The cysts
may also ensue during pregnancy. Their removal need not neces-
sarily interrupt the pregnancy. Mill.
Ovarian Sarcomata in Children— T. T. Higgins. Brit. Jour. Children's Dis.,

June, igi5.

Three cases are recorded which illustrate certain aspects of the
disease, namely, the insidious onset, with unexplained colicky pains,
later the appearance of a mobile lump, with possibly some precocious
menstruation, the steady enlargement of the abdomen with pain and
fever, the result of an adhesive peritonitis, occurring on the surface
of the growth, and finally the tendency to spread, by direct exten-
sion along lines of adhesion rather than by metastases. Sachs.
Toxicity of Urine, Scrum and Milk (Colostrum) during Preptanc)', Labor

and Puerperium— P. Werner and E. Kolisch, Archiv f. Gynakologie,

Vol. cm. No. I.

The urine of healthy non-pregnant women is non-poisonous.
Their serum is also non-toxic. The urine of healthy pregnant women
is poisonous. In pregnancy-nephritis the toxicity of the urine is
increased. In eclampsia the toxicity of the urine is reduced during
labor, but increases immediately after it has taken place. The serum
of healthy pregnant women is toxic. This is not the case with the
serum of non-pregnant women. In pregnancy-nephritis the serum
toxicity is also augmented. The serum of eclamptic women is, as a
rule, poisonous before dehvery has taken place, provided no edema
is present. In the presence of edemas the serum is non-toxic. Colos-

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300 The Archives of Diagnosis

tram exhibits a very small degree of toxicity. The toxicity of the
milk is most marked on the third day of the puerperium. There is
in this respect no difference between nephritic and eclamptic lying-
in women. Edema liquid of nephritis is poisonous; it is nou-
poisonous of eclamptics (pregnant and puerperients), but poisonous
of eclamptics in labor. Mill.

CholelithiaBH and Pregnancy— J. A. Amann, Monatsschr. f, Geburtshilfe u.

Gynakologie, Vol. XXXII, No. I.

During pregnancy and in the puerperium gall-stone colic occurs
rather frequently. A case of the author exhibited such alarming
symptoms that cholecystectomy had to be performed during preg-
nancy. The case was very complicated, as the appendix was ad-
herent to the gall-bladder and as there was an inflamed fibrous tumor
where the gall-bladder was grown to the abdominal wall. Mill.
Epilepsy and Pregnancy— C. Meyer, Archiv f. Psychiatric u. Nervenkrank-

heiten, Vol. LV, No. 2.

It is only the more recent literature upon the subject of epilepsy
and pregnancy that is of real value. The older literature did not
differentiate between eclampsia and epilepsy. Pregnancy may pro-
voke epileptic phenomena. It frequently influences the various man-
ifestations of epilepsy in a favorable as well as in an unfavorable
manner. Western.

Circulatory Diaturbance< in the Newborn— A. v. Reuss, Gynakologische

Rundschau, Vol. IX, No. i.

The icterus of the newborn depends in the main upon a hyper-
bilirubinemia, which is caused by an insufficiency of the youthful
liver cell. The albuminuria of the newborn seems to be due to cir-
culatory disturbances, not unlike those which give cause to orthotic
or lordotic albuminuria. In a similar manner the congestive hypere-
mia, which is rather physiologic in the newborn, may be explained.
Congestive hemorrhagia is but a continuation of the process that
stands at the bottom of the congestive hyperemia. Mill.

The Production of Icterus Neonatorum— T. Heynruann, Zeitschr. f. Ge-

burtshilfe u. Gynakolt^e, Vol. LXXVI, No. 3.

The causation of icterus in the newborn is in the first instance
dependent upon a perverse and incomplete function of the liver cells.
These cells are not able to perform the increased amount of neces-
sary work with which they are confronted in the first days of life.
The production of the icterus is enhanced by the congestive state
of the liver and the pronounced disintegration of the red blood cells
ensuing at this period. The cause of this disintegration is not defi-
nitely known. It is probably due to an increased activity of the
stellate cells of Kupffer, which would indicate that it is the liver
that gives rise to the destruction of the red cells. Mill.

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Vol. VIII OCTOBER, 1«16 No. 4

*pcctal flrtftlcf

THE SIGNIFICANCE OF THROMBO-PHLEBITIS IN

THROMBO-ANGIITIS OBJ.ITERANS

By LEO BUERGER , .

Associate ARending Surgeon and Associate m Surgical Pathology, Mt.

Sinai Hospital; Visiting Surgeon, Har Moriata Hospital; Instructor ..

in Clinical Surgery, GDlumbia University

New York

There is no phenomenon of more importance in elucidating thfs

true nature of the pathology of thrombo-angiitis obliterans thaq

the characteristic thrombo-phlebitis or "migrating phlebitis" of, this

disease. The association of thrombosis of superficial vems oi th«

upper and lower extremities with other evidences of obliteration

of the lat^r arteries occurs in a sufficiently large number of 4:ases

to make the affection of the veins almost pathognomonic. .

The name, Ihromba-angiitis obliterans, was proposed by mt: in
1908 for that interesting group of cases of presenile gangreie whach
had been incorrectly described by the Germans imder the naoie
endarteritis obliterans. It was shown at that time that the- pathology
of the disease had been misunderstood, and that the lesions are the
results of a thrombotic process, followed by organization and canali-:
zation' of the occlusive clot.

In this paper we wish first to cite the histories of a: si^cient
number of cases of thrombo-angiitis obliterans with accompanying
thrombo-phtebitis of the veins of the leg or arm to accentuate the

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302 The Archives of Diagnosis

points by means of which a correct diagnosis can be made, and
secondly, to discuss in brief the characteristic lesions of the veins,
so that the importance of future - researches on the etiolt^y of the
condition may be appreciated.

For the sake of deamess let us place the cases of thrombo-angiitis
obliterans attended with thrombo-phlebitis or migrating phlebitis
into five different groups. First, cases of thrombo-phlebitis without
symptoms ; second, thrombo-phlebitis with symptoms of limited vein
involvement; third, migrating phlebitis causing the patient to seek
treatment ; fourth, cases in which both the migrating phlebitis and
thrombo-angiitis obliterans play equally important roles in the symp-
tom-complex ; and fifth, migrating phlebitis involving both the upper
and lower extremities.

I. THKOMBO-PHLEBITIS WITHOUT SYMPTOMS

There are patients who have no knowledge of the occurrence of
any trouble in the veins of the leg, but in whose amputated limbs
extensive old, or old and recent thrombo-phlebitis of the internal
saphenous or its tributaries is discovered. Such a case was J. C,
who could recall nothing referable to a disturbance in the super-
ficial veins. Study of the vessels revealed old occlusion of a large
part of the saphena by virtue of a thrombotic process, and some
areas of more recent thrombo-phlebitis.

Case I. J. C, 45 years, Russian Hebrew, admitted to Mt. Sinai
Hospital May l8, 1908; Has eight children (all well) ; gives a rather
typical history of vascular disease of both lower extremities, re-
sulting in amputation of the left 1^ at the knee. Four years ago
he had "rheumatism" of the right leg with pain in the sole of the
foot and redness of the toes lasting eight months. Since then it
has not troubled him. The left leg, however, began to hurt him
last summer; he could not walk a block without taking a rest. His
big toe became "sore" recently, and now the pain in the foot is
constant. He is told that the big toe is becoming gangrenous, and
that his leg should be amputated, which he gladly permits.

With the observation just cited, no new clinical facts had been
adduced, but certain similarities between the thrombotic lesions of
the saphenous vein, as seen under the microscope, and the changes
characteristic of the closed deep vessels were deemed sufficiently

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Buerger: Thrombo-Phlebitis 303

si^estive to warrant the suspicion that here, in the superficial veins,
a new territory for the process "thrombo-angiitts obliterans" had
been found. We shall see in the histories that are to follow fur-
ther evidence in favor of this assumption.

II. THROMBO-PHLEBITIS WITH SYMPTOMS OF LIMITED VEIN
INVOLVEMENT

A more interesting group is represented in those p^ents who
come to us with active thrombo-phlebitis and penphlebittc manifes-
tations. Here and there along the course of the internal or external
saphenous vein, alterations in the skin and subcutaneous tissues
occur. These are in the form of 5mall, erythematous, slightly in-
durated patches, about a centimeter in diameter, and tender to the
touch. Were is not for the concomitant phenomena referable to
the tributaries of the saphenous or the trunk itself, the nature of
the appearance of these, however, or at other times. in the course
these cutaneous nodosities would have remained obscure. With
of the disease, cord-like thickenings of portions of the long saphen-
ous, with or without adhesions to the skin, are frequently observed.
As examples let us briefly tell the story of Cases 2 and 3 in Group II,

Case 2. S. S., 30 years old, Russian Hebrew, admitted to Mt.
Sinai Hospital July 8, 1907 ; father of one child ; has been suffering
for four years with "weak legs" ; for two years there has been pain
in his left foot. About one and one-half years ago the second toe
became gangrenous and was removed. Last winter his attention
was directed to the blueness of the toes ; it was difficult to keep the
left foot warm. For a couple of years he has noticed that "red
spots" come and go along the inner and outer side of the shin bone.
They are a little painful and disappear without treatment. Now he
seeks advice because the little toe looks as if it were going to die off.
Amputation just above the middle of the leg.

Diagnosis. — ^A typical case of thrombo-angiitis obliterans with
gangrene of the little toe of the left leg and cutaneous nodosities
along the course of the internal saphenous vein from the ankle up
to the region of the tubercle of the tibia ; probably closure of a part
of the saphenous vein.

The study of the vessels of the amputated leg showed extensive
occlusion of the posterior tibial, anterior tibial, peroneal, and plantar

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304 The Archives of Diagnosis

arteries (tbrombcnangiitis obliterans). The long saphenous vein
was filled for the most part with old organized tissue of a type
indistinguishable from that seen in the deep vessels, and some of
its tributaries were closed by more recent obturating masses. The
cutaneous nodules corresponded to the distribution of the finer
tributaries, but inasmuch as they had almost completely disappeared
at the time of operation, no histological examinations were made.
. As representatiTe of the occurrence of migrating throrobo-i*le-
bitis of the long saphenous and of erythematous nodosities in the
same patient, let us cite Case 3, who observed and related quite ac-
curately show the painful "hard cords" developed.
' Case 3. F. S., 37 years old, Russian Hebrew, father of two
healthy children, admitted to Mt Sinai Hospital Dispensary April
13, 1909; says that he remembers havii^ had peculiar pains in the
soles of both feet on walking a few blocks for the last three or four
years. About four months ago the btg toe began to trouble him,
but even before that he noticed hard cords along the inner side of
the leg. Since then the nail of the big toe came off, leaving a raw
wound which refuses to heal. The long, hard strands come and
go; sometimes they are seen high up on the leg; at others, three ot
four inches above the ankle. Besides this there are lumps further
back on the inner side of the leg. Patient does not return for treat-
ment, so that the further course of the disease is imknown.
' On physical estamination the usual signs of thrombo-angiitis were
found, with a trophic ulcer of the big toe. There were no evidences
of recent thrombosis of the long saphenous other than one hard
hod^ four inches above the ankle ; evidently the last attack of throm-
bo-phlebitis had subsided. The other leg showed somewhat less ad-
vanced symptoms of the disease.

Here, then, we are dealing with a case in which both the patient's
narrative and ocular evidence point to the association of super-
ficial and deep thromboses.

III. MIGRATING PHLEBITIS CAUSING THE PATIENT TO SEEK
TREATMENT

When the attacks of migrating phlebitis make their appearance
early in the history of the case, and when the attendant discomfort
and pain are sufficiently great, then the symptoms belonging to the

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Buerger : Thrombo-Phlebitis 305

true, deep-rooted affection — Ihrombo-angiitis obliterans — are some-
times wholly ignored by the patient and remain undiscovered by
the physician. Medical advice is sought only for the "lumps" and
"hard, tender strands" or "cords" that are oftentimes so disturbing.
Such observations are of no mean importance in di^nosts, since
they have taught me to seek for the early subjective and objective
signs of thrombo-angiitis in every patient in whom there are spon-
taneous and unaccountable attacks of inflammation of superficial
veins. Let us see what we can leam, then, from Group III, in which
migrating phlebitis causes the patient to seek treatment.

Case 4. E. B., 36 years old, Austrian Hebrew, consulted me on
January 17, 1909, with the history of having had stinging sensations
on the inner side of the right leg, low down, some three montha
previously, A few days after the onset of this trouble he could
feel a long, thickened "lump" behind the shin bone, a short distance
above the ankle. Soon after this, another swelling, not unlike a
"hard cord" appeared somewhat higher up on the leg, was very
tender, and was succeeded not many days later by a third somewhat
shorter strand.

Upon close questioning he admitted that although he seeks relief
from the symptoms mentioned, he has been annoyed for almost a
month before the beginning of the present affection by frequent
cramp-like pains in the calf of the right leg upon walking a few
(five or six) blocks.

Physical examination, January 17, 1909, revealed induration of
the tissues about the saji^enous vein, from the ankle to the upper
fourth of the leg. The distal portion presents a cord-like thicken-
ing, with scarcely aiiy inflammatory signs. Higher up, however,
the skin is adherent to the deeper hardened area, and is exi^edtngly
tender to the touch.

The dorsalis pedis and posterior tibial arteries of both legs are
pulseless; the femoi^s and popliteals can easily be felt to beat. Th^
big toe of the right fool has a cyanotic hue. ■ '

Course. — Jariuafy 31, his phlebitis was found much improved;
his right big toe often hurts him, "and his foot "easfly gets "cold'! and
"tired." ■ ■ - . ' ■ ■ i

' Two months later, Mardi, 1909, no! evidences of the old'thsomboi
jph^itis tan Ix found. Tbe .'big 'toe' ol jtbe Hgfat foot still sboiKa'a

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3o6 The Archives of Diagnosis

peculiar bluish discoloration, and the absence of pulsation in the
vessels is the same as before. There are no trophic disorders; the
most striking phenomenon is the vaso-motor disturbance in the big
toe.

In short, we have here an exquisite example of a combination of
early manifestations of thrombo-angiitis obliterans (pain on walk-
ing, evidences of disturbed circulation), with attacks of thrombo-
phlebitis in the territory of one of the saphenous veins.

Whereas pathologic proof of the correctness of the diagnosis —
thrombo-angiitis obliterans — is lacking in the last case, we are for-
tunate in being able to include here the history of another patient in
whom there were similar symptoms, and in whose amputated limb
and exsected veins we found ample material for anatomical inves-
tigation.

Case 5. M. K., 44 years, Russian Hebrew, father of three healthy
children, was admitted to Mt. Sinai Hospital on December 8, 1908.
His limbs never troubled him until about a year ago, when he felt
the presence of tender spots on the inner side of the right foot.
Soon other hard "lumps" and "cords" appeared ; some of these in
the neighborhood of the ankle, others higher up on the leg. After
two months these disappeared, only to recur after a very short in-
terval. Since then he has never been absolutely free from peculiar
"painful spots," and now, on admission, he still has signs of some
of them. About three months after the onset of these symptoms
he experienced pain in the big toe, especially on walking. This has
become gradually worse, so that he has been unable to get about
properly for almost two months. Of late he has often had cramps
in the calf and instep of the right leg after walking for a short dis-
tance. His chief complaint, however, is the painful condition of
the inner side of his right leg.

Physical examination showed evidences of circulatory disturbance
in the right lower extremity. Both the dorsalis pedis artery and
the posterior tibial were pulseless, although pulsation of both the
femoral and posterior tibial arteries could be easily detected.

Over the inner border of the right foot there is a red streak about
one-half inch in length. This corresponds to a tender indurated
mass which thins out and is lost as it is traced upward. A short
distance below the middle of the leg the upper end of a hard cord

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Buerger : Throm bo-Phlebitis 307

can be palpated. This extends down behind the border of the tibia
for more than two inches, is adherent to the skin, somewhat nodu-
lated, and marks the centre of an area of hypersensitive, swollen,
turgid skin. There are no trophic disturbances. Diagnosis — throm-
bo-angiilis, and thrombo-phiebitis of the internal saphenous and
some of its tributaries.

On December 15, 1908, a portion of the thrombosed saphenous
was removed for pathological examination.

On December 26, 1908, the physical examination was recorded
as follows : In the horizontal position the right foot has a light
shade of red; this is most marked over the big toe, and fades ofiE
towards the ankle. In the web between the third and fourth toes
there Js a superficial ulcer. On the inner side of the foot, almost
two inches from the internal malleolus, there is a hard, cord-like
nodule which is adherent to the skin. Behind the tibia there is the
scar left after removal of a portion of the saphenous vein. The
saphenous can no longer be felt.

On elevation of the foot, blanching sets in rapidly and pain be-
comes intense. The pendent foot turns very red (marked ery-
thromelia) ,

Further Course. — February 15, 1909, the pain in the foot has
been getting steadily worse, and the fourth toe is beginning to turn
black. On the 23d of February amputation at the knee was done,
at the request of the patient, for early gangrene of the fourth toe.

What additional information did the autopsy of the amputated
limb furnish? The prognostication that was made chnically in re-
gard to the condition of the long saphenous vein was confirmed, for,
as was expected, practically the whole of the main trunk of this
vessel was found converted into a fibrous cord, the result of an old
thrombotic lesion. It would lead me too far to describe the patho-
logical changes, and I shall refer to these later on in a summary of
what was characteristic of all the cases. Here let it suffice merely
to mention that the obliterative process had much in common with
that form which is typical of disease of the deep vessels. As for
the arteries, the plantars, peroneal, posterior tibial, and lowermost
portion of the popliteal were completely occluded by the brownish
organized tissue usually encountered in the disease under considera-
tion, whilst the deep veins were patent throughouf.

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3o8 Tee Archives of Diagnosis

For clearness, then, let us state our observation succinctly as fol-
lows : The case is one of Ihrombo-angiitis oblilerans, in which the
symptoms manifested themselves first in the form of migrating
phlebitis that has persisted almost the whole of the year's course of
the disease. The thrombotic lesion has affected the right leg and is
associated with the development of typical symptoms of thrombo-
angiitis. At the end of the y^r some of the deep vessels are closed,
for there is absence of pulsation in the dorsalis pedis and posterior
tibial. For a long time there are no trophic disturbances, but finally
in the thirteenth and fourteenth months of the disease, ulcers de-
velop and dry gangrene of one toe leads to amputation of the limb.

When the migrating phlebitis is a prodromal tnanifestation of
the disease, thrombo-angiitis obliterans, or, if it marks a relapse in
an apparently healed case, no phenomena referable to obliteration
of the deep vessels may be obtainable. In such instances the ex-
cision of the affected superficial vein, followed by microscopic cx-
amination, will frequently reveal the typical pathognomonic lesions
upon which a correct diagnosis may be based.

Case 6. H. P., 42 years, Russian Hebrew, seeks advice for a
hard lump in back of the left leg on November 15, 1912. Twenty
years ago the tip of the big toe of the right foot was removed in
Russia, ostensibly for frost-bite. Since then (the exact date being
unknown) the second toe of the same foot was also ablated. Save
for these affections, no symptoms referable to the extremities can
be recalled by the patient

Physical examination shows a small thrombosed nodule, appar-
ently associated with a varicose vein, over the calf of the left leg.
In the vicinity there are small nodules, seemingly connected wilii
tributaries of the external saphenous. There are no evidences of
closure of the peripheral vessels.

Histological examination of the excised nodule, December 7, re-
vealed the typical lesions of thrombo-angiitis obliterans.

Summary. — We have here, then, a case in which the history of
the loss of two toes points to the existence of an old-standing throm-
bo-angiitis obliterans, the disease having become spontaneously
cured. Recently there have developed evidences of involvement of
superficial veins, the histological studies corroborating the diagnosis.

Another striking instance of the cases in which the thrombo-

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Buerger : Thrombo- Phlebitis 309

angiitis obliterans symptxims are masked and not noticed by the
patient, and where the patient seeks advice because of migrating
phlebitis, is presented by the following case :

Case 7. J. W., Russian Hebrew, consulted me in November,
1911, because of red lumps in the left leg, and indefinite pains. He
thinks he had syphilis 16 years ago, and that the lumps now present
are due to this disease. The present trouble dates back about six
weeks.

Physical examination shows a number of nodules of the usual
type over the outer and posterior aspects of the left leg, and along
the course of the internal saphenous vein.

On November 26, one of these nodules was removed for micro-
scopic examination. Pathological examination shows the typical
lesions of thrombo-angiitis obliterans in the early stages, typical
giant cells, and miliary foci, Wassermann reaction on the 26th of
November was negative.

December 4, some of the nodules had disappeared completely.
The internal saphenous vein can be felt as a hard cord one-half
way up the leg.

February 16, 1912, a fresh nodule has appeared above the Achilles
tendon, another over the left calf, still another over the outer side
of the leg above the external malleolus.

The dorsalis pedis and posterior tibial vessels of the right leg
pulsate. The dorsalis pedis of the left does not pulsate. The pos-
terior tibial pulsates very faintly.

Finally, we may cite as exemplifying cases of this group, the fol-
lowing history:

Case 8. B. C, 39 years, Russian Hebrew, seeks advice on ac-
count of pain in the left leg, which came on about four months ago.
This seems to be associated with a nodule on the inner side of the
middle of the tibia, and a similar nodule somewhat lower down.
Three weeks ago another lump appeared on the outer aspect of the
right leg. He has no pain on walking, and none of the symptoms
of thrombo-angiitis obliterans.

Physical examination, December, 191 1 ; several typical phlebitic
nodules over the inner aspect of the left leg. The internal saphenous
vein, from a point just above the ankle up to the upper fifth of the

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310 The Archives of Diagnosis

leg, can be fett as a hard cord. Anteriorly, three inches above the
ankle there are two fused nodules in a somewhat reddened skin.

The dorsalis pedis and posterior tibial arteries are not felt in
the left leg. The posterior tibial pulse of the right leg is also im-
perceptible, though the dorsalis pedis pulsates faintly. There is no
erythromelta, but moderate ischemia on elevation of both limbs.

In short we have here a case in which the symptoms of migrating
phlebitis are prominent, the pulseless vessels and slight ischemia
being the only evidences of Ihrombo-angiitis obliterans.

On December 5 one of the nodules was removed from the left
leg for microscopic examination.

December r6. The phlebitis is extending from the region of the
excised nodule in the upper part of the leg, and a distinctly tender
cord, some 2J/2 inches long, can be felt along the course of the
saphenous.

December 22, 1911. The nodules in the right leg have almost
disappeared.

Still more interesting and instructive are those cases in which the
disease of the superficial vessels affects both legs and one or both
thighs and in which the signs of

IV. BOTH MIGRATING PHLEBITIS AND TH ROM BO- ANGIITIS PLAY
EQUALLY IMPORTANT ROLES IN THE SYMPTOM-COMPLEX

Case 9 will illustrate this variety. The patient could be observed
for almost a year, the progression of the obstructive changes in the
deep vessels could be closely followed by proper interpretation of
the varying circulatory phenomena in the leg, and many of the at-
tacks of thrombo-phlebitis in the territory of at least one saphenous
vein could be recorded.

