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THE BASIS OF
SYMPTOMS
THE PRINCIPLES OF CLINICAL PATHOLOGY
BY
DR. LUDOLPH KREHL
ORDINARY PROFESSOR AND DIRECTOR OF THE MEDICAL CLINIC IN HBIDBLBBRG
AUTHORIZED TRANSLATION FROM
THE SEVENTH GERMAN EDITION BY
ARTHUR FREDERIC BEIFELD, PH.B., M.D.
INSTRUCTOR IN MEDICINE, NORTHWESTERN UNIVERSITY MEDICAL SCHOOL, CHICAGO
WITH AN INTRODUCTION BY
A. W. HEWLETT, M.D.
PROFESSOR OF INTERNAL MEDICINE, UNIVERSITY OF MICHIGAN, ANN ARBOR
THIRD AMERICAN EDITION
PHILADELPHIA AND LONDON
J. B. LIPPINCOTT COMPANY
Copyright, 1905
by j. b. lippincott company
Copyright, 1907
by j. b. lippincott company
Copyright, 1916
bt j. b. lippincott company
Electrotyped and Printed by J. B. Lippincott Company
The Washington Square Press, Philadelphia, U. S. A.
r
TRANSLATOR'S PREFACE TO THE THIRD
AMERICAN EDITION
The translation into English of Professor Krehl's " Patholo-
gische Physiologic " is closely identified with the name of Dr.
Hewlett, who prepared the first two American editions of this
work from the third and fourth German editions, respectively.
It is with Dr. Hewlett's permission that I am offering to the
profession a third American edition based upon the seventh
edition of the Grcrman. Dr. Hewlett has also placed at my
disposal whatever of his I have found available — a privilege I
have freely used and for which I take great pleasure in acknowl-
edging my indebtedness. The title of the earlier translations,
Clinical Pathology, derived from the first German edition, has
been continued, as a subtitle, in this volume, the new title, The
Basis of Symptoms, having been selected to convey the immediate
relation of the contents to clinical medicine.
Noteworthy advances have been recorded in the medical
sciences since the publication of the second American edition.
Thus, the last German edition in its growth reflects in particular
the newer studies devoted to the cardiac arrhythmias; to the
leukaemias and pseudoleuksemias ; to such phases of infection and
immunity as anaphylaxis, complement fixation and chemotherapy;
to the phenomena of gastric secretion and motility; to the renal
functional tests and the role of the incoagulable nitrogen; and,
finally, to the glands of internal secretion, to gout, diabetes, fever,
etc. In addition, there has been included a new chapter on
" Constitutional Diseases and Diatheses,"
The last few years have been significant also for the part
which American science has contributed. There is scarcely a
field in which cisatlantic workers are not creditably represented;
while along many lines they are pioneers. I have made an effort
to take cognizance of this fact, and have inserted many notes
indicative of the same.
Particular attention has been devoted to the literature. Many
of the older, and classical, German references have been omitted
iii
iv TRANSLATOR'S PREFACE
and replaced by more recent studies, particularly when the latter
are in the nature of collective monographs. The numerous
American studies referred to in the text and footnotes contain,
as a rule, comprehensive bibliographies.
Professor Krehl's appended note on the cardiac arrhythmias
(referred to in his Preface) has been incorporated into the main
body of the text.
The translation though not a literal one, does not depart in any
essential way from the original text, and embodies, it is hoped, the
spirit of the latter. I have allowed myself the privilege of certain
condensations and slight rearrangements — all with the view of
rendering the material more serviceable to the readers for whom
it is intended. Editorial notes — several of which are taken from
the earlier American editions — ^are included in parentheses.
It is with keen pleasure, finally, that I acknowledge my debt
to Dr. R. G. Hoskins, Professor of Physiology in the North-
western University Medical School, for his constant stimulus and
many suggestions; and to Messrs. J. B. Lippincott Co. for their
cooperation throughout the preparation of the volume.
Arthur F. Beifeld.
Chicago, 1916.
AUTHOR'S PREFACE TO THE SEVENTH
GERMAN EDITION
With a greater trepidation than ever, I commit this revision
to the profession. In every department of pathological physiology
there are diligent workers and the literature has grown immeas-
urably. My assistants, with whom it has been my pleasure to
work, as well as Professor Schwenckenbecher, of Frankfurt, and
Professor Morawitz, of Freiburg, have • rendered me abundant
aid, without which I should have found it quite impossible, even
in small measure, to do justice to the wealth of material. De-
spite this, I cannot say, with any degree of certainty, that I am
cognizant even of the more important work from German sources ;
while of foreign literature I have given only suggestions.
I am deeply sensible of my shortcomings, and I have seriously
asked myself if the time has not arrived for a collaborative treat-
ment of the contents of this volume; for it has attained a scope,
which, unassisted, I can no longer hope to present evenly. There
is not a chapter, indeed, which my colleagues could not have
presented more ably.
Pathological physiology concerns the student, the teacher and
the clinician. In our profession it is linked with the best we have
in us, predicating thought and study and the desire to understand.
I do not say that the speculative mind is essential to the proper
conduct of medical practice; for success at the bedside is pre-
eminently and fittingly the fruit of a full and cumulative experi-
ence. To him indeed, who would advise mankind, experience is
all-important, but if this be the measure of his content, it is
well. Let him pursue his way.
Our profession embraces something larger and finer, how-
ever; it is like a faith whose God may be judged from the charac-
ter of him who worships. Thus to many comes the impulse to
devote themselves with fervor to something purer, higher and
less tangible; to ponder how the wondrous processes of life
unfold themselves in the sick; to understand how disease arises
out of health; to be a nature philosopher.
The tendency to speculate is deeply rooted in us of German
vi AUTHOR'S PREFACE
blood; to seize with winged thought what only calm, painstaking
study can elaborate and acquire. We like to construct in thought
edifices that can be erected only upon the foundation stones fur-
nished by the more suitable and exact methods of the laboratory.
And for each of us to have his own pathology still plays a prom-
inent and, in my opinion, a not desirable role.
To curb this tendency and to foster a more definite leaning
upon the biological sciences in general, is the desire of this volume
and its purpose. Its justification lies perhaps in the attempt to
correlate the functions of the different organs on a uniform bio-
logical basis ; for despite their individuality, they are efficient only
as parts of the larger whole. And to-day, more than ever, we
are agreed that he who will understand disease must see clearly
the interrelationship of all the organs — must consider the unit only
in its bearing upon the ensemble.
For reasons beyond my control the publication of this book
has been considerably delayed, so that when concluded, I would
fain have made a number of alterations. This being impossible,
I have appended a few notes on the cardiac arrhythmias.
References to the literature have been given with every pos-
sible care, yet I fear that many errors in volume and page citation
have crept in. L. Krehl.
CONTENTS
PAGE
Foreword, by A. W. Hewlett, M. D xi
Descriptive Note, by Professor William Osler xiii
Introduction xv
CHAPTER I
The Circulation i
The Importance of the Circulation; The Puknonary, or Lesser Circula-
tion; The Systemic, or Greater, Circtilation.
The Heart: The Adaptability of the Heart; Hypertrophy of the Heart;
Valvular Disease of the Heart; The Etiology of Valviilar Disease; Mus-
cular InsuflSciency; Aortic Insufficiency; Aortic Stenosis; Mitral Steno-
sis; Mitral Insufficiency; Valvular Lesions of the Right Side; Combined
V^vular Lesions; Hypertrophy of the Right Ventricle; Hypertrophy of
the Left Ventricle; Hypertrophy of Both Ventricles; Cardiac Changes
in Renal Disease; The "Athlete's Heart"; The "Beer-Heart"; The
Heart in Pregnancy; The Ability of the Heart to Hypertrophy; Con-
centric and Eccentric Hypertrophy; The Inefficiencies of a Compensated
Circulation; Myocardial Changes in Hypertrophied Hearts; Causes of
Broken Compensation in Hypertrophied Hearts; Causes of Primary
Insufficiency of the Heart Muscle; Results of Cardiac Weakness; Dis-
turbances of the Heart-Rate; Tachycardia; Bradycardia; Disturbances
of the Cardiac Rhythm; Extrasystoles; Perpetual Arrhythmia; Pulsus
Altemans — Hemisystoles; Heart-Block; Causes of Arrhythmia; The
Cardiac Impulse; The Heart-Sotmds; Cardiac Murmurs; Palpitation;
Cardiac Dyspnoea; Cardiac Pain.
The Arteries: The Arterial Blood-Pressure; Systolic and Diastolic
Pressures — The Pulse-Pressure; Physiological Variations in Blood-Pres-
sure; Pathologically Increased Blood-Pressure; Pathological Diminution
in Blood-Pressure.
The Veins: Venous Stasis; Venous Murmurs.
The Circtilation of the Lymph: CEdema; Composition of Exudates; Chy-
lous and Chyliform Ascites; Pulmonary CEdema.
CHAPTER II
The Blood 102
General Considerations.
Ancemia: Anaemia from Hemorrhage; General Considerations Relative
to Chronic Anaemias ; Chlorosis ; Secondary Anaemias ; Pernicious Anaemia ;
Haemoglobinaemia; Paroxysmal Hsemoglobinuria ; Other Causes which
Injure the Red Blood-Corpuscles; Systemic Effects of Rapid Destruction
of Red Blood-Corpuscles.
The White Blood- Corpuscles: Physiological Leucocytoses; Pathological
Leucocytoses; Leucopaenia; Leukaemia and Pseudoleukaemia.
Plasma and Serum — The Total Quantity of Blood: Coagulation; The
Blood-Serum; Salts of the Serum; Hydraemia; Polycythaemia; Plethora.
CHAPTER III
Infection and Immunity 151
Portals of Entry; The Factors Determining the Character of an Infec-
tion; Mixed and Secondary Infections; Varieties of Immunity; The
Factors Concerned in Immunity: (a) General Considerations; (b)
Complement and Amboceptor; (c) The Side-Chain Theory; The Haemo-
lytic Action of Alien Plasmas; Aiititoxins; Precipitation and Precipitins;
Complement Fixation — The Wassermann Reaction; Agglutination and
Agglutinins ; The Relation of Antitoxins and Bacteriolysins to Immunity ;
Anaphylaxis — Serum Disease; Phagocytosis and Immimity; Bacillus
Carriers; Chemotherapy — Salvarsan; Autoinfection; Conclusions.
vii
viii CONTENTS
CHAPTER IV
PAGB
Respiration 197
External Respiration: Means for Removing Harmful Material from
the Air-Passages; Stenosis of the Air-Passages; Bronchial Asthma;
Paralysis of the Respiratory Muscles; Loss of Pulmonary Elasticity —
Emphysema; Respiratory Changes of Nervous Origin — Cheyne-Stokes
Breathing; Pleural Effusions — Pneumothorax; Atelectasis; The Effects
of an Obliteration of the Air-Spaces; The Effects of Atmospheric
Pressure; Inhalation of Poisonous Gases; The Effects of Anaemia ; The
Effects of Circulatory Changes; Respiratory Compensation; Asphyxia.
Internal Respiration: Respiratory Sensations.
CHAPTER V
Digestion 229
Mouth and CEsophagus: Stomatitis ; The Saliva ; Diminished Secretion
of Saliva; Ptyalism; Composition and Reaction of Saliva; Swallowing;
(Esophageal Stenosis; Pressure Diverticula; Primary Dilatation of the
CEsophagus.
The Stomach: The Disturbances of Gastric Secretion; Hypersecretion
of Gastric Juice ; Hyperacidity — Ulcer of the Stomach ; Effects of Hyper-
secretion and Hyperacidity; Subaddity and Anacidity; Bacterial Action
in the Stomach.
Disturbances of Gastric Motility: Increased Peristalsis and Increased
Gastric Motihty; Motor Insufficiency and Gastric Dilatation; Causes
of Dilatation; Effects of Motor Insufficiency ; Belching and Vomiting;
Sensations Arising from the Stomach.
Disturbances in the Secretion of Bile: Gall-Stones; Exclusion of Bile
from the Intestines; Jaundice; Effects of Javmdice; Other Hepatic
Toxaemias.
Pancreatic Juice: Fat Necroses.
The Processes in the Intestines: The Effect of Poisons upon the
Intestines; Abnormal Bacterial Processes within the Gastit>-Intestinal
Tract; The Pathology of Absorption; Disturbances in the Intestinal
Movements; Diarrhoea; Nervous Diarrhoeas; Diarrhoeas in General
Diseases; Diarrhoeas of Intestinal Origin; Constipation; Causes of
Constipation; Effects of Constipation; Intestinal Obstruction ; Stran-
gulation; Meteorism; Abnormal Intestinal Sensations.
CHAPTER VI
Nutrition and Metabolism 304
Quantitative Variations in the Metabolism of Proteids and Fats: Caloric
Needs of the Body; Proteid Needs of the Body; Inanition;
Effects of an Oversupply of Food; Disturbances in Fat Metabolism;
Pathological Acctimulations of Fat ; Pathological Changes in the Metab-
olism of Proteids; Pathological Destruction of Proteid Material; The
Metabolism in Thyroid Disease.
Qualitative Changes in Meiabolism: Autolysis; Formation and Excretion
of Ammonia; Production of Organic Acids; Diabetic and Other Toxic
Comas; Relation Between Hepatic Disease and the Excretion of
Ammonia; Alkaptonuria; Cystinuria; The Adrenals — ^Addison's
Disease — Epinephrin.
CHAPTER VII
Disturbances of Carbohydrate Metabolism. Diabetes 343
Alimentary Glycosuria; Phlorhizin Glycosviria; Renal Diabetes; Epi-
nephrin Glycosuria; Transient Glycosurias.
Diabetes Mellitus: Mild and Severe Diabetes — Derivation of Sugar
from Proteids and Fats; The Glycogenic Function of the Liver in
Diabetes; The Consumption of Sugar in Diabetes; The Etiology of
Diabetes; Effects of Diabetes upon the Body; Theory of Diabetes.
CONTENTS ix
PAGE
CHAPTER VIII
The Metabolism of the Purin Bodies. Gout ^ . 364
Gout; Uric Acid in the Blood; Uric Acid in the Urine; The Cause of
the Local Deposits of Urates,
CHAPTER IX
Constitutional Diseases and Diatheses 372
CHAPTER X
Fever 381
Variations in the Clinical Picture of Fever; The Causes of Fever; The
Relation of the Nervous System to Fever; The Normal Regulation of
the Body Temperature; Heat-Stroke; Heat Regulation in Fever; Heat
Production in Fever; Heat Losses in Fever; Metabolism in Fever; The
Cause of the High Temperature in Fever; The Site of Heat Production;
The Heat-Regulatory Mechanism in Fever; Nutrition in Fever; Water
Retention in Fever; The Significance of Fever; The Temperature in
Collapse; Subnormal Temperature,
CHAPTER XI
The Secretion of Urine 413
The Effect of an Increased Flow of Blood through the Kidneys;
Diabetes Insipidus; The Effect of a Diminished Flow of Blood
through the Kidneys; The Effect of an Obstruction to the Escape
of Urine; The Effect of Lesions of the Secreting Membranes;
Albuminuria; Orthotic Albuminuria; The General Causes of Albu-
minuria; Albuminuria from Circulatory Disturbances of the Kidneys;
Toxic Albiuninurias; The Varieties of Proteids in the Urine; The Amount
of Albumin Excreted; Casts; The Effect of Changes in the Composition
of the Blood; The Localization of Functional Disturbances; The Effect
of Disturbances of the Urinary Secretion upon the Body; Uraemia.
The Urinary Passages: Urinary Calculi; The Symptoms of Urinary
Calcvili; The Origin of Pain in tJae Urinary Passages.
CHAPTER XII
The Nervous System 441
Disturbances of the Circulation; The Cerebrospinal Lymphatic System;
Increased Cerebral Pressure ; Cerebral Concussion ; Cerebral Hemorrhage
and Embolism; Disturbances of Motility; Disturbances of Coordination;
The Effect of the Reflexes upon Motion; Nervous Disturbances of Urina-
tion and Defecation ; Pathological Alterations in the Reflexes ; Strychnin
Poisoning and Tetanus; Contractures; Motor Irritative Symptoms; Dis-
turbances of Sensation; The Cutaneous Sensations; Orientation of our
Bodies in Space; Dizziness; Hyperalgesia; Irritative Sensory Symptoms;
The Influence of the Nervous System upon Tissue Nutrition ; The Effect
of Separating a Nerve-Fibre from its Cell; Nutritional Disturbances in
the Muscles; Changes in the Electrical Irritability of Muscles; Atrophy
from Cerebral Lesions; Muscular Atrophy from Diseases of Joints; Mus-
cular Dystrophies; Nutritional Disturbances in the Bones and Joints;
Influence of Nervous Diseases upon the Skin; Herpes Zoster.
FOREWORD
The remarkable development of pathologic anatomy during
the past century was reflected in the clinical medicine of the time.
Physical diagnosis reached its present plane of accuracy, the
ability to predict the anatomic changes found at autopsy became
the goal of certain clinical schools, and therapeutic nihilism be-
came the order of the day since it was obvious that no medicine
could have changed most of the alterations in structure that were
found at autopsy. Modern surgery has indeed been able to cut
many a Gordian knot prescribed by anatomic change ; but modem
medicine, though still directly dependent upon pathologic anatomy
for the interpretation of many clinical syndromes, has turned its
main path of development into other channels.
Anatomic changes do harm by interfering with certain func-
tions of the body, but functional alterations may also be present
without evident alterations of structure. The symptoms for
which a patient seeks relief are all due to changes in function.
Even when the physician cannot remove the anatomic cause of the
disease, he may yet be able to alter the bodily functions in such a
way as to relieve symptoms or other disease manifestations.
The functional outlook on disease requires from the physician
that he think not in terms of diseased structure alone but also in
terms of diseased physiology. The science of abnormal physiology
is at present passing through a period of rapid development. It
has been zealously studied in recent years by physiologists, experi-
mental pathologists, biochemists, immunologists and by clinicians
themselves. Modern pharmacology devotes itself mainly to the
effect of drugs upon physiological processes. The bearing of this
new knowledge upon the interpretation of clinical pictures and its
application in the treatment of disease are to my mind the most
important problems that lie before the modern clinical school.
In his book on Pathologische Physiologic, Ludolf Krehl has
sought to interpret the various pictures observed in the clinic
from the stand-point of disturbed physiology. That his work
has met with wide approval is evident from the fact that it has
passed through eight Grcrman editions and that it has been trans-
xi
xii FOREWORD
lated into a number of languages. The writer of this note is
responsible for the first and second American editions, and it was
with great pleasure that he learned of Dr. Bcif eld's willingness
to undertake a new American translation. To this new trans-
lation he wishes all success, not alone because such a work de-
serves success in itself but because success would indicate that
our profession is taking an interest in the fundamental principles
that underlie the modern development of internal medicine.
A. W. Hewlett.
January, 191 6.
DESCRIPTIVE NOTE
Knowing its worth, I very gladly agreed to write a brief
introductory preface to an American edition of Professor Krehl's
well-known work. Not that it needs any words of commendation.
A successful book in Germany, it has already been translated into
several languages, and has long since passed beyond the probation
stage; but a few words from me may serve to introduce it to
the English-speaking profession. Those of us who were brought
up on Williams's " Principles of Medicine " recall the pleasure
and the profit derived from it, mingled now with the regret that
we have no work of the same character to place in the hands of
our senior students. This want Professor Krehl's book will
supply. Herter's " Lectures on Chemical Pathology " cover part
of the ground, and Cohnheim's well-known " Lectures on General
Pathology" is somewhat similar. In Professor Krehl's work
disease is studied as a perversion of physiological function, and
the title " Clinical Pathology " expresses well the attempt which
is made in it to fill the gap between empirical and scientific medi-
cine. The facts presented are derived in part from studies upon
patients, and in part from experiments upon animals, designed
to explain clinical problems. The author has had the advantage
of prolonged laboratory training, to which has been added that
accurate knowledge of disease to be had only by years of study
and teaching in the wards. For such a work as this there is at
the present time great need. Every few years the laboratories
seem to run ahead of the clinics, and it takes time before the facts
of the one are fully appreciated by the other. In the complexity
of the problems, sometimes in the fascination of the scientific side,
we are apt to lose sight of the practical application to diagnosis
and to treatment of the facts obtained in the laboratories. The
surgeons have invaded the medical wards with great advantage to
our patients, and in many diseases to the great improvement of
the art of diagnosis. How helpful it would be if clinicians had
always at hand skilled physiologists, pathologists, and chemists
to apply their most advanced technic to clinical problems, and not
the technic alone, but the biological and chemical principles upon
ziii
»Y DESCRIPTIVE NOTE
which medicine as an exact natural science is founded. Prin-
ciples, as Plato reminds us, require constant revision and con-
sideration; and this book, representing a revision to date of the
"Principles of Clinical Pathology," will be most helpftd to all
students and teachers who wish to know the scientific basis of
our art.
(From the Second Edition.) WiLLIAM OSLER.
INTRODUCTION
The different chapters of this volume are concerned with a
consideration of the behavior of correlated organs under the
influence of a particular disturbance of function. Intended as
supplementary to texts on physiology and special pathological
anatomy, the attempt is not made to cover what properly be-
longs to those fields. The arrangement of material is that con-
ventional in the study of pathology in the German universities.
Conventional, too, is the treatment of the material — in part
an anatomical, and in part a physiological consideration of dis-
turbances in associated organs and functions. In this I am fol-
lowing also the current method of considering purely physiologi-
cal processes. This clear, dispassionate, and to him who would
know the phenomena of life, one might say sober, plan is a
product of the newly arisen physiology of the last century. The
new era was inaugurated with a mechanistic notion of the physical
and chemical workings of the individual organs. Therein lay the
tremendous advance of that transitional period — a change from
the speculative to the empirical treatment of the subject.
Pathology underwent a like alteration; dyscrasias and dia-
theses were displaced by clearly defined organ-changes. This
was the expression of the Virchow teaching, which associated
each disease with a local pathology and acknowledged no general-
ized conditions. The pathological point of view, therefore, did
not differ in any way from the physiological. But the lessons
learned at the autopsy table fall far short of what we must know
to understand the processes of life. In the failure to recognize
this lay the weakness and the narrowness of that intense period.
What we have contributed to normal and pathological physiol-
ogy in the effort to understand the life of the organs consists
chiefly in the employment of more exact methods and in the
recourse to physics and chemistry. How can the circulation be
regarded other than from a mechanical point of view, or the
digestion other than from the chemical or physico-chemical?
Pathology, in part then, is indeed only the normal under
peculiar conditions, called morbid. The fault may reside in a
constitutionally defective organ-correlation which leads to a dis-
xvi INTRODUCTION
turbance of function even under the ordinary conditions of life
(endogenous causes) ; or noxious factors may arise outside the
body (exogenous causes). Illustrative of the former is a congeni-
tally weak heart muscle, and, of the latter, a mitral regurgitation
on an infectious basis. In neither case can the owner of such a
heart compete in muscular efifort with normal men of his age and
strength. In both, the circulation goes on under morbid in-
fluences, which can be studied and understood only from the point
of view of physics, just as in normal conditions.
This is the guiding principle in the majority of processes
dealt with by this volume. Disease is synonymous with a per-
verted function of cells, organs and organ-complexes. The cell
is altered both in structure and in composition, or it is disturbed
by nervous or chemical influences (hormones). The result in
the average case is a functional deviation from the normal, and
a limitation in vitality and efficiency.
An exhaustive treatment of our subject would demand not
only a consideration of disordered cell function, but of the nature
of its physical, chemical and morphological changes. In only a
small minority of morbid conditions, however, has our knowl-
edge progressed to that degree. In one case we know the function
that is disturbed and the anatomical substratum; in another
chiefly the chemical anomaly, and in a third we are familiar
merely with certain functional abnormalities, the morphological
or chemical basis of which are still dark.
Our knowledge of morbid processes depends primarily upon
the stage of development of methods for their investigation. As
this varies considerably in different disorders, our acquaintance
with the pathology of individual organs is not uniform. This
reflects the stamp of dominant personalities upon the lines of
investigation pursued by their contemporaries. Controversies
as to the proper point of view — whether functional, chemical or
morphological — to be taken in the interpretation of the manifes-
tations of disease have been, and to some extent still are, preva-
lent. The barrenness of such discussion is obvious, for these
different aspects are closely bound together, granting that upon
certain conditions a particular line of reasoning throws more light
than another. Even so, under any circumstances, for a final
judgment as to any pathological state, the problem must be viewed
from every aspect.
mXRODUCTION xvu
Under pathological processes are included two essentially dif-
ferent types of events. The first is directly dependent upon the
morbid factor itself; thus in sublimate nephritis, the injury to the
renal epithelium may be looked upon as the immediate result of
the passage through the kidneys of mercury in combination. The
second type is exemplified in the dilatation of the left ventricle
in aortic insufficiency — an event produced by the response of the
organism to the valvular defect. Such a reaction represents an
effort toward healing and is per se not pathological. In both a
theoretical and a practical way these two types are diametrically
opposed. Our effort, therefore, must be to place each manifes-
tation of disease in one or the other of these categories, for such a
distinction is of great importance in therapy. In practice, indeed,
the tendency is to individualize too little.
In my opinion, then, there is but one correct way to study the
majority of morbid processes and the functional disorders of the
organs which produce them, and that is by a comprehensive com-
parison of physical and chemical anomalies in disease with con-
ditions as we know them in health.
The scope of theoretical pathology is no more limited by a
consideration of the disturbances that pertain to it than is that
of the normal life processes by the study of the functions of the
different organ-systems. The coordinate workings of the organs,
their place in the scheme of the whole — and through this their
efficiency — the structural and chemical building of the body from
a single cell, the wonderful problems of heredity, adaptation,
growth and death, the preservation of the characteristics of the
species and the relation of mind to matter — these are questions
which cannot be ignored if one wishes really to understand life.
Each has its pathological aspect, and each is wonderful in itself.
Some of these questions are touched upon in texts of general
pathology. But the remainder await the worker who shall corre-
late our present knowledge.
These are all problems naturally of pathological physiology — ■
problems which cannot be regarded as solved until their every
phase shall have been illuminated. The desideratum includes the
most comprehensive and difficult problems. In part they cannot
even be systematized, because as yet we have penetrated too little
into the fundamentals of normal biology. Even the general
principles which we must adduce in the solution of these problems
xviii INTRODUCTION
are not, in all respects, clear. To attempt to solve them purely
on a physical or chemical basis would be to build on false premises.
A something, not unlike the long forgotten vitalistic doctrine, is
manifest here, though it is a vitalism of a totally different charac-
ter from that applicable to the consideration of organ disturb-
ances.
But to what purpose all this here? To ask pardon because a
pathological physiology begins with the circulation, and because
in place of a well-rounded presentation only a picture here and
there can be offered. And also to explain why the subdivisions
of our subject fall into the well-worn tracks. We must dismem-
ber the processes occurring in each sick individual in order to
group them for convenience of classification under disorders of
particular organs. But in the living person, as the physician sees
him, things are quite different ; for at the bedside we must deter-
mine how a disturbance of the coordinate action of the different
organs affects the individual as a whole.
THE BASIS OF SYMPTOMS
CHAPTER I
THE CIRCULATION
The Importance of the Circulation. — ^The circulation is of
fundamental importance to the body. It is not, of course, true,
as was formerly believed, that the functions of the individual
organs depend primarily upon the amount of material that they
receive from the blood. Without doubt their activities depend
rather upon the condition of the parenchyma cells and upon the
stimuli which these receive from hormones and from the nervous
system. Yet it is certain that in warm-blooded animals, at least,
a sufficient supply of oxygen, salts and food materials to the
tissues is a necessary requisite for a normal course of life. Dis-
turbances of the circulation are, therefore, of great importance,
and the more complex the organ affected, the more serious are
the results of such disturbances.
The Pulmonary, or Lesser, Circulation. — A disordered con-
dition of the circulatory system may have its origin either in
the pump which propels the blood or in the tubes through which
the blood flows. The right ventricle drives venous blood at a
comparatively low pressure through the pulmonary vessels, which
form a system of short tubes whose combined area of cross-
section is very great. Through the walls of the capillaries, the
interchange of gases between the blood and the air in the lungs
occurs; and since this interchange takes place quite rapidly, the
pulmonary system of a large number of short tubes seems best
adapted to the purpose. The vessels play a relatively subordinate
part in controlling the circulation in the lungs, for the pulmonary
arteries possess little, if any, tone.^ So far as we know, the
different parts of the lungs are functionally equal, and there
would seem to be no necessity for a variation in the blood-supply
to different pulmonary areas, though theoretically it might be
highly desirable in morbid conditions of the lungs. During a
period of rest, when only a slight interchange of gases is neces-
sary, the rate of blood-flow in the lungs is comparatively slow ;
but during exercise, when larger amounts of gases must be inter-
1
V
2 THE BASIS OF SYMPTOMS
changed, a great quantity of blood is propelled through the lungs.
The increased respiratory movements assist the action of the heart
in maintaining this more rapid circulation.
The Systemic, or Greater, Circulation. — The relations are
quite different in the greater circulation. Here a higher blood-
pressure prevails at the outset, its height depending upon the con-
tractile strength of the left ventricle, and upon the size of the
smaller arteries. Variable amounts of blood may be made to pass
through different organs without any alteration of the general
arterial pressure, for, as the resistance to the flow through one
organ is lessened, the resistance through another may be corre-
spondingly increased. Such a mechanism is of the greatest ser-
vice, for here all parts are not of equal functional value as they
are in the case of the lungs, and it may be necessary to furnish
one organ with a rich supply of blood at one time, and then later
to do the same for another. The activity of the muscle-fibres
of the smaller arteries regulates the distribution of the blood
without at the same time necessarily altering the general blood-
pressure. Indeed, this latter must not sink below a certain point
if the brain and eye are to perform their functions properly.
The flow of blood in the veins is caused in part by the slight
blood-pressure transmitted through the capillaries from the arte-
ries and in part by other forces. Among the latter are the suction
exerted by the heart and the thoracic cavity, as well as the pump-
ing effect produced by the varying pressure of the muscles and
fasciae upon those veins that are provided with valves.
The Heart
The Adaptability of the Heart. — Any of the various
parts of the cardiovascular apparatus may be diseased without
necessarily disturbing the general circulation. This is due to
the fact that this apparatus, like so many others in the animal
body, possesses a compensatory mechanism. The compensatory
mechanism for pathological processes does not differ, however,
from that which a healthy man possesses and uses in order to
meet the varying physiological demands made upon the circu-
lation.
The amount o f work which the heart performs^
may be approximately estimated if we know the volume of
blood delivered at each systole, the velocity imparted to this
THE CIRCULATION 8
blood, the peripheral resistance and the number of heart-beats
in a unit of time. In other words, it depends upon the size of
the ventricular cavity in diastole, the number and intensity of
the ventricular contractions and the degree of constriction of the
hlood-vessels. The latter, in the lesser circulation, depends pri-
marily upon the condition of the lungs ; whereas, in the greater
circulation, it depends upon the condition of the smooth muscle-
fibres of the arteries and upon the vasomotor nerves which supply
them.
During the life of a healthy individual, the blood flows at
varying rates of speed — rapidly when the cells need much oxygen
or food material, slowly when this need is small. As stated above,
it is possible that the blood supply to an organ, or possibly to
several organs, should vary greatly without affecting the general
blood-flow. This is brought about by a contraction in one set of
vessels, compensating for a dilatation in another set. Yet this
compensation cannot meet all emergencies on account of the lim-
ited quantity of blood in the body. When large amounts of blood
are needed in several parts of the body at the same time, they can
be furnished only by increasing the velocity of the general blood-
stream.
We might think that propelling a larger amount of
blood would not necessarily increase the work of the heart, for,
as the volume of blood increased, the general blood-pressure
might be so decreased that the two would counterbalance each
other. As a matter of fact, however, this does not occur, and,
indeed, could not occur, on account of the relations that exist
between the amount of blood propelled, the general pressure and
the rate of flow. For example, if an extra supply of blood to the
body were necessary, a diminution in the general arterial pressure
would so reduce the difference in pressure between the arteries
and the veins that the rate of flow in the capillaries would be
insufficient to keep the heart supplied with fresh blood. Thus
it is that any great increase in the rate of flow is incompatible
with a lessened arterial pressure, and that consequently such an
increased flow necessarily entails more work for the heart.
The work of the heart may be increased in
another way, viz., by increasing the periph-
eral resistance. The latter varies frequently and consider-
ably even in health, for we know that the irritation of numerous
4 THE BASIS OF SYMPTOMS
sensory nerves will call forth contractions of the smaller
arteries and therewith increased resistance. It is theoretically
possible that this increased resistance should be overcome without
additional work for the heart, provided that as the resistance is
increased, the amount of blood delivered is correspondingly de-
creased. Such a condition, however, would slow the circulation
to such an extent that the body could not perform its functions
properly; and, as a matter of fact, it does not occur. We may
say, therefore, that any marked increase in the peripheral resis-
tance necessitates more work for the heart.
The heart is, as amatter of fact, thebestmotor
known to man. It performs equally well the small
amount of work necessary when a man is at complete rest, and
the large amount called forth by great exertion. It possesses,
therefore, the power of adapting itself to the varying demands
made upon it. Not every man's heart is capable of the most
extreme exertion, and "a tailor in a large city could hardly
furnish the circulation necessary for the ascent of the Matter-
horn." The weight of the muscular tissue of the heart — and
with this its capabilities — ^bears a certain relation to the weight
of the skeletal muscles. The tailor is unable to ascend the moun-
tain mainly because his general musculature is weak. If this be
improved by training, the heart also increases in its capabilities,
and usually at a more rapid rate. Indeed, a healthy
heart rarely fails in any effort. It possesses extreme
adaptability, and, what is of greater importance, the adapta-
tion occurs precisely at the time when most
needed. To this fact the body owes its remarkable capa-
city for work. For example, when a ventricle in diastole
becomes unusually filled (even up to six times its customary
capacity),^ the next systole, though it may not drive out all the
blood, propels at least several times the ordinary quantity. Fur-
thermore, if the arterial resistance be suddenly increased, it is
as promptly overcome by the succeeding ventricular contractions.
There is no time lost in experimentation: the demand and the
accompHshment occur together.* This wonderful adap-
tability of the heart expresses itself both in its
powers of dilatation and of contraction. Thus in
d i a s t o 1 e the ventricles will readily expand and take up greater
amounts of blood without a corresponding increase in their ten-
THE CIRCULATION £
sion. Only a slight pressure is necessary to distend the heart
after the first short period of suction is passed.^ When the
ventricle is nearly filled, however, the tension rapidly increases.
The same occurs even though much larger amounts of blood must
flow into the heart during each diastole. The elasticity of the
heart-muscle, which governs the resistance to the inflowing blood,
must, therefore, vary with the amount of fluid that is to enter.
By means of this variation it is possible for the ventricle to
receive very different amounts of blood within the same period of
time.
The contractility of the heart likewise bears a
certain relation to the amount of blood to be propelled: it also
accommodates itself to the increased demand. The ventricle is
able, therefore, to expel almost completely much more blood than
usual, and this even against greatly increased resistance.
This remarkable adaptability is usually regarded as a func-
tion of the muscle itself f for the ventricular apex possesses the
above properties to precisely the same degree as does the intact
organ.''^ To those who regard the few nerve fibres and ganglion
cells in the apex as possessing not only conducting but other
higher powers, this view may be unsatisfactory. At any rate,
the actual cause of the accommodation is no better
understood than is that of the automatic beat of the heart; while
additional complexities have been introduced by the important
studies on the structure of the conduction system.
So far as we know, the heart uses all its muscle-fibres at each
contraction. The increasedwork, therefore, is accom-
plished not by calling new fibres into play, but
by causing the old to contract more quickly and
more energetically. How is this brought about? In
a skeletal muscle, poisoned by curare, the strength of the con-
traction depends not only upon the stimulus but upon the weight
to be lifted. If we ascribe similar properties to the heart muscle,
we are led to the conclusion that the amount of distention directly
regulates the force of the subsequent contraction, v. Frey
rightly remarks that the response occurs too quickly to be a reflex
act. " It frequently happens that the heart does not feel the in-
creased resistance until the beginning of systole. It is then too
late for a reflex adjustment, and, if it waited for that, the next
contraction would be abortive. Experience, however, shows that
« THE BASIS OF SYMPTOMS
this is not the case ; indeed, the contractions which follow immedi-
ately after an increased call upon the heart are, as a rule, unusually
powerful."
Although the nervous system is not necessary for this
adaptation, yet it would seem that in many cases both the
elasticity and the contractility may be increased
by nervous influences. Kauders® has performed a re-
markable series of experiments, in which he has shown that an
increased resistance, produced by an irritation of a sensory nerve
— the sciatic, for example — is better overcome by the left ven-
tricle than the same degree of resistance produced by direct com-
pression of the aorta. In the latter case, the left ventricle failed
to do its work, and the pressure in the left auricle increased;
whereas in the former, the work was not only well done, but the
auricular pressure was even diminished. The left ventricle
worked here to better purpose, probably because it was favored
by nervous influences from the medulla.
As has been shown above, when the peripheral resistance is
increased, or when there is a demand for a greater blood supply,
the heart can meet the new requirements only by doing more
work. The slightly lengthened systole, which may occur under
these circumstances, and which amounts to not more than from
twenty to thirty per cent., does not lessen the work sufficiently
to compensate for the other factors.
The heart's capacity for work is indeed very great. Even
though, experimentally, the amount of blood in the ventricles
during diastole be increased sixfold, they are able to empty them-
selves almost completely; and a doubling of the arterial pressure
does not cause serious embarrassment. Yet, on the other hand,
an increase in the heart's activities is not with-
out its disadvantages. For, in the first place, the in-
creased work is made possible only by increasing the chemical
decompositions in its muscle; and, in the second, an excessive
rise in arterial pressure is by no means without danger, especially
if the blood-vessels are not perfectly healthy.
H3rpertrophy of the Heart. — Frequent and marked increase
in the work of the heart leads to secondary changes. In
this respect, so far as we know, the heart acts precisely like a
striated muscle. Continued exertion leads to its enlargement,
owing to the increase in size and number of its muscle-fibres.
THE CIRCULATION 7
It then reaches a new equilibrium and is able to accomplish with-
out effort tasks that formerly called its reserve force into play.
Bauer designates this as a "strengthening of the
h e a r t . " ^ When an increased effort is demanded of it, the
work is divided among more numerous and stronger fibres, and
it is therefore more easily performed. The extreme limits of
accommodation have also become greater, for we may assume
that the stronger hypertrophied muscle possesses a greater re-
serve force than the former weak muscle; and experience seems
to bear out this assumption.
If the weight of the heart muscle depends upon the amount
of work done, we should expect that the weight would vary in
different individuals.^ ° In the numerous and careful observa-
tions of W. Miiller^^ and of Hirsch,^^ such a variation has been
demonstrated, there being a definite ratio between the
weight of the heart and the total weight of liv-
ing body tissue, though this is not always the case, espe-
cially in youth. ^^ We have no method of directly determining
the amount of work that has been performed by a heart. Perhaps
it would be of value to know the work done by the body as a
whole, although different sorts of work affect the circulation
differently. It is also difficult to determine the total weight of
living tissue in a body, or even that of the muscular system, which
is of special importance. Thus far, statistics have dealt with the
relation that exists between the weight of the heart and the total
body weight; and although the latter introduces inaccuracies on
account of the varying amount of fat and the presence of oedema,
nevertheless the figures from a large amount of material have
shown that the ratio between the weight of the heart and that
of the body varies only within narrow limits, from which Hirsch
concludes that the activity and weight of the body musculature
exercise a determining influence upon the weight of the heart.
If this ratio of the weight of the heart to the
body weight be increased, we speak of an hyper-
trophy of the heart. Although such an hypertrophy may
arise from a variety of causes, it is questionable whether it ever
results from prolonged exertion alone. We know that severe
muscular exertion increases the weight of the heart, for the
amount of the blood to be propelled is much greater than normal
8 THE BASIS OF SYMPTOMS
and the arterial pressure is not diminished, but is usually in-
creased.^^ Under these circumstances, the heart necessarily be-
comes larger, but this increase in size is usually not out of pro-
portion to the accompanying increase in the skeletal musculature.
In other words, the relation existing between the heart-muscle
and the skeletal muscle is undisturbed, and in this sense no hyper-
trophy arises. We possess no very exact anatomical observations
on the size of the heart under such conditions. Clinical exam-
ination, however, usually fails to show any hypertrophy. Yet
some observations speak in favor of the view that hypertrophy
without weakness may result from prolonged over-exertion ; and
the orthodiagraphic method of examination bears out this concep-
tion.*'* Race-horses possess relatively large hearts, prolonged
exertion increases the weight of young dogs' hearts to a rela-
tively greater extent than it increases the weight of their muscles,*®
and skee-runners of Denmark, who were apparently healthy, have
been shown in several instances to have hypertrophy of the left
ventricle. We may say, nevertheless, that a relative increase in
the weight of the heart as a result of over-exertion is a great
rarity, and that when it occurs it is usually due to pathological
changes in the muscle. We shall return to this subject in speaking
of heart hypertrophy.
The specialized muscle fibres forming the
cardiac conduction system do not participate in the
hypertrophy of the ordinary heart-muscle.
Valvular Disease of the Heart. — ^As has been said, the heart
possesses the power of adjusting itself to varying circulatory
conditions which would otherwise interfere seriously with the
supply of blood to the body. It exercises this power not only
to meet the varying demands made upon it during health, but to
compensate for the destructive processes wrought by disease.
The function of the valves of the heart ^'^ is to
direct the current of blood in the proper direction. In order to
prevent leaks, the valves must be intact, they must be properly
controlled by the papillary muscles and the chordae tendinese, while
the openings which they close must be reduced in size by the con-
traction of the surrounding ring of muscle — a most important
factor. The orifices of the heart become much smaller during
systole, at which time they may be readily closed ; whereas during
diastole they are relatively too large for the valves.
THE CIRCULATION 9
The Etiology o£ Valvular Disease. — Diseases of the valve
segments may be produced by micro-organisms or their
toxins.^^ Acute articular rheumatism and the septic diseases
are the most frequent causes ; next to these we may name typhoid
fever, scarlet fever, variola, chorea and gonorrhoea. Indeed any
infectious disease may injure the heart valves and the heart muscle
as well.
The bacteria most frequently found in acute
endocarditis are the streptococci, staphylococci and pneumococci,
although other organisms, as the gonococci, are occasion? lly pres-
ent. In a number of instances, as in gonorrhoeal endocarditis, the
heart is simply one localizing point of a general infection. In
other cases, as in the acute exanthemata, the heart complications
are to be regarded as the result of secondary infections. The
original disease prepares the ground for the invasion of the organ-
isms which attack the heart valves.
Not infrequently, however, no bacteria are
found in the endocardial vegetations. It is pos-
sible in such instances that organisms have been present, but that
they have died out, or, on the other hand, that the condition may
have been produced not by the local action of micro-organisms,
but by toxins generated in some other part of the body. No
micro-organisms are found, as a rule, in the endocarditides compli-
cating carcinoma, tuberculosis or nephritis. Not infrequently
none has been found in the rheumatic endocarditis, though from
other cases of this disease various bacteria have been isolated.
The real cause of the heart complications of rheumatism is of
considerable interest, for rheumatism is analogous in many ways
to an infection with pyogenic cocci ^^ (seep. 153).
Infections may attack different parts of the heart, certain ones
showing a tendency to localize on the valves, others to involve
more especially the myocardium. The injury to the valves begins
with a degeneration of the endothelium, quickly followed by a
deposit of blood-platelets and by thrombi. The tissue reaction
comes later, and is more marked when the auriculoventricular
valves are affected than when the semilunar valves are diseased.
It is not our purpose to discuss the different anatomical and
clinical forms of endocarditis. Suffice it to say that by ulceration
and shrinkage the valves may be shortened or perforated, and
that by adhesions along their margins the orifices may be nar-
10 THE BASIS OF SYMPTOMS
rowed. Furthermore, owing to a concomitant myocardial affec-
tion, the orifices may not be properly closed during systole, or the
auriculoventricular valves may not be efficiently controlled by the
chordae tendineae. These latter factors are of no little importance.
For example, when at autopsy we see only a slight marginal affec-
tion of the mitral leaflets, whereas during life there had been a
decided functional insufficiency, we must regard the complicating
myocarditis rather than the valve lesion as the cause of the dis-
turbances in functions. No one who understands the closure
of the auriculoventricular orifices can believe that such a minimal
affection of the valve could possibly be the sole cause of a serious
insufficiency. It is an interesting fact that the endocarditides
complicating ulcerating carcinomata and tuberculosis are much
less frequently diagnosed than are those complicating rheuma-
tism. Since a myocarditis is usually absent in these cases, the
muscular rings contract well during systole, and the heart is less
likely to be rendered insufficient from the valvular affection.
Chronic endarteritis is another important
factor in the production of valvular disease.
This usually spreads from the aorta to the valves, though it may
arise primarily in the intima of the valvular vessels. The
great significance of syphilitic processes at the
root of the aorta in the causation of aortic insufficiency is
fully recognized to-day .2*^
Finally, the insufficiency may develop because the valves or
chordae tendinae are torn during very severe exertion, as the result
of a great rise in intracardiac pressure — a very uncommon acci-
dental
The large thrombi which are sometimes found in the left
auricle may hinder the flow of blood, and even produce the symp-
toms of a mitral stenosis. The clinical signs and symptoms so
produced are not as yet well understood.
The effects of valvular lesions may show them-
selves in two different ways — either the orifices are not properly
closed when they should be (insufficiency), or they can-
not be opened widely enough to allow the blood to pass through
freely (stenosis). Whether, in a given case, the one or the
other occurs — or, as frequently happens, both occur together —
depends upon the nature of the anatomical changes present.
The seat of the disease is in part dependent
THE CIRCULATION 11
upon the causative factor. Arteriosclerotic
lesions most frequently affect the left semilunar valves on
account of their proximity to the aorta. As a rule, a fresh
endocarditis will produce an insufficiency and not a sten-
osis. The valvular vegetations in conjunction with the diseased
heart muscle render the closure of the valves imperfect; whereas
in order to produce a stenosis, a chronic inflammation with ulti-
mate adhesions between the valve leaflets is necessary. The
grade of insufficiency, or of stenosis, i.e., the
amount of blood which in the former case flows back, and in
the latter is hindered from passing through the orifice, is deter-
mined partly by the condition of the heart muscle and partly by
the anatomical changes in the valves.
Muscular Insufficiency. — We have already mentioned the
great importance of a proper constriction of the valvular orifices
during systole by the surrounding ring of muscular tissue. A
faulty constriction may entail serious consequences, and the so-
called muscular insufficiencies are much more common than is
generally supposed. ^^ They occur most frequently as a result
of myocardial disease; and, in chronic myocarditis, especially,
they may lead to precisely the same disturbances of function as
does a shortening of the valve segments. Indeed, the diagnosis
between the two is often extraordinarily difficult; and many re-
ported instances of " healed valvular disease " are doubtless
merely improved cases of myocarditis with muscular insufficiency.
Muscular insufficiencies occur much more
frequently at the auriculoventricular orifices
than at thesemilunar openings. At the mitral orifice
they are usually due to a faulty contraction of the surrounding
ring of muscle, or possibly at times to a lack of control of the
valve segments by the papillary muscles and chordae tendineae.
On the right side of the heart the contraction of the ventricle,
as a whole, is usually at fault. According to v. Jiirgensen, the
slow contraction of the fatigued muscle may also interfere with
the closure of the valves. The term relative insuffi-
ciency has been used for the condition in which the orifice is
so widened that the valves are no longer able to close it. Al-
though this stretching of the opening may, indeed, occur, we must
insist that, after all, the essential factor is not the dilatation of
the ring, but the faulty constriction during systole.
12 THE BASIS OF SYMPTOMS
A relative insufficiency of the valves at the entrance to the
aorta is much less common. At times it is due to an insufficient
development of the muscle just beneath the semilunar valves;
or it may originate in a dilatation of the fibrous ring at the begin-
ning of the aorta.
Aortic Insufficiency. — It is now necessary to point out how
the various valvular lesions affect the distribution of the blood
in the body, and how the heart accommodates itself to the new
conditions arising from the valvular defects.
When there is an insufficiency of the aortic valves, a part of
the blood that is thrown into the aorta by the contraction of the
left ventricle is returned into that cavity during diastole. The
amount that flows back is determined by the size of the
pathological opening left by the improper closure of the valves,
by the difference between the pressure in the aorta and that
in the ventricle, and by the duration of diastole. An increased
heart-rate, which shortens more especially the diastolic period,
should be of advantage in aortic insufficiency, since it lessens the
amount of the leak backward.^^ CHnically, a rapid heart action
is not infrequently found associated with this lesion, but we are
ignorant of its cause. The walls of the ventricle are very flabby
during diastole, so that they are easily stretched by the stream
of blood flowing in under high pressure from the aorta. This
leads to a dilatation of the ventricular cavity, the amount of
dilatation depending upon the quantity of blood which flows back
and upon the degree of elasticity of the muscle wall. In early
diastole the ventricular wall is particularly flabby, but as the
filling proceeds, it becomes more tense, while toward the end of
diastole the tension increases rapidly. By thus increasing the
resistance to the inflowing blood the ventricle can protect itself
against overdistention.^^ We have already seen that this re-
sistance varies normally with the varying amounts of blood which
must be delivered, and that the ventricular wall becomes more
distensible whenever larger quantities of blood must be propelled
(p. 5). The abnormal filling of the ventricle in aortic insuffi-
ciency may or may not act as a hindrance to the entrance of blood
from the auricle. Whether the one or the other occurs depends
mainly upon this variation in the elasticity of the ventricular
musculature. If distention and elasticity go hand
in hand in order to accommodate the extra amount of blood.
THE CIRCULATION IS
it is possible that the auricle will empty itself as usual and that
there will be no disturbance in the flow of blood from the lungs.
Such cases do occur, and have been observed both clinically and
experimentally.
On the other hand, many patients with aortic in-
sufficiency show symptoms referable to a dam-
ming back of blood into the lungs. Their dyspnoea
and the marked accentuation of the pulmonic second sound are in-
dicative of increased pressure in the pulmonary circulation. It
is easy to understand how this might be brought about by an
uncomplicated aortic regurgitation; it is only necessary for the
tension of the ventricular wall to increase before all the blood
from the lungs has entered the ventricle. This would hinder the
entrance of blood from the auricle and would tend to produce a
pulmonary congestion. Furthermore, the suction of blood from
the lungs due to the expansion of the ventricle in early diastole
may also be diminished owing to the stream entering from the
aorta. We have both clinical and experimental evidence that
under such circumstances a pure aortic regurgitation may cause
a stasis of blood in the lungs.^^
In spite of its increased contents, the left ventricle in aortic
regurgitation empties itself in about the same length of time as
does the normal ventricle, although according to recent observa-
tions ^^ it may not empty itself so completely. For there is evi-
dence that the blood is not usually entirely expelled during systole
if the ventricular cavity be greatly dilated. This fact, however,
is really of no great importance in the matter under consideration,
for so long as the ventricular muscle is efficient, the residue of
blood left in the cavity at the end of systole is insignificant com-
pared with that which streams back from the aorta during diastole.
In a series of classical experiments, Rosenbach^^ has shown
that after artificially puncturing the aortic valves of a dog, all
the symptoms of an insufficiency occur without any marked
lowering of the mean arterial pressure. This experiment has
been frequently repeated, but with varying results. In rabbits,
the mean pressure is usually lowered as a result of the operation,
whereas in dogs it may remain normal, be lowered or even be
raised. These variable results probably depend, in the first place,
upon the strength of the heart, and, in the second place, upon the
severity of the lesion. The rabbit's weak heart cannot so readily
14 THE BASIS OF SYMPTOMS
compensate for the injury, and its blood-pressure sinks. The
dog's stronger heart readily overcomes a slight injury (e.g.,
puncture of the valve by a rod) ; whereas a more serious one
(e.g., tearing off a valve) results in a lowered mean blood-pressure.
It is possible that nervous reflexes may play some part in main-
taining the blood-pressure in these cases, especially when the
injury to the valves is sudden. The principal factor, however,
is undoubtedly the accommodation of the heart-muscle itself.
In man, moderate and severe cases of aortic
insufficiency are generally associated with a
very considerable pulse-pressure, evidenced by an
augmented systolic and a diminished diastolic pressure. ^^
All our experience goes to prove that a muscle will hyper-
trophy if it does an increased amount of work over a long period
of time. We should expect the same rule to apply to individual
parts of the heart, especially since their work is not limited to
eight or ten hours a day, but is continuous, day and night. The
work of the left ventricle is increased in aortic
insufficiency, for it must propel not only the blood which
enters from the auricle, but, in addition, that which leaks back
from the aorta during each diastole. The total amount expelled
is therefore increased, while the pressure against which it is
expelled is but little changed. Practical observations have shown
that in aortic insufficiency there is always an
hypertrophy of the left ventricle with a dilata-
tion of its cavity. The cavity is dilated on account of
the abnormal amount of blood which it must accommodate, and
the walls hypertrophy because of the extra work thrown upon
them. If the conditions for an increased pressure in the left
auricle, as described above (p. 13), are present, then its work and
the work of the right ventricle are also increased, and hyper-
trophy of these two parts of the heart results.
Unfortunately we possess no exact anatomical data concern-
ing these last points. The thickness of the heart wall at autopsy
is greatly influenced by the condition of the heart when it stopped
beating, whether it was in systole or diastole, so that we cannot
judge from such measurements as to whether such slight hyper-
trophy as would occur in the left auricle and the right ventricle
in cases of aortic insufficiency was present or not. Perhaps the
THE CIRCULATION 15
employment of W. Miiller's ^® method will throw more light on
the subject.
It is often erroneously stated that every aortic insufficiency
is accompanied by a considerable, and easily demonstrable, en-
largement of the left ventricle. When the muscle is efficient, the
degree of dilatation and hypertrophy is directly dependent upon
the amount of blood which regurgitates from the aorta. If a
third or fourth of the volume driven out leaks back, it is possible
that the lesion can readily be diagnosed clinically from the charac-
teristic murmur, but that the hypertrophy and dilatation of the
left ventricle will be so slight as to elude the ordinary methods
of physical examination.
Aortic Stenosis. — In stenosis of the aortic orifice the flow
of blood from the left ventricle into the aorta is impeded. It is
probable that even under physiological conditions this orifice is
not round and large during systole, but that it is encroached upon
by the contraction of the muscle which surrounds it and which
is an extension upward of the ventricular musculature. The
blood flows smoothly up to the contracted portion and then out
into the wider aorta. Under ordinary conditions, the delicate
semilunar valves are easily thrust aside. If, on account of dis-
ease, they become stiff and rigid, they hinder the escape of blood
more or less. The ventricle must, therefore, work against a
greater resistance. The prolongation of the ventricular systole,
which may be from seven to thirty per cent.^^ longer than normal,
is by no means proportionate to the increased resistance. The
lesion, therefore, causes a greater amount of work to be thrown
on the left ventricle. As a result of this extra work, we
always find an hypertrophied left ventricle in
cases of aortic stenosis. At first, there is no dilatation
of its cavity, and the auricle, lungs and right heart are entirely
unaffected. A dilatation will occur only when the heart
muscle can no longer accomplish the additional work, either
because the obstruction has become too great, or because the
muscle itself is weakened.
Mitral Stenosis. — Lesions at the mitral orifice produce more
complicated conditions than do those at the aortic, because they
lead to changes in the lungs and in the right heart.
In mitral stenosis ^^ there is a hindrance to the flow of blood
from the left auricle into the left ventricle. When the
16 THE BASIS OF SYMPTOMS
auricle contracts, it must overcome a greater re-
sistance, and this additional work leads to an
hypertrophy of its musculature.. On account of the
thin walls, however, its capacity for increased work is very lim-
ited, so that a dilatation occurs much earlier than in the
case of the ventricle. An important factor contributing to this
dilatation is the increased pressure which prevails in the pul-
monary veins. At each systole of the auricle, an unusual pro-
fHDrtion of its contents is forced back into the pulmonary veins
owing to the obstruction in front at the mitral orifice. During
diastole, therefore, the blood from the lungs enters the auricle
with more than ordinary force, the diastolic pressure in the
auricle is increased, and, owing to the diminished muscular tonus
during this period, the cavity becomes dilated.
The abnormal pressure in the pulmonary veins is transmitted
through the short and relatively wide capillaries of the lungs to
the pulmonary artery. Everything now depends upon the be-
havior of the right ventricle, which is placed in much the same
position as is the left ventricle in a case of aortic stenosis. The
pressure in the pulmonary artery must be maintained at a higher
level than usual, in order to conserve the difference in pressure
between the artery and vein, and, in turn, the flow of blood
through the lungs. We recognize this increased pul-
monary pressure, clinically, by the accentua-
tion of the pulmonic second sound. The extra
work necessitated by this high pressure is thrown upon
the right ventricle and leads to its hypertrophy.
The effect of mitral stenosis upon the left
ventricle ^2 depends entirely upon the amount of blood that
the latter receives. When the stenosis is slight and the right
heart maintains the necessary pressure in the pulmonary system,
the left ventricle is not affected, for it receives its customary-
supply of blood. If, however, the right heart cannot compensate
for the obstruction present, then the left ventricle is not filled to
the normal amount, its work is diminished and its muscle atro-
phies. This reasoning has been confirmed by the findings at
autopsy. In pure mitral stenosis, the left ven-
tricle is either normal or atrophied. If at times
an hypertrophy of the left ventricle has been found, it is to be
attributed to an associated mitral insufficiency of simultaneous
THE CIRCULATION 17
or previous origin. The two lesions are very frequently com-
bined, and this naturally modifies the resulting anatomical changes.
Mitral Insufficiency. — The conditions present in mitral in-
sufficiency are very similar to those in mitral stenosis. A part
of the contents of the left ventricle is thrown back into the auricle
during systole, and the degree of insufficiency may be measured
by the amount of blood which takes this backward course. The
lungs and the right heart are affected precisely as in the case of
mitral stenosis. The left auricle becomes dilated
and hypertrophied, and the blood-pressure in the pul-
monary system is raised. The work of the right ven-
tricle is increased by the heightened pulmonary pressure ;
whereas it tends to be lessened by the diminished amount of blood
that comes to it, and consequently by the lessened systolic output.
Ordinarily the effect of the increased pulmonic pressure pre-
dominates, and we find an accentuated pulmonic sec-
ond sound and at autopsy an hypertrophied right
ventricle. Sometimes these are not present, and we may
then assume that the left auricle dilates at each ventricular con-
traction to receive the regurgitated blood and that it empties itself
during its systole, thereby compensating in a measure for the
mitral defect. Such favorable conditions could only occur in the
milder grades of insufficiency.^^
During diastole the blood flows into the left ventricle with
unusual force, owing to the increased pressure in the auricle and
the pulmonary veins. There is also more blood to flow in on
account of the overfilling of the left auricle and the pulmonary
system with regurgitated blood. A certain amount of blood,
varying according to the grade of insufficiency, moves back and
forth at each beat between the left ventricle on the one hand,
and the left auricle and pulmonary blood-vessels on the other.
The ventricle, therefore, pumps more blood than usual, which
we have no reason to believe that it does against a lessened re-
sistance, for the mitral leak is hardly large enough to bring that
about. The increased work performed by the left
ventricle leads to its hypertrophy, a condition
always present in mitral insufficiency.^* The ventricular
cavityalsobecomesdilated owing to the larger quantity
of blood which it receives during diastole. Thus, hypertrophy
and dilatation of the left ventricle go hand in hand. This com-
2
18 THE BASIS OF SYMPTOMS
bination is of advantage not only in propelling the blood, but
probably also in withdrawing it from the auricle and from the
lungs during diastole.
Valvular Lesions of the Right Side of the Heart. — Valvu-
lar lesions of the right side of the heart give rise to second-
ary changes very similar to those which take place on the left side
under corresponding conditions. We must remember, however,
that the musculature of the right ventricle is relatively weak, and
that it is not capable of the same degree of accommodation as is
that of the left ventricle ; furthermore, that there is no powerful
ventricle directly behind the tricuspid orifice to compensate for its
disabilities. Valvular lesions of the right side of
the heart are characterized by the fact that they
develop almost exclusively during the fetal
period. Although the tricuspid valve is but rarely the seat
of a verrucous inflammation in later life, a relative insufficiency
of the tricuspid orifice is no uncommon sequel to valvular disease
of the left heart.^^ Disease of the pulmonary valve, developing
during adult life, is a great rarity.
During fetal life, micro-organisms in the blood-stream usually
injure the valves of the right side of the heart, whereas in extra-
uterine life those of the left side are the ones which are more
frequently affected. One is tempted to explain this remarkable
fact by the relative amounts of work done by the two sides or
by the influence of the aerated blood, since in fetal life it is the
right side which receives the oxygenated blood. We have no
proof, however, for either of these two hypotheses. A fetal
endocarditis is not uncommonly associated with
congenital malformations, such as septum de-
fects, transposition of the arteries or persist-
ence of the ductus Botalli.^^ Possibly the malforma-
tions are primary and tend to diminish the resistance of the endo-
cardium to infectious agents. This hypothesis would at least
be the most natural explanation of their almost exclusive pre-
dilection for the right heart. The most important of the con-
genital heart lesions is pulmonary stenosis. This anomaly, which
may be situated in the neighborhood of the valves, or at the
conus arteriosus, leads to hypertrophy of the right ventricle pre-
cisely as does an aortic stenosis to hypertrophy of the left. Of
the purely developmental anomalies only defects in the ventricular
THE CIRCULATION 19
septum are frequent; in these a systolic murmur is heard over
the sternum and occasionally over both lungs. Ordinarily they
cause no circulatory disturbances.
Combined Valvular Lesions. — The effects of valvular dis-
ease may be best studied when there is a simple stenosis or in-
sufficiency of a single valve, and when no complications are pres-
ent. Yet such simple cases are rare. In the right heart we fre-
quently find associated defects in development; in the left heart,
combinations of several valvular lesions. Pure mitral insufficiency
is comparatively frequent, but uncomplicated cases of mitral sten-
osis, or of aortic insufficiency or of aortic stenosis, are much rarer
than are the combinations of mitral insufficiency with
mitral stenosis, aortic insuffiency with aortic
stenosis or aortic insufficiency with double
mitral disease. The aortic semilunar valves are closely ad-
jacent to the aortic segment of the mitral valve, and when the
latter is diseased the former are also frequently affected.
The effect of a combination of valvular
lesions is the resultant of the effects of the individual lesions.
They may even tend to neutralize each other so that the com-
bination is less harmful than are the individual lesions. For
example, the dilatation of the left ventricle resulting from aortic
insufficiency may be lessened by an associated aortic stenosis ; and
although both mitral insufficiency and mitral stenosis act similarly
in damming the blood back into the lungs, they tend to neutralize
each other so far as their effect upon the left ventricle is con-
cerned. Indeed, we may say in general that the stenosis which
so often follows a valvular insufficiency may be of advantage in
that it limits the amount of blood which regurgitates. Caution is
indicated, however, in deciding this question in the individual
case, for other factors, especially the condition of the heart-
muscle, are often of paramount importance.
Hypertrophy of the Right Ventricle. — The work of the
right ventricle is directly dependent upon the condition of the
pulmonary circulation. Anything that increases the
pressure in the pulmonary vessels increases the
resistance against which the right ventricle
must force the blood. We have seen an illustration of
this in the case of mitral valve disease. Similar effects may
result from a weakened left ventricle which cannot com-
20 THE BASIS OF SYMPTOMS
pletely empty itself during systole. Its power of suction in
early diastole is also diminished, for this power depends upon the
elastic rebound after a powerful contraction,^^ or possibly upon
an active process in the muscle-fibres themselves.^^ The unex-
pelled blood in the ventricle and the lessened suction hinder the
entrance of blood from the lungs, raise the pressure in the pul-
monary circulation, and so increase the work of the right ventricle.
We have seen that the left ventricle can alter its elasticity under
certain circumstances, enabling it to hold a larger amount of blood
in each diastole, and the question naturally arises, "Why does
not the weakened ventricle do this instead of damming the blood
back into the lungs?" The reason seems to be that the muscle
tissue is so diseased that its elasticity as well as its contractility
is diminished.
Primary disturbances of the circulation in
the lungs may likewise affect the right heart.
We know that the resistance to the blood-flow in the pulmonary
vessels is normally very slight. Though large vascular areas,
even up to three-quarters of the total, may be thrown out of func-
tion, a sufficient amount of blood may still be sent through to the
left ventricle.^^ The right heart simply propels the blood through
the remaining pulmonary vessels with a greater velocity. The
open vessels are, indeed, dilated, but not sufficiently to compen-
sate for the others thrown out of function, so that the pressure
in the pulmonary artery rises. The dilatation of the vessels re-
maining open is quite different from that which takes place under
corresponding circumstances in the greater circulation. In the
latter, when a vessel is closed, the general pressure does not neces-
sarily rise, because vasomotor influences may produce a com-
pensatory vascular dilatation in other parts of the body; in the
lungs, the resulting dilatation is purely passive, and is due to the
increase of pressure in the pulmonary artery caused by the ob-
struction in one of its branches. This increased pressure necessi-
tates an increase in the amoimt of work done by the right
ventricle, which will be greater or less in any given case, depend-
ing upon the number and dilatability of the pulmonary vessels
remaining open. In case the increased work persists for some
time, hypertrophy of the right ventricle will ensue.
For this reason the right ventricle becomes hypertrophied as
a result of sclerosis of the pulmonary artery (a rare
THE CIRCULATION 21
condition) ; also in those more frequent pulmonary diseases which
lead to destruction or compression of the vessels, such as cir-
rhosis of the lungs from various causes, chronic pneu-
monia, pulmonary emphysema and thoracic de-
formities.^® Long-continued bronchitis is often
described as a cause of hypertrophy of the right ventricle, and
especially as a cause of the enlarged right heart found in children
who are subjects of this disease. It is difficult to say whether
the bronchial inflammation directly increases blood pressure or
whether the continual coughing gives rise to the hypertrophy of
the right ventricle by its effect on the intrathoracic pressure.
It has often been asserted that we have in tuberculosis
an exception to the general rule that chronic pulmonary disease
leads to hypertrophy of the right ventricle. To account for this
supposed exception, numerous explanations have been offered, one
of which is to the effect that the total quantity of blood is
diminished in this disease. We now know, however, that tuber-
culosis is no exception to the general rule. Anatomical investi-
gations*^ have shown that, in proportion to the body weight,
the weight of the right ventricle is increased in a large proportion
of those who die of consumption. Clinical evidence supports
the same view, for it is not uncommon to find an accentuation of
the pulmonic second sound in tuberculous patients. Nor from
the orthodiagraphic method ^^ cain any other conclusion be drawn.
To what extent individuals of the tuberculous habitus are en-
dowed with especially small hearts, and what bearing the latter
have on the development of the disease, are questions that cannot
be entered into in this place.* ^
Extensive pleuritic adhesions may also lead to an
hypertrophy of the right ventricle. Their interference with the
movements of the lungs doubtless deprives the pulmonary circu-
lation of the assistance in the aspiration of the blood usually
derived from these movements, so that additional work is thrown
on the right ventricle.
Hypertrophy of the Left Ventricle. — .The work of the
left ventricle is made greater by any increase
in the resistance to the flow of blood through the
peripheral arteries. A temporary increase in resistance
arising from vasomotor influences is not an uncommon physio-
logical occurrence.
22 THE BASIS OF SYMPTOMS
Of considerable importance as a cause of permanent increase
in the arterial pressure are certain forms of arterioscle-
rosis.^^ When the elasticity of the arteries is diminished,
they offer a greater resistance to dilating forces ; but once having
been dilated they do not so easily recover their original size.
Various opposing factors must, therefore, be considered. The
rigidity of certain areas may be neutralized by dilatation of other
areas. There is also a tendency for the affected vessels to become
permanently dilated. The precise effect of these various opposing
factors can only be determined by experimental investigations.
As a matter of fact, hypertrophy of the left ventricle develops
in only a small proportion of patients with uncomplicated arterio-
sclerosis. Those types accompanied by hyperten-
sion are the ones which regularly exhibit such an
hypertrophy. It is present, therefore, especially in cases of
sclerosis of the first part of the aorta and in
extensive sclerosis of the splanchnic vessels.
The splanchnic arteries are of such paramount importance in
controlling the peripheral resistance that when they are dis-
eased it is difficult or impossible to attain compensation by a
dilatation of other vascular areas. Other uncomplicated cases
of arteriosclerosis rarely show any marked degree of heart hyper-
trophy. The frequency of hypertension in arteriosclerosis is still
undetermined. Besides the paramount influence of the localiza-
tion of the process, as noted above, there are other factors, such
as the social status, mode of living and perhaps race, that play
a role.'*^ Hypertension is distinctly more common in the well-
to-do.
Various complications often render it ex-
tremely difficult to estimate the effect of
arteriosclerosis upon the heart. The same cause that
induces the disease of the arterial walls may also independently
act upon the heart muscle. As examples of such causes, we may
name the excessive use of alcoholic drinks, of coffee
and of tobacco, severe and continued exertion,
infectious diseases, and, above all, syphilis. Then,
too, arteriosclerosis itself may lead to degeneration of the heart
muscle owing to an involvement of the coronary arteries. Final^,
an associated chronic nephritis may produce an hyper-
trophy of the heart. We thus see how extremely difficult it is,
THE CIRCULATION 23
in the individual case, to determine whether the arteriosclerosis
is the direct cause of the heart hypertrophy or whether the latter
is due to some associated condition.
Another important question revolves about
the point as to whether arteriosclerotic hyper-
tension is due to the anatomical changes in the
vessel-walls, or to an augmented vascular tonus,
as is the case in the nephritides. (Indicative of the
latter hypothesis is the reported therapeutic efficacy, in some cases,
of papaverin, the action of which, as pointed out by Pal,^^ is to
cause a relaxation of smooth muscle. Excellent results have been
recorded in cases of uraemia due to vascular spasm, e.g., in scarla-
tinal nephritis, as contrasted with the type founded on extensive
anatomical changes in the renal vessels. — Ed.) In any event,
the determining moment will reside in the involvement of the
root of the aorta, or of a large number of smaller vessels. An-
gina pectoris and intermittent claudication are classical examples
of conditions in which vessel spasm plays an important part.
(And papaverin has likewise been found of great value in the
former. Experimentally, the drug causes a dilatation of the
coronary arteries.*''^ — Ed. )
The left-sided hypertrophy accompanying
aneurism of the aorta ^^ is to be ascribed to some complicat-
ing condition. It is difficult to see how a dilatation of the vessel
would increase the work of the heart, and, as a matter of fact, we
do see patients with aneurisms in whom there is no enlargement
of the left ventricle. When the latter occurs, we can usually
ascribe it to the arteriosclerosis — generally luetic — present, or to
an associated aortic insufficiency. Interesting in this connection
are the observations*^ indicating that hypertrophy of the left
ventricle and an increase in the elastic elements in the aorta may
follow the inhibition of regulating influences via the depressor
nerves.
Hypertrophy of the left ventricle may result from that rare
condition, congenital stenosis of the aorta. ^^ Such a narrowing
would increase the work of the heart by offering a greater resist-
ance to the blood-flow. In this anomaly, the hypertrophy may
not develop until late in life. If such be the case, we may assume
that the stenosis produced but little effect so long as there were
no great demands upon the heart, but that the hindrance made
24 THE BASIS OF SYMPTOMS
itself felt when a more active circulation was rendered necessary
by the exertions of later life.
Severe dyspnoea causes a marked rise in blood-pressure, and
it has long been a question whether moderate dyspnoea continued
over a long period of time may not give rise to hypertrophy of the
left ventricle. From recent observations,^^ we know that persons
with chronic dyspnoea do show an unusually high arterial
pressure, and there is reason to believe that this may ulti-
mately produce an hypertrophy of the left ven-
tricle.
Hypertrophy of Both Ventricles. — Hypertrophy of both
ventricles is produced by causes that increase the work of both.
Pericardial adhesions with mediastinitis are
usually reckoned among such causes; and it is easily conceivable
that these conditions might throw extra work upon the heart,
which must now move surrounding structures, even the chest wall,
with each contraction. As a matter of fact, we frequently find
heart hypertrophy associated with chronic pericarditis. It is
questionable, however, whether any causal relation exists between
the two, for in some cases no hypertrophy is present, and, indeed,
the heart may be atrophied. Since pericarditis is often associated
with disease of the heart muscle, the cases that show hypertrophy
should be studied with especial regard to the effect which these
myocardial changes may have had in the production of the hyper-
trophy.
It is theoretically possible that an increase in the num-
ber of beats per minute might lead to hypertrophy of
the heart. Such an increased heart-rate is seen in nervous people,
especially in association with hyperthyroidism or sexual excesses.
In our opinion, a more powerful heart-beat, sensed by
the patient as a palpitation, is another important cause of heart
hypertrophy, even in the absence of an accelerated beat. It has
been shown, furthermore, that in hyperthyroidism the blood-
pressure is frequently above the normal, due apparently to an
excitation of the vasomotor system."^ The conditions necessary
to produce an hypertrophy are, therefore, present, and as a matter
of fact, it is not uncommon to find enlargement of the heart
accompanying thyreotoxic states. It is probable, never-
theless, that this hypertrophy is due not so much to the rapid and
forcible heart-beat as to the direct action of toxic substances.
THE CIRCULATION 25
Tobacco, especially in the form of heavy cigars and when
burned in short-stemmed pipes, is also said to cause heart hyper-
trophy. The action is, undoubtedly, toxic in nature.
Cardiac Changes in Renal Disease. — The influence of renal
changes upon the heart presents a problem of considerable diffi-
culty.^^ In the majority of cases of acute and chronic Bright's
disease, there is an increased blood-pressure which, if of more
than four weeks' duration, leads to hypertrophy of the heart.
The left ventricle is first affected, and though ana-
tomical studies would indicate that there is a frequent coordinate
involvement of both the left and right ventricles, it is clear from
the studies of Hirsch^* that the former is the primary. Indeed,
as Passler^^ has shown, the right heart hypertrophies
only after the left has become insufficient, the
conditions being in nowise different, therefore, from those obtain-
ing in valvular disease of the left heart.
Accordingly, the increased demands made upon
the left ventricle must be the starting point of all
inquiries into the origin of nephritic heart hy-
pertrophy. Thus, we have a clear-cut and valuable analogy in
the hypertrophy incident to arteriosclerosis. The first point to
be determined is whether the type of the nephritis pres-
ent governs the development of increased arterial pressure and of
hypertrophy. The latter are, in my opinion, regularly absent in
those nephritides due to toxic disturbance of the epithelial cells,
as in arsenic, mercury and phosphorus poisoning, and also in the
group following the acute infections (diphtheria, typhoid fever,
sepsis). In scarlatinal nephritis, hypertrophy is of variable
occurrence; and in the s®-called acute primary form, it is also
occasionally observed. These primary types, incidentally, will be
diagnosed less frequently as we become better equipped to recog-
nize that they are often secondary to latent infections.
Among the chronic nephritides, the contracted kid-
ney is most often associated with heart enlarge-
ment ; in this form, indeed, the hypertrophy attains its high-
est grade. Yet there are typical examples of granular atrophy
of the kidney in which both the arterial tension and the size of
the heart are normal.^® In the so-called chronic interstitial and
chronic parenchymatous types, hypertension is also frequent,
though in the latter it is often absent — indeed, in the majority of
26 THE BASIS OF SYMPTOMS
cases according to some observers.^^ Pure amyloid kidney leads
to no heart changes. Conditions such as renal stone and tumors
of the lower abdomen, causing pressure upon both ureters and
leading to chronic hydronephrosis may also be followed by hyper-
trophy according to Cohnheim; yet this is surely an infrequent
event. (Chronic infections of the renal pelves, even though en-
tailing no obstruction to the flow of urine, not infrequently lead
to changes in the size of the left ventricle and in the arterial
tension as pronounced as those seen in granular kidneys; and
they may likewise terminate in uraemia. The differential diag-
nosis in such cases may be exceedingly difficult. — Ed. )
It is evident, therefore, that there is no constant re-
lation between the type of nephritis and the
occurrence of hypertrophy, though an enlargement of
the heart is most frequent and most pronounced in cases of gen-
uine contracted kidney. Nor is there a definite relationship ex-
isting between the localization of the renal process and the appear-
ance of circulatory changes, for the particular tendency of glome-
rulonephritis in this direction has not been proved. ^^ Indeed, I
am almost inclined to agree with those who believe that nephritis,
as an anatomical process, has no effect upon the heart and blood-
pressure, and that the latter suffer changes only as a result of
functional disturbances initiated by the nephritis.
The theory that the rise of blood-pressure is
due to an augmented viscosity of the blood ^® is
scarcely tenable, for though the work of the heart would
thereby be increased, the blood-pressure would be kept at its
normal level by a compensatory regulation of vascular tone. And,
furthermore, observations indicate that the viscosity of nephritic
blood does not differ from that of the normal.
A general decrease in the calibre of the blood-
vessels would explai-n everything, for even a slight
diminution, either in all the vessels or in the more important
vascular areas, would greatly increase the work of the heart, since
this varies inversely as the fourth power of the diameter of the
combined vessels. Such a change in diameter, if present, must
take place within a short space of time, as in acute nephritis, and
must last for years, as occurs in chronic interstitial nephritis. A
permanent narrowing of this sort might be due to disease of the
smaller arteries, itself either secondary to the nephritis or co-
THE CIRCULATION «7
ordinate with it. The latter conception is the more reasonable,
because it is scarcely likely that the noxious element leading to
heart hypertrophy in renal disease confines its action to the kid-
neys alone. This subject will be considered again under nephritic
oedema (p. 92).
That the cardiac hypertrophy and the hyper-
tension observed in nephritis are due to changes
in the peripheral blood-vessels is a classic con-
ception and one based on considerable evidence.^" Thus,
well-defined arteriosclerosis is frequently associated with
contracted kidney; further, the arteriocapiUary fi-
brosis of Gull and Sutton occurs in granular kidney; and in
a number of nephritides, acute inflammatory changes
in the vessels have been noted. Jores, in a comprehensive
and careful study, noted the frequency and extensiveness of
changes in the small vessels both of the kidneys and of other
organs. These changes may augment the work of the heart,
and raise the arterial tension in a purely mechanical way by in-
creasing the peripheral resistance ; but, in addition, the origin and
persistence of the high tension point with great probability to
an altered functional condition of the vessels.*^
That vascular disease leads to an irritable vasomotor condition
has already been noted in connection with atheromatous heart
hypertrophy (p. 22).
On the other hand, the origin and nature of the
increased arterial pressure in renal disease
point with certainty to an altered functional
condition of the vessels. The hypertension develops
early in acute nephritis, and during the course of acute and
chronic nephritides, the blood-pressure is subject to sudden and
excessive variations. It readily rises as a result of excitement,
exertion, abundant mixed food, and, most of all, as a result of
impending uraemia. It is lowered by a quiet life and a careful
diet, e.g., milk. In all renal diseases associated with high blood-
pressure, we frequently encounter considerable variations: of
pressure for which no cause is apparent.
It seems to me that these facts can only be ex-
plained by assuming a contracted state of the
smaller arteries which is liable to sudden and
excessive variations. One might naturally object to
28 THE BASIS OF SYMPTOMS
the assumption of a continued arterial spasm which lasts for
years. This is not what is here assumed, however. It is well
known that the arteries are normally maintained in a condition
of partial contraction and that this so-called tonus is largely regu-
lated through the nervous system, perhaps through an intermediate
and continuous epinephrin action (see p. 336). It seems to me
most probable that this normal tonus is increased in nephritis, and
that this causes the cardiovascular symptoms of this disease.
Thus we may say that in association with nephritis there arise
conditions favoring an increase in vasomotor tone. It is not
unlikely that it is brought about by a pressor action exerted by
the toxic materials that are retained. Possibly on this basis is
to be explained the beneficial effect in high tension cases of a
milk diet, in that it throws no added strain upon the already
overburdened kidneys, thus enabling them to excrete the uraemic
toxins. Our ignorance of the nature of these poisonous end-
products is no proof that chemical processes are not at work in
the production of high tension. Indeed, we are not as yet en-
tirely informed as to the substances which are excreted by the
glomeruli.
French observers have called attention to the possibility of
the coexistence of nephritis and disease of the
suprarenal glands, or other portions of the chromaffin
system. In the light of our present knowledge of the hyperten-
sive action of epinephrin, there is no theoretical objection to this
hypothesis; on the other hand, the epinephrin content of the blood
has not been found increased in nephritis.^^ As to the interesting
observation that the kidney tissues themselves contain substances
which raise the arterial pressure, little can at present be said.*^
In an examination of diseased kidneys, for instance, the amount
of such pressor substances was found not abnormally large; nor
is the presence of pressor bodies peculiar to the kidneys.
The foregoing discussion of the etiology of the cardiovascular
changes in nephritis leads naturally to a consideration of their
possible significance. The increase in the normal vas-
cular tonus is apparently of benefit in the
secretion of urine, for the filtration processes in the
glomeruli demand a certain capillary pressure and a certain capil-
lary flow. If the glomerular surface be diminished, then less
blood would come in contact with the glomerular epithelium and
THE CIRCULATION 29
less urine would be secreted. An Increased arterial pressure with
an increased glomerular flow will cause an increased secretion
from the healthy glomeruli and possibly from the diseased ones as
well. The increased arterial pressure then becomes advantageous
to the kidneys. At the same time, as we shall see (p. 34), it
may be a source of danger to other parts of the body.
We may sum up what we have said concerning the factors
concerned in the causation of nephritic hypertrophy of the left
ventricle by regarding the matter from a different, and, in my
opinion, better- founded point of view. Mention has been made
of the fact that nephritis as such need have no effect upon the
circulation; that the majority of nephroses are unaccompanied
by circulatory changes; and that in nephritides associated with
hypertension, arterial changes are always present. On the other
hand, we meet with cases showing similar arterial changes, accom-
panied by an increased blood-pressure and by an enlargement of
the heart, clinically indistinguishable from that occurring in granu-
lar atrophy of the kidney, but in which the kidneys are quite
normal; or, if definitely diseased, the type of the affection is
obscure (see under Hypertension, p. 84). I am more and more
convinced that these cases, which unquestionably are more fre-
quent than is the genuine contracted kidney, cannot fundamen-
tally be distinguished from the latter; and in this view I am
upheld by many.^* It is an error, in my opinion, to emphasize
the renal changes present in such cases. On the strength of
the investigation of Jores, we are justified, I believe, I n
attributing the heart hypertrophy and arterial
hypertension of most, if not all, cases of neph-
ritis, of arteriosclerosis, of the so-called
essential hypertension and of syphilitic hyper-
tension, to the concomitant action of vessel-
wall disease and fu n c t i o n a 1 vascular dis-
turbances. This, however, does not solve the genetic rela-
tion between the arterial and renal changes. I believe that we
have to do with a more or less generalized process affecting the
kidneys and vessels, equally and simultaneously.
The "Athlete's Heart."— As has been previously stated,
severe muscular exertion ordinarily increases the weight of the
heart in the same ratio as It increases the weight of the general
musculature. It is frequently assumed, however, that hyper-
30 THE BASIS OF SYMPTOMS
trophy of the heart may result from prolonged muscular exer-
tion. Such a relative increase in the heart's weight does perhaps
occur in individual cases in the absence of any impairment of
function, but this is certainly exceptional (see p. 8). When
over-activity affects the heart, it usually does so by causing a
primary weakness of the muscle ; yet here again it may frequently
be questioned whether this weakening should not be attributed
to some other associated causal agent, such as the excessive use of
alcoholic liquors, arteriosclerosis or renal disease. Further obser-
vations upon these questions are, therefore, necessary.
The recent orthodiagraphic observations^^ relative to a
diminution in the size of the heart following
severe muscular exertion are subject to two possible
interpretations, vis., that a functionally efficient organ empties
itself more completely in systole than under normal conditions,
or that the rapid heart action does not allow a proper diastolic
filling of the chambers and that the reduced orthodiagraphic
figure, therefore, is an evidence of beginning myocardial insuffi-
ciency.
The " Beer-Heart." — It is not uncommon to find weak hearts
with an hypertrophy of the muscle and a dilatation of the cavi-
ties in men who have been accustomed to drinking very large
quantities of beer. Such hearts are most frequently seen in
Munich, and may show extreme grades of hypertrophy. Excessive
wine-drinkers ocasionally suffer from a similar condition, whereas
drinkers of more concentrated alcoholic liquors are only very
rarely affected in this way ; they tend to develop cardiac weakness
unassociated with hypertrophy. In many beer-drinkers no other
etiological factor is present except the immoderate use of beer.
The majority, however, do very heavy work, and consume large
quantities of food in addition to their beer.
That the kidneys, or at least the blood-vessels,
are concerned in this type of hypertrophy seems
likely from the observation of F. Miiller^® that the majority of
beer-drinkers exhibit a more or less marked increase in blood-
pressure. The entire question, therefore, must be elaborated again.
Perhaps the conditions here are similar to those underlying
cyanotic induration of the kidney.
The cause of the enlargement of the heart in beer-drinkers
has been ascribed by some to an increase in the total amount of
THE CIRCULATION 81
blood, a genuine plethora. Autopsy studies apparently give
substance to this hypothesis. Experiments have been made to
show the effect of such a plethora upon the heart.^^ In rabbits
in which a genuine polycythaemic plethora was produced and
maintained for several months by injections of an homologous
blood, the weight of the heart was found not increased. Accord-
ingly, the work of the heart could not have been augmented. For
our purpose, these experiments lack the accessory factor residing in
the alcohol.
Personally, I have observed these heart changes in brewers,
laborers and students who drank immoderately, and who also
did heavy work, or took violent exercise. A number of such
people certainly did not give the impression of being " full-
blooded." It seems to me that the combination of beer-drinking
with heavy work was responsible for the heart condition; and
indeed I gained the impression that both the dilatation and the
hypertrophy tended to disappear if the patient changed his manner
of living.
Gourmands may at times acquire a similar heart condition,
probably from the large amounts of food and wine, the heavy
smoking and the not infrequent sexual excesses. In such cases the
picture is often complicated by arteriosclerosis and nephritis, and
myocardial weakness is generally prominent. Incidentally, we
may observe that the injurious action of tobacco upon the vessels
is now a well-recognized fact. '
The Heart in Pregnancy. — It has been frequently asserted,
especially by French observers, that there is an enlargement of
the heart during pregnancy. As a matter of fact, in pregnancy,
as in other conditions associated with a high position of the
diaphragm, the area of cardiac dulness is enlarged because the
heart approaches the chest wall. The truth is that pregnancy
exercises no effect on the heart other than that which could be
explained by the general increase in the weight of the body.®®
The Ability of the Heart to Hypertrophy.— It may be asked,
What conditions influence the power of the heart to hyper-
trophy ? We may mention three factors. In the first place, there
is the rapidity with which the new demands are
made on the heart. If, as usually occurs, the work is
gradually increased, the heart has time to hypertrophy gradually
and to attain ultimately an enormous size and greatly increased
82 THE BASIS OF SYMPTOMS
working capacity. In the second place, the degree of hypertrophy is
influenced by the amount of new work required. The
more work the heart does, the greater is the resulting hypertrophy.
As has been said, an enormous increase in work may be accom-
plished, provided the new demands are gradually increased. Yet
even sudden calls upon the healthy heart are well responded to up
to a certain limit. We can give no definite figures for this limit
in man, but we know from clinical experience that it is not a
low one. Experimentally, it has been shown that the heart of
a healthy dog is able to pump six times the customary quantity
of blood, and to overcome three times the usual blood-pressure.
The third and most important factor that influences the heart's
capacity to hypertrophy is the condition of the cardiac
muscle. Without a healthy muscle, the heart cannot accom-
modate itself to an increase in work. The general nutrition of
the body is of comparatively little significance, for Tangl^^ has
shown that even in the most emaciated animals hypertrophy of
the left ventricle will develop after an artificial valvular lesion.
We have no right, therefore, to attribute a lack of hypertrophy
to the poor general nutrition of the patient. It is to be attributed
solely to the fact that there has been no increase in the work of
the heart, which, in our opinion, is the case in amyloid kidney.
When additional work is required of the heart, there are only two
possibilities — either it responds and hypertrophies, or it weakens.
It is, of course, probable that when the body is well nourished the
heart is better able to respond and is less likely to weaken. We
may mention here that in childhood the heart possesses far greater
powers of adaptation than in later life, and that it is then able
to compensate to a very marked degree.
Concentric and Eccentric Hypertrophy. — ^The heart hyper-
trophies discussed thus far may be divided into two general
classes, according to the size of the ventricular cavities. When
the muscle increases with no enlargement of the cavity, we speak
of a simple (concentric) hypertrophy. On the con-
trary, the size of the cavity may also increase, and such a con-
dition is called an eccentric hypertrophy. This division
is applicable only to hearts which are properly compensated. As
soon as this fails, dilatation of a totally different nature occurs,
which shall be discussed later.
The ventricular cavity must become dilated during diastole
THE CIRCULATION 38
whenever it is necessary to pump more blood at each beat.
Whether the cavity is also dilated in systole, or not, depends upon
the completeness with which the ventricle empties itself. Experi-
mental evidence would lead us to the belief that an incomplete
expulsion of the blood is by no means infrequent. In heart-
failure this is the rule; but even when the heart is maintaining
a good circulation it does not empty itself completely when very
large amounts of blood must be propelled, or when the resistance
is much increased. Yet hypertrophy may occur even in a ven-
tricle which does not empty itself completely, so long as the work
of the heart is increased and the myocardium is responsive.
The Inefficiencies of a Compensated Circulation. — The hyper-
trophy which enables the heart to carry on the circulation under
pathological conditions is spoken of as a compensatory hyper-
trophy. This does not mean that the new circulatory mechanism
is just as effective as the old. According to the view of Romberg
and of the author, however, the power of the hypertrophied heart
muscle to accommodate itself to further new demands is equal
to that of the intact muscle.
Martins and Aschoff,'^^ on the contrary, regard the reserve
power of such a heart as inferior to that of the normal organ,
and explain thus the ease with which the owners become fatigued.
Yet we know that it is not uncommon for individuals with hyper-
trophied hearts to perform as much physical work as the healthy.
And, as Romberg has shown, animals with aortic insufficiency
are able to meet demands upon their heart muscle in a way that
would indicate that the myocardial reserve force is equally as
great as that of a non-hypertrophied organ.''*
Hypertrophy, therefore, may be regarded as
of great advantage to the heart in these cases,
for it not only enables the latter to accommodate
itself to additional burdens, but also, within
certain limits, makes possible the maintenance
of the circulation at practically the same effi-
cient level as in health.
In the foregoing discussion we have taken the ground that
hypertrophy in all cases represents the response of the cardiac
muscle to increased work. The views of earlier writers differed
from this; thus Buhl ascribed the hypertrophy in nephritis to
inflammatory changes in the myocardium. And even Albrecht'^^
s
84 THE BASIS OF SYMPTOMS
regards hypertrophy as the first stage of a progressive myocar-
ditis, and to the latter and the accompanying degenerative changes
he ascribes the eventual weakening of the heart. I am free to
admit that this conception of an inflammatory hyperplasia offers
an attractive solution of certain types of hypertrophy not ex-
plainable on a mechanical basis. The proof that this is the case,
however, is lacking.
And yet, as has been stated, a compensatory en-
largement of the heart cannot restore the circu-
lation to a normal condition, and for many reasons.
In the first place, the blood-pressure in the pulmonary system
must frequently be maintained at a higher level than usual, as
happens in many diseases of the left heart and of the lungs
(see p. 19). If the high pressure in the pulmonary circulation
continues for any length of time, the connective tissue of the
lungs increases and small quantities of blood are extravasated.
The resulting pigment is taken up by the alveolar epithelial cells,
and if these appear in the sputum, they are diagnostic of
chronic passive hypersemia of the lungs (heart-
failure cells). The increased pressure in the pulmonary
system, if at all marked, unquestionably interferes with
breathing. '^^ The tissues of a lung that is the seat of chronic
passive hyperaemia also seem to suffer in their nutrition and in
their resistance to infection. At least, such patients are very
susceptible to bronchitis, so that it seems as if the lungs
had become less able to resist organisms that may have entered
through the upper air-passages. And, in addition, atypical
pneumonias are not infrequently seen.'^*
Lesions of the right side of the heart not infrequently lead
to stasis in the veins of the general circulation.
Since the same condition is produced by any weakness of the
right ventricle, it will be considered in that connection.
All patients with continuously high arterial pressure are in
danger of the rupture of an artery, which is espe-
cially true if the walls of the arteries are already weakened. The
immediate cause of the hemorrhage is usually some act which
itself produces a further rise in pressure, such as excitement,
violent exertion, coitus and straining at stool. In patients with
arteriosclerosis or granular kidney, such acts are not infrequently
followed by hemorrhages into the brain or retina.
THE CIRCULATION 85
As IS well known, the characteristic pulse of aortic insuffi-
ciency is one of great excursion. It bounds up against the pal-
pating finger, and as suddenly recedes. It may be transmitted
to the capillaries, producing a visible capillary pulse. Such a
pulse is not without its effect upon the arterial wall. The rapid
and excessive distention may result ultimately in a stretching of
the artery, so that vasomotor influences are no longer able to
reduce it to its former size. The amount of blood in the body
is limited, and, since the dilated arteries contain more than nor-
mally, there may thus result an inadequate filling of
the rest of the vascular system. '^^ This is perhaps the
explanation of the poor circulation sometimes seen in cases of
aortic insufficiency in which there is no weakening of the left
ventricle.
Still another effect of an enlarged heart must be mentioned,
viz., the space taken up in the chest cavity and the resultant
compression of the other intrathoracic organs.
The foregoing considerations relative to hypertrophied hearts
are applicable to the individual case in variable degree, depending
upon what part of the heart has undergone hypertrophy, and
upon the cause of the latter. Certain valvular lesions, there-
fore, are less unfavorable than others ; thus an aortic insufficiency
of moderate grade or a combined aortic lesion tend to be less
injurious in their effects than do certain mitral affections, in
that the former involve the pulmonary circulation to a lesser
degree.
We have dealt thus far with the heart's condition so long as
the body is at rest. If patients with heart disease exercise, the
work of the heart is at times enormously increased. Thus we
see that although the hypertrophy of the heart may compensate
for the valvular lesion in certain particulars, it cannot restore the
circulatory conditions to their normal state.
Myocardial Changes in H^jrpertrcphied Hearts. — ^And yet the
chief source of difficulty with an hypertrophied heart does
not lie in any of the factors thus far mentioned, but rather in
the condition of the muscle itself. We have enlarged upon the
fact that a healthy hypertrophied muscle possesses capabilities
not differing from those of the normal muscle. The hyper-
trophied heart muscle and the enlarged biceps of the athlete are
comparable in some cases, but, unfortunately, it is not so in the
86 THE BASIS OF SYMPTOMS
majority of instances. For the very causes which lead
to hypertrophy of the heart often, at the same
time, produce pathological changes in the myo-
cardium. It will be recalled how frequently the infectious
diseases give rise to valvular lesions and consequently to heart
hypertrophy. In such infections the myocardium is almost in-
variably diseased, and often to a greater degree than the endo-
cardium. These diseases, and especially acute articular rheuma-
tism, cause degenerations of the muscle fibres, interstitial myo-
cardial inflammations and diseases of the arteries. It is indis-
putable that these disturb the functions of the heart muscle most
seriously. '^^ Such a disturbance may take the form of an acute
dilatation — which is not of a compensatory nature, due to the
necessity for an increased supply of blood — ^but which results
from the incomplete contractions of the heart-muscle. The dila-
tation of the right ventricle in the early stages of a mitral lesion
is usually of this nature. Chronic myocardial changes are like-
wise of great importance in the subsequent course of a valvular
disease.
Though observers are not agreed as to the frequency of well-
marked myocardial changes in valvular affairs — Aschoff, for ex-
ample, believing that the significance of such changes is greatly
overestimated'^^ — yet clinical experience has shown that the effi-
ciency of the heart-muscle plays a very important part in the
maintenance of the circulatory equilibrium. But as our present
knowledge of the anatomical alterations in the myocardium is
insufficient to explain its functional disturbances, there has sprung
up, very naturally, considerable speculation relative to muscular
injuries which have escaped our notice. Looking at the problem
in the broadest way, we can say that even the infectious myocar-
dial lesions are evidence simply of the action of some harmful
chemical influence. And as the extent of a myocardial process
cannot be taken as the measure of the diminished capabilities of
the heart, I must admit that some cases of insufiiciency are insus-
ceptible of explanation on the basis of the anatomical changes
present.
We may sum up then as follows: The insuffi-
ciencies of many valvular hypertrophies are
due to a damaged heart muscle, itself in certain
cases the result of inflammatory processes. The
THE CIRCULATION 37
latter may vary both in location and intensity, and bear no definite
relation to the kind or age of the valvular lesion. It adds an
uncertainty to the prognosis of valvular disease which must
always be taken into account. The progressive character of the
processes in question is another source of uncertainty. On the
one hand, the endocarditis may gradually progress and lead to
more and more extensive alterations in the valves ; while, on the
other hand, the heart muscle may gradually weaken so that it
becomes less and less able to respond to the increased calls made
upon it. A most unhappy combination !
The weakness of the hypertrophied heart
muscle in valvular conditions, apparently not of
infectious origin, is less easily explained. Hyper-
trophy of the right ventricle often arises from diseases
of the lungs. The progressive character of the pulmonary
disease may gradually throw an overwhelming burden upon the
right ventricle. In other cases, however, no such explanation
is possible, and we are entirely ignorant of the reason why the
hypertrophied ventricle weakens.
So far as the left ventricle is concerned, the relations
are comparatively simple when the hypertrophy is consequent
to arteriosclerosis, for it is well known that the coronary arteries
are frequently involved in this process and that coronary sclerosis
leads to most serious disturbances in the nutrition of the heart
muscle.
The hypertrophied hearts of patients with
nephritis are often singularly free from signs of weakness.
Many patients with granular kidneys maintain a good circulation
for years, and only in the last stages of the disease do they de-
velop signs of cardiac weakness and of uraemia. Albrecht^^
has recently shown that in such cases disease of the myocardium,
sufficient to account for all symptoms, is present.
It is extremely difficult to explain the cardiac weak-
ness that develops as a result of the abuse of beer
and wine, and also of excessive physical exer-
tion. In a number of these cases, the extensive fatty degenera-
tion and the fresh inflammatory processes are sufficient to account
for all the symptoms; but no satisfactory explanation can be
given of those cases in which there is cardiac weakness without
38 THE BASIS OF SYMPTOMS
demonstrable signs of disease in the myocardium. Further stud-
ies are necessary to throw light on such conditions.
We can now understand how it is that in many instances
the hypertrophied heart is less efficient than the normal organ.
Hypertrophy itself does not necessarily entail any weakness.
Theoretically, the hypertrophied organ possesses the same reserve
force as the healthy one. Such favorable hypertrophies are, in-
deed, observed, but unfortunately they are rare. In the majority
of cases the cause which induces the hypertrophy also damages the
capabilities of the muscle. The heart is so injured that it cannot
properly respond to an emergency at the very time when its power
to do so is most needed.
For this reason, many hypertrophied hearts are unable to
meet any additional call made upon them. They tire much more
readily than the normal organ, and when once tired they do not
recover so quickly; indeed, a serious or even irreparable damage
may result. On this account, the patient with heart disease is
repeatedly warned of the dangers of over-exertion. On this
account, also, women who have heart disease often do badly during
a confinement.
Causes of Broken Compensation in H)T)ertrophied Hearts. —
If a heart becomes unable to meet the increased demands
that are made upon it, we speak of a break in compen-
sation. This failure in compensation may be brought about in
several ways. In the first place, what is ordinarily a
moderate call upon the heart may be an excessive
one in certain forms of disease. Or, it is conceiv-
able that inflammatory processes at work in the heart
muscle interfere with, or even render impossible, its recovery;
for in a functionally impaired tissue, morbid processes find a
good soil for extension.
It frequently happens that a break in compensation occurs
even though the patient has taken great care not to exert him-
self. Such a break in compensation may improve, and even be
recovered from ; but, on the other hand, it may lead to permanent
insufficiency or death. The prognosis is decidedly better when
the compensation of the right ventricle is alone at fault; and the
breaks in compensation which occur in mitral disease are decidedly
more favorable than those which develop in a heart in which the
THE CIRCULATION 89
left or both ventricles are hypertrophled as a result of continued,
severe exertion, arteriosclerosis or active valve disease.
In a certain proportion of the cases in which such a decom-
pensation occurs, apparently spontaneously, it is to be attributed
to a fresh infectious process involving the heart muscle. A
second attack of acute articular rheumatism, a pneumonia or a
tonsillitis may in this manner be the immediate cause. It seems
as if the hypertrophled heart muscle formed a locus minoris re-
sistentice to the infecting organisms or to their toxins.
In another group of cases the apparently
spontaneous break in compensation is due to
the progressive character of the process that
caused the hypertrophy. The demands upon the heart
are gradually increased to such an extent that they cannot be
carried out. Among such progressive processes are to be reck-
oned many valvular lesions, pulmonary cirrhosis and emphysema,
arteriosclerosis, chronic nephritis and the excessive use of beer;
in a word, they include the majority of all the causes of heart
hypertrophy.
Finally, the break may occur, not from any increase in the
demands upon the hypertrophled heart, but from a pro-
gressive weakening of the muscle through myo-
cardial disease, which renders the heart unable to do even
its normal quota of work. This form of cardiac weakness will
be more fully considered below.
In a certain, though relatively small, number of the cases,
therefore, we are familiar with the causes of transitory and per-
manent disturbances in compensation. In particular, we are
ignorant as to the factors concerned in the majority of those
more or less rapid decompensations occurring in hypertrophled
hearts and which recover upon the proper administration of
digitalis (see also Auricular Fibrillation, p. 65).
The active principles of this drug stimulate both- the myocar-
dium and the cardiac vessels to more efficient contractions.*^^ To
be efficacious, therefore, digitalis must encounter a myocar-
dium which is still responsive. Herein lies the great prognostic
value of the preparation. Though of little apparent service in
the fresh inflammatory cardiac lesions, it is eminently successful
in many of the classical decompensations. Whether the action
of digitalis is physical, counteracting abnormal swelling of the
40 THE BASIS OF SYMPTOMS
muscle fibres, or chemical, restoring an altered sodium chlorid
balance, are questions requiring further elaboration.
It is a noteworthy fact that in the stage of broken compen-
sation the arterial blood-pressure is often, and according to some
observers, always increased ^° (Hochdruckstauung,
Sahli). To explain this we must fall back upon Traube's hy-
pothesis, viz., that vasomotor irritability is responsible (see also
p. 85).
Causes of Primary Insufficiency of the Heart Muscle. — Some
of the causes that lead to a primary weakness of the heart
muscle have already been mentioned in the last section. The
others may affect either hypertrophied or non-hypertrophied
hearts.®^
Of first importance among such causes are those which
interfere with the blood-supply to the cardiac
muscle, such as thrombosis, emboHsm and sclerosis of the
coronary arteries. The heart is exceedingly sensitive to changes
in its blood-supply.®^ Though the heart of a healthy rabbit has
been shown capable of withstanding an interrupted blood-supply
for a period of six minutes,®^ yet any prolonged ischaemia is as
badly borne by the heart as by any other organ. Hence the im-
portance of Eppinger's®* observation that the vessel diameter
in hypertrophic and insufficient hearts is diminished. If a large
portion of its wall be suddenly deprived of its nourishment, the
organ stops beating. This has been observed clinically when
an embolus has lodged in a coronary artery, and it
has been demonstrated experimentally by ligating one of the
circumflex vessels. In other cases, where the damage is less
extensive, the muscle wall may degenerate and rupture, leading
to a fatal hemorrhage within the pericardial sac.
The effect of occlusion of a smaller branch of a
coronary artery is variable. The usual consequence is a
weakening of the affected ventricle, a fall in pressure in the effer-
ent arterial trunks, and a rise in venous pressure. In some in-
stances the patient experiences a sensation of oppression or of
severe pain in the precordium, which may or may not herald a
fatal termination. Arrhythmia is usually present, and the rate is at
first slow and later accelerated. The heart may stop in fibrillary
twitchings, a condition in which the different muscle fibres con-
tract incoordinately and therefore uselessly. Porter®^ has
THE CIRCULATION 41
shown that it is possible to tie even large coronary branches
without causing the death of the animal. Correspondingly,
patients have been observed at autopsy who have apparently re-
covered from extensive infarctions of the heart muscle. There
is a slight anastomosis among the branches of the coronary arte-
ries, so that these can no longer be considered end-arteries in the
strictest sense of the term. The anastomosis, however, is insuffi-
cient to establish a collateral circulation if an area of any magni-
tude has been deprived of its regular blood-supply. An area
so affected undergoes anaemic necrosis. In general, therefore,
we may say that the occlusion of a coronary vessel of any magni-
tude is a matter of serious import.
Marked general anaemia also injures the
heart, either by causing degeneration of its muscle-fibres, or
by lowering their nutrition in some other, less obvious manner.
General bodily malnutrition exercises a similar un-
favorable influence upon the strength of the cardiac muscle, espe-
cially if the latter is otherwise subnormal, though symptoms are
lacking. It is comparatively unimportant whether the malnutri-
tion arise from poor food, gastro-intestinal disease or infectious
processe^^^ In regard to infectious diseases, however,
we must remember that they may injure the heart in a variety
of other ways, as by causing myocarditis, or through the direct
action of their toxins. The symptoms which arise under these
circumstances are irregularities of rhythm and, especially, those
disturbances referable to a diminution in the heart's capacity for
work.
A fresh inflammation of the heart, whether of
the endocardium, myocardium or pericardium, is injurious to
the heart's activities. In many cases there results an actual loss
of contractile tissue. As we have already mentioned, such changes
not infrequently affect hearts which are already hypertrophied.
They also occur, however, in previously normal hearts, espe-
cially from the general infectious diseases, such as acute articular
rheumatism, diphtheria, typhoid fever and scarlet fever. Such
an infectious myocarditis may develop at the height of the dis-
ease, or it may not develop until some weeks after the fever has
disappeared, as happens especially after diphtheria and typhoid
fever.®"^
Significant, in addition to the severity and
42 THE BASIS OF SYMPTOMS
the extent of the myocardial changes, is their
location. Attention has already been drawn to the fact that
a small lesion situated in an important area may entail more
serious consequences than a larger one located elsewhere. The
discovery of the cardiac conduction path, made up
of a specialized muscular tissue and of relatively limited extent,
has taught us the location of such important areas. The litera-
ture is rich in observations concerning anatomical changes in
the various parts of this system, which originates in the Keith-
Flack node, at the mouths of the great veins, and which traverses
the auricle to the node of Tawara, whence it is distributed by the
bundle of His and its two main trunks with their ramifications to
all parts of the ventricular walls. In a way, this peculiar muscle
path possesses a pathology of its own.®^ It takes no part either
in the hypertrophy or in the atrophy of the remainder of the
myocardium ; and it is endowed with an independent blood-supply.
Furthermore, it may independently be the site of fatty and in-
flammatory changes and of tumor growths. The significance of
these isolated changes in the causation of sudden death (heart-
block) is still a matter of controversy.*^
( Lewis ®^ has reviewed about fifty cases of clinical heart-
block, in none of which did a histological examination of the
His bundle and its branches fail to reveal pathological changes.
On the other hand, no case is on record of a complete destruction
of the bundle in which just prior to death conduction was normal.
Yet the presence of any lesion of the bundle short of a complete
break in continuity served in no way as an index of the functional
disturbances that may have been present intra vitam. In some
instances, with extensive structural changes in the bundle, or in
one or both main trunks, the degree of clinical dissociation may
have been slight or transitory; while in others with complete
dissociation, the bundle changes were less in evidence than in
hearts exhibiting no clinical manifestations at all. — Ed.)
In other respects, what has been said concerning the remainder
of the cardiac muscle, applies equally well to this specialized
system.
Numerous poisons may depress the activities of the heart,
in some instances after a primary stimulation, as occurs with
digitalis and muscarin. It is possible that similar poisons are
generated in the metabolism of the body. We know of at least
THE CIRCULATION 48
one disease in which the heart changes are probably due to such
a cause, viz., hyperthyroidism.^^ There is here an in-
crease in the rate and in the force of the heart's contractions. In
many cases, an hypertrophy of both ventricles develops, and not
a few of the patients die with the signs of a cardiac insufficiency.
At autopsy hypertrophy and dilatation of the heart are present,
but no characteristic changes are found in the cardiac muscle.®*
Since the blood-pressure in these cases is not always higher than
normal, we might attribute the hypertrophy to the more rapid
and forcible heart action, whether produced by nervous or toxic
influences.®^ It is possible that the cardiac disturbances of cer-
tain individuals with struma may be due to an associated tracheal
stenosis. But such a factor must be distinctly subordinate to the
toxic action of the glandular secretion.®^
The toxins produced by bacteria may likewise
injure the strength of the cardiac muscle. This has been proved
beyond question in the case of diphtheria toxin,®^ and is prob-
ably equally true of others.
It is difficult to say to what extent degenerations of
thecardiacmuscle injure the activities of the heart. Where
they are very extensive, there can be no doubt that they cause
serious disturbances. When, for example, in phosphorus poison-
ing, the ether extract amounts to twenty-six per cent, of the dried
muscle, instead of the normal eleven per cent., and when micro-
scopic examination shows that nearly every fibre is filled with fat
droplets, a diminished capacity for work is to be expected. We
are not yet able, however, to estimate the effect of the slight and
of the moderate grades of fatty or of hyalin degener-
ation. It is customary to attribute cardiac weakness to these
conditions. Yet we know that the degenerations may be found
in apparently strong as well as in weak hearts.®® Furthermore,
it is possible that the cause of the fatty degeneration may itself
independently weaken the cardiac muscle. Brown atrophy
has hardly any clinical significance; and we are not yet able to
say what functional effect is produced by fragmentation
of the cardiac muscle.
The so-called fatty heart ^'^ remains to be considered.
This term has been applied to two separate conditions — fatty
degeneration of the muscle fibres, and excessive fatty infiltration
into the interstitial tissue. The two affections have apparently
44 THE BASIS OF SYMPTOMS
nothing to do with each other; and fatty degeneration rarely
occurs to any marked degree in hearts which are the seat of fatty
infiltration. The latter are usually associated with a general
lipomatosis, and it is to them that the term fatty heart is more
commonly applied. It is uncertain how much this excessive fat
about the muscle-cells injures their functional activity. The mus-
cular tissue is often surprisingly reduced in such hearts, prob-
ably from the pressure of the fat; possibly, however, because
the atrophy of the muscle is primary, the infiltration of the fat
secondary {cf. progressive muscular dystrophy). The disturb-
ances of fimction in such hearts are probably due to the small
amount of cardiac muscle present, relative to the total body
weight. In other cases coronary sclerosis or an overindulgence
in wine or beer constitutes the cause of the cardiac weakness.
Finally, there is a group of cases exhibiting weakness of
the heart which falls into the class of so-called functional
disturbances. Such a term simply means that at present
we are ignorant as to the cause of these disturbances. The num-
ber of cases included in this group will progressively diminish
as our knowledge increases. At the present time we must place
in this category many of those cases of hypertrophy in which the
demands so increase that the heart is no longer able to meet
them, as well as many cases of heart weakness resulting from
disturbances of the general nutrition. Many of the apparent ner-
vous derangements must likewise be placed in this group.
Fatigue of the heart is just as little understood as is
fatigue of the skeletal muscles. We speak of fatigue when the
strength of a muscle diminishes as the result of exercise, and is
recovered after a period of rest. If the heart be diseased, it is
fatigued by a smaller amount of work than is the normal organ,
and not infrequently it recovers slowly or not at all.
If sudden excessive demands be made upon a normal heart,
it usually becomes fatigued, and after a rest it recovers. There
have been cases described, however, in which a heart, as the result
of a brief but excessive amount of work, was said to have been
permanently injured, or, indeed, to have given out entirely.
This has been looked upon as due to an excessive dilatation of
the heart.®^ We know that such an acute dilatation,
with an arrest in diastole, may be produced in animals by
greatly increasing the resistance against which the heart must
THE CmCUTATION 45
pump. The possibility that a similar result may occur in man
from excessive exertion cannot be denied absolutely. Yet the
probabilities are entirely against this view. In the reported cases
of heart-failure following exertion, too little attention has been
paid to the condition of the heart muscle, which has, in most
instances, been previously damaged.
There is no doubt that the diseased heart is not only easily
fatigued, but that it is especially liable to become overdistended.
When a convalescent from typhoid fever or diphtheria drops
dead after some unusual exertion, it is usually from this cause.
It is probable that fatigue or acute dilatation of a slightly damaged
heart frequently occurs without recognition; and there always
exists the danger that too much will be demanded of such a
weakened heart.
The influence of the nervous system upon the
heart remains to be considered.^^ It is theoretically possible
that gross or microscopical lesions of the central nervous system
should exercise an unfavorable influence upon the heart's activi-
ties because they injure the centres which regulate the organ, yet
we have at present no direct evidence to prove that an injurious
effect is actually produced in this way.
The central nervous system does in certain cases influence the
heart unfavorably, but it is through so-called psychic in-
fluences, which are of quite a different nature. It is well
known that sorrow, worry and care may affect the heart, not only
in its rhythm, but in its strength. ^°^ This is frequently observed
in those suffering from heart disease, but it may occur also in
healthy individuals. Indeed, the depression of the heart's activi-
ties may be so extreme as to terminate fatally. ^^^ Neurasthenics
frequently suffer from distressing cardiac sensations, from irregu-
larity of the heart's action and even from cardiac weakness.**'^
This last, however, is not common, and it is more frequently a
part of a general muscular weakness.
(In certain forms of heart-block, however, vagus in-
fluences seem to play an important role in cardiac function.
According to Lewis, ^°^ the vagus action in these cases is merely
that of bringing into being, or intensifying the existing clinical
manifestations, of an anatomical disturbance of the His bundle.
The action of the vagus is observed also in the so-called sinus
arrhythmias. — Ed. )
46 THE BASIS OF SYMPTOMS
Many are inclined to refer various disturbances of the heart's
function to disease of the nervous mechanism situated within the
heart itself, but we are without any exact knowledge on this
subject.
Cardiac weakness is ordinarily regarded as a weakness in
the contractile power of the heart. Yet disturbances in the dila-
tation of the heart might almost equally well lead to serious
consequences, for diastole is not merely a passive process. There
is probably an active dilatation at the beginning of diastole,^^*
and toward the end there is a rapid increase in the tension of the
muscular wall which limits the degree of filling of the ventricle.
If these acts are improperly performed, serious alterations in the
circulation would result ; the effects of such disturbances will per-
haps play an important part in the heart pathology of the future.
At present, however, we are quite ignorant of their practical
significance, though Brauer is of the opinion that certain of the
manifestations of an adhesive mediastino-pericarditis and the
gallop rhythm of contracted kidney are due to some such disturb-
ance in the dilatation of the heart.
Results of Cardiac Weakness. — In the consideration of the
effects of cardiac weakness upon the circulation, it is immaterial
whether the heart is primarily weakened so that it is unable to fulfil
the ordinary demands of the circulation, or whether the demands
are so increased that they become excessive.
Even the healthy ventricle does not expel the blood com-
pletely when increased quantities must be pumped with each con-
traction. If the auricle weakens, it soon ceases to
contract, especially if it be distended. This has been observed
experimentally and chnically.^^' If the ventricle be
weakened, it does not contract so completely as does the
normal one, and a smaller amount of blood than usual is expelled
at a reduced speed. The aorta is less completely filled, and the
arterial pressure sinks. The flow of blood into the ventricle is
impeded, for not only is there less available space in the ventricle
owing to the incomplete expulsion of blood, but the suction of
early diastole is also probably weakened. The result is that the
veins become distended, and the venous pressure increases.
The effects are best studied in those cases in
which both ventricles are equally or nearly
equally affected, which is, indeed, the commonest form
THE CIRCULATION 47
of cardiac weakness. The insufficiency of the left ventricle lowers
the systemic arterial pressure, while the insufficiency of the right
ventricle increases the pressure in the systemic veins. The dif-
ference in pressure between the veins and arteries, therefore, is
less than it is normally, and consequently the rate of flow in the
capillaries is lessened. At the same time, the distribution of
blood is affected, for the arteries contain less, the veins more,
blood than normal. Thus the result of a weakening of both ven-
tricles upon the greater circulation is a diminished arterial
pressure, an increased venous pressure, a diminution in the rate
of blood-flow and an overfilling of the veins with blood. Some-
what similar conditions result in the pulmonary circulation; in
the final analysis, the amount of blood in the latter will depend
upon whether the right heart or the left is the weaker.
If only one ventricle be weakened, or, as is
more frequently the case, if one be decidedly weaker than the
other, then the effects are quite different. Let us first consider
the consequences of a weakened left ventricle. This
leads to a lower pressure in the systemic arteries and consequently
to a slower rate of flow in the capillaries. The venous pressure
in the pulmonary system is increased, and this leads to increased
pressure in the pulmonary arteries, which necessitates more work
for the right ventricle, as we have already explained (p. 19).
Although the flow of blood through the lungs is maintained as
well or nearly as well as before, yet the pulmonary vessels are
overfilled and this is not without its effect ufKDn the interchange
of gases in the lungs (p. 34). Furthermore, these pulmonary
changes react upon the general circulation, for the intrathoracic
pressure is increased, and this lessens the aspiration of the blood
from the great veins. In this manner an uncomplicated weakness
of the left ventricle may cause stasis in the veins of the general
circulation. In practice, such a stasis is greatly favored by the
fact that nearly every case of weakness of the left ventricle is
associated with more or less weakness of the right.
It may be asked whether it is possible for the right ventricle
to pump its regular quota of blood if the left is only pumping
a part of what it should. Such a condition would ultimately lead
to an accumulation of all the blood of the body in the lungs. If
life is to be maintained, a stationary period must develop in which
both ventricles pump equal amounts of blood. But during the
48 THE BASIS OF SYMPTOMS
time that it is developing, there is a gradual accumulation of blood
in the lungs, so that in the fully developed condition there is an
abnormal distribution of blood, more being in the lungs and less
in the general circulation, even though both ventricles are now
pumping equal amounts.
If the right ventricle is insufficient, less blood
is sent into the pulmonary arteries, the pulmonary pressure falls,
and the rate of flow in the lungs is diminished. Less blood is
taken from the great veins of the general circulation, these be-
come swollen, and all the organs, especially the liver, become
hypersemic from the venous congestion. The blood-flow in the
general circulation is retarded, chiefly because the left ventricle
cannot pump more blood than is furnished to it by the weakened
right ventricle.
As a matter of fact, cases in which one ventricle
alone is weakened are extremely rare. Most in-
jurious agents affect both sides of the heart. Diseases of
the lungs, however, affect chiefly the right
heart, while arteriosclerosis and aortic insuffi-
ciency lead to disease of the left. In these con-
ditions, therefore, we are most likely to see pathological pictures
corresponding to those just described as characteristic of weak-
ness of only one ventricle. In all cases, the blood flow is retarded
and there is labored breathing on account of the lessened amount
of blood which traverses the lung in a unit of time. The dis-
turbances of breathing are greater when the left ventricle is
weakened, because this causes in addition a passive hyperaemia
of the lungs ; whereas when insufficiency of the right heart exists
alone, the blood tends to collect in the systemic veins without
producing a pulmonary congestion.
Of the harmful effects resulting from car-
diac weakness, the most serious is unquestionably the
slowing of the blood-current; next to this is the
change in blood-pressure. We are accustomed to re-
gard the latter as the more important, perhaps because estima-
tions of the blood-pressure are made with comparative ease.
Yet, in the last analysis, the rate of blood-flow is of greater
importance. This rate is, of course, largely dependent upon the
arterial pressure, owing to the narrow range within which the
venous pressure varies. (No deductions as to the rate of
THE CIRCULATION 49
blood-flow can be made from the systolic arterial pressure
alone, for with the same pressure the flow may vary enormously,
depending upon the amount of resistance which it encounters in
the smaller arterioles — ^the so-called diastolic pressure. The ease
and the comparative accuracy with which the latter can now be
estimated have led to numerous studies relative to its significance.
As an index of circulatory conditions, the diastolic pressure is
not subordinate in importance to the systolic; and possibly it is
greater. This subject will be referred to again. — Ed.) Nor
can we say that the higher the arterial pressure the more favorable
the condition, for a diminution under certain conditions is of
distinct advantage, and a great increase brings with it certain
dangers. On the other hand, the lowering of pressure must not
be excessive, for a certain arterial pressure is absolutely necessary
to maintain the rate of blood-flow essential for the proper per-
formance of the functions of the body.
Disturbances of the heart's strength lead to its enlargement
through a dilatation of its cavities. The weakened ventricle is
unable to empty itself as completely as does the healthy one, and
a certain amount of blood is left in it at the end of each systole.
In diastole, likewise, it contains more blood than normal. There
is, therefore, a dilatation of the ventricular cavity, and physical
examination demonstrates an enlargement of the area of cardiac
dulness. This dilatation ofstasis must be sharply
distinguished from the compensatory dilatation
which we have already described in connection with certain val-
vular lesions. The latter are hardly pathological, for they are
necessary in the accommodation of the heart to the new circu-
latory conditions. Only by a compensatory dilatation of this
sort is the heart enabled to maintain a proper circulation in
such valvular affections as aortic insufficiency (see p. 12). The
dilatation which we are here considering is not of a compensatory
nature, and it occurs only when the heart is unable to do its work.
Although the normal heart does not empty itself completely when
very large amounts of blood must be propelled, yet it soon regains
its usual condition after the extraordinary demands have passed.
In a case of pathological dilatation, however, a complete systole
never occurs, and the cardiac chambers are constantly overfilled.
This dilatation of a weakened heart may arise
from many causes. A heart may be unable to maintain the cir-
4
50 THE BASIS OF SYMPTOMS
culation even when the body is at rest, in which case it is in a state
of continual dilatation. On the other hand, the insufficiency may
develop only when some extraordinary demands are made upon
the heart; in this case the dilatation is temporary. Hypertro-
phied hearts are especially susceptible to dilatation. They may
maintain the circulation for years, in spite of the extra work
necessary, but finally injurious influences weaken the muscle, or
the work to be performed gradually increases beyond the capacity
of the heart, and dilatation follows. Frequently, hypertrophy
and dilatation develop together. This occurs when, at the same
time, increased work is necessary and injurious influences act
on the cardiac muscle. The ultimate outcome of such a case de-
pends upon the relation between these two factors. If the hyper-
trophy be in excess, the prognosis is comparatively good, whereas
if the dilatation preponderate it is comparatively bad. A dilated
heart may gradually strengthen and hypertrophy, so that it will
accommodate itself to the increased amount of work necessary.
One effect of the poor circulation is a de-
ficient supply of oxygen to, and an imperfect
removal of carbon dioxide from, the tissues. The
lessened blood-flow in the lungs also diminishes the interchange of
gases there. The patient feels that he needs more air. The lack
of oxygen and especially the presence of carbonic acid gas in
the blood stimulate certain cells of the medulla oblongata, and
this stimulation causes more frequent and deeper respirations.
( See Dyspnoea, in the chapter on Respiration. ) The increase in
respiratory movements may partly compensate for the slower
blood-flow, but it does not do so wholly. An added unfavorable
factor in these cases is the marked predisposition to bronchitis
and pneumonia.
The stasis of blood in the veins of the general
circulation is very apparent. The superficial veins
are enlarged and tortuous, and many, not before visible, appear.
The poorly aerated blood gives a bluish tinge to the skin, which is
usually most marked in the nose, ears, cheeks, fingers and toes,
probably on account of the relative coolness of these parts.
The highest grade of cyanosis without a correspondingly
great cardiac insufficiency is seen in congenital defects of the
right heart (morbus cseruleus). The fingers acquire a
characteristic club-shape, owing to nutritional changes in the
THE CIRCULATION 51
bones, and these, with the broad, dark-blue finger-nails, present a
very characteristic appearance. It is difficult to give an adequate
explanation of this cyanosis of congenital heart disease. A num-
ber of factors probably combine to bring it about. In the first
place, owing to the inability of the right ventricle to compensate
completely for the defect, there results an insufficient aeration of
the blood and a stasis — the latter being evident from the tortuosity
of the veins of the skin and of the ocular fundi. In the second
place, a defect in the ventricular septum, so commonly associated
with congenital lesions, allows the arterial and the venous blood
to mix. Finally, the well-known increase in the number of red
blood-corpuEcles in a unit-volume is probably an important factor,
which may account for certain cases of cyanosis that cannot be
explained in any other manner.
The venous hyperaemia causes a swelling of
distensible organs. The kidneys become enlarged and
dark blue, and their secretion is altered in a characteristic man-
ner. The liver becomes swollen, hard and tense, producing a
distressing feeling of pressure in the abdomen, or, indeed, actual
pain. The plasma escapes from the capillaries into the subcu-
taneous tissues, causing oedema ; and transudation into the serous
cavities may also take place.
If the veins are much swollen, they frequently
exhibit pulsations synchronous with phases of
the heart-beat in addition to those of respira-
tory origin. These pulsations ^*° are most marked in the
jugulars, but they may be present in the veins of the upper ex-
tremity or of the chest wall. We distinguish two types of
venous pulsation. The first is due to an insufficiency of
the valves of the afifected veins, which allows the pulsations nor-
mally present in the superior vena cava to be conducted to the
peripheral veins. Such a normal or negative venous
pulse arises from a hindrance to the venous flow of blood
caused by each contraction of the right auricle. The vein is
most distended during auricular systole just before the contrac-
tion of the ventricle. Tricuspid insufficiency produces a venous
pulse of a totally different character. Here, the vein is distended
by the blood which regurgitates from the right ventricle through
an insufficient tricuspid valve, and the greatest distention occurs
synchronously with or just after the ventricular systole. This is
52 THE BASIS OF SYMPTOMS
called a pathological, or positive, venous pulsa-
tion. Without the aid of accurate tracings, it is often ex-
tremely difficult to determine which form of pulsation is present,
owing to the irregular heart action and to the dyspnoea.
A positive venous pulse, though especially character-
istic of tricuspid insufficiency, occurs also in that type of car-
diac arrhythmia known as perpetual irregularity
(arrhythmia perpetua), which is dependent upon a dis-
turbance of the rhythmic beat of the auricles. The musculature
of the latter either shows no evidence of contractions, or is in
a state of fibrillation (see p. 66). The venous pulse, therefore,
fails to portray the oscillation due to the contraction of the
auricle, while during ventricular systole there exists a pronounced
hindrance to the flow of blood from the great veins. The result-
ing systolic wave in the venous pulse is naturally not so marked
as in the case of tricuspid insufficiency. A pathological venous
pulsation may occur also when extrasystoles arise in the junc-
tional tissues (atrio-ventricular extrasystoles),
and occasionally in paroxysmal tachycardia (see p. 56).
( Mackenzie ^^''^ formerly was of the opinion that auricular
fibrillation was due to the fact that the inception of cardiac rhythm
was transferred from its normal position — the sinus node — to the
auriculoventricular node of Aschoff-Tawara. He applied to this
condition, therefore, the term nodal rhythm, explaining in this
way the apparent synchronous contractions of the ventricle and
auricle, and the positive venous pulse. This conception of the
nature of auricular fibrillation has been completely disproved by
electrocardiographic studies, and is no longer held even by Mac-
kenzie.— Ed. )
Disturbances of the Heart-Rate. — Disturbances of the rate
of the heart may be due to a weakening of the organ, or may
be independent of a diminution in its strength. The heart-
rate varies greatly even in health. ^^^ It usually becomes slower
with age, although in extreme old age it may again become more
rapid. It is interesting to note that at this age the vagus tone
is slight, or may be completely absent.^*^® There are also great
individual variations in the heart-rate ; while some have a normal
rate of fifty-six to sixty-eight per minute, others have a pulse-rate
of seventy to eighty. As a rule, the rate is more rapid in women
than in men. It is not our intention to name all those influences
THE CIRCULATION 58
which affect the rate of a normal heart. The mode of action of
many is easily understood, whereas others have not yet been
explained.
Physiological studies ^*° have demonstrated that the con-
traction of the heart is initiated by a periodic
stimulation of the fibres situated at the en-
trance of the great veins into the auricles. The
impulse traverses the auricular muscle and is propagated via the
bundle of His to the ventricles. The His bundle is a part
of the so-called conduction path, a knowledge of which we owe
particularly to Aschoff, Monckeberg and their co-workers."^
The bundle is made up of specialized muscle fibres (Purkinje
fibres). Immediately above the auriculoventricular junction
lies a denser accumulation of this specialized tissue, known as the
Aschoff-Tawara node, which is unquestionably con-
cerned in the coordination and rhythm of the ventricular beat.
It is interesting to note that this node lies close to the point
regarded by Kronecker as the cardiac centre of coordination.
From the Tawara node run fibres of a similar nature to all
parts of the ventricles. A disturbance of the main trunk of the
His bundle causes the ventricles to assume the rate peculiar to
the isolated ventricle, i.e., about thirty to the minute; unquestion-
ably, however, the ventricles may have a higher automatic rate.
Near the entrance of the great veins into the auricles lies a
similar mass of differentiated tissue — the Keith-Flack
node. The evidence is still lacking to show that this node is
of particular significance in the initiation of automatic stimuli
from the sinus and auricles. ^^^ i^ t^^ light of our present
knowledge it seems more likely that all parts of the auricle are
of equal weight in automatic rhythm inauguration. And, in all
likelihood, even the propagation of the stimuli through the auricle
is by the ordinary musculature.^ ^^
Though automatic stimuli may arise at any point in the
myocardium, as Engelmann has always emphasized, those which
are of auricular origin take precedence over the ventricular be-
cause of their more rapid inception. On the whole, the studies
of Hering have led me to believe that we must return to the older
view of the power of any part of the cardiac muscle to originate
stimuli — a view which has been forced into the background by the
prominence which has recently been given to the function of the
54 THE BASIS OF SYMPTOMS
conduction path.^^* (Though observers are still not entirely in
accord as to the role of the sinus node in the initia-
tion of the normal heart-beat, yet the evidence favor-
ing this view is considerable. Thus, artificial stimulation applied
to the sinus node produces v^hat may be called a normal electro-
cardiogram, whereas stimuli applied elsewhere cause atypical pict-
ures. And the sinus tissue has been shown to be more irritable
than that of the remainder of the auricle; while of the two
auricles, the right begins to contract 0.01-0.03 second before the
left.— Ed.)
The rhythm of a normal heart may seem absolutely regular to
an ordinary observer, but more exact methods have shown that
there are distinct physiological differences in the duration of the
pulse-waves. According to Engelmann, the heart's action may
be affected in various ways. There may be variations not only
in the regular initiation of stimuli (chronotropiy), but in
the ability of the heart to respond to these stimuli (bath-
m o t r o p y) . Furthermore, the propagation of the stimuli over
the heart (dromotropy), as well as the contractility of the
muscle (inotropy), may be abnormally increased or dimin-
ished. The causes of disturbances of cardiac rate and rhythm
may lie either in the muscle itself or in its nervous connections.^^^
Thus we see how complicated are the conditions governing the
rate and rhythm of the heart, and how difficult it must be to
interpret the many clinical variations.
Though we shall not enter into the old controversy as to
whether the heart-beat is neurogenic or myogenic,^ ^® it is inter-
esting to note that the conduction system contains in addition
to differentiated muscle-fibres, numerous ganglion-cells and nerve-
fibres.
Rapid Heart Action (Tachycardia). — In certain conditions,
the cause of an abnormally rapid heart action is clear. For
example, atropin and similar drugs frequently increase
the heart-rate by paralyzing the terminations of the pneumo-
gastric nerve, although they can do this only in individuals in
whom the vagus normally exerts an inhibitory action upon the
heart. The same effect may be produced by pathological
conditions of thevagus fibres or nuclei. Thus the
rapid heart action which is so frequently observed at the end of
meningeal inflammations is due to a vagus paralysis following
THE CIRCULATION 55
the period of vagus stimulation. Not infrequently a pulse-rate
of I GO to 1 60 is observed in such cases, unassociated with any-
other cardiovascular symptoms.
It is more difficult to explain the rapid heart action due to
exertion, which is so frequently seen in convalescents, anae-
mic individuals and in those who have heart disease. It is pos-
sible that there is here an increased irritability either of the heart
itself or of its nervous connections, so that the chemical products
of muscular activity produce an unusual effect upon these tissues.
Fever also causes a rapid heart action, for the increased
temperature of the body stimulates both the central endings of
the accelerator nerves and the heart muscle itself. If no other
disturbing factors come into play, the rate of the heart increases
proportionately to the rise in temperature. This parallelism be-
tween the temperature and the heart-rate is missed in certain
infections. For example, in typhoid fever the pulse is relatively
slow. With a temperature of 104° F. (40° C), we may have
a pulse of seventy or eighty. In scarlet fever, on the other hand,
the pulse-rate is usually surprisingly rapid. In these diseases the
action of toxins probably modifies the usual relation between the
temperature and the pulse-rate.
A diminution in the arterial pressure is usually
accompanied by an acceleration of the pulse. In many cases this
is to be explained by the fact that there is a fall in cerebral pressure,
which stimulates the central endings of the accelerator nerves.
The purest example of this accelerating action is seen in the rapid
pulse of widespread vasomotor paralysis (see p. 86). We
frequently observe a rapid pulse in cases of cardiac weakness also,
but in such cases it is uncertain whether the rapid heart action is
attributable to the heart disease itself or to the fall in pressure.
Experiments on animals would seem to indicate that an uncom-
plicated cardiac weakness leads to less frequent contractions, a
fact favoring the hypothesis that the rapid action of the weakened
heart is really due to the stimulation of the accelerator fibres
occasioned by the lowering of the blood-pressure.
In hyperthyroidism, the tachycardia may be contin-
uous, or it may occur in paroxysms. The symptoms of this dis-
ease are now attributed by many to an excessive thyroid metabo-
lism, and it seems probable that the cardiac disturbances are like-
wise due to this cause (see Chapter VI). We are ignorant as
56 THE BASIS OF SYMPTOMS
to which part of the cardiac mechanism is affected in these cases,
whether it be the muscle, the cardiac gangha or the central
nervous connections.
The tachycardia of nervous people resembles that
occurring in hyperthyroidism. Even in healthy individuals an
increased heart-rate may be induced by various influences, as
exercise, psychic disturbances and indigestion, but in nervous
people the response to these influences is excessive. It is pos-
sible that the seat of the increased irritability is located in the
cardiac muscle, for similar variations in rate are seen in those
who suffer from disease of the myocardium, and in them at least
there is no reason to assume that the condition is in any way
dependent upon disturbances of the nervous system.
A rapid heart-rate may be produced by disease of
various other organs of the body, such as the periph-
eral nerves (especially of the left arm), the lungs, the liver, the
genitals and the gastro-intestinal canal. When the primary dis-
ease is cured, the cardiac disturbances disappear. Apparently
such disturbances are due to reflexes from the diseased organs,
a view which is supported by many facts. The patients are
usually neurotic, the disturbances come and go in perplexing
succession, and, furthermore, they usually arise from organs that
are innervated by the vagus. For reflexes apparently occur most
readily via nerves which carry both motor and sensory fibres.
The condition known as paroxysmal tachycardia H7 is char-
acterized by an enormously accelerated heart-rate, which begins
suddenly, lasts a short time and ceases as suddenly as it began.
It may affect individuals with apparently normal hearts, or it
may occur in those suffering from some definite cardiac disease.
The duration of the attack may be minutes, hours, days or even
weeks. The pulse-rate usually ranges between 1 50 and 300
per minute. The heart rhythm is regular and the sounds
dear. The difference between the quality of the first and that of
the second sound tends to disappear (embrydcardia), a
common phenomenon in any great acceleration of the cardiac rate.
The pulse is small; oftentimes it cannot be counted. The
blood-pressure is usually low, probably, because the
shortness of diastole does not allow time for a complete filling
of the ventricle. Wenckebach * ^^ has called attention to the fact
that because of this short diastole, an auricular systole may coin-
THE CIRCULATION 57
cide with the ventricular contraction of the preceding heart cycle,
thus obstructing the venous inflow, and accounting in all proba-
bility for the venous stasis, A ventricular venous
pulse may also be present (see p. 52). The patient may or may
not suffer from dyspnoea. The jugular veins are always swollen
and usually exhibit marked pulsations. Other signs of venous
stasis, such as swelling of the liver, albuminuria and even
oedema, may develop.
Occasionally, even at the beginning of an attack, the heart
is found to be enlarged; at times, however, it may be found
smaller than normal. The apex beat is generally feeble, though
the entire precordium may show a lively systolic quivering. Im-
mediately after the attack the heart returns to its former size.
Nevertheless, we have no right to consider this dilatation as the
cause of the paroxysm, for it has been found absent in some cases,
by the most careful observers. In my opinion, dilatation in these
cases is an evidence merely of cardiac weakness.
An acute distention of the lungs has also been
noted in certain cases at the onset of the attack, and the respiratory
movements of the borders of the lungs have been diminished.
To what extent these changes affect the heart is not definitely
known.
Subjective symptoms are always present. During the
paroxysm nearly all patients feel weak and faint, most of them
suffer from dyspnoea, and some experience the sense of impending
death. As a rule, the symptoms begin and end suddenly, fre-
quently with peculiar sensations in the precordium; yet in some
cases it is almost certain that the paroxysm may begin or end
gradually.
During the interval between attacks the heart is often normal,
so far as can be determined by physical examination. We should,
however, be very cautious in our judgment of such cases, for it
is difficult to exclude a coronary sclerosis, and many sufferers
from this form of tachycardia are the subjects of easily recognized
heart lesions.
The individual attack may begin spontaneously, or
it may be precipitated by some unusual exertion, by excitement or
by gastro-intestinal disturbances. These same causes normally
lead to an acceleration of the heart's action, and it may be some-
58 THE BASIS OF SYMPTOMS
what difficult to determine in the individual case whether the
attack is really one of paroxysmal tachycardia or not.
We are still unacquainted both with the nature of paroxysmal
tachycardia and with the cause of the individual attack. That
nervous factors are of importance is evidenced by the fact that in
certain cases pressure upon the vagus will end a paroxysm.
(Pressure upon the vagus other than manual will also at times
abort an attack; thus a similar effect may be produced by the
swallowing of liquids with the head tilted far back (Herz), or by
swallowing unchewed pieces of bread.^^^ — Ed.) The etiol-
ogy is unquestionably not a uniform one; in some cases the
central nervous system seems to be at fault, psychic influences
apparently precipitating the attack; while in others the disease
appears to be of local nervous origin.
(Though there is a distinct nervous element in a great many
cases of paroxysmal tachycardia, we are in a position to say, on
the basis of electrocardiographic studies, that the condition is
not, as was formerly believed, merely a neurosis. Many, if
not most, cases represent a displacement of
automatic impulse production from the normal
place — the sino-auricular node, the "pace-
maker" of the heart — to other parts of the myo-
cardium. This new point of origin is oftenest, it would
seem, in the auricles, though very rarely it may reside in the
ventricles or in the junctional tissues. — Ed.)
It is likely that no single explanation will suffice for all cases.* ^^
Possibly in some, the basis is extrasystolic, because the paroxysm
often seems to be precipitated by nervous influences and because
the latter in turn frequently give rise to extrasystoles. Accord-
ing to A. Hoffmann, cases exhibiting an exact doubling of the
normal rate suggest an extrasystolic character. Another theory
is that the sinus node is unduly irritable. Or it is conceivable that
this node normally initiates more stimuli than are represented
by heart-beats ; whereas in the tachycardial paroxysm each auto-
matic stimulus is followed by an actual beat. (Sinus tachycardias
usually begin and end gradually and are precipitated by excitement
or over-exertion. They are observed as a rule in neurotic individ-
uals, in whom insignificant causes are likely to increase the cardiac
rate enormously. Alcohol, nicotin, bacterial toxins and fever may
also be causative factors. In this type the pulse rhythm is normal,
THE CIRCULATION 59
and the electrocardiogram gives evidence that the contraction
wave arises homogenetically, i.e., in the Keith-Flack node. — Ed.)
Many unusual types of paroxysmal tachycardia have been re-
corded, such as exact doubling and quadrupling of the normal rate ;
while occasionally early in the attack a mid-wave is seen in the
pulse-tracing, in which case it may be difficult to determine whether
we are dealing with pulsus altemans or with a pulsus pseudo-
alternans.
We shall return to this subject in our consideration of the
cardiac arrhythmias (p. 62).
The effect of an acceleration of the heart-
rate upon the circulation is variable. It may lead in the
first place to an increased blood-flow ; but, on the other hand, the
shortening of diastole may cause an insufficient filling of the ven-
tricles, with a consequent retardation of the circulation. Thus,
experimental stimulation of the accelerator nerve produces more
rapid and powerful cardiac contractions and an improvement of
the circulation, whereas even the moderate acceleration caused by
a vagus paralysis may lead to a slowing of the blood-current. A
tachycardia may, therefore, affect the circulation of a patient in
various ways, and numerous other factors must be considered in
the individual case.
Slow Heart Action (Bradycardia). — A slow heart-rate
may be due, in the first place, to a stimulation of the
vagus nerve. We have an example of such an action in
the slow pulse of asphyxia, in which the venous blood power-
fully stimulates the central endings of the pneumogastric nerve.
This tends in a certain degree to counteract the great rise in
blood-pressure produced by the simultaneous constriction of the
splanchnic vessels.
The central terminations of the vagus are also stimulated by
any rise in the general arterial p res sure. ^^^ The
high blood-pressure in acute nephritis, for example, nearly always
causes a slowing of the pulse. If the pressure rises gradually,
however, and if it remains high for a long time, as happens in
chronic nephritis and in some cases of arteriosclerosis, there is
usually no reduction of the pulse-rate.
A rise in cerebral pressure will likewise stimulate
the vagus, and we always find a slow pulse in those conditions
which lead to a rapid increase of pressure in the cranial cavity,
60 THE BASIS OF SYMPTOMS
such as intracranial hemorrhages and extensive meningitis. In
such cases the vagus pulse is of great diagnostic significance.
Even the gradual increase in the cerebral pressure that results
from a brain tumor not infrequently causes a slow pulse.
Changes in the medulla, particularly in the region
of the nucleus of the pneumogastric nerve, may lead to a marked
slowing of the pulse and also to syncopal attacks. The similarity
of this picture to that of complete heart-block has led some to
refer the latter to such changes in the medulla. ^^^ This has no
scientific basis, however.
The vagus may also be stimulated reflexly.
The slow pulse observed at the onset of vomiting is caused in this
manner ; here the blood-pressure is probably lowered. This stimu-
lation is usually due to a reflex from the stomach, although the
vagus centre may be directly affected, as happens in the vomiting
from increased cerebral pressure, or from the action of such drugs
as apomorphin. Clinically, a reflex vagus pulse is frequently seen
in the acute dyspepsias of children, in peritonitis, in strangulation
of the intestines and in chronic constipation. In these cases there
is often an associated arrhythmia.
Bradycardia may be produced by the direct action of
certain poisons, as, for example, muscarin and the bile
salts.^^ In the early stages of catarrhal jaundice, there is
always a slowing of the heart-rate, and often irregularities of
rhythm. In the chronic jaundice accompanying diseases of the
liver itself, and in those associated with infectious diseases, the
bradycardia is often absent, probably because smaller amounts of
bile salts are manufactured, or because other factors influence
the heart. Even in the marked jaundice of chronic obstruction
of the common duct by stone or by tumor, there is frequently
no slowing of the pulse. This is probably due to a diminished
production of the bile salts; or possibly the body becomes accus-
tomed to their presence. Experimental investigations have shown
that the bile salts act both upon the central and the peripheral
terminations of the vag^s, as well as upon the cardiac muscle
itself, particularly in the region of the sinus node. In catarrhal
icterus, we cannot say at present which action is the most im-
portant. The hypothetical uraemia poison likewise
slows the heart-rate, but we are ignorant of the manner in which
it acts.
