processes and there is noticeable separation of the teeth. The lower lip may
protrude, the neck seems to be shortened, the ears are prominent and the alae
of the nose together with the eyelids, are enlarged; the tongue may be thickened.
The skin may be coarse, changed in color and moist but is not harsh, thickened
and dry as in myxoedema. The bones of the limbs and especially of the hands
and feet, are enlarged, the fingers and nails are broad and the hand possesses
a spade-like appearance. The enlargement is symmetrical and there is
no interference with function. The increase in size does not involve the
legs and arms until late in the disease when there may be an augmentation
of their circumference. The scapulae, ribs, sternum and vertebral column
may be affected, kyphosis being a not unusual late symptom. Muscular
atrophy is sometimes present; the genitals may be enlarged. Headache and
pains in the bones may occm*, the patient is lethargic and cerebration is slow.
The voice may be changed due to the lingual thickening and enlargement
of the laryngeal cartilages and the special senses may be dulled. Ocular
manifestations are frequent, a common early symptom being bitemporal
hemianopsia. Optic nerve atrophy is frequent and neuritis may be noted.
Menstrual disorders are not unusual and early menopause may occur. The
patient may suffer from dyspnoea, palpitation and cardiac h3rpertrophy and
there may be increased dulness over the manubrium sterni due to a persistent
The diagnosis is usually easy, the bony enlargement being general, not
of the extremities of the bones only as in arthritis deformans or of the shafts
alone as in osteitis deformans. Congenital progressive hypertrophy or giant
growth affects one extremity or one side of the body only.
The prognosis is entirely unfavorable as to recovery but life is usually
preserved for a long period unless terminated by intercurrent disease. Fatal
instances of acromegaly have been observed which were probably due to
842 DISEASES OF THE NERVOUS SYSTEM.
Treatment is unavailing. Thyroid extract gives no definite results and
the same may be stated of extract of the pituitary gland. The headache and
pain in the bones may be relieved by antip}Tine or acetphenetidine.
This is a rare disease characterized by an enlargement of the cranial bones
and in some instances, of those of the face. The condition is the result of an
hyperostosis due to a development of multiple osteophytes in the bones af-
fected. In addition to the increase in the size of the bones, osteomata may-
appear upon the outer or inner surfaces of the cranial bones which some-
times may press upon the subjacent structures and give rise to the symptoms
of tumor. The onset of the disease may occur in early life, sometimes fol-
lowing trauma. There is no known effective treatment.
Synonym. Paget's Disease.
Definition. A rare disease characterized by enlargement and softening
of the shafts of the long bones and sometimes of those of the spine and cra-
nium, those of the face being unaffected.
The changes in bony structure result in certain deformities such as a trian-
gular shape of the head, the base being upward, and spinal curvature, more
particularly a kyphosis in the dorsal or cervical region. The head is projected
anteriorly and the legs may be bowed outward, anteriorly or posteriorly, the
hips and lower thorax are widened and the abdomen becomes lozenge shaped.
.Etiology. The causation of the disease is unknown but the condition
has been considered to have a possible relationship to acromegaly or osteo-
Pathology. Microscopic examination of the bone structure reveals the
presence of a rarefying osteitis associated with the formation of new bony
lamellae, some of the Haversian canals being wider than normal while others
The symptoms consist chiefly of the deformities resulting from the bony-
Treatment appears to be vauleless.
HYPERTROPHIC PULMONARY OSTEOARTHROPATHY.
Definition. A condition characterized by enlargement of the bones of the
hands and feet especially in the neighborhood of joints. Occasionally the
ends of the bones of the forearm and les;s are involved. The affection is usu-
ally associated with some pulmonary lesion such as chronic bronchitis, emphy-
sema, tuberculosis, empyasma, fibroid phthisis or neoplasm.
Etiology. The causation of the affection is not definitely known. It is a
disease of adults and has been attributed to the toxins of the pulmonary lesion
which being taken into the circulation bring about an ossifying periostitis
by their irritant action; other hypotheses are that it is due to circulatory
obstruction and trophic nervous disorders or that the condition is a Henign
Pathology and symptoms. The bones of the head and face are not involved.