Case 9. H. R., 32 years, Russian Hebrew, admitted to Mt. Sinai
Dispensary August 9, 1908; has been suffering for five years. At
first it was a burning sensation in the toes of the left foot that gave
• him most concern, but later on he was troubled more by his inability
to walk distances on account of the sudden advent of attacks of
pain that were felt from the toes upward almost to the knee. In
cold weather he seems to be in poorest condition, for then his toes
get cold and blue, and walking is very difficult. Although this has
been going on for years, he has not found it necessary to consult

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Buerger: Thrombo-Piilebitis 311

a physician until something else in his right leg began to engage his
attention.

For the last five months long "streaks" or "swollen places" would
come and go over the inner side of the right leg, hehind the shin
bone. These are often very painful. A week ago a physician told
him that he had "phlebitis."

Physical examination on August 17, 1908. The vessels of the
right leg pulsate, but the left posterior tibial and dorsalis pedis can-
not be felt.

The right leg shows a tender cord with some edema around it,
extending from the ankle almost to the tibial tubercle. This corre-
sponds to the long saphenous, Erythromelia is definite on the" left
side; there are no trophic disturbances, and the circulation of the
right leg is fairly good.

From now on aggravation of his subjective condition went hand
in hand with the advancing lesions in the vessels. That an increase
in the extent of vascular occlusion took place from this time on could
be easily deduced from clinical observation.

On December 1, 1908, I have recorded the following: The right
foot looks pale (evidence of the beginning of ciroilatory dis-
turbances). After a short time it becomes slightly cyanotic. It
looks cadaveric when raised for a short time. There is no ery-
thromelia. The dorsalis pedis does not pulsate. A tributary of the
long saphenous about two inches long can be palpated as a tender
cord along the lower inner aspect of the right thigh; the skin over
it is reddened. There are two nodosities in and under the skin be-
low and to the inner side of the tubercle of the tibia. The left leg
shows marked erythromelia; blanching in the elevated position is
extreme ; the popliteal is open, but the dorsalis pedis and posterior
tibial arteries cannot be felt. There are no ulcers or other signs
of trophic disorder.

The steady advance of the occlusive process in the deep vessels
is well illustrated by the findings on December i, 1908. In August
alt the vessels of the right lower extremity pulsated in normal
fashion; now, in December, the dorsahs pedis is occluded. Corre-
sponding with this there is a new symptom, the blanching of the
foot. How remarkable that the disease of the deep vessels on the
right side should be so closely associated with the attack of migrat-

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312 The Archives of Diagnosis

ing phlebitis, the latter first attacking the saphenous in the leg, and
now appearing in the thigh t We have evidences of chronicity in
the affection of the superficial veins, and as regards the deep lesion,
we have been able to watch its gradual development both by its
effect on the palpable arteries and by the clinical manifestaticms it
has produced.

On January 31 the big toe of the left foot was swollen and red;
the nail was coming off. Immediately upon removing his shoe, the
right foot had a very white color, but soon cyanotic patches mingled
with the pallor all over the foot, especially in the re^on of the big
toe. The pain in the left foot was now excruciating and he con-
sented to an amputation with scarcely any reluctance. The left
leg was amputated at the upper fourth.

Examination of the vessels of the amputated limb showed oc-
clusion of the following arteries : dorsalis pedis, peroneal, plantars,
and posterior tibial. The anterior tibial artery was open through-
out most of its course. A large part of the long saphenous vein
was found occluded by an organizing thrombotic process.

Diagnosis. — Thrombo-angiitis obliterans.

In short, our patient presents the following features of interest:
(i) migrating thrombo-phlebitis of both saphenous veins; (2) in-
volvement of the same vein in its course through the thigh; (3)
associated progressive and synchronous development of the throm-
bosis in the superficial and deep vessels of the right lower extremity ;
and (4) absence of any cause for the lesion of the superficial ves-
sels.

Case 10. W. T., 26 years, Russian Hebrew, admitted to the Mt
Sinai Hospital* July 10, 1909.

In April, 1907, he was treated for gangrene of the third toe of
the left foot. Three months before admission to the hospital he
had been suffering with pain in the left calf and foot. Durii^ the
previous wititer (1906) the left foot did not seem to be normal,
so that he sought the advice of an orthopedist, who gave him the
usual treatment for flat feet. Latterly, he has had severe pain in
the calf, and shortly before admission gangrene of the third toe set

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Buerger : Thrombo-Phlebitis 313

in. He had an amputation performed on the 27th of May, 1907,
the left leg having been ablated at its upper third.

At that time my pathological studies revealed the usual changes
that are seen with thrombo-angiitis obliterans. The dorsalis pedis,
posterior tibial, the greater portion of the peroneal and plantar ar-
teries were closed.

Present Status (1909). — Since discharge, June 27, 1907, until
eight months ago, he seemed to be doing well. About this time
(8 months ago) he noticed the appearance of red streaks and no-
dules on the inner side of the right thigh. After a few days these
would disappear and new ones would appear in their stead, either
higher up on the thigh, or near the knee. They caused a peculiar
pricking sensation, and some were tender and painful. Lately, he
has been able to walk no more than two hundred steps without
resting.

The external manifestations on the loth of July, 1909, were as
follows :

A healed amputation scar in the left leg. In the dependent posi-
tion there is marked erythromelia of the right leg. Neither the dor-
salis pedis nor the posterior tibial can be felt to pulsate. On the
inner side of the thigh, near its middle, there is a sensitive strand,
which corresponds to the thrombosed saphenous vein. On the
outer side there are a number of hard, indurated, reddened nodules.
Over the inner side of the dorsum of the foot there are similar no-
dules and strands.

Diagnosis. — Migrating phlebitis and thrombo-angiitis obliterans.

In short, the history of this case reveals the following: Thrombo-
angiitis obliterans first involving the left lower extremity, leading
to amputation; insidious development of the same disease in the
right lower extremity, with extensive thrombosis of the superficial
veins of the thigh and leg.

The persistence of migrating phlebitis in the symptom-complex is
illustrated by the following history :

Case II. M. Gn., 28 years, Russian Hebrew, consulted me on the
13th of December, 1912. He has always been a heavy smoker (10-
15 cigarettes a day), and began to smoke at 12 years of age. For
about one year and a half he has had pain in both legs, particularly
in the right, which prevented walking, causing him to take frequent

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314 The Archives of Diagnosis

rests. He had been treated for about seven months for rheumatism
in a dispensary, and also received mercurial injections.

Physical exammalion demonstrated a moderate degree of erythro-
melta of both feet, particularly of the left, and small typical nodules,
evidencing involvement of superficial veins, over the territory of
the internal saphenous of the left leg. Similar nodules were found
in the right calf.

December 13, 1912, one of these nodules was removed for micro-
scopic examination and studied in the pathological laboratory of the
Mt. Sinai Hospital.

Neither the dorsalis pedis nor the posterior tibial arteries of either
leg pulsate. Trophic disturbances are present in the form of a small
ulcer.

Diagnosis. — Thrombo-angiitis obliterans involving both limbs with
migrating phlebitis of both l^s.

January 20, 1913, another superficial vein was excised and re-
moved from the right leg for microscopic examination.

February 8, 1913, still another small vein was removed from the
left leg for microscopic examination.

Patient was now lost sight of until June, 1914, when the left leg
had to be amputated for gangrene.

June 16, 1914, my notes record that the left leg has been ampu-
tated ; the right has distinct symptoms. There is chronic erythro-
melia, marked pain on walking, slight cyanosis in the dependent
position, marked blanching on elevation.

June 24, 1914. He does not seem to be improved with the use
of the diathermic treatment.

January 15, 1915. An ulcer has been present on the big toe of
the right foot and spontaneously healed. The foot has improved
considerably.

February 7, 191 5. There are still tender nodules over the pos-
terior aspect of the right leg. They are the typical nodosities be-
longing to migrating phlebitis. These have been present for six
weeks. The right foot is atrophic, pigmented, the big toe fairly
red; there is moderate erythromelia. Patient complains only of the
tender nodule in the back of the leg. The left stump is in good con-
dition.

Summary. — In short, we have here a case in which migrating

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Buerger: Thrombo- Phlebitis 315

phlebitis was observed to be present off and on from December,
1912, up to February 12, 1915, recurring therefore more than two
years and first observed in an acute or relapsing form; associated
with it the usual involvement of both limbs, amputation of one limb
having become necessary.

From the consideration of the data thus far presented it would
appear that the internal saphenous vein is the site of predilection
for that peculiar lesion which we have termed a migrating phlebitis.
In July, 1904, I had the opportunity of studying my first case in
which the veins of the upper extremity, too, were involved. Since
then several additional patients with a similar distribution of the
lesions have come under my observation. Four typical examples
may be cited here.

v. MIGRATING PHLEBITIS OR TH ROM BO-PHLEBITIS INVOLVING BOTH
UPPER AND LOWER EXTREMITIES

In three of the patients the disease has reached that stage of
chronicity in which the suffering is almost constant and in which
the limbs may be regarded as irretrievably lost. For there are cases
that become "cured" as far as symptoms are concerned. And by
"cured" in this sense we do not mean to imply that the pulseless
dorsalis pedis, posterior tibial, or both, begin to beat again, but
rather that, in spite of closed vessels, an adequate collateral circu-
lation has become established, as evidenced both by the absence of
the typical manifestations of impaired circulation, and by the
patient's improved subjective state. These three patients per contra
had the "severe" form of the disease, even though the issue, gan-
grene, was delayed far beyond our expectations.

Case 12. B. B., 34 years, Russian Hebrew, married, has no chil-
dren ; operator for eleven years. His malady began eight years ago,
when he first experienced pain in the right calf on walking. He
would be compelled to rest after walking four or five blocks. At
about the same time he often noticed that there were long "hard
cords" and "reddened lumps" over the front of both forearms (an-
teriorly) and over both legs. These would come and go, appear
without provocation, now in an arm, now in a leg. The lumps were
always small, pea-sized or slightly larger, and could be felt for two
or three days.

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3i6 The Archives op Diagnosis

He always felt better during the summer months. The nodules
in the legs were present almost every winter for the first five years.
Six years ago there was a "bad attack," in the course of which there
were ("Adern") "veins" or "nodules" behind and above the right
ankle. Then again, about three years ago, there was a repetition
of this trouble. Nodosities formed behind the shin bone on the
inner side of the right leg (region of saphenous) and the pain kept
him abed for almost ten weeks.

Thus, up to this time he complained of the following: pain in
the right calf on walking two to four blocks, painful nodules and
cords, and cramps in the toes and sole of the right foot at night.

For two years the left leg has given him concern ; the condition
is practically the same as that of the right. Last winter, January,
1909, there were "sores" — one at the tip of the big toe of the left
leg, and another at the end of the little toe of the right. He feels
best when his legs hang down (a variation from the usual state-
ment) ; but even in this position the toes often feel "dead." In the
same way his fingers get "numb" in winter; he thinks that there
is no blood in them.

Physical Examination. — In the right leg the toes have a tense,
reddened appearance, the second and third being discolored most,
the little toe having a cyanotic hue. Just behind the nail on the
plantar surface there is a deep fissure, the tips of which are ad-
herent. Slight pressure brings forth a drop of pus from the bottom
of the wound. The erythroraelia is marked over the dorsum of
the foot, as well as over the sole. Ischemia in the elevated position
is intense ; this posture excites severe pain. The femoral artery pul-
sates ; the popliteal, posterior tibial, and dorsalis pedis cannot be felt

The left leg is similarly affected ; the erythema is deeper and the
toes are more swollen. There is a trophic ulcer at the tip of the
big toe. The ischemia, too, is of a greater degree. All the vessels
(femoral included) fail to pulsate.

Summary. — This is a case which, according to the story, combines
thrombo-angiitis obliterans with migrating phlebitis of both upper
and lower extremities. There are at present no evidences of in-
volvement of superficial veins.

One of the most instructive of Hie cases of this series is a patient
in whom the attacks of inflammation and thrombosis of superficial

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Buerger: Thrombo-Phlebitis 317

veins dominated the clinical course for years before the symptoms
characteristic of thrombo-angiitis obliterans came into evidence.

Case 13. D. B., 35 years, Russian Hebrew, first seen by me July
16, 1904, when at Mt. Sinai Hospital. He had been treated in the
hospital eight years previously for "phlebitis" of the right leg; a
portion (5 inches) of a large vein was diseased at that time, and
the history states that the process was "migrating," moving up and
down the thigh. He says that this trouble lasted off and on for
two years. In 1903 there were "lumps" in and under the skin of
the right leg, and then, three months later, in the left leg. Such
swellings would last a week, develop into hard "tender spots" with
a covering of red skin, and on one occasion three such spots ap-
peared on the left arm, in front of and just below the elbow.

Physical examinatioit, July, 1904. In the left antecubital region
there is a thickened, slightly reddened cord about two inches long.
Another is situated on the ulnar aspect of the same forearm, near
the elbow. The right forearm presents a similar vein about three
inches from the elbow ; the skin is not reddened. On the inner side
of the right cubital space a subcutaneous adherent nodule can be
felt ; it is very tender. There are several such nodules in the right
calf and smaller ones over the left shin bone. No edema, but slight
cyanosis of both legs in the pendent position. A portion of one of
the thrombosed arm veins was extirpated for study.

Course. — A year later, 1905, symptoms referable to affection of
the deep vessels of the left lower extremity manifested themselves,
to wit: coldness and blueness of the left foot and superficial ulcers
on the toes.

Thus far our patient presented no striking addition to the s)'mp-
tom-complex under discussion, other than the thrombo-phlebitis of
the arm veins. In 1907, however, he developed a gangrenous patch
at the tip of the middle finger of the right hand. This rather unique
site for trophic manifestations is rarely seen in obliterating thrombo-
angiitis, and therefore deserves more detailed mention.

On February l, 1907, D. B. consulted me at the Good Samaritan
Dispensary. His doctor had been treating him for a "felon" of the
middle finger of the right hand. His hand had been cold for sev-
eral weeks, and the middle finger was painful. Four weeks pre-
viously a black "dead" spot formed on the tip of the finger, and

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3i8 The Archives of Diagnosis

since then, what with cutting it and self-treatment, he thought that
the present intensely painful affection had overtaken him.

Physical examination, February i, 1907. A portion of the tip of
the middle finger is gangrenous; there is no infection; the distal
phalanx seems to take part in the process of mortihcation. On the
dorsum of the hand, just over one of the veins, there is a bean-
sized indurated area ; the skin over it is adherent and tender. About
one inch above the wrist, behind the radius, there is a reddened hard
cord, more than an inch in length (doubtless a thrombosed vein).

The left foot is bluish, and there are a number of red nodosities
in the leg. They are placed over the course of the long saphenous
vein, one or two inches above the tip of the malleolus, and a couple
of others three to four inches above the ankle. The right leg shows
a thrombo-phlebitic, indurated process over the lower part of the
anterior tibial group of muscles.

Further Course. — The finger improves very slowly; in April it
is healed. The nodules in the upper extremities disappear after
three weeks. April 16, 1907, over the outer side of the right leg,
four inches below the tibial tubercle, the skin and subcutaneous tis-
sues are indurated. There are two hard areas further down. The
nodosities come and go, now in the right and now in the left leg.
On April 29, 1907, his left foot troubles him greatly. It is slightly
swollen ; the toes become deep red in the dependent position. The
right foot is slightly red in the same position. The femorals and
popliteals pulsate well. On June i the left foot is very painful;
the toes feel as if needles were sticking them.

November, 1907. Since the beginning of September the right
leg seems to be affected by the same disease as the left. New no-
dules of subcutaneous infiltration have appeared on the inner side
of the left leg and the inner side of the right knee. They seem to
have very little tendency to disappear. He often has pain in the
middle finger of the right hand, and this hand is colder than the left.

Physical Examination. — On holding both hands above his head
the right becomes blanched. When the hands hang, the right be-
comes cyanosed ; there is an admixture of red, so that there is a
mottling of red and blue (erythromeha of the upper extremity),
Both radial pulses are good. Lower Extremities. — On the inner
aspect of the right leg three nodules are seen, two near the tubercle

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Buerger : Thrombo- Phlebitis 319

of the tibia, a third one inch behind the middle of the crest of the
tibia. They are ^ to i inch in diameter, involve skin and subcu-
taneous tissues, and are red. Similar infiltrations are found on the
inner side of the left leg, two in the middle and upper third; two
others four inches above the ankle. They evidently follow the
course of the saphenous vein. The right foot has a bluish-red color.
The left is even more markedly discolored ; the second toe is en-
larged, looks angry, and presents a small superficial ulcer near the
nail. On December 19 (a warm day) the legs are red when they
hang down. There is no cyanosis. Both feet become cadaveric
when raised. A new cord has formed over the right wrist; it is
about an inch long, and lies over the radius ; a somewhat longer cord
is situated over the inner side of the right knee. (Salicylate of
mercury injections are administered.) On January 3, 1908, the
dorsalis pedis and posterior tibial arteries are pulseless. On Febru-
ary 7 he still has the painful cord over the right wrist, although he
has had seven injections of mercury. The right popliteal pulsates,
the left pulsates faintly ; both f emorals are open.

September 7, his right foot is worse than the left. The dorsalis
pedis and posterior tibials of both legs are evidently closed. At this
time the right popliteal does not pulsate; the left beats faintly (note
that this corresponds with the a^ravated subjective sensations of
the leg) ; both femorals are felt. Recent ulceration has occurred
in the web between big and second toes of the right foot. The toes
are intensely red in the dependent position. On November 19, in
the horizontal position, both feet possess a marked erythematous
hue.

On April 13, 1909, the patient came to the hospital for the ul-
cerated condition of both feet ; he cannot walk. Over the dorsum
of both feet there are superficial ulcerations, and there are a num-
ber of trophic ulcers in the webs of several of the toes. Under rest
in bed and local treatment all the wounds heal. By June 9 both legs
are in a condition of chronic erythromelia, even in the horizontal
position. The feet have a dusky red hue ; in the dependent position
there is an admixture of purple. The skin is shiny and appears
thinned, although the toes themselves are enlarged. Only the fe-
moral arteries pulsate; the ischemia in the elevated position is very
marked ; all the superficial ulcers have healed.

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320 The Archives of Diagnosis

Summary. — The total history up to the present time extends
through a period of about twelve years. During the first eight years
the clinical course was characterized by repeated attacks of migrat-
ing phlebitis of the superficial veins of the upper and lower extrem-
ities, and the appearance of cutaneous nodosities, due in all prob-
ability to circumscribed venous thromboses. These attacks were
accompanied by the usual pain and tenderness, some edema, and
secondary cutaneous manifestations. Towards the end of the first
period the prodromal indefinite pains of typical thrombo-angiitis
were noticed. These were followed by the development of marked
erythromelia of the left lower extremity, and of trophic disturbance.
Then came a cessation of the process on that side, only to give way
to a similar diseased condition on the right side, where it has caused
obliteration of the distal vessels and the popliteal. In short, a period
of occlusion of superficial veins was followed by a period of ar-
terial occlusion which attacked first the left, and then the right leg.

Does the paroxysmal nature of the involvement of the super-
ficial veins throw any light on the sequence of events in the deep
vessels? From my previous pathological studies* it seemed most
plausible to assume that certain territories of either arteries or veins
become rather suddenly thrombosed, after a fashion similar to the
thrombotic process occurring in the superficial veins of the lower
extremities. The history of the fourteenth case is exceedingly il-
luminating on this point, since it suggests that attacks of migrating
phlebitis of one leg may occur synchronously with paroxysmal pains
in the other leg, and that these latter pains are closely associated
with other signs clearly pointing to an exacerbation of the throm-
botic lesion in the deep vessels — "an attack (if we may so regard
it) of thrombo-angiitis obliterans." In other words, it seems more
than likely that, at any given time, the patient may be suffering
from a more or less acute disturbance, in the course of which both
superficial and deep vessels become closed.

Case 14. M. P., 34 years, Russian Hebrew, admitted to Mt. Sinai
Hospital in May, 1908. My history was taken on May 24, 1908.
Two years ago there were some "swollen places" on both legs, and
he had pain in the legs when he walked. One year ago he had at-
tacks of "phlebitis" ; this was the diagnosis at the Presbyterian Hos-

■Am. Jour. Med. Sci„ October, 1908.

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Buerger : Thrombo-Phlebitis 321

pital. The veins on the inner side of tfie left foreann and arm,
almost up to the armpit, were painful. The left saphenous at the
middle of the leg was also diseased at that time. He had been
treated at Mt. Sinai Hospital in August, 1907 (service of Dr.
Manges) for "phlebitis migrans." At that time no suspicion was
entertained as to the existence of the condition, thrombo-angiitis
obliterans.

Last winter he often had pain in the feet on walking, and this has
been much worse for the past four weeks. During the last two
months the symptoms of phlebitis have recurred in the left leg and
the left arm.

Present History. — For four days he has had excruciating pains
in the calf of the right leg, even when in bed. Besides this, he has
painful cords and "spots" in his left leg.

Physical Examination. — Both radials pulsate. The patient seems
to be very restless because of the pain in his right leg. In the right
leg neither the dorsalis pedis nor ttie posterior tibial artery can be
fek ; the popliteal artery is patent. The toes are slightly red in the
horizontal position ; there is marked erythema of the toes in the
pendent position. Ulcers and thromboses are absent. (Note made
May 24: The pain in this leg must be interpreted as suggesting
thrombosis of the deep vessels, because there is nothing else to ac-
count for his suffering; apparently no neuritis.)

In the left leg also absence of pulsation in the dorsalis pedis ar-
tery and posterior tibial artery is noted. Just behind the tibia, at
the middle of the leg, the saphenous vein is thrombosed, being ad-
herent to the skin, which is reddened. There are a number of no-
dules in its vicinity, probably corresponding to small tributaries.
There is erythromelia of moderate degree, but no marked ischemia
in the elevation posture. The popliteal artery is patent.

In the left arm a small portion of an anterior ulnar vein, tow
down, is indurated.

Briefly, then, the typical signs of bilateral thrombo-angiitis ob-
literans, without trophic disturbances, varicose veins, or infection,
are associated with attacks of thrombo-phlebitis of the superficial
veins of the upper and lower extremities.

On May 28, 1908, the pain in the right leg is gone, the cords are
disappearing, the ulnar thrombosis is no longer palpable.

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322 The Archives of DiACNOsts

I saw the patient again on December i, 1908. After leaving the
hospital he could walk but a block without stopping for a rest. For
about two weeks a new longer cord has traveled up from the middle
of the inner side of the left leg, behind the knee, to the lower part
of the thigh. There is another one behind the ankle and inner side
of the foot. In the calf there arc two tender bean-sized nodosities.
He says that the big toes always feel as if they were asleep, and he
often has an inclination to rub them to dissipate the feeling of
numbness. Examination shows his condition to be slightly worse
than it was in May, as regards sufficiency of circulation in both legs.

On June 15, 1909, he was again examined by me. He was then
a pitiful spectacle to behold. PuUing himself along on two crutches,
with an expression of fear written all over his face lest the contact
of the soles of his feet against the ground call forth excruciating
pain, with the aid of his wife he hnally seats himself, telling me
the following story: He has tried "everything" for his legs. He
has been treated in other hospitals since I last saw him, and now
he cannot walk at all. The big toe of the left foot hurts him un-
bearably, and his physicians are unable to ward off the coming of
those dreadfully painful "sores" and "fissures" that form without
reason on his soles, between the toes, and near the borders of the
nails. He cannot bear his weight on the legs at all. The effort to
walk was soon given up and he has permanently assumed the hori-
zontal position as the only one possible to be borne..