THE CIRCULATION 61
In all cases of continued vagus irritation the slowing of the
pulse is only of moderate grade, rarely going below 44 to 48 per
minute. The irregular pulse so frequently observed in these con-
ditions well corresponds with the results of experimental stimu-
lation of the nerve.
All varieties of bradycardia, other than those caused by vagus
stimulation, are difficult to explain. A slow pulse may be present
in neurotic individuals, but we are unable to say whether the
immediate cause lies in some alteration in the nervous system,
or in some changes in the heart muscle.
There is a group of bradycardias caused by
changes in the heart itself. An increase in intra-
cardiac pressure will cause a slowing of the heart-rate, as may
be observed in cases of aortic stenosis and also, in certain in-
stances, as a result of unusual, excessive exertion. In such cases
the bradycardia is advantageous for it tends to lessen the work
of the heart.
The bradycardias which follow infectious diseases
are likewise due to changes in the heart. They are analogous
to the subnormal temperature which is so frequently present under
like conditions. The slowing of the pulse is most marked after
pneumonia and typhoid fever. The injection of atropin does not
stop the bradycardias of this type, nor may it affect them at all.
Since atropin paralyzes the vagus terminals, and since the paralysis
of these terminals does not materially affect the bradycardias
under consideration, it must be inferred that they are due to
changes in the cardiac muscle. Many would attribute this slowing
of the heart to fatigue of the muscle, for there is usually an
increased cardiac action during infectious diseases. It seems
more probable, however, that post- febrile bradycardia is really
an expression of cardiac weakness. We know that the weakened
heart not infrequently contracts at a slower rate than normal.
We also know that other signs of weakness are frequently present
during convalescence, and that a cardiac insufficiency is especially
prone to develop at this time.
The bradycardias which appear at the height of infectious
diseases, especially that ominous slowing of the pulse during
the course of diphtheria, are doubtless to be referred to changes
in the cardiac muscle itself. Before they can be accurately classi-
fied, however, it will be necessary to determine their exact relation
62 THE BASIS OF SYMPTOMS
to the various degenerations in the heart muscle which occur in
these diseases. Anatomical changes in the myocardium may, as
is well known, lead to a marked slowing of the pulse. This is
seen in both acute and chronic myocarditis, as well as in the
changes which follow diseases of the coronary arteries. A defi-
nite opinion as to how the bradycardia is produced in these con-
ditions cannot be expressed without further observations based on
the newer methods of study. Thus we must determine in how
many of these cases the auricles and ventricles are beating inde-
pendently, due to an interruption in the bundle of His. For there
is little doubt that the latter is often afifected along with the non-
specialized cardiac muscle. This form will be considered imder
the arrhythmias (p. 6y).
The bradycardia of the puerperium^^ is probably
due to the decrease in the work of the heart which follows the
delivery of the child, though an augmented vagus tonus must
be considered in some cases.
We have already mentioned some of the effects of a
slow heart action upon the circulation. The heart
is enabled to recover itself during the lengthened diastolic pause,
and its work is, to a certain extent, diminished. The velocity of
the blood-current is lessened, yet this may be very slight if the
slowing of the heart is only moderate in degree. If the brady-
cardia be due to vagus irritation, the individual contractions are
not only less frequent, but they are less forcible, and the current
may be slowed considerably. Whenever the bradycardia is ex-
treme, the velocity of the blood-stream and the arterial pressure
are always markedly diminished. Such patients cannot exert
themselves without dyspncea, and even when at rest they may
suffer from syncopal attacks.
Disturbances of the Cardiac Rh5rthm. — We have already
outhned the normal mechanism of the heart-beat (p. 53), a
knowledge of which is essential to an understanding of the cardiac
arrhythmias. Here our concern is only with those anomalies of
the beat which are indicative of alterations in cardiac rhythm. ^^^
Though the arterial pulse, in rhythm and in frequency, corre-
sponds for the most part to the heart-beat, this is not always
the cause, for, on the one hand, the latter is not infrequently too
feeble to evoke an arterial pulse, and, on the other, because of the
unequal time consumed by strong and weak beats in reaching
THE CIRCULATION 08
the periphery, the pauses in the arterial pulse may be considerably
longer than those between the corresponding heart-beats.
Extrasystoles (Premature Contractions). — One of the com-
monest causes of cardiac arrhythmia is the occurrence of
extrasystoles, i.e., contractions accompanying or superimposed
upon the usual rhythm (pararrhythmia). The essential
feature of this type is an irritable myocardium which initiates a
premature contraction. Arterial hypertension is prob-
ably an important factor in some cases, for high blood-pressure
by greatly increasing the tension of the muscle thereby renders it
more irritable. Under these circumstances, only a slight added
stimulus is needed to provoke the extra beat. In other cases,
primary changes in the myocardium are at fault.
Nervous reflexes, via the vagus, for instance, are very prone to
excite premature contractions, though this has not been experi-
mentally verified by direct stimulation of nerve trunks.
Extrasystoles may arise at various points in
the heart- muscle — in the auricles, in the ven-
tricles and in the sino-auricular and auriculo-
ventricular nodes. The premature contraction generally
follows closely upon a normal one. It is inferior to the latter in
strength, partly because of the short diastole and partly because
it falls into the so-called refractory period of the heart
when the irritability of the latter is below normal. Obviously the
shorter the pause between a normal beat and extrasystole, the
weaker is the extra beat.
Following a ventricular extrasystole, with a pulse
of average rate, the next normal systole drops out, because the
stimulus which should produce it arises in the refractory period.
The second normal systole, however, occurs in its proper place;
and the interval between the normal beat before and after the
extrasystole is exactly twice that between two normal successive
contractions ("preservation of the physiological
stimulus interval," Engelmann). If, however, the
rate is abnormally slow, the correspondingly prolonged diastole
allows of a full compensatory pause after the premature con-
traction, in which case the next auricular beat is likewise followed
by a ventricular contraction (interpolated extrasystole).
The rhythm of the auricles is ordinarily not affected by ven-
tricular extrasystoles, though occasionally the latter produce sec-
64 THE BASIS OF SYMPTOMS
ondary, retrograde contractions in the auricles. The form of the
auricular wave in such cases will depend upon the irritability of its
muscle at the moment.
Auricular extrasystoles exert a variable influence
upon the above-mentioned physiological interval between stimuli,
i.e., the compensatory pause, depending upon whether the extra
beat originates nearer the venous or nearer the ventricular border
of the auricle. Premature beats initiated in the sino-auricular
node itself give rise to a complete compensatory pause, probably
because the succeeding normal stimulus produces no contraction.
Hence, the next auricular systole to appear falls approximately
in its appointed place. The compensatory pause is incomplete,
however, according to most observers, if the extra stimulus orig-
inates at a distance from the Keith-Flack node.
Not infrequently, the extra stimulus affects the auricle and
ventricle simultaneously, producing the so-called auriculo-
ventricular €xtra systole. In this case, the auricles
and ventricles contract synchronously (Mackenzie's nodal
rhythm), or the ventricle may precede the auricle. In either
case, the interval between the auricular and ventricular systoles
(the a-c interval) is shorter than normal.
It is obvious that manifold disturbances of rhythm may be
caused by these premature contractions, depending upon their
point of origin and their arrangement, i.e., singly, or in groups
of two (pulsus bigeminus), three (trigeminus), etc.
Though the study of these conditions has brought with it a great
advance in our understanding of the arrhythmias, I feel that the
tendency toward a subtle detail is overemphasized. A greater
reserve would be well, in view of the complexities present, the
meagreness of our present knowledge and the many interpre-
tations possible in each case. Assurance often takes the place of
exact knowledge.
As to the diagnostic significance of the extrasystolic arrhyth-
mias, there is likewise little known. They may occur both in
cases of myocardial disease and in conditions of nervous origin.
Subjective disturbances, such as a feeling of anxiety, or an un-
pleasant palpitation, are often present, especially in cases on an
apparent nervous basis. On physical examination, a loud first
tone, similar to that in mitral stenosis and corresponding to the
premature beat, is often heard. On the other hand, systolic mur-
THE CIRCULATION d5
murs which may have been present generally disappear, whether
because of the shortened systole, or because of other intrinsic dis-
turbances in the mechanism of the heart-beat, is not known.
Perpetual Arrhythmia (Auricular Fibrillation). — ^To those
pulse irregularities due to a displacement of the automatic
stimulus production from its normal position in the sinus
node, Wenckebach has given the name true arrhythmias
in distinction to the extrasystolic disturbances in which the abnor-
mal rhythm runs side by side with the normal (pararrhythmias).
In the severe cases of true arrhythmia the original rhythm is
almost or entirely unrecognizable ; contraction follows contraction
with bewildering irregularity, even though the heart may be fully
compensated. In some cases there is a positive venous
pulse similar to that in tricuspid insufficiency (see p. 52). The
oscillation in the jugular pulse due to auricular systole disappears
as such and is replaced by a series of insignificant waves. This
is the condition known as fibrillation of the auricles, which forms
the basis of the clinical picture called perpetual arrhythmia, or
pulsus irregularis perpetua. Cases have been observed in which
the auricle returned to its normal contraction modus after the
temporary disappearance of the fibrillation ^^^ (paroxysmal
fibrillation).
The condition of the auricles in this dis-
turbance is still not fully understood; possibly it differs in
different cases. Observers have been of various opinions, some
inclining to the belief that the auricular muscle is completely
paralyzed, others that the auricles and ventricles contract syn-
chronously, and still others that the auricular musculature is in
a state of fibrillation. Though polygraphic and electrocardio-
graphic studies do not warrant a definite interpretation of the
phenomenon, we can say that the auricles are generally dilated. ^^^
Perpetual arrhythmia is due either to an anomaly of stimulus
production — a displacement, as noted above — or to a disturbance
in the conduction of the stimulus from the sinus node to the
auricles,^ ^^ complicated by ventricular and perhaps by auriculo-
ventricular extrasystoles. This conception of the origin of per-
petual arrhythmia, though resting in some degree upon an ana-
tomical basis,^^® must not be accepted unreservedly, for, as
Aschoff points out, anatomical changes may be unsafe localizing
66 THE BASIS OF SYMPTOMS
criteria. Especially does the significance of ventricular extra-
systoles in the picture need further elucidation.
(Mention has already been made of the evolution of views as
to the nature of auricular fibrillation (p. 52) ; how, at first,
owing to the absence of the a-wave in the jugular tracing it was
assumed that the auricle was in a state of paralysis — a view which
had to be discarded because at autopsy the auricle was found to
be hypertrophic; how, later, because of the frequently observed
ventricular venous pulse, the idea was held that auricles and
ventricles contracted simultaneously (nodal rhythm) ; and how,
finally, by means of the electrocardiograph, it was demonstrated
that the auricles were not quiet, but were giving rise to countless
small waves, arising not at the normal place, but at innumerable
points in the auricle.
Auricular fibrillation is to-day looked upon as one of the
best-defined of the cardiac arrhythmias. Among its distinguish-
ing features are its very frequent association with
rheumatic endocarditis, particularly with mi-
tral stenosis — a relationship, indeed, which was noted long
before the significance of perpetual arrhythmia was understood;
further, a ventricular pulse which is extremely
irregular and usually rapid (unless a complicating
heart-block be present); not infrequently the ventricular
type of venous pulse, as already noted; and, finally, the
almost specific response to digitalis. ^^® — Ed.)
Pulsus Alternans: Hemisystoles. — In the case of two heart-
beats occurring in quick succession, whether of extrasystolic
nature or not, if the second beat be too feeble to produce a radial
pulse, the possibility is present that the phenomenon is caused by
a hemisystole, in which the two ventricles contract alternately, or
there is an alternation between a contraction of the entire beat
and that of the right ventricle. Such a regular succession of
strong beats and weak beats has been observed in animals whose
hearts have been injured. In this case we must assume either
that the contraction-producing stimuli are alternately weak and
strong, or that the heart responds with imequal strength to the
same stimulus, or that regularly occurring inotropic variations
are at work. A genuine pulsus alternans is not frequent in man ;
indeed many observers ^^^ believe that cases so diagnosed are in
reality due to extrasystoles (pulsus bigeminus). Electrocardio-
THE CIRCULATION 67
graphic studies *^^ have shown, however, that a true pulsus alter-
nans does occur in man, while in animals it may be produced by
the action of certain poisons. Pulsus altemans may be distin-
guished from extrasystolic bigeminy by the fact that the interval
between the complete and abortive systoles in the former are gener-
ally equal. As the alternating pulse is due in all probability to
variations in the contractile power of the heart it may be taken
as evidence of cardiac insufficiency, and is usually regarded as
of grave prognosis.
Heart-Block. — We have already described the path by which
stimuli arising in the sinus node are propagated over the auricle
to the node of Tawara and thence via the bundle of His to all
portions of the ventricles ; and we have noted that clinical heart-
block is generally, if not always, associated with changes in this
differentiated muscle-system (p. 42). According to the nature and
extent of the underlying anatomical process, the disturbance in
conduction may be partial (partial heart-block) or the pathway
may be completely severed (complete heart-block).
In cases of incomplete block, the resulting manifesta-
tions are extremely variable. Thus a periodic retardation in
conduction may cause a dropping out of single ventricular beats,
due to the fact that the stimulus following the block finds the
ventricle still in the refractory phase. A condition of this sort
may occur both in toxic and inflammatory injuries of the His
bundle. The greater the degree of the injury, the greater is the
number of ventricular beats to miss. Vagus stimulation also
has a certain bearing upon the dropping out of beats, though the
modus operandi is not clear ^^^ (see also p. 45), Minor grades
of disturbed conduction occur in various other conditions, espe-
cially in the infectious diseases and after the use of drugs such as
digitalis. ^^* In these last types, the auriculoventricular bundle
is probably the point of attack just as in the forms mentioned
above.
In cases of complete dissociation between auricles
and ventricles, each contracts with its own inherent rhythm.
That of the ventricles, in man, is ordinarily about thirty. Ac-
cording to Monckeberg^^^ this rate is probably found only when
the main trunk of the His bundle is interrupted; whereas in
disturbances in the Tawara node, the ventricles contract more
frequently, though less often than the auricles. Digitalis seems
68 THE BASIS OF SYMPTOMS
capable of increasing the automatic ventricular rate. (In incom-
plete block, on the contrary, digitalis is prone to cause a complete
dissociation. — Ed. )
Animal experiments have shown that a partial heart-block
can be made complete, the ventricles remaining motionless for a
brief period during the transition. And in man, likewise, it has
frequently been noted that the block may be incomplete at one
time and complete at another.
The Adams-Stokes symptom-complex 1 36 has its anatomical
basis in heart-block. Commonly arising in cases of coronary
sclerosis and chronic myocarditis, its distinctive objective phe-
nomenon is a marked bradycardia. Subjectively, the affected in-
dividual may be aware of no symptoms not dependent upon the
underlying heart lesion ; indeed it is noteworthy that many patients
with an extremely slow pulse are in nowise handicapped as to
occupation, ability to move about, and in general as to the enjoy-
ment of life. In characteristic cases, however, there occur attacks
of unconsciousness, associated apnoea and epileptiform convul-
sions. ( It is to this type with bradycardia, syncopal attacks and
epileptiform convulsions that the name Adams-Stokes syndrome
is generally applied. — Ed. )
I am of the opinion that in many even of the so-called cardiac
forms of the disease, cerebral changes play a part, for a quite
similar picture may be observed, in the complete absence of cardiac
pathology, in cases of cerebral arteriosclerosis. Nevertheless, I
do not wish to minimize the importance of the very striking asso-
ciation of complete block and these peculiar attacks. Nicolai has
recorded an interesting phenomenon in an individual with com-
plete dissociation, in whom exercise not only did not accelerate
the ventricular rate, but, on the contrary, slowed it.^^'^ Hoff-
mann ^^^ has frequently observed an acceleration of the automatic
beat of the ventricles in cases of complete dissociation.
There are additional disturbances of heart-
rhythm dependent upon anomalies in the properties of heart-
muscle, viz., conductivity, contractility, irritability and automatic
stimulus production, which, according to Engelmann, may occur
independently of one another. To the many experimental studies
and observations of Wenckebach and Hering we are indebted for
a better understanding of the manifold pulse irregularities that
may arise. At this point, we shall mention only the phenomenon
THE CIRCULATION 69
of grouped beats (Luciani) which has recently been ob-
served clinically by Wenckebach. In my opinion, however, a
certain reserve is still indicated in the interpretation of coupled
beats, for there exists a peculiar innate tendency in this regard
in the automatically beating ventricle, which would explain some
of the bigeminal and polygeminal pulses in heart-block. In other
cases, as already noted, bigeminy may be due to extrasystoles ;
while in still others it is the result of periodic disturbances of
conduction. As Wenckebach points out, therefore, there is much
included under bigeminy that belongs elsewhere.
Causes of Arrhythmia. — Myocardial disease is of
first importance in the causation of disturbances of the cardiac
rhythm. Inflammatory processes and infarcts resulting from
coronary disease are more frequently the anatomical substrata of
such arrhythmias than are the parenchymatous degenerations of
the muscle. A diminished supply of blood to the
heart may also lead to irregularity before the appearance of
serious myocardial changes. As we have previously noted, there
seems to be no definite relation between the extent of the myo-
cardial disease and the degree of irregularity. The loca-
tion of the process, however, is of paramount importance,
as is evident from the results of lesions of the His bundle. Dis-
ease of the auricular musculature is especially apt to lead to
irregularities in rhythm, according to many observers; yet our
knowledge as to the importance of the auricles, and in particular
of that area about the mouths of the great veins, in its bearing
upon cardiac arrhythmia is still incomplete.
Cardiac irregularity may also occur without
any demonstrable changes in the myocardium,
as, for example, in cases of acute dilatation of the heart following
excessive muscular exertion. To what extent nervous factors
play a role in such disturbances of the rhythm is not known. The
etiology of the so-called nervous arrhythmias is far
from clear. Stimulation of the vagus, as we know, may lead
to disturbances of conduction; and extrasystoles are especially
frequent in neurotic individuals (see also p. 64). Respiratory
variations in the frequency of the pulse are also particularly
marked in such individuals. In these cases the pulse is accelerated
at the beginning of inspiration and is retarded to such an extent
during expiration that we can speak of an actual irregularity.
70 THE BASIS OF SYMPTOMS
(This is one of the group of so-called sinus arrhythmias
— all probably of vagus origin — and which Mackenzie has called
the "youthful type" of irregularity. — Ed.)
Reflexes may give rise to irregularities of the heart's
action, as well as to tachycardia and bradycardia. We know
that if the endocardium be touched during the course of an
experiment, arrhythmia results. How important a part such
reflexes play in clinical pathology is imcertain. Possibly the
arrhythmia of endocarditis may arise from such reflexes; and
possibly the arrhythmias sometimes seen in gastro-intestinal dis-
eases are also of reflex nature. In both these examples, however,
there are usually other factors present which might produce an
irregular heart action.
Arrhythmia may be due to the action of poisons, nota-
bly of digitalis, caffein, tobacco and the toxins of ursemia. The
relation of digitalis to heart-block has already been considered
(p. 67). The irregular tobacco heart is well known. The
toxins of infectious diseases, especially those of typhoid fever and
diphtheria, may produce similar effects.
In chronic pericarditis and mediastinitis it is
possible for the new-formed connective tissue to compress the
aorta or the great veins during inspiration. This would lead to
a diminution or disappearance of the pulse during inspiration
(pulsus paradoxus).^^^ Not every pulsus paradoxus is
capable of being explained in this manner. It has been observed
in simple insufficiency of the heart, and esi>ecially in association
with stenosis of the larger air-passages, and under such circum-
stances the cause must lie in the heart itself.
The Cardiac Impulse. — If we inspect the chest of a normal
individual, a periodic heaving is usually seen in the fifth inter-
costal space, median to the mammary line. This is called the
cardiac impulse. It usually overlies the apex of the left ventricle,
which is thrust into the intercostal space with each systole. Dur-
ing diastole, the heart is flaccid and tends to assume the shape
given to it by its suroundings, but in systole it becomes rigid and
assumes its own characteristic form. This throws the apex
against the chest wall and is the principal factor in producing the
impulse. The main part of the impulse occurs during the first
period of systole at a time when all the valves are closed. The
THE CIRCULATION 71
heaving, however, continues a short time after the opening of
the aortic semilunar valves.
Many factors may, therefore, affect the cardiac impulse, such
as the position of the apex within the chest cavity, the force with
which the heart contracts, and the condition of the chest wall and
the overlying border of the left lung. Provided the latter do
not play too disturbing a role, we may say in general that a power-
ful systole will produce a strong heaving impulse, and a weak
systole will give rise to a small and soft impulse. It cannot be
assumed, however, that an extensive, strong impulse is always
due to a more powerful contraction of the heart-muscle.
A study of the apex-beat even by the ordinary methods of
physical examination enables one to form a rough estimate of
conditions in the heart, if he bears in mind the various factors
which enter into the formation of the beat normally, and those
which cause a change in its position, its breadth, its intensity, etc.
Cardiographic tracings are necessary, however, to give
us exact information about the apex-beat, though the value of
this instrumental method is somewhat impaired by the fact that
the characteristics of the beat vary considerably even in healthy
individuals. Thus the cardiogram alone gives important infor-
mation as to whether the apex-beat is formed by the left ventricle
or right ventricle; while combined with tracings taken from the
radial artery and jugular vein, the cardiogram serves as a valuable
time-index of the different phases of the cardiac cycle. The bulk
of our knowledge of the disturbances of heart rhythm was gained
through the use of such simultaneous records of the movements of
the ventricles and auricles (polygram).
The Heart-Sounds. — ^The heart-sounds may be altered either
in their intensity or their character. One of the most important
of these alterations is the increase in the intensity of
the pulmonic or the aortic second sound. This
accentuation is generally indicative of an abnormally high pressure
in the corresponding artery. Since the pressure in the aorta is
normally more than twice as great as that in the pulmonary
artery, one might think that the aortic second sound would be
normally much louder than the pulmonic second sound. Such is
not the case, however. Examination of healthy individuals shows
that there is but little difference between the second sounds in
either intensity or character. As a rule, the pulmonic second
72 THE BASIS OF SYMPTOMS
sound is relatively somewhat louder in childhood, but with advanc-
ing years the relation gradually changes until in old age the
aortic sound is usually the louder. This relative weakness of the
aortic second sound is due in part, at least, to differences in the
structure of the aorta and the pulmonary artery.
We have said that, in general, an accentuation of a second
sound indicates an increase of pressure in the corresponding artery.
Yet we meet cases in which increased pressure is present without
an accentuation of the corresponding sound; and, conversely,
accentuation of the second sound may be present without any
increase of pressure. Other factors must come into play. Of
these the proximity of the vessels to the chest wall is unquestion-
ably of importance. The physical condition of the arterial wall
also influences the sound produced, and not infrequently we
observe a loud, ringing aortic second sound in arteriosclerosis of
the first part of the aorta, even though there is no increase of
blood-pressure.
Accentuation of the pulmonic second sound is
caused by conditions which lead to an increase of pressure in the
pulmonary circulation. These conditions, which have already
been enumerated (see p. 19) include mitral disease, weakness of
the left ventricle, pulmonary emphysema, etc. The accentuation
is ordinarily associated with an hypertrophy of the right ventricle,
for both are caused by the increased pressure in the pulmonary
artery.
Accentuation of the first sound is present in many
cases of mitral stenosis, in which indeed it may be audible at
some distance from the chest wall. The most acceptable explana-
tion of this accentuated first sound is that it is due to a more
rapid systole of the left ventricle, occasioned by the abnormally
small amount of blood which this receives during diastole. The
same factors underlie the loud first sound heard in rapidly beating
hearts. Quincke has described abortive contractions of the heart
which follow immediately upon normal ones in which a good
filling of the ventricle was an impossibility and in which the systole
was short. In these the first sound was often, but not always,
louder than normal. The powerful contraction of an hyper-
trophied heart rarely produces a loud first sound, but usually an
impure and mufiled one. Weak and anaemic individuals, indeed.
THE CIRCULATION 78
frequently show surprisingly loud first heart-sounds, due prob-
ably to the associated tachycardia.
In certain cases, a doubling of one or other of the
heart-sounds is heard, so that three sounds may be distin-
guished instead of two. This is most frequently due to a redu-
plication of the second sounds, which may sometimes be heard
even in healthy individuals, more especially at the height of in-
spiration. It may also be present in various heart diseases, nota-
bly in affections of the mitral valves. This reduplication
of the second sound is caused by a non-simultaneous clos-
ure of the two sets of semilunar valves. It may be conceived
that the difference in the time of closure is due to an unequal
duration of the right and left ventricular systoles, because one
ventricle must do more work than the other. Such an explana-
tion accounts very well for the reduplication in mitral valve dis-
ease. Why it should occur in normal individuals, and why it
should be absent in cases where we have reason to believe that the
systole of one side is lengthened, is not so readily understood.
A doubling of the second sound is frequently heard at the apex
in cases of mitral stenosis. In this case the pause between the
two second sounds is longer than it usually is between redupli-
cated sounds. Possibly the extra tone is in reality a rudimentary
murmur, or is produced by the auricular contraction.
Reduplication of the first sound is less common
than reduplication of the second. In place of a single first sound,
we hear two, the second being, as a rule, the louder. This is
considered ordinarily to be due to a non-simultaneous contraction
of the two ventricles, but it must be admitted that the explanation
is not beyond question.
In gallop r h y t h m ^^^ we likewise hear three heart-sounds
instead of two, but the extra sound occurs at different times
in different individuals. In some it is heard shortly before the
first sound, being weaker and less ringing than this. In such
cases it seems to be produced by the contractions of the auricle.
"We know that the auricular contraction does produce a tone, but
that in health this so immediately precedes the ventricular sound
that it is merged into it and only one sound is heard for both
contractions. If a pause intervene between the two contractions,
we hear two sounds, and this seems to be the explanation for one
form of gallop rhythm. In the other form, the third sound occurs
74 THE BASIS OF SYMPTOMS
shortly after the second, and it is then associated with a diastolic
wave on the tracing from the cardiac impulse. Its exact cause
is not settled, though there is some evidence that it is due to
the ventricular diastole. ^*^ This second form of gallop rhythm
is said to be more serious than the first. Gallop rhythm is a sign
of cardiac weakness and is most frequently observed when an
hypertrophied heart weakens, above all when the hypertrophy
has been caused by nephritis. It may, however, result from
arteriosclerosis, myocarditis or acute infectious diseases.
The quality or character of the first sound may change, but
unfortunately the cause and the meaning of such changes are
but little understood. A muffled or impure sound may
be heard in the absence of any anatomical changes in the valves ;
but, on the other hand, such an impure sound may herald the onset
of a valvular lesion. Many such changes are perhaps caused by
some variation in the manner of the muscular contraction, or by
changes in the tension of the valves.
The first sound may be fainter than normal, even though the
ventricle is contracting powerfully; on the other hand, a faint
sound may be due to a weakening of the ventricular contraction.
I have observed a disappearance of the first sound in a case of
typhoid fever in which at autopsy no macroscopical changes were
found in the heart. In syncope, the heart sounds are often ex-
tremely faint; and since the pulse is also very weak, we must
assume that a weak heart action is responsible for the faintness
of the cardiac sounds.
Cardiac Murmurs. — If the auriculoventricular valves allow
the blood to flow back into the auricles during systole, eddies are
produced by the mingling of this stream of blood with the one
coming in from the great veins. These eddies set the valves and
heart wall in vibration very much as the violinist's bow causes
the strings of the violin to tremble. Such vibrations of the valves
give rise to the abnormal heart-sounds known as murmurs. A
murmur of this type assists us in diagnosing a regurgitation
through the tricuspid or mitral openings, as the case may be.
If the semilunar valves are insufficient, either because they
are shrunken, or because the orifice is dilated, the murmur is pro-
duced in diastole, when the blood streams from the aorta back
into the ventricle, and there causes the eddies which set the valves
in vibration. The murmur may be heard throughout diastole
THE CIRCULATION 75
or it may be present only in the earlier part, at which time the
negative pressure caused by the active dilatation of the ventricle
most favors a return flow from the aorta.
An obstruction to the flow of blood through any of the orifices
of the heart may also produce a murmur, and a simple roughening
of the valves at the aortic orifice may do the same. The murmur
caused by a stenosis of the mitral or of the tricuspid orifices is
heard during a part or the whole of the diastole of the ventricles.
When it persists throughout this period it is usually loudest at the
onset and at the termination. The former accentuation is caused
by the suction of the dilating ventricle, the latter by the auricular
contraction. More frequently these murmurs are heard only
during a part of the diastole, either at the beginning or at the end.
The latter, called a presystolic murmur, precedes and merges into
the first heart-sound, and is especially characteristic of mitral
stenosis.
The murmurs produced by a narrowing or roughening of the
semilunar valves are usually loud and rough. They occur at the
same time that the blood is passing from the ventricles into the
great arterial trunks. It is sometimes possible to demonstrate
that they begin somewhat later than the beginning of the cardiac
impulse, for it must be remembered that the first part of this
impulse corresponds to that j>eriod of the ventricular contraction
during which the intraventricular pressure is being raised to the
level of pressure which exists in the great arterial trunks. For
this reason no blood is leaving the ventricles during the first
portion of the cardiac impulse, and consequently no murmur due
to an obstruction at the aortic orifice can be produced at that time.
Murmurs vary greatly in intensity and in tonal character.
Not infrequently they are distinctly musical, particularly when
systolic. The cause of these variations in quality is not known.
In aortic stenosis the first sound may also disappear, not only
over the aortic area, but at the apex as well. The left ventricle
appears to contract without producing an audible first sound. This
is probably due to the gradual and prolonged systole which is so
characteristic of aortic stenosis. In aortic regurgitation the sec-
ond sound may become very faint or it may disappear entirely.
Various opinions are held as to the cause of those murmurs
which have been variously designated as accidental, functional
or haemic murmurs. They are usually systolic in time, and are
76 THE BASIS OF SYMPTOMS
most intense in the second intercostal space to the left of the
sternum and at the point of maximum cardiac impulse. It is
quite certain that they are not due to an endocarditis affecting
the mitral valves. We cannot exclude, with equal certainty, how-
ever, the presence of functional insufficiencies of the auriculo-
ventricular orifice. Indeed, it appears to me that this is the
cause of many of these murmurs. They are heard most fre-
quently in weak and anaemic individuals, such as would be most
liable to have a weak cardiac muscle, dilatation of the cavities
of the heart, and functional insufficiency of the mitral and tricus-
pid orifices. We do not mean to imply, however, that all acci-
dental murmurs are thus caused. Some, it may be, are due to
anomalies in muscle contraction, or as Liithje^*^ suggests, to a
physiological stenosis, as it were, of the pulmonary artery.
Palpitation. — Palpitation of the heart has been defined as an
irregular or forcible heart action perceptible to the individual
himself. In health, we are not ordinarily conscious of the action
of our hearts, unless it is much increased by exertion or by excite-
ment. It seems probable that there are sensory nerves in the
heart or in its vicinity which are stimulated under these circum-
stances. Pathological palpitation may be due either to an abnor-
mal heart action or to an increased irritability of these nerves,
rendering the individual abnormally sensitive. Naturally, both
causes may be operative in the same person.
An increased heart action does not necessarily produce the
sensation of palpitation. This fact is frequently illustrated in
cases of valvular disease, and is perhaps to be explained on the
assumption that the gradual development of the condition allows
the sensory nerves of the heart and adjacent structures to become
accustomed to the changed conditions. Not infrequently, how-
ever, patients with hypertrophy and dilatation of the heart suffer
from palpitation, especially during any exertion. In such cases
the heart is working up to the limits of its capabilities, and pos-
sibly the increased tension of the cardiac wall stimulates the sen-
sory nerves, and so produces the feeling of palpitation. This
would explain why in stasis dilatation, in which the tension of
the muscular wall is reduced, individuals often do not complain of
palpitation.
In yet other individuals, no definite connection between the
heart's action and the palpitation can be discovered. This is
THE CIRCULATION 77
especially true of the form associated with ansemia and that due
to certain poisons, notably tobacco, tea and coffee. In such cases
it is possible that the systole is modified, but it seems more prob-
able that the patient is conscious of his heart's action merely be-
cause of an increased irritability either of the cardiac nerves or
of their centres.
Cardiac Dyspnoea. — Shortness of breath is a very frequent
symptom of heart diseases. It is often associated with a sensa-
tion of oppression in the chest, or with a general feeling of
anxiety ; but it may occur alone. It may vary greatly in degree,
from the slightest dyspncea on exertion to the most extreme air-
hunger, even when at perfect rest. This s)rmptom is not charac-
teristic of any form of heart disease, but occurs whenever the
interchange of gases in the lungs is seriously interfered with.
Periodic interference with this interchange leads to periodic
dyspnoea, the so-called cardiac asthma.
The dyspnoeaof heart disease is always due to
an insufficient interchange of gases between
the blood and certain cells of the medulla (see
Chapter IV). Two causes are directly responsible for the
dyspnoea of heart disease. The first is the slowing of the
blood-stream, which diminishes the interchange of gases
in the lungs and in the respiratory centre of the medulla. Any
slowing of the blood-stream in the lungs beyond a certain limit
leads to an insufficient interchange of gases (see Chapter IV).
A second cause for the dyspnoea of heart disease lies in the
changes which take place in the alveolar epithelial
cells of the lungs, and which lead to a rigidity of the
pulmonary tissue. ^^^ These changes, which have already
been described (see p. 34) would, undoubtedly, interfere with the
interchange of gases in the lungs, even though the blood-stream
were not retarded.
The dyspnoea which develops only when the patient exerts him-
self is due to a relatively slow circulation, the rate of flow not
being increased proportionately to the demands for fresh blood.
Indeed the exertion may cause a fall of arterial pressure in patients
with heart disease.
The term cardiac asthma is applied to those
paroxysms of extremely severe dyspnoea which occur in individ-
uals who have heart disease. The dyspnoea is often of the most
78 THE BASIS OF SYMPTOMS
extreme grade, and may be accompanied by excessive anxiety and
a terrible sense of impending death. The paroxysms may begin
after a m^^al, after exercise, during the night or without any
apparent cause. They occur most frequently in those who have
arteriosclerosis or chronic nephritis. During the attack,
the pulse is usually rapid, soft and irregular in force and
frequency. The blood-pressure is usually lower than
normal, though in conditions of established high tension it usually
remains above normal. The most frequent cause of cardiac
asthma is a transient weakness of the left ven-
tricle. This raises the pressure in the pulmonary vessels and
so increases the work of the right heart. If the latter is unable
to accomplish the additional work so thrown upon it, there results
a diminution in the velocity of the general blood-current. In
addition to this we have a widespread and sudden overfilling of
the pulmonary capillaries which contributes toward the production
of the symptoms. In certain cases, the dyspnoea becomes less
when the right heart weakens. Since the pulmonary capillaries
would then be less distended, this favors the view that the dis-
tention of the capillaries is to some degree responsible for the
paroxysms of dyspnoea.
Patients suffering from heart disease frequently develop
dyspnoea from pulmonary complications, such as bronchitis, pneu-
monia and oedema, to which diseases they are, indeed, peculiarly
subject. In the French literature many other causes for the
dyspnoea of heart disease are enumerated, among which are toxic
and reflex influences. At present, however, there is little real
proof of the existence of such causes.
Cardiac Pain. — As has already been stated, a feeling of
intense anxiety often accompanies cardiac dyspnoea. This feel-
ing may occur alone, or it may be associated with pain in the
precordium. The latter, however, rarely occurs alone, except in
nervous individuals, in whom the pain is of psychic origin and
is simply referred to the periphery.
Cardiac pain, originating in the heart itself,
is seen especially in disease of the coronary
arteries and of the first part of the aorta. It
accompanies aortic more frequently than mitral lesions, because
the former are more often associated with arteriosclerosis.
Patients with various forms of myocarditis also frequently com-
THE CIRCULATION 79
plain of pain abour the heart and of cardiac distress, which may
either be constantly present or may occur in paroxysms. Often
there is no relation between these symptoms and the state of car-
diac efficiency ; generally, however, they represent a demand upon
the heart for increased work which it cannot perform.
The severity of the pain varies greatly. On the one hand,
the patient complains of sensations which trouble him mainly be-
cause they are unusual, while, on the other hand, the pain is of
such indescribable severity that death seems imminent. It is not
the place here to enter into a description of the clinical features
of these cases of angina pectoris. ^*^ They occur, almost without
exception, in those who have sclerosis of the coronary arteries.
The attack may come on without any apparent cause, though
usually it is precipitated by some unwonted excitement, by over-
exertion or by digestive disturbances. Most of the attacks are
due to cardiac weakness induced by these unfavorable circum-
stances.
We do not know what causes the pain of angina pectoris.
Arteriosclerosis of the coronary arteries is certainly present in
most cases, frequently causing a narrowing of the lumen of the
vessel. Perhaps it is the anaemia of certain parts of the heart
which causes the pain. Such a theory finds an analogy in the
condition known as intermittent claudication,^*^ in which, owing
to a narrowing of the arteries, pains and disturbances of function
develop in the legs whenever the patient walks some little dis-
tance. In some cases the anginal paroxyms cease, and this has
been attributed to a reopening of the vessel, although we have no
proof for such an hypothesis. Breuer calls attention to the fact
that we are not yet perfectly clear about intermittent claudication,
for we do not know how great a role spasmodic contraction of the
arteries may play in this condition. (Erb, who particularly stud-
ied this condition, finds excessive smoking a prominent
factor in the majority of cases. Elimination of tobacco may bring
about complete recovery, not only in intermittent claudication,
but also in some cases of angina pectoris. — Ed.) Nothnagel
believes that the pain may originate from the vessels themselves.
Such an hypothesis, attributing the pains of angina directly to
the spasmodically contracted vessel, is very attractive. It would
explain the fact that the paroxysms of pain may occur without
anatomical disease of the coronary vessels, as has been observed
80 THE BASIS OF SYMPTOMS
in nervous individuals and especially in those who use tobacco
to excess.
The anginal attack is often associated with a variably intense
vasoconstriction of other parts, especially of the cutaneous vessels.
Nothnagel has called this form angina pectoris vasomotoria. It may
be present both in cases due to coronary sclerosis, and in those of
purely psychic origin.
Many other questions in relation to angina are still unan-
swered, as, for example, the reason why the pains radiate to the
left brachial plexus, the cause of the syncope in some cases and
finally the cause of the sudden death. Every attack of true
angina is a menace to the life of the individual, and not infre-
quently the patient dies during the attack. In only one other
condition do we see an equally sudden death, and that is in
coronary embolism. The body may be found in the exact position
that it was in when the attack of angina began. No other signs
of asphyxia are present The cause of sudden death has never
been explained.
The Arteries
The condition of the arterial walls and the width of the
arteries exercise a considerable influence upon the flow of blood.
If the arteries were all fully dilated, it would be absolutely im-
possible for the heart to maintain the circulation, for the relatively
small quantity of blood in the body could not properly fill the
vessels. The width of the arteries is regulated mainly by reflexes
coming from various parts of the body; and by virtue of this
regulatory mechanism the heart is enabled to graduate its own
work. The condition of the vascular area under control of the
splanchnic nerves is of prime importance in its effect upon the
general arterial tension; though in man the cutaneous vessels
constitute a not inappreciable factor.
If the arteries leading to a certain part of the body dilate or
contract, the blood-supply to that part will be altered. These
changes are fully discussed in the ordinary text-books on physiol-
ogy and pathological anatomy, and need not be dwelt upon here.
Our concern shall be with those disorders of vascular function
which affect the circulation as a whole. An example of this we
have seen in arteriosclerosis, which frequently causes an increase
in arterial tension, particularly if it involve the root of the aorta
THE CIRCULATION 81
or the vessels of the splanchnic area. Furthermore, we have
already emphasized the fact that hypertension on an arterio-
sclerotic basis is not purely of a mechanical nature, but is due, in
large measure, to an altered vasomotor tonus. Indeed, it would
seem that certain cases of high blood-pressure are the result of a
primary augmentation of this tonus. These are the cases of so-
called essential hypertension. What relationship they
may bear to arteriosclerosis is not known, though it is possible that
they are precursors. (But recent extensive studies ^^^ appear
to indicate that a large proportion of such cases of idiopathic
hypertension, especially those with a systolic reading of i8o mm.
and over, are really due to anatomical changes in the kidneys,
despite the fact that they do not betray themselves during life
by urinary findings. Modern methods of determining the func-
tional efficiency of the kidneys (see pp. 427, 430) promise much
in the way of establishing the renal origin of such cases. — Ed.)
A widespread spasm of the vessel walls tends
to raise the arterial pressure by increasing the periph-
eral resistance against which the left ventricle must pump. In
cases of spasm affecting the numerous vessels under the control
of the splanchnic nerves, the general pressure is also increased,
but here the work of the ventricle is augmented by the fact that
the volume of blood in the periphery is greater because of the
emptying of the splanchnic vessels. Vessel-cramps of this sort
are seen in cases of asphyxia and in poisoning due to strychnin
and lead; and PaP*'' has emphasized their importance in other
conditions. The cause of these so-called vessel-crises is but
little understood. In some instances they are possibly of nervous
origin ; while in others they are of reflex nature, in which case they
probably possess a regulatory function, and have an intimate
relation to factors concerned in renal hypertension.
The Arterial Blood-Pressure. — The blood-pressure ^^^ in
the larger arteries is dependent mainly upon two factors — ^the
amount of blood pumped into the arterial system by the heart, and
the resistance offered to the escape of blood from this system
through the smaller arteries and capillaries. Of less importance
are the elasticity of the vessel- walls and the total quantity of
blood in the body. These various factors influencing blood-
pressure may interact upon each other in the most complicated
manner. For example, if the arterial pressure be increased from
6
82 THE BASIS OF SYMPTOMS
any cause, the vagus nerve is stimulated, with the result that the
heart is slowed and less blood is delivered into the aorta. In a
like manner, when the volume of blood is rapidly changed, the
blood-vessels change their calibre, so that, within certain limits,
the blood-pressure is not altered.
Systolic and Diastolic Pressures. The Pulse-Pressure. —
The arterial pulse is caused essentially by the variations of
pressure within the artery, produced by the intermittent expulsion
of blood from the heart. The highest point on this wave of
arterial pressure is called the systolic pressure, and the
lowest point the diastolic pressure. The difference be-
tween the two, i.e., the variation of pressure with each pulse, is
called the pulse-pressure. By means of the ordinary sphygmo-
manometer it is now possible to determine the diastolic pressure
with almost as great facility and accuracy as the systolic. This
has served as a strong stimulus to the study of the factors con-
cerned in the production and in the variations of the systolic,
diastolic and pulse-pressures and has necessitated a certain revision
of ideas formerly held as to the significance of hypertension.
The diastolic pressure^*® measures the peripheral re-
sistance and as such is probably a better index of the work thrown
upon the left ventricle than is the systolic. This is all the more
true, under given conditions, because the diastolic pressure seems
to maintain a more constant level than the systolic, which, as is
well known, may undergo marked and rapid changes, not only
physiologically, but especially in cases of hypertension. The
pulse-pressure represents the actual excess of pressure im-
pelling the blood to the periphery, or the "load" which the
heart must carry to maintain the circulation. Though observers
are not in complete accord as to what constitutes a normal pulse-
pressure, it may be said in general that a reading below 30 mm.
Hg. is low and one above 50 mm. is high. Thus, in a case of
hypertension, the outlook would depend not so much upon the
systolic pressure, as upon the pulse-pressure, which must be high
to maintain compensation. A rise in the diastolic pressure with-
out a corresponding increase in the systolic in such cases would
signify that the growing peripheral resistance is not met by in-
creased work on the part of the heart, or in other words that
the pulse-pressure was falling and decompensation was at hand.
The attempt has been made to correlate thecardiacout-
THE CIRCULATION 83
putperbea t — the blood flow from the heart — with the pulse-
pressure. In general, it is true that an increased systolic output
produces an augmented pulse-pressure and vice versa. That there
can be no absolutely definite ratio, however, between ventricular
output and pulse-pressure is evident from the fact that the elastic
integrity of the vascular wall and the fulness of the artery must
be taken into consideration. In arteriosclerosis, for example, and
in aortic insufficiency, the ratio of pulse-pressure to cardiac output
behaves contrary to the general rule.
Physiological Variations in Blood-Pressure. — A g e influences
the blood-pressure. During infancy the systolic pressure
usually ranges between 75 and 90 mm. of mercury; later, the
weight and height of the child appear to be more influential in
determining the pressure than is the age.^^^ In adults, age
and physical development, and to a lesser degree, sex
are important. The systolic pressure increases slightly with each
decade, ranging from 100-130 mm. in young adults to 130-145
mm. in old people. A pressure consistently above 150 mm. is
pathological. Women show slightly lower systolic values than
do men of the same age.
Excitement, anger and worry generally cause a
considerable rise of pressure. Though the pressure increase due
to worry is usually transitory, it is not unlikely that long-con-
tinued worry may lead to permanent hypertension. The question
of the emotions and epinephrin discharge is con-
sidered in another place (p. 338). The effect of exercise is
variable. Moderate exertion — as, for example, walking — may
diminish the diastolic pressure and increase the pulse-pressure;
severe exertion, on the contrary, tends to increase both the systolic
and diastolic readings, indicative apparently of the increased
cardiac activity. The effect of severe exertion is intensified if
the act requires mental effort. An increase of 10 to 20 mm.
generally accompanies the change from the recumbent to the erect
position. This normal response to exercise and to a change in
position has been made use of as a test of the functional efficiency
of the heart, an inefficient organ frequently responding with no
pressure rise and sometimes, indeed, with a slight fall. But as
previously noted, the behavior of the diastolic and pulse-pressures
in these cases would offer more valuable diagnostic criteria.
In the first two hours of undisturbed sleep, there may be
I
84 THE BASIS OF SYMPTOMS
a fall amounting to 20 mm., while the maximum for the day is
observed, as a rule, in the late afternoon.^ ^^ Considerable study-
has been devoted to the effect of altitude and of low
atmospheric pressures upon the blood-pressure. ^^^
Though some individuals exhibit no change under these con-
ditions, the effect in general would seem to be a slight reduction,
both in normal individuals and in those with hypertension.
In this connection may be mentioned also certain factors in
their bearing particularly upon cases of high arterial tension.
We have already noted that persons with high blood-pressure do
well rather than badly in high altitudes, in so far as the pressure
itself is concerned. Furthermore, recent work would indicate
that a protein diet and a large fluid intake do not
influence an uncomplicated hypertension unfavorably. Sweat
baths generally cause a pronounced drop in pressure, which
may persist for weeks ; while carbon dioxide baths and
the high frequency current have a similar, though less
constant, effect. ^^*
Pathologically Increased Blood-Pressure. — Emphasis has
already been placed upon the importance of the nephri-
tides in the production of continuous high pressure, whether
the renal lesion be evident from the urine or not. Attention has
been directed also to the factors which seem active in the causa-
tion of this form of hypertension, and in particular to mechanical
and functional alterations in the arterial walls. The high pressure
observed in arteriosclerosis, either generalized or involv-
ing particularly the first part of the aorta or the splanchnic vessels,
and in the so-called vessel-crises, probably bears a close
etiological relationship to renal hypertension. Interesting in this
respect are the most recent studies of Pal ^^'^ in which cases of
high pressure seemingly due to an increased arterial tonus, e.g.,
post-scarlatinal uraemia, and cases of more localized smooth-
muscle spasm — angina pectoris, bronchial asthma and pyloro-
spasm — yield to the action of papaverin, which is endowed with
the property of relaxing smooth muscle.
Poisoning with strychnin and lead probably pro-
duces an augmented arterial tension, as previously mentioned, by
causing widespread vessel-spasm. The effect of lead in this re-
spect is seen also in its tendency to cause anatomical vascular
and renal changes, and in its association with gout and diabetes.
THE CIRCULATION 85
The last diseases, however, may independently cause atheroma
and hypertension. Experimentally, digitalis raises the arte-
rial pressure by increasing the work of the heart and by causing
vasoconstriction. In cases of hypertension, however, particularly
when associated with cardiac decompensation, digitalis and allied
drugs not only improve the circulation, but often cause a drop in
pressure. ^^® Epinephrin, in pharmacological doses, produces
hypertension by constricting the peripheral vessels. The physi-
ological action of epinephrin is discussed elsewhere (p. 338).
Acute asphyxia or acute anaemia of the medul-
lary centres of the brain will stimulate the vasomotor centre
most powerfully, producing a contraction of the splanchnic vessels
and a great rise in arterial pressure. Such a cerebral anaemia
appears to be the cause of the extremely high blood pressures some-
times seen in cases of acute cerebral compression, a subject which
will be discussed in another place (p. 446) . Leadcolicis usu-
ally associated with high arterial pressure, and the early stages of
peritonitis are likewise frequently accompanied by such a
rise. Pain, even that caused by pinching the skin, usually
increases the systolic pressure in healthy individuals. — Ed.)
The effect of an increased peripheral resistance upon the gen-
eral circulation depends, for the most part, upon the behavior
of the left ventricle. If this were to act in an ideal manner, it
would contract more forcibly, and so, by raising the general
arterial pressure, would overcome the increased resistance. Un-
fortunately, however, when the peripheral resistance and the
arterial pressure are much increased, the left ventricle does not
empty itself completely, the pressure in the left auricle rises, and
a retardation of the blood-flow through the lungs occurs.
Pathological Diminution in Blood-Pressure. — W idespread
dilatation of the blood- vessels may lead to a serious
fall of arterial pressure and a slowing of the circulation, for, as
we have said, the total quantity of blood in the body is insufficient
to fill the blood-vessels properly if they are all widely dilated.
Such a widespread dilatation may result from a general loss
of arterial elasticity with a stretching and widening of the blood-
vessels. This has been observed in certain cases of aortic insuffi-
ciency (p. 35), and apparently in the late stages of arteriosclerosis
(p. 22).
Arterial dilatation may also result from a widespread
88 THE BASIS OF SYMPTOMS
loss of arterial tonus. Thus, if the splanchnic vessels
lose their tone, they become filled with blood, and the arteries
to the other parts of the body, especially to the skin and muscles,
are left comparatively empty. The patient becomes weak and
pale, the arterial and venous pressures fall, and the heart receives
an insufficient supply of blood. The pulse becomes soft and
rapid, and finally syncope supervenes. Such a patient is practi-
cally bled into his own abdominal vessels, and life may last only
a few hours or even minutes. If other arteries in addition to the
splanchnic vessels are dilated, the symptoms are intensified; yet
the condition of the splanchnic vessels is of paramount importance
on account of their great capacity.
A clinical picture, similar to that just described, may be
produced by toxic doses of such drugs as chloral and alcohol,
both of which will ultimately paralyze the vasomotor centre. A
similar picture is also presented by the so-called collapse that
sometimes occurs during the course of infectious dis-
eases. These symptoms are not those of ordinary heart failure,
for the pulmonary congestion and the stasis in the veins of the
general circulation are both lacking. The picture seems rather
to be caused by an insufficient supply of blood without stasis,
and is fully in accord with the assumption of an extensive vaso-
motor paralysis.
This question has been carefully studied in animals.^ ^^ The
great falls in pressure which occur at the height of experimental
infections with the pneumococcus, the diphtheria bacillus and the
bacillus pyocyaneus, have all been shown to be due to a paralysis
of the vasomotor centres. In pneumococcus infections, the heart
may even beat with more than its usual force, and may thus,
to a certain degree, compensate for the loss of vasomotor tone.
So long as its structure remains intact it can meet the extra
demands made upon it, such as the rise of blood-pressure caused
by asphyxia. In diphtheria infections, however, the heart is
usually also injured, and some, indeed, assert that the injury
to the heart is here the more important cause of the circulatory
disturbances. ^^^ It has also been definitely proved that in a per-
forative peritonitis experimentally induced, the cause of death
is a toxic paralysis of the vasomotor and respiratory centres.^*^^
The result of these animal experiments may be applied with
all the more confidence to man for the reason that the clinical
THE CIRCULATION 87
picture of collapse corresponds so closely to what we should
expect from a vasomotor paralysis. I have the impression that
the most severe circulatory disturbances in these diseases are due
to central vasomotor paralyses, preceded in many cases by local
lesions of the blood-vessels."^ As a rule, the heart "^ is also
affected apart from the changes in the arteries and thus the circu-
latory apparatus as a whole is damaged. Sometimes, indeed, the
cardiac weakness is more prominent than the vascular paralysis
but in either case the therapeutic indication is to improve the
circulation by strengthening the heart.
(Another form of extreme circulatory depression is that seen
in anaphylactic shock (see p. 1 79). Animal experiments have
shown that in this condition there is regularly a considerable fall
in blood-pressure, which may amount to 20 to 30 mm. Hg. Though
the splanchnic dilatation and medullary anaemia are probably the
chief factors in the production of this form of shock, it would
appear from electrocardiographic studies that the origin is partly
cardiac. ^^^
The cause of so-called surgical shock is still not definitely set-
tled; and it is not unlikely, as Yandell Henderson ^"^ has stated,
that the etiology is probably not uniform. In Crile's earlier pub-
lications,^®^ shock was attributed to an exhaustion of the vaso-
motor centre caused by severe traumatism to the peripheral
nerves. This in turn caused a fall in blood-pressure which was
regarded as the essential feature of the picture, and to the cor-
rection of which remedial measures were directed.
Objection has been made to this theory because it seemed inade-
quate to explain all cases and also because there may be a con-
siderable rise in pressure in the early stages of shock lasting until
the vasoconstriction caused by the centripetal stimuli finally gives
way to overstimulation and depression. And, more recently,
Crile^®'^ has come to believe that the essential substratum of shock
resides in specific changes in the brain-cells which bring about a
conversion of the potential energy of these cells into kinetic
energy. The direct cause of this change is ascribed by Crile to
injurious stimuli (noci impulses), such as fear of the operation,
fatigue, loss of sleep and those due to the anaesthesia itself, which
so lower the cerebral threshold of sensitiveness as to render it
susceptible to the trauma of the operation. The attempt is made,
therefore, to exclude these noci impulses by eliminating, so far as
88 THE BASIS OF SYMPTOMS
possible, the above mentioned psychic predisposing factors, and
also the pain and trauma of operation by a perfect anaesthesia,
both general and local. This method Crile has called anoci-
association.
Henderson believes that certain cases of shock, at least, are
due to acapnia — a, deficiency of carbon dioxide in the blood —
which occurs when various factors such as pain, trauma, exposure
of the tissues, fever, faulty anaesthesia, etc., lead to an increased
respiratory activity. This in turn causes a lowering of the
osmotic tension of the blood, a loss of fluid from the latter and
a diminution in the total volume of blood. The consequent fall
in venous pressure deprives the heart of an adequate supply of
blood which is evidenced by a diminished output in systole.
Henderson's theory, therefore, postulates a condition not unlike
hemorrhage. — Ed. )
A comprehensive and nice adaptability of the diameter of the
arterial tree to the activity of the heart is of great importance
in the maintenance of the circulation. An equal and perhaps
greater factor is the balance between the volume of blood in one
vascular field and that in others. Such an adjustment is essential
not because the total blood mass must be properly distributed
among the different vessels, but because correlated organs can
thus receive a sufficient supply. Romberg and O. Miiller^^^
have shown that in art^iosclerosis the vascular reflexes are mark-
edly disturbed. The same is true of those remarkable con-
ditions of local anaemia, such as Raynaud's disease, which at
present are regarded as of nervous origin.
The Veins
Venous Stasis. — It has already been shown that stasis of
the blood in the veins may result from cardiac weakness. The
stasis in the pulmonary circulation, produced by the weakness of
the left ventricle, may be overcome to a certain extent by the
increased activities of the right ventricle; whereas the stasis in
the veins of the general circulation, resulting from a weakness
of the right ventricle, cannot be thus overcome, and the entire
blood current is slowed.
General venous stasis may also be caused by diseases of the
lungs or by pressure upon the great veins. If the intrathoracic
pressure be increased, either by a diminution in the elasticity of
THE CmCULATION 89
the lungs (emphysema) or by a collection of fluid or gas in the
pleural cavities, or if the thoracic movements are lessened, as hap-
pens during superficial breathing, then a diminution in the flow
of blood to the heart results. Pressure upon the great veins by
tumors and especially by pericardial effusions may also interfere
with the return of venous blood to the heart. A pericardial
effusion may, indeed, cause sudden death by compressing the
venae cavse just before their entrance into the right auricle, and
so shutting off the entire blood-supply to the heart.
Venous Murmurs. — In certain individuals, especially in chlo-
rotic girls, a murmur may be heard over the bulbus jugularis.
This is usually louder on the right than on the left side, and is
known as the venous hum (bruit de diable). Its cause
is not well imderstood. Some believe that it is a murmur of
stenosis caused by the passage of the blood from the external
jugular vein into the jugular sinus; yet why this should occur
especially in anaemic individuals is not known. Sahli ^^"^ con-
siders that the blood flows more rapidly in anaemia, and that this
is the cause of the murmur ; and as the rate of flow in the anaemias
appears to be more rapid than normal, this explanation seems the
best at hand.
The Circulation of the Lymph
The lymph may be looked upon as the fluid that has escaped
from the capillaries. It carries material to the cells of the
parenchyma, and, laden with waste products, returns to the blood
by way of the lymphatic vessels. Its composition, therefore,
varies according to the organ from which it comes and according
to the activity of that organ.
We know of no diseases in which too little lymph escapes
through the capillary walls, although it seems probable that such
do exist.
CEdema. — Certain conditions lead to an accumulation of
l)miph in the lymphatic vessels and spaces, among which latter
the serous cavities may be included. Theoretically, such an
accumulation may be brought about, first, by an excessive
formation of lymph; secondly, by a hindrance to the
escape of lymph; and thirdly, by a combination of
the two. The quantity of fluid that passes through the capil-
lary walls depends, on the one hand, upon the difference in
90 THE BASIS OF SYMPTOMS
pressure between the blood in the capillaries and that of the lymph
in the surrounding tissues, and, on the other hand, upon the
permeability of the capillary walls themselves.
CEdema from Stasis. — QEdema may be caused by a stasis
of blood in the veins. This stasis may be merely local, as
when it is caused by an occlusion of a vein by thrombosis or
external pressure; or it may be general, as when it results
from pathological changes in the lungs, weakness of the right
heart, intrathoracic tumors and pleural or pericardial exudates.
The cedematous fluid that collects in the lymph-vessels and spaces
in such cases is poorer in proteids and leucocytes, but richer in
erythrocytes, than is normal lymph. The organs that become
most swollen are those in which the tissues are under the least
elastic tension, and in which the venous stasis is favored by
gravity. For this reason the oedema caused by general stasis is
usually first observed about the ankles and over the lower part
of the back.
The mere obstruction of a vein does not necessarily lead to
oedema, for a collateral venous circulation may be established.
After the experimental ligature of a vein, the occurrence of
oedema is greatly favored by the frequent accompanying arterial
hyperaemia.
Even an increased transudation of lymph does not necessarily
cause an oedema, for the excessive amount may be carried away
by the lymphatics. There must be, in addition, therefore, some
interference with the lymph-flow from the part. When general
venous stasis causes the oedema, the blood-pressure in the left
subclavian vein is naturally raised, and this would furnish the
interference with the flow of lymph into this vein from the thoracic
duct.
The lymph-flow may also be hindered in other ways. An in-
creased pressure in the capillaries is transmitted to the tissues
about them, which gradually become stretched and lose their elas-
ticity. The loss of elasticity diminishes the pressure normally
exerted by the tissues upon the lymph-spaces, the difference be-
tween the blood- and the lymph-pressures is, therefore, increased,
and exudation is favored. On the other hand, the diminished
pressure exerted by the tissues upon the lymph-spaces tends to
lessen the rate of lymph-flow from the tissues toward the thoracic
duct. For these reasons, the elasticity of the tissues
THE CIRCULATION 91
exercises a most important influence upon the
occurrence of oedema and different organs become swollen
to different degrees, even though they all are exposed to the same
venous stasis.
The mere obstruction of a lymphatic vessel rarely leads to
oedema, on account of the numerous anastomoses between the
lymphatics. If, however, the thoracic duct be obstructed, ascites
and oedema of the legs usually develop.
Inflammatory CEdema. — As is well known, inflammations
injure the walls of the capillaries. There is an active local hyper-
semia, and, at the same time, a slowing of the blood-current
caused by the changes in the vessel walls. The latter influence
the amount and character of the transudate, and consequently the
lymph of inflammation differs from that normally transuded, in
that it contains more albumin and more numerous blood-
corpuscles. Purulent inflammations are characterized by the
richness of their exudates in leucocytes, which are attracted thither
by the primary cause of the inflammation.
Inflammatory processes also interfere with the removal of
lymph from the tissues, for they directly diminish the tissue
elasticity, with the results just described. Even the elasticity
of tissues at some little distance from the inflammation may be
diminished, so that these also become oedematous, thus producing
the so-called collateral oed em a .
iNephritic CEdema. — Of the dropsies that accompany neph-
ritis ^^^ some are unquestionably due to simple stasis. We
have seen that the heart is often weakened in nephritis, in which
case it is obvious that we have to do with the ordinary dropsy
of heart disease. Here, however, we wish to consider those
nephritic oedemas that occur independently of any cardiac weak-
ness. They usually appear first in the subcutaneous tissues, and
especially in those that possess the least tension, as about the
ankles and eyelids, though not infrequently the great serous
cavities are early filled with fluid.
CEdema of this character is rarely seen in certain forms of
nephritis, especially in contracted kidneys, in the nephritides
caused by certain poisons (arsenic) and in those associated with
certain infectious diseases (pneumonia and typhoid fever). On
the other hand, oedema is common and often marked
in chronic parenchymatous nephritis, in in-
98 THE BASIS OF SYMPTOMS
flamed amyloid kidney, in scarlatinal nephritis
and in primary acute nephritis. We are still in no
position to state, however, whether the cedema in these cases
is due to the anatomical lesion per se or to the consequent func-
tional disturbance.
The urine inthe dropsical cases is f rquently dimin-
ished in amount and rich in albumin; yet the high percentage of
albumin can hardly be the cause of the oedema, for large quanti-
ties may be excreted with comparatively slight oedema, as, for
example, in imcomplicated amyloid disease of the kidney. Fur-
thermore, a reduction of the albumin in the blood cannot be the
sole cause of the oedema, for we know that with plenty of food
there is no diminution of albimiin in these cases. When cachexia
develops, the albumin may, indeed, be diminished and oedema may
api>ear, but this is of a different character and of relatively slight
degree.
It is possible that the oedema of nephritis is produced by a
primary retention of water in the body. In the
forms of the disease under consideration, less urine than normal
is usually secreted, and frequently the oedema increases as the
urine diminishes, and i/ice versa. Many writers, therefore, favor
the view that a primary retention of water in the bodies of these
patients dilutes their blood and so produces an hydraemia or an
hydrsemic plethora; and Hammerschlag^^^ has shown that a
diluted blood is usually present in these cases of nephritis. Never-
theless, the theory has many opponents. Most experimenters have
failed to produce an oedema by the mere infusion of salt solu-
tion.^'^*' Half of the blood has been withdrawn and replaced by
saline solution and enormous quantities of fluid have been infused
without producing any oedema. Some other factor, therefore,
seems to be necessary, and this is possibly an injury to the
vessel wall, just as in the inflammatory type. Magnus has
discovered a whole series of substances which will produce exten-
sive anasarca if injected into an hydraemic animal. Among these
are substances that are retained in the body after removal of
the kidneys.
One may assume, therefore, that some change in the
capillary walls is, in part, responsible for the oedema of
nephritis, though up to the present these changes have not been
demonstrated anatomically. We have already seen that such
THE CIRCULATION 93
h3^thetical changes in the blood-vessels probably account for the
cardiac hypertrophy in certain cases of nephritis. Recent ex-
perimental studies ^^^ devoted to this problem indicate that in
the nephritides produced by certain poisons the parenchymatous
changes are inadequate to explain the cedema, and that the latter
is doubtless due to a functional disturbance of the renal vessels.
Thus in uranium nephritis, which is essentially tubular in charac-
ter, cedema does not develop until the permeability of the renal
vessels and their ability to contract, and especially to dilate, are
affected. This would indicate a corresponding injury of the
cutaneous vessels.
Some nephritic cedemas apparently depend upon the reten-
tion of sodium chlorid in the body.^^^ The normal
individual excretes this salt at about the same rate as it is ingested,
so that the amount in the body remains nearly constant. In
nephritis, on the contrary, the excretion frequently does not follow
the same curve as the ingestion. The French school, especially,
has explained certain cases of nephritic oedema on the basis of a
retention of chlorids in the body. According to this hypothesis
the inability of the kidneys to eliminate sodium chlorid leads to
a retention of this salt in the body, and this retention, in turn,
necessitates an accumulation of water in the tissues in order to
maintain the proper osmotic relations. Attractive as is this con-
ception, it leaves much to be explained, for in many cases of
nephritic oedema there is no evidence of salt retention. ^^^
(Fischer ^'^^ has developed the theory of an increased
hydration capacity of the colloids to explain oedema.
Different colloids vary considerably in their ability to take up
water, a property which depends upon the reaction of the fluid
in which the colloid is immersed and upon the electrolytic content
of this fluid. According to Fischer, oedema is produced when
acids accumulate in the tissues and thus increase the affinity of the
colloids for water, granting, of course, that the supply of the
latter is adequate. The excess of acids represents either an in-
creased metabolic production, or a faulty removal of acids formed
in normal amount. In accordance with this conception oedema is
to be combated by the use of substances which diminish the affinity
of the colloids for water, namely, salts (electrolytes). Fischer
has recommended definite saline solutions and a definite technic
for the employment of these in cases of oedema. — Ed. )
94 THE BASIS OF SYMPTOMS
Other CEdemas. — We know little concerning the dropsies
caused by severe cachexias and by many diseases of the cord and
of the peripheral nerves. Changes in the composition of the
blood probably contribute to the causation of the fonner, while,
in the latter, paralyses of the muscles would interfere with the
movements of the lymph and so tend to produce oedema. Yet in
neither case do these seem to be the sole causes.
Composition of Exudates. — The composition of exudates
varies with their origin.^ "^^ Those due to inflammatory causes
usually contain four per cent, of albumin or over, while those
due to other causes, usually contain between o. i and 0.8 per cent.
The exudates that are poorest in albumin are those caused by
cachexias and by chronic nephritides, a percentage less than o.i
rarely being found except in serious renal diseases, especially
in amyloid disease of the kidney. The percentages of albumin
in exudates of a non-inflammatory character vary so much in the
individual cases that a classification according to this standard
is not possible. (Of considerably greater moment as a diagnostic
standard is the differential count of the white cells found in the
exudate ( cytodiagnosis ). Three typical formulas are described,
according to the variety of cells found in greatest abundance —
first, the lymphocytic, in tuberculous inflammations; second,
the polynuclear leucocytic in non-tuberculous infec-
tions ; and third, the endothelial in transudations. These
formulas appear to be fairly specific for the different types of most
exudates except the ascitic. — Ed.)
Chylous and Chyliform Ascites.^^^ — Exudates into the peri-
toneal cavity, and more rarely those into the pericardial and
pleural cavities, may contain considerable amounts of fat. This
may arise from a fatty degeneration of the cells of the exudate,
with subsequent disintegration of these cells. When the blood
contains large quantities of fat, the latter sometimes passes
through the capillary walls into the exudate. Such exudates into
the peritoneal cavity are called chyliform ascites.
In another group of cases, usually caused by carcinomata, the
abdominal lymphatics rupture and the chyle flows directly into
the peritoneal cavity, producing the so-called true chylous
ascites. The composition of the ascitic fluid then depends
largely upon the character of the food, and when certain fats
are ingested, they may be demonstrated in the ascitic fluid. Dur-
THE CIRCULATION 95
ing life it is often impossible to differentiate these two forms of
ascites.
Pulmonary (Edema. — CEdema of the lungs may result from
the same causes as does oedema of other parts of the body. The
exudation about an inflammatory area corresponds to the inflam-
matory oedema already described (p. 91 ) . On account of the rich
and peculiar blood-supply of the lungs, however, a local oedema
from stasis does not occur. If there be a hindrance to the blood-
flow through one part of the lungs, the blood merely takes another
course. No sharp line can be drawn between local inflammatory
oedema of the lungs and a small pneumonic patch.
Of great interest is the cause of the general pul-
monary oedema that so frequently terminates
cardiac, pulmonary and infectious diseases.
Two hypotheses have been advanced in explanation of this oedema.
The first considers that it is caused by stasis. If, experi-
mentally, the left ventricle of an animal be seriously injured
while the right is left intact, pulmonary oedema frequently de-
velops. The oedema in such instances is evidently caused by
stasis, and we have reason to believe that at least some pulmonary
oedemas of man are similarly produced. This, in all probability,
is the cause of the oedema that sometimes develops after sudden,
severe injury to the left heart, such as may be produced, for
example, by an aortic insufficiency.
In order to produce this oedema experimentally, it is necessary
that the left ventricle should be almost completely paralyzed ; for
if it be only relatively weakened, no oedema of the lungs ensues.^ ^"^
Now the general arterial pressure of patients with pulmonary
oedema, especially when the latter follows nephritis or arterio-
sclerosis, rarely reaches the low level that is experimentally neces-
sary, and in these patients, there is certainly no complete paralysis
of the left ventricle. Sahli, therefore, believes that general pul-
monary oedema results in most instances from changes in the
capillary walls. ^''^^ A number of facts support this view.
First, the oedema is unevenly distributed throughout the lungs;
and secondly, it is often associated with definite inflammatory
processes. Indeed, in heart disease, often no sharp line can be
drawn between the oedematous areas and the pneumonic patches
that are so frequently encountered. Some oedemas of the lungs
are, therefore, almost certainly of an inflammatory nature. Pos-
99 THE BASIS OF SYMPTOMS
sibly future observations on the percentage of albumin in the
oedematous fluid will give some indication as to the nature of
its cause.
Though it must be acknowledged that inflammatory processes
do contribute to the production of certain pulmonary cedemas,
nevertheless it seems to me that the weakness of the left ventricle
is, at least, of equal importance in most cases. The results of ani-
mal experimentation are not directly applicable to man. The
chronic pulmonary stasis that accompanies heart and kidney dis-
eases may induce changes in the walls of the capillaries of the
lung, so that a relatively slight weakness of the left ventricle could
produce cedema, which would not be the case if the vessels were
entirely healthy. Not infrequently, the physician sees patients
in whom a weakening of the left ventricle is followed by an cedema
of the lungs, which disappears with a strengthening of the
ventricle.
LITERATURE
* Knoll : Wiener Sitzungsber., mathem.-naturw. KL, 1899, iii, 5.
*Lewy: Zeitschft. f. klin. Med., xxxi, 321, 520; Frank, Zeitschft. f. Biol., xxxii,
428, and xxxvii, 483.
* Stolnikow : Du Bois' Arch., 1886, 1.
* Cohnheim : AUg. Path., 2nd edit., i, 40 ; v. Frey and Krehl, Du Bois' Arch.,
1890, 31 ; V. Frey, Arch. f. klin. Med., xlvi, 398; Frank, Zeitschft. f, Biol.,
xxxii '^70.
•Hesse: Arch. f. Anat, 1880, 328.
•Ludwig and Thiry: Wiener Sitzungsber., xlix, II, 421.
^ Cf. V. Frey : Arch, f . klin. Med., xlvi, 398 ; Krehl and Romberg, Arch, f . Exp.
Path., XXX, 49.
* Zeitschft. f. klin. Med., xxi, 61; cf. Grossmann, ibid., xxvii, 151.
' Bauer and Bollinger : Festschrift f . Pettenkof er, Munich, 1893.
" See Krehl, in the Nothnagel System (Diseases of the Heart Muscle).
" Die Massenverhaltnisse d. mensch. Herzens, 1884.
" Arch, f . klin. Med., Ixiv, 597.
" Bruns : Miinch. med. Wochenschft, 1909, No. 20.
"Moritz: Arch. f. klin. Med., Ixxvii, 339 (lit.).
" See Dietlen : Arch, f . klin. Med., Ixxxix, 604 ; xcii, 383.
" Kiilbs : Kongr. f . inn. Med., 1906, 430 ; cf. Grober, Arch, f . exp. Path., lix,
424. But see Bruns, l.c.
" See Albrecht : Der Herzmuskel, Part I ; Magnus- Alsleben, Arch, f . exp.
Path., Ivii, 48, 57.
" See Kolle- Wassermann : Handb., 1913 (lit.) ; D. Gerhardt, Die Endokarditis,
1914 (lit.); Lenhartz, Die sept. Erkrankh., in the Nothnagel System;
Norris, Studies in Cardiac Pathology, 191 1 (refers to numerous Ameri-
can studies).
** See Poynton and Payne : Researches on Rheumatism, 1913 ; Rosenow, Jour.
Inf. Dis., xi, 210 (references to previous work) ; Jour. Am. Med. Assn.,
Ix, 1223.
*" See Thorel, in Lubarsch-Ostertag, xiv, 415.
" Citron : Berl. klin. Wochenschft., 1908, No. 48 ; Donath, ibid., 1909, No. 45.
"See V. Jurgensen in the Nothnagel System; Krehl, ibid.; Albrecht, Der
Herzmuskel, 1903, 504; Magnus- Alsleben, l.c.; Thorel, l.c., 423.
THE CIRCULATION ©7
"Lewy: Zeitschft. f. klin. Med., xxxi, 539.
'^Kornfeld, Zeitschft. f. klin. Med., xxix, 91, 344, 450 ; Lewy, ibid., xxxii, 379.
*° Kornfeld : I.e. ; Romberg and Hasenfeld, Arch. f. exp. Path., xxxix, 333.
^'Johanssen and Tigerstedt: Skandinav. Arch. f. Phys., i, 131.
"Arch. f. exp. Path., ix, i.
"See Stewart, Arch, of Int. Med., i, 102.
"Miiller: Die Massenverhaltnisse, etc.
*" Luderitz : Zeitschft. f. klin. Med., xx, 374.
" See D. Gerhardt : Arch, f . exp. Path., xlv, 186.
"^Lenhartz: Munch, med. Wochenschft., 1890, No. 22; Dunbar, Arch. f. klin.
Med., xlix, 271 ; Baumbach, ibid., xlviii, 267.
"See Moritz: Arch, f, klin. Med., Ixvi, 421; D. Gerhardt, Kongr. f. inn.
Med., 1905, 192.
•* For a contrary view, see Strubell, Miinch. med. Wochenschft., 1908, 696.
* See V. Tabora : Deutsch. med. Wochenschft., 1908, No. 48.
** Vierordt, in the Nothnagel System ; Abelmann, Ergeb. d. inn. Med. u. Kin-
derheilk., 1913, xii, 143 (lit.).
" Krehl : Abhand. d. Sachs. Gesellsch. d. Wissensch., math.-physik. Kl., xvii,
No. 5.
** Cf. Brauer : Kongr. f . inn. Med., 1904.
*Lichtheim: Die Storungen d. Lungenkreislaufes, 1876.
^'Hirsch: Arch. f. klin. Med., Ixviii, 328 (lit).
"Hirsch: I.e.
*^ Beck : Arch, f . klin. Med., c, 429.
**Mandl and Selig: Prager. med. Wochenschft, 1907, No. 41; Foure Beau-
lieu, Revue d. 1. tubercul., series 2, vi. •
**See Krehl, in the Nothnagel System; v. Romberg, Herzkrankheiten, 3rd
edit., 430; V. Basch, Die Herzkrankheiten bci Atherosklerose, 1901 ;
Marchand, Atherosklerose, in Eulenburg's Realenzyklopadie, last edit.;
Fischer and Schlayer, Arch. f. klin. Med., xcviii, 164.
* Israel : Volkmann's Vortrage, 1907 ; Krehl, Deutsch. med. Wochenschft,
1905 ; Miinzenmayer, Wiener med. Wochenschft., 1909, Nos. 22 and 23.
*"Med. Klinik, 1913, No. 44 (refers to previous work). See also Macht,
Jour. Am. Med. Assn., 1915, Ixiv, 1489.
**PaI: I.C.; Macht, I.e.
**Lehmacher: Diss. Greifswald, 1908; Pagenstecher, Deutsch. med. Wochen-
schft., 1905, 327.
** Bittorf : Arch. f. klin. Med., Ixxxi ; Ognos, Virch, Arch., cxcviii ; Bruns
and Genner, Deutsch. med. Wochenschft, 1910, No. 37.
"Burke: Arch. f. klin. Med., Ixxi, 189; ApeU, Deutsch. med. Wochenschft,
1905, Nos. 30 and 31.
" Hensen : Arch, f . klin. Med., Ixviii, 479.
"Hochhaus : Deutsch. med. Wochenschft, 1900, No. 44; cf. Israel, Volkmann's
Vortrage, Nos. 449 and 450.
•* See Senator, in the Nothnagel System ; Deutsch. med. Wochenschft., 1903,
No. I ; F. Miiller, Path. Gesellschaft, 1905.
** Arch, f . klin. Med., Ixviii, 74.
" Volkmann's Vortrage, No. 408.
" See Jores : Arch, f . klin. Med., xciv, i.
" Buttermann : Arch, f . klin. Med., Ixxiv, I ; see also v, Bamberger, Volk-
mann's Vortrage, No. 173.
** See Jores : I.e.
"See Hirsch and Beck: Arch. f. klin. Med., Ixix., 503, and Ixxii, 560 (lit) ;
Determann, Die Viskositat d. Blutes, 1910.
^ Gull and Sutton : Medy-Chir. Trans., Iv ; Jores, I.e.
*^A. Loeb: Arch. f. klin. Med., Ixxxv, 348; Israel, I.e.
"Kretschmer: Arch. f. exp. Path., Ivii, 423; Kongr. f. inn. Med., 1910, 731;
Schlayer, Deutsch. med. Wochenschft., 1907, No. 46; A. Fraenkel. Arch,
f. exp. Path., Ix, 405 ; Broking and Trendelenburg, Arch, f . klin. Med.,
ciii, 168; Stewart, jour. Exp. Med., xiv, 377, and xv, 547.
7
98 THE BASIS OF SYMPTOMS
" Tigerstedt and Bergmann : Skandinav. Arch., viii; Bingel and Claus, Arch. f.
klin. Med., v, 412.
"See Volhard: Vortrag im Heidelberger Naturhistor. Verein, 191 1.
" Moritz : Miinch. med. Wochenschft., 1908, No. 14. See also Williamson,
Amer. Jour. Med. Sc, 1915, cxlix, 492.
* Personal communication.
"Hess: Arch. f. klin. Med., xcv, 482 (lit.).
•*W. Miiller: Die Massenverhaltnisse, etc., 217.
** Virch. Arch., cxvi, 432 ; Hasenfeld, Arch. f. klin. Med., Ixxvii, 763.
** Martius : Lubarsch-Ostertag, Ergeb., 1895, 45 ; Aschoff, Path. Gesellschaf t,
1910, 27, 28.
" Romberg and Hasenfeld : Arch, f . exp. Path., xxxix, 333.
"Der Herzmuskel, Part U.
" See Hering : Kongr. f. inn. Med., 1901, 603.
"Krehl: Erkrankungen d. Herzmuskels, no.
"Romberg and Hasenfeld: I.e.
"For a comprehensive consideration of this subject see Albrecht, Der
Herzmuskel, Part H.
"Aschoff and Tawara: Die heutige Lehre v. d. path.-anat. Grundlage d.
Herzschwache, etc., 1906; Lubarsch. Aerztl. Fortbildg., Jan., 191 1.
"Der Herzmuskel (lit.)-
'"Gottlieb: in Gottlieb-Meyer, Exp. Pharmakologie (translated by Halsey) ;
Schmiedeberg, Grundriss d. Pharmakologie; Janeway, Arch. Int. Med.,
1914, xiii, 37 (lit.).
** Sahli : Kongr. f . inn. Med., 1901 ; Lang and Manswetowa, Arch, f . klin.
Med., xciv, 455 (lit.).
*^ Ehrnrooth : Ueber d. plotzlichen Tod durch Herzlahmung, Berlin, IQ04.
"See Tigerstedt: Physiol, d. Kreislaufes, 190; Krehl, Erkrank. d. Herzmus-
kels, 369 (lit.).
** Lawen and Sievers : Zeitschft. f . Chirurgie, xciv, 580.
*♦ Med. Klinik, 1908, No. 14.
"'Jour, of Physiol., xv, 122; Jour, of Exp. Med., vol. i, p. i ; cf. Hirsch and
Spalteholz, Kongr. f. inn. Med., 1907.
*' See Romberg : Herzkrankheiten.
*" Romberg: Arch. f. klin. Med., xlviii, 369, and xlix, 413 (lit); see also
F. Meyer, Arch. f. exp. Path., Ix, 209, for studies in experimental myo-
carditis.
®* Literature under Cardiac Arrh3rthmias.
** See Aschoff and Tawara : Das Reizleitungssystem, etc. ; Monckeberg, Unter-
such. ii. d. Atrioventrikularbiindel, 1908; Berl. klin. Wochenschft., 1909,
No. 2 (lit).
•^Mechanism of the Heart Beat, 1911, 99 (lit).
"^ See Kraus, in v. Mehring's Lehrbuch., 8th edit., 1913 ; Minnich, Das Kropf-
herz, 1904.
•^Hezel: Zeitschft. f. Nervenheilk., iv, 353.
*' Mobius, in the Nothnagel System ; Kraus, Kongr. f . inn. Med., 1906
•* See O. Miiller, Blauel, Schlayer: Beitrage z. klin. Chir., Ixii, 119.
"Krehl: Herzmuskel (lit); F. Meyer, I.e.
*• Welch : Medical News, 1888 ; Pratt, Johns Hopkins Hosp. Bull., Oct, 1904 ;
Kraus, Berl. klin. Wochenschft., 1905 (Festnummer).
•" Romberg : Herzkrankheiten, 2nd edit, 524 ; Hirsch, Arch, f . klin. Med.,
Ixiv, 597; Miinch. med. Wochenschft., 1901, No. 47.
** See Krehl : Herzmuskel, 227 (lit.) ; de la Camp, Zeitschft f. klin. Med., li, i
(lit.).
** Krehl : Miinch. med. Wochenschft., 1906 ; Gibson, The Nervous Affections
of the Heart, 1905 ; studies of Romberg and of Hoffmann in Zeitschft. f.
Nervenheilkunde, xxxviii, 171, 186 (Gesell. deutsch. Nervenarzte, 1909),
*°° Rosenbach : Krankheiten d. Herzens.
^"^ Bollinger : Miinch. med. Wochenschft., 1888, No. 20.
I
THE CIRCULATION 99
*"* Bmswanger : Path. u. Therap. d. Neurasthenic, 1896.
'"" Mechanism of the Heart Beat, io8.
^•"See Ebstein, in Asher-Spiro, Ergeb., Ill, 2, 1904; Brauer, Kongr. f. inn.
Med., 1904, 187.
""D. Gerhardt: Arch. f. exp. Path., xlvii, 250; G. MuUer, Zeitschft. f. klih.
Med., Ivi, 520; Mackenzie, The Study of the Pulse, etc., 1902, Chap. xx.
*°*D. Gerhardt: Arch. f. exp. Path., xxxiv, 402 (Ht.) ; Mackenzie, The Study
of the Pulse, etc., 1902; Aug. Hoffmann, Funktionelle Diagnostik u.
Therap., etc., 1911; Lewis, Mechanism of the Heart Beat, 9 (lit.).
^•^ Diseases of the Heart, 2nd edit., 1914, 212.
^■^ See V. Korosy : Arch, f . klin. Med., ci, 267.
** Dehio : Arch, f . klin. Med., xli, 74.
""Gaskell: Jour, of Phys., iv, 44; Gaskell, in Schafer's Physiology; Engel-
mann, Pfliiger's Arch., Ixv, 535 (Ht.) ; Engelmann, Deutsche Klinik, iv, 215;
Carlson, Amer. Jour. Phys., xii, xv, xvi, xviii.
"^Tawara: Das Reizleitungssystem d. Saugetierherzens, 1906; Monckeberg,
Untersuch, ii. d. Atrioventrikularbundel, 1908; Keith and Flack, Lancet,
1906, 359.
"'Jager: Arch. f. klin. Med., c, i; Magnus- Alsleben, Arch. f. exp. Path.,
Ixiv, 228 ; cf. Hering, Path, (iesellschaft, 1910, 40.
""For the conflicting views on this subject see Rothberger, Thorel, Aschoff,
Monckeberg, Fahr: Path. Gesellschaft., 1910.
"* Hering: I.e.
"* Engelmann: Pfluger's Arch., Ixv, 109, 535; Ixi, 275; lix, 309; Ivi, 149; lii,
357; Arch, f, Phys., 1900, 315; 1902, 103; 1902, suppL, i,
"' See Engelmann : Deutsche Klinik, iv, II, 215 ; Joh, Miiller, Aerztl, Fortbildg.,
Jan., 191 1 ; Nicolai, Arch, f . Physiol., 1910.
"* See Hoffmann : Funktionelle Diagnostik ; Lewis, Mechanism of the Heart
Beat, 186,
"* Arch, f , klin. Med., ci, 402.
"* Herz : Die Herzkrankheiten, 240 ; Godlewski, Presse medicale, Dec. 10,
^ 1914-
For a discussion of the question, see D. Gerhardt : Ergeb. d. inn. Med.,
", 431.
*" See Kochmann : Ztrlbl. f. Phys., 1906, 418.
^ A. Hoffmann : Arch. f. klin. Med., c, 174.
""Brandenburg: Engelmann's Arch., 1903, suppl., 149; Berl. klin. Wochen-
schft., 1903, No. 38.
^See Hamm: Miinch. med. Wochenschft, 1910, No. 49 (lit.).
"•The reader can orient himself in this large field by consulting the literature
in such monographs as Lewis, The Mechanism of the Heart Beat ; Clinical
Electrocardiography ; numerous studies in Heart ; Lectures on the Heart,
191 5 ; Mackenzie, The Study of the Pulse ; Diseases of the Heart, 2nd edit. ;
A. Hoffmann, Funktionelle Diagnostik, 191 1; Die Elektrographie, 1914;
Vaquez, Les arythmies, 191 1.
^ Hering : Deutsch, med. Wochenschft., 1906, No. 6 ; Rothberger and Winter-
berg, Wiener klin. Wochenschft., 1909, No. 24.
^ Theopold : Arch, f . khn. Med., xc, 77.
^ Wenckebach : Engelmann's Arch, 1907.
""Schonberg: Frankfurter Zeitschft. f. Path., ii, 153; Hedinger, ibid,, 1910,
V, 296.
""Mackenzie: Brit. Med. Jour., 1905, i, 585, 702, 759.
'^ See Hering: Deutsch. med. Wochenschft,, 1903, No. 22; Zeitschft. f. exp.
Path., x, 14; Wenckebach, Die Arhythmien d. Herzens, 1903, 106; v.
Tabora, Miinch. med. Wochenschft., 1908, No. 14 (lit.) ; Hering, ibid..
No. 27; Rehberg, Zeitschft. f. klin. Med., Ixviii, 247 (lit.). For a recent
comprehensive monograph on alternation see Gravier, L'Alternance du
coeur, 1914.
100 THE BASIS OF SYMPTOMS
**^ Einthoven : Le telecardiogramme, Arch, internat. d. phys., 1906, iv, 132;
Kraus and Nicolai, Das Elektrokardiogramm, 1910; cf. Hewlett, Arch.
of Int. Med., 1908, ii, 139 ; Aug. Hoffmann, 1. c . See also Windle, Heart,
1910, ii, 95.
"" See H, E. Hering : Path. Gesellschaf t, 1910, 60.
^'^See Magnus-Alsleben : Zeitschft. f. klin. Med., Ixix, 82; Lewis, Mechanism
of the Heart Beat, 108.
^^ Arch. f. klin. Med., cii, 144.
"^ In addition to the literature already cited, see Erlanger, Jour, of Exp. Med.,
vii, 676, and viii, 8; Heineke, v. Hosslin and MiiUer, Arch. f. klin. Med.,
xciii, 459; Herxheimer and Kohl, ibid., xcviii, 330 (lit.).
*" Nicolai and Plesch : Deutsch. med. Wochenschft., 1909, No. 51.
"• Arch. f. klin. Med., c, 178.
"* F. M. Groedel : Zeitschft. f. klin. Med., Ixx, 47 ; Wenckebach, ibid., Ixxi, 402.
**"F. MiiUer: Miinch. med. Wochenschft, 1906, No. 17; Pawinski, Zeitschft.
f. klin. Med., Ixiv, 70 (lit.).
**^Brauer: Kongr. f. inn. Med., 1904, 187; Thayer and MacCallum, Amer.
Jour. Med. Sc, cxxxiii, 254.
^■"In Schmidt- Luthj e : Klin. Diagnostik, 1910, 248; see also Hochsinger, in
Pfaundler and Schlossman, Dis. of Children, iii; Arch. f. Kinderheilk.,
1913, Ix-lxi, 2,77', Wiener med. Wochenschft., Ixiii, 1538, 1613.
*** See Romanoff : Arch, f . exp. Path., Ixiv, 183 ; Bittorf and Forschbach, Zeit-
schft. f. klin. Med., Ixx, 474; Siebeck, Arch. f. khn. Med., c, 204.
***Huchard: Maladies du coeur, etc.; Neusser, Angina Pectoris, Ausgewahlte
Kapitel, No. 2 ; Osier, The Lumleian Lectures on Angina Pectoris, Lancet,
1910.
^^'Erb: Miinch. med. Wochenschft., 1904, 905; ibid., 1910, Nos. 21, 22 and
47 (lit).
^** For example, see Fischer : Arch, f . klin. Med., cix, 469 ; Orphuls, Arch.
Int. Med., ix, 156 (lit.).
^■^ Gefasskrisen, 1905; Med. Klinik, 1913, No. 44 (previous work cited).
^** The editor has made free use in the following editorial note of material
contained in Norris, Blood-Pressure, 1914 (lit.).
**• Warfield: Jour. Amer. Med. Assn., Ixi, 1254 (lit.) ; Amer. Jour. Med. Sci.,
cxlviii, 880.
™ Stone : Jour. Amer. Med. Assn., Ixi, 1256.
^Michael: Amer. Jour. Dis. Child., i, 272.
*" See Carroll: Assoc. Amer. Physicians, 1912, xxvii, 8; Weysel and Lutz,
Am. Jour. Phys., xxxii, 330 (lit.).
""Schneider and Hedblom: Am. Jour. Phys., xxiii, 90 (lit); Gardiner and
Hoagland, Trans. Amer. Climat. Assn., 1905; Douglas et al., Philosoph.
Trans., London (1913), B. 203, 185.
^^ See Norris: /. c, chap, xiii (lit).
""Med. Klinik, 1913, No. 44.
"•See Janeway: Arch. Int Med., 1914, xiii, 37 (lit).
"' Romberg, Passler, Bruhns, Miiller : Arch, f . klin. Med., Ixiv, 652 ; Passler
and Roily, ibid., Ixxvii, 96; Romberg, Berl. klin. Wochenschft., 1905,
No. SI.
^■"v. Steyskal: Zeitschft. f. klin. Med., xliv, 367, and Ii, 129.
"* Heineke : Arch, f . klin. Med., Ixix, 429.
^""Wiesel: Prag. Zeitschft. f. Heilkunde, 1905 and 1906; Ortner, ibid., 1905;
Wiesel. Wiener klin. Wochenschft., 1906, No. 24.
*** See Romberg : Herzkrankheiten ; Krehl, Erkrank. d. Herzmuskels.
*** Auer and Robinson : Jour, of Exp. Med., xviii, 450.
"* Amer. Jour. Phys., xxvii, 167 (lit.) ; Lancet, August, 1913, 727 (17th Inter-
nat. Med. Congr.) ; Berl. klin. Wochenschft., 1913, 1938. See also Mori-
son and Hooker, Am. Jour. Phys., 1915, xxxvii, 86.
*" Blood-Pressure in Surgery, 1903.
*** Anoci- Association, 1914 (lit).
THE CIRCULATION 101
** Romberg: Kongr. f. inn. Med., 1904, 60; Otfried Miiller, Deutsch. med.
Wochenschft., 1906, Nos. 38 and 39.
*" Sahli : Diagnostic Methods.
^^ Senator, in the Nothnagel System ; Strauss, Die chron. Nierenentziindungen,
etc., 1902.
^" Zeitschft. f. klin. Med., xxi, 475.
"° Cohnheim and Lichtheim: Virchow's Arch., Ixix, 106; Magnus, Arch. f. exp.
Path., xlii, 250.
"^ Heineke and Meyerstein : Arch, f . klin. Med., xc, loi ; Schlayer, Hedinger
and Takayasu, ibid., xci, 59.
^'^Verhandl. d. Kongr. f. inn. Med., 1910 (Magnus-Levy, Widal, Strauss);
Schlayer and Hedinger, 1. c. (lit.) ; Heineke and Meyerstein, 1. c. (lit.).
"^ See Blooker, Arch. f. kUn. Med., xcvi, 80.
"* CEdema and Nephritis, 2nd edit., 191 5.
"" Hoffmann : Arch. f. klin. Med., xliv, 413 (lit.).
"' See Gandin : Ergeb. d. inn. Med. u. Kinderheilk., 1913, xii.
*" Cohnheim and Welch : Virch. Arch., Ixxii, 375.
"* Sahli : Zeitschft. f . klin. Med., xiii, 482 ; Arch, f , exp, Path., xix, 433.
CHAPTER II
THE BLOOD
General Considerations. — The pathology of the blood* is
intimately associated with that of every individual organ in
the body, for it is the connecting link between all of them, receiv-
ing material from and giving material to each. Its constitution
depends, therefore, to a great extent upon the functional condition
of the different organs. It contains a great variety of sub-
stances; yet the rapidity of the blood-current, the minute quan-
tities of many of these present, and the rapid excretion of those
which are present in excess allow the blood to maintain a fairly
constant composition.
It is incorrect, therefore, to designate any particular tissue
as the blood-forming organ. Every tissue in the body furnishes
its contribution to the blood, and when an organ is spoken of as
a blood-forming organ it is usually implied that it gives
to the blood some of its more striking elements, the blood-
corpuscles.
Obviously then, the composition of the blood will change
whenever there are pathological changes in the activity of any
organ that furnishes metabolic products to the circulation.^
Viewed from this basis, there is a great number of blood diseases,
among them diabetes and the majority of hepatic and renal dis-
orders. Clinically, however, it is customary to speak of dis-
eases of the blood only when the changes in the blood dom-
inate the pathological picture, or when the cause of the blood
changes is unknown. As our knowledge of these conditions
increases, we shall probably find that the number of cases in which
the blood changes are really primary, the so-called diseases of the
blood, is exceedingly small, if, indeed, all such cases are not
secondary to disease elsewhere.^
Changes in the blood-cells and in the haemoglobin are recog-
nized with comparative ease and for this reason are better known
than are alterations in the composition of the plasma.
Anemia
Although the term anaemia is used to designate those con-
ditions in which the haemoglobin or the red blood-corpuscles, or
102
THE BLOOD 103
both, are reduced, it should not be assumed that these are the
only changes of consequence in anaemic blood. Alterations of
perhaps equal importance take place in other constituents, and
a proper understanding of anaemia will be possible only when we
shall have become acquainted with all these various changes. For
example, the integrity of the red corpuscles is intimately dependent
upon the molecular concentration of the plasma;* if they be
placed in solutions which contain either too large or too small
a quantity of salts they become either shrunken or swollen, and
in either case they may lose their haemoglobin. The proteids of
the plasma also seem to have some influence upon the property
of the red cells to retain their haemoglobin; and the presence of
certain poisons in the blood will, undoubtedly, cause the escape
of the haemoglobin from the stromata of the corpuscles.
Anaemia from Hemorrhage. — Anaemia in its simplest form
is due to an acute hemorrhage. If the loss of blood exceed a
certain limit — which is about fifty per cent, of the total quantity —
the amount left in the vessels is insufficient for the maintenance of
the circulation, and the patient dies with all the symptoms of acute
asphyxia, owing to the insufficient supply of blood to the tissues
and especially to certain parts of the brain. This subject of acute
asphyxia will be discussed in the chapter on respiration.
If the hemorrhage does not exceed this limit, the fluid portion
of the blood lost is rapidly replaced by fluids from the tissues and
food. The proteids and the corpuscles are replaced more grad-
ua,lly by an increased functional activity on the part of the tissues
which furnish them; and finally, after weeks, or perhaps months,
the blood regains its normal composition. During the first few
hours after a hemorrhage, therefore, the blood as a whole is
reduced in quantity. Then follows a dilution of that present with
lymph; and after this there comes the regeneration of the red
corpuscles. The newly-formed corpuscles are often smaller than
normal, but some may be very large and a few of them may con-
tain nuclei. For a considerable period after the hemorrhage,
the individual corpuscles contain less haemoglobin than do normal
ones, for this pigment is regenerated slowly as compared with the
erythrocytes,^ and for some time, therefore, the proportion be-
tween the percentage of haemoglobin and the number of red cor-
puscles remains less than the normal. The leucocytes in the
peripheral blood are usually increased in number for a short
104 THE BASIS OF SYMPTOMS
period after the hemorrhage. The rapidity with which the blood
is regenerated depends upon the amount of blood lost, upon the
general nutrition of the patient and upon the treatment which
he receives.
General Considerations Relative to the Chronic Anaemias. —
In the chronic anaemias the blood does not return so quickly
to the normal, because the cause of the anaemia remains opera-
tive. This cause may injure either the blood-forming organs
or the blood-corpuscles already free in the circulation. It is well
known that the blood of one animal may destroy the corpuscles of
another, and we must admit the possibiHty that similar toxic
substances may develop in the body under pathological con-
ditions. Indeed, there is evidence that this does occur in certain
diseases. Various poisons such as chloroform and potas-
sium chlorate exert a similar injurious action upon the red blood-
cells. It is also possible that an anaemia may be
produced by an acceleration of the normal de-
struction of the red blood-cells, which becomes so
rapid that the regenerative processes cannot keep pace with it.
Practically the same condition is produced when repeated,
small hemorrhages take place, for here again the loss
of blood may be so great that the normal regenerative processes
cannot supply the deficiency. This is illustrated by the anaemia
of miners, due to the ankylostoma duodenale.
On the other hand, the anaemia may arise, not from an ex-
cessive loss or destruction, but from an insufficient for-
mation of red blood-corpuscles, and it is often ex-
tremely difficult in the individual case to determine which of the
two is primary. An increase in the amount of iron de-
posited in the liver would indicate an abnormal destruc-
tion of red corpuscles.^ This organ normally contains a small
amount of iron, but in anaemia the amount is often greatly in-
creased ; and not infrequently the spleen, kidneys and bone-marrow
also show abnormal deposits of iron salts. In the anaemias that
are caused not by destruction but by losses of blood through
hemorrhage, such deposits do not occur; and, indeed, the iron
normally present in the tissues may be reduced, for it is utilized
in the formation of new corpuscles. An increased excretion of
pigments derived from the haemoglobin, viz., bilirubin and uro-
THE BLOOD 105
bilin, is also to a certain extent indicative of an increased destruc-
tion of the erythrocytes.
The red blood-corpuscles themselves frequently
undergo changes in anaemia. In the first place, they may be of
irregular shape, so that hardly any two look alike (poikilo-
cytosis). Then they may vary greatly in size (anisocy-
tosis), some being extremely small, the so-called micro-
c y t e s , while others are extremely large, the so-called macro-
c y t e s . Finally, they may show clear spaces in their protoplasm
(endog'lobular degenerations). All of these changes
are of a degenerative character.
Peculiarities of the red cells in the stained preparation are of
more uncertain significance. The normal mature erythrocyte is
acidophile, the stain being even, though somewhat more intense
toward the periphery. Youthful types, on the contrary, take
both the basic and the acid stains (polychromatophilia).^
Two facts speak distinctly for the view that polychromatophilia
is an evidence of immaturity. In the first place, this anomalous
staining is shown by cells still in the bone-marrow, which are
definitely immature because they contain nuclei; and further, in
the circulating blood, polychromatic erythrocytes are often seen
with nuclei in active mitosis, Polychromatophilia disappears as
the cell ripens, though it may return coincidently with the recur-
rence of certain injurious influences. On the other hand, this
staining peculiarity is seen also in cells undergoing disintegration
outside the blood-vessels, in which case the multi-tints are diffuse,
or collected where the nuclear remnants appear to be, or scattered
as granules through the stroma.^ The latter, known as g r a n u -
lar basophilia, is particularly well marked in the anaemia
of chronic lead poisoning. The old strife as to whether poly-
chromatophilia is a sign of regeneration or of degeneration seems
to have given way to the view that it may indicate either. In
the circulating blood, however, the phenomenon is generally an
index of immaturity.
Another evidence of regenerative processes is the presence of
nucleated red cells in the circulation. Normally, nuclea-
tion is restricted to the tissues in which erythrocytes are produced,
viz., the red marrow of the bones, and during fetal Hfe, the liver
and spleen,^ The red cells that pass into the blood, normally,
have already lost their nuclei. In conditions of active regenera-
106 THE BASIS OF SYMPTOMS
tion, however, such as are observed after severe hemorrhage,
nucleated red blood-corpuscles appear in the blood, released in all
probability before maturity. In the more severe grades of
anaemia, we encounter, in addition to the nucleated cells of nor-
mal size (normoblasts), abnormally large examples ( m e g a -
loblasts, gigantoblasts). The presence of the latter is
considered by some to indicate that regeneration has assumed a
pathological trend; in other words, that there has been a return
to the embryonic state. For reasons which will appear in the
discussion of pernicious anaemia, we prefer to regard these cells
merely as the products of an extremely stormy regeneration of
red corpuscles, and not as pathognomonic of pernicious anaemia
alone. If the demand for new cells is especially urgent, the nor-
mal resources prove inadequate and the blood-forming tissues
active in fetal life are again called upon. To this extent only
is the megaloblast a specific type or an evolutional product of the
embryonal red cells. ^°
The red bone-marrow is increased in quantity in many
forms of anaemia. Normally, this tissue is limited to the flat
bones and to the extremities of the long bones. If, however, the
necessity arises for a greater production of red cells, the red
marrow spreads over many bones, the change being in the nature
of a compensatory process.^ ^ We are among those who believe
that all increases of red marrow are of this nature, and that there
is no necessity for making a division between normal and patho-
logical red marrow.
Chlorosis. — Certain forms of chronic anaemia are sufficiently
well defined to be distinguished clinically. Of these, we shall
first consider chlorosis.^ ^ This occurs usually, perhaps exclu-
sively,^^ in girls at about the time of puberty. Its cause is
not well understood. Poor hygienic conditions are
certainly not the sole determining factor, for the disease occurs
with about equal frequency among the upper as well as the lower
classes. Some have ascribed chlorosis to disturbances of
the nervous system, others to diseases of the female
genitalia, but to both, it seems to me, without sufficient evi-
dence. As the only predisposing factors are those of age and
sex, it is not impossible that the ovaries play a role, especially
in susceptible individuals (v. Noorden).
The color of the skin in chlorosis usually varies from a slight
THE BLOOD 107
pallor to the typical, pale, greenish tint. The face, however,
may be of an unusually brilliant color (chlorosis rubra).
At times the patient is emaciated, though more frequently the fat
is well preserved. Nervous manifestations are usually prominent.
The blood always shows a diminution in the quantity of
haemoglobin to the unit-volume, and the individual red cor-
puscles are usually paler than normal. Many of them are
of small size, and some are deformed. In severe cases, nucleated
red corpuscles may be present, either of normal size or very
exceptionally of the megaloblastic type. In some cases, the num-
ber of red corpuscles is normal,^* but usually it is moderately
diminished. Limbeck ^^ states that of two hundred and seventy-
nine cases of chlorosis, only one hundred and five, or thirty-seven
per cent., showed no diminution in the number of the red cor-
puscles.
That the amount of haemoglobin is diminished has been
demonstrated by colorimetric, spectrophotometric and chemical
methods. The dried blood may show 0.03 i>er cent, of iron in-
stead of the normal 0.06 per cent. Nevertheless, there appear
to be mild cases of chlorosis showing no blood changes of signifi-
cance, despite the well-marked clinical picture, and in which iron
effects a complete cure.^® This would indicate that the blood
alterations in chlorosis are merely symptomatic.
As in other anaemias, the volume of the red cells is also
changed. The leucocytes do not vary greatly from the nor-
mal. The percentage of water in the serum is approximately
normal in the milder cases, whereas in the more severe ones it
is increased. The total quantity of blood in the body seems
considerable. Of other changes in the serum we know little.
From the fact that patients with chlorosis show a tendency to the
formation of venous thrombi, it has been assumed that their
blood contains larger amounts of fibrin ferment — an assumption,
however, which is incorrect. Not infrequently there is a retention
of water in the body of chlorotic patients, due possibly to an
increase in the total blood mass.^"^
Autopsies upon patients with chlorosis are few in number, and
these have shown surprisingly little that was abnormal.^® No
degenerative changes were present in the liver, heart or kidneys,
and no changes in the bone-marrow of the tibiae were found.
Virchow observed a general hypoplasia of the heart and blood-
108 THE BASIS OF SYMPTOMS
vessels, and especially a narrowing of the aorta, and these have
been assumed to be causative agents in the production of the
disease. This view, however, does not appear very reasonable,
for it is difficult to understand how chlorosis could heal as com-
pletely as it does if this were its cause ; and, furthermore, stenosis
of the aorta is known to produce quite a different set of symptoms.
Although chlorosis heals spontaneously in practically every
case, the healing is greatly accelerated by the
administration of iron.^® Indeed, proper food seems to
be of secondary importance, for chlorosis may develop in indi-
viduals who have lived in the best of surrotmdings. The bril-
liant results achieved by the administration of iron are in them-
selves almost characteristic of this type of anaemia, for in no
other form do we see such striking effects, save possibly in those
anaemias which result from hemorrhages.
The value of the administration of iron in chlorosis lends
support to the theory that the cause of the disease is an inadequate
or improper formation of the red blood-corpuscles. We possess
no evidence favoring the opposite possibility, zriz., that there is
a pathological destruction of the red cells, for degenerative
changes in the red corpuscles are not marked, jaundice does not
occur, and the quantity of pigments in the urine and faeces is
less than normal. These facts cannot be regarded as proof that
there is no pathological destruction of red cells in chlorosis, but
they certainly render it very improbable. Unfortunately, we
possess no evidence on the more decisive question as to whether
or not there is an excessive deposit of iron pigment in the liver.
Nevertheless, from the facts in our possession, we may assume
that the underlying cause of chlorosis is an insuf-
ficient formation of red blood-corpuscles.
The exact manner in which iron exerts a favorable effect upon
chlorosis still remains unsettled. The patients suffering from
this disease ordinarily show no marked digestive disturbances,^
although some, at least, seem to absorb fats poorly. There is
likewise no conclusive evidence that their absorption of iron from
the intestinal tract is less than normal, though the data upon this
point are not very accurate. It is difficult, therefore, to under-
stand why the iron salts in the food, which are sufficient for all
ordinary needs, are insufficient in chlorosis. It seems to me most
probable that iron cures chlorosis by acting as a stimulant to the
THE BLOOD 109
blood-forming organs, very much as does arsenic in certain other
forms of anaemia. ^^ (Indeed, it has been shown that iron and
arsenic in combination are more efficacious in chlorosis than
is iron alone. — Ed.)
Secondary Anaemias. — The remaining forms of anaemia ^^
are, for the most part, merely symptomatic of other pathological
conditions. When their etiology is known, they are termed sec-
ondary anaemias, in contradistinction to the so-called primary
anaemias, the causes of which are imknown. This classification
into primary and secondary anaemias is serviceable, but hardly
final, for it seems certain that as we become better acquainted with
the causation of anaemias the number of cases assigned to the
primary group will progressively diminish, and the number classi-
fied as secondary anaemias will correspondingly increase. So
closely may the blood pictures of the two types approach one
another that it is often extremely difficult, or indeed impossible,
to distinguish them. (Others, however, among them Naegeli,
are strongly of the opinion that the two are readily distinguish-
able.— Ed. )
A great variety of causes may give rise to mild
and moderately severe forms of secondary anae-
mia. Of these, we may first mention repeated hemor-
rhages, such as may occur from ulcer or carcinoma of the
stomach, from intestinal ulcerations, from hemorrhoids, from
uterine myomata, etc. Secondary anaemias may result, further-
more, from chronic poisoning, as by lead or mercury,
from gastro-intestinal disease, from malignant
tumors, from infections such as tuberculosis, syphilis
and malaria, and from chronic diseases of the liver,
kidneys, heart or nervous system. It should be re-
membered, however, that none of these diseases necessarily gives
rise to an anaemia, which is the result probably of some special
moment.
It is still uncertain in what manner many of these diseases
produce the anaemia. Infectious processes frequently injure the
red blood-corpuscles directly, as may be inferred from the de-
generation which they produce in these cells. Yet the destruction
of a few corpuscles, more or less, would hardly give rise to an
anaemia, for the loss of a considerable number would immediately
be balanced by regenerative processes. In malaria, the plasmodia
110 THE BASIS OF SYMPTOMS
certainly destroy the corpuscles in large numbers, and this seems
to be the direct cause of the malarial cachexia. In nephritis, the
reduction in the number of red cells per unit of volume may be
due in part to a dilution of the blood, and in part, as in hemor-
rhagic nephritis, to repeated losses of blood in the urine. An
injury to the blood-forming tissues is a possible explanation that
must not be lost sight of.
Insufficient nourishment will give rise to an anae-
mia in some cases. An absolute fast, even if continued up to
death, merely causes a reduction in the total quantity of blood
with no diminution in the haemoglobin or red corpuscles to the
unit of volume. ^^ If, after such a fast, food and liquids be taken
in sufficient quantity, water is rapidly added to the blood, with
a resulting reduction in the percentage of haemoglobin and in
the number of red cells per unit- volume. The prolonged use of
food, deficient in some important constituent,
will also cause an anaemia. For example, a continuous milk diet
will have this efifect, on account of the small quantity of iron in
the milk. Especially injurious is the combination of improper
food and continued hard work. Other favoring factors
are care and worry, poor light, poor air, lack of sleep, etc.
Patients with anaemia from such causes exhibit a striking im-
provement if their surroundings are bettered, and although their
absorption of iron may be less than normal, yet the simple
administration of salts of this metal, without a change in their
surroundings, has comparatively little effect upon their anaemia.^*
On the other hand, mild and moderately severe secondary
anaemias of this character may occur in patients who live under
the best of hygienic surroundings, in which case we are unable
to form any conception as to their cause. Many such individuals
seem to feel perfectly well, so that one might almost question
whether their anaemia was physiological or pathological. Others,
however, suffer from the same symptoms as do most anaemic
patients, these symptoms being especially marked upon exertion.
The blood picture in the secondary anaemias
may show considerable variations. In some patients the changes
are hardly demonstrable, while in others they may be of the most
extreme grade.
Certain possible fallacies in the methods of blood examination
should be noted. In the first place, the ordinary examination
THE BLOOD 111
of the blood may show nothing abnormal, and yet there may be
a reduction or an increase in the total quantity of blood in the
body. On the other hand, it is possible that the blood may be
of different constitution in different parts of the body, so that
the cutaneous capillaries contain relatively few or relatively many
corpuscles.^'' Such possibilities of error cannot be easily elim-
inated in our clinical methods of blood examination.
In secondary anaemia the red cells frequently vary in
staining properties (polychromatophilia) and in shape (poikilo-
cytosis). The dimensions of the cells may vary more widely
than in health, so that we find microcytes and occasionally megalo-
cytes. Signs of rapid regeneration are also frequently met with,
especially nucleated red cells of normal size (normoblasts), and,
very rarely, nucleated red cells of large size (megaloblasts).
All these changes are dependent rather upon the severity of the
anaemia than upon its cause. As a rule, the white cells are
normal unless some special cause for a leucocytosis is present.
Changes in the blood-serum will be considered in another place.
Pernicious Anaemia. — In the third form of anaemia, the
so-called pernicious form, the changes suffered by the red
cells reach their maximum. Their number is greatly reduced ;
and Quincke has reported a case in which only one hundred and
forty-three thousand per cubic millimetre were counted. The
haemoglobin is also markedly diminished, although, as a
rule, it is relatively less reduced than is the number of the red
corpuscles; in other words, the average red corpuscle contains
as much coloring matter as the normal cell, and often indeed more
(characteristic high color-index). ^^ Poikilocy-
tosis becomes extreme. At times, only a small proportion of
the red cells present a normal appearance, the majority showing
some one or other of the many changes which have already been
described. Nucleated red cells are especially numerous —
the most characteristic and often the predominating form being
the megaloblast. The nuclei of these cells are often found
in the process of division. The leucocytes are only rarely
increased ; usually their number is normal or is diminished. ( These
changes are subject to great variations depending upon the activity
or exhaustion of the bone-marrow. — Ed.)
As a rule, in pernicious anaemia, theblood serum is not
particularly deficient in solids. Grawitz^^ found, however, that
112 THE BASIS OF SYMPTOMS
such a deficit is apt to be marked in those cases of severe ansemia
which are due to malignant tumors or to chronic infectious dis-
eases. Indeed, he has shown experimentally that pieces of car-
cinoma introduced into the circulation of animals will attract
lymph and thereby cause a dilution of the blood-plasma. The
weight of the total solids of the blood is always markedly dimin-
ished^® owing to the small number of corpuscles. The total
amount of blood in the body also appears to be less than normal,
if we may judge from the impressions received at the bedside and
at autopsy.
The effects of a very severe ansemia upon the
patient are often most striking. His brain and muscles are easily
fatigued, he suffers from shortness of breath and from fainting
spells, and gastric secretion is diminished or entirely absent.
There is often a great tendency to bleeding, especially into the
skin and retinae. Fatty degeneration of various organs is the
rule, being especially marked in the liver, the kidneys and above
all in the heart-muscle. Not infrequently, fever is present, due
possibly to substances liberated from the disintegrated red blood-
c»rpuscles, though as to this explanation there is still some
uncertainty.
Very remarkable changes are found in the central nervous
system in pernicious anaemia.^ The most frequent anatomical
lesion is degeneration of the posterior columns of the spinal cord,
though the lateral columns and the gray matter may also be dis-
eased. The cause of these changes is still uncertain. Some be-
lieve that they are caused by hemorrhages, others that they are
due independently to toxic influences.
The pernicious form of ansemia must be re-
garded merely as a symptom-complex which may
be caused by a variety of pathological processes.
For a certain group of cases no cause has yet been
found, ^^^ and to these is given the name of essen-
tial pernicious ansemia, or the Biermer- Addi son
type of ansemia. ^^ Such cases appear to be especially fre-
quent in certain localities, e.g., Switzerland.
The blood-picture which we have described was at one time
regarded as characteristic of this essential pernicious ansemia of
tmknown causation; yet time has shown that the same
blood-findings may be present in anaemias of
THE BLOOD 113
known origin.^^ There has been a continual en-
deavor on the part of certain investigators to
differentiate these two forms of pernicious
anaemia, and special emphasis has been laid upon the pres-
ence of megaloblasts as favoring the diagnosis of the essential per-
nicious form. Yet megaloblasts have also been found in the
secondary form of pernicious anaemia. Among the diseases
which have given rise to a pernicious type of
anaemia are syphilis, carcinoma of the stomach, gastric ulcer,
ulcerating carcinoma of the uterus, hepatic affections and diseases
of the bone-marrow. Hunter has stated that the condition may
be produced by a chronic intoxication from oral sepsis, yet this
view has not received general acceptance. It has also been
asserted that pernicious anaemia is caused by toxins of intestinal
origin. Atrophy of the gastro-intestinal mucous membrane is
frequently present in pernicious anaemia, but we know that it may
also occur without causing the disease. Some believe that re-
peated small hemorrhages may be a causative factor, although
this is denied by others. It is universally agreed, however, that
at least two forms of intestinal parasites, bothriocephalus latus
and ankylostoma duodenale, may produce a pernicious type of
anaemia. From these numerous observations it has
been proved that it is impossible to draw any
sharp distinguishing line between those anaemias
of a pernicious type that are due to known causes,
and those that appear to be primary.
Our views on pernicious anaemia will hardly
meet with general approval. That the term "per-
nicious" is applicable only to the essential Biermer type and to
bothriocephalus anaemia is universally agreed. But no less
authoritative a haematologist than Naegeli denies that the anaemia
of gastric carcinoma and of ankylostomiasis is of this type. The
effort is constant to find in the blood changes
that will distinguish the pernicious from the
non-pernicious forms. The presence of megalo-
blasts was at first regarded as a distinctive criterion, while
now the high color-index is emphasized. According to
Ni£geli, an index over one does not occur in cancer of the
stomach ; in this, however, Pappenheim does not concur. In our
opinion, a high index is merely a sign of great regeneration,
8
114 THE BASIS OF SYMPTOMS
such as occurs in embryonic blood.^^ Too great importance,
therefore, must not be attached to details of this kind, and espe-
cially must the blood changes not be over-emphasized at the
expense of changes in other organs. Only a better understand-
ing of the etiological factors will enable us to write the last word
on these anaemias.
In what manner the various causes affect the
blood is not always clear. With the possible exception
of the ankylostoma duodenale, it seems improbable that losses
of blood play any great role. In the case of malignant
tumors, hsemolytic toxins are possibly responsible for the
blood condition. It seems very probable also that this is the
case in the anaemia produced by the bothriocephalus latus.^^ Re-
cent studies have attached great importance to the action of a
lipoid substance in the causation of bothriocephalus anaemia
and of haemolytic conditions generally .^^ Apparently, many in-
dividuals harboring intestinal parasites become immunized against
their poisons, a supposition which would explain the fact that
a man may have the parasites in his intestines without manifesting
any symptoms, and that periods of improvement and relapse may
alternate.
Theprognosisof the pernicious form of anaemia depends
mainly upon its cause. In the primary, essential form, the out-
come is usually fatal; in the secondary forms, recovery may
take place if the cause be discovered and removed, and if the
process be not already too far advanced. This is especially true
of those cases due to intestinal parasites.
In pernicious anaemia there is unquestion-
ably an increased destruction of the red blood-
corpuscles, as is proved especially by the abnormal deposits
of iron salts in the liver and in other organs. This destruction,
further, is probably of toxic origin, for the anaemias caused by
losses of blood or of serum, even though most severe, are unac-
companied by such deposits of iron. The pigmentation so fre-
quently found in the spleen, the bone-marrow, the kidneys and
the liver, the not infrequent jaundice,^^ the increase in the coloring
matter of the urine, and the recently reported haemoglobinaemia
likewise support the idea that in pernicious anaemia there is an
unusual destruction of the red blood-corpuscles.
On the other hand, we have evidence that there is also
THE BLOOD 115
an increased regeneration of erythrocytes, for
the red bone-marrow spreads to parts of the bones from which it is
normally absent, and in this red marrow are found erythrocytes
of various kinds, but more particularly the large nucleated variety
known as megaloblasts. By the escape of these cells into the
blood, one of the most characteristic features of pernicious
ansemia is produced. And, furthermore, there is a return to
embryonic conditions in that certain organs, particularly the liver
and spleen, once more take on a blood-building function, evi-
denced by the myeloid metaplasia.
In pernicious anaemia, therefore, there is both an increased
destruction and an increased regeneration of red corpuscles, but
we do not know at present which process is primarily at fault.
Perhaps the destruction of the erythrocytes is so intense that even
the most marked regeneration does not replace the cells destroyed ;
or perhaps the new cells are so imperfect that they cannot resist
the normal wear and tear in the body, and consequently disinte-
grate with abnormal ease. Some hold that the disease
consists essentially in a return to the embryonal
type of blood formation. Yet there is no reason to
consider that the blood and marrow changes are other than would
result from an excessively active regeneration of erythrocytes,
with the escape of immature corpuscles into the circulating blood.
We do, however, possess direct evidence that the red corpuscles of
pernicious ansemia are more vulnerable to injury than the normal
corpuscles, and that they may be destroyed with comparative ease.
This seems to be especially true of the malignant ansemia of
syphilis. (A considerable literature ^^ has appeared in the past
few years relative to the removal of the spleen in cases
of pernicious ansemia. The indication for the opera-
tion cannot be drawn along the same lines as that for haemolytic
jaundice, because pernicious ansemia, as a rule, exhibits no
fragility of the red blood-cells, but rather an increased resistance
to hypotonic salt solutions (Tiirk). Observers are by no means
in accord as to the cases appropriate for operation, nor as to the
evidence of improvement following splenectomy. — Ed.)
In addition to the Biermer type of pernicious ansemia, there
is one in which the regeneration of erythrocytes seems to be
particularly at fault. This is the so-called aplastic anaemia."
The blood-picture is not especially characteristic, aside from the
116 THE BASIS OF SYMPTOMS
complete absence of all forms of nucleated red corpuscles. The
prognosis of the aplastic anaemias is no less grave than that in the
usual form. At autopsy, the bone-marrow appears excessively
poor in erythroblasts and sometimes also in leucocytes. Infec-
tions of different sorts, malaria for example, are possible causa-
tive factors in some of these ansemias.^^ Animals subjected to
repeated venesection, and at the same time receiving insufficient
food, may show a similar bone-marrow.***
It must be emphasized, incidentally, that in severe anae-
mias especially, the blood-picture is by no means
an infallible index of conditions in the blood-
building organs. Megaloblast formation in the bone-
marrow may be marked without the appearance of a single one
of these cells in the circulation. A certain reserve, therefore, is
indicated in the diagnosis of aplastic anaemia.
Haemoglobinaemia. — Thus far we have considered the haemo-
globin only as it constitutes a part of the red blood-corpuscles.
If it escapes from the latter into the plasma, the condition is
known as haemoglobinaemia.'*^ Haemoglobin which has become
free in the plasma is quickly removed, principally by the liver,
and, to a lesser extent, by the spleen and the bone-marrow. If
these organs fail to remove it completely, it is excreted in the
urine, giving rise to haemoglobinuria. According to
Ponfick, the latter is produced when about one-sixtieth of the
total haemoglobin of the blood is set free from the cells. The
stromata of the cells which have lost their haemoglobin are de-
posited in the spleen, and cause a swelling of that organ. Since
the liver manufactures bile-pigments from haemoglobin, the bile
becomes unusually rich in coloring matter and the faeces become
darker. The haemoglobin which is removed by the liver and
kidneys is naturally lost to the body, but even that which remains
dissolved in the plasma is in part rendered useless as an oxygen-
carrier by being transformed into methaemoglobin, a compound
isomeric with oxyhaemoglobin, but differing from it, in that it is
unable to give up its oxygen in the tissues.
Such a passage of the haemoglobin from the corpuscles into
the plasma, or, as it is called, haemo lysis, may be brought
about by several causes. The osmotic tension of
the red cells may be so increased that they become
unable to retain their haemoglobin; or, on the other hand, a
THE BLOOD 117
lowering of the osmotic pressure of the plasma
may bring about the same result. The latter seems to be of
comparatively little importance, for normal red cells are resistant
to considerable changes in the osmotic pressure of the plasma,
and large amounts of water may be infi^sed into the circulation
without causing a laking of the blood. Of far greater importance
as a cause of laking are chemical changes in the cor-
puscular stromata and envelopes, v^hich are com-
posed largely of fat-like substances.*^
We have said that the haemoglobin free in the
plasma may become converted in part into met-
hsemoglobirt. Certain poisons possess the property of effect-
ing this conversion of the haemoglobin directly within the red
cells. If the injury to these cells be not too severe, it is possible
that the methaemoglobin so produced may be transformed again
into oxyhaemoglobin. If the corpuscles are more seriously dam-
aged, however, they disintegrate and their coloring-matter passes
into solution.
Three different processes may, therefore, give rise to hsemo-
globinaemia: first, osmotic changes in the plasma; secondly, a
primary injury to the red blood-corpuscles ; and thirdly, a primary
transformation of the oxyhaemoglobin into methaemoglobin.
These processes may run courses quite independent of each other,
but for the most part they are combined, to some extent, and
it is often difficult, in the individual case, to say which was really
the primary change.
Of the poisons*^ which will give rise to a lak-
ing of the blood, we may name those of the poisonous
fungi, the bile salts, arseniuretted hydrogen and the plasma of
alien animals. The toxins produced by micro-
organisms may also injure the corpuscles; and haemoglo-
binaemia has been observed in severe cases of typhoid fever,
scarlet fever and other infectious processes, being especially
severe in certain forms of tropical malaria (black-wafer
fever). In such cases the plasma dissolves its own corpuscles.
Italian observers have described such a globulicidal action of
the plasma in association with a great variety of diseases. When-
ever the destruction of the corpuscles exceeds a certain limit,
haemoglobinaemia and, ultimately, haemoglobinuria occur.
According to the recent observations** from Hofmeister's
118 THE BASIS OF SYMPTOMS
laboratory, it seems probable that those substances which dissolve
erythrocytes do so by dissolving or precipitating the constituents
of the stromata, especially the lecithin and cholesterin.
Paroxysmal Haemoglobinuria. — The condition known as
paroxysmal haemoglobinuria^^ is characterized by the pas-
sage of red to dark-brown urine. The latter contains
some of the more usual forms of albumin, but its characteristic
color is due to the presence of free oxyhsemoglobin and met-
hsemoglobin, with few if any red blood-corpuscles in
the typical cases. The paroxysm is usually accompanied
by chills, fever and pains in various parts of the body. As a
rule, the liver and spleen become enlarged, and, in addition, jaun-
dice may develop. Occasionally, a sense of anxiousness, or of
suffocation, is complained of. After a few hours or days, the
symptoms disappear, and only the dark-colored faeces remain as
evidence of the paroxysm which has just ceased. In other cases,
subjective manifestations may be practically absent, or on the
contrary, extremely severe.
Malaria and particularly syphilis appear to be
predisposing causes of this disease. In some individuals the
attack is precipitated by muscular exertion, in others by
exposure to cold. Indeed, some patients void the charac-
teristic urine whenever they are exposed to a low temperature,
or even when a hand is dipped into iced water. During the inter-
vals between the paroxysms, the patient may appear to be per-
fectly well, or he may continue to show albumin in the urine.
Ralfe has reported the case of a man who had cyclic albuminuria
in conjunction with paroxysmal haemoglobinuria, and a similar
case has been observed by the author.
The escape of the haemoglobin is due to the
action of an haemolysin^^ of inconstant properties. In
the majority of cases, it would seem that an amboceptor-like
body is fixed to the red blood-cells only at low temperatures.
The haemolytic system would then be completed by complement
normally present in the individual's serum. The amount of com-
plement available, however, apparently varies greatly,*''^ being
especially low at the height of an attack. Such a diminution
would be compensatory in nature, as it would halt further
Jiaemolysis and thus end the paroxysm; while in the intervals
THE BLOOD 119
between attacks, it is likely that the haemolytic amboceptor is
greatly reduced or even absent.
There is no evidence to show that the red cells themselves have
suffered an injury in paroxysmal hsemoglobinuria ; nevertheless
they are generally credited with harboring the noxious factor,
because the serum does not contain it. As a matter of fact, the
red corpuscles sometimes appear to have an abnormally low resis-
tance, though the significance of this is not clear.^® Possibly
variations in the partial pressure of carbon dioxide in the blood
play a part in the haemolytic process.
The haemoglobinuria is generally accompanied by a haemo-
globinaemia, though cases are on record in which the plasma con-
tained no coloring matter. It is by no means impossible, there-
fore, that complement first becomes active in the kidneys. The
position of syphilis in this condition presents an interesting prob-
lem, namely, that of a possible relationship between the hsemolysin
concerned in the Wassermann reaction and the haemolytic ambo-
ceptor active in haemoglobinuria.
The periodic attacks in the condition under discussion bear
a close resemblance clinically to those following transfusion with
an alien blood. It is reasonable to assume, therefore, that both
are of similar origin, this being an intoxication with substances
derived from the erythrocytes — in one case the individual's own
corpuscles, and, in the other, cells of a foreign blood. It is of
practical importance, however, to remember that the blood par-
ticularly of anaemic individuals may contain isolysins,*^ so that
the transfusion even of human blood may not be entirely free
from danger. On the other hand, it is possible that severe
haemolytic paroxysms lead to improvement or complete recovery
in anaemic conditions by stimulating the bone-marrow.
Other Causes Which Injure the Red Blood-Corpuscles. —
Extensive superficial burns may cause the red cor-
puscles to break up into smaller particles,^*' and lead to a libera-
tion of haemoglobin in the plasma, not only from these disinte-
grated corpuscles but from others, which, microscopically at least,
appear to be normal. The oxyhaemoglobin, dissolved in the
plasma, is taken up by the liver and kidneys, partly as methaemo-
globin, the urine consequently containing both these pigments.
The cellular residues are taken up especially by the spleen and
120 THE BASIS OF SYMPTOMS
bone-marrow, and, to a lesser extent, by other organs. The
symptoms they produce will be described later.
Many poisons are able to convert the haemoglobin of the
red blood-corpuscles into methsemoglobin,^^ among the more im-
portant of which are potassium chlorate, acetanilid
and other coal-tar products. The first does not exert the same
action upon the blood of all species of animals, the corpuscles
of some appearing to be especially resistant to its action. Even
in the same individual, accessory factors may render the cor-
puscles more or less vulnerable to the action of potassium chlorate.
Thus, Mering has shown that the red cells are rendered susceptible
by fever or by a reduction in the normal alkalinity of the blood,
produced by the administration of mineral acids. The toxic
effects of the administration of potassium chlorate appear, there-
fore, to depend upon two factors — ^first, upon the amount of the
salt in the blood at a given time, and secondly, upon the resistance
possessed by the red corpuscles.
Systemic Effects Resulting from the Rapid Destruction of
Red Blood-Corpuscles. — The effects of such a rapid disintegra-
tion of red cells upon the body as a whole depend partly upon
the loss of functioning haemoglobin and partly upon
the toxicsubstances derived from the destroyed corpuscles.
In very severe intoxications with potassium chlorate, death results
from the diminution in the respiratory capacity of the blood,
caused by the loss of haemoglobin.^^
The destruction of a large number of red corpuscles sets free
in the plasma certain substances, apparently enzymes, which tend
to produce intravascular clotting. A limited quantity
of such substances may be neutralized or destroyed by the living
organism ; but when they appear in very large amounts, they give
rise to thrombi in the smaller blood-vessels.^^ As results of such
thrombi, necroses occur in various tissues; and the gravity of the
intoxication often depends upon the localities in which the coagula
form.
The fact that there is a slow coagulation of the blood in
certain cases of extensive burns in no way excludes the possi-
bility that thrombi have formed, for we know that the presence
of substances in the blood which favor coagulation may in turn
give rise to substances having the very opposite effect, so that ulti-
mately coagulation will be retarded. Opinions differ as to the role
THE BLOOD 121
played by these thrombi in states of rapid blood destruction.
Some observers have found them in the majority of cases, while
others have missed them with equal frequency.^^
The large quantities of haemoglobin or methsemoglobin which
may pass into the urine in these conditions seem to injure the
kidneys directly, and not infrequently the urine contains large
amounts of albumin, numerous blood and epithelial cells, and a
great variety of casts, the most characteristic of which are com-
posed of clumps of blood-pigment. The quantity of urine may
diminish up to complete anuria, and the patient may die of uraemia.
Anatomically, the uriniferous tubules are found to be blocked
with masses of pigment, and in addition the epithelium itself
seems to be injured. It is quite possible that some of these
changes are due to the products of destruction of the stromata,
but this is not certain.''^
The White Blood-Corpuscles
The white blood-corpuscles ^° may be divided into groups
according to their size, the character of their nuclei and the
staining reactions of their protoplasm. About seventy per cent,
are made up of cells that are slightly larger than red corpuscles,
and that contain irregular nuclei and protoplasmic granules stain-
ing with neutral anilin stains (polymorphonuclear neu-
trophil es). From twenty-five to twenty-eight per cent, are
made up of mononuclear cells, from two to four per cent, of which
are quite large (large mononuclears and transi-
tional cells), while the remainder are about the size of red
blood-corpuscles (lymphocytes). In addition to these cells,
there are from one to four per cent, of eosinophiles,
characterized by the presence of large acid-staining granules in
their protoplasm, and from one-half to two per cent, of cells con-
taining large irregular basic granules (the mast-cells). In
infants and young children, the lymphocytes are relatively more
numerous and they may even exceed the neutrophilic polymorpho-
nuclears.
Arneth,^^ more recently, has further subdivided the poly-
nuclear leucocytes on the basis of the shape, number and size of
their nuclear subdivisions, and has studied the variations in these
particulars in different infections. His views rest upon the
assumption that the immature polynuclears possess a nucleus
122 THE BASIS OF SYMPTOMS
which is almost round, whereas more mature cells exhibit a num-
ber of more or less distinct nuclear parts. From this general
aspect, Arneth's view may be subscribed to. Further study,
however, is needed to substantiate the rather far-reaching de-
ductions as to degeneration and regeneration, diagnosis, prog-
nosis and treatment, etc., which some observers see fit to draw
on the strength of Arneth's work. More recent writings,^^ in-
deed, have vigorously questioned the full scope of Arneth's inter-
pretation. Nevertheless, a definitive judgment as to the value
of the method is not justifiable at this time. (Naegeli, in the
second edition of his book, summarizes the present status of the
question and points out that there remains little of the original
structure of the Arneth theory. — Ed.)
Little is known of the chemistry of the different
types of white cells. Minkowski has found the same
nucleinic acids in all white cells, though combined with different
substances in the various types. Pus-cells, as well as bone-mar-
row elements, and the ordinary polynuclear leucocytes of the
blood, are able to oxidize certain substances ^^ such as the acid
in guaiac resin, by means of an enzyme-like body, or oxydase,
which they contain — a property not possessed by the mono-
nuclear cells originating in the thymus, spleen and lymph-nodes.
Still other oxydase reactions are shown by cells of the myeloid
system, and not by those of the lymphoid. The recently described
indophenol reaction ^^ of Winkler and Schultz is of this
character. (The oxydase reactions have found a considerable
application in the differentiation of acute myeloid from acute
lymphoid leukaemia, by determining, among other methods, the
source — whether myeloid or lymphoid — of certain large mono-
nuclear cells, with a non-granular cytoplasm, which occur in
both forms of acute leukaemia.*'^ — Ed.)
The source of the different leucocytes is still,
in my opinion, an open question, and this must be settled before
a classification is possible. The observer who believes that a
given white blood-cell has invariable characteristics is inclined
to ascribe it to a definite origin. Ehrlich has attempted such a
classification, as is well known. The lymphocytes, according to
him, arise only in lymphoid tissue, and the ordinary polynuclears
are descendants of mononuclear bone-marrow cells. By many,
however, this division is criticised because based upon too uncer-
THE BLOOD 128
tain and variable a standard.^^ Thus, the lymphocytes are also
said to be capable of spontaneous movement. Nevertheless, in
a general way, and especially in recent years, hsematologists are
inclined to accept Ehrlich's strictly genetic subdivision into
lymphoid and myeloid. Nsegeli and Schridde are the strongest
proponents of this dualistic theory. Unlike Pappenheim and
others, they do not believe in a common lymphoid mother cell in
extra-uterine life, inclining rather to the view that the fore-
runners of the myelocytes — the myeloblasts — can be distinguished
morphologically from the original lymphoid cell.
It is best, perhaps, to concede that some of these problems
are still unsettled ; in my opinion, they require a constant revision
to prevent further research from taking a restricted bent because
of pre-existing premature conclusions.
Physiological Leucocytoses. — The number of leucocytes in
a cubic centimetre of blood is normally between six and eight
thousand. Children have, on the average, somewhat more —
about nine thousand; weak and poorly nourished persons appre-
ciably fewer. Arneth gives as the average for the fasting healthy
adult, five to six thousand. The number of leucocytes in the
peripheral blood varies even in the same individual at different
times. Thus it is usually increased after a meal, especially
one rich in proteids.^^ Such a digestion leucocy-
te s i s is absent in some individuals normally, but it is especially
apt to be absent in certain diseases, above all in carcinoma of the
stomach. During pregnancy, more particularly in the
later months, the number of leucocytes is increased. A leucocy-
tosis is also physiological in the new-born. Cold baths
and exercise®^ likewise increase the number of leucocytes in
the peripheral blood. Some regard this latter as an effect of the
more rapid blood-current, which tears the leucocytes away from
the vessel walls of the internal organs and throws them into the
general circulation, and especially into the peripheral capillaries
from which the samples of blood are taken. Grawitz looks upon
it as a genuine new formation of corpuscles.
The conditions which we have just been describing have been
termed physiological leucocytoses. The increase in the number
of white cells does not usually exceed thirty per cent, of the nor-
mal, although in children the number may be doubled. The pro-
portion between the mononuclear and the polynuclear cells remains
124 THE BASIS OF SYMPTOMS
unchanged in this form of leucocytosis. Since the counts are
made from the blood of the peripheral capillaries, the question
arises, Is there an actual increase in the total number of leucocytes
in the blood, or is there merely a redistribution of the cells, more
going to the periphery and fewer remaining in the interior of the
body? Studies on animals have shown that there is normally a
greater number of leucocytes at the periphery than in the internal
organs, but that during the digestion leucocytosis, at least, the
number in both places is increased. The new cells are probably
derived from the lymph and from the various organs of the body,
for no signs of an active regeneration of these cells are to be
found. The digestion leucocytosis seems to be due to the presence
of substances in the blood which attract the leucocytes (chemo-
taxis). Such substances appear to be present in largest amounts
after the ingestion of proteid food, though not all varieties of
proteid food exert the same influence. Indeed, it is uncertain just
which products of digestion are responsible for the normal diges-
tion leucocytosis. Possibly this leucocytosis indicates a trans-
portation of proteid material from the intestines to other parts of
the body.
A hyperleucocytosis is frequently, but not always, preceded
by a hypoleucocytosis.*'^ Lowit interpreted this as a primary-
destruction of the white corpuscles which precedes a regeneration.
Goldscheider and Jacob and others, on the contrary, failed to find
any sign of destruction, and believe that this hypoleucocytosis is
caused by a massing of the leucocytes in the capillaries of the
lungs. More work is necessary to decide this question.
Pathological Leucocytoses. — Many infections cause an
increase in the number of white blood-corpuscles in the peripheral
blood — the so-called pathological leucocytosis.^® Although the
same varieties of leucocytes are present as in health, the relative
proportions are usually changed. In the more common forms of
pathological leucocytosis, the percentage of lymphocytes is dimin-
ished, whereas that of the polymorphonuclear neutro-
philes is increase d — from eighty-eight to ninety-five per
cent, of the latter being frequently found, as compared with the
normal of seventy to eighty per cent.
In other forms of pathological leucocytosis, the relative
number of the lymphocytes is increased, such a
blood-picture being presented by many cases ofpertussis. Of
THE BLOOD 125
special interest would be the investigation of the blood-changes
in those diseases which give rise to exudates rich in lymphocytes,
such as tuberculous meningitis and pleurisy, and certain chronic
cord lesions.
The influence of the nervous system upon the number of white
cells would seem to be shown by recent studies. *^'^ Substances like
epinephrin, which stimulate the sympathetic system, produce
neutrophilic leucocytoses, while those acting upon the vagus, such
as pilocarpin, cause an eosinophilic leucocytosis, or a lymphocy-
tosis. These observations, however, must be viewed conserva-
tively.
Still another form of leucocytosis is characterized by the
relative increase in the eosinophilic white
blood-corpuscles. This has been observed in bronchial
asthma, trichinosis and a variety of other diseases. (In most
infections — scarlet fever being an exception — the eosinophiles are
absent during the height of the disease. Their reappearance is
regarded as a favorable sign. — Ed.)
Pathological leucocytosis of the neutrophilic
type occurs especially as the result of inflammatory processes
and, above all, in association with those which are accompanied by
a purulent exudation, although the latter is not a necessary con-
comitant. In certain infectious diseases, e.g., typhoid fever,
malaria and uncomplicated tuberculosis, there is usually no increase
in the number of white blood-corpuscles in the circulating blood.
The infectious leucocytoses are probably caused
either by the secretions of the living bacteria, or by the disinte-
grated bodies of dead ones. Experimentally, it has been shown
that various constituents of the bacterial cell may exert an attrac-
tive influence upon the leucocytes (positivechemotaxis).^^
Many other substances also appear to exert such a chemotactic
influence; and the same substance may, under one set of circum-
stances, attract the leucocytes, and, under another, repel them.
The origin of the extra leucocytes has not yet been definitely set-
ted — we do not know whether they are derived from the bone-
marrow, the lymph-glands or possibly from other tissues. The
purpose of these pathological leucocytoses is probably one of
resistance to the invading micro-organisms.
Leucocytoses of the neutrophilic type may also result from
hemorrhage and from malignant cachexias. ^^ The
126 THE BASIS OF SYMPTOMS
latter, however, do not always cause an increase in the number of
leucocytes in the peripheral blood; nor do we know what is the
determining factor in the individual case. Grawitz found that
after injecting carcinomatous material into an animal's blood,
the latter became more dilute, and the number of leucocytes was
frequently increased. These changes were believed to result
from an increased flow of lymph into the blood — a possible ex-
planation not only of the leucocytoses due to malignant disease,
but of those which follow acute hemorrhage.
Leucocytoses in which the eosinophilic cells
are increased occur in a variety of diseases, of which we
may mention bronchial asthma, various cutaneous lesions, tri-
chinosis'^^ and infections with intestinal parasites. It is interest-
ing that in most of these diseases there exists a local collection
of eosinophilic cells at the main seat of the disease : for example,
in the bronchi and in the exudate of bronchial asthma,'^ ^ in the
lesions of certain skin affections and about the embryos in
trichinosis.
The number of white cells in the blood in pathological leucocy-
toses usually ranges between ten thousand and thirty thousand
per cubic millimetre. Higher counts do occur, however, though
rarely, if ever, exceeding eighty thousand.
Leucopaenia. — A diminution in the number of leucocytes in
the peripheral blood, a leucopaenia, occurs in a variety of diseasae.
It has been observed in cachexias, intoxications, many anaemias
and in some infectious diseases, notably in typhoid fever
and malaria.
In such leucopaenias, the proportion between the numbers of
the various kinds of white cells is usually changed. For example,
in typhoid fever there is a relative increase in the number of
lymphocytes. The cause of the leucopsenias is un-
known. Possibly they are due to a negative chemotaxis, or to
some lesion of the sites of origin of the leucocytes. In typhoid,
indeed, the bone-marrow is poor in myelocytes, which would
explain the relative, but not the absolute, lymphocytosis generally
observed.
Little is known of pathological alterations in the blood-
platelets."^* It is generally agreed that these bodies are intimately
associated with the phenomena of blood coagulation, in that they
take a part in the formation of fibrin- ferment. In certain con-
THE BLOOD 127
ditions, indeed, for example, in severe anaemias, delayed clotting
and a diminished number of platelets go hand in hand. The
platelets contain also a ferment capable of splitting polypeptids.'^^
These facts would indicate that the platelets are biological entities,
and not merely disintegrated erythrocytes. Their origin is not
known, nor are the variations they undergo in pathological con-
ditions, aside from the fact that they are reduced in certain severe
anaemias. (Their extreme reduction in pernicious anaemia seems
to have a diagnostic value ; while in chronic myeloid leukaemia they
are generally enormously increased. — Ed.)