There is enlargement of the terminal phalanges and the nails are increased
in size and curved over the finger ends causing the so-called clubbed fingers.
There may be osteitis and thickening of the shafts of the long bones and joint
effusions; spinal curvatures are rare but may result from direct extension of
the pulmonary disease. Muscular atrophy from disuse may be present.
The course of the affection is protracted and its development is slow although
in occasional instances the evolution of the deformities is moderately rapid.
Pain and tenderness are infrequently observed.
Treatment. The deformities cannot be influenced by medication. The
chief indication is to combat the go-existing pulmonary condition by ap-
Definition. A chronic condition characterized by local or generalized
stiffening and induration of the skin.
There are two types of the disease; the diffuse and the circumscribed, the
latter being also known as morphcea.
.etiology. The circumscribed type is the more common and may be of
trophoneiirotic causation. The diffuse form is probably of similar origin
and seems to be predisposed to by exposure and attacks of rheumatism. It
may develop as a complication of exophthalmic goitre or in association with
Raynaud's disease. Both forms occur more frequently in women and usually
in middle adult life.
Pathology. There is no change in the epidermis; there is an increase in
the connective tissue of the corium and an hyperplasia of the subcutaneous
connective tissue probably resulting from arterial changes. The glands of
the skin are not altered but there may be atrophy of the thyroid gland. In
the diffuse form of the disease the cutaneous changes are general while in
morphcea they are localized.
Symptoms. The diffuse type of scleroderma is rarer and more obstinate
than the circumscribed. The skin of the extremities, of the face, of the chest
844 DISEASES OF THE NERVOUS SYSTEM.
or of the neck is fia"st affected; the skin becomes firm and tense and upon
movement a peculiar stiffness is observed; later it becomes brawny and indu-
rated and, while sometimes its normal appearance persists, it is more often
smooth and glossy. Ultimately the skin becomes so hard and inelastic that
flexion of the joints which are covered by the affected tissue is difficult or
impossible. When the face is involved the expression is lost and the lips
may become immobile. Cyanosis of the extremities may occur due to vaso-
motor disturbances and pigmentation resembling that of Addison's disease
may be observed. When the condition is not general it tends to symmetry
of distribution which the circumscribed type of the disease does not. The
course of the affection is chronic, months often being required for its develop-
ment. While it may persist in statu quo for years at times it gradually disap-
pears leaving no trace.
Sclerodactyly may be considered as related to scleroderma. Here the fingers
become atrophied and their skin is thickened and glossy; the nails are dis-
torted and pigment, ulcerations and excoriations may appear over the joints.
The circumscribed form or morphoea is characterized by the appearance
of brawny, waxy patches upon the skin, usually of the breasts or neck, some-
times along the course of the nerves. Hj^eraemia with pruritus may be an
initial symptom, later there may be deposition of pigment or entire loss of
coloring matter (leucoderma). The patches often develop and spread with
rapidity and there may be sensory distiirbances. While the cutaneous mani-
festations may persist for only a few weeks, at other times they remain for
years; iiltimately, however, they usually disappear.
Treatment. The only medication that seems to exercise any effect over
the condition is thyroid extract. Instances have been reported in which
much benefit was derived from its administration. It may be necessary to
continue its use for years. Tonics should be given, iron, codliver oil and
especially arsenic. The salicylates and phenyl salicylate in doses of lo to 15
grains (0.66 to i.o) three times daily have been recommended and the use
of the galvanic current upon the lesions has been advised.
The patients should be kept warmly clothed and protected from exposure.
Warm baths and massage of the affected parts with bland oils or, in protracted
and obstinate instances, with oil of turpentine well diluted with olive oil
should be employed to lessen the stiffness of the skin.
Definition. A trophoneurosis characterized by the development of a furrow
in the digito-plantar fold and finally resulting in amputation of the toe.
.Etiology. This disease affects the dark skinned races almost exclusively.
It is not infrequent in Brazil, India and Africa and has been observed in the
United States. Traumatism may act as a predisposing factor. No specific
cause is known.
Pathology. Microscopically a constricting band of fibrous tissue is seen
about the base of the toe; this gradually becomes tighter, the member swells,
becomes disintegrated without suppuration, and finally falls off.