Physical e-vamination shows intense erythromelia of both feet,
with a slight cyanotic hue, as in Case 12, D. B. The middle por-
tion of the internal saphenous vein for about an inch of its course
through the leg is converted into a hard, tender cord. There is
a nodosity 0.5 x i cm. three inches below the left tibial tubercle
and two inches outside of the crest of the tibia. All the toes of
both feet are somewhat enlarged ; they look stiff and turgid when
held in the dependent position. The blanching of the raised feet
is extreme.

Resume of Case 14. — Recurring thrombo-phlebitis migrans of
both upper and lower extremities, gradual development of the se-
vere chronic clinical type of thrombo-angiitis obliterans without
gangrene, symptoms indicating the simultaneous paroxysmal at-
tack of superficial and deep vascular channels.

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Buerger: Thrombo-Phlebitis 323

One of the best examples of extensive disease of the veins in all
four extremities is that presented by Case 15, Because of the de-
velopment of an adequate collateral circulation, obstruction and
closure of the deep vessels had apparently produced no symptoms
in the left leg, whilst the disease had made considerable progress in
the right leg. Signs of an active migrating phlebitis could be found
only in the lower extremities, but the definite statements of the
patient leave no doubt as to the correctness of the view that he had
had attacks of phlebitis in the upper extremities at one time.

Case 15, M, G., ■^'j years, Russian Hebrew, married, has two
healthy children ; consulted me August 6, 1909. Four years ago he
had tender "cords" or "lumps" on both forearms and also on the
inner side of the arms. These soon disappeared and have not re-
curred ; at that time, however, there was also a similar condition in
the calf of the right leg and inner side of the left leg. He was quite
free from trouble until a year ago, when similar painful spots de-
veloped in the legs.

For three months he has had wakeful nights, because of pain in
.both feet, especially in the right. His toes get cold and he cannot
walk because of the sudden advent of cramps in the calves. The
"cords" in the right leg have now disappeared, butr they are still
present in the left leg, where they come and go.

Physical examination, August 6, 1909. Both lower extremities
present the typical signs of thrombo- angiitis obliterans. Evidences
of circulatory insufficiency are most marked in the right leg, where
there is marked erythema in the horizontal and pendent positions.
Both legs become intensely blanched when elevated. All three ves-
sels (dorsalis pedis, posterior tibial, and popliteal) are pulseless on
the right, whereas a very faint pulsation in the upper part of the
left popliteal can be detected, the distal vessels evidently being
closed. There are no ulcers.

Just below the middle of the course of the saphenous of the left
leg a hard, knobbed, tender cord can be easily felt. At the inner
border of the foot there is an erythematous nodule which is tender.

On August 8 about one inch of the thrombosed saphenous of the
left leg was excised under local anesthesia for diagnostic purposes.
The vein was filled with recent clot, and was fairly adherent to its
bed, showing an active periphlebitis.

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324 The Archives of Diagnosis

In September, 1909, the right leg was amputated three inches be-
low the knee by Dr. Hurley of the Sydenham Hospital, because of
gangrene of the toes.

On October 27, 1910, he says that there was considerable pain
in the sole of the left foot, and that he could not walk more than
two blocks without stopping for rest. Ever since the operation he
has had recurrent attacks during which the same hard cords or
nodules which he had before developed in the left leg. Several
of these are now present, and he has had them for three weeks.

Physical examination, October 27, 1910, shows a nodosity in the
middle of the left leg, and two or three confluent nodosities above
the malleolus. There is marked erythromelia, and the pulses are
absent in the popliteal, posterior tibial, and dorsalis pedis.

November 10, 1911. The phlebitic process is still present. Fresh
nodules are making their appearance. The evidences of obliteration
of deep vessels of the left leg are more striking, and the disease,
thrombo-angiitis obliterans, is evidently making progress, with signs
of the development of trophic disorders.

Epicrisis. — We are dealing here with a case of bilateral thrombo-
angiitis obliterans with associated migrating phlebitis which had
originally affected both forearms, and for more than two years has
shown itself also in the lower extremity. The persistence of the
migrating phlebitis and the chronicity of the deep vessels, thrombo-
angiitis obliterans, of the left leg, are features worthy of note.

Here (Case 15) we are dealing with a case presenting active
signs of thrombo-angiitis of the vessels of the lower extremities for
three months. At the same time, there were recurring attacks of
phlebitis of the upper and lower extremities. At times he sought
advice because of the phlebitis ; at other times, because of the symp-
toms referable to the deep-seated disease. Four years after the
onset of the disease the findings were as follows:

The results of advanced closure of the arteries of both lower ex-
tremities ; absence of any recent or active symptoms in one of the
legs ; distinct signs of a slowly progressing involvement of the cir-
culation of the other limb, with recurring attacks of phlebitis of
both saphenous veins, without ulcers, trophic disturbances, vari-
cosities, or evidences of inflammation.

These facts lead us to the following conclusions:

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Buerger : Thrombo-Phlebitis 325

First, that the phlebitis plays no subsidiary role in the symptom-
complex of some of these cases.

Second, that the disease, when it affects the upper extremities, is
less enduring than in the lower extremities.

Third, that we have here another link in the chain of evidence
speaking for an identical cause for the disease of the deep arteries
and veins and tfie superficial veins.

PATHOLOGY

In 1908 our studies of the pathology of nineteen amputated limbs
in thrombo-angiitis obliterans had clearly demonstrated the throm-
botic nature of the vascular occlusion. It was also shown that the
pictures formerly interpreted as results of a thickening of the in-
tima were produced by organization and canalization of red ob-
turating thrombi. It was found Chat the disease involves the deep
arteries and veins of both the lower and upper extremities, com-
mmicing by preference in the vessels of the foot, such as the dor-
salis pedis and plantars and their larger branches, ascending so as
to sometimes close even the iliacs and aorta. Qinical and patho-
logical data led to the assumption that the progression of the throm-
botic process takes place rather in attacks or sudden exacerbations
than by a gradual ascent ; that larger or smaller territories of the
deep vessels become suddenly closed, just as the saphenous veins
are wont to be thrombosed and inflamed from other causes — in other
words, that the process is a migrating thrombosis of the deep ves-
sels comparable to the migrating phlebitis of the extremities.

A cursory study would lead one astray as to the significance of
the most common lesions seen in the arteries and veins, for it would
fail to reveal the fact that there are two distinct phases in the pa-
thology of the disease. The lesion most commonly encountered is
but the result of the organization of thrombi, and of importance
in our investigation only in so far as it is productive of the pic-
tures that may be confused with endarteritis obliterans. More in-
teresting and more valuable tor investigation is the "acute stage,"
or earliest lesion, that occurs simultaneously with, or shortly after
the onset of the thrombosis. This early stage was found in the
vessels of but two of the amputated limbs. In these certain specific
morphological alterations were encountered, whose meaning was

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326 The Archives op Diagnosis

not understood at that time. These histological changes appeared
to be characteristic of the disease, thrombo-angiitis obliterans, not
having been met with in vessels thrombosed through other causes.
The regularity of the occurrence of the typical lesions aroused the
suspicion that here was a specific morphological alteration, due to
a specific cause.

In short, whereas the usual changes in most of the vessels of an
amputated limb represent the healed stage of the disease, that in
which a fibrous mass containing canalizing vessels has taken the
place of the original clot, there is another early or acute stage of
the disease which alone is of value in throwing light upon the true
nature of the process. It is only at this particular period in the
history of the pathological process that the media is diffusely in-
filtrated with leukocytes, and that the lumen is filled with red clot,
in which certain typical miliary giant-cell foci* make their appear-
ance. It is these foci that lend a characteristic appearance to the
thrombotic lesion of thrombo-angiitis obliterans.

When these lesions were first referred to in 1908 their significance
was not understood, although the suspicion was already aroused
at that time that they were specific for the disease and probably
represented a peculiar reaction on the part of the tissues to some
toxin or organism. It seemed clear, too, that it would be a difficult
matter to obtain an adequate amount of material from the deep
vessels for the study of the acute stage of the disease. It was here
that we had to pause in our deductions, when we were fortunate
enough to encounter a most interesting fact, that the superficial or
subcutaneous veins of the upper and lower extremities may also
be affected by the disease, thrombo-angiitis obliterans. Thus, in
1909, the association of migrating phlebitis of the subcutaneous veins
of the extremities was noted in eleven cases. From a study of the
clinical history of the cases, and of the histology of the affected sub-
cutaneous veins, exsected during various stages of the disease, the
following conclusions were drawn:

I. The disease thrombo-angiitis obliterans is often associated with
thrombo-phlebitis of superficial veins of the arms and legs.

'Buerger, Mitteilungen aus den Grenzgebieten der Medtzin und Chinirgie.
31 Band, 1910.
Do— Am. Jour. Med. Sci., October. 1908.

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Buerger : Thrombo-Phlebitis 327

2. Certain peculiar cutaneous nodosities are characteristic mani-
festations in many cases.

3. The disease of the superficial veins may be subsidiary or it
may dominate the chnical picture. Objective signs referable to
these vessels should be regarded as extremely suspicious marks
of the synchronous development of thrombo -angiitis obliterans, in
the form of pulseless vessels, erythromelia, blanching of the leg in
elevated posture, cold and blue toes, pain in the calf of the leg
brought on by walking, and other typical phenomena.

4. Migrating thrombo-phlebitis may give no symptoms, the signs
referable to the deep vessels being of most importance.

5. Patients may suffer at one time from migrating thrombo-
phlebitis, at another from the progress of the occlusive change in
the deeper vessels.

6. One of the cases suggests the possibility that attacks of trouble
in surface veins may occur simultaneously with similar exacerba-
tions of disease in deep vessels of another limb.

7. The morbid process resulting in the production of cutaneous
nodosities and thrombosed superficial veins is independent of vari-
cosities, of infection, or of trophic disorders in the territory which
they drain.

8. The vessels of the upper extremity may be affected by the
lesion thrombo-angiitis obliterans.

9. Thrombo-phlebitis in the arm and forearm should arouse sus-
picion as regards involvement of the deep vessels of the legs.

10. Further studies should be directed towards solving the rela-
tionship between the two thrombotic lesions that we have described.
Perhaps excision of nodules and veins early in the disease, explora-
tory incision for inquiry into the condition of the deep vessels, and
bacteriological and serum investigations along the proper lines will
do much to enlighten us in our interpretation of this most puzzling
symptom-complex. Although absolute proof is lacking, it seems
more than probable that the same determining causative factor is
responsible for the lesions of both the superficial and deep vessels. -

Since 1909 I have been able to gather data on fifteen additional
cases in which the superficial veins were involved and have brought
the number of exsected veins up to twenty-five. In these, both the
acute and healed stages of the disease were found. From a con-

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328 The Archives bF Diagnosis

sideration of the pathological pictures the conclusion was reached
that the specific characteristic lesion of thrombo-angiitts obliterans
may affect the deep as well as the superficial vessels ; that it is in
the veins that we shall have to look to find material for investiga-
tion of the causative agent; and that not only do the superficial
veins present the typical military giant-cell foci, but they also
demonstrate that these foci are a later stage, or attempt at organi-
zation of purulent foci. In other words, the finding of miliary pus
foci in the subcutaneous veins as precursors of the typical giant-
cell foci was noted in a sufficient number of instances to warrant
the conclusion that this lesion represents the acute stage of the dis-
ease, and suggested, too, that the thrombotic process must be caused
by the presence of some organism.

From the investigation on the twenty-five exsected superficial
veins, with a comparative study of the lesions in the deep vessels,
the following conclusions were drawn :

An acute inflammatory stage is the initial manifestation of the
pathology of the disease, thrombo-angiitis obliterans. Certain punt'
lent foci are developed strongly suggesting the presence of some
specific toxin, or, more probably, some microbial agent. The de-
structive influence of these foci is evidenced in their action on the
angioblasts, whose true purpose is thwarted, the result being the
elaboration of a morphologic complex, distinctive and characteristic
for the disease. Just as in tuberculosis, and doubtless in Hodg-
kin's disease, certain well-known structural products represent the
specific reaction of the tissues to some organism, so here, too, the
changes described are absolutely typical and diagnostic. Their
raison d'etre, it is hoped, has been explained.

Besides these changes, the production of aseptic, bland clot plays
a part in the development of the occlusive tissue ; whilst the infil-
tration of the media and adventitia makes for the adhesive fibrosis
in the deep vessels, and the distinctly palpable products of peri-
phlebitis in the subcutaneous veins. The change of the acute into
the healed connective stage is rapid, a type of occlusion resulting
which has for a long time been regarded as due to an "endarteritis
obhterans."

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Mettles: Borderland Psychoses 339

If we have been unsuccessful in our search for the offending
agent, it is hoped that we have at least clearly shown how the prob-
lem should be attacked, and where we must expect to find the causa-
tive agent of the disease.

Certain it is, then, that the recognition of the associated migrat-
ing phlebitis is not only important in diagnosis, but affords the
terrain for the discovery of the etiology of the affection.

THE DIAGNOSIS OF THE BORDERLAND PSYCHOSES:

A WARNING

By L. HARRISON METTLER

Professor and Head, Department of Neurology and Clinical Neurology,

College of Medicine of ihc University of Illinois; Neuroli^st,

Norwegian Lutheran Deaconess Home and Hospital

Chicago

"We must not forget that, as the doctor shows, and must show, a
searching interest for the psychology of his patient, so, too, the
patient, if he has an active mind, gains some familiarity with the
psychology of the doctor, and assumes a corresponding attitude
toward him. . . . Therefore, I maintain that a doctor must be
analyzed before he practices analysis, . . . The Indians, when
America was discovered by the Spaniards, took the horses of the
conquerors, which were strange to them, for large pigs, because
only pigs were familiar to their experience. This is the mental
process which we always employ in recognizing unknown
things." — ^JUNG.

The term psychosis has a broader meaning than that usually given
it by the psychiatrists. It is a stock word in psychology and means
merely a "change in the field of consciousness," or better still, "the
mental constitution or condition." It is in this broader sense that
the psychoses will be discussed in this paper. Again, it will be
noted that I have used the adjective borderland, instead of "bor-
derline" so common among the authors, in the title of this paper.
There is no "borderline" among the psychoses, for human mentali-
zation is a graded manifestation, from idiocy at its lowest point to
an indefinite, ever-advancing high point. There is no fixed point

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330 The Archives of Diagnosis

or middle line anywhere in this concept of universal mentalization.
The normal for any one time, place, or race has not, and probably
never will be established. The nearest approach to a standard of
measurement possible is that of a numerical average. The average,
however, is always a shifting and variable factor. The average of
one nation is not the same as that of another. The average of one
age is not the same as that of another age. The average mentali-
zation in Africa is not the same as that in Europe and neither can
be called in the true sense the normal. The average mentalization
of the ancient Greeks is not the same as that of the modem Greeks,
nor can either be strictly referred to as the normal. Psychosis is
not a thing or entity ; it is merely a reaction, an appearance, an out-
ward manifestation, complex and variable, dependent upon innumer>
able underlying factors concerned with past influences (heredity,
organic evolution, etc.) and with present influences (physiological
function, environment, etc.). This relativity, variability, and in-
stability being true of the average psychosis, it is obvious that no
strict definition of the abnormal psychosis, or insanity so-called, is
possible. Only well out at the extremes of this graded universal
mentalization can a clear picture be drawn as to what for conveni-
ence may be spoken of as insanity. No mind at all or idiocy and
gross imbecility can be easily recognized. Unusual mentalization
or exaggerated degrees of psychosis can be clearly detected. Neither
idiocy nor genius being within that broad midland of averages, both
are put down as forms of insanity, as equally abnormal psychoses,
freaks of nature. If our definitions, classifications and diagnoses of
insanity could be limited to these gross pictures of mental aberra-
tion we might more often find ourselves in the right. At least we
should not be subjected to such witticisms as that all the world is
insane but part of it builds asylums to incarcerate the other part in
OTxJer to make itself feel that it is not quite so insane. It is because
of our inability to define both great wit and little wit that the poet
is justified in exclaiming, "Great wits are sure to madness near
allied and thin partitions do their bounds divide," and the philos-
opher in writing, "The insane, for the most part, reason correctly
but from false principles ; while they do not perceive that their
premises are incorrect." According to the former, many an inmate
of an asylum might well have been given a niche in the Hall of

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Mettler: Borderland Psychoses 331

Fame ; while according to the latter, many a supposedly sane indi-
vidual would be occupying a cell in the State institution. So-called
insanity is a gross affair and being always the expression of some
bodily or organic ailment or deficiency, is not hard to diagnose
when an exhaustive examination of the patient is made. Now, most
of the writers upon the so-called borderland cases that I have read
speak of the frankly defective and grossly abnormally acting indi-
viduals. In a word, their borderland, or as too many of them un-
fortunately say, "borderline," cases are merely definite, mild de-
grees of permanent mental aberration. These constitute a large and
most interesting class. Today they are being studied more than
any other group of cases. Heretofore they have been granted too
much liberty and as a result society has often become the victim
of their crimes and grossly anti-social ideas. This whole class of
defectives, easily recognized when thoroughly studied, and calling
for better and more radical control than has heretofore been given
them, is not what I mean by the borderland psychoses. The cases
I refer to are actual borderland cases. Some of them are on one
side of the borderland and some of them on the other. The same
case may at one time be regarded as insane, at another as perfectly
sane. These doubtful cases that flit, as it were, through the hazy
area between health and disease are the ones that give us our real
difhculties in diagnosis. Physically and organically, so far as all
outward signs indicate, they are healthy. Their physical examina-
tion usually reveals nothing abnormal. Their heredity may be nega-
tive and their environment seems to be all that could be desired.
And yet they think and act queerly at times and not infrequently
have been sent to the psychopathic hospital. How are we to detect
these cases? Are there any reliable criteria by which we can pro-
nounce them sane or insane? What is sanity or insanity as applied
to them? They certainly do not think and live like their milieu.
They even cause much anxiety and disturbance. How insane, or
how likely to become insane, is a psychoneurotic of this sort? These
are a few of the questions which we all devoutly wish at times Hiat
we could answer. These are the real borderland cases that tax our
skill and patience to the limit.

One thing is fully recognized today in psychiatry, namely, that it
is not the mind so-called that is diseased but the body or organ of

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332 The Archives of Diagnosis

whose function the mtnd is but the expression. In other words,
insanity always means organic disease or inadequacy, A psychiatric
diagnosis always depends for its accuracy upon the diagnosis of the
underlying functional and organic abnormality. This is not always
easy because the inherited weakness, the degenerative inadeqiucy,
the acquired toxemia, the parasitical infection or the pathological
tissue change may all be so slight or beyond our means of research
as to be quite overlooked. In such a case the diagnosis of the men-
tal malady, no matter how well the mental symptomatolc^y presents
itself, lacks more or less in completeness and definiteness. An ele-
ment of error becomes more and more insistent in proportion to
the absence of this underlying organic diagnosis. This is the reason
why errors are so common in the diagnosis of mental diseases —
errors which are obviously and manifoldly enhanced by the want
of thoroughness on the part of the ignorant or careless examiner.
With care and thoroughness, resulting in the detection of some basic
organic disease, a fairly positive diagnosis of the nature of the
mental aberration may be established when the latter is of the
slightest and most evanescent character. Like a "pathognomonic
symptom," it may be said, the presence or absence of the underly-
ing organic disease fixes the sane or insane character of the vic-
tim's mental vagaries. The only question at issue is the discovery
of this underlying disease. Here we approach the borderland type
of psychoses as I understand the term.

There are cases, however, calling for a psychiatric diagnosis in
which the most careful and complete examination fails to reveal
any organic basic disease. These may be cases of incipient disease,
as, for instance, general paresis in which for some reason or other
the tests for luetic infection have all proved to be negative (and
every one of large experience has seen a few such cases) ; or they
may be cases whose mental manifestations may be due to strange
and unusual causes not falling under the general head of pathology.
In both sets of cases time usually reveals the real nature and cause
of the apparently unusual psychosis. Hence the frequent necessity
of a preliminary observation and treatment of these cases in a sani-
tarium before a positive diagnosis can be established.

There are times when it is desirable, however, to make a diag-
nosis, if at all possible, without delay. At all events, the laity

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Mettler: Borderland Psychoses 333

usually insist upon some sort of a diagnosis and prognosis before
waiting so long. In these cases where all physical findings are
apparently wanting and yet the patient seems to act queerly and to
be quite out of harmony with his immediate and general mental
environment, the examiner is forced to make some sort of a diag-
nosis upon the purely psychological data presented by the one being
examined. The question becomes one then of psychology. This
sort of an examination is unique. There is nothing like it in the
entire realm of medicine and surgery. It is one mind examining
another mind ; like a definition trying to define itself ; a use of
terms used to explain themselves. Blunders and disasters frequently
follow efforts in this field; so much so that many physicians wisely
refuse to pass any opinion, while many more unfortunately illus-
trate the saying that fools rush in where angels fear to tread. The
examiner's own psychosis is here as much at stake as that of the
one being examined.

In these cases all the psychical exhibitions may be, or seem to be,
aberrant, but usually the trouble lies markedly in one sphere alone.
The memory, the imagination, the volition, the reason, the atten-
tion, the consciousness, the final judgment may all be out of har-
mony with the requirements of the environment; but as a rule the
trouble will be found to be chiefly in the realm of the ideas, with
all that the word idea connotes.

Tanzi writes that "irregularities of ideation form one of the two
foundations of clinical psychiatry, and indeed, the more character-
istic of the two: they can be grouped into those that relate to the
rapidity of association, the logical value of the ideas, their absolute
quantity, and their arrangement." But just here is where the dif-
ficulty arises. Who and what is to establish the proper rapidity
of the association of these ideas, or their logical value, the proper
quantity that they should show, and how they ought to be arranged?
The opinions of a Shakespeare or a Goethe in regard to all of these
qualifications of ideas, if put into force, would send a good many
supposedly normal people to the idiot wards of the hospital.

Here is just where our trouble begins in the diagnosis of the real
borderland cases wherein no discoverable organic lesion or intoxi-
cation can be established. The symptomatology of these cases is
wholly of the psyche and the presentations upon which we must

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334 The Archives of Diagnosis

depend lie wholly in the sphere of the ideas. It is because of this
that craziness has been satirically declared at times to be universal ;
that discoverers, inventors, writers, artists, scientists, reformers, and
enthusiasts of all sorts are sometimes seriously regarded as mentally
unbalanced ; that genius has been identified with insanity by so many
of the followers of Lombroso ; that faddists, ritualists, followers of
all sorts of isms, Christian Scientists, spiritualists, and other re-
ligious and semi-religious devotees have been regarded at times as
more or less crack-brained. It is a human weakness, a phase, as it
were, of human objectiBcation, shown individually and racially, to
feel and say, "We are sane; all others whose ideas do not agree
with ours must be somewhat insane." This is the popular It^c,
and as such can well be allowed to pass ; but unfortunately the same
sort of logic has too often invaded scientific circles, and today, in
some quarters, seems to be dominating our psychiatry, I refer, of
course, to some of the conclusions that emanate from the Freudian
school of psychoanalysis, from the extreme believers in the value
of such mental tests as the Binet-Simon, Yerkes, and others, and
from a few of the teachers and writers of psychiatry who over-
value the classification of mental symptoms, calling them mental
diseases.

