Functional pathology of internal diseases

Preface

The study of disease from tlie functional standpoint has progressed rapidly in recent years. Advances in physiology, biochemistry, immunology and experimental pathology, as well as the careful and systematic study of patients, have thrown much new light upon disturbances of function. To the physician these advances have been of increasing significance. !N"ot only have they served to interpret the clinical pictures with which he comes in contact, but they have pointed the way to new diagnostic methods and have furnished new indications for treatment.

The present book deals with those changes in function that are presented by patients suffering from internal diseases. The rapid progress \n this field and the fact that it has been attacked from so many points of view make its presentation by a single individual one of peculiar difiiculty. It is to be hoped, however, that a selection and discussion of topics by one whose primary interest lies in the clinic will pi'ove of value to those who are also dealing with patients.

In order to make the presentation more brief and more readable, historical and controversial matter has in general been omitted and the author has often expressed an arbitrary opinion on still debatable subjects. For more complete discussions the reader is referred to the larger monographs and reviews cited at the end of each chapter. In these, summarized accounts of the earlier literature will be found. Additional references, mainly to recent literature, have also been cited, and for the benefit of those who do not read foreign languages preference has been given to articles that have appeared in English.

A. W. Hewlett.

Chapter I. The Circulation PAOB

Heart . 2

Dyuaniics of the Heart Muscle 2

Isometric and Isotonic Contraction 2

Reaction to Varying Arterial Resistance .... 6

Reaction to Varying Inflows 7

Influence of Heart Rate 8

Normal Heart Shadow in Man 10

Incompleteness of Ventricular Systole 11

Dynamics of Weakened Heart 12

Causes of Cardiac Weakness 15

Fatigue 15

Functional InsutHcieney Ifi

Anatomical Changes in the ^lyocardium . . . . Ifi

Cardiac Dilatation 17

Hypertrophy of the Heart 19

Weight of the Heart 19

Strength of the Hypertrophied Muscle 21

Work of the Heart 22

Efi^ects of Exercise upon the Circulation 22

Exercise and Cardiac Hypertrophy 27

Valvular Lesions 28

Aortic Stenosis ' . .29

Aortic Insufficiency 31

Mitral Stenosis 33

Mitral Insufflciency 35

Valvular Lesions of the Right Heart 36

Congenital Heart Lesions 38

Combined Valvular Lesions 38

Effect of Some Extraneous Factors upon the Heart ... 39

Arterial Hypertension 39

Pulmonary Disease 40

Plethora, Anemia, etc 42

vrii via

Compensation and Decompensation

Compensation

Causes of Broken Compensation Effects of Decompensation

Disturbances of Cardiac Rate and Ivbythm

Fundamental Properties of the Heart Muscle Refractory Period The Pacemaker of the Heart Conduction Paths Heart Muscle and Nerves .

Clinical Methods for Studying the Cardiac Mechanical Methods .

Electrical Methods Sinus Variations in Rate and Rhythm Normal Heart Rate .

Sinus Tachycardias .

Sinus Bradycardias . . .

Sinus Arhythmias Disturbances of Conduction Sino-auricular Block .

Auriculoventricular Block .

Lengthened As-Vs Interval .

Partial Block Complete Heart Block .

Blocks in Branches of the His Bundle Causes of Auriculoventricular Block Nei'vous and Toxic Organic Causes ...

Ectopic Beats, Extrasystoles .

Homogenetic Beats and Rhythms Heterogenetic Beats ...

Auricular Extrasystoles Auriciiloventricular Extrasystoles Ventricular Extrasystoles .

Interpolated Ventricular Extrasystoles

Retrograde Extrasystoles Recurrence of Extrasystoles Pathogenesis of Extrasystoles