Symptoms. The little toe is most often involved. The furrow is first
seen upon its inner aspect, increases laterally, becomes deeper, the toe swells
and burning pain may extend to the foot or up the leg. Finally the swelling
disappears and the toe is spontaneously amputated leaving a dry scab behind.
Constitutional manifestations are wholly wanting.
The prognosis is favorable as regards recovery although the process may
persist for a number of years.
Treatment is entirely surgical. Early in the affection the constricting
band should be severed. After the toe has degenerated amputation will
846 DISEASES OF THE MUSCULAR SYSTEM.
DISEASES OF THE MUSCULAR SYSTEM.
Synonym. Suppurative Myositis.
Definition. An acute or subacute inflammation of striped muscle due to
an infectious agent.
etiology. The disease has been observed most frequently in Japan and
seems in most cases to be due to infection with the staphylococcus pyogenes
aureus, while more rarely the albus is found co-existing or the streptococcus
seems to be responsible for the condition.
Pathology. The distinctive lesions seem to be firmness, brittleness and
fatty degeneration of the muscles involved, serous infiltration and hyper-
plasia of the intermuscular septa. Abscesses may be present in the substance
of the affected muscles and an irregular erythematous rash is often seen.
Symptoms. The muscles of the limbs are more usually affected but those
of the body and the heart muscle may participate in the infection. The onset
of the disease is usually sudden with marked febrile movement and prostra-
tion. There is swelling of the muscles with slight oedema and an erythemat-
ous rash upon the body and limbs. There is pain in the muscles, motion
increases this symptom. Paraesthesiag may occur in lieu of the pain. Later
abscesses with their ordinary symptoms may form in the substance of the
mnscles and pyaemia may follow.
Cases have been reported in which atrophy of the affected muscles occurred
but these may have been instances of acute progressive muscvilar atrophy.
The disease has been called pseudo-trichinosis from its resemblance to
The coinse of infectious myositis lasts from one month to a year or more.
Polymyositis Haemorrhagica is the name given to form of myositis differ-
ing little from the preceding except for the fact that during its course haemor-
rhages between the muscle fibres occur and circulatory symptoms resulting
from involvement of the heart muscle are observed.
OSSIFYING MYOSITIS. 847
Synonym. Myositis Progressiva Ossificans.
This is a rare disease characterized by a calcification of the muscles. It
is seen most often in males and is likely to begin about the age of puberty.
Its course is very protracted and finally most of the muscles may become
involved. The process begins with fever and swelling and redness of the
muscles affected; induration persists after the acuity of the condition has
disappeared and the indurated areas are finally transformed into bony sub-
stance. Entire muscles may become ossified. Theories advanced to account
for the process are that the bone development originates from the periosteum
or that the bone develops according to Cohnheim's law of foetal inclusion and
is a true osteoma. Traumatism seems to be an exciting cause.
Treatment. This consists in all varieties of myositis in relieving the symp-
toms as they arise. The abscesses in the suppurative type should be opened
and drained and the bony growths of the ossifying form may be excised if
Synonyms. Lipomatosis Luxiirians Muscularis; Atrophia Muscularium
Definition. A paralytic condition of the muscles associated with atrophy
which is obscured by hyperplasia of the interstitial fatty tissue.
.etiology. Heredity is the only recognized causal factor and is of consider-
able influence. The disease is one which affects children chiefly and boys
more than girls. It is usually transmitted through the mother although she
may not have been herself afflicted. It is often seen in several successive
generations and may occur in several individuals in the same generation.
It usually develops before puberty but may appear as late as the twenty-fifth
year or beyond that age.
Pathology. The nervous system is seldom affected, the chief lesion being
in the muscles themselves. The muscle fibres first are increased in size, their
nuclei become more numerous and the connective tissue is increased. Later
the muscle fibres atrophy and become fissured, the connective tissue becomes
much hypertrophied and there is marked increase in the fatty tissue between
the muscle fibres.