In legal phraseology a man should always be tried by his peers.
The same general principle should obtain when one mind, or set of
minds, examines another mind. When an individual is regarded as
queer and is presented for examination, the whole realm of his ideas
should be taken into consideration and the force and value of those
ideas met by a similar rapidity, quantity, and versatility of ideas on
the part of the examiner or examiners. For example, I once saw
in consultation a well-known concert violinist who was thought to
be a very superior musical genius and was suspected of insanity
only after he had smashed his violin and threatened the life of his
mother. A long conversation with him in one of his lucid intervals
upon music, of which I have made some study, showed me that in
this art alone an earlier examination would have demonstrated
that not only was he most superficial in his knowledge and concep-
tion of this, the greatest of the arts, but his wonderful rendition
of it was more or less akin to that of Blind Tom or of what the

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Mettler: Borderland Psychoses 335

French would call the idiot-savant. This patient, instead of being
a great artist, was a defective and has long been in an asylum.

Per contra, let me cite the following illustrations, all of whom
were presented as cases of possibly serious mental alienation.

A very successful business man was depressed and melancholy,
even to the point of weeping at most unexpected times. No physical
findings, after a most competent examination at the hands of a
number of well-known speciahsts, could be discovered ; and his
home and social environment were all that could be desired. He
was utterly indifferent to all the usual forms of amusement and
displayed a marked aboulia when they were urged upon him. By
early and incessant attention to business he had so narrowed his
mental horizon that when he began to relinquish business cares and
have more leisure time on his hands, he found himself mentally
stranded and knew not what to do to entertain himself. His affairs
were in a satisfactory state. He traveled extensively. He had no
patience with the playing of mere games. He did not like reading
and the selections he attempted were most ill-advised. He was
thoroughly unhappy without a cause. And yet the cause was amply
apparent to a psychologist, though unacknowledged by the patient
and his family. It was a case of mental poverty, not insanity.

A briUiant woman, with strong and active literary tastes but in-
clined to be somewhat erratic, developed a hysteroid state of mind,
even to the point of wandering away from her home one night.
A very cursory psychoanalysis revealed the fact that her environ-
ment, her restraints, and her enforced activities were all in direct
opposition to her tastes, modes of thinking and ambitions. A change
of environment and a correction of some of her erroneous habits
restored her to the condition of a happy and normal existence. She
was the victim, not of insanity but most uncongenial surroundings.

A rather amusing case that showed so much psychoneurotic dis-
turbance that her husband brought her to me for examination of
her sanity, was that of a woman who understood not a word of
her husband's language, he and all of his family being French. The
couple were devoted to each other and she always spoke of her
husband in the highest terms. Of course he spoke English as well
as French, In spite of her "nervousness" and occasional hysteroid
outbreaks, I could discover nothing really abnormal with the woman.

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336 The Archives of Diagnosis

After many conferences and a close study of her confidences, I
learned that her whole trouble was anxiety, dissatisfaction and in-
jured pride caused by her husband's devotion to his family and
her frequent visits with him there, where she sat stupidly listenii^
to conversations of which she understood not a word.

A pampered daughter of wealthy and foolish parents married a
successful young business man. The loneliness of her home was
so intense to her that she developed a highly psychoneurotic condi-
tion. She had periods of mental abstraction when she would wan-
der out of her home. Once or twice in her morning deshabille she
followed her husband in a daze to his office. All of this, of course,
embarrassed him and her family. Many opinions were sought,
some of which frankly stated that the case was one of borderland
insanity. After the death of the father the girl lived most inti-
mately with her mother, who was a most self-indulgent and undis-
ciplined woman. They slept together, and were never out of each
other's sight, day or night. This intimate and foolish association
was suddenly broken off when the girl entered her own home as a
bride. A prolonged isolation in a hospital from husband as well as
family restored tiie young woman to normal state.

The early history of a young man whom I watched for over a
year easily accounted for his marked homosexual tendencies.
Vicious education, association and habits entered into the etiology
of his acquired homosexuality. Recovery took place in a year under
treatment.

Seeing a sister's haby poisoned by rat poison and holding it in
her arms when it died so shocked a young woman that long after
marriage she refused to have a child of her own. Both she and her
husband really wanted a child and were apparently able to have
one. Sexual intercourse kept the wife in a constant state of fear.
To overcome this the husband refrained. This was again inter-
preted by the wife as indifference and want of affection on his part.
She became highly hysterical and even insanity was spoken of.
A judicious psychotherapy and insistence upon a normal sexual
life with the hope of begetting ababy have completely restored the
woman's health and the happiness of the home. She is now the
mother of two vigorous children with not a sign of a psychoneu-

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Mettler : Borderland Psychoses 337

A clergyman once came to me on account of extreme bashfulness
and distress, when in company, that he was offensive to everybody
about him. Being a thinker and a scholar, he wondered whether
this indicated some oncoming mental trouble, for he felt sure that
there was no real ground for him to feel this way. The history
revealed the fact that, like a fish out of water, he was both intel-
lectually and culturally far in advance of the little humdrum, com-
monplace hamlet in which he was located. He lacked the mental
stimulation that comes from intercourse with equals and received,
on the other hand, much criticism from those who in their pride re-
sented his almost unavoidable instruction. A long period of this
sort of thing in a sensitive individual had at last resulted in the
peculiar and distressing self-depreciation for which he came to me.
He was a most instructive and entertaining man to meet. Whether
my seances with their psychotherapeutic ministrations ultimatdy
overcame the trouble I know not. The patient declared he felt
better and I decided that there was nothing of the "borderland"
psychosis about the case-
But why go on enumerating more cases? Every practitioner sees
them and sometimes to his sorrow. They cause him much loss of
time and expenditure of brain matter. Lucky he is if he can always
distinguish the real from the apparent psychosis in these borderland
cases.

In conclusion, the following propositions seem to me to be worthy
of reiteration :

1. Borderland cases are not those that are frankly and definitely
recognized to be insane. The usual so-called borderland cases are
generally far enough away from the accepted normal to be easily
recognized as being really pathological. The adjective borderland
should be applied only to those cases which reveal a state of mind
out of hamiony with the accepted normality of its environment and
which may or may not be pathological or, in old terminology, in-
sane, according to the findings of a thoroughgoing physical and
psychological examination,

2. The somatic and the psychological manifestations are the only
means whereby wc can establish the diagnosis of these cases. While
the latter are most in evidence usually, the former are the more
important, in conjunction with the latter, in establishing the posi-

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338 The Archives of Diagnosis

tiveness of the diagnosis. When the somatic and psychological
symptoms are both obtainable the diagnosis of the case is compara-
tively easy, and resolves itself into a diagnosis practically of the
organic or functional disease of which the somatic manifestations
are the prime symptoms.

3. There are borderland cases so slight or so insidious that noth-
ing but the mental manifestations appear to be out of the ordinary.
The bodily state reveals nothing abnormal, so far as all the modem
means of examination can detect. As a rule, these cases are mere
misfits. They are out of harmony with their entourage. Some-
times they never get into a proper environment and so they always
seem queer, a little unbalanced, possibly a borderland psychosis or
psychoneurosis. The management of these individuals is obvious.

4. The correct diagnosis of these misfit cases, apparently border-
land cases, reveahng, as they often do, nothing but psychological
eccentricities, is always a matter of relativity. Not only is the pa-
tient under critical examination but the examiner and the com-
munity are subject to the same relative examination.

5. The diagnosis of a mental state, unlike the diagnosis of any
other functional activity of the organism, involves a knowledge of
all the workings of the himian intellect and emotions, which is a
knowledge of the whole of the human race, its history, its produc-
tions, and its trends, a vast subject indeed !

6. Averages and normals are not the same things by any means.

7. We have average standards in abundance ; normals we literally
know nothing of. Averages are always relative; normals, in re-
lation to so fluctuating and evanescent a thing as psychosis, are in-
conceivable. Mind and normality, in the true sense, are incom-
patible terms. Normal stands for fixity ; mind for ever active and
reactive variability. An imbecile is normal in a community of im-
beciles; a Shakespeare is abnormal in a community of common-
place mentality.

8. Society has a perfect right to legislate what it feels to be a
desirable (average) standard mentalization conducive to the preser-
vation of its own welfare; society has no right to declare a mind
normal or abnormal, except along the very coarsest, persistent
lines, until it includes in its standard the highest, noblest, and most

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Hart: Abnormalities of Myocardial Function 339

perfect (which is often unknown to society) degree of mental and
moral thinking. What is to determine such a standard, the lowest,
the middle average, or the highest types of intellect? It is all a
matter of relativity and environment. This is what renders the
diagnosis of these real borderland psychoses a task of unusual dif-
ficulty.

THE DIAGNOSIS OF ABNORMALITIES OF MYOCARDIAL

FUNCTION

By T. STUART HART

Assistant Professor of Clinical Medicine, College of Physicians and Surgeons,

Columbia University ; Visiting Physician, Presbyterian Hospital

New York

VI. AURICULAR FLUTTER

Closely allied to "Auricular paroxysmal tachycardia," discussed
in the last paper, is an abnormal functional activity of the heart
usually designated as auricular flutter.* The terms "Auricular
tachycardia" (Robinson), "Auricular tachyrhythmia" (Hoffmann),
and "Auricular tachysystole" (Rihl) have also been applied to this
condition.

The chief distinguishing feature of this group is the rapid, rhyth-
mic, coordinated systoles of the auricle, the contractions usually
occurring at a rate between 250 and 300 per minute. The auricular
rate is so rapid that the ventricle is unable to respond to each im-
pulse so that the ventricular rate is always slower than the auricular.
The abnormal activity may occur in short paroxysms lasting only a
few minutes or may be continued for days or weeks. It seems quite
probable that this peculiar activity differs essentially from that of
auricular paroxysmal tachycardia only in respect to the rate of the
auricular contractions; in paroxysmal auricular tachycardia the
auricular rate usually does not exceed 250 per minute and the ven-
tricles respond to each auricular stimulus; in auricular flutter the
auricular rate is much faster and the ventricles are unable to re-
spond to each auricular stimulus.

*Jolly and Ritchie, . Heart, 1910-11, H, 77.

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340 The Archives of Diagnosis

experimental production

As early as 1887 MacWilHam* described the phenomena which
result from the application of a weak faradic current to the exposed
auricular wall as follows; "It sets the auricles into a rapid flutter
... the movements are regular: they seem to consist in a series
of contractions originating in the stimulated area and thence spread
over the rest of the tissue. The movement does not show any dis-
tinct sign of incoordination: it looks like a rapid series of contrac-
tion waves passing over the auricular wall." Under these condi-
tions the ventricular rate is accelerated but is usually one-half or
less than one-half of the auricular rate. In a heart beating 140 to
180 per minute such faradization may induce an auricular rate o£
500 to 600 per minute while the ventricular rate may be 200 to 300
per minute. If faradization of the auricles is stopped the "auricular
flutter" may continue for a considerable time and then the auricle
may resume its physiological rate.

In the frog's heart "auricular flutter" lasting as long as two min-
utes, starting suddenly and terminating abruptly, may be induced
by a single induction shock applied to the sinusf or some portion of
the auricle.:^

While the auricles are in "flutter" vagus stimulation may change
the flutter into a condition of "fibrillation" and slow the ventricle ;
it does not, however, slow the coordinated contractions of the auricle.
It is possible, as suggested by Ritchie, that excessive stimulation
of the accelerator nerves may be a factor in producing flutter in
an otherwise healthy heart.

MECHAKISM
Experimental and electrocardiographic evidence indicates that
auricular flutter is characterized by a rapid rhythmic series of auricu-
lar contractions having their origin in some point of the auricular
musculature other than the sinus node. Nearly all paroxysms of
auricular flutter are preceded and followed by extrasystoles which
interrupt the physiological rhythm more or less frequently; the
extrasystoles are auricular in origin and probably arise in the wall

•Journ. of Physiology, 1887, VIII, 296.

tLovcn : Mitteilungen vom physiol. Laboratorium in Stockholm, 18S6, IV, 16.

)Enselmann: Arch, t. d. ges. Physiol., 1897, LXV, 109,

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Hart: Abnormalities of Myocafdial Function 341

of the upper chamber at a point which becomes the pacemaker for
the paroxysm. That the irritability of this point is very great may
be concluded from the great rapidity of the auricular systoles. The
mechanism is the same as that of auricular paroxysmal tachycardia
but in flutter the auricular rate is so great that the capacity of the
bundle of His to convey stimuli is exceeded and the ventricle re-
sponds only to every second or third auricular impulse. In most
cases the ventricular response is perfectly rhythmic and there is one
ventricular contraction to two or three auricular contractions. Less
commonly the ventricular contractions are arhythmic and respond
at one time to each second auricular impulse, at another time to each
third or fourth impulse from the upper chamber.

The activity may be regarded as an auricular tachycardia with
a functional depression of the property of conduction in the A-V
bundle. We conclude that a real depression of conduction exists
because we know that in "paroxysmal tachycardia" the ventricle may
respond to the auricular impulses at a rate above 230 per minute.

ncchaniim of auric

.of different types. TIk acrowi

auricle and traveling upward. The Ihickneu or^the lines repiesenling ventricular sys-
lole indicate Ibe rerative effect of the Kveral conlradioni in maintaininE an adequate
circulation. The obliquity of the A-V line indicati;* the varying length of the conduc
tioD time. Ag = auricular lyitole. A-V = conduction from the auricle lo the ventricle.
V> = veniriculat lytcole.

ilUUUUilUIUlU
1 11 1 IT 1 11 r n I II I r T T "

' I -iV i V i V i

attack the auricles

"1 1 [TrrTTTTTTTTTTTTTTTTt I

'1 '1 fr'l'Wlf\ \ \

lower grade of irreguUn.^ ^

to the firat, aecond, third or fou

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342 The Archives of Diagnosis

yet in "auricular flutter" the rate of the lower chamber of the heart
is usually not above 120; rarely it attains a rate of 160 per minute.
Ritchie* has reported a patient with a ventricular rate at times under
40 ; in this case there was probably an organic lesion of the bundle
of His.

Figure i shows in diagrammatic form the mechanism of a par-
oxysm in which the ventricle responds rhythmically to every third
auricular impulse ; during the attack the ventricular rate is accele-
rated but is only one-third the rate of the auricle. Each ventricular
systole of the paroxysm is less forcible, since the property of con-
tractility has not had the same time to recover as is permitted dur-
ing the physiological rate. The exhaustion of the capacity of con-
duction in the A-V bundle, due to the abnormal shower of auricu-
lar impulses, is indicated by the obliquity of the line representing the
period of the passage of the stimulus from the auricle to the ven-
tricle.

In figure 2 are plotted the auricular and ventricular activities
of a paroxysm of flutter in which the ventricular response is very
irregular; the lower chamber follows the first, second, third or
fourth auricular impulse in a seemingly haphazard fashion. The
conduction period is variable and prolonged. The ventricular con-
tractions have a force proportional to the preceding diastolic period.
The difficulty of differentiating such a mechanism from that of
"auricular fibrillation" is apparent. If the ventricular response had
been rhythmic up to the time of the final beats of the paroxysm,
it is easy to see how the pulse and heart sounds might suggest the
occurrence of an extrasystole only.

ETIOLOGY AND PATHOLOGY

The reported cases of auricular flutter indicate that it occurs con-
siderably more often among men than women. It may occur at
any age; the earliest subject which has been put on record was 5
years old. All the cases which I have observed, with one excep-
tion (14 years), have been over 50 years of age. Ritchie in his
analysis of 49 cases found that 70 per cent, occurred after the for-
tieth year.
•"Auricular Flutter," London, 1914, 36.

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Hart: Abnormalities of Myocardial Function 343

Auricular flutter rarely occurs without some other evidence of
damage to the cardiac tissues ; about a third of the cases show a de-
fect of the mitral valve. Dilatation of the auricles is a common
antecedent condition. Pericarditis has been present in several cases.
General arteriosclerosis in which the coronaries have participated
has been found in a number of instances.

The acute infections, such as diphtheria and rheumatic fever, have
been the evident causative agent in about 20 per cent, of the cases
thus far reported. Evidence of a syphilitic infection is obtained in
at least 10 per cent.

It has been suggested that an abnormal balance of external ner-
vous control may be an element in the production of auricular flut-
ter, but no anatomical lesion which would indicate a removal of
vagus influence or a 'hypertonic activity of the accelerators has thus
far been demonstrated.

Such evidence as is at hand leads us to beHeve that this abnormal
activity has its origin in a lesion in the auricular wall which con-
stitutes a focus of increased irritability.

In the few post-mortems which have been reported, in those who
have been the subjects of auricular flutter, histological examinations
have failed to demonstrate a particular focus in the auricular wall
to which one could ascribe the functional change, but general in-
flammatory and degenerative changes of the myocardium are not
wanting. Dilatation of the auricles with fibrous, fatty or lymphocy-
tic infiltration of the walls is the most common finding. Atheroma
of the coronaries and calcareous deposits in the arterial wall sug-
gesting an interference with the nutrition of the heart musculature
have been found in several instances. These lesions frequently in-
volve a large part of the heart muscle and may include the sinus
node and A-V bundle. Ritchie (Case III) found changes in the
sinus node consisting of lymphocytic infiltration. Hemorrhage and
granular degeneration of the nodes are reported by Hume.* I have
obtained autopsies in three cases, men of 51, 54 and 55 years, re-
spectively. Each showed sclerosis of the coronaries and extensive
fibrous myocarditis; in each very httle normal heart muscle could
be found. Each had an old infarct of the left ventricular wall.

*Heart, 1913-14, V, 25.

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344 The Archives of Diagnosis

identification

A careful history and physical examination may lead us to sus-
pect "auricular flutter," but one can only be sure of the correctness
of the diagnosis when fortified by the evidence of graphic records.
The pulsation of the veins of the neck gives us certain information
in regard to the activity of the right auricle, a very rapid rhythmic
pulsation of the jugular vein, showing a continuous series of waves
at absolutely equal time intervals and two or three times as rapid
as the ventricular rate, as determined by auscultation, suggests an
auricular flutter, but it is quite evident that by mere inspection it is
most difficult to count and correctly determine the spacing of the
small venous waves. In cases of established auricular flutter I have
repeatedly tried to elicit auscultatory evidence of the rapid auricu-
lar activity with complete failure.

The ventricular contractions may be perfectly rhythmic and so
accelerated that one may suspect a true "paroxysmal tachycardia"
(see paper V). As a rule, in "auricular flutter" the ventricular
activity is less rhythmic and not as fast as is the case in "paroxysmal
tachycardia." The irregular ventricular activity of "flutter" is most
often mistaken for the far more common disturbance known as
"auricular fibrillation" (see paper VII). In most cases of "auricular
flutter" the arhythmia is not as great as in "auricular fibrillation" and
in the latter the ventricular form of the venous pulse may aid in dis-
tinguishing the two conditions ; however, without the assistance of
graphic records the separation of these groups is practically impos-
sible.

When the ventricular rate is only 40 or less and perfectly rhyth-
mic, one at once suspects a condition of heart block. If in such a
case the jugulars are pulsating rhythmically at a rate of 200 or more
per minute, one can be reasonably sure that a condition of "auricu-
lar flutter" coexists.

There are certain types of irregular ventricular response when
the auricle is in flutter which simulate forms of extrasystolic ac-
tivity. For example, if for considerable periods there is a ventricu-
lar response to every third auricular impulse and this established
rhythm is broken by a ventricular response to the second auricular
impulse, which is in turn followed by a ventricular contraction after
four auricular systoles, the early beat and the succeeding pause may

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Hart: Abnormalities of Myocardial Function 345

give one the impression of an extrasystole with a compensatory
pause (see figure 2).

The polygram is often of material aid in making a diagnosis of
auricular flutter and the jugular tracing may demonstrate the rapid
rhythmic activity of the right auricle. The analysis of the jugular
curve is, however, often obscure, since the record of the waves of
auricular activity is distorted by the c and v waves characteristic of
the normal venous tracing. We should bear in mind that the a, c,
V and h waves of the normal jugular pulse do not follow one an-
other at exactly equal intervals of time, and when we can detect
in the jugular record such a rhythmic series of waves two, three

or four times as rapid as the ventricular rate, we have strong
grounds for suspecting a condition of auricular tachycardia.

Figure 3 was secured from a case of "auricular flutter" in which
there were regularly three auricular contractions to one ventricu-
lar. The ventricular rate was 92, the auricular rate 276 per minute.
One of the a waves of each cycle is simultaneous with the c wave.
The ventricle contracts in perfect rhythm.

A type of irregular ventricular response is shown in figure 4.
The jugular record is composed of a rhythmic series of o waves at
a rate of 280 per minute, which can be picked out by careful meas-
urement ; the pure auricular record is distorted by c and v waves of
each cycle and the whole is superimposed on the respiratory curve.

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346 The Archives of Diagnosis

The ventricle is contracting at a rate of 102 per minute ; the ventricle
usually responds to the fourth auricular impulse, but occasionally
(at X) it responds to the second auricular impulse. This type of
irregular ventricular response would strongly suggest occasional
auricular extrasystoles were it not for the evidence obtained from
the jugular tracing. The analysis of both of these polygrams was
verified by electrocardiographic records taken at the same time.

The electrocardiogram must be our final court of appeal in sub-
stantiating a diagnosis of "auricular flutter." Even here the evi-
dence is sometimes obscure, and it is wise to have records taken by
the three standard leads in order to be certain of our interpretation.

Figures s (lead I), 6 (lead II), and 7 (lead III) were taken
from the same patient at intervals of about one minute and indicate
the differences in the records secured by different derivations. Us-
ually the analysis is most easily made from leads II and III, but
this is not always the case. In these records the ventricle is beat-
ing rhythmically at a rate of 84 per minute ; the auricle is contracting
at a rate of 336 per minute. One of the auricular (F) waves of
each cycle is submerged in the R defection of the ventricular cycle.
The T wave of the ventricular complex is evident only in leads I and
II as a slight distortion of the rhythmically recurring P waves.

In figures 8, 9, 10, and 11 are shown four records from four
distinct cases of auricular flutter indicating the variations which
such a group of cases may present.

In figure 8 is reproduced a curve taken from a patient by lead I.

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Hart: Abnormalities of Myocardial Function 347

t H. S. Lad I,

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348 The Archives of Diagnosis

Fic. 8

Fic. 9

. L«d II. As:Vii:4:i. As = 4<i>- Vs = ii8. Time = o.a s«ond.

Fic. 10

Auricular fluller wiih irregutar ventricular responst. Lead III. As - jBo.

