physician being less to learn the character of his ailment than to obtain relief.
In formulating a method of treatment for a given affection the various
therapeutic measures at oiu" disposal must be considered separately, and, more
than aU, in prescribing for our patient we must not use the diagnosis as a figur-
ative peg upon which to hang a varied series of methods of treatment selected
haphazard, but we should, remembering the while that most important and very
definite entity the personal equation, treat the patient and not his disease.
With a view toward systematizing and correlating our knowledge careful
records of all patients should be kept and the following method of recording
histories, physical examinations and other data is suggested.
CASE RECORD:
Record data'jbelow:
Name — Age — Occupation — Social Condition —
Birth-place — Place of Residence — Date oe
Examination.
History. — Hereditary Tendencies — Notable Habits —
General Surroundings — Previous Illness and Ac-
cidents — Causes, Manner of Attack, Duration and
Course of Present Illness.
SYMPTOMS:
Alimentary System. — Deglutition — Appetite — Sensa-
tions during Fasting and after Eating {Discomfort
— Pain — Weight — Distention — Heartburn — Nau-
sea) — Acidity — Flatulence — Eructation — Pyrosis —
Vomiting. State of Bowels {Frequency — Color of
Stools — Tenesmus.)
Circulatory System. — Subjective Phenomena {Pain —
Palpitation — Faintness — Dyspncea).
Respiratory System. — Breathing {Painfulness) — Cough
— Larynx {Pain).
Integumentary System. — Subjective Phenomena — Skin
{Dryness — Itching — Moisture) .
Urinary System. — Subjective Phenomena {Pain in Loins,
Bladder or Urethra) — Micturition {Frequency).
Reproductive System. — Male — Abnormal Discharges
— Functions — Subjective Phenomena. Female —
Catamenia — Pregnancies — Abnormal Discharges —
Subjective Phenomena.
Nervous System.
Sensory Functions. — Sensations {Pain — Heat — Cold —
Formicatio7i — Numbness— Tingling — Girdle Pain —
Vertigo) .
Motor Functions. — Organic Reflex {Swallowing —
Breathing — Micturition — Defcecation).
Vasomotor and Trophic Functions. — Subjective Phenom-
ena.
Cerebral and Mental Functions. — Subjective Phenomena
— Sleep.
Locomotory System. — Subjective Phenomena.
XXV
SIGNS:
Status Pr^skns.
General Facts.— Height— Weight— General Appearance
{Temperament— A ttitude and Expression)— Tem-per-
ature.
Alimentary System. — Lips— Teeth— Gums — Tongue-
Fauces — {Characters, Macroscopic and Microscopic,
of Vomitea Matters) — Character of Fjeces — {Macro-
scopic aiid Microscopic Examinations) — Abdomen
{Prominence — Retraction — Distention — Flaccidity
— Tenderness — Fluctuation — Outline of Normal or
Abnormal Contents) — Rontgen-ray Examination.
Hemopoietic System. — Lymphatic Vessels and Glands
— Ductless Glands {Spleen— Thyroid) — Microscop-
ical Characters of Blood — Hsemoglobin Percentage— -
Specific Gravity — Coagulation Time — Cryoscopic
Examination.
Circulatory System. — Inspection {Form and Appear-
ance of Precordium) — Palpation {Position and Char-
acter of Cardiac Impulse) — Percussion {Superficial
and Deep Outline) — Auscultation {Rhythm and
Quality of Somids in Mitral, Tricuspid, Aortic and
Pulmonary Areas, over General Surface of Heart
and Main Vessels) — Pulse {Frequency — Rhythm —
Character — Sphygmo graphic Tracings) — Arteries,
Veins and Capillaries — -Rontgen-ray Examination —
Blood Pressure Estimation.
Record data below:
Respiratory System. — Breathing {Frequency — Rhythm
— Type) — Sputa {Macroscopic and Microscopic Char-
acters) — Nares {Rhinoscopic Examination) — Phar-
\Tix — LarvTix — {Voice — Tenderness — Laryngoscopic
Examination) — Inspection {Form and Action of
Thorax) — Mensuration {Spirometric Tests) — VaXpz.-
tion {Vocal Fremitus) — Percussion {Anterior and Pos-
terior, on both 5/(fe5)— Auscultation {Determination,
during Natural and Deep Respiration, of the Dura-
tion of the Sounds, their Character, Acco?npaniments,
and of the Vocal Resonance — Tussive Signs) — Ront-
gen-ray Examination.
xxvi
SIGNS (Continued) :
Integumentary System. — Obesity — Emaciation-
(Edema — Emphysema — Eruptions {Distribution-
Elements of Skin Involved — Type — Cause).