Leukaemia and Pseudoleukaemia. — (The author uses the term
pseudoleuksemia, for the most part, in the strict sense, as denoting
the condition in which the pathological picture, both gross and
microscopic, is typically leukaemic, but in which the characteristic
leukaemic changes are absent in the blood. This so-called aleukaemic
leukaemia may be either lymphoid or myeloid. This strict inter-
pretation excludes the many conditions, such as malignant granu-
lomatosis (Hodgkin's disease), tuberculosis, syphilis, lymphosar-
coma tosis, etc., which clinically may bear a close resemblance to
pseudoleukaemia. — Ed, )
In leukaemia and pseudoleukaemia,'^* there is
obviously a conjoined disturbance of the bone-
marrow, the lymphadenoid tissues and of the
spleen; and, in addition, there are generally
changes in the blood. It is convenient, first, to consider
the two diseases together and then in their relationship to on^
another. The change in both consists of a hyperplasia of the
spleen, lymph-nodes and bone-marrow, or only of two of these
organs; in leukaemia, the bone-marrow is apparently involved in
all cases.
Two types of leukaemia are recognized, depend-
ing upon the character of the cells present in the circulation and
in the haemapoietic organs. Corresponding also to the types of
cells found increased in the blood, the hyperplasias in the different
organs concerned in blood building — bone-marrow, spleen, lymph-
nodes, liver, intestines — exhibit diverse cells (myeloid and
lymphoid hyperplasia). In pseudoleukaemia, the histo-
logical changes in the above-mentioned organs generally resemble
those of lymphoid leukaemia, though In some cases the myeloid
type is observed.
128 THE BASIS OF SYMPTOMS
The bone-marrovv'^^ of the long bones does not consist
chiefly of fat cells, as in the healthy adult, but returns to its
lymphoid character, such as one sees in childhood, and in the
anaemias. In color it varies from a deep red to a grayish-yellow,
though the findings are not uniform in all cases either of leukaemia
or of pseudoleuksemia. At times, the marrow is indistinguish-
able, grossly and microscopically, from that seen in many anaemias.
Histologically, there are observed nucleated red cells of all types,
and in addition an enormous number of leucocytes. The latter,
indeed, may be so numerous as to lend to the marrow a pus-like
appearance. These white cells are of myeloid type in some cases,
and of lymphoid in others.
In the spleen and lymph-nodes the hyperplasia,
according to the general opinion, has no specific anatomical char-
acter. The growth in lymphoid leukaemia concerns the autoch-
tonous lymphoid tissue; while in the myeloid form, there is a
growth of cells of the bone-marrow type, i.e., there occurs a
myeloid conversion of the lymph-node.
These hyperplasias are not confined to the bone-marrow,
lymph-nodes and spleen, but appear wherever there is lymphoid
or myeloid tissue capable of growth. Even the cells of the vessel
walls — comprising the original mother-substance — may be the
source of new cells. The lymphoid and myeloid cell-accumula-
tions occurring in the liver, spleen, intestines, thymus, skin, ton-
sils, choroid, etc., are partly metastatic in nature and partly meta-
plastic. Pappenheim, Naegeli, indeed haematologists generally,
view this as a metaplasia in loco and not as a blood-cell coloniza-
tion, i.e., transported from elsewhere. In the lymphoid processes,
the hyperplasia seems to be more widely distributed than in the
myeloid."^®
In the leukaemias there is generally a marked,
often an enormous, increase in the white cells in
the blood, while in pseudoleukaemia there is
either no increase or at most a moderate one. Ac-
cording to Pinkus,'^^ there is regularly a relative increase in the
lymphocytes in pseudoleukaemia, and herein lies the intimate rela-
tionship between the latter and lymphoid leukaemia. Indeed, the
two conditions differ only in the fact that the number of white
cells in the blood is increased in the one and normal in the other.
This criterion has certain limitations, however, for, as already
THE BLOOD 120
mentioned, pseudoleukaemias occur with a myeloid type of origin
and with myeloid blood-changes (amyelsemic and sub-
myelaemic leukaemias). We distinguish, therefore, be-
tween myeloid and lymphoid tissue hyperplasias, with or without
an increase of the corresponding cells in the circulating blood.
The leukaemias may be differentiated from the leucocytoses, in
a general way, by the greater increase in the white cells. In the
former, values of three to five hundred thousand cells are not
infrequent ; at times, indeed, the white cells may be as numerous
as the red. In a leucocytosis, on the contrary, a white count above
eighty thousand scarcely occurs. A more important index, how-
ever, of the leuksemic nature of a process resides in the types
of white cells present, for the number of cells may undergo con-
siderable variations during the course of the disease. (A diminu-
tion, for example, may occur during an intercurrent acute infec-
tion, and also as a result of X-ray therapy."^® The use of ben-
zene,"^^ as recommended by Koranyi, has produced similar results.
In these cases, however, though the total number of white cells
may be reduced even to a normal level, the differential count
ordinarily shows little change in the relative proportion of patho-
logical cells present, the blood remaining typically leukaemic. —
Ed.) The former tendency, therefore, of looking upon the num-
ber of white cells as the sole criterion of a leukaemia resulted in
a narrow and indistinct picture of the disease, so that to-day it is
difficult to interpret the earlier literature on the subject. An
unequivocal diagnosis of leukaemia demands not
only a careful histological scrutiny of the organs
involved, but also the demonstration of certain
types of wh ite cells in the blood.
Characteristic of the leukaemias is the presence in the circu-
lation of cells normally absent, and particularly is the relative
proportion of the different forms unlike that in the leucocytoses.
In the latter, the polynuclear neutrophiles preponderate; in leu-
kaemia, on the contrary, mononuclear types are always strongly in
evidence, their number varying within wide Hmits. In the acute
leukaemias the mononuclear forms are much more numerous than
in the chronic; indeed, they may comprise ninety-nine per cent,
of all the white cells present.
Two types of leukaemia are distinguished ac-
cording to their blood-pictures. The first exhibits
0
ISO THE BASIS OF SYMPTOMS
a great many large mononuclear cells with abundant, predom-
inantly neutrophilic, granules in the cytoplasm (myelocytes).
The polytiuclear neutrophils are absolutely increased though rela-
tively diminished. Various atypical leucocytes are common, as
are nucleated red corpuscles, usually of moderate size. (Indeed
the very multiplicity of atypical forms is indicative of myeloid
leukaemia. — Ed. )
Myelocytes, though absent from normal blood, are not pathog-
nomonic of leukaemia, for they occur, less abundantly it is true, in
other conditions,^^ notably in the infectious diseases, and in
severe anaemias. An interesting resemblance to the blood of
myeloid leukaemia is that due to tumors which have given rise
to metastases in the bone-marrow.
In the second type of leukaemia (lymphoid or lymph-
aticleukaemia), the prevailing cell is the small, or moderately
large, mononuclear, the so-called lymphocyte, with a large nucleus
and a narrow rim of non-granular cytoplasm. The other types
of white cells, in particular the polynuclear neutrophiles, are rela-
tively and often absolutely decreased. Eosinophiles and myelo-
cytes are usually absent, though in certain cases of lymphatic
leukaemia the latter cell may be fairly numerous. The red cell
count may remain unchanged for a long time, later being dimin-
ished. Nucleation is rare.
The two forms just described are readily differentiated, for
the predominant cell in each points to a hyperplasia of the myeloid
or lymphoid tissues, as the case may be. The type of cell found
in the blood is not indicative of the organ whence it originated ;
whether the spleen or lymph-nodes are predominantly affected is
more readily judged from the ordinary methods of physical
examination.
A genuine anaemia is generally observed in
leukaemia and pseudoleukaemia; both oligoc3rthaemia
and oligochromaemia are present. Poikilocytes and nucleated red
cells of various sizes may be seen. In certain cases, therefore, the
blood may closely resemble that of myeloid pseudoleukaemia and
of the Bicrmer type of pernicious anaemia.*^ These are the cases
of so-called leukanaemia (Leube), the nature of which is little
understood, though the blood-changes point to a coincident injury
to the erythropoietic and leukopoietic functions of the bone-
marrow. (Certain observers, such as Naegeli, seriously doubt the
THE BLOOD 131
existence of such a leukanaemia, believing that more rigid analyses
would show that conditions going under this name are in reality
pernicious anaemia, myeloid leukaemia — acute or chronic — or other
processes. — Ed. )
The blood-serum in leukaemia sometimes contains
proteids not normally present. Nucleo-albumins and deutero-
albumoses have been found, but at present the meaning of these
findings is not clear. Charcot-Leyden crystals have been found
in myeloid leukaemia in the blood, as well as in the fluids of the
spleen. These crystals appear to bear some relation to the pres-
ence of eosinophilic cells.
Leukaemia is generally a disease of middle life, though it may
occur both in children and in the aged. It terminates fatally in
practically all cases : instances of recovery were not unlikely leuco-
cytoses. The beneficial action of the X-ray ^^ has recently
come to the fore, thorough rcentgenization of the spleen and of
the long bones often producing not only a marked decrease in the
number of leucocytes, but also a decided reduction in the size of
the spleen and lymph-nodes. The action of the rays seems to be
exerted both upon the marrow and upon the white cells in the
blood. Improvement, approaching recovery, has been observed;
but this is temporary and the blood qualitatively usually remains
leukaemic. The author has seen conditions aggravated by the use
of the rays. (The use ofbenzene has already been commented
upon. Its effects are generally similar to those of the X-ray ; the
results, indeed, seem best when the two methods are combined.
The toxic action of benzene, particularly upon the kidneys, and
perhaps also upon the erythrocytes, demands caution in its em-
ployment.— Ed. )
The course of the leukaemias is essentially chronic.
In recent years, however, acute cases have been described which
lead to exitus within a period of weeks, or even days.
The acute leukaemias are truly remarkable conditions charac-
terized by a pronounced hemorrhagic diathesis and by an extremely
rapid course. As fever is generally present, there may be a great
resemblance to an acute infection. The leukaemic nature of the
process consists in an increase in the white blood-cells and in an
alteration in the types present. The number of leucocytes is
highly variable and the increase is often insignificant. As a rule
the predominating — sometimes practically the only — cell present
182 THE BASIS OF SYMPTOMS
isalargemononucleartype^^withan undifferen-
tiated protoplasm, resembling the lymphoid mother-cell.
In other cases, however, somewhat similar mononuclear cells sug-
gest rather a myeloid origin. (These two cells are the 1 y m p h o -
blast and myeloblast, respectively, and the leukaemias
themselves are known as acute lymphatic (lymphoid) and acute
myeloid (myeloblastic). — Ed.) A classification of these acute
conditions is, for the present, best not attempted, first because of
the difficulty of distinguishing between these two types of large
mononuclear cells ; further, because in certain cases in which the
cells in the blood were apparently lymphoid, no hyperplasia of the
corresponding tissue was found; and finally because "mixed-
cell" leukaemias occur, or one type may apparently go over
into the other. The general tendency to-day is to catalogue the
major part of these acute leukaemias as myeloid ; for though the
large cells of the latter are very similar to cells of lymphoid origin,
yet the staining properties of the protoplasm are more suggestive
of the forerunners of the myelocytes.
Two manifestations of leukaemia — ^the fever and the hemor-
rhages— are of particular interest. The temperature, which is
often of a hectic type, cannot be explained on the basis of a compli-
cation. A tendency to hemorrhage into the skin, the choroid and
the organs generally is particularly common in the acute leu-
kaemias.
Both of these manifestations are important because of the
possible relation they bear to the destruction of the blood-cor-
puscles. Hemorrhages and fever may also occur in pseudoleu-
kaemia, the temperature at times assuming a characteristic relap-
sing character with periods of apyrexia (Ebstein).^^ (This type
of fever is not present in aleukaemic leukaemias, but rather in those
pseudoleukaemic types of a granulomatous nature, which will be
discussed below. — Ed. ) Pseudoleukaemia may also run a rapidly
fatal course.
The chief feature, therefore, differentiating
pseudoleukaemia from the ordinary types of leu-
kaemia is the number of leucocytes in the unit-
volumeofblood. A conversion of a pseudoleukaemia into a
true lymphatic leukaemia is very rare, although a few such cases
have been reported. In one of these, a rupture of the hyper-
plastic tissue of a pseudoleukaemic gland into a vein could be
THE BLOOD 133
directly demonstrated, and coincidently a lymphatic leukaemia
developed.®^ Nevertheless, border-line types of both leukaemia
and pseudoleuksemia, as well as transitional forms, are surely very
infrequent. Much more commonly, each disease runs a typical
clinical course from beginning to end. Yet the two are doubt-
lessly closely related, being perhaps different forms of the same
morbid process.
Of prime importance is the question of the relation which
the changes in the spleen, the lymphatic apparatus and the bone-
marrow bear to each other — and of the relation which these
changes bear to the causation of the diseases under consideration.
As a rule, all three of these organs are involved, usually in such
a manner that the changes in two predominate. A normal bone-
marrow is never present, though specific alterations may be absent.
In some cases, the marrow changes can be recognized only with
the microscope;*^ and not infrequently the bone-marrow is the
only tissue involved.
Also of great importance is the question whether the anatomi-
cal changes in these organs are primary or secondary. This much
is certain, that in lymphatic leukaemia and lymphatic pseudoleu-
kaemia, the lymphadenoid tissue is hyperplastic, while in the mye-
loid forms, the bone-marrow elements are in a state of growth. If
one regards these processes as affections of the myeloid and
lymphoid systems respectively, the question as to the primary
focus, from the general pathological point of view, is of no great
moment,*^ for the disease may originate wherever there is lymph-
oid or myeloid tissue. In myeloid leukaemia, nevertheless, the
tendency is to emphasize the crucial importance of the bone-
marrow, because in adults this is the principal myeloid organ.
The conditions still grouped under the common caption
pseudoleukaemia undoubtedly differ clinically in many particu-
lars. The recent tendency** is to separate those on an infectious
(granulomatous) basis from others hyperplastic in character.
The last only are leukaemic in nature, differing from the usual
leukaemias, as has already been stated, merely in the absence of
leukaemic elements in the circulating blood.
(A great deal of attention has been devoted in recent years
to that type of pseudoleukaemia belonging properly, it would seem,
to the granulomas, and known otherwise as Hodgkin's disease or
malignant granuloma." This does not include the varieties due
184 THE BASIS OF SYMPTOMS
to syphilis or to tuberculosis in its usual form. Clinically, it
may be indistinguishable from the true pseudoleukaemias
(a leuksemic leukaemias) on the one hand, and from neo-
plastic growths on the other. The microscopic examination, how-
ever, usually makes a diagnosis possible, revealing changes more
or less constantly observed, but variously interpreted, Sternberg
regards the condition as a peculiar form of tuberculosis and finds an
unusual type of giant-cell, to which Reed^*' has also
called attention. Frsenkel and Much®^ consider the disease to be
due to a granular form of the tubercle bacillus which appears only
with a special staining technic. More recently, Bunting and
Yates and others ^^ have isolated a pleomorphic diph-
theroid bacillus from the affected lymph-nodes, by means
of which they state that they have transferred the disease to
rhesus monkeys. The former also describes a characteristic
blood-picture for the disease.^^ The monograph of Kurt Ziegler
will give the reader a comprehensive insight into the present con-
ceptions of the condition. — Ed.)
Kundrat's lymphoBarcoma occupies a peculiar position among
the pseudoleukaemias. The localized swellings of the lymph-
nodes which characterize it are genuine neoplasms. This con-
dition, therefore, both etiologically and pathologically, is an entity,
and a third type of pseudoleukaemia. The microscopic examina-
tion of a specimen of excised node may be essential to distin-
guish this from the other two forms of pseudoleuksemia.
In lymphoid leukaemia, the lymphatic tissues of the lymph-
glands, the spleen, the intestines or of the bone-marrow, are
increased. Whether the lymphocytes present in the blood orig-
inate solely from the bone-marrow, or from the various collec-
tions of lymphoid cells throughout the body, is not yet definitely
known. It is of considerable interest, however, that instances of
lymphatic leukaemia without enlargement of the lymph-glands have
been reported. Such cases demonstrate how careful we must be
not to assume that lymphatic leukaemia is essentially a disease of
the lymphatic glands. It seems more probable, indeed, that it is
primarily a disease of the lymphoid tissue of the bone-marrow,
though recent work has shown that numerous mitoses may be
present in other organs; and it is quite possible that white cor-
puscles may arise in tissues which normally produced these cells
only during embryonic life, as, for example, the liver.
THE BLOOD 186
In regard to the nature of the pathological process in
leukaemia, we wish again to recall the observation from
Marchand's laboratory on a case of lymphatic leukaemia which
apparently originated from the rupture of a hyperplastic lymph-
atic gland into a vein. Many facts favor the view that a growth
of cells into the blood-stream is the cause of the blood-changes
in leukaemia. Thus, as illustrated, pseudoleukaemia may change
into a true leukaemia by the rupture of a hyperplastic gland into
the circulation.
This is readily understood because hyperplasias of myeloid and
lymphoid tissues give rise to tumor-like growths (possibly of in-
fectious origin).®^ In the present opinion of most observers,
however, the leukaemias are to be separated from the genuine
tumors.®^ Since the conditions in the bone-marrow especially
favor such a rupture into the blood-stream, pathological changes
in this tissue are most apt to give rise to leukaemia.
The theory that leukaemia is due, not to an excessive produc-
tion, but to a diminished destruction of the leucocytes, deserves to
be considered merely to be condemned, for it has been proved that
the destruction of these cells, far from being decreased, is actually
increased. Many leucocytes may be seen in blood-preparations in
various stages of degeneration, and the increased elimination of
uric acid and of the xanthin bases in the urine indicates an in-
creased destruction of the nucleoproteids of the body, which are
derived, in all probability, from the nuclei of the leucocytes (see
P-365).
Toxic influences also play an undoubted part in the pathology
of leukaemia. Speaking for this are the peculiar forms of retinitis
occasionally seen; further, a characteristic nephritis; and also
degenerative changes in the central nervous system.
The ultimate cause of leukaemia and pseudoleukaemia is still
imknown. It is possible that the recent experimental production
of the disease in birds by the injection of leukaemic blood ®^ may
pave the way for a fuller understanding of the conditions.
Plasma and Serum. The Total Quantity of Blood
Little is known about pure plasma, principally because it is so
difficult to preserve it without coagulation. The serum resulting
from coagulation differs from the plasma within the blood-vessels
in that it contains no fibrinogen, but does contain fibringlobulin
136 THE BASIS OF SYMPTOMS
and the fibrin ferment. Probably other changes, at present but lit-
tle understood, also take place in the proteids of the blood during
coagulation.
Coagulation. — When normal blood coagulates, about o.i to
0.4 per cent, of its weight separates as fibrin. This may be patho-
logically increased up to i.o or 1.3 per cent., an increase which
is seen especially in diseases accompanied by inflammatory exuda-
tions, such as pneumonia, pleurisy and acute articular rheumatism.
In other infections, notably in typhoid fever, this increase of
fibrin is not found. There exists a certain parallelism between
the number of leucocytes and the amount of fibrin in the blood,
but the parallelism is by no means a strict one,^'' and in leukaemia
the fibrin may not be increased at all.*®
In other diseases the quantity of fibrin in the blood is dimin-
ished; and in a case of hemorrhagic smallpox, for example, no
fibrin could be obtained. The same has been noted in phosphorus
poisoning. Diminution of fibrin is usually found in severe infec-
tions and in severe injuries to the general nutrition, as in septi-
caemias, long-continued suppurations, anaemias, etc.
Our knowledge** of the physiology of blood-coagulation is
still so limited that it would be hazardous to speculate on the
significance of pathological variations in the amount of fibrin
in the blood and the effect that these variations have upon coagula-
tion. It has been assumed that if the amount of fibrin be dimin-
ished, the blood will coagulate slowly and there will be a tendency
to hemorrhages; whereas, if the amount be increased, coagulation
will be rapid and there will be a tendency to thrombosis. These
assumptions, however, are not sufficiently supported by facts.
Disturbances of coagulability ^^^ have been generally assumed
to explain the family disease of haemophilia. As a matter
of fact, Sahli^^^ was able to demonstrate that the coagulation
time between the periods of hemorrhage was slower in these
patients than normal ; but that during the hemorrhages it was not
particularly slow. He is inclined to attribute the bleeding of
haemophilics to lesions of the vessel walls, which on the one hand
tear with abnormal ease and on the other yield too little of a
substance that is necessary for coagulation (thrombokinase).
The Blood-Serum. — ^All substances formed in the metabolic
processes within the body and all food-stuffs introduced from with-
out pass through the blood ; they may, however, be present there
THE BLOOD 137
only in minute traces, because they are so quickly removed by
the various organs. It would be impossible to discuss in this
place all those conditions in which some constituent or other of
the serum is changed, as happens, for example, in diabetes, and
it seems better to reserve such a discussion for the chapters on
metabolic disorders.
One substance, however, may be mentioned in this connec-
tion, viz., fat. Fatty substances are constantly present in the
blood, ^^2 the amount being increased during the digestion of meals
containing much fat. Under pathological conditions, the quantity
of fat in the blood may become so great — even up to 20 per cent. —
that particles can be recognized microscopically between the red
corpuscles, especially if they have been stained by osmic acid.^**^
This condition, known as 1 i p ae m i a , is relatively uncommon.
It occurs in various pathological conditions, especially in diabetes,
and is frequently merely transitory.
In discussing the chemistry of the blood-serum,
we shall consider especially the proportions of proteids, salts and
water. According to Hammarsten's analyses, 9.2 per cent, of the
serum consists of solids, of which 7.6 per cent, are proteids. Since
the proteids form the greater part of the solid material in the
serum, they and the water ordinarily vary in inverse ratio to
each other, a high percentage of proteids being accompanied by a
relatively low percentage of water, and vice versa.
The proteids of the serum consist chemically of albu-
min and various forms of globulin. Recent biological work,
however, has shown such a variety in the proteids of the blood
that we can no longer regard the above simple chemical division
as in any way a final one; and when we remember that in all
probability each organ contributes its quota to the blood, it seems
impossible that the division into the albumin and globulins could
be any other than a mere classification of the proteids present
under these group names. The serum of healthy men contains
somewhat more albumin than globulin, the ratio being about 4.5
to 3.1. This ratio differs in different species of animals,^*'* and
varies in the same individual under different circumstances. Dur-
ing fasting, the globulins become relatively increased to a slight
extent.
Our knowledge of the proteids of the blood has undergone a
complete revolution within recent years.**^" The researches on
138 THE BASIS OF SYMPTOMS
immunity have brought to light important functions of the blood
which were hardly suspected previously. The substances which
bring about these so-called biological reactions cannot be separated
from the proteids by purely chemical means, though we have no
direct proof that they are themselves of a proteid nature.
Among the substances under consideration are those which
possess the property of accelerating the decomposition of other
compounds, i.e., they are of the nature of ferments. If we
may assume that the decomposition of different compounds re-
quires the action of different ferments, then the number of fer-
ments present in the blood must be considerable. Some of these
are proteolytic, some amylolytic, others oxydases and coagulating
enzymes, ^^^
Recent studies indicate the presence also of numerous a n t i -
ferments. Whether these are actually antibodies, or merely
the products of the action of colloids upon the ferments, is not
definitely known. Anti ferments occur normally in the blood of
healthy individuals and may also be produced by the injection of
ferments, in the nature of an immunization. Particular interest
has lately been directed to the subject of antitrypsin, which is
often abundantly present in the cachexias.***'^
Besides the proteids there are many other nitrogenous sub-
stances regularly present in small amounts in the serum, with many
of which we are still unfamiliar. Taken together they are known
as the residual or non-coagulable nitrogen. ^^^
This residue is comprised chiefly of the end-products of metabol-
ism, substances which go over into urea, and are ordinarily re-
moved by the urine. They are increased, therefore, when elimina-
tion is imperfect — for example, in nephritis, uraemia and in
different febrile conditions. In great part such an increase is to
be attributed to urea retention. (The importance of this in
modern renal functional tests will be considered in Chapter XI. —
Ed.) The entire fabric of proteid metabolism would reveal itself
if the building-stones of the proteids — ^t heamino-acids and
similar bodie s — could be isolated from the blood, and espe-
cially from the intestinal veins.
In processes such as phosphorus poisoning, accompanied by
considerable tissue necrosis, amino-acids have been found in the
blood, but here the proteid split-products have naturally no rela-
tion to digestive processes. Recently Bingel ^^^ has demonstrated
THE BLOOD 189
glycocoll in normal serum, a discovery possibly significant in view
of what has been said.
(Considerable progress, indeed, has been made along these
very lines. Abderhalden,^^^ using enormous amounts of blood
at a time, has succeeded in demonstrating the presence of amino-
acids in the serum by the direct isolation and identification of
a number of these proteid split-products. As the blood contains
these acids even in starvation, Abderhalden conceives of the possi-
bility of a fixed amino-acid content, comparable in a way to the
constant sugar concentration.
More recently Abel, Rowntree and Turner ^^^ have isolated
from the blood, by a process of dialysis, two amino-acid deriva-
tives of proteid — alanin and valin — in crystalline form. By the
same method they have identified histidin and creatinin and lactic
and beta-oxybutyric acids. — Ed.)
The Salts of the Serum. — ^The salts of the serum are for the
most part made up of sodium chlorid, sodium carbonate and the
phosphates of the alkalies. Other salts are present only in minimal
quantities, and some, such as calcium phosphate, are present in
the plasma, but are removed from the serum by the fibrin during
coagulation. The variations of the salts of the blood in health
and in disease have never been satisfactorily worked out.*^^ This
is unfortunate, for, without doubt, they exercise an important
influence upon the blood-corpuscles and upon the proteids of the
plasma. The maintenance of the molecular concentration of the
serum at a constant level, as determined by cryoscopy, is extremely
important. ^^^
The Percentage of Water in the Blood. Hydraemia. — The
relative amounts of proteids and water in the serum vary even
in health, although the limits of these variations are not accurately
known. The variations in disease have been only incompletely
studied ; ^^^ but we know that they frequently remain within
the normal limits, even in the severest diseases. The most evi-
dent thickening of the blood, i.e., the greatest relative increase
in the proteids, is seen in Asiatic cholera, and depends upon the
loss of fluids from the body.
When the unit of blood is deficient in proteid material, we
speak of an h y d r se m I a , or a watering of the plasma.^ ^^ This
condition frequently develops as a result of emaciating
diseases. If the heart and kidneys are in order, the hydraemia
140 THE BASIS OF SYMPTOMS
is probably due to a primary diminution in the pro-
teids of the blood, although we must remember that a
destruction of the proteids of the body does not necessarily pro-
duce a watery condition of the plasma. Among the emaciating
diseases which may cause an hydrsemia of this character are inani-
tion, repeated hemorrhages, anaemias, malignant tumors and
severe chronic infections. Although an hydrsemia frequently
develops in the above conditions, it does not necessarily do so.
We are not justified, therefore, in concluding that a rapid con-
sumption or a diminished supply of proteid material is alone re-
sponsible for the hydrsemias of this class. Other factors, at pres-
ent little understood, undoubtedly play a part. Until we know
more of the functions and source of the proteids of the plasma,
it will be impossible to harmonize the many contradictory facts
relating to this class of hydraemias.
It is possible that an hydrsemia may be caused not only by a
primary reduction of the proteid constituents of the blood, but
also by a primary increase in the amount of water.
The hydrsemias associated with the diseases of the kidneys and
with cardiac insufficiencies are probably in part of this nature.
According to Hammerschlag, chronic interstitial nephritis rarely
causes a watery condition of the blood, and chronic parenchy-
matous nephritis sometimes fails to do so. Hydrsemia is fre-
quently present in the latter, however, and it is most marked
when there is polyuria. Under such circumstances, the specific
gravity of the blood may fall from the normal of 1.030 to 1.020.
Other observers have obtained results which differ somewhat from
those of Hammerschlag; yet some of these, based upon total nitro-
gen determinations, must be rejected as inaccurate on account of
the frequent retention in nephritic blood of other nitrogenous
bodies than proteids.
The hydrsemia which is undoubtedly present m many cases
of nephritis can be caused only in part by the loss of albumin,
for the hydrsemia and the amount of albumin in the urine bear
no definite relation to each other. In many cases of nephritis,
water is retained in the body, for less is excreted through the
kidneys, and often less also through the skin. These two factors
— ^the loss of albumin in the urine and the retention of water in
the body — are sufficient to explain the hydrsemia present in many
cases of nephritis, though hardly in all, for some patients with
r
THE BLOOD 141
hydrsemia are excreting large amounts of urine. Recent stud-
ies ^^^ attribute the retention of water to a deficient
sodium chlorid elimination, the retained water serving
merely to restore the balance of osmotic tension. To what extent
variationsinthecolloid s — in this case the proteids of the
serum — are influential in water retention, is a question that, for
the present, cannot be answered. (See p. 93 in chapter on
oedema. )
Certain patients, suffering from heart disease in the stage
of broken compensation, show a watery condition of the blood —
both the specific gravity and the proportion of proteids in the
blood being diminished. A weakness of the right ven-
tricle is apparently the prime factor in the production of such
an hydraemia.^ ^' When the circulation improves and the venous
pressure falls, the blood tends to return to its normal composition.
This hydrsemia occurs in a comparatively small profKDrtion of all
cases of broken compensation ; but, where it does occur, it usually
disappears with an improvement in the circulation. In these
cases, the loss of proteids from the blood is ordinarily not very
great, but there is frequently a retention of water which would
tend to dilute the blood.
It seems very probable to us that the hydrsemias which accom-
pany cardiac and renal diseases are for the most part caused by
such a retention of water in the body ; that there is, in fact, an
increased quantity of watery blood in the body, a so-called
hydraemic plethora. Such an hypothesis would well ex-
plain the fact that with the development of cardiac insufficiency
not only the proteids, but the number of corpuscles to the unit-
volume of blood, are diminished, and that, with an improvement
in the circulation, the blood again becomes normal. There is no
reason why the blood should not become oedematous just as do the
tissues. Possibly the waj:er is held back in the body by substances
which attract it (see above). Grawitz believes that the increased
amount of water in the blood is derived from the lymph which
diffuses into the capillaries, owing to the low pressure existing
there. Yet we know that in the conditions under consideration,
fluids pass from the capillaries into the lymph-spaces, so that these
become distended. The relations must, therefore, be quite com-
plicated, and the final results are dependent upon which process
takes place the more rapidly.
142 THE BASIS OF SYMPTOMS
Polycythaemia. — In not a few cases of chronic stasis, the capil-
lary blood is more concentrated than normal. At least it contains
many more red blood-corpuscles and correspondingly more haemo-
globin to the unit-volume. The composition of the serum in these
cases has not yet been finally settled, but good observers ^ ^^ have
found it to be diluted. This increase in the number of the ery-
throcytes is found especially in cases of long-continued
venous stasis, such as occurs in congenital heart lesions, in
chronic pulmonary disease and in insufficiency of the right ven-
tricle. Investigations thus far have all been made upon the blood
of the cutaneous capillaries or veins, so that we are unable to dis-
cuss the relative concentration of the blood in the different vessels
of the body. The observations of Askanazy, however, would
indicate that conditions are the same in the visceral as in the
peripheral vessels — that is, that the polycythaemia is general.
The number of erythrocytes in these cases is often
very great — from six to even twelve million per cubic millimetre ;
and at the same time the serum is usually more dilute than normal.
This latter fact would seem to indicate that the increased number
of corpuscles is not due to a loss of water from the blood. Marie
and Hayem explain the increase in the number of red blood-
corpuscles as a compensatory process which tends to neutralize
the insufficient oxidation of the blood caused by the stasis. ^^®
There is another form ^^^ of polycythaemia, apparently primary
in nature, in which the corpuscular increase is persistent. This
type (polycjrthaemia rubra vera), first described by Vaquez, regu-
larly shows an increase in the red corpuscles, as high often as
ten million per cubic millimetre. This condition is due, in all
probability, to an increased formation of red cells,
rather than to a retarded degeneration, in view of the presence of
nucleated erythrocytes and of myelocytes in the
blood (Tiirk), and because of the finding of a hyperplastic red
bone-marrow. In many cases, in addition to the polycythaemia,
there is present also an enlargement of the spleen and
liver and an increased arterial tension (Geis-
bock). It is possible that nephritis and arteriosclerosis play
a part in the hypertension cases. The causes of this primary
polycythaemia are unknown. The theory that the haemoglobin is
primarily at fault and that its lessened oxygen-carrying power
necessitates a compensatory increase in the red cells is hardly
THE BLOOD 148
tenable. In the author's case, indeed, there was an increased
gaseous interchange in the tissues. A more probable explanation
is that the condition depends upon a hyperplasia of the red
marrow, of unknown origin.
Extremely interesting are the changes which take
place in the blood when an animal passes from a
region of high to one of low atmospheric pres-
sure.^^^ Within a short period of time, the number of red
corpuscles to the cubic millimetre of blood is increased, and the
haemoglobin likewise, but more slowly. These changes affect the
blood in all parts of the circulatory apparatus, though they are less
marked, possibly, in the arteries than in the veins and capillaries
of the skin. The higher the elevation, the greater is the number
of red corpuscles. The highest figures which have been reported
are from the Cordilleras, at an elevation of over twelve thousand
feet. All the animals at these heights have an extraordinary-
number of red corpuscles — the llama, for example, having sixteen
million to the cubic millimetre. The amount of oxygen in the
blood, however, is about the same as in that of animals at lower
levels. When a man or animal descends from these heights to the
sea level, the number of red cells diminishes correspondingly.
There is almost universal agreement among authors in regard to
the increase in the number of erythrocytes per unit-volume at high
elevations, and the few negative observations are due probably
to too short a stay at the high altitude, or to complicating con-
ditions, such as mountain sickness.
This increase is unquestionably caused by the
low atmospheric pressure, for it can be produced ex-
perimentally by subjecting animals to low pressures under the
air-pump. Some consider that the total number of
red cells in the body is actually increased in such
cases, and that this serves to compensate for the lessened pressure
of the oxygen in the lungs. If, indeed, new cells are formed, we
have little microscopical evidence of it, for nucleated red cor-
puscles have been seen by very few, and most authors expressly
state that they were absent. Furthermore, it is difficult on such
an hypothesis to account for the rapid disappearance of red cells
when the animal returns to a lower altitude, for positive signs of
a destruction of red corpuscles, such as jaundice and a deposition
of iron in the liver, have not been observed under these conditions.
144 THE BASIS OF SYMPTOMS
Yet we know that the absence of these signs is by no means abso-
lute proof that no destruction of the red cells has taken place,
for they have been missed in cases in which an extensive destruc-
tion certainly had occurred.
Another explanation that has been offered for the increase
in the number of the erythrocytes at high altitudes is that it is
due to a loss of water from the blood; yet this meets
with almost equal difificulties. Beyond question, the dryness of
the air, the exposure to the sun's rays, and the deeper respirations
increase the loss of water from the body, yet a healthy man would
ordinarily replace this water by taking more fluids by the mouth.
The supposed loss of water should also lead to a more concen-
trated serum, as well as to an increased number of red blood-
corpuscles; but it is very doubtful if this concentration of the
serum actually occurs. The sera of two rabbits in Basel contained
7.62 and 7.96 per cent, of solids respectively, whereas in Arosa, at
a high elevation, the percentages were 7.79 and 8.02, an incon-
siderable change compared with the changes in the erythrocytes,
Grawitz found some increased concentration in the sera of ani-
mals which had been kept under low pressures in Berlin, but here
again the increased concentration was in no way proportional
to the increase in the number of the red blood-corpuscles. Fur-
thermore, a concentration of the blood by evaporation is only
possible when the tissues likewise lose large quantities of water,
and such a loss of weight certainly does not occur either in men
or in animals subjected to low atmospheric pressures. Finally, an
increase in the number of erythrocytes also takes place when the
animals are prevented from losing excessive amounts of water by
being kept in rarefied air saturated with water vapor.
According to a third theory, the increase in the number of red
blood-corpuscles at high elevations is due to the passage of
plasma out of the blood-vessels into the lymph-
atic system. At present, this seems to be the most plausible
explanation for the known facts ; yet it is also open to objections,
especially in view of the fact that the red blood-corpuscles and
the haemoglobin do not increase at precisely the same rate.
The crucial test for deciding whether or not the haemoglobin
actually increases at high altitudes would be the determination of
the total quantity of haemoglobm in the body. If this be in-
creased in animals exposed to low atmospheric pressures, we may
THE BLOOD 145
then assume that there is indeed a total increase in the red blood-
cells and in their pigment under these influences. Unfortunately,
the experiments which have been undertaken to decide this point
have given contradictory results. Some observers found no in-
crease in the total amount of haemoglobin in the body, others have
found a slight increase, while still others have found a marked
increase. The inaccuracies in the methods for determining the
total haemoglobin in the body probably account for these discrepan-
cies in results.
An increase in the number of the red blood-corpuscles to the
unit-volume is also seen in phosphorous and carbon monoxide
poisoning, but we are ignorant as to its exact cause.
Plethora. — There is no reason a priori why an increase in the
total quantity of blood in the body should not take place,^^^ for
it is known that the parenchyma of other organs may increase in
bulk. It is impossible, however, to obtain direct proof of such an
increase so far as human blood is concerned, for as yet we have
no accurate method of determining the total quantity of the blood
in man.
The doctrine of an increased quantity of blood — a true ple-
thora— played a great role in the older hsematology, and various
symptoms were believed to be caused by the " full-blooded " con-
dition of the patient. While we must acknowledge that many of
these cases will not stand the rigid criticism of modern times, and
that the anaemia of many of these individuals was the probable
cause of their symptoms, yet there are certain facts which favor
a belief in the occurrence of a true plethora. Thus, many patients
feel better after having been bled, and although this fact is in no
sense a proof that a condition of plethora existed previous to the
bleeding, nevertheless it cannot be entirely disregarded. More
important is the testimony of such pathologists as v. Reckling-
hausen and Bollinger, who give it as their impression that at
autopsy many bodies seem abnormally rich in blood. That the
amount of blood in animals may vary greatly not only in different
species, but in different individuals of the same species, has been
definitely proved by the work of Bergmann and Bollinger. They
have demonstrated that the character of the food may exert a
marked influence upon the total quantity of blood in the bodies of
animals.
We are justified in suspecting a condition of plethora whenever
10
146 THE BASIS OF SYMPTOMS
an individual who habitually consumes excessive amounts of food
and drink, and who has large muscles and much fat, shows a
continued hypersemia of the surface of his body, and has an
enlarged heart, a full pulse and wide arteries. Although we may
be unable to prove that a plethora exists in such individuals, never-
theless the experience of pathologists, and the experimental evi-
dence above referred to, both justify such a probable diagnosis.
The interesting observations of Geisbock^^^ would indicate that
a plethora of this kind may accompany a condition of hyper-
globulism and increased blood-pressure (polycythaemia
hypertonica).
Certain observations seem opposed to the doctrine of plethora,
more especially the fact that if animals are infused with sera
or salt solution, the excess of fluid is rapidly removed from the
circulation, and no increase in the total quantity of blood is pro-
duced. Yet the conditions of such an experiment are quite dif-
ferent from the chronic changes which are believed to lead to
plethora in man ; and, furthermore, it is quite possible that under
pathological conditions the ability thus to remove large quantities
of fluid from the circulation may be lost.
We hold, therefore, that although the doctrine of a true
plethora has not been absolutely proved, its existence is very
probable. The long-continued ingestion of excessive amounts
of food seems to be the most potent causative factor. Yet it is
apparently only one factor, and others of which we are now
ignorant may play a part in its causation.
Until recently, the doctrine of a diminution in the total quan-
tity of blood was as little capable of direct proof as was the doc-
trine of plethora. The improvements in the methods ^^^ for the
determination of the total blood mass have brought with them a
greater accuracy in this respect, with the result that clinicians,
as well as pathologists, have been strengthened in their belief that a
plethora does exist. Especially interesting is the plethora of
chlorosis, nephritis and of polycythaemia. In severe anaemias, on
the contrary, there would appear to be a diminution not only in the
number of cells to the unit of volume, but in the quantity of blood
as a whole.
LITERATURE
* Newer works on haematology: Tiirk, Klin. Hamatologte ; Pappenheim,
Folia hamatologica ; Naegeli, Blutkrankh. u. Blutdiagnostik, 2nd edit.,
1912; Straus, Blutkrankh., in v. Noorden's Handb. d. Path. d. Stoflf-
THE BLOOD 147
wechs., and edit., 1906 (Metabolism and Practical Medicine) ; Hunter,
Severest Anaemias, 1909; Ehrlich, Lazarus and Naegeli, Die Anamie,
2nd edit., 1909. For the pathology of the blood in childhood, see Flesch,
Ergeb. d. inn. Med., 1909, iii, and Japha, in Pflaundler and Schlossmann,
1910, ii.
' Erben : Ueber d. chem. Zuzammensetzg. d. Blutes, etc., 1905.
•Pappenheim: Fol. hamatol, ix, II, 177.
* Hamburger : Osmot. Druck. u. lonenlehre, Wiesbaden, 1902 and 1904; Over-
ton, in Nagel's Handb. d. Physiologic, ii, 828; v. Koranyi and Richter, in
Physikal. Chemie u. Medizin, 1907, i, 265.
'Inagaki: Zeitschft. f. Biol., 1907, xlix, JT, Stornjakoff, Arch. f. klin. Med.,
ci, 251.
' Quincke : See Stiihlen, Arch, f , klin. Med., liv, 248 ; Meyer, Ueber Resorp-
tion u. Ausscheidung d. Eisens, in Asher-Spiro, Ergeb., 1906, v.
^Ehrlich: Kongr. f. inn. Med., 1892, 39; Dunin, Volkmann's Vortrage, N.S.,
cxxxv, 413.
* Cohn: Miinch. med. Wochenschft., 1900, No. 6 (lit.).
* Neumann : Virchow's Arch., cxix, 385 ; Noll, in Asher-Spiro, Ergebnisse,
1903, ii ; Seemann, ibid., 1904, iii.
'^ See Naegeli, Blutkrankheiten, 2nd edition.
" Neumann : 1. c.
" Graeber : Zur Diagnostik d. Blutkrankheiten, Studies from the Medico-
Clinical Institute, Munich, 1890, ii ; v. Noorden, in Nothnagel's System.
" For a contrary opinion, see Byron Bramwell, Clinical Studies, 1907, v.
** Graeber : 1. c. ; Naegeli, Die Blutkrankheiten ; Morawitz, Munch, med.
Wochenschft., 1910, No. 27.
"Limbeck: Klin. Path. d. Blutes.
" Morawitz : 1. c. ; Seiler, Korresp.-Blatt f . Schweiz. Aerzte, 1909, No. 17.
"See especially v. Noorden, 1. c. ; Grawitz, Klin. Path. d. Blutes, 191 1.
" Birch-Hirschfeld : Kongr. f . inn. Med., 1892, 17 ; Grawitz, 1. c.
^ Kongr. f. inn. Med., Munich, 1895; Wandel, Arch. f. klin. Med., xc, 52.
'"v. Noorden: 1. c, 68 (lit.).
° Meyer : Ergebn. d. Physiol., 1906, v ; Morawitz, 1. c.
^ Gerhardt : Kongr. f. inn. Med., 1910.
" Miiller, Munck et al. : Virchow's Arch., cxxxi, Suppl.
** V. Hosslin : Miinch. med. Wochenschft., 1890, Nos. 38 and 39.
"•Sahli: Schweiz. Korrespondenzblatt, 1886, Nos. 21 and 22; Vermehren,
reviewed in Deutsch. med. Wochenschft., 1903, No. 16.
** Naegeli: 2nd edition (lit.).
"Klin. Path. d. Blutes, 297.
" Rumpf : Mittheil. aus d. Hamburger Staatskrankenanstalten, iii, 1.
"Nonne: Arch. f. Psychiatric, xxv, 421; Zeitschft. f. Nervenheilk., vi, 311,
and xiv, 192; Mosse and Rothmann, Deutsch. med. Wochenschft., 1906,
Nos. 4 and 5.
^ Pappenheim : Fol. hamatol., x, II, 217 ; Roth, Zeitschft. f. klin. Med., 1914,
Ixxix, 266.
"Hunter: Severest Anaemias, 1909. Sec Med. Klinik, 1908, Nos. 41-43 for
a comprehensive survey of the etiology, diagnosis and treatment of per-
nicious anaemia.
** For a very complete discussion and literature on the etiology of pernicious
anaemia, see Naegeli, 2nd edition, 1914 ; also Grawitz, 4th edition. See also
Schnitter, Arch. f. klin. Med., 1915, cxvii, 151.
"Meyer and Heineke: Miinch. med. Wochenschft., 1906, No. 17; Gesell. f.
Morph. u. Physiol, in Munich, 1908, V.
"^Schaumann and Tallquist: Deutsch. med. Wochenschft., 1898, No. 20;
Tallquist, Zeitschft. f. klin. Med., Ixi, 427-
"Bang: Ergeb. d. Physiol., viii, 463; Korschun and Morgenroth, Berl. klin.
Wochenschft, 1902, No. 37; Kongr. f. inn. Med., 1910; Schaumann,
Deutsch. med. Wochenschft., 1910, No. 26.
148 THE BASIS OF SYMPTOMS
" Syllaba : Reviewed in Fol. hamatol., 1904, i, 283.
"Eppinger: Wiener Gesell. f. inn. Med., April 15, 1913; Decastello, Wiener
Gesell. d. Aertze, May 30, 1913; Klemperer and Hirschfeld, Therap. d.
Gegenwart, 1913, No. 9 ; Tiirk, Deutsch. med. Wochenschft., 1914, No. 8.
•* Pappenheim : Fol. hamatol., 1908, v, 758.
** Aubertin : Les reactions sanguines, These de Paris, 1905.
** Blumenthal and Morawitz : Arch. f. klin. Med., xcii, 25.
*^ Lazarus : Die Hamoglobinamie, in Nothnagel's System.
**Albrecht: Verhandlg. d. path. Gesellschaft, 1903, 104; Koeppe, Pfliiger's
Arch., xcix, 33.
**Hoflfmann: Konstitutionskrankheiten, 185 (lit.); Ponfick, Virchow's Arch.,
Ixxxviii, 445.
** Pascucci : Hof meister's Beitrage, vi, 543, 552.
" Chvostek: Uber d. Wesen d. paroxys. Hamoglob., 1894 (lit.) ; Stempel, Zen-
tralbl. f. d. Grenzgeb., 1902, Nos. 5 and 7 (lit. to 1900) ; Widal and Ros-
taine, C. r. soc biol., 1905 ; Donath and Landsteiner, Zeitschft. f . klin.
Med., Iviii, 173 ; Eason, Jour, of Path, and Bact., xi, 167 ; More, Noda and
Benjamin, Munch, med. Wochenschft., 1909, No. 11.
*• Donath and Landsteiner : 1. c. ; Zentralbl. f . Bakt., xlv, 205.
** Graf e and Miiller : Arch, f . exp. Path., lix, 97.
** Choroschiloff : Zeitschft. f . klin. Med., Ixiv, 430 ; Meyer and Emmerich,
Arch. f. klin. Med., xcvi, Nos. 3 and 4.
*• Landsteiner and Leiner : Zentralbl. f . Bakt, xxxviii, 458.
** Wilms: Mitth. a. d. Grenzgeb., viii, 393; Hedinger, Schweiz. Korrespon-
denzblatt, 1907, No. 20.
"Hoffmann: (footnote 43); v. Mering, Das chlorsaure Kali, 1885; Falken-
berg, Diss. Marburg, 1890 (Marchand).
"* Marchand : 1. c. ; Limbeck, Arch, f . exp. Path., xxvi, 39.
"Morawitz: Arch. f. klin. Med., Ixxix, I.
"* Silbermann : Virchow's Arch., ccxix, 488; Welti, Ziegler's Beitrage, iv,
519; Wilms, Grenzgebiete, viii, 393.
" Schmidt : Arch, f . klin. Med., xci, 225.
** Cf. footnote i and also Sternberg, Path. d. Primarerkrankungen d. lymphat.
u. hamatopoietischen Apparate, 1905; Helly, Die hamatopoietischen Or-
gane, 1906; Turk u. Schridde, Verhandl. d. 80. Naturforschervers.,
Cologne, 1908; Pappenheim, Fol. hamatologica (many studies).
•' D. neutroph. Leukozyten, etc., 1904 ; Hiller, Fol. hamatolog, ii, 85.
"Bourmoff and Brugsch: Zeitschft. f. klin. Med., Ixiii, 489; Pollitzer, Arch.
f. kUn. Med., xcii, i ; Naegeli, Blutkrankheiten, 2nd edit., 2^3 (lit.).
^ Brandenburg : Miinch. med. Wochenschft., 1900, No. 6 ; E. Meyer, ibid.,
1903, No. 35-
•* Schultze : ibid., 1909, No. 4, and 1910, No. 42 ; Winkler, Fol. hamatol., iv, 32.
"Herz: Die akute Leukamie, 191 1; Naegeli, 1. c.
" See especially Pappenheim : Virchow's Arch., clvii, 54 ; clix, 40 ; clxiv, 374 ;
Fol. hamatolog., 1904-1908; Atlas d. mensch. Blutzellen; Blumenthal, La
genese des cellules sanguines, 1904; K. Ziegler, Exp. u. klin. Untersuch.
ii. d. Histogenese d. myeloid. Leukamie, 1906.
•*Goodall, Gulland and Paton: Journ. of Phys., xxx, i.
•* Grawitz : Deutsch. med. Wochenschft., 1910, No. 29; EUermann and Erland-
sen. Arch. f. exp. Path. u. Pharm., Ixiv, 28.
*° Schwenkenbecher and Siegel : Arch, f . klin. Med., xcii, 303.
'° Ziegler and Schlecht : Arch, f . klin. Med., xcii, 564.
" Bestelli, Falta and Schweiger : Zeitschft. f . klin. Med., Ixxi.
** Lowit : Studien z. Phys. u. Path. d. Blutes u. d. Lymphe, 1892 ; Goldscheider
and Jakob, Zeitschft. f. klin Med., xxv, 403; Fohl, Arch. f. exp. Path.,
XXV, 51.
•»v. Limbeck: L c, 267 (lit).
"Brown: Jour, of Exp. Med., 1898, No. 3; Staubli, Die Trichinosis, 1911.
*^ Heineke and Deutschmann : Munich, med. Wochenschft., 1906, No. 17 ;
Staubli, Ergeb. d. inn. Med., 1910, vi.
THE BLOOD 149
"Schwalbe, in Lubarsch-Ostertag, Ergeb., 1904, viii, 150; Aynauds, Le
globulin des mammi feres, These de Paris, 1909.
'* Abderhalden and Deetjen: Zeitschft. f. physiol. Chem., liii, 280; Deetjen,
Virchow's Arch., clxiv, 239.
" Newer literature : Sternberg, Pathol, d. Primarerkrankung d. lymphat. u.
hamapoiet. Apparates, 1905 ; Schridde, Miinch. med. Wochenschf t., 1908,
No. 20; V. Domarus, Fol. hamatolog., 1908, vi, 337; Ebstein, Path. u.
Thierap. d. Leukamie, 1909; Herz, Die akute Leukamie, 191 1; numerous
studies in the Folia hamatologica, 1904-15.
" Helly : Die hamatopoietischen Organe, 1906.
"Ziegler: Fol. hamatolog., vi, 113; Butterfield, Arch. f. klin. Med., xcii, 336;
Fischer, Myeloische Metaplasie u. fotale Blutbildung, 1909.
" In the Nothnagel System.
"Kongr. f. inn, Med., 1905,
"Koranyi: Berl. klin. Wochenschft., 1912, xlix, 1357. Literature to 1913
in Sappington and Pearson, Jour. Am. Med. Assn., 1914, Ixiii, 143.
**MiilIer: Zentralbl. f. Path., 1894, 623 (lit.); Tiirk, Wiener klin. Wochen-
schft., 1907, No. 6.
"v. Leube: Ueber Leukamie, Deutsche Klinik, III; Nsegeli, Die Blutkrank-
heiten (contrary view).
^'De la Camp: Therap. d. Gegenwart, 1905 (lit.) ; Helber and Linser, Arch. f.
klin. Med., Ixxxiii, 479.
**For a discussion of this subject and the complete literature, see Herz, Die
acute Leukamie.
**Berl. klin. Wochenschft., 1887, Nos. 31 and 45; Hoffmann, 1. c, 106; West-
phal. Arch. f. klin. Med., li, 103.
" Marchand, published by Claus : Ueber das maligne Lymphom, Dissert. No.
SI, Marburg, 1888; Benda, Kongr. f. inn. Med., 1897, 380.
**Dennig: Miinch. med. Wochenschft., 1901, No. 4.
*' Cf. Naegeli : 1. c. ; Schridde, Miinch. med. Wochenschft., 1908, No. 20.
** Pappenheim : Fol. hamatol., ii, 291 ; Verhandl, d. Berl. hamatolog. Gesellsch.,
ibid., 1909, vii; K. Ziegler, Die Hodgkinsche Krankheit, 191 1.
**0. Meyer, and K. Meyer: Berl. klin. Wochenschft., 1912, No. 36; Blumberg,
Mitth. a. d. Grenzgeb., xxiv, 1912; Jacobsthal, Munch, med. Wochenschft.,
1910, No. 19; Beumelburg, Beitr. z. Klinik. d. Tuberk., 1912, xxiii; Negri
and Mieremet, Centralbl. f. Bakt., 1913, Ixviii; Hirschfeld, Ergeb. d. inn.
Med., 191 1, vii, 161; Steiger, Zeitschft, f. klin. Med., 1914, Ixxix, 452.
"Johns Hopkins Hosp. Reports, x, 133 (lit. to 1902); Longcope, Bull, of
the Ayer Clin. Lab., No. i; Simmons, Jour, of Med. Research, ix; Gib-
bons, Am. Jour, of Med. Sci., cxxxii. No. 11.
*^ Munch, med. Wochenschft., 1910, No. 13 ; Zeitschft. f. Hyg., 1910, Ixvii ;
Fraenkel, Miinch. med. Wochenschft., 1911, No. 23, and Deutsch. med.
Wochenschft., 1912, No. 14.
"Arch, of Int. Med., 1913, 236; Bunting, Jour. Am. Med. Assn., 1913, Ixi,
1803 ; Billings and Rosenow, ibid., 2122.
"Johns Hopkins Hosp. Bull., xxii, 369, and xxv, 173.
•*Banti: Zentralbl. f. Path., xv, i; Sternberg, Verhand. d. path. Gesellsch.,
1903, vi, 30, 34-
•° Fabian, Naegeli and Schatiloff : Virch. Arch., clxxxx, 436.
"Ellermann and Bang: Zentralbl. f. Bakt., 1908, xlvi, No. 7; Zeitschft. f.
Hyg. u. Inf ektionskrank., Ixiii ; Jutaka Kon, Virch. Arch., clxxxx.
" Moll : Wiener klin. Wochenschft., 1903, No. 44.
•"Pfeiffer: Zentralbl. f. inn. Med., 1904, No. 32.
•* Morawitz and Rehn : Arch, f . exp. Path., 1907, Iviii, 41 ; Langstein and
Meyer, Hofmeister's Beitrage, v, 69.
*"" Schittenhelm and Lutter : Zeitschft. f . exp. Path., ii, 562.
*""Arch. f. klin. Med., xcix, Nos. 5 and 6; Morawitz and Lessen, ibid., xciv,
no.
^"Rumpf : Virch. Arch., clxxiv, 163.
160 THE BASIS OF SYMPTOMS
White: Lancet, 1903, 1007; Magnus-Levy and Meyer, in Oppenheimer,
Handb. d. Biochem., 1908, iv, 459.
*** Halliburton : TTie Essentials of Chem. Physiology, 1909; Hammarsten,
Lehrb., 7th edition, 1910 (translation 1911).
**" Morawitz and Oppenheimer : Handb. d. Biochem., 1908, 91.
*•* Oppenheimer : Die Fermente u. ihre Wirkungen, 2nd edit., 1909.
*" Brieger and Trebing: Berl. klin. Wochenschft, 1908, 1041, 1349; v. Berg-
mann and Meyer, ibid., 1908, No. 37.
*°* Strauss: Die chron. Nierenkrankh., etc., 1902 (lit.); v. Noorden, Handb.
d. Path. d. Stoffwechs., 2nd edition, i, 1026; Letsche, Zeitschft. f. physiol.
Chem., 1907, liii, 31. For other literature, see pp. 427, 430 (renal func-
tion).
*°*Bingel: Zeitschft. f. physiol. Chem., Ivii, 382; Howell, Am. Jour. Physiol-
ogy, 1906, xvii, 273.
"'Zeitschft. f. physiol. Chem., 1913, Ixxxviii, 478.
"^Jour. Pharm. and Exp. Therapy, 1914, v, 275, 6n.
*" Albu and Neuberg : Physiol, u. Path. d. Mineralstoffwechsels, 1906.
"' Hamburger : Osmot. Druck u. lonenlehre, 1902.
"* Morawitz: Oppenheimer, Handb. d. Biochemie, 1910, iv (Path. d. Wasser-
u. Mineralstoflfwechsels).
*" V. Limbeck : Klin. Path. d. Blutes, 2nd edit., 86.
"* Widal : Les regimes dechlorures, etc., Congres f rangais de med., Liege,
1905 ; Ambard, Les retentions chlorures, Paris, 1905.
"^ Stintzing and Gumprecht : Arch, f . klin. Med., liii, 265 ; Grawitz, ibid., liv,
588.
"* Hammerschlag : Zeitschft. f . klin. Med., xxi, 475 ; Grawitz, 1. c.
^ Literature on this type : Hess, Arch. f. klin. Med., Ixxix, 128 (lit.) ; Marie,
Mercredi med., 1895, No. 3; Hayem, ibid.. No. 4; Fromherz, Miinch. med.
Wochenschft., 1903, No. 40.
""Vaquez: C. r. soc. biol.. May 7, 1892; Osier, Am. Jour. Med. Sc, August,
1903; Tiirk, Wiener klin. Wochenschft., 1904, Nos. 6 and 7; Geisbock,
Arch. f. klin. Med., Ixxxiii, 396; Senator, Die Polyzythamie, 1910.
"^ Jaquet : Ueber d. physiol. Wirkung d. Hohenklimas, Programm. Basel, 1904 ;
Douglas, Haldane et al., Phil. Trans., London, 1913, B. 203, 185 ; Masing
and Morawitz, Arch. f. klin. Med., xcviii, i ; Cohnheim and Weber, ibid.,
1913, ex, 225; Laquer, ibid., 189; Fitz Gerald, Proc. Roy. Soc. (B), 1914,
Ixxxviii, 248.
"** Meyer: Jahreskurse f. arztl. Fortbild., March, 1910.
"* Geisbock : Arch, f . klin. Med., Ixxxiii, 396.
^Haldane and Smith: Jour, of Physiol., xxv, 334; ibid., xliv, 305; Plesch,
Hamodynamische Studien, 1906; Morawitz and Siebeck, Arch. f. exper.
Path. u. Pharm., lix, 364.
CHAPTER III
INFECTION AND IMMUNITY
( With the Collaboration of Dr. E. Levy, Strassburg)
In this chapter we purpose considering the various means by
which the animal body resists the invasion of pathogenic micro-
organisms.^
The Portals of Entry. — How bacteria, under ordinary con-
ditions, gain entrance to the body is still not definitely known.
The body-surfaces are constantly beset by innumerable micro-
organisms, among them the ordinary agents of inflammation and
suppuration : they are present on the skin, in the nose and mouth,
in the trachea and gastro-intestinal tract, and in the vagina and
urethra. Despite their intimate relation to the major part of
those surfaces which lie between the organs and the outer world,
they seldom gain access to the former ; at least, according to our
present conception, morbid processes are initiated with relative
infrequency by bacteria which are normally present on these
surfaces.
It is evident, therefore, that some protective mechanism holds
the organisms in check — this protective function, without doubt,
residing in the cells which constitute these surfaces (see below) ;
for the normal epithelium of the skin and of the
respiratory and digestive tracts is able, as a rule,
to prevent the invasion of micro-organisms.
Solid particles other than bacteria encounter an equal diffi-
culty. In the case of mercurial ointment, which seems to be an
exception to this rule, soluble fatty-acid salts ^ are no doubt
formed on the skin in a manner analogous to the emulsification
of fat before its absorption by the intestines. In view of the
fact that leucocytes can pass between the epithelial cells, it is
possible that they may carry back with them bacteria which they
have taken up on the body-surfaces. Were this true, it would
indeed be a marvellous process, for the body would thereby infect
itself. The ingested bacteria would, undoubtedly, be destroyed in
many instances by the white cells ; yet this would not be the case
in aerogenic tuberculosis of the bronchial lymph-nodes. Here the
151
152 THE BASIS OF SYMPTOMS
survival of the bacteria, per se, might be regarded as evidence
of the disease and indeed its very incipiency. And in the present
status of our knowledge this would actually seem to be true.
This migration of the leucocytes might have a double purpose :
first, to carry to the organs the solid portions of the food, and
secondly, to take up the bacteria similarly as solid particles, rely-
ing upon their ability to destroy them. Such a mechanism would
be advantageous to the body, in that, without danger, it could pro-
tect itself against certain micro-organisms.
The acute infections due to the entrance of
bacteria through the skin presuppose an injury to the
epithelium, which may, however, be insignificant.^ Thus Garre
was able to produce a genuine furuncle on his left arm by rubbing
staphylococcus pyogenes into the skin; and guinea-pigs may be
infected with plague by rubbing the cultures into the freshly-
shaved skin. The minimal injury to the epithelium in. both of
these examples enabled the micro-organisms to enter.
Our knowledge of the method by which infections
enter through the mucous membranes is very lim-
ited. Tonsillar diseases appear to play an important role
in predisposing to infections with the pyogenic cocci. The wan-
dering of the leucocytes through the epithelium of the tonsils, and
the frequent local lesions, render them especially permeable to
bacteria, and in turn to a general bactersemia.
The nose, with the accessory sinuses and the
nasopharynx, catches and holds in its numerous corners
and folds the micro-organisms that enter. Its lymphatic tissues,
and especially the nasal tonsil, are exposed to the same dangers as
are the faucial tonsils. The secretions of the nose are bacteri-
cidal; but in the rat, at least, this does not afford efficient pro-
tection against plague bacilli, for the introduction of a few of
the latter into the nose of this animal will lead to a fatal infection.
(The importance of so-called focal infections *has only re-
cently, it would seem, received the emphasis it deserves. That
a systemic or localized disease may arise on the basis of a pre-
existing sluggish, or even latent, infectious focus, has l6ng been
known. It is to clinical and experimental observations of the last
few years, however, that we owe a better understanding of the
part these infections play in pathological processes.
The focus is most commonly located in the head, the ton-
INFECTION AND IMMUNITY 163
sils and the lymphatic tissues of the nasopharynx being the
favorite sites. An infected tonsillar crypt, often in a deeply buried
organ, which may have caused few if any symptoms, is a frequent
finding. Chronic alveolar abscess, infections of the nasal sinuses,
of the middle ear and mastoid, and less often of the gall-bladder,
appendix or prostate, may be foci in other cases.
The morbid processes induced by bacteria, or bacterial toxins,
emanating from these sources are manifold ; and they may be acute
or chronic in nature. To the former belong rheumatic fever,
endocarditis, both ulcerative and benign, and the different bacter-
aemias; to the latter, chronic arthritis (often the so-called arthritis
deformans), myocarditis, nephritis and degenerative changes in
the vessel-walls.
The brilliant results in many cases following the surgical re-
moval of the offending focus speak forcefully for the correctness
of this conception of the significance of focal infections.
It was in connection with his studies on focal infections that
Rosenow^ elaborated his view of mutation in the strep-
tococcus-pneumococcus group. This would say, in
brief, that the streptococcus, the organism most frequently con-
cerned in these infections, may undergo changes in pathogenicity
and in cultural characteristics by a variation in the conditions of
growth and by animal passage. Thus in one phase of mutation
the streptococcus may cause an arthritis, in another an endocar-
ditis, and in still another a pneumonia. The production of acute
gastric ulcer,^ as a mutation phase, will be discussed in another
place. — Ed. )
Theair-passagesof healthy individuals, below the upper
part of the trachea, are generally considered sterile; only on forced
inspiration may bacteria penetrate to the finer bronchi. Should
the bacteria penetrate to the alveoli themselves, the delicate epi-
thelium of the air-cells would hardly prevent them from passing
through, for we know that solid particles, if inhaled in great
numbers, such as occurs in the dust-diseases, are often deposited
in the pulmonary tissues. Many observers believe that bacteria
may similarly enter the lungs if they are sufficiently numerous in
the inspired air. Such invaders may cause diseases of the lungs
themselves, or they may be carried to the neighboring lymph-
nodes, there to multiply, or to be destroyed or to remain latent.
The lungs seem to be well equipped to destroy bacteria that may
154 THE BASIS OF SYMPTOMS
reach them, and even though they become inflamed, this inflamma-
tion may protect the rest of the body from a general invasion.
Indeed, it seems to be rare for a general infection to gain admit-
tance to the body via the lungs, without causing a primary disease
of these organs or of their lymphatic apparatus.
The factors which favor an infection of the
air-passages have been accurately determined in animals,'^
much more so, indeed, than in man. A large number of
micro-organisms in the inspired air undoubtedly
favors infection, especially if the individual breathes deeply. These
bacteria may be present not only in dry dust, but may be car-
ried by minute moist droplets which have been thrown out into the
air by other persons in coughing, sneezing or talking.* Infection of
the lungs may also be induced by the aspiration of substances, such
as food and water, carrying bacteria in with them.
The virulence of the bacteria inhaled is also of
importance, as is likewise an inflammation of the upi>er air-
passages, which favors the migration of micro-organisms into the
lungs. Exposure to cold and to dampness is generally
believed to predispose to the development of infectious processes
in the bronchi and lungs, possibly by lowering the resistance of the
epithelial linings. If the inspired air is not filtered by passage
through the winding upper respiratory tract, infection of the lungs
is directly favored; for this reason a tracheal cannula is always
a menace. Animals with weak respiratory muscles are prac-
tically certain to die if they breathe through such a cannula ; and,
for the same reason, inflammations of the air-passages are rela-
tively frequent in mouth-breathers.
The gastro-intestinal tract is continually receiving
micro-organisms which have been swallowed in the food and
saliva. Some of these are quickly destroyed by the action of
the hydrochloric acid; yet since the stomach begins to empty itself
shortly after the food enters, and since the acid first secreted is
bound by the proteids of the food, and since, finally, the gastric
juice does not penetrate the interior of many large food particles,
the possibility always exists that virulent organisms will pass
through the stomach into the intestines.
As to the bowel itself, it may be said, in general, that solid
particles, without amoeboid movements, are unable to penetrate
the intact mucous membrane, even fat first requiring emulsifi-
INFECTION AND IMMUNITY 155
cation. Though phagocytic white cells are able to pass between
the epithelial cells, it is still undetermined whether they can carry
back with them solid substances. It is possible that micro-organ-
isms penetrate the bowel wall in some way peculiar to themselves.
That penetration does occur is illustrated in the case of cholera, of
tuberculosis and of trypanosomiasis. The crucial question is
whether the organisms can pass through an intact epithelium or
must first injure the latter in such a way as to facilitate their
entrance. Ficker^ found in rabbits, dogs and cats of the suckling
age that the normal epithelium was no barrier to the passage of
bacteria, while in adults of the same species, a certain period of
fasting was necessary to render the epithelium permeable. Hard
work, thirst, and inflammatory changes in the intestinal lining are
all factors favoring the penetration not only of micro-organisms,
but also of proteid substances, ferments and toxins, according to
Holle.i<^
Baumgarten^^ has shown experimentally that tubercle bacilli
rapidly disappear from the intestinal contents, and that a few
may afterwards be found in the lymphatic follicles and nodes
of the intestines, having been carried in, in all likelihood, during
the absorption of fluid. As the tubercle bacilli are not motile,
and as there is no evidence that the leucocytes have carried the
bacilli through the mucosa, the conception of a transportation by
the fluids absorbed seems not unlikely, particularly in view of
the very low specific gravity of the Koch bacillus.
It is not impossible that the mode of penetration is peculiar
to the organism. Thus the typhoid bacillus and the cholera vibrio
multiply prodigiously in the lumen before invading the mucosa,
thereby possibly producing toxins which first injure the epithelium
and pave the way. In dogs, for example, the congestion caused
by podophyllin renders the intestinal lining permeable to bacteria.^ ^
And, finally, the possibility of organisms entering the blood during
digestion has never been disproved.
Granting that bacteria can penetrate the intact intestinal wall,
they certainly cannot do this easily, and many circumstances in-
fluence the process. In the first place, the number of bac-
teria present is of great importance. Then, too, a rapid
transit through the intestines may serve as a protec-
tion against invasion. Possibly this is the reason that many
diseases of the intestines, such as typhoid fever, affect principally
156 THE BASIS OF SYMPTOMS
the ileum, where peristalsis is slower than in the jejunum, and
where the organisms have a better chance to cling to the walls and
multiply. Furthermore, as is well known, thenormal floraof
the intestines may cause strange bacteria to dis-
appear by outgrowing them; and thus many pathogenic
micro-organisms, if introduced into the intestines, rapidly disap-
pear without producing symptoms. Finally, the normal
mucous membrane seems to have the property of
exerting a destructive influence upon the micro-
organisms in the intestinal canal. ^^ Toxins, except-
ing that of botulism, are not absorbed by the normal mucosa of
the bowel ; they are either destroyed or rendered non-toxic by the
digestive fexments.
Conditions in the vagina are somewhat similar to those
in the bowel. There, also, we have a normal flora, which may
injure strange invaders ; while the acid reaction of the secretions
of the vagina is unfavorable to the development of most patho-
genic bacteria.
It is evident from all that has been said, that numerous de-
fenses against the invasion of micro-organisms are present on
the surfaces of the body. The difficulty of passing the intact epi-
thelium, the acidity and bactericidal properties of many of the
secretions, the conflict with the normal flora — all of these serve
to protect the body against bacterial invasion. The very efficacy
of these barriers resides, it would seem, in their complexity.
V, Behring ^^ has called attention to the fact that an animal may
be highly susceptible to inoculation with a micro-organism and yet
be quite insusceptible to the corresponding natural disease, appar-
ently because it is able to prevent the entrance of the organism into
its body (mouse anthrax, guinea-pig tuberculosis). Infection
under natural conditions is, therefore, a complicated process and
points to the breaking down of the defensive forces at the body
surfaces.
The Factors Determining the Character of an Infection. —
The manifestations of infection vary considerably, depending
upon the virulence of the invading organisms, the number of the
latter, their toxicity, the portal of entry and the resistance of the
individual.
Upon what factors the virulence of micro-organisms depends
INFECTION AND IMMUNITY 157
is only partly understood. With a few exceptions, such as an-
thrax and plague, the virulence varies considerably from time to
time, and even during the course of a single infection. As a
rule, it increases up to the height of a disease and diminishes with
convalescence. Organisms possessing capsules are in general less
readily destroyed than those without. Bail and his co-workers ^^
believe that the virulence of bacteria depends upon substances they
secrete, called by them aggressins, which keep the phagocytes at a
distance. This conception, however, is by no means generally held.
Though the contagiousness of a disease ordinarily runs hand in
hand with the virulence of the causative organism, this need not
be true, as is proved by an epidemic of typhoid fever which we
observed. The mode of transmission was by direct contact, and
in the seventy cases there were no deaths, despite the fact that the
majority were in children and many in enfeebled individuals.
The number of micro-organisms introduced into the body is
also of great importance. A certain number of even highly
virulent bacteria is necessary in order to cause a fatal infection.
This minimum lethal dose varies indirectly as the resis-
tance of the animal and directly with the virulence of the bacteria.
Only a very few of the most virulent may be necessary to infect
highly susceptible animals. If more are introduced, the period
of incubation becomes shorter and death follows more quickly.
The portal of entry of infecting organisms influences both the
character and the course of the infection. If bacteria are intro-
duced directly into the blood-stream, as happens in general in-
fections with the pus cocci, or with the bacilli of anthrax or tuber-
culosis, the resulting disease runs a stormy course. Furthermore,
the same staphylococci which will cause a pyaemia if introduced
into a vein, usually produce only a local lesion if injected subcu-
taneously. There are indeed exceptions to this general rule.
Cattle, for example, are readily infected with rauschbrand subcu-
taneously, but withstand intravenous injections of the same
material ; and man is most susceptible to the cholera vibrio when
the latter is in the gastro-intestinal tract.
The virulence of infecting micro-organisms, and their tendency
to cause a general intoxication, depend to a great extent upon the
toxins they produce. In the case of the diphtheria and tetanus
bacilli these toxins pass into solution; and filtered cultures con-
taining these soluble poisons give rise to the same symptoms as
158 THE BASIS OF SYMPTOMS
do the bacilli themselves. The bacterial toxins resemble ferments
in many ways, for example, in their susceptibility to moist heat, to
light, to oxygen, etc. Their extreme potency, exceeding that of
any other known substance, also suggests a relationship to the
enzymes.
The method of dissemination of tetanus toxin is quite
unlike that of any known alkaloidal poison, such as strychnin, for
example. The latter is carried to the susceptible cells by the blood-
current, whereas tetanus toxin travels through the nerves from
the point of infection to the central ganglion cells, upon which it
exerts its poisonous action.^* These ganglion cells cannot be
reached directly by way of the blood or lymph, though they are
affected by injections of the toxins directly into the nerves or into
the spinal cord. It is this mode of diffusion of the tetanus toxin
that renders so unsatisfactory the specific therapy of the disease.
(Recent clinical and experimental studies ^'^ point the way to a
more rational and successful treatment of tetanus. The use of
antitoxin as early as possible, and the employment of a suffi-
ciently large dosage — injected at the outset intravenously and
intraspinously, and later subcutaneously, in order to maintain the
antitoxin content of the blood at an efficient level — ^have materially
lowered the mortality statistics of those who have employed this
method. — Ed. )
When the injections of tetanus toxin are made into the cord,
the incubation period intervening before the development of
symptoms, which is otherwise so prolonged in tetanus, is much
shortened or entirely absent. The incubation period for tetanus,
therefore, appears to be the time consumed by the toxin in travel-
ling from the point at which it enters the body to the cells upon
which it exerts its poisonous action. This mode of dissemination
explains the fact that in experimental tetanus the spasm first
develops in the extremity infected ; for the toxin travelling up the
nerve, first acts upon the corresponding part of the cord. In man,
however, the muscles of the jaw are usually first affected.
Diphtheria toxin, in so far as it affects the nervous sys-
tem, may likewise travel along the nerves, for it is a well-known
clinical fact that the nerves most frequently paralyzed are those
situated in the neighborhood of the local lesion. The virus
of hydrophobia, and of acute anterior poliomyelitis, also
progress along the nerve trunks.
INFECTION AND IMMUNITY 159
Potent toxins can be extracted from the bodies of many bac-
teria which previously have been carefully killed. This was first
demonstrated by Pfeiffer in the case of the cholera vibrio, and later
was shown to be true also of the typhoid and colon bacilli and of
other organisms. These poisons are called endotoxins be-
cause they adhere very closely to the bodies of the bacteria, and
unlike the toxins of diphtheria and tetanus, are practically insolu-
ble. They may be compared with the endoenzymes of the yeast
plant. With every infection, therefore, there is an intoxication
from substances produced by the bacteria, whether they form
soluble toxins or not ; this has recently been established in the case
of dysentery.^^ It is probable, further, that insoluble toxins may
provoke the formation of antitoxins ^^ (anti-endotoxins) just
as do those of diphtheria and tetanus, though this view is not
generally accepted.^®
The infecting organisms may do harm in still other ways, as
when in a general bactersemia they plug the smaller
blood-vessels of important organs. We have learned in recent
years that blood infections are by no means uncommon. Bacteria
may be cultivated from the blood of most typhoid fever patients,
and from no small proportion of patients with pneumonia, ery-
sipelas and other diseases. We have come, therefore, to regard
bactersemias with less apprehension than formerly.
Many pathogenic organisms produce toxins that will dissolve
red blood-corpuscles, as was first shown by Ehrlich for the tetanus
bacillus.
The resistance of the individual, finally, is of great significance
in determining whether infection shall occur and what character
it shall exhibit. The pre-bacteriological era laid great emphasis
upon exposure to cold, over-exertion, poor nutri-
tion and trauma as the direct causes of disease ; to-day, even
though we recognize them merely as predisposing causes, we prob-
ably pay too little attention to them. Certain organisms, such
as those of anthrax, plague and glanders, are so intensely virulent
that they need no such predisposing factors to pave the way for
them; but with the majority of bacteria some such favoring in-
fluence seems necessary unless the infective agent is present in
overwhelming numbers. It is possible that the bacteria them-
selves produce substances that enable them to gain a foothold.
In typhoid epidemics due to contaminated milk, the latter acts not
160 THE BASIS OF SYMPTOMS
only as a vehicle, but also as an excellent culture medium in which
the bacilli may grow and throw out their metabolic products.
It cannot be doubted that chilling of the body predisposes
to tonsillitis, bronchitis and pneumonia, though how it does this
is not known, despite the many attempts made to solve the prob-
lem.^^ Of the various explanations offered, such as lowering of
the body temperature, circulatory disorders and injuries to the
cells, none has been definitely established. Possibly the action of
cold is to inhibit the formation of bacteriolytic amboceptors.
Fatigue and inanition also lower the individual's resistance in
some undetermined way. And, finally, trauma and alcoholic in-
toxication ^2 have been shown, both clinically and experimentally,
to render the individual more susceptible to infection.
Mixed and Secondary Infections. — In a number of infectious
diseases, more than one variety of micro-organism is found;
streptococci are often present in diphtheria, and the pus-cocci in
tetanus. This is spoken of as a mixed infection. This
symbiotic growth may either increase or diminish the virulence
of one of the organisms. For example, isolated tetanus spores
injected into the tissues of susceptible animals produce the dis-
ease only when in association with other bacteria. The latter
seem to prepare the way by causing a necrosis of the tissues;
for an aseptic mechanical injury will do the same. The converse
— a diminution of the virulence of one organism caused by the
presence of another — ^has not been positively demonstrated. Were
this not a possibility, however, it would be difficult to explain
the comparative in frequency of tetanus in view of the wide dis-
tribution of the bacillus and the marked susceptibility of man.
The cultural antagonism of bacteria is more an inhibition of
growth by soluble bacterial metabolic products than an actual
destruction.23
We speak of a secondary infection when a second,
or even a third, infection is superimposed upon the primary one.
Secondary infections occur most frequently in those diseases
which damage the skin or mucous membranes, thereby inviting the
entrance of whatever bacteria that may happen to be present
there. The secondary infections with streptococci, such as may
develop in the course of scarlet fever, smallpox or dysentery, are
especially feared. They often change the clinical picture com-
pletely ; the fever 'takes on a different type, and various compli-
INFECTION AND IMMUNITY 161
cations develop such as otitis, arthritis or endocarditis. Not in-
frequently the secondary infection dominates the scene and be-
comes the immediate cause of death. This is well illustrated
in cases of septic diphtheria or scarlatina, in which the strepto-
coccus infection provokes the fatal issue. An appropriate therapy
will take into account both the primary disease and the secondary
infection.
Varieties of Immunity. — Even after bacteria have succeeded
in passing the protective barriers at the surfaces, there is con-
siderable evidence to show that there exists a marked individual
variation in the ability to resist infection. Of the many exposed
to a disease, only certain individuals contract it, although we may
be certain that many others have received the pathogenic bacteria
into their bodies. Certain bacteria may be very pathogenic for
one species of animals and almost without effect on another closely
related species. Indeed the resistance of the same individual
varies under different conditions.
These facts lead us to believe that the animal body has the
power to render pathogenic organisms innocuous, even after they
have entered the body, and before they have done any harm. This
phenomenon is called immunity, which, in turn, may be natural or
acquired. The former is natural to the individual ; the latter has
been acquired either naturally by having passed through the
disease in question, or artificially by some method of inoculation.
There are two general methods of producing an artificial
immunity. In the first, the causative organism, or some material
derived from it, is injected into the individual to be immunized.
The latter then passes through a sickness with a febrile reaction,
etc., following which he becomes more or less immune to future
infections with the same organism. This is the active type
of artificially acquired immunity, because it is
gained by the individual's having had the disease in a more or less
modified form. In establishing this form of immunity, the
material used is either injected in very small amounts, or its
virulence is attenuated, so that a mild type of the disease will
be produced. The immunity following such procedures develops
gradually, but it is very durable, and, even though antibodies are
withdrawn from the blood by venesection, new ones are formed.
As examples of active artificial immunization, we may mention
Wright's antityphoid inoculations, the Pasteur
11
162 THE BASIS OF SYMPTOMS
treatment of rabies and the antitoxic immunity against
anthrax acquired by animals after injections of attenuated anthrax
bacilli.
The second form of artificial immunity — passive immunity-
is produced by the injection of antibodies formed in the blood of
another animal. For this purpose, it is customary to use the
blood-serum of animals that have already acquired an active im-
munity to the disease in question. Passive acquired immunity
develops immediately after the injection, but it soon disappears,
usually in the course of a few weeks, probably because antibodies
produced in another animal are in the nature of foreign substances,
and as such are rapidly eliminated. Precipitins may also play a
part in this elimination,^* It is perhaps due to the close relation-
ship of these antibodies to the normal proteids of the plasma that
the former are able to exist at all in an alien blood.
The disadvantages, therefore, of an active immu-
nity are first that the animal organism must pass through a
given disease, and secondly, that protection is delayed for at least
ten days. The weakness of the passive form is its
short duration. To offset these drawbacks, recourse has been
taken to active-passive immunization, in which
attenuated bacteria, or their products, plus an immune serum, are
injected together or separately.^^ But one must bear in mind,
in connection with this modification, that the greater the bulk of
serum injected, the fewer are the antibodies formed.^^ Bea-
red k a has obviated this difficulty by employing only the amount
of serum that the bacteria can bind, removing the excess by cen-
trifugation and washing. This method produces an immunity
in twenty-four to ninety-six hours, which persists for months.^'^
The Factors Concerned in Immunity, (a) General Con-
siderations.— Bacterial poisons stimulate the production in the
body of substances capable of entering into a kind of combination
with these poisons, and thus rendering them harmless. We call
these substances antitoxins. When the defenses of the body
against microbic infection are strengthened by an increased for-
mation of these immune bodies, the animals thereby become insus-
ceptible to the disease in question, irrespective of the employment
of any other means calculated to increase their resistance.
The natural ability to resist bacteria is assumed to be aug-
mented in part by an increase of bactericidal substances in the
INFECTION AND IMMUNITY 1&
blood — a leucocytosis perhaps representing the intermediate step,
in that these substances are supposed to be the products of the
white cells. It is true that many of the phenomena of immunity
are associated with a leucocytosis; and, indeed, a blood rich in
white cells is supposed to be more strongly bactericidal than one
with few leucocytes. ^^
The invading organisms are destroyed, therefore, in the im-
mune bodies before they can produce morbid changes. This
destruction must occur rapidly if the host is to suffer no injury,
because bacterial activity is itself rapid. The actual cause
of the death of micro-organisms would seem, in
many cases, to reside in unfavorable conditions
for their growth, such as the composition of the tissues
which they have invaded, and perhaps also the body tempjerature
of the host. (The matter of the oxygen tension of the
tissues would seem to be an important factor in this connec-
tion. The streptococcus, for example, when grown under differ-
ent oxygen conditions, exhibits variable characteristics, not only
in its cultural behavior and its morphology, but also in the
experimental lesions which it produces.^^ — Ed.)
Mycotic growth in vitro is influenced by the character
of the salts present in the media and by their osmotic
tension. These considerations scarcely apply to the living host,
however, as the animal body is unceasing in its effort to keep
osmotic conditions constant.
More important, in our opinion, in their influence on bacterial
life are variations in the proteids of the lymph and
blood. The blood-serum is often endowed with bactericidal
and antitoxic properties, whereby bacteria are disintegrated, either
at once, or after preliminary agglutination. That this is not
merely the action of an alien medium upon the micro-organisms is
shown by the fact that this bactericidal power is lost if the serum
be heated for thirty minutes at 55° C, a temperature which does
not produce changes in the proteids. As enzymic activity is also
frequently subject to similar conditions, it is not unnatural to
assume that the bactericidal properties of sera are comparable in a
way to ferment action, and are, therefore, attributes of the serum
proteids. The nature of the bactericidal substances will be more
fully considered in another place.
Also important in the part played by the bactericidal power of
164 THE BASIS OF SYMPTOMS
the blood is the question whether the lymph and other tissue-juices
are similarly endowed. As a matter of fact, the latter do contain
bactericidal substances, though it is questionable whether they are
comparable to those of the serum.
The bactericidal property of the body fluids does not neces-
sarily go pari passu with the degree of immunity present. White
rats, for example, are insusceptible to anthrax, yet their serum
readily destroys the anthrax bacillus ; while the blood of rabbits,
which are highly susceptible to the same disease, readily destroys
the organism.^'' In these instances, however, the bacteria-destroy-
ing substances differ from those just discussed, for they are inac-
tive in vivo; furthermore they are not of leucocytic origin, but
arise from the blood platelets in the process of coagulation ; and,
finally, they are not inactivated by a temperature of 56° C.
Herein lies a justification of the warning of Metchnikoff not to
apply unreservedly the results of experiments in vitro to con-
ditions in the living organism.
The problems of acquired immunity demand special considera-
tion. This type is characteristically seen after recovery from
certain diseases, the acute exanthems being most constant in this
respect. Other diseases, such as typhoid fever, generally render
the individual immune for many years, or even permanently.
Diphtheria and cholera, on the contrary, confer a briefer protec-
tion; while in still others, such as erysipelas, after a short im-
munity the predisposition to another attack is actually increased.
The degree of immunity does not run parallel with the severity
of the disease which produced it; in certain individuals, indeed,
a very mild infection may cause a high degree of protection.
We are in no position to interpret immunity phenomena in the
acute exanthems, because the causative organisms are not known.
It is not unlikely, however, that in conditions such as typhoid
fever and cholera, to which certain individuals are naturally im-
mune, the inherited bactericidal power is appreciably reinforced
by active immunization. This reinforcement is specific, extend-
ing only to the micro-organisms which have brought about the
immune state. The serum of typhoid convalescents, for example,
is highly bactericidal to typhoid bacilli, and only in a lesser degree
to organisms closely related to the latter.
The study of these problems has illuminated in a most extra-
INFECTION AND IMMUNITY 166
ordinary way many fundamental processes, of which only the most
important can be touched upon here.
First in importance, is the ability of the blood-serum to in-
hibit the chemical action of certain alien substances and to destroy
unicellular organisms of all types and also individual cells of
more complex life. Herein lies the power of the higher animals
to protect themselves against the toxins and bacteria which have
passed the barriers at the body surfaces. Nor does this process
of bacteriolysis set free the toxic materials contained in the bac-
terial bodies, for the resulting split-products of the latter are non-
toxics^
(b) Complement and Amboceptor. — Two bodies take part in
the destruction and lysis of alien cells. Of these, one is of the
nature of an enzyme; and the reaction and osmotic tension of
normal serum and a suitable temperature are essential to its
action. Kept at 56° C. for thirty minutes or cooled at 0°, it is
inactivated; while at body temperature, it is most potent. This
substance is constantly present in normal blood, though in variable
amount; but what causes it to appear and to disappear is not
known. This body has been variously called alexin ( Buchner) ,
complement (Ehrlich) and cytase (Metchnikoff). Ob-
viously there are many different alexins, in view of their differing
behavior, and also of the similarity of their action upon diverse
micro-organisms. The controversy over the question of the unity
or multiplicity of these substances is still active {cf. Haemolysis).
Metchnikoff distinguishes between macrocytases, the fer-
ment of the macrophages (large lymphocytes) and micro cy-
tases, formed by the microphages (polynuclears). We are of
the opinion of Ehrlich that there are many complements, in view
of studies showing that these bodies may lose one type of activity
and still exhibit one or more other types.
Complement, per se, is probably inactive both in immunized
and non-immunized animals. The source of complement is gener-
ally attributed to the leucocytes, though whether it arises through
destruction or injury of the white cells (phagolysis), or represents
the secretion of the living cells, is unsettled. Fluids rich in
leucocytes generally exhibit a strong alexin action, hence Metchni-
koff's view that the type of white cells is a factor.^^ The com-
position of complement will be considered under " Haemolysis "
(p. 168).
166 THE BASIS OF SYIVIPTOMS
The other substance essential to complement activity is gener-
ally resistant to temperatures over 60°. If present in normal
serum, its amount is insignificant. It increases enormously, how-
ever, if the blood has been subjected to certain preliminary prep-
arations, or the individual has passed through a disease. Im-
munization is synonymous with an increase in the second body,
complement remaining unaltered. Various names have also been
given to this substance — immune body (Pfeiffer), sub-
stance sensibilitatrice (Bordet), preparator
(Gruber) , f i x a t e u r (Metchnikoff ) , and intermediary
body or amboceptor (EhrHch).
That complement and amboceptor are distinct bodies is evi-
denced by their differing behavior to heat, as already noted.
Thus, serum containing both, if heated to 56° C, becomes inac-
tive, but if added, after heating, to normal serum (containing only
complement), its activity is restored (reactivation). Activation
and reactivation do not represent newly-discovered phenomena,
though they were differently interpreted in the past.
Amboceptor is taken up and held by cells (bacteria) to the
destruction of which it is indispensable. Upon this phenomenon
rested Ehrlich's method of separating the immune bodies from
the serum. The union of amboceptor and micro-organism occurs
even at temperatures only slightly above 0° C, hence quite
excluding the possibility of complement activity.
The intermediary body has a specific affinity for the cells
which it attacks. The property of a serum to act upon different
bacteria, and upon cells of higher organisms, resides in the
possession of different immune bodies, each the product of a
specific process. This specificity is the fundament of immunity,
and will be discussed in that connection.
(c) The Side-Chain Theory. — We come now to the considera-
tion of the mode of action of the amboceptor upon the cells of
the animal organism, and of its relationship to complement. The
very multiplicity of names speaks for the divergence of opinion
as to the behavior of the immune bodies. Gruber and Metchnikoff
attribute to the latter merely the function of enabling complement
to act upon the cells. Bordet compares its action with that of
a mordant; while Ehrlich looks upon it as an intermediate sub-
stance which links complement to the cells.
Ehrlich's views are based upon stereochemical con-
INFECTION AND IMMUNITY 167
siderations. Complement possesses no atom-groups by
means of which it can unite with those of the cells; amboceptor,
however, is endowed with such haptophore groups. In
addition, and by virtue of similar groups, amboceptor is
complementophile. The avidity of the intermediary
body is greater for the cell than for complement, hence the union
with the former occurs first. This phenomenon makes possible
the extraction from the serum of specific amboceptors.
How is this specific affinity of amboceptor for certain cells to
be explained? If proteid-like substances gain entrance to the
body, some are quickly eliminated, obviously because they are
taken up by cells. As this robs them of their identity, or, in the
case of toxins, renders them non-toxic, it must be assumed that
they combine with some peripheral atom of the cellular proto-
plasm. Ehrlich conceives of these protoplasmic atoms as " side-
chains" of the large proteid molecule, each cellular proteid
having numerous and diverse side-chains. The alien substance
is held if an appropriate side-chain is present. This is
evident in tissues which have been functionally injured by the
alien body ; and upon this local phenomenon the theory of Ehrlich
was originally founded. To-day, however, the process is no
longer considered purely a local one; for amboceptor formation
and alien cell fixation are thought to occur also in tissues not so
injured.
It is a characteristic of the living cell to react
to the stimulus produced by the union of side-
chains in amount far out of proportion to the de-
mand. The excess are cast off and circulate in
the blood as antibodies. The degree of new formation
of chains depends essentially upon the character and intensity of
the stimulus; thus the cells may be so injured by an espyecially
severe infection as to be rendered incapable of producing immune
bodies.
The vulnerable point in the side-chain theory, in our opinion,
is that relating to the production of new chains by the injured
molecule. This has been likened to the reaction of tissues to an
irritant, a reaction which may be so pronounced that the new
tissue is produced in excess. The two processes, however, are
fundamentally different, for, on the one hand, we are dealing with
the reaction of living tissues as a whole to an injury, while, on the
168 THE BASIS OF SYMPTOMS
other, it is a reaction involving individual molecules. No reaction
analogous to this is known to chemistry.
The Haemolytic Action of Alien Plasmas. — The destruction
of red blood-corpuscles by alien blood has become a matter of
great interest in recent years, for the study of the factors con-
cerned in the phenomenon has enormously increased our knowl-
edge not only of physiological processes in general, but also of the
principles of the bactericidal action of the blood-serum.^^
That the blood of a given animal can dissolve out the haemo-
globin of the erythrocytes of another species has long been known.
Certain animals are particularly sensitive in this respect and some
sera are especially toxic. To a certain degree, indeed, the mutual
interaction of the sera of different animals is constant; yet enor-
mous individual variations occur, and sera are known which
produce haemolysis even in animals of the same species.^* As
hypotonic salt solutions likewise cause laking,
it is natural to ask whether haemolysis is merely
the effect produced by a serum of different
osmotic tension. ^^ Morphologically, indeed, red cells sub-
jected to the action of an alien blood, on the one hand, and to a
hypotonic salt solution on the other, are much alike.
Other investigators see in haemolysis a proc-
ess similar to that just discussed in connection
with bacterial destruction, i.e ., based upon the
action of a complement plus an amboceptor. The
complement in this case is also unable to withstand a temperature
of 56° C, and is inactive without the intermediate action of an-
other body even in the normal destruction of red cells. Dog
serum, for example, heated to 56° is no longer haemolytic, but if to
it be added fresh guinea-pig serum, per se inactive, the haemolyzing
power is restored. This experiment indicates incidentally that
amboceptor is present in normal dog serum. By a process of
dialysis, complement (guinea-pig serum) can be shown to con-
sist of two simpler bodies, the so-called mid-piece and end-piece,
which differ physically and chemically.^^
The haemolytic action of a serum may be intensified if the
animal (A) from which it is derived be first injected over a long
period with the red cells of the animal of the other species (B)."
The essential element provoking the haemolytic power is the stro-
mata of the red cells of B, irrespective of whether the serum of
INFECTION AND IMMUNITY 169
A was haemolytic for B before the preliminary treatment. In
other words, the stromata of B's cells injected into A, endow the
serum of the latter with the power of dissolving out the haemo-
globin of the cells of the former. The haemolytic action is specifi-
cally confined to the red cells of the species used in the experiment.
Immune (haemolytic) serum, like normal serum, is inactivated
by a temperature of 56°, and reactivated by the addition of fresh
serum from an untreated animal.
There are additional points of analogy to the process of bac-
terial immunization. Thus, essential to the haemolytic power of
the body destroyed at 56° is the action of another which may be
heated to 60° with impunity ; and further, this second body tends
to multiply. Unlike complement, it is specific, being fixed only by
those red cells marked for haemolysis. The amboceptor con-
cerned in haemolysis may be isolated in a manner similar to that
described for the bacterial immune body (see p. 167).
As a given serum is able on the one hand to dissolve red cells
of diverse animals, and, on the other, after being heated to 56°, is
susceptible of reactivation by the addition of various complements,
it is natural to assume that normal blood contains diverse ambo-
ceptors and complements. In fact, both normal and immune sera
may be deprived seriatim of specific haemolysins. Ehrlich has
shown this experimentally in the varying behavior of haemolysins
toward the red cells of the same species. We shall return to this
question of multiple amboceptors, both for red cells and for bac-
teria, particularly because in a physiological way it is difficult of
conception.
Recent studies ^^ indicate that in the haemo-
lytic process, a lipoid envelope, or a union of
lipoids and proteids in the red cells, undergoes
disintegration, and that the antigen of artificially pro-
duced haemolysis is a lipoid body. This conception is even more
probable in the case of substances from the red cells which inhibit
haemolysis in vitro. Complement also is supposed to contain
lipoids.^*^ A definite conclusion, however, as to the significance in
haemolysis of these fat-like bodies is not yet warranted. Meyer ^®
disputes the part played by lipoids, because they are insoluble in
the ordinary fat solvents, and even in specific lipoid solvents.
Antitoxins. — In the matter of the immunity gained by the
animal body to toxins in general, we shall confine ourselves to
170 THE BASIS OF SYMPTOMS
the fact that bacterial poisons are robbed of their toxicity by
certain constituents of the serum. For this discovery we are in-
debted to V. Behring, who found that the blood of animals inocu-
lated with the diphtheria bacillus, rendered innocuous the toxin
of this organism.
A considerable number of chemical substances of diverse
origin and closely related to the enzymes are altered by bodies
which they encounter in certain sera. That actual destruction
of the poisons does not occur is shown by the fact that they may
still be demonstrated after the antitoxic action. What actually
occurs is a fixation of the toxin by the antitoxin.
This would indicate that the reaction is one of col-
loids,*^ at least in the case of antitoxin, which is always com-
bined with a proteid.
The source of antitoxin is variously ascribed. Buch-
ner originally contended that it arose within the body through
alterations in the toxin, thus explaining its essential specificity.
It is our opinion that antitoxin is the reaction product of the
organism to the poison. Behring's famous formula reads: In
the living organism a given substance, which, if present in the
cells means poisoning, occurring in the blood itself promotes
recovery.
To discuss certain factors pertinent to the question of anti-
toxins would be repetition. Thus, Ehrlich's conception of anti-
body formation is based on that of antitoxin production. The
principles of the side-chain theory apply equally well to the
process of toxin fixation, and to the conception of immoderate
over-production of side-chains, which, cast into the circulation,
represent the individual's immunity to the poison in question.
Antitoxin formation is not confined to those cells which clini-
cally have been subjected to the action of the poison, but is the
product of all cells with suitable side-chains. This is a further
evidence of the comprehensiveness of the Ehrlich theory. The
hen and the alligator are highly insensitive to tetanus, yet they
readily produce tetanus antitoxin; in other words, tissues other
than nervous possess the appropriate receptors. Again, tetanus
toxin remains inert for a long time in the blood of the turtle, and
yet no antitoxin is formed, because suitable side-chains are not
present. Hence, tetanus occurs only when the central nervous
system can fix the toxin.
INFECTION AND IMMUNITY 171
Once the stimulation to antitoxin formation is initiated, anti-
bodies continue to be produced for a long period. For this reason,
the immimity acquired by passing through a disease is more or less
durable, and for the same reason, the blood of animals strongly
immunized may be repeatedly withdrawn, and yet that which
is left will always develop new antitoxin. Similarly the injection
of pilocarpin will increase the amount of antitoxin in the blood,
probably because it stimulates the cells to secrete.
Remarkable it is, however, that antibodies — this applies less
to antitoxins than to other immune bodies — can persist in the
blood. No other explanation seems possible than that their molec-
ular construction is altered and that they become, in fact, normal
constituents of the blood, endowed with the properties of its
proteids. This would explain both their permanence and their
chemical action.* ^
Antitoxin is constant and abundant only in
the blood of animals which have passed through
a disease or have been artificially immunized to
that disease. Yet it may be present in the serum of
healthy individuals, and even in the blood of the new-born. This
remarkable fact is explainable in accordance with the Ehrlich
hypothesis on the assumption that for some reason the side-chains
for which the toxin has an affinity have been cast loose into the
circulation.
Antitoxins multiply exclusively, or at least
most energetically, in response to the toxins
which have stimulated their production. They
are less resistant than toxins to light and oxygen, and are injured
by a moist heat of 6o°-70° C. In experimental immunization,
the antitoxin content of the blood begins to increase with the
fifth day — the maximum for diphtheria occurring on the tenth
day and for tetanus on the seventeenth. Thereupon occurs a de-
cline which reaches a stationary level in about two weeks and is
maintained for some time. Antitoxin is present not only in the
blood, but to some extent in all the body fluids, even in the milk."*^
Precipitation and Precipitins. — ^Just as microbic poisons are
rendered harmless by normal, and particularly by immune, sera,
so any type of proteid (in clear solution) may be precipitated by
blood artificially inoculated with the same material. The bodies
calling forth this reaction are known as precipitins.** The
172 THE BASIS OF SYMPTOMS
proteid substances (antigens) employed in this type of immu-
nization are called precipitinogens and the resulting
product a precipitate. Most precipitinogens are proteids
alien to the animal injected, isoprecipitins rarely being formed.
These precipitins cannot be separated from the globulins of the
blood.
An acid reaction, especially if due to organic acids, is most
favorable to precipitation, and salts, irrespective of their nature,
are essential. An excess of precipitinogen prevents the reaction
(so-called specific inhibition). ^^ Inhibition is spoken of
as non-specific if an alien proteid solution of high con-
centration retards the appearance of the precipitate, or holds it
in suspension. For these reasons, the phenomenon is regarded
as a colloidal reaction; and as precipitinogen and pre-
cipitin are used up in the process, there can be no question of an
enzymic action.
Precipitins are relatively resistant to certain influences, as,
for instance, to a long-continued temperature over 60° C, to
desiccation and even to putrefaction. They cause precipitates
not only with their specific precipitinogens, but also, though less
actively, with related prot&ids. The more closely related a given
proteid is to the body employed in immunization, the more pro-
nounced is the precipitate. Upon this basis rests the employ-
ment of the reaction in the problems of evolution. Only in
a quantitative way, therefore, may the reaction
be regarded as specific.
Furthermore, the precipitins of an immune serum cause pre-
cipitation with other proteids of the organism which furnished the
original precipitinogen; thus, the serum of an animal immunized
with human blood, precipitates human sperm, human milk, etc.
Ehrlich looks upon precipitins as side chains comparable in general
with antitoxins and bacterial antibodies.
The precipitin reaction has already found a considerable prac-
tical application and with further development will undoubtedly
prove of great value in differential diagnosis. In the infectious
diseases, the proteids of bacterial metabolism — the precipitinogens
— ^may be found in the blood and tissues; and at a later period,
the corresponding precipitins. It is not necessary to know the
organism itself to identify these two bodies. Attempts have also
been made to adapt the reaction to the diagnosis of carcinoma;
INFECTION AND IMMUNITY 173
further, to demonstrate that the substances responsible for puer-
peral eclampsia are of fetal origin ; and finally, to isolate the toxic
proteid of bothriocephalus infection, and to establish that the
albumin in nephritic urine comes from the body proteid itself.
In medical jurisprudence the precipitation reaction
has proved of great assistance, particularly in determining whether
a given specimen of blood is from man or not. Uhlenhuth's ^^
method of immunization with proteids of allied species, e.g., man
and ape, faciHtates the diagnosis between the blood of these two.
The precipitin reaction persists in material which has been exposed
to desiccation for as long as seventy years, or which has been
frozen, or exposed to sunlight or moderately decomposed.
Complement Fixation. The Wassermann Reaction. — Still
another advance, eventuating in the combination of the precipi-
tation and the hsemolysis reactions, followed the discovery by
Bordet and Gengou**^ that the bringing together of red corpuscles
or bacteria with their specific immune sera (so-called sensi-
tization) led to the fixation of complement. In other words,
each time antigen is brought into contact with its antibody, com-
plement vanishes. The disappearance of comple-
ment, evidenced by the non-appearance of haemo-
lysis, is striking even in minimal precipitin reactions. To
an otherwise suitable hsemolytic system, composed of red cells,
amboceptor and complement, the addition of precipitinogen and
its antiserum inhibits haemolysis if complement is fixed. The
proteids of human blood are sensitive in this way up to a dilution
of one hundred thousand and more.*^
Antigens and their antibodies may also, as already noted, be
demonstrated in the case of micro-organisms not susceptible of
cultivation, or where we have to do with unknown viruses, for
they are present in extracts of definitely diseased organs, and
late in the process in the serum of the affected individual, and
also in the serum of animals immunized with the organ extracts.
The evidence of the presence of antigen and
antibody in a hsemolytic system is the inhibition
of haemolysis. This phenomenon enables one, by varying
the experimental conditions, to demonstrate in a given serum,
or inflammatory fluid, the presence of antigen in the early stages
of a disease, and of antibody in the later stages, or whether the
disease is actually infectious or not.*^
174 THE BASIS OF SYMPTOMS
Wassermann and his co-workers, on the basis of these reac-
tions, have evolved a serum reaction for syphilis. It was at first
beheved that the bringing together of syphiHtic antigen (ex-
tract of the fetal luetic liver) and antibody (luetic serum) was
essential to the fixation of complement and the consequent inhibi-
tion of haemolysis when red cells with their specific amboceptors
were added. Further study, however, revealed the astonishing
fact that extracts of luetic organs were by no means necessary
and that alcoholic extracts of normal organs sufficed. Com-
plement fixation, therefore, occurs as a consequence not
of the meeting of luetic antigen and luetic antibody, but as the
result of the contact of a normal body substance with luetic
serum. These substitutes for antigen, being soluble in alcohol,
are probably lipoids.
An entirely satisfactory explanation of the Wassermann reac-
tion is, for the present, wanting. This does not detract, however,
from its great practical value.®*^ Many observers insist on the
use of syphilitic antigen in order to obtain the most dependable
results. If extracts of normal organs (heart-muscle) are em-
ployed, great care must be exercised in keeping them of uniform
composition.
(The principle of complement fixation has
been adapted to the diagnosis of other condi-
tions, though with results far less satisfactory and constant
than in the case of syphilis. In certain types of gonorrhoeae^
and in echinococcus disease,^^ the reaction has proved of consider-
able practical value; in tuberculosis,^^ typhoid fever and other
diseases, it has generally been discarded. Gonorrhoeal comple-
ment fixation, unlike that occurring in syphilis, is a biologically
specific antigen-antibody interaction. — Ed.)
Agglutination and Agglutinins. — The phenomenon of agglu-
tination is a further type of reaction exerted by the blood-serum,
upon alien cells and bacteria. It is manifested by a clumping and
precipitation of the latter.^* The relation of agglutination to the
process of immunity is still not clear. The fact that the agglu-
tinins are less sensitive to heat than are immune bodies is scarcely
a distinguishiiig mark, for the latter are themselves not constant
in this respect. Though the agglutinating property of a serum
is largely independent of its bactericidal power, yet it appears that
agglutination has some influence upon the destruction of the
INFECTION AND IMMUNITY 175
clumped cells. Nevertheless agglutinated bacteria may live a long
time, and, furthermore, dead bacteria will also clump.
The current interpretation of the nature of agglutination is
that a portion of the bacterial substance (the agglutinogen)
is bound by the antibody (agglutinin) which it gives rise
to. This is also in all probability a reaction of colloids.
The agglutinins are combined in a few minutes,^^ but hours may
elapse, especially at low temperatures, before agglutination is
distinctly manifested. Centrifugation noticeably hastens the pre-
cipitate.^® In the Ehrlich theory, agglutinins are
analogous to precipitins, antitoxins, hsemoly-
sins, etc. Temperatures over 70° C. are necessary to destroy
them; and they resist desiccation, to a certain degree light, and
even decomposition, but they are inactive in solutions not con-
taining salts.
Normal serum is only feebly agglutinating, dilutions of i : 50
generally inhibiting the phenomenon. Immune sera, on the con-
trary, are powerfully agglutinative, dilutions of even i : 100,000
clumping typhoid baciUi. Quantitatively, therefore,
agglutination, like precipitation, is specific;
for although closely related micro-organisms may also be agglu-
tinated (group agglutinins) by a specific serum, this occurs only
in comparatively low dilutions. The higher dilutions act only
on the specific micro-organisms that caused the infection. Agglu-
tinins may also be found in insignificant amounts in extracts of
organs freed from their blood, and in milk, pus, etc.
The agglutinins appear in the blood of warm-blooded animals
in from three to ten days after the inoculation of bacteria or their
products. They increase rapidly in amount for about a week, and
then diminish more or less gradually. As a rule, the typhoid
agglutinins disappear from the blood of man after about one
year, though there are many exceptions to this rule.
(In this connection may be mentioned the method of vac-
cination against typhoid introduced by Wright." The
vaccine is obtained from a bouillon or agar culture of the bacilli,
killed at a temperature of 54° to 55° C. Three injections are
made at intervals of ten days, the first of five hundred million of
the bacteria, the last two of one billion each. The injections
usually produce a mild local reaction, and variably severe con-
stitutional symptoms of fever, headache, malaise, etc. Immunity
k
176 THE BASIS OF SYMPTOMS
is granted by an increase in the agglutinating and bactericidal
powers of the blood. The duration of the Widal reaction after
vaccination is as yet undetermined; at any rate, in cases sugr
gestive of typhoid, a previous vaccination must be taken into
account when the agglutinating power of the suspected serum is
being determined.
Statistics based upon vaccination in the British and American
armies ^^ indicate that protection against typhoid is granted in
the vast majority of cases. How long this immunity endures
has not been definitely established ; it would seem, however, that
revaccination every four years is quite sufficient. — Ed.)
The Relation of Antitoxins and Bacteriolysins to Immunity. —
Observers, generally, have attributed the state of immunity pro-
duced by spontaneous and experimental infection with organisms
not known to f onn soluble toxins, to the appearance of bactericidal
substances in the blood. Investigation has shown, however, that
the blood-serum becomes bactericidal before the disease has run
its course — in typhoid, for example, at a time when immunization
could not possibly have been established; and furthermore, that
the same serum is less bactericidal in cultural studies than when
employed in the living animals.^® These facts indicate that the
power of destroying micro-organisms is not the
only element in the acquisition of immunity.
In diseases due to bacteria producing a solu-
ble toxin, the formation of antitoxin is, with-
out doubt, one of the chief factors in recover y —
hence, the adaptation of antitoxin immediately after its discovery
both to the prevention and the cure of diphtheria. Recovery is
possible only if toxin already anchored is rendered harmless by the
antitoxin introduced. It soon became apparent, however, that
to cure, considerably more antitoxin was needed than to im-
munize, and that the longer the disease had been in progress,
the more antitoxin was called for, so that at a certain point even
enormous doses were unavailing.^^' In the practical application
of serum therapy, a knowledge of these factors is indispensable.
Large doses of serum, therefore, are indicated, and of a concen-
tration as high as possible to obviate the effects of large amounts
of an alien proteid.
Ehriich introduced a method of standardization of
the different immune sera. In the case of diphtheria
INFECTION AND IMMUNITY 177
antitoxin, for instance, the immunizing unit was contained in a
serum one cubic centimetre of which neutraHzed toxin equivalent
to one hundred times the lethal dose for the guinea-pig. But
as the standard toxin solutions were not stable, this method has
not continued in use, and, at present, sera are controlled with a
standard immune serum in powdered condition and protected from
the light and air, in the Ehrlich Institute.
The curative value of diphtheria antitoxin as
against living Klebs-Loeffler bacilli, according to some observers,
does not run parallel with its antitoxic titer. It is possible that
the avidity with which toxin and antitoxin combine is also a
factor, and that a serum of high potency may display only a slight
avidity of this sort.^^ This conception, however, is vigorously
attacked by those who say that the therapeutic value of a serum
depends upon the number of immunizing units it contains.^ ^
Antitoxic sera disappear rapidly from the circulation (see
p. 162). In diphtheria epidemics, therefore, the indication is to
repeat the prophylactic dose ; yet the danger of anaphylaxis must
be considered (see below) .
(B. Schick®^ has suggested a method for de-
termining whether an individual exposed to
diphtheria is in need of prophylactic injections
of the serum, in this way obviating the promiscuous use of
the latter and the dangers of anaphylaxis when the disease has
actually developed. This method, which is based upon the exist-
ence of some degree of natural immunity in the individual, con-
sists of the intracutaneous injection of an exceedingly small fixed
dose of diphtheria toxin. If the serum of the person who has
been exposed contains no antibodies, a local inflammatory reaction
occurs, and antitoxin is indicated. — Ed. )
Injected subcutaneously, antitoxin is slowly absorbed, the
blood not attaining its maximum concentration until after the
third day. The advantage of the intramuscular method resides
in the fact that absorption is well advanced within the first twenty-
four hours. The most rapid results follow intravenous injec-
tion.^^ In meningococcus meningitis the serum must be
brought into direct contact with the micro-organisms. It would
seem that the tendency has been to employ antitoxin in too small
doses, especially when sufficient time has elapsed to have allowed
12
178 THE BASIS OF SYMPTOMS
toxin to become anchored to the cells. In recent years, indeed,
heavier doses have been the rule.^^
In the therapeutic application of the principles of immunity,
attempts were made, even at an early period, to create an active
immunity both during the incubation period of a disease and
during its early course. The Pasteur treatment in rabies is an
example. Later, efforts were made to cure typhoid fever by
injections of killed bacilli. (The results both with the method
of active immunization and with injections of typhoid immune sera
have been generally unsatisfactory; at any rate, far less encourag-
ing than those obtained by prophylactic vaccination against typhoid
fever. The sensitized virus-vaccine of Besredka seems to offer a
more encouraging outlook. — Ed. ) In chronic infections the indi-
cation for vaccine and serum therapy is clearer. (Vaccines and
immune sera have proved highly efficacious in certain well-chosen
chronic conditions ; but their promiscuous use and their commer-
cialization have brought this method of active immunization into
more or less disrepute, so that to-day it is much less employed
than formerly. — Ed.) The introduction of tuberculin by Koch
also led to the extensive application to tuberculosis of this mode
of treatment. The so-called opsonic therapy of Wright (see
p. 189) is based upon similar principles. The rapid and enduring
immunity given by the combined active-passive method with ex-
tremely small doses of sera has led to its therapeutic adaptation,^*
in puerperal septicaemia among other conditions.
Anaphylaxis. Serum Disease. — In all types of immunization
the tissues build reactive substances more rapidly and abundantly
when antigen is repeatedly injected. The cells thereby become
endowed with an altered power of reaction, by v. Pirquet, who
first recognized the practical significance of the phenomenon,
termed allergic; instead of immune, they become hyper-
sensitive. This was observed by v. Behring in horses, which
succumbed to a relatively small dose of toxin, though their blood
contained abundant antitoxin. The Ehrlich theory would ex-
plain this paradox on the assumption that side-chains held closely
by the tissue-cells possess a greater affinity for toxin than does
antitoxin — the chains free in the blood.
Allergie is exhibited more regularly after the parenteral intro-
duction of alien proteids than after toxin injection. This type
of hypersensitiveness, known as anaphylaxis, after Richet,®'^
INFECTION AND IMMUNITY 179
must be reckoned with as an unwelcome by-eflfect both in active
and passive immunization. Untiring research speedily estab-
lished this apparently enigmatic process on a firm basis.®® Fried-
berger, indeed, has recently demonstrated anaphylatoxin in vitro.
The fundamental experiment best suited to
demonstrate the phenomenon is the following: A
guinea-pig is injected subcutaneously with a foreign proteid, e.g.,
one milligram of normal sheep serum. This injection represents
the preparation or sensitization. In ten days, five
milligrams of the same serum are given intravenously — the
reinjection. The animal at once becomes restless, has
severe convulsions and within five minutes dies in asphyxia. The
characteristic manifestations are dyspnoea, paralysis
of the peripheral vasomotor apparatus — ^hence a marked fall in
blood-pressure — leucopaenia, even to the absence of the poly-
nuclears, a fall in temperature as great at times as io° C, spasm
of the bronchial muscles and a consequent pronounced pulmonary
emphysema, a diminished coagulability of the blood, and a reduc-
tion of complement in the serum.
An intraperitoneal reinjection produces the same symptom-
complex, except that the duration is prolonged and death is not
inevitable. If the second injection be subcutaneous and not too
large, there appears locally an oedema which quickly becomes
hemorrhagic and ends in sluggish ulcers (Arthus). By the intra-
venous route, sensitization may be produced and reinjection made
with infinitesimally small amounts of sheep serum — for the for-
mer, the one five-thousandth part of the fatal intravenous dose,
and for the latter, the one one-thousandth.
An incubationperiodof about ten days must be allowed
to elapse between the first and second injections — a fact allying
anaphylaxis with the phenomena of infection and immunity. The
allergic state may continue for a long period, in guinea-pigs up
to two years (Rosenau and Anderson) and in man up to five
(Curie), Man, however, is far less sensitive to reinjection than
is the guinea-pig. All warm-blooded animals are more or less
predisposed to anaphylaxis, while of cold-blooded, only the frog
has thus far been sensitized.
The reaction occurs irrespective of the kind of alien proteid
used, whether animal, vegetable or bacterial. The determining
component of the serum is the euglobulin. Pointing to the
180 THE BASIS OF SYMPTOMS
specificity of anaphylaxis is the fact that the
same proteid must be used for sensitization and
reinjection. Rosenau and Anderson showed that guinea-
pigs could be sensitized by the oral administration of abundant
proteid in the food, followed by parenteral inoculation of the
same proteid. Indeed, using the proteid of the crystalline lens,
rabbits were made allergic by oral introduction both in sensitiza-
tion and in reinjection.
Certain non-alien proteids may also provoke anaphylaxis in a
manner analogous to precipitation phenomena already noted.
Guinea-pigs, for example, may be so sensitized by the proteid of
the guinea-pig's lens — even by its own lens proteid — as to react
typically upon reinjection of the same body. Similar results have
been obtained with the spermatozoa and ova of the same species,
especially when the former are injected into pregnant animals.
The transmission of allergic to the offspring is the first evi-
dence of the hereditary nature of an apparent predisposition to
a disease. Such an inherited sensitiveness lasts only about six
weeks and is transmitted exclusively by the mother's serum (to
the offspring).
The fact that the blood-serum of a sensitized animal, if intro-
duced into another animal, renders the latter also allergic
(passive anaphylaxis) points convincingly to the immu-
nologic character of anaphylaxis.
Serum disease, a special type of anaphylaxis which we
shall consider in another place, is ascribed by v. Pirquet to the
meeting of an alien proteid with its specific antibody. It would
carry us too far afield to review the various theories adduced in
explanation of the anaphylactic reaction. That of Nicolle,^®
which seems to explain the phenomena of immunity in general,
merits special consideration. According to this theory, there are
two classes of antibodies formed, coagulins and lysins, the for-
mer embracing antitoxins, precipitins and agglutinins, the latter
perhaps all lytic antibodies which together with complement ren-
der accessible the actual poison in antigen. If the latter is rein-
jected into the immune organism, it is held by the coagulin and
destroyed by the lysins. If these last, however, prematurely grasp
antigen, then, with the aid of complement, toxin is quickly set
free. On this assumption Nicolle was able to demonstrate that
the serum of anaphylactized animals, together with the antigen
INFECTION AND IMMUNITY 181
employed, led to fixation of complement (diphtheria toxin with
the serum of animals sensitized with the same toxin).
Friedberger has succeeded in isolating anaphylatoxin
starting with these premises, viz., first, that unprepared animals
may be made anaphylactic by receiving a mixture of sensitized
serum plus the specific antigen; and, secondly, that complement
is essential to the formation of the anaphylactic poison. His
method was as follows: Horse serum (antigen) was mixed with
its antibody (rabbit serum sensitized with horse serum) and to
the resulting precipitate — ^first carefully washed with physiologi-
cal salt solution — was added complement (fresh guinea-pig
serum). The precipitate occurring here was removed by cen-
trifugation. The supernatant guinea-pig serum produced in ani-
mals (not previously sensitized) classical anaphylactic shock, and
must, therefore, have contained the anaphylactic poison. One
milligram of an alien serum was sufficient to call forth an active
anaphylatoxin; in the production of the latter, therefore, not
the amount but rather the number of antibodies is important. If
the latter are over-abundant, the proteid molecules disintegrate
too rapidly, while the toxic intermediary products are transformed
into simpler, innocuous substances. The same is true when the
antibody action is too prolonged.
Anaphylaxis, therefore, is an antibody reac-
tion and as such must be identified with other
immunity phenomena. Antiproteins, then, would prop-
erly be classed with the amboceptors, though they are not to be
identified with the bacteriolytic amboceptor. Bacteriolysis indeed
interferes with anaphylatoxin formation. Normal serum, among
the other antibodies it contains, also contains one in small amount
which can split proteid in the presence of complement and which
is increased enormously if the specific antigen be injected.
A foreign proteid after the first injection is slowly disin-
tegrated; after the second, when antibodies are abundantly pres-
ent, the latter and the alien proteid are brought into sudden
contact, the proteid is rapidly split with the aid of complement,
and the intermediate products — probably identical with those of
intestinal digestion — exert a toxic action, in all likelihood, because
they cannot be eliminated as is the case in the digestive tract.
This conception of the mechanism of anaphylaxis is strengthened
by the fact that certain anaphylactic manifestations are identical
182 THE BASIS OF SYMPTOMS
with those of peptone poisoning; anatomically, too, the picture
is the same.
If a sensitized animal be reinjected with a dose of foreign
proteid, insufficient to cause death, antibody formation is arrested
in such a manner that a third injection of the same antigen, even
in large amount, and following quickly upon the second, is borne
with impunity. This condition is called antianaphylaxis
(seep. 185).
What is known as primary anaphylaxis may be illus-
trated as follows : If a normal animal receives a large dose of
an alien proteid — not great enough, however, to cause death —
this proteid is partially split by those antibodies normally present
in the serum. Simultaneously, the injection leads to the formation
of new antibodies, with the result that a certain residue of the
foreign proteid, together with these antibodies, exist side by
side without interaction, due apparently to some peculiar regula-
tory mechanism. If this serum be injected into a normal animal,
however, this mechanism is ineffective, the antigen residue com-
bines with antibody and anaphylaxis results. The practical im-
portance of this is obvious : a serum must not be withdrawn too
soon after the reinjection, as free antigen may still be present. It
is advisable, furthermore, to test curative sera before distribution
with this possibility in mind.
One millionth of a milligram of a protein substance injected
into a sensitized guinea-pig causes fever, whereas, in a normal
animal five centigrams are necessary. In this connection, we
would note that several decades ago, the author ^*^ produced a
febrile reaction with proteids of all kinds and also with their
split-products, the reaction becoming more marked with the repe-
tition of the injections. Even at that early period, the author
asked himself whether substances of different thermic attributes
arose only after the disintegration of the bacteria in the living
organism. A more or less constant fever was produced by Fried-
berger and Mita, in sensitized animals, by continued parenteral
injections of minimal proteid doses. Injection of larger amounts,
however, at the height of the artificial fever, led to a pronounced
fall in temperature and to the condition of anaphylaxis. Further,
if the sensitized animal was injected with the given proteid during
the incubation period, a febrile reaction took place, but with a
considerably smaller dose than in normal animals. Friedberger
INFECTION AND IMMUNITY 188
concludes from this that antibody formation does not take place
suddenly from the seventh to the tenth day, but that it begins
in the second twenty- four hours and gradually increases. This
observation is of importance in the matter of the negative phase.
Local anaphylaxis does not predicate the existence of
sessile receptors, but rather the local accumulation of antigen
which combines with antibody free in the circulation at that par-
ticular point. On this basis, Friedberger explains pulmonary in-
filtration in pneumonia, pneumococci collecting in the lungs and
there coming into contact with their specific antibodies. The
resultant systemic manifestations are due to anaphylatoxin for-
mation. Friedberger and Mita produced fever and aseptic in-
flammation in the lungs of sensitized guinea-pigs by having them
inhale the specific serum. Thus the fever curve, and all of the
other characteristic symptoms of different infections, may be
imitated by the continued parenteral injection of a foreign, per se
non-toxic, proteid by varying the dosage, the interval between
injections and the point of injection, and by producing a variation
in the number of antibodies formed and used up — or otherwise
expressed, in the resultant amount of anaphylatoxin. Herein
would reside the link between infection, immunity and anaphylaxis
as set forth at an earlier period by Wolff-Eisner, whose concep-
tion, however, was purely hypothetical and differently formulated.
Infection from this point of view represents
an attenuated and protracted anaphylaxis, the
incubation period corresponding to the preparation of the animal.
As long as the infection continues, a minimal parenteral proteid
introduction is taking place, for the infectious agents are constantly
multiplying and undergoing destruction. The analogues in the
anaphylactic process would be minimal doses of artificially intro-
duced amorphous proteid, a variably great consumption of anti-
bodies, antianaphylaxis, local processes, fever, etc.
In the opinion of Friedberger, there is only one anaphylatoxin.
The analogue of this he finds in the uniform protein split-products
arising from the most diverse proteids in the course of intestinal
digestion. The union of antibody with its appropriate antigen,
therefore, would represent the only element of specificity in the
process. He bases this conception upon the observation that by
intravenous injection of proteid split-products, a symptom-
complex is produced identical with that of anaphylaxis. This has
184 THE BASIS OF SYMPTOMS
been confirmed from many sides. Biedl and Kraus had similar
results with peptone. In Friedberger's mind it is unnecessary to
assimie that in the different infectious diseases — excluding those
which give rise to soluble toxins (tetanus, diphtheria, botulism) —
in addition to anaphylatoxin, there is formed another peculiarly
specific poison.
In our opinion, Friedberger has gone too far in his attempt to
identify the phenomena of infection with those of anaphylaxis,
granting that much in the clinical picture of the former can best
be interpreted on an allergic basis. Nevertheless, peculiar to each
infection are many features not thereby accounted for and which
postulate the assumption of a specific poison. The striking*
somnolence in hen cholera is a case in point, as Pasteur has shown
that this same symptom may be produced without the injection
of living bacilli if a bouillon filtrate of the organism — enormous
in amount it is true — be introduced. Here it is not an indifferent
poison that is acting, for still larger doses of the filtrate cause
death. Klemperer is also of the opinion that the characteristic
pictures of the different infections are to be interpreted with diffi-
culty except on the basis of specific toxins, citing as an example
the necessity of assuming the presence of the toxin of the tubercle
bacillus to explain caseation. Friedberger, in reply, calls atten-
tion to the fact that reinjection of proteid in sensitized rabbits
causes necrosis and caseation. Citron, on the other hand, points
out that if there were but one anaphylatoxin, active immunization
to one infection would necessarily mean that it existed to all.
As we have already noted, the anaphylactic state may also be
produced by feeding foreign proteids. On this ground, possibly,
are to be explained those urticarial conditions which
follow the ingestion of a particular food. Here
we must assume that as a result of abnormal intestinal permea-
bility, due in turn perhaps to digestive disorders, proteid enters
the circulation after a preliminary splitting by the intestinal fer-
ments. This would be equivalent then to parenteral introduction,
and minute amounts would suffice. Possibly, an albuminous food
is not unequivocally necessary to produce this urticarial phe-
nomenon ; the specific antibody may have been previously formed,
or have arisen with the first occurrence of intestinal permeability.
The idiosyncrasy of certain children to cow's milk, evidenced by
INFECTION AND IMMUNITY 185
fever, vomiting and diarrhoea, asthma, convulsions and collapse,
is very likely anaphylactic in nature.
The so-called serum disease, because of its clinical bearing, is
the best known and most important type of anaphylaxis. To
V. Pirquet and Schick is due the credit of first calling attention
to the symptom-complex. It occurs in about ten per cent, of indi-
viduals receiving for the first time an injection of an immune
serum (as a rule that of immunized horses). The incuba-
tion period is roughly ten days, which represents the time
required for the formation of sufficient antibodies. Accompa-
nied by fever, there occurs an urticarial, sometimes a polymorphous
exanthem, generally starting from the site of injection. The rash
persists for two to three days, or longer, the lesions appearing
in crops. Pain in the joints and muscles and an albuminuria may
be present. Indeed, the picture of serum-sickness may differ in
no respect from that of an acute infection.
It is evident from the foregoing that serum anaphylaxis occurs
most frequently after the reinjection of an immune serum, when
the interval between the injections is not less than ten to twelve
days. With this incubation period, the symptoms begin at once
(v. Pirquet's immediate reaction). Serum disease, like experi-
mental anaphylaxis, occurs most readily after intravenous injec-
tions.
To prevent serum disease, it has been suggested that the
prophylactic injection be made with an immune serum obtained
from sheep or cattle, to the end that horse serum may then be
employed without risk if the disease develops despite the pre-
ventive dose. In the Pasteur Institute the sera are heated at 56°
C. for a number of days and are thus made less toxic. The same is
true of sera which have been allowed to stand for a long period.
Apparently the best method of guarding against serum disease
is by first rendering the individual antianaphylactic, by introducing
subcutaneously or intravenously, in high dilution, a small amount
of the serum indicated, and gradually increasing the dose, until
after several hours the full injection may be made (Besredka).'^*
Friedberger accomplishes the same purpose by running the full
dose into a vein, very slowly, consuming at least ten minutes in
the process. The good results of both methods reside in the
using up of anaphylactic antibodies.
To anaphylaxis, further, are ascribed the toxic manifestations
186 THE BASIS OF SYMPTOMS
sometimes observed, when in the course of an operation, the fluid
contents of an echinococcus cyst escape into the free
peritoneal cavity. In this case, the individual has been prepared
by the absorption of the proteid of the parasite during the course
of the disease; while the shock itself is due to the peritoneal
absorption, consequent to the operation. Eclampsia is also
classified by some among the anaphylactic processes. The mother
is assumed to be sensitized by the amniotic fluid, the onset of
symptoms following a later more energetic absorption. This
hypothesis seems to be borne out by the observation that guinea-
pigs, sensitized with the serum of an eclamptic, exhibit anaphy-
lactic shock after a subsequent injection of liquor amnii. Hay
f-ever is undoubtedly an allergic manifestation. Symptoms
do not appear until the second decade; during the first years of
life there is taking place, by inhalation, an absorption of the
foreign proteid (pollen) leading to antibody formation. Repe-
tition of the inhalation, analogous to the reinjection of some alien
proteid, calls forth the hay fever attack in the late summer. That
this conception is well founded is evidenced by the fact that injec-
tions of the same pollen proteid, at any time of the year, cause hay
fever. Whether the sensitization due to tuberculin belongs in this
category remains to be seen ; thus far, at any rate, it has not been
passively conferred.
(Many local allergic manifestations are of con-
siderable diagnostic worth.'^^ Prominent among these are the
different local tuberculin reactions — the v. Pirquet and the Moro
percutaneous tests, the intracutaneous test of Mantoux, the
ophthalmo-tuberculin reaction of Calmette and Wolff-Eisner, and
the " Stichreaktion " of Escherich ; further, the luetin percutaneous
phenomenon of Noguchi; the gonococcus local reaction (Irons) ;
and the ophthalmo-reaction in typhoid ( Chantemesse) . Essential
to a proper interpretation of these reactions is an understanding
not only of their value, but also of their limitations in the different
types and stages of the above-mentioned conditions.
The Abderhalden immune-ferment reaction may properly be
spoken of in this place, as it represents an outgrowth of studies
directed toward the explanation of the phenomena of anaphylaxis.
Observers generally agree with Vaughan that the toxic manifes-
tations of anaphylaxis are due to the poisonous substances formed
by the rapid splitting of foreign proteids. That is to say, the
INFECTION AND IMMUNITY 187
process of sensitization leads to the production of ferments capable
of splitting proteid when reinjected. Some of these ferments are
non-specific, i.e., they can disintegrate other proteids than those
which stimulated their formation. Certain ferments, on the con-
trary, are specific for a particular proteid. Of the latter the
first to be thoroughly studied was that produced in the maternal
organism by the action of the chorionic epithelium (placenta).
Placental extract brought into contact with the blood-serum of
pregnant women is split into the simpler proteid molecules, such
as the amino-acids, etc.
The technical phase of the test rests upon the principle that
proteid, being a colloid, does not dialyze through appropriate
membranes, but that the crystalloid split-products do pass through
such membranes, after which their presence can be recognized
by appropriate tests (ninhydrin).
From the adaptation of the immune- ferment reaction to the
early diagnosis of pregnancy, the test has found a wide application
in other morbid processes, particularly carcinoma, psycopathic
conditions, tuberculosis, thyroid anomalies, etc.
Despite the vast amount of work reported in the past few
years, tending to confirm the conception of Abderhalden, the
specificity of the reaction has lately been seriously questioned.''^^ A
final judgment as to its value, therefore, must be reserved. — Ed.)
Phagocytosis and Immunity.-^Wandering cells, derived partly
from the white cells of the blood, and in part from the fixed tissue
cells, pervade all parts of the body, carrying with them materials
of diverse kinds. They appear wherever there is a foreign body
— one not soluble in the tissue juices, or assimilable by the cells —
and remove it. This activity is not purely mechanical, for they
can also dissolve and destroy substances by means of an enzyme-
like body which they secrete. The wandering cells posssess, there-
fore, a double function : the one of dissolving foreign bodies, that
they may be washed away by the blood and lymph ; the other of
first disintegrating these bodies and then carrying them away.
These cells appear in certain morbid processes, being attracted
to the proper place, in all likelihood, by chemotrophic influences.
Their role in disease is merely a broadening and
a continuation of their physiological activity.
Nevertheless, in our opinion, these cells cannot be regarded merely
as scavengers. Even though the end-products of metabolism are
188 THE BASIS OF SYMPTOMS
absorbed only in solution, there is nothing to indicate that these
cells do not play a part in the transportation of intermediate solid
metabolic products. Or, in the vernacular, it might be said that
they not only clean the streets, but also take part in the business
activities of those who dwell in the street.
These functions of the wandering cells were early adduced in
the explanation of immunity phenomena. The theory of phago-
cytosis, linked with the name of Metchnikoff, has been defended
by him with great acumen and against many dissenters."^* It is
beyond question that these cells seize upon micro-organisms, even
living ones, for Metchnikoff was able to grow anthrax bacilli
engulfed by phagocytes; and it is no whit less certain that the
greater number of invading bacteria in certain experimental infec-
tions are removed from the inflammatory focus by the phagocytes.
The polynuclear leucocytes constitute an important factor in
the fight against bacteria. To them Metchnikoff has given the
name microphages, in distinction to the macrophages,
the large mononuclear phagocytes which are able to devour and
digest foreign cells. The microphages digest the bacteria by means
of an enzyme (microcytase) which is analogous to Buchner's
alexin; the macrophages, for their part, digest blood-corpuscles
and other cells by means of their macrocytase. Metch-
nikoff leaves open the question as to whether there are only these
two cytases, in contradistinction to Ehrlich who conceives of the
multiplicity of complement in every species of animal.
The bacteria-destroying cytase escapes from the phagocytes
only when they are injured by noxious substances in the blood or
in the products of inflammation (phagolysis). In this re*
spect, the views of Metchnikoff and Buchner are diametrically
opposed, for the alexins of the latter are assumed to be circulating
free in the body fluids. The work of Gruber and Futaki"^^
indicates that the outspoken phagocytic power of the leucocytes
of the hen toward anthrax is the source of the inherited immunity
of the hen to this disease. The same observers found that anthrax
bacilli protected themselves against the phagocytes by the forma-
tion of capsules, which have no chemotactic influence; but after
subcutaneous injection of the same micro-organism into the hen
and dog, the bacilli produced no capsules and were immediately
destroyed. In the sensitive guinea-pig and rabbit, however, the
phagocytes are not of great defensive worth; this is due probably
INFECTION AND IMMUNITY 189
to complicated biochemical differences between the lymph of
susceptible and non-susceptible animals.
As to amboceptor, Metchnikoff's point of view is as follows:
In the course of the intracellular digestion of bacteria by the
microphages, two enzymes are successively active, the so-called
fixateurs, which prepare the ground, and thereupon the micro-
cytase. The fixateurs, in most infections, differ from the cytases
in their looser combination with the phagocytes, and in their
tendency to an enormous increase in the immuninizing process.
Immune sera, therefore, are rich in fixateurs. In the living
organism the digestion takes place for the most part within the
phagocytes. In the Pfeiffer phenomenon, according to Metchni-
koff, there occurs first of all phagolysis in consequence of the
injection of injury-producing bacteria, and following this the
escape of cytase. Phagocytosis plays a determining role in other
phases of the Pfeiffer reaction. For example, if an animal im-
munized to cholera be killed at a time when the inflammatory
exudate shows only spores, a careful examination of the j>eri-
toneal folds and of the omentum yields many leucocytes filled
with vibrios.
That an augmented phagocytosis is the only
constant phenomenon observed in the process of
immunity is undeniable. We have already called attention
to the fact that the factors concerned in bacteriolysis are insuffi-
cient to explain all of the elements of an acquired immunity.
Indeed, the effect of certain immune sera — Aronson's strepto-
coccus serum, pneumococcus serum, etc. — which are not bacteri-
cidal, Metchnikoff ascribes entirely to phagocytic activity. And
this view has been confirmed by experiments in vitro.
The action of an immune serum, according to this conception,
is exerted solely upon the bacteria, even in high dilution specifically
preparing them for inclusion in the phagocytes (bacteriotropic
serum) ; and bacteriotropins have been demonstrated even in the
bacteriolytic sera of typhoid and cholera (Neufeld)."^^ Wright
and his collaborators,'^''' prior to Neufeld's publication, described
the opsonins, bodies found in normal serum, and similar in
behavior to bacteriotropins.
Wright has elaborated a most detailed procedure to estimate
this action of the serum quantitatively. The patient's serum, and,
as a control, that of a healthy individual, are brought into contact
190 THE BASIS OF SYMPTOMS
with leucocytes and bacteria and kept at a temperature of 37° C.
for fifteen minutes, after which by counting the organisms con-
tained within one hundred leucocytes, the average per white cell
can be determined (phagocytic count). The opsonic
index is obtained by dividing the phagocytic count of the
patient's serum by that of the normal serum. The ratio between
two healthy sera is fairly constant, varying only between 0.8 and
1.2; in disease, on the contrary, the index is diminished or very
inconstant. Wright has recommended a therapeutic appHcation
of the opKSonic theory by means of the subcutaneous injection of
killed micro-organisms or of their metabolic products (vaccines,
see p. 178), this procedure tending to raise the opsonic index.
Wright's method is merely active immunization during the course
of the morbid process.
Following an injection the index first falls (negative
phase ; period of antitoxin formation). The dosage must be
so gauged as not to produce too great a reduction of the index;
and the injection must be so timed as to allow the preceding nega-
tive phase to have run its course. The possible dangers attending
this last, however, have surely been exaggerated,'^^ and Wright
himself now insists only that the dosage be such that the general
reaction be slight. (Indeed the routine determination of the
opsonic index in vaccine therapy has generally been discarded
as being too laborious and not necessary. The focal and consti-
tutional manifestations seem to be safe guides for the determina-
tion of the dose and the time-interval. — Ed.)
Opsonins and tropins are not identical. The former are inacti-
vated at 56° C, the latter not. Opsonins, further, are supposed
to have a complex structure, i.e.j composed of amboceptor and
complement. Nor can opsonins be grouped with the lysins in the
present status of our knowledge. In the process of immunization,
tropins, as such, and the amboceptor portion of the opsonins, are
increased. The phagocytes are able to destroy certain types of
bacterial life, but as this is not true with respect to all micro-
organisms, the action of the tropins and opsonins cannot be com-
pared throughout. If we assume that the fixateurs of Metchnikoff
are the equivalents of the bacteriotropins, i.e., that their role is
that of fixateurs phagocytaires, then the phagocytic theory and the
humoral theory can readily be harmonized. The aggressins, as
inhibitors of phagocytosis, fit well into this conception, and are
INFECTION AND IMMUNITY 191
perhaps to be regarded as the antagonists of opsonins and tropins.
The theory of Metchnikoff would accordingly assume a kind of
antitoxic immunity, both because the aggressins are credited with
a toxic action, and because soluble metabolic products — and there
is no essential difference between soluble toxins and the substances
of the bacterial bodies — have an aggressin-like power. Indeed, a
specific antiaggressin serum has been produced for filtrates of
typhoid bacilli. Nevertheless the school of Metchnikoff is firmly
of the opinion that the phagocytes per se can seize upon even
highly virulent bacteria (spontaneous phagocytosis).
Bacillus Carriers. — Even after complete recovery from an in-
fectious disease, an individual may harbor the specific micro-
organism (bacillus carriers). After cholera and typhoid fever,
the causative organism may be isolated from the faeces, and after
diphtheria from the mucous membrane of the throat. This per-
sistence of the bacteria may be brief, or a matter of months, years
and even decades. Bacillus-carriers can undoubtedly be the source
of infection in others, even though the organism may be of an
attenuated type, for the latter can readily infect individuals with
a lowered resistance. Many endemics are unquestionably due to
bacillus-carriers. In protozoon affairs, carriers play an even
more important role, for here the parasite may persist not only
after the conclusion of the disease proper, but even after prophy-
lactic inoculation.
Chemotherapy. Salvarsan. — In the conflict between the living
organism and bacteria, the former may be victorious, the latter
may gain the upper hand, or there occurs a mutual adaptation in
the matter of metabolic products, protective forces, etc. Toler-
ance represents the stage of perfect adaptation. The host is then
a bacillus-carrier. It may happen, however, during an infection
that the major portion of the bacteria is rendered harmless, while
the more resistant minority survives. These multiply, becoming
more resistant to the individual's protective forces, and finally,
after a short interval of apparent good health, lead to a recurrence
of symptoms. This is probably the case in relapsing fever. The
splendid studies of Ehrlich,'^^ indeed, have shown that micro-
organisms can be made resistant to certain well-characterized
poisons, as, for example, trypanosomes to atoxyl, to fuchsin and
to trypan red, preparations injurious to these parasites, and thus
producing atoxyl-fast strains, etc. This resistance to poisons is
192 THE BASIS OF SYMPTOMS
inheritable and specific with respect to all the members of a chemi-
cal group. This is practically important in showing the necessity
of changing remedial agents from time to time, and of combining
them; which is in keeping with the most recent work of the
Ehrlich Institute showing that trypanosomes may be made to lose
acquired characteristics in the process of fecundation and trans-
mission through insects.
These observations have enabled Ehrlich ®° to identify atoxyl,
which is so important in the destruction of trypanosomes, as the
sodium salt of p-aminophenylarsanilic acid — a discovery which
paved the way for the synthetic elaboration of the arsenic domain.
By acetylization, for example, sodium acetyl arsinalate (arsacetin)
was produced, a body less toxic, but not less potent than atoxyl,
and therapeutically, therefore, because of the larger dose per-
missible, much more efficacious. The foregoing applies, however,
only to animals, for in man arsacetin was found to be just as
toxic as atoxyl. Some of the trypanosome-destroying substances,
the arsenious acids, for instance, act promptly upon the parasite,
in vitro, while atoxyl and arsacetin, even in a one or two per cent,
solution, have no such effect, despite their brilliant action in vivo.
Ehrlich has shown this paradoxical behavior to be associated
with reduction processes ; that is, with the reduction products of
atoxyl and arsacetin — these products in turn having a marked
reducing power — ^he succeeded in producing, in vitro also, an
enormous trypanosomicidal action; while in the animal body,
they exhibited an even greater toxicity to the parasites. In the
reduction products, arsenic has only a triple valence, similar to
arsenious acid, itself intensely potent, but far too toxic for animals.
The problem, then, was to elaborate reduction products, not
to leave their formation to the animal organism, and to combine
these products with other reducing substances. Ehrlich conceived
of the cells as possessing different molecular groups, or chemo-
receptors, which are able to unite with different combinations, as,
for example, trypanosomes with an arseno-receptor and also with
an acetico-receptor. If the latter unites more readily with the
acetic acid group of the arsacetin than do the cells of the infected
animal with the arsenic group, arsenic will be drawn to the parasite
and thus the acetic acid group, per se harmless, makes possible
the arsenic" action. In the Ehrlich nomenclature the acetic acid
group is parasitotropic, the arsenic itself being organotropic; the
INFECTION AND IMMUNITY 19S
latter, however, plays no part in the process because the parasito-
tropic groups cause too rapid a union with the parasite. The crux
of the matter then was to find molecules or groups which should
bind the arsenic element of the poison to the parasite.
On. the basis of work carried out along these lines, Ehrlich
gave to the world his spirochgeticidal preparation 606 (sal-
varsan), dioxydiaminoarsenobenzol, after convincing himself
that the spirilla possessed an amino-oxy-receptor ; and he thus
paved the way for successful chemotherapy.
Autoinfection. — In individuals who are not demonstrably sick,
particularly in those from the milieu of a patient, specific organ-
isms, Klebs-Loefiler bacilli, pneumococci, typhoid bacilli, may
often be found. It remains to be determined whether the pus-
cocci present on the body surfaces are to be looked upon as relics
of an earlier infection, or as pathogenic organisms residing in the
ostensibly healthy. These various bacteria are generally harmless,
perhaps because the host has been rendered immune by a mild
infection. To another, however, they may be virulent; indeed,
even in the host himself, they may cause disease if his resisting
powers have been lowered (autoinfection).