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Hart: Abnormalities of Myocardial Function 349

In this instance the ventricular rate is 166; the auricular rate is
332 per minute. The ventricular and auricular complexes are in
part superimposed so that the analysis at first glance seems obscure ;
by the aid of records taken by leads II and III (not reproduced)
we could clearly establish a rhythmic rapid activity of the auricle
at double the rate of tlie ventricle. The question arises in this case
as to which of the auricular stimuli excites the activity of the lower
chamber. We cannot answer this question positively but we have
strong evidence for presuming that the earlier of the auricular
stimuli (.P,) is the one to which the succeeding ventricular contrac-

tion is the response. If the response was to the stimulus delivered
at Pj the conduction time (Pa-Q) would be abnormally short.
While it is not inconceivable that in certain cases the property of
conduction may be heightened, all our experience goes to show that
in those cases of auricular flutter in which we have positive evidence,
conduction is normal or depressed (usually the latter). It is never
demonstrably shortened, hence we are led to believe that in every
case the conduction time is longer than the normal and therefore
in the instance shown in figure 8 it is probable that the ventricle
responds to P, rather than to P^.

A case in which the lower chamber response follows four auricu-
lar contractions is depicted in figure 9. The ventricular rate is
128; the auricular rate is 492. Both chambers contract rhythmically
but the auricle four times as often as the ventricle.

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350 The Archives of Diagnosis

Irregular ventricular responses arc shown in figures lo and ii.
In figure lo the auricle is beating rhythmically 280 times per
minute; the ventricle responds to every second or third auricular
stimulus.

Fig. 12

cvilar laic jSS. Rtg

In figure 11 the res|K)iise is to the second, third, or fourth auricu-
lar stimulus. This record is further complicated by an unusual com-
plex indicating one ventricular beat having its origin in a point
in the ventricular wall quite different from the other ventricular
contractions, which are of supraventricular origin.

A record from a case of "flutter" with a very rapid rhythmic re-
sponse is represented in figure 12. The auricular rate is 388; every

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Hart: Abnormalities of Myocardial Function 351

other auricular complex is submerged in a ventricular complex which
occurs 194 times per minute. The ratio of the rate of the upper to
the lower chambers is as 2 is to 1. A record from the same case
(figure 13) taken 15 days later, after the patient had taken digi-
talis, shows complete irregularity and a rate of 46 per minute. There
are at this time no coordinated contractions of the auricle, but its
activity is one of "fibrillation."

CLINICAL COURSE AKD SIGNIFICANCE

Auricular flutter is occasionally the only evidence obtainable of
a defective myocardium, though quite commonly extrasystoles pre-
cede and follow the paroxysms. In such patients careful examina-
tion fails to reveal any organic change in the valves, endocardium or
pericardium, and the only evidences of functional disturbance are
those elicited during the paroxysm. During the attack, which comes
on abruptly and terminates suddenly, the patient may be very un-
comfortable. He is conscious of an unusual commotion in the chest;
the accelerated and irregular activity of the ventricle may be the
cause of considerable apprehension; this may be accompanied by
some dyspncea, precordial distress and prostration if the paroxysm
is prolonged. Some attacks may extend over days or even weeks,
the earlier alarm and dyspnoea may subside, and the patient may re-
sume his usual occupation aware only of the continuing "palpita-
tion."

In most cases there are other evidences of myocardial damage
and the "auricular flutter" throws an additional load on a heart
already overtaxed. In such patients the general signs of cardiac
insufficiency may have been present before the onset of the auricu-
lar acceleration, or the unusual stress occasioned by the new rhythm
may be too much for a heart barely able to preserve an adequate
blood stream ; its narrow margin of safety is quickly exhausted, and
signs and symptoms of cardiac insufficiency rapidly appear. The
extent and severity of the symptoms depend to a very large degree
on the condition of the heart before the attack; the auricular flutter
may last for days or weeks, yet ultimately the heart may recover a
normal rhythm and perform its work with reasonable efficiency ; or
in a short time there may develop dyspnoea, congestion of the liver

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352 The Archives of Diagnosis

and lungs, edema of the extremities, Cheyne- Stokes respiration,
giddiness, unconsciousness and- collapse.

A patient may have many attacks of auricular flutter or it may
appear only as a terminal event. Once established, the attacks are

Fig. 14

Fig. 15

Pat:
later.

rhythm tak.

r^'tr^y^ra.

nij

s™t

prone to recur and each one is apt to persist for a longer time. Oc-
casionally one sees attacks of flutter alternating with periods of nor-
mal rhythm ; more often "auricular flutter" passes into "auricular
fibrillation," which may persist indefinitely or may, in turn, give

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Hart: Abnormalities of Myocardial Function

icmber 38. i;i4- A-jrlcuUt fibrillatioi
tubjecl, the firit of IhMe wai taken d
le lubKquciit rccordi.

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354 The Archives of Diagnosis

way to a physiological rhythm. With a return to a normal rhythm
the symptoms usually improve.

The tendency to resume a normal rhythm is seen in figures 14
and 15, taken from the same patient at intervals of eleven days.
Figure 14 shows auricular flutter at 300 per minute with an ir-
regular ventricular response interrupted at X by a ventricular extra-
systole. In figure 15 is seen the sequential rhythm of eleven days
later interrupted by an extrasystole of the same type as that which
occurred during the period of "flutter."

Figure 16 was taken from a patient during her first paroxysm
of flutter, which had its onset during an attack of lobar pneumonia
in March, 1912. In December, 1914, she returned to the hospital
with broken cardiac compensation. Her record taken at that time
(figure 17) shows a sequential rhythm, A few days later she be-
gan to fibrillate (figure 18) and has continued this condition up to
the present time (6 months later).

The clinical significance of auricular flutter lies in the fact that
it indicates a considerable degree of damage present in the auricu-
lar wall. That the damage may be temporarily repaired is indicated
by the recovery of normal rhythm, but the tendency to repeated and
more severe attacks suggests that usually the repair is incomplete.

The welfare of the patient depends to a large degree on the con-
dition of the ventricle. With a normal ventricular muscle the patient
will withstand many attacks of "auricular tachycardia" with com-
parative immunity. With a damaged ventricle the outlook is much
less propitious. Unfortunately the myocardial damage is rarely
limited to the auricle. In "auricular flutter" a slow, regular re-
sponse of the ventricle is favorable; a rapid, irregular ventricular
response makes the outlook more serious. The cliange to a condi-
tion of auricular fibrillation and a slowing of the ventricle under
digitalis are to be regarded as a favorable sequence of events. The
return to a normal rhythm is to be welcomed but by no means as-
sures complete recovery.

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Williams : Hypoadrenia Miscalled Neurasthenia 355

HYPOADRENIA MISCALLED NEURASTHENIA.

DIAGNOSIS AND PROGNOSIS

By TOM A. WILLIAMS

Neurologist to Epiphany Dispensary and Freedmen's Hospital; Lecturer on

Nervous and Mental Diseases, Howard University ; Corresp.

M. Soc. de Neurologie de Paris, etc.

Washington, D. C.

Twenty years ago the name neurasthenia was satisfactory to
general practitioners and to neurologists, the disease being charac-
terized by weakness of muscle, nerve and mind.

A disease in which this weakness was extreme, and usually fatal
in from a few weeks to ten years, was described by Addison in
1855, and was found to be due to partial destruction of the suprare-
nal glands.

But besides Addison's disease there are many degrees of insuf-
' ficiency of these glands; and we are now beginning to comprehend
that many symptoms long observed heretofore are due to lesions
thereof, causing reduction in the quantity of adrenal secretion and
hence hypoadrenia.

As the writer has said previously,* the term neurasthenia amounts
to nothing more than a convenient cloak for failure to investigate a
case sufficiently, and in speaking of hypoadrenia as a cause of neu-
rasthenia it is desired to call attention to the parallel existing be-
tween what has been called neurasthenia and the present conception
of hypoadrenia.

Various authors have given the following as some of the symp-
toms of neurasthenia: failing strength, prostration after exertion,
cold extremities, anemia, constipation, loss of control of attention,
weakness of memory, weak will power, inability to perform mental
work, incapacity of decision, abdominal throbbing from pulsating
aorta.

Compare the now well-known symptoms of hypoadrenia : asthenia,
sensitiveness to cold and cold extremities, hypotension, weak cardiac
action and pulse, anorexia, anemia, slow metabolism, constipation,
sometimes psychasthenia, as well as others which appeared in the
cases reported herewith.

■Archives of Diagnosis, 1909. Differential Diagnosis of Neurasthenia.

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356 The Akchives of Diagnosis

Hypoadrenia may result from the wasting of old age, the toxins
of the infectious diseases, hemorrhages into the substance of the
gland due to high blood-pressure, or perhaps from exhaustion by
long-standing emotions.

So that neurasthenia, we may realize, is hypoadrenia.

We know something of its pathology, but no one ever knew of a
satisfactory pathology of neurasthenia. The symptoms of hypoad-
renia stand out clearly, which never could be said of neurasthenia ;
and armed with this more definite knowledge, we can formulate and
carry out better ideas for its treatment.

An instructive case is that of a mechanic fifty-seven years old, re-
ported elsewhere,* whose history showed malaria as a cause of his
adrenal deficiency, and whose subsecjuent symptoms might easily
have lead to a diagnosis of neurasthenia. He felt unable to work
because he was weak and dizzy, he had that throbbing in the ab-
domen which has been mentioned as a symptom of neurasthenia,
and asthenia was present in marked degree. But he also had a
slight tremor of hands and face, a hint of von Graefe's sign, and
hypotension, his systolic pressure being io8. It was clear that
hypoadrenia was the cause of his trouble, and adrenal substance
cured him in two weeks.

A still more interesting example was an official in a responsible
. position whose mental depression, asthenia, languor, flabby muscles,
and incapacity of decision made a very good picture of neurasthenia,
and he feared dementia. There was some tremor. Hypotension was
evident, systolic pressure being loo at forty years of age.

Adrenal therapy improved him so that he was able to accom-
plish the work that he formerly could not do. Later he reduced
the dose until able to go without it.

A woman who had a postpuerperal psychosis, attacks of melan-
choly, had lost interest in life, food had no taste, was in despair be-
cause she wished to cease child-bearing. This might have been
called neurasthenia, but there was brown pigmentation of the skin
and a systolic pressure of 112, which soon fell to 90. At first 4
grains daily of adrenal substance was given without any visible
effect. The dose being doubled, however, improvement was rapid,

•Jour. A. M. A., November g, 1913.

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Williams: Hypoadrenia Miscalled Neurasthenia 357

and afterward the dose was successfully reduced. This result con-
firmed the diagnosis of hypoadrenia.

A professor of economics had headaches for six years, worse
after using eyes, had soreness over whole body, especially the neck,
dull pain over sacrum, and a tired voice. Oculists had failed to re-
heve him. He felt disinclined to take exercisej a change from his
former habits, and he had no sexual desire. A diagnosis of neuras-
thenia would have seemed appropriate. He had scarlet fever in his
youth, and an attack of the grippe had greatly aggravated his symp-
toms, and these toxic sources of adrenal weakness suggested adrenal
therapy, though hypotension was very moderate, systolic presst^e
being 114. He improved on small doses, and was afterwards able
to do effective work if it was limited to four hours a day. He has
later recovered completely.

A man of forty who was soon to be married feared he was im-
potent, and worrying about this had run him down until he was in
despair. He was depressed and was quickly fatigued, and was
found to have a pigmented abdomen and a systolic pressure of I03.
He was given adrenal substance and fully recovered, as a result
of this and appropriate psychotherapy to prevent the emotional
stress to which he had subjected himself.

These cases were all referred to me by fellow practitioners as
neurasthenics previous to about three years ago. Since then, a num-
ber of others have been brought me, but to relate them would merely
be a repetition of the facts.

Some cases do not do as well as these which have been mentioned,
however, and an instance is seen in an ethnologist thirty years of
age, who felt that his mind was shadowy and nothing seemed real.

He had intestinal flatulence, especially after worrying, sometimes
foul tongue, indigestion, dizziness and morning headaches from
autointoxication, constipation and sudden insomnia. A temporary
gain was soon lost after taking cold. His systolic pressure was only
102, so he was given adrenal substance, in small doses at first.
There being no rise of blood-pressure, the dose was gradually in-
creased until he was taking 14 grains a day, with varying pressure,
and still feeling discomfort. His improvement was slight, but he
worried less and the treatment was continued, in the hope that he
would learn to tax himself less in his work, and that thus his func-

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358 The Archives of Diagnosis

ttonal adequacy would increase. The patient fully recovered after
a year.

The fact that some instances of hypoadrenia are commencing
Addison's disease, and are destined to terminate fatally when the
adrenal glands are destroyed, makes it conspicuously necessary to
have a clear knowledge of the real conditions that cause the symp-
toms, as a diagnosis of neurasthenia under such circumstances would
be unfortunate.

Thus the daughter of a Boston physician began to tire easily at
study and at play. A long rest was prescribed and she took a long
trip to Europe, but the asthenia increased and finally became ex-
treme, the bronzing of the skin decided and the pupils dilated. A
diagnosis of extreme hypoadreiialism was made, adrenal substance
was given by the mouth and under the skin, but the patient died a
week after the treatment was commenced. At autopsy the cortex
of the adrenal glands was found to be nearly all destroyed, only
part of the medulla and the capsule being left.

Another case was that of a married woman of thirty-four who
had a nervous breakdown from overwork. She lost weight, had
anemia and asthenia and also feeble heart. Dilatation of the
stomach, sunken eyes, pale mucous membrane and rales in the chest
suggested tuberculosis. There was brown pigmentation of the skin
and a systolic pressure of 86, She died a few weeks later, and as
necropsy was refused it is impossible to say whether the failure of
adrenal secretion which caused her death was due to tuberculosis
or was a simple atrophy as in the preceding case.

My object has been to show by these instances that when we are
confronted with patients who have great asthenia, lack of concen-
tration, and more or less of the long list of symptoms heretofore
assigned to neurasthenia, we must not be content to stop with the
latter as a diagnosis. If, in addition, there are low blood-pressure,
subnormal temperature, pigmentary changes, hypoadrenia may be
the cause of the depression.

I feel sure that this syndrome is much more frequent than has
been suspected. In a special neurological practice by no means
large I have already seen upwards of- a score of such cases.

In spite of the rapid recovery of some cases, it is not wise to diag-
nose hypoadrenia therapeutically, for some patients do not improve

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Williams: Hypoadrenia Miscalled Neurasthenia 359

for long periods. To give adrenal substances for long is unsafe, as
over-stimulation of vegetative functions and internal secretions
might ensue. Even if no direct ill effects occurred, however, valu-
able time would be lost were the patient's neurasthenic state due to
another condition than hypoadrenia.

The diagnostic criteria were stated as follows in my paper to
the American Medical Association in 1913:

Asthenia. — From conditions of physical causation characterized
by great fatigability and feeble circulation the diagnosis would of
course be made by the current procedures of clinical medicine, on
which I need not enlarge here.

Psychasthcnia. — Patients of the type I have described are often
labeled psychasthenics because of their feeling of inadequacy, the
most prominent feature in psychasthenia. But the genesis of this
feeling in hypoadrenalism is a real physical tire occurring only
during exertion, while the genesis of the inadequate feeling in psy-
chasthenia is from a besetment or apprehension, and it always passes
off while the patient is actively exerting himself with muscles or
mind. If there is any feeling of panic because of the dread of his
incapacity in a hypoadrenal patient, this is a purely secondary and
normal reaction to physical fact ; and it is very easily dealt with by
enlightenment, as my cases illustrate. Furthermore, psychasthenics
present a vast series of intellectual, emotional and often motorial
symptoms, the combination of which is characteristic, and the source
of which can be detected by analysis of the psyche.

Hysterical Nosophobia and Its Consequences. — The seeming ex-
haustion and asthenia so often found as a result of a patient's belief
in the malfunctioning of a stomach, heart, intestine, limb or brain
is a phenomenon of mental attitude induced in the same way as is
the case in the little child who suddenly becomes tired when his
work or play is no longer to his liking. It is merely a lack of the
toughening of "psychologic fiber" necessary to social welfare. It
is a phenomenon induced by suggestion, and its name is hysteria.
The real physical exhaustion which may occur after long continu-
ance of hysteric attitudes like this is secondary to the depressing
emotions sometimes induced in the patient's mind.

From melancholia the incapacity of hypoadrenalism is distin-
guished by the absence of the retardation of thought and movement

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360 The Archives of Diagnosis

always present in the true melancholic, in whom, furthermore, the
responsiveness increases in speed and effectiveness as the day goes
on and when the stimuli are augmented and longer continued,
whereas in hypoadrenalism the patient is at his best early in the day
and the more work he does the worse he becomes.

Concerning neurasthenia, it should be evident that I have ceased
to recognize any such nosologic rubric, regarding the term merely
as a convenient cloak for failure to investigate a case sufRciently,
and placing all the patients who were thus formerly diagnosed in
categories corresponding to the etiologic factor which has deter-
mined their condition.

A NEW SYMPTOM OF ULCER AT OR ABOUT THE

DUODENAL PORTION OF THE PYLORUS

Bv HEINRICH STERN

New York

The symptom described hereafter is, as far as I could ascertain,
not alluded to in literature. Yet it occurs very frequently, as it
was present in practically every case of ulcer at or about the duo-
denal portion of the pylorus that has come under my observation
during the past year. The symptom is, without doubt, character-
istic of duodenal ulcer, and all but one of the patients exhibiting
it were men. In addition to this particular symptom the same
patients complained of other symptoms pointing to an ulcerative
process within the duodenum, as, for instance, the hunger-pain, and
they usually showed most of the signs as disclosed by a chemical
and physical (including the rontgenological ) examination.

The symptom is both of an objective and subjective nature. It
is subjective because it is a reaction to pyloro-epigastric discomfort
or pain; it is objective because it is a visible evidence that the
patient voluntarily or involuntarily assumes that posture which
gives him most comfort.

This posture constitutes the sign or symptom. The patient, try-
ing to stretch out his epigastrium on account of the relief obtained
thereby, often prefers standing to sitting; when in discomfort while
resting upon a chair he sits in a slanting position in such a manner
that chest, abdomen and legs form a perfect incline. When ex-

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Stern : Ulcer of the Duodenum 361

periencing discomfort while in bed, the patient tries to lie as straight
as possible, often on the left, but never on the right side.

The patient, of course, will always speak of his discomfort or
pain, but will hardly ever mention the posture he assumes when in
distress unless he be directly questioned about it. This is readily
understood when we consider that many patients stretch the pyloro-
epigastric region in an entirely instinctive manner. (When in the
physician's office, the patient naturally feels under a certain restraint,
and he does not assume the posture which gives him most comfort.)

It seems almost as if the patient with a duodenal ulcer occupies
by preference the posture which is the reverse of that by which he
has acquired the lesion. With very few exceptions, the body of the
individual during the process of development of a duodenal ulcer,
especially when at work, is bent over, the curve being in the pyloro-
epigastric region. Very often this region impinges upon a hard
object, as a working table, for instance. This is especially the case
in right-handed people. (I have never seen a case of duodenal ulcer
in left-handed persons.) This curve is bound to interfere more
or less with the blood supply of the peculiarly-shaped duodenum,
and the production of a localized necrotic spot, commonly styled
an ulcer, is not difficult to explain. (Corsets worn by women are
apt to prevent this injury.)

On this occasion I shall not attempt to discuss why the drawing
out of the body, its stretching, is pathognomonic of ulcer about the
distal and not about the proximate side of the pylorus. It probably
finds its explanation in the anatomic conditions and relations of the
duodenum.

The symptom or sign is of especial value in differential diagnosis.
It is not present in gastric ulcer. In gall-stone colic, the patient
usually lies on his left side with legs drawn up. In appendiceal
colic, as well as in the common affections of the cecum and the
colon in general, the body of the patient, when sitting, is bent over;
when lying, his legs are more or less flexed.

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362 The Archives of Diagnosis

RARE FORMS OF PERICARDITIS

By GUSTAV singer

Vienna, Austria

Despite a number of refined physical methods, among which radi-
ology is a very welcome ally, the clinical recognition of the inflam-
matory processes of the pericardium leaves much to be desired.
It may even happen that these processes are only recognized at the
autopsy table. This is hardly astonishing in dry pericarditic af-
fections with fleeting intravital symptoms; however, cases of peri-
cardial exudate may be clinically overlooked by the most experienced
and painstaking examiner.

The' importance of the inflammatory diseases of the pericardium
justifies the thorough revision of all the criteria of an exact diagno-
sis. In this communication, however, I wish to discuss some forms
of pericarditis which are little known, but are of great import in
diagnostic as well as prognostic respects.

The relationship of inflammatory processes of the pericardium
to stenocardia gives rise to a unique clinical syndrome. It is quite
plausible that certain clinical points of connection appear in this
symptom-complex. We know, for instance, that acute pericarditis
without premonitory symptoms is sometimes associated with a dull,
occasionally quite violent pain about the anterior chest-wall. In
case a noticeable appearance of apprehension ensues in addition to
the precordial pain (a frequent factor in acute cardiac disease) a
symptom-complex resembling that of angina pectoris may be pro-
duced.

I shall particularly discuss those cases in which, in previously
entirely healthy persons, the typical picture of the stenocardia at-
tack is produced suddenly like in angina pectoris. In these cases
the attacks may repeat themselves or may continue for days until
the appearance of friction sounds in the characteristic location or
until the production of the pericardial exudate, phenomena which
leave no doubt that the patient suffers from a pericarditic affection.

PERICARDITIS ANGINOSA

This form of pericarditis, as some believe, may be ushered in
with initial symptoms which entirely resemble angina pectoris. In

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Singer: Rare Forms of Pericarditis 363

other words, angina pectoris may not necessarily point to coronary
disease, but it may fully develop in the form of the symptom-com-
plex of pericarditis. Another group of authors is of the opinion
that stenocardia and coronary disease are an inseparable pathologi-
cal unity, and declares that pericarditis (even the acute febrile form
of the same) appearing together with stenocardic attacks, is the
result of certain affections of the coronary arteries, especially of
thrombosis with following myomalacia. According to this assump-
tion, the pericarditis arises as a secondary inflammation, on account
of the involvement of the visceral portion, the epicardium.

It is especially Kernig who has reported a series of cases of peri-
carditis following stenocardia, and who has endeavored to show
that an occlusion of the coronary arteries was at the foundation of
each particular instance.

Despite the convincing and anatomically verified conditions, the
temporary combination of stenocardia and inflammatory pericar-
ditis is not always caused by coronary disease. There are cases
with sound coronary arteries in which the syndrome "pericarditis-
angina pectoris" is a characteristic manifestation of the inflamma-
tory cardiac pain. The following case may serve to illustrate my
contention.

A man, forty-five years old. Was examined by me previously
and found clinically entirely well. The day before he visited me
he had, on going into the cold air from a warm place, an attack of
very violent cramp-like pains in the chest, together with much op-
pression and dyspnea. He could not proceed and was brought home
by a physician, who described the attack as a typically stenocardic
one. The examination showed some pallor, no abnormality of the
pulse or the size of the heart. A systolic and a diastolic murmur
were noticeable at the apex ; at the base, however, the sounds were
clear and not accentuated. The liver was somewhat enlarged.
Tonometric measurements showed 125 mm. in the morning and 115
mm. in the evening. The Rontgen examination showed a dilatation
of the shadow of the aorta at its root and an enlargement of the left
auricle. The thorax during inspiration showed superficial excur-
sions, and the patient complained of vague pains corresponding to
the location of the diaphragm. During the next few days no tem-
perature elevation was observed. The blood pressure, however,

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364 The Archives of Diagnosis

was increased ; the pains continued, and a phenomenon which was
present right from the beginning of the attack, pulsus paradoxus,
was observed.