Urinary System. — Urine — Quantity — Color — Specific
Gravity — Chemical Reactions (Acidity — Alkalinity
— Albumin — Sugar — Bile — Indican — Amount of
Urea and Uric Acid) — Sediment {Macroscopic and
Microscopic Characters) — Cr}'oscopic Examination —
Rontgen-ray Examination.
Reproductive System. — Male — Testicle — Epididymis
— Prostate — Urethra {Endoscopic Exa?nination) —
Bladder {Cystoscopic Examination and Result of
Ureteral Catheterization) — Abnormal Discharges.
Female — Ovaries — Tubes — Pelvic Cavity — Uterus
— Vagina {Examination with Speculum) — Urethra
{Endoscopic Examination) — Bladder {Cystoscopic
Examination and Result of Ureteral Catheterization)
— Abnormal Discharges.
Nervous System.
Sensory Functions. — Sensibility to Touch {Msthesio-
m,etric Examiiiation) — Heat — Tickling — Pain —
Muscular Sense — Sight {Ophthalmoscopic Examin-
ation) — Hearing {Otoscopic and Horological Exam-
ination) — Taste^Smell.
Motor Functions. — Skin Reflex — Tendon Reflex — \o\-
untary {Systematic Exa?nination of Muscles) — Co-
ordinating — Electric Irritability {Faradic, Galvanic).
Vasomotor and Trophic Functions. — {Congestion — Pallor
— (Edema — Inflammation — Sloughing — Wasting —
Perspiration.)
Cerebral and Mental Functions. — Intelligence {Halluci-
nations — Illusions — Delusions — Delirium — Torpor
— Coma — Coma- Vigil) — Attention — Memory —
Emotion — Speech — {Comprehension of Language,
heard, seen — Utterance of Language, spoken, written)
— Rontgen-ray Examination.
Record data below:
Locomotory System. — Bones — Joints — {Pain — Swelling
— Effusion — Mobility — Rontgen-ray Examination)
— Muscles {Rigidity — Flaccidity — Cramp — Twitch-
ing, general or fibrillary — Hypertrophy — Atrophy —
Dynamometric Examinatiort) .
XXMl
DIAGNOSIS:
PROGNOSIS:
TREATMENT:
Medicinal:
Physical: (Electricity, massage, hydrotherapy, etc.).
Dietetic :
Hygienic:
General Directions:
Subsequent History:
XXVlll
PRACTICAL MEDICINE
CHAPTER I.
THE INFECTIOUS DISEASES.
ENTERIC FEVER.
Synonyms. Typhoid Fever; Typhus Abdominalis; Gastro-enteric Fever;
Nervous Fever.
Definition. Enteric fever is an acute infectious febrile disease character-
ized by inflammation and ulceration of the Peyer's patches or lymph follicles
of the intestine, by swelling and inflammation of the mesenteric glands,
enlargement of the spleen and a petechial eruption.
.etiology. The specific cause of enteric fever is the bacillus typhosus of
Eberth-Gaffky. This bacillus is to be found in the stools, the inine, the blood,
the lymph patches of the intestines, the lymph glands, the spleen, the skin
eruption and in the marrow and various organs. It usually enters the organ-
ism in infected water or milk or upon contaminated food, such as oysters which
have been bedded near sewer exits, or green vegetables which have been
fertilized by means of sewage. It is contended by some that the bacillus is air
borne and may enter the respiratory system upon the inspired air and thus
reach the blood. Sewage to be contaminated by the bacillus must have
received either directly or indirectly the discharges from a case of the disease.
Enteric fever is more common in the young adult than in childhood, middle
or old age and seems to attack the vigorous and healthy as often as the weak
and enfeebled. Men seem more susceptible than women, but this is probably
because they are more liable to exposure. The disease is most frequently
seen in the late summer and early autumn and may occur in almost any climate.
It is commonly endemic but epidemics occur at intervals. One who has once
had the disease seldom suffers from a second attack.
Pathology. The most characteristic lesion of enteric fever is the inflam-
mation of the solitary and agminated glands of the small intestine. These
glands are first congested and swollen, later they disintegrate and necrose,
and the formation of ulcers takes place. When a solitary gland is involved
the ulcer is small and round; in the agminated glands it is oval with its long
z
2 THE INFECTIOUS DISEASES.
diameter parallel to the long axis of the intestine. The borders of the ulcers
are raised; their bases, which may consist of the sub mucosa, the muscular
coat of the bowel or of peritoneeum are necrotic. The ulcer may erode all the
coats of the gut and the peritonaeum, and perforation take place, local or
general peritonitis resulting. More usually, fortunately, the ulcer gradually
heals but the return of the glandular tissue to normal does not take place.