Symptoms. The symptoms of the paralysis appear before the evidences of
the pseudo-hypertrophy. The child is unsteady upon his legs, the movements
are clumsy, especially so in jumping and in ascending stairs. Examination
848 DISEASES OF THE MUSCULAR SYSTEM.
reveals what seems to be an enlargement of certain muscles; the pseudo-hy-
pertrophy being especially evident in the calves and later in the extensors of
the leg, the glutei and the lumbar muscles; those of the upper extremity are
seldom affected save the deltoid and triceps. Walking becomes difl&cult,
and the characteristic waddling gait with shoulders thrown back, abdomen
protruded, and the lumbar lordosis accentuated, is evident; the nates are
prominent and the feet far apart. As the legs are raised the feet drop because
of weakness of the dorsal flexors of the foot. A very characteristic symptom
is elicited by placing the child on the floor and bidding him to rise. He first
gets on all fours, rises to his feet by drawing his arms along the floor and assumes
an erect position by climbing his own legs by drawing the hands up the
limbs until one knee is reached, then with this as a vantage point he raises
the body, then grasping the other knee forces himself into the erect position.
Palpation reveals the fact that while the size of the muscles is large their
consistency, instead of being normally firm, is soft and flabby. True atrophy
of some muscles, especially of those of the arm, without the replacement of
their lost substance by fat, may be present.
There is no sensory disturbance, the sphincters are not affected and the
mentality is usually unimpaired. The electrical irritability of the muscles
is less acute than normal because of the loss of muscle substance but the
reaction of degeneration is absent; the knee jerk is sometimes lost and there
may be mottling of the skin, especially over the legs.
The prognosis is grave, the patient seldom living to grow up.
JUVENILE MUSCULAR DYSTROPHY.
This type of dystrophy is less frequent than the preceding affection and oc-
curs in slightly older subjects although found as a rule before the age of twenty.
Heredity plays the same part in its aetiology as it does in that of pseudo-hy-
pertrophic paralysis. The disease begins usually in the arms and shoiilders
and involves the pectorales, trapezius, latissimus dorsi and triceps; later the
glutei, the quadriceps extensor, the peronei and tibialis anticus are affected.
More rarely the latter muscles are first attacked; the muscles of the hands
and feet are not affected although muscles of the limbs other than those men-
tioned may finally participate in the disease, and certain groups are likely to
be the subject of a true or pseudo-hypertrophy. When the serratus is involved
there is a projection of the scapula which is quite typical.
The gait is waddling and locomotion may finally become impossible.
Bulbar symptoms are rarely seen; the atrophy, however, may involve the
diaphragm and cause death. The course of the disease is protracted, Erb
giving thirty-eight years as its longest limit, and the prognosis is distinctly
MUSCULAR DYSTROPHY OF THE LANDOUZY-DEJERINE TYPE. 849
MUSCULAR DYSTROPHY OF THE LANDOUZY-DEJERINE TYPE.
This affection is also termed Juvenile Palsy of the Facio-scapulo-humeral
Type and is hereditary in the same sense as are the two preceding diseases.
It may begin as late as the thirtieth year of life and is characterized by a
muscular wasting involving primarily the facial muscles. The eyes cannot
be entirely closed and phonation, whistling and laughing are difi&cult. The
facial expression (Jades myopathique) is characteristic, the eyes being partly
closed, the cheeks hollowed and the upper lip dependent (the tapir mouth).
There are no fibrillary contractions and the electrical reaction is unchanged.
The masseters and temporals, the internal muscles of the eye and those of
the forearm and hand are not affected.
MUSCULAR ATROPHY OF THE PERONEAL TYPE.
This form of muscular atrophy begins late in childhood or even after puberty.
Heredity is a factor in its causation and it is met more often in males. The
muscles on the anterior surface of the leg, the extensor longus hallucis, exten-
sor communis digitorum and the peronei are first involved; pes equinus or
equino varus may result; the calf muscles may become affected later in the
disease and after many years those of the hands and forearms. Fibrillary
contractions are present and the reaction of degeneration and various sensory
and vaso-motor disturbances may occur, the affection thus differing from
the previously described types of muscular dystrophy.
In this disease peripheral nerve degeneration and ascending degeneration
of the posterior columns of the cord have been made out post-morten and in
view of these findings the condition may be considered as the result of a neuritis.