Conclusions. — We may sum up the question of specific im-
munity thus: The blood, both under certain normal conditions
and after recovery from disease, natural or artificial, is able at
times to destroy micro-organisms, to prepare them for phagocy-
tosis and to neutralize their toxic products. In the second place,
the phagocytes are capable of engulfing bacteria and rendering
them harmless. Both mechanisms, depending upon circum-
stances, provide the animal body with a defense against harmful
bacteria. But neither each by itself nor even the two combined
are sufficient in all cases to explain immunity in its entirety. A
fuller understanding of these problems will come only with
further study.
In what way do certain individuals successfully resist an infec-
tion, and why do others succumb? And why do fewer bacteria
cause an infection in animals living under ordinary conditions
than experimental results would teach ? Once again we must fall
back upon the protective forces residing in the body-surfaces to
explain these individual variations. Even different groups of the
same species react differently to microbic invasion. Race, age,
18
194 THE BASIS OF SYMPTOMS
mental depression and a subnormal state of nutrition — all of these
are additional factors.®^
The mechanism of recovery from an infection has an intimate
bearing upon the question of the protective forces. In those
diseases which exert a toxic action — and in the final analysis, all
diseases will probably belong in this category — the result is death
if the toxin, because of its amount or strength, can no longer be
neutralized. Recovery may occur by the formation or artificial
introduction of antitoxin, though cure is sometimes spontaneous.
This may occur in tetanus with no antitoxin in the blood,®^ in
which case the cells evidently become insensitive to the toxin
(histogenic immunity).
LITERATURE
*Aschoff: Ehrlich's Seitenkettentheorie, etc., Zeitschft. f. allg. Phys., 1902.
i; Buchner, Schutzimpfung, in Penzoldt-Stintzing, Gesamte Therapie, 3rd
edit., 1902, i — revision in 4th edit., 1909 (Levy) ; Ehrlich, Gesam. Abhandl.
ii. Immunitat, 1904; Metchnikoff, Immunity in Infect. Diseases, 1905;
Jacoby, Immunitat u. Disposition, 1906; v. Baumgarten, Lehrb. d. Pathog.
Bakterien, 191 1; Krause, Allg. Mikrobiol., 1910; Jordan, Bacteriology,
1912; Kolle and Wassermann, Handb. d. Path. Mikro-organismen, 1911-13.
* Schmiedeberg : Grundriss d. Arzneimittellehre, 5th edit.
*Cf. Lenhartz, in the Nothnagel System.
* Billings: Arch. Int. Med., 1909, iv, 409; ibid., 1912, ix, 484; Jour. Am. Med.
Assn., 1913, Ixi, 819.
' Jour. Infect. Dis., 1910, vii, 410 ; Jour. Am. Med. Assn., 1913, Ix, 1223 ; Jour.
Infect. Dis., 1914, xiv, i. See also Thiele and Embleton, Zeitschft. f. Im-
munitatsforsch., 1913, xix, 643.
' Jour. Am. Med. Assn., 1913, Ixi, 1942,
*Klipstein: Zeitschft. f. klin. Med., xxxiv, 191.
*Fliigge: Zeitschft. f. Hygiene, xxv, 179; xxx, 107; xxxviii, i.
' Arch. f. Hygiene, lii, 179 ; liv, 354 ; Ivii, 56.
"Zentralbl. f. Bakt., xliv (orig.), 325.
"Zeitschft. f. klin. Med., x, 49.
" Basset and Carre : Sem. med., 1907, 264.
"Bienstock: Die med. Wochenschft., 1901, Nos. 2>i, 34-
"Diphtherie, in the Bibliothek Coler., 1901, 95.
"Arch. f. Hygiene, lii, 272; liii, 302; Zentralbl. f. Bakt., xl, 371; E. Levy and
Fornet, Deutsch. med. Wochenschft., 1906, No. 26' E. Levy and Gran-
strom, Zentralbl. f. Bakt., xlv, 360.
" Meyer and Ransom : Arch, f . exp. Path., xlix, 369.
" Irons : Jour. Infect. Dis., xv, 367 ; Ashhurst and John, Amer. Jour. Med. Sc,
cxlv, 860; ibid., clvi, yj; Park and Nicoll, Am. Med. Assn., Ixiii, 235.
"Dorr: Das Dysenterietoxin, 1907.
"MacFayden and Rowland: Zentralbl. f. Bakt., xxxiv, 618, and xxxv, 415;
Besredka, Annal. Pasteur, xix, xx; Kraus and v. Stenitzer, Wiener klin.
Wochenschft, 1907, No. 12.
■"Pfeiffer and Bessau: Zentralbl. f. Bakt., Ivi, 344 (Part I); Bessau, ibid.,
Ivii, 27.
"^Siegel: Zeitschft. f. exp. Path., v.
*■ C. Frankel : Berl. klin. Wochenschft., 1905 ; Kruschilin, Zeitschft. f. Im-
munitatsforsch., i, 407.
" E. Levy and Gaehtgens : Arbeiten a. d. Kais. Gesundheitsamt, xxv, 1907.
INFECTION AND IMMUNITY 195
'* Dehne and Hamburger : Wiener klin. Wochenschft, 1907, 817.
*° Koch : Reisberichte, 1908 ; Kolle and Turner, Zeitschft. f . Hygiene, xxix,
309; Calmette and Salimbeni, Annales Pasteur, xiii, 905.
*• Beinarowitsch : Arch. d. sciences biol., vi.
" Annales Pasteur, xvi, 918.
""Hahn: Arch. f. Hygiene, 1907, xxviii, 312.
**Rosenow: Jour. Infect. Dis., 1914, xiv, 31.
** Gruber and Futaki : Miinch. med. Wochenschft., 1907, No. 6.
" Pfeiffer and Bessau : Zentralbl. f. Bakt, 1910, Ivi, 344.
" For a different view as to the source of complement, see Neufeld, Arbeiten
a. d. Kais. Gesundheitsamt, xxviii, 125 ; Schneider, Arch, f . Hyg., Ixx, 40.
''Aschoff:^ Zeitschft. f. Allg. Phys., i, 389; Sachs, Ergeb. d. allg. Path., vii
and xi.
** Ehrlich and Morgenroth : Berl. klin. Wochenschft., 1900. No. 21.
"v. Baumgarten: Festschrift f. Jaffe, Braunschweig, igoi, 279.
■•Ferrata: Berl. klin. Wochenschft., 1907, 366; Brand, ibid., 1907, 1075.
" Belfanti and Carbone, cited by Aschoff, 1. c ; Bordet, many studies in the
Annales Pasteur; Ehrlich, Gesam. Arbeit, z. Immunitatsforsch., 1904.
" Eisler : Zeitschft. f. Immunitatsforsch., ii, 159.
" Landsteiner and H. Ehrlich : Zentralbl. f . Bakt., xlv, 247.
*• Zeitschft. f. Immunitatsforsch., iii, 114.
*^ Porges, in Handb. d. Technik. u. Methodik d. Immunitatsforsch., of Kraus
and Levaditi, ii, 1136.
**v. Behring. Kasseler Naturforscherversammlung, 1903; Romer, Beitrage z.
exp. Therap., Part 9; Dehne and Hamburger, Wiener klin. Wochenschft.,
1904, No. 29; Hamburger, Miinch. med. Wochenschft., 1907, No. 6.
*• Ehrlich and Wassermann: Zeitschft. f. Hyg., xviii, 239; Romer, Zeitschft. f.
Immunitatsforsch., i, 171.
** Wassermann and Schiitze : Berl. klin. Wochenschft., 1901, 187 ; Uhlenhuth,
Das biol. Verfahr. z. Erkennung u. Unterscheid. von Menschen u. Tierblut.,
1905 ; Blum, Zentralbl. f. allg. Path., xvii, 1905.
" Michaelis : Hof meister's Beitrage, iv, 59.
•* Uhlenhuth : Zentralbl. f. Bakt., xxxviii, suppl., 36 (review). See also
Deutsch. med. Wochenschft., 1906, No. 31.
■" Annales Pasteur, xv, 289.
** Neisser and Sachs : Berl. klin. Wochenschft., 1905, No. 44 ; ibid., 1906, No. 3.
* Wassermann, Neisser and Bruck, Wassermann and Plant, Bruck and
Schlucht, in the Deutsch. med. Wochenschft., 1906, and the Berl. klin.
Wochenschft., 1907.
" See collective article of Meyer in Fol. neurobiol., 1908, 652. See also Noguchi,
Jour. Exp. Med., xv, 557; Serum Diag. of SyphiHs, 2nd edit., 1915.
"Mueller and Oppenheim: Wiener klin. Wochenschft., xx, 849; Schwartz and
McNeil, Amer. Jour. Med. Sc, cxli, 964, and cxliv, 815.
"Hahn: Miinch. med. Wochenschft., 1912, 1483; Thomsen and Magnussen,
Berl. klin. Wochenschft., 1912, 1183.
"Lowenstein and Liidke, in Kraus-Levaditi (supplement, vol.), 191 2.
•* Gruber and Durham: Miinch. med. Wochenschft., 1896, 285; Gruber, ibid.,
1899, No. 41.
"■ Eisenberg and Volk : Zeitschft. f . Hyg., xl, 155.
"Gaethgens: Munch, med. Wochenschft., 1906, 1351.
" Brit. Med. Jour., Jan., 1897, 16 ; Lancet, Sept., 1896, 807 ; ibid., Sept., 1902, 654.
See also Metchnikoff and Besredka, Ann. Pasteur, xxv, 193 (sensitized
vaccine).
" Russell : Am. Jour. Med. Sc, clxvi, 803 ; Ann. Report Surg.-Gen., U. S. Navy,
1913-
■• Topper and Jaffe : Zeitschft. f. Hyg., hi, 393.
•"v. Behring: Zeitschft. f. Hyg., xii, i, 10, 45; v, Behring and Knorr, ibid.,
xiii, 407.
"Kraus and Schwoner; Zentralbl. f. Bakt., xlvii, 124.
196 THE BASIS OF SYMPTOMS
"Berghaus: Zentralbl. f. Bakt., xlviii, 450.
"Mtinch. med. Wochenschft., 1913, 2608; Zeitschft. f. d. ges. exp. Med.,
1914, 83 ; Park, Zingher and Serota, Archives of Pediatrics, xxxi, 481 ;
Weaver and Maher, Jour. Inf. Diseases, 1915, xvi, 342.
"Smith and Henderson: Jour, of Hyg., vii, 205; Levin, Zeitschft. f. Im-
munitatsforsch., i, 3.
* Meyer : Berl. med. Gesell., June 9, 1909 ; Arch, f . exp. Path., Ix, 208.
" Levy and Hamm : Miinch. med. Wochenschft., 1909.
"Ann. Pasteur, xxi, 497.
" v. Pirquet and Schick : Serum Disease ; H. Pf eiffer. Das Problem d. Eiweiss-
anaphylaxie, 1910 (lit. to June, 1910) ; Friedberger, Deutsch. med. Woch-
enschft., 191 1 ; Miinch. med. Wochenschft., 1910; Berl. klin. Wochenschft,
1910, 191 1 ; Zeitschft. f. Immunitatsforsch., vii, viii; Vaughan, Prot. Split
Products in Relation to Immunity and Disease, 1913 (Ht.), and Jour. Am.
Med. Assn., 1914, Ixii, 583 ; Rosenau and Anderson, Hyg. Bull., Nos. 29,
36,45,50 (P. H. and M. H. S.).
•* Ann. Pasteur, xxii, Nos. i, 2, 3.
^"Krehl, and Krehl and Matthes: Arch. f. exp. Path., xxxv, 222; xxxvi, 417
, (1895).
" See Besredka's report on antianaphylaxis, read at the 17th Inter. Med. Cong.,
London, 1913, abstracted and translated in the Lancet, Aug., 1913, 462.
" For the literature bearing on these phenomena and on the Abderhalden
reaction, see Dick, in Billings-Irons, Therapeusis, v.
" For example, see Jobling, Eggstein and Petersen, Jour. Exp. Med., 191 5, xxi,
227 (lit).
" Metchnikoff : Immunity in Infect Diseases, 1905 ; also Ergeb. d. allg. Path., xi.
" Miinch. med. Wochenschft., 1907, No. 6.
'^^See Neufeld, in Kolle-Wassermann, Handb. ii (suppl.), 1908.
" Proc. Royal Soc, London, Ixxii, 357 ; Ixxiii, 128 ; Ixxiv, 147 ; Rosenthal, Med.
Klinik, 1907; Wright and Bullock, Michaelis, Handb. d. Path. Microorg.,
1913, iii-
" Pf eiffer and Friedberger : Zentralbl. f . Bakt., xlvii. Part I, 503.
" Berl. klin. Wochenschft., 1907, 233, 280, 310, 341.
*" Ehrlich and Hata : Die exp. Chemotherapie d. Spirillosen, 1910 ; Ehrlich,
address in Path, and Chemotherap., 17th Inter. Med. Congr., London,
1913 (Lancet, Aug., 1913, 445). See also Abhand. ii. Salvar.san, with pref-
ace and remarks by Ehrlich, i, ii, iii.
" Dieudonne : Schutzimpf ung u. Serumtherapie, 2nd edit, 4.
**Vincenzi: Deutsch. med. Wochenschft, 1908.
CHAPTER IV
RESPIRATION
The cells of the body continually receive oxygen from the
blood and continually give up the carbon dioxide formed in their
metabolism to the blood- and lymph-streams. In the lungs the
blood takes up a new supply of oxygen and unburdens itself of the
carbondioxide it has transported from the tissues. These proc-
esses, as a whole, constitute respiration.^ The interchange of
gases between the tissues and the blood is called internal
respiration, and that between the blood and the air, ex-
ternal respiration. It is obvious that each is intimately
dependent upon the other — the ventilation of the lungs, for exam-
ple, serving merely to guarantee a fresh supply of oxygen to the
blood and the elimination of accumulated carbon dioxide.
External Respiration. — Essential, first of all, to external res-
piration is an uninterrupted supply of air. A pregnant source of
danger is the juxta-position of the air- and food-passages in the
pharynx, for foreign bodies that may enter the former often cau^^
grave inflammatory conditions. The mechanism designed to pre-
vent this will be discussed elsewhere (see p. 198) .
Means for Removing Harmful Material from the Air-
Passages. — The respiratory apparatus is able, as a rule, to rid
itself of foreign particles that have passed the defenses at the
glottis, or have reached the bronchi in other ways. Of first im-
portance in this respect is the movement of the epithelial cilia,'
which by their slight but constant activity impel such particles
from the bronchioles into the larynx. Were we more familiar
with disturbances of this protoplasmic movement, we might better
understand the underlying causes of certain bronchial and pul-
monary diseases.
As the activity of the cilia is probably the most important
factor in transporting foreign bodies from the lower to the upper
respiratory passages, any disturbance of this movement is ob-
viously a more potent source of harm, in contributing to the stag-
nation of inflammatory products, than is even the suppression of
coughing, Furthermore, since the cilia seem to be whipped on by
197
198 THE BASIS OF SYMPTOMS
inflammatory irritation, it is reasonable to assume that they
attempt also to expel invading bacteria, as a defensive measure.
The second mechanism that aids in protecting the lungs is
the secretion of mucus upon the surfaces of the air-passages.' Small
bodies, such as particles of coal-dust and bacteria, are caught in
this mucus and thereby prevented from penetrating the air-cells ;
they are then carried away by the action of the ciliated epithelium.
When the foreign bodies are inspired in great numbers, however,
or the secretion of mucus or the movements of the cilia are ham-
pered by inflammation, these defensive barriers fall away.
The lungs are guarded, further, by our sense of smell, which
warns against noxious admixtures in the air to be breathed.
Sneezing^ also plays a part by keeping the nasal passages clear for
the entrance of air. Sneezing begins with a deep inspiration.
The powerful expiration succeeding this, forcibly carries with
it through the mouth and nose the movable foreign bodies which,
by their irritation of the nasal mucous membrane, have initiated
the reflex.
Coughing serves as an additional guard and eliminating force.
The reflex which induces the act, and which is gen-
erally carried by the vagus, may be initiated from the larynx below
the vocal cords, from the posterior part of the trachea and the
region of the bifurcation, from a diseased pleura, from a patho-
logically enlarged spleen or liver,"* and according to some observ-
ers, from the stomach and uterus.^
Th e act of coughing begins with a deep inspiration.
This is followed by a powerful contraction of the expiratory
muscles. At first, the air that should be forced out meets the
obstruction of a closed larynx; later, the vocal cords yield to the
pressure of the air and the latter is propelled through the opening
with great violence. As the soft palate closes the passage into
the nose, the current of air carries whatever is in the larynx or
trachea up into the mouth. Possibly the contents of the larger,
and even those of the smaller, bronchi may be removed by cough-
ing, despite an antagonistic force arising at the bifurcation. In
our opinion, however, the movements of the cilia play the main
part in transporting material from the alveoli up to the bifur-
catioft of the trachea, whence coughing readily carries it into the
mouth.
The impulse setting in motion the mechanism of coughing orig-
RESPIRATION 199
inates in the medulla, near the respiratory centre, and responds
to stimuli carried by the pneumogastric nerve from the regions
already enumerated. That coughing may also be of central origin
is indicated from observations in nervous individuals : our ability
to cough voluntarily is further evidence.
A reflex cough from the regions mentioned occurs when they
have been stimulated beyond a certain point, the degree of stimu-
lation necessary varying, however, with conditions. We may say,
in general, that the irritability of the nerves is increased by acute
inflammations of the mucous membranes, in which case coughing
is produced by abnormally slight stimulation. Certain drugs, on
the contrary, as well as certain diseases of the brain, diminish the
irritability of the nervous mechanism and thus raise the threshold
of stimulation. Chronic inflammation of the mucosa may have a
similar effect.
In the first class of cases, coughing may be induced by very
slight chemical or mechanical impurities in the inspired air ; in the
second, no coughing results from stimuli that would ordinarily be
effective. An absence or weakness of coughing may likewise
result from disease of the motor half of the reflex arc, as has been
observed in serious lesions of the nervous system, as well as
in any condition of enfeebled musculature. Whatever the cause
of the diminished ability to cough, the lungs are endangered
because undesirable substances, whether exogenous or endogenous,
are not expelled. This danger is much enhanced when the move-
ments of the ciliated epithelium are also hampered. Every phys-
ician knows and fears the dangers of such conditions, so often met
with in the aged and in those greatly weakened by disease.
The stagnating material readily decomposes, but whether this
is due to micro-organisms which are held back simultaneously, or
to others which have entered from the larger tubes because of the
inefficacy of the defensive forces previously described, is not
known. The latter seems to me the more probable inasmuch as
many observers have found the normal lungs sterile,® though
it is true that pathogenic organisms may be present in the lungs
of healthy animals.''' The variations in the depth of respiration
and in the number of organisms inspired probably explain the
divergent observations. That the bacteria of the inspired air,
though relatively few in number, do not always reach the finer
200 THE BASIS OF SYMPTOMS
bronchi and the alveoli is due, no doubt, to the various protective
forces mentioned above.
The act of coughing is beneficial when it protects
the lungs against disease by removing foreign material and ex-
cessive secretions, but it is useless when caused by an abnor-
mal irritability of the air-passages, or by reflexes from other
organs, because in these cases it has nothing to expel. Here,
indeed, it becomes highly undesirable, for it is by no
means an indifferent process to the organism. The forcible ex-
pirations cause a distinct increase in intrathoracic pressure, thereby
interfering with the entrance of blood into the chest, and also
a general rise in arterial tension. These may have as their sequelae
the rupture of an artery, an incomplete filling of the heart and
a marked pulmonary distention (volumen pulmonum auctum).
Stenosis of the Air-Passages. — External respiration is endan-
gered by any narrowing of the air-passages which hinders the
access of fresh air and the egress of vitiated. The signifi-
cance of such a stenosis depends upon its loca-
tion. The nasal passages, for example, may be com-
pletely blocked, and yet cause only a temporary discomfort and
feeling of suffocation, for breathing goes on through the mouth
and is not interfered with by eating. To the infant at the breast,
however, a severe " snuffles " may render nursing so difficult as to
cause grave inanition.
A stenosis situated between the pharnyx and
the bifurcation of the trachea has a quite different
significance. The obstruction may be the result of pressure from
without — struma, mediastinal tumor, aneurism — ^pressing upon the
air-passages, or of disease of the respiratory tract itself, such as
an oedema of the larynx. The most frequent site of
mischief is at the glottis, for here, especially in the
case of children, the passage is narrowest. Illustrative of this
are three conditions, characterized by their sudden onset and
brief duration. These are pseudocroup, spasm of the glottis
and the paroxysm of pertussis. Each, in our opinion, is essen-
tially the result of a spasm of the adductor muscles of the cords.
In pseudocroup, an added factor is an ultra-acute laryngitis,
which may be seen under favorable conditions and may persist
for hours after the attack has ceased, as is evidenced by the
hoarseness and cough. The adductor spasm in this condition is
RESPIRATION 201
possibly the result of the inflammatory process ; it need not be of
high degree to occlude the narrow laryngeal opening of the child.
Whooping-cough,' on the contrary, is generally not associ-
ated with inflammatory changes. The voice is clear, and the
laryngoscopic examination negative. The factors involved in
the muscle-spasm — at the basis, apparently, of the paroxysm — are
not clear.
Spasm of the glottis (laryngismus stridulus) affects chiefly rhach-
itic children and is often associated with thymus enlargement
and manifestations of tetany. In this connection paediatricians
speak of a spasmophilic constitution.
A stenosis of the respiratory passages would
materially curtail the ventilation of the lungs
were it not for a compensatory increase in the
rate and depth of respiration. This equalizing
mechanism is unquestionably the result of a
varying activity of the respiratory centre de-
pending upon alterations in the carbon dioxide
tensionoftheblood. A diminished oxygen content, with
a correspondingly augmented carbonic acid concentration, is
known to render the centre more active. It would be decidedly
advantageous, however, if sufficient oxygen were furnished
through increased respiratory movements before a change were
manifested in the partial pressure of the blood gases.
In the light of more recent studies® it would appear that in
the stenoses under consideration the respiratory type actually
does undergo a change, becoming slower and deeper, and this
before the oxygen and carbon dioxide partial pressures in
the alveoli are affected. In this way is obviated tissue-injury
consequent to oxygen deficiency. In tracheal stenosis, therefore,
the alteration in respiration would be of reflex nature and inde-
pendent of the changes in gas tension.
The effect of a tracheal stenosis is seen in the
more forcible contraction of the usual inspiratory muscles and in
the innervation from the respiratory centre of new groups of
muscles. As the air cannot enter the chest cavity readily, a con-
siderable negative pressure prevails there during inspiration, and
the softer parts of the thorax are forced inward by the atmos-
pheric pressure without. The result is the well-known in-
spiratory retraction of the epigastrium, of the soft tis-
202 THE BASIS OF SYMPTOMS
sues above the sternum and clavicles, and of the lateral portions of
the chest wall.
The last-mentioned phenomenon, as shown by Gerhardt, can
scarcely be due to the direct pull of the diaphragm, for this would
demand a downward dislocation of the liver or a marked fixation
of the lower ribs. Yet even without these prerequisites, the soft
ribs of rickets exhibit a distinct retraction in cases of laryngeal
stenosis.
It is to be noted further that the difference between the intra-
alveolar and atmospheric pressures in itself creates a not incon-
siderable resistance to the inspiratory muscles, and thereby an
added respiratory obstruction.
The inspirations accompanying laryngeal or
tracheal stenosis are not only more powerful
than normal, but more prolonged. This is to be
explained on the basis of an automatic regulation (Selbst-
steuerung^®) of the duration of the respiratory phases, i.e.,
when the distention of the lungs has reached a certain point, ex-
piration is initiated by a reflex through the vagus. (The recent
experimental studies of Boothby and Berry, however, do not tend
to confirm this conception.!^ — Ed.) As the air enters the lungs
slowly in tracheal stenosis, a distention sufficient to induce this
reflex is delayed and inspiration is accordingly prolonged. Ex-
piration is also lengthened because the air cannot escape readily
from the lungs on account of the stenosis, added to which is the
inherent inferiority of the expiratory muscles.
Expiration, normally, is a purely passive act due to the elastic
recoil of the chest wall and the lungs; but in the conditions under
consideration, expiration becomes active through the intervention
of certain accessory muscles called into action by the respiratory
centre and tending to force up the diaphragm and to compress
the thorax laterally. In stenosis of the trachea and larynx, there-
fore, expiration is lengthened, is more powerful and is converted
from a passive into an active process.
During both respiratory phases there may be heard a charac-
teristic stridor as the air passes through the narrowing. The
respiratory rate is naturally slower in view of the prolongation of
both inspiration and expiration. Another consequence of these
conditions is the relatively high position of the lung bases during
RESPIRATION 203
the respiratory pause, as is evidenced by observations on the posi-
tion of the diaphragm in diphtheritic laryngeal stenosis. ^^
This slowing and deepening of respiration is advantageous to
the patient; for experimental work has shown that if the trachea
be artificially narrowed, such a compensatory mechanism allows
more air to enter and to escape from the lungs than is represented
by the normal tidal air.^^ Conditions have been shown to be
similar in man. Coincident with the increase in respired air per
minute is a considerable diminution of the partial pressure of
carbon dioxide in the alveoli. It is true that the extra exertion
involved consumes more oxygen, but, with the individual at rest,
the deeper inspirations enable the supply to meet the demand.
A paralysis of the posterior crico-arytenoid muscles, which
separate the cords during inspiration, interferes purely with this
phase, for the cords then hang limply and are sucked in by the
air as it enters, leaving only a chink between them. This pro-
duces an inspiratory stenosis, while expiration is free and unhin-
dered. Membranes and polyps which float loosely above the
glottis may similarly give rise to an inspiratory dyspnoea ; whereas
those below are likely to affect only expiration.
The entrance of air into the alveoli may also
be hindered by a narrowing of the coarser or
finer bronchi. The results will depend entirely upon the
site and extent of the lesion. If the main bronchus on one side
be obstructed, the corresponding half of the chest expands less
than the other, the normal respiratory murmurs are diminished
or absent on this side and a stridor, caused by the stenosis, is heard.
The breathing becomes labored, but ordinarily it does not assume
the characteristic slow, deep rhythm of tracheal stenosis, evidently
because the unaffected side acts as the pace-maker.
Conditions vary with the rapidity of devel-
opment of a stenosis. If this be sudden, immediate
asphyxia may occur, but if gradual, the degree of discomfort
may be slight because the individual learns to conserve his oxygen
ration by reducing his exertions to a minimum. In this way, indi-
viduals with distinctly reduced respiratory capabilities may lead
a fairly comfortable existence — ^how comfortable depending upon
the extent of the lesion and upon the oxygen need.
The large bronchi may be narrowed by many of
the causes leading to tracheal stenosis, as, for instance, by tumors
204 THE BASIS OF SYMPTOMS
or cicatrices from within, or by tumors or aneurisms pressing upon
them from without. On account of the large calibre of these tubes,
a swelling of the mucous membrane does not ordinarily obstruct
the passage of air. In the case of the smaller bronchi, on the
contrary, the most frequent cause of obstruction is just such an
inflammation of the lining mucous membrane. If only the larger
bronchi are involved in a bronchitis, little effect, therefore, is pro-
duced upon the interchange of gases in the lungs ; whereas i f
the smaller tubes are affected, the results are far
more serious. This is especially true of children on account of
the narrowness of their air-passages, and is also true of those
with kyphoscoliosis, for their pulmonary surface is thereby already
reduced.
In every severe bronchitis, the breathing is superficial and
hurried, the rate not infrequently rising to sixty or eighty per
minute. Febrile types exhibit the most rapid rate, for fever per se
accelerates the breathing. The same respiratory changes occur
also in extensive non-febrile cases. The factors causing this
alteration in the breathing are not understood. A mere retention
of carbon dioxide in the blood — the normal respiratory stimulus ^^
— will not produce this effect. The conception of a peculiar stimu-
lation exerted by carbon dioxide from diseased lungs is not satis-
factory because it is not known that the gas actually does act upon
the vagus endings; nor would the carbon dioxide tension in the
alveoli be favorable for such a stimulation. It is possible that
the inflammation as such stimulates the vagus terminations. In
conditions such as pneumonia in which an augmented respiratory
volume is out of the question, compensation can be effected only by
an increase in rate.^^ Finally, we must not lose sight of the fact
that the respiratory changes may be due to the products of incom-
plete oxidation, comparable to the alterations in breathing accom-
panying muscular activity. ^^
Bronchial Asthma. — The condition known as bronchial
asthma ^'^ may properly be considered here, because its char-
acteristic paroxysms are assumed to be due to a nar-
rowing of the entire bronchial tree. These attacks exhibit an
extraordinarily severe dyspnoea which is independent of the con-
dition of the heart. Usually nocturnal at first, they may later
occur at any time and last for hours or days. Though both res-
piratory phases are powerful and prolonged, expiration is the more
RESPIRATION 205
labored. Cyanosis and inspiratory retraction of the soft parts
are rarely absent. The breathing is generally hurried. During
the paroxysm the lungs are markedly distended, and soon attain
the maximum inspiratory position. Auscultation yields profuse
rhonchi of all types. Early in the disease patients are comfortable
in the intervals, but as time goes on, bronchial catarrh, cough and
intermittent dyspnoea are often present.
These asthmatic paroxysms occur particularly as phases of a
chronic exudative bronchiolitis (Curschmann).*^
The tough mucinous sputum, Curschmann spirals and Charcot-
Leyden crystals speak for a specific process, which Miiller,^^ on the
basis of chemical sputum analyses, is inclined to regard rather as a
disorder of secretion than as an inflammation in the strict sense.
The eosinophilia in the blood and sputum of asthmatics, and
also in the membranous discharges of mucous colitis, and further,
the neuropathic constitution common to both, have inclined
Striimpell to the view that both are of similar origin, possibly
an eosinophilic diathesis. Be this as it may, asthmatic
paroxysms are practically pathognomonic of bronchiolitis exu-
dativa. Similar paroxysms, it is true, do occur in emphysema;
and it may be difficult to determine whether the emphysema or
the asthma is primary.
Diverse factors can apparently precipitate an attack, for ex-
ample, affections of the nasal mucosa, possibly by reflex action. It
is conceivable that the mucous membranes of the bronchi and of
the nose are affected by similar influences, or that simultaneous
changes in both are manifestations of the same (eosinophilic)
process.
The most unusual moments may bring on a paroxysm, as, for
instance, a peculiar odor, in the asthma of hay fever. One thinks
involuntarily of anaphylaxis. The tendency of many observers
to regard asthma as the equivalent of anaphylactic sensitization,
and to identify the paroxysm with anaphylactic shock,
rests upon a certain basis of fact.^^ An unstable nervous organ-
ization is common to both. In asthma, furthermore, aerogenic
introduction of the provocative material can occur only in minimal
amounts, which fits in well with conditions peculiar to sensitization
and reinjection in anaphylaxis.
The dyspnoea and the pulmonary distention seen in asthma
must first be explained before we can understand the nature of
206 THE BASIS OF SYMPTOMS
the paroxysm itself. We have seen that during inspiration — and
even more during expiration — there is evidence of a marked ob-
struction, which is of rapid onset and of relatively short duration,
and which quickly leads to a pulmonary distention. What con-
stitutes this hindrance to the passage of air has been variously
explained. In the bronchiolitic type it is natural to assume an
inflammatory plugging of the finer tubes. More plausible perhaps
is an acute non-inflammatory hypersemia of the medium-sized
tubes, in view of the analogous condition of the nasal mucosa;
for this would not only permit of a common explanation of these
two conditions which seem to be so intimately related, but would
also, regarded as a vasomotor phenomenon, be in keeping with
the nervous element in asthma. StriimpelPi happily compares
the asthmatic attack with an urticarial eruption, which is also
of short duration and a secretory neurosis.
The most acceptable explanatio n — one accounting
for all of the phenomena of the paroxysm — is that of a
spasm of the smooth muscle of the fine and
medium-sized bronchi superimposed upon in-
flammatory or vasomotor swelling of the mu-
cous membranes. Experimental studies seem to indicate
that pulmonary distention may unquestionably be due to such a
spasm. The predominating expiratory dyspnoea would then be
ascribed to the narrowing of the bronchioles, with their yielding
walls, by the pressure exerted laterally upon the chest wall during
expiration; though no other explanation is needed than is given
by the loss of elasticity consequent to the pulmonary distention,
and by the fact that the expiratory forces are naturally weak.
Vasomotor swelling and bronchial spasm, therefore, explain
all of the phenomena of asthma. A spasm of the diaphragm is
inconceivable, for the diaphragm, unlike the involuntary muscle
in the bronchial wall, can hardly remain in a state of tonic con-
traction for hours at a time without tiring and, as radiographic
studies have shown, does not occur. The symptoms of the
paroxysm also fit in well with the conception of anaphylactic
shock, both in the vasomotor manifestations and in the intimate
association of nervous and muscular factors.
Paralysis of the Respiratory Muscles. — The aeration of the
lungs suffers if the thorax or the lungs cannot sufficiently expand
and contract. A rigidity of the chest wall alone ordinarily does
RESPIRATION 207
little harm, for the compensatory increase in the movements of
the thorax as a whole, and of the diaphragm, could move the
lungs sufficiently to keep them ventilated.
More serious is disease of the respiratory muscles or of the
nerves which supply them. The former occurs in the muscular
atrophies and in trichinosis; the latter in peripheral neuritis, or
in intracranial conditions such as inflammation, tumor or hemor-
rhage. The diaphragm and the other muscles of respiration may
be paralyzed together or separately. The movements of the
diaphragm may be seriously hampered by inflammation of its
pleural or peritoneal surfaces, and by abdominal distention whether
from fluid, gas or tumor — all of which interfere with respiration
by forcing the diaphragm up and by offering an abnormal resis-
tance to its inspiratory descent.
The degree of disturbance of respiratory function from these
various causes is closely dependent upon the extent and the loca-
tion of the disease. Death quickly follows the simultaneous in-
volvement of all of the inspiratory muscles. Of the more limited
conditions, equally fatal is bilateral paralysis of the diaphragm,
as occurs in disease of both phrenic nerves. A less serious
paralysis may not cause death, but merely interferes with the inter-
change of gases in the lungs. If the compensatory increase in the
movements of the unaffected muscles is not sufficient, the vicarious
inspiratory muscles, previously referred to, are called upon, lead-
ing to bizarre types of breathing, such as the pure costal in a
man, etc. The rate may also be increased in these conditions,
particularly when pain is a factor.
Loss of Pulmonary Elasticity. Emphysema. — As has already
been mentioned, the elasticity of the lungs plays an important role
in normal respiration, for it is one of the main factors in forcing
the air out during expiration. If the lungs are immoderately
distended, or if their elasticity is otherwise diminished, the ten-
dency to collapse is more or less lost. Such a loss of elasticity
of the lungs, as a whole or in part, may follow diseases associated
with violent inspiration or coughing, or those in which the egress
of air is obstructed. If a major portion of the lungs has lost its
elasticity from overdistention, respiration is handicapped because
the distended lung does not exhibit the normal tendency to collapse
on expiration, and not being fully collapsed, cannot expand so
well on inspiration. Volumen pulmonum auctum,
208 THE BASIS OF SYMPTOMS
therefore, diminishes the functional capacity of the lung tissues
by rendering it less elastic. Removal of the cause, however,
may bring about a restoration of function if the damage is not
too great.
Genuine emphysema of the lungs acts similarly by
diminishing the pulmonary elasticity. It is more serious than
mere overdistention, because the damage it causes is irreparable,
and especially because it leads also to an actual loss of lung sub-
stance. Many alveolar septa disappear, and the respiratory sur-
face of the lungs is markedly contracted. The loss of the septa
leads to an obliteration of many pulmonary capillaries, in this
way increasing the resistance to the flow of blood through the
lungs. The consequence is an hypertrophy of the right ventricle,
evidenced by the accentuation of the pulmonary second sound.
Emphysema does not, as a rule, involve both lungs uniformly, but
is most pronounced along the free margins in front.
Prominent among the theories advanced to ex-
plain pulmonary emphysema ^^ are the mechanical
and the toxic-inflammatory. According to the former,
the elastic tissue suffers purely from mechanical interference with
the respiratory movements ; while, in the latter, the damage is the
result of inflammation and its products. Tendeloo favors me-
chanical factors because emphysema is most marked where the
forces leading to overdistention are most active, and he attributes
variations in the resistance of elastic tissue both to congenital
inferiority and to acquired injury.
Speaking also for mechanical influences is the fact that
although true emphysema is comparatively rare, emphysematous
changes secondary to long-continued asthma may be regarded
almost as the rule.
Calcification of the first costal cartilage with a resultant rigid
distention of the thoracic cage has also been suggested as the chief
factor in emphysema.^^ Upon this view is based a surgical treat-
ment of the condition. 2*
•Experimental studies have explained the cause of dyspnoea in
emphysema on the ground of an unequal arterialization of the
blood. As many of the alveoli are rendered functionally incapa-
ble in emphysema, oxygenation in the lungs is patchy, so to speak,
the result being a disturbance of the oxygen tension in the blood
as a whole.^^
RESPIRATION 209
Respiratory Changes of Nervous Origin. Cheyne-Stokes
Breathing. — Disturbances of the respiratory centre may also affect
the ventilation of the lungs. With an increase in intracranial
pressure, the respirations usually become slower and deeper,
and frequently, also, more irregular. Anatomical lesions that
injure, without destroying, the respiratory centre may give rise
to similar effects.
The peculiar type of breathing known as Cheyne-Stokes
respiration may be considered in this place.^^ In this con-
dition the respiratory rhythm is broken by pauses of apnoea.
After one of these pauses the respirations are at first weak and
superficial, but gradually they become stronger and stronger, until
they are exceedingly labored. Following the extreme dyspnoea,
the respirations gradually diminish in strength until they cease
altogether in the period of apncea, and the cycle of events is com-
pleted. Accompanying this anomaly there are frequently mani-
festations suggesting involvement of other parts of the brain.
The patient may lie in a stupor during the apnoea, to awake during
the period of dyspnoea with oppressive sensations of air-hunger.
The pupils may be contracted and rigid during the pause and
become dilated and mobile during the dyspnoea. The pulse is
generally unaffected though it may exhibit distinct variations in
frequency and tension. Important among the causes of
Cheyne-Stokes breathing are ursemia and diseases of
the heart and brain.
The explanation of this phenomenon was be-
lieved by Traube to reside in an altered irritability of the res-
piratory centre. Filehne,^''^ who observed similar respiratory
changes in rabbits under deep morphin narcosis, came to the
conclusion, on the basis of comparative respiratory and blood-
pressure tracings, that the respiratory centre had become less irri-
table than the vasomotor. As is well known, blood with a suffi-
cient carbon dioxide tension furnishes the stimulus to both. In
the opinion of Filehne, then, the blood is not sufficiently venous
during the pause to stimulate the respiratory centre, but does
contain enough carbon dioxide to activate the vasomotor centre.
The resulting constriction of the arteries going to the brain finally
renders the blood sufficiently venous to stimulate the less irritable
respiratory centre. The breathing then gradually deepens and the
blood becomes better aerated. The vasomotor centre, no longer
14
210 THB BASIS OF SYMPTOMS
stimulated by venous blood, allows the vessels to dilate, and in
this way a fresh supply of arterial blood reaches the respiratory
centre. The latter is thereby deprived of the necessary carbon
dioxide stimulus and the animal stops breathing. Thus the cycle
is completed and a new one can begin.
Rosenbach ^® has vigorously disputed this theory. In his opin-
ion, certain portions of the brain, especially the respiratory centre,
are rendered less irritable by nutritional disorders, the normal
periodic exhaustion being simultaneously increased. He attached
no importance, therefore, to variations in the gas content of the
blood. Douglas and Haldane^® have recently shown that by
artificially causing an oxygen deficit in the blood, a periodic res-
piratory rhythm could be produced, and that this periodicity was
attributable to changes in the gas tension. How far their results
go in explaining Cheyne-Stokes breathing in man, it is difficult to
say. Pembrey and Allen ^*^ showed that the pauses in this phe-
nomenon could be eliminated not only by an inspiratory air rich
in carbon dioxide, but also by one with a high oxygen content,
and further by a stimulation of sensory nerves.
It is impossible to discuss the various explanations given for
this type of breathing, mainly because so few of the facts are
known. It should be remembered, however, that even healthy
individuals often show a tendency to periodic breathing, as, for
example, in sleep ; and that many animals normally show this type
of breathing. For this reason, the conception that Cheyne-Stokes
breathing is due to some disturbance in the nervous connection
between the cerebral cortex and the respiratory centre in the
medulla, seems especially noteworthy and fruitful.^*
Changes in the respiratory centre are probably
responsible for the abnormal breathing seen in certain intoxica-
tions— ^such, for example, as the spasmodic breathing
of hydrocyanic acid poisoing, or the deep res-
pirations of diabetes, uraemia and other condi-
tions— some autointoxications, others acidoses.^^ The latter
are characterized by frequent and extraordinarily deep breathing
(air-hunger) occurring without demonstrable pulmonary
changes. The cause of air-hunger is supposed by some to reside
in the increased irritability of the respiratory centre to such acids
as carbonic and lactic.^^
The frequent and superficial respirations of salicylic
RESPIRATION 211
acid poisoning, and the various forms of dyspnoea which
may be present in hysteria, also seem to be due to nervous
influences. And finally, the respiratory centre may be affected
by reflexes from various parts of the body, especially from the
abdominal organs. The conditions known as asthma dys-
pepticum, asthma uterinum, etc., are of this nature.^*
Pleural Effusions. Pneumothorax. — Even though the move-
ments of the chest are normal, and the air can reach the alveoli,
respiratory difficulties may arise from a diminution of the
total functionating pulmonary surface. Such a
diminution may be caused by various diseases, either because they
fill the alveoli with inflammatory products, as happens in pneu-
monia, or because they obliterate them by pressure from without,
as happens in large pleural effusions.
When fluid collects in the pleural cavity, the
lung at first retracts by virtue of its elasticity ; but as the effusion
grows, retraction is succeeded by complete collapse. As pointed
out by Gerhardt, however, the mechanism is not as clear as was
formerly supposed. The tension residing in a pleural exudate
is not commensurate with the size of the latter, for in the most
massive exudates, Gerhardt ^^ found a more pronounced negative
pressure than in the intact pleural cavity. That is to say, the
lungs may suffer compression, but the mere fact that they are
airless is not necessarily the result of such compression. More
evidence is needed to explain the factors present here, especially
those active in the expansion or collapse of the lung bases.
A pleural effusion does harm in several ways.
In the first place, the retraction and compression of
the lung on the side of the fluid naturally diminish the
surface available for the interchange of gases.
Further, since the pressure in the affected cavity is higher than
that in the healthy pleural cavity, the mediastinum is dis-
located toward the sound side, thus embarrassing the healthy
lung as well. The circulation is also materially
affected, for the negative pressure normally present in the
thorax is diminished, and the venous flow from the periphery
toward the heart is consequently retarded. Large exudates may
even compress or kink the inferior vena cava. Finally, the in-
creased pressure upon the capillaries of the lungs raises the
212 THE BASIS OF SYMPTOMS
resistance in the pulmonary circulation, thus in-
creasing the work of the right ventricle (see p. 19).
If air penetrates the pleural cavity through a wound in the
chest wall, or through an opening in a lung produced by such
causes as tuberculosis, abscess, gangrene or injury, it gives rise
to many of the same results as does an effusion. When such a
pneximothorax communicates freely with the external air, the
pressure in the affected cavity will be the atmospheric pressure.
If, however, the perforation closes, a portion of the air is absorbed
and the pressure, though less than that of the atmosphere, remains
greater than that on the unaffected side. If, finally, the opening
be of a valvular nature, permitting air to enter the pleural cavity,
but preventing its exit, the pressure within will exceed the atmos-
pheric, at least during rest and expiration, and not only the lung
of the affected side, but that of the other also will be subjected
to considerable pressure.
The seriousness of a pneumothorarx, depends
mainly upon the functional capacity of the
healthy lung. If this can functionate without interference,
all the demands of the resting body may be met, even though the
pneumothorax should have developed suddenly. Unfortunately,
the healthy lung is often encroached upon by the mediastinum,
because the latter is thrust past the median line by the high
pressure in the affected cavity.^® When the opening into the
pleural cavity is a large one, and admits of free communication
with the external air, each inspiration dislocates the mediastinum
toward the healthy side and the air cannot enter the sound lung
as well as normally. The consequences are less severe if the
mediastinum is very rigid or the abnormal opening small. The
severe collapse which sometimes follows a large perforation into
the pleural cavity may be prevented experimentally by checking
the displacement of the mediastinum. In general, a right-sided
pneumothorax is more serious than one on the left side, because of
the greater capacity of the former.
If the abnormal opening is small enough to prevent any con-
siderable passage of air, the air in the pneumothorax becomes
rarefied during inspiration, the lungs expand and pull upon the
mediastinum, and the patient may experience practically no dis-
comfort.
These variations in the size of the perforation
RESPIRATION 213
and in the degree of mediastinal dislocation ex-
plain the extraordinary differences in the clinical picture of
pneumothorax, and also why, in surgically produced pneumo-
thorax, the dyspnoea may be relieved by suturing the lung into
the opening in the chest wall. The dyspnoea in this condition is
clearly the result of the to and fro displacement of the mediastinum
and the consequent imperfect ventilation of the still functionating
respiratory surfaces.^'^
Modern pulmonary surgery has considerably increased our
understanding of pneumothorax. We now know that the all-
important factor is the tension in the abnormal pleural cavity.
The recent studies on artificial respiration, however, have shown
— and this physiologists have long known — that respiratory move-
ments are essential only to a certain degree for the ventilation
of the lungs; indeed they are quite unnecessary if an animal be
allowed to breathe pure oxygen.^^ This throws considerable light
also upon the transportation of air from the medium-sized bronchi
to the alveoli in normal respiration.
Bruns found an hypertrophy of the right ventricle in experi-
mental pneumothorax; and his studies, and those of Brauer, indi-
cate that the collapsed lung receives less blood than the other.
If one of the larger bronchi perforates directly into the
mediastinum, air rushes not only into the latter, but also into the
subcutaneous tissues of the entire body, and a severe cardiac
insufficiency may follow.
(It may not be out of place merely to mention the fact that
with an increasing knowledge of intrapleural pressure conditions,
the field of pulmonary surgery has recently developed apace, con-
firming the prediction of Billroth, made half a century ago, that
"what is now medical will tend to become surgical." The revival
of artificial pneumothorax for certain types of pul-
monary tuberculosis; the methods of surgical collapse of
a diseased lung, particularly those of Wilms and Sauer-
bruch, and even complete resection of an affected
lobe — all of these attest to the foresightedness of the master,
at least in the realm of pulmonary disease. — Ed.)
Atelectasis. — An inflammation of the smaller
bronchi may decrease the respiratory surface of the lungs,
for the oedema of the mucosa easily occludes their lumina, render-
ing useless the corresponding alveoli. If the occlusion persists for
214 THE BASIS OF SYMPTOMS
any length of time, the air in these alveoH is soon absorbed and
the condition of atelectasis is established. The oxygen and car-
bon dioxide are rapidly absorbed, the nitrogen more slowly. The
gases are absorbed because the alveoli tend to contract, thereby
keeping the partial pressure of the different gases within them
at a higher level than the tension of these same gases in the blood.
Atelectasis may also be caused by compression of the
lungs, as from large pleural effusions or pneumothorax. In-
deed, the alveoli may become atelectatic without bronchial occlu-
sion or compression from without. For example, the portion of
the lung which dips into the fluid of a small pleural exudate is not
subjected to a positive pressure, and yet it is usually found to be
airless. Interference with the movements of the
diaphragm, it would seem, may also produce atelectases of
this type. The importance of the last, following operation upon
the abdominal organs, has probably received too little attention,
for to it may be attributed many of the transient so-called pneu-
monias and hypostatic conditions, which in reality are probably
localized atelectases of the lung bases. An added factor in these
conditions is the lowering of the general resistance such as fol-
lows prolonged anaesthesia, or severe operations even without
anaesthesia.
The Effects of an Obliteration of the Air-Spaces.— -The
disturbances produced by a d iminution of the
functioning surface of the lungs depend upon
several factors, viz . , the amount of pulmonary
surface thrown out of function, the rapidity
with which this occurs, the demands of the
body for fresh oxygen and the degree to which
an increase in the respiratory movements can
compensate for the disabled tissue.
The respiratory movements in conditions of atelectasis are
generally deef>er and often more rapid, particularly in febrile
cases, for the heated blood seems to stimulate the respiratory
centre not only directly, but through reflexes from the skin. The
breathing may be hurried, however, even in the absence of fever.
The explanation of this goes back to the deeper inspirations
observed in atelectasis, which are in turn probably due to the
stimulation of the respiratory centre by the carbon dioxide re-
tained in the blood. The more prolonged inspiratory movements
RESPIRATION 215
enlarge the chest cavity, and, since many of the collapsed alveoli
do not expand, the functioning ones must expand all the more.
This excessive distention of certain alveoli probably stimulates
the vagus endings, thus ending inspiration, as we have seen, and
rendering the succeeding expirations prompt and forcible, and
thus perhaps increasing the respiratory rate. Accurate analyses
of the blood gases or of the alveolar air would furnish a more
satisfactory foundation for this theory. Sensory stimuli arising
in the lungs may also play a part in accelerating the respiratory
rate.
A diminished respiratory surface may sometimes cause a super-
ficial and rapid type of breathing. This is likely to occur in such
conditions as dry pleurisy or peritonitis localized about the dia-
phragm, in which inspiration is curtailed by painful reflexes. The
irritability of the respiratory centre is not dissipated thereby, so
that a new inspiration follows immediately. Hence the breathing
is both shallow and hurried.
In the last analysis, respiratory efficiency depends upon the
uniformity with which the air is distributed to the alveoli. ^^ In
emphysema and in cardiac dyspnoea, the distribution is far less
uniform than in health. As the partial pressure of carbon dioxide
in the inspired air is low in these conditions, the expired air is
also relatively poor in this gas. Hence to bring the carbon dioxide
output per unit volume of air up to a normal level, the amount of
air taken in and given out in a given time-unit must be increased ;
and this is synonymous with dyspnoea.
Disturbances in the interchange of gases in the lungs may
arise from changes in the chemical or physical character of the
alveolar membranes, even though this interchange has been shown
to be merely one of diffusion. The dyspnoea of patients with
chronic passive hyperaemia consequent to heart disease is probably
of this nature.
The Effects of Atmospheric Pressure Upon Respiration. —
Variations in the composition of the air must produce certain
effects upon the animal organism, for the passage of the gases
through the alveolar membranes depends primarily upon the rela-
tion existing between the partial pressure of these gases in the
blood and in the air-cells. The partial pressure of the oxygen in
ithe lungs may be diminished either by diminishing the atmos-
pheric pressure as a whole, or by reducing the relative proportion
216 THE BASIS OF SYMPTOMS
of oxygen in ordinary air. Practically, the latter is seen only
when an animal is allowed to breathe in a small air-tight space
until the oxygen is reduced. The symptoms produced are those of
asphyxia and will be spoken of in that connection (p. 222),
The effects of low atmospheric pressure^*' are frequently seen
especially in those who make balloon ascensions, and in those
who reach great heights in mountain climbing. The symp-
toms may be merely unpleasant at first, but at higher eleva-
tions they become actually dangerous. The height at which
symptoms develop varies for different individuals and under dif-
ferent conditions. Dyspnoea, headache, prostration, paralysis of
the extremities, and finally complete unconsciousness may occur
during a balloon ascension; and a similar set of symptoms, vis.,
fatigue, headache, sleepiness, palpitation, nausea, rapid pulse and
respiration, and especially dyspnoea, are characteristic of
mountain-sickness. In neither case are the symptoms
caused by the mere reduction of atmospheric pressure, but are
due in part to the cold, the wind, the dazzling light and the
bodily and mental strain. That the rarefied air, however, is the
main cause of the disturbances, even in mountain climbing, is evi-
dent from the fact that symptoms may appear in individuals who
do not climb, but are carried up the mountain.
A considerable rarefaction of the respired air may occasion
no disturbance in the interchange of gases in the lungs. Most
animals and men will endure, without serious consequences, a
reduction of the atmospheric pressure from the normal of 760 mm.
down to 450 or 400 mm. of mercury; and some can withstand
a reduction to half an atmosphere or less. The manner in which
the individual breathes is of great importance in determining his
ability to withstand these reductions of pressure. Those accus-
tomed to keeping their lungs well ventilated resist a lowering of
pressure comparatively well, for they know how to keep the par-
tial pressure of oxygen in the alveoH at a relatively high level.
Anything that acts unfavorably upon the mechanics of respira-
tion, such as cold, wind, loss of sleep, etc., renders the individual
more susceptible to a diminution in atmospheric pressure. For
these reasons there are great individual variations in the ability
to withstand rarefied air, and animals, as well as men, living at
high altitudes gradually learn to breathe deeply so that the par-
tial pressure of oxygen in their alveoli shall be sufficiently high.
RESPIRATION 217
This explains the apparently paradoxical observation that deep
breathing, though it adds the factor of muscular exertion, tends
to diminish the dyspnoea at high altitudes. A sudden change to an
atmosphere of low barometric pressure is not so easily borne, hence
the symptoms in the first mountain climb or balloon ascension.
According to certain observers,^ ^ the interchange of gases
in the lungs is not affected until the pressure of the external air
reaches about half an atmosphere. If the pressure be reduced
below this, the elimination of carbon dioxide is markedly in-
creased, and the absorption of oxygen is also somewhat increased,
though relatively less so, at least in the early stages.
Observations by Zuntz, however, extending over several weeks,
upon persons near the summit of Monte Rosa (elevation 4500
metres) showed in most cases a considerable increase in the con-
sumption of oxygen and in the respiratory rate. More recent
studies of the same observer ^^ indicate, nevertheless, that this
increase, both with the individual at rest and at work, is not so
great as was formerly believed. The persons subjected to these
experiments did not seem to become acclimated to the changed
conditions within the period of several weeks that they spent in
the high altitude.
The oxygen-carrying capacity of the haemo-
globin does not diminish at the same rate as
does the partial pressure of the oxygen to which
it is exposed. Thus Hiifner*^ has shown that with the
partial pressure of oxygen at 124 mm. — corresponding to an ele-
vation of 2000 metres — ninety per cent, of the haemoglobin re-
mains undissociated ; at a partial pressure corresponding to an
elevation of 4000 metres, eighty-eight per cent. ; and at one corre-
sponding to 6000 metres, eighty-five per cent. The decomposition
of oxyhsemoglobin may, therefore, be relatively slight at these
high altitudes, which accounts for the considerable ability of the
animal body to resist reductions of pressure. It is only on the
basis of such observations that we can account for the ability
of balloonists to ascend to elevations of 10,000 metres and more.
It must be borne in mind, however, that the partial pressure
of the oxygen in the lungs may be considerably lower even than is
its partial pressure in the outside air. As the blood becomes
insufficiently aerated, the respiratory movements are increased and
the partial pressure of the oxygen in the alveoli is raised. This
218 THE BASIS OF SYMPTOMS
constitutes a most important mechanism whereby the body is able
to compensate for reductions in the atmospheric pressure. Mus-
cular exercise sometimes relieves the unpleasant symptoms of a
rarefied atmosphere, probably by stimulating the respiratory
movements.
In conclusion, we may say that the effects of a high
altitude are due mainly to a diminution in the
tension of the oxygen, and, to a lesser extent, to other
causes. The conditions are very complicated, and it must be
acknowledged that various factors, such as circulatory disturb-
ances, may contribute to the production of symptoms. In my
opinion, however, the lack of oxygen is the essential cause, a view
that is supported especially by the fact that the symptoms of
those who ascend to great elevations in balloons are often promptly
relieved by inhalations of oxygen.
Increasing the density of the air up to twice the normal
pressure is, according to recent observations, without any effect
upon the "quality or quantity" of the respiratory interchange
of gases. The increased appetite and the emaciation that are
seen in individuals subjected to high pressures cannot, therefore,
be ascribed to anomalies of respiration.
(An interesting condition is that seen in caisson workers,
divers and miners, and which is known as caisson disease or com-
pressed-air disease.*^ Here, unlike the conditions enumerated
above, the nitrogen of the air seems to play the chief role. Dur-
ing compression, this gas is absorbed under great pressure, rapidly
saturating the tissues. Saturation takes place quickly, the reverse
much more slowly. The danger in this disease resides, therefore,
in a too rapid decompression, which leads to the formation of
nitrogen bubbles, especially in the venous blood and fatty tissue,
and to a dissemination of nitrogen emboli. These emboli lodge
chiefly in the spinal cord ; hence the prominence of cord symptoms,
paraplegia, pains in the legs, etc., in the clinical picture. Pressures
of several atmospheres lead to no untoward results if decompres-
sion is allowed to take place slowly. — Ed.)
The Inhalation of Poisonous Gases.— -The atmospheric air may
contain substances which are poisonous to the body. A certain
protection against these poisonous admixtures is furnished by
our sense of smell, which warns against such gases as ammonia
RESPIRATION 219
and sulphuretted hydrogen. In the case of hydrocyanic acid, the
odor may be perceived only after the ix)ison has exerted its deadly
action.
Carbon monoxide, as usually inhaled, is mixed with
gases, e.g., illuminating gas, which possess an odor. Carbon
monoxide poisoning is of especial importance because of the
marked affinity it possesses for haemoglobin.^^ When the air
contains about one part in a thousand of carbon monoxide, the
latter passes into the blood where it unites with a portion of the
haemoglobin in such a manner that the latter can no longer com-
bine with oxygen to form oxyhaemoglobin. If only a small
amount of haemoglobin is thus rendered functionless, the damage
is slight, the patient experiencing only a few symptoms, such as
headache, etc. If he then breathes good air, the carbon monoxide
haemoglobin is either excreted as such, or the combination is grad-
ually broken up by the mass action of fresh oxygen. In severe
cases of poisoning, on the contrary, the blood can no longer fur-
nish the necessary oxygen to the body.
Under such circumstances, the carbon dioxide is excreted
through the lungs as usual, but the supply of oxygen is diminished :
this becomes dangerous when about one-half of the total haemo-
globin is decomposed. In rabbits killed by monoxide, only twenty
to thirty per cent, of the normal amount of oxygen was found in
the blood at the time of death. Part of the carbon monoxide
in the blood passes into the tissues and there exerts its anaesthetic
action. The respiratory centre soon becomes unresponsive, so
that respiration ceases entirely: the picture is quite different,
therefore, from that of acute asphyxia. If the individual be
placed in an atmosphere of ordinary air, or, better still, be allowed
to breathe pure oxygen, the carbon monoxide haemoglobin is grad-
ually dissociated and a recovery may be effected. Considerable
light has been thrown upon this subject by improved methods
for the determination of the total blood-mass by means of carbon
monoxide inhalations.*^
The Effects of Anasmia upon Respiration. — The supply of
oxygen to the tissues may be influenced by a reduction of haemo-
globin. If the quantity of this pigment in the circulating blood
be too small, or if it be replaced by some useless combination,
such as carbon monoxide- or methaemoglobin, the cells may receive
insufficient oxygen. In acute hemorrhage, death results from this
220 THE BASIS OF SYMPTOMS
cause when about seventy per cent, of the total haemoglobin bulk
is lost.
If the loss of haemoglobin or of blood be very gradual, the
body can accustom itself to the changed conditions, so that a
much greater reduction is possible. We do not know to what
limits such a gradual reduction of the haemoglobin may go,
because our clinical methods unfortunately do not determine
the total amount of the pigment itself, but only the content of
the blood per unit volume. This much may be said, however,
that a gradual diminution to one-tenth of its normal bulk can still
be endured.
The manner in which the organism accommo-
dates itself to a gradual loss of haemoglobin is not
well understood.^^ It has been suggested that in anaemic states
the haemoglobin undergoes some change whereby it is enabled
to transport more oxygen. This view, however, seems scarcely
tenable. Furthermore, the total amount of oxygen absorbed and
of carbon dioxide eliminated during rest is little, if any, below the
normal limits, even though the anaemia be severe. Such patients
learn to restrict their movements as much as possible, and so to
lessen their need for oxygen; and although the amount of oxygen
which they consume during rest is the same as that used by a
healthy individual, their gaseous interchange during exercise is
much less than normal. Then it is that their lessened ability to
transport oxygen is most noticeable; and every physician knows
how incapable of exertion anaemic persons are.
Since, in an anaemic person, a small amount of haemoglobin
must supply the tissues with the usual amount of oxygen, at least
during rest, it follows that either the haemoglobin present makes
more frequent journeys from the lungs to the tissues, or that it
gives up more oxygen to the cells at each journey. Apparently
both of these methods of compensation are used. Certain it is
that the circulatory rate is increased, for the heart throws out
more blood at each beat and the number of beats per minute is
increased. Of less importance is the fact that the oxyhaemoglobin
is generally more fully utilized. This theory of a more complete
utilization of the oxygen supplied to the cells assumes the truth
of the current view — and none more satisfactory has as yet been
offered — that oxidation up to the end-products of metabolism
occurs in the tissues themselves.
RESPIRATION 221
The Effect of Circulatory Changes upon Respiration. — If the
cells are to receive a proper supply of oxygen, it is not only neces-
sary that there should be sufficient air in the lungs and sufficient
haemoglobin in the blood, but that there be also a sufficiently rapid
blood-stream. The haemoglobin takes up oxygen from the alveolar
surfaces very rapidly, and no advantage, therefore, is derived
from a slowing of the blood-current through the lungs. When the
blood-current is so retarded, however, that the respiratory centre
is insufficiently aerated, the cells in the medulla are stimulated
and the respiratory movements are deepened. This respiratory
compensation is of special value in circulatory disturbances, be-
cause it not only maintains the oxygen tension in the alveoli at a
higher level, but also directly assists the flow of blood.
Respiratory Compensation. — It is evident, therefore, that con-
ditions which injure external respiration set in motion a com-
pensatory mechanism which is designed to guard against the harm-
ful effects of a lessened internal respiration. The degree
to which such compensation is possible depends
first upon the magnitude of the disturbance:
should an aortic aneurism, for instance, rupture into the lungs,
filling the alveoli with blood, no increase, however great, in the
depth of respiration can undo the damage. Compensation depends
further upon the efficiency of the tools designed for the purpose,
viz., a movable chest wall, good respiratory mus-
cles and a strong heart; and these in turn depend upon
the age of the individual, his constitution and the soundness of his
organs in general. The respiratory needs of the body
also influence the extent to which compensation is possible; thus
the demand for oxygen when the body is at rest is less than
during exercise or digestion. And finally, of importance is the
rapidity with which the changes have become
established; a gradual development favors good compensa-
tion, for persons with disturbances of respiration learn in time
to minimize their need of oxygen.
Mention has already been made of the efficiency of this com-
pensatory mechanism in anaemia. Studies have also been made
of the gas interchange in other pathological conditions. It has
been shown, for example, that in rabbits a pleural effusion or a
closed pneumothorax of moderate grade does not influence to any
marked degree the quantity of oxygen absorbed or of carbon
222 THE BASIS OF SYMPTOMS
dioxide eliminated by the lungs. An open pneumothorax of one
side produces equally little disturbance in rabbits and dogs. In
man also, the effect of various diseases upon the interchange of
gases has been studied by accurate methods. In emphysema, bron-
chitis, tuberculosis, pneumonia and pleurisy, even when marked
dyspnoea was present, the interchange between the lungs and the
external air was found to be approximately normal. Yet when
there is dyspnoea, additional oxygen is used up by the increased
respiratory movements, and, if this were deducted from the total
amount of oxygen consumed by such patients, there might prove
to be some reduction, after all, in their exchange of gases. The
latter seems all the more probable in view of the fact that the
respiratory interchange of gases in the above conditions tends to
diminish as the hindrance to the entrance of air increases.
It must not be assumed, however, that because the ventilation
of the lungs remains practically normal, internal respiration is
also unaffected; for it is possible that the tension of the oxygen
in the blood might be abnormally low or that of the carbon dioxide
abnormally high. Either would influence the interchange of gases
between the blood and the tissues. Dyspnoea, indeed, is usually
caused by just such changes in the blood going to the medulla.
Asphyxia. — W^hen disturbances of external respiration be-
come considerably greater than can be met by the compensatory
mechanism, asphyxia is produced. The symptoms of asphyxia vary
with the rapidity of its onset, being milder and less characteristic
in gradually progressive cases. Hand in hand with the reduced
oxygen content of the blood goes an increased carbon dioxide
volume. The latter exerts some anaesthetic effect and when active
over a long period of time, as in chronic asphyxia, diminishes the
irritability of the respiratory centre to a point incompatible with
life. Effects of lack of oxygen, therefore, do not become apparent,
because the medulla has been narcotized by the carbon dioxide.
Acute asphyxia is produced by suddenly cutting off
the oxygen supply to a brain which is still irritable. Practically,
this does not happen very often, but it may result from a filling
of the lungs with fluid, from the collapse of a diseased trachea or
from a rapidly fatal hemorrhage. The lack of oxygen causes
first an increase in the depth and strength of respiration, which
is followed by characteristic changes in the circulation. The
vasomotor centre is powerfully stimulated, and this causes the
RESPIRATION 223
splanchnic vessels to contract, the cutaneous vessels to dilate, and
produces a marked rise in the general arterial pressure. As the
vagus is also stimulated, the heart is slowed. These changes are
designed to furnish the brain with the greatest possible amount
of blood, and, thereby, oxygen. In the later stages of acute
asphyxia, generalized tonic and clonic convulsions occur, and
finally, after a brief period of paralysis, death supervenes.
Internal Respiration. — The internal respiration has necessarily
entered at many points into our discussion of the disorders of
external respiration, for the two are intimately interdependent.
Thus we have emphasized how changes in the internal respiration
of the respiratory centre may cause a compensatory increase in
the movements of the chest.
The effect of disturbances of external res-
piration upon the interchange of gases in other
tissues remains to be considered. The need of the cells for
oxygen is determined primarily by their functional activity; it
must be emphasized, however, that the supply must be sufficient if
they are to use all the oxygen that they require. It is indeed
true that for a time the cells can do without oxygen,^^ because they
are still able to fall back upon their intramolecular supply, yet this
is of little practical importance.
Normally, the blood carries much more oxygen than is needed
by the tissues, and when it leaves them its supply is by no means
exhausted. We have evidence that this excess of oxygen is not
a useless luxury, but that it is beneficial, and that a relative scarcity
of the gas in the tissues is directly harmful. It has been shown,
at any rate, that in dyspnceic dogs the proteid decomposition is
increased; and although the same has not regularly been proved
for man, it suggests the harm which may follow an insufficient
aeration of the blood.^^ According to Rosenquist, severe anaemias
exhibit periodic increases in the nitrogen output (p. 319), but
whether this is due to the anaemia itself, or to the underlying cause
of the anaemia, is problematical. It has been shown also that glu-
cose and lactic acid may appear in the urine of dyspnoeic animals,
and that lactic acid may be present in the urine of dyspnoeic men.
Finally, the respiratory quotient becomes greater than the normal
if the oxygen supply is restricted. Though the explanation of
these various findings is uncertain, they tend to show that a dimin-
224 THE BASIS OF SYMPTOMS
ished tension of oxygen in the tissues leads to an abnormal
metabolism.
In order to estimate the oxygen supply to the tissues, it is
necessary to know the amount of this gas in the blood.^® Unfor-
tunately we possess but little information bearing directly upon
this point. In animals with an open pneumothorax, the quantity
of oxygen is much diminished in the arterial blood, and it is this
diminution that stimulates the medullary centres, causing such
fMDwerful respirations that one lung is able to do the work of two.
We possess no other data as to the gases in the blood in respiratory
diseases. The mere fact that the alveolar interchange of gases
does not vary from the normal proves nothing, for this might
be true even though the absolute amount of each gas in the blood
varied greatly. The cyanosis of many patients with respiratory
diseases would lead one to the belief that their blood is rich in
reduced haemoglobin ; in some cases this is undoubtedly true, while
in others practically normal conditions are found.
Internal respiration may also be primarily
disturbed, i.e., by changes in the parenchyma cells or in the
tissue fluids. A retarded blood-flow or a lack of functionating
haemoglobin interferes not only with the interchange of gases in
the lung, but also with the interchange in the tissues. Primary
disorders of the internal respiration may arise when arterio-
sclerotic changes, thrombosis or embolism interfere with the
circulation of a limited area. Compensation is possible here
only by the establishment of a collateral circulation. If the cere-
bral arteries are blocked, the resulting anaemia of the brain pro-
duces the symptoms of acute asphyxia. Finally, the displacement
of oxyhaemoglobin by carbon monoxide- or methaemoglobin causes
a primary disturbance of internal, as well as of external, respira-
tion.
The transportation of carbon dioxide may be
affected by changes in the blood, especially those
produced by an acid intoxication. The additional acid in aci-
dosis is partly neutralized by an increased formation of
ammonia (see p. 327), and partly by some of the fixed alkalies
of the blood. This diminishes the free alkali in the blood avail-
able for carbon dioxide transportation. In rabbits with severe
acidosis, the carbon dioxide content of the blood was found to
be reduced from the normal twenty-five per cent, by volume down
RESPIRATION 2f25
to two per cent. Under such conditions, the plasma quickly be-
comes saturated with carbonic acid gas, and some of the latter
accumulates in the tissues. Observers ^^ have found, neverthe-
less, that the blood in severe cases of diabetic acidosis, if under
ordinary carbon dioxide tension, can still absorb considerable
amounts of the gas — in these cases, at least, invalidating the
assumption that there is a disorder of carbon dioxide transporta-
tion. Conditions are further complicated by the presence, in
human diabetes, of a number of other grave manifestations which
dominate the picture. In the acid intoxication of rabbits, the
oxidative processes in the body are also considerably diminished,
for both the absorption of oxygen from the blood and the elimina-
tion of carbon dioxide are reduced. Since the amount of oxygen
in the blood is not decreased, the lowered oxidations in the tis-
sues must be referred to changes in the cells, induced perhaps by
the toxic action of the retained carbon dioxide. In the acidosis
of rabbits, therefore, the retention of carbonic acid gas in the
tissues affects both internal and external respiration.
In dogs, and in carnivora in general, much larger amounts
of acid are tolerated, for, owing to the relatively high proteid
metabolism, much more ammonia is available for the neutraliza-
tion of any acid present, and for the protection of the fixed alkalies
of the blood. Men and carnivora in general, therefore, can resist
a considerable amount of acid, disposing of really enormous
quantities in some pathological conditions.
Internal respiration finally may be altered by changes in
the parenchyma cells, either physiological, as by rest
and activity, and by cold and heat, or pathological, as by the
various metabolic diseases. In phosphorus and hydrocyanic acid
poisoning many of the cells lose, to a variable degree, their ability
to take up oxygen and to form carbon dioxide. Though the
external respiration and the gases of the blood are both normal,
the interchange of gases in the tissues is much reduced, because
the cells are poisoned. The animal dies of internal asphyxia;
and in prussic acid poisoning the most violent respiratory convul-
sive movements may result from the asphyxia of the medullary
centre.
Respiratory Sensations. — The most important abnormal sen-
sation associated with respiration is that known as dyspnoea.
The term has been used by some to designate disturbances in
15
226 THE BASIS OF SYI^IPTOMS
the respiratory act itself, but we prefer to limit its use to the
subjective sensation of an air-hunger. Dyspnoea, in this
sense, is always produced by an insufficient gas interchange in the
tissues, and especially by a diminution in the supply of oxygen to
certain parts of the brain. The associated retention of carbon
dioxide is apparently not at fault, for it may be breathed in large
quantities without any such effect. Frequently the respiratory
movements are increased without any sensation of dyspnoea; in
such cases the retention of carbon dioxide would seem to be the
important factor in producing the more marked respiratory move-
ments.
How the oxygen is prevented from reaching the brain is
immaterial, so far as the dyspnoea is concerned. The respiratory
surface of the lungs may be diminished, the blood may flow
slowly, or the red corpuscles or the tissue cells may have lost
their ability to take up oxygen. Dyspnoea depends rather upon
the functional activity of the cells and the degree to which their
demand for oxygen is answered ; many patients, therefore, experi-
ence no discomfort as long as they are quiet. Furthermore, they
gradually learn to do their work with a minimum expenditure of
energy, thus reducing their need of oxygen, and, in turn, their
dyspnoea.
Actual pain may also arise in respiratory diseases. It
is generally believed that the lungs themselves contain no sensory
fibres, and that what seems to be pulmonary pain is really due to
an associated disease of the pleura or chest wall. Severe pain is
frequently present in dry pleurisy, and as the latter often accom-
panies disease of the lungs, it lies close at hand to attribute the
pain to the pleural involvement. I am not entirely convinced,
however, that this is always the case, for pain may be present
in diseases of the lungs unaccompanied by pleurisy.
LITERATURE
*• Consult A. Fraenkel, Diagnostik u. Symptomatologie der Lungenkrank-
heiten, i8go, for a general text on the pathology of respiration.
Lommel: Arch. f. klin. Med., xciv, 365.
F. Miiller: Miinch. med. Wochenschft., 1897, No. 49.
* Naunyn : Arch, f . klin. Med., xxiii, 423.
*Edlefsen: Arch. f. klin. Med. xxvi, 200. For a discussion of this subject,
see A. Fraenkel, Diagnostik u. Symptomatologie der Lungenkrankheiten, 90.
Barthel: Zentralbl. f. Bakteriol., xxiv, Pt. I, 401, 576.
Diirck : Arch, f . klin. Med., Iviii, 368 ; Zentralbl. f . Bakt., xlii, Ft. I, 574.
For a more recent description of pertussis, see Sticker, in the NoUinagel
System.
I
RESPIRATION 227
• Morawitz and Siebeck : Arch, f . klin. Med., xcvii, 219.
"Breuer: Wiener Sitzungsber., Ivii, 11, 909; Rosenthal, in Hermann's Hand-
buch, iv, II ; Gad, in Gad and Heyman's Lehrbuch d. Physiol., Berlin,
1892 ; Head, Jour, of Physiology, x, i, 279.
" Boothby and Berry : Amer. Jour. Physiol., xxxvii, 433 ; see also Boothby and
Shamoff, ibid., 418.
" Liebermeister : Deutsch. med. Wochenschft, 1908, No. 39; Siebeck, Arch. f.
klin. Med., xcvii, 219; Forschbach and Bittorf, Miinch. med. Wochen-
schft, 1910, No. 25; Bruns, Zeitschft. f. exp. Path. u. Then, vii, 494.
" Kohler : Arch. f. exp. Path., vii, i.
" Haldane and Priestley : Jour, of Physiol., xxxii, 225 ; Schenk, in Asher-
Spiro, 1908, vii, 71.
" Siebeck : Arch, f . klin, Med., c, 204.
" Haldane et al. : Jour, of Physiology, xxxii, xxxvii, et seq.
"F. A. Hoffmann, in the Nothnagel System; A. Schmidt, Das Bronchial-
asthma, Wiirzburger Abhand. Ill, 7.
"Kongress f. inn. Med., 1858, 237, 371 (discussion and literature); Riegel,
ibid., 257 ; Hack, ibid., 70.
" Sitzber. d. Gesell. zur Bef or. der ges. Naturwissensch., Marburg, 1896,
No. 6.
*° See Meltzer : Jour. Am. Med. Assoc, 1910, No. 12.
**Mediz. Klinik, 1908, No. i.
" Tendeloo : Die Ursachen. d. Lungenkrankheiten, Wiesbaden, 1902 ; A. Hoff-
mann, in the Nothnagel System; Loeschke, Deutsch. med. Wochenschft.,
191 1, No. 20.
** W. A. Freund : "Qber primare Thoraxanomalien, Berlin, 1906.
•*Friedrich: Marburger naturforschende Gesellschaft, 1908.
" Siebeck: Arch. f. klin. Med., 1911, cii, 390.
" Traube : Beitr., ii, 882, and iii, 103 ; Sokolow and Luchinger, Pfliiger's Arch.,
xxiii, 283; Lowit, Prag. med. Wochenschft, 1880, Nos. 47-50; Unverricht,
Kongr. f. inn. Med., 1892, 399.
" Arch. f. exp. Path., x, 242, and xi, 45 ; Zeitschft f. klin. Med., ii, 255.
"Zeitschft f. klin. Med., i, 583, and ii, 713.
*" Jour, of Physiol., xxxviii, 401 ; Douglas, ibid., xl, 454.
•"Jour, of Physiol., xxxii (Proc. Physiol. Soc). Consult also Pembrey,
Beddard and French, Jour, of Physiol. (Proc. Physiol. Soc), xxxiv;
Pembrey, Jour, of Path, and Bact., xii, 258, and xiv, 409; Y. Henderson,
Amer. Jour, of Physiol., xxv.
■^ Unverricht : Kongr. f. inn. Med., 1892, 399.
" Kussmaul : Arch, f . klin. Med., xiv, I ; Senator, Zeitschft. f . klin. Med.,
vii, 235.
** Beddard, Pembrey and Spriggs: Jour, of Physiol., xxxi (Proc. of Royal
Soc).
"Boas: Arch. f. Verdauungskrankh., ii, 345.
"Arch. f. exp. Path. (Festschrift), 1908, 228.
•• See Garre-Quincke : Grundriss d. Lungenchirurgie, Jena, 1903, 40 ; Friedrich,
Arch. f. klin. Chin, Ixxxii, 1147, and Marburger Sitzungsber., 1908, No. 6;
Sauerbruch, Bruns' Beitrage, Ix, 450.
" See Brauer : Uber Pneumothorax, Marburger Programm, 1906 ; Beitr. z.
Klinik d. Tuberk., xii, 49.
'*Volhard: Miinch. med. Wochenschft, 1908, No. 5.
"Siebeck: Zeitschft. f. Biol., xl, 267; Arch. f. klin. Med., cii, 390; Versamm.
d. Naturf. u. Arzte (Karlsruhe), 1911.
*'For a comprehensive study of this subject, see Douglas et al. : Physiolog.
Observations made on Pike's Peak, Philosoph. Trans., London, 1913,
B. 203, 185 (lit.) ; also Cohnheim, Physiol, des Alpinismus, in Asher-
Spiro, Ergeb, ii, I, 612; Zuntz, Muller and Caspari, Hohenklima u.
Bergwanderungen in ihrer Wirkung auf den Menschen, 1906.
*Fraenkel and Geppert: Ubcr d. Wirkungen d. verdiinn. Luft auf d. Organ-
ismus, Berlin; Loewy, Unters. ii. Resp. und Circ, etc, Berlin, 1895.
228 THE BASIS OF SYMPTOMS
** Durig and Zuntz : Engelmann's Archiv, 1904, Suppl., 135, 417.
**Hufner: Engelmann's Archiv., 1901, 187.
** Hill and Greenwood : Caisson Sickness, 1912 ; Silberstein, in Weyl's Handb.
d. Arbeiterkrankheiten, 1908; Thompson, Occupational Diseases, 1914,
467; Bassoe, in a Report on Compressed Air Disease (111. State Commis-
sion on Occupational Disease), 191 1.
*" Hiif ner : Arch, f . exp. Path., xlviii, 87 ; Mosso, Die Atmung in den Tunnels
u. d. Wirkung d. Kohlenoxyds, quoted from Jahresber. f. Tierchemie,
XXX, 576; Haldane, Jour, of Phys., xviii, 201; see also Douglas, Haldane
and J. B. S. Haldane, ibid., 1912, xliv, 75.
*• Haldane and Smith: Jour, of Phys., xxv, 334. For the improved technic
of Douglas and Haldane, see Jour, of Phys., 1912, xliv, 305.
*'Hiifner: Engelmann's Arch., 1903, 217; Morawitz and Rohmer, Arch. f.
klin. Med., xciv; Masing and Siebeck, ibid., xcix, 130; Douglas, Jour, of
Phys., xxxix, 453; Plesch, Hamodynamische Studien, Berlin, 1909.
* Lesser : Das Leben ohne Sauerstoff, Ergeb. d. Phys., 1909, viii, 742.
•See V. Noorden: Path. d. Stoffwechsels, ist edit. 318, and the chapter
on Metabolism (Metabolism and Pract. Medicine).
•"For recent collected studies on the g^ses of the blood see Barcroft: Ergeb.
d. Phys., 1908, viii, 699, and Loewy in the Handb. d. Biochem. (Oppenr
heimer), 1908, iv, 10, et seq.
" Beddard, Pembrey and Spriggs, Jour, of Phys., xxxvii (Proc. of the Physiol.
Soc).
CHAPTER V
DIGESTION
The Mouth and (Esophagus. — Digestion includes ail' of the
processes which assist in preparing the food for use in the body.
Disturbances of digestion begin, therefore, in the mouth. Here
the food is seized by the teeth and is ground up so that it shall
present a greater surface to the action of the digestive juices.
Serious disturbances may follow improper trituration of the food,
whether this results from diseases of the teeth, the maxillary
bones or the temporomaxillary joints, or from weakness of the
muscles which move the food about within the mouth. If the
facial nerves are paralyzed, the food collects in the cheeks and
cannot be forced back into the mouth, A paralysis of the tongue
interferes not only with chewing, but with the passage of food
into the throat. When chewing becomes a painful procedure,
malnutrition may be a consequence ; for many patients with ulcera-
tions in the mouth, or with inflammations of the tonsils, throat
or parotid glands, would rather suffer from hunger than from
the pain which is caused by the taking of food. Both the intensity
and the duration of such diseases influence the amount of disturb-
ance which they produce.
Stomatitis. — The causes of stomatitis* are various. If par-
ticles of food are retained in the mouth, they decompose, and
the products of decomposition, acting as irritants, may pave the
way for the invasion of micro-organisms. Inflammations are
especially apt to occur when the growth of bacteria is favored
by carious teeth, or when, as the result of severe illnesses, but
little saliva is secreted, and the mouth is allowed to become foul
owing to the stuporous condition of the patient. The stomatitis
which so often accompanies severe diabetes is greatly
favored by the caries of the teeth and by the organic acids,
both of which are frequently present in the mouths of these
patients. The oidium of thrush produces acids, and these un-
doubtedly irritate the mucous membrane directly and favor sec-
ondary infections. Acids and alkalies introduced into the mouth
may destroy its coverings and so cause inflammations. The
stomatitis of scurvy seems to be of a different character
229
230 THE BASIS OF SYMPTOMS
from that caused by other infectious diseases, for it develops
early in the disease, and is particularly severe. The scor-
butic gingivitis appears to be a specific effect of the disease,
though its true cause is as little understood as is that of the other
scorbutic manifestations. (An ulcerative, even gangrenous,
stomatitis is a very frequent and diagnostically important mani-
festation of the acute leukaemias; in this case, the ne-
crosis probably occurs in the areas of hemorrhagic infiltration. —
Ed.)
Stomatitis endangers the health of the patient, first of all, by
diminishing the ingestion of food — this diminution resulting
partly from the tenderness of the mucous membrane, and partly
from the loss of appetite caused by the disagreeable taste in the
mouth. In the second place, the number of bacteria in the mouth
is enormously increased, and vast numbers are swallowed. The
ability of the stomach to destroy this material is naturally limited,
its disinfecting power often being most reduced in the very dis-
eases with which the stomatitis is associated.
The Saliva. — The different salivary glands produce secretions
of variable composition, and each is dependent upon specific
stimuli for its activity. We are not familiar, however, with these
different factors, and for that reason speak of saliva as the sum
of the several secretions. The saliva, in addition to its digestive
function, lubricates the food bolus for its passage down the
oesophagus, and also, by diluting irritating and corrosive fluids,
helps to protect the stomach and oesophagus from injury.
Diminished Secretion of Saliva. — The quantity of saliva is
diminished in certain infectious diseases, such as pneumonia and
typhoid fever ; in certain poisonings, as by atropin ; in all diseases
which are accompanied by great losses of water, such as cholera,
diabetes and interstitial nephritis ; and, finally, in those paralyses
of the facial nerve that involve the chorda tympani, A diminution
of the saliva is always accompanied by a reduction in the activity
of the buccal mucous glands. The resulting dryness of the mouth
not only interferes with the cleansing of the mouth, but also with
the acts of chewing, swallowing and speaking.
To what degree a lack of ptyalin is injurious has not been
definitely settled. It was formerly considered that this ferment
played an insignificant part in the processes of digestion ; but we
now know that large quantities of starch are converted into dex-
DIGESTION 231
trin ^ in the mouth and in the stomach by the action of this fer-
ment. The conversion continues in the stomach even after a
considerable grade of acidity is present, particularly within the
larger particles of food, of which only the surfaces are acted
upon by the gastric juice. In addition, saliva can exert a further
effect in the intestines where it is reactivated by the pancreatic
juice.^
Ptyalism. — ^An increase in the secretion of saliva, so-called
ptyalism, may result from an irritation of the chorda tympani
nerve as it passes through the middle ear. Impressionable persons
frequently have a marked flow of saliva when they think about
food, or even when they imagine that they have taken calomel.
Ptyalism also accompanies all irritative conditions of the mucous
membrane of the mouth, such as may result, for example, from
stomatitis. The ptyalism of mercurial poisoning is due
in all probability to a central or peripheral stimulation of the
nervous connections of the salivary glands. It is possible also
that the parenchyma cells are directly affected by the poison.
Mercurial stomatitis usually follows the ptyalism and is due to
some irritating mercurial compound present in the saliva. This
stomatitis will, in turn, increase the salivation, thus establishing
a vicious circle.
There is a remarkable increase in the amount of saliva in
certain chronic diseases of the medulla oblongata, particularly in
bulbar paralysis. This has been compared by some ob-
servers to the paralytic secretion which appears in animals after
all the salivary nerves have been cut. The latter begins about
twenty-four hours after the operation, lasts about one week, and
gradually ceases on account of the degeneration of the secreting
cells. In both conditions, furthermore, atropin will inhibit the
secretion. The two differ, however, in the length of time over
which the salivation lasts and in the amount of saliva secreted,
the quantity being much greater in the case of bulbar paralysis.
It seems to me very probable that the ptyalism of bulbar paralysis
is not a paralytic secretion, but is due to an irritation of the cells
of the medulla, which occurs as they degenerate. It is compara-
ble, therefore, to the fibrillary muscular twitchings so often seen
when the large motor cells of the cord are undergoing degenera-
tion. Certain it is that the saliva is really increased in these cases
of bulbar paralysis, and that the condition is not merely a loss of
232 THE BASIS OF SYMPTOMS
normal saliva occasioned by a paralysis of the muscles of the
mouth; indeed, the salivation is frequently present even before
the muscles have become markedly weakened.
An increased flow of saliva may be caused finally by reflexes
from other parts of the body, as from an ulcer of the stomach,
from the uterus during pregnancy, from the trigeminal nerve in
cases of trifacial neuralgia, etc., and by an increased irritability
of the nervous system, as in neurasthenia and hysteria.
In all these conditions the saliva presents the characteristics
of that obtained by stimulation of the chorda tympani, i.e., it is
increased in amount, but poor in solids.
An increased secretion of saliva is especially unpleasant when
it drips from the mouth, as happens in cases of bulbar paralysis.
Even when it is swallowed it may be disadvantageous, for the
large quantity of alkaline, mucous fluid, rich in bacteria, is inju-
rious to gastric digestion.
Composition and Reaction of the Saliva. — ^The saliva may con-
tain abnormal constituents, such, for example, as the compounds
of iodin and bromin, when the latter have been administered.
Whether other substances pass into the saliva or not depends
largely upon the amount present in the plasma. Urea is thus
excreted only in those pathological conditions which increase its
concentration in the blood, as in severe nephritis. Other con-
stituents of the blood, such as sugar, rarely pass into the salivary
secretion. It is unnecessary to enumerate the various substances
which sometimes appear in the saliva, for the subject has but little
pathological significance.
The reaction of the saliva varies in the healthy individual
'during the process of digestion. In the fasting condition it is
usually weakly acid, but after taking food it becomes alkaline.
On the other hand, in diabetes, in fever and in dyspeptic individ-
uals, it is not infrequently constantly acid, in some instances owing
to the presence of the products of bacterial decomposition. The
pure parotid saliva is said to be acid in severe diabetes, but the
cause of the acidity is not known ; and some observers have found
it to be alkaline even in severe forms of the disease.
Swallowing. — ^The passage of food from the mouth into the
oesophagus is accompanied by special dangers, for it must cross
the respiratory tract in the pharynx. The trachea must be closed
off below by the epiglottis, and the nasal passage above by the
DIGESTION 233
soft palate and the superior constrictors of the pharynx. This
intricate mechanism is controlled by reflexes through the trigem-
inal and vagus nerves. The centripetal impulses arise from the
mucous membrane of the throat; and the centre which presides
over swallowing is situated in the medulla.
Disturbances of the act of swallowing may be
caused by a diminished irritability either of the cen-
tre or of the sensory nerves. This is seen in certain
intoxications, notably in those due to morphin, chloroform and
chloral, in diabetic coma and ursemic coma, as well as in some
diseases of the nerves. Disturbances of swallowing may also
arise from a paralysis of the necessary muscles,
caused either by a disease of the motor nuclei in the medulla, as
in bulbar paralysis or medullary tumors, or by a neuritis itself,
such as is seen so frequently after diphtheria. Furthermore,
difficulty in swallowing may arise not from a paralysis, but from
aspasmofthenecessarymuscles, as occurs in hydro-
phobia, tetanus and hysteria. Finally, defects in the
palate, usually caused by syphilitic ulcerations, interfere with
the act of swallowing.
In these conditions, the food may pass either into the nose or
into the trachea. The latter is the more serious, for if the food
with its many bacteria enters the lungs, pneumonia, and not infre-
quently gangrene, result. The entrance of food into the nasal
cavity is less dangerous. Coughing and sneezing are the usual
results. Yet these may cause the patient such great discomfort
that he refrains from eating; and it is even possible that a large
portion of his nourishment may be lost through the nose. When
swallowing causes pain, the patient may take insufficient nourish-
ment, just as is the case when chewing is painful.
CEsophageal Stenosis. — Diseases of the oesophagus^ usually
produce symptoms by obstructing the passage of food. This
obstruction may be due, in the first place, to a muscular
spasm, as in hydrophobia and hysteria (globus hystericus).
Such a condition is rarely very serious, because in the case of
hysteria it is usually finally overcome, and in hydrophobia there
are other more immediate dangers. Occasionally, however, a
spasm of the lower end of the oesophagus, particularly at the
cardia (cardiospasm), may produce symptoms very like those
of a mechanical stenosis. Still, it is not certain that cardiospasm
I
234 THE BASIS OF SYMPTOMS
is not the result of some disorder of the nerve supply, particularly
of the vagus.
Of greater importance are permanent obstructions, such as
may be caused by the contraction of scar tissue, by
tumors or by pressure from without. The milder
stenoses interfere only with the swallowing of the coarser foods ;
the more severe ones may stop even fluids. Normally, we do not
feel our food after it has once passed the pharynx ; but the patient
with an obstruction often complains that he can feel the food
stop in a definite place. Above the point of obstruction the oesopha-
gus usually becomes dilated, owing to the stasis of material;
and the muscular tissue surrounding the dilatation undergoes
hypertrophy. Some of the food which cannot be forced through
the narrowed passage stagnates in situ, undergoing decomposition.
The remainder is immediately returned into the mouth. This
regurgitation of food is quite different from vomiting, and the
patient himself usually appreciates the difference; for the food
swallowed appears to return of itself, the individual experiences
no nausea, and his abdominal muscles are not brought into action.
'Apparently the obstruction to the passage of food increases the
contractions of the muscular tissues of the oesophagus. Many
believe that the increased pressure on the food simply forces it
upward, and that there is no true antiperistalsis in these cases.
Personally, however, I see no reason to exclude the possibility
that antiperistaltic movements do play a part in the regurgitation
of food. (The probability of an antiperistaltic factor is strength-
ened by the undoubted occurrence, as shown by radiographic
methods, of similar waves in pyloric and intestinal obstruction,
while in the colon, antiperistalsis is normal. — Ed. )
Pressure Diverticula. — The so-called pressure diverticula^
usually spring from the upper and posterior part of the oesophagus.
They seem to originate from a primary weakness of
the oesophageal wall, produced by such causes as foreign
bodies, traumatism or possibly congenital defects in the muscle.
The wall of the diverticulum is composed of the mucous mem-
brane, the submucosa and a thin layer of muscle. As the sac
becomes larger, a part of the food passes into it instead of
going down the oesophagus. This food is in part immediately
regurgitated, but enough may remain in the diverticulum to press
upon the oesophagus and so to occlude it ; and it is only after the
DIGESTION 235
sac has been emptied of its contents that a free passage is again
opened into the stomach. The symptoms caused by such
a diverticulum vary greatly, depending, for the most part, upon
the ease with which the sac is filled and emptied. The food which
stagnates in the sac may decompose and cause ulcerations of the
mucous membrane, and these in turn may give rise to very severe
pain. A pressure diverticulum is, therefore, a considerable men-
ace to the health of the patient, and it is fortunate that the
condition is a rare one.
Primary Dilatation of the (Esophagus. — Difficulties in swal-
lowing may be caused by a diffuse or localized oesophageal dilata-
tion, unaccompanied by any demonstrable anatomical obstruction.^
It is very likely that in many of these cases the dilatation is due
to a functional stenosis originating in aspasmofthemus-
cle at the lower end of the oesophagus. Such spasms
may be primary, or they may be reflexly caused by ulcerations of
the mucous membrane. In some instances the dilatation has a
congenital origin. The symptoms of such dilata-
tions are very similar to those of ordinary stenoses, vi:3., obstruc-
tion to the passage of food, stasis in the dilated sac and regurgi-
tation. When there is a partial anatomical stenosis, or a func-
tional stenosis from spasm of the cardia, the symptoms may per-
sist for many years with intervals of perfect health. The picture
sometimes resembles that of rumination, especially if the dila-
tation affects that portion of the lower oesophagus which lies be-
tween the diaphragm and the cardiac orifice of the stomach.
In another class of cases, the course of the disease is exceed-
ingly rapid, and autopsy discloses an oesophagus widely dilated,
filled with food and yet without demonstrable stenosis. A con-
dition similar to this may be produced experimentally by cutting
both vagi in the neck of a dog. This operation causes a paralysis
of the oesophageal musculature, so that even though the cardia
apparently remains open, food does not pass into the stomach,
but accumulates in the oesophagus, decomposes and causes death.
The cases of acute oesophageal dilatation in man,
above referred to, are probably due to a similar primary paralysis
of the muscles; and Kraus has described a patient who died of
this condition, in whom at autopsy both vagi were found to be
diseased.
Painful sensations rarely originate in the oesopha-
236 THE BASIS OF SYMPTOMS
gus, first, because painful affections, such as ulcer, are rare in this
portion of the digestive tract, and secondly, because this is a
comparatively insensitive organ. Yet, as we have already men-
tioned, diverticula may occasion great pain, as may also spasm
of the oesophageal muscles.
Rupture of the oesophagus is very rare. It is
usually a complication of some definite lesion of the v^rall, such as
carcinoma or erosion from acids or alkalies. It may, however,
occur in apparently healthy individuals, though the cause in such
cases is unknown.
The Stomach. — The stomach '^ acts as a reservoir for the
large quantities of food which are ingested at each meal. Some
of this food is absorbed in the stomach, but most of it, including
practically all the water, is gradually passed on into the duodenum,
after having been acted upon by the gastric juice. Strangely
enough, the opinion has become current that the stomach is a
superfluous organ. It is, indeed, true that animals as well as men
have continued to live after a practically complete gastrectomy,
and that life may be maintained by artificially introducing food
into the intestines below the stomach. Indeed, a dog without a
stomach may live on quite a varied diet, even though it include
decomposing meat. Notwithstanding these facts, it remains true
that the less cause a man has to consider his digestion, the better
is his health, and the stomach stands as a most important prepara-
tory organ, which receives the varying kinds and quantities of
food, and shields the more delicate intestines from the harm which
these foods might produce if directly introduced. (An example
of the importance of the stomach in this respect is seen in the
so-called gastrogenous diarrhoeas, occurring in certain cases of
gastric achylia and attributed to the entrance of coarse food
particles, especially connective tissue, into the intestines, the lining
of which is thereby mechanically irritated. — Ed.)
It is possible to obtain pure gastric juice from animals,^ but
from man we are able ordinarily to obtain only mixtures contain-
ing both gastric juice and food. In a number of appropriate cases,
however, we have been able to study pure gastric juice
also in man ; these observations have shown the secretion to have
an acidity approximately the same as that in the dog, vis., o . 4
to 0.5 per cent, hydrochloric acid^ (see p. 240).
At the height of digestion, the hydrochloric acid is present
DIGESTION 2S7
in the stomach in various combinations. In the first place, some has
imited with the inorganic bases or basic salts of the food, or has
even decomposed salts of the weaker acids. Secondly, a portion
of the hydrochloric acid combines with certain basic organic com-
pounds. Of these, the most important practically are the com-
binations between the hydrochloric acid and the various proteids
of the gastric contents. These combinations are dissociated by
hydrolysis. The generally accepted view is that this loose union
of acid and proteid is the essential substratum of what is known
as the combined hydrochloric acid.^^ In all proba-
bility, however, more complex conditions are influential here.
Finally, a certain amount of free, un combined hy-
drochloric acid is usually present in the gastric contents.
Yet this may be absent, even at the height of digestion in some
individuals, and it is questionable whether such an absence is
always pathological or not, for some of these individuals appear
to be in a state of perfect health. Organic acids may be intro-
duced in the food, but they are not formed in the healthy stomach ;
and lactic acid, for example, is never a product of normal gastric
digestion.
The total amount of acid secreted depends mainly
upon the quantity and quality of the food taken. The secretion
apparently continues until the free and combined hydrochloric
acid in the gastric contents reaches a certain percentage. Pre-
cisely to what degree the secretion of acid depends upon the char-
acter of the nourishment, and to what degree it is subject to
individual variations, has not been completely worked out.^^
The Disturbances of Gastric Secretion. — The mucous mem-
brane of the stomach usually continues to manufacture the zymo-
gens of pepsin and rennin, even though the secretion of hydro-
chloric acid has partly or wholly ceased. Only in the most ad-
vanced changes of the mucosa are these ferments much diminished
or altogether absent. Such a lack of ferments, constituting the
so-called achylia gastrica, may be seen in advanced
atrophic gastritis, in carcinoma of the stomach and in certain
neuroses.
There is no immediate relation, however, between the secre-
tion of gastric ferments and of hydrochloric acid, for even in
the complete absence of the latter, there are considerable varia-
tions in the amount of zymogens in the gastric juice. Hence, the
238 THE BASIS OF SYMPTOMS
clinical picture of achylia gastrica is by no means well defined ; ^^
though it may occur in any of the conditions already enumerated,
it is often the chief manifestation in individuals who possess
simply an irritable digestive tract.
No symptoms are necessarily produced by a mere absence of
gastric juice so long as the motility of the stomach remains good,
and it is a remarkable fact that this motility is often increased in
cases of achylia. We know little of the anatomical changes in
the mucous membrane which lead to a cessation of secretion, and
we are especially ignorant as to the role which nervous influences
play in producing this condition. The secretion of rennin (lab
ferment) parallels that of pepsin. ^^ (And the quantitative de-
termination of the former affords a rough clinical index, likewise,
of the amount of pepsin secreted. — Ed.)
What furnishes the normal stimulus to gastric
secretion? Pawlow has shown that the most important factor
in dogs is the appetite, which is stimulated by sensory influences
travelling along the first, second, fifth and ninth cranial nerves.
The term "psychic" as applied to this secretion in dogs is an
unfortimate one, because it is not strictly such, or at least need not
be. Whether the appetite plays an equal role in man is still
undetermined.^* At any rate, there is considerable evidence to
show that an active gastric juice is secreted when there are
certain types of food in the stomach— or more correctly
in the pars pylorica — and in the intestines, and further in response
to reflexes from other parts of the body. Among substances
having this stimulating power are the meat extractives, milk
and probably the saliva. Mechanical irritation of the
gastric mucous membrane also seems to be a factor.^ °
Just how important in man the appetite is in stimulating the
flow of gastric juice must be left in abeyance. It is my opinion
that other factors are more significant, vis., ordinary sensory
stimuli, the act of chewing and chemical stimula-
tion of the stomach lining.^® Furthermore, the importance of
habi t in this regard, as emphasized by Schiile, seems to me vital.
In general, I should say that in man purely psychic factors are
not of first importance, ^''^ but rather physical processes with a
psychic component. This approaches closely the physiological
reflex.
It is possible, too, that some substance secreted by the buccal
DIGESTION 239
mucosa and analogous to secretin, plays a part in the stimulation
of the gastric juice.^^ The saliva and the chewing of the
food are also seemingly of importance.
Hypersecretion of Gastric Juice. — We are better informed in
the matter of variations in the hydrochloric acid content of the
gastric juice, though even here, for reasons already mentioned,
there are many things that are by no means clear. Most accessible
to study are the conditions associated with pathological hyper-
secretions of the gastric juice.
The stomach of a healthy fasting man is
either empty or it contains a small amount of
fluid, which may or may not show free acid. Some obser-
vers believe that the fasting stomach is always empty, ^^ while
others hold that it usually contains active gastric juice which
sometimes amounts to fifty or one hundred cubic centimetres.^**
In our experience, it has been found empty in some cases, while
in others it has contained a small quantity of secretion, possibly
caused by material (saliva) swallowed.
(In the past few years, there have appeared many studies
devoted to conditions governing the secretion and com-
position of gastric juice in man. The observations
referred to have been made upon individuals with
oesophageal stenoses and gastric fistulae.
Carlson, in a recent report,^^ has given the results of
his studies in a young man upon whom a gastrostomy was per-
formed because of a complete cicatricial stenosis of the oesopha-
gus. Confirming, in general, the observations in normal individ-
uals, he found that the fasting stomach contained on an average
twenty c.c. of fluid — the range being from eight to fifty c.c.
This fluid was made up in part of the secretion of the gastric
glands and also of material that had regurgitated from the duo-
denum. The daily and seasonal variations noted, he has attrib-
uted to differences in tonicity of the empty stomach, which allow
a varying amount of duodenal contents to flow back.
Furthermore, differing with Pawlow, and, in the main, agree-
ing with Boldyreff, in their animal studies, Carlson has
found that the gastric glands in man are in a
state of continuous secretion, the juice being poor
in hydrochloric acid — especially when the rate of secretion is
slow — and rich in pepsin. This continuous secretion varied from
240 THE BASIS OF SYMPTOMS
two to fifty c.c. per hour and seemed to depend upon several
possible factors, such as the vagus secretory tonus, and the action
of products of the auto-digestion of the gastric juice itself. Carl-
son, on the basis of his own observations and those of others
working under similar conditions, has estimated that a normal
adult secretes an average of fifteen hundred c.c. gas-
tric juice in the course of a day.
The seeing, smelling and thinking of food caused only a slight
secretion of gastric juice in Carlson's subject; this he has attrib-
uted to the fact that he had to do with an individual for whom
the taste of food was essential. Pawlow has also observed con-
siderable individual variations in dogs in this respect.
The pure gastric juice obtained from these patients
with fistulae, by different investigators, contained from 0.35
to 0,5 per cent, of hydrochloric acid. This percen-
tage, though considerably higher than that usually given for
human gastric juice, has been rather constant in different individ-
uals, and in the same individual under different circumstances;
so much so that Bickel believes that what is usually designated
as hyperacidity in man is in reality a hypersecretion. The ex-
cessive production of gastric juice merely raises the percentage
of acid in the mixture of juice and food which is subjected to
the ordinary clinical analysis. Even in the most marked in-
stances of "hyperacidity" the total acid in the gastric contents
does not exceed that of normal pure gastric juice.
Of other factors which influence gastric secretion may be
mentioned anger, which decreases the secretion in both man and
dogs. Furthermore, as necessary conditions of secretion, the
body must contain sufficient water and sufficient chlorids. A
deficiency in either causes less gastric juice to be secreted, without,
however, influencing its strength. — Ed.)
Pathologically, the stomach may contain large amounts of
fluid, even when the individual is fasting. The percentage of
hydrochloric acid in this abnormal secretion may be low, or it
may equal that of pure gastric juice (circa 0.5 per cent). At
the height of digestion, such patients also exhibit a variably acid
secretion.
Hypersecretion^ may occur as a continuous, or
— and this is the more frequent — as a periodic condition
in certain general disturbances of the nervous system, such as
DIGESTION 241
fever, hysteria, migraine and neurasthenia, or as evidence of a
local lesion, notably gastric ulcer. Occasionally, the gastric dis-
order associated with hypersecretion appears, in a sense, to be
primary (dyspepsia acida). In some cases, the
amount of juice poured out seems to be particularly large when
digestion is at its height (digestive hypersecretion).
The cause of the hypersecretion appears to be an increased
irritability either of the mucous membrane of the stomach or of
its secretory nerves. In many cases, even after a long period
of hypersecretion and hyperacidity, no anatomical changes
are demonstrable in the gastric mucous membrane,^^ which
would seem to indicate that, in these cases at least, the condi-
tion is of nervous origin. It is possible that a hypersecretion
is sometimes caused by a stimulation of the secretory centres in
the brain, and when this is so the condition may be comparable
to the salivation that is so often present in progressive bulbar
paralysis.
Hyperacidity. Ulcer of the Stomach. — In still other cases,^ the
stomach in the fasting state is normal, but at the height of digestion
exhibits a percentage of .acid as high as that of pure gastric juice,
i.e., 0.4 to 0.5 per cent. This condition of simple hyperacidity
probably arises in different ways. It might be looked upon, for
example, as the result of the secretion of an abnormally acid
gastric juice; while, on the other hand, the conception of an
increased secretion of normal acidity, especially if combined with
motor insufficiency, would explain conditions no less satisfac-
torily.
Attention has already been called to the very frequent
association of hypersecretion and hyperacid-
ity. In gastric ulcer, however, a pure hyperacidity is not in-
frequently met with. The relation between the two is of par-
ticular interest, because some observers look upon the hyperacid
condition as the cause of the ulcer. In animals, tissue defects
of the gastric mucosa, produced by trauma or otherwise, nearly
always heal rapidly.^^ The wall of the stomach opposite the
point of injury contracts, thereby protecting the abrasion, to a
certain extent, from the action of the gastric juice and enabling
the epithelium rapidly to bridge over the defect. In man, on the
contrary, gastric ulcer is characterized by its extraordinary
chronicity.
16
242 THE BASIS OF SYMPTOMS
A double etiological relation seems to exist between hyper-
acidity and round ulcer of the stomach. On the one hand, the
irritation of the nerves at the base of the ulcer apparently in-
creases the secretion of gastric juice ; while, on the other, a hyper-
acidity would interfere with the healing of any defect in the
mucous membrane, and an anatomical lesion would, therefore, be
more apt to lead to a chronic ulceration. Chronicity would also be
favored by local vascular disease, in particular by thrombosis of
the smaller gastric arteries,^® by vasomotor irritability and by con-
stitutional disorders, such as anaemia. The greater the hyper-
acidity, the more readily would abrasions go over into chronic
ulcer. The excess of acid acts not by digesting the injured area,
but by interfering with the formation of granulations. Healing
naturally becomes more difficult if the defect has existed for
some time, and induration of the margins and base has occurred.
The view that an absence of antipepsin plays a role in the etiology
of round ulcer still lacks confirmation.
Certain recent observations ^^ have emphasized the role of
infectious processes in the production of gastric
ulcer. Mycotic necroses of the gastric mucosa do indeed occur,
and it is conceivable that these are transformed into genuine
ulcers by the joint action of the bacteria and the gastric juice.
(Rosenow, among others, has produced ulcer of the stomach by
the injection of streptococci.^® — Ed.)
The etiology of gastric ulcer is far from clear.
Not infrequently, for example, hyperacidity is not present, and
on the other hand a high degree of acidity is often unaccom-
panied by ulcer. (The cause of the original tissue defect is per-
haps more readily understood than is the reason for its failure
to heal. Chronic ulcers have been produced in rabbits by section
of the vagi,^* though in what way is not known. In dogs, the
feeding of colon bacilli^** has likewise proved successful. The
action of the acid gastric juice probably plays an important part,
either directly by its corrosive effect upon the ulcer, or indirectly
by causing a spasm of the pylorus, delayed emptying and further
accumulation of acid material.^^ — Ed.)
Effects of Hypersecretion and H)rperacidity. — In discussing
the effects of an excessive secretion of hydrochloric acid, it is
possible to consider hyperacidity and hypersecretion together.
Disturbances are produced by the excess of acid ; and these occur
DIGESTION 249
during digestion in cases of pure hyperacidity, during fasting in
cases of hypersecretion, and during both states when the two are
combined. As Riegel has said, the results in all cases are due
rather to the profuse secretion than to the high acidity of the
juice secreted. In the presence of an excess of acid, the diges-
tion of starch in the stomach ceases altogether. The
proteids are digested, but whether normally or not is not
known. The patient frequently suffers from severe pain and
from vomiting, for both of which the hyperacidity is usually
directly responsible, for they are generally relieved by the ad-
ministration of substances which will combine with acids, such as
alkalies and proteids.
The effect of an increased secretion upon the gastric motility
will be discussed in another place, though we may mention here
that not infrequently a hypersecretion is followed by dilata-
tion of the stomach (Riegel). What effect the hyper-
acid gastric contents exert upon the intestines and upon
the intestinal digestion is not definitely known. Pos-
sibly the poor nutrition of many patients with hyperacidity is
due to the difficulty in neutralizing the hyperacid material which
reaches the intestines and to a consequent insufficient absorption
of nourishment. But, as a rule, this is not the only cause of their
poor nutrition ; the pain, the partial starvation caused by the fear
that food will cause pain, and the loss of material by vomiting,
all tend to produce emaciation. Constipation is also fre-
quently associated with hyperacidity.
The symptoms of gastric ulcer are, in part, those
of hyperacidity; yet the pain is usually more intense, probably
because the base of the ulcer is especially sensitive. The pain
may be very severe, however, even though there be hypochlor-
hydria. Then, too, a series of complications may follow in the
train of the ulcer. Arteries may be eroded and hemorrhage
ensue ; the gastric wall may be perforated with resultant adhesions,
abscesses or peritonitis. The number of such complications is
unfortunately a large one.
Subacidity and Anacidity. — A diminution of gastric acidity
is met with distinctly more often than is an increase. A certain
caution, however, is indicated in the interpretation of diminished
acidity, for the causative factors are complex. The amount of
free hydrochloric acid may be lowered, or free acid may be en-
S44 THE BASIS OF SYMPTOMS
tirely absent ; in either case the total acidity may be low, or normal
or even higher than normal. The absence of free acid does not
necessarily mean that none is being secreted; for acid poured
out in normal amount may combine with unusual avidity, particu-
larly with proteids. We can form no idea of the total amount
of acid secreted, because of the intimate relation in man between
the quantity secreted, reabsorbed and propelled into the intestines.
Free hydrochloric acid is absent in many
acute gastric disturbances, functional as well as ana-
tomical, notably in those associated with the acute infectious
diseases. Anacidity is seen more frequently, however, in
chronic diseases of the stomach, as in atrophy or
amyloid degeneration of the mucous membrane, and espe-
cially in carcinoma. Diseases of other abdom-
inal organs — of the liver, for example — may also inhibit the
gastric secretion ; and general conditions such as per-
nicious anaemia, advanced tuberculosis and cachexia may all be
associated with an absence of free hydrochloric acid in the gas-
tric contents. A complete anacidity, however, does not develop
rapidly, but is the result of a gradual fall from the practically
constant and not inconsiderable degree of free acidity seen in
health, under fixed external conditions. This gradual approach
to total anacidity is common in the chronic dyspepsias.
We have already emphasized that a decrease both in free
and combined acid may be the result of diverse factors. As the
secretory conditions in a healthy individual who leads an even
and regular Hfe are fairly constant ^^ — and incidentally different
from those under which pure gastric juice is obtained — we must
assume that there is some regulating mechanism at work, the
action of which is easily and often disturbed in pathological con-
ditions, and not infrequently even in health, when the routine of a
regular existence is upset.
The two conditions adduced in explanation of an
acid reduction have already been alluded to, viz., an actual
diminution in the amount of gastric juice se-
creted— whether there is a pure secretion containing less acid
is not known — and secondly, the production in consid-
erable amount of substances which combine with
free acid.^^ The last is, undoubtedly, true in carcinoma of
the stomach, for hydrochloric acid continues to be secreted in
DIGESTION 245
this condition; while the amount of combined chlorid may not
only equal, but exceed the normal, ^^
Clinical experience speaks also for this second hypothesis.
Thus free acid may be present in carcinoma; this is the rule, in
fact, in the early stages, particularly when the carcinoma has de-
veloped upon the site of an old ulcer.^^ It is more difficult to
understand the anacidity associated with malignancy of neighbor-
ing communicating structures, as, for example, the oesophagus
and gall-bladder.
When the hydrochloric acid in the gastric contents is reduced,
theptyalinis able to act for a long time upon the food, unless
its activity is interfered with by the presence of organic acids.
Digestion of the proteids is usually diminished or
absent, according to the reduction in the amount of hydrochloric
acid.^^ (A carcinoma of the stomach, however, apparently pro-
duces ferments capable of causing an even deeper cleavage of
proteids than does pepsin.^^ The use of one of these ferments,
which will split glycyltryptophan, has been suggested
by Neubauer and Fischer ^^ in the diagnosis of gastric cancer.
The test as originally employed, and some of its modifications,
seem to have a certain value, when disturbing factors such as the
regurgitation of the duodenal contents can be eliminated. — Ed.)
A diminished proteid digestion in the stomach does not neces-
sarily mean a loss of food material to the body, for with a proper
dietary the intestinal digestion can compensate for the inefficiency
of the stomach, and the nitrogenous material in the body may
not only be maintained at the old level, but in some cases the store
may be actually increased (v. Noorden). And I am convinced
that nitrogen equilibrium may be conserved even with
individuals on ordinary diet, for many such, despite the anacid-
ity, are quite free from symptoms.
Bacterial Action in the Stomach. — The normal gastric juice
possesses decided antiseptic properties, owing principally to its
acidity. Whether the pepsin is of great importance or not in
this respect is still a matter of dispute. Cells are usually digestible
only when they are dead ; yet, in the opinion of some, pepsin plays
an important part in limiting bacterial growth, more especially
the growth of those organisms which give rise to lactic acid fer-
mentation. An acidity of 0.2 per cent, in a test-tube will, after
a long time, destroy many bacteria, such, for example, as the
246 THE BASIS OF SYMPTOMS
typhoid bacillus, the cholera vibrio and the bacteria of decom-
position and fermentation; whereas other organisms, and espe-
cially spores, are not greatly injured by this amount of acid.
Yet conditions in the test-tube are not the same as those in the
stomach. Many parts of the food do not come into intimate con-
tact with the gastric juice at all, either because they are quickly
passed on into the intestines, or because they lie in the centres
of large particles which are not broken up in the stomach.
Furthermore, a large part of the hydrochloric acid secreted is
immediately bound by the proteids, etc., and these combinations
are known to be less antiseptic than is free hydrochloric acid,
though even they may kill cholera bacilli. It is evident, there-
fore, that the bactericidal powers of the gastric
secretion are limited, and that numbers of micro-
organisms are constantly being passed on into the intestines.
On the other hand, an abundant multiplication of bacteria
within the stomach is prevented mainly by the normal evacuation
of its contents. Even though hydrochloric acid is absent,
no bacterial decomposition ordinarily takes
place so long as the motility of the stomach re-
mains good and its contents are regularly passed on into the
intestines before the bacteria have time to multiply. The con-
dition most favorable to bacterial decomposition is the stagnation
of material in the stomach; when this last is present, the grade
of acidity plays a most important part in the determination of the
variety of micro-organisms which shall multiply, and this in
turn determines the' character of the decompositions that shall'
take place.
If free and abundant hydrochloric acid be present in stagnated
gastric contents, the ordinary putrefactive decomposi-
tions of proteid material rarely take place. The fer-
mentation of carbohydrates, however, does occur:
sugar is transformed into alcohol and carbon dioxide, alcohol into
acetic acid, dextrose into lactic acid, butyric acid, carbon dioxide
and hydrogen, etc. The gases which ordinarily result from
these fermentations are carbon dioxide, hydrogen and traces of
methane. These, together with swallowed air, usually make up
the bulk of the gases present in the stomach during gastric fer-
mentations. Each of these fermentations may be carried on by
a number of micro-organisms that will resist an acid reaction
DIGESTION 247
of not too high a grade ;^^ but yeasts and sarcinae are those most
commonly found. Occasionally, similar fermentative processes
occur even though the gastric acidity is very high. Here, possi-
bly, the products of fermentation cause a reflex flow of gastric
juice.^°
If the stagnation is accompanied by a diminu-
tion or absence of hydrochloric acid, then oppor-
tunity is given for the multiplication of a greater variety of
micro-organisms. These may even cause putrefaction of proteid
material. More frequently, however, they give rise to fermen-
tative processes similar to those just described. Yet there is a
special tendency to the production of lactic, butyric and other
volatile organic acids. ^^ Lactic acid fermentation
is particularly characteristic of gastric stagnation in the absence
of hydrochloric acid; and if this be present in sufficiently large
quantities it tends to inhibit the growth of many bacteria which
would otherwise give rise to putrefactive processes. A special
lactic acid bacillus (Oppler-Boas bacillus) is then
frequently present in enormous numbers in the gastric contents.
From a consideration of these facts, it will be seen that no
one kind of bacterial decomposition is pathognomonic of any par-
ticular clinical condition. The decomposition depends rather
upon the varieties of micro-organisms which have been intro-
duced into the stomach, upon the opportunity which they have
had to multiply and upon the kind of food which is subjected
to their activities. The relation between carcinoma of the
stomach and lactic acid fermentation must be
judged from such a general stand-point. The two frequently
occur together, but this depends upon the fact that stagnation,
absence of free hydrochloric acid and diminution in the ferments
— the very conditions which favor the development of lactic acid
fermentation — are most frequently present in cancer of the
stomach. If, as rarely happens, the combination of a gastric
stagnation and an absence of free hydrochloric acid is caused by
some condition other than carcinoma, lactic acid fermentation
might occur ; though some maintain that lactic acid is formed only
in the presence of a ferment-like body, which is found in cancer
tissue, blood-serum, etc.^^ Very remarkable decompositions have
been observed in some stomachs, for example, the production of
sulphuretted hydrogen, when free hydrochloric acid was absent.
248 THE BASIS OF SYMPTOMS
The acidity of the gastric contents exerts no small influence
upon the chemical processes in the intestines, ^^ and
we may say here that, in general, as the acidity in the stomach
diminishes, the putrefaction in the intestines tends to increase.
This subject will be more fully considered below.
It sometimes happens that fermentation occurs in the gastric
contents, even though there is no diminution either in the secre-
tion of acid or in the motility of the stomach. In such cases it
is possible that the condition is due to the introduction of
excessive amounts of fermentable material, to-
gether with the agents which cause the fermentation.** The lat-
ter would in turn affect the gastric motility, and a disturbed
motility would favor further fermentation.
Abnormal fermentative processes do harm to
the stomach in various ways. The products of fer-
mentation may irritate and injure the gastric mu-
cosa, producing loss of appetite, pain, vomiting and possibly
spasmodic closure of the pylorus with diminished gastric motility.
Gases may be produced in large quantities, causing abnormal
distention and belching. The abnormal secretion of fluid by the
stomach, together with the distention by gases, would favor the
development ofgastricdilatation. At times, toxicsub-
stances are produced in gastric fermentations, and these may
give rise to a varied category of general symptoms (see p. 255).
We know very little about the function of the
mucus secreted by the stomach, which is unfortunate, be-
cause it is quite probable that this may exert some protective
influence in certain pathological conditions. The amount of
mucus secreted in diseased conditions varies greatly; and it is
present in different forms,* ^ depending upon the action of hydro-
chloric acid. At times, possibly, there may occur a hypersecretion
of mucus on a nervous basis,*® similar to a hypersecretion of
gastric juice,
The Disturbances of Gastric Motility
The normal movements of the different parts of the stomach
are fairly well known.*"^ The fundus acts as a reservoir for the
food. Its wall shows peristaltic movements, but the pressure
within it is comparatively low. The antrum pyloricum contracts
periodically, several times a minute, although it may at times
DIGESTION 249
contract irregularly. During a contraction, the pressure exerted
upon its contents is considerable, being over a half metre of water
in man. Since its cavity is shut off from the fundus by the
sphincter-Hke action of its proximal portion, its contents may be
propelled into the intestines only when this muscular ring relaxes.
(The opening and closing of the pylorus is in part, at least, de-
pendent upon the so-called acid-reflex ( Hirsch, Serd-
jukow, Cannon). ^^ Relaxation of the pylorus occurs when free
hydrochloric acid appears; and when the acid contents thus re-
leased reach the duodenum, they not only initiate a reflex which
closes the pylorus behind them, but also stimulate the flow of the
alkaline pancreatic secretions. The latter, in turn, gradually
neutralize the acid material which has reached the intestines, and
thus permit of another pyloric relaxation, and the repetition of
the cycle.
Other factors, however, seem to be influential in this mechan-
ism.*^ Thus in dogs, the mechanical irritation of coarse food
particles keeps the pylorus in a contracted state ; and infiltrations
of the gastric wall, even though at a distance from the pyloric
end, affect its opening and closure. An illustration of this last
is the pylorospasm of gastric ulcer without hyperacidity. On the
other hand, a carcinoma not situated at the pylorus may, with
normal conditions of acidity, be associated with a permanent
pyloric insufficiency. And, finally, pyloric insufficiency, and par-
ticularly pylorospasm, may exist in the complete absence of gastric
and duodenal changes. This nervous type of spasm may be pro-
voked by morphin, physostygmin and cold, and ended by means
of atropin and papaverin.
The pyloric play, so-called, is therefore of a more
complex nature probably than has heretofore been supposed.
Possibly innervation factors as yet little understood play an im-
portant part. — Ed.) The antrum pyloricum seems to pick the
fluid and finely divided portion of the gastric contents out of the
fundus, and in this manner to regulate still further the emptying
of the stomach.
The cause of the gastric movements is very un-
certain. In the first place, like all other unstriated muscles, the'
stomach has periods of rest alternating with periods of activity.
Some have believed that the acidity exerts a great influence
upon the gastric movements, yet we know that under pathological
250 THE BASIS OF SYMPTOMS
conditions at least, no definite relation exists between the motility
of the stomach and the acidity of its contents. The delayed
emptying seen so often in cases of hyperacidity may be ascribed
to an increased activity of the duodenal reflex mentioned above;
while the rapid emptying, on the other hand, associated with
diminished and absent acidity, is probably due to the weakness
of the pyloric reflex, and may be regarded as the rule in achylia
gastrica. The consistencyof the contents certainly in-
fluences gastric motility. Large solid particles are thrust back
into the fundus by the antrum, whereas soft masses are allowed
to pass through into the intestines. Warm material tends
to increase the peristalsis and to relax the pyloric sphincter.^®
Although careful studies have been made as to the length of
time that certain foods remain in the stomach,®^ more work is
needed upon abundant mixed diets.
(Cannon, in his work on cats, has carefully studied the
effects of different foods, singly and combined, upon the activity
of the pylorus. Carbohydrates, which make little demand upon
the gastric acidity, pass quickly into the duodenum. The proteid
curve is a gradual one because this food unites with the first acid
secreted, and thus delays the appearance of sufficient free acid
to provoke the pyloric reflex. Fats likewise remain for a long
period in the stomach because of their known inhibitory effect
upon the secretion of acid. Cannon has also elaborated the action
of combinations of these foods. — Ed. )
Increased Peristalsis and Increased Gastric Motility. — At
times the peristaltic movements of the stomach are increased,
and its contents are emptied more rapidly than normal. Yet
this rapid emptying does not necessarily occur; for, when a hin-
drance to the exit of food is present, the powerful contractions
of the muscle may be unable to expel the food even within the
normal period of time. Frequently the patient is rendered ex-
tremely uncomfortable by the excessive gastric peristalsis, and the
movements of the stomach may be plainly visible through the
abdominal wall. In some cases this condition of "peristaltic
unrest " is dependent upon a primary pyloric stenosis ; in others,
it is probably caused by an excessive irritability of the nervous
connections of the stomach, and it is then frequently accompanied
by violent peristalsis of the intestines. As we have already said,
the stomach may empty itself with unusual rapidity in achylia
DIGESTION «61
gastrica, though in this case there are usually no associated sen-
sations of increased peristalsis. We must be cautious, however,
in linking a rapid emptying with any particular secretory anomaly,
for hypermotility may occur also with hypersecretion.^^
Motor Insufficiency and Gastric Dilatation. — Much more fre-
quent than an increased is a diminished gastric motility, and a
consequent delayed or incomplete emptying of the organ. This
is seen, among other conditions, in acute and chronic
gastritis, and particularly in carcinoma. Cancer may
act in this way not only when it causes an anatomical pyloric
stenosis, but also when it is situated in regions the involvement
of which has no relation, necessarily, to the emptying of the
stomach. In this case, the disturbance of motility is associated
with anomalies of secretion ; the interaction of the two, however,
is not understood. Either may be the consequence of the ana-
tomical lesion, or the secretory disorder may lead to the motor
insufficiency. Yet the latter not infrequently occurs primarily,
the secretory conditions being quite normal.
We are as yet unacquainted with those factors, a knowledge
of which would be most instructive, vi^.^ what lesions of the
nervous apparatus and of the musculature underlie these motor
disorders, and to what extent is the muscle of the antrum and
of the fundus crippled. Possibly Moritz's method of estimating
the pressure in the different parts of the stomach will prove of
value in this regard.^^
The motility of the antrum, and particularly of the pylorus,
is obviously intimately influenced by what would seem to be in-
significant factors, not only under pathological conditions, but
even in health.^* I am of the opinion, indeed, that gastric pathol-
ogy is much more a matter of motor than of secretory disturb-
ances. The prominence of the latter in diseases of the stomach
is due to the fact that our methods of estimating motor disorders
are too little refined. Even roentgenoscopy is not entirely satis-
factory, because it carries with it the use of an abnormal meal
which in itself may affect gastric motility.
The effect of a motor insufficiency is that the
stomach does not empty itself as quickly as a normal organ under
the same conditions. So long as the degree of insufficiency is
slight, this is the only consequence. If, on the contrary, there
is a considerable stagnation of food, which in decomposing builds
262 THE BASIS OF SYMPTOMS
substances such as gases which distend the stomach, or such as
fatty acids, which injure the mucosa; and if, further, secretory
anomaHes exist which favor the decomposition of the stagnant
material, then the motor insufficiency leads to dilatation.
The secretion of fluids in large amount also predisposes strongly
to dilatation in view of the insignificant power of the stomach to
absorb them. That food stagnation may produce secretory dis-
turbances is indicated by the studies of Kausch, in which a change
in secretion was observed after a successful gastro-enterostomy.^'
Causes of Dilatation, — Dilatation may result from a variety
of causes. In the first place, it may follow a mechanical
stenosis of the pylorus, such as may be caused by
tumors, contracted scars or pressure from without. It is quite
probable also that it may follow a spastic contraction
of the pyloric muscle, which arises from reflexes
from ulcers, from sensitive spots on the mucosa or perhaps from
the irritation of a normal mucous membrane by caustic sub-
stances or even by hyperacid secretions. In the latter case, it
is the duodenal mucosa and not the gastric, as formerly sup-
posed, that seems to initiate the reflex.^* In infants, a primary
pylorospasm is not infrequently observed.^'^
Every stenosis of the pylorus increases the work of the
muscle in the antrum pyloricum. This additional work causes
the muscle to hypertrophy just as additional work elsewhere will
lead to an hypertrophy of the corresponding muscle. The more
powerful contractions of the hypertrophied gastric muscle may
for a time neutralize the effects of even a considerable stenosis.
To what extent this is possible depends upon the strength of the
hypertrophied muscle. Ultimately the hindrance to the exit of
food may exceed the compensatory power of the antrum, and the
stomach will no longer be able to empty itself completely. Dila-
tation then begins, and this is frequently favored by a concomitant
weakening of the antrum caused by a degeneration of its smooth
muscle-fibres.
Anomalies in the form and position of the
stomach may also lead to dilatation. °* Our former ideas as
to the position of the organ have undergone complete revision as
a result of radiographic methods of examination.^* As a rule
it lies p)erpendicularly with an upward kinking at the pyloric
antrum (siphon form of Groedel). Changes in its im-
DIGESTION 258
mediate surroundings, tight lacing, enteroptosis — all of these exer-
cise a most pronounced influence upon the ability of the stomach
to empty itself. Such conditions may cause, in the first place,
an actual narrowing of the gastric outlet, as happens, for example,
when an abnormally low stomach presses upon or kinks the duo-
denum. Then, too, the low position of the fundus in gastroptosis
increases the difference in the level between it and the pylorus,
and renders a greater amount of work necessary to lift the con-
tents out of the stomach. Very remarkable dilata-
tions sometimes follow laparotomy or develop in
the course of acute infectious diseases.^^ The stomach becomes
enormously distended within the course of a few hours. In some
of these cases the dilatation apparently results from an acute
obstruction in the duodenum, due to a kinking as noted above,
and the motor insufficiency is especially apt to occur if the
gastric wall has previously been diseased. Anomalies in the
position of the stomach may also play a role.
(According to Mayo Robson®^ acute dilatation of
the stomach is due to a paralytic condition of its wall which
leads to an overdistention with gases and with excessive secretion,
this in turn producing a kinking at the pylorus or at the duodeno-
jejunal flexure. This is comparable to the intestinal obstruction
occurring in a loop of paralyzed bowel which becomes distended
with fluids and gases, and by its very weight causes a kinking
of the intestine just below. — Ed.)
In other cases of gastric dilatation, no hindrance to the exit
of food is apparent. Such dilatations have been met with in
chronic gastritis, ulcer and carcinoma, in cases of hyperacidity and
hypersecretion, and finally in association with enteroptosis, neuras-
thenia and diseases of the spinal cord. Possibly, certain cases of
ulcer and hyperacidity occupy a peculiar position in the produc-
tion of dilatation, in that the stenosis is functional and due to a
pylorospasm.
The so-called atonic type of dilatation would pre-
sent no interpretative difficulties were it not for the fact that
dilatation is not always accompanied by a delayed emptying of
the organ ; on the contrary, indeed, the stomach may empty itself
very slowly even though such a dilatation is absent, and conversely
a dilatation may have no effect upon gastric motility. Conditions
here are very similar to those observed in the varying behavior
254 THE BASIS OF SYMPTOMS
of cardiac dilatation and cardiac efficiency. It is important to
remember that an apparent dilatation does not necessarily mean
an actual enlargement, for in conditions such as enteroptosis, it
is difficult to estimate the size of the stomach. Nevertheless,
gastric dilatation may occur with a normal emptying time,^^ in
which case the only explanation possible seems to reside in a pri-
marily lowered tonus of the fundus musculature, while the con-
tractions occurring during digestion remain of normal strength.
This condition is known as gastric atony.
Finally, gastric fermentation may cause a dila-
tation of the stomach. Fermentation is, of course, a com-
mon sequel to dilatation, yet in some instances it is primary. In
Naunyn's cases,®^ dilatation and disturbances of gastric motility
resulted from the introduction of large numbers of micro-organ-
isms, together with easily decomposable food ; and the dilatation
disappeared as soon as the gastric contents were removed. The
abnormal fermentation gives rise to large amounts of gas, which
would, undoubtedly, interfere with the movements of the stomach.
Possibly, also, the acid products of fermentation lead to a reflex
spasm of the pylorus, comparable to that occurring with a hyper-
secretion of hydrochloric acid.
Effects of Motor Insufficiency. — The results of a motor insuffi-
ciency of the stomach may be very serious. In the first place,
if the obstruction at the pylorus is nearly complete, the patient
will die from lack of nourishment unless a communi-
cation be established by operative means between the stomach
and the intestines. If the obstruction is incomplete, but sufficient
to cause considerable stagnation, favorable conditions are present
for the growth of micro-organisms, and the development of
various abnormal decompositions. The presence or
absence of free hydrochloric acid in the stagnated contents is
an important factor in determining which micro-organisms shall
develop and what shall be the character of the abnormal decom-
positions. As a rule, an atonic stomach absorbs material poorly,
and the retention of digestive products (albumoses,
etc.) in the gastric contents will interfere, to a certain extent, with
the further progress of digestion. Possibly, also, abnormal quan-
tities of true peptones are formed when the food remains
in the stomach, and these cause a direct irritation of the gastric
mucous membrane. Lastly, decomposed material and
DIGESTION 255
large numbers of bacteria are passed on into the
intestines, where they may irritate the more delicate mem-
brane and initiate further abnormal decompositions.
Very remarkable nervous symptoms sometimes develop as a
result of gastric dilatation.^^ Of these we may name the fully
developed and rudimentary forms of tetany, epileptiform con-
vulsions, tonic muscular contractions resembling tetanus, and,
finally, symptoms of general depression and collapse. These
symptoms usually occur in cases in which dilatation is associated
with a hyperacid secretion, but the latter is not absolutely neces-
sary. The cause or causes of these nervous symp-
toms are not well understood. One is tempted to assume that
toxic substances are formed in the abnormal fermentations, and
that these produce the symptoms by their action upon the nervous
system. Indeed, French observers have prepared extracts from
the stomach contents and have shown that they may give rise
in animals to somewhat similar nervous disturbances. Yet these
experiments need careful confirmation before much weight is to
be attached to them. In some patients, no such poisons could be
found; and Fleiner is of the opinion that mechanical causes, such
as an overfilling of the stomach with a stretching of its parts, or
perhaps the loss of fluids from the body, may play a more important
role in the production of these symptoms.
Belching and Vomiting. — In addition to the normal move-
ments of the stomach, others rriay occur which tend to empty its
contents in the direction of the oesophagus. Waves of anti-
peristalsis have been directly observed in cases of gastric
dilatation. (With the adaptation of the X-ray to gastric pathol-
ogy, antiperistalsis has assumed an important place in the diag-
nosis of pyloric stenosis.®^ — Ed.)
By belching, we understand an expulsion of gas from
the digestive tract through the mouth. Air in the oesophagus is
easily expelled, for a powerful inspiratory movement with a closed
epiglottis will draw air into the oesophagus which may afterwards
be expelled during expiration. The gases may, however, come
from the stomach, and they then consist either of air which has
been swallowed, or of gases which have arisen from abnormal
fermentations, vis., carbon dioxide, hydrogen and methane. The
gas frequently carries with it small amounts of liquid into the
throat; and if this contains fatty acids, as it frequently does in
^6 THE BASIS OF SYMPTOMS
gastric fermentation, it gives rise to the burning sensation known
as pyrosis. Hydrochloric acid itself may also be carried up
and likewise produce unpleasant acid sensations.
The combination of movements by which the gas is expelled
consists, on the one hand, of a relaxation of the sphincter at the
cardiac end of the stomach, and, on the other, of a contraction
of the abdominal muscles and diaphragm, whereby the intra-
abdominal pressure is increased. Possibly, in some cases, the
stomach also assists by contracting upon its contents. This com-
plicated mechanism is most frequently set in motion by reflexes
from the stomach or peritoneum.
In certain cases the same movements take the form of a clonic
spasm, and this produces the condition known as hiccough-
ing. Hiccoughing is also incited by reflexes from the stomach
and peritoneum, but it may furthermore arise from causes situated
in the central nervous system, as is the case in the hiccoughing
of hysteria and of severe lesions of the medulla.
Vomiting^® is produced by a series of movements of the
respiratory, abdominal and gastric muscles, which follow each
other in a certain definite sequence, and which culminate in the
expulsion of the contents of the stomach through the mouth.
Vomiting is initiated by a deep inspiration, followed by a spas-
modic contraction of the abdominal expiratory muscles, during
which the glottis is closed and the diaphragm is held in a low
position. The pyloric orifice is tightly contracted, the cardia is
relaxed, and the stomach itself, though usually relaxed, may pos-
sibly perform antiperistaltic movements. During the primary
deep inspiration some of the gastric contents are probably aspir-
ated into the oesophagus, for the circular muscles of this tube are
relaxed and its longitudinal muscles are contracted. When,
finally, the abdominal muscles contract, the intra-abdominal pres-
sure is greatly raised, and the contents of the stomach and of the
oesophagus are expelled through the mouth.
This complicated mechanism is governed by a special centre
in the medulla, situated not far from the respiratory centre. The
"vomiting centre" may be acted upon directly by
intracranial diseases and by poisons, or it may be
stimulated reflexly through the vagus fibres from
the stomach, especially from the terminations of those which
supply the neighborhood of the cardiac orifice. Vomiting may
DIGESTION «57
also be caused by reflexes from other organs, espe-
cially from the peritoneum, uterus, etc.
The act of vomiting not only affects the stomach, but also
to a marked degree the general blood-pressure and the intra-
thoracic pressure. Traube has shown that at the beginning of
the act the blood-pressure falls, and that the slow pulse is due
to a vagus stimulation. Toward the end of the act both the
blood-pressure and the pulse-rate are greatly increased. The sali-
vation and the sweating which occur at the beginning of vomiting
demonstrate how wide-spread are the changes incident to this act.
Sensations Arising from the Stomach. — A healthy man is not
conscious of his stomach except when he is hungry or when the
organ is overfilled. The sensation of hunger^^ is undoubt-
edly dependent to a great extent upon the condition of the stomach,
though we do not know the exact changes which give rise to this
sensation. It seems probable that the intestines also influence
the sense of hunger, for patients with intestinal fistulse have been
observed whose hunger was not fully satisfied when food was
put into the stomach, but was appeased if food material was
also introduced into the intestines. The mental condition likewise
influences the sensation of hunger, as is well known. To what
extent the needs of the body for new material influence the sensa-
tion is still uncertain; yet these needs do seem to exprt some
influence, and the hunger of diabetes as well as that following
muscular exertion seem to be examples of " tissue hunger." Of
all these various factors that may influence hunger the condition
of the stomach is the most important.
(Certain observers, Howell®^ among others, believe that no
appreciable distinction can be made between hunger and
appetite. Others, however, draw a sharp line between the
two, defining hunger as the primitive, uneducated call for food,
and appetite as the desire for food based upon previous pleasurable
experience. According to Pawlow,^^ they differ also in their
effect upon the secretion of gastric juice, hunger inhibiting the
flow and appetite increasing it.
It is generally agreed that hunger is the psychic counterpart
of a physical phenomenon evidenced by the so-called hun-
ger contraction waves of the stomach. Boldyreff,
who first recorded these in dogs, and Cannon and Washburn,
who observed them in man, have described them as of periodic
17
258 THE BASIS OF SYMPTOMS
occurrence with intervals of complete quiescence. C a r 1 s o n 7**
on the contrary, believes that the stomach is never
quiet and that the small, continuously occurring contractions
increase in size and even become tetanic when the hunger state
begins. These contractions may be recorded graphically by means
of appropriate apparatus in individuals with gastric fistulse, and
in normal individuals during a period of fasting (Carlson) . — Ed.)
Abnormally increased hunger is sometimes seen
in patients with gastric ulcer or in those with hyperacidity, espe-
cially when there is an accompanying hypermotility of the
stomach.
As a rule, however, gastric disturbances diminish the sensation
of hunger, and the patient then has less inclination to take food
(loss of appetite). Diminished hunger and loss of appetite
are not precisely synonymous, for a person may say that he is
hungry, and yet he will not eat, because he " has no appetite " for
the food set before him. Loss of appetite accompanies many
disturbances both of the gastric secretion and of gastric motility,
btit its exact cause is not known.
The sensations of fulness and pressure, which the
healthy person experiences only after a full meal, become patho-
logical if they are present when the stomach is not much distended.
These sensations are produced more readily when the distention
takes place rapidly than when it occurs gradually. This would
seem to indicate that an increased tension of the stomach wall
is an important factor in their production.
Gastric pain is frequently due to ulcerations of the
wall of the stomach, whether these be rotmd ulcers or are pro-
duced by carcinomata or by the action of corrosive poisons. It
seems very probable that the pain in such cases is caused by the
irritating action of the acid gastric contents upon the exposed base
of the ulcer. Indeed, we know the acid may cause most intense
pain, even when there is no ulceration. In such cases the pain
may possibly result from a direct irritation of the terminals of the
sensory nerves in the stomach wall ; yet it seems more likely that,
in most cases, it is due to a muscular spasm, more especially of
the pyloric or the cardiac orifices. The sensation popularly known
ascrampsinthestomach may, therefore, in some instances
be actually due to spasm of the gastric muscula-
ture. As we have said, such cramps are frequently caused by
DIGESTION 259
hyperacid secretions, or by ulcerations. Gastric pains may, how-
ever, be of a neuralgic character; in this category belong some
of the conditions called cardialgia. We are as ignorant
concerning the nature of these as we are of neuralgias in general.
The terrible pains which accompany the gastric crises of
tabes and of other spinal affections are perhaps due to irrita-
tive-degenerative processes in the pneumogastric nerve. ( In the
tabetic cases, beneficial results have been reported following the
severance of the sensory roots of the seventh to tenth dorsal
nerves.''^^ — Ed.)
Disturbances of the stomach may lead to a great variety of
symptoms in other parts of the body. We have already men-
tioned the attacks of tetany and related symptoms. There may
also be various vasomotor disorders, parsesthesias, neuralgias, mi-
graine and vertigo, as well as disturbances in the innervation of
the heart (irregular action) and of the lungs (cough). Some of
these symptoms are of a reflex nature; others are probably due
to poisons absorbed from the stomach. The investigation of this
latter class of cases promises interesting results in the future.
(Another type of painful sensation that may properly be
spoken of here is that called abdominal angina, "^^ analo-
gous, etiologically, to angina pectoris and to intermittent claudi-
cation. In this condition, the abdominal aorta and its branches
are the seat of sclerosis, added to which there is usually the factor
of vascular spasm. In addition to severe abdominal pain, these
cases exhibit sudden and marked tympanites, constipation and
sometimes renal disorders. — Ed.)
It is especially characteristic of the stomach that disturbances
of its functions are combined in the most varied manner, and that
one disturbance tends to bring others in its train. In certain
cases it is possible to determine which of these is primary and
which are secondary; in other cases, we cannot make such a
separation.
Functional disturbances of the stomach are
not accompanied by constant anatomical changes, and the con-
dition known as gastric catarrh is especially destitute of any well-
defined pathological-anatomical basis. The relation between func-
tional and anatomical changes in the stomach is not easily studied,
because so few gastric disorders are fatal and because the stomach
changes so rapidly after death. For these reasons we know com-
260 THE BASIS OF SYMPTOMS
paratively little about the relation between functional and ana-
tomical changes in the stomach.
Not infrequently patients complain of loss of appetite, nausea
and sensations of pressure in the abdomen, and yet the most care-
ful investigations fail to reveal any secretory or motor changes.
In a certain proportion of these cases it is possible that an
unusual sensitiveness of the stomach exists, and
that if the patients are careful in their diet they are relieved of
the discomfort. In other cases, however, the symptoms seem to
occur quite independently of the quantity and quality of the
nourishment, and to depend rather upon the psychic state
of the individual. To this class of cases Leube has given the
name of nervous dyspepsias. The frequency of the
latter increases as the resistance of people to the unpleasant things
of life diminishes. We all know the great influence the mind
exerts upon the digestion, and it is easy to conceive that this in-
fluence might be pathologically intensified in neurotic individuals.
Indeed, secretory and possibly even motor functions of the stom-
ach may be thus affected. Striimpell has termed such cases
psychic dyspepsias. Dreyfuss,'^^ who has given this sub-
ject especial attention, has found the chief predisposing conditions
to be an inherited or acquired neuropathic disposition, epilepsy,
hysteria and circular insanity,
Disturbances in the Secretion of Bile^*
We know little of the variations which diseases cause in the
amount and composition of the bile. Physiological experiments
would seem to indicate that the amount is diminished in all those
conditions in which but little food is taken. This diminution
affects especially the water and the bile salts ; but we are less cer-
tain as to the effect of inanition upon the bile pigments, for con-
siderable variations in these occur normally.
