The principles of clinical pathology; a text-book for students and physicians

Front matter

Oass Book

COPYRIGHT DEPOSIT

THE PRINCIPLES

Preface To The Second American Edition

The present volume has been revised from the fourth German edition of Krehl's " Pathologische Physiologic" The subjects of immunity, heart hypertrophy in nephritis, water metabolism in fever, etc., were found to be considerably altered. In addition to these the translator has practically rewritten the paragraphs dealing with the cardiac arrhythmias, has added some pulse tracings, and has inserted many references to the English and American literature.

A. W. HEWLETT.

San Francisco, 1907.

TRANSLATOR'S PREFACE TO THE FIRST AMERICAN EDITION

This volume is translated from the third German edition of Professor Krehl's " Pathologische Physiologic" I have, however, used the title of the first German edition, — viz., " The Principles of Clinical Pathology." This change was made partly because the terms pathological physiology are comparatively unfamiliar to the English and American profession, and partly because it seemed desirable to emphasize the fact that the book deals especially with the problems that confront the clinician.

A literal translation was not attempted. Many abstract discussions have been abbreviated, and in a few places the material has been slightly rearranged, in order to present it in what seemed to be a more natural sequence. Yet no alterations of the author's views have been made, except these were indicated by enclosing them in parentheses ; and I have endeavored throughout to maintain the spirit of the original work. A few paragraphs have been added, mainly upon subjects that have attained a certain prominence in the recent American literature, such as the subjects of blood-pressure, surgical shock, and hemorrhagic pancreatitis.

The original edition contains copious references to the German literature. Many of these have been omitted, more especially those referring to the older literature and to the well-known German text-books. In their place, I have added quite a number of English references, which may be of some assistance to those who do not read German and who desire to look up more elaborate discussions of many of the subjects. Unfortunately our own literature is often rather fragmentary ;

2 TRANSLATOR'S PREFACE

for many of the fields dealt with have been developed almost exclusively by continental writers.

In conclusion, I desire to express my indebtedness to Drs. W. E. Garrey, George Blumer, and W. F. Beerman for assistance in reading and correcting portions of the manuscript.

A. W. HEWLETT.

San Francisco, 1905.

Preface To The Fourth German Edition

Medical instruction at the present time is beset with veryconsiderable difficulties. Within a few years, the student must be so prepared that he shall be able to assume independent care of patients. Two classes of medical knowledge must be imparted to him which may be used according to the nature of the disease; for, unfortunately, at the present time a single method is not available. . «

After the student has become acquainted with the main ' principles of normal anatomy and physiology in the early years of his medical training, he begins the study of abnormal processes in the pathological laboratory and in the clinics, and he is shown how to make his knowledge useful to patients. It must be acknowledged, however, that this portion of his training is more or less independent of what has preceded it. Much of what he now learns belongs to the domain of " medical empiricism " ; because at the present time we are dependent upon this class of knowledge for the recognition and treatment of many diseases. It should be cultivated, therefore, with the greatest care. According to this method, a pathological process or a clinical picture is recognized from the combination of symptoms present ; because, in the past, generations of physicians have learned to associate the two. The empirical method of treatment is likewise founded on the experience of the past, which has been acquired by a more or less blind groping in the dark. Both the empirical diagnosis and the empirical treatment ignore the underlying causes and their associated perversions of physiological function. Since they describe and do not explain, they are to be classed with the descriptive sciences. Success in empirical medicine

6 PREFACE TO THE FOURTH GERMAN EDITION

depends upon the ability to observe sharply and accurately, upon the ability to combine properly the symptoms and signs, and upon the possession of a sufficient number of memory pictures with which one may compare the case at hand. Our empirical instruction must seek to provide the student with a great number of possible combinations of signs and symptoms, though at best we cannot supply the experience that will come with years.