In a mimber of the cases the large intestine is involved as also may be the
appendix. In either of these situations perforation may occur.
Inflammation of the mesenteric lymphatic glands and of the spleen is
likely to occur, resulting in increase in the size of these structures. The spleen
is usually palpable and may be enlarged to two or three times its normal size.
Abscesses have been reported.
Thromboses of the veins may occiu", especially of those of the leg. Arterial
thrombosis is rare. The pericardium, myocardium or endocardium may be
the seat of inflammation due to the infection.
Respiratory lesions such as inflammations of the larynx, bronchi, or pleura
are not infrequent. Empyaema is rare.
The liver is the seat of an acute degeneration, with granular and at times
fatty changes in its cells. Abscess may occur. The bacillus has been found
in the gall bladder and a typhoid cholecystitis may occur.
The kidneys also imdergo an acute degeneration in their parenchyma,
rarely there may be an acute nephritis. Abscesses of the kidney are rare.
Pyelitis and cystitis may complicate the disease.
Lesions in the nervous system are infrequent, but meningitis has been
met as well as cerebral abscess.
Abscesses in various parts of the body, notably under the periosteum and
in the parotid gland, are not uncommon.
Course and Symptoms. The incubation period is usually about two
weeks, and may be accompanied by lassitude and lack of appetite. Occa-
sionally the patient may continue up and about after the onset of the disease
(walking typhoid). The inception of enteric fever is gradual, with headache,
general bodily pains, nausea and vomiting and a rise of temperature. Chilly
feelings may occur, but a distinct chill is not common. There may be nose-
bleed and slight bronchitis, evidenced by cough. In children the onset is
more usually acute. The bowels may be loose or constipated. There may be
abdominal tenderness and distention. About the eighth day the eruption,
consisting of small isolated, rose-colored, slightly elevated round or oval spots
of about 2 to 4 millimeters in diameter, appears. These disappear on pressure
only to reappear when the pressure is removed. They are seen earliest upon
the back, and sHghtly later upon the front of the chest and abdomen. They
may be found upon the arms and thighs, but very rarely upon the forearms
and legs. They appear in successive crops, each crop lasting 2 to 4 days,
ENTERIC FEVER. 3
while the eruptive period lasts from 2 to 21 days. Relapses show afresh
eruption and the spots may appear after the establishment of convalescence.
The course of the disease usually lasts about four weeks and to each week
belong certain symptoms.
The typical temperature of enteric fever is as follows: After the chill
at onset the temperature rises and during the week following it is high at
night and lower in the morning, but day by day the differences between these
temperatures become less. During the second week the temperature is
continuously high and there is little difference between that of the morning
Fig. I. — Clinical chart of
and showing the temperature
enteric fever of four weeks' duration without complications
as uninfluenced by baths or other treatment.
and that of the evening. In the third week the morning temperature becomes
lower while that of the evening remains as high as during the second week.
The typical fourth week temperature is one in which the morning temperature
falls gradually lower and that of the evening does likewise, dropping to a
lower level each day until both it and the morning temperature reach
normal.
Complications may alter the course of the temperature. Intestinal haem-
orrhages are usually followed by a rapid and distinct fall. The height of the
temperature is commonly in direct proportion to the severity of the infection
and usually in fatal cases, unless death results from one of the complications
4 THE INFECTIOUS DISEASES.
above mentioned, the temperature remains high \mtil death takes place;
infrequently, however, death may supervene without the temperature ever
having reached a very high level.
The pulse usually bears a direct relation to the temperature curve. In the
first week it is full, tense and strong and from 90 to 100 per minute; during
the second week, especially in severe infections, it is likely to become rapid,
feeble and possibly dicrotic.
Various departures from the typical temperature are not rare. When
the disease begins with a chiU the temperature may rise at once as high as
103° F. or 104° F. (39.5°-4o° C). Not infrequently does defervescence take
place at the end of the second week and the temperature fall to normal
within 24 hours. A temperature higher in the morning and lower in the
evening may occur but has no especial significance. Sudden falls in tem-
perature usually indicate an intestinal haemorrhage or perforation. Hyper-
pyrexia is rare but may be observed just before death. Chills may occur,
as stated, at the onset of the disease; at intervals during its progress; with the
incidence of complications; after the use of antipyretic drugs or baths; or
during convalescence with no assignable cause.