Substances not ordinarily present may appear in the bile.
Thus when the sugar in the blood exceeds 0.3 per cent, it is ex-
creted by the liver, and the same is true of other substances, among
which the antiseptics may prove of practical significance. Albu-
min api>ears in the bile at times, e.g., after the use of alcohol.
The secretion of pigments may be diminished, as happens in
some instances of degeneration of the hepatic cells during infec-
tious diseases. The pigment content is high in passive hyperaemia
DIGESTION 261
of the liver ; while in numerous conditions it undergoes consider-
able variations.
It is possible to affect the composition of the bile through
changes in the blood. When large numbers of red
blood-corpuscles are destroyed, the liberated pig-
ment is taken up by the various organs, especially by the liver
(p. 1 1 6). This directly influences the bile. Its quantity is at first
diminished, the formation of the pigments from the haemoglobin
is increased, and the bile salts are either normal or are diminished.
Not infrequently the oxy haemoglobin itself passes into the bile,
even long before it appears in the urine.
The composition of the bile is affected also by certain
poisons, among which are toluylendiamin, arseniuretted hy-
drogen and phosphorus. The first two destroy the red corpuscles
of the blood, but phosphorus does not do so in mammals. In the
earlier stages of intoxications with these compounds, the total
quantity of the bile is usually diminished, the pigments are in-
creased, and the bile salts only slightly increased or even consider-
ably diminished. Owing to an increase in its content of nucleo-
proteids, the bile becomes thick and viscid. In the later stages
of these intoxications, the bile increases in quantity, its composi-
tion varying in different ways. These quantitative and qualitative
changes are produced in part by the destructive action of certain
of these poisons upon the red blood-corpuscles. Yet this is not
the only cause of the biliary changes. The main factor seems
rather to be a stimulation of the liver cells to the production of
an abnormal secretion.
Gail-Stones. — Gall-stones'^^ usually originate in the gall-blad-
der. At times only one stone is found ; more frequently, however,
several or many are present. The numerous calculi so frequently
found in the gall-bladder at autopsy are in many instances all of
about the same size. In other cases, they occur in groups as, for
example, one or two large, ten or twelve medium-sized and fifty
or more tiny stones. Such have been termed generations of gall-
stones. The explanation for this grouping of stones seems to be
that during some pathological process in the past several nuclei
originated, and that when once started the stones tended to act
as centres about which the bile constituents were deposited. This
continued until some change in the conditions in the bladder
allowed a fresh set of stones to start.
262 THE BASIS OF SYMPTOMS
Gall-stones are composed, for the most part, of chol-
esterin and of the calcium salt of bilirubin. Both
these substances usually enter into the composition of the stone,
but some stones are formed entirely of one or the other of
them. Other materials which may be present in biliary calculi
are calcium carbonate, salts of the heavy metals, pure bile pig-
ments and derivatives of these pigments.
The calcium salts probably arise, for the most part, from the
epithelial cells of the biliary passages, their amount being inde-
pendent of the diet. This is true also of the cholesterin, which
is dissolved in the bile through the agency of cholates, soaps and
fats. These solvents may hold far greater amounts of cholesterin
in solution than ever occur in the bile.
Under certain conditions, nevertheless, bile preserved
aseptically may spontaneously precipitate
cholesterin crystals. It is possible that desquamated
epithelium favors this process. There is no difficulty, therefore,
in understanding how cholesterin stones may arise if conditions,
such as tight-lacing, pregnancy, etc., are present, which predispose
to the stasis of bile. According to Aschoff the cholesterin stone
showing radiating lines is the result of a sterile breaking up of
bile. This concrement usually occurs singly, grows slowly and
has an uneven surface corresponding to veins of crystallization
of varying length. Its chemical structure speaks for a normal
bile, not for one changed by inflammatory processes. A 1 1
other types of stone — and these comprise the majority —
arise on an infectious basis.
The normal bile of a healthy individual is generally
sterile, despite the free communication between the biliary
and intestinal tracts."^* This is to be attributed to the constant
movement of the bile which sweeps before it all alien bodies, even
micro-organisms which have been artificially introduced.^'^ Liga-
tion of the common duct, however, and the consequent bile stag-
nation, permit of a ready growth of bacteria. Indeed, in animal
experiment, the mere ligation of the duct will cause infection of the
bile. In this case, the micro-organisms probably enter the biliary
tract from the intestines, despite the ligature.
In certain infections, notably typhoid fever and
pneumonia, the bile frequently contains micro-organisms.'^*
It is probable that in the case of the colon bacillus, infection has
DIGESTION 263
occurred via the bowel ; while with the typhoid bacillus, particu-
larly, the source is hsematogenous. French observers pointed out
many years ago the frequency of cholangitis and cholecystitis as
sequelae of typhoid and paratyphoid infections, and to this we
fully subscribe.
The bacterial infection produces an inflam-
mation of the mucous membrane and a desqua-
mation of its epithelial cells. These latter contain
undissolved cholesterin. They likewise contain calcium salts, and
these probably react to form the insoluble calcium salt of bili-
rubin. From this salt, as well as from the amorphous cholesterin
in the cells, the biliary calculus takes its origin. Its further growth
is carried on by the deposition and recrystallization of new mate-
rial, especially of cholesterin.
Several facts favor the view that gall-stones result from in-
fectious catarrhs of the biliary passages. Thus, bacteria may be
recovered from the centres of gall-stones, although this is possible
only in the minority of cases. Gall-stones have also been produced
experimentally by causing biliary stasis and by infecting the bile-
passages with bacteria of low virulence.'''^ As we have already
stated, groups of stones in a gall-bladder are frequently of about
the same size and presumably of the same age, and it may be in-
ferred that they have all originated at about the same time from
a common cause. Infection of the bile-passages is by no means an
infrequent event after certain infectious diseases, especially after
typhoid fever, and it is quite conceivable that this furnished the
common cause for the formation of a number of stones, and that
afterwards the bacteria died out of the bile and no new stones
were formed. In other cases, typhoid bacilli live for years in the
gall-bladder and pass thence at periods into the intestines, to leave
the body along with the faeces. Here the conditions for a con-
tinued new formation of stones are present.
Cholelithiasis frequently produces no symptoms; and
especially is this so when the calculi lie quietly in the gall-bladder
without occluding any of the ducts. Gall-stones may, however,
give rise to severe pains, as well as to inflammations, peritoneal
adhesions, perforations and septic infections of the liver. All of
these evil consequences are initiated by an inflammation of the
gall-bladder containing the stones. Riedel believes that this in-
flammation may be induced merely by the presence of the stone,
264 THE BASIS OF SYMPTOMS
which acts as a foreign body, but that in some cases, at least, it is
started by a traumatism. The cystic duct is then likely to become
occluded either by the extension of the inflammation to its mucous
membrane or by the lodgement of a stone within it. Hydrops
of the gall-bladder ensues. Its original contents of bile
become modified by interchange with the lymphatic fluids. The
chelates early disappear, the pigments follow them, and finally a
clear fluid is left, which contains salts, cholesterin, nucleo-albumin
and characteristic proteids. If bacteria are present they may cause
suppuration. The inflamed wall of the gall-bladder may ulcerate,
it may become adherent to surrounding structures or it may per-
forate. Not infrequently the stone passes through the cystic duct
and occludes the common duct. It may then produce a variety
of inflammatory processes in the liver, the peritoneum, the stomach
and the intestines.
The stagnation of bile and the injury to the walls of the
biliary passages — ^both common results of gall-stones — greatly
favor the development of secondary infections, both enterogenous
and hsematogenous, via the portal vein. The obstruction caused
by the stones is conducive to the multiplication of bacteria which
have thus entered the bile, and inflammatory processes of all kinds
result.
Carcinoma t a sometimes complicate gall-stones, and in
such cases it is supposed that they are caused by the irritation
of the mucous membrane. Indeed, carcinoma of the bile-passages
arises almost exclusively on the basis of cholelithiasis.
Biliary colic is the most feared manifestation of gall-stones.
It is characterized by attacks of violent pain in the region of the
liver and is usually accompanied by vomiting and fever and some-
times by jaundice. The paroxysm may last for hours or days.
The colicky pains are caused by the inflammation and distention of
the tract and by the spasmodic contractions of the muscle in the
gall-bladder and ducts. In a certain number of cases the attack
is precipitated by the passage of a small stone from a wide into
a narrow passage, as happens at the exit from the gall-bladder, or
just before the entrance into the duodenum. Yet such is not
always the case. A gall-bladder which contains large stones, and
which is isolated by an old occlusion of its duct, is not infrequently
the seat of colic. Indeed, colic may come from a gall-
bladder which contains no stones and which is
DIGESTION 265
merely shrunken and surrounded by adhesions. The immediate
cause of the paroxysm of biHary colic, not only in these excej)-
tional cases, but possibly in all, is an inflammation of the bile-
passages. This may either drive the stone into a narrower portion
of the duct, or it may cause the mucous membrane to swell about
the stone, thus occluding the passage. The fever and jaundice
that so often accompany biliary colic will be discussed in another
place (p. 266),
The Exclusion of Bile from the Intestines. — The bile may be
excluded from the intestines by gall-stones lodged in the
common or hepatic ducts, by tumors growing within them
or pressing upon them from without, or finally by catarrhal
inflammations which cause a swelling of the mucous mem-
brane, and so occlude the narrower portions of the passages,
especially the exit of the common duct at the papilla of Vater and
the smaller bile capillaries within the liver.
The effect of an occlusion of the common
duct varies with the site of the obstruction. If the latter be
seated high up, bile alone is excluded from the intestines ; whereas,
if it be at the papilla of Vater, the pancreatic juice may also in
part or altogether be shut off. Experiments upon dogs have
shown that when no bile can enter the intestines the diges-
tion and absorption of proteids and carbohy-
drates proceeds approximately in a normal manner, whereas
the absorption of fats is seriously interfered with; only
about forty per cent, of the fat taken in the food being absorbed,
as compared with the normal of ninety per cent. Fr. Muller^^
has shown that the same relations hold good for man. If bile be
excluded from the intestines, the absorption of carbohydrates is
not affected and the absorption of proteids is only slightly les-
sened; while, on the other hand, from sixty to eighty per cent, of
the fat taken in the food escapes absorption as compared with
the normal of from seven to eleven per cent. The "clay
color" of the stools in these cases is caused partly by
the absence of bile pigments and partly by the presence of ex-
cessive quantities of fat. It is difficult to explain the cause of
this diminished absorption of fat on the theory that the latter
is taken up from the lumen of the intestines as fine particles. If,
however, we assume that it is absorbed in a state of solution after
having undergone hydrolytic cleavage,®^ then the important role
266 THE BASIS OF SYMPTOMS
played by the bile might in part be explained by the fact that
the chelates are capable of holding large quantities of fatty acids
in solution.®^
(Hewlett®^ has shown that the bile may assist the digestion
and absorption of fats in other ways. In the first place, the emulsi-
fication of fats is favored by the presence of bile; and in the
second, the bile accelerates the fat-splitting action of the pancreatic
juice eightfold and even more. There appears, therefore, to be a
sufficient physiological explanation for the effect which follows an
exclusion of the bile from the intestines. — Ed. )
Even though the bile be excluded from the intestinal tract,
it is possible to maintain nutrition by paying sufficient attention
to the diet, which should, under these circum-
stances, consist mainly of proteids and carbo-
hydrates. If the food contains much fat, the latter under-
goes excessive cleavage through the action of the pancreatic juice
and of the intestinal bacteria. The products of this decomposition
irritate the intestinal mucous membrane and may lead to dis-
turbances of its functions. For this reason the administration of
fats to patients with biliary obstruction is not only useless but
frequently injurious. We are not yet certain what effect the
absence of bile exerts upon the bacterial decomposi-
tions which normally take place in the intestines. The putre-
faction of proteids^* has been found to be increased in some
instances, while in others it has been diminished. It is very
doubtful if the bile exerts any antiseptic action upon the growth
of micro-organisms in the intestines, for Strasburger^^ found
no increase, and even a diminution, in the number of bacteria
in the faeces in cases of complete biliary obstruction. Possibly,
however, the absence of bile allows the intestinal decompositions
to pursue an abnormal course.
Jaundice. — If the lumen of the common duct be obstructed,
and if the liver cells continue to secrete bile, the gall-bladder and
the bile-passages become filled with the secretion, the pressure
of the bile within them increases, the liver cells are forced apart,
and the bile is absorbed into the lymphatic system or directly into
the blood.^* It thus enters the general circulation and permeates
all the organs of the body. The liver cells may, indeed, resecrete
some of the constituents out of the blood ; yet this has little effect,
DIGESTION 267
for, the passage into the intestines being obstructed, these con-
stituents are again reabsorbed.
In jaundice, the bile pigments are deposited in various tissues,
and the skin assumes a color which varies from a light yellow
to a dark green or brown. Whether these different shades are
due to a blending of varying amounts of bile pigments with the
color of the skin, or whether they arise from a conversion of
bilirubin into other pigments, has not been decided. The jaundice
may be visible within a few hours after the obstruction has taken
place, though usually it does not appear for from one to three
days. The retained bile pigments are excreted by the kidneys
and by the sweat-glands ; but they do not, as a rule, appear in the
tears, the saliva or the gastric juice.
Of the constituents of the bile which pass into the lymph and
the blood, the bile salts are of especial interest on account
of their known toxic properties. During the first few days of
jaundice they can frequently be detected in the urine, but in the
later stages they are usually absent. Concerning the quantitative
relations of other constituents of the bile — to what extent they
are formed, to what extent eliminated in the various secretions,
and to what degree destroyed in the body — we know but little.
Jaundice may arise not only from an obstruction to the flow
of bile through the larger passages, but from obstructions
located in the smaller biliary capillaries. These
produce the jaundice which may accompany various diseases of
the liver, such as cirrhosis, carcinoma, cholangitis and calculi of
the finer ducts. The "biliary thrombi" described by
Eppinger are a fruitful cause of such obstructions. The develop-
ment of jaundice is dependent less upon the nature of the disease
than upon its location, the essential factor being an obstruction to
the exit of bile. The jaundice that so frequently accompanies
gall-stones may be due to the lodgement of a stone in the common
or hepatic ducts, or to an associated inflammation of the mucous
membrane. According to Riedel, the latter is the more common.^^
Closure of the cystic duct does not ordinarily cause jaundice.
The resorption of the stagnating bile is influenced not only
by the degree of mechanical obstruction, but also by the consis-
tency of the secretion. A thick viscid bile, rich in pigments, may
be reabsorbed even when the obstruction is a comparatively slight
one, such as might be caused, for example, by a catarrh of the
268 THE BASIS OF SYMPTOMS
bile-passages, by a biliary thrombus or by the swelling of liver
cells which have undergone fatty degeneration. The icterus
of phosphorous and of toluy lendiamin poison-
ings is usually produced in this manner ,^^ as is that which
may accompany snake-bites, pneumonia, pyaemia,
septicaemia and various other intoxications and
infections. In none of these can a marked obstruction to
the outflow of bile be demonstrated. This fact gave rise to the
theory that the jaundice in such cases does not depend upon the
changes in the liver, but upon the formation of biliary pigments
in other parts of the body. It is, indeed, possible for bilirubin
to be formed outside of the liver, for this happens in old blood-
clots ; yet the amount thus formed is very small and never produces
jaundice. Indeed, we may say that, so far as we know, jaun-
dice is always of hepatic origin, and that we have no
proof that a haematogenous type can occur.
Conditions are particularly favorable for the resorption of
bile when the biliary capillaries are narrowed by catarrh. Thrombi
in the bile-passages, upon which Eppinger has laid emphasis, are
especially prone to occur when the composition of the bile is
altered by abnormal conditions of secretion. Such an alteration
is frequent ; indeed, even fibrinogen may appear in the bile-ducts.
The occurrence of these thrombi may well explain, on a mechanical
basis, some of those difficult cases of icterus — in phosphorous
poisoning, haemolytic conditions and in the infectious diseases —
which give no evidence of a gross obstruction to the flow of the
bile. It must be admitted, however,' that this conception of a
mechanical obstruction is in some cases based upon purely hypo-
thetical considerations. The question here resolves itself into a
study of the conditions under which the liver cells might pour their
secretions directly into the blood or lymphatic systems, rather than
into the bile capillaries.*^ A better understanding of the part
the parenchyma cells play in these processes would possibly throw
considerable light upon this vexed problem.
The etiology of the so-called catarrhal ictenis is but little
understood. The view formerly held was that of Virchow, who
looked upon the duodenal catarrh with an occlusion of the papilla
of Vater by a mucus plug as the underlying cause. But the
observation of Eppinger ®° — the occlusion of the common duct
as a result of the swelling of its lymphoid tissues — shows what
DIGESTION 269
variable factors may be present. My clinical experience has led
me to believe more and more that this form of jaundice is gener-
ally due to changes in the liver cells, rather than in the bile-
passages, in other words that we have to do with ahepatitis.
The cause of icterus neonatorum which occurs in about sixty
per cent, of all new-born children is not well understood.^^ This
much is certain, that it results from the resorption of bile ; for not
only the pigments, but the bile salts as well, are found in the
various body fluids. It seems probable also that icterus neona-
torum is associated with a destruction of the red
blood-corpuscles, for it is especially apt to develop in
those infants who have had the cord tied late and who have re-
ceived, therefore, a larger amount of blood from the placenta.
We know that jaundice frequently accompanies an increased de-
struction of red blood-corpuscles, as happens in paroxysmal
hsemoglobinuria, but the attempts to produce it experimentally
by the introduction of haemoglobin have hitherto failed. There
seems, therefore, to be some other factor present than the mere
destruction of the erythrocytes. Possibly, as Quincke believed,
the jaundice of the new-born is due to the resorption of
bile from the intestines. This theory receives some
support from the fact that for several days after birth the blood
from the intestines may not go through the liver, but may pass
directly into the general circulation from the portal vein by way
of the ductus venosus. An infectious origin has also
been suggested (Czerny and Keller).
(Considerable attention has lately been devoted to another
form of icterus, the so-called hsemolytic icterus.^ ^ Two types are
recognized, the congenital and the acquired. In both
there is an acholuric jaundice with urobilinuria
and splenomegaly. A striking feature of the congenital
type is the evidence of a diminished resistance of the
erythrocytes to hypotonic salt solutions; while in the
acquired form the fragility of the (unwashed) corpuscles does
not vary greatly from the normal. The blood-picture of the
acquired type may in some cases closely resemble that of per-
nicious anaemia. This form of jaundice is of particular interest
in view of the therapeutic success, reported by many observers,^^
of splenectomy. — Ed.)
Effects of Jaundice. — The obstruction to the flow of bile may
270 THE BASIS OF SYMPTOMS
cut off this secretion from the intestines with the results which
have already been described (p. 266). On the other side, the
liver cells are affected. They become compressed and
separated ; and, though for a time they may continue to perform
their functions normally, nevertheless, after a while, they suffer
both in structure and in function. Areas of necrosis and inflam-
mation may appear. These are due in part to the toxic action of
the bile itself, and, in part, to the infections that are so prone
to appear in stagnating bile. It is impossible to apply the experi-
mental data upon this subject to man, because the various animals
differ so greatly in the effect produced by a stasis of bile upon
the liver.
It is difficult to decide which constituents of the bile produce
each of the varied general symptoms of jaundice. The cholates
seem to be the most toxic in their action, although recently atten-
tion has been directed to the poisonous properties of the biliary
pigments.** The itching of the skin so frequently pres-
ent is apparently due to the deposit of pigment in the skin. In
the early stages of jaundice the heart's action may be-
come slow and irregular, both in force and frequency, and the
blood-pressure may fall (see p. 60). These symptoms seem to
be due to the action of the bile salts, for even small doses of
sodium cholate stimulate the central endings of the vag^s nerve,
and larger doses act upon the heart itself. The convul-
sions that very rarely occur in the beginning of jaundice are
also possibly due to the action of the bile salts, for the injection
of very large amounts of cholates will produce convulsions. True
cholate intoxication occurs in man only when the obstruction
to the outflow of bile is complete or nearly so, and when the
formation of these salts is not materially interfered with. It
may^ accompany catarrhal jaundice, cholelithiasis and carcino-
matous obstruction. Yet the cholate symptoms are by no means
always present in jaundice, and often they last only a short time;
for the quantity of bile salts in the blood varies enormously and
it is usually small in the later stages of an obstruction.*^ This
is due apparently to the fact that the hepatic cells may lose their
ability more or less to produce the bile salts, as well as to the
constant endeavor on the part of the liver to remove bile salts
from the blood. For these reasons there are frequently no signs
of cholate intoxication even when the jaundice is most profound.
DIGESTION 271
Other Hepatic Toxasmias. — At times serious toxic disturl>
ances develop in the later stages of liver disease, and these may or
may not be accompanied by jaundice. The patient becomes stupor-
ous and delirious, and after a few days of high fever and perhaps
convulsions, death usually closes the scene. The condition resem-
bles the termination of certain other metabolic diseases, such as
the coma of diabetes and the uraemia of nephritis. It is very
improbable that these late toxic symptoms are in any way caused
by a resorption of bile, for, in the first place, the picture differs
from a cholate intoxication in the high fever and in the frequency
of general convulsions; and in the second place, diseases of the
liver may terminate in this manner even though hardly any
jaundice is present, and even though, furthermore, on account of
the extensive destruction of hepatic cells, it is probable that only
very small quantities of the bile salts are manufactured.
A wide-spread degeneration of the liver cells seems to be the
underlying cause of these toxaemias. The hepatic cells are known
to perform very important metabolic functions, such as the storing
of carbohydrates, the formation of urea out of ammonium salts,
the conversion of toxic aromatic compounds into the comparatively
harmless ethereal sulphates, and the disposal of various other
poisons absorbed from the intestines. It may, therefore, be easily
understood how seriously the metabolism might suffer when the
liver is thrown out of function. Possibly the above toxaemias are
caused by poisonous compounds which would normally be ren-
dered non-toxic in the liver. Of great interest in this connection
is the fact that geese will frequently die of convulsions after
extirpation of the liver, if they are fed on a rich nitrogenous
diet.®' The same holds true for dogs if an Eck fistula between
the portal vein and the inferior vena cava permits the blood to
flow from the intestines directly into the general circulation with-
out traversing the liver, under which circumstances the liver cells
gradually degenerate. Certain symptoms presented by these ani-
mals would seem to be due to the action of the carbamic acid. If
ammonium carbamate be injected into the portal blood of normal
animals, it is converted into urea in the liver. In animals from
which the liver has been extirpated or thrown out of function this
does not occur, and in them the carbamic compounds would be free
to produce toxic symptoms.
The toxaemia associated with extensive hepatic disease may
272 THE BASIS OF SYMPTOMS
also possibly be due to the formation of poisonous compounds
from the disintegrating liver cells. Finally, some of these intoxi-
cations are undoubtedly of infectious origin, as is probably the
case in acute yellow atrophy and in the not infrequent infections
of the biliary passages which follow chronic obstruction.
Considerable attention has been given in recent years to the
factors governing the appearance of urobilin (hydrobilirubin)
and its forerunner, urobilinogen, in the urine and in
the fseces.^''^ Urobilinogen is derived from bilirubin by the reduc-
ing action of the intestinal flora. In man, urobilinogen and urobilin
are formed exclusively — or at least predominantly — in the intes-
tinal tract; whether they may arise in the liver also, as in dogs,
is not improbable, though not confirmed. From the intestines,
hydrobilirubin passes into the circulation and is excreted in part
by the kidneys as urobilin. Normally, then, urobilin and uro-
bilinogen occur in the urine, but in negligibly small amounts. The
greater part of the urobilin thus absorbed from the intestines is
returned to the liver, and passing once more into the bile, again
reaches the bowel.
In many hepatic disorders, this intermediate urobilin
circulation is disturbed. The urobilin returning to the
injured liver cells is no longer excreted by them into the bile,
but is thrown into the lymph and blood and is then excreted
by the kidneys in large amount. Urobilinuria may, therefore, be
regarded as the best and most constant clinical index of a dis-
turbed liver function. (Unlike alimentary galactosuria, however,
it is not significant of particular hepatic derangements — cirrhoses,
catarrhal icterus — ^but may occur in any condition deleteriously
affecting the liver function, e.g., cirrhosis, passive hyperaemia,
malignancy and even parenchymatous degeneration accompanying
the acute infections ( Bauer ).^®
It is evident from what has been said concerning the forma-
tion and circulation of urobilin, that in complete closure
of the common duct, no urobilin can be formed
because no bilirubin reaches the bowel. In these
cases, the absence of the former in the urine and faeces speaks
for a complete, as against an incomplete, occlusion of the duct.
The same is true in practically every respect of urobilinogen,
which is readily oxidized into urobilin by a brief exposure to light
and air and is, therefore, not so accessible to study, In hepatic
DIGESTION 278
insufficiency — when the common duct is patent — it may be demon-
strated in freshly voided urine by the Ehrlich aldehyde
reaction or by means of the spectroscope. — Ed. )
The Pancreatic Juice
The complete exclusion of the pancreatic juice from the intes-
tines without a concomitant exclusion of bile is extremely rare,
for the gland usually possesses two functioning ducts.^^ A clos-
ure of both of these is uncommon; and a total degeneration of
the secreting glandular parenchyma is likewise very exceptional.
By far the most frequent site of a pancreatic obstruction is the
papilla of Vater, and here not only the duct of Wirsung, but
the common bile-duct would be closed. One can never be certain
to what extent the pancreatic juice is diminished when the duct
of Wirsung alone is occluded, because the secretion still finds an
exit via the duct of Santorini.
For these reasons we are insufficiently acquainted with the
results of a simple exclusion of the pancreatic juice
from the intestines. F. Miiller ^°^ studied the faeces of
several patients who had extensive pancreatic degeneration, and
found that the absorption of carbohydrates in the
digestive tract was not at all affected by the disease, that the
absorption of the proteids was only slightly affected,
and that the total quantity of fats absorbed was like-
wise not far from the normal. The cleavage of fats in
the intestines, however, was considerably diminished; for,
of the fat in the faeces, only forty per cent, was found to be
split into fatty acids and soaps, as against the normal of about
eighty-four per cent. These figures correspond well with those
obtained in animals with ligated ducts. (Other observers, how-
ever, have come to different conclusions both as to amount of fat
absorbed from the intestines in pancreatic disease and as to the
extent of cleavage. The variations in observations relative to
cleavage are due probably to differences in the type of fat in-
gested— whether emulsified or not — and to individual differences
in the fat-splitting jx)wer of the stomach.^^^ — Ed.) Miiller's
results, too, would be more significant, had he been able to make
more extended observations on the amount of fat utilized, par-
ticularly when larger amounts of fatty food were ingested.
(A greater part of the pancreas may be rendered functionless,
18
274 THE BASIS OF SYMPTOMS
experimentally, or by such conditions as extensive cirrhosis, car-
cinoma, softening or even by an apparently complete closure of
the main excretory duct by stones, without the appearance of
digestive anomalies. This is due in all probability to the
vicarious action of the succus entericus, the
bile and the gastric juice, and to the patency of
the accessory pancreatic duct. But when the loss of
function is complete, certain changes in the faeces manifest them-
selves which have a practical value in diagnosis. Thus, char-
acteristic of severe pancreatic lesions are large
fatty stools — not acholic, however, as in complete biliary
obstruction; further, the predominance, as a rule, of neutral
fat in these stools; the presence of large amounts of undi-
gested muscle fibres, only about one-half of the ingested
proteid being utilized ; the persistence of the nuclei in
muscle fibres taken in the food, the gastric juice not hav-
ing the power to digest nuclei; and finally, the evidence of
putrefaction and sometimes of f ermentation.^^^ —
Ed.)
The experimental studies of Abelmann have demonstrated the
serious impairment of absorption which follows
the extirpation of the pancreas of animals.
About fifty-six per cent, of the ingested proteids, twenty to forty
per cent, of the carbohydrates and all of the non-emulsified fats
appeared in the faeces. Of the latter, from thirty to eighty-five
per cent, had undergone cleavage into fatty acids and soaps. If
the fat were introduced in the form of a natural emulsion, such
as milk, a considerably larger proportion — about thirty to fifty
per cent. — was absorbed by the intestines. Other experimenters
have obtained quite different results ;^®^ in many cases the fat
was not absorbed at all, and in others up to eighty per cent, was
absorbed. It seems to me that the results of these experiments
cannot be applied directly to human pathology, for extirpation of
the pancreas is attended with considerable shock to the animal
and we have no data as to how the secretion of bile is influenced
by these operations. Furthermore, the internal secretion of the
pancreas plays a significant part in these processes, particularly in
that of fat absorption. Possibly the entire resorptive power of the
intestinal mucosa is regulated by this secretion ^^^ (see chap. VII ) .
Fat Necroses. — Attention must be directed further to a severe
DIGESTION 275
picture which may result from the extravasation of pancreatic
juice into the peritoneal cavity. This may be due to trauma;
while in other cases there is no evidence of injury, but instead a
back flow of bile into the duct of Wirsung, such as occurs, for
example, when the papilla of Vater is blocked by a stone. The
pancreatic juice activated by the bile or intestinal secretions causes
an auto-digestion and necrosis of the gland, and leads to a de-
struction of the fatty tissue, not only about the pancreas, but
often in the entire abdominal cavity and even in the pleural
cavities. This condition was first described by Balser^^° under
the name of fat necrosis.
The fat in the neighborhood of the pancreas assumes a peculiar
light, opaque appearance due to its decomposition into free fatty
acids and fatty acid salts, particularly those of calcium. ^°® These
necrobiotic changes lead in turn to a melting away of the tissue,
and to the formation of abscess-cavities which are filled with
necrotic material.
' Fat necroses may be produced experiment-
ally by plugging the pancreatic arteries, by the injection of
oil, bile or intestinal juice into the pancreatic ducts, by the intro-
duction of activated trypsin into the ducts, by the implantation of
a normal pancreas into the abdominal cavity of a healthy animal
and finally by allowing the pancreatic duct to pour its contents
into the free abdominal cavity. Both the necroses and fatal out-
come in the implantation experiments may be prevented, however,
by a preliminary immunization of the animal with trypsin.^*'^
The clinical picture in animal experiments involves complex
factors. Fischler^^® showed the important role of the liver in
these particulars. Animals with an Eck fistula, for example, are
extremely sensitive to lesions of the pancreas ; a mere handling of,
or pulling upon, the gland, which ordinarily have the effect of
producing only slight areas of necroses, and are borne with
impunity by a healthy animal, cause in those with the fistula
a severe set of disturbances. A very characteristic central
necrosis of the liver lobules occurs coincident with the appearance
of the lime salts of the fatty acids in the liver cells. The animal
dies in twelve to thirty-six hours with severe nervous manifes-
tations. On the other hand, if there has been a previous immu-
nization with trypsin, these liver changes do not appear and the
276 THE BASIS OF SYMPTOMS
animal survives. This is further evidence of the chemical rela-
tionship existing between the liver and the pancreas.
The clinical manifestations are variously explained on the basis
of an intoxication with trypsin, with the substances arising in the
necrosis of the pancreas, with soaps and with the split-products
of the ferments set free in the process. ^^®
The Processes in the Intestines
The Effect of Poisons Upon the Intestines. — ^The intestines
may be injured by various substances, such as the fatty acids,
the metallic salts, aromatic compounds, etc. Many of these are
used therapeutically, while others may be taken in the food. It
is not easy to separate those which are toxic from those which are
not, for the susceptibility of different individuals varies enor-
mously in this respect. Even such a marked poison as arsenious
acid, which in most men causes a violent enteritis, may become
comparatively harmless through habituation ; and quantities may
then be borne which would ordinarily be almost immediately
fatal.
Toxic substances may be elaborated outside the body by the
action of bacteria. These include the so-called ptomains,^^"
many of which, such as neurin, mydalein and mytilotoxin, are
extremely poisonous. Since such compounds are formed only
in the later stages of putrefaction, an intoxication from this source
is most apt to follow the ingestion of decomposed food. Specific
toxins, formed by specific bacteria, e.g., the anaerobic ba-
cillus botulinus, may also be introduced with the food.
Some of these poisonous substances injure the wall of the intes-
tines, producing anatomical and functional disturbances, while
others are absorbed and produce more general symptoms. It is
often difficult to determine whether a certain intoxication resulted
from poisons introduced with the food, or whether it arose from
toxins which were produced within the intestines by the abnormal
action of bacteria; yet in some instances the former is by far the
more probable, for the symptoms appear almost immediately after
the ingestion of the decomposed food. The same is also true
when the intoxication is caused by material which has been cooked,
such as meat, fish, sausage, oysters and eggs, for it is then very
improbable that any living organisms other than spores were
introduced.
DIGESTION 277
Abnormal Bacterial Processes within the Gastro-Intestinal
Tract. — Numerous bacteria are regularly carried into the stomach
with the food. A portion of these are there destroyed, some are
reduced in virulence, and a part pass on but slightly injured into
the duodenum. Of these, some decompose the carbohydrates and
split the fats, thus producing organic acids, such as acetic, lactic
and succinic acids, even in the small intestines. In the lower
ileum, and especially in the colon, the bacterial decompositions
normally become more marked, and here the putrefaction of the
proteids is a normal process.
The number of bacteria in the human intes-
tines varies greatly. ^^^ The dried faeces of a healthy man are
made up of one-eighth to one- fourth, by weight, of bacteria. Yet
the upper small intestines in fasting animals, at least, are almost
free from micro-organisms, which would seem to indicate that
they regulate their bacterial flora to a marked degree. ^^^
Certain factors apparently inhibit bacterial
growth in the small intestines. As we have seen,
the hydrochloric acid of the stomach diminishes the number of
bacteria present in the food, and it is probable that the bile acids,
the fatty acids produced by cleavage of the fats, and the intestinal
secretions exert a certain antiseptic action in the upper intestines.
The living epithelium itself possesses bactericidal power ; while,
according to certain observers, the feebly bactericidal succus en-
tericus is rendered more potent, in vitro at least, by the pancreatic
juice. Of greater importance, however, is the rapid tran-
sit of material through the duodenum and
ileum, for the few hours that food remains there do not
allow sufficient time for the bacteria to multiply. Fortunately,
in the large intestines, where the transit is slower and where the
bacterial action is most marked, the greater portion of nutritive
material has already been absorbed, and the bacteria find less to
decompose.
Another protection against the growth of strange bacteria
in the intestines is the inhibitory action which the
normal flora seems to exert upon the growth of
outsiders. ^^^ For this reason, the normal flora of the in-
testines is probably very useful. Whether it is absolutely neces-
sary or not, is a question that has received different, though not
irreconcilable, answers from different investigators.^^* Guinea-
878 THE BASIS OF SYMPTOMS
pigs may be reared upon sterilized milk ; whereas chickens do not
thrive on bacteria-free food — an observation which would appear
to supi>ort the view that the presence of micro-organisms in the
gastro-intestinal tract is necessary during extrafetal life. In
man, at least, the intestinal bacteria are important in the digestion
of cellulose, upon which the ordinary enzymes do not act.
Whatever the importance may be of the intestinal flora in the
digestion and absorption of food, it is probable that these micro-
organisms are of great, perhaps vital, significance as protective
forces against the invasion of alien bacteria. To this we have
already referred (p. 156).
The kind of micro-organisms in the intes-
tines depends partly upon the food taken, and partly upon
the condition under which the individual lives.* *^ The intestinal
contents of a new-born infant are sterile, but after birth they
quickly become infected, and at the end of the fourth day a fully
developed intestinal flora is present. The latter varies with the
kind of food used — whether mother's or cow's milk — and further
with each change in the food in later life. Upon this phenomenon
are based the attempts that have been made to expel certain flora
from the bowel by altering the diet.**^
So long as the epithelium remains intact and healthy, the body
is fairly well protected from invasion by the bacteria which hap-
pens to be present in the intestines.*" The epithelial cells form
a protective bulkhead, their antibacterial action being attributed
by some authors to their content of nucleinic acid and its com-
binations, substances which are acid in reaction and will cause a
precipitation of proteids.**^ Yet the protection afforded to the
body by the intestinal mucosa is not an absolute one. Apparently
the tubercle bacillus may penetrate the intact mucous membrane,
and slight lesions will certainly render the epithelium permeable
to many bacteria.**®
The soluble products of bacterial action frequently pass
through the normal mucosa and in so doing they may possibly
render an important service to the individual by immunizing him
against the action of the bacteria from which they are derived.
These toxins, which are of a proteid nature, may in many cases
be digested in the intestines, just as are other proteids; yet it
would appear that this does not occur in the intestines of in-
DIGESTION «70
f ants.* ^ Antitoxins penetrate the epithelium only when dissolved
in homologous milk.*^*
Many intestinal diseases, perhaps the majority of
them, are due to abnormal bacterial action within
the intestines. The bacteria ordinarily present may in-
crease in number or in virulence, or bacteria that are not usually
present may give rise to pathological changes. Such foreign
micro-organisms must, of course, be introduced from without;
thus it is manifestly impossible, for example, to acquire cholera
at a time when no cholera bacilli are about. Yet it is often
extremely difficult to be certain of the absence of pathogenic
germs in a certain locality, for individuals, not themselves ill,
may harbor and distribute virulent bacilli {e.g., from chronic
typhoid infections of the bile-passages or urinary bladder). The
mere introduction of pathogenic bacteria does not necessarily do
any harm; for just as large numbers of harmless bacteria daily
enter the gastro-intestinal canal and there disappear, so may
pathogenic organisms be destroyed without their producing any
ill effect. They succumb to the various protective agencies in
the stomach and intestines that have already been described. In
some cases, however, the bacteria introduced are so numerous
or so virulent that they cause the disease in practically every indi-
vidual in whom they enter, as is illustrated by the fact that every
person who has partaken of a particular dish may become ill.
Possibly, aggressin-like bodies are present in an infected food.
It is often impossible to say in what manner the infection
has taken place, whether it is by overcoming the normal inhabitants
of the intestines, or by causing a lesion of the mucosa, etc. Appar-
ently different factors enter into consideration in different infec-
tions. We know, for example, that the cholera vibrio is extremely
sensitive to the acid reaction of the gastric juice; and clinical
experience has shown that the disease is especially apt to attack
individuals who have presumably a lessened gastric acidity, caused
either by some slight digestive disturbance or by great fear of
contracting the disease.
Intestinal indigestion is apt to be produced
in some individuals by certain articles of diet,
and it is quite possible that these articles allow the bacteria nor-
mally present in the intestines to proliferate with abnormal rapid-
ity, or that they reduce the resistance which the flora of the intes-
280 THE BASIS OF SYMPTOMS
tines normally exerts against foreign invaders. In some cases,
however, they cause the indigestion by directly influencing the
secretions poured into the intestinal canal. The first of these
possibilities seems to be exemplified in the case of infants, for
in them some very slight qualitative or quantitative change in the
food may induce a dangerous proliferation of bacteria, quite
independently of the bacterial contents of the food ingested.
The evidence would indicate that this applies also to adults. ^^^
A severe colitis, for example, may be caused to disappear by the
giving of proteids in place of carbohydrates. In my opinion,
abnormal bacterial activity occupies the foreground even in diges-
tive disturbances produced by errors of diet.
On the other hand, the abnormal bacterial growth may follow
changes in the secretory or motor functions of the intestines. The
normal emptying of the faeces is one of the most important means
by which abnormal bacterial growths are limited; and changes in
the secretions are perhaps of equal importance.
How frequently the normal inhabitants of the intestinal tract
produce disease has not yet been fully determined. It is certain
that they may give rise to a peritonitis when the bowel ruptures
or when its wall becomes abnormally permeable, as happens in
strangulation. Local infections may take place when the intes-
tinal wall is injured, and this is the probable cause of many cases
of colon bacillus cystitis. Beyond this we know little about such
enterogenous auto-infections. (Generalized infections with the
colon bacillus have, however, been frequently demonstrated by
blood-cultures. — Ed.) Possibly some of the infantile diarrhoeas
are caused by a change in virulence in the normal intestinal flora.
(The factors concerned in the causation of infantile diarrhcEas
seem to be considerably more complex than was at first supposed,
and have recently received a great deal of attention. A dysentery
bacillus similar in many ways to the Shiga organism has been iso-
lated in a large number of cases.^^^ In others, the colon bacillus,
the bacterium lactis aerogenes and the ordinary pyogenic cocci
seem to have played a prominent part, either alone or associated
with the dysentery bacillus. It is possible that the bacterial role
has been overestimated and that other conditions, such as an
increased permeability of the intestinal wall, allowing an aug-
mented absorption of toxic materials, bacterial or metabolic, are
also of great moment. Such an increased absorptive tendency,
DIGESTION 281
it would seem, may be caused by the intense summer
heat.i24_ED)
An abnormal growth of bacteria in the intes-
tinesmayharmthebodyinseveralways. Either the
poisons formed may be absorbed and cause a general toxaemia,
or they may act directly upon the mucosa itself and so interfere
with its functions. Frequently the mucosa undergoes anatomical
alterations, such as degenerations of the epithelium, inflammations
and ulcerations. These latter are important, for when they occur,
the barriers to invasion are let down and bacteria may penetrate
the mucosa and cause a general infection.
Various toxic compounds result from bacterial decompositions
in the bowel. Of these, some, such as lactic acid, butyric acid
and acetic acid, have already been mentioned in speaking of the
abnormal fermentative processes in the stomach. These acids
are regularly produced in the small intestines; but under patho-
logical conditions, the quantity so formed may be enormously
increased. They irritate the intestines, increase the peristaltic
movements and may cause lesions of the epithelium. This is
particularly the case in infants because of the greater suscepti-
bility to injury of their intestinal lining. Gases, such as hydro-
gen, carbon dioxide and methane, likewise may be produced in
excessive quantity and cause tympanites and intestinal colic.
An excessive proteid decomposition in the
intestines gives rise to all the various products of putrefaction,
among them indol, skatol, phenol and other compounds belonging
to the aromatic series of compounds. Many of these
are rendered non-toxic after absorption, through combination
with sulphuric acid, glycocoll, glycuronic acid, etc. These com-
binations apparently take place in the liver, ^^^ and the com-
pounds thus produced are excreted by the kidneys. These aro-
matic bodies are normally formed almost exclusively in the large
intestines. Their amount depends upon a variety of factors,
of which the most important are the quantity of material in the
chyme that can undergo putrefaction, the amount of substances
present which will exert an antiseptic action, the varieties of
bacteria present and the rapidity with which the material passes
through the intestines.
(Our best index of the amount of putrefaction
which is taking place in the intestines is the quantitative deter-
282 THE BASIS OF SYMPTOMS
mination of the ethereal or aromatic sulphates in
the urine; ^^® for, as has been said, the aromatic products
of putrefaction are largely eliminated as such sulphates, when
once they have been absorbed from the intestines; while the
quantity of these substances arising in the metabolic processes is
negligible. An increased output of these bodies in the urine speaks
particularly for intestinal stasis. Ordinary constipation is often
associated with a more or less marked increase, and intestinal
obstruction is regularly associated with the elimination of large
quantities of ethereal sulphates in the urine.
We do not know how serious the absorption of these aromatic
bodies from the intestines is. Indol, when administered by mouth,
is only moderately toxic, and individuals vary considerably in their
susceptibility to its action. Small doses are liable to produce
frontal headaches and a condition of nervous irritability and rest-
lessness ; larger doses may cause diarrhoea, or marked irritability,
insomnia and mental restlessness. The continued administration
of enough indol to cause a constant and decided reaction
for indican in the urine is capable of inducing neuras-
thenic symptoms. It is very probable, therefore, that the
neurasthenia which is so often seen in cases of chronic intestinal
indigestion is in part due to the absorption of the aromatic
products of putrefaction. — Ed.)
It is also possible that the nephritis which so frequently follows
intestinal obstruction is caused by the products of intestinal
decomposition. ^^'^
Many disturbances in the function of the intestines have
been ascribed to the action of protozoa, though their etiological
relationship has been well established for only one disease — en-
demic dysentery.^^^ The virulence of the ameba of dysentery
for cats leaves us in no doubt as to its pathogenicity. Yet not
all cases clinically classified as dysentery are due to the action of
this amoeba.
The Pathology of Absorption. — ^Absorption takes place
throughout the small intestines, being more rapid for organic
substances at least, in the upper than in the lower portion. Ac-
cording to the most trustworthy observations, but little nutritive
material is absorbed by the large intestines.
The manner in which many diseases of the intestines affect
the absorption of food is not fully known. Those circulatory
DIGESTION 283
disturbances that produce a slower blood-current lead to a diminu-
tion in the absorption of fats, but do not affect that of sugars
and proteids.^^^ Fat absorption is also reduced whenever
the lymphatic vessels that drain the intestines are obstructed, as
may happen in tuberculosis of the mesenteric lymph-nodes. The
diseases that affect the intestines only in isolated areas, such
as typhoid fever, have almost no influence upon absorption. On
the other hand, wide-spread diffuse diseases of the mucosa, such
as enteritis and amyloid degeneration, as well as caseation of the
mesenteric lymphatic nodes, will diminish the fat absorption if
they are moderately severe, and will reduce the absorption of all
kinds of food if they are very severe. This loss of material is
caused partly by the changes in the mucosa itself and partly by
the rapid passage of the food through the intestinal tract, though
diarrhoea alone does not necessarily diminish absorption. ^^® On
the whole, our knowledge of this important field is extremely
limited, particularly with respect to disturbances of absorption in
the individual intestinal, and also systemic, disorders. In tuber-
culosis, without bowel involvement, Plesch^^^ has found that the
absorption of all types of food material is reduced by one-half.
In the healthy individual, the greater part of the water in
the food is absorbed in the upper small intestines.^^^ If the
amount of water in the intestinal contents be increased, this may
arise, first, from a diminished absorption of water from the food,
due either to the presence of salts or other bodies which raise the
osmotic tension of the intestinal contents, or to a too rapid passage
of the chyme through the intestines. A rapid transit of material
through the large intestines always diminishes the absorption of
water. Drinking large amounts, on the other hand, frequently has
no effect upon the faeces.
In the second place, an increase in the amount of
water in the faeces may result from excessive secretion.
We know that the stomach secretes water readily, and there is
abundant reason to believe that the intestines may likewise furnish
large quantities of fluid to their contents, either by the process
of transudation or by that of secretion. The most remarkable
example of watery faeces is furnished by the "rice-water"
stools of Asiatic cholera. These contain only a trace
of albumin, an amylolytic enzyme and hardly any salt except
sodium chlorid. Their composition approaches that of the nor-
284 THE BASIS OF SYMPTOMS
mal intestinal secretion, differing from an ordinary inflammatory
exudate in the low proportion of proteids present and in the
amylolytic ferment.^^^ Cohnheim believed, therefore, that the
rice-water stools of cholera were caused by an increase in the
intestinal secretions, rather than by an inflammatory exudation.
Yet later researches have shown that the essential pathological
process in cholera is an intense inflammation of the mucous mem-
brane, so that the question as to the inflammatory or secretory
nature of the fluid still remains unsettled.
(The theory of MacCallum^^^ that saline cathartics
produce a watery stool purely by their stimulation of the intes-
tinal secretions has not been confirmed by the more recent work
of Frankl and of Auer,^^^ who found that these concentrated
salts act principally by virtue of their power to absorb and to
hold water, and that their stimulative effect is of subordinate
importance. They found further that the subcutaneous and intra-
venous injections of the salines do not cause diarrhoea; in concen-
trated solution, indeed, they may cause constipation by inducing
diuresis and loss of water from the blood and tissues. — Ed.)
Disturbances in the Intestinal Movements. — In discussing
this subject, it is necessary to consider separately the small and
the large intestines, for the peristaltic movements in each are
quite different. During a complete fast, rest prevails throughout
the entire gastro-enteric tract, whereas digestion leads to
peristaltic movements of the small intestines.
These consist, in the first place, of progressive waves of
contraction which affect the circular muscle
over a limited area, and which travel forward, tending to
carry the chyme with them. The second form of movement is
produced by a simultaneous contraction of the cir-
cular and longitudinal fibres, and this results in a
twisting of the intestinal coils, which tends to bring different
parts of the chyme into contact with the mucosa. (Meltzer and
Auer ^^° have described a third movement of the small intestines
— the so-called peristaltic rush, which consists of a rapid
peristaltic contraction, following a relaxation of a considera-
ble part of the small bowel — ^which may even pass uninterruptedly
from the duodenum to the ileocsecal valve. Rhythmic
segmentation (Cannon) is another type of movement ob-
served in the small intestines. In cats fed with food containing
DIGESTION 285
bismuth, the Rontgen rays show a rhythmic breaking up of the
food column into small segments, which are then joined together
again. The process occurs at the rate of thirty times a minute
in the cat. This movement serves to mix the contents of the
bowel and not to further their progress, which depends rather upon
an associated peristalsis. Antiperistalsis, finally, may
be observed in cases of obstruction in the small bowel. — Ed.)
According to Holzknecht,"'^ the colon of the healthy in-
dividual exhibits rhythmic propulsive waves, which impel the
faeces onward for a considerable distance and then cease for
several seconds. Three or four such waves serve to drive the
faecal column through the entire large bowel. Other observers,
however, deny the existence of this peristaltic movement. It
would appear, furthermore, that a kind of contraction ring is
situated half-way along the transverse colon, at which point the
formation of the stool begins. Proximal to this ring, the chyme
remains relatively motionless; when it tends to move forward,
it is forced back into the caecum by antiperistaltic
waves. By this means the contents of the large bowel are
thoroughly mixed and absorption is not hurried.
Ziilzer ^^^ has described substances which arise in the stomach
wall during the process of digestion, and which, if injected into
rabbits, cause a lively peristalsis extending throughout the intes-
tinal tract. This same body — called by him ''peristaltic
hormone' ' — occurs also in other organs, particularly in the
spleen. The physiological significance of this hormone in the
initiation of intestinal peristalsis is not known ; practically, how-
ever, it has proved of value in the treatment of certain cases of
constipation.
Diarrhoea. — Defecation is a partly voluntary, partly reflex act,
which is initiated by the presence of more or less faeces in the
rectum. In many individuals defecation occurs regularly at the
same time each day, while in others it occurs very irregularly.
In diarrhoea, the large intestines fill rapidly and frequently with
fluid contents, and their peristaltic movements are increased.
Added to this is an inhibition of the antiperistaltic waves already
referred to, which normally tend to hold the faeces back until
properly constituted. The small intestines, however, may or may
not be affected. The milder and more transitory diarrhoeas usually
do not involve the small intestines, as may be inferred from the
286 THE BASIS OF SYMPTOMS
character of the faeces. On the other hand, in many conditions,
such as typhoid fever, the small intestines are affected and the
stools contain undecomposed biliary pigments and abnormal quan-
tities of unabsorbed food material. This difference in the be-
havior of the large and small bowel is not well understood. It is
possible that a given stimulus produces a lively peristalsis in the
one and has little or no effect upon the other.
Nervous Diarrhoeas. — The cause of the diarrhoea may lie
outside of the intestines. In many individuals a mere cooling of
the skin or a feeling of nervousness will produce diarrhoea without
necessarily disturbing the general health. A gradual transition
may be seen in such cases from the physiological to the patho-
logical ; in the one, a pronounced stimulus is necessary to produce
any effect, whereas, in the other, a little excitement or even the
fear of a diarrhoea may be enough to bring it on. Such individ-
uals often show other neurasthenic or hysterical
stigmata. It seems probable that their central nervous sys-
tem affects the peristalsis of the intestines through the vagus and
splanchnic nerves. Even normally, the peristaltic movements
are influenced to a certain extent by the central nervous system,
while in these pathological conditions this influence is greatly
exaggerated. In some of these cases, however, the irritability
of the intestines themselves may possibly be increased so that they
respond excessively to normal stimuli.
Diarrhoeas may also accompany anatomical diseases
of the nervous system, as happens, for example, in the
intestinal crises of tabes. It is quite certain that in these cases
the diarrhoeas are dependent upon changes either in the nerves
or in the central nervous system, yet definite proof of this is
wanting. The watery character of the faeces in nervous diar-
rhoeas may be due, in part, to the rapid transit of material through
the intestines, though it seems probable that it is more often
caused by a nervous hypersecretion from the intestinal mucosa,
a condition which would find an analogy in the well-known in-
stances of nervous secretion of saliva, gastric juice and urine.
In hysterical girls, the small intestines are frequently the seat
of increased peristalsis, often giving rise to constant gurgling
sounds, without, however, causing diarrhoea. That these peri-
staltic movements are dependent upon mental influences is sup-
\
DIGESTION 287
ported by the fact that they are most liable to occur at the very
times at which the patient wishes to suppress them.
When the hypersecretion affects the large intestines, the mucus
and proteids in the secretion may form tubular and membranous
casts, which are afterwards passed in the faeces. This disease,
known as colica mucosa (memfbranous colitis), has,
in most instances at least, nothing whatever to do with an in-
flammation of the mucous membrane,^^^ but is a pure secretory
neurosis. It usually occurs in nervous women, and may be accom-
panied by the most violent paroxysms of colic. At times, how-
ever, very similar membranous structures may result from true
inflammatory processes in the intestines, for example, in con-
valescence from typhoid fever.
Diarrhoeas in General Diseases. — Intermediate between these
diarrhoeas of nervous origin and those due to causes situated
within the intestines, is a second group, viz., those that accompany
general diseases. Several possibilities suggest themselves as to
the cause of this class of diarrhoeas. In the first place, the general
disease may so weaken the resistance of the intes-
tinal mucosa that the latter falls a prey to the normal flora
of the intestines or to bacteria which are introduced into the
gastro-intestinal canal, either by mouth, or by the secretions from
the infected body. In the second place, toxins produced by
the general disease may directly cause the diarrhoea, just as do
other poisons. Some infectious diseases, such as pneumonia,
rarely cause diarrhoea ; whereas others, such as measles, frequently
do so. Diarrhoea not infrequently complicates chronic nephritis.
DiarrhcEas of Intestinal Origin. — The third and most import-
ant class of diarrhoeas is that caused by the excessive stimulation
of the intestinal mucosa by the intestinal contents. The materials
which act as stimulants are in the first place coarse, hard
food remnants, especially cellulose, which resist the action
of the intestinal secretions and bacteria. In the second place, and
more commonly, the peristalsis is excited by chemical
irritants, which may either be introduced from without or
be produced within the intestinal canal. Of these, we shall name
only the organic acids and the gases which result from fermen-
tation.^^^ These are of the greatest importance in the production
of many diarrhoeas. Whether or not water alone will in-
crease the peristalsis has not been definitely settled. We know.
288 THE BASIS OF SYMPTOMS
however, that diseases which interfere with the absorption of
water by the small intestines may lead to diarrhcea, as is the case
with amyloid degeneration of the intestines.
Diarrhoea is favored by an increased irritability of the intes-
tinal mucous membrane, muscle or nerves, for normal stimuli
then give rise to excessive responses. Such an increased irrita-
bility of the intestines is probably present in most acute inflam-
mations of the mucous membrane. In acute enteritis,
for example, the diarrhoea is due to the combination of two causes
— increased intestinal irritability and increased stimulation of the
intestines by the products of abnormal fermentations. In
chronic enteritis there is frequently no increase in the
irritability of the mucous membrane. Even in intestinal ulcera-
tions, the irritability may not be increased, this being especially
true of the chronic ulcerations.
The effect of diarrhoea upon the body depends
to a great extent upon its cause. If the food is hurried through
the upper part of the small intestines, its absorption may be seri-
ously interfered with and the patient may suffer from malnu-
trition. On the other hand, when the diarrhoea is due entirely
to an increased peristalsis of the large intestines, it is often sur-
prisingly well borne, for the most nourishing part of the food has
already been absorbed before the large bowel was reached.
Constipation. — In constipation, the chyme remains in the large
intestines for an abnormally long time, and more water is absorbed
from it than usual, with the result that the faeces become hard
and are passed less frequently than usual. ^^^ It is impossible
to draw any sharp line here between what is pathological and what
is physiological. We may say in general, however, that infrequent
defecation can only be regarded as pathological when it gives rise
to symptoms. Constipation is undoubtedly caused by abnormali-
ties of the large intestines; yet it is unprofitable to speculate on
the exact nature of these abnormalities so long as we do not even
know why the normal intestines empty themselves so infrequently.
Causes of Constipation. — In a certain proportion of cases the
constipation is caused by improper food. We have stated
that the material in the bowels furnishes the normal stimulus to
intestinal peristalsis. Every animal must take food that furnishes
the necessary amount of stimulus. Thus an herbivore will die of
constipation if it be totally deprived of the cellulose which nor-
DIGESTION 289
mally excites its peristalsis, and even carnivorous animals may
suffer seriously from constipation if fed solely on such easily
absorbable material as milk, eggs and meat, A certain number
of men place themselves on just such a diet. Though their intes-
tines possess a normal irritability, the stimulus to peristalsis is
lacking and they suffer from constipation. If they take foods
which stimulate the intestines either by reason of their coarse,
indigestible character, or because of their content of chemical
irritants, such as the organic acids, then the constipation is cured.
A lack of water in the chyme may also lead to constipation.
This is probably the cause of the form which so frequently
accompanies dilatation of the stomach, with hypersecretion and
the vomiting of large quantities of fluid.
In other cases of constipation, the normal irritabil-
ity of the intestines is reduced more or less, and
consequently the normal stimuli are not followed by the customary
response. This is apparently the cause of the constipation which
sometimes accompanies chronic catarrh and atrophy of the mucous
membrane of the large intestines.
It is evident that no irritation will prove of any value when
the muscular coat of the intestines is greatly weakened by mus-
cular paralysis or atrophy.^^^ Such a muscular
atrophy may or may not be associated with atrophy of the
mucous membrane. Peritonitis is frequently accompanied by
constipation and even by total paralysis of the intestines.
Although the ganglia and their nervous connections within
the intestinal walls are now believed to control peristalsis,^^^
nevertheless the exact effect of disease of these structures is not
known. Degeneration of this nervous apparatus has
been described in cases of lead poisoning and of chronic consti-
pation, yet similar changes have been observed in other con-
ditions.
Constipation may be associated with diseases of the
central nervous system, such as neurasthenia, melan-
cholia and many organic changes. The cause of this constipation
is not always clear. The view that it is due to a spastic con-
dition of the muscle of the large bowel is scarcely tenable, not
only because tonic contractions of smooth muscle can scarcely
persist for months and even years, but also because the clinical
picture is quite different from that of spastic constipation.
19
£90 THE BASIS OF SYMPTOMS
Thus we see that many causes may lead to constipation. Im-
proper food, reduced irritability of the intestines, weakness of
the intestinal musculature, abnormal nervous influences — all may
act independently or in combination. Some cases of constipation
are cured by exercise, although we do not know how it is effected.
The act of defecation is often assisted by the con-
tractions of the abdominal muscles, although in the perfectly
healthy man this is not necessary, and the peristalsis of the large
intestines suffices to empty them. In most cases of constipation,
the intestinal peristalsis is primarily at fault and it is rare to
find the rectum filled with unexpelled faeces. If such be the case,
however, then either the presence of the faeces in this locality fails
to produce the normal stimulus to defecation, or the abdominal
muscles do not furnish the help which may be necessary to expel
the accumulated material.
.Finally, there is a form of constipation which is due to a tonic
spasm of the smooth muscle of the intestine.^** Such a spasm
may be produced by the action of lead and by meningitis; and
the condition may also occur in association with neurasthenia
and hypochondriacal conditions. In spastic constipa-
tion, certain |X)rtions of the intestines, especially of the colon,
are firmly contracted and do not propel the chyme. Antiperi-
stalsis is possibly an additional factor.^*^ These contracted in-
testines may sometimes be felt through the abdominal wall as
round, hard, somewhat sensitive cords. The spasm of the intes-
tines frequently causes colic, and the faeces are often hard and
of small calibre, the latter the result of the spasm.
Effects of Constipation. — The effects of constipation are for
the most part subjective, and the general nutrition of the patient
rarely suffers. Defecation is often extremely difficult, and the
worry about this tends to upset the nervous equilibrium of the
patient. Immediately after defecation he feels brighter and his
head feels freer. These sensations are partly suggestive, as is
evidenced by the fact that they are most pronounced in individuals
who worry most about their condition.
Yet they are not entirely suggestive, for leaving out of con-
sideration the ill-defined and much-abused application of the term
auto-intoxication, we meet with cases of constipation exhibiting
albumin and casts in the urine, both of which disap-
pear after a thorough evacuation of the bowels.^** And the same
DIGESTION 291
urinary anomalies may appear in cases of constipation produced
by opium or tannalbin. We must not lose sight, therefore, of the
possibility of the absorption of toxic materials.
Intestinal Obstruction. — ^Two degrees of intestinal obstruction
are recognized — the incomplete and the complete.
Among the factors leading to delay or complete
blocking of the progress of the intestinal con-
tents are inflammatory and malignant strictures, foreign bod-
ies, gall-stones, invagination, kinks in the bowel, compression from
without and strangulation in hernial openings and by fibrous
bands. The view that paralysis of a short portion of the bowel
may be equivalent to a stenosis is no longer tenable ; for the chyme
suffers no delay in passing through a section of intestine made
inactive by a sarcomatous infiltration of its walls. When stenosis
does occur in a paralyzed loop, it is due to a kinking in the latter,
the result in turn of its lack of tone and of the torsion which it
undergoes in its overfilled state. This is a frequent mechanism
in postoperative ileus.
Pocket s — either congenital or formed by inflammatory
bands — are of common occurrence in the peritoneal cavity ; among
such are the bursa omentalis and those formed by inflammatory
adhesions about the caecum and in the pelvis. Into these openings
slips a loop of bowel, not as a result of peristaltic movements, but
by virtue of the combined action of gravity and the contractions
of the abdominal muscles. Here the loop may be merely fixed,
or incarcerated by the elastic recoil of the distended hernial ring.
In external hernias this mechanism is especially well illustrated.
In consequence of the constriction, there occurs a rapid venous
stasis in the affected loop of the bowel, followed by oedema, an
increase in volume of the loop, and finally, when the hernial ring
can no longer accommodate the swollen bowel, an obstruction
to the faecal movement.
In cases in which the stasis and oedema are less marked and
the portion of intestines is firmly fixed but not incarcerated, the
loop may increase in size by another mechanism, as pointed out
by Wilms.^*'^ Here, peristalsis impels the contents of the her-
niated bowel toward the hernial opening, where a further move-
ment is hindered by the greater or less obstruction existing at the
ring. As a result, the impeded contents distend the bowel at this
point, the distention serving to pull upon the g^t behind it. To
292 THE BASIS OF SYMPTOMS
this pulling is added the tensile force of the rapidly accumulating
contents, as incarceration proceeds at the hernial ring.
No adequate explanation has yet been given
for the sudden obstruction that sometimes de-
velops in hernias which have existed for a long
time without producing symptoms. Experiments
on the cadaver have, indeed, demonstrated that when the intes-
tinal coils are overfilled it is difficult to empty them, for they tend
to become kinked, and the mucous membrane often slides over the
muscularis, so that it lies in folds at the neck of the sac. Yet these
exj>eriments do not explain why, at a particular time, the intestines
should become overfilled; and, furthermore, the neck of the sac
may not be especially narrow in these chronic cases. It seems to
me that insufficient attention has been paid to the possibility that
there may be a primary paralysis of the muscularis in these cases,
which would allow the intestinal contents to accumulate at one
spot. This hypothesis may possibly serve to explain many cases
in which no mechanical cause can be found for the obstruction.
The question cannot be finally answered, however, until we possess
more evidence from clinical and experimental sources.
If a piece of intestine possesses a long mesentery with a short
attachment to the posterior abdominal wall, as is the case, for
example, with the sigmoid flexure, it is liable to become twisted
about its pedicle, thus producing the condition known as vol-
vulus. The rapid distention with gas that follows the volvulus
interferes with the movements of the intestines and prevents them
from untwisting, and the lumen of the canal is obliterated at the
point of twisting.
Intestinal obstruction may result finally if a portion of the
intestines is carried downward toward the anus within the portion
immediately succeeding it. The cause of such an intussus-
ception is somewhat obscure.^^* It cannot be reproduced
experimentally by the mere paralysis of an intestinal loop. It
would appear rather as if one portion of intestines drew itself
over another that was tetanically contracted, and that the invagina-
tion increased by the successive inclusion of freshly contracted
portions. A similar process is frequently seen in the normal
intestines, but the invagination is then neither extensive nor per-
manent. We do not know what interferes with a straightening
out of the canal in the pathological cases. When the invagination
DIGESTION 293
has once passed beyond a certain limit, the circulation of the
enclosed intestines is interfered with, and oedema follows.
In all these obstructions the symptoms depend
mainly upon the degree of stenosis and the ra-
pidity with which it develops. If the lumen of the
bowel is only partially and gradually encroached upon, the intes-
tines lying immediately above the obstruction contract more
forcibly than usual and their muscular tissue undergoes hyper-
trophy.^*^ The cause of these increased contractions resides
essentially in the greater work demanded of the hyp>ertrophied
muscles. A moderate stenosis may last for months without giv-
ing rise to any symptoms other than slight constipation whenever
the food is not properly chosen. When the hypertrophy can no
longer keep pace with the amount of work demanded, the mani-
festations of stenosis appear. This occurs sooner in the large
than in the small bowel, as is most clearly seen in old age.
If the lumen of the bowel is totally occluded, the resulting
symptoms are entirely different from those of a gradual and par-
tial obstruction. A total occlusion may develop acutely, or it
may come on during the course of a chronic obstruction, owing
to the inability of the muscle to force material past the partial
stenosis. In either case the intestinal contents stagnate above the
point of obstruction. The bacteria then multiply rapidly, for
their growth is no longer held in check by the onward movement
of the chyme. The resulting decompositions are of various
kinds, depending partly upon the bacteria present and partly upon
the material subjected to their action. When the obstruction
affects the lower part of the small intestines, large quantities of
unabsorbed food material stagnate, and putrefaction is very
marked; whereas, if the large intestines are affected, some time
may pass before any abnormal decomjxDsition is apparent, because
most of the nourishment has already been extracted from the
chyme. When putrefaction occurs, all its varied products are
formed, and often in large amounts. Of these, the aromatic com-
pounds, such as indol and phenol, combine in the body with
sulphuric acid to form the comparatively harmless ethereal
sulphates. As a result there is often a marked increase in the
quantity of indican and of ethereal sulphates in the urine (see
p. 281). It is possible, however, that some of the poisonous com-
pounds resulting from the intestinal decomposition may escape
294 THE BASIS OF SYMPTOMS
neutralization, and that they are responsible for many of the
general symptoms of intestinal obstruction. For example, the
complicating nephritis is possibly of such a toxic origin.
The most frequent symptom of intestinal obstruction is
obstinate constipation. Yet in certain forms of ob-
struction, especially in intussusception, there may be d i a r -
rhoeal discharges, composed not of faeces, but of inflam-
matory or secretory products of the mucous membrane at and
below the obstruction.
As a rule, however, the portion of the intestines below the
obstruction is totally paralyzed, and not even flatus escapes through
the anus. Gases collect above the obstruction and gradually back
up in the direction of the stomach. The intestines which are
thus distended contract vigorously, peristaltic and tetanic contrac-
tions alternating with each other. These can be frequently
observed through the abdominal wall, especially if the obstruction
is an old one and the muscularis has had time to hypertrophy.
These muscular contractions, especially the tonic ones, frequently
give rise to the most violent colic. The patient begins to
vomit soon after the obstruction sets in. At first, the vomitus
consists merely of the gastric contents mixed with bile-stained
material from the duodenum. If the vomiting continues,
however, thin, greenish-yellow material, of a faecal odor, may
appear. ^^^ This material undoubtedly comes from the intestines,
and is composed in part of unabsorbed, decomposed food, and in
part of the products of intestinal secretion.
The mechanism by which this material reaches the stomach
is not perfectly clear. One's first thought would be that anti-
peristaltic movements play an important part,^^^ for
these occur in other conditions, and, even though they have not
been directly observed in intestinal obstruction, no reason exists
a priori why they should not be present. Indeed, since we have
learned that antiperistalsis is normal in the colon, we are more
than ever inclined to assume that a similar mechanism is present
in the small intestines. (And, indeed, fluoroscopy has made us
familiar with antiperistaltic waves in cases of stenosis in the
small bowel and at the pylorus. — Ed.)
As the obstruction continues, the patient loses in weight and
strength rapidly. The period of increased peristalsis is later fol-
lowed by one of paralysis of the intestines. At first, this cessation
DIGESTION 295
of intestinal movements is caused merely by the overdistention
of the intestines; for it has been shown, experimentally, that
greatly distended intestines cease to contract, but that they will
begin to do so again as soon as the tension is diminished. In the
later stages of obstruction, however, the intestinal par-
alysis is absolute; and, experimentally at least, no move-
ments can be elicited. This entire absence of peristaltic movements
in intestinal obstruction indicates an exceedingly grave condition,
and if help is not forthcoming, the patient dies in collapse.
Though it is generally agreed that a period of increased peri-
stalsis always precedes the period of paralysis in chronic obstruc-
tion, some consider that this primary period may be absent in
acute obstruction. Yet it seems to me that a primary period
of increased peristalsis is present even in these patients. When
this is of short duration or apparently altogether absent, the
cessation of intestinal movements is, in my opinion, usually due to
an inflammation of the intestinal wall.
Strangulation. — The severity of the symptoms varies greatly
in different cases of obstruction. In some, the meteorism, faecal
vomiting and collapse do not occur for days; whereas in others
these symptoms develop within a few hours after the obstruction
takes place. These variations depend largely upon the nature of
the occlusion. A simple closure of the lumen of the intestines is
much less dangerous than a so-called strangulation, which may
accompany any of the different forms of intestinal obstruction. ^^^
In this latter condition the blood-supply of the intestines is affected.
The mesenteric and intestinal veins are pressed upon and occluded,
the arteries continue to send blood into the intestines, and cedema
results. These vascular changes, together with injuries to the
nerves of the peritoneum, are apparently responsible for the rapid
and alarming symptoms which ensue. The walls of the intestines
become infiltrated with fluid, and bacterial decomposition proceeds
with excessive rapidity within the lumen of the strangulated
bowel. The products of this bacterial activity injure the intes-
tinal walls, so that they no longer oppose the normal resistance to
the gases which are formed. Consequently the strangulated piece
of intestine becomes enormously distended (local meteorism).
The violent peristaltic movements produce the most intense pain,
and vomiting becomes uncontrollable. Added to these are certain
systemic manifestations, such as the general circulatory changes,
296 THE BASIS OF SYMPTOMS
the collapse and the rapid loss of strength. The circulatory dis-
turbances are caused, in the first place, by reflexes from the peri-
toneum that act upon the heart and vessels, but especially by those
that influence the splanchnic vascular area. In the second place,
they are probably produced directly by the toxic action of putre-
factive products absorbed from the intestines.
Meteorism. — The intestines of healthy individuals contain
gases ^^^ composed in part of swallowed air and in part of thos?
which arise from the decomposition of the intestinal contents by
the digestive juices, and especially by bacteria. When air is
swallowed, the oxygen in it is rapidly absorbed, so that the small
intestines rarely contain this gas. The nitrogen, however, remain^
in the canal for a much longer time. Carbon dioxide is set free
by the action of acids upon the carbonates in pancreatic juice, bile
and succus entericus, but it is generated in much larger quantities
during carbohydrate fermentation. The latter also yields hydro-
gen and marsh gas; and the putrefaction of proteids produces
small quantities of hydrogen sulphid. Of these various gases,
the carbon dioxide is readily absorbed by the blood, the nitrogen,
methane and hydrogen, on the contrary, much more slowly. The
quantity and quality of the intestinal gases vary greatly, even in
a healthy man; for they depend largely upon the quality and
quantity of the food taken and upon the varieties of bacteria that
happen to be present.
These intestinal gases may produce some variation in the size
of the abdomen, but rarely does great distention result, for the
normal intestines can, to a certain extent, dispose of the gases
they contain, either by absorption, or by expulsion through the
anus, both processes depending largely upon the tonus of the
smooth muscle.
In gastro-intestinal diseases much larger quantities of gas
may be formed, and those produced in greatest abundance are
usually the very ones which are least easily absorbed, vis., methane
and hydrogen. Yet a mere increased production of gas does not
necessarily cause meteorism either in a healthy individual, or even
in some patients with intestinal obstruction. It would appear
that a diminished muscular tonus and an insufficient absorptive
capacity are of much greater importance in the production of
tympanites than is an excessive formation of gases. For this
reason, meteorism is especially marked in peritonitis and acute
DIGESTION 297
strangulation. If the intestines once yield to the pressure of gas
within them, a vicious circle is established, for this very disten-
tion embarrasses their circulation, and so diminishes their ability
to absorb gas.
Meteorism tends to develop, therefore, when-
ever a weakness of the intestinal musculature
is associated with an over-production of gas
within the intestines. The milder forms of tympan-
ites are seen in connection with dyspepsias, enteritides and typhoid
fever ; the more severe in association with peritonitis and intestinal
obstruction.
The meteorism that is present at times in hysterical
patients has not been satisfactorily explained, but seems to
depend in part upon transitory paralyses of the muscle, and in
part upon the swallowing of large amounts of air. Hysterical
paralyses are common enough in other parts of the body, and we
see no reason why they should not occur in the intestines; and
the fact seems well established that many hysterical individuals
swallow air in considerable quantities. That some cases may be
due to a spasm of the diaphragm associated with a relaxed abdom-
inal wall is evidenced by the fact that they disappear under anaes-
thesia.
Abnormal Intestinal Sensations. — ^These are various. In the
first place, a distention of the intestines will produce the sen-
sation of fulness in the abdomen, and if the distention
be marked, dyspnoea may result, owing to the high position
of the diaphragm.
Colic results from violent contractions of the intestines.
It has been said that colic is never produced by the normal peri-
staltic movements, but only by tetanic states of the intestinal
musculature. These are liable to occur whenever the stimuli for
peristaltic movements are especially strong. The most severe
forms of colic are seen in connection with intestinal obstruction
and lead poisoning. Less severe is the colic which may accompany
intestinal catarrah and cholera nostra. The pain of colic has
been located by some in the muscles, in which case it would be
analogous to that caused by cramps in voluntary muscles. By
others, it has been located in the peritoneum, for we know that,
like the other serous membranes, the peritoneum is an exceedingly
298 THE BASIS OF SYMPTOMS
sensitive structure, and inflammations in it are always accompanied
by severe pain.
The cause of painful sensations referred to the
viscera is still unsettled. It has long been known that the brain
is insensitive to pressure and to mechanical irritation, and a
similar absence of painful sensations is true also in the case of
the stomach and intestines. Lennander^^^ has attributed the
pain of intestinal colic to the pressure exerted by the dilated bowel
upon the sensitive parietal peritoneum ; while Wilms ^^^ regards
the traction upon the sensory nerve-containing mesentery as the
explanation. Both are agreed that the pain arises outside of the
stomach and bowel ; yet, under certain conditions, the latter may
at times be the seat of pain.^^^ At any rate, the idea that local
anaesthesia in intestinal operations is equivalent to general, must
be relinquished in view of the fact that the bowel is insensitive
even when no anaesthetic is employed. Nevertheless, I am not
convinced that pain may not arise in the internal organs. Pos-
sibly, the sensitiveness of an organ is more important than the
strength of the irritation ; or in other words, that pain originates
in the viscera only when the threshold of sensibility is lowered
by disease.
The pain of appendicitis and ofcholecystitis
is due to the inflammation present. In renal and biliary
colic, the Hkeliest explanation of the pain is the pull exerted
by a distended renal pelvis and gall-bladder, respectively, upon
the nerves in the biliary passages and ureter; it is possible, how-
ever, that the most important factor is the dragging upon the
peritoneum, as suggested by Wilms.
Still other pains are unquestionably to be referred to the
peritoneum, such, for example, as those which accompany peri-
toneal adhesions. These adhesions which, as a rule,
follow some previous inflammation, often cause the most annoy-
ing pain, which becomes worse when the bands are dragged
upon.^^^ The pain of peritoneal adhesions is of the greatest prac-
tical importance, for it may harass the patient for years after the
original disease has subsided.
A somewhat similar pain is often experienced by nervous
individuals, and seems to be of a neuralgic nature, for no anatomi-
cal basis can be discovered for it. It will be discussed, therefore,
in connection with diseases of the nervous system.
DIGESTION 299
Diseases of the anal orifice are often the source
of severe pain. Each time that hard fasces pass over the in-
flamed or ulcerated mucosa the most intense agony is experienced.
Perhaps even more unpleasant is the condition known as
tenesmus, in which a constant, violent desire to defecate
harasses the patient. This is especially liable to be present in
diseases of the rectum. The inflammatory changes of dysentery
frequently cause this constant desire to defecate, but, owing to
the lack of faecal material in the rectum, nothing is passed except
inflammatory products and these with most excruciating pain.
LITERATURE
^For the literature of stomatitis and ptyalism see Hoffendahl and Brugsch,
respectively, in the Kraus-Brugsch System, 1914.
*J. Miiller: Kongr. f. inn. Med., 1901, 321.
'Roger and Simon: C. r. soc. biol., Ixii, 1070.
* Kraus and Ridder, in the Nothnagel System ; Ridder, in the Kraus-Brugsch
System, 1914 (lit.).
"Starck: Die Divertikel u. Erweitg. d. Speiserohre, 191 1; Die Osophago-
skopie, 1905.
* Kraus and Ridder : 1. c. ; Starck, 1. c. ; Einhorn, Am. Jour. Med. Sc, October,
1910; Best, Arch. f. Verdauungskrankh., xvi, 464.
^ For physiology of digestion : O. Cohnheim, D. Phys. d. Verdauung u. Ernah-
rung, 1908; Fuld, in the Kraus-Brugsch System; Bickel, in Oppenheimer's
Handb. d. Biochemie; Tigerstedt, Lehrb. d. Physiologic d. Mensch., 7th
edit., 1913 (Chap, on Metabolism and Nutrition); Ellenberger and
Scheunert, in Zuntz-Loewy, Lehrb. d. Phys., 2nd edit., 1913, Chap, xvii;
Starling, Principles of Human Physiology, 1912. For pathology of diges-
tion : V. Tabora-Riegel, in the Nothnagel System ; Riegel, Magenkrank-
heiten ; Boas, Magenkrankheiten ; Pick, Magenkrankheiten.
* Pawlow : The Work of the Digestive Glands, 1903.
' Bickel : Kongr. f . inn. Med., 1906, 481 ; Cohnheim, 1. c. See also Rehf uss
and Hawk, Jour. Am. Med. Assn., 1914, Ixiii, 2088 (lit.).
"Erb: Zeitschft. f. Biol., xli (lit.) ; Castex, Arch. f. klin. Med., c, 148.
" Driest : Untersuch. ii. d. Salzsauregeh. d. Mageninhaltes, Diss. Greif swald,
1902; Kornemann, Arch. f. Verdauungskrankh., viii, 369; Rose, Arch. f.
klin. Med., xcv, 508, 518.
" Kuttner : Zeitschft. f . klin. Med., xlv, i ; Boas, Magenkrankheiten, 4th
edit., ii.
" Blum and Fuld : Berl. klin. Wochenschft., 1905, 106.
" Bickel : Zeitschft. f . physikal. Ther., 1907, 325 ; Umber, Berl. klin. Wochen-
schft, 1905, 56; Carlson, Amer. Jour, of Phys., 191 5, xxxvii, 50.
" Gross : Arch, f . Verdauungskrankh., xii, 507 ; Maly's Jahresber., 1906, xxxvi,
chapt. viii (lit.) ; Fuld, in Kraus-Brugsch (lit.) ; Edkins, Jour, of Phys.,
xxxiv, 133; Wolfsberg, Zeitschft. f. phys. Chem., 1914, xic, 344 (a recent
study devoted to the effect of different foods on the flow of gastric juice),
"Schiile: Arch. f. klin. Med., Ixxi, iii; Umber, I. c. ; Sommerfeld, Engel-
mann's Arch., 1905, 455 (suppl.).
" Cf. Bickel : Kongr. f . inn. Med., 1906, 485.
"Edkins: Proc. Royal. Soc, Ixxvi (B), 376; Jour. Physiol., xxxiv, 132.
** See Nothnagel's System (Dis. of the Stomach); Ewald, Klinik d. Ver-
dauungskrankh.; Fleiner, Lehrbuch, 192.
*" Martins: Deutsch. med. Wochenschft., 1894, No. 32; Gentgen, ibid., 1907,
1404.
800 THE BASIS OF SYMPTOMS
" Amer. Jour. Physiol., xxxvii, 50 (lit. on the factors governing the secretion
of gastric juice).
^Allard: Arch. f. Verdauungskrankh., xv, 161 (lit.).
" Strauss and Bleichroder : Untersuch. ii. d. Magensaftfluss, 1903.
'*Bickel: Biochem. Zeitschft., i, 153; Bubow, Arch. Verdauungskrankh.,
xii, I.
'"Matthes: Ziegler's Beitrage, xiii, 309; Moller, Ergeb. d. inn. Med., vii,
520 (collective article).
""^ Payr : Deutsch. med. Wochenschf t., 1909, Nos. 36, ^y ; Arch, f . klin. Chir.,
xciii, 436.
"Matthes: 1. c. ; Moller, 1. c.
"Jour, Am. Med. Assn., 1913, Ixi, 1942.
*'Orphiils: Jour. exp. Med., viii, 181.
"Turck: Jour. Am. Med. Assn., xlvi, 1753.
" Hamburger and Friedman : Arch. Int. Med., xiv, 722 ; Jour. Am. Med.
Assn., 1914, Ixiii, 380.
•"Rose: Arch. f. klin. Med., xcv, 508; Rehfuss and Hawk, Jour. Am. Med.
Assn., 1914, Ixiii, 2088.
** Emerson: Arch. f. klin. Med., Ixxii, 415.
"Reissner: Zeitschft. f. klin. Med., xliv, 87.
"Hauser: Munch, med. Wochenschf t., 1910, No. 23-
■* Rosenberg : Zeitschft. f . klin. Med., Ivi, 449.
"Emerson: Arch. f. klin. Med., Ixxii, 415.
" Neubauer and Fischer : Arch, f . klin. Med., xcvii, 449 ; Weinstein, Jour.
Am. Med. Assn., Ivii, 1420. See also Sanford and Rosenbloom, Arch.
Int. Med., ix, 445 ; Jaque and Woodyat, ibid., x, 560.
*" Strauss and Bialocour : Zeitschft. f. klin. Med., xxviii, 567.
*• Minkowski : Mitth. a. d. med. Klinik z. Konigsberg, Leipzig, 1888.
** Rosenheim and Richter : Zeitschft. f . klin. Med., xxviii, 505,
** Sick : Arch, f . klin. Med., Ixxxvi, 370.
^'v. Tabora: Arch. f. klin. Med., Ixxxvii, 254,
" Naunyn : Arch, f . klin. Med., xxxi, 225.
** A. Schmidt : Arch, f . klin. Med., Ivii, 65.
*• Dauber: Arch. f. Verdauungskrankh., ii, 167.
*'' Starling, in Asher-Spiro, i. Part 2, 446 ; Sick and Tedesco, Arch. f. klin.
Med., xcii, 416; v. Bergmann, in the Kraus-Brugsch System (lit,);
Cannon, The Mechanical Factors of Digestion, 1911, (This volume em-
braces Dr. Cannon's studies in this field to 191 1 and contains a very
complete literature.)
** Hirsch, v, Mehring and Moritz : Studies from Pawlow Institute ; Cannon, 1. c.
*• v, Bergmann : Die Rontgenuntersuchung d. Magens, in the Kraus-Brugsch
System, v, 403.
" Schiile : Zeitschft. f . klin, Med., xx, 80.
" V. Leube : Arch, f . klin. Med., xxxv, i ; Penzoldt, ibid., Ii, 535 ; Cannon,
1. c, chaps, viii, ix, and x.
" Forschbach : Arch, f . Verdauungskrankh., xv, 182.
"C/. Sick: Arch. f. khn. Med., Ixxxviii, 169.
" Rose : Arch, f . klin. Med., xcv, 508.
"Mitth. a. d. Grenzgeb., iv, 347.
" Rutimeyer : Arch, f . Verdauungskrankh., vii, 67.
" Ibrahim : Ergeb. d. inn. Med. u. Kinderheilk.,. i, 208.
■* Fleiner : Verdauungskrankh., i, 208.
"* Rieder : Fortschritte a. d. Geb. d. Rontgenstrahlen, viii, 141 ; Holzknecht,
Reports from his laboratory, Fischer. Jena ; Groedel, Arch. f. klin. Med.,
xc, 433 (lit.) ; V. Bergmann, in the Kraus-Brugsch System (lit).
~ Fleiner : 1. c. ; Albrecht, Virch. Arch., clvi, 285.
" In Keen's Surgery, iii, 949.
^ Stiller : Berl. klin. Wochenschft., 1901, No. 39.
* Arch, f . klin. Med., xxxi, 225.
DIGESTION 301
*^' See Fleiner : Arch, f . Verdauungskrankh., i, 243 ; also Die Verdauungs-
krankheiten (lit.) ; F. Miiller, Kongr. f. inn. Med., 1898, 167.
^ See Jonas : Deutsch. med. Wochenschft., 1906, No. 23 ; Franz Groedel, in
Lehmann's med. Atlanten, vii, 198.
" See Magnus, in Asher-Spiro, Biophysik, 1903, 64.
^ Cannon : 1. c. ; Carlson, many studies in the Amer. Jour, of Physiology,
xxxi, xxxii, xxxiii, xxxiv, xxxvi.
** Text-book of Physiology, 1913, 284.
* Pawlow : 1. c.
"> Loc. cit.
" Foerster and H. Kiittner : Beitr. z. klin. Chir., Ixiii, No. 2.
" See Pal : Wiener med. Wochenschft., 1904, Nos. 14 and 15.
^*Die nervose Dyspepsie, 1908.
" For literature, see Minkowski, in Ergeb. d. allg. Path., ii, 696 ; Quincke
and Hoppe-Seyler, Diseases of the Liver, in the Nothnagel System.
" See Aschoff and Bacmeister : Die CholeHthiasis, 1909.
'"Fraenkel and Krause: Zeitschft. f. Hyg., xxxii, 97; Gilbert and Lesebomlet,
C. r. soc. biol., 1903, 664; Ehret and Stolz, Mitth. a. d. Grenzgeb., vi-viii.
" Naunyn : Klinik d. Cholelithiasis.
"Forster: Miinch. med. Wochenschft., 1908, No. i.
*' See Naunyn, Proc. 13th Inter. Med. Congr., Paris.
•" Zeitschft. f. klin. Med., xii, 45.
"Krehl: His' Arch., 1890, 97; Pfliiger, Pfliiger's Arch., Ixxxviii, 222, 431;
xc, I.
"Matthes and Marquardsen: Kongr. f. inn. Med., 1898, 358.
** Johns Hopkins Hosp. Bull., 1905, xvi, 20.
•*Brieger: Zeitschft. f. klin. Med., iii, 465; Miiller, ibid., 45.
"Zeitschft. f. klin. Med., xlix, 432.
"Gerhardt: Kongr. f. inn. Med., 1897, 460; Eppinger's studies collected in
Ergeb. d. inn, Med. u. Kind., i, 107.
" See Ehret and Stolz, Mitth. a. d. Grenzgeb., x, 150.
** Stadelmann : Der Ikterus, 1891 ; Eppinger, 1. c.
•* Minkowski: Ergeb. d. Path., xcvii. Part 2, 705; Zeitschft. f. klin. Med.,
Iv, 34 ; Mod. Clin. Med., Digestive Diseases, 332.
•" Wiener klin. Wochenschft., 1908, No. 14.
'* Quincke, in the Nothnagel System ; Heubner, Lehrbuch, 3rd edit., i, 103.
** Chauffard : Semaine med., 1907 xxvii, 25 ; 1908, xxviii, 49 ; Rolleston, Clin.
Journal, 1908; Tileston and Griffin, Amer. Jour. Med. Sc, 1910, cxxxix,
847; Thayer and Morris, Johns Hopkins Hosp. Bull., xxii, 85 (lit);
Meyerstein, Ergeb. d. inn. Med., 1913, xii.
" Klemperer : Therap. d. Gegenwart, 1914, No. i ; Tiirk, Deutsch. med.
Wochenschft., 1914, No. 8; Miihsam, ibid.
" Stadelmann : Zeitschft. f. Biol., xxxiv, 57.
"Yeo and Herroun: Jour, of Phys., v, 116; Stadelmann, 1. c.
•* Minkowski: Arch. f. exp. Path., xxi, 41.
" Newer literature : Fischler, Das Urobilin, etc., 1906 ; Kongr. f . inn. Med.,
1908, 544; Hildebrand, Miinch. med. Wochenschft., 1909, Nos. 14 and 15;
Zeitschft. f. klin. Med., lix, 351 ; Friedr. Meyer-Betz., Ergeb. d. inn. Med.,
xii, 733 (lit.) ; Wilbur and Addis, Arch. Int. Med., 1914, xiii, 235 (lit.).
'* Bauer : Wiener med. Wochenschft., 1906, xxi, 2537 ; Deutsch. med. Wochen-
schft., 1908, No. 35; Wiener klin. Wochenschft., 1912, 39; see also Hoff-
mann, Zeitschft. f. exp. Path., 1914, xvi, 337.
"Opie: Diseases of the Pancreas; A. Schmidt, Deutsch. med. Wochenschft.,
1908, No. 23 ; Arch, f . klin. Med., Ixxxvii, 456.
'•^Zeitschft. f. klin. Med., xii, 45; Brugsch, ibid., Iviii, SiQ-
^•'Ad. Schmidt: Die Funktionspriifg. d. Darmes, 1908, 49 (lit.).
'"^ Schmidt : 1. c, 50. See also Schmidt-Strasburger, Die Fazes d. Menschen,
etc., 4th edit., 191 5.
"*Oser, in the Nothnagel System (lit.).
302 THE BASIS OF SYMPTOMS
*** Fleckseder : Arch, f . exp. Path., lix, 407 ; Lombroso, ibid., Ixvi, 99.
^*" Kongr. f. inn. Med., 1892, 450.
*°* Langerhans : Virch. Arch., cxxii, 252 ; Benda, ibid., clxi, 194.
^'" V. Bergmann and Guleke : Miinch. med. Wochenschft., 1910, No. 32 ; Opie,
Diseases of the Pancreas, 40; Johns Hopkins Hosp. Bull., xii, 182.
*°°Fischler: Arch. f. klin. Med., c, 329, and ciii, 156.
*" See also Flexner: Jour. exp. Med., ii, 413, and Hewlett, Jour. Med. Re-
search, ix, 277.
"" See van Ermengen, in Kolle-Wassermann, ii, 637.
"^ Metchnikoff : Les microbes intestinaux. Bull, de I'lnstitut Pasteur, 1903, i,
217, 264; Strasburger, Zeitschft. f. klin. Med., xlvi, 413; xlviii, 491;
Moro, Arch. f. Kinderheilk., xliii.
"* Kohlbrugge, ref. in Baumgarten's Jahresber., 1901, 895 ; Roily, Deutsch.
med. Wochenschft., 1906, No. 43 ; see also Gushing and CoUingwood,
Contributions to the Science of Medicine, Balto., 1900, 543.
"*Bienstock: Die med. Wochenschft., 1901, Nos. 33 and 34; Arch. f. Hyg.,
xxxix, 390 (Ht.) ; Roily and Liebermeister, Arch. f. klin. Med., Ixxxiii,
413-
"* Thierf elder and Nuttal : Zeitschft. f. phys. Chem., xxi, 109; xxii, 62; Schot-
telius, Arch. f. Hyg., xlvii, 177 ; Metchnikoff, Ann. Pasteur, 1901, 631 ;
Moro, Verhandl. d. Gesellsch. f . Kinderheilk., 1905, 190.
*"Lit. in Baumgarten's Jahresber., in the chapter, Vorkommen u. Bedeut. d.
Mikroorg., etc. ; Tissier, Recherches sur la flore intest. d. nourissons,
1900.
""Moro: Miinch. med. Wochenschft., 1908, No. 31 ; Combe, Med. Klinik., 1909,
Nos. 19 and 20; see also Seifert, Deutsch. med. Wochenschft, 191 1, No. 23.
"^Schott: Zentralbl. f. Bakt., xxix, i, 239, 291.
*" Klemperer : Deutsch. med. Wochenschft., 1894, No. 20 ; H. and A. Kossel,
Du Bois' Arch., 1894, 200.
"" Posner and Cohn : Berl. klin. Wochenschft., 1900, No. 36.
"• Behring : Naturforscherversamm. zu Kassel, 1903.
*** Salge : Jahrb. f. Kinderheilk., Ix, i.
^ Rosenheim : Deutsch. med. Wochenschft, 1908, Nos. 7 and 8 ; Baumstark,
ibid., 1911, No. 16.
^ Studies from the Rockefeller Inst, for Med. Research, ii, 1904.
^ See, for example, Cameron : Brit. Jour, of Child., 1913, x, 205 ; E. Schlesin-
ger, Deutsch. med. Wochenschft., 1912, xxxviii, 558; Helmholz, Jour.
Am. Med. Assn., 1914, Ixiii, 1371.
^ Fischler : Arch, f . klin. Med., civ ; Adrian, Arch, f . Verdauungskrankh., i,
179 (lit).
"•Herter: Lectures on Chem. Pathol., 202; N. Y. Med. Jour., 1898, 89; many
studies on indol an ' skatol in Jour, of Biol. Chem., i-v ; Gerhardt, Ergeb.
d. Physiol., 1904 (iii, Part I), 107 (lit) ; EUinger, ibid., 1907, vi, 29 (lit).
""Frank: Berl. klin. Wochenschft., 1887, No. 38. See also Krause, allg.
Mikrobiologie, 191 1, 281.
*** Councilmann and Lafleur : Johns Hopkins Hosp. Rep., iii ; Kartulis, in
Kolle-Wassermann, Handb., Suppl., i, 347.
"*Miiller: Kongr. f. inn. Med., 1887, 404; Zeitschft f. khn. Med., xii, 45;
Grassmann, ibid., xv, 183.
"" Dapper : Zeitschft. f. klin. Med., xxxi, 382.
^ Zeitschft f . Exp. Path., iii, 446.
^ V. Mering : Kongr. f . inn. Med., 1893, 471 ; Moritz, ibid.
^Kiihne: Berl. klin. Wochenschft, 1868, 170.
"* Am. Jour, of Phys., x, loi, 259.
*" Franicl : Arch, f . exp. Path., 1907, Ivii, 386 ; Auer, Amer. Jour, of Phys.,
1906, xvii, 15 (lit) ; Jour, of Biol. Chem., 1908, iv, 197 (lit).
*** Amer. Jour, of Phys., 1907, xx, 266.
*" Miinch. med. Wochenschft., 1909, No. 47. See also Boehm, Arch. f. klin.
Med., cii, 431 (lit), and Cannon, 1. c.
DIGESTION 303
^Ziilzer, Dohrn and Marker: Berl. klin. Wochenschft., 1908, No. 46; Kanert,
Miinch. med. Wochenschft., 1911, No. 17; Glitsch, ibid., No. 23.
"•Nothnagel: Dis. of the Intestines, in his System (lit.).
^" Bokai : Arch. f. exp. Path., xxiii, 209, and xxiv, 153.
^" Lohrisch : Arch, f . klin. Med., Ixxix, 383 ; Tomascewski, Med. Klinik., 1909,
No. 12.
^*^ Nothnagel : Zeitschft. f. klin. Med., iv, 422.
*" Magnus : Pfliiger's Arch., cii and ciii ; Jour, of Phys., xxxiii, 34.
*■" Fleiner : Berl. klin. Wochenschft., 1893, No. 3 ; Boas, Darmkrankh., 2nd
edit., 570.
*** Boas : Arch, f . Verdauungskrankh., xv, 683.
^^Boehm: Arch. f. klin. Med., cii, 431 ; Miiller, Kongr. f. inn. Med., 1898,
149; Combe, Intestinal Auto-Intoxication, 1908; Ebstein, Berl. klin.
Wochenschft., 1909, No. 41, and Die chron. Stuhlverstopfg., 1901 ; Robit-
schek, Berl. klin. Wochenschft., 1910, No. 18.
"' Der Ileus, Deutsch. Chirurgie, No. 46 g.
*** Nothnagel : Dis. of the Intestines, in his System ; Wilms, 1. c.
^**Herczel: Zeitschft. f. klin. Med., xi, 221.
"" Leichtenstern : Kongr. f . inn. Med., 1889, 56 ; Nothnagel, 1. c. ; Wilms, 1. c.
'"^ Hernmehr : Arch, f . Verdauungskrankh., viii, 59.
"^Kirstein: Deutsch. med. Wochenschft., 1889, No. 49; v. Mikulicz, Therap.
d. Gegenwart, 1900. For more recent studies on the causes of the toxic
manifestations of intestinal obstruction see Hartwell, Jour. exp. Med.,
1913, xviii, 139; Bunting and Jones, ibid., 1913, xvii, 192, and xviii, 25;
Whipple, Stone and Bernheim, ibid., 1913, xvii, 286, 307.
*" Cf. Fries : Amer. Jour. Phys., xvi, 468,
^" Grenzgebiete, xv and xvi.
"* Zeitschft. f . Chirurg., c, 372.
"'Ritter: Zentralbl. f. Chir., 1908, No. 20 (lit.).
"' Riedel : Arch. f. klin. Chir,, xlvii, 153 ; Vogel, Deutsch. Zeitschft. f. Chir.,
Ixiii, 296.
CHAPTER VI
NUTRITION AND METABOLISM
The activities of the living cells are associated with chemical
changes within them, and with an interchange of food and waste
material with their surroundings. The sum of all these
processes is termed metabolism. A discussion of
nutrition and metabolism ought properly to deal with each organ
individually, for it is obvious that different tissues require differ-
ent food materials and give rise to different waste products. In-
deed, the various organs are more or less interdependent upon
one another, and one organ, for example, may need material that
has been elaborated by another, or may transform waste products
derived from another. This interdependence — or chemical
correlation,^ as it is known to-day — predicates the activities
of hormones, or substances which, elaborated by one organ,
exert a specific influence upon another. Though the existence of
such substances has long been assumed, it is only recently that we
have acquired some knowledge of their origin and characteristics.
They are the products particularly of the ductless glands, though
it is probable that every organ takes a part in their formation.
The disorders of these internal secretions — and our
acquaintance with these disorders is still largely undeveloped —
we shall consider in connection with the various processes in which
they play a role.
In the present state of our knowledge, however, we are
unable to discuss metabolism from the standpoint of the individual
organs, but are obliged rather to consider the metabolic processes
that take place in the body as a whole. Our knowledge
of these processes is derived mainly from exam-
inations of the food ingested and of the various
waste products eliminated.
The Quantitative Variations in the Metabolism of
Proteids and Fats
In order to maintain the body, it is necessary to sui)ply it with
water, mineral salts and organic bodies, i.e., proteids, carbohy-
drates and fats. It is not quite certain, however, that this enumer-
S04
NUTRITION AND METABOLISM 305
ation is complete and that there are not other, still undiscovered,
needs of the body.
The Caloric Needs of the Body. — The food ingested is utilized
partly to repair the tissue waste, and partly to furnish energy
for muscular movements, bodily heat and for the respiratory
and circulatory activities. For these last purposes, it is practically
immaterial in what form the energy is provided — whether it be
as carbohydrates, fats or proteids — the essential point being that
the quantity of food is sufficient. The energy contained in the
various foodstuffs is transformed by the body into mechanical
work, chemical work and especially into heat. Indeed, Rubner ^
has shown that almost the entire energy of the food leaves the
resting body in the form of heat, and that the heat which results
from combustion in the body is the same as that which would be
produced were the foods burned outside to the same waste
products.
(The unit for measuring quantities of heat is the large
calorie, which represents the amount of heat necessary to
raise the temperature of a kilogram of water one centigrade
degree. When equal weights of different foodstuffs are burned
in the body, different quantities of heat are liberated. Thus each
gram of fat produces about 9.3 calories, each gram of carbohy-
drates about 4.1 calories, and each gram of proteids about 4.1
calories. It will be seen from these figures that the energy de-
rived from fat is relatively greater than that derived from carbo-
hydrates or proteids. Indeed, one gram of fat furnishes about
the same energy as do 2.3 grams of either of the other two. It
is possible, with certain limitations, to replace any constituent of
the diet by any other, without disturbing the equilibrium of metab-
olism, providing due attention be paid the caloric value of each
foodstuff. Each gram of fat in the food, for example, may be
replaced by 2.3 grams of carbohydrates, etc. It is furthermore
possible to calculate the total quantity of energy contained in any
particular diet and in this manner to estimate whether or not
this diet contains a sufficient amount of energy to cover the
caloric needs of the individual.
The amount of energy that must be supplied to the body de-
pends primarily upon the activities of the tissues, and is subject
to many influences. This amount has been estimated empirically
from the mean quantity of food taken by different individuals.
20
306 THE BASIS OF SYMPTOMS
We quote from Lusk^ the following "standard" die-
taries for a man of seventy kilograms:
(Weights in Grams)
Light Work: Voit Rubner Atwater
Protein 123 100
Fat 46 *
Carbohydrates 377 *
Calories 2445 2700
Medium Work:
Protein 118 127 125
Fat 56 52 *
Carbohydrates 500 509 *
Calories 3055 2868 3400
Hard Work:
Protein 145 165 150
Fat 100 70 *
Carbohydrates 500 565 *
Calories 3574 3362 4150
* Carbohydrates and fats to make up the full value. — Ed. )
A small person needs a relatively greater supply of energy per
kilo of weight, for, as is well known, a small body has a relatively
large surface, and consequently loses more heat in comparison
to its weight. This is one reason why children need more food
than adults in proportion to their weight. On the other hand,
stout individuals need relatively less food; instead of the normal
thirty- four to forty-five calories, they require only about twenty-
six to thirty-six calories per kilo of body weight. This difference
is due to the fact that a large body has a relatively small surface;
that the thick layer of- fat protects these persons from heat losses ;
that the fat itself is practically dead tissue in the body and does
not consume energy; and, finally, that stout individuals usually
take a minimal amount of exercise.
Not all variations in the caloric needs of different individuals
are thus easily explained, and there are reasons for assuming that
the cells of different persons manifest different needs for energy.
At least, no other satisfactory explanation can be given for the
fact that certain men seem to require very much smaller quantities
of proteids and of energy than do others.
The Proteid Needs of the Body. — ^The food must furnish the
body not only with a sufficient amount of energy, but also with
a certain minimum of proteids, which is utilized in part in the
NUTRITION AND METABOLISM 307
repair of the waste within the cells. In view of the extensive
splitting undergone by the proteids in the intestines,* it is con-
ceivable that the body might be properly maintained if, instead
of the proteids themselves, their split-products (amino-acids and
ammonium salts) were substituted in correct proportion. And,
in fact, this has been done with success, using the products of the
digestion of meat and milk. Unpublished studies of Grafe would
indicate that in young undernourished animals whose diet has
contained insufficient proteids and an excess of carbohydrates,
ammonium salts are indeed utilized, if one may judge from the
persistently high percentage of ammonia nitrogen retained.
The minimal amount of proteid ^ necessary
for the needs of the body varies with the condition of proteid
nutrition that is to be maintained, with the kind of proteid given,
with the nature and amount of other foods given and with the
work which the body performs. The lowest minimum recorded "
is 0.02 gram nitrogen per kilogram body-weight. Although the
quantity given by Voit seems considerable (one hundred and
eighteen grams of proteid for a man of seventy kilograms), and
although less (even twenty-five to forty grams) is sufficient for
an individual when other forms of food are taken in great abund-
ance,'^ nevertheless there is a growing inclination to regard these
older figures as approximately correct for a healthy individual,
and to believe that the capabilities of the body are apt to be
diminished if less than this amount of proteid food be taken. On
the other hand, as Rubner has shown, proteids in the food should
not exceed a certain maximum proportion, for if they do, an
excessive amount of heat is liberated immediately after meals,
and this is not only useless, but may be directly harmful if the
heat regulation in the body be imperfect.
The cells are capable of repairing their proteid waste irre-
spective of whether the food contains a diversity of proteids or a
single one. But in what way the proteids are conveyed to the
cells is not known, though it is likely that the source is the blood
plasma. Nor is it known whether the cells are supplied with fully
formed proteids or with the split-products of the latter from which
they synthetize their own proteids.® That the body may build
up its nucleins for the most part is known.^
Certain facts lead us to believe that even the minimal proteid
requirement is considerably in excess of that needed to repair
308 THE BASIS OF SYMPTOMS
tissue waste. This excess enters into the formation of energy. In
this second function, however, proteids may be entirely replaced
by carbohydrates and almost completely by fats.^^
Inanition. — Inanition may be due to a variety of causes.
Of these the most important are, first, an insufficient in-
gestion of food — either from lack of food or lack of appe-
tite— and secondly, an insufficient absorption of
material from the gastro-intestinal canal. Prac-
tically, inanition is most frequently seen in connection with dis-
eases of the digestive system.
It is necessary to distinguish an insufficient supply of food
as a whole — a caloric insufficienc y — from an insuffi-
cient supply of proteid material — a proteid insuffi-
ci ency. These two are more or less independent of each
other, it being possible, for example, that a patient should gain
in weight, and yet suffer from an insufficiency of proteids, or
vice versa.
If too little food be supplied to the body, the in-
dividual must live upon his own tissues. His glycogen
and fats can furnish him with energy. In addition to this,
however, he consumes a certain minimal quantity of pro-
teids, which is, for the most part, sacrificed by the less im-
portant organs of his body. The amount of proteids thus con-
sumed depends partly upon the quantity of fat and glycogen at
his disposal and partly upon individual peculiarities, which, in a
particular case, tend to maintain it at a fairly constant level.
During the first few days of an absolute fast the excretion
of nitrogen is comparatively high, owing to proteids that
had been taken just before the fast began. As this excess of
nitrogen is being eliminated, the quantity in the urine gradually
sinks to a minimum; though the fall is sometimes interrupted
about the third or fourth day, possibly because the glycogen
in the body is exhausted. Toward the end of the fast the pre-
mortal rise of nitrogen excretion occurs, which is due
to the lessened amount of fat for consumption and to a larger
derivation of energy from the proteids alone.
During the earlier stages of starvation, therefore, the energy
necessary for muscular movements and for heat is supplied by
the combustion of the glycogen and fats stored up in the body.
The more valuable proteid material is thus protected from con-
NUTRITION AND METABOLISM 309
sumption. When the store of non-nitrogenous material comes
to an end, however, the proteids themselves must be utilized to
supply the necessary energy to the body.^^ The living tissues
then break down rapidly; yet a certain discrimination still takes
place. The more important organs live at the expense of the
less important; and Voit has shown that the former will retain
their normal weight practically unaltered to the end. The greatest
loss is sustained by the muscles, glands and fatty tissues; while
the heart and central nervous system are spared to the very last.^^
Absolute starvation is rarely seen by the physician, but partial
inanition is by no means infrequent, and its treatment furnishes
one of the most important problems that confront him. Usually,
in these cases, both the total caloric energy and the proteids in
the diet are insufficient. The amount of this deficiency may vary
up to absolute starvation.
The effects of starvation upon the individual de-
pend, in the first place, upon how complete it is. If the body
consumes thirty-five calories per kilo a day, and receives only
ten from the food, it must supply twenty-five calories from its
own substance, and the condition is naturally a much more serious
one than if it had received thirty calories in the food and had
supplied only five from its own substance. Furthermore, star-
vation is withstood much better if the patient be stout, for he
then has a larger amount of fat that can be utilized to supply
energy. This serves to postpone the time at which the non-
nitrogenous stores in the body give out, and the living tissue itself
must be consumed to supply energy. Finally, the course of inani-
tion is influenced by the demands made upon the energy within the
body ; thus, the condition is a more serious one when the individ-
ual must work, or when he is not well protected by clothing, etc.,
from losses of heat.
In certain diseases, hunger and insufficient
nourishment are often surprisingly well borne
— ^better indeed than they are in health — for the body seems to
be able to limit its consumption of proteids and energy. Aston-
ishingly low figures have been found in such cases; indeed,
patients have often gained in weight on a diet that would be
entirely insufficient for a healthy man.^^ The amount of heat
produced in the body during a short fast is about the same as
when the individual is consuming moderate amounts of food. If
310 THE BASIS OF SYMPTOMS
the patient suffers from prolonged partial starvation, however,
the amount of heat produced in the body seems to be lessened ;
and it would seem that the ability to limit the expenditure of
energy is much greater in wasting diseases, such as diabetes, for
example, than in hunger states of short duration in which no
opportunity is given for accommodation to the new conditions.
The Effects of an Oversupply of Food. — It is necessary to
discuss the effects of increasing the nitrogenous and the non-
nitrogenous elements in the food separately, for the laws govern-
ing each are different. We may say, in a general sort of way,
that the cells of the body ordinarily decompose all the p ro-
te ids taken in the food. When proteids are taken in abund-
ance, and the total caloric energy of the food is not too greatly
increased, there is merely a slight retention of nitrogenous mate-
rial during the first few days of the new diet. Very soon, however,
the body reaches a condition in which it is consuming all the
proteids furnished to it, and it is then said to be in nitrog-
enous equilibrium.
If the tissues happen to be in need of new material, as is the
case during growth and convalescence, it is possible that a con-
siderable proportion of the extra supply of proteids may be
retained in the body and may be built up into living tissue.
It is even possible to cause a considerable retention of
nitrogenous material in the bodies of normal animals
by feeding them with large quantities of both nitrogenous and
non-nitrogenous food.^* Apparently the same result may be
attained even more easily in man.^^ We do not know certainly
whether this nitrogenous material is retained in the body as pro-
teids or as other compounds. It is interesting to note in this
connection that when growing children or convalescents retain
nitrogenous material in their bodies, they are taking a diet that
contains an excessive amount of energy.^®
The ingestion of fats, but especially of carbohy-
drates, in great excess tends to diminish the excretion of
nitrogen in the urine; or, in other words, it tends to cause a
retention of nitrogenous material in the body. This fact has
been variously interpreted. E. Voit considers that the cells
utilize those foods which are supplied to them in greatest abund-
ance; whereas Pfluger and others believe that the selection of
material for consumption is a property of the living protoplasm,
I
NUTRITION AND METABOLISM Sll
and as such is almost independent of which foods are supplied
in excess. We cannot enter into a discussion of this physiological
problem, but may state our belief that the growth of living tissue
depends primarily upon the activities of the cells. In virtue of
some unknown property, the cells grow and multiply, and their
growth and multiplication are especially excited by functional
activity; providing, of course, that a supply of building material
is at hand. When the physician wishes to increase the living
protoplasm of the body, therefore, he should remember that it is
more important to increase the functional activities of the cells
than to furnish the body with an oversupply of food.
Among the materials essential to the building of the larger
proteid molecule seem to be certain intermediate products of
carbohydrate consumption — t he keto-acids. This explains,
possibly, the favorable influence of carbohydrates in the mainten-
ance of nitrogen equilibrium.
We have seen that the amount of energy needed by the body
depends primarily upon the work performed and the heat ex-
pended. A person lying in a warm bed, for example, expends less
energy than does one who works hard eight or ten hours each day,
or who is exposed to very cold weather. When excessive quanti-
ties of non-nitrogenous food are taken in the diet, a portion of
the excess is decomposed into its end products, carbon dioxide
and water; thus Rubner has shown that the feeding even of
greatly excessive amounts of fat leads to no appreciable increase
in heat production. So far as man is concerned, what constitutes
such an excess is still undetermined ; in all probability individual
variations play an important part.
Stahelin ^^ has observed in cases of tuberculosis an enormous
increase in energy expenditure following the ingestion of proteids.
Certain individuals do not gain weight despite a diet of extremely
high caloric value. According to Grafe,^^ this is due not to a
deficient absorption from the intestines, but to a greatly augmented
metabolism both in the fasting condition and after the taking of
food.
Disturbances in Fat Metabolism. — We have said that if large
quantities of non-nitrogenous material are taken in the food, the
unused excess is stored up in the body either as glycogen or as
fat. The quantity of fat in the body depends, therefore, to a
812 THE BASIS OF SYMPTOMS
great extent upon the relation that exists between the supply of,
and the demand for, energy-producing material.
Different classes of foodstuffs produce dif-
ferent effects as regards the tendency to accu-
mulate fat. For example, when proteids are eaten, the
general metabolism is accelerated far more than when fats or
carbohydrates are taken, and consequently less energy is left
for storage. The question as to whether fat is ever formed
directly from the proteids or not, has been settled to the extent that
it is known that sugar is split off from proteids and that fat
arises from sugar. At any rate, an excess of proteid material in
the food would favor a retention of fat in the body, for the reason
that the non-nitrogenous products of proteid cleavage may be
utilized for energy. This would spare the fats and carbohydrates
and allow them to be stored.
The carbohydrates of the diet that are not burned
immediately are deposited in the body partly as glycogen and
partly as fat.^^ That carbohydrates may give rise to fat in the
body has been demonstrated repeatedly. This transformation
takes place with the elimination of oxygen, which is subsequently
used in metabolism. Consequently more carbon dioxide is elim-
inated from the lungs than corresponds to the oxygen absorbed.
The respiratory quotient, or ratio of the former to the latter, may
rise, therefore, to as high a figure as 1.3 during this formation
of fat from carbohydrates.^^ The fat that is thus formed is rich
in stearin and plamitin, but poor in olein. In what part of the
body the transformation takes place is not known, though there
is some evidence that it occurs in the liver.
If fat is ingested in excessive quantities, it is deposited
as such in the body. The composition of animal fat is, therefore,
to a certain degree, dependent upon the composition of the fats
taken by the mouth. In spite of this fact, however, the body fat
in man and in many animals preserves a fairly constant composi-
tion. This may be explained on the assumption that the body
tends to pick certain fats out of the food for storage, or that
the food commonly taken is really of a more constant composition
than is ordinarily believed. Possibly the main reason for this
uniformity resides in the fact that a great part of the body fat
arises from carbohydrates.
The relation of the ingestion of fluids to fat
NUTRITION AND METABOLISM 313
metabolism is a much-discussed and still unsettled subject.
Many stout individuals drink a considerable quantity of liquids,
especially of beer, and it often happens that when the latter is
stricken from the diet, a loss of weight promptly follows. This
result is due in part to the loss of energy that would be derived
from the alcohol and carbohydrates of the beer; but it may be
due in part to the lessened quantity of fluids taken. Small
amounts of other drinks, such as coffee, tea, bouillon or light wine,
are often taken to increase the appetite, and if these be omitted
the individual may eat less and so lose weight from this cause.
Although these facts are of the greatest practical importance,
they have no theoretical bearing on the question as to whether or
not fluids directly influence the storage or decomposition of fats
in the body. Though this question has not yet been satisfactorily
settled,^ ^ it seems worth while to review some of the evidence
bearing upon it, and to call attention to some of the difficulties
encountered in its solution.
It is a surprising fact that while animals are being fattened
very little water is usually allowed them,^^ from which we may
infer that a relatively dry diet certainly does not seriously inter-
fere with the accumulation of fat in the body.
The question as to the effect of liquids upon the accumulation
of fat in man is a difficult one to solve ; for in him the only method
whereby we can practically estimate a gain or loss of fat is weigh-
ing, and a difference in weight might equally well be caused by a
change in the quantity of proteids, of glycogen or of water in the
body. The first two of these may be neglected, practically, for
the variations that they undergo are not great. The third, how-
ever, is of the utmost importance in a consideration of this ques-
tion, and constitutes a considerable source of error whenever we
assume that a gain or loss of weight is necessarily caused by a
correspondingly great gain or loss of body fat.
Stout persons ordinarily drink large quantities of water, prob-
ably because they perspire so freely, and this water is not all
immediately excreted, but is stored in part in the body. If now
the patient refrains from drinking water, and takes much exercise,
he loses weight rapidly. The main cause of this early loss of
weight, however, is the loss of water, the result being merely a
drying-out of the body.^^ Indirectly this loss of water may assist
in reducing the fat in the body, for when the weight of a stout per-
314 THE BASIS OF SYMPTOMS
son is lessened by the loss of fluids, it is possible that he will take
more exercise and so consume more fat.
It will be seen from these considerations that different factors
render this question a most difficult one to solve. At present we
possess no conclusive evidence that the limitation of fluids directly
influences fat metabolism ; though such a limitation may indirectly
reduce the weight of the body either by removing water from it,
by diminishing the amount of food taken or by increasing the
ability to take exercise.
Pathological Accumulations of Fat. — No sharp distinction
can be made between pathological and physiological accumulations
of fat, and it is often merely a matter of opinion as to whether
a given person is too stout or not. The line separating the normal
from the abnormal should be drawn at the point where the general
health and the capabilities of the individual begin to be impaired.
When these are affected, we are justified in speaking of a patho-
logical accumulation of fat.
Fat tends to collect in certain parts of the body, especially
in the subcutaneous tissues and the mesentery, and about the
heart, the kidneys and the liver. In young animals it may also
collect in the muscles between the individual muscle-fibres,^^
whereas in older animals it tends to accumulate in the above-
mentioned situations.
The individual who suffers from excessive accumulations of
fat gradually becomes less and less able to work. This is due, in
part, to the increased weight of the body, for more exertion is
required to execute the same movements. On this account, fat
persons are inclined to avoid all unnecessary exertion. This be-
ing the case, their muscles tend to atrophy from disuse, and the
disproportion between the body-weight and the individual's loco-
motive power constantly increases. The patient avoids movements
because his body is too heavy; and the lack of exercise weakens
his muscles so that he is less able to move. Most stout people
also perspire very readily, because their thick layer of fat dimin-
ishes the amount of heat given off from the surface of the body
by radiation and conduction. This sweating is very unpleasant,
and furnishes another excuse for their avoiding exercise.
In Rubner's laboratory, the capabilities of lean and stout men
have been carefully studied under different conditions of tempera-
ture and humidity,^^ and it has been shown that as the temperature
NUTRITION AND METABOLISM 315
and humidity of the air increase the ability of stout people to work
diminishes rapidly, for they quickly become overheated and per-
spire profusely. Their fat thus renders them less able to work
and soon causes unpleasant subjective sensations from over-
heating.
Finally, very stout people avoid exertion because they get out
of breath so easily. Their dyspnoea is due, in the first place, to the
increase in abdominal fat, which limits the movements of the
diaphragm; in the second place, to the additional weight of the
body which necessitates more actual work for the accomplishment
of the same movements ; in the third place, to a weakness of the
muscles or to an associated anaemia; and finally, it is due to the
cardiac disturbances which are so often present in obese individ-
uals and which have already been described (p. 43). It is thus
apparent that excessively fat persons suffer in a variety of ways,
partly on account of the presence of the fat itself and partly on
account of the weakness of the general or cardiac musculature.
The primary cause of obesity lies in a dispro-
portion between the energy taken in the food
and the amount expended by the body. As we have
just said, stout people usually show a disinclination to exercise,
and this, by diminishing the expenditure of energy, favors the
deposition of new fat in the body. Furthermore, many stout
persons eat to excess, and the carbohydrates and fats in their diet
are especially disadvantageous. In certain instances, the absorp-
tion of proteids seems to be diminished, and the patient suffers,
at one and the same time, from too much fat and too little pro-
teid.^* Alcoholic beverages certainly tend to increase obesity.
In the first place, they furnish a not inconsiderable amount of
energy in the form of alcohol, and frequently also in the form of
carbohydrates (beer) ; and, in the second place, they tend to take
away the energies of the individual and so to diminish the exercise
that he takes.
These causes, singly or together, are responsible for most
cases of obesity. It is merely a problem in arithmetic. A certain
amount of energy is taken in the form of food, a certain amount
is lost as heat and work, and the remainder is stored up in the
body mainly as fat. As soon as the accumulation of fat begins
to deter the patient from taking active exercise, a vicious circle is
established and he tends to increase in weight more and more.
316 THE BASIS OF SYMPTOMS
The question has been raised as to whether all cases of obesity
can be explained in this comparatively simple manner. Physicians
certainly have the impression that not all cases are due to a simple
disproportion between the energy taken in and that given out;
and it seems as if many persons, in spite of abundant nourishment
and little exercise, remain lean, whereas others become stout,
even though they eat but little and do considerable work.
It is extremely difficult to form a judgment on this question.
In the first place, it often happens that, although the patient thinks
he is not eating to excess, he is really doing so. Then we have no
accurate method for determining the amount of exercise that he
takes. There are the most extraordinary individual variations
in this respect, as can be readily imagined if we compare a nervous
individual, constantly in motion and all his muscles tense, with a
phlegmatic person who never executes an unnecessary movement.
The energy expended by each is vastly different, even while they
are accomplishing the same task. Finally, factors that influence
heat losses must be considered, such as, for example, the thickness
of the clothing, the temperature of the surrounding air, its mois-
ture, etc. All these influence, to some degree, the consumption
of energy in the body.
Yet, even allowing for all of them, there still remains the
impression that some men exhibit an unusual relationship between
the diet, the exercise taken and the fat deposited. Some chil-
dren,^^ for example, show a remarkable tendency to become stout ;
or certain families are known for the obesity of their members;
some anaemic persons tend to accumulate fat, etc. To be sure, it
may be answered that when the parent eats to excess, the children
learn the same habit, or that the anaemias tend to limit the amount
of exercise taken, etc. Nevertheless, the impression remains that,
for some unknown cause, certain individuals possess a peculiar
tendency to lay on fat.
We should not, however, trust to impressions. The question
is one that can be solved only by careful and exact experiments,
and up to the present these have furnished no evidence which
would indicate that such a constitutional tendency to
obesity, in the sense of a slower rate of metabolism, actually
exists. For example, Rubner has shown that, of two brothers,
one stout and the other thin, the former burned up even more
fat than the latter. Others have demonstrated that stout persons
NUTRITION AND METABOLISM 317
consume a normal amount of oxygen and give off a normal
amount of carbonic acid gas during fasting; ^^ and, although the
increase in heat production that immediately follows the taking
of food is said to be less in stout than in thin persons, v/e are
hardly justified from this fact alone in assuming a slower rate
of metabolism in the former.
Recent studies have shown that a slower rate of metabolism
actually may be present in obesity. The caloric needs in the ex-
periments of V. Bergmann and Stahelin ^^ were so small that one
must assume the possibility of a constitutional adiposity. Graf e ^^
has shown that a similar diminution of energy expenditure may
occur also in comatose conditions.
The gain in weight that so often follows castration has
been cited as an example of a constitutional change leading to
obesity. It is certain that many, though not all, castrated animals
and men gain in weight. We may question, however, whether
this gain is directly due to the loss of a hypothetical accelerating
influence of the genital organs upon metabolism, or whether the
gain is not indirectly due to changes in the temperature of the
individual, in his appetite for food, his desire to exercise, etc.
Liithje^^ has made a careful comparative study of the nitrogen-
ous metabolism, and a partial study of the carbon and mineral
metabolisms of castrated and normal dogs over a period of more
than a year, and, finally, at the end of this time, he has determined
the total composition of their bodies. As no differences could be
found between the normal and pathological animals, we must con-
clude from, these experiments that castration does not directly
affect the body metabolism. Although other observers ^^ have
found certain differences by other methods, nevertheless it seems
to me that Liithje's experiments are the most conclusive we have.
Nor have studies on castrated women cast any doubt upon the
validity of his results.
This much is certain, that obesity results from a failure to
consume all of the nourishment taken ; but that a lessened rate of
cellular metabolism also plays an important part in certain cases,
has been shown by recent observations.^^
The association of obesity with anaemia, with
gout, with arteriosclerosis and with various
forms of calculi, should be mentioned here, though the
exact causal relation between these is unknown to us. Further-
318 THE BASIS OF SYMPTOMS
more, when we compare the many similarities in the picture of
myxcedema and obesity, we need not hesitate in attrib-
uting to a lessened activity of the thyroid gland a
part in the abnormal accumulation of fat. (And, finally, various
types of adiposity — adiposis universalis, dystrophia adiposo-
genitalis, adiposis dolorosa — have come to be regarded as mani-
festations in many cases of an insufficiency of the pos-
terior lobe of the hypophysis, associated w'ith
an increased tolerance for carbohydrates. This
accumulation of fat may be due to a primary hypopituitarism,
or it may follow a period of increased hypophysial activity, the
end stage being called by Gushing^* dyspituitarism. — Ed.)
Pathological Changes in the Metabolism of Proteids. — As has
been described, the growing child and the convalescent from in-
fectious diseases are both able to retain some of the nitrogen
taken in the food; whereas a normal individual under like cir-
stances would soon come into a condition of nitrogenous equi-
librium. Even in the above instances, however, a great excess
of food is usually taken, for such individuals have an enormous
appetite.
Pathological Destruction of Proteid Material. — If, as has been
said, the ingestion of proteids falls below a certain limit, or if the
body has no non-nitrogenous material at its disposal, and is not
oversupplied with proteids in the food, then the living nitrogenous
substances in the tissues must be consumed to supply the body
needs. In the class of cases which we now wish to consider, how-
ever, there is a pathological consumption of the body substance,
and especially of its proteids,^ ^ even though an ordinary amount
of food be taken. If such a patient fasts, his excretion of nitrogen
is considerably greater than is that of a normal individual of like
weight, etc. If an attempt be made to bring him into a condition
of nitrogenous equilibrium, it is often a complete failure, for as
proteids are added to his diet the consumption of nitrogenous
material also increases, so that the output of nitrogen remains
constantly somewhat greater than the intake. In certain of these
cases, however, it is possible to maintain a nitrogenous equi-
librium by using enormous quantities of food.
We must not lose sight of the fact, however, that what we
call a pathological destruction may be only a disturbance in the
power of the body to synthetize proteids — a process which prob-
NUTRITION AND METABOLISM 319
ably plays a larger role in metabolism than is generally supposed.
And it is possible that fats and carbohydrates have an altered
influence upon proteid metabolism in the pathological types of
proteid destruction we are considering. For example, in certain
disorders of the liver, a considerably larger amount of carbohy-
drates than under normal conditions is necessary to insure a proper
fat consumption without an associated destruction of the body
proteids.^^
A pathological proteid destruction of this
character takes place in all forms of fever, and will be
referred to again in that connection. It also occurs in many
patients with carcinomata^^ and other malignant tumors,
in many with tuberculosis, even though no fever is pres-
ent, in severe anaemias^® and in certain intoxica-
tions, as from phosphorus. ^^ Possibly, also, it is pres-
ent in other conditions, such as scleroderma, lichen ruber and
pemphigus vegetans. In these conditions, it is not the disease
per se which determines the destruction, but rather some con-
dition, as yet not understood, of the tissues themselves.
In the chronic leukaemias, even in those without fever, metabo-
lism as a whole is increased, though proteid destruction is appar-
ently unaffected.*^
In the conditions enumerated, excessive quantities of fat are
also frequently consumed, for the diet is often an insufficient one,
but this consumption follows the ordinary physiological laws of
inanition; whereas the destruction of proteids is of a pathological
character. Which cells of the body suffer most from this con-
sumption of proteids has never been determined, though one would
be inclined to believe the loss falls on the same organs as it does
in inanition (see p. 308).
Not all patients with carcinomata, severe anaemias or tuber-
culosis suffer from this increased destruction of proteids; and it
would appear, therefore, that other factors are operative in these
cases. In view of the fact that certain poisons, such as phos-
phorus, may accelerate the destruction of proteid material,
F. Miiller has advanced the hypothesis that toxic sub-
stances are also responsible for the increased
proteid destruction in certain cases of carcinoma.
These toxic substances have never been isolated, yet there is
every reason to believe that this explanation is a correct one.
320 THE BASIS OF SYMPTOMS
Only when this hypothetical poison is produced does the disease
lead to a destruction of proteid material. This theory is sup-
ported by the fact that in tuberculosis and carcinoma we some-
times see toxic symptoms resembling those of diabetic coma.
In the light of our present conception that the body may build
its own proteids from the simpler components of the latter, it is
possible that a patfiological proteid destruction may be due to a
toxic disturbance of this synthetic process. As amino-acids are
built up from keto-acids (an intermediate step in the combustion
of carbohydrates) and ammonium salts, it is readily understood
how carbohydrates may affect the elimination of nitrogen.*^
In carcinoma, special factors play a role in the destruction
of proteids. According to Blumenthal,*^ ulceration of the pri-
mary growth and the formation of metastases have a distinct
influence upon the body proteids. Schmidt ^^ attributes this to
the formation of a heterolytic ferment, which under given con-
ditions enters the circulation. Though this is still disputed,**
Abderhalden observed certain differences in the behavior of fer-
ments from healthy and carcinomatous tissues (see p. i86).
A pathologically increased nitrogenous metabolism is most
serious, for it becomes impossible to maintain the patient's nutri-
tion, and the loss of proteids may eventually prove fatal.
The Metabolism in Thyroid Disease. — Many patients with
exophthalmic goitre manifest no peculiarities as regards their
metabolism ; others, however, show periods of fair to good nutri-
tion alternating with periods of emaciation. This emaciation
may occur even when the appetite is considerably increased.
One of F, Miiller's patients,*^ for example, weighing only twenty-
nine kilos (sixty- four pounds), lost both in nitrogen and general
weight, even though the diet furnished as much as sixty-eight
grams of proteids per day and fifty-eight calories for each kilo
of body weight. In such cases a pathological consumption of
both nitrogenous and non-nitrogenous material is undoubtedly
taking place in the body. Steyrer,*^ on the contrary, found no
increase in nitrogen elimination or in metabolism as a whole,
in cases of hyperthyroidism which were given thyroid extract.
Magnus-Levy *''^ observed an increased oxygen consumption in
hyperthyroidism whether the individual was at rest or not, due
probably to the marked motor unrest. As a rule, it is possible
NUTRITION AND METABOLISM 321
to attain a nitrogenous and caloric equilibrium in these patients
by giving them very large quantities of food.*®
It is very interesting that, in Matthes's cases, the excessive
consumption of proteid material disappeared after the removal
of a large part of the thyroid gland, thus conclusively demon-
strating that the pathological thyroid function in-
creased the consumption of nitrogenous and
non-nitrogenous material in the body. It was
found, furthermore, that when the substance of the thyroid gland
was administered to these patients after their operations, the
excretion of nitrogen rose to what it had been previously.
The amounts of oxygen absorbed and of car-
bon dioxide eliminated by patients with exoph-
thalmic goitre are greater than the normal.*®
This is in accord with the observation that after the removal
of the thyroid gland from rabbits, these animals show an abnor-
mally low "respiratory interchange of gases" when fasting;
and, if thyroid substance be then administered to them, this inter-
change returns to the normal.^^ We see, therefore, that in cer-
tain patients with exophthalmic goitre there is an increased con-
sumption not only of proteids but also of non-nitrogenous mate-
rials. In this last feature the metabolism differs from the increased
proteid metabolism of carcinoma; and it is possible that the loss
of proteids in exophthalmic goitre is merely secondary to the loss
of non-nitrogenous material. °^
The administration of the thyroid gland to
healthy men or animals, either by way of the digestive tract
or by subcutaneous injections, increases the bodily consumption
of proteids and fats.^^ In a certain proportion of cases this loss
may be covered by an abundant diet. Here again it is uncertain
whether the destruction of proteids is secondary to the destruction
of fats or not, though in general it would appear that the proteids
are directly affected and not because of a deficiency of fats.
Metabolism, as a whole, is sometimes moderately increased
after thyroid extract administration, and at other times unchanged.
Hence, the loss in weight suffered by stout individuals who have
been given thyroid extract cannot be due solely to a generally
augmented metabolism, but must depend in great part upon the
increased exercise which is prescribed.
It is not unlikely that a physiological func-
21
322 THE BASIS OF SYMPTOMS
tion of the thyroid gland is the regulation of the
body metabolism. At any rate, we often meet with in-
dividuals whose metabolic processes exhibit marked quantitative
changes and whose thyroid glands suggest variations from the
normal, not in the sense of an exophthalmic goitre. For example,
an emaciation often follows the exhibition of small doses of
iodin, which clinically bears a close resemblance to thyroid
cachexia. Peculiar factors must be at work here, however, for
iodin ordinarily does not augment metabolism.^^
If the function of the thyroid gland be dimin-
ished below a certain point, nutritional disturbances may de-
velop in the skin, nails, bones and other organs. ^^ The skin
becomes thick and immobile, owing to a collection of mucin-like
material in the corium, the connective-tissue fibrils thicken and
the hair falls out. Weakness of the muscles and disturbances of
sensation are associated with a general loss of intelligence; and
if the glands be removed from growing animals, the growth may
be stunted. Metabolism in these cases is gener-
ally and markedly slowed and diminished, both
as regards the destruction of proteids and the
consumption of energy in general. ^^ After extir-
pation of the thyroid, fats and carbohydrates do not reduce proteid
destruction to nearly as marked a degree as they do normally. ^^
In general the manifestations of thyroid insufficiency depend
upon the rapidity with which the changes in its secretion have
occurred and particularly upon the age of the individual.
These symptoms closely resemble those of myxcedema
and cretinism,^''^ conditions in which the thyroid gland is
found to be diseased or absent. The variations in symptoms seen
in these diseases are probably due to the varying intensity and
character of the thyroid lesion, as well as to the age of the patient
when the disease began. The changes in myxcedema and cretinism
are to be attributed, therefore, to an insufficient function on the
part of the thyroid gland. As proof of this we have the remark-
able results obtained by the administration of thyroid substance
to these patients.^^ It is important to remember that partially
developed cases (formes frustes) of hypothyroidism, as well as of
hyperthyroidism, are not uncommon among all peoples.
Exophthalmic goitre, on the contrary, is probably
due to an increased thyroid function,^* In favor of
NUTRITION AND METABOLISM 323
this view are the facts that a partial extirpation of the thyroid
has improved or cured many patients with this disease, and that
the administration of large quantities of thyroid substance to a
normal individual will produce symptoms resembling, to a certain
degree, those of exophthalmic goitre.
The picture of hyperthyroidism is a variable
one.*^^ The individual case may be mild or severe, and its course
chronic or very rapid. Of great theoretical importance is the
question whether the manifestations of this disease are the result
merely of a hypersecretion of the normal products of the thyroid
gland or whether there is an associated chemical alteration of the
latter. Though this question is still sub judice, it seems to me
that the change is purely a quantitative one; speaking for this
are the results of surgical interference, as well as the production
of the characteristic symptoms in animals and in man by feeding
not only extracts of the gland, but also iodin and its compounds.^^
Baumann has familiarized us with the role of the thyroid in iodin
economy, and has shown that in certain individuals — in those
particularly whose thyroids are already functionally disturbed —
the exhibition even of small doses of iodin suffices to render the
thyroid overactive.
The activities of the thyroid are also intimately bound up
with those of the nervous system. Many cases of hy-
perthyroidism are of nervous origin. That the
nervous system directly or indirectly stimulates the gland is a
possibility, for we are still uncertain whether hyperthyroidism
rests upon a primary disturbance of the thyroid gland. The
glands of internal secretion are all intimately de-
pendent upon nervous and psychic factors, and the evidence of
the latter is almost a regular accompaniment of hyperthyroidism.
The pathological substratum of Basedow's
disease is not specific, despite the frequency of such findings
as changes in the colloid and an epithelial hyperplasia, as well
as lymphoid infiltration.^^ At any rate, the clinical picture may
arise in association with strumas of various types or even in the
apparent absence of thyroid changes.
The symptom-complex, as we have already empha-
sized, is extraordinarily variable. Rudimentary forms
with a few manifestations are extremely common. Personally,
I am strongly convinced that from a simple goitre a series of
324 THE BASIS OF SYMPTOMS
thyreotoxic conditions may arise, varying from the mildest to
the most severe types. It is advisable perhaps, for clinical reasons,
to distinguish these transitional forms, such as the K r o p f -
herz, though this represents merely one manifestation of the
many. On the other hand, one of the characteristic evidences of
hyperthyroidism — an augmented metabolism — ^may be absent even
in severe cases of the disorder.
The origin of the various symptoms of Basedow's disease is
not known. Certain factors point to increased sympathetic irrita-
bility. Furthermore, we would call attention again to the interre-
lationship of the ductless glands, though the weighty observa-
tions^^ reported from the Gottlieb institute relative to a non-
increase of epinephrin in the blood of Basedow patients suggest
caution in this respect.
There seems good reason to believe, despite the inherent com-
plexity of the problem, that the thyreotoxicoses are susceptible
of clear-cut classification; though I would discard such vague
subdivisions as vagotropic and sympathicotropic,^* and also a
classification based upon the poly valence of the thyroid substances.
The parathyroid glands are functionally distinct from
the thyroids, and their complete removal from animals is followed
by tetany. ^^ In accordance with this experimental fact is the
experience that in those clinics where the method of extirpation
of the thyroid involved a simultaneous removal of the parathyroids
the patients showed a special tendency to tetany. The exact way
in which the parathyroids affect the nervous system is not known.
(It would appear from the studies of several observers®® that
the parathyroids exert their effect, in part at least, via the sym-
pathetic nervous system. Complete extirpation of
the glands in dogs leads to a marked increase of vasomotor
irritability. That this may be a result of calcium deficiency is
indicated by the fact that subsequent injections of calcium salts
tend to restore this irritability to its normal level. — Ed. )
The Qualitative Changes in Metabolism
Unfortunately, we know but little concerning the intermediary
stages through which the various constituents of the body pass
before they are finally eliminated through the excretory organs
as highly oxidized products. Though it would be logical to
discuss the catabolism of each substance separately, and to follow
NUTRITION AND METABOLISM 325
each to its excretion, this is not possible with our present limited
knowledge. For this reason, therefore, we shall merely consider,
first, certain facts concerning the proteids, and, later, certain
abnormal excretory products.
The proteids taken in the food are split up in the body
into nitrogenous and non-nitrogenous constituents. The former
probably consist of ammonium compounds; and the greater part
of these are synthesized into urea, probably in the liver, and
are then eliminated through the kidneys. Nitrogen is present in
the urine in various forms, about eighty-five per cent, being urea,
from two to five per cent, ammonia, and the remaining ten per
cent, a variety of compounds of which uric acid and the purin
bases form a large part.
Whether or not the proteid catabolism in the body follows
the same course as it does in the digestive tract — ^viz., albumoses,
peptones and amino-acids — has not yet been determined. Patho-
logically, at least, albumoses and amino-acids may be formed,
for they are demonstrable in the urine, as will be shown in dis-
cussing the subject of autolysis (p. 326).
Autolysis. — If the organs of the body are kept aseptically at
37° C. for some time, their proteids undergo hydrolytic
cleavage, owing to the action of enzymes that are present in
the cells.^^ Albumoses and peptones have not been demonstrated
as products of this "autolysis," presumably because they are so rap-
idly split up into amino-acids, basic substances, fatty acids, hydro-
gen sulphid, carbohydrates, etc. The nucleo-proteids are decom-
posed into proteids and the nucleinic acids, and the latter in turn
into phosphoric acid and the purin bases. It is an interesting fact
that the enzymes in any particular class of cells will split up the
proteids of those cells more readily than they will proteids from
other sources. To what extent the cleavage of proteids within
the normal body resembles autolysis is not known, for normally
the intermediary products of proteid catabolism, such as the
amino-acids, do not appear in the urine. This last is not
conclusive, however, for it is possible that the normal organism
oxidizes them so rapidly that their existence is a short one. Speak-
ing for this hypothesis is the fact that even in conditions in which
large amounts of proteid are hydrolyzed (phosphorus poisoning,
acute yellow atrophy of the liver) amino-acids may not appear
in the urine, or, if they do, their amount is small. Albu-
326 THE BASIS OF SYMPTOMS
moses^® have been found by some observers in the blood of
healthy individuals, but this has not been generally confirmed*^
(c/. p. 139).
The products of a hydrolytic cleavage of pro-
teids are, however, excreted under pathological
conditions, especially when dead cells or fibrin are left to
themselves, as occurs in abscesses, in the resolving stage
of pneumonia,"^* in acute yellow atrophy of the
liver and in phosphorus poisoning. In these condi-
tions, albumoses and even peptones may appear in the urine.
Since the above conditions are caused by toxic or infectious
processes, the question naturally arises as to whether the hydro-
lytic cleavage of the proteids is due directly to the toxins or bacteria
that cause the disease, or whether it is due to the action of intra-
cellular enzymes and is of the nature of an autolysis. The former
view seems rather improbable, for Miiller has shown that the
pneumonic exudate exhibits no tendency to undergo hydrolytic
cleavage so long as but few leucocytes are present, even though
the bacteria have been constantly at hand. As has already been
mentioned, the tissues, even when free from all bacteria, contain
proteolytic enzymes, and it seems probable that these are respon-
sible for the abnormal decomposition in the above-mentioned
conditions.
During the involution of the puerperal uterus
the muscle-fibres also undergo autolysis, and the resulting products
may appear in the urine."^^
In many diseases of the liver no abnormal end-
products of proteid decomposition are excreted. In other more
serious and extensive hepatic conditions, various pathological
substances appear, and in acute yellow atrophy and phosphorus
poisoning, especially, the urine may contain albumoses,'^ or even
peptones,''^^ as well as leucin, tyrosin, para-oxyphenylacetic acid
and lysin."^* These substances appear to arise mainly from an
autolysis of the liver cells, but in some cases the quantity in the
blood is so great that they could not possibly have all originated
in this manner, and some must have come from other tissues.'^®
By means of Emil Fischer's improved technic for the detection
of amino-acids,'^^ we have learned that these bodies are present
in not inconsiderable amount in the urine even of healthy indi-
NUTRITION AND METABOLISM 327
viduals J^ They appear also in such conditions as gout, leukaemia
and the infectious diseases, though not in excessive quantities.
The Formation and Excretion of Ammonia. — Normally,
from two to five per cent, of the total nitrogen excreted appears
in the urine in the form of ammonium salts. Under pathological
conditions, however, the proportion may be greatly increased;
and in acute yellow atrophy, for example, it may reach thirty-
seven per cent., and in starvation even fifty-seven per cent.
An increased excretion of ammonia is not the result of an
increased production of this compound within the body; for large
quantities of the ammonium salts of organic acids may be taken
by the mouth with only an insignificant increase in their elimina-
tion in the urine.'® The quantity of ammonium
salts in the urine is to be regarded rather as an in-
dication of an excessive quantity of acid in the
body. The ammonia normally formed in metabolism, instead
of being transformed into urea, combines with the excessive acids,
and is excreted by the kidneys as the ammonium salts of these
acids. The body thereby retains for the most part its fixed alka-
lies for the transportation of carbon dioxide. Eppinger"^^ sees
in the differing behavior of herbivora and carnivora in respect
to their ability to neutralize excessive acids, only the result of
their dissimilar foods ; in other words, he believes that the am-
monia employed in the neutralization of acids arises not from the
body proteids, but from those ingested. Indeed, the administration
of large amounts of alkalies may cause a complete disappearance
of the urinary ammonia. Walter®^ found that, after adminis-
tering hydrochloric acid to dogs, about three- fourths of it was
neutralized by ammonia in the body, while most of the remainder
went to raise the acidity of the urine, and a small part apparently
combined with the fixed alkalies of the blood. This last effect is
serious, for the ability of the blood to carry carbon dioxide is
thereby diminished (see p. 224).
An excessive excretion of ammonia is indicative, therefore,
of an excessive amount of acid in the body. The amount
of ammonia in the urine is increased whenever
the proteids of the diet are increased at the ex-
pense of the carbohydrates, for the reason that pro-
teids furnish an acid ash. The amount is increased, furthermore,
whenever there is a pathological breaking down of
328 THE BASIS OF SYMPTOMS
the tissues, for this is equivalent to an increased proteid
catabolism. In diabetes, an excessive amount of organic
acids may be formed, thus increasing the elimination of ammo-
nium salts. Finally, an abnormal excretion of ammonia is the
rule infebrileconditions^^ and may also accompany various
chronic diseases, especially of the liver. In
phosphorus poisoning, the output is both relatively and
absolutely increased and may reach seventeen per cent.