In contrast to the empirical method of procedure, the rational method views the symptom-complex as the manifestation of a disturbance of physiological function ; and it assumes that with a sufficient knowledge of physiology and of the site and kind of the pathological changes we should be able to deduce the symptoms. Beyond doubt this is the ideal method of procedure and the goal of the future. Toward this we must strive with all our capabilities. This method like the empirical one rests largely upon the art, the experience, and the personality of the physician; but the attitude toward disease, instead of a descriptive one, becomes an exact scientific one.

At the present time, both these methods of regarding disease live side by side. Certain diseases can be regarded only from the purely empirical standpoint ; others allow a scientific exposition. In the majority of diseases, however, some symptoms are only describable while others can be interpreted as well. For the man who desires to be at the same time both a practitioner and a pathologist, the mastery of both methods of analysis is enormous in its details. Yet it is important that we should clearly distinguish our empirical procedures from our rational ones, for only in this way is it possible to advance our calling to the position of a biological science.

In the development of each one of us, there is a tendency in the earlier years of our studies to regard things medical from the biological standpoint. This is due to our early training in the natural sciences and to the fact that we seldom

Preface To The Fourth German Edition 7

appreciate the difficulty of approaching medicine from the scientific point of view. Owing to the imperfect development of internal medicine as a natural science, the physician gradually finds that success at the bedside is possible without scientific attainments and he comes more and more to rely upon empirical knowledge. He thus ceases to judge medicine by the same exact standards as are used in other departments of biology. The result of this attitude is that progress is hindered.

The purpose of the present volume is to present so far as possible a rational explanation of pathological phenomena and to awaken interest among physicians and students in the theory of disease processes. If this purpose has not been attained, criticisms are welcome, for I believe that without criticism there is no progress. As a personal excuse for omissions I would say, however, that I have never undervalued the biological sister sciences, but that, as a clinician who desires to be a teacher and who loves his calling as a practitioner, it is extremely difficult for me to cover the literature in the neighboring sciences and that this difficulty increases from year to year.

This edition has appeared so soon after the preceding one that I have asked my assistants, Drs. Blum, Loeb, Morawitz, and Schwenkenbecher, as well as my former assistant, Prof. Liithje, to assist me in looking through the literature. The chapter on infection and immunity has been entirely changed in form through the kindly help of Prof. E. Levy, whose ideas have been adopted without question because I recognized his mastery of the subject. I desire here to thank these for their friendly aid. L. Krehl.

Strassburg, January, 1906.

Table Of Contents

PAGE

Introductory Note by Prof. Osler 15

CHAPTER I. The Heart 23

Importance of the Circulation, 23; Pulmonary Circulation, 23; General Circulation, 24; Adaptability of the Heart, 25; Hypertrophy of the Heart, 30; Valvular Diseases, 32; Etiology of Valvular Disease, 33; Muscular Insufficiency, 35; Aortic Insufficiency, 36; Aortic Stenosis, 40; Mitral Stenosis, 41; Mitral Insufficiency, 43 ; Valvular Lesions of the Right Side, 44 ; Combined Valvular Lesions, 45; Hypertrophy of the Right Ventricle, 46; Hypertrophy of the Left Ventricle, 48; Hypertrophy of both Ventricles, 51; Cardiac Changes in Renal Disease, 52; The "Athlete's Heart," 57 ; The " Beer Heart," 58 ; Heart in Pregnancy, 59; Ability of the Heart to Hypertrophy, 59; Concentric and Eccentric Hypertrophy, 60; Inefficiencies of a Compensated Circulation, 61 ; Myocardial Changes in Hypertrophied Hearts, 64 ; Causes of Broken Compensation in Hypertrophied Hearts, 68; Causes of Primary Insufficiency of the Heart Muscle, 69; Results of Cardiac Weakness, 75; Disturbances of the Heart-Rate, 83 ; Tachycardia, 84 ; Bradycardia, 89 ; Arrhythmia, 93 ; Forms of Arrhythmia, 93 ; Causes of Arrhythmia, 101 ; Cardiac Impulse, 103; Heart Sounds, 104; Cardiac Murmurs, 109; Palpitation, in; Cardiac Dyspnoea, 112; Cardiac Pain, 114.