The chills may be accompanied by sweating, but profuse diaphoresis is
rare, though at times the abdomen and chest may be moist especially during
the reaction from a bath.
Rises of temperature after defervescence (recrudescences) may take place
even after there has been no febrile movement for several days. These
may continue for a nimiber of days and then cease. Accompanying them
there is no constitutional disturbance, but they caU for increased vigilance
on the part of the physician. They are usually the result of improper feeding,
constipation or mental excitement.
Certain cases in which convalescence has apparently become estab-
lished continue to show an evening rise of temperature of one or two
degrees (F.). This may be due to starvation but should cause the physician
to search for compHcations, such as abscess. In excessively nervous patients
such an evening rise is frequent, but if no other symptoms are manifest it
may be disregarded and it often disappears if the patient be allowed to sit up,
allowed small amounts of sohd food and the use of the thermometer be dis-
continued.
Relapses are due to a fresh infection with the bacillus typhosus and last
varying periods of time; as a rule they are shorter in course than the original
attack. The temperature rises and declines gradually and is accompanied
by a return of the symptoms.
Afebrile enteric fever has been described by certain observers but is appar-
ently of rare occmrence.
The facial appearance of enteric fever has been described as typical. Early
ENTERIC FEVER. 5
in the disease the face is flushed and the eyes are bright; by the beginning
of the second week the expression becomes apathetic and at the height of the
disease it is dull and listless — the typhoid facies. The lips and cheeks may
retain a good color throughout the disease.
The typhoid tongue is at first moist with a white coat down its center. Its
edges and tip are red. In mild cases the tongue continues moist but in severe
types of the disease it becomes dry, brown, cracked and glazed in the later
weeks. Sordes may make its appearance. As convalescence progresses
the tongue gradually assumes its normal condition.
The spleen is regularly enlarged, soft and may usually be palpated with-
out difficulty.
Unusual Modes of Onset, a. Ambulatory or walking enteric fever: In
this type of the disease the patient remains up and attempts to go about his usual
occupation. He realizes that he is not in perfect health but feels hardly ill
enough to go to bed. When he is first seen by the physician he may have a
high fever and a well-developed rash. These cases often prove severe because
of lack of proper treatment in the early stages.
b. With marked gastro-intestinal symptoms: The nausea may be severe
and the vomiting almost continuous and very difficult to control. Profuse
diarrhoea may be present.
c. The usual cough accompanying the onset may be much accentuated
and the chill and pain in the side of such character as to suggest pneumonia.
d. With symptoms referable to the kidneys: Rarely we may observe
an onset distinguished by bloody urine containing albumin and casts.
e. With pronounced nervous symptoms: Agonizing and obstinate head-
ache or facial neuralgia may be initial symptoms. In certain cases when the
patient has continued about during the early weeks delirium may be the first
marked symptom. Rarely the disease may begin with muscular twitchings
or convulsions, stiffness of the neck and photophobia. Drowsiness, apathy
and stupor may exist for some days before other and more typical symptoms
develop. Very infrequently is mania the first symptom. In alcoholic patients
the various nervous manifestations are especially marked.
f. Intestinal haemorrhage or perforation rarely occur as symptoms of
onset.
Each week of the course of enteric fever in a typical case is marked by
a special set of symptoms. During the incubation period — varying from
lo to 21 days, usually about two weeks — the patient suffers from indefinite
malaise, nausea, headache and general soreness.
First Week. The invasion of the disease is marked by chilly feelings,
more rarely by a distinct chill, severe frontal headache and pains in back
and limbs; the tongue is coated down its center, its edges and tip are redder
and the papillae more prominent than normal. There often is spontaneous
6 THE INPECTIOUS DISEASES.
nose-bleed and there is likely to be cough due to slight laryngitis or bronchitis.
The eyes are suffused. The patient is thirsty and often conscious that his
temperature is elevated. He complains of weariness, insomnia and nausea
which is often accompanied by vomiting. Constipation is the rule but
diarrhoea may be present. There may be sore throat with discomfort on
deglutition. During this stage of the infection the patient may continue up
and about, but usually he finds that he is more comfortable in bed. The
course of temperature has been described; by the fifth or sixth day it reaches
an evening elevation of 103° to 103.5° F. (39.5° to 39.8° C). The pulse
is rapid, strong and tense, 90 to 100 per minute. Very rarely is it dicrotic.