That the increased elimination of ammonia is purely secondary
has been proved by the fact that, if alkalies be administered to
patients who excrete excessive quantities of ammonia in the urine,
the abnormal acid in the body will be neutralized, the excessive
excretion of ammonium compounds diminished and the excretion
of urea correspondingly increased.
In some instances the origin of the abnormal acid-
it y is readily determined. Mineral acids may have been
taken by mouth, either accidentally or with suicidal intent. In
phosphorus poisoning, the rapid destruction of cellular
protoplasm liberates the sulphur and phosphorus contained in
the proteid molecules, and these give rise to sulphuric and phos-
phoric acids in considerable quantities. In addition to these,
various organic acids, such as lactic and aromatic acids, are formed
in phosphorus poisoning, and this excessive acid production is
sufficient to account for the increased excretion of ammonia
which takes place in this condition. In many diseases, however,
the explanation is not so close at hand and we must assume that
organic acids are produced to account for the increased ammonia
excretion.
The Production of Organic Acids. — Organic acids, especially
carbonic and carbamic acids, are being constantly formed in nor-
mal metabolism. These particular acids, however, are not elim-
inated in ammonia combinations, for the carbonic acid leaves the
body, for the most part, through the lungs, and the ammonium
salt of carbamic acid can be transformed into urea in the liver.
The organic acids that are most frequently eliminated as ammo-
nium compouHds are beta-oxybutyric and diacetic
acids.
It is remarkable that sarcolactic acid is not more fre-
quently found in the urine, for we know that it is normally formed
in considerable quantity during muscular activity. Under such
NUTRITION AND METABOLISM 329
circumstances, however, it is apparently rapidly oxidized. It prob-
ably arises from the non-nitrogenous products of proteid cleavage,
although it is possible that it may also arise in part from the
carbohydrates, in view of the close relationship that we now know
to exist between the latter and proteids. Pathologically,^ ^ lactic
acid has been found in the urine in cases of phosphorus poison-
ing, trichinosis, pernicious anaemia, severe heart disease, acute
yellow atrophy and in animals during arsenical poisoning and after
severe hemorrhage. Yet in none of these conditions, with the
possible exceptions of phosphorus poisoning and acute yellow
atrophy, does lactic acid regularly appear in the urine. In some
instances, its appearance is due to a diminution in the oxidative
processes within the body,®^ especially in the liver, and, in still
others, to unknown causes. Ethyliden-lactic acid has
been found in the urine in severe cases of diabetes, and at times
propionic and acetic acids have also been found.
Of all the organic acids, beta-oxybutyric is the most
important in this respect, for it appears in the urine not very
infrequently, and is sometimes excreted in enormous quantities.
By oxidation of this acid, diacetic acid is formed; though
the process may be reversed — ^beta-oxybutyric acid is formed from
diacetic acid by reduction — as recent studies ®* have shown. Ace-
tone probably does not arise in the cellular metabolism proper,
but rather in the lungs and kidneys, through which it is excreted,
in the former case giving to the breath the characteristic " fruity "
odor. The condition underlying the building of these so-called
acetone bodies is known as acidosis.*^
Normally these bodies are oxidized to carbon dioxide and
water in the body, and only traces, at most, of acetone are excreted
in the urine. Under various abnormal conditions,
however, they may leave the body unoxidized. This
may occur during hunger,^® after anaesthesia, during a salt-free
diet,®^ in many cases of diabetes,^* and, in general, in severe
states of inanition. Experimentally, beta-oxybutyric acid may
appear in the urine of dogs after phlorhizin poisoning*^ and after
extirpation of the pancreas, though the latter is rare. At times,
some one or several of these compounds, but especially acetone,
will appear in the urine without any apparent cause.*^ It is pos-
sible in these obscure cases, that it arises from the absorption of
toxic substances from the intestines ; yet even in the acid intoxi-
830 THE BASIS OF SYMPTOMS
cations occurring especially in children, and associated with pro-
fuse diarrhoeas, the acidosis is not intestinal in origin, but rather
the result of a carbohydrate deficiency. It was formerly held that
the acetone bodies might be formed within the intestinal canal,
but at present there is but little inclination to refer their origin
to this source. In the majority of cases, at least, they are pro-
duced during the intermediary metabolism within the body.
As beta-oxybutyric acid and its derivatives are not of regular
occurrence in the conditions mentioned above, we must assume
that special factors are influential. Prominent among these is a
deficiency of carbohydrates, be it that the amount
ingested is too small, as in starvation, or, with a sufficient
supply, that it is improperly utilized, as in diabetes. The
acetone bodies occur promptly in man and in the ape during star-
vation, and in dogs, on the contrary, very tardily. This starva-
tion acidosis disappears forthwith if carbohydrates or even pro-
teids in large amounts are ingested. In the latter case, the carbo-
hydrate arising from the proteid is apparently the influential
element.
Though the lack of carbohydrates is, undoubtedly, an im-
portant factor in the causation of acidosis, it is just as certainly
not the sole one in all cases. In many of these there is an inter-
mediate and as yet unknown anomaly in carbohydrate metabolism
which plays the determining role; though in still others, the
utilization of carbohydrates seems to be quite normal.
In no condition do the acetone bodies appear
in the urine in such quantities as in diabetes mel-
litus. Our knowledge of the conditions underlying their
formation and excretion is derived principally from studies of
exj>erimental diabetes in animals and of the disease in man.
Acidosis is common and pronounced in phlorhizinized animals.
After pancreas extirpation, on the contrary, it is decidedly less
frequent. In human diabetes it may or may not be present, being
most likely to occur in the very severe cases, i.e., those with a low
sugar tolerance. The transition from a mixed to a strict meat diet
favors its appearance or intensifies it if it is already present. A
diminished combustion of carbohydrates in the
intermediary metabolism is, therefore, an import-
ant factor in the causation of diabetic acidosis,
though not the only and determining factor. Nor does proteid
NUTRITION AND METABOLISM 331
destruction play this important role, for Weintraub®^ has ob-
served an acid intoxication in cases of nitrogen equilibrium and
indeed of nitrogen retention.
Though the ultimate cause of diabetic acidosis is not known,
it is probable that it resides in an anomaly of the intermediary
metabolism of certain cells, linked, on the one hand, with a dis-
turbed carbohydrate utilization and, on the other, with an in-
creased consumption of fat.
The main source of the acetone bodies is still not
definitely settled. In this connection, our attention is focussed
upon the proteids and fats, rather than upon the carbohydrates
as was formerly the case. We must assume that in some instances,
at least, both proteids and fats contribute to their formation, for
in cases of maximal beta-oxybutyric acid production, the nitrogen
output is greatly below what we should expect if proteids were
the sole source of the acid.®^
Our knowledge of the origin of the acetone bodies has been
appreciably increased in recent years both as a result of animal
experiments®* (perfusion, etc.) and of observations in severe
cases of human diabetes based on the feeding of various sub-
stances.®* These have shown that beta-oxybutyric acid represents
a point of contact in the metabolism of two main food-stuffs, viz.,
fats and proteids, in that the catabolism of both occurs via this
acid. This is the more interesting because there exists an anal-
ogous point of contact in the case of proteids and carbohydrates
in the next simpler oxyacid, lactic. Of the amino-acids, leucin,
ty rosin and phenylalanin build oxybutyric acid ; while of the fatty
acids, butyric and capronic acids and their higher homologues
with an even number of carbon atoms, have a similar property.
Though these various observations are of great theoretical interest,
we cannot enter into fuller detail, except to mention the fact that
certain fatty acids of the aliphatic series — as well as substances
which go over into sugars — are capable of strongly inhibiting
the formation of beta-oxybutyric acid, Of such acids, glutaric
is of particular interest ®® because its exhibition in phlorhizinized
dogs — and occasionally in severe human diabetes — not only checks
acidosis, but also the formation of sugar from proteid.
' Attention has already been called to the fact that the normal
organism is capable of oxidizing considerable amounts of the
332 THE BASIS OF SYI^IPTOMS
acetone bodies, which is not the case in diabetes. That this
process may take place in the Hver is undoubted.^^
An important question is whether diabetic acidosis is due not
only to a deficient destruction of the acetone bodies, but also
to an increased formation. This question involves and is identical
with another, viz., Does the decomposition of the higher fatty
acids normally go beyond oxybutyric acid ? That this actually does
occur would appear from the finding of a diacetic acid formation
in the normal liver. On a mathematical basis, it may be conceded
that the split-products of fats and proteids are changed into oxy-
butyric acid; and it is known that the healthy body can easily
destroy large amounts of oxybutyric and diacetic acids. Despite
all of these observations, however, it remains to be proved that
there is a constant construction of beta-oxybutyric acid. Indeed,
there are many facts speaking against this hypothesis, among
others that the amount of this acid increases in proportion to the
degree of acidosis, or in other words, with the severity of the
metabolic disturbance.
The Effects of an Excessive Formation of Organic Acids.
Diabetic and Other Toxic Comas. — The specific action of the
acetone bodies is a comparatively slight one. Acetone in
large doses will produce a sort of drunkenness, similar to that
caused by alcohol, and it is possible that in certain intestinal
diseases of children it may cause a feeling of fatigue. The effect
produced by beta-oxybutyric and diacetic acids is,
for the most part, not a specific toxic effect of these compounds,
but is due rather to their acid properties. However, recent stud-
ies®^ in particular tend to emphasize the specific nature of the
intoxication. In virtue of their acid properties, these organic
acids will combine with basic substances in the body, and tend to
carry them away in the urine. In this manner they produce the
symptoms of an acid intoxication (see p. 224).
In the comas that accompany diabetes, car-
cinoma and some intestinal diseases, large quanti-
ties of beta-oxybutyric acid are usually eliminated in the urine.
The patient becomes stupid and sleepy or, at times, irritable. The
temperature falls, the respirations become deep and often more
frequent, and the heart's action becomes rapid.
The immediate cause of diabetic coma is unknown,
but it seems to be precipitated in some instances by a too rigorous
I
NUTRITION AND METABOLISM 833
meat and fat diet, by digestive disturbances, overwork, infectious
diseases, alcoholic intoxication, etc. The symptoms are certainly
very similar to those that result from acid intoxications experi-
mentally produced ; and in no other condition are such enormous
quantities of beta-oxybutyric acid found in the urine as at the
onset of diabetic coma. The ability of the blood to carry carbon
dioxide is usually found to be consideraby diminished during dia-
betic coma, just as it is in experimental acid intoxications (see
p. 224 ) . These facts indicate the acid character o f the intoxication.
On the other hand, in some comas complicating diabetes, no
increased elimination of acids has been found. Yet such cases are
quite rare, for, as a rule, the symptoms of diabetic coma are
accompanied by an acid intoxication. The coma is preceded by
an increased formation of beta-oxybutyric acid in the body, and
large quantities of this acid may appear in the urine as the ammo-
nium salt. During the coma, however, the elimination frequently
does not keep pace with the acid formation, and consequently
considerable amounts are retained in the body. Careful estima-
tions of the amounts thus retained demonstrate that they are
sufficient to give rise to coma. In some cases, it is possible to abort
the coma, partly or completely, by the use of large quantities of
soda, which serves to neutralize the acid in the body.®*
Those rare cases of diabetic coma without increased acid
formation are, according to Naunyn, produced by other toxic
substances, which act directly upon the cerebral cells, and especially
upon the cells of the respiratory centre. The exact nature of these
toxic substances is unknown, but from the diversity of symptoms
seen in diabetic coma it is readily conceivable that more than one
cause is operative.
The Relation between Hepatic Disease and the Excretion of
Ammonia. — The greater portion of the nitrogenous waste which
does not serve to neutralize acids leaves the body in the form
of urea. We know that the liver can convert many ammonium
salts, such as the carbamates, into urea, and Minkowski's experi-
ments on birds would seem to indicate that this is a portion of the
normal hepatic function.®® On the other hand, we are not certain
that all the eliminated urea is thus formed in the liver, nor, indeed,
that it is all derived from ammonium salts.
These questions are of the greatest importance, for it is
possible that some relation may exist between
334 THE BASIS OF SYMPTOMS
hepatic diseases, on the one hand, and the amount
of urea formed out of ammonium salts, on the
other. Not infrequently it happens that the liver is found to be
diseased when large quantities of ammonia have appeared in the
urine. We have seen that one cause of an increased excretion
of ammonia is an acid intoxication, in which case the ammonia
serves merely to neutralize the excess of acid. Is it not possible,
however, that large amounts of ammonia may be excreted for the
reason that the liver is so diseased that it cannot form urea out
of ammonium salts? Such a serious loss of function could only
result from a most extensive destruction of liver cells, if we may
draw an analogy from the corresponding effects produced by
diseases of the pancreas and of the thyroid gland.
An increased excretion of ammonium com-
poundsattheexpenseof urea has been observed in dif-
ferent forms of hepatic disease, such as cirrhosis, tumors
and extensive degenerations, though these urinary
changes do not accompany all serious diseases of the liver. ^°®
Weintraub discovered that if ammonium salts were administered
to patients even in the advanced stages of hepatic disease, these
salts were converted into urea just as they are in healthy individ-
uals, thus demonstrating that these patients are still able to trans-
form large quantities of ammonium salts. Glaessner,^®^ on the
other hand, found in cases of extensive degenerative changes in
the liver cells (cirrhosis, phosphorus poisoning, fatty liver,
syphilis of the liver) that amino-acids ingested were eliminated
in part as such, whereas the normal organ transforms them com-
pletely into urea. The administration of alkalies in these hepatic
disorders would permit of a decision as to whether the ammonia
acts as a neutralizing agent; for were this the case it would be
appreciably diminished after the giving of soda. For the present,
therefore, the question must be left in abeyance as to whether
the increased output of ammonia in the urine in diseases of the
liver is the consequence merely of an acid intoxication.
Alkaptonuria. — The tyrosin and phenylalanin groups of the
proteid molecule give rise at times to the formation of dioxy-
phenylacetic acid (homogentisic acid). When this acid is
excreted by the kidneys, the urine turns dark on standing or on the
addition of alkalies, and the condition is termed alkaptonuria.^®^
These urines will reduce Fehling's solution, and the condition may
NUTRITION AND METABOLISM 335
be mistaken for a glycosuria. Though patients with alkaptonuria
ordinarily show no other clinical peculiarities, attention hasi"
recently been called to manifestations which would indicate that
there exists a profound constitutional disturbance similar, in a
sense, to that of diabetes. For example, wounds may heal slowly
in such patients ; ^^^ and further, it is not unlikely that alkapto-
nuria is the forerunner of ochronosis *°* — a congenital con-
dition, with, at times, a family tendency — and which is associated
with changes in the joint cartilages. In this event, the severe
joint disturbances observed in some cases of ochronosis might be
regarded as due to the metabolic disturbance under consideration
(arthritis alkaptonurica).
Although it was formerly believed that the substances giving
rise to the reaction for alkapton were produced in the intestines,
it now seems certain that the oxyacids concerned arise within the
body during the intermediary metabolism, and that they appear
in the urine because the organism is incapable of
breaking down the tyrosin and alanin groups of
the proteid molecule in a normal manner.
Interesting and extensive studies ^^^ have been undertaken to
determine what must be the constitution of these aromatic oxy-
acids to allow of their transformation into homogentisic acid in
the alkaptonuric individual. These studies point to the existence
of certain steric arrangements both of the side chains and of the
nucleus of the proteid molecule. ^^^ The subject is of particular
interest in the light it throws on the normal catabolism of the
aromatic amino-acids in warm-blooded animals.^"^ It has an
immediate bearing, therefore, upon the question as to whether
alkaptonuria represents a qualitative change in intermediary
metabolism, or whether the destruction of the aromatic oxyacids
proceeds normally via homogentisic acid, the characteristic feat-
ure of the process being merely a splitting of the oxy-amino-acids
without a breaking up of the benzol ring. Both theories have
been espoused. Speaking against the first is the fact that the
tolerance to homogentisic acid and tyrosin may not be the same.
The amount of homogentisic acid appearing in the urine de-
pends in general, therefore, upon the quantity and form of proteid
destroyed, the tyrosin content of the latter being the determining
factor. We have yet to learn in what organ the transformation
of tyrosin and phenylalanin into alkapton occurs. Proteid metab-
336 THE BASIS OF SYMPTOMS
olism, as a whole, remains within normal bounds; the nitrogen
output in particular is unchanged. All of this would indicate that
there is no qualitative disturbance of proteid metabolism, but
rather that the latter ceases when but half completed.
Cystinuria.i*>8 — In this anomaly, there exists a disturbance in
the metabolism of the aliphatic amino-acids. Cyst in, which
makes up the greater part of the unoxidized sulphur in the pro-
teid molecule, is eliminated in the urine because of
the inability of the organism to utilize it. This
condition is remarkable in that the individuals affected can burn
cystin when administered as such, but are unable to metabolize
the cystin group of the proteid molecule.^®^
Baumann and his pupils formerly believed that cystin was
formed in the intestines, because cystinuria is frequently asso-
ciated with the appearance in the urine of diamins (putrescin
and cadaverin),^^^ which occur in the faeces both in abnormal
intestinal conditions and even physiologically in small amount.
As diaminuria does not always accompany cystinuria, however,
it is possible that the interdependence of the two is slight.
It seems unlikely that the diamins are entirely of intestinal
origin. A comparison of the metabolic processes in cystinuria
with those concerned in the catabolism of the aromatic amino-
acids, points to this origin as being in the intermediary metab-
olism, particularly in the liver, where cystin is normally converted
into taurin. Recent studies show that leucin and tyrosin among
other amino-acids may be excreted.^ ^^ The cystinuric individual
can utilize neither the monamino-acids in his food (tyrosin,
asparagin), nor the diamino-acids ; the latter he excretes as dia-
mins. The degree of the disturbance, however, varies with dif-
ferent individuals, for some can burn both the endogenous and
exogenous amino-acids.^ ^^ Important accessory factors, there-
fore, are the amount of amino-acids occurring in the intermediary
metabolism, as well as the tissue in which the latter is to occur.
Cystinuria, therefore, would appear to be a constitutional anomaly
closely related essentially, to alkaptonuria.
The presence of cystin stones in the bladder may cause dis-
turbances in such individuals.
The Adrenals. Addison's Disease. Epinephrin. — A d d i -
son's disease is generally associated with changes, primary
or secondary, in the adrenal glands ;^^® though, on the one hand.
NUTRITION AND METABOLISM 337
cases are observed with normal adrenals, and on the other, exten-
sive changes may involve these organs without producing manifes-
tations of the disease. I shall not go into a discussion of these
problems, first, because it would carry us too far, and, further,
because our knowledge rests upon too insecure a footing. In my
opinion, it can only be said, on the basis of the best observations,
that the Addison symptom-complex and disease
of the adrenals are intimately related, proba-
bly in the way of a diminished function of the
latter. It is not a question of a decreased activity of the
adrenal medulla and thereby of a lessened production of
epinephrin, because the latter arises from all parts of the chro-
mafiEin system, v. Neusser and Wiesel, in view of this fact,
regarded the disease as due to a constitutional weak-
ness of the entire chromaffin system. This is an
interesting hypothesis, explaining as it does those cases of
Addison's disease with intact adrenals; for, in view of the close
relation existing between the chromaffin and the sympathetic
nervous systems, we might assume that there exist changes in the
chromaffin cells outside of the adrenals or changes in the secre-
tory nerves. In some cases of Addison's disease, however, the
entire chromaffin system seems quite normal; and, furthermore,
there are observers who look upon changes in the adrenal cortex
as the cause of morbus Addisonii.
The interrelationship of the medullary and
cortical substances of these glands is still un-
determined despite the tremendous amount of study de-
voted to the subject. In my opinion, if one is to hold fast to
the etiological significance of adrenal disease in the Addison
symptom-complex, he must assume that the medulla and cortex
are both involved.
The function of the cortex is not known. On the
other hand, an epinephrin deficiency or a diminished sympathetic
activity falls short of explaining even the majority of the
manifestations of this disease. The diminished
arterial tension ordinarily observed in these cases is readily ex-
plained on an epinephrin deficiency. But the prostration and
lethargy, the muscular weakness, the anaemia and the gastric
disturbances are in part, at least, not due to this cause. Some
observers do not look upon the pigmentation as an integral feature
22
338 THE BASIS OF SYMPTOMS
of the condition ; others attribute it to changes in the sympathetic
system. Biedl's theory that the mother substance of epinephrin
is converted directly or indirectly into the Addison pigment is
an interesting possibility.
(Among those who regard an insufficiency of the
adrenal cortex as the cause of the characteristic asthenia
of this disease are Biedl and Loewi. The former bases his opin-
ion upon extirpation experiments in animals in which the cortex
and medulla are separate; the latter upon cases of Addison's
disease in individuals in whom only the cortex was found insuffi-
cient. Crowe ^^^ has recently added a convincing extirpation
and ligation experiment to the evidence.
The views as to the function of epinephrin have
undergone a considerable change in the past few years. It is
generally agreed, in the first place, that epinephrin is a product of
the medullary substance of the adrenals; that it acts only upon
structures possessing a sympathetic innervation, selectively stimu-
lating, in all probability, the so-called myoneural junc-
tion or terminal receptive substance; and that it
exerts its characteristic activity in very high dilutions. The most
recent studies ^^^ would indicate that epinephrin is not present in
the blood under ordinary conditions, but, on the contrary, is
poured out only in periods of emergency.
The recent work of Cannon and his co-workers has given
us an entirely new conception of the significance of epinephrin.
According to Cannon, epinephrin plays adefi-
nite role in enabling the individual to meet suc-
cessfully the emergencies of life. Various emo-
tions— ^pain, fear, anger, etc. — cause a reflex secretion of epi-
nephrin and assist in the execution of the physical counterparts
of the emotions, vijs., combat, flight, and so on. As the muscles
are chiefly concerned in these bodily activities they are assumed
to benefit to the greatest extent in the epinephrin discharge. The
inhibition of intestinal peristalsis causes a shifting of blood from
the bowel to the muscles, as does also the constriction of the
splanchnic and cutaneous vessels. The hyperglycaemia conse-
quent upon epinephrin discharge would furnish the muscles with
the needed additional food-supply. More oxygen for the crisis
is supplied by a dilatation of the bronchioles. Furthermore, the
efficiency of fatigued muscle is greatly improved by epinephrin;
NUTRITION AND METABOLISM SS9
and, finally, within certain limits, the coagulation time of the
blood is diminished.
In contrast with this physiological conception are the experi-
mental results due to the injection of epinephrin in pharmacologi-
cal doses. There are many facts, for example, indicating that epi-
nephrin is not concerned with a permanent hypertension
and with arteriosclerosis.^^'^ Among these are the lim-
ited capacity of the adrenals to manufacture epinephrin; the fact
that epinephrin in sufficient amount to maintain an augmented
arterial tension would at the same time paralyze intestinal activity ;
the fact that glycosuria appears before a rise in blood-pressure;
and, finally, that the anatomical changes observed in the vessel-
walls after repeated injections of epinephrin differ in many par-
ticulars from those seen in arteriosclerotic conditions in man, —
Ed.)
LITERATURE
*Krehl: Arch. f. klin. Med., Ixxxviii, 351; Biedl, Innere Sekretion, 2nfd
edit., 1913 (The Internal Secretory Organs, etc., New York, 1913).
'Gesetze d. Energieverbrauchs ; also Physiol, d. Nahrung u. Ernahr., in v.
Leyden's Handb. d. Ernahrungstherapie.
* Lusk : Science of Nutrition, 2nd edit., 222.
*Abderhalden et al. : Zeitschft. f. Physiol. Chem., xlii toi Ixviii; Frank and
Schittenhelm, Munch, med. Wochenschft., 191 1, No. 24.
"Rubner: 1. c. ; Sitzungsber. d. kgl. preuss. Akad. d. Wissensch., 1911, 440,
•Grafe: Zeitschft. f. physiol. Chem., 191 1, Ixv, 29.
'' Cf. V. Noorden: Path. d. Stoffwechsels, 2nd edit., 320 (Metabolism and
Practical Medicine, London, 1907) ; Chittenden, Physiol. Economy in
Nutrition, 1904.
* See Abderhalden and London : Zeitschft. f . phys. Chem., liv, 80 ; Freund,
Zeitschft. f. exp. Path., iv, i; Rubner, 1. c. (Sitzungsber., etc., chap. xix).
For a recent study of the fate of the protein digestion products, see Van
Slyke and Meyer, Jour. Biol. Chem., 1913, xvi, 197.
•Neumeister: Phys. Chemie, 2nd edit., 364.
** Rubner: Arch. f. Hyg., 1908, Ixvi, 7.
"C Voit: Physiol, d. Stoffwechsels, 93; E. Voit, Zeitschft. f. Biol., xH, 550;
Schulz, Miinch, med. Wochenschft., 1899, No, 16.
" C. Voit : Stoffwechsel, 95 ; Sedelmayer, Zeitschft. f. Biol., xxxvii, 35. For
the effect of starvation upon the blood, see Ash, Arch. Int. Med., 1914,
xiv, 8.
**F. Miiller: Zeitschft, f. klin. Med., xvi, 496; Klemperer, ibid., 550; Richter,
Arch. f. exp. Path., xliv, 239; Magnus-Levy, Zeitschft. f. klm. Med., Ix,
199.
" Pfliiger : Pfliiger's Arch., Ixxvii, 424. ^
"Liithje: Zeitschft. f. klin. Med., xliv, 22; Kaufmann, Zeitschft. f. diat.
Then, vii, Nos. 7 and 8 (lit).
**Camerer: Zeitschft. f. Biol., xxxiii, 320; Heubner, Zeitschft, f. diat. Then,
v. No. I ; Liithje and Berger, Arch. f. klin. Med., Ixxxi, 278 (lit.) ; Rub-
ner, Arch. f. Anat. u. Phys. (Phys. Section), 191 1.
" Zeitschft. f. klin. Med., Ixvi, 39, 241.
"Kongr. f. inn. Med., 191 1, 546; Grafe and Graham, Zeitschft, f. phys.
Chem., 191 1, Ixxiii, i; Grafe and Koch, Arch. f. klin. Med., ci, 209.
340 THE BASIS OF SYMPTOMS
"C/, Rosenfeld, in Asher-Spiro, Ergeb., i, I, 651, and ii, I, 50 (lit).
^Bleibtreu: Pflugrer's Arch., Ixxxv, 651.
"Oertel: Allg. Then d. Kreislaufstor., 1891, 147; see also Salomon, Uber
Durkstkuren, in v. Noorden's Samml. klin. Abhandl., No. 6, 1905 (Chap.
on Obesity).
** Hennenberg : Kongr. f. inn. Med., 1885, 46; Vogel, Jour. f. Landwirtschaft.,
xxxix, 37.
"Dennig: Zeitschft. f. physikal. Then, i, 281; Zuntz, Therap. d. Gegenwart,
July, 1901.
" Miiller : Path. d. Stoffwechs., in v. Leyden's Handb., 204.
*• Schattenf roh : Arch, f . Hyg., xxxviii, 92 ; Wolpert, ibid., xxxix, 298 ;
Rubner, Beitrage z. Ernahr. im Knabenalter, 1902.
*■ Rubner : Beitrage, 1. c, 68.
" Cf. Hoffmann : Konstitutionskrankh., 253.
" See Magnus-Levy : Zeitschft. f . klin. Med., xxxiii, 301 (lit.) ; Jaquet and
Svenson, ibid., xli, 376; Zuntz, 1. c. ; Brugsch, in the Kraus-Brugsch
System.
**v. Bergmann: Zeitschft. f. exp. Path., v, 646; Deutsch. med. Wochenschft.,
1909, 14; Stahelin, Deutsch. med. Wochenschft., 1909, No. 14; Zeitschft.
f. klin. Med., Ixv, 425.
•"Arch. f. klin. Med., 191 1, cii, 15.
"" Arch. f. exp. Path., xlviii, 184, and 1, 268.
•* Loewy and Richter : Zentralbl. f . Phys., 1902, No. 17 ; Loewy, ibid., No. 50 ;
Loewy, in Asher-Spiro, Ergeb., ii, I (lit.).
" Cf. Rubner : Die Ernahrung, etc., 70 ; see also v. Bergmann, in Oppen-
heimer, Handb. d. Biochem., iv, 194.
■*For a discussion of this subject see Gushing: The Pituitary Body, etc.,
1912, 257 (lit.).
"F. Miiller, G. Klemperer: Zeitschft. f. klin. Med., xvi, 496, 550, resp.;
Miiller, Kongr. f. inn. Med., 1889, 396.
" Tallquist : Arch, f . Hyg., Ixv, 39.
" Miiller : 1. c. ; Klemperer, 1. c.
"* Striimpell : Arch. d. Heilkunde, xvii, 547 ; Rosenquist, Zeitschft. f. klin.
Med., xlix, 193.
** Fraenkel and Rohmann : Zeitschft. f . physiol. Chem., iv, 439.
*° Graf e : Arch, f . klin. Med., cii, 40 ; see also Strauss, in v. Noorden's Handb.
d. Path. d. Stoffwechsels, i, 896.
*^ Embden and Schmitz : Biochem. Zeitschft., 1910, xxix, 423.
** Die chem. Vorgange bei d. Krebskrankh., 1906.
*' In V. Noorden's Handbuch, 2nd edit., ii, 373.
** See Kepinow: Zeitschft. f. Krebsforsch., vii (lit).
*Arch. f. klin. Med., Ii, 401.
*" Zeitschft. f. exp. Path., iv, 720.
"Zeitschft. f. klin. Med., xxxiii, 269; Berl. klin. Wochenschft., 1895, No. 30;
also in v Noorden's Handb, ii, 311.
** Scholz : Zentralbl. f . klin. Med., 1895, Nos. 43 and 44 ; Matthes, Kongr. f.
inn. Med., 1897, 232.
** Magnus-Levy : 1. c.
■^Maier: Beitrage z. Kenntniss d. Stoffwechsels thyreoekt. Kaninchen, Diss.
Wiirzburg, 1900.
"F. Miiller: 1. c, and Kongr. f. inn. Med., 1897, 239; Magnus-Levy, 1. c.
"Schondorff: Pfliiger's Arch., Ixvi, 395; Voit, Zentralbl. f. Biol., xxxv, 116.
■^Magnus-Levy: Zeitschft. f. klin. Med., Hi, 201.
" See Ewald, in the Nothnagel System ; v. Eiselsberg, Deutsch. Chirurgie,
No. 38 ; Kraus and Kocher, Kongr. f . inn. Med., 1906.
"^ Eppinger, Falta and Rudinger, Zeitschft. f . klin. Med., Ixvii, 380.
"See Biedl: Innere Sekretion (lit).
" Scholz : Klin. u. anat. Untersuch. ii. d. Kretinismus, 1906.
"* Osier : Amer. Jour. Med. Sc, cxiv, Z77-
*See Mobius, in the Nothnagel System (lit).
NUTRITION AND I^IETABOLISM 341
"Verhand. d. Karlsruher Naturforscherversamm., 191 1; Deutsche med.
Wochenschft., 191 1, No. 48.
" See Wiener : Arch, f . exp. Path., Ixi, 297 ; Oswald, Chemische Pathologic,
1907 ; Hofmeister's Beitrage, ii, 545 ; Pfliiger's Arch., cxxix.
"Simmonds: Karlsruher Naturforscherversamm., 191 1, For a recent mono-
graph see Rautmann, Grenzgebiete, xxviii, No. 3; Wilson, Am. Jour.
Med. Sci., 1913, cxlvi, 781 ; Plummer, ibid., 790.
"O'Connor: Munch, med. Wochenschft., 191 1, No. 27.
•* Cf. Eppinger and Hess : tjber Vagotonie, 1910.
* MacCallum and Davidson : Med. News, April 8, 1905.
" Hoskins and Wheelon : Am. Jour, Phys., xxxiv, 263.
" Salkowski : Deutsch. Klinik, xi, 147.
** v. Bergmann and Langstein : Hofmeister's Beitrage, vi, 27,
*Abderhalden and Oppenheimer: Zeitschft. f. physiol. Chem., xliii, 155.
™F. Miiller: Kongr. f. inn. Med., 1902, 192; Simon, Arch. f. klin. Med., Ixx,
604.
"Langstein and Neubauer: Miinch. med. Wochenschft., 1902, 1249; Ehrstrom,
Arch. f. Gyn., Ixiii, 695.
"v. Jaksch: Zeitschft. f. klin. Med., vi, 413; Robitschek, Deutsch. med.
Wochenschft., 1893, No. 24.
" Stadelmann : Untersuch. ii. Peptonurie, 1894, 90 ; Miura, Virch. Arch., ci,
317-
" Neuberg and Richter : Deutsch. med. Wochenschft, 1904, No. 14 ; Abder-
halden and Bergell, Zeitschft. f. phys. Chem., xxxix, 9; Wohlgemuth,
ibid., xliv, 74.
" A E. Taylor : Jour. Med. Research, viii, 424.
"Fischer and Bergell: Berich. d. deutsch. chem. Gesell., 1902, xxxv (HI),
m 3779-
"Henriques and Sorensen; Zeitschft. f. physiol. Chem., Ixiii, 27; Ixiv, 120;
Yoshida, Biochem. Zeitschft., xxiii, 239.
'*Rumpf: Kongr. f. inn. Med., 1896, 509; Virch. Arch., cxliii, i; Zeitschft. f.
Biol., xxxi.
'• Zeitschft. f . exp. Path., iii, 530, and Wiener klin. Wochenschft, 1906, No. 5.
""Arch. f. exp. Path., vii, 148.
**Rumpf : Virch, Arch., cxliii, i.
** See V. Noorden's Handbuch.
'^ Mandel and Lusk : Jour. Am, Med, Assn., xlviii, 1804,
**Maase: Phys. Gesellsch., Berlin, March 13, 1910; Blum, Munch, med,
Wochenschft., 1910, No. 13 (lit.) ; Neubauer, Kongr. f, inn. Med., 1910,
566; Wakeman and Dakin, Jour, of Biol, Chem., 1909, vi, 373; ibid.,
1910, viii, 105.
*'See Baer: Therapeut, Monatshefte, 1908; Blum, Med, Klinik, 1908, No.
44; Magnus-Levy, Ergeb. d. inn. Med., i, 352; Ewing, Arch. Int Med., ii,
330; Lusk, ibid., iii, i.
** Lehmann, Muller et al. : Virch. Arch., cxxxi, Suppl.
■"Taylor: Univ. of Calif. Publications, Pathology.
** Stadelmann : Arch, f . exp. Path., xvii, 419 ; Minkowski, ibid., xviii, 35 ;
Kiilz, Zeitschft. f. Biol., xx, 165,
*v. Mehring: Zeitschft. f. klin. Med., xvi, 431; Minkowski, Arch. f. exp.
Path., xxxi, 85.
'"Lorenz: Zeitschft f. klin. Med., xix, 18; Kraus, Ergeb. d. allg. Path.,
1895, 617.
^ Arch, f . exp. Path., xxxiv, 169.
"* See Magnus-Levy : Ergeb. d. inn. Med., i, 372, 384.
** Embden and Almagia : Hofmeister's Beitrage, vi, 44 ; Embden and Kal-
berlah, ibid., viii, 120; Embden et al., ibid., 129.
"*Baer and Blum: Arch. f. exp. Path., Iv, 98; Ivi, 92; lix, 321; Ixv, i; Borch-
ardt and Lange, Hofmeister's Beitrage, ix, 116.
*Baer and Blum: Hofmeister's Beitrage, x, 80; xi, lor; Arch, f, exp. Path.,
191 1, Ixv, I.
342 THE BASIS OF SYMPTOMS
•* Embden and Michaud : Hof meister's Beitrage, xi, 332 ; Biochem. Zeitschft,
xi, 262.
" Wilbur : Jour. Am. Med. Assn., 1904, 1228 ; Ehrmann, Esser and Loewy,
Zeitschft. f. klin. Med., Ixxii, 496.
'^Liithje: Zeitschft. f. klin. Med., xliii, 225; Marchand, Munch, med. Wochen-
schft., 1912, No. 4.
•" Minkowski : Arch, f . exp. Path., xxxi, 214.
'■^ Weintraub : Arch. f. exp. Path., xxxi, 30 ; Miinzer, ibid., xxxiii, 180.
"''Zeitschft. f. exp. Path., iv, 336; Prey, Zeitschft. f. klin. Med,, Ixxii, 383.
As to the role of the liver in the formation of urea from amino-acids,
however, see Fiske and Sumner, Jour. Biol. Chem., 1914, xviii, 285.
*'Samuely: Zentralbl. f. Stoflfwechsel, vii (lit.); Fromherz, Biochem. Zen-
tralbl., viii, i; Neubauer, Arch. f. klin. Med., xcv, 211; Abderhalden and
Massini, Zeitschft. f. phys. Chem., Ixvi, 140.
"^ Allard and Gross : Grenzgebiete, xix, 24.
*°*Allard and Gross: 1. c. ; Arch. f. exp. Path., lix, 384; Landois, Virch.
Arch., cxiii, 275.
** Abderhalden, Bloch and Rona: Zeitschft. f. physiol. Chem., lii, 435;
Neubauer, Arch. f. klin. Med., xcv, 211.
^'^ Fromherz : 1. c.
^'^ Neubauer : 1. c.
"' See Neuberg, in v. Noorden's Handbuch, 2nd edit., II, 464 (Metab. and
Practical Medicine) ; Loewy and Neuberg, Biochem. Zeitschft. ii, 438.
'■"Wolf and Shaffer: Jour, of Biol. Chem., iv, 439; William and Wolf, ibid.,
vi, 337-
"* Thiele : Jour, of Phys., xxxvi, 68.
*" Abderhalden and Schittenhelm : Zeitschft. f. physiol, Chem., xlv, 468;
Neuberg and Loewy, ibid., xliii, 338.
"* Simon : Zeitschft. f . physiol. Chem., xlv, 357 ; Alsberg and Folin, Am.
Jour. Phys., xiv, 54.
"*v. Neusser and Wiesel: Die Erkrank. d. Nebennieren, 2nd edit, 1910;
Bittorf, Die Path. d. Nebennieren, 1908; Biedl, Innere Sekretion, 2nd
edit., 1913 (complete lit); Goldzieher, Die Nebennieren, 1911; Falta,
Die Blutdriisen, 1914. (Translated by Meyers, 1915.)
"* Communication before the Amer. Soc. for Exp. Path., Dec. 30, 1913, quoted
from Hoskins, Jour. Amer. Med. Assn., 1914, Ixii, 1803 (lit).
"* Stewart : Jour. Exp. Med., xiv, 377 ; xv, 547.
"'Cannon: Am. Jour, of Phys., 1914, xxxiii, 356; Cannon, Bodily Changes
in Pain, Hunger, Fear and Rage, New York, 191 5.
*^^For the complete literature see Biedl, 2nd edit., 1913.
CHAPTER VII
DISTURBANCES IN CARBOHYDRATE METABOLISM.
DIABETES
In this chapter we shall limit our discussion to dextrose, or
grape-sugar; for although other sugars, such as Isevulose^ and
pentoses,^ may appear in the urine, the meaning of these findings
is not yet sufficiently clear to be discussed in connection with
dextrose.
The cells of the body that use dextrose, especially the muscle-
cells, take it out of the blood; yet the amount in the plasma re-
mains nearly constant, for whenever the percentage falls below
the normal, new sugar is supplied to the blood, mainly from the
glycogen store in the liver. The liver glycogen is derived, for
the most part, from the carbohydrates, and, to a lesser extent,
from the proteids taken in the food.^ The sugar that is absorbed
from the intestines goes to the liver by way of the portal vein,
where it is converted into glycogen by a process of dehydration
and polymerization. The non-nitrogenous products of proteid
cleavage may also be converted into glycogen, by a synthetic
process ; * and, as there can no longer be any doubt that a complete
splitting of the proteid molecule occurs in the intestines, it is
reasonable to assume that this synthesis of glycogen likewise takes
place in the liver. The latter acts, therefore, as a store-house for
carbohydrate material, holding it back when it is present in the
blood in excess, and giving it out when the percentage falls. The
muscles likewise are capable of storing sugar.
In a healthy man, the sugar in the blood varies but little, the
quantity remaining constantly in the neighborhood of o.i per
cent. If, for any reason, more than this is present in the general
circulation without being immediately consumed, it is eliminated
by the kidneys, and the urine then contains more than the trace of
dextrose normally present.
Alimentary Glycosuria. — As we have said, the liver possesses
the property of removing from the portal blood any excessive
quantity of sugar that may be present there. If, for example,
a limited quantity of dextrose be injected into the portal vein,
the excess disappears from the blood; whereas, if the same quan-
343
344 THE BASIS OF SYMPTOMS
tity be injected Into a systemic vein, the percentage in the general
circulation is increased and sugar is excreted by the kidneys.
Yet, when very large amounts of dextrose are taken by mouth
and are absorbed from the intestinal canal within a short space of
time, the percentage in the blood may rise above the normal, either
because the liver cannot hold all the sugar coming to it through
the portal vein, or because some sugar reaches the general circu-
lation through the lymphatics without traversing the liver. In
keeping with this latter hypothesis is the markedly lowered toler-
ance exhibited by dogs with an Eck fistula.®
Under such circumstances, dextrose may be excreted by the
kidneys, a condition that is spoken of as alimentary gly-
cosuria.^ The quantity of sugar that must be taken by
mouth in order to produce an alimentary glycosuria varies in dif-
ferent individuals, though it is apparently constant for the same
individual. It does not necessarily follow, however, that a certain
person is in an early stage of diabetes merely because he passes
dextrose in the urine after taking a relatively small quantity by
mouth. Yet such may be the case. Minkowski has shown, for
example, that whereas the removal of the whole of the pancreas
is followed by a diabetes, the removal of a part may cause merely
an inability to take much sugar in the food without having it
appear in the urine. Furthermore, clinical experience has demon-
strated that in some cases a marked alimentary
glycosuria gradually passes over into a true
diabetes mellitus. In still others, on the contrary, it
would appear to be quite without significance.
The occurrence of an alimentary glycosuria
in a healthy man is greatly favored by alcoholic drinks,
and especially by the ingestion of large quantities of
beer.'^ It is impossible to say why this should be so, and
whether the effect, in the case of beer, is to be attributed more to
its alcohol or to its maltose. Muscular exertion and heating of
the body, on the contrary, tend to diminish the excretion of sugar
in alimentary glycosuria, just as in true diabetes.®
Lactose may also appear in the urine after excessive quan-
tities have been taken in the food, but it appears there more fre-
quently because it has been resorbed from the mammary glands
of nursing women, owing to a stasis of milk. Some special factor
seems to favor its excretion in these cases, for the amount absorbed
DIABETES 345
would appear to be too small to give rise to an ordinary alimentary
glycosuria.
Many studies have been made relative to the ease with which
an alimentary glycosuria may be produced in different diseases.
These investigations, unfortunately, are not based upon conditions
as found in a normal individual, for the patient is generally in the
fasting state, and is given large amounts of pure dextrose. De-
spite this, such patients rarely exhibit an alimentary glycosuria;
nor is it generally true that individuals with hepatic dis-
ease are especially prone to show such a glycosuria,^ at least
when dextrose is given; though it is a fact that a laevulo-
suria is more readily produced in similar conditions.^^ I
should advise caution, however, in assuming the existence of a
disordered liver function from the appearance of such a glycosuria,
for we have learned, beyond question, that the specific activity of
an organ — and this applies particularly to the liver — ^may persist
even though the major part of its cells be destroyed or severely
damaged.
In phosphorus poisoning, however, and thyreo-
toxic states, sugar passes into the urine with particular
case. Certain observers have interpreted the thyreotoxic form
as an epinephrin glycosuria and as representing an increased
stimulation exerted by the thyroid gland upon
the chromaffin system. ^^ This needs further confirma-
tion, however. Alimentary glycosuria occurs, further, in many
cases of hysteria and neurasthenia, in the trau-
matic neuroses and in the infectious diseases. In
the latter, and also in cachectic states, the mere ingestion of starch
may lead to a similar result. These various observations show
how conservative we must be in interpreting such transitory and
etiologically uncertain glycosurias.
Phlorhizin Glycosuria.^^ — phlorhizin is a glucosid, i.e.,
it is capable of being split up into dextrose and a proteid radicle,
the former component representing about forty per cent, of the
whole. The glycosuria following its administration is peculiar
in that it is probably not accompanied by an in-
creased percentage of dextrose in the blood.
Though certain observers *^ have found a hyperglycsemia in this
condition, the majority have noted no such increase in the blood-
sugar, but rather a diminution ; and, indeed, no increase was noted
346 THE BASIS OF SYMPTOMS
even after removal of the kidneys. Pfliiger explains these diverse
findings on the basis that in the blood-sugar determinations no
distinction was made between free sugar and sugar com-
bined loosely with colloids, only the former taking
part in the phenomenon. This hypothesis can scarcely be
accepted, however, because the sugar of the blood is
actually in solution.^*
It is possible that a phlorhizin glycosuria, being unaccom-
panied, as is generally held, by a hyperglycaemia, is due to t o x i c
changes in the renal cells which have deprived them of
the power of holding back sugar. Another, far less likely, ex-
planation is that the phlorhizin loses its sugar radicle (ph lor-
es e) in the kidneys and that this is at once converted into
dextrose and eliminated, while the residue of the phlorhizin mole-
cule (phloretin) combines once more with sugar and the
process is repeated. The amount of dextrose that appears in the
urine after phlorhizination, however, is so great that it cannot
be accounted for by a mere splitting off of the glucosid; and,
furthermore, it is certain that the administration of this substance
causes an actual removal of dextrose from the body.
In phlorhizin poisoning, the sugar excreted
is derived, first of all, from the glycogen of the
liver, which early disappears. It seems certain that it is also
derived from the proteids of the body, for it is known
that glucose continues to be excreted in phlorhizin poisoning,
even though the animal be fasting and its liver presumably free
of glycogen. The proteid decomposition is accelerated owing
to the failure to consume carbohydrates ; and even beta-oxybutyric
acid may be excreted. If phlorhizin be given to fasting animals,
a fatty degeneration of the liver is produced, which can be pre-
vented if the animal be fed on proteids or carbohydrates. At
times, the amount of sugar excreted after taking phlorhizin is so
great that it seems as if it must be formed in part from the
fats of the body,^'^ a possibility that will be considered in
another place (p. 351).
Renal Diabetes. — The glycosuria of phlorhizin poisoning,
therefore, is characterized by the fact that the amount of sugar
in the blood is not increased ; and it seems probable that in this
condition, as well as in certain cases of marked diuresis, the result-
ing glycosuria is due to an inability on the part of the
DIABETES 347
renal cells to hold back the sugar normally pres-
ent in the blood. Little is known about such conditions
in man, but recent observations have tended to show that glyco-
suria may result from just such a renal insufficiency. To these
cases has been given the name of renal diabetes. Liithje^^ has
shown that the sugar was present in the blood of his patient in
less than the normal quantity, thus demonstrating that the glyco-
suria was due to some abnormal permeability on the part of the
kidneys toward dextrose. Neubauer,^''^ on the other hand, has
observed hyperglycsemia without glycosuria in cases of nephritis
with hypertension. The amount of sugar excreted by
such patients is independent, to a great extent, of
the amount taken in the food; yet this is not especially
characteristic of renal diabetes, for the same is true of certain
forms of diabetes mellitus.
Epinephrin Glycosuria. — An increase in the percentage of
sugar in the blood occurs also when epinephrin in large amounts
is introduced into the circulation.^® Epinephrin is supposed to
^'mobilize" sugar. The amount of the latter entering the
blood is directly proportional to the amount of epinephrin present,
and is dependent, furthermore, upon the size of the animal's
glycogen store ; for with a diminution of the latter, larger amounts
of epinephrin are required to mobilize the same amount of sugar.
As epinephrin is capable of causing a considerable increase in the
degree of proteid destruction in fasting animals,^® it is evident
that a glycosuria (and a storing up of glycogen ^^) tends to occur
also in such animals. The blood constantly contains epinephrin,
which acts, it may be, to regulate the vascular tonus. It is also
very likely that the sugar-content of the blood is similarly under
the influence of epinephrin and in turn of the sympathetic ner-
vous system. (For the most recent studies relative to the func-
tion of epinephrin and to the interpretation of the symptoms of
Addison's disease, the reader is referred to the preceding chapter,
p. 336.— Ed.)
Transient Glycosurias. — Glycosurias lasting only a few hours
or days ^^ have been observed after various intoxica-
tions, infections, injuries and diseases of the
central nervous system.
Of these transient glycosurias, the best studied is that which
results from a puncture of a certain limited area
348 THE BASIS OF SYMPTOMS
in the floor of the fourth ventricle of animals.
In these cases, the appearance of sugar in the urine is always
preceded by an increase in the amount present in the blood, and
it is favored by a large store of glycogen in the liver. If glucose
be injected into a mesenteric vein in these animals, it is not taken
up by the liver as it normally should be, but passes into the general
circulation and is then excreted by the kidneys. If the splanchnic
nerves be cut, or if the liver be removed, a puncture of the fourth
ventricle has no effect upon the urine; while the extirpation of
the suprarenals likewise prevents a piqure glycosuria. ^^ Fur-
thermore, after puncture of the ventricle, the amount of epinephrin
in the serum has been found increased,^^ though this needs con-
firmation for the plasma. All these facts seem to indicate that
the glycogen of the liver is the source of the ex-
cessive amount of sugar in the blood and that the
puncture causes the glycosuria by influencing the gly-
cogenic function of the liver via the adrenals,
epinephrin and the sympathetic system. This
would point to the action of the same mechanism both in piqiire
and in epinephrin glycosurias, the former being of central origin,
the latter peripheral. Epinephrin, for instance, causes a glyco-
suria after the splanchnic nerves have been cut.^^ Eppinger,
Falta and Rudinger have made the interesting observation that
the glycosuria of animals from which the pancreas has been re-
moved is increased by the injection of epinephrin,^^
(Our knowledge of the position of the hypophysis*® in
carbohydrate metabolism is at best fragmentary. According to
certain observers (Borchardt), injections of the whole gland
extract in rabbits usually cause a glycosuria; while Gushing was
able almost without exception to produce a glycosuria — with
hyperglycsemia — in rabbits, by intravenous injections
of posterior lobe extracts and even of cerebro-
spinal fluid (assumed to contain the secretions of the pos-
terior lobe). These various results have not been confirmed by
all observers.
Gushing believes the following interpretation of the role of
the hypophysis in carbohydrate metabolism to be permissible:
" Normal posterior lobe activity is essential to effective carbo-
hydrate metabolism. An intravenous injection of posterior lobe
extract produces glycogenolysis . . ., [whereas] a diminu-
DIABETES S49
tion of posterior lobe secretion occurring in certain conditions
of hypopituitarism — whether experimentally produced or the
result of disease) leads to an acquired high tolerance of sugars
The glycosuria frequently noted in cases of acromegaly
and gigantism, according to this conception, would be due
to the pressure of a hyperplastic anterior lobe upon the posterior
lobe, causing first stimulation and later cessation of the secretion
of the posterior lobe.
The mechanism of hypophysial glycosuria is
not well understood. It might be assumed to reside in a pri-
mary disturbance of the pituitary body, or on the other hand,
to act via the nervous system or other internal secretions, e.g.,
epinephrin and the sympathetic system. It is possible, however,
that the functional disorder of the hypophysis is only a co-ordinate
part of a more general disturbance of endosecretory activity. —
Ed.)
Our recently acquired knowledge of the conditions underlying
epinephrin glycosuria have thrown considerable light upon the
nature of piqure diabetes; and it is possible that we shall be able
to correlate the different non-diabetic glycosurias by the variations
in the blood-sugar and in the glycogen content of the liver, as
well as by the results observed when the splanchnic nerves are
severed.
Diabetes Mellitus
Diabetes mellitus is characterized by a glycosuria that is not
due to any of the above-mentioned causes, and especially not to
the ingestion of large amounts of grape-sugar. Usually, the
dextrose is constantly present in the urine, though it may be found
only periodically. In some cases of diabetes, Isevulose and pentoses
also appear in the urine. The glycosuria of diabetes mellitus
always results from an excessive amount of sugar in the blood,
ahyperglycsemia; instead of the normal percentage of about
O.I, it may rise even to 0.7 per cent. On the other hand, the
contention of F. Miiller that the behavior of the kidneys in diabetes
needs further study is a sound one.^^ For example, in dogs,
after pancreas removal, there may be a considerable hypergly-
csemia without a glycosuria, and a number of similar observations
have recently been reported in human diabetes.^* Possibly the
860 THE BASIS OF SYMPTOMS
total amount of sugar passing through the renal
vessels is of more imp>ortance in determining its appearance
in the urine than is the percentage present. Indeed, in the light of
present knowledge, one may well ask whether hyperglycaemia
actually plays a determining role in the causation of glycosuria.
If one accepts a hyperglycaemia as the sine qua non of the
diabetic glycosuria, he must assume the existence of a renal im-
permeability ^® for the many cases in which there is an increase
in the percentage of glucose in the blood unaccompanied by its
appearance in the urine. As a matter of fact, it has been experi-
mentally shown that the permeability of the kidneys for sugar may
be raised or lowered by means of certain toxins.^^ In man,
however, it would seem more likely that the kidneys are more or
less unaffected by the percentage of sugar in the blood, rather than
that the absence of a glycosuria in hyperglycaemic states is the
result of a diminished renal permeability. It is possible, though,
that diabetes does cause specific alterations in renal function, in
view of the fact that it is known to injure the renal epithelium.
Mild and Severe Diabetes ; Derivation of Sugar from Proteids
and Fats. — In the milder forms of diabetes, sugar does not appear
in the urine if no carbohydrates, i.e., sugars, starches, etc., are
taken in the food. Great individual variations ex-
ist as to the quantity of carbohydrate material
that must be taken in order to produce glyco-
suria. On the one hand, a patient may be able to take one
hundred and fifty grams or more of starch in twenty-four hours,
without suffering from glycosuria; while, on the other, a glyco-
suria may result when only twenty-five to thirty grams are taken.
The essence of a correct diabetic therapy resides in the effort
to determine the individual's tolerance ; and this is done by spar-
ing, as far as possible, the mechanism of sugar metabolism.^^ Not
all carbohydrates show the same tendency to cause glycosuria in
these patients,^' and many, for example, will tolerate lactose in
the food even better than starch.
The mild form of diabetes is distinguishable from
alimentary glycosuria by the fact that starch is not tolerated ; for,
so far as we know, a mere excess of starch in the diet of a normal
individual never leads to the excretion of an abnormal quantity
of sugar in the urine. Possibly, however, exceptions do occur
to this rule, notably in the case of the infectious diseases.
DIABETES 351
In the more severe forms of diabetes, sugar is
excreted in the urine even when no carbohydrates are taken by
mouth, and in some — the most severe — cases the glycosuria con-
tinues even when the patient is fasting. In these cases, the sugar
may come either from the glycogen of the ingested meat and from
that arising in the abnormal diabetic metabolism, or it may come
from proteids or f ats.^^ The origin from the glycogen has not been
disputed, but observers have not always been agreed as to the part
proteids and fats take in the formation of sugar .^^ It is now
generally accepted that sugar may arise from fats'®
and proteids or from both. Proteid is a more fertile
source because it undergoes a more complete splitting, even in
the intestines, than does fat.
Particularly interesting is the intolerance of certain
diabetics to proteid foods. Naunyn, especially, has
shown that many diabetic individuals become sugar- free only if
their proteid intake is kept within definite limits. Certain patients
cannot tolerate an increase in their proteid quota as readily as
the ingestion of carbohydrates.'^ This would seem to indicate
that the metabolic fault is situated where the keto-acids
are normally burned, or built up into sugar-like bodies after the
splitting off of ammonia.
It was formerly believed . that this distinction be-
tween mild and severe cases of diabetes was a sharp
one, and that it rested upon fundamental differences in the tis-
sues. In the mild cases, the body was unable to assimilate carbo-
hydrate material introduced as such, but was able to consume the
carbohydrate molecules split off from the proteids; whereas, in
the severe cases, neither could be utilized. Yet we now know
that no such sharp distinction can be drawn ; '^ that the one con-
dition shades into the other; and that, finally, the body may be
able to consume a considerable proportion of the carbohydrates
taken in the food, even though the diabetes is so severe that gly-
cosuria persists during fasting.'^ Notwithstanding these facts,
the above distinction has a certain clinical value;
and a case of diabetes can hardly be considered a mild one if
the body is unable to assimilate a given amount of carbohydrate
material in the food without the excretion of sugar in the urine.
352 THE BASIS OF SYMPTOMS
The Glycogenic Function of the Liver in Diabetes. — The im-
mediate cause of the glycosuria in human diabetes resides, accord-
ing to present conceptions, in a hyperglycsemia, which is
the result in turn of an inability on the part of the
liver to polymerize the sugar it receives and to
store it as glycogen. The lessened efficiency of the liver,
in this respect, varies considerably in different cases, and upon
this fact depends the variable tolerance to carbohydrates of differ-
ent patients. The glycogenic power of the liver is
never completely lost; as a rule it is raised when in-
creasing amounts of sugar are carried to the organ, i.e., ingested;
though, infrequently, in cases of mild diabetes, the excretion of
sugar is more or less independent of the amount of carbohydrates
in the food.
We have already called attention to the fact that variable
amounts of carbohydrates must be taken by different diabetics to
cause the appearance of sugar in the urine, and that no single
factor has so great an influence in raising the assimilative capacity
as sparing the mechanism of sugar metabolism.
Thus, a diabetic who to-day can tolerate one hundred grams of
white bread, may, in the course of a few months, if kept within
his tolerance limit, be able to assimilate one hundred and twenty
to one hundred and forty grams with no ensuing glycosuria. This
is an answer to the skepticism still expressed occasionally as to
the value of a dietetic therapy in diabetes.
Certain diabetics are better equipped to take
care of Isevulose, and starchy foods which are converted
into laevo-rotatory sugars, than of dextro-rotatory carbohydrates.
We must not generalize too widely in this particular, however,
for even among diabetics with a relatively high tolerance for ordi-
nary starches, there is no uniformity in their ability to handle
Isevulose ; and in the severe cases with a low tolerance, particularly
when acidosis is present, laevulose is no better borne than dex-
trose.^^ The crux of this matter is that every type of carbo-
hydrate used in a diabetic for the first time is
well taken care of for a short period, irrespective of the steric
grouping of its molecules.
In regard to the question as to whether the dia-
betic builds more sugar than the normal indi-
vidual we can answer in the negative for the milder cases;
DIABETES 353
for every condition is satisfied by the assumption that the blood
contains more than its normal percentage of sugar simply because
the liver cannot store it as glycogen. In another place we shall
consider whether the tissues are able to burn the excess of sugar
carried them by such blood.
Certain severe cases, on the other hand, persist-
ently excrete more sugar than can be accounted
for by the carbohydrates in their food. Even on
a strict proteid and fat diet such individuals lose large amounts
of sugar. As we have noted, this sugar-excess is de-
rived from proteids and to a lesser degree from
fats. If one is of the opinion that the formation of sugar
from proteids is physiological, he must distinguish sharply be-
tween diabetics who can assimilate proteids and
those who cannot. For there are, undoubtedly, patients
who tolerate enormous quantities of proteids, yet who excrete
sugar after the ingestion even of small amounts of bread. One
can only conclude that the behavior of the tissues to exogenous
sugar is different from that to endogenous. The distinction has
a practical bearing upon the origin of acidosis (see p. 330).
At any rate, in these severe cases, the liver is unable to store
glycogen from proteid sugar any better than that from ingested
carbohydrates, and the result is in both cases a hyperglycsemia and
a glycosuria. Thus the liver occupies the foreground in both,
though it is not improbable that other tissues, such as the muscles,
are co-ordinately involved.
The Consumption of Sugar in Diabetes. — We now come to
the question as to whether the diabetic body is able to burn sugar
normally. Investigations on the respiratory inter-
change of gases have furnished evidence that the oxidation
of sugar in certain diabetic patients is diminished.^^ We know
that when carbohydrates are completely burned, the volume of
carbon dioxide given off is equal to the volume of oxygen con-
sumed; i.e., the respiratory quotient is i.o. For the combustion
of proteids and fats, however, relatively more oxygen is neces-
sary ; and, in the case of the higher fats, the ratio of carbon dioxide
to oxygen is about 7 to 10 or 0.7. When carbohydrates are the
main source of energy to the body, therefore, the ratio between
the carbon dioxide given off and the oxygen absorbed approaches
1.0; whereas when fats and proteids furnish most of the energy,
23
354 THE BASIS OF SYMPTOMS
this ratio falls. It has been found that diabetic patients upon an
ordinary mixed diet show a lower respiratory quotient than do
normal individuals upon the same diet. From this fact it may be
inferred that, in spite of the large amount of glucose circulating
in their blood, the utilization of carbohydrate ma-
terial by diabetic patients is deficient, and that
most of their energy is derived from fats and
proteids. Abnormally low values, i.e., below 0.74, are to
be explained in part by a co-existing acidosis and in part by a
conversion of proteids and fats into sugar. Indeed, the de-
gree of reduction of the respiratory coeffi-
cient may be looked upon as an index of the
severity of a particular case.
It appears, also, that this change in the respiratory quotient is
more marked in the severe than in the mild forms of diabetes;
in other words, the former burn less sugar than the latter. This
view is further supported by the effect that muscular exer-
cise and fever have upon the excretion of sugar. In the
milder forms of the disease, muscular exercise tends to diminish
the glycosuria, apparently because the body utilizes the sugar cir-
culating in the blood. In the more severe cases, on the contrary,
muscular exercise exerts but little effect upon the glycosuria, for
the body can utilize comparatively little sugar. In dogs whose
pancreas has been completely removed, muscular exercise does not
reduce the sugar excretion, but after a partial removal, it regu-
larly diminishes the glycosuria. Hence, the pancreas, or at least
a part of it, is essential to the combustion of sugar.
Thus we see that there is not only an insuf-
ficiency of the glycogen reservoirs in diabetes,
which permits an excess of sugar to enter the
circulation, but that there is, in addition, a
lessened ability on the part of the body to burn
the sugar. If the former alone were true, the respiratory
quotient would increase in proportion to the amount of carbo-
hydrates ingested, just as in health, for despite the sugar loss
the blood continues to carry it in excess.
The nature of this lessened capacity for con-
suming sugar is not well understood. Unfortunately, we
know little concerning the manner in which sugar is normally
utilized in the body, or concerning the intermediary stages, such
DIABETES 355
as lactic acid or glycuronic acid, through which it may pass. There
seems to be no general diminution in the oxidative ability of the
body, for such substances as benzene, lactic acid, fat and fre-
quently even laevulose, are consumed normally. Diabetes
consists rather in a specific limitation of the
ability to consume dextrose; and it seems as if the
diabetic body fails especially to initiate the combustion of this
sugar. Nor is this all. Normally, carbohydrates can be con-
verted into fat in the body, but in diabetes this power is dimin-
ished or lost.
We are acquainted with at least one factor that is
necessary for a proper combustion of the sugar
in the body. This is the pancreas."*^ If this gland be
extirpated from dogs, their ability to burn sugars is certainly
diminished. The same holds true for carnivorous birds and for
reptiles and amphibia. When about twenty per cent, of the pan-
creas is left at an operation, an alimentary glycosuria or a dia-
betes of the milder type may result ; whereas, if the whole gland
be excised, a diabetes of the severe type is the consequence.
There exists still a considerable diversity of opinion, even
among the most competent investigators, as to the conditions essen-
tial to the causation of pancreatic diabetes, and as to the signifi-
cance of its clinical manifestations.*^ A possible explanation
of certain conflicting results resides in the difficulty of completely
removing the pancreas, even when this is the object sought. The
significance of the duodenum in this type of diabetes has also
received considerable attention. In rana esculenta extirpation of
the duodenum causes an even more severe diabetes than does pan-
creas removal; this is not the case, however, in warm-blooded
animals.
Liithje** has shown that if, in a fasting animal, a portion
of the gland be left, the initial glycosuria will completely disap-
pear in the later stages of starvation, and the percentage of sugar
in the blood will return to normal. We must conclude, therefore,
that in this form of diabetes it is still possible for an animal to
consume sugar. The consumption is greater when the external
temperature is high than when it is low.*^
The full significance of the pancreas in the
mechanism of sugar metabolism is still unsettled.*^
The most likely interpretation hinges on the conception of an
356 THE BASIS OF SYMPTOMS
internal secretion. Cohnheim believes it necessary to
assume the combined action of such a secretion and of muscle
extract. Pfluger, on the other hand, emphasizes the importance
of the nervous system in the mechanism.
Glycosuria may be produced not only by extirpation of the
pancreas, but also by removal of the salivary glands and of the
thyroid.*'^ Furthermore, the hypophysis (see p. 348) and
the chromaffin system play a part in sugar metabolism ;
and we have already referred to the glycosuria produced by the
injection of epinephrin (see p. 347). Loewi^® has made
the interesting observation that the instillation of a drop of
epinephrin into the conjunctival sac of animals whose pancreas
has been removed causes a mydriasis, and that the latter does
not occur in normal animals. This has been noted also in cer-
tain cases of human diabetes probably of pancreatic origin, as
well as occasionally in hyperthyroidism. The inference to be
drawn from the foregoing is that the pancreas inhibits the sensi-
tiveness to epinephrin of certain organs of sympathetic innerva-
tion, whereas the thyroid augments this sensitiveness. Eppinger,
Falta and Rudinger*^ have studied the interrelationship
of the pancreas, the thyroid and the chromaffin
system with respect to proteid and carbohydrate metabolism,
and have shown a complicated interaction of these organs, in
part stimulative, in part inhibitory. Possibly, certain cases of
human diabetes may be explained on the basis of such an inter-
action.
The liver has recently not received the attention it de-
serves as a factor in diabetes. Newer work has again focused
our attention upon this organ, and properly too, because of its
intimate relation to other glands, particularly the pancreas.
Finally, as regards the pancreas, we must ask whether the
secretions of the cells of Langerhans alone are of impor-
tance in sugar metabolism, or whether the pancreatic cells in
general share this function. Observers are not unanimous on this
point. '^ It would appear, however, from the comprehensive stud-
ies of Weichselbaum ^^ that a painstaking examination will show
striking pathological alterations in the islands of Langerhans in
all cases of human diabetes.
The Etiology of Diabetes. — The tendency to acquire diabetes
may be inherited, not alone from parents that have had the
DIABETES 357
disease itself, but also from those who have had gout, obes-
ity or nervous disorders.
Diabetes sometimes follows severe cerebral concus-
sions and injuries, as well as violent fright and
other psychic traumata. Arteriosclerosis and
syphilis are frequently associated with diabetes, though we
do not know whether they cause it by their action upon the
cerebral structures or not. Definite anatomical lesions of the
brain, especially when situated in the neighborhood of the fourth
ventricle, undoubtedly can produce diabetes, though this is a very
rare event.
At times, diabetes is accompanied by diseases of the
liver or pancreas. The condition of the pancreas in dia-
betes is of especial interest on account of the glycosuria produced
by an extirpation of this gland in animals. °^ Even the older
investigators occasionally noted changes in the gland in cases of
diabetes. If the pancreas is completely destroyed by disease,
without leading to death within the first twenty-four hours, dia-
betes always develops. Primary carcinomata of the pancreas, how-
ever, may completely destroy the gland without producing dia-
betes, apparently because the carcinoma itself retains some of
the functions of the normal tissues. We have already noted
Naunyn's analogous observation, i.e., that a carcinoma of the liver
may secrete bile. It is our opinion, based on Weichselbaum's
studies, that typical and severe cases of diabetes are due in all
instances to lesions of the Langerhans islets.
Effects of Diabetes Upon the Body. — In diabetes, a certain
proportion of the energy taken in the food is not utilized by the
body, and it is necessary, therefore, to cover the loss by more
abundant nourishment. Even in severe forms of the disease,
the loss of carbohydrates may be covered by the administration
of large amounts of fats and proteids, providing, of course, that
the gastro-intestinal canal can absorb the necessary amount of
material. Fortunately, this is usually possible and only rarely
is absorption markedly reduced in diabetes. ^^ The greater an
individual's need for energy, the more difficult will it be to main-
tain his nutrition when his ability to utilize carbohydrates is
lessened. Yet the combined skill of physician and cook will often
accomplish wonders in this respect. If the diabetic
patient absorbs sufficient nourishment, his
858 THE BASIS OF SYMPTOMS
metabolism does not, as a rule, differ from that
of a healthy individual upon the same diet. If
it is impossible to furnish sufficient energy to
him, his fat and body proteids are consumed,
just as are those of a healthy individual during
partial starvation. Some diabetics seem to consume the
proteid material in their bodies with abnormal rapidity.^* But
this is probably due to the fact that diabetics, as has been experi-
mentally demonstrated, need more proteid food to maintain their
nitrogen equilibrium than do normal individuals, and that if this
added quota is not forthcoming they must consume their own
proteids, especially since they cannot burn carbohydrates and thus
spare proteids. From what has been said, it will be seen that in
the more severe forms of diabetes, malnutrition frequently de-
velops; for the patient is either unwilling or unable to take a
sufficient quantity of fats and proteids to cover his total needs,
and, in addition, his consumption of proteid material is sometimes
abnormally rapid.
The metabolism in diabetic patients frequently shows other
peculiarities as the disease becomes more advanced. Various
organic acids, especially beta-oxybutyric and diacetic acids,
are formed in the body. Indeed, they are produced in such quanti-
ties in no other condition as in some cases of diabetes mellitus.
We have already stated that when an excessive amount of acid is
present in the body, it is neutralized by the ammonia which would
otherwise have been converted into urea (p. ^y^y^. For this reason
the excretion of organic acids in diabetes is associated with a
relatively increased elimination of ammonia and a
relatively diminished excretion of urea in the urine.
The source of the acetone and of the diacetic and beta-oxybutyric
acids is of great theoretical and practical interest, for the resulting
acidosis is apparently the most important cause of the dreaded
diabetic coma (see p. 332). Unfortunately, however, the cause
of the acidosis and the source of the acids is but little understood
(see p. 328).
In diabetes, the nutrition of different parts of the body suffers
in various ways. The crystalline lens of the eye may become
opaque (diabetic cataract), and degeneration of the retina
and choroid coat may develop. The arteries are often
found to be sclerotic.
DIABETES 359
Tissues that are permeated with sugar seem to offer an excellent
medium for the growth of micro-organisms, and it is well known
how frequently diabetics become infected and how often these
infections terminate in gangrene. The diabetic gangrene
is due, in part, to the presence of excessive amounts of sugar in
the tissue and, in part, to the diminished blood-supply caused by
an associated arteriosclerosis. Patients with diabetes are fur-
thermore very susceptible to tuberculosis, and here again
the process shows a special tendency to develop into gangrene.
Other complications, such as furunculosis, caries of the
teeth, gingivitis and stomatitis, are also frequently present in
diabetic patients.
We know comparatively little concerning the relation
that lesions of the kidneys bear to diabetes mel-
litus. Albuminuria is a not infrequent complication of the
disease^"* In some cases it is due to a true nephritis, produced
by the same cause which gave rise to the diabetes, such as arterio-
sclerosis, for example; in other cases it is apparently quite an
accidental complication. When the albuminuria develops late in
the diabetes, it may be questioned whether the continuous passage
of sugar through the kidneys has not directly harmed the secreting
cells. In this connection we may recall the glycogenic degeneration
of the kidney so often found in diabetes."^ The immediate cause
of this degeneration, and its relation to albuminuria are, however,
insufficiently understood. That primary lesions of the kidney
may cause glycosuria (renal diabetes) seems very probable (see
p. 346).
The amount of urine is often enormously increased in
diabetes, and as much as ten or fifteen litres may be passed in
twenty-four hours. This is undoubtedly dependent upon the
abnormal quantity of sugar in the blood ; for if, by proper methods,
the latter be diminished, the amount of urine also diminishes.
Conversely, the greatest diuresis occurs in the cases with the
largest amounts of sugar in the urine. The accumulation of
dextrose in the blood, or in certain tissues, seems to produce an
intense thirst, and the water that is taken for this causes
the increase in the amount of urine. Yet there exists no definite
relation between the amount of urine, the excretion of sugar and
the feeling of thirst ; and it has been shown, for example, that even
360 THE BASIS OF SYMPTOMS
though the same quantities of sugar are being excreted daily, the
quantity of urine may be different in different patients.
Theory of Diabetes. — From the foregoing facts we shall now
try to formulate a theory of diabetes mellitus. The sugar is
excreted in the urine because of a hypergly-
c se m i a — a n excess of sugar in the blood. One
cause of this excess in the blood is that the
liver has lost the property of storing up the dex-
trose that comes to it either from the food (mild
form) or from the splitting up of proteids in the
body (severe form). To confirm the correctness of this
distinction, however, further evidence is needed.
It is impossible to say to what extent the glycogenic functions
of other organs, such as the muscles, are impaired in diabetes. It
seems certain, however, that in some way the pancreas assists
the liver and muscles in their glycogenic function, and that human
diabetes is generally the result of a disturbance of the islands
of Langerhans. The loss of the pancreas function not only seems
to interfere with the power of the liver to store glycogen, but also
to cause the liver to release its glycogen in amounts far in excess
of those called for by the tissues. For, after the pancreas has
been removed from dogs, even in the fasting state, hyperglycsemia
and glycosuria appear at once, and the liver becomes glycogen-
free much more rapidly than in starving dogs whose pancreas is
intact.
In the milder cases of diabetes, it is possible that no other
disturbances of function are present than the above-mentioned im-
pairment of the glycogenic functions in the body. In the
more severe forms of diabetes, however, there is un-
doubtedly a diminution in the ability of certain
cells of the body, perhaps of the muscle-cells or
even of all cells, to assimilate sugar. The pan-
creas seems to assist in the assimilation of sugar in the body,
not only through its influence on the glycogenic function of the
liver, but possibly also by furnishing an internal secretion that
activates the glycolytic ferments in the muscles. This action of
the pancreas is perhaps similar to that of the enterokinase of the
intestines which converts a protrypsin into a trypsin, or to the
intermediary body that plays such an important part in haemolysis.
The glycc^enic function of the liver may certainly be influenced
DIABETES 361
through the nervous system, as is proved by the effects
of the experimental puncture of the fourth ventricle; and it is
quite possible that the nervous system serves in some way to
connect the liver and the muscles. This influence of the nervous
system upon the glycogenic function of the liver would explain
the etiological relation between nervous lesions and diabetes, a
relationship that has been insisted upon by so many clinicians.
Finally, we know that a glycosuria may be caused
by lesions of different organs, especially of
the liver, the pancreas, the thyroid, the adre-
nals and possibly by diseases of still other
organs. Ultimately, it may be possible to distinguish different
forms of the disease according to their origin; even now, indeed,
V. Noorden^'^ has attempted such an etiological classifi-
cation on the basis of the interrelationship of
the ductless glands. And, even though diabetes is
apparently associated in most cases with lesions of the islands
of Langerhans, it is not improbable that these endosecretions
may be influential in determining the characteristics of the par-
ticular case.
LITERATURE
* Adler : Pfliiger's Arch., cxxxix, 93.
' F. M'uller : Path. d. Ernahrung, 235 ; Blumenthal, Deutsche Khnik, iii, 305.
"Kiilz: Festschrift f. C. Ludwig, Marburg, 1890; E. Pfliiger, Das Glykogen,
2nd edit., 1905; Pfliiger and Junkersdorf, Pfluger's Arch., cxxxi, 201.
* Langstein : Asher-Spiro, Ergebnisse, i, I, 63 ; Embden and Almagia, Hof-
meister's Beitrage, vii, 298.
*De Filippi: Zeitschft. f. Biol., xlix, 11.
•v. Noorden: Zuckerkrankheit, 5th edit, 19 (Ht.) ; Baer, in Naunyn, Dia-
betes, 2nd edit., 31. For the subject of aHment. galactosuria see Bauer,
Wiener med. Wochenschft., 1906, 2537.
* Renter: Jahr. d. Hamburgischen Staatskrankenanstalten, vii (2), ^^ (Ht.).
* Grober : Arch, f . khn. Med., xcv, 137.
•Strauss: Berl. kUn. Wochenschft., 1898, 51.
"Chajes: Deutsch. med. Wochenschft., 1904, 19; Hohlweg, Arch. f. khn.
Med., xcvii, 443.
" Eppinger, Falta and Rudinger : Zeitschft. f. Klin. Med., Ixvi, i, and Ixvii, 380.
"Glaessner: Zentralbl. f. Stoffwechsel, vii, 673, 705; papers by Lusk et al.,
Amer. Jour. Phys., i, iii, ix and x; also the monograph by Lusk, Phlor-
hizin Glykosurie, Ergeb. d. Physiol., 1912, xiii, 315 (Ht.).
" Pavy : Jour, of Phys., xx ; Pfluger, Pfliiger's Arch., xcvi, 338.
"Michaelis and Rona: Biochem. Zeitschft, xiv, 476; v. Hess and McGuigan,
Jour, of Pharm. and Exp. Then, 1914, vi, 45 (lit.).
"Rumpf, Hartogh and Schumm: Arch. f. exp. Path., xlv, 11.
"Miinch. med. Wochenschft, 1901, 38; Bonninger, Deutsch. med. Wochen-
schft., 1908, 34; Weiland, Arch. f. klin. Med., cii, 167. See also Frank
(Harmless forms of diabetes in young individuals), Therap. d. Gegen-
wart Nov., 1914, 439-
" Biochem. Zeitschft., xxv, 284.
S62 THE BASIS OF SYMPTOMS
"PoUak: Arch. f. exp. Path., Ixi, 157; Loewi, in v. Noorden's Handb., 2nd
edit., 810 (Metab. and Pract. Medicine, London, 1907) ; Biedl, Innere
Sekretion (Int. Secretory Organs, New York, 1913) ; Landau, Zeitschft.
f. klin. Med., 1914, Ixxix, 201.
"Eppinger, Falta and Rudinger: Zeitschft. f. klin. Med., Ixvi, i; Underbill
and Closson, Amer. Jour, of Phys., xvii, 75.
*> Pollak : 1. c, 166.
"^ Claude-Bernard : LeQons sur diabetes, etc. ; Pfliiger, Pfliiger's Arch., xcvi,
303, 860.
'^ Mayer: C. r. soc. biol, 1906, 1123.
** Waterman and Smit : Pfluger's Arch., cxxiv, 198.
»* Pollak: 1. c.
" Zeitschft. f. klin. Med., Ixvi, 15 et seq.
""For a discussion of this subject see Gushing: The Pituitary Body and its
Disorders, 1912, 16, 261 (lit).
"^ See especially Naunyn : Diabetes Melitus, in Nothnagel's spez. Path., vii, i,
1906, 2nd edit. (The Nothnagel System) ; v. Noorden, Die Zucker-
krankheit, 6th edit., 1912, and New Aspects of Diabetes, New York, 1913 ;
Lepine, Le diabetes sucre, 1909; Allen Glycosuria and Diabetes, Boston,
1913 ; Magnus-Levy, in Kraus-Brugsch, Spez. Path. u. Therap. inn.
Krankheiten, 1913; Pavy, Garbohydrate Metabolism and Diabetes, 1906;
Gammidge, Glycosuria and Allied Gonditions, 1913; Lusk, Elements of
the Science of Nutrition, 2nd edit, 1909; Benedict and Joslin, Mletab-
olism in Diabetes Mellitus, Garnegie Institute, Washington, 1910, and A
Study of Metabolism in Severe Diabetes, 1912.
"•Leyden's Handb. d. Ernahrungstherapie, 2nd edit, i, 226.
*° HoUinger : Arch, f . klin. Med., xcii, 217.
'" See v. Noorden, 1. c.
*^ Pollak: Arch. f. exp. Path., Ixiv, 415.
■' Staubli : Arch, f . klin. Med., xciii, 107.
•* Falta and Gigon : Zeitschft. f. klin. Med., Ixi, 297.
** Pfliiger : Pfliiger's Arch., cviii, and Das Glykogen u. seine Beziehung zur
Zuckerkrankheit, 2nd edit., Bonn, 1905.
*° Pfliiger and Junkersdorf : Pfliiger's Arch., cxxxi, 201.
*' For literature relative to the formation of sugar from fat see Pfliiger :
Das Glykogen, etc.: Rumpf, Hartogh and Schumm, Arch. f. exp. Path.,
Iv and Ivi; Falta and Gigon, Zeitschft. f. klin. Med., Ixv, 328; Gigon,
Arch. f. klin. Med., xcvii, 376.
" Staubli : Arch, f . klin. Med., xciii, 107 ; Gigon, Miinch. med. Wochenschft.,
1909, 907 ; Gigon and Massini, Arch, f . klin. Med., xcvi, 531.
** Naunyn, in Volkmann's Vortragen, Nos. 349, 350 ; Naunyn, Diabetes mel-
itus.
*» Fr. Miiller : Path. d. Ernahrung, 228.
*° Bauer : Wiener med. Wochenschft., 1906, 2537 ; Petetti, Berl. klin. Wochen-
schft., 1907, 156; Brasch, Zeitschft f. Biol., 1, 113.
" Magnus-Levy : Verhand. d. physiolog. Gesell. z. Berlin, 1904, Nos. 5-8 ;
Lusk, Science of Nutrition; Benedict and Joslin, Metabolism in Diabetes
Mellitus, 1910.
*■ v. Mering and Minkowski : Arch. f. exp. Path., xxvi, 371 ; Minkowski, ibid.,
xxxi, 85 ; Sandmeyer, Zeitschft. f. Biol., xxxi, 12.
*'Liithje: Miinch. med. Wochenschft, 1903, 1537.
** See Pfliiger : Pfluger's Arch., cviii ; Pfluger, Das Glykogen u. seine Bez.
z. Diabetes, 2nd edit, 1905 (lit).
"Liithje: Kongr. f. inn. Med., 1905, 298; ibid., 1907, 264.
**Gohnheim: Zeitschft. f. physiol. Ghemie, xxxix, xlii, xliii, xlvii; Hall,
Amer. Jour, of Phys., xviii, 283.
" Pfliiger : Das Glykogen, etc., 2nd edit., 1905.
** Loewi : Arch, f . exp. Path., lix, 83.
" Kongr. f . inn. Med., 1908, 345, 352.
DIABETES 363
"Sauerbeck, in Asher-Spiro; Virchow's Arch., clxvii, Suppl., i; Karaka-
scheff, Arch. f. klin. Med., Ixxvii, 290; Marchand, ibid., 312; Herxheimer,
Verhand. d. path. Gesell., 1909, 276. See also Bensley, Amer. Jour. Anat.,
191 1, xii, 297 (intra-vital staining technic and recognition of islet cells).
"Wiener klin. Wochenschft., 191 1, No. 5.
" Minkowski : Ergeb., in Lubarsch-Ostertag., 1897, 94 (lit.) ; Sauerbeck, ibid.,
1904, viii, (2), 538.
"Salomon: Deutsch. Klinik, xii, 527.
"v. Mering, in Penzoldt-Stintzing : Handb. d. spez. Therap., 3rd edit., ii,
part 3. Benedict and Joslin, Publ. of the Carnegie Inst., Washington,
Nos. 135 and 176.
"' See Naunyn, v. Noorden, 1 c.
*°Fichtner: Arch. f. klin. Med., xlv, 112.
" V. Noorden : Die Zuckerkrankheit, 5th edit, 154.
CHAPTER VIII
THE METABOLISM OF THE PURIN BODIES. GOUT
The nitrogen derived from a certain class of proteids, the
nucleo-proteids, is not excreted in the form of urea
and ammonium salts to the same extent as is that derived from
ordinary proteids.^ The characteristic constituents that enter
into the composition of the nucleo-proteids are the nucleinic
acids. When these undergo cleavage, they give rise to the
purin or alloxuric bases, among which are adenin,
guanin, xanthin and hypoxanthin. A small portion of these
bases appears in the urine as such, but the greater part is elim-
inated in an oxidized form, as uric acid. The uric acid
and the purin bases are often spoken of together as the purin
bodies.
The mechanism underlying the conversion
of the nucleo-proteids into the purin bodies is
one of ferment action. ^ From the nucleins of the cells
anuclease splits off the purin bases adenin and guanin. The
latter are changed by a hydrolytic ferment into xanthin
and hypoxanthin. An oxydase converts hypoxanthin into
xanthin, and the latter in turn into uric acid. These ferments are
widely distributed in the animal body. In man about fifty to sixty
per cent, of the uric acid is destroyed by still another, urico-
lytic, fermen t — u r i c a s e — chiefly in the liver, muscles and
kidneys. As this uricolytic enzyme is absent from the blood,^ a
certain portion of the nitrogen of the purin bases appears in the
urine as urea.
Most of the uric acid that appears in the urine
is derived in this manner from nucleo-proteids
that are broken down in the body, or from purin
bases or related compounds, such as caffein
or theobromin, that are taken in the food. Not
all of the uric acid, however, is derived from these sources, for
it is now practically certain that this acid may be formed
synthetically in the human body, just as it is in the
bodies of birds.* Nor does all of the nitrogen contained in the
nucleinic acids appear in the urine as uric acid or related com-
804
GOUT 365
pounds, for a certain proportion is converted into urea in the
body. This latter fact gives some basis to the old conception
that uric acid represents an early stage in the formation of urea.
The quantity of purin bases in the urine
serves therefore as a rough index of the bodily con-
sumption of nucleo-proteids and purin bodies,
derived either from the cellular metabolism or directly from the
food. Yet, as we have seen, it cannot serve as an accurate and
absolute index of such consumption ; for, on the one hand, not all
of the nitrogen in the nucleinic acid appears in the urine as purin
bodies, and, on the other hand, these bodies may be formed syn-
thetically within the living organism.
Cell nuclei are very rich in nuclei- proteids;
and when the food taken contains many nuclei, as is the case
with thymus gland, for example, the amount of purin bodies in the
urine is greatly increased. Conversely, if a person avoids those
substances which can be readily converted into purin bodies, such
as the nucleo-proteids of meats and seeds, the caffein of coffee,
etc., the quantity of uric acid in the urine is diminished, and that
which does appear there represents the amount actually formed
within the body. The amount of this endogenous uric acid
has been found to be different in different individuals, though it
is fairly constant for the same individual at different times.*^
It is apparently somewhat influenced by the ingestion of large
quantities of non-nitrogenous food.
The elimination of endogenous uric acid is in-
creased whenever large numbers of cells rich in nucleo-pro-
teids are being destroyed in the body. This was early demon-
strated for a particular kind of cells, the leucocytes; and this
fact, among others, led Horbaczewski to the belief that the leuco-
C)rtes are a specific source of purin bodies, a view now proved
to be incorrect.® Leucocytoses are, however, frequently
accompanied by an increased elimination of purin bodies; and
when this is so, we may assume that an abnormal destruction of
leucocytes is taking place in the body. Very large amounts of
uric acid are excreted in the majority of cases of leukaemia
(64 per cent). Gottlieb'^ has demonstrated in some leukaemias
an increase in the excretion of the purin bases ; while other obser-
vers,® in a series of cases, have found the excretion both of uric
acid and of the bases to be increased. The leuksemic increase in
S66 THE BASIS OF SYMPTOMS
the purin bodies likewise speaks for an augmented destruction
of leucocytes.
The urine of the new-born child also contains re-
markably large quantities of uric acid. These are found at about
the same time that uric acid infarcts are most liable to
occur in the kidneys. The explanation of this increased elimina-
tion resides possibly in the marked destruction of leucocytes which
occurs in the first days of life and which leads to a saturation
of the tissues with the purin bodies, just as in leukaemia;^ while
the small amount of urine excreted at this time favors the precipi-
tation of uric acid.
Gout. — Gout ^^ is characterized by the deposition of mono-
sodium urate crystals in various parts of the body, especially in
the hyalin and fibrous cartilages, in the tendons, in the subcu-
taneous and intermuscular connective tissues and in the kidneys.
These deposits take the form of clusters of needle-like crystals.
No symptoms may be caused by such a deposition of urates, espe-
cially when it takes place gradually and in certain localities, as
the subcutaneous tissues and some cartilages. These urate
deposits, known as tophi, often attain a large size, and
they may then break through the skin, or again disappear with-
out having caused any unpleasant sensations. In these cases, it
seems improbable that the uric acid should have been formed
locally by the cells, for the strands of connective tissue are pushed
aside, and the tophi increase in size by new deposits on their
exteriors.
On the other hand, the deposition of urates in the tissues may
lead to a more or less marked inflammatory reaction in the
neighborhood, and this may be accompanied by the characteristic
paroxysm of acute gout. Suddenly, or after some pro-
dromal symptoms, the patient is awakened at night by violent
j>ains in one or more joints, usually in the metatarsophalangeal
joints of the great toes. The affected joint and the neighboring
tissues become intensely inflamed, and the skin over them becomes
cedematous. These very acute symptoms usually do not last
long, and after a few hours or days they all disappear without
necessarily leaving any alterations in the joint that can be demon-
strated even by anatomical methods. These typical acute gouty
paroxysms may recur at varying intervals; but gradually they
become less and less characteristic, the patient becomes cachectic
GOUT 867
and the "regular gout" is said to have become trans-
formed into the asthenic form.
The exact cause of these typical paroxysms is
uncertain. According to one view the inflammation is caused
by the deposition of uric acid or some of its
derivatives in the tissues. That this deposition is an
important, if not the determining, factor in the gouty attack is
indicated by the following facts: Before the paroxysm, the
amount of uric acid in the blood is increased, whereas during the
attack and shortly thereafter, the amount is greatly reduced.
Again, it is possible to produce typical paroxysms in gouty indi-
viduals who have lived on purin-free food for a long time, by
feeding them large amounts of food rich in the purin bodies.^ ^
Gouty attacks may occur, furthermore, following a pneumonia
when nucleins (leucocytes) in large numbers are breaking down.^^
Finally, characteristic tophi have been produced in rabbits
by injections of uric acid.^^ Following the injection the latter
is converted into the insoluble sodium urate and about the pre-
cipitate are seen the inflammatory phenomena characteristic of
the gouty attack, zns., the infiltration of polynuclear leucocytes, the
appearance of phagocytes and the growth of connective tissue.
Indeed, it was demonstrated many years ago that the salts of uric
acid have a far more rapid and irritating action than does uric
acid itself. Apparently, therefore, it is the deposition of the
crystallized urates which brings about the inflammatory reaction,
which is not necessarily painful, however.
Why this deposition occurs periodically and only in certain
tissues is not known. And we are equally ignorant concerning
the nature of many associated gouty manifesta-
tions, such as the granular kidney and the heart
changes, the pulmonary, nervous and ocular com-
plications and the general cachexia.
It is said that a tendency to gout may be in-
herited, and that the disease may be caused by excesses in
food and drink. We believe, however, that caution is necessary
in the acceptance of these views, for they rest not upon convincing
statistics, but rather upon so-called clinical experience and im-
pressions. More accurate data on this subject are therefore very
desirable. That chronic lead poisoning favors the
development of gout can hardly be doubted,** though how it does
368 THE BASIS OF SYMPTOMS
so is quite uncertain. The nature of the relationship between
gout and diabetes mellitus, and between gout and
obesity, are Hkewise unsolved.
Uric Acid in the Blood During Gout. — During, and also be-
tween, the gouty paroxysms, uric acid crystallizes out of the
blood with abnormal ease, even though the diet has for months
contained no purin bodies, and though the heart and kidneys are
free from changes.^ ^ It crystallizes out of normal blood in a
similar manner only when a large amount of nuclein compounds
have been taken in the food. In pathological conditions other
than gout, especially in leukaemia and in pneumonia after the
crisis, however, large quantities of uric acid will at times crystal-
lize out of the blood just as it does in acute gout. And in chronic
nephritis with uraemia, uric acid may readily be demonstrated in
the blood. ^® To explain the practically constant uric acid con-
tent of the blood in gout, one must assume that the power of
certain organs to break up the acid has been diminished.^ ''^
The fundamental question as to the solubil-
ity of uric acid in the blood has recently been elabo-
rated in its more important aspects by Gudzent.^^ As Emil
Fischer first demonstrated, uric acid occurs in two forms, the
one corresponding to the laktam formula, the other to the
laktim formula. Both series form primary salts which differ
only in their solubility. Gudzent was able to demonstrate that
the laktamurate, while the more soluble, was extremely unstable
and was immediately converted into the more stable laktim modifi-
cation. He has shown further that radium is capable not only
of retarding the change from the soluble to the insoluble salt,
but also has the power to convert the insoluble laktim into the
more soluble laktam. ^^ Up>on these observations is based the
recently advocated and eminently successful radium therapy
of gout. 20
That uric acid exists In the blood only as the sodium salt
appears well established ;2^ accordingly, the view that it is com-
bined with nucleinic acid in the blood and tissues seems unten-
able.22 As soon as one hundred c.c. of blood serum contain more
than 18,4 mg. of laktamurate or 8.3 laktimurate, the conditions
are favorable for the deposition of the uric acid salts.^^
More difficult of understanding are the causes of this super-
saturation of the blood with uric acid and of its deposition only
GOUT 369
in certain tissues. Significant with respect to the latter is the
observation that cartilage possesses an especial affinity for uric
acid, which crystallizes out as sodium urate in this tissue. We
are thus brought a step nearer to an understanding of how tophi
are formed.
Another question still undetermined is whether, with a given
concentration of uric acid in the blood, deposition occurs more
readily in gouty individuals than in non-gouty. Leukaemia is a
condition in point; here, though unusually high uric acid values
are observed, gouty manifestations are distinctly infrequent.
Nevertheless, they are occasionally observed in typical form. 2*
The Uric Acid in the Urine in Gout. — Previous to the gouty
paroxysms, there is a diminished excretion of uric acid in the
urine; whereas, during and just after the paroxysm, more is ex-
creted not only than before,^^ but also than in the intervals between
the attacks, and this too on a meat-free diet.^® The excretion
of the purin bases is also said to be increased along with the
increase in uric acid, though there is some doubt as to this. The
endogenous uric acid excretion exhibits a similar behavior; after
the paroxysm, indeed, it may fall below the normal ^'^ and in the
intervals it remains at the lower limit of the normal.^® If food
rich in nuclein compounds, e.g., thymus, be taken during the
paroxysm, the uric acid is not excreted so well as it is by a normal
individual.^
In chronic gout, and during the intervals between the
paroxysms of acute gout, no definite abnormalities in the excretion
of uric acid can be demonstrated, although Soetbeer believes that
after the administration of meat the excretion of uric acid does
not follow precisely the normal course, and that in some cases it is
quantitatively diminished or delayed.
Brugsch and Schittenhelm ^^ found that the excretion of
endogenous uric acid was, on the average, diminished, even though
the amount of uric acid in the blood was increased and the kidneys
were functionating properly. The formation of urea from
exogenous purin bodies was delayed in gouty individuals ; while
the total uric acid formation from all sources was likewise re-
tarded. Hence, there exists a disturbance of uric acid
formation, uric acid destruction and uric acid
elimination. Bloch^* has made similar observations and
emphasizes the importance of the disturbance in endogenous purin
24
370
THE BASIS OF SYMPTOMS
metabolism. Umber,^^ q^ the contrary, whose curves indicate
a subnormal elimination of uric acid in the gouty, regards the
retention of uric acid as the essential feature. That retention
does play an important part seems to be indicated by the success
generally reported from the use ofatophan^^ which apparently
exerts a specific eliminative action on the kidneys.
One might be inclined, therefore, to attribute the increase of
uric acid in gouty blood to an insufficient excretion
of urates by the kidneys, a supposition which receives
some support from the fact that other nitrogenous waste products
may also be retained in the body, both in the acute paroxysms
and in chronic gout.^^ Indeed, evidence has been accumulated
which indicates that the kidneys are functionally de-
ranged even early in the course of gout.^^ The
gouty granular kidney, however, is a late manifestation. That
unusual conditions are present would appear from the retention
of ammonium and potassium salts during the gouty paroxysm.^*
The metabolism of proteids, other than that of the nucleo-proteids,
is entirely normal in gout.^'^
The Cause of the Local Deposits of Urates. — According to
many of the best observers,^^ the local deposits of the urates
in gout are caused by changes in the cells of the
affected regions. This seems to be true in the primary
attacks at least. As has been mentioned, however, there is less
reason to believe that the more chronic deposits in the subcu-
taneous tissues, etc., are caused by primary cellular changes.
Ebstein has laid great weight upon a primary necrosis of the tissue
as the cause of the precipitation of urates, but later researches
have not supported his views. The solution of this problem would
seem to reside in studies which shall determine in what way, and
to what degree, substances related to uric acid are held in solution.
LITERATURE
*The more recent studies are found in Brugsch and Schittenhelm : Der
NukleinstoflFwechsel u. seine Storungen, Jena, 1910; Bloch, Biochem.
Zentralbl., v (collective report) ; Schittenhelm, Die Fermente d. Nuklein-
stoffwechsels u. d. Wirkung, in Handb. d. biochem. Arbeitsmethoden
(Abderhalden), 1910, ii, 420; E. Fischer, Untersuch. in d. Puringruppe
(1882-1906), Berlin, 1906; Brugsch, in Kraus-Brugsch, Spez. Path. u.
Therapie inn. Krankheiten, 1913 (lit.).
"Schittenhelm: Zeitschft. f. physiol. Chemie, xlv, 354, and 1, 30; Wiechowski
and Wiener, Hofmeister's Beitrage, ix, 247; Schittenhelm and Schmidt;
Zeitschft. f. exp. Path., iv.
GOUT 371
• Brugsch and Schittenhelm : Zeitschft. f. exp. Path., iv.
* Minkowski: Die Gicht, in the Nothnagel System; Wiener, Asher-Spiro,
Ergeb., i, I, 555. and ii, Z7T> SchmoU, Johns Hopkins Hospital Bull., xv,
'Burian and Schur: Pfliiger's Arch., Ixxx, 241, and Ixxxvii, 239; Rockwood,
Am. Jour. Phys., xii, 38.
•Wiener: 1. c, 585.
' Gottlieb and Bondzynski, Arch. f. exp. Path., xxxvi, 127.
*Kiilman: Zeitschft. f. klin. Med., xxviii, 524; Kolisch and Dostel, Wiener
klin. Wochenschft, 1895, Nos. 2Z and 24.
'Niemann: Jahrb. d. Kinderheilk., 1910, Ixxi, 586 (lit.).
*°More recent literature on gout (see also footnote i) : Ebstein, Natur. u.
Behand. d. Gicht, Wiesbaden, 1906 ; Minkowski, 1. c. ; v. Noorden,
Path. d. Stoffwechsels, 2nd edit., 1908, ii, 138; Schittenhelm, Natur. u.
Wesen. d. Gicht, Med. Klinik, 4th supplement ; Schittenhelm and Schmidt,
Die Gicht u. ihre diatetische Therapie, Halle 1910; Kongr. f. inn. Med.,
Wiesbaden, 1910 ; F. H. McCrudden, Uric Acid, New York, 1906.
** Brugsch : Zeitschft. f. exp. Path., vi, 278.
" Ebstein : Munch, med. Wochenschft., 1907, No. 34.
" Van Loghems : Zentralbl. f. d. ges. Phys. u. Path. d. Stoflfwechs., new series,
1907, 244.
" Liithje : Zeitschft. f. klin. Med., xxix, 266.
" Brugsch and Schittenhelm : Zeitschft. f . exp. Path., iv.
" Magnus-Levy : Virch. Arch., clii, 107 ; Zeitschft. f . klin. Med., xxxvi, 372.
" Brugsch and Schittenhelm : Zeitschft. f . exp. Path., iv.
"Zentralbl. f. d. ges. Phys. u. Path. d. Stoffwechsels, 1910, v, 289. Criticism
by Bechhold and Ziegler, Biochem. Zeitschft., 1910, xxiv, 146.
" Deutsch. med. Wochenschft., 1909, No. 21 ; Med. Klinik, 1910, No. 42.
*" Kongr. f . inn. Med., Wiesbaden, 1910.
** Brugsch: Zeitschft. f. exp. Path., vi; Schittenhelm, ibid., 1909, vii; Gudzent,
Zeitschft. f. physiol. Chem., Ixiii, 455,
""Minkowski: Das Wesen d. Gicht, Vienna, 1903.
** Gudzent : 1. c.
** Gliickmann : Leukamie und Gicht, Berlin, Inaugural Dissert., 1910.
•"His: Arch. f. klin. Med., Ixv, 156; Magnus-Levy, Zeitschft. f. klin. Med.,
xxxvi, 380.
* Soetbeer : Miinch. med. Wochenschft., 1907, No. 28.
^ Brugsch : Zeitschft. f. exp. Path., ii, 619.
" Brugsch : 1. c. ; Brugsch and Schittenhelm, Zeitschft. f. exp. Path., iv.
* Vogt : Arch, f . klin. Med., Ixxi. 21 ; Soetbeer, Zeitschft. f . physiol. Chem.,
xl, 25 ; Bloch : Arch, f . klin. Med., Ixxxiii, 499.
** Brugsch and Schittenhelm : Zeitschft. f . exp. Path., iv, 480.
^ Bloch : Zeitschft. f . physiol. Chem., Ii, 472.
** Umber : Kongr. f . inn. Med., 1910, 436.
" Nicolaier and Dorn : Arch. f. klin. Med., xciii, 331 ; Weintraub, Kongr. f.
inn. Med., 1911, 482; Georgiewski, Deutsch. med. Wochenschft, 1911,
No. 22.
"*Vogel: Zeitschft. f. klin. Med., xxiv, 512; Schmoll, ibid., xxix, 210;
Magnus-Levy, ibid., xxxvi, 380; Vogt, Arch. f. klin. Med., Ixxi, 21.
«Vogt:l. c.
" Soetbeer : Zeitschft. f. physiol. Chemie, xl, 55.
" Brugsch and Schittenhelm : Zeitschft. f . exp. Path., iv, 538.
"Klemperer, Horbaczewski, v, Noorden.
CHAPTER IX
CONSTITUTIONAL DISEASES AND DIATHESES
Thus far, we have considered metabolic anomalies in so far
as they have concerned variations in the amounts of materials
utilized by the body, or alterations in the catabolism of the normal
constituents of the food and tissues. The index of such anoma-
lies is the appearance of incompletely metabolized substances in
the urine — findings which open to us the significant, extensive and
practically unexplored domain of the so-called intermediary
metabolism.
It has already been noted that in the normal metabolism of
certain organs, there arise substances which influence the activity
of other organs. Thus the field of intermediary metabolism coin-
cides with that of the chemical correlation of the
organs,^ which seems to explain from the physiological and
pathological points of view what investigators have long since
sought to establish from the morphological, vi2., the indivisibility
of the organism. The nervous system has until recently been
regarded as the essential mechanism whereby the functions of
the different bodily units are harmonized; now, however, the
belief is held that many other organs, perhaps all, mutually in-
fluence one another in a chemical way by means of the so-called
hormones. The sphere of the latter is apparently unlim-
ited, for the activity even of the nervous system may be stimulated
or depressed to a great extent by chemical means. The subject
is so vast and complicated, however, that we can touch upon only
a few features which seem perhaps best established.
The gonads, the hypophysis, the pineal gland,
the thyroid and the suprarenals, in some complex and
imexplained manner, are not only mutually interdependent in their
own development, but they influence also the growth of the bones,
the skin, the muscles and the general bodily and mental structure.
The bone changes occurring in pregnancy and after
castration have long been familiar to us; while osteoma-
lacia has been ascribed to a disturbed ovarian function.
Disease of the hypophysis (see pp. 318, 348, 415) plays a part in
the causation of acromegaly, a condition characterized by
372
CONSTITUTIONAL DISEASES AND DIATHESES 373
a hyperplasia of the bones and soft tissues at certain points,
associated with inflammatory manifestations ; further, by marked
deposits of fat beneath the skin, and by a diminution of both
mental and physical, particularly sexual, power. In all probability
these disturbances are the result of an increased functional activ-
ity of the cells of the anterior lobe of the hypophysis. Speaking
for this are the benefits observed following removal of the gland
in cases of acromegaly.^ That the hypophysis and the
sexual glands are intimately related would appear also
from the specific changes which the hypophysial cells undergo in
pregnancy.^ The thyroid and the hypophysis are also
closely correlated; the former is often affected in cases of acro-
megaly, and, furthermore, myxcedema and acromegaly have cer-
tain symptoms in common.
All of this goes to show that caution is indicated in
attributing to a particular organ the primary
changes leading to acromegaly; indeed, it is espe-
cially characteristic of all of these "nutritional disorders" that
they exhibit manifestations which might be due to a lesion of
any of a number of organs coincidently involved, thus rendering
the determination of the primary disturbance practically impos-
sible.
In pineal gland disease,* the characteristic clinical picture is in
many respects the antithesis of the acromegalic, in that we observe
premature development of the bones, skin, hair and sexual organs,
and often a mental precocity. As for the thymus, its entire ana-
tomical development, its persistence through adolescence, its re-
gression as growth nears completion — all speak for its role in the
building of the body. The condition known as persistent
thymus has a clinical bearing. The so-called status
thymico-lymphaticus^ rests in part upon a constitu-
tional, and, in part, upon a morbid basis. I am not prepared
to say, however, in what way the thymus is concerned in this
condition; it is possible that the gland affects the sexual organs
and the nutrition of the bones. In the cases of sudden death
among children, however, the role of the thymus cannot be over-
looked.
In the foregoing conditions, the disturbance in function of one
organ carries with it a disturbance of one or several other organs.
What conclusion can we draw from this as to the effect of such
374 THE BASIS OF SYMPTOMS
changes upon the organism as a whole ? This opens up the prob-
lems of "local pathology" as contrasted with
"constitutionalpathology." Formerly, emphasis was
laid upon the involvement of the entire body in most diseases;®
as evidence of this were the constitutional and crasial teachings.
Later, under the influence of pathological anatomy and physiol-
ogy, interest turned to the disturbances in structure, or in function,
of certain organs and organ-systems. The physicians of our
generation have acquired their training in this strongly localistic
atmosphere, in which everything was explained on a physical or
chemical basis and was interpreted in terms of weights and meas-
ures. We regarded scornfully the erases and diatheses of the
earlier teachers, and forgot how narrow we ourselves were
becoming.
Now the pendulum has swung back once more, and we are
beginning to understand that this "local pathology" is not com-
prehensive enough. Thus we meet with disturbances of function
for which no organic substratum can be discovered — or indeed
could be responsible — and in which a more general and extensive
derangement must be assumed ; while in some conditions, though a
local change is found, and is without doubt etiologically significant,
such a change is not sufficient to explain the functional disturb-
ance in all of its phases.
This does not mean, however, that the older teachings must be
readopted in toto, but only that certain fundamental truths which
they contained must be employed in building a new conception of
pathology. Indeed, we must pick to pieces and analyze the
elements of the diatheses, the dyscrasias and the constitutional
anomalies — the scrofulous, the haemorrhagic, the gouty and the
arthritic diatheses — and determine what of truth they contain.
The older conception of the diatheses has again gained a foothold
among the pediatricians in Germany, at least. We refer, in
particular, to the lymphatic status and the exudative
diathesis.*^
Let us cite a few examples of constitutional diseases and
peculiarities. The serum-albumins of different spe-
cies are for the present chemically indistinguishable, yet each
is shown to have individual characteristics by the phenomena of
precipitation. A given serum-albumin will not, as a rule, destroy
the erythrocytes of animals of its own species. In cases in which
CONSTITUTIONAL DISEASES AND DIATHESES 375
haemolysis does occur, we may assume that there exists a con-
stitutional anomaly of the animal affected. Even though this
peculiarity has been demonstrated only for a single type of proteid
and for a single type of cell, it is likely that there exists a general
constitutional fault. Again, in hsemophilic families,
the blood coagulates slowly. There is a deficiency in thrombo-
kinase,^ present in all the tissues normally. This deficiency in-
volves the blood-corpuscles, so far as our present knowledge goes,
yet it is probable that all the other cells are likewise poorly supplied
with this ferment.
Further, taking tuberculosis as an example of the infec-
tious diseases, we have reasons to believe that in this condition
the body as a whole is affected. Tuberculosis and syphilis
were regarded as general diseases long before their infectious
nature was determined; thus the term syphilitic dia-
thesis was once employed. Later, when our interests centred
in anatomical and bacteriological studies, tuberculosis in particu-
lar was regarded from the localistic point of view. Still later
came the proof that in many infections — in typhoid fever, for
example — the causative organisms did not remain localized, but
entered the blood and caused changes in the most widely separated
organs; and that in cases of pulmonary tuberculosis the bacilli
might also invade the blood and the organs.® The general nature
of the tuberculous infection was further confirmed by the dis-
covery of V. Pirquet^^ which pointed to a cutaneous
change in consequence of a general infection. The most signifi-
cant feature of the reaction is its appearance even when the dis-
ease focus is insignificant and causes no symptoms. Could we
establish a similar reaction on the part of other tissues, we should
be fully justified in calling tuberculosis a constitutional disease.
In syphilis the principles involved are much like those
in tuberculosis. As pointed out by Martins the conception of
a constitutional syphilis arose by way of contrast with the local-
ized primary lesion; yet the appearance in other parts of the
body of specific luetic manifestations does not say that the entire
organism is involved. Conditions such as tabes dorsalis, on the
contrary, which are not immediately syphilitic, may well be re-
garded as due to a constitutional alteration of the cells on a luetic
basis. The principles underlying the luetin and Wasser-
376 THE BASIS OF SYMPTOMS
mann reactions are also in keeping with the conception of
a constitutional disease.
The question arises as to the features which distinguish such
a general pathological alteration from disease in the current appli-
cation of the term. The mere fact that in the former a number,
perhaps all, of the organs are involved is too imstable a criterion,
fluctuating as it does from time to time with the development of
our knowledge. We are constantly discovering indeed that dis-
eases to all appearances local are in reality affections of the most
extensive type. The infections are a case in point. In the mere
matter of a widespread involvement, therefore, many, or perhaps
all, diseases are general in that they usually produce changes in
more than one organ ; while the subdivision into acute and chronic
forms would be as applicable to constitutional disorders as to the
infectious diseases, for example.
But features of another kind characterized
the constitutional diseases, the dyscrasias and
the diatheses as the terms were employed by the
older writers.. First of all, was the fact that the mani-
festations were permanent. Though the process
might at times begin abruptly, it lasted for years and even through-
out life. Frequently, furthermore, there was a congenital
element. Haemophilia is illustrative of these factors. As is
well known, this condition is inherited in certain families, being
transmitted through the females, who themselves are unaffected,
to the males.
Still another characteristic of the constitutional diseases is
their resemblance in a way to malformations or
to anomalies of structure^* rather than to dis-
eases in the present acceptance of the term. The
haemophiliac is, as a rule, not sick so long as there is no provo-
cation for bleeding; rather is he endowed with a tendency to
become sick. In the same sense, I interpret the exudative dia-
thesis of Czerny.
Some of the conditions under discussion, however, are more
than a mere disease tendency; they are actually diseases.
Thus the so-called uratic diathesis is frequently associated
with manifestations due to renal sand and renal stones. It is
convenient to define diathesis as a tendency to disease, and a
constitutional disorder as a condition embracing a disease. At
CONSTITUTIONAL DISEASES AND DIATHESES 377
any rate, the attempt should be made to distinguish be-
tween disposition and diathesis, on the one hand,
and actual disease, on the other.
Three possible factors are concerned in the etiol-
ogy of the constitutional anomalies. A portion of
them are congenital in the sense that the germinal cells
have been injured. It is not difficult to understand how an injury
to these cells may lead to widespread cellular abnormalities in
extra-uterine life. The anomaly may then be the direct outcome
of this early cell injury; or it may be expressed in a weaker
anlage which later leads to disease because the possessor is unable
to resist the wear and tear of every-day life. This is well illus-
trated in the inherited psychopathic tendency of certain indi-
viduals.
In other cases the condition is acquired. The causa-
tive factors in this type are infections, intoxications and
faulty living conditions in the way of light, air, habitation, sleep
and food. It is well known that these latter factors tend to
diminish the individual's resistance, his efficiency, etc. Under
their influence an inferior strain of men is produced. The action
is not merely quantitative, i.e., leading to a physical and mental
subnormality, but also qualitative, as the unequal resistance to
infections indicates.
In the older descriptions of the diatheses and constitutional
anomalies, no distinction was made between those of infectious
origin, on the one hand, and the toxic and congenital forms on the
other. To-day the infectious diseases are sharply separated from
the latter. Yet it is just in the infections that our recently
acquired knowledge of the functional and morphological changes
in the different organs have given us an insight into the wide-
spread nature of bacterial processes. The conditions of gen-
eral weakness so often seen after the infection
has subsided have much in common with what we are
pleased to call constitutional disorders. This is particularly true
of such chronic infections as malaria, syphilis and
tuberculosis, which indeed were formerly classified as
dyscrasias, diatheses and constitutional diseases. We repeat,
therefore, that in the consideration of the infectious diseases, we
encounter at one point or another the various elements which
go to make up a constitutional disorder — at one time direct mani-
378 THE BASIS OF SYMPTOMS
festations of the infection, at others a pronounced depression
of the general nutrition, functional disorders of the organs, and
the tendency to peculiar complications, as, for example, tabes and
paralytic dementia in syphilis.
As for the chronic intoxications and the ca-
chectic states observed in malignant processes,
we are of the opinion that they properly belong in the category
of constitutional anomalies. This indeed was the old view;
while now the general tendency is to assign them elsewhere. That
chronic lead poisoning is a constitutional disorder is
evidenced by the impaired nutrition, the involvement of many
organs (brain, nerves, vessels and kidneys) and the tendency to
other diseases, such as gout. By cachexia is meant not a
mere undernourishment, but rather a nutritional state which in
general is below par. Still to be solved in this question is the
cause of the characteristic cachectic color of the skin, and of the
oedema of the tissues, both of which indicate the general nature
of the process.
The literature devoted to constitutional diseases and diatheses
speaks for the great diversity of the conditions included therein.
This is due in part to the great difficulty in distinguishing between
diseases which are local and those which are general, and in part
also to the tendency to place among the constitutional disorders
those conditions which have no distinct local pathology. Dia-
betes mellitus and diabetes insipidus are illustrative of
this. Depending upon the point of view, the flooding of the
tissues with sugar may be regarded either as secondary to some
local lesion, or as proof per se of the constitutional nature of the
process.
Obesity is to be regarded as a constitutional disease only
in those cases in which there is actually a metabolic anomaly pres-
ent, not when the condition is due to excesses in eating. Gout
we have seen results from a disturbance in the metabolism of
the purin bodies. Whether this is indicative of a constitutional
process depends, to a great extent, upon individual opinion, just
as in the case of diabetes, though not unimportant is the question
as to what cells are involved in the disturbance of purin metabolism
and how widespread is the disorder.
As proof of the constitutional nature of gout and of diabetes,
has been urged the close relationship between the two, as well
I
CONSTITUTIONAL DISEASES AND DIATHESES 379
as to obesity. It is true that these three conditions frequently
show a family tendency and that in individuals with any one of
the three disorders there is often a family history of the other
two. Yet these observations scarcely afford a sufficient basis
for the assumption of a constitutional anomaly. And in par-
ticular is there need for a greater accuracy in the diagnosis of
gout, and for a better understanding of the relationship of obesity
to nutrition. These are essentially physiological problems, entail-
ing a fuller knowledge of the metabolism of the purin bodies and
of sugar. And finally, there remains the problem of the posi-
tionofdiabetesjobesityandgou t — ^particularly the lat-
ter— ^in the calculous, uratic and arthritic dia-
theses.
A more extensive clinical knowledge, in my opinion, is what
is necessary to a better understanding of the constitutional dis-
eases and diatheses. There has been too little empiricism in the
past and too much preconception; too much mere assertion and
too few observations as to the fundamental manifestations and
attributes of the diatheses. This indefiniteness is particularly
true of the so-called arthritic diathesis, under which in
the literature are included absolutely unrelated conditions.
The exudative diathesis and lymphatism are
apparently closely related, and both are in turn related to the
arthritic constitution. Lymphatism and the exudative diathesis,
as they are seen in the child, have what most of the other reputed
constitutional anomalies have not, vis., a well-elaborated disposi-
tional and clinical basis. The exudative diatheses of
eosinophilic nature (asthmatic catarrh, mucous
colitis) are especially interesting. Spasmophilia of
children, characterized as it is by an augmented nervous
irritability on the one hand, and on the other by a relationship to
tetany and the later development of nervous disorders, urgently
demands further study.
The uratic diathesis carries with it all the inherent
interpretative difficulties that have been noted in connection with
gout. On the other hand, it is characterized by a tendency to
cause direct manifestations. As for rickets and chlo-
rosis, we may speak only of general diseases, not of diatheses,
otherwise we should lose sight of the actual significance of a
380 THE BASIS OF SYMPTOMS
constitutional disorder, and include under the latter any local
disease with involvement of other organs.^ ^
LITERATURE
* Naturforscherversamm. in Stuttgart, 1906 (Starling, Krehl) ; ibid., igii
(Biedl, Morawitz) ; Biedl, Innere Sekretion (The Internal Secretory
Organs, New York, 1913) ; Falta, Die Blutdriisen, 1913 (translated by
Meyers, IQIS)-
*Exner (Hochenegg) : Wiener klin. Wochenschft., 1909, No. 18; v. Eisels-
berg, ibid., 287; Deutsch. Zeitschft. f. Chirurgie, c, 317; Gushing, The
Pituitary Body, etc., 1912.
•Erdheim and Stumm: Ziegler's Beitrage, xlvi, i. See also Lewis, Johns
Hopkins Hosp. Bull., 1905, xvi, 157, and Jour. Am. Med. Assn., 1910,
Iv, 1002.
* See Biedl, Falta.
' See V. Neusser : Der Status Thymicolymphaticus, Ausgewahlte Kapitel, iv,
1911.
•Martius: Pathogenese inn. Krankh., Part 2, 158.
' Czerny : Die exud. Diathese, Jahrb. f . Kinderheilk., Ixi ; Pfaundler, Kongr.
f. inn. Med., 191 1.
* Sahli : Zeitschft. f . klin. Med., Ivi, 264 ; Morawitz and Lessen, Arch, f . klin.
Med., xciv, no.
* Liebermeister, Jr.: Kongr. f. inn. Med., 1907, 180.
^ Die Allergic ; also Ergeb. d. inn. Med., 1908, i, 420.
"J. Cohnheim: Allg. Path., ii, ist edit. (Introduction) ; Krehl, Path. Physio-
logie, 6th edit. (Introduction).
" For more recent literature see His, Pfaundler, Block, Mendelssohn : Kongr.
f. inn. Med. 1911 (lit.) ; Mors, Lubarsch-Ostertag, 1910, xiv.
CHAPTER X
FEVER
Fever is characterized by a pathological increase in the tem-
perature of the body. Whereas the rectal temperature of a
healthy individual at complete rest rarely exceeds 37.5° C. (99.3°
R), it may, in febrile states, reach 41° or 42°, and very excep-
tionally, even 44°.
As a rule, the diurnal variations of fever are of
the same character as are those which take place in health, i.e.,
there is an elevation toward evening and a fall toward morning.
Those who work at night and sleep during the day show at times
the inverse type of diurnal variation both in health and fever.
Thus we see that the same causes, such as food, light, work, etc.,
which influence the temperature curve of healthy persons, affect
also the variations in the temperature of febrile patients. Never-
theless, the temperature in fever is much less con-
stant than in health, and the considerable variations that
it undergoes are due partly to external influences and partly to
causes which escape our present methods of observation.
Variations in the Clinical Picture of Fever. — These depend,
in the first place, upon the cause of the fever. Most
fevers are of bacterial origin, and, as is well known, bacteria
may vary in their virulence, conditions of growth and duration
of hfe — all of which determine the temperature-picture of the
disease which they cause, as well as its other manifestations. So
far as malarial fever is concerned, we know that the paroxysms
occur when the causative organisms are at a particular stage of
development. The same is true of certain septic diseases. All
in all, therefore, despite certain deviations, we may say that the
infectious diseases as a rule have characteristic fever curves.
In the second place, the clinical picture presented by fever
depends largely upon the condition of the individ-
ual affected — upon his strength, nutrition and degree of
immunity. During epidemics, different febrile manifestations
occur in different individuals. We may say, in general, that
young and strong patients react with a higher fever to an infec-
tion than do old and feeble ones. Indeed, the temperature may
381
382 THE BASIS OF SYMPTOMS
actually fall in the latter class of patients. We possess analogous
experimental observations ; ^ thus, it is impossible to produce
fever by the injection of certain non-bacterial chemicals into fast-
ing animals, though the same substances will regularly cause a
fever in well-fed animals. Bacterial infections, on the contrary,
may cause an elevation of temperature whether the animal be
starving or well fed.
The numerous other symptoms seen in fever — some due to
the fever itself, others to its underlying cause — are also subject
to considerable variations. These depend in part upon the height
of the temperature, for this influences the rate of the proteid and
other decompositions, as well as the cardiac and respiratory rates.
Yet no exact ratio exists between the severity of these phenomena
and the degree of temperature, because other factors, especially
toxic influences, play so great a role. This has already been dis-
cussed so far as the pulse-rate is concerned (see p. 55).
Indeed, we may say, in general, that the symptoms of
infection and intoxication predominate in the
clinical picture of fever, and that many of the phe-
nomena which were formally attributed to the high temperature
are now ascribed to the action of toxins. Thus the psychic
changes, the gastro-intestinal disturbances and the susceptibility
of the respiratory tract to complicating inflammations, are all of
toxic rather than of thermic origin. They are rarely seen in the
"aseptic fever" following simple fractures; whereas, they are
most prominent in such pronounced intoxications as typhoid fever.
These symptoms also depend to a certain extent upon individual
peculiarities — ^heavy drinkers, for example, being very prone to
show serious nervous manifestations.
These various considerations go to show how difficult it is
to distinguish between the clinical picture of fever per se and the
manifestations dependent upon the cause of the fever. Indeed,
they often merge so closely into one another as to be incapable of
separation. A more intimate knowledge of the characteristics
of the etiologic factors, particularly those of the infectious dis-
eases, will probably tend to do away with the present tendency of
regarding the febrile picture as a well-demarcated unit in the
disease process as a whole.
The Causes of Fever. — The most diverse causes may give
rise to fever.^ It may be produced, first of all, by the en-
FEVER S83
trance of living or dead bacteria, or their prod-
ucts, actuallyintotheblood. Yet the mere presence of
micro-organisms in the circulation does not necessarily raise the
temperature of the body, for many bacteria which produce fever in
certain animals fail to do so in others. Indeed, an animal may die
from an infection and its heat production may be markedly in-
creased, and yet, on account of the elimination of the extra heat
from the body, there may be no rise of temperature.^ This
would indicate that the fever in bacterial disease is due to the dis-
turbance of some definite mechanism. Protozoa may also give
rise to fever, as in the case of malaria and of certain experimental
infections.^
The substances that cause the fever are very
possibly of a proteid nature, for complex substances iso-
lated from the bodies of bacteria may give rise to fever if injected
into men or animals.^ It is questionable, however, whether these
substances are themselves proteids, or whether it is merely difficult
to separate them from proteids. Some have attempted to show
that there is a non-proteid, fever-producing substance common to
all bacteria,^ but the evidence for this is very inconclusive.
Though bacteria and bacterial products are, undoubtedly, the
most important causes of fever, they are not the only ones. Fever
may be produced by the destruction of large num-
bers of cells in the body, even though micro-organisms
play no part in the destructive processes. As examples of such,
we may recall the fever that so frequently follows a simple
fracture, or that which may follow large interstitial hemorrhages.'^
The substance which gives rise to these aseptic fevers is
still unknown.
The fact that fever may be produced by bodies not derived
from bacteria has led to careful studies concerning the action of
numerous chemical substances upon the temperature of warm-
blooded animals. These studies^ have demonstrated that fever
may be caused by the injection of various forms of
proteids, whether the latter are assimilated or not, and
whether they be of complex or comparatively simple structure.
Elevations of temperature also follow the injections of many
organic compounds and salts. Different animals, furthermore,
differ in their susceptibility to the action of these substances.
It has long been known that injections of certain
384 THE BASIS OF SYMPTOMS
salts may produce fever in animals. Finkelstein has re-
cently made the interesting observation that the oral administra-
tion to infants of a one to three per cent, solution of sodium
chlorid likewise causes an elevation of temperature. In in-
fants suffering from gastro-intestinal conditions, smaller amounts,
or weaker concentrations, of such solutions, are necessary to
bring this about than is the case with healthy infants.^ In adults,
the parenteral introduction of isotonic salt solution causes fever.
But individual differences in susceptibility are especially marked
in the tendency to exhibit this so-called sodium chlorid
fever. (Recent work ^^ has questioned the authenticity of the
febrile reactions following salt injections, attributing the fever
rather to impurities in the water used to dissolve
the salt. Certain by-effects of salvarsan have been laid to
the same cause. The use of water freshly distilled obviates this
factor. — Ed. )
Is it not possible that a single chemical sub-
stance is the cause of all fevers? Though this is
conceivable, our present information^^ does not enable us to
identify it. I am of the opinion, however, that such an hypothesis
is almost necessary in view of the fact that a single mechanism
seems to underlie all fevers. Common to all infections is a
marked cellular destruction from which this hypothetical sub-
stance might be assumed to arise. The many studies devoted to
this problem have shown, among other things, that the destruction
of red blood-cells,^^ whether they be those of the particular animal
itself, or from animals of the same or different species, gives rise
to fever-producing substances which pass into the serum and do
not primarily cling to the red cells.
The blood-platelets are also of undoubted influence
in the causation of fever.^^ The injection of intact platelets
(obtained in citrate solution) causes no febrile reaction; but as
soon as they are disintegrated, they give rise to substances of a
pyrogenic character. (Vaughan^* and others have shown that
typical fevers may be produced by the enzymic destruc-
tion of proteids in the body; and MandeP^ has stated
that fever may be produced by the administration of
purinbases, such as xanthin or caffein. — Ed. )
The Relation of the Nervous System to Fever. — Granting
that fever may be produced by the action of micro-organisms and
I
FEVER S85
of chemical substances, bacterial or otherwise, the question arises
as to whether these are the only causes of fever. That the ner-
vous system exerts an important influence upon the heat regulat-
ing centre, is well known. Thus, a division of the cer-
vical cord in animals brings about a marked disturbance
of the heat-regulatory apparatus. Different animals behave dif-
ferently in this respect, depending upon the level of the injury.
Rabbits with a severed dorsal cord react as do healthy animals,^®
if the heat loss due to vasomotor paralysis is held within bounds
by an elevation of the external temperature to about 22° C. The
chemical heat regulation of such animals is preserved, for they
react with fever to infections and to the injection of pyrogenic
substances. If, however, the division be made above the first
dorsal segment, the animals lose both their physical and chemical
regulation ; in this case a surrounding temperature of about 29° C.
is necessary to maintain their body temperature at its normal level,
while their power to react with fever is entirely gone.
The probabilities are that when the cord is severed in the
cervical region, the cervical and dorsal sympathetic fibres are cut
off from the central nervous system; for a division of the dorsal
cord, plus a resection of the stellate ganglion, or a severance of
the seventh and eighth cervical roots — whence the sympathetic
originates to pass to the stellate ganglion — produces the same
results. The fact that injections of epinephrin and
coca in likewise cause fever ^'^ is in keeping with the assump-
tion that the sympathetic system plays an extremely
important part in the process; and we shall encounter another
proof of this in the behavior of the blood sugar in fever. Rumpf
has shown that narcosis in cool external temperatures leads
to a considerable diminution in heat production, guinea-pigs
exhibiting a fall of 10° C, and more, under these conditions.
An intact nervous apparatus is essential also to the production of
fever, the latter not appearing, as we have seen, after section
of the cord high up, or when an animal is narcotized.
In view of the importance of the nervous system in the pro-
duction and regulation of fever, there is no reason to believe that
the heat-regulating centre may not be primarily diseased or in-
fluenced by impulses from other parts of the cen-
tral nervous system. Many observations purporting to
be examples of such a nervous fever will not stand the
25
386 THE BASIS OF SYMPTOMS
scrutiny of a rigid criticism. For example, in poliomyelitis,
polioencephalitis and meningitis, the elevation of temperature is
probably due to the infection; while in other conditions, such
as large cerebral hemorrhages, it is due in all likelihood to the
absorption of the disintegration products of the red corpuscles
or the injured tissue cells.
In other conditions, the nervous lesion seems to exert a more
direct influence upon the bodily temperature. At times, gen-
eral convulsions, associated with stupor, lead to excessive
elevations of temperature, though at other times, when the con-
vulsions are produced by certain drugs, there may be an actual
reduction of temperature.^^ In the latter instances, the heat regu-
lation is affected, and it would seem that the poisons leading to the
convulsions also diminish the production of heat in the body.
We know that muscular movements will raise the
temperature of even a healthy person, if the elimination of heat
is interfered with — an observation that has also been experimen-
tally established in animals.^® If, however, the extra heat that is
liberated during exercise can be eliminated, no rise of temperature
results. As a rule, therefore, convulsions do not materially alter
the body temperature. A rise of temperature is especially apt to
be produced by convulsions when there is reason to believe that
the heat-regulating mechanism is paralyzed. For example, fever
is rarely present in the earlier stages of tetanus; and the rise
of temperature toward the end of the disease would appear to be
caused by a paralysis of the heat-regulating centre. The high tem-
perature that has been observed in many cases of status epi-
leptic u s and in heat-stroke is perhaps to be explained
in a similar manner. Possibly, also, the elevations of tempera-
ture in hysterical individuals, which have been de-
scribed by some writers, are of this character, though never having
witnessed a true hysterical fever, I personally feel somewhat
skeptical as to its existence.
Experimentally, it is possible to produce fever in animals by
injuring the brain. A characteristic example of this is the tem-
perature elevation which can be caused in almost every case i f
a long needle be thrust into the mid-brain of
rabbits.^^ The fever produced by such a puncture begins
several hours after the operation, continues for days and may
reach a considerable height. The production of heat in the body
FEVER 387
is increased, and the loss of heat Hkewise, but to a lesser degree.
The loss of heat by evaporation from the skin is relatively greater
than it is in the case of infectious fevers. Furthermore, the
increased heat production is almost entirely
due to the (augmented) consumption of non-ni-
trogenous material, a fact which also serves to
differentiate this from ordinary fever, in
which a characteristic hydrolytic cleavage of
proteids takes place. ^^ During the fever resulting
from a puncture of the brain, the liver ^^ is the warmest organ
of the body, and its glycogen store rapidly disappears. Indeed,
unless there is a store of glycogen in the body, no rise in tempera-
ture follows the puncture of the brain. It is apparent, therefore,
that the elevation of temperature caused by puncture of the brain
differs from that due to an infection in several important par-
ticulars.
Experimental lesions of other portions of the
brain, i.e., other than the typical mid-brain puncture, may
also produce fever, according to certain observers,^^ though with
a far less degree of certainty. The problems concerned here open
a wide field for research.
It is very questionable whether fever is ever
caused by reflexes. The elevations of temperature
which may occur during biliary colic and those which
may follow urethral operations (catheter fever) are often
regarded as instances of reflex fevers. Yet, in my opinion, it is
much more probable that we are here dealing with fevers caused
either by the absorption of toxic products or by actual infections.
Elevations of temperature have been observed after inju-
ries to the spinal cord. Such elevations occur most fre-
quently in association with severe contusions of the cervical
region, produced by fractures of the corresponding vertebrae.
Temperatures as high as 42° to 44° C. (106.5° to 111° F.) have
been observed in such conditions. ^^ It is possible to produce the
same effect experimentally by crushing the uppermost part of the
cervical cord of large dogs. After injuries of this kind, the
temperature does not always become elevated, and it may, indeed,
fall. These varying results of the experiment are
due to the fact that if the cord of a warm-blooded animal be
severed high up, the body temperature becomes a plaything of
388 THE BASIS OF SYMPTOMS
circumstances. When the temperature of its surroundings is
high, the heat production is increased, and when the surrounding
temperature is low, the heat production is diminished; in other
words, there is no regulation of the production of heat in the
body. This is one reason why animals easily become overheated
or cooled off after they have sustained severe contusions of the
cervical cord.
Other factors besides the surrounding tem-
perature also play a part in the elevation of the tempera-
ture that takes place in cord injuries, though upon these points
we are less certain. It is possible, for example, that the
peripheral circulation is so altered that the loss of heat
from the body is diminished. Furthermore, the crushing of the
cord — a manner of injury which seems to be an important requisite
for a high temperature — ^may possibly produce an irrita-
tion of the corresponding muscles, and so directly
increase the production of heat in the body. This is apparently
the reason why the elevation of temperature is more likely to take
place in men and large dogs than it is in small animals. The
former have a relatively small surface from which to lose heat,
and a relatively large musculature in which an increased heat
production can take place. We see, therefore, that the rise
of temperature that may follow cord injuries is
due, partly, to a loss of heat regulation, and
partly, in all probability, to an increased pro-
duction and a diminished loss of heat from the
body. The condition, therefore, differs essentially from that
present in true fever (see p. 391 et seq.).
The Normal Regulation of the Body Temperature. — The tem-
perature of man is maintained at an almost constant level under
the most varying conditions ; indeed, it varies less than that of any
other animal. We shall, therefore, first consider the mechanism
by which the temperature is normally maintained at this uniform
level. ^^
If large quantities of heat are suddenly set
free in the body from any cause, such as muscular work or
the ingestion of large amounts of food, the total loss of heat
from the body is correspondingly increased. The cutaneous ves-
sels dilate and the warmer skin loses heat more rapidly by radia-
tion and conduction. The affected person perspires more freely.
FEVER 389
and the loss of heat by evaporation of water from the lungs is
likewise increased. Whether the one or the other of these various
means for eliminating heat is utilized to a greater or less extent
in the individual case depends upon a variety of conditions,
which cannot be considered in this place.
If, on the other hand, a warm-blooded ani-
mal is exposed to cold, it is able to protect itself from
considerable losses of heat, which would otherwise tend to reduce
its temperature. The skin vessels contract and the heat losses
through conduction and radiation are diminished. Men ordinarily
wear thicker clothes under these circumstances and so surround
their bodies with a layer of comparatively warm air. The fur
of animals and the fat of obese persons also diminish heat losses.
By these means it is possible to maintain the normal bodily tem-
perature, even when the individual is exposed to moderate de-
grees of cold. If, however, this mechanism is insufficient to meet
the emergency, then a new factor is called into play. The pro-
duction of heat in the body is increased, the site of this increased
production being the muscles, according to the best authorities.
When a man is exposed to cold, therefore, the first regulatory
mechanism that serves to maintain his body temperature at the
normal level is of a physical character, i.e., losses of heat are
prevented. As we have just seen, however, this means of regu-
lation may be insufficient, and the exposure to cold is then fol-
lowed by an increased production of heat in the body. Frequently,
the individual feels chilly and shivers, and thereby increases the
combustion in his body; but, even though no gross muscular
movements occur, the body metabolism may be increased, as has
been proved by recent experiments. In either case, the extra
heat is generated mainly by the combustion of non-nitrogenous
material,^^ just as it is when heat originates from muscular
activity. This regulation of the body temperature by variations
in the heat production is termed a chemical regulation
in contradistinction to that which depends upon variations in the
heat losses, the so-called physical regulation.
The point at which the chemical mechanism steps in to main-
tain the temperature of the body depends in part upon the degree
to which the animal is able to limit his loss of heat, and in part
upon the amount of exercise and food which have been taken.
The heat that is immediately set free after exercise or eating is
390 THE BASIS OF SYMPTOMS
ordinarily quickly disfKDsed of by an increased elimination of
heat; but if the body is exposed to cold, this extra heat serves
to maintain the body temperature. It thus obviates the necessity
of calling the chemical regulation into play.
These are, in brief, the means whereby the healthy man
regulates his bodily temperature under varying external and
internal conditions. Under certain circumstances,
however, even the normal mechanism is insuffi-
cient to keep the body at a constant temperature.
For example, if heat be applied to the surface of the body, and
if, at the same time, the compensatory loss of heat be interfered
with, a rise in temperature necessarily follows. For this reason,
every man becomes warmer in a steam bath, or in a warm-water
bath of 40° C. (104° F.) or over. Possibly, however, some be-
come warmer than others under the same conditions.
An increased production of heat within the
body by excessive chemical decompositions may
also cause a rise in temperature, an event of more
frequent occurrence than is generally supposed. ^^ Muscular
exertion, even if not very severe, may thus raise the tem-
perature of the body. In this respect, different individuals cer-
tainly react differently; the novice becomes overheated in doing
a certain piece of work more easily than does the adept, mainly
because he uses more energy to accomplish the same result. An-
other factor that is of great importance here is the ease with
which heat may be eliminated from the body.
This explains many of the apparent contradictions met with in
the literature concerning the effect of muscular exertion upon the
body temperature. The man that makes the ascent of Monte
Rosa does not become warmer from the great exertion, because
the low temperature and the dryness of the surrounding air
greatly favor the loss of heat from his skin and lungs. Yet more
recent investigations have shown that severe muscular exertion
performed in high altitudes at low temperatures often causes
fever. ^ On the other hand, the temperatures of soldiers fre-
quently rise during forced marches, for they are heavily dressed
and they must often travel in a warm, moist climate.
Heat-Stroke. — If the temperature of the body becomes con-
siderably elevated from such outside causes, we speak of it as
heat-stroke.^® The temperature under these conditions may
FEVER 391
reach 43° C. (110° F.) or over, the pulse becomes rapid, the
patient becomes dizzy or dehrious, and in severe cases, coma and
death terminate the scene. The high temperature often persists
in these patients for hours, or even days, after the actual cause
of the stroke is over. This would seem to point to some in-
jury to the heat-regulatory mechanism. Heat-
stroke patients are often described as being pale, livid or cyanotic,
conditions which indicate an improper peripheral circulation and a
consequent imperfect regulation of the heat losses from the
surface of the body. This poor peripheral circulation is appar-
ently due to an injury to the regulating centres in the brain,
though the nature of this injury is not known.
The experience of military surgeons has taught us that ex-
cessive heat is most liable to affect those who are in some way
indisposed, who are foot-sore or who are convalescent from
severe illness ; and it has frequently been observed clinically that
persons who are ill, particularly anaemic or tuberculous patients,
are especially prone to show a rise of temperature after exercise,
or even after meals.
In heat-stroke, the conditions are very complicated, and the
rise of temperature is not due to external forces
alone. Other factors are certainly present, for different indi-
viduals show considerable differences in their susceptibility to
changes in their environment. Some lose heat more readily than
others, a fact that is especially true of thin individuals as com-
pared with stout ones. Heart lesions render a patient very
susceptible to heat-stroke, for a good peripheral circulation is
a necessity when the losses of the heat from the body must
be increased,^^ (An overindulgence in alcohol also
renders an individual more susceptible to heat-stroke. Finally,
those who have once had a sunstroke may manifest for years
a markedly increased susceptibility to changes in the temperature
about them. — Ed.) All these facts demonstrate that changes in
the external conditions are not the sole factors which produce
the sunstroke. The mechanism for losing heat is undoubtedly
less efficient in some individuals than in others ; and, in so far as
the heat-stroke depends upon an insufficiency of heat elimination,
it bears a certain resemblance to true fever.
Heat Regulation in Fever. — The cause of the high tempera-
ture of fever must be some disproportion between the
892 THE BASIS OF SYMPTOMS
production and the loss of heat in the body.
Theoretically, fever might be caused either by an excessive heat
production without a corresponding increase in the heat loss, or
by a diminution in the heat loss without a corresponding diminu-
tion in the heat production. We now purpose considering which
of these conditions actually exists in fever, and whether or not
all cases of fever are produced in the same manner.
Two general methods have been employed to determine the
amount of heat produced in the body. In the first, the amount
of heat lost has been directly measured in a calorimeter (direct
calorimetry);in the second, the products of combustion have
been determined and the heat produced calculated (indirect
calorimetry). The two methods have been shown to yield
identical results in the healthy animal,^^ and we have every reason
to believe that the results would also be the same in fever, although
this has not yet been definitely proved on account of technical
difficulties.^^
Heat Production in Fever. — I n the vast majority of
all fevers the production ofheat is increased.
This has been proved for different diseases of man,^^ such as
pneumonia, typhoid fever, pleurisy, erysipelas, tuberculin fever,
etc., as well as for various septic diseases of animals, and for
fevers produced experimentally by injections of bacteria and
various chemical substances.^*
This increase in heat production is seen both at the time
when the temperature is rising and at the height
of the fever. It is greatest of all during the chill
which initiates so many infections, obviously on account of the
violent muscular contractions that take place at the time. During
the height of the fever, it is found to be the most marked in
those who breathe violently, from whatever cause — here also
because of the excessive muscular exertion. If we eliminate these
cases, in which the heat production is accelerated by muscular
activity, then the increased production of heat in fever usually
amounts to from ten to sixty per cent., the average being about
twenty to thirty per cent.
In a small number of cases no apparent in-
crease of heat production above the normal
limits can be demonstrated.^^ Such observations
have been made, for the most part, upon patients in whom there
FEVER 893
was but little fever, or in whom the fever was long-continued.
In the latter class of cases, it is necessary to remember that the
organism tends to limit its metabolism in long-
continued illnesses, so that although the quantity of
oxygen consumed by these patients with fever may not have
exceeded the normal limits, it was in reality above what would
have been consumed had no fever been present. In such cases,
comparative determinations should be made upon the same indi-
vidual during periods of fever and of apyrexia; for I do not
believe that the possibility of fever without an increase of heat
production has been definitively established.
In still another class of cases, high fever may be
associated with an unusually low production of
heat, vis., when there is a tendency to collapse. As we
shall see later, a diminution in the heat production is one of the
characteristics of collapse, and even when a tendency to this
condition is present, the heat production may be lessened.
Thus we see that in the great majority of all cases of fever,
and especially in fevers of short duration, the production of heat
in the body is increased. This increase is most marked at the
beginning of acute infectious diseases ; while in chronic wasting
diseases the heat production tends to become limited, and when
the temperature is falling it may even be less than normal.
As we have said, the average increase in the heat
production in fever is about 20 to 30 per cent.
Such an increase is not extraordinary when we remember that
Rubner was able to increase the heat production in dogs sixty per
cent, solely by feeding them with large quantities of proteid food,
and that in severe muscular exertion the heat production may
be several times as great as during rest. Normally, the body
can dispose of much larger amounts of heat than are liberated
within it during fever, so that the cause of the high temperature in
fever cannot be an increased production of heat alone.
Indeed, a portion of the increase in heat pro-
duction is due to the elevation of the body tem-
perature itself, for we know that oxidative processes in
general are accelerated by heat. Pfliiger has estimated that for
every increase of 1° C. in a rabbit's temperature, its heat pro-
duction increases about six per cent. ; and the same has been
shown to be true when the temperature of man is artificially ele-
S94 THE BASIS OF SYMPTOMS
vated.^^ Thus we see that an increase of heat production,
amounting to about twelve to eighteen per cent, of the normal,
might easily be regarded as an effect rather than as a cause of
the increased bodily temperature. The excessive heat production
in fever, therefore, may be explained in part as a result of in-
creased muscular movements and in part as the result of the
higher temperature of the body. The remaining increase in heat
production is very slight, especially if it be compared with that
which results from violent exercise or from the ingestion of large
quantities of proteid food.
Heat Losses in Fever. — During the rise of temperature the
loss of heat from the body is almost always found to be dimin-
ished, the losses by radiation and conduction from the skin being
especially limited. The amount lost by evaporation of water is
frequently increased, however, for, even at this period, the
metabolic processes in the body may be accelerated. Yet the
increased loss by evaporation does not neutralize the decrease
in loss by conduction and radiation ; and often, furthermore, the
loss of water is also less than normal. Thus, at the onset of
fever, the animal utilizes all the means at its disposal to raise its
temperature, the production of heat being increased and the losses
diminished.