Chapter II

The Arterial Blood-Pressure, 117; Systolic and Diastolic Pressures: Pulse-Pressure, 117; Physiological Variations in Blood- Pressure, 119; Pathologically Increased Blood-Pressure, 119; Pathological Diminution in Blood-Pressure, 120; Arterial Pulse, 122; Venous Stasis, 123; Venous-Murmurs, 124; (Edema, 124; Composition of Exudates, 129; Chylous and Chyliform Ascites, 130; Pulmonary (Edema, 131.

Chapter III

The Red Blood-Corpuscles, 134; Anaemia from Hemorrhage, 134; General Considerations relative to Chronic Anaemias, 135;

10 TABLE OF CONTENTS

The Blood — Continued page

Chlorosis, 138; Secondary Anaemias, 141; Pernicious Anaemia, 144; Hcemoglobinaemia, 149; Paroxysmal Hemoglobinuria, 151; Other Causes which Injure the Red Blood-Corpuscles, 153; Systemic Effects from Rapid Destruction of Red Blood-Corpuscles, 154; The White Blood-Corpuscles, 155; Physiological Leucocytoses, 156; Pathological Leucocytoses, 158; Leucopenia, 160; Leukaemia and Pseudoleukaemia, 161; The Blood Platelets, 168; Plasma and Serum: Total Quantity of Blood, 168; Coagulation, 169; Blood-Serum, 170; Salts of the Serum, 172; Hydremia, 172; Polycythsemia, 175; Plethora, 179.

Chapter IV

Portals of Entry, 182; Virulence of Infection, 188; Toxins, 188; Mixed and Secondary Infections, 190 ; Bacillus Carriers, 191 ; Lowered Resistance, 191; Varieties of Immunity, 192; Antitoxins: The "Side-Chain" Theory, 194; The Hemolytic Action of Alien Plasmas, 198; Bacteriolytic Action of the Blood-Serum, 200 ; The Precipitins, 202 ; Agglutination, 203 ; Relation of Antitoxins and Bacteriolysins to Immunity, 204 ; Phagocytosis and Immunity, 206; Conclusions, 208.

Chapter V

The External Respiration, 210; Means for Removing Harmful Material from the Air-Passages, 210; Stenosis of the Air-Passages, 214; Bronchial Asthma, 219; Paralysis of the Respiratory Muscles, 221 ; Loss of Pulmonary Elasticity : Emphysema, 222 ; Changes in Respiration of Nervous Origin: Cheynes-Stokes Phenomenon, 224 ; Pleural Effusions and Pneumothorax, 227 ; Atelectasis, 229; Effects of Obliteration of Air-Spaces, 230; Effects of Atmospheric Pressure, 231 ; Inhalation of Poisonous Gases, 234; Effects of Anaemia, 235; Effects of Circulatory Changes, 237; Respiratory Compensation, 237; Asphyxia, 239; The Internal Respiration, 240; Respiratory Sensations, 243.

Chapter VI

Mouth and (Esophagus, 245 ; Stomatitis, 245 ; Diminished Secretion of Saliva, 246 ; Ptyalism, 247 ; Composition and Reaction of Saliva, 248; Swallowing, 249; (Esophageal Stenosis, 250; Pressure Diverticula, 251; Primary Dilatation of the (Esophagus, 252; The Stomach, 253; The Disturbances of Gastric Secretion, 255; Hypersecretion of Gastric Juice, 257; Round Ulcer, 259; Effects