The intensity of the symptoms of the first attack was never re-
peated. Continued observation of the patient showed friction sounds
in the left mammary and axillary lines. Synchronously with these
there ensued violent pains in the thoracic musculature, of the
muscles in the extremities and in the articulations of the shoulders
and hands. Fever was never present. The muscular pains oc-
curred again during the next two years, and it was finally admitted
by the patient that he had always had similar pains in the spring
and autumn. The liver became smaller, the pulsus paradoxus and
the abnormal sounds disappeared. An affection of the aorta or the
peripheral blood vessels could never be determined. The patient,
an alpine climber, never gave up this sport, and at no time could
any affection of any part of his circulatory apparatus be detected.

I do not doubt, though a strict proof has not been furnished, that
in this case there had existed a rheumatic, latent pericarditis and
mediastinopericarditis (pulsus paradoxus) for some time until the
sudden acute attack resembling angina pectoris ushered in a frank
state of the condition, and that for this reason the stenocardia was
not associated with a vascular affection, but was merely a symptom
of dry pericarditis. The enlargement of the liver, which disappeared
after a few weeks without medication, is of some import as a symp-
tom of pericarditis.

A case of Andral, which is cited by a number of authors, deserves
brief mention in this place. The patient was a man, thirty-one years
old, who was affected with acute articular rheumatism. On the
second day of his disease he had violent pains lasting the entire
night and the following day. At the same time there existed
arhythmia, tachycardia with intermissions, small pulse, most pro-
nounced anxiety, pallor, and cold extremities. After twenty-nine
hours of this agony the patient died. Necropsy showed that the
entire internal surface of the pericardium was covered with a white,
membranous exudate beneath which the pericardium was strongly
reddened. The organ was filled with an ounce of greenish-serous
fluid. The heart, the endocardium, the lai^e vessels, the abdominal
organs and the brain showed no pathological alterations.

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Singer: Rare Forms of Pericarditis ' 365

The cause of the stenocardic pains in pericarditis is, according to
Pawinski, due to an affection of the cardiac plexus which is com-
posed of the fibers of the vagus and the sympatheticus. It was
Neusser, however, who put into the proper hght the appearance of
pericarditis under the symptom-complex of angina pectoris. He
says that acute exudates into the pericardium may like hematomata
call forth a dull precordial pain. This confirms the observations
of French clinicians concerning the occurrence of neuritis of the
phrenic nerve in such cases.

As far back as 1S91, Curschmann has shown that in initial cases
of arteriosclerosis calcium deposits at the roots of the coronary ves-
sels may engender ischemia and stenocardic attacks. These findings
served Pawinski as well as Neusser to explain those stenocardias
in which the lumen of the coronary arteries is compressed and
stenosed. However, there are rare cases of angina pectoris causing
sudden death in which necropsy only demonstrates a synechia of
the pericardium without a narrowing of the lumen of the coronary
vessels.

The stenocardias with intact coronary arteries, of which quite a
large number are reported in medical literature, form the founda-
tion of the neuritic theory of angina pectoris. In this connection
it is of great importance what Neusser has stated in regard of the
production of angina pectoris. He says : "Angina pectoris can not
only be explained because of ischemia of the cardiac muscle, and
its production is not solely caused by the mechanical narrowing of
the vessels. Besides the stabile factor of the anatomical stenosis
of the vascular lumen there exists a labile factor, vis., an active
vasoconstriction due to hypertrophy of the muscularis. Besides,
there may be an increased irritability of the nerves and ganglia
situated in the vascular walls."

The many authoritative investigations have definitely demon-
strated that pericarditis sicca or exudativa may be associated with
unmistakable stenocardia. Especially those cases of stenocardia
are suspicious of latent or not demonstrable pericarditis, in which
the anginal attack is not paroxysmal and brief, but enduring and
appearing as status anginosus ; cases in which the attacks ensue in
early life when arteriosclerosis has as yet not supervened, or which
are associated with or tntercur during rheumatic affections; cases

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366 The Archives of Diagnosis

in which syphilis may be excluded and in which the violent pain
during the first few days is soon coupled with elevation of tempera-
ture.

The proper interpretation is often dependent upon the audibility
in the typical locations of the friction sounds which are often quite
transitory. If these sounds are not heard, many instances of the
affection will never be recognized. Generally speaking, frequent,
regularly appearing, stenocardia pains supervening for a rather pro-
tracted period in the absence of gross changes (dilatation of the
aorta, aneurism, demonstrable aortic disease, pronounced arterio-
sclerosis) point to latent pericarditis.

Patients who are supposed to suffer from angina pectoris often
state that they feel quite well when at rest and feel no oppression
whatever, but complain that the slightest effort at walking, espe-
cially in the street (even in mild weather) compels them to stop.
They experience no difficulty in breathing, but assert that an unde-
iinable sensation constrains them. This symptom, in my opinion,
strongly points to the presence of pericarditis.

A woman patient, whom I am treating for ten years for an old
mitral stenosis and insufficiency, showed aforementioned phenomena.
During a night, while in the country for the summer, she had sud-
den attacks of violent constriction pains in the chest which were
pronounced to be of an anginal character by the local physician.
The symptoms were repeated with greater or lesser intensity. A
disease condition developed for some weeks which was principally
characterized by depression, feeling of anxiety and vague phenomena
pointing to the heart. During this time I saw the patient once, but
could not determine any change from her physical condition previous
to the attack. Pronounced symptoms of decompensation were not
present. After some weeks I was again summoned, but the patient's
condition had not undergone any material change. However, no
progress in the subjective condition was noticeable. She complained
that, without feeling very sick, she was compelled to lie in bed as
she would break down after having made a few steps on account
of a feeling of weakness and severe oppression in the chest. For
the first time I found a distinct change in the physical findings.
There were loud scraping friction sounds over the entire heart, and
the attending physician corroborated that the patient had had peri-

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Singer: Rare Forms of PERicARDiTts 367

carditic friction for some time, but that the resemblance of the first
attack to stenocardia had been very great. Strict rest in bed was
ordered, after which subfebrile temperatures ensued. Antiphlo-
gistic treatment, etc., caused rehef after a comparatively short time.
The patient has never had a stenocardia-like attack since.

uremic pericarditis

In fully developed uremic conditions circumscribed friction
sounds, localized about the base of the heart, are nearly always
audible. These sounds are such a regular phenomenon that I look
upon the occurrence of dry afebrile pericarditis in vague cases as
a pathognomonic symptom of uremia.

Associated with this symptom there exist mostly the characteristic
uremic disturbances of respiration and the peculiar symptom first
described by Drasche in choleratyphoid, viz., a mealy deposit upon
the skin, especially upon forehead and the nose, consisting of very
fine urea crystals. The appearance of this symptom seals tfie gloomy
fate of the patient. In numerous cases that perished I have ex-
amined the fibrin deposit of the pericardium, which is invariably
sterile, for the presence of urea, and I was always able to demon-
strate a large number of crystals by the addition of nitric acid.. In
these cases we have to deal, therefore, with a retention toxicosis
of the skin and the serous membranes.

In this form of dry pericarditis the first appearance of the fric-
tion sounds over the base of the heart is also characteristic. In
case the fibrous exudate in the region of its primary location is but
small or the conditions for the production of friction sounds are
not sufficiently favorable, the physical, often evanescent, signs qf
dry pericarditis may not be present at all. Still in such cases the
consequences of the compression of the vascular roots by the exu-
date, especially about the roots of the coronary arteries, may super-
vene in a form completely agreeing with the typical signs of steno-
cardia.

The conditions favoring this phenomenon undoubtedly exist quite
frequently. This anatomical localization is, as has been shown, a
possible explanation of the association of pericarditis and angina
pectoris.

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368 The Archives of Diagnosis

DIAGNOSIS OF GENITOURINARY CONDITIONS IN '

WOMEN BY MEANS OF THE RONTGEN RAY.

By G. S. PETERKIN

Seattle. Washington

Every one of us knows that the minds of the highest and the low-
est of mankind are compounded of the same elements, held subject
to the same laws of action ; that the knowledge any one of us pos-
sesses must come through the ordinary channels of sense — sight,
hearing, smell, taste, touch, and the muscular sense.

The correctness of the perception of an object obtained by an in-
dividual through his senses is usually iii proportion not alone to the
accuracy of any one sense, but to the number of senses used to cor-
roborate the primary impression made upon his brain. To prove
the truth of a perception to others, means of making an exact ob-
jective record must be devised. Then the perception will be ac-
cepted and can be used as a means of comparison, making knowl-
edge scientific, instead of speculative. This psychological axiom
is clearly expressed in the slang phrase, "Show me !"

It is the purpose of this article to show that a method of making
the sense of touch — palpation — a matter of record has been de-
veloped, and the diagnosis of genital and urinary diseases in women
has been placed, therefore, on a scientific basis, instead of being al-
most wholly speculative.

The means to this end is an X-ray pessary. The technic of its
employment will be briefly presented, with evidence to substantiate
the statements made as to its utility.

How this instrument can accomplish its object will be better un-
derstood when we call to mind the following facts :

1st. That the ureters, as they pass along the cervix between the
broad ligaments, are virtually firmly attached to this organ (Fig.
I,a).

2nd. That practically the entire base of the bladder is firmly at-
tached to the body and cervix of the uterus for at least one and one-
half inches (3.7 cm.) (Fig. i, bj.

3rd. That the bladder is attached to the vaginal wall, the anterior-
superior portion of which, in turn, receives its support directly from
the uterus (Fig. i, c).

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PETERKIN: Genitourinary Conditions in Women 369

t^t^^^j^f M at^wtt^mi- */ iMt&*. &

m.thcJ <,f m.*/^r,

A-flt'f /■•>"">'•"■'/,

m,ih,dUiioi ~,jj^,fjlf.,^ji,/,^f.r

a>(.^" •trtft'-'i /t— — '^'' <-.

... - ,_,^^,

Fig. 2

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370

The Archives of Diagnosis

Therefore, if the situation and the mobility of the uterine cervix
can be accurately determined and recorded, the position of the
uterus, the effect of the various positions of the same on the blad-
der and kidneys, and also the result of intra-abdominal pressure
upon the urinary and other pelvic organs, would become a matter
of scientific knowledge.

4th. The Rontgen rays show the position of metal in any part
of the body. If a metal cervical pessary, therefore, can be so in-
serted in the cervix as not to interfere with the mobility of the
uterus, we can readily obtain a picture of same in any position of
that organ.

5th. By selecting fixed points on the body for measurement, the
exact position and extent of the uterus can be ascertained and re-
corded.

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Peterkin: Genitourinary Conditions in Women

37'

The fixed points so selected are as follows (Fig. 2) :

1. A horizontal line through the middle of the symphysis pubis.

2. A vertical line which intersects the horizontal at the median
line of the body, i.e., at the middle of the cartilage of the symphysis
pubis.

The following measurements enable one to determine the exact
position of the uterus:

Fic. 4

Old pesaary in si In

1. The distance from the middle of the base of the pessary to
The vertical line (Fig. 2, a).

2. The distance from the middle of the base of the pessary to the
horizontal line (Fig. 2, b).

3. The angle of the shank of the pessary to a horizontal line drawn
from the anterior to the posterior surface of the patient (Fig. 2, c).

X-RAY PESSARY TECHNIC

I. Inserting Pessary

Patient is placed in position for vaginal examination. The larg-
est possible speculum is inserted, cervix brought into view, ren-
dered aseptic and sterilized pessary inserted.

That the radiographic technic and the technic of interpreting the

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372 The Archives of Diagnosis

radiographic findings may be recognized to be correct in principle,
though as yet not wholly so in detail, we will briefly outline the
evolution ot the X-ray pessary.

1. 90'

i 7f

i. ty

>. ff

• )

• ^

!. it ■

6 if

7- />■

/ .• ^

In our first enthusiasm we had not counted on the importance
of shape. The shadow cast by an uninterrupted round base of a
brass pessary (Fig. 3, a) did not allow the drawing of any con-
clusion as to whether the pessary had rotated or was pointing back-
ward or forward, or both (Fig. 4).

To overcome this and facilitate measurement of angles, a square
base was devised (Fig. 3, b), with one rounded comer (Fig. 3, c),
the round comer making it possible to see on the X-ray plate
whether the pessary had remained in the cervix as originally in-
serted or rotated. Furthermore, the pessary being composed
throughout of the same metal, the base completely eclipsed the
shank when extremely tilted anteriorly or posteriorly, making the

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Peterkin : Genitourinary Conditioxs in Women 373

measurement of the angle at which the uterus was tilted an im-
possibility.

Later the important addition of a round opening cut in the base
was made (Fig. 3, d), which affords another identification mark

as to the tilting of the pessary, by observing the size and shape of
the hole on the X-ray plate (Fig. 5), Fig. 6 illustrates in the fol-
lowing order (a, b, c) the evolution and development of the holder
for inserting the X-ray pessary.

The latest pessary (Fig. 7), though by no means perfect, still
has many advantages, which are as follows :

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374

The Archives of Diagnosis

The shank is composed of rubber and the base of very light
metal, with the result that its light weight will not interfere with
the position of the uterus, as that of the first pessary possibly did,
since the difference in weight is 13. i grams, or nearly J^ ounce.

In order to show any rotation or other movement of the uterus,
the round hole in the base is always placed in one position. The
position selected in our work is anterior and to the left side of the
patient.

The four triangles free from metal enable one to see readily the
cervical os, facilitate insertion of the instrument, and also permit
one, knowing the position of the round hole in the base, to note the
extent and the character of the uterine displacement by observing
on the X-ray plate which triangle of the pessary is obscured.

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Peterkin: Genitourinary Conditions in Women 375

2. X-Ray Techtik

The series of pictures taken of normal and abnormal cases in
various positions, Trendelenburg, standing, lying, without corsets,
with corsets, with corsets laced tightly, etc., with many other points
of evolution and technic, are omitted.

The fact exists, as already intimated, that to date we do not pos-
sess accurate knowledge as to the position of the normal nou-preg-
nated uterus, the extent of its mobility, or its position under vari-

Palpiiion

ous conditions, normal or abnormal. The only means of asicrlaln-
ing the same is by palpation — a means that demands displacement
from the' normal, the overcoming of muscular resistance (Fig. 8),
with entire failure to recognize intra-abdominal pressure as a factor.
Moreover, it is a method that permits of ascertaining the positioti
of the uterus in virtually but one position — the lithotomy position,
not standing, with corsets, without corsets, etc.

Our present ocular knowledge is just as incomplete, for it is ob-
tained at operation under general anesthesia or post-mortem. In

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376 The Archives of Diagnosis

both these conditions two important factors governing the normal
position of the uterus are entirely ignored — that is, intra-abdominat
pressure and muscular tonicity.

Fig. 9

P.li,n. lying, wilhou. corwls

But look at Fig. 9. There you see in a patient lying free from
clothing the position of a normal uterus. In the next plate (Fig.
10) is shown the position the uterus assumed in the same patient
standing, without corsets. Fig. 1 1 shows the position this uterus
assumed when corsets were laced tightly, patient standing, waist
compressed 2j4 inches.

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Peterkin: Genitourinary Conditions in Wo:

377

In these three plates, the positions are different — so different as
to be clearly apparent.

Here every physician reading this article sees — (think of it!) —
has the same exact ocuiar perception of the position of a normal
uterus in a living subject under these varying conditions. Have
you ever before seen the position of a normal uterus in a living,
conscious woman with abdominal wall intact? I think nott

Fig. 12 is a diagrammatic drawing made to readily illustrate the

-Jf.. ......

.»,-,..

Jf,-.— .

.K., .

(I. ..

«. -r

^'"^Sfc-

Fig. 12

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378 The Archives of Diagnosis

difference in the range of motion in a virgin and multipara with
lax intra-uterine ligaments and procidentia as shown by a series of
X-ray plates taken with pessary in situ. The red line is the center
of the symphysis pubis ; the black horizontal lines on the left, marked
"H" above same, show the position under varying conditions in a
virgin : those on the right, marked "B," variation in a multipara.
The difference in the range of motion and position is readily seen.

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Peterkin: Genitourinary Conditions in Women 379

Is this knowledge as to the mobility of the uterus of practical
value? I would say "Yes," in so far that whatever operation is
employed to rectify uterine displacement, the principle governing
it should be such as to permit the cervix a free range of motion
between i cm. (.4 inch) and 7 cm. (2.8 inch) above the middle of
the symphysis pubis. Again, the range of mobility obtained before
operation will give information as to the tonicity of the uterine
ligaments, therefore not only indicate the character of the opera-

tion which is the best — whether suspension of the uterus, shorten-
ing of the ligaments, or both — but the exact amount of shortening
of ligaments necessary, etc.

By means of the X-ray and the X-ray |>essary, pathologic condi-
tions in the genital and urinary apparatus in women may be seen
as they exist before operation, and after operation the exact imme-
diate and late post-operative results, and thus statistics of value as
to the effect of various operations of suspension, etc., for proci-
dentia, cystocele, etc., may be compiled. The exact character of

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380 The Archives of Diagnosis

such pathologic condition and the results of operation, until the
advent of this X-ray pessary, every one of us could surmise, but
could not demonstrate.

It is my behef that this instrument — the X-ray pessary — will open
a large and fertile field of study that will not only improve our
knowledge of the genital and urinary diseases in women, but enable
us to attain a much needed improvement in our surgical treatment.

The points taken are illustrated by the following:

Palicnl lying, wilhout caiwu, bladder fillfd

Fig- 13. normal patient, new pessary, bladder filled.

Corroborates the statement that by observing the angle obliterated
the position of the uterus can be defined. Here the posterior angle
is partly effaced, demonstrating a tendency to retroflexion, due to
fully distended bladder.

The next two illustrations (14 and 15), multipara with procidentia
and cystocele, prove that we can ascertain the effects of corsets or
constriction of the abdomen upon |>elvic organs.

Fig. 14, bladder empty, patient lying, without corsets. Note the
position of uterus. Fig. 15, patient standing. Note effects of old-
fashioned, tightly laced corsets — uterus well depressed below sym-
physis.

The next two illustrations (16 and 17), multipara, procidentia

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Peterkin: Genitourinary Conditions in Women 381

and cystocele, present two methods of X-ray diagnosis to show (i)
how much the cystocele is due to relaxation of vaginal walls, (2) to
the displacement of uterus. Fig. i5 exhibits the position the uterus
assumes, patient lying, as illustrated by X-ray pessary, position of
mouth of bladder as shown by X-ray catheter. Fig. 17 shows posi-
tion of uterus, also of mouth of bladder, when the patient is stand-
ing. The exact difference is plainly discernible.

Figs. 18, 19 and 20 show the position of uterus in a nullipara,
slight procidentia, no symptoms, bladder filled with two per cent
silver iodide. Fig, 18, patient lying. Note the bladder is above the
symphysis pubis, as is also the cervix uteri. Fig. 19, patient stand-
ing, exhibits bladder sufficiently below symphysis to permit of a
diagnosis of cystocele, but the causative factor is the more pro-
nounced procidentia, as evidenced by the position of pessary, which
is not only considerably below center of symphysis pubis, but also
much below bladder. Fig. 20 is taken with patient standing, but
bearing down. Note there is practically no difference of uterus
between this and Fig. 19, showing the value of an intact vaginal
wall as a uterine support.

Fig. 21 is a diagrammatic drawing we employ in our case his-
tories in noting position of uterus and bladder.

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382

The Archives of Diagnosis

Though this means of diagnosis is in its experimental stage,
nevertheless when a patient comes who has urinary symptoms, fre-
quency, etc., with various diagnoses as to degree and form of mal-
position of the uterus (as varied as the number of physicians con-

Drawing for case historic!, .\-ray— (a) shadow of bladder: (b) shadow of lymphriis.

Normal— bladder and ressary above symphysis. Cysioccic— bladder and

prsiary briovt center of symphysis

suited), one can make the diagnosis, demonstrate the findings in
black and white to the patient on the X-ray plate; then is the prac-
tical value of the X-ray pessary evident. It makes the diagnosis
an exact science— which the public is not slow to appreciate.

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Kilduffe: Urinalysis 383

URINALYSIS AND THE GENERAL PRACTITIONER

By ROBERT KILDUFFE. JR.

Director. Pathological Laboratory. Chester Hospital

Chester, Pa.

This is an age of scientific medicine, or, as might be said, of
etiologic medicine, having as its keystone accuracy in diagnosis,
pointing tlie way to accuracy in treatment; and each year the en-
ergies and the skill of the theorist, the investigator, and the clinician
are bent toward the development and perfection of diagnosis as an
exact science.

It is not my intention to even touch upon the many advances in
diagnostic technic which belong fairly and entirely to the laboratory
man, but rather to confine myself to those within the reach of the
general practitioner — and not to all of them, for if he but realized
it, his activities in this field are far from restricted — but to one
a lone — u rinaly si s .

Urinalysis is one of the most useful, and most neglected, of diag-
nostic procedures at the service of the general practitioner. This
is a statement which can be made without fear of contradiction, for
the method of urinalysis as practised by the average practitioner
consists, as a rule, of one of two ancient and classic procedures.
The first of these is to allow the bottle to stand until obtrusively
ammoniacal and then drop it into the waste-basket, and the second,
to employ the "sink test," which has, at least, the value of rapidity
and cleanliness.

The explanation, I believe, lies mainly in the multiplicity of tests
vkrith which the various text books and manuals abound, and the
amount of apparatus necessary for their performance — to say noth-
ing of the skill and experience demanded by their technic and the
interpretation of results.

It is true that there are laboratories galore from which voluminous
reports may be had, and reports of great value to those who can
interpret them, but either the patient cannot or will not pay for the
examination, or they are so exceedingly complete as to still further
becloud the diagnosis of a doubtful case, and again the urinalysis is
neglected or its results pooh-poohed.

I would like at this point to say a few words in regard to the inter-

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384 The Archives of Diagnosis

pretadon of a urinalysis and of laboratory reports in general. Let
it be borne in mind that anyone, without exception, can be taught
to put this and that together in a test tube, or to make this or that
stain, or prepare, section, and stain a tissue, and successfully carry
the performance to its ultimate conclusion — and the result is simply
a completed test. The interpretation of the result, the meaning of
that test with regard to that definite case, is a very different matter
entirely and requires an altogether different person. It is the man
behind the test who makes it worth doing. The man who thinks
that surgery, that drugs, that electricity, or massage alon^ are cure-
alls, is close kin to him who thinks that the art of diagnosis rests
alone with the laboratory ; that all he has to do is to drop a test in the
slot and draw out a neatly printed diagnostic card in return ; and
he wears the same blue spectacles and travels in the same rut with
the man who looks upon the laboratory as a fanciful and orna-
mental way of wasting time.

Let us not forget that there is not a single advance in either
medicine or surgery, in pathology, hygiene, or sanitation, which
does not depend upon the cooperation of the laboratory worker, upon
his ingenuity, his skill, and above all, his patience. Remember-
ing that, let us treat him fairly as a brother consultant and as such,
entitled to his due.