Its course is chronic and little can be done in the way of treatment other than
to correct the deformities by means of apparatus or operations.
The treatment of the various types of muscular dystropy is most unsatis-
factory but the measures suitable in progressive spinal muscular atrophy
(see p. 742) may be employed. The general health should be considered,
exercise in moderation prescribed and massage of the affected muscles with
oil is indicated. Electricity may be beneficial. After the patient becomes
bedridden care should be taken to prevent contractures and bed sores.
850 PARASITIC DISEASES.
The psorosperms, sporozoa or cytozoa, are classed among the lowest forms
of the protozoa. These organisms are very common in the invertebrates and
are not very rare in mammals. Of the psorosperms the coccidium ovijorme
or cuniculi and the coccidium hominis are the most important. The former
produces in the rabbit a condition characterized by the development of whitish
nodules in the liver which vary in size and are due to circumscribed dilata-
tions of the bile ducts. In man a similar condition (Internal Psorospermiasis)
may result in which there may be hepatic tenderness with chills, fever, prostra-
tion, stupor and finally coma; the nodules in the liver are sometimes palpable.
After death whitish growths have been found in the peritonaeum, pericardium,
liver, spleen and kidneys.
The parasites have also been observed in the kidneys, ureters and intestine.
In the former instance frequent urination of bloody urine has been noted and
obstruction of the ureter with resulting hydronephrosis has been described.
Intestinal psorospermiasis causes gastroenteric irritation with increasing
prostration until the patient may lapse into the typhoid condition.
External Psorospermiasis is said to occiir and is characterized by a hard,
crusty, papular eruption upon the face, abdomen, lumbar region and groin;
later the papules tend to become confluent. The sporozoa are found in the
cutaneous lesions in this form of the condition as well as in those of cutaneous
carcinoma and Paget's disease. Whether these organisms have any relation
to the causation of these latter is undecided. In so-called dermatitis coccid-
ioides bodies resembling psorosperms have been found to be blastomyces.
Psorosperm infection reaches man upon such vegetables as spinach, lettuce,
cabbage, etc., which are eaten uncooked and are liable to contamination by
the excreta of lower animals in which the affection occurs, consequently the
condition may be in great measure prevented by proper attention to the
cleaning of green vegetables.
Treatment. The injection of i to 1000 to i to 5000 solution of quinine
has been suggested but it can hardly be effectual unless the medicament
comes into contact with the parasite in the intestine. The treatment of
psorospermiasis is otherwise symptomatic.
Other protozoa which cause disease in man are the amceba coli and the
Plasmodium malarice. These have been considered in the section upon the
Different forms of distomata or flukes are found in various situations in
the human body.
Distomiasis of the Liver is due to infection with one of the liver flukes (Dis-
tomata). These organisms are of the family Fascolidce of which five species
have been found in the human system. The most common is the liver fluke
(Jasciola hepatica) which inhabits the bile passages of ruminants, and par-
ticularly the horse, rabbit, sheep, goat and ass. The eggs of the fluke escape
in the intestinal evacuations of these animals and under favorable conditions
embryos extrude from these ova which are ingested by snails where they
undergo further development and are finally cast off to attach themselves to
certain water plants and, with these, are eaten by animals.
Symptoms. When present in large number in the human bile ducts the
flukes cause an irregular diarrhoea which at first may be bloody, the liver is
enlarged and jaundice may be evidenced at intervals. The patient may com-
plain of pain, there is seldom any marked febrile movement. The affection
is a chronic one and finally anaemia and emaciation appear with ascites and
general oedema. Temporary amelioration of the symptoms rnay take place
but permanent recovery is very rare, the disease ultimately resulting fatally.
An endemic type of hepatic distomiasis occurs in Japan from which children
are the chief sufferers. The ova are easily demonstrated in the faeces.
Treatment consists in combating the symptoms as they arise. Phenyl
salicylate in large doses, male fern and naphthalene have been suggested.
Pulmonary Distomiasis due to the distoma pulmonale or lung fluke is occa-
sionally observed. This form of fluke has been found in the lungs of the