Rapid Ectopic Rhythms Paroxysmal Tachycardia Auricular Flutter

Mecbani

COITTENTS ix

PAQB

Auricular Fibrillation ' ... 77

Pulse Deficit in Auricular Fibrillation .... 80

Digitalis and Auricular Fibrillation 80

Permanent and Paroxysmal Auricular Fibrillation . . 80

Eelation of Fibrillation to Ectopic Auricular Beats . 81

Pathogenesis of Auricular Fibrillation .... 82

Ventricular Fibrillation 83

Pulsus alternans 84

Heart Sounds and Heart Murmurs 86

Changes in Loudness and Quality 86

Si)lit Sounds 87

Accessory Heart Sounds 88

Gallop Rhythm 88

Valvular Murmurs 90

Accidental Murmurs 92

Some Manifestations of Heart Disease .92

Cyanosis 92

Cardiac Dyspnea 94

Cardiac Edema 94

Pulmonary Edema 95

Cardiac Sensations 96

Palpitation 96

Cardiac Pain 97

The Blood Vessels 99

Physiological Consideration 99

Transient Arterial Hypertension 103

Chronic Arterial Hypertension 105

Eelation to Renal Disease 106

Immediate Cause of Chronic Hypertension .... 107

Arterial Changes 107

Secondary Lesions 109

Hypotension t . . . 110

Syncope 110

Effects of Hemorrhage Ill

Surgical and Traumatic Shock 112

Circulatory Failure in the Infectious Diseases . . .114

The Pulse Pressure 115

Local Vascular Changes 116

Form of the Arterial Pulse . . .• 116

Chapter 11. Digestion and Absorption

PAOB

Disturbances in the Esophagus 131

Mechanical Obstructions of the Esophagus . . . .132

Spastic Obstructions 133

Cardiospasm 133

Atony of the Esophagus 135

Insufficiency of the Cardiac Sphincter 135

Aerophagia 136

Esophageal Diverticula 137

Disturbances of Gastric Secretion 138

Stimulants to Gastric Secretion . . . . .138

Nervous Secretion 138

Chemical Secretion 139

Properties of the Gastric Juice 139

Hyperacidity and Hypersecretion 140

Eelation of Hyperacidity to Gastric ^lotility . . . 141

Effect of Hyperacidity on Gastric Digestion . . . 142

Symptoms of Hyperacidity 142

Causes of Hyperacidity 143

Hypersecretion 144

Achlorhydria and Related Conditions 144

Relation to Gastric Motility 145

Effect on Gastric and Intestinal Digestion . . . 145

Symptoms of Achlorhydria 146

Causes of Achlorhydria 147

Excessive Secretion of Mucus 148

Disturbances of Gastric Motility 148

The Control of the Pylorus 150

Gastric Motility in Secretory Disturbances .... 152

Gastric Atony 153

Nature of Atony 153

Effect on Gastric Position 154

Effect on Gastric Motility 154

Etiology of Atony 154

Pyloric Obstruction 155

Causes 155

Effect on Motility 155

CONTENTS xi

PAGE

Acute Dilatatioij of the Stomach 156

Vomiting 158

Mecharfism 158

Causes of Vomiting 159

Continuous Vomiting IfiO

Gastric Motility after Gastro-entevostoniy . . . .160

Peptic Ulcer 162

Relation to Gastric Secretion 163

Vascular Disease 164

Nervous Theories 165

Infectious and Toxic Causes 166

Conclusion 166

Motor Activities of the Stomach in Ulcer . . . .166

Carcinoma of the Stomach 168

Effects on Gastric Form. and Motility 168

Effects on Gastric Digestion 168

Gastric Sensations 170

Appetite, Hunger and Repletion 170

Gastric Pain 172

The Intestines . . .174

Eunctions of the Small Intestines 174

Functions of the Large Intestines 175

The Exclusion of Pancreatic Juice from the Intestines . . 176 The Exclusion of Bile from the Intestines . . . .179