TABLE OF CONTENTS 11

The Digestion — Continued page

of Hypersecretion and Hyperacidity, 260; Subacidity and Anacidity, 262; Bacterial Action in the Stomach, 264; Disturbances of Motility, 267; Increased Peristalsis and Increased Motility, 269; Motor Insufficiency and Dilatation, 269; Causes of Dilatation, 271 ; Effects of Motor Insufficiency, 273 ; Belching and Vomiting, 275 ; Sensations from the Stomach, 277 ; Disturbances in the Secretion of Bile, 280 ; Gail-Stones, 281 ; Exclusion of Bile from Intestines, 286; Jaundice, 288; Other Hepatic Toxaemias, 293; Pancreatic Juice, 294; Fat Necroses, 296; Relation of the Bile to Pancreatic Disease, 297; Processes in the Intestines, 298; Effects of Poisons, 298 ; Abnormal Bacterial Processes within the Gastrointestinal Tract, 299; Pathology of Absorption, 307; Disturbances in the Intestinal Movements, 309; Diarrhoeas, 310; Constipation, 314; Obstruction, 317; Strangulation, 322; Meteorism, 323; Abnormal Intestinal Sensations, 325.

Chapter VII

Quantitative Variations in Metabolism of Fats and Proteids, 328; Caloric Needs of Body, 328 ; Proteid Needs of Body, 331 ; Inanition, 332 ; Effects of an Oversupply of Food, 335 ; Disturbances in Fat Metabolism, 338 ; Pathological Accumulations of Fat, 341 ; Pathological Destruction of Proteid Material, 346; Metabolism in Thyroid Disease, 348; Qualitative Changes in Metabolism, 351; Autolysis, 352; Formation and Excretion of Ammonia, 354; Production of Organic Acids, 355 ; Diabetic and Other Toxic Comas, 358; Relation between Hepatic Disease and the Excretion of Ammonia, 360 ; Alkaptonuria, 361 ; Cystinuria, 362.

Chapter VIII

Disturbances in Carbohydrate Metabolism. Diabetes 364

Alimentary Glycosuria, 365 ; Phloridzin Glycosuria, 366 ; Renal Diabetes, 368; Transient Glycosurias, 368; Diabetes Mellitus, 369; Mild and Severe Forms, 370; Derivation of Sugar from Proteids and Fats, 371 ; Glycogenic Function of the Liver in Diabetes, 373; Consumption of Sugar in Diabetes, 375; Etiology of Diabetes, 378; Effects of Diabetes upon the Body, 379; Theory of Diabetes, 382.

Chapter IX

The Metabolism of the Purin Bodies. Gout 384

Gout, 386; Uric Acid in the Blood, 388; Uric Acid in the Urine, 389; The Cause of the Local Deposits of Urates, 390; Theory of Gout, 391.

12 TABLE OF CONTENTS

Chapter X. Page

Normal Regulation of the Body Temperature, 393; Heat-Stroke, 395; Heat Regulation in Fever, 397; Heat Production in Fever, 398; Heat Losses in Fever, 400; Metabolism in Fever, 404; Cause of the High Temperature, 408; Site of Heat Production, 409; Heat-Regulatory Mechanism in Fever, 410; Causes of Fever, 414 ; Variations in the Clinical Picture of Fever, 420 ; Nutrition in Fever, 421 ; Water Retention in Fever, 422 ; Significance of Fever, 423 ; Temperature in Collapse, 426 ; Subnormal Temperature, 428.

CHAPTER XL

Effects of an Increased Blood-Flow, 429; Diabetes Insipidus, 431; Effects of Diminished Blood-Flow, 432 ; Effects of Obstruction to the Escape of Urine, 433; Effects of Lesions of the Secreting Membrane, 434; Albuminuria, 436; Casts, 444; Effect of Changes in the Composition of the Blood, 445; Uraemia, 448; Urinary Passages, 452 ; Urinary Calculi, 453 ; Pain in the Urinary Passages, 457.

Chapter XII

Circulatory Disturbances, 458 ; Increased Cerebral Pressure, 461 ; Cerebral Concussion, 466; Disturbances of Motility, 467; Disturbances of Co-ordination, 471 ; Effect of Reflexes upon Motion, 477; Nervous Disturbances of Urination and Defecation, 478; Alterations of Reflexes, 479; Strychnine Poisoning and Tetanus, 482; Contractures, 483; Motor Irritative Symptoms, 486; Disturbances of Sensation, 488; Dizziness, 492; The Influence of the Nervous System upon Tissue Nutrition, 496; Muscular Atrophies, 498; Herpes Zoster, 505.