By the end of the week the typical enteric facies is evident. A few spots
may be seen and the spleen may be palpable.
Second Week. As the second week progresses all the symptoms become
more marked vnth the exception of the headache and other pains and the
nausea and vomiting; these usually cease. The temperatiire continues high
(io3°-io4° F. — 39.5° to 40° C.) with slight morning remissions. The pulse
becomes softer, feebler and more rapid (ioa-120). Bodily weakness is pro-
nounced. The tongue is drj^, brown and tremulous; there is likely to be
diarrhoea, 3 to 5 thin, pale, yellowish-brown movements a day (pea-soup
stools). Mild delirium may appear late in this week; at first it is present
only at night, later it lasts through the day as weU and the patient shows
other effects of the toxin of the disease upon the nervous system, such as
photophobia, slight deafness and muscular twitchings. If there is no delir-
ium the patient lies in a lethargic condition, takes no interest in his surround-
ings and makes no requests.
Third Week. The symptoms of the second week continue and become
more pronounced. The temperature continues high but as the week nears
its close the morning temperature is likely to fall to a lower level (ioi°-io2° F.,
38.4°-38.8° C). The pulse may become very rapid and weak and dicrotism
may be manifest. The tongue becomes more dry and cracked and the
patient may be unable to protrude it. Bed sores may appear and retention
of iirine and incontinence of fseces may occtir. The symptoms of cerebral
poisoning become more marked, the muscular twitchings {suhsuUus tendi-
num) are more noticeable and the patient may pick at the bed coverings or
grasp at imaginary objects. Intestinal hsemorrhage may be evidenced by
blood-tinged stools or blood in considerable quantity may flow from the
rectum, leaving the patient in collapse with a sudden fall in temperature,
imperceptible pulse and other symptoms of extreme weakness. Pulmonary
congestion or pneumonia may complicate the disease during this week.
Meteorism is not rare. The patient may die or continue to the
Fourth Week. Now the morning temperature faUs stiU lower and the
evening rise gradually becomes less until the former reaches normal and the
ENTERIC FEVER. 7
latter ioi°-io2° F. (38.4°-38.8° C.)- As the temperature diminishes the
other symptoms gradually ameliorate, the tongue loses its dry, cracked appear-
ance and becomes moist, the pulse is stronger, the nervous manifestations
disappear, and the appetite becomes more vigorous.
Fifth Week. The patient may immediately proceed to complete recovery,
the febrile movement may last two or three weeks longer, or after a normal
temperature lasting several days a relapse may take place.
Convalescence is slow. The patient is extremely weak although he may
feel well and be very hungry. He is able to sit up but for a few moments
at a time and walking is quite impossible. Relapses may be brought on
by errors in diet or by over-exertion. The patient often loses his hair for a
time and it usually is a number of months before full strength is recovered.
Dysmenorrhcea is a common sequel in women.
Menstruation usually takes place as in health diuring the first or second
week, but later and in convalescence it may be absent. Pregnant women,
though they seldom contract the disease, often abort during its course.
Complications. Thrombosis of the veins, more particularly of the left
femoral — although it may occur in both femoral veins — takes place in about
I percent, of all cases. Recovery is the rule unless emboli dislodged from
the clot find their way to the heart, in which case sudden death takes place.
There is usually phlebitis of greater or less extent as well as thrombosis, and
arterial thrombosis is a possible occurrence. The bacillus typhosus has been
found in the thrombi.
Hcemorrhage from the bowel is a serious complication and is the result
of the erosion of a vessel wall by the ulcerative process. It is said to occur
in about 5 percent, of the cases. It is by no means necessarily fatal, recovery
having taken place after the loss of large quantities of blood per rectum. Such
a haemorrhage is evidenced by rapid drop of temperature, pallor, coldness of
the extremities and other symptoms of collapse.
Perforation is also marked by a sudden fall in temperature as well as by
severe abdominal pain and symptoms of coUapse. The pain is rarely localized
but is usually general over the whole abdomen. This is a markedly fatal
complication, the only chance for recovery being immediate siu-gical inter-
ference; otherwise general peritonitis results.
Peritonitis without perforation may occur by extension of the inflammation
within the intestine to the peritoneeum surrounding it. It is a grave, though
not necessarily fatal complication.
Parotitis followed by suppuration is rare. The infection reaches the gland
by means of Stensen's duct.
Cancrum oris may complicate or follow the disease in children. Gangrene