Disturbances in the Functions of the Intestinal Mucosa . 180

Motor Disturbances of the Intestines 181

Small Intestines 181

Large Intestines 182

Chronic Constipation 184

Pathogenesis of Constipation 185

Lack of Normal Stimuli 185

Mechanical Causes 186

Functional Motor Disturbances 186

(a) Dyschezia 187

(b) Ascending Stasis 188

(c) Transverse Stasis 188

(d) Ileal Stasis 189

Symptoms of Constipation 189

Diarrhea 190 xii CONTENTS

PAGE

Pathogenesis of Diarrhea 190

Excess of Stimi;li 190

Increased Irritability of the Intestines . . . .191

Motility Changes in Diarrhea 191

Intestinal Obstruction ld-2

Motor Disturbances 192

General Symptoms 193

Intestinal Paresis 194

Intestinal Pain 195

Intestinal Auto-intoxication 196

Chapter III. The Metabolism Methods of Study 207

The Rate of Metabolism 209

Physiological Variations in a Given Individual . . . 209

(a) Muscidar Exercise 209

(b) Effect of Food 210

The Basal Metabolism 212

Normal Basal Metabolism 212

Pathological Variations in the Basal Metabolism . . 213

Obesity 215

Effect on Body Functions 219

Stan-ation / .220

Partial Inanition 223

The Protein-building Stones 225

Amino Acid Requirements of the Body 228

Nitrogenous Equilibrium 230

Protein Requirements of the Body 2C0

Protein Starvation 232

Excessive Protein Destruction 232

Autolysis 233

Imperfect Decomposition of Amino Acids ... 235

Hepatic Disease, etc 235

Cystinuria 23G

Alcaptonuria 237

Ochronosis 238

Melanin 238

PAOB

Diseases Due to Deficient Diets 239

Inorganic Salts 240

Lipoids 241

Beriberi 242

Scurvy 242

Some Disturbances in the Lipoids 243

Lipemia ''^^

Fatty Degeneration 244

Cholesterin 246

Cholesterinemia -^■*"