LIST OF ILLUSTRATIONS

PAGE

Fig. 1. — The "Normal" venous pulse 81

Fig. 2. — Positive venous pulse 82

Fig. 3. — The effect of an extra stimulus applied to the ventricle.... 94

Fig. 4. — The effect of an extra stimulus applied to the auricle 95

Fig. 5. — Extrasystoles of the ventricular type 96

Fig. 6. — Extrasystoles of the auricular type 97

Fig. 7. — Tracing from a bigeminal pulse 98

Fig. 8. — Partial heart-block 99

INTRODUCTORY 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 medicine. 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

16 INTRODUCTORY NOTE

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 in 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 technique to clinical problems, and not the technique alone, but the biological and chemical principles upon which medicine as an exact natural science is founded. Principles, as Plato reminds us, require constant revision and consideration ; and this book, representing a revision to date of the " Principles of Clinical Pathology," will be most helpful to all students and teachers who wish to know the scientific basis of our art.

William Osler.

Introduction

Pathological physiology is one among the sciences that contribute toward our knowledge of diseased processes. In his famous book on " General Pathology," Cohnheim has defined disease as a peculiar, abnormal course of the same processes that make up the life phenomena of healthy individuals. We term these vital processes normal when they occur in the majority of individuals and when these latter feel well and are able to accomplish their average amount of work.

In many instances, it is easy to determine whether the functions of the body are following a normal or an abnormal course ; in others, the question is a very difficult one to decide.

The whole series of living beings, from the lowest up to the highest, are liable to be afflicted with disease. Yet different species, even though they are closely related, may vary considerably from one another, not only in their morphological but in their functional characteristics. For example, it would be pathological if a mammal excreted as much uric acid in its urine as does a normal bird. The question as to whether a given function is or is not normal can only be answered by comparing individuals of the same species.

These remarks might appear superfluous, inasmuch as the primary object of this book is to discuss pathological disturbances in man. Yet a satisfactory understanding of these latter is not possible except we make critical use of the data obtained from animals.

I shall not attempt to discuss the outlook that the method of comparative study opens for us in our knowledge of pathological processes. Hitherto this method of study has played but a minor role in developing this field, for the means and opportunities for pursuing this line of work have been lacking. Yet if pathology is to remain abreast of the other branches of biology, we must have a closer relationship between the pathological and the veterinarian laboratories, and the natural diseases of animals must be studied with a view to the light that they may throw on those of man. Even now, extensive use is made of animal experiments in the study of pathological processes and these experiments have become an almost indispensable aid in such study. In estimating the value of these experiments, however, due regard must be paid to the morphological and functional differences between man and the animals used.

Very considerable individual differences may occur even within a single species. For example, there are men whose stomach contents at the height of digestion contain no free hydrochloric acid, and, although such men differ in this respect from the great majority of their fellows, nevertheless they may show absolutely no digestive symptoms and no diminution in their capacity for work. In, my opinion, such individuals can hardly be regarded as being sick, although it must be acknowledged that they stand near the border line between the normal and the pathological. Another class of men show for years clear and unmistakable functional disturbances in some organ or group of organs, and yet they are not incapacitated to the slightest degree for work. Theoretically such men are sick; practically, we hardly know whether to say they are sick or healthy.

The physician must be clear in his own mind about this great difference between the theoretical and the practical ; and although we are dealing in this book principally with the former, yet it will not be amiss to emphasize this fact, that many individuals who show definite pathological changes are perfectly healthy to all practical intents and purposes.

We should designate as diseased, therefore, all those life processes which differ from the ones that occur in the majority of the members of a species, and which, in addition, affect the individual's capacity for work or the duration of his life.