We would not call in a surgeon and, depriving him of the history
and physical examination, say — "Here is a twisted knee — what is
the matter with it ?" Or a physician and say — "Here is a man with a
cough — what has he got?" But it is quite the proper procedure to
get a specimen of urine, or of blood, and because we find albumin
or an anemia, to expect an answer to the question, "What has he
got?" Or, in spite of the fact that the same cells which in the skin
of the hand are normal, in the breast spell carcinoma, to cut a piece
squarely from the center of a tumor mass, to put it into the first
solution at hand, or even, as I have seen, none at all, and without
any history, without any knowledge of the symptoms, without any
idea of where the specimen came from, to ask the pathologist, "What
has he got?" We all know the mere presence of albumin in the
urine does not make a diagnosis of Bright's disease, that there are
many factors which must enter into the interpretation of its pres-
ence and determine its diagnostic value — in a word, that it is the

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Kilduffe: Urinalysis 385

interpretation of the test that counts; but if we cannot interpret it,
do we consult the books, or better still, give the laboratory man the
same facts we possess in regard to the patient and ask his interpre-
tation as we would any other consultant ? We do not. We either
disregard the analysis or take it as another evidence of the useless-
ness of laboratory examinations in a doubtful case.

Do not think that you can always make the diagnosis by the
laboratory alone or without it ; the diagnosis is always the sum total
of the history, the physical examination and the laboratory test, and
not infrequently it is the last which points the way.

Returning from this digression, it is my purpose to call attention
briefly to the value of a routine analysis in all cases, and what is
more important, to the small number and extreme simplicity of
certain tests which are as easily made and as easily interpreted by
the general practitioner.

It may be of interest to note, briefly, the more salient points in
the history and evolution of this most ancient procedure — the diag-
nosis of pathological conditions by the examination of the urine.

In the British Museum are fragments of a Syllabarium or dic-
tionary of words relating to parts of the body, among which are
signs and words relating to urine which show that as early as 4000
B. C, the Babylonian physicians had noted changes in its color and
composition.

The Hindu physicians, in their earliest records, make frequent
and lengthy reference to the examination and character of the urine,
and under each of the twenty morbid conditions which constituted
their pathology are grouped various classifications of the urinary
changes. It is interesting to note that they describe a "honey urine"
which would attract ants (which fact they used as a test), thus evi-
dencing a knowledge of diabetes, and, moreover, they noted its
relation to carbuncle and other skin affections, and commented upon
the hereditary and congenital forms of this disease.

As early as 100 B. C. Charaka describes enlarged prostate as
follows : "Deranged wind between the bladder and rectum pro-
duces a hard ball like a stone which is the cause of suppression of
urine and causes much pain and swelling of the bladder."

In the early Greek era, 400 B, C, we find Hippocrates frequently
urging the importance of the examination of the urine in prog-

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386 The Archives ok Diagnosis

nosis, and he writes at length on Its characteristics in various con-
ditions, many of his comments, though too lengthy to be included
here, being extremely shrewd and interesting.

Galen, in 130 A. D., largely follows the teachings of Hippocrates,
as does Paulus Aequinata, a famous physician of the seventh cen-
tury who wrote extensively on the subject.

In 610 A. D. Theophilus makes the first reference to the appli-
cation of heat and alludes to the cloudiness sometimes arising,

Ismail of Jurgani, a Persian physician of the eleventh century,
gives detailed directions as to the manner in which a urinalysis shall
be made, recommends the collection of a twenty-four hours' quan-
tity, and enumerates the points to be noted — color, consistency,
transparency, cjuantity, sediment, o<lor, and froth.

Such was the dignity of urinalysis that Johannes Actuarius, who
died about 1283, held the position of uroscopist to the Byzantine
court and wrote an extensive work on the subject, being the first
to recommend the use of a graduated glass to measure the deposit.

In the early Middle Ages inspection of the urine came second to
the pulse, and a chronicler of the time shows us that there are
some medical procedures of that age still in vogue when he says
that, after concluding his examination, and before retiring, the
physician usually promised that, with God's help, the patient would
recover, but "he would take care to inform the friends of the patient
that the illness is a serious one, so that, should the patient get well,
the merit may be due to him, or should the result be fatal, the
friends of the deceased are there to witness that he had noted the
serious nature of the disease from the first,"

Probably the earliest book published in the English language on
urinalysis is entitled "The Judycyall of Uryns," and is said to have
been printed in 1512.

Another such manual was published in 1540, and still another,
"The Urynal of Physik," in 1548 by Mayster Robert Recorde, which
is very detailed in its directions.

Up to this time urinalysis consisted almost entirely of inspec-
tion, the diagnosis and prognosis being made on its appearance, and
it was not until 1655 that the first inquiry was made into its com-
position by Van Helmont, who also devised a method of deter-
mining its weight.

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Kilduffe: Urinalysis 387

We must not forget here the influence of that peculiar combina-
tion of scientist and quack, Paracelsus, who, referring all diseases
to the chemicals of which, he said, the body was formed, namely,
mercury, sulphur and salt — mercury belonging to the lower
limbs — distilled the urine to determine which element was in excess,
thus determining the location and nature of the disease.

In 1674 Thos. Willis made the first observation of the sweet taste
of diabetic urine, thus paving the way for the distinction between
diabetes insipidus and glycosuria.

Considering the importance given to the examination of the urine
and the impression made upon the imagination of the ignorant, it
is not surprising that quack urologists of every description abounded,
who, gathering their auditors in the market-place, without ever
seeing the patient, by inspection of the urine did not hesitate to
extend their divinatory powers to all kinds of predictions beyond
the range of medicine.

It became a common practice for apothecaries to collect speci-
mens and take them to physicians, who by inspection made a diag-
nosis, leaving the treatment to the man of drugs, and to such an
extent did this go that it later was forbidden by law.

Shakespeare alludes to the examination of urine in King Henry
IV when Sir John Falstaff asks his page: "Sirrah, what says the
. doctor to my water?" The page replies: "He says, sir, the water
itself is a good, healthy water, but for the party that o\vns it, he
might have more diseases than he knows for."

The first estimation of specific gravity was made about 1712 by
Boorhaave, a Dutch physician, and inaugurated an era of scientific
urinalysis; in 1720 he also discovered urea, and in 1772 Mathew
Dobson, of Liverpool, demonstrated sugar in diabetic urine.

Bite was discovered in 1789 by Cruikshank; a test for albumin
in i8or by Jaroll, and in 1841 the first test for sugar was described
by Trommer, the test which now, modified, bears Fehling's name.

From this on to our own day tha gradual evolution of modern
laboratory methods is familiar to us all. Unfortunately, in some
respects, the subject has become so complex that the average prac-
titioner has become confused in its mazes, and not infrequently, at
first puzzled, later becomes dubious and ends by disregarding the
matter almost entirely.

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388 The Archives of Diagnosis

For the man who makes his own examinations — ^and there are a
few who cannot — there are two valuable principles to remember :

1. It is better to know one test well; to understand its fallacies
and its limitations, its interpretation, than to have a smattering
knowledge of many and a thorough understanding of none.

2. It is not the test but its interpretation that counts.

With these facts in mind, we come to our tests, and I hope to
present a short and simple routine method of urinalysis which will
help to clear up many a knotty point and indicate the case in which
the more detailed methods of the laboratory man are called for.

I shall not go into details as to the interpretation of the tests, as
that depends upon the man and his reading, but merely give the
tests themselves.

I. Quantity. — This is a point of marked diagnostic value, but,
even though necessitating no extra labor on the part of the physician,
is, nevertheless, except in the exceptional case, almost entirely
neglected.

It is almost needless for me to emphasize the almost utter use-
lessness of the perfunctory examination of one single specimen
passed simply for that examination.

It is true that cases of glycosuria and albuminuria in which the
pathological elements are constantly present in large amounts are
readily detected by such an examination, but these are not the cases
in which a urinalysis has its greatest value ; the diagnosis, and to
some extent, the progress of tiie case, are clear from the symptoms.

It is in the border-line case that we need, and look for help, and
when we remember the changes in the character of the urine and
its constituents which may be due to factors of diet and habits of
life; when we remember that there may be marked fluctuation of
sugar and albumin, or of pus, blood, bile, etc., at different periods
during twenty- four hours ; that casts may occur in showers and be
absent in the interim, the fallacy of any conclusions drawn from
the examination, no matter how careful, of a single specimen are
at once apparent.

I would make a strong plea, ttien, for the examination of a speci-
men from the mixed twenty-four hours' quantity. Its collection is
an easy matter and involves but very simple directions to the patient :

I. To empty the bladder at some definite time.

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Kilduffe: Urinalysis 389

2. To keep every portion of urine passed from that time to the
corresponding hour next day, including what the bladder then con-
tains.

3. To measure this quantity and bring two ounces for examina-
tion.

The addition of 5 to 10 grains of boric acid will effectually pre-
vent decomposition and will not interfere with any tests.

If we bear in mind that the daily output is influenced by the
habits of the patient with regard to the amount of fluid ingested,
the nature and quantity of food, the blood pressure, temperature
and amount of exercise, and apply these factors to the individual,
we are often at once placed in possession of valuable data as to that
individual's renal functional ability.

The normal twenty-four hours' quantity in the United States
may arbitrarily be placed at 1,000 to 1,200 cc. in the male, and 900
to 1,100 cc. in the female.

2. Inspection. — This is another neglected factor. Much may
often be learned by merely looking at a specimen. Its color is of
interest, often an indication of the presence of blood, pus, or bile,
or certain drugs, as, for example, the smoky appearance of carbolic
urine, the yellow of santonin, the red of logwood, etc.

In this connection it is well to remember that in cases of hysteria
and malingering dyes may be purposely added. Remember, too, that
the greater the density the darker the color, and vice versa, is a
general rule of value; that an acid urine and a febrile urine are
generally darker, and that a very pale urine, though generally indi-
cating an excessive ingestion of water, may indicate chronic inter-
stitial nephritis, diabetes (either variety), hysteria, or the various

3. Specific Gravity. — This is only of value, and can only convey
information when taken from the twenty-four hours' quantity. Un-
der such conditions it is, in a general way, an index of the metabolic
processes of the body, increasing as the solids increase, the amount
of urine remaining the same. The normal range of variation is
from 1,015 to 1,025, and by multiplying the last two decimal points
by two we get the solids for 1,000 cc, from which the twenty-four
hours' amount is readily calculated.

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390 The Archives of Diagnosis

We come now to the actual tests, and it is my hope to present them
in such simple form that their routine use will be stimulated.

4. Albumin. — For general use the best and most dependable test
is the nitric acid contact test, which should be performed in every
detail exactly as follows :

1. Do not make the test in a test tube.

2. Do not stratify the urine on the acid.

3. Into a small conical glass (medicine glass) pour 10 to 20 cc.
of urine and, inclining the glass, allow 6 to 10 cc. of nitric acid to
flow down the side, forming a distinct zone below the urine.

4. Allow the test to stand five minutes.

In almost every specimen, in the clear urine above the point of
contact a fine white ring will appear after standing. This is not
albumin and although information on this point is not exact, is
generally referred to urates and has no clinical significance.

The white albumin ring appears almost at the point of contact
and, to some extent, varies in amount and intensity with the amount
of albumin present, and if much is present the cloudiness will grad-
ually extend upwards into the supernatant urine. If bile is present,
beneath the albumin disc the characteristic green ring will be seen ;
urea, if present in more than 25 grams to the hter, will cause a hoar-
frost of urea nitrate on the sides of the glass.

A transparent ring, varying in color from pink to brick red, seen
in the body of the urine is referable to normal urinary pigment.

Indican appears as a violet ring above the so-called urate ring.

Remembering that certain resinous bodies may be precipitated
from turpentine, balsam of tolu, capaiba, etc., which cloudiness, if
shaken with alcohol, at once disappears, it is evident that this simple
test is of incalculable value and its routine and general adoption
cannot be too strongly urged.

In the exceptional case, where there may be some doubt as to
the reaction, I have made use of the following simple but effective
modification of technic: Into a test tube three-quarters full of
urine introduce a 2 cc. pipette charged with nitric acid. If, with
the tube held against a dark background, the acid is released in
spurts, albumin appears like little clouds of smoke from a gun
whirling up into the clear urine above which acts as a control.

Bearing in mind the albuminuria which may follow the exces-

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Kilduffe: Urinalysis 391

sive ingestion of albuminous foods over the assimilation limit, and
excluding that due to blood, pus, etc., the interpretation of the test
is clear, and it is to be noted that there is a growing tendency to
cast aside so-called "physiological albuminuria" and regard the
presence of albumin in every case as a pathological phenomenon.

Quantitative Estimation. — This is equally simple, the only appa-
ratus required being the familiar Esbach tube. For seven years I
have used, and would advise Tsuchiya's reagent as having several
advantages over Esbach's in that it is more stable, more accurate
in not precipitating as many extraneous substances, and does not
stain. It can be readily made by any druggist from the following
formula: Phosphotungstic Acid, 1.5 gram; Alcohol 95%, 95 cc. ;
Cone. HCl, 5 cc.

To make the test pour urine into the tube to the mark U, add the
reagent to the mark R, invert several times and set aside for 8 to
12 hours. The graduations of the tube refer to grams per liter.
The reaction of the specimen must be acid.

Sugar. — I have not used Fehling's solution for this test for some
years, preferring to use Benedict's reagent, which has the following
formula: Copper sulphate, 17.3 grams; Sodium citrate, 173.0
grams; Sodium carbonate, 100.0 grams; Water, 1,000 cc. Bene-
dict's reagent is based upon the same principles as Fehling's solu-
tion — the reduction of copper sulphate — and has the same end re-
action ; a yellow or red precipitates in the presence of sugar ; but the
solution has several advantages: (a) it is stable, (b) there is only
one solution, (c) it is slightly more delicate.

The technic is extremely simple. The solution is diluted and
used exactly as in Fehling's test, or the simple modification of tech-
nic described below may be used with decided increase in the deli-
cacy of the test and provides an effective safeguard against some
of the fallacies:

1. Acidify and boil a few cubic centimeters of urine in a test tube,
thus precipitating any albumin present.

2. Boil a few cubic centimeters of the diluted reagent in another
test tube.

3. Place a small filter with moistened filter paper in the reagent
tube with the beveled edge of the funnel against the side of the
tube.

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392 The Archives of Diagnosis

4. Pour the boiling urine into the filter.

As the hot urine runs through the fiher it stratifies upon the hot
reagent and, in the presence of sugar, a beautiful ring reaction will
be obtained.

By this technic the delicacy of the test is decidedly increased and,
moreover, fallacious reactions due to albumin and the reduction of
copper by creatinin, etc., are effectually eliminated.

Bear in mind the fallacies of any test depending upon the reduc-
tion of copper sulphate. Not only certain drugs such as benzoic
acid, salicylic acid, glycerin, chloral, sulphonal, etc., but certain
other substances normally present in the urine may cause reduction.
These, however, even if the above technic is not used, may be dis-
regarded if the precaution is taken not to boil the test after the addi-
tion of the urine.

The quantitative estimation of sugar, which is extremely im-
portant, as a rule, requires more skill, practice and apparatus than
are generally at the disposal of the busy practitioner, and I pass
it over, suggesting only to those who desire to do it the use of
Purdy's solution as having the advantages of a clear and unmis-
takable end reaction, thus necessitating only one estimation.

There are many other tests of simple technic, but it is better to
do a few tests always than many only once in a while, and I pass
them over. The examination of the sediment, while of extreme
value as the only reliable test for pus and blood and the only test
for casts, and a means of obtaining much and varied information,
I leave to the laboratory man, for it lies in his domain, as it requires
not only a microscope but also what is more important, the man be-
hind the 'scope to interpret what the picture means.

To him also belongs the phenolsulphonephthalein functional test,
which should be done more frequently in practice, for, not only
harmless to the patient and simple in technic, it can give us much
information as to changes and derangements of renal function even
before the microscope or the test tube can detect any variation from
the normal.

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Progress of Diagnosis and Prognosis

^gceiECK of Biagnofffti anb ^tognoKtK

GENERAL METHODS OF EXAMINATION— SYSTEMIC

AFFECTIONS— DISORDERS OF GENERAL

METABOLISM

Alveolar Carbon Dioxid Detertnmations — E. P, Poulton, Brit, Med. Jour.,

Sept, II, igis-

If the urine in a case of diabetes gives a negative result with the
nitroprussid test, it is useless to make an alveolar carbon-dioxid
determination, for it will always fall within normal limits. The
alveolar carbon-dioxid determination is a sure guide as an index of
the degree of acidosis in those cases in which the urine contains
acetone bodies. In such cases it is usually impossible to determine
the degree of severity by means of the ferric chlorid or nitroprussid
tests alone. In cases in which the alveolar carbon-dioxid pressure
is lower than normal, care must be taken to prevent the onset of
coma. A value of 2 per cent, means that coma may supervene within
24 hours. A value of 3 or 4 per cent, is less dangerous. Sachs.
Acidosis in Diabetes Hellitui— A. P. Beddard, M. S. Peubry and E. J.

SnuGGS, Brit Med. Jour., Sept 11, 1915.

The analysis of the carbon dioxid in the alveolar air spaces of the
lungs affords an index of the degree of acidosis and a guide in
treatment and prognosis. In cases of diabetes, there exists a rela-
tion between the alkalinity of the, serum and the amount of carbon
dioxid in the venous blood ; the two rise and fall together without
being actually parallel. Sachs.

Occurrence of Arsenic in the Female Orcanism— V. Frommek, Archiv f.

Gynakologie, Vol. CTII, No. 2, 1915.

In pregnant animals, to whom arsenic was administered, the
transmission of arsenic from the mother-animal to the placenta and
fetus could be demonstrated in every instance. In the human or-
ganism the presence of arsenic is very likely due to alimentation.
This is of import in forensic medicine and in biochemical respect.
In a number of human organisms arsenic in variable amounts could
be demonstrated. Symptoms of gravidity and eclampsia are in
many respects analogous to such of arsenic, phosphorous, etc.

Mill.
Staining Cells in the Cerebrospinal Fluid—B. Leuchen, Med. Rec, Sept

". 1915.

In staining cells in the cerebrospinal fluid, author uses an equal
amount of two solutions. No. i consists of an equal amount of

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394 The Archives of Diagnosis

benztdin in glacial acetic acid and No. 2 consists of hydrogen peroxid.
By means of a white blood pipet, he draws up the stain to 0.5 and
then the spinal fluid up to ir. This mixture is then put on a count-
ing chamber. The red blood cells are stained blue ; the polymorphus
cells are a light yellow while the nucleus is made visible by having
blue granules in it. In the lymphocytes the periphery is a ring of
dark blue, while the middle of the cell is unstained, except for some
blue granules. The periphery of the plasma cells is a dark blue,
almost black, while the middle of the cell is clear, Sachs.

The OTigiii of Local Bosinophile Cells— B. Pbotakis, Zeitschr. f. experi-

mentelle Pathologic u. Therapie, Vol. XVII, No. 2.

Eosinophile cells of the blood and bone marrow Sow to such
regions where specific, attracting substances are accumulated. If
the latter accumulate in a certain localized area they attract a num-
ber of eosinophile leukocytes from the blood and bone marrow,
giving rise thereby to a local eosinophilia. Western.

Aleukia Hemorrhacica— E. Frank, Berliner kitn. Wochenschr., Sept. 13, 1915.

The aplastic anemia, which should more <lefinitely be denomi-
nated aleukia hemorrhagica, is not a primary hemolytic erythrotoxi-
cosis with secondary absence of regeneration, but a primary leuko-
myelotoxicosis with secondary anemia. The latter bears partially
a post-hemorrhagic, partially a myelophthisic character. Aleukia
hemorrhagica is a well-circumscribed atfection, and not a special
form of certain secondary anemias or of the Birmer-Ehrlich
anemia. Mill.

A Urobilin Test of the Urine and the Feces— A. Edelmanm, Wiener klin.

Wochenschr,, Sept. 9, igis.

Author describes a modification of Schmidt's test. Two reagents
are necessary: (A) a concentrated alcoholic solution of mercury
bichlorid, (B) a 10% clearly filtered alcoholic solution of zinc
chlorid. Besides these amyl alcohol is essential. About 10 cc.
urine is added to half its volume of A. To this is added amy!
alcohol and the entire mixture well shaken. To the alcohol layer,
which forms rapidly on top of the mixture, a few cubic centimeters
of B. is added. In case larger amounts of urobilin are contained
in the urine, the alcohol assumes a ros e- red coloration ; addition of
the zinc chlorid solution calls forth a beautiful green fluorescence.
Even small amounts of urobilin are recognizable by this test by
employing after the reaction has been displayed a convex lense
(pocket lantern) by which a green cone of light is produced in
the liquid. The fluorescence reactions only ensue when the media
are clear. In the urine the reaction is displayed in about one, in the
stools in about two minutes. Mill.

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Progress of Diagnosis and Prognosis 395

DiagBOBis of MetuUtic Tumon of tbe Bone-Harrow from the Blood

Exuninatioii— J. v. Boznowski, Zeitschr. f. klin. Medizin, Vol. LXXXI,

Nos. 5 and 6.

The appearance in large numbers of myelocytes in the blood of
cachectic persons points with great probability to the presence of
bone-marrow metastases of a malignant tumor. This is especially
the case when the malignant tumor is demonstrable, and when there
exists a grave secondary anemia with very large amounts of normo-
blasts, occasionally also megaloblasts, with or without synchronous
leukocytosis. Western,

Pathology of the "Cold"— Aufrecht, Deutsches Archiv f. klin, Medizin, Vol

CXVIl, No. 6.

"A cold" is due to coagulation of fibrin in the blood current.
The cause of this coagulation is due to the injury of the leukocytes
circulating through the vessels of the cooled-ofF portions of the
body. The consequence of the coagulation is a hemorrhage in the
peripheral blood vessels clogged by the coagulated fibrin. These
changes are not engendered by bacteria. The fibrin coagulatioir,
however, and its causative factor are pathological processes.

Western.

The Influence of Muacular Activity upon the Blood Sugar— W. v.
MoRACzEwSKi, Berliner klin. Wochenschr., Oct. 4, 1915.
The blood sugar is increased after almost every diet when work
is performed. This is especially the case in a person tending to
glycosuria. The diabetic shows a distinct increase in blood sugar
also after the ingestion of a fatty diet. The muscular activity test
is therefore equal in value to the ingestion of sugar to determine
whether and in what degree an organism tends to glycosuria.

Mill.
Pitnitary Gland in Diabetes Hellitus and Diaorders of the Glands of In-
ternal Secretions- H. J. B. Fry, Quart Jour, Med. (London), July, 1915.
Definite histological changes occur in the anterior lobe of the
pituitary in cases of diabetes in the form of adenomatous masses of
eosinophilic cells, colloid invasion of the anterior lobe, and areas of
cellular degeneration. In acute prancreatitis and carcinoma of the
pancreas, changes in the pituitary are absent or slight. No histologi-
cal changes were observed in a case of Addison's disease or in a
case of status thymo-lymphaticus. Increase in the weight of the
pituitary occurs in myxedema due to increase of the connective tis-
sue elements and hyperplasia of the chief cells. In goiter there is
hyperplasia of the chromophile cells, especially of the eosinophilic
granular cells and increase of colloid in the interglandular cleft.