The loss of heat from the surface of the body is regulated
mainly by the contraction of the cutaneous blood-
vessels. At the onset of many diseases, these vessels con-
tract excessively, and, as a consequence, the skin becomes cold
and either pale or cyanotic. This cooling of the skin produces
in turn a sensation of cold throughout the body and sets in motion
the chemical mechanism already referred to (p. 389), which in-
creases the heat production within the body. Clonic muscular
movements, giving rise to the so-called chill, are a conse-
quence. During the chill the temperature rises rapidly to a great
height, for the muscular movements greatly increase the heat
production, and, at the same time, the heat losses are reduced
on account of the contracted cutaneous arteries. That these
muscular contractions are due primarily to the coolness of the
skin is proved by the fact that if the skin of these patients be
warmed the " chill " ceases. Such chills are particularly charac-
teristic of some diseases, and it seems probable that the agents
FEVER 395
which cause certain fevers show a special tendency to produce a
constriction of the cutaneous vessels, and consequently a chill.
In the great majority of cases the total loss
of heat is increased at the height of the fever.
This is necessarily true when the heat production is increased,
and the temperature is constant, for it is obvious that if the
extra heat produced were not immediately given off the tempera-
ture of the body would be raised.
In animals, the acceleration in heat losses affects conduction,
radiation and evaporation, all to about the same degree, so that
the ratio between the first two and the third remains practically
the same as in health, i.e., the loss by evaporation amounts to
about sixteen to seventeen per cent, of the total loss of heat.^^
In my opinion, however, we are not permitted to infer from this
that sufficient evaporation from the body takes place in fever, for
it has been shown that if the heat production be increased by
other means, the losses by evaporation are relatively much more
increased than are the losses by radiation and conduction.^^
In man it has been found that while the temperature is rising,
the elimination of water from the skin approaches the lower
normal limits, whereas at the height of the fever it is about fifteen
per cent, above normal.^^ During a fall in temperature, it is
increased in proportion to the rapidity of the fall. The taking
of food markedly increases the evaporation from the skin, both in
the healthy and in the feverish. The elimination of water from
the lungs is increased proportionately to the greater volume of
air used.
In conclusion, it may be said that at the height of a
fever the heat losses vary with the heat produc-
tion, but always remain somewhat less, so that
an increase in the temperature of the body is the
result.
The conduction and radiation of heat from the skin are
governed mainly by the amount of blood that traverses the
cutaneous capillaries, and, since the latter are usually dilated at
the height of the fever, the skin is ordinarily reddened at this
time. Yet many questions concerning the cutaneous vessels in
fever are still unsolved. They certainly respond excessively to
stimulation, either mechanical or thermic, and for this reason,
fever patients easily become chilled when exposed to a draught
396 THE BASIS OF SYMPTOMS
of air, etc. Animals with fever also react excessively to re-
flexes which affect the cutaneous vessels through the medulla.
Many have held that the cutaneous vessels of fever patients
are subject to frequent and rapid variations in their state of
contraction. This is certainly not always so, however, for,
though recent and careful observations on animals have shown
that during the rise of temperature considerable variations in the
heat loss may take place, the same is by no means true during the
height of the fever. Furthermore, there are no very marked
variations in the skin temperature of man during typhoid fever,
rheumatic endocarditis and many other conditions.*^
For a better understanding, therefore, of the mechanism
governing heat losses as a whole, we require, in addition to our
knowledge that the loss by evaporation is small, quantitative stud-
ies bearing on the losses by radiation and conduction.
The heat loss during the fall of temperature
differs under different conditions. When the fall of tempera-
ture takes place by crisis, the loss of heat is greatly in-
creased by the sweating and by the increased radiation and con-
duction from the skin. When the fall of temperature takes
place very gradually, however, the heat loss is often very
slight. In such cases the fall is due mainly to a diminished
heat production, as has been definitely proved for animals, and
as is probably equally true for man. In the majority of cases,
however, the fall of temperature seems to be due to
a combination of diminished heat production
and increased heat loss. Sweating, even in febrile
cases, does not necessarily produce a fall in temperature.*^
Metabolism in Fever. — During the rise of temperature, as well
as during the height of the fever, the oxidative pro-
cesses in the body are usually increased.*^ They
run parallel to the heat production, and, indeed, may be used to
measure heat production (indirect calorimetry), providing that
we know what compounds are being oxidized and what the end-
products are. Chills and rapid respirations, i.e., muscular activ-
ity, greatly accelerate the metabolism, and a high temperature will
do the same. In some cases of fever, however, there is no apparent
increase in the metabolic process (p. 392) . No strict paral-
lelism exists between the rate of decomposition
and the elevation of temperature;*^ and many in-
FEVER 397
fections run their course with comparatively slight fever and yet
with relatively rapid rates of oxidation.
On the contrary, we occasionally meet with cases, which
despite their febrile character seem to exhibit
no increase in oxygen consumption. Such a finding
nevertheless does not warrant the assumption that the oxidative
processes are not accelerated. It is true that brief observations
made during fevers which have persisted over a long period will,
as the days go by, show a gradual diminution in nitrogen elim-
ination, oxygen combustion and sweat secretion — or, in other
words, a lessened heat production and heat loss — but figures thus
obtained are not an accurate criterion of metabolic processes
during the fever as a whole. Short periods of observation must
also take into account how metabolic conditions vary with the
stage of the fever. The conception is prevalent, nevertheless, that
there are occasional cases in which during the febrile course
the oxidative processes are not increased.^^ I cannot convince
myself, however, that these will bear a rigid scrutiny, for, as I
have already said, we must adhere to the maxim that in fever heat
production is increased.
Recent studies have given us a fairly comprehensive knowl-
edge of the substances which are decomposed in
fever. In all but the milder cases of infection, the febrile
patient is undernourished. Because of his loss of
appetite, he generally takes insufficient food unless special meas-
ures are resorted to.^^ Yet he needs more nourishment than the
normal individual, because of the energy consumed in the in-
creased heat production. For the same reason, his decomposition
processes exceed those of a normal person on the same dietetic
regime. Nor do the kinds of substances which are decomposed
differ in any way in the two cases. It is true that the febrile
patient in a fasting condition decomposes more proteid than does
an individual in a state of inanition, but with no infection or
fever; yet so far as the total consumption of energy goes, the
percentage of nitrogen excreted runs parallel in the two. I f
the patient with fever be given an adequate diet,
his nitrogen equilibrium will be maintained and
his strength conserved.'*® Herein lies the difficulty, for
such patients are almost always in a state of inanition due, on
the one hand, to their anorexia and, on the other, to their greater
398 THE BASIS OF SYMPTOMS
caloric need. The combination of diminished caloric intake and
increased caloric need explains the high proteid decomposition
ordinarily observed in fever.
The rapidity of proteid consumption varies in
different infections and with the stage of the disease. Further-
more, it is quite independent of the height of the fever.^^
The decomposition of proteids to their ordinary end-products
accounts, in part, for the increased production of heat in fever,
but as this source is inadequate, non-nitrogenous sub-
stances are utilized just as is the case in starvation. Gly-
cogen plays an insignificant role, because it is rapidly con-
sumed, and further because it is not stored up to any great
extent in fever.*® Fat, therefore, must provide the remainder
of the energy required.*^ In brief, metabolism in fever
follows the same laws as in starvation, as is evi-
denced by the fact that the respiratory quotient in the two states —
the nourishment being the same — is identical. The abnormally
low quotient formerly frequently observed in febrile patients we
now know to have been based upon too short a period of obser-
vation.^®
The augmented proteid combustion in fever is due, in part,
therefore, to the associated inanition, and in part to the generally
increased production of heat. We have already noted that fever
per se accelerates the processes of combustion, and in this the
tissue proteids also naturally take part. So far as man is con-
cerned,^^ it has been shown that if the temperature is artificially
raised to 39° C. the proteid decomposition is not affected ; whereas,
if the temperature reaches 40° C, an increase in proteid destruc-
tion is said to take place. In these investigations, however, the
total consumption of energy has not been taken into consideration.
Nor does proteid destruction take place along different lines
from those in simple inanition.^^ The formation of albumoses
is not of frequent enough occurrence to be looked upon as charac-
teristic of fever, as was formerly supposed.^^ Most of the
end-products of proteid decomposition that ap-
pear in the urine do not differ qualitatively from those present
in health. Thus the urea is relatively reduced and the ammonium
salts of organic acids increased. The increase in the amount
of these organic acids in the blood is the probable cause of the
diminution in the amount of carbon dioxide that is present there.
FEVER 399
As a rule, the creatinin is also increased in the urine. We have
no positive information as to the amount of uric acid formed
during fever.
That the amount of heat set free in fever by the processes of
combustion corresponds to that determined by direct calorimetry,
is evidence, in my opinion, of the contention that the excess of
heat which is generally produced in fever arises solely from chemi-
cal decompositions, just as does the total heat production in the
normal individual. In other words, there is no special mechanism
of heat production in fever. The view ^* that heat is produced in
fever by peculiar processes of hydration can be discarded, for
the accumulation of water in the tissues during long-continued
fevers does not differ from that in cachectic conditions unasso-
ciated with fever. Indeed, in the process of hydration, heat is
utilized, not set free.^^
The Cause of the High Temperature in Fever. — We have
already said that a rise in temperature must always be due to a
disproportion between the heat production and the heat loss in
the body. Since the production of heat in fever is
greater than in health, it is theoretically possible that
this increased production of heat may be the sole cause of the
high temperature. Yet we know that large amounts of heat
may be produced in the normal individual by muscular exertion,
and that these do not ordinarily cause any marked rise in tem-
perature. It might be urged, therefore, that in fever the fault
lies in the mechanism which regulates the heat
loss, or, in other words, that the heat in fever is produced
in such a manner that it does not furnish the normal stimulus
to the mechanism that increases heat loss. This would be an
acceptable theory were the mechanism of heat production in fever
different from that in the healthy person; but as this is not the
case we are in no position to say whether the mechanism which
increases the loss of heat from the body is relatively inactive or
not. We would emphasize the fact, however, that there exist
no grounds for such an assumption.
The Site of the Heat Production in Fever, — The character
of the metabolic changes in fever gives us no definite idea as to
the tissues especially affected, for, as we have seen, the urine
contains only such decomposition products as appear when there
is cellular destruction of any sort in the body. The evidence
400 THE BASIS OF SYMPTOMS
in favor of an increased consumption of red blood-
corpuscles is very inconclusive. Neither the increased
amounts of potassium salts in the urine nor the abnormal pigments
there present can be considered to prove a widespread destruction
of these elements ; and the blood-picture itself is inconsistent with
such a conception.
Observations on the temperature of the blood
returning from various parts of the body do, how-
ever, give us some data as to the site of the heat production.
Heidenhain and Korner found that when artificial fever had been
produced in dogs by the injection of pus, the blood returning
from the legs was warmer than that in the right ventricle.^*
Numerous other observers ^^ have since shown that, in artificial
fever, the venous blood returning from the kidneys, and espe-
cially from the liver, is warmer than that from the muscles and
the skin. From these observations, we may infer that the
excessive heat of fever is produced mainly in
the large glands and the muscles; but to what extent each
of these participates in its production is very uncertain.
Since the glycogen of the body is consumed during fever, ^®
and since the artificial fever produced by puncture of the brain
likewise brings about a consumption of glycogen — and indeed
occurs only when there exists a store of glycogen in the body ^^ —
it seems highly probable that the cause of the increased heat
production in ordinary fever is a stimulation of the central ner-
vous system, similar to that induced by the puncture.®*^
The Heat-Regulatory Mechanism in Fever. — In the healthy
individual, a proper heat regulation cannot be maintained unless
certain parts of the mid-brain are intact. If these parts of the
brain be destroyed, or if the spinal cord be cut at a high level,
then the temperature depends largely upon that of the surround-
ings, just as it does in the case of cold-blooded animals. Though
the exact location of these heat-regulating centres is
not known, it would appear from the studies of Isenschmid and
myself that the basal ganglia are of fundamental impor-
tance in this regard.
It would seem probable that this nervous mechanism which
regulates the temperature of the body is diseased in fever. The
observations bearing on this question have dealt, for the most part,
with the effect of procedures which withdraw heat from the body;
FEVER 401
and experiments on men as well as animals have shown that if heat
be artificially withdrawn from the body by cold baths, etc., the
compensatory increase in the heat production is less if the animal
has a fever than if it be normal. In certain experiments on ani-
mals, indeed, there may be absolutely no increased production
of heat under these circumstances.®^
It follows that the temperature of febrile animals is more
readily reduced by artificial cooling than is that of normal animals,
and that, other things being equal, the patient with fever may be
cooled off with comparative ease. It is also probable that his
temperature may be more easily raised by artificial means. For
example, animals more readily acquire a high temperature from
warm surroundings if they have been previously treated with
injections of pus.®^ In apparent contradiction to these facts is
the observation that the temperature of an animal with fever is
sometimes made higher by exposure to cold, possibly because
the cold increases the heat production within the body.
It is evident, therefore, that in fever the organism reacts
qualitatively to a cooling or heating of the body surfaces like
a normal animal. Quantitatively, however, there exist differ-
ences, in that in pyretic conditions the response to external changes
is not so prompt or so complete. Furthermore, conditions are
similar in fever states with respect to the heat which the animal
itself produces. Thus weakly individuals, tuberculous patients
and those running a slight temperature or convalescing from an
infection, often exhibit fever after muscular exertion or after
heavy meals.®^ In the case of typhoid fever and tuberculosis, a
diet of high caloric worth ordinarily causes no rise in temperature,
probably because the heat loss is increased by evaporation from
the skin.®* Though the latter is not so great as in health, it
serves nevertheless as an efficient regulatory factor.
We may say then, at this point, that though heat regu-
lation is maintained in fever, the regulatory
apparatus is less responsive than in health to cer-
tain demands made upon it.
It is a matter of common clinical experience that the tem-
perature of patients with fever is less resistant
to external influence than is that of normal in-
dividuals. This lack of resistance differs in amount in dif-
ferent diseases and may even vary at different periods of the
26
402 THE BASIS OF SYMPTOMS
same disease. During typhoid fever, for example, the tempera-
ture can usually be reduced more readily in the later than in the
earlier weeks of the illness. One reason why fever patients are
particularly susceptible to the antipyretic action of the cold
bath is that their cutaneous vessels react abnormally to stimuli.
It is when these vessels remain dilated for a considerable period
after the cold bath that the most marked falls in temperature
occur.®^ The antipyretic drugs also reduce the tempera-
tures of fever patients much more effectually than they do those
of normal individuals;^^ and here again these drugs are not
equally effective in all cases nor in the same case at all stages of the
disease. Thus we see that the temperature does not resist exter-
nal influences during fever so well as it does during health, partly
because the regulatory mechanism is less effective, and partly
because the peripheral blood-vessels react abnormally to stimuli.
Even during the convalescence from infec-
tious diseases, the temperature regulation is
often imperfect. Patients who are recovering from ty-
phoid fever, for example, easily acquire an elevation of tempera-
ture after eating large amounts of food or after excessive exercise,
apparently because they cannot eliminate the large quantity of heat
that has been suddenly liberated in their bodies. An analogous
condition is seen in many captive animals, and it seems as if their
temperature regulation were injured to a certain extent by the life
of captivity. Thus Finkler has observed a temperature of 40° C.
(104° F.) in starving guinea-pigs after a full meal.
In view of the fact that the temperature is elevated in fever,
and that heat regulation is maintained, it may be said that con-
ditions are to a certain extent correctly described by Lieber-
meister's formula, viz., that the heat-regulatory
centre in fever is "set at a higher level." This
hypothesis is at present so widely accepted because of the current
tendency to regard each natural process — in this case, fever — as
essential to the life of the individual.
This formula represents the facts in so far as it concerns heat
regulation. But there is more to fever than a mere regulation of
heat; otherwise in febrile states we should expect to find only
the evidences of this "higher-pitched" regulation. This, how-
ever, is rarely the case. First and foremost, fever is generally,
in my opinion always, associated with an enormously increased
FEVER 40S
heat production. The adherents of Liebermeister's theory meet
this objection by observing that the symptoms accompanying the
new level of regulation vary with the cause of the fever. Though
this is to a certain extent true, such associated symptoms, e.g., an
increase in heat production, are actually a part of the febrile
process. This applies equally well to fever produced by chemical
means, in which case an infection plays no part. It is true that
in bacterial affairs, the micro-organisms are capable of augment-
ing the decomposition processes, possibly without at the same time
causing fever. This has definitely been shown to be the case
among cold-blooded animals in which fever cannot be produced
because there is no mechanism of heat regulation. As for warm-
blooded animals, the effects of febrile infections have been little
studied. It is highly probable, however, that the microbic agency
itself may be the cause of the increased decomposition processes,
and to this extent the protagonists of Liebermeister are justified
in assuming that it is difficult, perhaps impossible, to separate the
consequences of infection from those of fever. But this reason-
ing is not applicable to the so-called aseptic fever which occurs
after the injection of albumoses or following blood extravasations
into the tissues. Here, too, there is an increased production of
heat and this increase is not a direct effect but associated with the
symptom-complex of fever.
Heat regulation is a complex process, bring-
ing into play factors which act independently
upon heat production and heat loss. Loss and pro-
duction are regulated under different conditions by different
physiological tools; the former by conduction, radiation and
evaporation, and the latter by the decomposition of the constituents
of the food or of the tissues. In my opinion, fever brings about
an alteration in all the various components of this mechanism,
though the extent to which each is affected varies with the case.
The faculty of regulation is, on the whole, preserved. I am of
the opinion that there exists always a hyperstimulation of those
places which have to do with heat production, or, in other words,
a peculiar linking of disturbed heat production and heat elimina-
tion.^^ The centres for the regulation of the latter are variably
affected, but on the whole they are inefficient. In this particular
we are agreed with Liebermeister, viz., that the regulatory func-
tion in its entirety is "higher pitched." But conditions vary
404 THE BASIS OF SYMPTOMS
greatly in different cases. The cutaneous vessels may be con-
stricted or dilated. Sweating is always present to some extent,
and oftentimes greatly increased — not infrequently, indeed, during
a chill. This variable behavior of the centres depends upon
the nature r.nd virulence of the infection, upon the constitution
of the patient and upon the stage of the disease.
The explanation of the different phases of the febrile process
resides, therefore, in the behavior of the heat-regulating centres
in the brain, upon which the hypothetical fever-producing sub-
stances are assumed to act. We have already discussed the facts
for and against the conception of a single substance
being responsible for all fevers. In view of
Friedberger's epochal work on anaphy latoxin,
we are in a better position to answer this question. The irrita-
bility of the heat-regulating centre is unquestionably subject to
great variations, being particularly susceptible to chemical actions
and infectious processes. Friedberger ^® has made quantitative
studies of the effects produced by reinjection in animals sensitized
with foreign proteids. Small doses of the specific proteid caused
fever; while collapse, with subnormal temperature, and even death,
followed the injection of larger amounts. Friedberger's obser-
vations are based ui>on specific reactions which are of genuine
anaphylactic nature. In this sense, fever may be looked
upon as the most delicate response of a sensi-
tized animal. The doses necessary to cause the rise in
temperature are incalculably small. Furthermore, Friedberger
was able by varying his dosage to produce every known type of
fever curve. Though anaphylatoxin is not a specific substance,
its mode of origin is specific; and as such it might be looked
upon as the uniform cause of infectious fevers, producing the
ktter by stimulation of the heat-regulating centre.
The Nutrition in Fever. — The nutrition is always
impaired in fevers of long duration, because, as we now know
and as we have already noted, the patients do not take a sufficient
quantity of food. Their appetites are often very poor, though
this may not be the case in the hectic fever of tuberculosis. For
these reasons most patients with fever become emaciated and
weak, and the weakness is often greater than can be accounted
for by the lack of food alone, being dependent, as we have seen,
FEVER 405
upon the excessive consumption of both the proteid and non-
proteid materials of the body.
On the other hand, in long-continued infections,
a tendency to limit the metabolic processes is
often manifest, and in the terminal stages of chronic dis-
eases the proteid decomposition and the total oxidations in the
body often reach a surprisingly low level. This adaptation en-
ables many a person to undergo a long-continued illness which
would otherwise prove fatal. Though the excessive consumption
of proteid material is common to all forms of fever, it seems
very probable that certain infections are particularly harmful in
this respect.
The cause of the various forms of cellular degeneration that
occur so frequently in fever is not yet definitely determined.
Some believe that the high temperature may cause the degenera-
tive changes,®^ whereas others hold that the temperature alone
will not produce them.'^^ It is impossible at present to reconcile
these varying views.
The Water Retention in Fever. — Years ago Leyden^^ made
the observation that patients with fever frequently lose but little
weight during the course of the acute process — i.e., at the time
when the consumption of material in the body is most active — but
that the principal loss in their weight takes place during convales-
cence. He explained these results by assuming that there is a
retention of water in the body during fever. From that time
up to the present this question has awakened general interest.
In its discussion one might distinguish between an absolute
retention of water and a mere relative retention, i.e.,
an increase in the proportion of water in the tissues. So far as an
absolute retention is concerned, this is not caused by a high tem-
perature or by the infection itself. Only when the kidneys or
heart are diseased is there an absolute insufficiency of water
elimination during fever. In general, there is no absolute decrease
in the excretion, but on the contrary a slight increase, correspond-
ing to the increased rate of metabolism. The diminished urine
which is so often seen in the early days of an infectious disease is
compensated for by an increased evaporation of water from the
skin and lungs. The increased urine during defervescence, as
occurs, for example, during the late weeks of typhoid fever, is due
to the fact that at this time the sweating sinks to a minimum.^ ^
406 THE BASIS OF SYMPTOMS
Less heat is eliminated because less is produced in the late stages
of long-continued infectious diseases (p. 393).
The relative amount of water in the tissues
does not change during fevers of short dura-
tion, such as pneumonia, but in long-continued
fevers, such as typhoid or tuberculosis, the
tissues become relatively rich in fluids and
poor in solids. The cause of this seems to lie in the ex-
cessive proteid destruction, resembling in this respect the cachexia
of carcinoma. A normal individual rapidly excretes any addi-
tional water that may be introduced into his body, up to three
litres or more per day. Why the patient with fever fails to excrete
the extra liquid in his tissues is not known, though we suspect that
it is because the extra water is retained chiefly within the cells
themselves and does not reach the blood or lymph. To what
extent this water accumulation may be due to the retention of
nitrogenous substances or to an altered salt metabolism, is at
present undetermined.
The Significance of Fever. — Whether or not the elevation of
temperature is of advantage to the infected organism is a subject
that has engaged the attention of physicians from the most remote
times down to the present. Three conflicting views have been
advocated. According to the first, the elevation of tem-
perature is in itself dangerous to the patient, '^^
and may even be the cause of death; according to the second,
the danger of the infectious process depends
only to a very slight extent upon the high tem-
perature, and according to the third, the high tem-
perature is advantageous, for by this means the in-
fected body is " cleansed by fire." '''^ The treatment of fever must
depend, to a large extent, upon the view that is accepted by the
physician.
Is the elevation of temperature in the course of an infection
useful, harmful or of no particular significance? So long as
the elevation remains within moderate limits, it
may certainly be regarded as relatively harm-
less. The rapid pulse and respirations, the loss of appetite and
the possible parenchymatous degeneration of the organs, in so far
as they are directly caused by the temperature, are not in them-
selves very dangerous. If, on the contrary, the elevation of tem-
FEVER 407
perature is very great, it may undoubtedly be harmful, for
the same dangers are threatened as in a heat-stroke. Yet such
dangerously high temperatures are comparatively rare in fever;
and the reason why a high temperature is generally regarded as a
bad sign in an infectious disease is that it indicates a severe
infection. This is well illustrated by the fact that high tempera-
tures in malaria are generally regarded with a certain amount
of indifiference, whereas the same temperatures in rheumatic fever
or pneumonia would be looked upon with alarm.
Whether the elevation of temperature is directly bene-
ficial to the infected organism or not, is a question
that is not so easily settled. In recent years there has been a
tendency to apply the Darwinian theory to pathological processes
in general, and to say, for example, that fever could never have
survived throughout immeasurable time were it not inherited
as a useful weapon in the struggle for existence. Yet one may
question to what extent the Darwinian theory applies to pathologi-
cal conditions,'^ ^ for it seems equally reasonable to regard fever
as a blind reaction against an injury, possibly useful or possibly
harmful. The question is not one that can be solved by such
philosophical considerations, and the final answer must be based
upon established facts, derived either from bedside observations
or from animal experiments.
Unfortunately, clinical studies have done little to solve this
problem. We have, it is true, accumulated extensive statistics
on the course of infectious diseases, especially of typhoid fever,
under the expectant and antipyretic forms of treatment. Yet, even
though we acknowledge the advantage of the latter treatment, we
are helped but little to a solution of our problem, for cold water
not only lowers the temperature of the body, but it influences the
disease in many other ways; and antipyretic drugs introduce
abnormal chemical processes into the metabolism, and above all
act upon the patient's nervous system and mental condition.
It is possible that at a higher temperature the growth or
virulence of the micro-organisms which cause the disease may be
diminished. At present, however, we are unable to say definitely
to what extent this actually occurs in disease.
We do possess, however, a number of observations on the
effect of increasing an animal's temperature after it has been
artificially infected. Infection with diphtheria bacilli, chicken
408 THE BASIS OF SYMPTOMS
cholera bacilli and pneumobacilli run a milder course in rabbits
if the temperature be artificially elevated by puncture of the
brain ;^® and intoxications with hydrolytic ferments are also less
virulent at higher temperatures J ^ The same has been found to
be true for erysipelas infections in rabbits,'^® and the number of
such examples could be still further multiplied.
Perhaps the action or formation of antibodies is favored by
the high temperature. Kast'^^ found that Pfeiffer's antibody
against typhoid bacilli was more efficient at higher temperatures ;
though, on the other hand, antipyretic treatment does not seem
to influence the formation of the immune body in man.®^
We possess, therefore, some noteworthy experiments
which support the view that the elevation of
temperature during an infection is directly
beneficial to the infected organism. It must be
admitted, however, that only a beginning has been made, and
that more observations are necessary before the question can be
regarded as definitely settled, and before we shall know whether
it is the increased temperature itself or some associated changes
in metabolism that benefit the patient.
The Temperature in Collapse. — ^We have had frequent occa-
sion to mention that the temperature during fever is subject to
great variations, and that it tends to rise or fall from relatively
insignificant causes. A great fall of temperature during an
infection has long been recognized as a dangerous symptom,
mainly because it so frequently heralds the onset of collapse ; this
has been observed experimentally. The ordinary fever-producing
agents may cause a reduction in an animal's temperature if they
are especially potent, or if the animals used are very " weak " or
"non-resistant." It is difficult to say what constitutes this
"weakness" or "lack of resistance" on the part of infected
individuals, though it is possible that the condition of the circu-
lation plays an important role.
Not only the resistance of the individual, but
the kind and quantity of toxins are of impor-
tance in the production of collapse. The same
substance that will give rise to fever in small doses will lead
to collapse if given in large doses. This is well illustrated in the
case of Koch's tuberculin.^^ If this substance be given to ani-
mals in very large doses, the production of heat in the body is
FEVER 409
actually diminished, and in the fatal cases only fifty-three per
cent, of the normal amount of heat may be produced. At autopsy,
the vessels in the abdomen, and especially those belonging to the
intestines, are found to be dilated. This finding agrees with the
observations of Romberg, Passler and Bruhns (see page 86),
who showed that the circulatory failure in infectious diseases
was principally caused by a central vascular paralysis, affecting
especially the splanchnic vessels. The dilatation of these vessels
allows so much blood to collect in them that the heart is no longer
properly filled from the veins, the general blood-pressure falls,
and the activity of the muscles becomes so reduced that, in spite
of the fact that the heat losses are greatly diminished, the body is
no longer able to maintain its normal temperature. Thus we see
that the fall of temperature in collapse occurs at a time when
less heat than normal is produced in the body.
A certain antagonism exists, therefore, between
fever and collapse. In fever, both the heat production
and the heat losses are increased, the former being especially accel-
erated. In collapse, both of these are diminished, but the heat
production is more diminished than is the heat loss. On the
other hand, fever and collapse resemble each other in certain
respects, for in both too small an amount of blood passes through
the cutaneous vessels.*^ Indeed, they tend to shade into each
other, and, as we have seen, the one or the other may result from
the same cause, depending upon the factors already described.
Of interest is the fact that in death from anaphylactic shock,
we encounter a similar overloading of the splanchnic vessels
(see p. 87).
Subnormal Temperature. — Subnormal temperatures are seen
not only during collapse from infectious diseases,
but also after extensive injuries, severe hemor-
rhages, long-continued narcosis, perforative
peritonitis and various other severe lesions within
the peritoneal cavity. In many of these, the same con-
ditions are present as in collapse, though it is incorrect to regard
all subnormal temperatures as symptoms of collapse.^^
Subnormal temperatures are more common than is generally
supposed. They are often seen during convalescence
from infectious diseases, and are then generally due
to a diminished production of heat combined with an inefficient
410 THE BASIS OF SYMPTOMS
heat regulation. A subnormal temperature frequently accom-
panies intoxications with alcohol or related
drugs. These lessen the rate of oxidation in the body, and,
in addition, interfere with the mechanism regulating the loss of
heat from the skin.** Consequently, an intoxicated man is less
able to withstand cold than is a healthy individual, and if exposed
to cold, the temperature of his body is more liable to fall.
When the temperature of the body becomes very low, narcosis,
and finally a general paralysis, result. The narcosis will, in turn,
favor a further lowering of the temperature, for the body can
no longer increase its production of heat by muscular activity.
Even in ordinary sleep the heat regulation is less efficient than
during the waking hours, and this lack of regulation is much
more marked during deep narcosis. For these reasons, the danger
of freezing to death is best combated by continued muscular move-
ments, for these not only increase the production of heat, but they
reduce the tendency to go to sleep.
We do not know how low the temperature may fall without
causing death, though it is certain that both men and animals
have recovered from very low temperatures.*^
LITERATURE
* Krehl and Matthes : Arch, f . exp. Path., xl, 430 ; Roily, Arch, f . klin. Med,
Ixxviii, 248.
* Krehl: Arch. f. exp. Path., xxxv, 222 (lit.) ; Nebelthau, ibid., Ixiv, 385.
' Riethus : Arch. f. exp. Path., xliv, 253.
* Cf. Pfeiffer, in Penzoldt-Stintzing, Handb. ; Krehl and Matthes, Arch. f.
exp. Path., xxxviii, 284.
'Buchner: Berl. klin. Wochenschft., 1890, No. 10; Miinch. med. Wochen-
schft., 1891, No. 49; Krehl, Arch. f. exp. Path., xxxv, 222.
'Centanni: Deutsch. med. Wochenschft., 1894, Nos. 7 and 8; cf. Voges,
Zeitschft. f. Hyg., xvii, 474.
'' See Freund : Arch, f . klin. Med., cv, 44.
* Krehl and Matthes : Arch, f . klin. Med., liv, 39 (lit.) ; Klemperer, Natur-
forscherversamm., 1903, ii, II, 67.
' Meyer : Deutsch. med. Wochenschft., 1909, No. 5 ; Bingel, Arch. f. exp.
Path., Ixiv, I ; Freund, ibid., Ixv, 225.
*" Samuelson : Monatschft. f. Kinderheilk., x, 465 ; Bendix and Bergmann,
ibid., 387.
" Krehl and Matthes : Arch, f . klin. Med., liv, 501 ; Schulthess, ibid., Iviii,
32s, and Ix, 55.
" Freund : Arch, f . klin. Med., cv, 44.
" Freund : Arch, f . klin. Med., 1912, cvi, 556.
" Protein Split Products, 1913.
" Amer. Jour. Phys., x, 452 ; xx, 439.
" Freund and Strasmann : Arch, f . exp. Path., 1912, Ixix, 12.
" Freund : Arch. f. exp. Path., Ixv, 225.
" Harnack and Schwegmann : Arch. f. exp. Path., xl, 151 ; Hamack, ibid^
xlv, 45. 447.
FEVER 411
"See Kionka: Intemat. Arch. f. Pharmakodynamie, v, iii (lit.).
^ Gottlieb : Arch, f . exp. Path., xx, 167 ; Schultze, ibid., xliii, 193 ; Aronsohn,
Virch. Arch., clxix, 501.
^ Roily : Arch, f . klin. Med., Ixxviii, 289.
" Hirsch and Roily : Arch, f . klin. Med., Ixxv, 307.
" White : Jour, of Phys., xi, i ; Aisenstat, Arch, f . Phys., 1909, 475 ; Sachs,
Jour. Exp. Med., xiv, 408 (lit.).
""See Th. Kocher: Grenzgebiete, i, 415 (Ht.).
^ See Rubner's classical work. Die Gesetze des Energieverbrauchs bei d.
Ernahrung, 1902; Benedict, Am. Jour. Phys., xi, 145.
"°v. Bergmann; Kongr. f. inn. Med., 191 1, 490.
''Hiller: Zeitschft. f. klin. Med., xxiii, 399; Wolpcrt, Arch. f. Hyg., xxvi, 32.
^ Zuntz : Hohenklima u. Bergwanderungen, 1906, 394.
^ Zuntz : Berl. klin. Wochenschft., 1896, No. 32 ; Bonnette, Le coup de
chaleur dans les pays temperes, etc., 1905.
^ Thurn : Deutsch. militararztl. Zeitschft., 1895, 289.
'' Rubner : Zeitschft. f. Biol., N. F., xii, 73.
^- See Krehl and Matthes : Arch. f. exp. Path., xxxviii, 284.
^ Roily and Hornig : Arch, f . klin. Med., xcv, 74 ; Roily, Kongr. f . inn. Med.,
1911, 512 ; Grafe, Arch. f. klin. Med., ci, 209.
"Krehl and Matthes: Arch. f. exp. Path., xxxviii, 284; Freund and Grafe,
ibid., Ixvii, 55.
*° Kraus and Chvostek : Wiener kHn. Wochenschft., 1891, Nos. 6 and 7 ; Krehlj
and Matthes, Arch. f. exp. Path., xxxviii, 284; Steyrer, Zeitschft. f, exp.
Path., iv, 720.
**Linser and Schmidt: Arch. f. klin. Med., Ixxix, 514.
^ Nebelthau : Zeitschft. f . Biol., xxxi, 293 ; Krehl and Matthes, Arch, f . exp.
Path., xxxviii, 284.
"Rubner: Arch. f. Hyg., xi, 256; Wolpert, ibid., xxvi, 32, 68; Zuntz, Berl.
khn. Wochenschft., 1896, No. 32.
~ Schwenkenbecher and Inagaki : Arch, f . exp. Path., liv, 168, Lang, Arch.
f. Klin. Med., Ixxix, 343.
*° Nebelthau : 1. c. ; Krehl and Matthes, 1. c. ; Griinewald, Arch, f . klin. Med.,
Ixxviii, 333.
■"StaheHn: Zeitschft. f. klin. Med., Ixvi, 241.
** See footnote 33.
^ See Riethus : Arch, f . exp. Path., xliv, 247.
■" Steyrer : Zeitschft. f . exp. Path., iv, 720.
** Coleman: Jour. Am. Med. Assn., 1909, 1145; Shaffer and Coleman, Arch.
Int. Med., iv, 538; Grafe, in studies presented to the Karlsruher Natur-
forscherversamm., 191 1.
*° Loening : Klin. Jahrb., xviii, i ; Grafe, Arch, f . klin. Med., ci, 209.
*' Loening : 1. c.
** Hirsch, Miiller and Roily : Arch, f . klin. Med., Ixxv, 307 ; Roily, ibid., Ixxviii,
250; Ott, ibid., Ixxi, 263.
** May : Zeitschft. f. Biol., xxx, i ; Stahelin, Arch. f. Hyg., xlix, 77.
"" See Grafe : Arch, f . klin. Med., ci, 209 ; Roily, ibid., ciii, 93.
"Linser and Schmid: Arch. f. klin. Med., Ixxix, 514.
"'Mohr: Zeitschft. f. klin. Med., Hi, 371.
" Morawitz and Dietschy : Arch, f . exp. Path., liv, 88 ; Schultess, Arch, f .
klin. Med., Iviii, 315, and Ix, 55; Krehl and Matthes, ibid., liv, 501.
" Herz : Untersuch. ii. Warme and Fieber, 1893 ; Kongr. f . inn. Med., 1896, 86.
" F. Kraus : Wiener klin. Wochenschft., 1894, No. 15.
■^Pfluger's Arch, iii, 562.
'^ Krehl and Kratsch : Arch, f . exp. Path., xli, 185 ; Hirsch and Miiller, Arch.
f . klin. Med., Ixxv, 287.
" Hirsch and Roily . Arch, f . klin. Med., Ixxv, 305 ; Roily, ibid., Ixxviii, 250.
" Roily : 1. c. ; for an opposed view, see Senator and Richter, Zeitschft. f .
klin. Med., liv, 16.
412 THE BASIS OF SYMPTOMS
** See Gottlieb, in Meyer and Gottlieb, Pharmacology (Halsey, Philadelphia,
.1914.453)-
" Liebermeister : Path. d. Fiebers, 341 ; Colasanti, Pfliiger's Arch., xiv, 125 ;
Finkler, ibid., lix, 98 ; Zuntz, Du Bois Arch., 1882, 43.
*" Dobrzanski and Naunyn : Arch, f . exp. Path., i, 181 ; Finkler, 1. c.
"^Penzoldt and Birgelen: Miinch. med. Wochenschft., 1899, Nos. 15-17; Ott,
ibid., 1901, No. 50, and 1902, No. 38; Schroder and Briihl, ibid., 1902,
Nos. 33-35-
" Schwenkenbecher and Tuteur : Arch, f . exp. Path., Ivii, 285 ; Lang, Arch, f .
klin. Med., Ixxx, 353 ; Lcening, Klin. Jahrb., 1908, xix, 105.
" Finkler : Kongr. f. Inn. Med., 1888, 314.
** Gottlieb : Arch. f. exp. Path., xxvi, 419, and xxviii, 167.
*^ Cf. Schmiedeberg : Grundriss d. Pharmakologie, 4th edit.
^ See especially, Zeitschft. f. Immunitatsforsch., x, 1 ; Miinch. med. Wochen-
schft, 1910, Nos. 50 and 51.
"Liebermeister: Path. d. Fiebers, 427.
'" Naunyn : Arch, f . exp. Path., xviii, 49.
" Arch, f . klin. Med., v, 366.
" Schwenckenbecker and Inagaki : Arch. f. exp. Path., liv, 168.
'"' Liebermeister : Path. d. Fiebers, 423 ; Krehl, Ergeb. d. allg. Path., 1896, 409.
" Pfluger : Pfliiger's Arch., xiv, 502 ; Unverricht, Volkmann's Vortrage, N. F.,
No. 159-
'° See Ziegler : Miinch. med. Wochenschft., 1896, No. 43.
'• Loewy and Richter : Virch. Arch., cxlv, 49.
" Hildebrandt : Virch. Arch., cxxi, i.
^'Filehne: Jour, of Phys., xvii (Proc. Physiol. Soc).
" Kongr. f. inn. Med., 1896, 2,7; Paech, Diss. Breslau, 1900; Roily and Meltzer,
Arch. f. klin. Med., xciv, 335; Liidke, ibid., xcv, 425 (lit).
""Lemaire: Arch, internat. de pharmacodyn., v, 225; Schiitze: Zeitschft. f.
Hyg., xxxviii, 205.
•^Matthes: Arch. f. exp. Path., xxxvi, 437; xxxviii, 299; Krehl, ibid., xxxv,
222.
*^ Maragliano : Zeitschft. f. klin. Med., xiv, 309; xvii, 291.
^ Janssen : Arch, f . klin. Med., liii, 247.
"Rumpf : Pfliigers Arch., xxxiii, 538.
" Janssen ; 1. c. ; Cohnheim, Allg, Path., 2nd edit, ii, 489«
CHAPTER XI
THE SECRETION OF URINE
The major portion of the solid waste products that arise
in the body leaves it by way of the kidneys. As we have already
had occasion to describe many of these substances, it is not our
purpose to review in this place the origin of each, but rather
to deal with the mechanism of secretion itself; though it must
be admitted that it is often impossible to draw a sharp line between
the secreting mechanism and the products that are eliminated.
The composition of the urine depends partly upon the con-
dition of the secreting cells in the kidneys and partly upon
the quality and quantity of blood which passes through these
organs. These factors are more or less interdependent one upon
the other. For example, if the blood-stream through the kidneys
be slowed, not only does less blood come into contact with the
secreting cells, but the latter are liable to suffer in structure and
function. On the other hand, if the renal cells are primarily
injured, this frequently affects the circulation through the kid-
neys. It is often very difficult, therefore, to tell which part of
the renal apparatus is primarily involved.
The Effect of an Increased Flow of Blood through the
Kidneys.! — It is a general rule that the quantity of urine secreted
varies directly with the quantity of blood that flows
through the kidneys. It varies likewise with the dif-
ference between the pressure of the blood in the
capillaries and the pressure of the urine within
the uriniferous tubules. When the total quantity of
urine is increased, the percentage of solid materials decreases, and
vice versa; yet this percentage of solids nearly always remains
within certain limits, rarely going above twelve per cent, or below
three-tenths per cent. The relation between the total quantity
of solids excreted and the total quantity of urine seems to be
subject to considerable variation; and the different solids often
vary independently of one another.
Whenever more blood flows through the kidneys, therefore,
the amount of urine is increased. The cause of the increased
blood-flow may lie either in a higher arterial pressure, unaccom-
413
I
414 THE BASIS OF SYMPTOMS
panied by a corresponding contraction of the renal vessels, or
it may be due to a local dilatation of these vessels, while the
general blood-pressure remains constant.^
Many forms of chronic nephritis are accompanied by
a high blood-pressure (see p. 25), and this always causes an
increased secretion of urine, if a sufficient number of functioning
renal cells are present, and if the increase in the general blood-
pressure is not accompanied by a constriction of the renal vessels
of such a degree as to prevent a more rapid blood-flow through the
kidneys. As we have said, the increased elimination of water in
such cases reduces the percentage of solids in the urine. The
absolute excretion of the different solids, however, in these forms
of nephritis varies greatly,^ being dependent, apparently, to a
great extent upon the condition of the epithelial cells. On the
other hand, an increased secretion of urine in chronic nephritis
is less frequent than is generally believed, occurring according
to one observer* in only one-third to one-half of the cases. The
increased blood-pressure that follows the administration
of digitalis to patients with heart disease also frequently
causes an increased elimination of urine, because the renal circu-
lation is improved.
Diabetes Insipidus. — The second condition leading to an in-
creased flow of blood through the kidneys is a local dila-
tation of their vessels, the arterial pressure remaining
constant. This can be experimentally proved by cutting the renal
nerves.
Such a dilatation of the renal vessels is a possible cause of
diabetes insipidus,^ a disease which is characterized clinically by
the excretion of large amounts of dilute, sugar-free urine, without
an associated increase in the general arterial pressure. The ex-
cessive amount of urine frequently carries out with it demonstrable
quantities of inosite, and at times the total quantity of nitrogen
is also increased. This latter increase is caused in part by the
large amounts of meat eaten; for many of these patients, for
some unknown cause, have excessive appetites, just as have
patients with diabetes mellitus. In those cases of diabetes insipidus
in which an abnormal appetite is associated etiologically with an
excessive thirst — and into this categoiy falls the majority of
cases — the suspicion is strong that we have to do with a poly-
dipsia of psychic origin. The evidence that disturb-
THE SECRETION OF URINE 415
ances of proteid metabolism occur in diabetes insipidus is not
convincing, nor is it likely that such do occur.^
We really know very little concerning the etiology of
diabetes insipidus. It unquestionably occurs at times
as a family disease. Syphilis also plays an etiological
role. In some cases, anatomical lesions of the cere-
bellum, the pons or the medulla have been found —
findings which accord well with the experimental observation that
injuries to corresponding parts of the brain may lead to polyuria.'^
Yet there is some uncertainty as to the exact part of the brain that
must be affected in order to produce this increased flow of urine,
and further as to the manner in which such an injury brings about
the polyuria. In some cases the evidence at our disposal points to
a disturbance of the vasomotor system, leading to a local dilatation
of the renal arteries. Such an hypothesis, however, would
scarcely explain all of the clinical manifestations.
Oftentimes it is impossible to say whether the poly-
dipsia or the polyuria is primary, for the former
may also be due to certain cerebral lesions. There is little doubt,
however, as we have noted above, that some of the cases diag-
nosed as diabetes insipidus are in reality instances of psychic
polydipsia. To the latter belong those severe cases passing twenty
or more litres per day; further, those in which the individual is
addicted to the drinking of abnormal fluids, such as urine; and
finally those in which water alone is capable of assuaging the
thirst.
The characteristic feature of the disorder, according to Meyer,
is in some cases the inability of the kidneys to ex-
crete a urine of normal concentration,® because of
which a polyuria is of regulatory significance in removing the
waste products of metabolism. In such cases a disturbance of the
renal epithelium must be assumed ; while in others, in which the
kidneys have not lost the power of delivering a concentrated urine
and in which the increased thirst is the prominent symptom, the
polyuria would seem to be due to an abnormal dilution of the
blood. It is evident, therefore, that what we term diabetes in-
sipidus is not of uniform etiology.
(Clinical and experimental data point strongly to the etio-
logical importance of the hypophysis in dia-
betes insipidus. The frequent association of the disease
416 THE BASIS OF SYMPTOMS
with lesions of the base of the brain and interpeduncular space —
especially with basal gummatous meningitis — is well-recognized.
A more critical study has shown that such lesions often involve,
or are restricted to, the posterior lobe of the pitui-
tary body.® In keeping with these findings is the presence
in the posterior lobe of a diuretic substance distinct from the
pressor body it contains (Magnus and Schafer). Lewis and
Matthews ^^ were able to produce a transient polyuria in dogs
in one-half of their cases by operative procedures. From the
fact that the most constant finding in those animals exhibiting a
polyuria was a remnant of the epithelial covering of the posterior
lobe, the pars intermedia, they have concluded that dia-
betes insipidus is due to a hypyersecretion of the diuretic sub-
stance of the posterior lobe, this substance being the product of
the epithelial cells of the pars intennedia — Ed. )
Under pathological conditions, we frequently see transitory
increases or diminutions in the secretion of urine — increases in
hysteria, after epileptic convulsions or after ureteral catheteriza-
tion, diminutions in these same conditions or after operations on,
or injuries of, the kidneys. It seems probable that many passing
variations in the secretion of urine are caused by circulatory
disturbances in the kidneys which are of reflex origin.
The Effect of a Diminished Flow of Blood through the
Kidneys. — If the quantity of blood that flows through the kidneys
be diminished, a small amount of highly concentrated urine is
secreted; in other words, the diminution in the total solids does
not parallel that of the water.
The cause of such a diminished blood-flow
may be either local or general. Locally, a con-
traction of the renal vessels will diminish the renal circulation,
and it may do so even though the general blood-pressure be
increased from a contraction of many other arteries. This local
constriction of the renal arteries is the cause of the diminished
secretion of urine in asphyxia, in strychnin and epinephrin poison-
ing** and in epileptic and eclamptic convulsions.
In the second place, a diminished renal circulation may occur
in the absence of any local constriction of the renal vessels, either
because the general arterial pressure is reduced
or because the pressure in the renal veins is
raised. The reduction of the general arterial pressure may
THE SECRETION OF URINE 417
result from a widespread vasomotor paralysis or from a weaken-
ing of the left ventricle. The pressure in the renal veins may be
raised, either by an occlusion of these veins, or of the vena cava
inferior; by an increase in the general venous pressure from a
weakening of the right ventricle; or by a diminution in the
aspirating action of the thorax. The most marked effect upon
the renal circulation will naturally be produced when a lowering
of the general arterial pressure is combined with a rise in the
venous pressure. This combination occurs when both
ventricles are weakened, and this is indeed the most
frequent cause of an insufficient flow of blood through the kid-
neys. It is met with in many varieties of cardiac dis-
ease, whether these affect the endocardium, the myocardium
or the pericardium.
Aside from cases of cardiac stasis, a diminished amount of
urine is observed most frequently in the acute nephrit-
ides, a finding in keeping with the fundamental pathological
fact that the blood-stream is slowed in inflamed tissues. In
human nephritis, however, it has always been a matter of com-
ment that the clinical manifestations are often out of all propor-
tion to the anatomical changes in the kidneys. Schlayer and
Takayasu ^^ have thrown considerable light upon this subject by
showing that even the most trivial glomerular lesion may cause
severe disturbances of urinary secretion and of the ability of
the renal vessels to contract and dilate.
This impairment of the vessel function occurs chiefly in the
so-called vascular nephritides, though the tubular types
are not unaffected in this respect. In all inflammatory renal
processes, therefore, a disturbance of vascular integrity must be
taken into account, whether the glomeruli exhibit a characteristic
swelling of the epithelium, or seem to be normal. The disturb-
ance may cause either a lowered vascular irritability, in which
case the urinary secretion is diminished, or an augmented irrita-
bility leading to an increased secretion. This behavior of the
vessels applies not only to the experimental nephritides, but also
to acute and chronic cases in man.
In many of these circulatory disturbances, proteids from the
blood pass through into the urine ; yet, since this is probably due
to changes in the epithelial cells, we shall defer its consideration
to another place.
27
418 THE BASIS OF SYMPTOMS
The Effect of an Obstruction to the Escape of Urine. — The
obstruction to the escape of urine may be situated within
the kidney itself. The uriniferous tubules may be com-
pressed by scar tissue, or their lumina may be occluded by casts
or by precipitates of haemoglobin, bilirubin, uric acid, calcium
salts, etc. It is questionable, however, if such precipitates, with
the exception of haemoglobin, really offer much resistance to
the escape of urine; and it is quite possible that they lie in the
tubules merely because the amount of water secreted is insufficient
to carry them away.
On the other hand, the obstruction to the exit of urine may
be situated outside of the kidneys, in the lower urinary
passages, in which case it may be caused by calculi, tumors, scar
tissues, etc. The effect of such obstructions upon the total quan-
tity of urine secreted depends, in the first place, upon whether
they hinder the outflow from one or from both kidneys. If the
former be the case, the affected kidney will eliminate less urine
than normal, but the urinary material retained in the blood will
stimulate the other kidney and cause it to do extra work and
to hypertrophy. The urine, as a whole, therefore, will not be
greatly altered.
The effect of an obstruction upon the secretory activity of
the affected kidney depends largely upon the degree of
obstruction.^^ If this be so complete that the urine is
retained under a pressure amounting to sixty millimetres of
mercury or more, the affected kidney ceases to secrete.^* If the
obstruction be less complete, so that the urinary pressure above
the obstruction be less than sixty millimetres, the secretion con-
tinues, the rapidity of secretion diminishing in proportion to
the increase in pressure of the retained urine.^^ The details con-
cerning the cessation of secretion are not very well understood.
At first, the retained urine merely serves to distend the urinary
passages. As the pressure increases, however, a portion of the
urine appears to be resorbed through the cells of the urinary
tubules, which then become oedematous. Finally, the overfilled
tubules and the swollen cells press upon the veins and capillaries,
thereby diminishing their size and lessening the rapidity of the
flow of blood through the kidneys. This, in turn, diminishes the
secretion of urine.
If the obstruction to the flow of urine from a kidney
THE SECRETION OF URINE 419
be complete and permanent, the corresponding kidney
atrophies, and only a moderate grade of hydronephrosis develops.
If, however, the obstruction be incomplete, or if it
be more or less intermittent, the structure and the function of
the kidney are but Httle affected. Its pelvis, however, gradually
dilates, and an enormous hydronephrosis may be produced.
The Effect of Lesions of the Secreting Membranes. — We
have already mentioned the susceptibility of the renal epithelium
to changes in the quantity and quality of blood that passes through
the kidneys. Several membranes separate the blood in the capil-
laries from the lumina of the uriniferous tubules, viz., the capil-
lary walls, the basement membranes and the epithelial cells. The
possibility exists, therefore, that lesions of any one of these might
render the secretory apparatus abnormally permeable. Appa-
rently, however, lesions of the capillary walls are of comparatively
little importance; and it may be said in general that the
secretion depends rather upon the parenchyma
cells than upon the endothelial lining of the
capillaries. Indeed, widespread amyloid degeneration of the
renal capillaries has been observed without resultant changes in
the urine. It must not be overlooked, however, that so far as the
epithelial constituents of these secreting membranes are concerned,
different substances in the urine are eliminated by different renal
structures.
All lesions of the epithelial cells, degenerative as well as
inflammatory, and especially those which involve the glomeruli,
tend to diminish the secretion of water. Yet, in many cases of
nephritis this tendency is more than neutralized by an associated
increase in the amount of blood that flows through the kidneys,
for, as we have seen, this tends to increase the excretion of urine.
Th e quantity of urine, therefore, that is elim-
inated in pathological renal conditions de-
pends mainly upon these two sets of factors:
first, the degree and the extent of the damage
to the secreting cells, and secondly, the quan-
tity and quality of blood which comes into con-
tact with them. In widespread acute nephritis,
the excretion of water is nearly always diminished, whereas in
chronic diseases of the kidney, especially if these
be of limited extent, the effects of the increased work of the
420 THE BASIS OF SYMPTOMS
heart, the high blood-pressure and the well-maintained renal
circulation predominate, such patients frequently secreting even
more urine than does a normal individual. However, when car-
diac failure appears, and the general blood-pressure falls, the
amount of urine secreted by these patients is immediately
diminished.
In diseases of the kidney, a diminution in the excretion of
solids is often one of the earliest signs. The elimination of the
various solids varies greatly and for reasons but little understood.
The sodium chlorid usually follows the same law as the water;
the phosphates, sulphates and nitrogenous compounds usually vary
together ; while the uric acid pursues its own independent course.
Albuminuria. — Although it has been generally considered that
normal urine contains no albumin, recent work has rendered it
very probable that traces of albumin, as well as of
sugar, are normally present.^® In order to demon-
strate this trace of albumin, however, it is necessary to make
use of special methods, such as the concentration of large quanti-
ties of urine. This albumin is believed by Senator and Morner
to be derived from the blood by a process of filtration through the
glomeruli. Owing to the presence of chondroidin-sulphuric or
nucleinic acids in the urine, this albumin may be precipitated by
adding acetic acid. One should be cautious, therefore, and not
conclude too hastily that the precipitate that so often results from
the addition of acetic acid to urine is necessarily due to mucin
or nucleo-albumin, derived from the cells of the kidneys or urinary
passages.^ ^ The urine may, however, contain true mucin, which
is free from phosphorus and which is derived from the epithelium
of the urinary passages. ^^
There are persons who continually, or at inter-
vals, show easily demonstrable quantities of
albumin in their urine without feeling ill in
any way. We cannot assume that the kidneys of such indi-
viduals are absolutely normal, in spite of the fact that the ordinary
symptoms of chronic nephritis are absent and that the affected
persons remain, so far as appearances are concerned, perfectly
healthy. It is certain that chronic nephritis frequently follows
quite a different course from that ordinarily described in our text-
books on medicine, and it is possible that many of these cases
represent exceedingly mild forms of the disease.
THE SECRETION OF URINE 421
Orthotic Albuminuria. — ^An albuminuria is of frequent occur-
rence in childhood and during the period of puberty, especially
in delicate and anaemic individuals. Adolescence is prob-
ably a factor in some of these cases, for the condition often tends
gradually to disappear after this period. Many of these indi-
viduals suggest a constitutional fault, and not a few
improve as their general strength is built up. This type of
albuminuria may also exhibit a tendency to occur in
families. And finally, noxious influences of various kinds — ■
for example, the infectious diseases — favor the onset'
of the condition.
Orthotic albuminuria is associated essentially with a
change from the recumbent to the erect post-
ure. It appears most readily in the morning after arising.
If the individual remains upon his feet throughout the day, the
albuminuria either disappears entirely, or is reduced to an in-
significant amount. In many cases the diurnal variations show
a definite cycle, vis., a maximum secretion in the morning, a
disappearance of albumin at noon and a secondary rise in the
afternoon. Muscular exertion and cold baths tend to
increase the albuminuria, and in some cases to precipitate it.
Exercise is more potent in this respect in the morning hours.
Excitement is another possible causative factor. Food tak-
ing is probably of little significance; in some cases, indeed,
the albumin has been observed to disappear after eating.^^
It is evident, therefore, that the occurrence of an orthotic
albuminuria depends upon many and diverse factors. The con-
ception that the condition is essentially due to circulatory
disturbances accords well with the fact that a postural
change is apparently the most important precipitating cause. The
observations of Loeb^® speak for this hypothesis. Jehle^^ has
emphasized the importance of a lumbar lordosis as an
etiologic factor and has shown that no albuminuria appears even
in the erect posture if the lordosis be corrected. (Among other
views as to the cause of orthotic albuminuria may be mentioned
that of Teissier ^^ who looks upon the condition as an evidence
of latent tuberculosis, and that of Erlanger and
Hooker 23 who emphasize as the pathogenetic moment a
diminished pulse pressure in the glomeruli^
422 THE BASIS OF SYMFI'OMS
which leads to a retarded blood flow and possibly also to transi-
tory injury of the vessel walls. — Ed.)
The proteids excreted by these patients have been shown
beyond question to be the same as those normally present in the
blood, viz., albumin and globulin. In this respect, therefore,
the albuminuria in the orthotic type does not differ from that
present in nephritis. In other ways, however, the two conditions
have nothing in common, even though the excretion of albumin
in the nephritides may also be influenced by the bodily position.
I have observed a nimiber of such cases myself over a long period
of years, and have never seen one go over into a true nephritis.
Heubner^* has had the opportunity of examining at autopsy a
case of orthotic albuminuria (in which death was due to a cerebral
embolism) and found the kidneys normal throughout.
Orthotic albuminuria may be cited as an example of a local
circulatory disorder founded on the basis of a "constitutional
weakness." The same type is predisposed during puberty to other
local vascular disturbances, for example, syncopal attacks. In
many individuals, however, exhibiting similar transitory albu-
minurias, no such constitutional fault is discernible.
The Geneteil Causes of Albuminuria. — The local disturbance
in albuminuria we now know to be due to an abnormal
permeability of the renal epithelium by reason
of which the proteids of the blood are enabled
to pass into the urine. This abnormal permeability
must reside either in the renal cells themselves or in the basement
membranes, for the walls of the capillaries will allow proteids to
pass through normally. The epithelium of the glomeruli appears
to be particularly susceptible to agents that increase the permea-
bility in this manner ; ^^ whereas the cells of the convoluted tubules
are thus affected only when the injurious agent is very powerful.
It is difficult to judge, however, to what extent the latter have
become permeable, for the coagulated proteids often seen in the
lumina of these tubules must have come, in part at least, from the
g'lomeruli above. A priori there is no evidence against the
assumption that the tubular epithelium if injured can secrete
albumin just as do other diseased parenchymatous cells. ^® As a
matter of fact, this has been shown to occur in experimental toxic
nephritis.^'^
We do not know the nature of the changes which render the
THE SECRETION OF URINE 423
epithelial cells permeable for proteids. In many cases of albu-
minuria, no anatomical lesions of the kidney are demonstrable,
while, on the other hand, granular and even fatty degeneration of
the cells may be present, without any consequent albuminuria.
Some have attached a certain significance to a loss of flagella from
the cells of the convoluted tubules, yet it seems improbable that
this should be of much importance, for these flagella may also
be lost in conditions in which no albuminuria has been present.
The more we attempt to correlate the grade of albuminuria with
the extent of the anatomical involvement of the kidneys, the
more forcibly will we be confronted with the meagreness of our
knowledge of these conditions.
Albuminuria from Circulatory Disturbances of the Kidneys. —
Circulatory disturbances of the kidneys may lead to changes in
the epithelium and to albuminuria if the velocity of blood-flow
through them sinks below a certain limit. ^^ What this limit is,
is not definitely known, though it seems to be different in different
individuals. The retarded renal circulation may be
due to a number of causes, such as obstruction of the
renal veins, increase in the general venous pressure, spasm of the
renal arteries from lead colic, tetanus, etc., or an increased pressure
within the urinary passages, with secondary pressure upon the
renal capillaries and veins. It seems probable that the retarded
circulation primarily injures the renal cells, either by failing to
supply them with sufficient food, or by failing to remove properly
the waste products derived from their metabolic activities.
Toxic Albuminurias. — It is easy to conceive how poisonous
substances circulating in the blood might injure the epithelial cells
of the kidney and render them permeable to proteids. Such an
effect may be produced by metallic poisons, by the bal-
sams, etc., as well as by the more complex bacterial and
other toxins. The various albuminurias that occur dur-
ing the infectious diseases and those occurring during pregnancy
belong, for the most part, in this category of toxic albuminurias.
It is not a great step from these degenerative processes to the true
renal inflammations. In the former only the parenchyma cells
are affected, whereas in the latter the blood-vessels and the inter-
stitial tissues are more or less diseased. Many poisons, in small
doses, will produce degenerations, and in long-continued or very
large doses, inflammations; whereas, others seem to cause an
424 THE BASIS OF SYMPTOMS
inflammation from the start. Why some should thus affect the
epithelium primarily and others the interstitial tissue is not known.
Schlayer and Hedinger^^ have distinguished two groups of
toxic nephritides according to the functional disturb-
ance present. In the first — of which cantharadin ne-
phritis is an example — the renal vessels are primarily
damaged, with the result that the secretion of urine is rapidly
inhibited, though anatomical changes in the kidneys are slight or
absent. In chromium nephritis, on the contrary, the
tubules are the seat of the injury, the vessels at first being
unaffected, and polyuria often being present. Yet despite the
undoubted affinity of certain poisons for particular tissues, it is
extremely difficult by elective poisoning to interfere merely with
the function of the different types of cells.
The poisons that produce these toxic albuminurias are usually
formed in the body during acute infectious processes ; and, even in
the so-called primary forms of nephritis, bacteria have been found
in some instances in the urine, thus rendering it probable that the
nephritis was of infectious origin. According to the opinion of
experienced clinicians, nephritis may at times develop after ex-
posure to cold, as from a severe wetting or from sleeping
upon the ground, but as yet no adequate explanation has been
offered of the manner in which such a nephritis is caused. ^^
The Varieties of Proteids in the Urine. — Most of the proteids
that appear in the urine during renal diseases come from the
blood-plasma, though as we have seen, a small quantity is possibly
derived from the renal epithelial cells themselves. No definite
ratio exists, however, between the amounts of albumin and glo-
bulin appearing in the urine.^^ Great importance was attached
to this ratio when no distinction among the globulins was known.
As a matter of fact the ratio between the albumin and the
globulins, and between the two globulins (euglobulin
and pseudoglobulin) varies considerably, and inde-
pendently, it would seem, of the extent or type of the renal
lesion, of the state of the circulation and of the individual's
general condition.
Though the albumin and globulin of the blood include the
greater part of the proteids appearing in the urine in the cases
of disease of the secreting cells hitherto studied, this does not say
that these are the only proteids that may appear under these con-
THE SECRETION OF URINE 425
ditions. It Is not impossible that in certain processes, the infec-
tious diseases, for example, toxic albumin and globulins not identi-
cal with those of the blood, may arise and pass into the urine.
The Amount of Albumin Excreted. — The amount of albumin
in the urine depends primarily upon the degree and extent of the
injury to the secreting cells, and is largely independent
of the quantity of urine excreted. In addition it
seems to be influenced by the same factors which produce the
so-called physiological albuminurias — posture, muscular exertion,
etc.
Casts. — The diseased renal epithelium may become permeable
to the red and white corpuscles of the blood, which can then
pass into the urine. In addition to these blood-cells and the
desquamated renal cells themselves, pathological urines often
contain casts of the interiors of the uriniferous tubules. These
casts are most frequently composed of a hyaline or granular
material, but they may contain in addition various cells. The
material composing them has been regarded by some authors
as fibrin, parts of it often giving the Weigert reaction; yet it is
questionable whether this hyaline material is true fibrin or not.
Two theories as to the formation of casts have
been advanced. According to the one, they result from the coagu-
lation of the constituents of the blood that escape into the urinif-
erous tubules ; while, according to the other and more acceptable
theory, they are derived more directly from substances present
in the renal cells, and are thus significant of the action of a noxious
influence upon these cells. ^^ Casts may be looked upon as the
earliest evidence of an injury of the renal epi-
thelium,^^ and as such they may appear in the urine even
before albumin. In fact, the only relation existing between the
appearance of casts and of albumin is that each is a sign of a
damaged epithelium.
The Effect of Changes in the Composition of the Blood. —
The amount of water in the body directly influences
the secretion of urine, and it is well known, for example, that he
who drinks much will also urinate much. Indeed, excessive
drinking may be the primary cause of certain cases classified as
diabetes insipidus, for it is possible to cure some of them merely by
limiting the quantity of fluids taken by mouth. And the polyuria
of certain cases of diabetes mellitus is of the same nature.
426 THE BASIS OF SYMPTOMS
On the other hand, if the water in the body be
diminished, either because the patient drinks Httle, or be-
cause he loses much water by other channels, the quantity of
urine is correspondingly diminished. We see such a diminution
after excessive sweating, especially in a dry climate, as well as
in many diarrhceal disturbances, such as Asiatic cholera. The
exact cause of the many variations in the amount of urine, which
obviously serve to maintain a constant concentration of the blood,
is not known.
Many solidsubstances also tend to increase the urinary
secretion, among which are many of the constituents of normal
urine. These bodies appear in the urine, not in proportion to their
concentration in the blood, but depending upon whether their
concentration in the blood is greater or less than normal. If
present in greater amount than normal, they are rapidly excreted ;
if present in an amount less than normal, their excretion is greatly
diminished. This depends upon the fact that the secreting cells
have a different level of permeability for each of the substances
under consideration. In this way the kidney tends to maintain
the blood at a constant composition. And for this reason, also,
the examination of the urine often furnishes the physician with
valuable evidence as to the concentration of any particular sub-
stance in the blood. Careful and extensive metabolic studies are
imperative in the particular case, however, because even normal
individuals living under constant conditions may exhibit consider-
able and unexplainable variations in nitrogen and sodium chlorid
elimination.^*
When any solid is being excreted, it tends to carry a certain
amount of water along with it into the urine. Advantage is taken
of this fact in the use of certain substances as diuretics. ^°
The bulk of the solid substances eliminated by the kidneys con-
sists of waste products of digestion and of cellular metabolism.
The most important of these have already been considered (see
the chapter on Metabolism).
Special mention, however, must be made of the pro-
t e i d s . We have said that normal kidneys hold back these con-
stituents of the blood plasma most carefully. This is not true,
however, of all proteids that may happen to be present in the blood.
Of the many that have been artificially introduced into the circu-
lation a small number, such as egg albumin, casein and haemo-
THE SECRETION OF URINE 427
globin, immediately pass through into the urine, ^^ Even when
uncoagulated egg albumin is taken by mouth in large quantities,
some will often be excreted by the kidneys. Now, abnormal
p rote ids are undoubtedly formed in the body during some
pathological processes, and especially during the infectious dis-
eases, and it seems not improbable that many of the albuminurias
present in these conditions are due, not to a primary injury
to the renal structures, but to the elimination of abnormal proteids
that cannot be assimilated in the body. So, too, those proteids
sometimes found in the urine during leukaemia, and which are
precipitated by the addition of acetic acid, are also possibly ex-
creted because they cannot be assimilated. In fact, such abnormal
proteids have been demonstrated in the blood itself.
Albumoses and peptones will also appear in the
urine if they be injected into the circulation in sufficiently large
quantities. They do not appear normally during digestion,
apparently because they undergo a further cleavage in the intes-
tines. Possibly this splitting process does not take place under
certain pathological conditions and this may explain the albu-
mosuria s occasionally seen in connection with ulcerations of
the intestinal wall.^^ In other conditions, as in fever, albumoses
are formed during a pathological destruction of the proteids of
the body, and here again they may appear in the urine.
Living bacteria may be excreted by the apparently intact kid-
neys, and so reach the urine. They can undoubtedly pass through
the glomeruli in this manner, for micro-organisms have been seen
within these structures.
The Localization of Functional Disturbances. — For a proper
appreciation of pathological alterations in renal function, we
must have clearly in mind the mechanism of elimination under
normal conditions.^® Physiologists are for the most part agreed
that the excretion of different substances is car-
ried out by particular elements of the renal tis-
sue. Thus to the glomeruli, primarily, is generally accredited
the elimination of water,^^ though this function may in turn be
affected by the condition of the circulation in the tubules. Yet
the factors underlying the excretion of water — to some of which
we have made reference in the preceding paragraphs — are appar-
ently far from simple. Indeed, capable observers ^° have attrib^
uted to the tubules the task of eliminating the water. Further-
428 THE BASIS OF SYMPTOMS
more, the amount of water excreted is assuredly dependent upon
the sodium chlorid elimination.^^
An extensive literature has developed along the line of func-
tional disturbances in diseased kidneys. In a way, the more
recent studies are as ambiguous as the older ones. The problem
is indeed a difficult one, for, as a rule, the nephritides do not
involve a particular structure, but are diffuse, while the tissues
that remain free not only functionate as "before, but may become
compensatorily active. These various considerations must not
be lost sight of in the interpretation of the different functional dis-
orders. Important strides have been made, however, in the clas-
sification of the nephritides according to the
disturbance of function present. ^^ Thus, in some
cases, the elimination of urea may be interfered with,
while that of sodium chlorid is normal, and vice versa.
A disturbed urea and lactose elimination is attributed by
many to a functional disorder of the glomeruli, while a failure
to excrete salt is looked upon as evidence of an injured tubular
epithelium. Observers are not lacking, however, who have dif-
ferent views as to the elimination of urea and sodium chlorid; and
the old conception of Ludwig, i.e., that the excretion of water
and of crystalloids takes place by a process of filtration in the
glomeruli, has once more been revived.
It may easily occur, therefore, that a diseased kidney is no
longer capable of maintaining the normal composition of the
blood. The acutely inflamed organ is appreciably less efficient
than the normal one.^^ The most diverse types of anatomical
change may be responsible for these functional disturbances. The
present lack of harmony between clinical and autopsy findings in
cases of nephritides is familiar to all of us. A high degree
of functional insufficiency may arise with
apparently insignificant anatomical changes,
a phenomenon which Schlayer has also observed in experimental
nephritis.
The Effect of Disturbances of the Urinary Secretion upon
the Body. — Diseases of the kidneys may affect the body in at least
two ways — either by allowing substances to pass out which
ought to be retained, or by retaining substances which ought to pass
out. Of the substances that escape abnormally, albumin is the only
one of importance. (Sugar appears in the urine in abnormal
THE SECRETION OF URINE 429
amount for a different reason, viz., because its concentration in the
diabetic blood is increased.) The actual loss of proteids by this
channel is, however, relatively slight, amounting to only a small
number of grams a day. It seems quite improbable that this
small loss should in itself produce much effect upon the body as a
whole, though it cannot be denied that it may affect the composi-
tion of the blood to some extent (see p. 140).
On the other hand, the retention of substances in the body that
should normally be excreted apparently leads to a variety of dis-
turbances, among them oedema, arterial hypertension and uraemia.
Uraemia. — Not infrequently, during the course of renal dis-
ease, a group of symptoms develops which seems to be caused by
some sort of intoxication. This is called uraemia,^* and it pre-
sents the most varied clinical picture. The patient
may become apathetic or comatose, or, on the contrary, extremely
irritable. He may have local or general convulsions, or suffer
from paralyses of various parts of his body. Sometimes he
becomes blind, though the eyes are objectively normal. The
heart's action is at first slow and irregular, but later very rapid ;
the respirations become deeper or assume the Cheyne-Stokes type ;
finally there may be vomiting and diarrhoea. These are the most
important symptoms of this condition. They occur singly or in
groups, and they may develop suddenly or slowly. The greater
number of them is evidently due to cerebral disturbances, prob-
ably to changes in the nerve cells similar to those seen in botulism
and in mushroom poisoning.
It has recently been urged that these many and varied symp-
toms do not all arise from a common cause, a view with which I
am inclined to agree. Yet it is difficult to decide this question,
for, as is well known, the same poison may act quite differently
upon different individuals, and upon different organs in different
patients, owing to individual variations in susceptibility. As we
shall see, furthermore, there are reasons for believing that a
number of causes may be operative in the production of uraemia.
Beyond doubt, the symptoms of uraemia are caused by some
sort of poisoning, and our first supposition would naturally be
that this intoxication is due to the retention of
substances in the body that should normally be
excreted by the kidneys. As a matter of fact, patients
in uraemia frequently excrete abnormally small amounts of urine
430 THE BASIS OF SYMPTOMS
and of urinary solids, particularly those of a nitrogenous charac-
ter.*^ Indeed, the excretion of various solids may be diminished
even though the quantity of urine be increased. This latter fact
has been advanced as an argument against the toxsemic nature of
uraemia. The point is not well taken, however, for if the onset
of uraemia manifestations happens to coincide with the resorption
of oedematous fluids — and hence with an increased output of
urine — we may properly assume that poisons which have accumu-
lated in the tissues are then washed into the circulation and are
thus enabled to exert their toxic action.
The retention of urinary substances in the body has, further-
more, been directly demonstrated by examinations of the blood.
The number of molecules in the plasma is increased during uraemia,
for its freezing point is lowered. Since its electrical conductivity
is unaltered, however, the increased concentration of the blood
cannot be due to an excess of electrolytes, such as salts, but must
be laid to an excess of organic molecules of some sort.*^ Chemi-
cal examinations have shown that these are mostly organic
nitrogenous compounds that have resulted from
proteid decomposition, and constituting the so-called
residual or non-coagulable nitrogen.
Recent literature contains many studies indicating the im-
portance of the non-coagulable or non-protein nitrogen element
in the production of uraemia and in renal insufficiency in general.*''^
The retention of these bodies is greatest in cases of contracted
kidney which are on the verge of uraemia;** while in the other
forms of nephritis the amount is considerably less. Though
urea is included in this residual nitrogen, we can readily eliminate
it as a factor in the production of uraemia, for, as we shall at
once see, it is non-toxic. Hence, for the non-coagulable nitrogen
to be of significance in uraemia, it must contain poisonous products
of proteid metabolism. Soetbeer,*^ in fact, has shown that in
nephrectomized animals these toxic albuminous substances are
present most abundantly in the blood, and to a less extent in the
brain and other organs.
(The efforts to localize the disturbance of renal function by
the ability of the kidneys to excrete certain substances introduced
into the circulation (see p. 427) have not met with a very great
success. This has been due to the fact already alluded to that
anatomical changes in the organs — except possibly in acute cases
i
THE SECRETION OF URINE 431
— are ordinarily not confined to a single structure but tend to be
more or less diffuse. For this reason, attention has been focused
more recently upon the concentration in the blood of
the non-protein nitrogen as an index of the
functional efficiency of the kidneys, particularly
in view of the fact that the quantitative methods of determination
have been greatly simplified.^" In general, observers are agreed
that the degree of retention of these bodies is of value both in
a diagnostic and prognostic way.^^ Attention has already been
directed to those cases of arterial hypertension without apparent
renal involvement in which the estimation of the non-coagulable
nitrogen may speak unequivocably for a nephritis (p. 8i).
It has been asserted further that another and simpler func-
tional test parallels so closely the residual nitrogen determination
as to be available for routine work. This is the phenol-
•sulphonphthalein test of Rowntree and Geraghty.
The considerable literature devoted to this point is in general
confirmatory. ^2 — Ed. )
A number of facts speak against the view that uraemia is
caused by the retention of substances that are normally excreted
through the kidneys In the first place, an absolute anuria may
persist for days, without producing uraemic symptoms, and, fur-
thermore, even though death results from suppression of urine,
the associated symptoms do not precisely coincide with those of
uraemia. Patients with anuria seem to pass gradually into coma
without any irritative cerebral symptoms, and the uraemic hyper-
tension, bradycardia and convulsions are generally absent. Fur-
thermore, experimental ligation of both ureters is better borne
than is extirpation of the kidneys.
No well-defined substance has yet been found
that is both retained in the body during uraemia
and is capable of producing uraemic symptoms
when injected into a normal animal. Many such sub-
stances have been described, yet not one has stood the test of time.
Urea, for example, is retained in the body during uraemia, yet it is
not toxic in these amounts,^^ and a similar retention may continue
for days without the appearance of uraemic symptoms. Some
have regarded the potassium salts as toxic agents, yet the quantity
of these salts in the blood of uraemic dogs was not found to be
increased. The evidence regarding creatin and uric acid in their
432 THE BASIS OF SYMPTOMS
relation to uraemia is likewise very inconclusive. Yet, despite the
apparent non-relationship to uraemia of these various nitrogenous
bodies, as individuals, there is little doubt that a retention of
nitrogenous substances in the aggregate plays an important part in
the condition (p. 431).
The urine even in health, however, possesses certain toxic
properties, the exact cause of which is at present unknown,^*
Its poisonous action is frequently increased in disease, and it is
quite possible that in nephritis toxic substances are
formed in abnormally large quantities, and that they are not
eliminated properly by the kidneys. Yet this is a pure hypothesis
built upon a very insecure foundation, for but little reliance can be
placed upon inferences as to the toxicity of normal and patho-
logical urines, when the inferences are derived from the effects of
injections of the whole urine into animals. Until some definite
toxic substance can be isolated, this hypothesis will continue to
retain a more or less questionable standing.
Finally, there exists the possibility that uraemia is due not
to a failure on the part of the kidney to eliminate poisonous sub-
stances from the body, but to a pathological altera-
tion in some of its metabolic functions. Of these
functions, we know comparatively little; yet that the kidney does
possess such functions is proved by the well-known fact that the
renal cells can form hippuric acid out of benzoic acid and glycocoll.
Brown-Sequard^^ has elaborated the theory that the kid-
ney furnishes an internal secretion to the body, and he
has attempted to explain uraemia from this standpoint. Various
effects are said to follow the injection of renal extracts,
and it has been found that substances tending to raise the blood-
pressure are present in normal kidneys, and that they are present
in especially large quantities in pathological kidneys ^^ (but see
P- 339)- The theory of Ascoli*^^ that nephrolysins are of
importance in the production of uraemia has not been confirmed. ^^
Possibly, further work along these suggestive lines will aid us in
our understanding of uraemia.
In conclusion, we may say that although a complete suppres-
sion of urine is fatal, the symptoms produced are not absolutely
identical with those of uraemia. The convulsions, the increased
blood-pressure and the slow pulse — all of which occur so fre-
quently in uraemia — are in all probability caused not by the reten-
THE SECRETION OF URINE 433
tion of normal urinary products but by some special uraemic toxin.
This hypothetical toxin acts especially upon the central nervous
system, and here more particularly upon the cerebral cortex and
the medullary centres. In either place it may produce a stimu-
lation or a paralysis.^*
The Urinary Passages
Any portion of the urinary passage from the kidney to the
mouth of the urethra may be diseased. Affections of
the urinary bladder and of the renal pelves stand
in close etiological relation to one another. If, for example,
one of the latter is inflamed, the infected urine that flows into
the bladder may there cause changes. On the other hand, if the
former be the seat of an inflammation, this may easily spread
upward through the ureters to the pelves of the kidneys. Pyelitis
is most frequently caused by just such an ascending infection,
and every long-continued cystitis is a menace to the patient, for it
may produce an inflammation of the renal pelvis or of the kidney
itself. Certain infections, especially tuberculosis, affect the renal
pelvis primarily, in which case the process enters through the
kidneys.
Pathological conditions of the urinary bladder may
be caused by vesical calculi, by the irritative or infectious charac-
ter of the urine that comes from the kidneys or by inflammations
in the neighborhood that extend into it by contiguity. More fre-
quently, however, the infectious agent reaches the bladder through
the urethra. It is possible that in some instances bacteria enter
from the anterior urethra, because the sphincters are weakened
or paralyzed ; but as a rule the micro-organisms are directly intro-
duced by a catheter or some other instrument. Such an intro-
duction of bacteria into the bladder does not necessarily cause an
inflammation, for the normal, complete evacuation of this organ
protects it to a certain extent against infection. On the other
hand, infection is greatly favored by stasis of the
urine, and for this reason prostatic hypertrophy, urethral
strictures, vesical calculi, tumors, etc., are frequently followed
by cystitis.
When bacteria develop in the stagnating contents of the blad-
der they may cause various urinary decompositions.
Of these none is more frequent than the so-called ammoniacal
28
434 THE BASIS OF SYIVIPTOMS
decomposition, in which a portion of the urea is transformed into
ammonium carbonate, and which may be brought about by various
bacteria. In other forms of urinary decomposition the neutral
sulphur in the urine is converted into hydrogen sulphid. The
effects of such fermentations are both general and local. The
ammonium salts and the hydrogen sulphid may be absorbed
through the altered vesical mucous membrane and produce their
general toxic effects. In addition to this, the ammonia directly
attacks the bladder mucosa.
Urinary Calculi. — Urinary calculi®^ may be composed of
various materials, such as uric acid, the urates, calcium oxalate,
cystin, the carbonates and phosphates of the alkaline earths, etc.
In addition to one or more of these, the calculus always contains
a framework of a proteid-like substance, and this is often so inti-
mately mixed with the salts present that chemical methods are
necessary to distinguish them. In some cases the proteid element
is so pronounced that we speak of proteid stones.®^ Some stones
are of uniform structure throughout, while others show a more
or less concentric arrangement, owing to the fact that layers of
one substance alternate with layers of another.
An organic framework is present not alone in
formed urinary calculi, but in urinary crystals of every descrip-
tion.^^ This fact is of considerable theoretical interest; and
whereas it was formerly supposed that the organic framework
was pathological, and was a necessary condition for the formation
of calculi, it is now regarded as a physiological structure and
comparatively harmless. The material out of which this frame-
work is composed is apparently present in every urine, and is
precipitated along with the inorganic salts. No special explana-
tion, therefore, of the presence of this organic framework in
urinary calculi would seem to be necessary.
Ebstein,®^ however, has expressed the opinion that the organic
framework of the crystals is quite different from that of the
renal calculi. The framework of the latter, in his opinion, is
formed only when, under pathological conditions, an abundance
of proteid material arises in the urinary passages. The albumin
and mucin normally present in the urine are not adequate for this
purpose. In my opinion, the problem is satisfactorily solved on
the basis that the salts, when precipitated, carry proteid material
with them, just as other minerals are able to take up proteid
THE SECRETION OF URINE 435
substances. This calculous proteid framework varies with the
composition of the urine. It is always secondary, however, to
the precipitation of the stone-forming salts.
The calculi most frequently found in the bladder are com-
posed of uric acid or of the urates. Uric acid stones are
often formed in the kidneys themselves and apparently even dur-
ing the earliest periods of life. As is well known, uric acid de-
posits are frequently present in the uriniferous tubules of the
fcetus and of the new-born infant, forming the so-called uric
acid infarcts. For our present purposes, it is immaterial whether
the uric acid in these cases is excreted in excessive amounts, or
whether it is merely precipitated with unusual ease ; for the for-
mation of calculi depends primarily upon the precipitation of
salts. Apparently these renal deposits in new-born infants are
normally washed out of the kidneys and out of the urinary
passages without causing any symptoms. Possibly, however, the
infarcts stand in some close causal relation to the formation
of uric acid stones in childhood.
Since the formation of these calculi depends primarily upon
the precipitation of the uric acid out of the urine, two factors
are of importance in this respect, first, the amount of uric
acid secreted, and secondly, the ability of the urine
to hold this in solution. Of these, the latter is the
more important and the more variable. Urine dissolves far more
uric acid than does pure water.®* Normally, the uric acid is
present in the urine mainly as a mono-sodium salt. The mono-
sodium phosphate of the urine, however, tends to take the sodium
away from the mono-urate, forming a di-sodium phosphate and
leaving free uric acid, which is comparatively insoluble. The
presence of free carbonic acid in the urine tends to hold uric
acid in solution.®^ It is, furthermore, quite possible that uric acid
is often held in solution in the urine as some special combination.
We know, for example, that the quantity of urea in the urine
affects the solubility of uric acid, and it is probable that other
organic substances will do the same. Uric acid calculi are often
associated with gout, the two being grouped together under the
name of the uric acid diathesis. We have already seen
that the uric acid within the body is probably held in solution in
organic combinations (c/. p. 368), and the same may be equally
true concerning the urine. We may say, therefore, that the precipi-
436 THE BASIS OF SYMPTOMS
tation of uric acid out of the urine depends upon numerous factors
and that the presence or absence of other substances probably plays
a more important role than does the mere quantity of the acid
itself. The more important and difficult element of the problem,
however, is the determination of the mode of formation of the
primary nucleus. When the latter is once present, the calculus will
arise in due time by the precipitation of uric acid from normal
urine.
The mode of origin of oxalate calculi is not better
understood. The solution of calcium oxalate in the urine is
greatly favored by an acid reaction. If this latter be reduced
from any cause, the mono-sodium phosphate tends to be converted
into di-sodium phosphate, and the precipitation of calcium oxalate
is favored ; yet this appears to be only one factor in the process.®^
The phosphates of the alkaline earths are solu-
ble in the urine mainly as mono- or di-phosphatic salts, and they
tend to be precipitated when the reaction of the urine becomes
alkaline and normal phosphates are formed. Ammonium-mag-
nesium phosphate is also formed under these circumstances.
These phosphatic calculi are formed almost ex-
clusively in the bladder, but they frequently precipitate about
a nucleus composed of some other material, such as a uric acid
stone or some foreign body that has been artificially introduced
into the bladder. Their formation is greatly favored by
stagnation of urine, and, as a consequence, they occur
most frequently in association with cystitis ; for this, as we have
shown, is itself favored by stagnation, and is frequently accom-
panied by an alkaline reaction of the urine, owing to the associated
ammoniacal fermentation. To stagnation, also, is probably due
the formation of calculi in individuals with cord lesions.
In the condition known as phosphaturia, calculus for-
mation does not take place, though the phosphates are present in
the urine in sufficient amount to render it cloiidy, either when
passed or shortly afterward. These phosphatic precipitates,
which are made up chiefly of calcium and magnesium phosphate
and carbonate, appear when the diet is rich in alkalies or when
there has been a loss of acid from the body, as is seen for example
in gastric hyperacidity. Though the causes of phosphaturia are
generally unknown, it is a fact that the condition is often seen
in young individuals of a nervous constitu-
THE SECRETION OF URINE 4S7
t i on .*''^ The French, indeed, speak of a phosphatic diabetes and
see in the condition a pronounced nervous element. Why, in phos-
phaturia, there occurs an increased elimination of calcium salts
through the urine at the expense of the usual intestinal excretion
is not definitely understood, Soetbeer has suggested the presence
of a colitis as the cause of this lessened intestinal elimination, but
this has been disputed.
C y s t i n and xanthin calculi are extremely rare. The
former is a substance containing sulphur, and is derived from
proteid sources. It appears to result from an inability on the
part of the body to complete the destruction of the sulphur-
containing portion of the proteid molecule (p. 336). Apparently,
it never occurs in normal urine. Xanthin is present even in nor-
mal urine in small amounts, but the cause of its precipitation is not
understood.
The Symptoms of Urinary Calculi. — The hard, uneven stones,
especially the uric acid or calcium oxalate calculi, irritate the
mucous membrane of the urinary tract and cause inflammations,
pain and hemorrhages. If the calculus obstruct a ureter, attacks
of renal colic, with severe pain and vomiting, may follow.
If the occlusion persists for a long period of time, hydro-
nephrosis and the other sequelae of urinary retention are
likely to develop.
Vesical calculi may suddenly stop the flow of urine by drop-
ping before the mouth of the urethra. This gives rise to vesi-
cal tenesmus, which is not, however, a pathognomonic
symptom of calculi, but may be produced by inflammations of
the neck of the bladder, by vesical tumors or even by a highly
concentrated urine. The symptoms of vesical tenesmus are very
similar to those of tenesmus of the rectum. The irritation of the
neck of the bladder causes a frequent desire to urinate, and the
bladder consequently contracts frequently and forcibly, causing
considerable pain; yet, on account of the small amount of urine
present, but little can be voided.
The Origin of Pain in the Urinary Passages. — A diseased kid-
ney may cause pain, or at any rate, a dull feeling of pressure in
the lumbar region. This is not infrequently observed in associa-
tion with acute or chronic nephritis. More severe pains are
usually due to affections of the lower urinary passages, and they,
as a rule, are caused by a spasm of the smooth muscle
438
THE BASIS OF SYMPTOMS
lining the urinary tract. These spasms are caused by
reflexes from the mucous membrane, which originate either from
the irritation produced by a foreign body, or from inflammatory
or ulcerative processes in the mucous membrane itself. The mus-
cular spasm in these cases is comparable to that which gives rise
to biliary or intestinal colic. Apparently the mucous membrane
possesses nerves of sensation, the direct irritation of which may
also cause pain.
LITERATURE
* Consult the fundamental studies from Ludwig's laboratory, in the Wiener
Sitzungsber. ; Heidenhain, in Hermann's Handb. d. Phys., v, I ; J. Munk
and Senator, Virch. Arch., cxiv, i. Cf. Spiro and Vogt, in Asher-Spiro,
Ergebnisse, i, I, 414; Loewi, Arch. f. exp. Path., xlviii, 410.
• See Gottlieb and Magnus : Arch, f . exp. Path., xlv, 223 ; Starling, Jour, of
Phys., xxiv, 317.
* Cf. V. Noorden: Path. d. Stoffwechsels, 2nd edit., I, 969 (Metabolism and
Practical Medicine, London, 1907).
* Nagel : Arch, f . klin. Med., Ixxxviii, 562.
' For the more recent studies see Ebstein, Arch, f . klin. Med., xcv, i ; Weber
and Gross, Ergeb. d. inn. Med., iii, i ; Schwenkenbecher, Miinch. med.
Wochenschft, 1909, No. 50; Umber, in Kraus-Brugsch, Spez. Path. u.
Therap., 1913.
' Tallquist : Zeitschf t. f . klin. Med., xHx, 181 ; Hirschf eld, Salkowski Fest-
schrift, Berlin, 1904.
^ Claude Bernard : Legons de phys., i ; Eckhard, Beitr. z. Anat. u. Phys., iv, v,
vi, and Zeitschft. f. Biol., xliv, 407.
• E. Meyer : Arch, f . klin. Med., Ixxxiii, i ; v. Koranyi, Die wissenschaf tl.
Grundlagen d. Kryoskopie, 1904. See also Finkelburg, Arch. f. klin.
Med., xci, 345; Weil, ibid., xciii, 198; Fitz, Arch, of Int. Med., 1914, xiv,
706.
• See for example, Simmonds : Miinch. med. Wochenschft., 1913, No. 3, and
1914, No. 4; Goldzieher, Deutsch. path. Gesell., xvi, 272; Berblinger,
ibid., 281 ; Gushing, The Pituitary Body.
" Transactions of the Chicago Path. Society, ix, 15.
"Gottlieb: Arch. f. exp. Path., xliii. 286.
"Takayasu: Arch. f. khn. Med., xcii, 127; Schlayer and Takayasu, ibid.,
xcviii, 17, and ci, 333; Schlayer, ibid., cii, 311.
"See Cohnheim: Allg. Path., ii.
" Hermann : Wiener Sitzber., xlv, II, 317.
"Cushny: Jour, of Phys., xxviii, 431; Allard, Arch. f. exp. Path., Ivii, 241.
" See Posner : Virch. Arch., civ, 497 ; Leube, Zeitschft. f . klin. Med., xiii, I ;
Morner, Skand. Arch. f. Phys., vi, 332.
" See Huppert, in Neubauer-Vogel, Harnanalyse, 9th edit., i, 277.
" Morner : 1. c. ; v. Noorden, Arch, f . klin. Med., xxxviii, 204.
" Edel : Miinch. med. Wochenschft., 1901, Nos. 46 and 47.
" Arch, f . exp. Path., liv, 14 ; Arch, f . klin. Med., Ixxxiii, 452.
** Miinch. med. Wochenschft., 1908, No. 12 ; Die lordotische Albuminuric,
1909; Ergeb. d. inn. Med., 1913, xii, 808 (lit.).
*" Semaine medicale, 1899, 425, and 1904, 356 ; Kongr. Lyon, 1905.
•* Johns Hopkins Hosp. Reports, xii, 145.
**Berl. klin. Wochenschft., 1907, No. i; Lehrbuch d. Kinderkeilkunde, 191 1,
II, 508. See also Langstein, in Pfaundler and Schlossmann, Handbuch.
THE SECRETION OF URINE 439
"See Schmid: Arch. f. exp. Path,, liii, 419; Gross, Ziegler's Beitrage, li,
528 (lit).
*■ Cf. F. Miiller, Ref erat.
" Schlayer and Hedinger : Arch, f . exp. Med., xc, i.
** See Hermann: 1. c. ; Overbeck, ibid., xlvii, II, 189; Litten, Zeitschft. f. klin.
Med., i and xxii; Heidenhain, 1. c.
** Loc. cit.
■* See Frerichs : Die Brightsche Nierenkrankheit ; Siegel, Deutsch. med.
Wochenschft., 1908, No. 11.
"See Cloetta: Arch. f. exp. Path., xlii, 453 (lit.); Wallerstein, Dissertation
Strassburg, 1902 ; Gross, Arch, f . klin. Med., Ixxxvi, 578.
•*See Luthje: Arch. f. klin. Med., Ixxiv, 163; Wallerstein, Zeitschft. f.
klin. Med., Iviii; Gross, Ziegler's Beitrage, li, 528 (lit.).
"* Liithje : 1. c. ; Klieneberger and Oxenius, ibid., Ixxx, 25.
"Brauner: Zeitschft. f. klin. Med., Ixv, 438. See also Baetjer, Arch. Int.
Med., 1913, xi, 593 (Renal Superpermeability).
•"H. Meyer, in Meyer and Gottlieb: Pharmakologie, 2nd edit., 312 (English
translation by Halsey, 1914).
" See Neumeister : Physiolog. Chem., 2nd edit., 301,
" Schultess : Arch, f . klin. Med., Iviii, 325 ; ibid., Ix, 55.
" See Metzner : Nagel's Handb. d. Physiologic, II, 207.
** Cf. the previously cited studies of Schlayer.
* V. Monakow : Arch, f . klin. Med., cii, 248.
** Gross : Ziegler's Beitrage, li, 528 ; Frey, Pfliiger's Arch., cxxxix, and Deutsch.
med. Wochenschft., 191 1, No. 23.
** Schlayer : 1. c. ; v. Monakow, 1. c. ; Gross, 1. c. ; Pearce, Arch. Int. Med., v,
133 (lit.). See also Rowntree and Geraghty, The Value and Limitations
of Functional Renal Tests, Jour. Am. Med. Assn., 1913, Ixi, 939.
^'Soetbeer: Zeitschft. f. phys. Chem., xxxv, 85; Rowntree and Geraghty:
Arch. Int. Med., ix, 308.
**See Honigmann, in Lubarsch-Ostertag, Ergeb., i and viii; Ascoli, Vor-
lesungen ii. Uramie, 1903; Bernard, Les fonctions du rein dans les
nephrites chronique, Paris, 1900, 713; F. Miiller: Deutsch. path. Gesell.,
1905; v. Noorden, Handbuch, 2nd edit., 1041 (Metabolism and Pract.
Med.).
*^ Cf. Obermayer and Popper: Zeitschft. f. klin. Med. Ixxii, 332 (recent
studies and lit.). See also Tileston and Comfort, Arch. Int. Med., 1914,
xiv, 620 (lit.) ; Rowntree and Fitz., ibid., xi, 258.
•■Bicicel: Deutsch. med. Wochenschft., 1902, No. 28; Engelmann, Grenzge-
biete, xii, 396.
" See for example Rowntree and Fitz : 1. c. ; Tileston and Comfort, 1. c.
*" Strauss : Die chron. Nierenentziindungen, 1902 ; F. Miiller, Path. Gesell-
schaft, 1905; Hohburg, Arch. f. klin. Med., civ, 216; Tileston and Com-
fort, 1. c. ; Foster, ibid., 1915, xv, 356.
*" Kongr. f . inn. Med., 1909, 226.
"Folin and Denis: Jour. Biol. Chem., xi, 527; ibid., xiv, 33; Marshall, ibid.,
1913, XV, 487 (Blood Urea).
" For a recent discussion see Tileston and Comfort : 1. c.
"For a brief collective study see Elliott: Jour. Amer. Med. Assn., 1915, Ixiv,
1886 (lit).
"^ Soetbeer : Zeitschft. f. physiol. Chem., xxxv, 85. For an opposed view see
Voit Zeitschft. f. Biol., iv.
"Bouchard: Lectures on Auto-Intoxication in Disease, 1906; Honigmann,
1. c. (lit) ; Abelous and Bardier, Soc. de biologic, 1910, Ixix, 121,
''See Biedl: Innere Sekretion, 1913 (Internal Secretory Organs, 1913.).
" Bingel and Claus : Arch, f . klin. Med., c, 412.
" Ascoli : Uramie.
440 THE BASIS OF SYMPTOMS
"Pearce: Univ. of Penn. Med. Bull., xvi, 217; Arch. Int. Med., 1910, v, 133
(lit).
" Landois : Die Uramie.
"Ultzmann: Deutsche Chirurgie, No. 32; Ktimmel, Verhandl. d. ersten
Urologenkong., Vienna, 1907, 294; Rosenbach, Grenzgebiete, xxii, 630;
Kleinschmidt, Die Harnsteine, 191 1 (under Aschoff).
° Morawitz and Adrian : Mitt. a. d. Grenzgeb., xvii, 579.
** Moritz : Kongr. f . inn. Med., 1896, 523.
*° Ebstein : Deutsch. med. Wochenschf t., 1908, No. 32.
" Bunge : Physiol. Chem., 3rd edit., 308.
" Klemperer : Zeitschft. f. physikal. Therapie., iv, 48.
■^ Klemperer : Berl. klin. Wochenschft., 1901, 1289; Klemperer and Tritschler,
Zeitschft. f. klin. Med., xliv, 337.
" See Soetbeer : Jahrb. f . Kinderheilk, Ivi, i ; Soetbeer and Krieger, Arch,
f. klin. Med., Ixxii, 553; Langstein, Medizin. Klinik, 1906, No. 16, Klem-
perer, Therap. d. Gegenwart, 1908.
CHAPTER XII
THE NERVOUS SYSTEM
The activities of the nervous system give rise to two classes
of phenomena — those pertaining to the body and those pertaining
to the mind. We do not purpose considering the latter, nor even
discussing the relationship that exists between the body and the
mind. In the present chapter, we plan to limit our discussion,
in a general way, to those disturbances of the nervous system
which do not affect the mind, even though this division is an arti-
ficial one and cannot be carried out strictly and consistently.
The nervous symptoms that we shall consider may be divided
into two main groups. Those in the first group are called focal
symptoms, because they are caused by pathological changes
involving certain limited portions of the nervous system. Those
in the second group are termed general symptoms, be-
cause the agent that causes them affects the nervous system as a
whole. Of these general symptoms, some evidently proceed from
certain definite localities ; while the origin of many others cannot
be traced. The same general injurious agent may act upon all
parts of the nervous system, yet it affects certain portions more
than others, because the former happen to be more vulnerable to
the particular agent in question.
Disturbances of the Circulation. — The central nervous system
must receive a sufficient supply of blood in order to functionate
properly. Some of the symptoms that result from circulatory
disturbances have already been mentioned in the chapter on res-
piration. We spoke there of the extraordinary sensitive-
ness of the respiratory centre to any change in
the quantity or quality of the blood that comes to it,
as well as of the effects of such changes upon other medullary
centres. The cerebral cortex is not affected until some time after
the medulla, at which time the consciousness becomes clouded
and the horrible sense of suffocation is diminished or lost. Al-
though the brain is ordinarily extremely sensitive to circulatory
changes, it often appears as if it can accommodate itself to an
insufficient blood supply in chronic circulatory derangements. It
is extremely difficult, however, to form an accurate judgment on
441
443
THE BASIS OF SYMPTOMS
this question, for we have no method of measuring the circulatory
disturbances in the brain; yet it is often truly astonishing to see
wha.t little effect the most pronounced chronic venous stasis or the
most marked arterial anaemia produce upon the cerebral functions.
The temporary loss of consciousness known as fainting
is usually due to an acute cerebral anaemia. It may occur in
strong and healthy individuals, but it is much more frequent in
anaemic girls or in older individuals with degeneration of the
cerebral arteries. During the fainting spell the patient loses
consciousness, falls and lies for a time, breathing quietly, but
with a pale, non-cyanosed face. Finally, after a while, he grad-
ually recovers. Although the cerebrum has ceased to act, the
medulla appears to perform its functions quite normally, just as
it does during light narcosis. It seems improbable, therefore, that
the disturbance of circulation in fainting affects all parts of the
brain equally; for if this were so, we should expect medullary
symptoms. We know that localized anaemias frequently occur
in other parts of the body, and that in arteriosclerosis such cir-
cumscribed circulatory derangements are particularly frequent;
and it seems quite possible that the anaemia causing the syncope
affects only a part of the brain, as might happen, for example,
if certain vessels became narrowed either by a spasm or by a
relative thickening of their walls.
Other anaemic manifestations of nervous ori-
gin are more difficult to explain. Some, such as headache,
ringing in the ears, spots before the eyes and dizziness, appear
to be irritative in character; while others, such as the com-
mon feeling of lassitude, are depressive. These symptoms
are generally ascribed to a cerebral anaemia which either dimin-
ishes the oxygen supply to the brain or affects its nutrition in
some other way ; but these suppositions have not yet been definitely
proved. There are many other possibilities. Chemical sub-
stances, resulting from pathological alterations of the general
metabolism, may poison the brain in some manner ; and it is even
possible that the symptoms do not originate in the brain at all,
but in the peripheral sense organs. Finally, Lenhartz ^ has shown
that the headache and dizziness of chlorosis may be associated
with an increase in the subarachnoid pressure.
The Cerebrospinal Lymphatic System. — ^The brain and spinal
cord are suspended in a fluid that is constantly changing through
ife
THE NERVOUS SYSTEM 443
the processes of secretion and absorption. We need not describe
the many advantages of this mechanism ; how it acts as a cushion
about the dehcate nervous structures when the body is jarred, nor
how the brain is protected from rapid alterations in arterial pres-
sure by the layer of lymphatic fluid that encircles each of its
blood-vessels.
Most observers have found the pressure of the cere-
brospinal fluid to be normally rather low, although it
apparently varies considerably in different individuals.^ Its
height depends in part upon the general blood-pressure, but mainly
upon the relation that exists between the secretion and the absorp-
tion of the lymph. The characteristic composition of the
cerebrospinal fluid — vis., a low percentage of albumin
and a high percentage of potassium salts — shows that it is not
an ordinary transudate, but a secretory product from certain cells,
probably those of the choroid plexuses.^ The resorption*
of this fluid takes place mainly in the Pacchionian cor-
puscles and to a lesser extent in the lymphatics of the nose and
neck.**
Increased Cerebral Pressure. — The pressure of the cerebro-
spinal fluid may be pathologically increased to varying degrees
and by different causes.® For example, tumors may bring this
about merely because they take up space within the cranial cavity,
though they are especially liable to do so when they press upon
the veins of Galen and thus impede the outflow of venous blood.
Intracranial hemorrhages may also increase the
cerebrospinal pressure.
If the cranial cavity becomes crowded irpm any cause, the
brain substance cannot be compressed into a smaller space, for
the nervous tissue is practically incompressible.''' A certain relief
is afforded, however, by the escape of cerebrospinal fluid into
those portions of the dura mater that are comparatively disten-
sible, such as is the dura of the cord. A new equilibrium of
pressure is then established. What the new pressure will be
depends upon the size of the compressing agent, the distensi-
bility of the dura and, finally, upon the relation that exists between
the secretion and absorption of cerebrospinal fluid. It is apparent
that when so many factors enter into the final result the same
cause may produce quite different effects in different individuals.
From these considerations it would appear that when a
444 THE BASIS OF SYMPTOMS
hard body is added to the contents of the skull
the increase in pressure would be roughly propor-
tionate to the size of the "foreign body," and
that the space taken up by smaller bodies could be fairly well
compensated for by the escape of lymph from the cranial cavity.®
In some cases, however, especially in certain brain tumors,® no
such definite relation seems to exist between the size of the tumor
and the increase in the cerebrospinal pressure. The smallest tumor
may cause a tremendous rise in pressure. Furthermore, if some
of the cerebrospinal fluid be drawn off in order to relieve the
pressure, it will frequently re-collect with great rapidity. These
facts do not accord with the view that brain tumors increase the
cerebral pressure solely by their mechanical action. It
would seem rather as if the production or the absorption of the
cerebrospinal fluid were directly affected. Possibly the condi-
tions present are analogous to those that exist in tumors of the
pleura or of the peritoneum, i.e., some sort of an inflam-
matory process is taking place in the arachnoid.^** In
favor of this view are the facts that the cerebrospinal fluid of
these patients often contains more albumin than normally,^ ^ and
that the accompanying choked disk is almost certainly of an in-
flammatory nature.
The increased cerebral pressure that accompanies menin-
gitis is caused by a disturbance in the balance between the
production and absorption of cerebrospinal fluid. It seems prob-
able, indeed, that both the production is increased and the absorj>-
tion diminished in this condition.
The chronic hydrocephalus of children is char-
acterized by a large collection of cerebrospinal fluid, but its cause
is not well understood. Perhaps a mild inflammatory process is
present (ependymitis), though this seems improbable in most
cases, from the fact that the percentage of albumin in the fluid
is not increased. Chlorotic girls frequently show an in-
creased cerebral pressure, yet here again the cause is very uncer-
tain. The mild optic neuritis often seen in these patients may
possibly be produced by the increased cerebral pressure, though
it seems more probable that it results directly from the poor
nutrition of the optic nerve. That the headache accompanying
cases of arterial hypertension (nephritis, arterioscle-
rosis) is often the result of an increased cerebral pressure is
THE NERVOUS SYSTEM 445
evidenced by the benefit seen in many instances after a lum-
bar puncture.
When the pressure of the cerebrospinal fluid is increased from
any of these causes, certain symptoms usually follow, among
which are headache, general bodily and psychic weakness, and
characteristic alterations in the ocular fundi — the so-called
choked disks. These have been termed the symptoms
of latent cerebral pressure, and they are supposed to
be caused by the tissue changes that follow the increased pressure
in the cranial cavity. Possibly they depend less upon the height
than upon the duration of the increased pressure.^ ^ It would
be interesting to know what the minimum pressure is that can
produce a choked disk, but the data at our disposal do not suffice
to determine this.^^ And it may be that the individual variations
are so considerable that no definite minimum can be fixed.
Although choked disk is one of the most important clinical
signs of increased cerebral pressure, the manner in which it is
produced is still very uncertain. ^^ According to the opinion of
most ophthalmologists, a mere increase in the intracranial pressure
does not suffice to cause it, and other factors must be present.
Anatomically, it usually appears to be a true inflammation, in-
volving both the nerve and the neighboring retina. The optic
papilla is swollen, and there is an associated oedema and venous
stasis, but we do not know whether the cedema and stasis ordina-
rily develop before the inflammation or not. That stasis alone
should cause the inflammation is contrary to all our pathological
experience with oedema in other parts of the body. It is quite
possible that some inflammatory irritant, produced by the changes
within the brain, acts upon the retina. According to this view,
two factors contribute to the causation of
choked disk: first, an increase in the pressure of
the fluid within the optic sheath; and secondly,
some unknown inflammatory agent. This hy-
pothesis would explain many peculiar cases in which a choked disk
is absent even though the intracranial pressure is high, as happens
in some cases of hydrocephalus; here it would appear that the
inflammatory factor is absent. On the other hand, in intracranial
conditions of slow development, such as in certain abscesses and
tumors, choked disk is often absent because there is no increase
in intracranial tension.
446 THE BASIS OF SYMPTOMS
If the pressure of the cerebrospinal fluid be still further
increased, a second series of phenomena develop, the so-called
direct, or manifest, symptoms of cerebral pres-
sure. The essential cause of these is a disturbance of
the cerebral circulation. We have already described
the peculiar conditions that govern the intracranial pressure and
how space may be made for foreign bodies by an escape of lymph.
When, in spite of this compensatory mechanism, the pressure
attains a certain height, those parts of the vascular system that
can be compressed most easily — i.e., the veins just before their
entrance into the rigid sinuses — ^become narrowed or even closed.
The resulting stasis of blood increases the pressure in the cor-
responding capillaries and the veins are then opened again, so that
they alternately open and close, or, as Grashey says, they vibrate. ^"^
It is not certain what cerebral manifestations accompany this
phenomenon. From experimental data, it would appear that the
really characteristic symptoms of cerebral com-
pression only begin at about the time when the
intracranial pressure becomes sufficient to
compress the arteries. It is then that we have the
characteristic stupor, the vomiting, the slowing
of the pulse and the respirations, and finally the
general epileptiform convulsions. The primary
cause of these symptoms seems to be an arterial anaemia that occurs
because the subarachnoid pressure is greater than the arterial
pressure. It is theoretically possible, therefore, that these symp-
toms could be produced either by a rise in the subarachnoid pres-
sure or by a fall in the arterial pressure. When the nervous
symptoms of increased cerebral pressure have once become estab-
lished, they may continue for some time, even though the intra-
cranial pressure lessens, for the reason that less force is required
to hold the vessels closed than to compress them originally.
The absolute amount of cerebral pressure necessary to produce
these direct symptoms is, therefore, rather indefinite, and it often,
happens that during the course of indirect symptoms, the direct
ones will appear and again disappear, apparently on account of
circulatory disturbances.
According to Gushing, a continuation of life after com-
pression of the cerebral arteries has once taken place, is made
possible only by an increase in arterial pressure. The latter is
I
THE NERVOUS SYSTEM 447
brought about by a stimulation of the vasomotor centre as a
result of the anaemia. To what extent these experimental obser-
vations relative to the interaction of the intracranial tension and
the cerebral circulation are pertinent to conditions in man, is still
undetermined. So far as I know no observations have been made
which bear upon such variations in blood-pressure consequent to
an increased intracranial pressure. (A rise of blood-pressure
after cerebral hemorrhages in man has been demonstrated, the
extent of the rise being looked upon as an index of the amount
of compression exerted upon the medulla. ^^ — Ed.)
The recent tendency, it would seem, has been to emphasize the
circulatory basis of the manifestations of increased intracranial
pressure, thereby underestimating the importance of changes in
the brain substance itself as the cause. Symptoms of increased
pressure may appear even in the absence of a cerebral anaemia,
indeed even when the indications are that the arteries are well
filled. Too little importance has been attached to
the important, if not predominant, role played
by compression, distortion and displacement of
the cerebral tissue itself.
Cerebral Concussion. — The symptoms of cerebral con-
cussion differ considerably from those of compression. The pale,
unconscious patient lies with relaxed muscles and with weak
respirations. His pulse is soft and small, its rate being either
increased or diminished. His pupils are often immobile ; and
vomiting frequently occurs. Indeed, he might be thought to
be suffering from a fainting spell.
Cerebral concussion is ordinarily produced by a violent blow
upon the head or upon some other part of the body, yet no
definite relation seems to exist between the
force of the blow and the severity of the symp-
toms, and even serious cerebral injuries due to violence may be
unaccompanied by any of the typical manifestations. The symp-
toms of concussion are essentially those of cerebral inactivity,
reaching different grades in different cases. In the milder form
of concussion, the cerebral cortex alone is affected (unconscious-
ness), in the more severe forms the medullary centres become
involved (respiratory and circulatory disturbances), while, in the
most severe, the vital functions are suspended.
No definite anatomical changes in the brain.
?-
i>
448 THE BASIS OF SYMPTOMS
common to all cases of concussion, have been
f o un d .^'^ The symptoms can hardly be due to circulatory dis-
turbances, for they have been produced on bloodless frogs. It
seems quite probable that they are caused by injuries to the
finer connections between the nerve-cells in the brain; and we
know that very severe concussions may even produce slight but
demonstrable lesions in the central nervous system.
K o c h e r has called attention to the fact that cerebral con-
cussion, so-called, is hardly of uniform etiology. He has sug-
gested as a more suitable term, acute brain compression
(Hirnpressung), the chief manifestations in the process
being, in his opinion, the phenomena of acute compression, and
the consequent lesions of the nervous tissue. I am likewise of the
opinion that we must be reserved in our interpretation of cerebral
concussion, both because of the poorly defined clinical picture,
which may closely resemble conditions due to definite anatomical
lesions, and also because of our inability to produce in animals
an exact replica of the picture in man.
Cerebral Hemorrhage and Embolism. — Closely related to the
manifestations of increased intracranial pressure are those asso-
ciated with disturbances in the cerebral arteries, and known as
cerebral insult. Apoplexy is generally due to altera-
tions in the vessel walls — the so-called miliary aneurisms.
The latter, under the influence of an augmented blood-
pressure, or even with a normal tension, rupture and per-
mit of an escape of blood into the surrounding tissues. The
extent of the hemorrhage and its rapidity of formation depend
upon the size of the vessel and of the opening in its wall. The
severity of the picture varies with the increase in in-
tracranial pressure and with the amount of the extravasation.
There is ordinarily a loss of consciousness and a slowing of the
pulse and respirations. The early fall in temperature is succeeded
by a rise. Death often occurs without a return of consciousness.
These symptoms are the direct result of the cerebral trauma,
consequent to the extravasation of blood ; added to the extensive
destruction of brain-tissue is the damage wrought by the increase
in intracranial tension. In other cases, the insult is gradual in
nature, probably because only a small amount of blood escapes
at one time, in which event the actual destruction of tissue is
slight and the increase in tension is slow and limited. In those
f
THE NERVOUS SYSTEM 449
cases in which the insult is entirely absent, the hemorrhage has
been small and gradual, and the tissue destruction and increase in
tension insignificant, for here the cerebrospinal fluid has had time
to distribute itself elsewhere. As the vessels of the cortex are
smaller, and exhibit a lower pressure than do those of the base,
a rupture of the former is attended with less pronounced insult
manifestations.
The symptoms consequent upon a sudden closure of
a cerebral vessel are so similar to those associated with
a hemorrhage as often to be indistinguishable from them. As
Marchand has pointed out, the closure of a cerebral artery is
quickly followed by a stasis in the neighboring capillaries and
veins. The anaemia of certain parts of the brain thereby pro-
duced, accounts in all Hkelihood for the loss of consciousness.
The next stage is one of cerebral oedema, to which are due the
symptoms of increased pressure. The focal symptoms accom-
panying hemorrhage and embolism depend upon the location of
the tissue injury, just as is the case with tumors.
Disturbances of Motility. — The direct motor impulses travel
from the cerebrum to the muscles through two sets of fibres.
Of these, the first begins in the ganglion cells of the cortical motor
area and pass by way of the pyramidal tracts to the anterior
horn cells of the spinal cord, or to the corresponding nuclei of
the pons or medulla. The terminal fibres of these upper
neurons are believed by rhany merely to touch the lower
ganglion cells, and by others to be continuous with them.^^ The
second or lower set of neurons begins in the large motor
cells of the cord and medulla, and extends thence to the periph-
eral muscles. The voluntary nervous impulse proceeding to the
muscles may be interfered with at any point along this long
course, with a resulting loss of muscular function. Disturbances
of motility may arise, however, from other causes, such as lesions
of the muscles, bones and joints, on the one hand, and from
lesions of those parts of the nervous apparatus that assist in
co-ordinating the movements, or that furnish the will power, on
the other.
Some hold that the voluntary motor impulses pass through
the cerebellum. However this may be, diseases of the
cerebellum unquestionably influence our volun-
tary, movements,^* independently of their effect upon our
29 "
450 THE BASIS OF SYMPTOMS
sense of equilibrium. The innervation of muscles is greatly-
affected by the centripetal impulses that go from them to the
brain. These centripetal impulses pass through the cerebellum,
so that cerebellar disease at times gives rise to typical ataxia even
in the absence of any disturbances of cutaneous sensation. Since
the fibres from the cerebellum to the cerebrum undergo decussa-
tion, and since the impulses from the cerebrum to the muscles
again cross the median line, a unilateral lesion of the cerebellum
will interfere with the movements of the muscles on the corre-
sponding side of the body, and this interference may be so marked
as to cause a true cerebellar hemiplegia.
If a person is unable to move a certain group of muscles,
we speak of it as a paralysis. If the strength of the
movement is merely weakened, we speak of it as a paresis.
Finally, if the movements are uncertain and irregular, so that
a desired movement cannot be accurately carried out, we speak
of it as an ataxia.
Paralyses of Psychic Origin . — This class com-
prises many of the motor disturbances that occur in insane
patients, especially during stupor, as well as many of the
hysterical paralyses. It hardly lies within the prov-
ince of this book to discuss the nature of these cases, although
the subject is an extremely interesting one. It would be neces-
sary to consider the nature of the will, and the relation that
sensations, conceptions and memory bear to it, and then, finally,
to take up the manner in which these relations may be disturbed
in the various pathological conditions in question.^
Such "psychical paralyses" are character-
ized clinically, mainly by their distribution.
We do not will a single muscle to contract, but we will a certain
movement to take place, and this movement ordinarily involves
the use of numerous muscles. Correspondingly, the paralyses
now under consideration do not affect single muscles, but involve
whole extremities or the execution of certain movements. For
example, a patient may be able to move his legs in every direction
without any incoordination, and yet be unable to walk. Or be
may be able to execute all ordinary movements with his hand, but
be unable to write.
Closely related to these psychic paralyses is the condition
known as a p r a x i a ,^^ characterized by an inability to per-
THE NERVOUS SYSTEM 451
form skilled movements with the limbs, though the motor power
is intact. The dog becomes apractic after removal of the motor
area. As Liepmann and Wilson have shown, the area in man
concerned in these skilled movements is located in the first and
second convolutions of the left side. The condition is generally
ascribed to a loss of motor "concepts," and is of interest par-
ticularly because of the insight it gives into the nature of psychic
paralyses.
Paralyses from Lesions of the Motor
Tracts. — The ganglion cells of the upper motor neurons
are situated in the so-called motor area of the cerebral cortex,
and the symptoms that result from an injury to this part of the
brain depend upon the portion of the motor area that is affected.
The axis cylinders of these cells may be injured at any point
between their origin and their final termination about the large
motor cells of the cord or medulla. The effect of an injury to this
motor tract depends both upon which nerve-fibres are injured
and upon the severity of the injury. The motor fibres seem
to be more susceptible to pressure and stretching than are the
sensory. Injuries to this upper tract are caused most commonly
by tumors, inflammations and hemorrhages. The ganglion cells
in the cord, or their processes in the nerves, may be affected by
metallic poisons, such as lead, by the action of micro-organisms
or toxins, as in meningitis, myehtis and neuritis, or finally by
disturbances of the blood-supply.
Paralyses from Lesions of the Muscles . — Dis-
eases of the muscles naturally interfere with their functional capa-
bilities ; as examples of such we may mention the muscular disa-
bility which accompanies the dystrophies, trichinosis, polymyositis
and the parenchymatous degenerations that follow some acute
infectious diseases.
Paralyses from Vascular Disturbances. — Dis-
turbances of the blood-supply to muscles may also interfere with
their capabilities. Veterinarians have long known that arterial
disease in the legs of horses seriously affects their powers of
locomotion. The same is true of man, and the resulting in-
termittent claudication is apparently much more
frequent than is generally supposed. ^^ If the arteries supplying
an extremity become very narrow, the quantity of blood that
reaches this extremity may be sufficient to meet all ordinary needs.
452 THE BASIS OF SYMPTOMS
but at the same time it may be insufficient for any extraordinary
demands. When the patient walks, therefore, the increased de-
mands of the muscles for fresh blood cannot be supplied, and,
after a certain distance, the leg becomes fatigued and painful,
so that the patient can walk no farther. If he rests, however,
the power gradually returns and the pain leaves his legs, because
the supply of blood is again sufficient. These characteristic
symptoms of intermittent claudication are usually associated with
definite anatomical alterations — usually an obliterating
endarteriti s — in the vessels of the affected extremities. Not
infrequently, these vascular changes eventually lead to gangrene.
Apparently a similar intermittent disturbance of function may be
caused by a functional, spasmodic narrowing of the
arteries from nervous causes. The parallelism be-
tween intermittent claudication and angina pectoris is, therefore,
rather striking, for both are usually associated with arterio-
sclerosis, but both may apparently be caused by a nervous spasm
of the corresponding arteries.
Myotonia Congenita . — The members of certain fami-
lies, from youth on, are unable to relax their muscles normally
after contraction, because the muscle remains in a sort of tetanus.
This rigidity is most pronounced after a period of rest, while, as
a rule, it lessens after each repetition of the movement. The
muscles themselves are usually quite strong, even more so than
normally. We may infer that the cause of the disability is located
in the muscle itself, for its reaction to the electric current is
abnormal (Erb's myotonic reaction), and its anatomi-
cal structure is also considerably altered.^^
Asthenic Bulbar Paralysis.^* — This disease, other-
wise known as myasthenia gravis pseudo-paraly-
tica, is characterized clinically by the ease with which certain
muscles become fatigued after comparatively slight exertion.
This fatigue occurs after voluntary use of the muscles, as well
as after stimulation by the electric current, but the ease with
which the fatigue develops seems to vary from time to time.
Certain muscles, especially those supplied from the medulla, tend
especially to be affected. This disease involves the motor appara-
tus, yet the exact point affected is not known, for anatomical
investigations have thus far failed to show any lesion.
Disturbances of Coordination. — Before we proceed to the
THE NERVOUS SYSTEM 453
discussion of the disturbances of coordination,^^ it is necessary
to consider the mechanism whereby we normally
govern our movements, so that they shall be executed
in a precise and exact manner. The consideration of the normal
mechanism of coordination presents certain difficulties, however,
for we are not certain that it is the same in every case. The
adult executes many movements at will, whereas there are others
that he learns only by practise. Of the latter, some, such as
piano-playing, are learned only by certain individuals, while others,
such as walking, speaking and writing, are learned by all men,
this being facilitated, doubtlessly, by the fact that our fore-
fathers have practised these movements for generations. There
is a gradual transition from the movements that must be learned
to the purely voluntary movements, and from these voluntary
movements again there is a gradual transition to the purely in-
voluntary movements. To this second transitional class belong
those movements of a reflex or automatic type, such as breathing
and suckling, that are executed from birth on. As an illustration
of the difficulty encountered in attempting to separate these dif-
ferent classes of movements, we may cite the fact that, while
swimming must be learned by man, many animals can swim when
they first enter the water.
There are, therefore, all grades of transition from
the pure reflex movements to the most complex
volitional acts. Indeed, the transition occurs many
times in the life of a single individual, for movements that were
once learned only with the utmost attention and volition are
ultimately executed almost unconsciously, merely by willing
to do them. At first, these complex acts are carried out under the
conscious guidance of all our senses, particularly those of sight,
touch, position, etc., but by practice they come to be executed
without the individual constituent movements of the act coming
to our consciousness.
We know something about the nervous mechanism
that underlies these complex practised move-
ments and the more complicated reflexes. These
movements may be set in motion voluntarily, or by nervous
impulses from the periphery, or, finally, by but little-understood
internal chemical changes. Since the resulting movements are
varied more or less to suit the occasion, it seems improbable
454 THE BASIS OF SYMPTOMS
that they should be guided by a completely developed mechanism
lying within the central nervous system. It would appear rather
as if they were guided by impulses from the periph-
ery, a supyposition which receives strong support from the ex-
periments that have been performed on frogs, dogs and monkeys.^
If the posterior nerve-roots in these animals be cut — i.e., if the
sensory impulses from the periphery be eliminated — not only
the complicated reflexes but the more complex practised move-
ments, such as jumping and running, can no longer be carried out
as the animal wills, with exactness and precision. Some muscles
contract too strongly, others too feebly, and still others at the
wrong time, so that the resulting movement, as a whole, loses its
precision, and the picture is very similar to that seen in certain
nervous diseases that occur in man, especially tabes.
Since an electrical stimulation of the motor region of the
cerebral cortex gives rise to movements, not of individual muscles,
but of coordinated groups of muscles, we are led to infer that,
in the cortex, movements, and not individual muscles, are repre-
sented.^'^ A further grouping of muscles for the execution of
certain movements occurs in the anterior horn cells of the spinal
cord and in the root-fibres. It is quite certain, therefore, that a
certain degree of coordination is derived from
this arrangement of the cells in the motor ner-
vous system, though, as we have seen, this
grouping is not sufficient for complex acts.
For these we depend more or less upon periph-
eral sensory impulses. We may or we may not be
conscious of these impulses, yet even when we are not conscious
of them, they may be utilized by the lower centres in the mechan-
ism of coordination. These two forms of sensation, conscious
and unconscious, cannot be strictly separated from each other,
for our consciousness of them depends largely upon the attention
that we direct to them. Clinical evidence based upon many cases
of syringomyelia indicates that in man the loss of sensation pro-
ceeding from the skin is in itself insufficient to destroy coordina-
tion.
Many varieties of sensation may affect our
movements. Of these, we may name the senses of sight
and of hearing, those of pressure upon the skin, muscles, ten-
dons and joints, and, finally, the senses of position and of motion.
THE NERVOUS SYSTEM 455
Some of these are of greater importance than others ; and we have
seen, for example, that the senses of sight and of hearing alone
are inadequate in the monkey and the dog to maintain coordina-
tion during such complex movements as jumping and running.
Of the sensations mentioned, the most important in
the coordination of voluntary movements are
those derived from the tendons, the joints and
the eyes. ^® If the two former are affected in the first inter-
phalangeal joints, for example, then even such simple movements
as the flexion and extension of the fingers may become ataxic.
In addition to these sensations from the joints, tendons and eyes,
others from the muscles may also play a considerable role in
governing our movements.
While the grouping of muscles according to their use in the
motor nervous apparatus may, therefore, furnish a rough sort
of coordination, this is insufficient for the finer move-
ments. For their execution, centripetal impulses
from the periphery are necessary in order to control the
time at which the individual muscles shall begin their contractions,
the force with which they shall contract and the time during which
they shall remain contracted.
After this preliminary discussion of the theory of coordina-
tion, it remains to inquire to what extent disturbances of sensation
have been actually found in patients who suffer from ataxia, i.e.,
from an inability to carry out movements in a precise and accurate
manner. It is quite certain that ataxia may occur without any
demonstrable diminution in the cutaneous senses of pressure, tem-
perature or pain.^** On the other hand, it has not been
shown that ataxia ever occurs independently of
all sensory disturbances, and the earlier cases that
were believed to prove this were not sufficiently investigated as
to the finer losses of sensation in the joints and muscles.^^
Frenkel, in studying one hundred and fifty cases of tabes, failed
to find a single instance of ataxia unaccompanied by sensory
changes, at least in the joints and muscles.^^ We may say, there-
fore, that the main cause of tabetic ataxia is a de-
ficiency in the impulses proceeding from the joints and muscles.
That this deficiency may be, to a certain extent, compensated
for in other ways, is shown by the reliance which ataxic indi-
viduals place upon their visual impressions. Possibly the
456 THE BASIS OF SYMPTOMS
absent reflexes as well as the diminution in mus-
cular tonus, also play a not inconsiderable part in the
motor disturbances of tabetics.^^
We now come to a consideration of the effect exer-
cised by known disturbances of sensation upon,
coordination. In other words, do such disturbances
necessarily lead to ataxia? Many young, apparently hysterical,
persons have been observed who have shown extensive anaes-
thesias of the skin and of the deeper structures, without, how-
ever, exhibiting any true ataxia.^^ When they kept their eyes
open, their movements were perfectly normal, which, as we have
seen, was not the case when, experimentally, all sensory impulses
from an extremity were cut off. If these patients closed their
eyes, their voluntary movements were indeed somewhat abnormal,
but no true ataxia was present. To my mind, however, it is neces-
sary to be very cautious in our interpretation of these observa-
tions, because the sensory disturbances were apparently of an
hysterical character. Hysterical disturbances of sen-
sations unquestionably have their seat in the most central
part of the nervous system — in the mind itself, so to speak —
and even though these patients are not conscious of their sensa-
tions, the latter may certainly be utilized by the lower centres for
coordination. In no other way can we explain the fact that
an hysterical girl, with an absolute insensibility of her hands,
is able to execute the most delicate hand-work. Indeed, many
hysterical patients do not know that they have anaesthesias, mainly
because the latter do not cause any motor disturbances. It seems
probable, therefore, that in the cases cited above the ataxia was
absent because the patients unconsciously utilized the centripetal
impulses coming from the extremities.
Investigations on other forms of complete lack of sensation
are so few that it is impossible to render a final verdict concerning
the effect that these produce upon coordination. Striimpell,
however, has recently published a case in which a complete
absence of sensation in the right arm affected movements most
seriously. So long as the patient's eyes were kept open, the
ataxia was comparatively slight, but, as soon as they were closed,
the incoordination became extreme.^*
We have shown that centripetal sensory im-
pulses are absolutely necessary for a proper
THE NERVOUS SYSTEM 457
coordination of any complex act. The lesion that
produces the incoordination, however, does not necessarily lie
in the peripheral tracts, but may be so situated in the central
nervous system that it hinders, in some manner, the transmission
of impulses across this system, as has been shown in a number
of cases.^^ Ataxias may, therefore, be due to different causes,
and the resulting clinical picture is not always the same. When
we speak of ataxia in general we usually refer to the tabetic type,
for that is the most common and the best understood form. In
this form, the ataxia is always accompanied by demonstrable
sensory changes.
If, from any cause, our movements become more or less inco-
ordinated, then we attempt to compensate for the loss of peripheral
control by directing them through the higher centres, very much
as does one who is trying for the first time to execute a difficult
movement. The movement, thus directed, is usually performed
more slowly and less accurately than is one automatically regu-
lated. Indeed, it not infrequently happens that when a normal
individual attempts to execute some difficult feat particularly well,
i.e., when he watches each individual movement, the act is done
particularly badly. This shows the superiority of the automatic
regulation over the volitional. A compensation for losses of
centripetal control may be developed, however, in another way.
When the sensory impulses from the affected extremity are not
all shut off, the patient may learn to utilize those that are left to
a far greater extent than they were ever used previously, and
so to develop a new automatic regulation.
Disturbances of sensation may affect the
functions of the body in other ways than by
causing ataxia;^® and here again the loss of certain sen-
sations may be compensated for, to a certain extent, by other
sensations, and especially by those that come from the eyes.
For this reason, it frequently happens that such disturbances
become manifest only when the patient closes his eyes. When
the sense of touch in the hands is lost, the patient is unable to
grasp objects properly or to gain an idea of the contour of sur-
faces, unless the eyes follow the movements of the hand. If the
senses of position and of motion are diminished, all the finer
movements that depend upon the position of the body or of the
hand in space are not executed accurately except imder ocular
458 THE BASIS OF SYMPTOMS
control. The deaf-mute, whose semicircular canals are destroyed,
becomes imsteady as soon as his eyes are closed, just as does the
ataxic tabetic.
The ataxias, depending upon their anatomical origin, have
been classified as peripheral, spinal , pontine, cere-
bellar and cerebral; and each of these types presents to
a certain extent a characteristic clinical complex. This is readily
understandable even for those cases due to disturbances of centri-
petal sensory impulses, for the latter must take paths which vary
with the difference in location of the lesion in the above-men-
tioned forms.
The disturbances of coordination seen in
cerebellar lesions deserve a final word.^''^ Certain of
these disturbances differ in nowise from those of the tabetic.
There is this difference, however, that in cerebellar affairs the
ataxia becomes less pronounced when the patient lies in bed,
for the cerebellum has to do essentially with static control and
with the coordination of such movements as walking, standing
and running, which are not immediately under voluntary control,
but are influenced rather by impulses from such sensory organs
as the semicircular canals and the eyes.^^ Lewandowsky ^^ has
well expressed the function of the cerebellum in this respect in
his statement "that the cerebellum governs those phases of our
movements not under the influence of the cerebral threshold of
consciousness."
The Effect upon Motion of Variations in the Reflexes. —
Although the reflexes have been carefully studied, especially in
regard to their diagnostic significance, very little attention has
been paid to the important influence that they exert upon our
voluntary movements, this being due to the effect that they
have upon the state of contraction of the muscles.
In addition to this they serve to protect the joints from
forcible and sudden motions.**^
It is extremely difficult to estimate the precise injury that
is caused by an absence of the tendon reflexes, for such absence
is usually associated either with paralysis or with definite sensory
changes. The important part played by the latter in the causa-
tion of disturbances of movement has already been emphasized —
a mechanism which may also be regarded as a reflex. The stud-
ies of Sherrington*^ in this field have been extremely elucidative.
THE NERVOUS SYSTEM 459
When the reflexes are much exaggerated, the tension of the
muscles is increased to such a degree that the slightest irritation
will call forth a reflex spasm. With every motion, the
tendons and ligaments, especially those opposing the movement,
are put more or less upon the stretch. This initiates reflex muscu-
lar contractions, which tend especially to affect the antagonists
of the muscles that are innervated. As a result, all movements
become stiff, and in very bad cases even impossible. This reflex
innervation of antagonistic muscles may cause such uncertainty
of movement that the resulting picture resembles true ataxia, e.g.,
in multiple sclerosis.
Nervous Disturbances of Urination and Defecation. — The
reflex acts of urination and defecation are so far under the control
of the will that, up to a certain limit, we can inhibit or initiate
them. The nervous impulses running from the brain to the lower
centres merely prevent or permit the reflex that is initiated by
peripheral sensations.
The reflex centres that control defecation
and urination are not situated in the cord, as has been
generally supposed, but lie in the sympathetic system.^ ^ The
centripetal impulses that these centres receive from their corre-
sponding organs are, in part, excited by distention of the organ.
Yet distention is only one of the factors that initiate the reflex,
for we urinate different amounts at different times, and much less
when the mucous membrane of the bladder is inflamed, or when
the urine is concentrated, highly acid and irritating.
In the new-born infant, urination and defecation are purely
reflex phenomena. When the centripetal impulses become sufii-
ciently strong, the reflex mechanism is set in motion and the
viscus is emptied. Only through careful training does the child
learn to govern these reflexes and gradually to bring them within
the normal limits of control.
If the impulses running from the cerebrum to the lower
centres be interrupted from any cause, voluntary control over
evacuation is lost. For a time after these impulses are cut off,
the bladder remains full and continually overflows (incon-
tinence from retention), but gradually it comes to
empty itself reflexly at intervals, just as it does during infancy.
Since this reflex emptying of the bladder may occur even when
the lumbar cord is destroyed, the centre lies outside the cord.
460
THE BASIS OF SYMPTOMS
Other nervous lesions cause variable disturbances. For ex-
ample, a loss of centripetal impulses from the bladder to the reflex
centre will lead to a pure retention; while a diminution in these
impulses will lead to difficulty in passing urine, to straining and
to delay in starting the stream. Lesions of the motor paths may
cause similar disturbances, such as slow urination and the reten-
tion of urine in consequence of a paresis of the detrusor, and con-
tinual dribbling as the result of a weakness of the sphincter. Irri-
.tative lesions of the tracts that connect the cerebrum with the
reflex centre may cause retention of urine from spasm of the
sphincters. Finally, it must be remembered that the external
sphincter is a voluntary muscle, and that when it is pvaralyzed
there may result merely an inability to hold the urine when the
bladder becomes filled.
The nervous disturbances of defecation appear to be very
similar to those of urination.
Pathological Alterations in the Reflexes. — In a pure reflex,
the sensory impulse acts immediately upon the motor apparatus
without the intervention of the will. The reflex mechanism con-
sists, therefore, of the sensory apparatus, the motor apparatus and
the connection between the two. The latter may be situated either
in the brain, the spinal cord or the sympathetic system.
The Deep Reflexes . — Those reflexes which arise from
the tendons, periosteum or bones, and of which the patellar
reflex is the best-known example, traverse the spinal cord or the
subcortical portions of the brain. They are subject to many and
diverse influences, which may act either directly upon the sensory
or motor apparatus, or, more indirectly, may tend to inhibit or
to further the transference of the impulse from the sensory to
the motor side of the reflex arc.*^
Even normally there is a great variation in the intensity of
the reflexes, not only in different individuals, but in the same
individual at different times, the latter being especially true of
" nervous " patients. The reflexes tend to be exaggerated during
fatigue, as well as in marantic and cachectic conditions. They
show considerable variations in the infectious diseases. They
usually disappear just before death.
If the reflex arc be broken at any point, whether
in the sensory, the motor or central portion, the corresponding
reflex is abolished. In the earliest stages of tabes dorsalis, for
THE NERVOUS SYSTEM 461
example, the knee-jerks may be absent because that part of the
cord through which the sensory portion of the reflex must travel
has degenerated. Even when the reflex is absent, however,
it is possible that the path is not completely blocked, but only
to the extent that it inhibits the reflex taking place under ordi-
nary conditions. If such be the case, then a cerebral lesion that
would normally increase the reflex may cause the lost one to
return. This has been observed in a number of cases.**
A disease of the reflex arc, such as a neuritis, at
times causes an exaggeration of the corresponding reflex. It is
possible that in these cases the inflamed sensory nerves show
an increased irritability or conductivity ; though it is also possible,
as Sternberg believes, that the exaggeration is caused by changes
in the reflex centre.
The deep reflexes may be influenced by lesions that lie
outside of the reflex apparatus itself. The most
important of these are the lesions which interrupt the
passage of impulses from the cerebrum, or pos-
sibly also from the subcortical centres, down to
the lower spinal reflex centres. Injuries of this
character are usually followed by an exaggeration of the deep
reflexes, and it has been assumed that this results from a blocking
of the inhibitory influence which the brain is supposed to exert
upon the spinal centres.*^ Yet the correctness of this interpre-
tation may justly be questioned, for numerous observations have
established the fact that the patellar reflexes may totally disappear
after a complete transverse section of the spinal cord.*® In some
such cases, however, the tendon reflexes have persisted in spite
of the transverse lesion ; and experiments upon dogs and monkeys
have yielded equally conflicting results. In them, a complete
section of the cord may be followed either by increased or by
diminished reflexes. Immediately after the operation on these
animals, the reflexes are usually abolished, but they gradually
return after a certain length of time. The primary injury itself
may possibly inhibit them for a time, thus causing their early
disappearance ; but their continued absence in clinical cases cannot
be accounted for in this manner. Trendelenburg and Munk, on
the basis of their experimental studies, have come to the conclusion
that the brain exerts a stimulating, rather than an inhibiting
influence, upon the spinal centres, and that the continued absence
462 THE BASIS OF SYMPTOMS
of the reflexes observed after section of the cord high up is
generally the result of secondary changes.'*'^
The Superficial Reflexes. — These are of a more
complex character than are the deep reflexes, and their nature
is less understood.'*® A relatively slight stimulus applied to the
skin or to a mucous membrane will often elicit a relatively strong
response, and the resulting movements are usually slower and
more under the control of the will than are the deep reflexes.
It is quite possible that the nervous path that some of these skin
reflexes follow traverses the cerebrum, and that this is the reason
why they are so often absent in the very conditions in which the
tendon reflexes are exaggerated. Yet this is very questionable
and the data at our disposal do not permit us to formulate even
an hypothesis as to the nature of the superficial reflexes.
Strychnin Poisoning and Tetanus. — The violent muscular
contractions that characterize these conditions are caused by an
increased irritability of the cells in the spinal cord. In strychnin
poisoning, the convulsions are of a purely reflex nature, i.e.,
they are excited by sensory impulses from the periphery. In
tetanus, some are of this character, while others are due to a
primary stimulation of the large motor cells in the cord. These
cells, undoubtedly, become abnormally irritable in tetanus, and
some remarkable anatomical changes in them have been described.
The brilliant researches of Meyer and Ransom^® have shown
that the tetanus toxin travels from the periphery to the
spinal cord through the axis-cylinders of the nerves, and that it
cannot attack the cord directly from the blood or lymph. The
nerves must first be entered. For example, if tetanus antitoxin
be injected into certain nerve-trunks of cin animal, and if, at the
same time, the toxin be injected into the blood or lymph, the
regions corresponding to the nerves that have received the anti-
toxin are not affected during the ensuing tetanus. When tetanus
toxin is injected directly into the spinal cord, the incubation period
that elapses before the appearance of symptoms is reduced to
about two and a half hours. This demonstrates that the long
incubation period usually present in tetanus is due to the time
consumed by the toxin in travelling from the periphery to the
central structures.
The tetanus toxin first affects the motor cells of the cord in
such a way as to irritate them and to cause a tonic spasm of the
THE NERVOUS SYSTEM 463
corresponding muscles, the spasm not being of a reflex character.
The toxin then spreads to neighboring cells, especially to the motor
cells lying on the opposite side of the cord, with resulting convul-
sions in the same muscles as those first affected, but on the opposite
side of the body. Still later, when the poison affects the sensory
portion of the reflex arc, reflex convulsions occur ; yet only those
reflexes are increased which pass through the affected parts of
the cord.
The sensory nerve-fibres do not seem to be affected by the
tetanus toxin under ordinary conditions ; yet Meyer and Ransom
have shown that if the toxin be injected directly into the posterior
nerve-roots, the first symptoms of the poisoning are attacks of
violent pain — the so-called tetanus dolorosus.
Tetanus in man differs from that produced experimentally
in animals in that the muscles first affected are usually those of
the jaw, causing the well-known trismus ; whereas, experimentally,
the convulsions begin in the muscles that correspond to the point
of inoculation.
It is a noteworthy fact that tetanus antitoxin cannot be iso-
lated from the nervous structures it involves ; nor does it appear
capable of penetrating these structures. This speaks against the
assumption that an antitoxin is produced in the cells specifically
attacked by the poison. If the latter be prevented from reaching
the central nervous system, by cutting the nerves of the extremity
into which it is injected, there occurs a marked formation of
antitoxin and the establishment of an immunity. ^^
Contractures. — The bones about a joint are not infrequently
held in a more or less fixed position. This may be due to a num-
ber of causes, such as diseases of the joints, scars in the skin
or muscles, and changes in the muscles, either primary or second-
ary to nervous lesions. Any of these might be termed con-
tractures, though it is customary to restrict the use of the term
to those limitations of motion that follow disease of the muscles
or of the nerves.^^
If, for any reason, certain muscles remain shortened over a
long period of time, this shortening tends to become permanent,
and the movements of the joint are then correspondingly limited.
This condition is spoken of as a passive contracture.
Of the causes that may lead to such a shortening of the muscles,
we may name the maintenance of a certain posture
464 THE BASIS OF SYMPTOMS
foralongtime. In this manner, a foot-drop is not infre-
quently produced by the pressure of the bedclothes during a long
illness. When certain groups of muscles are weakened or
paralyzed, either from disease of the muscles themselves or from
disease of their nervous connections, the antagonistic muscles, not
meeting with the normal resistance to their action, tend to move
the joint into an abnormal position and to hold it there. When-
ever the joint has been held in a certain position for a long time,
it tends to be fixed in this position both by the development of
adhesions about the joint itself and by anatomical alterations in
the shortened muscles. Passive contractures have been produced
experimentally in monkeys by the extirpation of portions of the
cerebral cortex, and by subsequently keeping the animals in such
small cages that their movements were very much limited.^^
In active contractures, the joints are held in an
abnormal position by the tonic contraction of certain groups of
muscles. Since there is usually an associated increase in the
tendon reflexes in these cases, they have been termed by some,
spastic contractures. The cause of the muscular
spasm which produces the contracture is not always clear, and
it may not be the same in all cases. As we have said, the re-
flexes are usually exaggerated in active contrac-
tures, yet not necessarily so, and in some cases they remain
unaffected.
When the reflexes are increased, the contractures might pos-
sibly be caused by an unequal reflex stimulation of
the different groups of muscles about a joint.
To my mind, however, this explanation is not an entirely satis-
factory one, for it seems very probable that, in many cases, at
least, the contractures and the exaggerated reflexes are both due
to a common cause.