All theories of life processes, physiological as well as pathological, must be carried back to the elementary constituents of the body. Disease arises from changes in a certain set of cells, or of organs, or of groups of organs; for the cells that normally work together are not necessarily grouped together, but they may be distributed over different parts of the body. We are learning more and more that certain functions necessitate the combined action of different classes of cells.

Functional disturbances naturally coincide with, and are caused by, physical, chemical, or morphological changes in the body cells. This dictum is in no way altered by the fact that these chemical and morphological changes may not be demonstrable with the methods at our disposal. It is customary to distinguish those disturbances in which no such changes in the cells have been found (functional disturbances) from those in which such changes have been demonstrated (organic lesions). Yet this distinction is a more or less accidental one, depending as it does upon what happens to be the state of our knowledge at the time when the division is made.

A complete theory of pathological phenomena must embrace not only a knowledge of the functional disturbances in the affected cells, but a knowledge of their chemical, physical, and morphological changes as well. At present, our knowledge in all these directions is satisfactory for only a few diseases. For others, it has developed along functional and anatomical lines, for a third group, along functional and chemical lines, and finally, for a fourth group, the functional changes alone are known to us and we are ignorant as to their anatomical or chemical basis.

The development of our knowledge in one or another of these directions depends, in the first place, upon the degree to which our methods of investigation can solve the problems presented. These methods will suffice for certain problems in certain diseases but not for others, so that we have an unequal development along different lines. In the second place, the master minds of the time tend to develop our knowledge along the lines that happen to interest them most, and these lines gain thereby a certain prominence. Controversies have been waged and still are waged as to which is of greatest importance, the functional, chemical, or morphological view of disease. The uselessness of such a controversy is apparent when we remember that all these changes necessarily go together and that we must look at a disease from every point of view. Nevertheless, it is true that one point of view may be more luminous than another in respect to any particular class of diseases.

Diseases result either from primary defects in the living protoplasm or from the protoplasm being placed under such abnormal conditions that it cannot compensate for the changes in its environment. In the first class of cases, the abnormality consists in an improper organization of the protoplasm. The affected individual is then either diseased from birth, or he is born apparently healthy but is unable to withstand the ordinary wear and tear of life as a normal person should. Consequently, the structure, composition, or functions of his tissues suffer. Such primary endogenous weakness apparently plays a not inconsiderable role in the etiology of disease.

Of greater importance, however, is the effect that injurious external influences exert upon the living substance of the body. When these injuries affect the composition, structure, or functions of the cells, they become causes of disease. These causes are of the most varied kinds. Heat and cold, humidity and dryness, electricity, chemicals, all these may affect the body; but more important than any of them is the penetration of abnormal forms of life into the body.

Whether a man shall become sick or not, depends, therefore, in the first place, upon the way that he is originally constituted

(endogenous causes), and, in the second place, upon the more or less accidental injuries to which he is exposed (exogenous causes). Furthermore, the effectiveness of the latter class of causes depends largely upon factors that lie within the individual. There are, indeed, poisons which in a certain dose will kill practically any one, and there are infections that will attack all or nearly all individuals exposed to them. Nevertheless, the majority of all infectious and toxic processes affect only a certain proportion of the individuals exposed. The causes of this difference in susceptibility are naturally complex and not always the same ; but in the main they depend upon the physiological organization of the individual.

In a complete discussion of diseased phenomena, the vital processes and the alterations in these processes and in the elementary constituents of the body must be considered from various points of view. In the present book, we propose to present only one of these. Just as physiology deals with the functions of the normal body, so pathological physiology deals with the functions when organs are placed under pathological conditions; and this is the subject of our discourse.

The field covered by this book serves, in the main, to fill out the gap left in the subject of pathology after the subjects of general pathology and of special pathological anatomy have been eliminated. In classifying the material, I have followed the classification that is customary in the German universities, and I have utilized material that has especially appealed to me as a clinician. Many subjects that are usually discussed in our text-books on general pathology, such as local circulatory disturbances, have been omitted, even though they should rightly be included in a book of this character. Whether the choice of material has been a fortunate one or not, remains to be decided

THE PRINCIPLES