Sachs.

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396 The Archives of Diagnosis

INFECTIOUS DISEASES
Examination of TubercuIouB> Meningeal Spinal Fluid by Means of the

Ninhjrdrin Reaction~V. Kafka, Munchener raed. Wochenschr., Oct 5,

1915.

The ninhydrin test with the spinal fluid, as employed by Nobel,
cannot l>e employed in the differential diagnosis between the tuber-
culous and other forms of acute meningitis. In affections of the
central nervous system in which there is an increase of spinal liquid
albumin, the test should only be utilized with very great caution. The
differential diagnosis between these affections may be accomplished
by dialyzation of the spinal liquor with distilled water and employing
the ninhydrin test with the dialysate. Mill,

Tubercle Bacilli in the Blood of Tuberculous Patients— L. Kessel, Am.

Jour. Med. Sei., Sept, 1915.

Author pursued the following methods : i. The blood taken from
patients with advanced pulmonary tuberculosis was inoculated
directly into the peritoneal cavities of guinea-pigs. 2. The blood
from some of these patients was treated and examined microscopi-
cally. 3. The blood from tuberculous patients who had previously
received an injection of tuberculin was inoculated intraperitoneaily
into guinea-pigs. 4. The blood was withdrawn from tuberculous
patients who had previously received a tuberculin injection, and after
removal of the serum intraperitoneal injections were made into
guinea-pigs. 5. The blood, -after removal of the serum, was planted
upon culture tubes of gentian-violet media. The following sum-
mary of his observations is given by author: i. Blood withdrawn
from 38 patients was inoculated intraperitoneaily into guinea-pigs.
Autopsies and microscopic sections two to three months later failed
to reveal any evidence of tuberculosis. 2. Microscopic examination
of the blood withdrawn from 10 patients yielded negative results.
The many sources of error in the microscopic examination of blood
for tubercle bacilli have been pointed out. 3. The blood of 7
patients previously subjected to a tuberculin injection was inoculated
intraperitoneaily into guinea-pigs. Autopsies and microscopic sec-
tions failed to reveal any evidence of tuberculosis. 4. In 3 patients
who had previously received a tuberculin injection, blood was with-
drawn and after removal of the serum was inoculated intraperi-
toneaily into guinea-pigs. One of the pigs developed an extensive
tuberculosis. 5. An attempt made to grow the tubercle bacilli
directly from the blood proved unsuccessful. The negative results
yielded by these 47 cases do not prove conclusively that tubercle
bacilli are never present in the circulation, but they stroi^ly suggest
that a bacillemia, such as is present in other infectious diseases, is at
least uncommon in pulmonary tuberculosis even in advanced stages
of the disease. It may be that from time to time tubercle bacilli

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Progress of Diagnosis and Prognosis 397

are washed into the circulation from a pulmonary focus, and that
they rapidly disappear from the blood. That such a rapid departure
from the blood does occur, has been demonstrated in the case of
rabbits in whom tubercle bacilli could no longer be recovered from
the blood thirty minutes after their intravenous inoculation (Hey-
mann and Otto). When the blood of 10 patients previously sub-
jected to a tuberculin injection was inoculated into guinea-pigs, one
of the animals presented a generalized tuberculosis at autopsy. It
would be unwise to draw conclusions from one positive result, but
the 9 negative results coincide with our daily clinical experience,
for if a therapeutic tuberculin injection could cause virulent tubercle
bacilh to appear in the circulation the development of acute miliary
tuberculosis would be a common occurrence. Nevertheless, the
question of a possible mobilization of tubercle bacilli following
diagnostic and therapeutic tuberculin inoculations deserves careful
investigation. Sachs.

Percnuion and the DiagnoBis of Apical Tuberculosia — A. Schneidek,

Deutsche med. Wochcnschr,, Aug. 12, 1915;

Tuberculosis of the pulmonary apices is', as a rule, physically first
demonstrable by auscultation. Negative percussatory findings do
not exclude a tuberculous affection of the apices. In spite of such
negative findings there may be present an extensive moist tuber-
culous catarrh. Tuberculosis of the pulmonary apices is in most
cases only demonstrable by percussion when the Rdntgen examina-
tion is already positive. Mill,
Early Diagnosis of Pulmonary TuberculoHS— E. G. Glover, Quart. Jour.

Med. (London), July, 1915.

Sixty-two per cent, of cases coming under observation as sup-
posed cases of early phthisis, but with no bacilli in the sputum,
proved to be negative. Nevertheless such negative cases may present
clinical signs of impairment of percussion-note, breath sounds and
resonance, at, at least, one apex. Moist sounds in such cases are
almost invariably absent. Therefore it is not justifiable to diagnose
active tuberculosis on the strength only of impairment of the per-
cussion note at an apex. Active disease confined to one apex with
a repeatedly negative sputum is not common. Where moist sounds
are present, further investigation is needed to exclude or confirm
the presence of active disease. When this investigation takes place,
the form of the complement- fixation reaction along with the estima-
tion of the opsonic index may make a final diagnosis without
recourse to test injections of tuberculin, Sachs.

Graves' Disease and Tuberculosis— Sc hi nzittgeb, Beitrage r. Klinik d,

Tuberkulose, Vol. XXXIII, Noa. i to 3.

Basedow disease occurs not more frequently in the presence of
pulmonary tuberculosis than in that of other diseases. It is dubious

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398 The Archives of Diagnosis

whether or not the symptoms of the first stage of pulmonary tuber-
culosis, as cardiac palpitation for instance, have anything to do with
Basedow disease. Fry.

Tests for S7phil»— H. C. Bkown and K. R. K. Ivekga, Indian Jour. Med.
Research, July, 191S-

The first test for syphilis which the authors have devised is de-
pendent on the fact that when an aqueous solution of platinum
chlorid is added to an alcoholic extract of normal serum, a much
heavier precipitate is produced than in the cases of an extract of
syphilitic serum. The results of this test parallel those of the Was-
sermann reaction and Flemming's modification. The second test is
a natural consequence of the first test. Since one of the properties
of lecithin differentiates a syphilitic from a normal serum, the other
should also do. The capacity for activating cobra venom is dif-
ferent in the two serums. Fifty-five serums tested bore out this
conclusion. Sachs.

Splenic Enlargement in Early Syphilift— U. J. Wile and J. A. Eluot, Am.

Jour. Med. Sci., Oct, 191S.

The spleen was definitely enlarged in 36 out of 100 cases of early
syphilis studied by authors. It was hard and firm in 17 cases, tender
in 6 and soft in 3. Twenty-seven of the 36 cases showed impair-
ment of health, but it must also be noted that there was impairment
of health in 22 per cent, of those cases in which the spleen was not
enlarged. Sachs.

Congenital Syphilis in Prematnrely-Born Infants— A. Reicre, Zdtschr.

f. Kinderheilkunde, Vol. Xll, No. 6, 1915,

Among prematurely-born infants there are comparatively more
affected with syphilis than among those born at term. Syphilid
premature births exhibit a high mortality, especially when the luetic
manifestations appear early, and when the mother has had a number
of premature births or abortions. Mill.

Gonorrhea: Complement-Fixation Test— A. A. Uhle and W. H. Mackeh-

NEY, N. Y. Med. Jour., Oct. g, 1915.

The blood of 141 individuals was tested by each of 4 competent
serologists for complement-fixation. Fifteen of the 141 were nor-
mal controls. One laboratory reported negative in all of these cases,
while the other three serologists gave positive reports in from 6.6
to 13.3 per cent. In 37 cases, all of which, while suffering from other
diseases, denied ever having had gonorrhea and presented no clinical
evidence of the disease, three serologists reported positive findings
in from 13.5 per cent, to 35.1 per cent, and one laboratory found
all the bloods to be negative. Of 18 cases clinically cured for over
five years, all of the laboratories agreed on a negative report in 8

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Progress of Diagnosis and Prognosis 399

cases. In 11 cases of acute gonorrhea of less than 4 months' dura-
tion, all of the laboratories agreed in a negative report in 3 cases.

Sachs.
Defeneration FomiB of Gonococci — Asch and Ai>ler, Miinchener med.
Wochenschr., Sept. 28, 1915.

The bacteriological diagnosis of acute gonorrhea is comparatively
easy. This is by no means the case if the urethritis has attained
a certain degree of chronicity. Here a vast number of other bacteria
are found besides the gonococci. This fact makes the diagnosis
more difficult. Authors demonstrated that in most cases the
gonococci are only Gram-negative in the acute stage of the infection ;
gradually they become iodine-fast. In order to differentiate between
the degeneration forms of gonococci and other diplococci frequent
controls of the secretion are necessary. Degenerated gonococci are
infrequently found within leukocytes; they occur oftener upon
epithelial cells. In most instances, however, they are lying entirely
free between the formed elements. Mill.

Spirochetal Ulceration of Tonuls— W. Wingbave, Lancet, July 24, 1915.

Spirochetal ulceration of the tonsil is characterized by: (l) a
deeply excavated and sloughing ulcer on one tonsil; (2) offensively
fetid breath; and (3) the presence of spirochetes and fusiform bod-
ies in great numbers. The cases may be divided into the acute
cases which last from 4 to 7 days, and into the subacute which last
from 2 to 3 weeks. The spirocheta fetida, or Vincent's spirochete,
is the etiological factor in the disease. Sachs.

Vincenfi Angina— J. Harper, Glasgow Med. Jour., July, 191S-

Vincent's angina may appear in what are apparently totally dif-
ferent forms. It is not so rare a condition as one would suppose.
It may follow an acute, subacute, or chronic course. Cases of sus-
pected diphtheria which give a negative result on bacteriological
examination should be examined for the organism of Vincent's
angina, and also this should be done in cases of suspected syphilis
with ulceration of the throat which do not yield to treatment and
in which the Wassermann reaction is negative. Sachs.

Paratyphoid Fever— H. Robinsok, Lancet, Oct. 16, 1915.

Paratyphoid fever is a much shorter and milder disease than
typhoid fever. Headache and abdominal pain are the most con-
stant symptoms. Definite rose spots in successive crops are found
in 60 per cent, of the cases. The paratyphoid bacillus may not be
isolated from the feces until the fever has subsided. A quantitative
Widal reaction is of great diagnostic help, when frequently repeated
by one who has had much experience with this reaction and when
taken in conjunction with the clinical findings. Sachs.

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400 The Archives of Diagnosis

Tfae Value of the Ag^utination Teit in Persons Inoculated with Typhoid
Vaccine — E, Reiss, Mundiener med. Wochenschr., Sept ar, 1915.
In persons prophylactically inoculated with typhoid vaccine the

agglutination test possesses no diagnostic value whatever. Mill.

"Vaccination Spleen" Tumefaction and Typhoid Diagnosia — Goldscheideb,

Deutsche med, Wochenschr,, Oct 7, 1915.

TTie tumefaction of the spleen often ensuing after preventive
typhoid vaccination may cause diagnostic difficulties. Another
febrile affection may be mistaken for typhoid fever and genuine
typhoid spleen for "vaccination spleen." Author found that the
disappearance of the vaccination spleen occurs in about 6 per cent,
of the cases in the manner that after 2 months there still persists
some tumefaction and that 3 months after vaccination no swelling
of the spleen is detectable. It is hence necessary that in every case
of fever and splenic tumor it be determined if and when a pre-
ventive typhoid vaccination has been done, and that a close observa-
tion of the patient be instituted. Palpation and percussion of the
spleen have again attained greater importance since we know that
the bacteriological typhoid diagnosis is often disappointing. The
spleen tumor may develop within a very brief period. Soldiers
with typhoid show almost always a tumor when they report
themselves ill. Mill.

Typhoid without Fever— F. Meyex, Munchener med. Wochenschr. (Feldirzt-

liche Beilage), Oct 5. igiS-

By reason of the bacteriological examination of the blood and
feces we are enabled to recognize certain disease pictures as typhoid
fever which are entirely discrepant from the clinical resemblance
to the classical symptom-complex of this disease. We know for a
long time that genuine typhoid fever may not present any intestinal
symptoms. On the other hand meningitides, pneumonias and renal
affections may be caused by the clinical localization of the typhoid
bacillus. Hence the clinical diagnosis has to a certain degree yielded
to the bacteriological examination and thus considers as typhoid all
those infections which are due to the typhoid bacillus. It is here,
of course, presupposed that the bacillus has realty found its way into
the tissues and caused disease phenomena. Accepting this definition
of typhoid fever, author and others have lately approached the ques-
tion whether or not there may be typhoids without fever. In other
words, can a normal vigorous body be the host in his organs and
the blood current of bacilli without reacting by an increase of body
temperature and general or localized disease phenomena? Author
describes 3 cases, taking the positive standpoint. These patients
were not carriers of bacilli as was evidenced by the many fecal
examinations. Mill.

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Progress of Diagnosis and Prognosis 401

Nephrotyphoid — F. Deutsch, Wiener klin, Wochenschr., Sept, 9, 1915.

Two young girls living in the same house were affected with acute
nephritis and high fever. The urine of both patients contained
large numbers of typhoid bacilli. There were no other symptoms
of typhoid. A brother of the girl who was first infected had died
a short time before. He had also suffered from nephritis and there
is little doubt that this was likewise of typhoid origin. Mill.

Nutnber and Foniu of White Cells in Typhus Fever — M. Matthes,

Miinchener med. Wochenschr., Oct 5, 1915.

The ordinary findings in typhus fever, viz : moderate leukocytosis
and preponderance of polynuclear cells, in dubious cases point to
typhus and not to typhoid. The blood picture of the latter is char-
acterized by leukopenia with a synchronous lymphocytosis. The
blood picture in cases of typhus fever with a low leukocyte count
(20 per cent.) cannot be differentiated from that of measles (for
the reason that the polynuclear cells are also increased) unless the
presence of azurophile granula is of especial import. A relative
polynucleosis in the presence of a low general count may indicate
typhus fever. A total count of 30CX) and below points to typhoid
fever in dubious cases. Mill.

Artificial Hyperemia in the Diagnosis of Typhus Fever (Fleckfieber) —

C. DiETSCH, .Munchener med. Wochenschr, Sept. 7, 1915.

Artificial hyperemia is of value in the better recognition of a non-
characteristic or unpronounced exanthema; it is of import m the
differential diagnosis between typhus and typhoid ; it renders the
exanthema of typhus distinctly visible, and in cases, already recon-
valescent or cured, it demonstrates so long as some pigmentation
still persists, that the disease has been typhus. Mill.

Sero-Diagnosis of Larved Cases of Chronic Dysentery— H. Sisauss,

Deutsche med. Wochenschr., Sept. 9, 1915.

A rather large number of cases of grave colitis is due to dysentery
as proved by sero-diagnosis. Sero-diagnosis may also differentiate
between dysentery and paratyphoid from cases of simple, non-
hemorrhagic cohtis. Mill. ■

Demonstration of Meningococci in the Cerebrospinal Liquid— E. Frankei,

Deutsche med. Wochenschr., Sept. 9. I9i5-

Author mixes a few cubic centimeters of ascites-ager-bouillon
with an equal amount of spinal fluid obtained by lumbar puncture.
After standing in a temperature of 37 deg. C. for J2 to 14 hours,
meningococci may often be demonstrated in the sediment in large
numbers. Mill.

Spasmodic Symptoma in Rbeamatiam — F. J. Poyntok, Lancet, Oct. 9, I9i5>

Poynton considers migraine, muscular spasm, paroxysmal sensory

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402 The Archives of Diagnosis

symptoms and anginal attacks, when associated with a rheumatic
history, as spasmodic symptoms in the course of this disease.

Sachs.
Pertusrii— V. Lance, Berliner klin. Wochenschr., Oct. ii, 1915.

Pertussis is an infection, starting and ending with a catarrhal
jtage. Between the inaugural and terminating catarrh a convulsive
stage ensues. This is characterized by the appearance of convulsive
attacks of cough. No special catarrhal condition is responsible for
the cough attacks. These are undoubtedly due to the nervous sys-
tem. The irritation ensues in the central system, and it is con-
ducted over various paths to the periphery. The therapy must be
directed toward the nervous system. Mill.

Goiter, Cretiniun and ChaKas' DiseaBe— R. Krans, F. Rosekbusch and

C. Macgio, Wiener klin. Wochenschr., Sept. 2, 1915.

Authors come to the conclusion that the disease-picture described
by Chagas: goiter, myxedema, idiocy and diplegia, caused by
schizotrypanosoma cruzi, is not as yet an absolutely demonstrated
clinical fact. Mill.

ActinomycoBis— V. Z. G)re, Brit. Jour. Surg., July, 1915.

Actinomycosis is frequently overlooked or wrongly diagnosed as
septic or syphilitic infection, or as sarcoma. It should always be
considered in the diagnosis in the case of any newly-formed sub-
acute or chronic swelling in the region of the mouth, face, thorax,'
neck or right side of the abdomen. Infection with the fungus nearly
always occurs from the alimentary tract. There are two clinical
forms of the disease, the hard and the soft. The hard variety
softens after two or three months. Peri-buccal infections comprise
the majority of the cases. The features of the hard peri-buccal
form are very characteristic and can often be diagnosed long before
pathological investigation can give much help. Sachs.

Respirator; Signs in TrichinoBiB — G. R. Minot and F. M. Rackmann,

Am. Jour. Med. Sci., Oct, 1915.

Authors review the histories of 102 cases of trichinosis. In 50
per cent, of these cases in which respiratory signs and symptoms
were noted, 16 patients had cough without abnormal physical signs
in the lungs, 17 had cough with abnormal lung signs, and 18 patients
had abnormal signs in the lungs without cough. The duration of
these signs seemed to depend on the length of time the temperature
remained elevated, the signs disappearing as the temperature fell.
If the signs in the lungs were slight, they only remained a few days,
and only at the height of the fever. In 9 cases the signs were
suggestive of pneumonia. Sachs.

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CONTENTS

SPECIAL ARTICLES

PAGE

Tb« Significance of Thrombo-PhlebitiB in Thrombo-Anciitia Oblit-
erans 301

By Leo Buerger, Associate Attending Surgeon and Associate in
Surgical Pathology, Ut. Sinai Hospital^ visiting Surgeon, Har
Moriah Hospital ; Instructor in Ginical Surgery, Columbia
University, New York.
The Diagnodt of the Borderland Ptychosei: s Warning .... 329
By L. Harsisok Mbtiux, Professor and Head, Department of
Netirolo^ and Qinical Neurology, College of Medicine of the
University of Illinois; Neurologist, Norwegian Lutheran
Deaconess Home and Hospital, Chicago.
Tbe Diagnoiia of Abnonnalitiea of Myocardial Function .... 339
By T. Stuart Hakt^ Assistant Professor of Ginical Medicine,
College of Phjrsicians and Surgeons, Columbia Universi^;
Visiting Physician, Presbyterian Hospital, New York.
HTpoadrenia Hiacalled Neurasthenia. Diagnoaia aod Prognoda 355
By Tom A. Williams, Neurologist to Epiphany Dispensary and
Freedmen's Hospital; Lecturer on Nervous and Mental Dis-
eases, Howard University; Corresp, M. Soc de Neurologic
de Paris, etc., Washington, D. C
A New STmptom of Uker at or About the Dnodenal Portion of

the Prloms 360

By Heinsich Sicbn, New York.

Sare Forms of Pericarditis 36a

By GusTAV Singes, Vienna, Austria.
Diagnosis of Genitourinary Conditions in Women by Means of

the RSntgen Ray 36S

By G. S. Petekkin, Seattle, Washington.

VrinalysiB and the General Practitioner 383

By R(»ERT KiLDUFi^ Ja., Director, Pathological Laboratory,
Chester Hospital, Chester, Pa.

PROGRESS OF DIAGNOSIS AND PROGNOSIS

Alveolar Carbon Dioxid DeterminatioDs. By E. P. Poulton , . .

Acidosis in Diabetes Mellitus. By A. P. Beddard, M. S. Pembry and

E. J. Spriggs

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ii Contents

PACE

Occurrence of Arsenic in the Female Organism. By V. Frommer . 393

Staining Cells in the Cerebrospinal Fluid. By B. Lemdien . . . 393

The Origin of Local Eosinoptiile Cells. By B. Photakis .... 394

Aleukia Hemorrhagica. By E. Frank 394

A Urobilin Test of the Urine and the Feces. By A. Edelmann . . 3^^
Diagnosis of Metastatic Tumors of the Bone-Marrow from the Blood

Examination. By J. v. Roznowski 395

Pathology of the "Cold." By Aufrecht 395

The Influence of Muscular Activity upon the Blood Sugar. By W. v.

Moraczewski 395

l>ituitary'GUnd iji Diabetes MelliTus and Disordtrs'of the Glands of

Internal Secretions. By H. J, B. Fry 395

INFECTIOUS DISEASES

lExaminatton of Tuberculous-Meningeal Spinal Huid by Means of the

Minhydrin Reaction. By V. Kafka 396

Tubercle Badlli in the Blood of Tuberculous Patients. By L. Kessel 396

Percussion and the Diagnosis of Apical Tuberculosis. By A. Schneider 397

Early Diagnosis of Pulmonary Tuberculosis, By E. G. Glover . . 397

Graves' Diseast and Tuberculosis. By Schiniinger 397

Tests for Syphilis. By H. C. Brown and K R. K. lyenga .... 398

Splenic Enlargement in Early Syphilis. By U, J. Wile and J. A. Elliot 398

Congenital Syphilis in Prematurely- Bom Infants. By A. Reiche . . 39?
-Gonorrhea: Complement -Fixation Test. By A. A. Uhle and W. H.

Mackenney 398

Degeneration Forms of GonocOcci, By Asch and Adler .... 399

Spirochetal Ulceration of Tonsils. By W. Wingrave 399

Vincent's Angina. By J. Harper 399

.Paratyphoid Fever. By H, Robinson ............... . . 399

The Value of the Agglutination Test in Persons Inoculated with

Typhoid Vaccine. By E. Reiss 400

'Vaccination Spleen" Tutnefactiori arid Typhoid Diagnosis. By Gold-

scheider 4*>

Typhoid without Fever. By F. Meyer 406

V^hrotyphoid. ■ By -F. • Deutsch .■.-.■.■.■. 401

Number and Forms of White Cells in Typhus Fever. By M. Matth'es 401

Artificial . Hypejemia . in. the Diagnosis of Typhus Fever {Fleck- ''

fieber). . By C. Dietsch 401

Sero- Diagnosis of Larved Cases of Chronic 'Dysentery. By H. Strauss 401
Demonstration of Meningococci in the Cerebrospinal Liquid. By

E. Frankel 401

Spasmodic Symptoms in Rheumatism. By F. J. Poynton .... 401

Pertussis. By V. Lange '402

Goiter,' Cretinism and Chagas' Disease. By R. Krans, F. Rosenbusdi

and C. Maggio . . . . ■ . . . ■. . .• 400

AdincMUycosis. By V. Z. Cope ...;.:. 402

^spirjitop'^igfis in Xri<Jiin,osis. By.G. R. Mtoot^nd F. M. Riddna^a . 402

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Full text of "The Archives of diagnosis, a quarterly journal devoted to the study and the progress of diagnosis and prognosis"

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