Local Cholesterin Deposits 247

Formation of Acids in the Body 248

Lactic Acid * , 248

The Neutrality of the Blood 249

(1) The Blood Salts 249

(2) Elimination of Acids 249

(3) Increased Ammonia Formation . . . .250

Definition of Acidosis 250

Evidence of Acidosis 251

(2) Respiratory Changes 251

(3) The Urine 251

Symptoms of Acidosis ^"^-^

Chapter IV. Disturbances in Carbohydrate Metabolism Renal Glycosurias 258

Phlorhizin Glycosuria "59

Other Renal Glycosurias 261

Renal Glycosurias in Man ....••• 262

Alimentary Glycosuria and Related Conditions .... 262

Alimentary Glycosuria 262

Alimentary Levulosuria 268

Alimentary Galactosuria 267

Glycosuria from Discharge of the Glycogen Reservoirs- . . 268

Nervous Glycosurias 268

Glycosuria from Central Disease 269

Emotional Glycosuria 269

Glycosuria from Disease of the Hypophysis . . .270

Epinephrin Glycosuria ......•• 270 xiv CONTENTS

PAGE

Diabetes mellitus, Pancreatic Diabetes 272

Experimental Pancreatic Dialietes 273

The Pancreas in Human Diabetes 274

Hyperglycemia in Diabetes 276

Classification of Diabetes 277

Derivation of Sugar in Diabetes 278

Carbohydrates 279

Proteins 280

The D :N P.atio 280

Fats 283

Energy Requirements in Diabetes 284

Energy Supply in Diabetes 284

Glycogen in Diabetes 285

Respiratory Quotient in Diabetes ..'.... 286

Effects of Exercise 287

Theories of Diabetes 287

Symptoms and Complications of Diabetes .... 289

Emaciation and Polyphagia 289

Polyuria and Thirst . " 289

Diminished Resistance to Infection 290

Nutritional Changes . . 291

The Acetone Bodies 291

Diabetic Coma 291

Conditions in which Acetone Bodies Occur . . . 292

Interi-elationship of the Acetone Bodies .... 294

Derivation of the Acetone Bodies 295

Cause of Diabetic Coma 299

Pentosuria 300

Chapter V. The Purin Metabolism. Gout Normal Purin Metabolism 307

Catabolism of Nucleoproteiiis 307

Sources of Purin Bodies 308

Conversion of the Purin Bodies 308

Normal Excretion of Uric Acid 310

Increased Purin Metabolism 311

The Purin Metabolism in Gout 311

Etiology of Gout 311

Uric Acid Excretion in Gout 312

Uric Acid in the Blood 313

Local Deposits of Urates 315

CONTENTS XV

FAOB

Cause of the Acute Attacks 315

Effect of Atophan 316

Theory of Gout 317

Eeferences 319

Chapter VI. The Liver and Pancreas Functions of the Liver 321

* Disturbances in the Secretion of Bile 322

Tm]X)rtant Constituents of the Bile 322

Bile Pigments 322

Bile Salts : . 323

Cholesterin , 323

Jaundice . 323

Obstructive Jaundice 324

Hemolytic Jaundice 325

Infectious Jaundice 326

Jaundice in Organic Liver Disease 328

Icterus neonatorum 328

Symptoms of Jaundice 329

Eunctional Disturbances of the Hepatic Cells . . . .330

Urobilin in Hepatic Disease 331

Carlxjhydrate Metabolism in Hepatic Disease . . . 332

Nitrogenous Metabolism in Hepatic Disease .... 333

Other Functional Disturbances in Hepatic Disease . . 335

Fibrinogen 335

Blood Lipase 335

Elimination of Phenoltetrachlorphthaleiu . . . 330

Cholemia . . .336

Gall-stones 337

Frequency 337

• Composition and Structure 337

Pathogenesis of Gall-stones 338

Secondary Infections in Cholelithiasis 340

Biliary Colic . 341

Fat Necroses 341

Acute Hemorrhagic Necrosis of the Pancreas .... 342 xvi CONTEI^TS

Chapter VII. Disturbances of Respiration PAGE

The Dead Space 346

Changes in Lung Volume 348

The Regulation of Pulmonary Ventilation .... 349

Afferent Nervous Stimuli 349

Chemical Regulation 349

Changes in the Respiratory Center 350

Transportation of Gases in the Blood 351

Periodic Breathing 353

Respiration and Acid Intoxication 361

Respiration at High Altitudes 363

Mountain Sickness 363

Increased Atmospheric Pressure 365

Caisson Disease 365

Diminished Oxygen-carrying Capacity of the Blood . . 367

Carbon ]\[onoxid Poisoning 367

Methemoglobinemia 368

Anemia 368

Respiration in Cardiac Disease 370

Cardiac Asthma 375

Orthopnea 375

Stenosis of the Upper Air Passages . . . . . 376

Bronchial Asthma 377

Pulmonary Emphysema 379

Loss of Respiratory Surface 382

Diseases of the Pleura 383

Pleural Pain 383

Pleuritic Effusions 385

Pneumothorax 387

Open ^387

Closed 388

Valvular 388

Mechanical .... - ^91

Cilia 391

Smooth Muscle 392

Coughing 392

CONTENTS xvii

Chapter VIII. Disturbances oJ Kidney Function PAoa

Polyuria 400

Oliguria — Anuria 407

Anuria 409

Albuminuria 411

Physiologic Albuminurias 411

Pathologic Causes of Albuminuria 414

Cylindruria 415

Experimental JSTephritis 410

Retention of Nitrogenous Waste Products 419

Retention of Individual Nitrogenous Products . . . 424

Nitrogen Waste in the Tissues 425

Symptoms of Nitrogenous Retention 425

Relation to other Renal Functions 425

Prognosis 428

Salt Retention. Nephritic Edema 428

Normal Relations 428

Salt Retention in Nephritis 430

Differences Between Salt and Nitrogenous Retentions . . 435

Symptoms of Salt Retention 435

Dry Retention 436

Sodium Bicarbonate Edema 436

Primary Water Retention 436

Renal and Extrarenal Eactors 437

Relation of Edema to other Nephritic ^lanifcstatinns . . 439

Acidosis and Renal Disease 439

Renal Eunction in Heart Disease 441

Renal Function in Eclampsia 442

Uremia 443

Uremia With Marked Nitrogenous Retention . . . 444

Uremia Without Marked Nitrogenous Retention . . . 446

Renal Calculi 446

Precipitation of Salts in the Urine 446

Composition of Calculi . 447

Hydronephrosis 448

Experimental Production 448

Etiology in ]\lau 449

Symptoms 450

Renal Pain 450 xviu CONTENTS

Chapter IX. Disturbances of Heat Regulation — Fever PAGB

Physiological Variations in the Temperature of the Body . .459

(a) In Different Animals 459

(b) ISTormal Variations of Temperature in Man . . . 459 Regulation Against Overheating and Overcooling . . . 461

Normal Regulation of Body Temperature .... 461

RegTilation Against Overheating 461

Sunstroke 464

RegTilation Against Overcooling 466

Freezing 467

Effect of Spinal Cord Section 468

The Conception of Fever 470

Types of Fever 470

Heat Regulation in Fever 471

Sudden Changes of Temperature 471

Imperfect Heat Regulation in Fever 474

Metabolism in Fever 475

Nitrogenous Metabolism 476

Non-nitrogenous Metabolism 477

Salt and Water Retention 478

Causes of Fever 481

Lesions of the Central Nervous System 481

Simple Chemical Substances 483

Injection of Foreign Protein 483

Infections 484

Significance of Fever 485