Mann^^ has given a very plausible explanation of post-
hemiplegic contractures. He first calls attention to the fact that
these contractures affect especially the muscles that are least
paralyzed. In the complicated innervation that directs every
voluntary movement, there is apparently not only a stimu-
lation of the muscles that produce the move-
ment, but an inhibition of the antagonistic
muscles. A cerebral disease, therefore, will not only paralyze
certain muscles, but will, at the same time, diminish the inhibitory
THE NERVOUS SYSTEM 465
impulses sent to their antagonists. This lack of inhibition would
explain the contracture in the antagonistic muscles ; and Mann's
hypothesis accords very well with the experimental results of
H. E. Hering.5^
At the outset, every complete cerebral paralysis is flaccid, and
contractures do not occur until the paralyses of the different
muscle-groups affected recede in unequal degree. Cen-
tripetal sensory impulses likewise favor the ap-
pearance of contractures, whereas the absence of such
impulses tend to prevent them {e.g., in tabes). It is evident,
therefore, that the mechanism of contracture production is a
complex one, depending upon the reflex, and possibly also the
direct, stimulation of muscle-groups of antagonistic action, and
upon the net result of paralysis and inhibition. That contractures
tend to be limited to certain groups of muscles would seem to
be due to an unequal stimulation of contiguous cortical areas.
In many cases, irritative processes seem to cause the tonic
muscular spasm, though it must be admitted that no very sharp
line can be drawn between an irritation and a diminution of
inhibitory influences.^^ The valuable studies of Forster^^
have shown how complicated is the mechanism of spastic con-
tractures. A remarkable fact, according to him, is that in the
spastic type, no less than in the passive, the long-contin-
ued maintenance of a part in one position plays
an important role. If a muscle has once become short-
ened by habituation to a certain position, it is more difficult
to overcome this after the removal of the cerebral inhibiting
influences. And, furthermore, by making use of the observation
that voluntary movements also tend to be inhibited, Forster was
able to influence even the type of spastic contracture.
A contracture, therefore, is a subcortical reflex representing
an increase in the resistance offered by every muscle to forces
which tend to lengthen it. The form of the contracture depends
upon the position customary to the limbs and also upon the
degree of restitution of voluntary movements, which, in turn,
differs with the parts affected.
Two views have been advanced as to the cause of the
contractures that develop in joint disease. Ac-
cording to the one, the muscle spasm is caused
reflexly from the joint, owing to a strong stimulation
30
466 THE BASIS OF SYMPTOMS
of the sensory nerves there. This view is supported by the
fact that the tendon reflexes are often increased in these con-
ditions. Personally, however, I am inclined to favor the view
that the muscle spasm and peculiar posture assumed by these
patients are both the result of a desire to avoid pain;
though it must be admitted that this does not explain the increased
tendon reflexes.
Hysterical contractures are usually, but not always,
associated with exaggerated reflexes. They would appear to be
due in part to this exaggeration ; in part, perhaps, to a diminution
of the inhibitory control normally exercised by the brain over
the lower spinal centres.
Motor Irritative Symptoms. — Tremor may be defined as a
series of regular oscillatory muscular movements about a fixed
axis. The rate of these oscillations, their amplitude and the
number of muscles affected, all vary in individual cases. In many
conditions, the tremor occurs only during volimtary movements ;
in others, it is more intense during rest. All forms of tremor
cease during sleep. Unfortunately we cannot discuss tremor,
because, in our opinion, absolutely nothing is known as to its real
cause,®"^ and because it is not our purpose to enter into clinical
or diagnostic details.
According to Bonhoeffer, the choreiform movements that
sometimes develop after a hemiplegia are usually caused by
lesions of the superior cerebellar peduncles, °^
which would interrupt the centripetal impulses that pass through
the cerebellum on their way to the motor region of the cerebral
cortex. The muscle tonus in these conditions is usually dimin-
ished,^^ a fact which lends some support to the hypothesis that
the cerebellar function is affected.
In a variety of pathological conditions, certain voluntary
movements are regularly accompanied by other purposeless,
so-called associated movements.** As we have already stated,
the innervation for a voluntary movement is extremely complex,
impulses being sent to a great number of muscles. The muscular
contractions that would result from all these motor impulses are,
however, controlled by other impulses that come in from the
periphery. If this peripheral control be lost, it is possible that
certain acts should be accompanied by extra, purposeless move-
ments which would be suppressed in the normal individual. The
THE NERVOUS SYSTEM 467
associated movements that may occur in tabes dorsalis are, there-
fore, related in a way to the ataxia, for both depend upon a loss
of centripetal peripheral control.
Convulsions may be of the clonic type, i.e., the muscles
are alternately contracted and relaxed with corresponding move-
ments of different parts of the body; or they may be of the
tonic type, i.e., the contraction is continuous and the parts
affected simply become rigid. Finally, the two forms of con-
vulsions, tonic and clonic, may alternate with each other.
Convulsions may be caused either by stimulation of the motor
tracts or nerve-cells. For example, diseases of the cervical or
dorsal cord may cause convulsive movements in the legs owing
to an irritation of the motor tracts ; lesions of the internal capsule
may cause convulsions in the opposite half of the body; disease
of the cerebral cortex in the corresponding extremity, etc. It
would appear, however, that the stimulation of the
cerebral cortex is more likely to produce convulsions than
is stimulation of any other part of the motor apparatus.
The paradigm of cortical convulsions is the so-called Jack-
Bonian epilepsy, which is characterized by its limitation, at the
outset, to certain groups of muscles, whence it spreads, as a rule,
to the entire body. The convulsions are generally followed by
a more or less transitory paralysis of the affected muscles. The
order of progression of the convulsions corresponds to the
arrangement of the cortical centres governing the particular
groups of muscles.
Many poisons produce convulsions, some of which, such
as the uraemic and diabetic poisons, are formed within
the body during pathological processes. It is impossible to say,
however, upon which part of the central nervous system these
poisonous substances act, though in all probability it is the cortex.
Epilepsy ^^ is apparently due to an excessive irritability of
the central nervous structures. The convulsions themselves may
be precipitated by sensory impulses from some part of the surface
of the body, but more frequently they come on spontaneously,
or, at least, without any discoverable cause. The attack is
often preceded by certain characteristic psychic or bodily warn-
ings (aura). The patient then becomes unconscious and gen-
eral convulsions occur, which are at first tonic and later clonic
in character. It is possible to induce tonic as well as clonic
468
THE BASIS OF SYMPTOMS
convulsions in animals by stimulating various parts of the brain,
such as the medulla, the pons and the sensory and motor regions
of the cortex. Of these convulsions, no type presents so great a
similarity to the attacks of epilepsy as does that which follows
stimulation of the cerebral cortex. The latter may be either fully
developed or rudimentary in type, and it often continues after the
stimulation has ceased. The similarity that exists between the
convulsions of epilepsy and those that follow stimulation of the
cerebral cortex favors the view that epilepsy is of cortical
origin. This view is supported furthermore by certain clinical
facts, such as the frequency of rudimentary epileptic attacks, the
associated unconsciousness, the spread of the convulsions in
accordance with the cortical representation of muscles and the
frequent occurrence of sensory aura.
Disturbances of Sensation. — The pathology of sensation is so
intimately associated with the mind itself that our consideration
of this subject will necessarily be limited, for, as we have already
said, we do not purpose discussing psychic changes. It will be
necessary to limit our discussion in still another way, vis., by
omitting the special senses of sight and hearing, for these subjects
require so much special knowledge that we cannot do justice to
them.
Disturbances of sensation may be either irritative or
paralytic in character, and the sensory mechanism may be
injured at any point from its beginning in an end organ at the
periphery to its termination in the central perceptive part of the
cerebrum. If the peripheral sense organ is injured, if conduction
of the impulse through the nerve or cord be interrupted, or if,
finally, the connections in the brain be thrown out of function,
the sensation will be either distorted in some manner, or it will
not be perceived at all.
In certain spinal or peripheral diseases, the sensations are,
indeed, perceived, but they travel at a slower rate than normal.
This occurs most frequently in tabes dorsalis and affects oftenest
the cutaneous sensation of pain. We do not know exactlv how
this delayed sensation is caused.
When a certain injurious agent afifects at one time a number
of nerve-fibres of different functions, the sensory fibres usually
resist the injury better than do the motor. Under such circum-
stances, the motor fibres may be paralyzed, while the sensory
THE NERVOUS SYSTEM 460
fibres are merely irritated and cause pain. This combination of
symptoms is seen especially from pressure upon the spinal cord,
producing the characteristic picture of paraplegia dolo-
rosa.
Our whole knowledge of the external world comes to us
through centripetal nervous impulses, all the functions of our
bodies being more or less affected by them. Thus, the sensations
of light, sound and temperature influence metabolism, muscular
activity and respiration. When one form of sensation is lost,
the others become more acute because more attention is directed
to them, the best known example of this being the acute sense of
touch that is developed in blind individuals.
The Cutaneous Sensations. — The nerves of pressure, pain,
heat and cold, each possess definite and characteristic endings
in the skin.^^ These delicately constructed end-organs are with-
out doubt injured in some skin diseases, although, so far as I
know, no thorough study of such injuries has yet been made.
Diseases of the nerves or of the central apparatus may also affect
the cutaneous sensations, and any one of the latter may be dis-
turbed without the others being affected. Such "partial
anaesthesias" may result from disease either of the nerves
or of the central nervous system, but they are especially frequent
in tabes and in syringomyelia. The occurrence of such
partial anaesthesias is of great practical and theoretical interest,
for it implies that special nerves exist for each of the cutaneous
sensations. In particular, it tends to prove that pain is
due to the stimulation of special pain fibres,
and not to the overstimulation of other varie-
ties of fibres. The physiological observation that cer-
tain points in the skin are sensitive to pain alone and others to
pressure alone, likewise supports this view. It must be noted,
however, that even so experienced an investigator as Gold-
scheider^^ denies the existence of special nerves for pain.
Lesions of the peripheral nerves may also affect the different
skin sensations to different degrees, and in this manner give rise
to partial anaesthesias; but the most pronounced instances of this
condition are usually observed in diseases of the spinal cord.
The fibres that transmit the various forms of cutaneous sensation
apparently run in different parts of the cord, with the result that
a limited lesion may block some of them and leave others intact.
470
THE BASIS OF SYMPTOMS
The path pursued by the sensory fibres in the
central nervous system is an extremely complex one.
A portion of the fibres that carry impulses to the brain cross
by way of the anterior commissure to the opposite side of the cord
shortly after they enter it. This is the explanation of the
Brown-Sequard symptom-complex. If one-half of
the spinal cord be destroyed, the muscles on that side below the
level of the lesion will be paralyzed, with an associated loss of
the sense of position. The cutaneous sensations that are inter-
rupted, however, are those that come from the opposite side of the
body below the lesion.
When the sensory tracts reach the brain, they connect with
various reflex and automatic centres, some finally terminating in
the cerebral cortex, apparently in the neighborhood of the motor
areas that govern the movements of corresponding parts of the
body. For this reason, lesions of the cortical motor area usually
produce a diminution, though not a complete loss, of sensation in
those parts of the body that correspond to the paralysis. So
far as sight and hearing are concerned, we know that a sensation
may be perceived without its meaning being recognized (soul
blindness) ; thus a patient may hear the ringing of a bell, but he
tmable to tell what causes the sound.
The sensory disturbances due to diseases of
the peripheral nerves demand a special word. The
observation that severance of a cutaneous nerve does not render
the area supplied by that nerve entirely anaesthetic has been
explained on the basis of nerve anastomoses and the overlapping
of nerve supplies. Head and his co-workers®* have elaborated
another theory, zns., that cutaneous sensation is carried by
three distinct types of nerve fibres, exclusive of
those for the feeling of cold, heat and pain. Those for deep
sensibility course with the motor fibres, entering the anterior
horns, traversing the cord to the posterior roots and thence enter-
ing the spinal tracts. Through the medium of these fibres it is
assumed that we experience the sensations of pressure, pain
and movement of the deeper structures. Superficial sensation,
according to Head, falls into two classes, which he terms " e p i -
critical" and **protopathic," the first conveying the
finer impulses, the latter the coarser. The epicritical fibres are
said to correspond approximately to the anatomical distribution
THE NERVOUS SYSTEM 471
of a given nerve, and to regenerate much more slowly than do the
protopathic fibres. This hypothesis has not been unchallenged.^''
Every sensation produces at the same time a
more or less definite impression of the place
whence the sensation has come. In the case of the
eyes and skin, this localization is very accurate; in the case of the
mucous membrane near the outside of the body it is somewhat
less accurate; while in the case of the deeper mucous membranes
and the organs within the body, it is inaccurate and entirely unre-
liable. In certain nervous lesions, especially in those about the
optic thalami, the cutaneous sensations are perceived, but the
ability to localize them is more or less lost. Curiously enough,
this sense of locality is well preserved in cortical lesions.^^ Ob-
servers are not agreed as to whether this sensory anomaly is due
chiefly to a loss of the sense of movement, or of cutaneous
sensation ; at any rate, it is most marked when both are involved.
The Orientation of Our Bodies in Spaces'^ — We derive infor-
mation as to the position of our bodies in space from a number
of sources. Our eyes aid us by means of the images upon the
retinae and by their motion within the orbits; the internal
ear enables us to estimate changes in the rate of direction of
our movements ; and other more or less valuable data are derived
from the muscles, tendons, bones, joints, skin,
etc. Even though we are not conscious of these various sensa-
tions, they all influence to some extent the conception that we
have as to our position in space.
Certain of these sensations may be lost without much effect
upon our powers of orientation, for the reason that other
sensations compensate for the lost ones.®® The
blind man moves about a room with great precision so long as he
can use his sense of touch; and the deaf-mute hardly seems to
be affected by the loss of his internal ears. It is an interesting
fact, however, that deaf-mutes do show a diminished power of
orientation, and that they behave quite differently from normal
individuals when they are turned about rapidly.®* The tabetic
who has lost certain of the sensory impulses coming from his
legs depends very much upon his visual impressions, and if these
be taken away from him by closing his eyes he will often imme-
diately fall to the ground. We see, therefore, that various disor-
ders of the peripheral sensory apparatus will disturb the sense of
472
THE BASIS OF SYMPTOMS
our position in space. The same effect may also result from
lesions of the central mechanism in the brain — ^above all, from
lesions of the cerebellum.
DizzinessJ<^ — We do not mean by dizziness a partial, transi-
tory loss of consciousness, but a feeling that we are unable to
control our equilibrium. This feeling usually results from an
inability on the part of the central apparatus to
harmonize the various centripetal impulses that
come to it.''* For example, if certain ocular muscles are
paralyzed, the images of an object looked at do not fall upon
corresponding points of the two retinae as they normally should,
and consequently the impressions derived from the two eyes will
not correspond to each other. This causes a sensation of dizzi-
ness, which may usually be relieved if the impressions derived
from the offending eye are excluded by closing it. Diseases
of the semicircular canals, of the sacculus or
utriculus, or of their central nervous connec-
tions in the cerebellum, are especially likely to cause
dizziness, which is most marked when the disease is limited to
one side.
In aural vertigo (Meniere's disease), the dizziness is usually
associated with disturbances of hearing.^* The cochlear branch
of the auditory nerve transmits sensations of soimd ; whereas the
vestibular branch, proceeding from the vestibule and the semi-
circular canals, carries impulses that are caused by changes in
the rate or direction of our movements. The symptom of dizzi-
ness in aural vertigo undoubtedly results from disturb-
ances in the impulses carried by the vestibular
nerve. The associated anomalies of hearing are easily under-
stood when we consider the close proximity of the two nerves and
of their end organs. In many cases, the sensation of dizziness
will disappear if the patient remain perfectly quiet, while in
others they are constantly present even though the patient be still,
and under such circumstances they are most harassing.
The dizziness of aural vertigo is probably due to an irritation
of the vestibular nerve, or of its connections, rather than to a
mere lack of function. The patient becomes dizzy because the
impressions received from this source do not coincide with those
received from other parts of the body. That the dizziness in these
cases is not due to a mere lack of sensation from the internal
THE NERVOUS SYSTEM 473
ear is rendered probable by the fact that the typical symptoms
of aural vertigo are rarely seen in those deaf-mutes in whom
the internal ear is entirely functionless.
Aural vertigo, as well as cerebellar vertigo, is frequently asso-
ciated with other symptoms, such as vomiting, uncertainty in the
voluntary muscular movements, especially in walking, and peculiar
movements of the eyes. At present, however, it is impossible to
explain these associated symptoms very satisfactorily.
The sensation of dizziness may also be produced by many other
causes, such as alcoholic intoxication, cerebral pressure, anaemia
and circulatory disturbances ; yet the exact mode of its causation
in these conditions is not known.
Hyperalgesia. — Increased sensitiveness to painful stimuli that
are applied to the skin has been observed in various diseases of
the cord and of the more central endings of the sensory tracts.
The transition from the normal to the pathological, however, is
here a very gradual one, and individuals of a " sensitive " nature
are certainly more susceptible to pain than are those of a phleg-
matic type. The hypersensitiveness of hysterical patients is prob-
ably of this perceptive character. Peripheral abnormalities rarely
give rise to hyperalgesia, although a neuritis will sometimes do so.
Occasionally, as in cord lesions, hyperalgesia may result from the
summation of many stimuli, no one of which in itself
is sufficient to give rise to a painful sensation.
Irritative Sensory Symptoms. — These differ from the pre-
ceding in that the pain results not from hypersensitiveness to
normal stimuli, but from a pathological irritation of the sensory
mechanism.
Itching IS usually caused by an irritation of the sensory
organs in the skin, though sometimes, as in multiple sclerosis,
it may result from lesions of the conducting apparatus. It accom-
panies most cutaneous diseases, but, for some unknown reason,
it tends to be absent in certain lesions, such as those produced
by syphilis. Not infrequently, itching is present when no cutaneous
changes can be demonstrated, as, for example, in jaundice and
diabetes. It is possible that in these cases the central apparatus
is directly irritated. On the other hand, paraesthesias, such as
numbness and tickling, rarely accompany cutaneous dis-
eases, but are caused usually by nerve or cord lesions. They
have also been observed in the extremity that corresponded to
474 THE BASIS OF SYMPTOMS
a point of softening in the sensory sphere of the cerebral cortex.
They seem, therefore, to be caused by an irritation of the sensory
tracts.
Abnormal sensations of heat and cold are some-
times experienced, but it is often difficult to distinguish these
from the accompanying sense of pain.
In our opinion, pain is normally caused by the stimulation
of special pain fibres or sensory end organs. Heavy pressure,
for example, will deform the skin and so stimulate the pain
points. Pain also results from various inflammations and de-
generations of the nerves, such as may be caused by alcohol,
arsenic, malaria, etc. The nerves may also cause pain even when
no demonstrable lesion is present, as happens in the neuralgias.
It is remarkable that pathological processes within the central
nervous system itself rarely produce much pain, so long as the
peripheral nerves, the posterior roots and the meninges remain
unaffected. Surgeons and physiologists have frequently demon-
strated that the brain itself is practically insensible; and although
it cannot be denied that the pain fibres may be stimulated within
the central nervous system,*^^ yet the general fact remains that
such a stimulation is not easily brought about.
Many hysterical pains are probably of a central,
" psychic " nature, but these are not related in any way to organic
lesions of the cerebral cortex.
The Influence of the Nervous System upon the Tissue
Nutrition. — The nutrition of a tissue depends primarily upon the
activities of its individual cells. It is, indeed, necessary that
food material should be supplied to it from the blood in sufficient
quantities, yet this food supply alone does not stimulate the
growth of the cell. That stimulus must come from the paren-
chyma itself.
The exact part that the nervous system plays in this process
is not at all clear. Beyond question, it exerts a very important
influence upon the nutrition of certain tissues. Is this influence,
however, due merely to the fact that the cells do not functionate
properly without nervous impulses, or do the nerves contain some
specific, nutritional, " trophic " fibres ?
The Effect of Separating a Nerve-Fibre from Its Cell. — The
nerve-fibres degenerate if they are separated from their ganglion
cells, or if these cells are destroyed. This is explained, according
THE NERVOUS SYSTEM 475
to the neuron theory, on the assumption that the nerve-fibre, a long
process of the ganglionic cell, dies when it is separated from its
mother cell.
It is not our intention to consider the validity of the
neuron theory nor the recent arguments advanced both in
favor and against it. The cells and their axis-cylinders un-
doubtedly have an intimate histological relationship. On the
other hand, we can no longer subscribe to the neuron theory
in its original form,'^* for there can be no question of the im-
portant part played by nervous structures other than the ganglion
cells and axones, e.g., the neurofibrillse. (The neuron theory,
though in its entirety i>erhaps not unassailable, seems to be the
most acceptable at our disposal, and is held by the majority of
physiologists. Especially indicative of the fact that the nerve-
cells are concerned not merely with the nutrition of the conducting
fibres, but themselves take part in the transmission of impulses,
are the brilliant researches of Harrison "^^ who was able to
show in vitro that the growth of the axis-cylinder occurs when all
other nervous structures are eliminated but the nerve-cells whence
they arise. — Ed. )
Some indeed assert that the mere separation of the fibre from
the cell, or rather, the cessation of the influence that the cell exerts
over the fibre, is not the cause of the degeneration, but that the
latter is due directly to the traumatism of the operation.'''® It is
jxDSsible, for example, experimentally, to interrupt the transmission
of nervous impulses through a fibre for a very long time without
having any degeneration take place; but although the ordinary
nervous impulses were interrupted in such a case, we cannot be
sure that the nutritional impulses were likewise affected.
Even though the nerve-fibre is a part of the ganglion cell, the
two must be, to a certain extent, independent of each other, for the
fibres seem to be relatively much more susceptible to the action
of certain toxins. The neuritis that follows the circulation of
these toxins in the blood apparently occurs either because the
fibres contain elements for which the toxins show a special affinity,
or because the fibres are so remote from their nutritional centres,
the cells. The fact that medullated nerve-fibres pursue a different
course of regeneration than do the non-medullated, suggests that
the medullary sheath plays an important part in this selective
action of toxins upon the nerve-fibres. In many cases the nerves
476 THE BASIS OF SYMPTOMS
are capable of exchanging material with their surroundings, as is
evidenced especially by the fact that the tetanus toxin travels from
the periphery to the cord through the axis cylinders. Possibly
the toxins of other infectious diseases pursue this same course,
and if this were so it might explain the special susceptibility of
the nerve-fibres to the toxins of infectious processes.
In some instances, as in lead poisoning, different portions of
the nerve-cell may be affected, and consequently, widely different
nervous symptoms may be produced. Certain of the systemic
diseases of the spinal cord show various transitions into one
another; and it is easy to conceive, for example, that the same
cause might produce in one person a progressive muscular atrophy,
in another, an amyotrophic lateral sclerosis, and in a third, a true
spastic paraplegia, depending upon whether the pyramidal tracts
or the motor cells of the anterior horns were more especially
affected.
When a ganglion cell is separated from its
peripheral neuron, the former also undergoes certain
changes,*^^ which reach their height in about eighteen days. After
this, a portion of the injured cells may be restored to their normal
condition. If the cell continues to be functionless, however,
for the reason that the peripheral nerve cannot regenerate, then
it gradually undergoes atrophy. This happens, for example, after
amputations; and the younger the individual the greater is the
cell destruction. These facts are of considerable theoretical
interest, for they show that the normal existence of a
ganglion cell depends largely upon its ability to
exercise its function. Degeneration occurs in the sen-
sory cells because they receive no impulses from the periphery,
and in the motor cells when they no longer receive those indirect
stimuli from the muscles and other tissues whicih normally play
so great a part in the regulation of their activities.
It is apparent, therefore, that our knowledge of the factors
concerned in degeneration and regeneration of nervous elements
is by no means complete, even though we regard the neuron as
embracing all of the structures concerned in the functional activi-
ties of the nervous system — a view, incidentally, which is un-
doubtedly too narrow. The interpretative difficulties are only
increased, however, if we go beyond the neuron and attribute
special properties to other structures, such as the fibrillae, etc.
THE NERVOUS SYSTEM 477
Nutritional Disturbances in the Muscles. — When the muscles
are separated from the spinal cells that innervate them, they
degenerate. The degenerative changes consist mainly in
alterations of their chemical composition''^^ and
of'theirelectrical irritability. Prominent among the
chemical changes, according to Rumpf, is a marked diminution
in the potassium, and a considerable increase in the sodium, salts.
In addition to these, a simple reduction of their contractile sub-
stance without degenerative changes takes place.*^® The reduc-
tion of the quantity of protoplasm is caused by the inactivity,
and is, therefore, an atrophy from disuse. The microscopical
signs of degeneration, such as the granular and waxy degenera-
tions, are not due to the separation of the muscles from the cord,
but to some associated action of toxic substances.
Changes in the Electrical Irritability of Muscles.^^* — After
a muscle has been separated from its ganglion cells for a certain
time, it responds abnormally to the electric current. These
changes constitute the so-called reaction of degenera-
tion. It will no longer contract when its nerve is stimulated
in any manner by the electric current, nor will it contract
when it is itself directly stimulated by an ordinary interrupted
current. Even the healthy muscle does not contract if very high
frequency currents are applied to it, so that the loss of irritability
that the degenerated muscle shows toward an interrupted current
is merely one of degree. It is an exaggeration of the normal.
In this respect, the degenerated muscle behaves like a smooth
muscle, for the latter also usually fails to respond to an inter-
rupted current.
The muscle that is separated from its ganglion cells will,
however, respond for a long time to interruptions of the galvanic
current; and it will, indeed, respond to a much weaker current
than does the normal muscle. The contraction produced by this
current is not a prompt and short one, as is the case with the
normal muscle, but is very slow and easily passes into tetanus. A
slow contraction of this kind is also seen in the smooth muscle,
in the fatigued striated muscle, in the muscle subjected to cooling
by carbon dioxide®^ and in certain intoxications and cachectic
conditions. The contraction curve of the cooled muscle — espe-
cially the gradual ascent — may so closely resemble that of the
reaction of partial degeneration as to be indistinguishable at
478 THE BASIS OF SYMPTOMS
times, even by capable observers. In certain fundamental par-
ticulars, therefore, the fatigued or cooled muscle reacts exactly
as does the degenerated.
The degenerated muscle, instead of responding more strongly
to a closure of the current when the cathode is placed upon it,
frequently contracts more strongly to the anodal closure. It has
been commonly assumed that this change is due to some funda-
mental alteration in its protoplasm, whereby it is rendered more
irritable to the anodal closure ; yet such does not seem to be the
case. The muscle conducts the current, and, when the cathode
is placed over its centre, for example, the current enters at the
end and this receives an anodal stimulation. In the normal
muscle the cathode causes a stronger contraction, because it is
placed over the point of greatest irritability, i.e., the entrance
of the nerve into the muscle. The centre of the degenerated mus-
cle, however, early loses its irritability, and the extremities become
the most irritable parts. When, therefore, an electric pole is
placed over the centre of a degenerated muscle, and the current is
closed, the end of the muscle receives the main stimulation. For
this reason the maximal contraction is obtained when the anode is
placed on the muscle, for the cathodal stimulus then acts upon
its more irritable extremity.^^ If the degenerated sartorius mus-
cle of a frog be isolated and stimulated, it shows no diminution
in its irritability to the cathodal, as compared with the anodal,
closure.®^
More recently the attempt has been made to explain these
phenomena on a physico-chemical basis.®* According
to Nernst, the contraction of a healthy muscle is due to an
accumulation of electrolytes at the cathode. R e i s s , using frog-
muscle preparations freed from nervous connections, has found
that in degenerative conditions the normal cathodal
accumulation is replaced by an anodal, i.e., the
electrolytes gather about the anode instead of
the cathode when the circuit is closed.®*^ Though
it is true, as pointed out above, that degenerated muscle exhibits
an altered salt content,^® and that this alteration might account
for such a reversal in the response to cathodal and anodal closure,
yet there exist a number of objections, both interpretative and
technical to the Reiss hypothesis.®'^
In certain instances, such as in trichinosis and some muscular
THE NERVOUS SYSTEM 479
dystrophies, the reaction of degeneration has been present without
demonstrable lesions of the nerves. At the present time, how-
ever, these cases cannot be accepted as proof that the reaction
of degeneration may occur independently of nervous lesions, for
it is almost impossible to exclude changes in the finer nerve fila-
ments. Nor have the observations on cases of this kind taken into
account the pronounced effect of temperature variations, such as
cooling, to which attention has already been called. Against
Striimpell's view that the reaction of degeneration is simply the
response of a nerveless muscle speaks the fact that curarized mus-
cle does not exhibit this phenomenon.
When a motor nerve is injured, but not entirely destroyed,
electrical changes of a less marked degree take place in the muscles
— the so-called partial reaction of degeneration.
Atrophy from Cerebral Lesions. — When muscles are paralyzed
from a cerebral lesion, the resulting atrophy develops more grad-
ually and is of slighter extent than that which follows the division
of a peripheral nerve, and it is, furthermore, unaccompanied by
the reaction of degeneration. In such cerebral paralyses, only
one form of stimulation — the voluntary — is shut off from the
paralyzed muscle. The reflex and automatic stimulations from
the lower centres continue to act upon it. The paralyzed muscles
frequently do contract from reflex stimulation, and even when
they do not apparently do so, they still maintain their muscular
tonus. The paralyzed muscle that retains a connection with its
ganglion cells exhibits a more active metabolism than the paralyzed
muscle that is separated from these cells, a further proof that
the former maintains a certain amount of activity.
In certain instances, especially in the young, cortical lesions
have been followed by marked changes in the lower neurons and
by a rapid atrophy of the muscles.^* The electrical reaction in
these cases is, usually qualitatively normal, although, in a few, the
slow contraction of degeneration has been present. The upper
neurons apparently exercise some influence upon the peripheral
neurons, and when this is cut off in early life, the latter may
degenerate.®*
Muscular Atrophy from Diseases of the Joints.^*' — The
atrophies about diseased joints often develop more rapidly and
are more severe than those which are caused by cerebral lesions.
As a rule, they do not affect equally all muscles about the joint,
480 THE BASIS OF SYMPTOMS
but tend especially to injure the extensors. The severity of the
muscular atrophy bears no definite relation to the intensity or
variety of the joint lesion. The electrical irritability of the
muscle is usually reduced, but no typical reaction of degeneration
is present. This form of atrophy differs, therefore, from that
caused by cerebral lesions in its intensity and in the rapidity with
which it develops, and from that caused by nerve-lesions in the
absence of a reaction of degeneration.
Various attempts have been made to explain
these muscular atrophies about diseased joints.
The French, following Charcot's lead, have generally con-
sidered that the nervous impulses sent from the joint to the
cord influence the motor cells there, and that a disturb-
ance of the impulses from these cells causes the
atrophy. The Germans, following Striimpell, have been
more inclined to attribute these muscular atrophies to an ex-
tension of the disease by contiguity from the
joint to the muscle, though it must be admitted that, experi-
mentally, at least, no inflammation of the muscle is necessarily
present, and that the muscles atrophy throughout their entire
length, and not merely in the neighborhood of the joint. Finally,
attention has been called to the fact that the most seriously affected
muscles are precisely those whose movements are most limited by
the joint disease, so that the atrophy is probably caused, in part
at least, by disuse,®^
The Muscular Dystrophies. — This disease-group, which ex-
hibits a distinct hereditary and family tendency, is characterized
by a very gradual atrophy of certain muscles. It usually begins
in childhood or early youth. Several types have been described,
but it seems very probable that they are all but different variations
of the same disease. Anatomically, we find many atrophied
fibres, and, in addition to these, usually a number of thickened
fibres, which may, indeed, be so numerous that the muscle as a
whole appears to be hypertrophied. The adipose tissue between
the muscle fibres is sometimes so increased in amount as to pro-
duce a large, weak muscle, the so-called pseudohyper-
trophy. In the great majority of these cases, no reac-
tion of degeneration is present, while in the few in-
stances in which it has been found, it is extremely difficult to
exclude some slight involvement of the finer nerve-filaments.
THE NERVOUS SYSTEM 481
or the eflfect of cooling. Even the presence of changes in the
spinal cord, such as have been described,® ^ do not permit us to
assume that this disease is of central origin; for, as we have
seen, an atrophy of the ganglion cells may follow a primary
peripheral condition, such as an amputation. In a few cases,
classified among the dystrophies, some complication may have
caused the cord lesion.
Nutritional Disturbances of Nervous Origin in the Bones and
Joints. — After an acute anterior poliomyelitis in children, the
bones of the paralyzed extremities frequently fail to develop to
their normal size; whereas, after the cerebral infantile palsies,
their growth is rarely much affected. In the former cases, the
absence of the varying pressures and movements to which the
bones are normally subjected, may diminish their blood-
supply and so retard their development; but it is possible,
on the other hand, that this retardation is due to an absence of
specific, trophic influences. In adults, nutritional
changes in the bones rarely result from diseases of the peripheral
motor neurons alone.
In a variety of other nervous diseases, especially in
syringomyelia and tabes, as well as in certain periph-
eral lesions, very remarkable nutritional disturbances take place
in the bones and joints.®^ The anatomical changes in the joints
often resemble those of arthritis deformans, but they differ from
these in certain particulars, especially in the more abundant
effusion, the greater destruction of the joint, the rapid course and
the frequent absence of all pain. In a certain proportion of these
cases, the lesions are, undoubtedly, due to an absence of
the sense of temperature and pain. I have myself
seen a man with syringomyelia who, while at work, frequently
injured himself from grasping live coals, who paid no attention
to his wounds on account of the absence of pain, and who event-
ually developed the most pronounced deformities in his bones
and joints. Such observations are not infrequent. In loco-
motor ataxia, also, injuries are frequently overlooked on account
of the loss of sensation in the joints and muscles. In spite of
these observations, however, the opinion of the authorities is now
gradually turning toward that of Charcot, who held that
the arthropathies are caused, in many instances at least, by a
loss of trophic impulses from the cord. Patients
81
482 THE BASIS OF SYMPTOMS
have been observed in whom the most severe joint destructions
have followed within a few days after nervous lesions, without
any demonstrable mechanical injury.
In some nervous diseases the bones are abnormally thin, and
they may be fractured from very slight causes, or even, to all
appearances, spontaneously. Various cord changes have been
found in such patients,^* and in some cases a neuritis has been
present. Although a number of other explanations has been
offered for this abnormally brittle character of the
bones, it seems probable that a lack of trophic influences is
the cause in many cases. In others, local changes, especially
syphilitic, may be present in the bone. Nor must the chemical
action of the correlated internal secretions be overlooked.
The Influence of Nervous Diseases upon the Skin. — It is
well known that those parts of the skin which are exposed to
continued pressure tend in time to become reddened and swollen,
and eventually to die. Such ulcerations, of which bed-sores
furnish the most familiar examples, may develop under a great
variety of conditions, depending mainly upon the nutrition of
the cells and the constancy of the pressure applied. They are seen
especially in patients with nervous, infectious or metabolic dis-
eases, who have lain for a long time in one iX)sition. In a
certain proportion of the nervous cases — for these are the ones
that especially interest us — the ulceration is favored by the cuta-
neous anaesthesia, and by the soiling of the skin with urine and
faeces, owing to a paralysis of the bladder and rectum. As
evidence of the importance of these factors, we may instance the
brilliant results that follow the proper care of this class of patients.
IWhile we must admit, therefore, that the anaesthesia and
lack of cleanliness are important factors in the causation
of these ulcerations, yet, in my opinion, they are not the only
causes that are present, for at times the ulcers develop very
rapidly even when there is no loss of sensation and no loss of
bladder or rectal control. In this last class of cases, trophic
disturbances certainly play an important role. To what
extent such trophic disturbances and to what extent the other
factors enter into the causation of the ordinary bed-sores that
develop during nervous diseases can only be determined by modern
observations during a proper care of the patient.
Herpes Zoster. — This remarkable eruption is associated with
THE NERVOUS SYSTEM 483
disturbances of the peripheral nerves, usually an inflamma-
tion of the sensory ganglion itself or of the
nerve. (Rosenow,^^ in a recent study, has been able to pro-
duce in rabbits and other animals herpes of the skin, tongue or
lips, and lesions in the corresponding spinal ganglion by the intra-
venous injection of emulsions of extirpated tonsils, of mixed and
pure streptococcal cultures from tonsils or pyorrhoeal pockets,
and of streptococci in pure culture from the spinal fluid. In the
affected ganglion were found, as a rule, hemorrhages and round-
cell infiltrations, and Gram positive diplococci and short chains. —
Ed.)
The mere loss of a sensory nerve or ganglion does not cause
nutritional disturbances in the skin or mucous membranes. This
has been sufficiently proved by the results of extirpation of the
Gasserian ganglion for facial neuralgia.^® After such extirpa-
tions, trophic disturbances of the skin over the face or of the
mucous membrane of the nose or mouth do not occur. Even the
cornea and conjunctiva remain intact if protected from direct
injury. The keratitis observed in animals after excision of the
trigeminus is due to the dry condition of the eye.®"^ Since in
man the eye may be kept moist by proper precautions, no keratitis
necessarily results after the nerve is severed.
LITERATURE
* Miinch. med. Wochenschft., 1896, Nos. 8 and 9.
' D. Gerhardt : Grenzgebiete, xiii, 501.
*Weed: Jour. Med. Research, 1914, xxvi (N. S.), no (lit).
* Weed : Jour. Med. Research, 1914, xxvi( N. S.), 91 (lit.).
'These subjects have recently been reviewed by Gushing: Jour. Med. Re-
search, 1914, xxvi (N. S.), I, and by Frazier, Jour. Am. Med. Assn.,
1915, Ixiv, 1 1 19.
' Gushing : Grenzgebiete, ix and xviii ; Amer. Jour. Med. Sc, cxxiv and cxxv
(N. S.) ; Kocher, in the Nothnagel System; Leonhardt, Zeitschft. f.
Chirurgie, Ixxi, 35- _ _
'Grashey: Allg. Zeitschft. f. Psychiatrie, xliii, 267.
* See Sauerbruch : Mitth. a. d. Grenzgeb., 3rd suppl., 1907.
" Wernicke : Gehirnkrankheiten, iii, 253 ; Strtimpell, Spez. Path. u. Therap. ;
Oppenheim, Die Geschwulste d. Gehrins, in the Nothnagel System.
" Gowers : Diseases of the Nervous System, ii ; Elschnig, v. Graf e's Arch, f .
Ophthalmologic, xli, II, 179.
" Lenhartz : Miinch med. Wochenschft., 1896, Nos. 8 and 9.
" Cf. Falkenheim and Naunyn : Arch, f . exp. Path., xxii, 301.
"See Quincke: Deutsche Klinik, vi, 351 (Mod. (Tlinical Medicine); Allard,
Ergeb. d. inn. Med., iii, 100; Stadelmann, Grenzgebiete, ii, 549.
"See Schmidt-Rimpler, in the Nothnagel System; Abelsdorf, in Lewandow-
sky's Handbuch, i, 873; Elschnig, 1. c; Leber, in Grafe-Saemisch. Handb.,
V, 759.
484 THE BASIS OF SYMPTOMS
"Grashey: 1. c. ; Kocher, in the Nothnagel System; Gushing, Grenzgebiete,
ix, ^^:s•, and Amer. Jour. Med. Sc, cxxiv, 375; Sauerbruch, Grenzge-
biete, 3rd suppl., 1907, 939.
"Gushing: 1. c. and Amer. Jour. Med. Sc, 1903, cxxv, 1017.
"C/. Kocher: 1. c; Trendelenburg and Windscheid, Neurolog. Zentralbl.,
1909, xxviii, 1 194.
"Bethe: Allg. Anat. u. Phys. d. Nervensystems, 1903; Nissl, Die Neuronen-
lehre, 1903.
"Mann: Monatsschrift f. Psych, u. Neurol., xii, 280; Bruns, Berl. klin.
Wochenschft., 1900, Nos. 25 and 26.
* Consuh Striimpell, Ziehen, KraepeUn and the studies of Breuer and Freud ;
Binswanger, Die Hysterie, in the Nothnagel System ; Kohnstamm, Thera-
pie d. Gegenwart, 191 1.
"Liepmann: Das Kxankheitsbild d. Apraxie, 1900; Die Storungen d. Han-
delns bei Gehirnkranken, 1905 ; Heilbronner, in Lewandowsky's Handb.,
i, 983 (lit) ; Wilson, Brain, ig*^.
""Erb: Kongr. f .inn. Med., 1904, 104; Bing, Beihefte z. Med. Klinik, 1907,
No. S; Erb, Miinch. med. Wochenschft, 1910, Nos. 21, 22 and 47 (lit.).
'^Erb: Die Thomsenesche Krankheit, 1886; Jensen, Arch. f. klin. Med.,
Ixxvii, 246.
'^ See Strumpell: Zeitschft. f. Nervenheilk., viii, 16 (lit.).
"Frenkel: Die Behandl. d. tabischen Ataxic, 1900 (translation into English
by Freyberger) ; Forster, Die Physiol, u. Path. d. Koordination, 1902 ;
Lewandowsky, Ataxic, in Lewandowsky's Handb., i, 815.
••Hering: Arch. f. exp. Path., xxxviii, 266, and Neurolog. Zentralbl, 1897,
No. 23.
" Beevor and Horsley : Philosoph. Trans., 1900, clxxxi, 129.
** Goldscheider : Zeitschft. f. klin. Med., xv, 82.
* Friedreich : Virch. Arch., Ixviii, 168.
•"Erb: Neurol. Zentralbl., 1895, No. 2; Vierordt, Berl. klin. Wochenschft.,
1886, No. 21.
** Frenkel : Neurol. Zentralbl., 1897, Nos. 15 and 16.
** Frenkel : Neurol. Zentralbl., 1896, No. 8.
" Striimpell : Arch, f . KUn. Med., xxii, 332 ; Heyne, ibid., xlvii, 75 ; v. Ziemssen,
ibid., xlvii, 89.
** Striimpell : Zeitschft. f. Nervenheilk, xxiii, i.
*^Liithje: Zeitschft. f. Nervenheilk, xxii, 280; Bickel, Miinch. med. Wochen-
schft., 1903, No. 5.
"Exner: Pfliiger's Arch., xlviii, 592; Striimpell, Zeitschft. f. Nervenheilk,
xxiii, i.
"See Ande Tomas: La fonction cerebelleuse, 191 1; Babinski, Revue de
medicine interne, 1909.
"Edinger: Neurol. Zentralbl., 1910, 706.
* Handb. d. Neurologic, i, 362.
*• Sternberg : Die Sehnenreflexe, 1893, 272.
" Integrative Action of the "Nervous System, 1906 ; tJber d. Zusammenwirken
d. Riickenmarkreflexe, in Asher-Spiro, Ergeb., 1905, iv, IL
** L. R. Miiller : Zeitschft. f . Nervenheilk, xxi, 86.
** See Sternberg: Die Sehnenreflexe (ht.) ; Lewandowsky, Handb. d. Neu-
rologic, i, 582; G. Hoffmann, Rubner's Arch., 1910, 223.
^Sternberg: 1. c, 178; Jendrassik: Arch. f. klin. Med., Hi, 569.
"Cf. Bickel : Zeitschft. f. Nervenheilk., xxi, 304.
* Sternberg: 1. c, 142 (lit) ; D. Gerhardt, Zeitschft. f. Nervenheilk., vi, 127;
Bruns, Arch, f . Psych., xxv, 759, and xxviii, 133 ; Nonne, ibid., xxxiii,
393; Kron, Zeitschft. f. Nervenheilk., xxii, 24; Kausch, Grenzgeb., vii,
541.
•Munk: Sitzungsber. d. Preuss. Akademie, xHv.
THE NERVOUS SYSTEM 485
** Jendrassik : 1. c; Ziehen, Ergebnisse, etc., 6i6; Striimpell, Zeitschft. f.
Nervenheilk., xv, 254.
** Arch, f . exp. Path., xliv, 369 ; Meyer, Festschrift f , Jaffe, 297.
*Loewi and Hans Meyer: Arch. f. exp. Path., Schmedeberg Festschrift
(1908), 355.
" See Monakow : Gehirnpathologie, in the Nothnagel System ; Lewandowsky,
Handbuch, i, 685.
"Munk: Du Bois' Arch., 1896, 564; Sitzungsber. d. Preuss. Akad., xxxi, 823.
** Monatschefte f. Psych, u. Neurol., i, 409; iv, 45, 123.
" Pfliiger's Arch., Ixx.
** See Sternberg : Die Sehnenreflexe, etc., Leyden and Goldscheider, Krank-
heiten d. Ruckenmarks, 117; Munk, 1. c.
**Die Kontrakturen bei d. Erkrankungen d. Pyramidenbahn, 1906.
"Mobius: Diagnostik, 2nd edit.; Stephan, Arch. f. Psych., xviii, 734, and
xix, 18.
" Bonhoeff er : Monatshef te f . Psych, u. Neurol., i, 6, and x, 383.
** Bonhoeffer : Monatshefte f . Psych, u. Neurol., iii, 239
*" Foerster : Die Mitbewegungen, 1903.
*^ See especially Binswanger : Die Epilepsie, in the Nothnagel System ; Fuchs,
Wiener klin. Wochenschft., 1910, No. 17.
**v. Frey: Berichte d. Kgl. S. Gesellschaft d. Wissenschaften, math.-phys.
Kl., March 4, 1895 ; Abhand. d. Sachs. Ges. d. Wissenschaften, xxiii, 175.
" Uber den Schmerz, 1894.
"Head: Kongr. f. inn. Med., 1909, 168; Head, Rivers and Sherren, Brain,
190S, 1908.
"Goldscheider: Mediz. Klinik, 1911, No. 8; Zeitschft. f. inn. Med., Ixxiv, 270.
*• See Ziehen : Ergebnisse, etc., 604.
" Cf. Hartmann : Die Orientierung, 1902 ; v. Cyon, Das Ohrlabyrinth als
Organ, etc., 1908.
** Bickel : Deutsch. med. Wochenschft., 1901, No. 12.
"Kreidl: Pfliiger's Arch., li, 119.
"Hitzig: Der Schwindel, in the Nothnagel System (lit.).
' See Frankl-Hochwart : Menieres Symptom-Complex, in the Nothnagel Sys-
tem (lit.) ; Barany, in Lewandowsky's Handbuch, i, 919; J. R. Ewald,
Vortrag auf. d. siidwestdeutsch^n Neurologenversamm., 1910.
" Ziehen : Ergebnisse, etc., 604.
''Goldscheider: Uber den Schmerz, 1894, 24 et seq. ; Schaffer, Neurolog.
Zentralbl. 1909, 224.
" See Nissl : Die Neuronenlehre, 1903 ; Held, Die Entwickelung d. Nervenge-
webes, 1909; Bielschowsky, in Lewandowsky's Handbuch., i, 3.
"Jour, of Exp. Zoology, iv, 239; ibid., ix, 787. See also Barker, Jour. Am.
Med. Assn., 1906, xlvi, 929, 1006; Ingebrigsten, Studies from the Rocke-
feller Inst., 1914, xviii, 350.
"Bethe: Allg. Anat. u. Phys. d. Nervensystems, 1903.
"See Marinesco: Neurol. Zentralbl., 1892, 463, 505, 564 (lit); Bethe, 1, c;
Marinesco, La cellule nerveuse, 1909.
"Rumpf: Arch. f. klin. Med., Ixxix, 158; Reiss, Die elekt. Entartungs-
reaktion, 191 1, 7^-
*• Jamin : Exp. Untersuchungen zur Lehre v. d. Atrophie gelahmter Muskein,
1904 (lit.).
"Erb: Elektrotherapie, 2nd edit.; Biedermann, Elektrophysiologie, 1895;
Reiss, 1. c.
"C/. Achelis (Schenck) : Pfluger's Arch., cvi; Reinecke (Verworn), Zeit-
schft. f. allg. Phys., viii, 422; Schenck, Marburger Sitzber., 1904, No. 2.
*■ Wiener : Arch, f . klin. Med., Ix, 264.
"Krehl: Unpublished experiments.
** Cf. Wilke and Meyerhof : Pfluger's Arch., cxxxvi, i.
486 THE BASIS OF SYMPTOMS
" Reiss : 1. c
**Rumpf:l. c
" See Wiener : Arch, f . klin. Med., Ix, 264.
"Quincke: Arch. f. klin. Med., xlii, 492; Steinert, Zeitschft. f. Nervenheilk.,
xxiv, i.
" Goldscheider : Berl. klin. Wochenschft., 1894, 421 ; Steinert, 1. c, and Arch.
f. klin. Med., Ixxxiv, 445.
•"Charcot: Lectures; Charcot, Progres med., April i, 1893; Strumpell,
Munch, med. Wochenschft., 1888, No. 13.
" Sulzer : Anat. Untersuchungen viber Muskelatrophie artik. Ursprungs, Fest-
schrift f. Hagenbach-Burckhardt, 1897.
"See Bing: Arch. f. klin. Med., Ixxxiii, 199; Forster, Charite-Annalen, xxxii.
''Charcot's Lectures; Weizsacker, in Brun's Beitrage, iii, 22; Kredel, Volk-
mann's Vortrage, No. 309.
•* Oppenheim and Siemerling : Arch, f . Psych., xviii, 98, 487.
•'Rosenow and Oftedal: Jour. Am. Med. Assn., 1915, Ixiv, 1968.
" F. Krause : Die Neuralgic d. Trigeminus, 1896.
"E. V. Hippel, Jr.: Graefe's Arch^ xxxv, 217 (lit).
INDEX
Abderhalden reaction, i86, 187
Abdominal angina, 259
Abdominal muscles, function of, 290
Absorption, disturbances of gastric,
254
of intestinal, from alteration
of bowel contents,
282
in absence of bile, 265
in diseases of bowel, 282,
283
in pancreatic disease, 273,
274
Acapnia, as a cause of shock, 88
Accelerator nerves, influence of, upon
heart beat, 55
Accidental murmurs, 75
Acetanilid, action of, on red blood-
corpuscles, 120
Acetic acid, in urine, in metabolic dis-
orders, 329
Acetone bodies, formation of, 328-332
occurrence of, 329
in diabetes, 330, 358
toxic action of, 332
Achylia gastrica, 237
gastric motility in, 250
Acid intoxications, effect of, upon the
heart, 332
upon the nervous system, 332
upon respiration, 210, 224, 332
upon the temperature, 332
origin of, 328
treatment of, 333
Acidosis, in chronic hepatic disease,
328
in diabetes mellitus, 330, 332,
333, 358
nature of, 329
origin of, 330
respiratory disturbances due to,
210, 224, 332
Acids, organic, origin of, in intes-
tinal contents, 281, 330
in the body, in metabolic dis-
orders, 327, 328, 329
in the stomach, in stagnation,
246
significance of, in the causation of
diarrhoeas, 287
toxic manifestations of, 332
Acromegaly, relation of hypophysis
to, 372
Adams-Stokes symptom-complex, dis-
turbances of cardiac rhythm in, 68
Addison's disease, significance of
adrenals in, 336
Adenie. See Pseudoleukaemia.
Adolescence, albuminuria of, 421
Adrenalin. See Epinephrin.
Agglutination and agglutinins, 174
Aggressins, i57, 190, 279
Air, effect of composition of, on
respiration, 215, 218
of pressure variations of, on res-
piration, 215
on the blood, 143
Air-passages (see also Respiratory),
infections of, 153
stenoses of, pulsus paradoxus in,
70
respiratory disturbances in,
201-204
sterility of the lower, 153, 199
Albumin, percentage of, in the blood-
serum, 137
Albuminuria, 420-425
alternation of, with haemoglobi-
nuria, 118
causes of pathological, 423
of physiological, 420, 421
due to circulatory disturbances,
423
to intoxications, 423
following ingestion of egg-albu-
min, 426
psychic disturbances, 421
cold-baths, 421
in amyloid kidney, 419
in diabetes, 359
in haemoglobinaemia, 121
in the infectious diseases, 421, 423
in nephritis, 423, 424
injuries of renal epithelium, rela-
tion of, to, 422-424
occurrence of, in families, 421
orthotic, 421
pathogenesis of, 422
physiological (functional), 420
relation of, to renal oedema, 140
results of, 428
total daily excretion of, 425
varieties of albumin in, 422, 424,
426
Albumosuria, in metabolic disturb-
ances, 326, 427
in fever, 398
487
488
INDEX
Alcoholism, chronic and gout, 367
arterial changes in, 86
as a cause of cardiac weakness, 37
of increased blood-pressure
and cardiac hypertrophy, 30
dilatation of heart in, 30, 31
effect of, upon accumulation of
fat, 313
upon the body temperature,
410
Aleuksemic leukaemias, 127, 129, 132
Alexins, 165, 188
action of, 118, 166, 167, 173-174
source of, 165
varieties of, 169
Alkaptonuria, 334-336
Allergic. See Anaphylaxis.
Amboceptors, 165, 166, 167, 168, 189
action of, according to Ehrlich's
side-chain theory, 166
according to Metchnikoff, 189
effect of cold upon, 118, 160
relation of, to alexins, 165, 166
Aminoacids, in hepatic disease, 326
in the blood, 138, 139
normal metabolism of, 335
of the urine : origin of, from hy-
drolytic cleavage of pro-
teids, 325, 326
normal, 326
source of, 335
Ammonia, excretion of, as urea, 327,
333
in urinary stasis, 433
increased formation of, patho-
logical, due to proteid de-
struction, 327, 328
physiological, 327
role of, in neutralization of
harmful acids, z^l, 328, 334
Amyloid degeneration of the kidneys,
behavior of heart in, 26, 32
oedema in, 92
urine in, 419
Anaphylactic shock, 87, 179, 205
Anaphylaxis, 178-187
development of, during immu-
nization, 178
infection and, 183, 184
local reactions in, 183, 186
mode of origin of, 180, 181
passive, 180
relation of, to hay fever, urti-
caria, eclampsia and echino-
coccus disease, 184-186
to infection, 183, 184
serum disease as a manifestation
of, 180, 185
symptoms of, 179, 181
transmission of, 180
Anaphylatoxin, 181, 183, 184
in relation to fever, 404
Anasarca, cutaneous, factors under-
lying, 89-94
Ansemia, 102
acute, due to hemorrhage, 103
aplastic, 115
blood-flow in, 89
blood, in pernicious, iii-iiS
in secondary mild and moder-
ately severe, no, iii
body temperature in, 1 12
bone-marrow in, 106, 115
chronic, 104
cardiac insufficiency in, 41
due to deficient and improper
food, no
to repeated hemorrhages,
109
types of, 109
differentiation of various forms
of, 112, 113, 114
essential (Biermer) type of, 112-
114
gas interchange in lungs, in, 219
general blood changes in, 105, 106
in miners, 104
mild and moderately severe sec-
ondary, causes of, 104, 109, no
nervous system in, pernicious, 112
nutritional disturbances in, 319
oedema in, 94
pernicious, in
primary, 109
pulse frequency in, 55
severe, course of, 114
Aneurism of the aorta, hypertrophy
of left ventricle in, 23
stenosis of upper air-passages
caused by, 200
Angina, abdominal, 259
Angina pectoris, 79
etiology of, 79
sudden death, due to, 80
symptoms of, 79, 80
vasomotoria, 80
Ankylostoma duodenale, ansemia due
to, 104, 113
Anoci-association, 88
Antianaphylaxis, 182, 185
Antibodies, action of, with antigen,
content of, in immune sera, 176
immunization with prepared, 162
increase of, in the body, 162
persistence of, in the blood, 161,
162, 171
source of, 167, 170
Antiferments, in the blood-serum,
138
INDEX
489
Antigens, characteristics and action
of, 172, 173
Antiperistalsis, gastric, in pyloric
stenosis, 255
oesophageal, 234
intestinal, in ileus, 285, 294
normal, in colon, 285
Antitoxins, action of, 170, 176
origin of, 162, 170
union of, with the proteids of the
blood, 170
Anuria, in renal circulatory disturb-
ances of nervous origin, 416
in uraemia, 431
Aortic insufficiency, blood-pressure in,
14
character of heart-tones in, 74, 75
combined with aortic stenosis, 19
compensation in, 33, 35
effect of, upon lungs and respira-
tion, 13, 35
murmurs in, 74, 75
pain in, 78
pulse in, 35
pulse-pressure in, 14, 83
relative, 12
significance of syphilis in etiology
of, ID
Aortic stenosis, 15
bradycardia in, 61
heart murmurs in, 75
hypertrophy of left ventricle in,
15. 23
precordial pain in, 78
Aortic tones, character of, in chronic
nephritis, 74
accentuation of, 71
Aplastic anaemia, 115
Apoplexy, blood-pressure in, 447
cause of, 448
symptoms of insult in, 448, 449
Appetite, and hunger, 257, 258
causes of loss of, 258
disturbances of, in affections of
mouth, 230
influence of, on secretion of gas-
tric juice, 238, 240
loss of, in fever, 404
Apraxia, 450
Arneth's classification of the poly-
nuclear leucocytes, 121
Arrhythmia, cardiac, 62-70
accompanying lesions of His
bundle, 42, 45, 6^
as a result of disturbances of
conductivity, 42, 45, 67, 69
associated with dyspepsia, 70
due to cardiac muscle disease,
69
due to poisons, 70
Arrhythmia, cardiac, due to vagus
stimulation, 45, 67, 69, 70
extrasystolic, 63
in nervous conditions of
heart, 69
perpetual, 65
reflex, 63, 70
respiratory, 69, 70
sinus, 70
Arsenic, value of, combined with iron,
in chlorosis, 109
Arseniuretted hydrogen poisoning,
composition of bile in, 261
haemoglobinaemia in, 117
Arterial paralysis, 85
heart beat in, 55
symptoms of, 86
Arteries, hypertension in, 81
increased resistance in, in neph-
ritis, 26, 27, 28
inflammatory lesions of, 27, 87
influence of heart upon, 80, 88
narrowing of, in cases of local
dilatation elsewhere, 2, 80
rupture of, 34
sclerosis of, 80
significance of, in the circulation,
80
spasm of, 2T, 79, 81
tonus of, 26-28, 80
varying diameter of, 80, 88
Arteriosclerosis, cardiac hypertrophy
due to, 20, 22
cardiac insufficiency due to, zTt
39, 48 .
contracted kidney associated with^
27
disturbances of locomotion due
to, 452
heart sounds in, 72
increased arterial pressure in, 22^
22,. 80, 84
in diabetes, 359
pulse-pressure in, 83
vasomotor disturbances in, 88
Arthritis alkaptonurica, 335
deformans, 481
and focal infections, 153
Artificial pneumothorax, 213
Ascites, chylous and chyliform, 94
with anasarca, 91
Asphyxia, arterial spasm in, 85, 223
blood in, 222
heart-beat in, 59, 223
nervous disturbances in, 223
occurrence and manifestations of^
103, 222
urine in, 416
Associated movements, 466
Asthenic bulbar paralysis, 452
490
INDEX
Asthma, bronchial, 204-206
behavior of lungs in, 205, 206
complications and exciting causes
of, 205
nature of paroxysm in, 205, 206
nervous, 205
relation of, to anaphylactic shock,
205, 206
symptoms of, 204
Asthma cardiac, causes of, ^^
lungs in, 78
Asthma dyspepticum, 211
Ataxia, 450, 455-458
and centripetal influences, 455
in cerebellar disease, 458
tabetic, 454
origin of, 455
types of, 458
Atelectasis, pulmonary, 213
*' Athlete's heart," 29
Atmospheric pressure, effect of, on
blood, 143
on respiration, 215
Atony of the stomach, 253, 254
Atophan, in gout, 370
Atrophy, muscular, through disuse,
477, 480
electrical reactions in, 477-479
Atropin poisoning, diminution of buc-
cal secretions in, 230
effect of, on the heart-beat,
54, 61
Auricular tone in gallop rhythm, t^
Autoinfection, 193
enterogenous, 280
Autolysis, 325
Bacillus carriers, 191
Bactersemia, 159
Bacteria, fever-producing, 381, 382
general intoxication due to, 157
importance of capsule of, 157
of the number of, 157
minimum lethal dose of, 157
natural resistance to, 161, 162
portals of entry of, 151, 157
toxins of, 157
upon the body-surfaces, 151, 193
virulence of, 157
increase of, by symbiosis, 160
Bacterial processes, in the biliary pas-
sages, 262-264
in the intestines, 277-282
advantages of, 277, 278
effect of variations in
diet upon, 278
in the absence of bile, 266
pathogenic action of, 279
in the mouth, 229, 230
in the stomach, 245-^48
Bacterial processes, in stomach, fol-
lowing introduction of
decomposable food, 248
in gastric atony and dila-
tation, 246, 254
in the absence of free
acid, 247
results of, 248
in the urinary passages, 433
Bactericidal action of blood-serum,
162, 163, 164, 176
Bacteriohasmolysins, 159
Bacteriolysis, products of, 165
Bacteriotropins in bacteriolytic im-
mune sera, 189, 190
Basedow's disease. See Hyperthy-
roidism.
Baths, cold, albuminuria following,
421
in fever, 401
Beer, effect of excessive use of, on
alimentary glycosuria, 344
on the formation of fat, 313,
315
on the heart, 30, 37
on the kidneys, 30
Belching, 255
Benzene therapy in leukaemia, 129, 131
Beta-oxybutyric acid in the urine in
diabetes, 329, 330, 358
in metabolic disorders,
328-332
Biermer's ansemia, 112. (See also
Pernicious anaemia.)
blood regeneration in, 114, 115
Bile, action of, on pancreas, 275
changes in, due to action of
poisons on blood and liver, 261
effect of exclusion of, from Intes-
tines, 265
in haemoglobinaemia, 116
pigment content of, in conditions
of stasis, 260
resorption of, into circulation,
266-^68
Bile, resorption of, effect of, upon the
body, 270
upon the heart-beat, 60,
270
Bile secretion, anomalies of, in
amount, 260, 261
in composition, 260, 261
in intoxications, 261
disturbances of, by bacterial
action, 262
by calculi, 261
by exclusion from intes-
tines, 265, 266
INDEX
491
Bile secretion, effects of disturbed:
jaundice, 265, 266
upon the intestines, 265
Bile, stasis of, and biliary calculi, 262,
264
anatomical changes in liver
in, 270, 271
cerebral symptoms in long-
continued, 271
local from obstructions in
smaller capillaries, 267
Biliary colic. See Gall-stones.
Biliary salts, effect of, on pulse, 60,
270
on red blood-corpuscles,
117
Black-water fever, 117
Bladder, causes of tenesmus of, 437
innervation for emptying of, 459
Blood, conditions essential to arterial-
ization of, 208
effect of composition of, upon
respiration, exter-
nal, 219
internal, 223, 224
upon the secretion of
urine, 426
in acid intoxications, 224
in anaemias, 105, 106, no, 111-116
in burns, 119
in cardiac dilatation, 141, 142
in changes in atmospheric pres-
sure, 143-145
in chlorosis, 107-iog
in circulatory disorders, 141, 142
in congenital heart lesions, 50
in gout, 368
in hydraemia, 139-141
in leukaemia, 129^133
in nephritis, 140, 141
in phosphorus and carbon mo-
noxide poisoning, 145, 219, 225
in pseudoleukaemia, 128, 130, 132-
regeneration of, 103, 105, 100, 114
sites of formation of, 102
Blood coagulation, after destruction
of erythrocytes, 120
factors concerned in, 120,
126, 135. 136
in intoxications and burns,
120
in severe anaemias, 127
time of, 136
Blood-corpuscles, red, anomalies of,
after burns, 119
in anaemias, 103-106, 107, no,
III, 114-116
in form, 105, in
Blood-corpuscles, red, in haemoglobin,
105, 107, III
in staining properties, 105
in structure, 105, 119
changes in haemoglobin of, by
conversion into met-
haemoglobin, 116, 117,
118, 119, 120
by destruction of the
stromata, 116, 117, 118,
119, 121
significance of, 120
effect of blood-plasma upon, 103
of oxygen deficiency upon,
142
in chlorosis, 107
nucleated, 105, 107, in, 113, 116,
130, 143
number of, in cardiac disorders,
51, 142
in low atmospheric pressures,
143
pathological increase of, per
volume-unit, 142
regeneration of, 105, 115
resistance of, to haemolysins, 118
to hypotonic salt solutions,
115.269
Blood-corpuscles, white, chemical
characteristics of different
types of, 122
eosinophilic, 125, 205
ferments of, 122, 188, 189
granules of, 121
in anaemias, 107, in, 126
in leukaemias, 128-133
number of, 123
diminished (leucopaenia),
III, 126
increased (leucocytosis),
123-126
physiologically, 123
pathologically, 103,
III, 124, 128
percentage of different forms
of, in leucocytoses,
123, 124, 125
in leukaemias, 129
in normal blood, 121
in pseudoleukaemias, 128
phagocytic properties of, 187-
189
polymorphonuclear, 121, 123,
124
Arneth's subdivision of,
121
source of, 122
lymphoid, 122
myeloid, 122
49£
INDEX
" Blood diseases," behavior of haemo-
globin and red cells in, 102
definition of, 102
origin of, 102
Blood-flow, rate of, in relation to
systolic pressure, 48
significance of cardiac accelera-
tion on, 59
through the kidneys, effect of, on
secretion of urine, 413,
416
on albuminuria, 423
(See also Circulation and Circu-
latory disturbances.)
Blood-plasma, antibacterial and anti-
toxic properties of, 163-165
fibrin content of, 136
proteids of, 137
solution of haemoglobin in, 116,
117, 118, 119
Blood-platelets, ferments of, and
coagulation, 126
in leuksemia and pernicious
anaemia, 127
Blood-pressure, arterial, effect of, on
heart-beat, 55, 59, 63
on secretion of urine,
413, 316
diastolic, 82
diminished, results of, 55, 85, 416
effect of exercise upon, 83
increased, 80, 81, 84
as a cause of left ventricular
hypertrophy, 29
associated with polythemia
and splenomegaly, 142, 146
causes of, in nephritis, 26, 27,
28, 29
in broken compensation, 40
in infections of renal pelves,
26
results of, 34, 59
in aortic insufficiency, 14
in arteriosclerosis, 22, 23, 27
in compensated hearts, dangers
. °^' 34 .
in dyspnoeic conditions, 24
in nephritis, 25-29
physiological variations of, 83
regulation of, 80, 81, 88
systolic, 82
venous, increased, 47, 48
results of, 50^-52
Blood, quantity of, diminished, iii,
112, 146
increased, 145
without alterations in the
serum, 145, 146
with watery scrum, 92,
139
Blood, quantity of, in chlorosis, 107
in the body : its distribution
per unit of time in circula-
tion, 345
in the kidneys, and influence
of same upon secretion of
urine, 413
Blood-serum, action of, upon chemi-
cal substances, 165, 170
curative and immunizing ac-
tion of, 162-165
enzymic action of, 138
fat content of, 137
ferment inhibitory action of,
138
functional differentiation of,
from plasma, 135
proteids of, 137, 138
in hydraemia, 139
in leukaemia, 131
residual nitrogen of, 138, 430,
431
salt content of, 137, 139
water in, 137, 139^141
in chlorosis, 107
in pernicious anaemia, ili
in renal oedema, 92
Blood supply, to brain, 441
to heart, 40
to the organs, effect of vascu-
lar tonus upon, 80
Blood toxins, haemolytic and met-
haemoglobin forming, 117
Blood, total solids of, in polycy-
thaemia, 142
in pernicious anaemia, 112
Blood-vessels, circulatory disturb-
ances in, 3
in the arteries, 80, 81
in the veins, 88
effect of tobacco upon, 31
hypertonus of, in arterio-
sclerosis, 22, 23
essential, 29, 81
in chronic nephritis, 25-
29, 84
injuries of, as a cause of
anaemia, 103
role of, in movement of
blood, I, 80
Body, position of : change from hori-
zontal to vertical as a cause of
albuminuria, 421
Body weight, in fever, 404
in inanition, 309
in obesity, 314
Bone, diseases of, due to nutritional
disturbances, 481
INDEX
493
Bone-marrow changes in anaemias,
105, 106, III, 114, 115, 116
in leuksemia and pseudo-
leukaemia, 127, 128, 133
genetic significance of, 133
in polycythemia, 142
Bothriocephalus latus, as a cause of
anaemia, 113, 114
Botulism, 276
Bradycardia, causes of, 59^2
in Adams-Stokes disease, 68
significance of, for the circula-
tion, 62
Bronchial stenosis, causes of, 203
effect of, upon respiration,
203, 204
in bronchial asthma, 204, 206
Bronchiolitis exudativa, relation of,
to asthma, 205
Bronchitis, as a cause of cardiac
hypertrophy in children, 21
gaseous interchange in, 222
in passive hypersemia of lungs, 34
respiratory movements in, 204
Brown atrophy of the heart, in medi-
astino-pericarditis, 24
pathological significance of,
43
Brown-Sequard paralysis, character-
istics of, 470
Bulbar paralysis, asthenic, muscular
weakness in, 452
salivation in, 231
Bundle of His, relation of to heart
block, 42, 45. 67
Burns, blood changes due to, 119
Cachexia, blood in, 126
in diabetes, 358
strumipriva, 322
Caisson disease, 218
Calculi, biliary, 261
urinary, 434
Caloric needs of the body, 305
Capillaries, circulation in, 2, 3
Carbohydrates, metabolism of, 310,
311, 3^2
quantitative disturbances of,
343
in diabetes, 349 350
therapeutic value of, in acidosis,
330
Carbon dioxide, amount of, in blood
in acid intoxications, 224
anaesthetic action of, 222
Carbon monoxide poisoning, blood in,
114 219
respiratory disturbances in. 219
Carcinoma of the stomach, digestion
of proteids in, 245
proteolytic ferments in, 245
secretion of hydrochloric
acid in, 244
Carcinomatosis, anaemia in, 109
pernicious form of anaemia in,
113
proteid destruction in, 319 320
valvular disease in, 9, 10
Cardiac im.pulse, 70
pain, 78
and anxiety, of local origin,
78
of psychic origin, 78
Cardiac output per beat, and the
pulse-pressure, 82, 83
Cardjalgia, 259
Cardiography, 71
Castration, relation of, to fat deposits,
317
Casts in urine, in nephritis, 425
Cells, destruction and solution of, 165
effects of, on increase of living
substance, 311
effect of nervous system upon,
474
ferments of, and the splitting of
proteid, 325, 326
gas metabolism of, 197, 223-225
oxygen need in, 223, 224
metabolism of, 304
proteid destruction in, 327,
397, 398
proteid need in, 306-308
sugar need in, 343
resistance of, to bacterial poisons,
161, 278
side-chains of, 166
Cerebral concussion, 447
embolism, 449
hemorrhage, 448
Cerebral cortex, circulatory disturb-
ances of, 441
motor function of, and its
disturbances, 451
Cerebral pressure, 443
blood-pressure in, 446
causes of, 443-445
choked disk in, 445
direct manifestations of, 446
due to hemorrhage, 443, 447
in brain tumors, 444
in chronic hydrocephalus, 444
in meningitis, 444
indirect (latent) symptoms
of, 445
pulse in, 59, 446
respiratory movements in, 446
494
INDEX
Cerebral symptoms, In anaemia, 112,
441, 442
in Cheyne-Stokes respiration,
209
in diabetes, 332, 333
in fever, 386
in functional disturbances of
nervous system, general
and focal, 441
in stasis of bile, 270, 271
Cerebral tumors, pressure symptoms
in, 444, 445, 446
Cerebrospinal fluid, composition of,
443. ^ . ^
secretion and resorption of,
443
significance of, in increased
intracranial pressure, 443~
447
Cervical cord, injuries of, eflFect of,
on temperature, 385, 387, 388
Charcot-Leyden crystals, in the blood,
in leukaemia, 131
in the sputum, in asthma, 205
Chemotaxis, importance of, in leuco-
cytosis, 124
Chemotherapy, in infectious diseases.
Chewing, disorders of, and digestion,
229, 230
Cheyne-Stokes respiration, manifes-
tations of, 2og
theories as to cause of, 209,
210
Chloral, eflfect of, on vasomotor cen-
ter, 86
Chlorosis, blood in, 107
causes of, 107, 108
color of skin in, 106
incidence of, 106
intracranial pressure in, 444
parenchymatous changes in, 107
significance of hypolastic aorta in,
107
value of iron in, 108
water retention in, 107, 146
Choked disk, 445
Cholera Asiatica, blood in, 139
stools in, 283
vibrio of, distribution of, 279
increases of, in bowel,
iss, 157
toxic action of, 159
Cholesterin stones, 262
Chorea, disturbances of motility in,
466
Chromium nephritis, 424
Chylous and chyliform ascites, 94
Cilia, protective function of, 197, 198
Circulation, i
anomalies of, 1
demands on, in health, 3, 4
in anaemia, 220
in aortic insufficiency, 12, 35
in the arteries, 2, 80
in the capillaries, 2
in compensated cardiac lesions,
33-35
in cardiac weakness, 46-52
in tachycardia, 59
in the kidneys, and secretion of
urine, 413, 416
in the veins, 2, 88
pulmonary, i, 2
in aortic insufficiency, 13
influence of, on respiration,
220
relation of blood-pressure
and rate of flow in, 3
significance of, in the func-
tioning of the organs, i
significance of the contrac-
tile and elastic attributes of
arteries in, 5, 6, 80, 81
systemic, 2
Circulatory disturbances, blood in,
141, 142
effect of, on composition and
secretion of urine, 413,
416
en respiration, 220, 223
in the arteries, 80, 81
in asphyxia, 85, 222
in the brain, manifestation of,
441, 442
in infectious diseases, 86, 87
in nephritis, 25
in pneumothorax, 213
in shock, 87, 88
in the veins, 50-52, 88, 90
Coagulation of the blood. See blood
Coagulation
Cold, action of, in paroxysmal haemo-
globinuria, 1 18
on the body temperature, 389
Colic, biliary, 264
gastric, 258
intestinal, 297
renal, 437
Colica mucosa, 287
Collapse, in dilatation of stomach,
255
in fever, causes and symptoms of,
4c:^, 409
in infectious diseases, circulatory
changes in, 86, 409
temperature in, 408
INDEX
495
Colloids, increased hydration capacity
of, as a cause of oedema, 93
to precipitation, 172
relation of, to agglutination, 175
Color-index in pernicious anaemia,
III, 113
Coma, acidosis as a cause of, 332
carcinomatous and enterogenous,
332
diabetic, 332, 333, 358
symptoms and treatment of,
332, 333 .
Compensation, cardiac, blood-pressure
in disturbed, 40
cause of breaks in, in hyper-
trophied hearts, 38
in non-hypertrophied, 40
transitory and permanent
breaks in, 38, 39
value of digitalis in loss of,
39, 66
Compensatory regulations, in chronic
inanition, 309, 310
in heart disease, 2
in respiratory diseases, 221
Complement. See Alexins
fixation, mechanism of, 173
Concussion, cerebral (Commotio
cerebri), 447
Congenital heart disease, lesions of,
18
polycythemia in, 142
Constipation, 288-291
bradycardia in, 60
in hyperacidity, 243
Constitutional diseases, as sequelae of
other diseases, 377
causes of, 377
chronic course of, 376
definition of, 376
etiology of acquired, 377
general bodily changes in, as
distinguished from local,
374, 375
metabolism in, 372
predisposition to, 376
relation of, to chronic infec-
tions, 375
to chronic intoxications,
378
to diatheses, 376
Contagion, relation of virulence to,
157
Contraction of the heart, mechanism
underlying, 53, 54
Contractures, 463-466
Convalescence, heart action in, 55, 61
nitrogen retention in, 310
temperature in, 402, 409
Convulsions, causes of, 467
Convulsions, clonic and tonic, 467
epileptic, 467, 468
fever, after cerebral, 386
in Adams-Stokes disease, 68
in chronic biliary obstruction, 270
in hepatic toxaemias, 271
in Jacksonian epilepsy, 467
in strychnin poisoning and te-
tanus, 462
in uraemia, 429
point of origin of epileptic, 468
reflex, 462, 467
spontaneous, 467
Coordination, disturbances of, in cere-
bellar disease, 458
in tabes, 454, 4.55, 457
theory of, 452-455
Coronary disease, as a cause of heart
weakness, 40, 41
bradycardia due to, 62
pain and anxiety in, 78, 79
relation of, to Adams-Stokes
disease, 68
to angina pectoris, 79
sudden death in, 80
Coughing advantages and disadvan-
tages of, 200
centre for, 198, 199
diminished, 199
mechanism of, 198
Creatinin in urine of febrile patients,
399 .
Cretinism, relation of thyroid to, 322
Crises, gastric, of tabes, 259
Curschmann's spirals, in asthmatic
sputum, 205
Cutaneous reflexes, 462
Cutaneous sensations, disturbances of,
455,. 456, 457, 468, 469-471
irritative phenomena in, 473
Cyanosis, caused by venous stasis, 50
congenital, 50
gas content of blood in, 224
Cyanotic induration of kidneys, heart
in, 30
Cystin calculi, 336
Cystinuria, 336
Cystitis, causes and dangers of, 433
Cytodiagnosis, 94
Cytolytic properties of blood serum,
165, 166
Decubitus, 482
Defecation, bacterial inhibiting action
of, 280
complete cessation of: results,
293, 294, 295
increased frequency of, 285-288
innervation for, 460
painful, 299
496
INDEX
Degeneration, fatty, in pernicious
anaemia, 112
glycogenic, of the renal epithe-
lium, 359
of the heart muscle, functional
significance of, 43
of the muscles, 451, 477
of the nerves (secondary), 474
in pernicious anaemia, 112
of the red blood-corpuscles, in
anaemia, 104, 105, 114
Delirium in long-continued biliary
stasis, 271
Developmental anomalies of heart and
large vessels in the etiology
of valvular lesions, 18
as a cause of venous stasis
and cyanosis, 50, 51, 142
Diabetes insipidus, 414-416
causes of, 415
hypophysis and, 415
influence of composition of
blood upon, 425
nature and symptoms of, 414,
415
relation of ; to diabetes melli-
tus, 414
vasomotor influences in, 415
Diabetes mellitus, 349
acidosis in, 328, 329, 330, 358
amount of urine in, 359, 425
anomalies of sugar combus-
tion in, 353
causes of sugar excretion in,
349, 352
coma in, 332, 358 _
composition of urine in, 349,
359
constitutional character of,
378
etiology of, 356
glycosuria in, 349, 350
hyperglycemia in, 349, 352
limit of assimilation for car-
bohydrates, 350, 352
mild and severe forms of, 350
nutritional disturbances in,
357-359
oxidations in, 355
pathology of, 356
proteid destruction in, 358
proteid intolerance in, 351
renal, 346
respiratory quotient in, 353
results of, 357, 358, 359
role of internal secretions in,
.356
significance of liver in, 352,
353, 356
Diabetes mellitus, significance of pan-
creas in, 354, 355, 356, 357
stomatitis and dental caries
in, 229, 359
sugar consumption in, 353
sugar formation in : from
carbohydrates and proteids,
350, 352
thirst in, 359
utilization of dextrose in, 357
Diacetic acid in the urine, 329
Diaminuria, 336
Diaphragm, paralysis of, as a cause of
respiratory disturbances, 207
Diarrhoea, causes of, from without
the bowel, 286
from within, by irritation of
abnormal contents, 287
effect of, on the body, 288
faeces in, 285, 286
gastrogenous, 236
increased peristalsis of colon in,
285
infantile, 280
in uraemia, 429
nervous, 286
without subjective disturbances,
286
Diastole, disturbances of, and their
effect upon cardiac efficiency, 46
split heart tones at beginning of,
73
variations in length of, 5, 46
Diathesis, differentiation of, from
constitutional disease, 376, 378
eosinophihc, 379
exudative, 379
syphilitic, 375, 377
uratic, 376, 379
Digestion, bacterial processes in, 245,
254, 277
disturbances of, due to abnormal
processes in bowel, 276
absence of pancreatic
juice, 273, 274
anomalies of absorption,
282 _
bacterial activity, 277
disorders of motility, 284
narrowing of bowel
lumen, 291
due to affections of teeth,
mouth and throat, 229
due to disturbances of biliary
secretion, 265
due to oesophageal disease,
232
due to gastric disorders, 236
gastric dilatation in, 251
INDEX
497
Digestion, disturbances of, due to gas-
tric disorders, motor
disturbances in, 248
psychic origin of, 260
regurgitation and vomit-
ing in, 255
secretory disturbances in,
237
leucocytosis in, 123
Digitalis, action of, upon the heart,
39, 42, 66, 67, 68
upon the kidneys, 414
Dilatation of the heart, 44, 49
of the stomach, 251
Diphtheria toxin and antitoxin, 43,
157, 158, 159, 176-178
Diphtheroid bacillus in Hodgkin's dis-
ease, 134
Disease, tendency to, 376, 377
Diuretics, action of, 414, 42i5
Diverticula of the oesophagus. See
CEsophagus
Dizziness, 472
in cerebral anaemia, 442
Ductless glands, interrelationship of,
372, 2,73
Ductus Botalli, potency of, 18
Dysentery, endemic, etiology of, 282
mixed infection in, 160
Dyspepsia, acida, 241
effect of, on the heart, 60, 70
nervous, 260
psychic, 260
Dysphagia, 233-236
Dyspnoea, blood-pressure in, 24
cardiac, 34, 77
causes of, 78
chronic, v^rith hypertension and
heart hypertrophy, 24
expiratory, 202
in bronchial asthma, 204, 205
inspiratory, 201
in tracheal stenosis, 201
subjective symptoms of, 225
Dystrophies, muscular, 480
Eclampsia, puerperal, anaphylactic
symptoms in, 186
CEdema, causes of, 89-94
collateral, 91
composition of fluids in, 90,
94 , , .
due to mcreased hydration
capacity of colloids, 93. 141
experimental, 90, 93, 95
from sodium chlorid reten-
tion, 93, 141
in anaemia, malignant disease
and chronic infections, 94
in nervous diseases, 94
CEdema, causes of, in stasis, localiza-
tion of, 90
nature of, 89
nephritic, 91, 140
pulmonary, 95
Ehrlich's side chain theory, 166
Embolism, cerebral, 448
of the coronary arteries, 40
Embryocardia, 56
Emphysema, pulmonary, asthmatic
attacks in, 205
cardiac hypertrophy in, 21
causes of, 208
condition of lungs in, 208
gas interchange in lungs in,
207, 215, 222
Endarteritis, chronic, as a cause of
valvular lesions, 10
obliterans, effects of, upon move-
ments of legs, 452
Endocarditis, acute, 9
bacteria in, 9
chronic, 10
effect of, on heart valves, 9, 10, 18
on heart muscle, 27, 38, 41
fetal, 18
infectious, 9, 41
in focal infections, 153
rheumatic, 9
toxic, 9
verrucous, 9, 18
Enteroptosis, gastric motility in, 253
Enzymes, gastric, diminished secre-
tion of, 237
in blood-serum, 138
in carcinoma of stomach, 245
of the cells, 325
proteid splitting, in leucocytes, 189
uricolytic, 364
Endotoxins, 159
Eosinophilia, general, local, 12S, 126
prognostic importance of, 125
Epilepsy, 467
urine during convulsions in, 416
Epinephrin, emergency functions of,
338
influence of, upon the blood-pres-
sure, 28, 339
upon the excretion of sugar
in the urine, 345, 347, 348,
349
Epithelium, ciliated, of the air pas-
sages, function of, 197
normal, as a barrier against
micro-organisms, 207
renal, permeability of, to proteids
of blood, 422
to sugar, 346
Erythrocytes. See Blood-corpuscles,
red
498
INDEX
(Esophagus, affections of, 232-36
Ethereal sulphates in urine, as an
index of putrefaction in the intes-
tines, 281, 293
motor disturbances in,
248
psychic origin of, 260
Exanthems, acute, immunity follow-
ing, 164
Exchange of gases, compensatory
mechanisms for, in disturb-
ances of external respira-
tion, 221
in pulmonic and pleural dis-
eases, 221
in anaemia, 219
in bronchitis, 222
Excitement, effect of, on albuminuria,
421
on intestinal persistalsis, 286
on the heart rate, 56
on the size of the heart, 24
Exertion, as a cause of cardiac accel-
eration, 55
cardiac hypertrophy, 6, 29
cardiac insufficiency, 30, 38, 44
diminution in size of heart, fol-
lowing, 30
effect of excessive, in etiology of
infections, 159
on albuminuria, 421
Exophthalmic goitre. See Hyper-
thyroidism
Expiration, in stenosis of air-pas-
sages, 202
in volumen puimonum auctum,
207
Exposure to cold, significance of, in
the etiology of infections, 159
Extrasystoles ( Premature contrac-
tions), 63
causes of, 63
in paroxysmal tachycardia, 58
interpolated, 63
ventricular and atrioventricular,
63
Extremities, disturbed movement of,
due to anomalies of sensation, 454-
457
Eye, disturbances of, in anaemia, 442
in diabetes, 358
Facial paralysis, effect of, on chewing,
229
Fat, in the blood-serum, 137
in the faeces, in absence of pan-
creatic juice, 273
in pericardial, pleural and peri-
toneal exudates, 94
of food, metabolism of, 304, 311
Fat necroses, 274
Fat storage in the body, 311. See also
Obesity, 314-318
Fatty heart, 43
Faeces, after exclusion of bile from
intestines, 265
bacterial content of, 266, 277
in pancreatic disease, 273
stagnation of, 288, 291
water content of, diminished, 288
increased, 283
Fermentation, ammoniacal, in the
urine, 433
in the intestines, 281
in the mouth, 229
in the stomach, 245-248
nervous symptoms of, 255
relation of, to atony, 254
Ferments. See Enzymes
Fever, 381
acidosis in, 328, 398
aseptic, 382, 403
blood in, 398
causes of, 382
collapse in, 408
diurnal variations in, 381
effect of age and nutrition upon,
381
of cooling and heating upon,
401
of food upon, 394, 402
of nervous system upon, 384
of, on respiration, 204
experimental, 382, 383, 386, 387
glycogen in, 387, 400
heat losses in, 394
heat production in, 392, 399
heat regulation in, 400-404
hectic, 132, 404 (in leukaemia)
hysterical, 386
in leukaemia, 132
in pernicious anaemia, 112
in pseudoleukaemia, 132
individual disposition towards,
384
in convulsions, 386
Liebermeister's theory of heat
regulation in, 402
metabolism in, 396^399
nutrition in, 404
proteid destruction in, 397
pulse-rate in, 55
reflex, 386
significance of, for the body, 406
symptoms of, 381
water retention in, 405
Fibrin content of blood, 135, 136
Fixateur (Metchnikoff), 166, 189
Fluid intake, importance of, in obesity,
312-314
INDEX
499
Focal infections, 152
relation of to herpes zoster,
483
symptoms of nervous lesions,
441
Foods, effect of different upon gastric
emptying, 250
Foreign bodies, in the bladder, and
the formation of stones, 436
in the respiratory apparatus,
removal of, 197-200
Fragrnentation of the heart muscle, 43
Functional murmurs, 75
Gall-stones, colic in, 264
composition of, 262
dangers of, 263
fever in lodgment of, 387
formation of, 261-263
intestinal obstruction from, 291
jaundice in, 265, 267
stenosis of common duct by, 265
Ganglion cells, relation of, to nutri-
tion of nerve fibres, 474, 476
Gangrene, in diabetes, 359
in intermittent claudication, 452
in nervous disease, 482
Gases, exchange of between blood and
tissues, 197, 223
in disorders of external
respiration, 223
in fever, 396
in the lungs, i, 197
in anaemia, 219, 221
in bronchitis, 222
in cardiac dilatation, 50
in cardiac dyspnoea, ^^
in pulmonary and pleural dis-
eases, 221
mechanism for regulation of, in
disorders of external respira-
tion, 221
Gastric digestion, 236
bacterial processes in, 245 254
disturbances of, absorption in, 254
from anomalies of gastric
movements, 250, 251
from anomalies of secretion,
22,7
from atony, 253
from delayed emptying, 246
from dilatation, 252
examination of, 236, 237, 240
diagnostic significance of, 259
fermentation in, 246, 247, 252, 254
leucocytosis in, 123
pain in, 258
secretion of gastric juice in, 236,
240
stomach contents in, 236, 240
Gastric diseases. See stomach.
Gastric juice, absence of free acid in,
244
acidity of, 236, 237, 240
diminished, 243
increased, 241
antiseptic action of, 245
diminished secretion of, 244
effect of, upon the cholera vibrio,
279
upon the intestines, 236, 243,
248
hypersecretion of, 239^241
continuous, 240
with hyperacidity, 241, 253
in the fasting condition, 239
secretion of, factors underlying,
238-240
Gastrogenous dyspepsias, 22,(i
Gastro-intestinal tract, abnormal bac-
terial processes in, 245, 277
infections of 154-156
Geisbocks disease, 142, 146
Gingivitis, in scurvy, 229
Globuhn, blood serum content of, 137
Glomeruli, changes in, and their rela-
tion to the heart, 26, 28
to the secretion of urine,
417
sensitiveness of epithelium of, 422
Glottis, spasm of, 201
Glycogen, formation of, 312, 343
in diabetes, 351, 360
in fever, 387, 398
Glycosuria, alimentary, 343
condition of kidneys in, 346,
350, 359
from beer, 344
occurrence of in different dis-
eases, 345
relation of, to diabetes, 344
diabetic, 349
effect of kind of sugar upon, 350
epinephrin, 338, 347, 349, 356, 361
experimental, 347
following injuries, 357
hypophysis in relation to, 348
individual disposition to, 344
in infections, 345
phlorhizin, 345
significance of pancreas in, 355
transient, 347
Glycyltryptophan test in gastric car-
cinoma, 24s
Goitre, effect of exophthalmic on
heart rate, 55
on respiration, 200
Gonococci, as a cause of valvular dis-
ease, 9
500
INDEX
Gout, 364
action of atophan in, 370
of radium in, 368
acute attack of, 366, 369
associated pathology of, 367
asthenic and regular, 367
blood in, 368
chronic, 369
constitutional nature of, 378
deposits in, 367
theories of, 367, 368, 369
tophi in, 366
uric acid metabolism in, 364, 368,
369
Granular (contracted) kidney, asso-
ciated with arterio-
sclerosis, 27
with gallop rhythm, 46
blood-pressure in, 2S, 84
cardiac hypertrophy in, 22, 25,
26
hemorrhages in, 34
residual (non-coagulable) ni-
trogen in, 430
secretion of urine in, 414, 419
Graves' disease. See Hyperthyroid-
ism.
Hay fever, and anaphylaxis, 205
Headache, in cerebral anaemia, 442
Heart (see also cardiac), accommoda-
tive power of the
hypertrophied, 6,
31, 33. 38
of the normal, 4-6
adaptability of, 2
beat of, 52
accelerated, 54
by reflex influences, 56
irregular, 61, 62-70
retarded, 59
blood-supply of, 40
brown atrophy of, 43
capabilities of the hypertrophied,
31. 32, 33, 35-40
of the normal, 2-6
cavities of, in hypertrophy, 32
diminution in size of, after
overexertion, 30
congenital defects of septum of,
18
elasticity and contractility of, 4-6
fatigue of, 44
function of, i
influence of nervous system upon,
45
in pregnancy, 31
lesions of, in His bundle, 42, 67
output per beat of, 4, 5, 6, 82
Heart, overdistention and overexer-
tion of, 44
ratio of weight of, to body
weight, 7, 29
reserve strength of hypertrophied,
33
strengthening of, 7
Heart-block, 42, 45, 67
Adams-Stokes symptom-com-
plex and, 68
Heart dilatation, acute transitory, in
paroxysmal tachycardia, 57
chronic, due to stasis of blood
in heart, 49
compensatory, 12, 17, 49
Heart, diseases of, anaemia in, 109
hydraemia in, 141
relation of, to nephritis, 25-
29
secretion of urine in, 417
Heart failure cells in the sputum, 34
Heart hypertrophy, 6
ability of 1 eart to hypertrophy, 31
and dilatation, 32, 49
causes of, 6, 19-31
causes of insufficiency in, 35-40
compensatory, 31, 32, 33, 34
concentric and eccentric, 32
condition of heart muscle in, 33,
34. 35-38
effect of, on the heart beat, 76
on the lungs and respiration,
34, 35
in smokers, 25
of the left ventricle in aortic
aneurism, 23
in aortic insufliciency, 14
in aortic stenosis, 15
in arteriosclerosis, 22, 37
in mitral insufficiency, 17
in renal disease, 25-29
of the right ventricle, in mitral
lesions, 15, 17, 19
in pulmonary disease, 20,
21
in pulmonary stenosis, 18
in tuberculosis, 21
origin of bilateral, 24, 25
Heart impulse. See Cardiac impulse
Heart murmurs, 74-76
Heart muscle, effect of degenerations
of upon function, 41, 42, 43
Heart, palpitation of, 76
Heart poisons, accelerating, 54
causing irregularities, 70
effect of, on heart action, 42,
43.
slowing, 60
Heart sounds, 71-74
INDEX
501
Heart, valvular disease of, 8
arteriosclerotic, lo
causes of, 9
combined, 19
compensation in, 33
congenital, of the right side,
18
due to tearing of valves and
chordae, 10
extracardial effects of, 34
heart muscle in, 32
left sided, 12-18
pathology of, 9
right sided, 19
syphilitic, 10
Heart weakness, as a cause of asys-
tole, 33
causes of, 35-38
of primary, 40
effect of, on secretion of
urine, 417, 423
functional, 44
of both ventricles, 46
of the left ventricle, 20, 37, 47
of the right ventricle, 37, 48
primary, 40
pulse in, 52, 55
relation of, to angina pec-
toris, 78
results of, 46
symptoms of, 49-52
Heart, work of, factors determining, 2
in conservation of accommo-
dation, 2-6
increased, of the left ventri-
cle, 21-24
of the right ventricle,
18,19
in the pulmonary circula-
tion, I
in the systemic circulation, 2
in varying demands on circu-
lation, 2-6
on exertion, 6, 7, 8, 29, 30
quantitative"! actors in, 6
relation of, to hypertrophy,
6-8
to subjective symptoms,
76
Heat regulation, in fever, 391
heat losses in, during rise
of temperature, 394
during fall, 396
heat production in, 392
site of, 399
mechanism of, 400
experimental factors
bearing upon, 385-
388
Heart regulation, in health, regulation
of, chemical and physi-
cal, 389
mechanism of, 388
in obesity, 314, 389
Heat stroke, 390
Hemic murmurs, 75
Hemiplegia, cerebellar, 450
contractures in, 463
muscular atrophy in, 479
Hemisystoles, 66
Haemoglobin, changes in bile from
liberation of, 261
conversion of, into methaemoglo-
bin, 116, 117
by entrance of poisons into
red cells, 117, 120
importance of, in respiration, 116,
120, 219, 220
in the anaemias, 102, 103, 105, 107,
III
in changes of atmospheric pres-
sure, 143, 144
in chlorosis, 107
in polycythemia, 142
solution of, in blood, 103, 116-118,
168
Haemoglobinsemia, 116
Haemoglobinuria, 116
paroxysmal, 118
Hsemolysins, 118, 168
Haemolysis, by the blood serum, 168,
169
in paroxysmal haemoglobinuria,
118
inhibition of, in the Wassermann
reaction, 173
relation of, to bactericidal proc-
esses, 168, 169
substances active in. 168, 169
Haemophilia, 136, 375, 376
Hemorrhages, as a cause of anaemia,
103, 109
of hydraemia, 140
of leucocytosis, 125
into the organs, in leukaemia, 132
in pseudoleukaemia, 132
Haepatic toxaemia, see liver
Hernia, 291
Herpes zoster, 482
Hiccough, 256
High altitudes, blood in, 143
metabolism in, 218
pulmonary gas interchange
and respiratory movements
in, 215-218
Hodgkin's disease, 133. See also
Pseudoleukaemia
Homogentisic acid, in urine, 334
502
INDEX
Hormones, action of, 304, 372
origin of, 304
stimulating eflfect of, on cells, i
Hunger, 257, 258
gastric contraction waves under-
lying, 257
appetite and, 257
Hydraemia, causes of, 139-141
relation of, to oedema, 92
with retention of water, 140, 141
without retention of water, 140
Hydrobilirubin, origin of, 272
Hydrocephalus, chronic, 444
Hydrochloric acid of the gastric juice,
236, 237, 240
absence of, 244
action of, upon microorganisms,
154, 245, 246
diminution of, 243-246
increased, 241-243
in gastric carcinoma, 244-245
Hydrocyanic acid poisoning, as a
cause of respiratory
spasm, 210
effect of, on internal res-
piration, 225
Hydronephrosis, mechanism of pro-
duction of, 418
Hydrophobia, oesophageal spasm in,
233
Hydrops, in acute and chronic
nephritis, 91
in cachexias and nervous dis-
eases, 94
Hyperalgesia, 473
Hyperaemia, active, in inflammations,
91
venous, in cardiac stasis, 50-52
Hyperaesthesia, nature and causes of,
473
Hyperglycaemia, alimentary, 344
diabetic, 349, 350, 352
Hyperplasia, lymphoid and myeloid,
127, 128, 130
Hyperthyroidism (Graves's disease),
action of upon the heart, 43
causes of, 322, 323
disturbances of the internal secre-
tions in, 323
glycosuria in, 345
pathology of, 323
proteid and fat metabolism in, 321
pulse-rate in, 55
relation of, to changes in thyroid
gland, 322
to nervous system, 323
rudimentary forms of, 323
symptoms of, 323
Hypertonicity of the arteries, essen-
tial, 81
Hypertonicity of arteries, in arterio-
sclerosis, 27, 28, 29, 81
Hypophysis, in diabetes insipidus, 415
in obesity 318
manifestations of disturbed func-
tion of : acromegaly, y]2
relation of, to glycosuria, 348
Hysteria, anaesthesia in, 456
contractures in, 466
diarrhoea in, 286
oesophageal spasm in, 233
fever in, 386
heart action in: paroxysmal
tachycardia, 58
meteorism in, 297
sensory disturbances in, 456, 473,
474
Icterus. See also Jaundice
catarrhalis, 2^
gravis, 271
haemolytic, 269
neonatorum, 269
Idiosyncrasies toward foods, 184, 260
of children to cow's milk (ana-
phylactic manifestations), 184
Ileus. See Intestinal obstruction.
Immune bodies, 166
diverse, 166, 169
isolation of, 166
normally in blood, 171
production of, in active immunity,
161, 163
Immune- ferment reaction (Abderhal-
den), 186
Immune sera, 162
antibody content of, 176, 177
haemolytic action of, 169
Immunity, acquired, 161, 164, 189
basis of, in infections with organ-
isms not forming soluble toxins,
176
epidemiologic and experimental,
.156
histogenic, 194
inherited, 161, 164
Schick's method of determining,
177
relation of, to bactericidal powers
of blood, 164
theories of, 166, 188
Immunization, active, 161, 178
active-passive, 162, 178
antitoxic, 176, 177, 191
duration of, 162, 177
passive, 162, 176, 177
reaction in, 178
Inanition, as a cause of anaemia, 110
as a cause of hydraemia, 140
as predisposing to infections, 159
INDEX
503
Inanition, causes of, 308
complete, 309
formation and excretion of acids
in, 329
in fever, 397, 398, 404
nitrogen excretion in, 318
partial, 309
results of, 309
types of, 308
Incoordination, 452
Indol, toxic effect of, 282
Indophenol reaction, 122
Infection, and immunity, 151
effect of portal of entry upon
character and course of, i57
factors influencing character
of, 156
general, of gastro-intestinal
origin, 155, 280
of pulmonary origin, 154
of vaginal origin, 156
manifestations of, in affected
organism, 156
protective barriers against,
151-156
resistance of organism to,
159, 161, 278
significance of epithelial
lesions, in acute, 151
Infectious diseases, albuminuria in,
421
anaemia in, 109, 116
bacillus carriers caused by, 191,
193
collapse in, 86, 87
fever course in, 381
heart complications in, 9, 25, 36,
39, 41, 43
haemoglobinaemia in, 117
hydraemia in, 140
immunity after, 164
intoxications in, 157
leucpcytosis in, 125
metabolism in long-standing, 319,
396
proteid destruction in, 319
pulse in, 61, 70
recovery in, 194
saliva in, 230
Inflammations, blood- and lymph-
vessel changes in, 91
collateral oedema in, 91
leucocytosis in, 125
purulent exudates in, 91
Inspiratory disturbances, from loss of
pulmonary elasticity, 207
in paralysis of vocal cords,
203
in spasm of vocal cords, 200
Inspiratory disturbances in stenosis
of upper air passages, 201, 202
Insufficiency, of heart valves, aortic,
12
in hypertrophied hearts, 35, 36, 37,
38,39
mitral, 17
muscular, 11
primary, 40
relative. 11
tricuspid, 18
Intermediary bodies. See Ambocep-
tors
Intermittent claudication, 79, 451
Internal secretions, interrelationship
of, 372, 373
Intestinal crises of tabes, 286
Intestinal diseases, absorption in, 282
as a cause of anaemia, 109, 113
of digestive disturbances,
282
due to absence of bile, 265
of pancreatic secre-
tion, 273, 274
to bacterial processes in
bowel, 277
to bacterial toxins, 281
to disorders of motility,
284
to protozoa, 282
to secretory disorders,
283
to toxic substances, 276
effect of, on heart, 60
inflammatory, 291
pain in, 297
Intestinal epithelium, behavior of to-
ward bacteria and their products,
154, 277, 278
Intestinal gases, effect of, on intes-
tinal movements, 287
in intestinal stenosis, 294
origin of, in health, 296
in diseases of the gastro-
intestinal canal, 296
Intestinal movements, antiperistaltic,
in ileus, 294
associated with pain, 295, 297
cessation of, in complete sten-
osis, 294, 295
decreased, by central nervous
influences, 289
by diminished irritability
of bowel wall, 289
by muscle spasm, 290
by paralysis of circum-
scribed bowel seg-
ments, 291
504
INDEX
Intestinal movements, increased, by
cooling of the skin, 286
by inflammatory condi-
tions, 288
by irritation of abnormal
contents, 287
by nervous influences, 286
local nervous mechanism for,
289
normal, of the colon, 285
of the jejunum and
ileum, 284
Intestinal musculature, paralysis of,
289, 291
spasm of, 290, 293, 294, 297
condition of abdominal
wall in, 290
Intestinal obstruction, causes of, 291,
292
course of, 295
mechanism of, different types
of, 291, 292
results of, 293, 294, 295, 296
Intestinal parasites, as a cause of
anaemia, 113, 114
of eosinophilia, 126
Intestinal secretions, anomalies of,
283, 284
Intestines, spasm of, as a cause of
constipation, 290
in obstruction, 293, 294, 297
Intoxication, after operation in
echinococcus disease (anaphy-
laxis), 185, 186
in diabetes, 358
in fever, 382
in hepatic disease with chronic
biHary stasis, 271
in intestinal afifections, 276
in nephritis, 429
Invagination (intussusception), mech-
anism of, 292
Iron, increase of, in the liver, due to
excessive destruction of ery-
throcytes, 104, 114, 143
lack of, as a cause of anaemia, no
value of, in chlorosis, 108
Irritative phenomena in cerebral anae-
mia, 442
Islands of Langerhans in diabetes,
356, 360
Tsolysins, in anaemia, 119
Isoprecipitins, 172
Itching, in diseases of sensory cuta-
neous end-organs, 473
Jaundice, 266
heart action in, 60, 270
haemolytic. 269
in anaemia, 114
Joint disease, as a cause of muscular
atrophy, 479
nutritional disturbances in,
481
Jugular veins, murmurs in, 89
pulsations in, in auricular
fibrillation, 52, 65, 66
in nodal rhythm, 52
in paroxysmal tachycar-
dia, 52, 57
negative, 51
positive, 52, 57, 65, 66
Keith-Flack node, 52, 53, 54, 58
Keto-acids, function of in metabolism,
311, 320, 357
Kidneys (see also Renal), atrophy of,
due to occlusion of urinary pas-
sages, 419
calculi in, and in renal pelvis, 434
function of, 413
as regulators of composition
of blood, 426
hypertrophy of, 418
relation of lesions of, to albu-
minuria, 422, 423, 424
to glycosuria, 343, 344, 346,
347, 349. 350, 359
to haemoglobinaemia, 121
to uraemia, 429
secretion of, with diminished cir-
culation, 416
with increased circulation, 413
Kidneys, inflammation of, albumin-
uria in, 423
cardiac dilatation in, 31
cardiac weakness in, 31, 37, 39
composition of blood in, 109
(anaemia), 139 (hydraemia)
oedema in, 91
functional disturbances in,
424, 428
increased blood-pressure and
heart hypertrophy in, 25-29,
81, 84
in diabetes, 359
non-coagulable nitrogen in,
430, 431
phenol sulphonapthalein test
in, 431
pulse in, 59
types of, according to disturb-
ance of function present,
428
uraemia in, 429
urine in, 414, 417, 423, 424
Kropfherz, 43, 324
Kundrat's lymphosarcoma, 134
Kyphoscoliosis, as a cause of respira-
tory disturbances, 204
INDEX
505
Labyrinthin dizziness, 472
Lactic acid, formation and excretion
of, in metabolic disorders, 329
Lactimurate and lactamurate, 368
Lactosuria, 344
Laryngeal stenosis, effect of, on res-
piratory movements, 200-203
Lead poisoning, and gout, 367
anaemia in, 109
arterial spasm in, 81, 84
hypertension in, 84
Leucocytes. See Blood-corpuscles,
white
Leucocytosis, after hemorrhages, 125
diemotaxis in, 124, 125
degrees of, 126
eosinophilic, in asthma, 125, 126
in helminthiasis and trichin-
osis, I2S, 126
inflammatory, 125
in children (pertussis), 124
in malignancy, 125
neutrophilic, 124, 125
of the new-born, 123
physiological, 123
ratio of different types of white
cells in pathological, 124, 125,
126
relation of nervous system to, 125
Leucopsenia, 126
Leukansemia, 130
Leukaemia, 127
acute, 131
stomatitis in, 230
aleukaemic, 127, 129
blood in, 128-132
causes of, 135
chronic, 129, 131
combined with anaemia, 130
course of, 131
differentiation of, from leucocy-
tosis, 129
effect of X-rays upon, 129, 131
of benzene upon, 129, 131
histological changes in, 127, 128,
129
increase of urinary purin bases in,
365
in children, 131
lymphoid, 130, 132
mixed-cell, 132
myeloid, 129, 130, 132 _
oxidase reaction in, 122
pathogenesis of, 135
prognosis of, 131
submyelemic, 129
symptoms of, 132
Laevulose, assimilation of, by dia-
betics, 352
in urine, in diabetes, 343, 349
Lasvulosuria, alimentary, in hepatic
disease, 345
Lipaemia, 137
Lipoids, significance of, in haemolysis,
114, 169
Liver, acute yellow atrophy of, metab-
olism in, 325, 326, 329
Liver, disturbances of, acidosis in, 328
alterations of bile in, 260, 261
aminoacids in, 326
anaemia in, 109, 113 ^
excretion of ammonia in, 333
in cardiac stasis, 51
in diabetes, 357, 361
in jaundice, 269, 270
metabolic anomalies in, 326,
333
toxaemia in, 271
urine in, 326, 333
Liver, role of, glycogenic, 343, 352
in combating poisons ab-
sorbed from intestines, 281
in conversion of carbohy-
drates into fats, 312
in diabetes, 352
in fever, 387
in hsemoglobinsemia, 116
in urea formation, 333
Local pathology as contrasted with
constitutional, 374
Luetin reaction as an index of the
constitutional nature of syphilis, 375
Lungs (see also Pulmonary), anti-
septic action of, 153
brown induration of, 34
diseases of, cardiac dilatation in,
cardiac hypertrophy m, 20, 21
cardiac insufficiency in, 37, 47,
48
gas interchange in the lungs
in, 221, 222
distention of, in bronchial asthma,
205, 206
in paroxysmal tachycardia, 57
oedema of, 95
infections of, 153, 154
loss of elasticity of, 207. See also
Emphysaema
mechanisms for protection of, 197
Lymph, bactericidal properties of, 163,
164
circulation of, 89
in central nervous system,
442, 443
composition of, 89, 94
in inflammations, 91, 94
excessive accumulation of, in
lymph spaces, 89
obstruction to flow of, 89, 90, 91
506
INDEX
Lymphatics, occlusion of, 91
pressure conditions in, 89, 90
pressure difference between capil-
laries and, 89, 90
Lymph-nodes, leukaemic hyperplasia
of, 127, 128
genetic significance of, 133
Lymphocytes, in normal blood, 121
in pathological blood, 124, 126,
130
Lymphosarcoma, Kundrat's, 127, 134
Macrocytase, 188
Macrocytosis and microcytosis, 105
Macrophages, 188
Malaria, blood in, 109, 116, 118 (par-
oxysmal haemoglobinuria)-
fever in, 381
Malnutrition (see also Inanition),
effect of previous state of nu-
trition upon. 309
effect of exercise upon, 309
factors in, 308, 318
in various diseases, 309
results of, 309
Mediastino-pericarditis, heart hyper-
trophy in, 24
pulsus paradoxus in, 70
Megaloblasts, 106, 107, iii, 113, 115
Meniere's disease, 472
Meningitis, cerebral pressure in, 444
serum therapy in, 177
Mercury, absorption of, through the
skin, 151
ptyalism and stomatitis from,
231
Metabolism, ammonia formation in,
course of, with dietetic sufficiency,
formation and excretion of purin
bases in, 364
of organic acids in. 328-333
of poisons in, and their effect
upon heart, 42, 43
in constitutional diseases, 372
in fever, 396
influence of cellular activity upon,
3"
of thyroid gland upon, 320
intermediary, 372
of carbohydrates : quantitative
disturbances of, 343
of the fats, 304, 311-318
of the proteids, 318, 325
proteid needs in, 306
Meteorism, 296
Microcytase. 188
Microorganisms, behavior of animal
body towards, 151, 159, 161
Microorganisms, cultural media for,
and their importance, 163
oxygen tension of, 163
in affections of the mouth, 229,
230
of the intestines, 277
of the urinary passages, 433
in the bile, 262, 263, 264, 268
in nephritis and albuminuria, 424,
427
in valvular lesions, 9
metabolic products of: action of,
on heart, 42, 43
numbers of, in fatal infections,
157
obstacles to entrance of, into
body, 151
role of, in hydrolytic cleavage of
proteids, 326
significance of the normal intes-
tinal, 277, 278
of the pathological intestinal,
279, 280, 281
virulence of, 156
Micturition, disturbances of, 459
Milk, antitoxin content of, 171
as a cultural medium for B. ty-
phosus, 159
hypotensive action of, 28
Mitral insufficiency, 17
circulatory disturbances due
to, 17
combined with other lesions,
16, 19
compensation in, 17
heart murmurs in, 74, 76
heart sounds in, 72, 73
Mitral stenosis, 15
and insufficiency, 16, 19
compensation in, 15
heart murmurs in, 75
heart sounds in, 72, 73
relation of, to auricular fibril-
lation, 66
Mixed infections, 160
Monosodium urate, in gout, 366, 368
in the formation of vesical
calculi, 435
Morbus ceruleus, 50
Motility, disturbances of, atactic, 452-
458
choreiform, 466
due to anomalies of sensation,
455
to abnormal irritability
of the cerebral struct-
ures, 467
to contractures, 463
to disturbances of re-
flexes, 460
INDEX
507
Motility, due to incoordination, 452
to muscle disease, 451
from intermittent claudica-
tion, 451
from lesions of motor tracts,
451
from psychic paralyses, 450
Mountain sickness, diminished oxygen
tension in, 216
Mouth, affections of, 229, 232
in diabetes, 229, 359
Movements of the body, effect of, on
albuminuria, 421
on the body temperature,
386
on the distribution of the
blood, 2
on the excretion of sugar
in diabetes, 354
on the leucocytes, 123
Movements, voluntary, disorders of,
452-454
disturbances of sensation of,
454, 455
effect of centripetal impulses
upon, 454-458
of exaggeration of re-
flexes upon, 459
of loss of reflexes upon,
458
varieties of, 453
Mucous colitis, 205, 287
Mucus, production of, in the respira-
tory passages, 198
in the stomach, 248
Muscarin, action of, on the heart, 42,
60
Muscles, as a storehouse for sugar,
353-
disturbances of, due to faulty
blood-supply, 451
innervation of, 449, 450
disturbed, 451, 452, 466, 477-
479, 480 ...
ocular, loss of orientation in
paralyses of, 472
tetanus of, 462
Muscular atrophy, altered chemical
composition of muscles in,
477
degenerative, 477, 478, 479
dystrophies in, 480
from disuse, 477, 479
in joint disease, 479
in obesity, 314
reaction of degeneration in,
477
partial, 479
Muscular contractions, epileptiform
and tetanoid, in gastric dilatation,
25s
Muscular exertion, as a cause of heart
hypertrophy, 29
of diminution in size of
heart, 30
of increased arterial
pressure, 83
effect of, on the blood, 118, .
123
on the body temperature,
386, 390
on the hypertrophied
heart muscle, 35, 37
Muscular insufficiency of heart, 11, 40
Myasthaenia gravis, 452
Myocarditis, cardiac pain in, 78
heart beat in, 56, 61, 62, 63, 64, 68,
. 69 .
infectious, 41, 43
in hypertrophied hearts, 35
in valvular disease, 10, 11, 38, 39
primary, 41
significance of location of, 41, 42
Myotonia congenita (Thomsen's dis-
ease), 452
myotonic reaction in, 452
Myxoedema, thyroid function in, 322
Nephritis. See Kidneys, inflamma-
tion of
Nerve cells, degeneration of, 476
independence of, 475
Nerves, degeneration of, primary, due
to poisons and disturbed
blood-supply, 451
secondary, 474
Nervous diseases, anaemia in, 109
constipation in, 289
diarrhoea in, 286
oedema in, 94
fever in, 385, 386
from gastric dilatation, 255
Nervous system, effect of, on regula-
tion of vascular diameter,
80, 88
functional disorders of, 441
contractures in, 463
general symptoms in, 441
in acidosis, 332
focal symptoms in, 441
motor disturbances in, 449
reflex disturbances in,
458, 460
sensory disturbances in,
468
influence of, on the heart-
beat, 45
508
INDEX
Nervous system, influence of, on tem-
perature regulation,
384, 400
on tissue nutrition, 474
influence of diphtheria and
tetanus toxins upon, 158, 462
motor system affections of,
476
of the intestines, disturbed
motility due to, 289
pathology of, in pernicious
anaemia, 112
relation of, to diabetes, 347,
357, 361
sympathetic : centres for
defecation and urination,
459
Neuralgia of the stomach, 259
Neurasthenia, constipation in, 289
diarrhoea in, 286
heart-beat in, 56, 58, 61, 69
Neuritis, 475
Neuron theory, 474, 475
Newborn, antitoxin in blood of, 171
jaundice of, 269
leucocytosis of, 123
renal infarcts in, 366, 435
Nitrogenous equilibrium, 310, 318 _
Nitrogen excretion in the urine, in-
creased, in disease,
318-320, 327 (am-
monia)
in health, due to diet, 327
influence of carbohydrates
upon, 319, 327
in fever, 397, 398
Noci impulses in relation to shock, 87
Nodal rhytl m, 52, 64, 66
Node of Aschoff-Tawara, 52, 53, 67
of Keith-Flack, 52, 53. 54, 58
Non-coagulable nitrogen, in the blood,
in uraemia, 430, 431
Nose, diseases of, relation of to
asthma, 205
Nourishment in relation to albu-
minuria, 421
Nursing infant, eff"ect of food upon
intestinal flora of, 278
effect of nasal obstruction
upon nutrition of, 200
Nutrition, caloric needs of body in,
essential substances in mainten-
ance of, 304, 305
metabolism of proteids and fats
in, qualitative, 324
quantitative, 304, 318
nitrogen equilibrium in, 310
undernourishment in, 308
Nutritional disturbances, as a result
of nervous lesions, 474-483
effect of, upon the blood, no
upon the heart muscle, 41
from abnormal proteid de-
struction, 318-320
due to toxic substances,
.319
in hyperthyroidism, 320
from destruction of fats, 319,
321
from obesity, 313
in anaemia, no
in cystinuria, 336
in diabetes, 357, 358
in fever, 397, 398, 404
in the muscles, 477
of the bones and joints, 481
of the nerves, 474-476
of the skin, 482
Obesity, 314
associated with anaemia, 315, 316,
cardiac disturbances in, 43, 44, 315
causes of, 315-318
constitutional, 316, 378
diminished efficiency due to, 314,
315
hereditary influences in, 316
in childhood, 316
ox)'gen consumption in, 317
relation of, to diabetes, 357
significance of hypophysis in, 318
Occlusion of the bowel, causes of, 291
course of, 295 (strangulation)
Ochronosis, relation of, to alkapto-
nuria, 335
Oligemia, 146
Oligocythemia in chlorosis, 107
in nephritis, 109
Ophthalmoplegia as a cause of dizzi-
ness, 472
Opsonins, 189
in therapy (Wright), 190
Optic neuritis, in cerebral pressure.
See Choked Disk
Orientation of the body in space, 471
loss of, dizziness in, 472
due to labyrinthin disease,
472
due to ocular palsies, 472
mechanism of, 471
Orthotic albuminuria, 421
theories as to cause of, 421
Oxalate calculi, 436
Oxidative processes in fever, 396
Oxyacids, origin of, in intermediary
metabolism, 328, 335
INDEX
500
Oxydase reaction, in cells of bone-
marrow origin, 122
Oxygen tension, intraalveolar, res-
piratory movements in
diminished, 215, 216,
218
oxygen supply to tissues
in, 215-218
of the tissues, in relation to
bacterial growth, 163
Pain, causes of, 474
delayed perception of, 468
in angina pectoris, 79
in diseases of the mouth, 229, 230
in oesophageal disease, 233, 235
in gall-stones, 263, 264
in gastric disturbances, 243, 259
in intestinal diseases, 298, 299
in the precordium, 78
in respiratory disturbances, 226
in urinary calculi, 437
on urination, 437
origin of, 474
psychic, 474
Palpitation of the heart, 76
Pancreatic diabetes, 355~357. 360, 361
acidosis in, 330, 358
Pancreatic juice, effect of absence of,
upon gastric and intestinal
digestion, 273, 274
effect of penetration of, into
abdominal cavity, 275
secretion of, 273
Paralyses, 449-452
Brown- Sequard, 470
cerebral, contractures in, 464
in uraemia, 429
psychic, 450
sensory, 456 (in ataxia), 468
Paraplegia dolorosa, 469
Pararhythmias, cardiac, 63, 65
due to extrasystoles, 63
Parathyroid glands, effects of re-
moval of, 324
Pareses, motor disturbances in, 450
of the gastric musculature, effects
of, 251, 254
Paraesthesias, due to gastric disorders,
259
due to disease of the peripheral
and spinal sensory paths, 473
Paroxysmal tachycardia, 56
methods for ending paroxysm
in, 58
pathogenesis of, 58
Pericardial adhesions, as a cause of
heart hypertrophy, 24
as a cause of pulsus para-
doxus, 70
Periosteal reflexes, 460
Peristaltic hormone, 285
Peristaltic rust, 284
Peritonitis, bradycardia in, 60
constipation in, 289
exudates in, 94
tympany in, 297
vascular changes in fatal cases of,
86
Pernicious anaemia, iii
indication for splenectomy in,
IIS
Perpetual arrhythmia, 39, 52, 65
Pertussis, nature of paroxysms in, 20l
Phagocytosis, theory of, 187
Phagolysis, 165, 188
Phlorhizin glycosuria, acidosis in, 329
causes of, 345, 346
in starvation, 346
Phosphatic calculi, 436
Phosphaturia, calcium elimination in,
436 . , . ' .
Phosphorus poisoning, acidosis in,
328, 329
bile in, 261
blood in, 145 (polycythemia)
hydrolytic cleavage of pro-
teids in, 325, 326
internal respiration in, 225
jaundice in, 268
metabolism in, 325, 326
urine in, 325, 326, 345
Pigmentation, cutaneous, in jaundice,
267, 270
of the bone-marrow, liver and
spleen in pernicious anaemia,
114
Pineal gland disease, 373
Pirquet test, as indication of the
constitutional nature of tubercu-
losis, 375
Plethora, behavior of heart in, 30, 31
genuine, 145
with hyperglobulism and hy-
pertension, 146
serous in hydraemia, 141
Pleuritis, exudative, effect of, on gas
interchange in lungs,
221
on respiration, 211
on vena cava, 211
obliterative, as a cause of heart
hypertrophy, 21
Pneumococci, in endocarditis, 9
Pneumonia, bradycardia following, 61
hypertrophy of right ventricle in,
21
interchange of gases in the lungs
in, 222
respiration in, 211
510
INDEX
Pneumothorax, artificial, Sl'^
behavior of healthy lung and me-
diastinum in, 212
circulatory disturbances in, 213
interchange of gases in lungs in,
221
pressure relations in closed and
open, 212
Poikilocytosis, in anaemia, 105
in chlorosis, 107
in pernicious anaemia, ill
in secondary anaemia, iii
Poisons, action of, upon the bile, 261
upon the blood, 104, 109, 113,
117, 120
upon the heart, 25, 42, 54, 60,
70, 79 (nicotin)
upon the intestinal processes,
276
upon metabolism, 319, 320
upon the nervous system, 451,
467 ^
upon respiration, when mixed
with inspired air, 218
as a cause of albuminuria, 423
of anaemia, 109, 113
of jaundice, 268
eflfect of, on proteid decomposi-
tion, 319, 320
on respiration, 218, 224, 225
in leucopenia, 126
in methemoglobinaemia, 120
in polycythaemia, 145
resistance of parasites to (chemo-
therapy), 191
Poisons, iS7~iS9
bacterial, action of, upon the
heart muscle, 43
protective forces of the
body against, 169
Polyarthritis rheumatica, heart com-
plications of, 9, 39, 41
Polychromatophilia, 105, ill
Polycythaemia, 142
Polydipsia of psychic origin, 414, 415
Polyuria, following catheterization of
ureters, 416
from drinking of excessive
fluids, 425
in diabetes insipidus, 414
in diabetes mellitus, 359
in epileptic attacks, 416
in nephritis, 414
in paralysis of renal nerves,
414
Portals of entry, in infections, 151
Posture, effect of, on albuminuria, 421
Potassium chlorate, action of, on red
blood-corpuscles, 120
Potassium salts, in their relation to
uraemia, 431
Precipitins, 171
importance of, in medico-legal
conditions, 173
Pregnancy, blood in, 123
heart in, 31, 38, 62
urine in, 423 (albuminuria)
Premature contractions of the heart,
63
Propionic acid in the urine in metabo-
lic disorders, 329
Proteids, bacterial, as a cause of
fever, 383
Proteids, pathological destruction of :
causes of, 318-320
course and products of,
325-327
dangers of, 320
hydration products of,
325-327
in anaemias, 223, 319
in carcinoma, 319, 320
in diabetes, 358
in fever, 319, 382, 397,
. 398
in intermediary metabo-
lism, 324, 32s
ammonia formation
in, 327
significance of liver in,
333 (excretion of
ammonia)
of thyroid substance
in, 321
Proteid needs of the body, 306
Proteids, of the blood serum, 137
amount of, 137
occurrence of, in the
urine, 422, 424
proteid ratio in, 137
of the food, chemotactic action
of, on leucocytes, 124
qualitative metabolism of,
324.
quantitative metabolism
of, 304, 311, 318
of the urine, source of, 424
total daily excretion of,
425
types and chemistry of,
422, 424, 425, 426, 427
produced by bacterial processes in
the intestines, 281
significance of, in heat production,
383, 394
Protozoa, intestinal, as causes of
anaemia, 109
of dysentery, 282
of fever, 383
INDEX
511
Pseudocroup, 200
Pseudoleukaemia (see also Hodgkin's
disease), 127, 133
blood changes in, 128, 130, 132
definition of, broad, 133
strict, 127
differentiation of, from tubercu-
lous and sarcomatous processes,
127, 134
fever and hemorrhages in, 132
lymph glandular hyperplasia in,
127, 128, 133, 135
pathogenesis of, 132, 135
relation of, to leukaemia, 127, 128,
129, 132, 133, 13S
types of, 133
Ptomains, toxic symptoms due to in-
troduction of, into intestines, 276
Ptyalism, 231
Puberty, albuminuria in, 421
sinus arrhythmia in, 70
Puerperium, bradycardia of, 62
Pulmonary circulation, i
condition of, in compensated
heart lesions, 34
disorders of and their effect
on right heart, 19-21,
39
in cardiac asthma, 78
in valvular disease, 13,
16, 17
Pulmonary diseases. See Lungs
Pulmonary insufficiency, 18
Pulmonary rigidity, in cardiac
asthma, "JJ
Pulmonary stenosis, 18
Pulmonary tuberculosis, gas inter-
change in lungs in, 222
heart hypertrophy in, 21
in diabetes, 359
transmission of, by moist
droplets, 154
Pulmonic second sound, accentuation
of, 71, ^2
character of, in aortic insuffi-
ciency, 13
in mitral insufficiency, Vj
in mitral stenosis, 16
in pulmonary tubercu-
losis, 21
reduplication of, "jz
Pulse, arterial, acceleration of, 54-59
behavior of in cardiac
asthma, 78
in Cheyne-Stokes
breathing, 209
bigeminy of, 64, 66, 67, 69
effect of cerebral influences
upon, 55, 59, 60
Pulse, arterial, effect of reflex in-
fluences upon, 56, 60, 70
in aortic insufficiency, 35
in paroxysmal tachycardia,
. 56
inequahty of, 66, 70 (pulsus
paradoxus)
irregularity of, 62-69
causes of, 69
origin of (heart-beat), 53,
67
retardation of (bradycar«
cardia), 59^2
in Adams-Stokes syn-
drome, 68
variations in, in health, 52,
54
respiratory, 69, 70
Pulse-pressure, 82
in aortic insufficiency, 14
relation of to cardiac output per
beat, 82
Pulse, venous, origin of, 51
negative, 51
positive, 52
in auricular fibrillation,,
52, 65, 66
in nodal rhythm, 52
in paroxysmal tachycar-
dia, 57
in tricuspid insufficiency,
52
Pulsus, alternans, 66
bigeminus, 64, 66, drj, 69
celer, in aortic insufficiency, 35
irregularis perpetuus, 65
paradoxus, 70
pseudoalternans, 59
Puncture of the brain, as a cause of
fever, 386, 400
of glycosuria, 347
Pupils in Cheyne-Stokes breathing,
209
Purin bodies, 364
as a cause of fever, 384
Pyaemic processes due to mixed infec-
tions, 160
Pyloric reflex, 249
stenosis, 250, 252, 254, 255
Pyogenic organisms, action of, intro-
duced subcutaneously and
intravenously, 157
as a cause of valvular disease;,
9
Pyrosis, 256
Reynaud's disease, vascular reflexes
in, 88
Reaction of degeneration, 477-479
partial, 479
512
DTOEX
Receptors, 167 (side-chains), 170, 192
Rectum, disturbed emptying of, due
to nervous causes, 459, 460
Reflexes, absence of, 458
disturbances of deep and super-
ficial, 460-462
effect of, on defecation and urina-
tion, 459
on the heart-beat, 56, 60, 70
on respiration, 211
on the secretion of saliva, 232
on vessel tonus, 80
on voluntary movements, 453,
458
increased, 459
in strychnin poisoning and teta-
nus, 462
origin of, 460
Regeneration of red blood-corpuscles,
105, 115
Relapsing fever in Hodgkin's disease,
132
Renal diabetes, 346
Renal function, disturbed, localization
of, 427, 430
phenolsulphonephthalein
test in, 431
Renal vessels, effect of diameter of,
on the secretion of urine, 413, 416,
423, 424 . . , ,
Rennin, secretion of, as an mdex of
pepsin secretion, 238
Residual nitrogen, in the blood, 138
in uraemia, 430, 431
Resistance, against infection, artificial,
161, 162, 175 (typhoid
vaccination), 178
natural, 161, 177 (Schick
test)
bacterial, increased, 191
Respiration, accelerated, 204, 214
automatic regulation of, 202
Cheney-Stokes phenomenon in,
209
deep, 203, 210, 214
effect of atmospheric pressure
upon, 215, 218
of changes in the alveolar
membranes upon, 215
of composition of air upon,
215
of the blood upon, 120,
219, 220
of stenoses of the air-pas-
sages upon, 200-204
of temperature upon, 214
of the pulmonary circulation
in, 220
Respiration, effect of uniform distri-
bution of inspired air in the
alveoli upon, 208, 215
external, 197
importance of olfactory nerves in,
198, 218
phases of, 202, 203
protective mechanisms for, 197-
200
regulation of the normal, 204, 209
slow, 202, 203, 209
superficial, 204
undisturbed, conditions essential
to, 197
Respiration, internal, 223
Respiratory apparatus, methods of re-
moving foreign material from, 197-
200
Respiratory centre, alterations in the
activity of. See Cheyne-
Stokes breathing, 209
disturbances of, as a cause of
cardiac dyspnoea, "jj
sensitiveness of, to changes in
gas content of blood, 201,
222, 441
Respiratory disturbances, effect of on
gaseous interchange in
tissues, 223
on total interchange of
gases, 221, 222
from altered irritability of
the centre, 209
from diminution of the res-
piratory surfaces, 211, 213,
214
from insufficient distention of
thorax and lungs, 206-208
from paralysis of respiratory-
muscles, 206
from poisons in inspired air,
218
from stenoses in air-passages,
200
altered respiratory move-
ments in, 201, 202
from variations in composi-
tion of air, 215-218
in anaemia, 219
in asphyxia, 222
in bronchitis, 204
in emphysema, 207
in heart diseases, 13, 34, 50,
in intoxications, 210
in obesity, 315
in paroxysmal tachycardia, 57
in uraemia, 210, 429
in volumen pulmonum auc-
tum, 207
EsTDEX
513
Respiratory disturbances, mechanism
for compensation of, 221
subjective manifestations of,
22s
Respiratory muscles, diseases of, and
their effect upon respiration, 206
Rheumatism, as a cause of heart dis-
ease, 9, 39, 41
of muscular atrophy, 479
Rhythm of the heart, normal, 52-54
pathological, 62-70
Rhythmic segmentation, 284
Rontgen rays, in leukaemia, 129, 131
Rupture of arteries due to increased
blood-pressure, 34
of the oesophagus, 236
Saline cathartics, mode of action of,
284
Saliva, anomalies in secretion and
composition of, 230^232
Salivary glands, reflex stimulation of,
232
Salvarsan, theory underlying produc-
tion of, 191
Sarcolactic acid in the urine, 328
Scarlatinal nephritis, cardiac hyper-
trophy in, 25
oedema in, 92
Schick test, 177
Scurvy, mouth symptoms of, 229
Secondary infections, 160
Secretion, disturbances of, gastric,
237-245, 252
intestinal, 283
pancreatic, 273
salivary, 230-232
Semicircular canals, disease of, as a
cause of dizziness, 472
Sensitization of red blood-corpuscles
and bacteria, 173
Sensory disturbances, cutaneous, 469,
473
delayed perception of, 468
from the heart, 78
from the intestines, 297
from the lungs, 225
in diseases of the peripheral
nerves, 468, 469, 470
of the spinal cord, 468,
469, 470 .
irritative manifestations of,
468, 473
localization in, 471
of the stomach, 243, 257
painful, 474
paralytic manifestations in,
468
Yoluntary movements in, 455-
457
Septic diseases, heart complications
of, 9
hypinosis in, 136
in mixed infections, 160, 161
Septum defects, cardiac, 18
Serodiagnosis in gonorrhoea, echino-
coccus disease and other condi-
tions, 174
in syphilis, 173, 174
in typhoid fever, 174, 175
Serum disease, 178, 180, 185
prevention of, 177 (Schick
test), 185
Serum of the blood (see also Blood
Serum), agglutination in,
aminoacids in, 139
antitoxins of, 169
bacteriotropins of, 189, 190
cytolytic properties of, 162-
168, 169
diminution of proteids in, 139,
140
fat in, 137
ferments and anti ferments in,
138
immunological characteristics
of, 162-165
inactivation and reactivation
of, 166
precipitins in, 171
proteids in, 137
watering of, 139-141
Shock, anaphylactic, 87, 179
surgical, 87
acapnia in, 88
anoci-association in, 87, 88
venous pressure in, 88
Side-chain theory, 166
Sinus arrhythmias, 70
tachycardias, 58 ^
Skee runners, cardiac hypertrophy
in, 8
Skin, blood-vessels of, in fever, 394,
395, 396
in normal regulation of body
terfiperature, 388, 389
in stasis dilatation of the
heart, 50
nutritional disturbances of, 482
reflexes of, 462
water excretion of, in fever, 395,
396, 404, 405
Sneezing, 198
Sodium chlorid, as a cause of fever,
384
retention of, as a cause of
oedema, 93
Spasm, of the arterial muscles, 79
(angina pectoris), 81, 84, 452
514
INDEX
Spasm of the oesophagus, 233 (cardio-
spasm)
of the intestinal musculature, 290
tonic, in occlusion of the
bowel, 294, 297
of the pylorus, as a cause of gas-
tric dilatation, 252, 253
Spasmophilia in children, 379
Spinal cord, diseases of, in anaemia,
112
injuries of, and temperature
regulation, 385, 387, 400
Spleen, hyperplasia of, in leukaemia
and pseudoleukaemia, 127,
128, 130, 133
in polycythaemia, 142
Splenectomy in pernicious anaemia,
IIS
m haemolytic uterus, 269
Sputum in asthma, 205
Staphylococci, in the etiology of
endocarditis, 9
Stasis, cardiac, secretion of urine in,
417
oedema from, 90, 95, 96 (pul-
monary oedema)
in aortic insufficiency, 13
in decompensated hearts, 34,
47, 48, 49. 50, SI
in paroxysmal tachycardia,
57
venous, manifestations of, 50,
142 (polycythemia)
Stenocardia. See Angina Pectoris
Stenosis, of the bowel, 291-296
of the cardiac orifices, 10, 15, 18
of the oesophagus, 233
of the pylorus, 252, 254
of the respiratory passages, 200,
204
Sternberg's peculiar form of tubercu-
losis, 134
Stomach (see also Gastric) affections
of, absence of free acid in
chronic, 244
as a cause of secondary anae-
mia, 109
as a cause of cardiac arrhyth-
mia, 70
as a cause of pernicious anae-
mia, 113
bradycardia in, 60
paroxysmal tachycardia and,
57
Stomach, atony of, 253
Stomach, dilatation of, 248, 251, 252,
254
acute, 253
atonic, 253
Stomach, dilatation of, bacterial de-
composition in, 248, 254
disturbed resorption in, 254
due to anomalies of position
and form, 252
fulness and pressure in, 258
in hyperacidity and hyperse-
cretion, 243
in pyloric stenosis, 252
nervous symptoms of, 255
without pyloric stenosis, 253
Stomach, emptying of, delayed, 251,
252, 254
effect of, on gastric flora, 254
of character of g^astric
contents upon, 250
hurried, 250
pyloric reflex in, 249
through the cardia, 255
Stomach, movements of, 248
hunger contraction waves in,
257
Stomach, secretions of. See Gastric
Juice
Stomatitis, 229
in acute leukaemias, 230
Strangulation of the intestines, 295
Streptococci, in focal infections, 153
in mixed infections, 160, 161
on the heart valves, 9
mutation of, 153
Struma, cardiac disturbances due to,
55.. 56, 323. 324 (exophthalmic
goitre)
respiratory disturbances due to,
200
Strychnin poisoning, arterial spasm
in, 81, 84 ^
convulsions in, 462
urine in, 416
Substance sensibilisatrice (Bordet),
166
Subjective disturbances, cardiac, 76,
17, 78
dyspeptic, 257^-260
intestinal, 297-299
respiratory, 225
urinary, 437
Sugar content, of the blood, 343
after phlorhizination, 345
346
in diabetes, 349
in renal diabetes, 346
in transitory glycosurias,
348
of the urine, in hypergly-
caemia, 344, 348, 349
Surgical shock. See Shock
Swallowing, 232
INDEX
515
Sweat, secretion of, in fever, 395, 396,
404, 405
in obesity, 313, 314
Sypathetic system, role of, in causa-
tion of fever, 385
Syncope, 442
action of, on the heart, 74
Syphilis, etiological role of, in anae-
mias, 109, 113
in aortic insufficiency, 10
in hasmoglobinuria, 118
serodiagnosis of, 174
Tachycardia, 54~59
paroxysmal, 56
causes of, 58
symptoms of, 56
sinus, 58
Teeth, diseases of, in diabetes, 229,
359
effect of, upon digestion, 229
relation of, to focal infec-
tions, 153
Temperature of the body (see also
Fever), centres for the
regulation of, 400, 403
diurnal variations in, 381
effect of exercise upon, 390
elevations of, in fever, 381 _
in injury of the mid-
brain, 386
in collapse, 408
in heat-stroke, 390
Liebermeister's theory of
higher pitched level of, 402
lowering of, by toxic mate-
rials, 410
pulse-rate and, 55
regulation of, in fever, 391,
400
in health, 388
subnormal, 409
Tendon reflexes (see also Reflexes),
conditions underlying, 460
effect of, on motility, 458
exaggerated, contractures in,
464
in disturbances of the reflex
arc, 460
in dissociation of brain and
reflex centres, 461
Tenesmus, rectal, 299
vesical, 437
Tetanus, action of spores of, in mixed
infections, 160
antitoxin content of blood in, 170,
causes of insusceptibility to, 170
convulsions in, 462
Tetanus, haemolytic action of bacillus
of, 159
spread of toxin in, 158, 462
treatment of, 158
Tetany, relation of, to gastric dilata-
tion, 255
Throat, affections of, 229, 232
Thrombokinase, in coagulation of
blood, 136, 375
Thymus, importance of, in bodily de-
velopment, 373
in sudden death, 373
Thyroid gland (see also Hyperthy-
roidism), effect of,
upon the heart, 55, 56,
323, 324
upon metabolism, 320
function of, 321, 322
results of extirpation of, 322
Tobacco, as a cause of angina pec-
toris, 79
of arrhythmia, 70
of intermittent claudication,
79
of palpitation, tj
Toluylendiamin, action of, on secre-
tion of bile, 261
Tongue, diseases of and disturbances
of chewing, 229
paralysis of, as a cause of
dysphagia, 229, 233
Tonsils, importance of, as portals of
entry for microorganisms,
152
in focal infections, 152, 153
Tonus of the arteries,
effect of, on blood-pressure.
Tophi,
Toxic albuminurias, 423
Toxic symptoms. See Intoxication
Toxins, bacterial, 157-159
action of blood serum upon,
169
of gastric juice upon, 245
as a cause of albuminuria, 423
of cardiac disease, 9, 43
of haemoglobinaemia, 117
of intestinal disorders,
276
minimum lethal dose of, 157
Tracheal stenoses, effect of, on res-
piratory movements, 201
Transfusion in anaemia, dangers of,
119
Transudate formation, due to venous
stasis, 51, 90
Trauma, as an etiological factor in
infections, 159
Tremor, 466
516
INDEX
Tricuspid lesions, i8
venous pulse in, 51
Trigeminal nerve, relation of, to
trophic disturbances in eyes and
face, 483
Trypanosomes, destruction of
(chemotherapy), 191
Tubercle bacillus, passage of, through
intestinal wall, 155
Tuberculosis, as a cause of anaemia,
109
of cardiac hypertrophy, 21
of valvular lesions, 9
general bodily changes in, 375
proteid destruction in, 319
serodiagnosis of, 174
Tuberculosis glandular, resemblance
of, to pseudoleuksemia, 127, 134
Tumors, malignant, as a cause of anae-
mia, 109, 113
of increased proteid de-
struction, 319
Tympanites, 296
Typhoid fever, blood in, 126
bradycardia following, 61
dissemination of, by bacillus
carriers, 191, 279
immunity after, 164
local allergic in (chante-
messe), 186
prophylactic vaccination in,
17s
serodiagnosis of, 174
vaccine and serum therapy
of, 178
Tyrosin, relation of to alkaptonuria,
335
Ulcer, gastric, complications of, 243,
253
etiology of chronic, 242
hyperacidity in, 241
infection in the etiology of,
242
intestinal, effect of, on peristalsis,
288
Urea, elimination of, in fever, 398
significance in functional
tests, 428
formation of, 333
in uraemia, 431
Uraemia, 429^433
heart action in, 60, 70, 429
hypertension in, 28
in chronic infections of renal
pelves, 26
Ureteral stenosis, secretion of urine
in, 418, 419
Urethral fever, 387
Uric acid, excretion of, in the urine,
364
in gout, 369
in leukaemia, 365
in the new-born, 366
in the blood, in gout, 368
in calculi, 435
origin of, 364, 365
Uric acid infarcts of the new-born,
366,435
Urinary bladder, relation of, to renal
pelves, 433
Urinary calculi, 434
Urinary fermentation, ammoniacal in
urinary stagnation in the bladder,
433
Urinary passages, formation of cal-
culi in, 434
inflammations of, 433
occlusion of, 418
painful sensations in, 437
Urine, characteristics of, in acidosis,
327, 329
in burns, 119
in diabetes insipidus, 414
in diabetes mellitus, 330, 332,
359
in dyspnoea, 223
in fever, 39i8, 495
in haemoglobinaemia, 1 18, 121
in hepatic disease, 334
in hyperglycaemia, 344
in infections of the urinary
passages, 433, 434
in intestinal obstruction, 293
in jaundice, 267
in pernicious anaemia, 114
in phosphorus poisoning, 345
in renal oedema, 92
in urinary retention, 433, 434
Urine, secretion of, diminished, 416,
417
disturbed, sequelae of, 428
functional disturbances and
their localization in rela-
tion to, 427
increased, 413-416
influence of circulation in
kidneys upon, 413, 416
of composition of the
blood upon, 425
of diuretic substances
upon, 426
in disturbances of innerva-
tion, 459
of elimination of formed
elements (casts),
42s
of urmary solids,
420, 426
INDEX
617
Urine, secretion of, in disturbances of
elimination of water, 419,
426, 427
in lesions of the secreting
membranes, 419
in obstruction in the kidneys
by blocking of the tubules,
418
outside the kidneys (uni-
lateral), 418
mechanism of, 413, 427
Urobilin and urobilinogen in urine
and faeces, diagnostic
significance of, 272
formation and circulation
of, 272
Vaccines, immunization with, 175, 178
Vagina, infections in, 156
Vagotonus, in old age, 52
in the puerperium, 62
Vagus, relation of, to arrhythmia, 69,
7° t- •
to asphyxia, 59, 223
to bradycardia, 59^1, 62
to heart block, 45, 67
to paroxysmal tachycardia, 58
to respiration, 202, 204
Vascular crises, 81, 84
Vascular disease, as a cause of dis-
turbances of motility, 451
Vascular spasm, in angina pectoris, 79
in intermittent claudication,
79, 451
Vasomotor paralysis, as a cause 01
tachycardia, 55
in the infectious diseases, 8i6
Veins, circulatory disturbances of, due
to anomalous heart
action, 50, 88
to disorders of the lungs,
116
to pressure upon the
great veins, 116
Veins, increased blood-pressure in, 47,
88, 90
lymph transudation from, in
venous stasis, 90
murmurs in, 89
pulsations in, in cardiac stasis, 51
Venous hum, 89
Vesical tenesmus, 437
Vocal cords, paralysis of, 203
spasm of, 200, 201
Volumen pulmonum auctum, effect of,
on respiration, 200, 207
Volvulus, 292
Vomiting, 255
Wandering cells, role of, in the proc-
ess of immunity, 187, 193
Wassermann reaction, in syphilis, 174
as an indication of the constitu-
tional nature of syphilis, 375
Water, absorption of, through the in-
testines, 283, 288
effect of, on the storage of fat,
312
elimination of, in fever, 388, 395,
405
through the kidneys, 413, 414,
416, 419, 424, 425, 426, 427
retention of, in nephritis, 92, 140,
141
Water content of the serum, 137
in chlorosis, 107
Whooping cough, 201
Wright's method of vaccination
against typhoid fever, 175
Xanthin, in the urine, 364
in urinary calculi, 437
X-rays in leukaemia, 129, 131
Zymogens. See Enzymes
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