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 This is a special edition of an established title widely used by colleges and
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Statistics for Managers

Using Microsoft® Excel®

The ninth edition of Statistics for Managers Using Microsoft® Excel ® is an information

Statistics for Managers

powerhouse that continues to focus on data analysis and the interpretation of
Microsoft Excel statistical results. It helps students see the importance of statistics
® ®
in their careers by using examples from those functional areas of business,
such as management, accounting, finance, and marketing, that may become Using Microsoft Excel
their specialization. Written in a concise style, this book emphasizes definitions
as the foundation for understanding statistical concepts and guides readers to NINTH EDITION
reach conclusions and make managerial decisions based primarily on statistical
information.
David M. Levine • David F. Stephan • Kathryn A. Szabat
New to This Edition
• A new chapter, Business Analytics, that defines terms students may encounter in other
courses or outside the classroom
• Tables that summarize results of hypothesis tests and regression examples, along with
the conclusions that those results support, in Chapters 10 through 13

EDITION
NINTH
• Tableau Guides that explain how to use Tableau Public, the data visualization software,
as a complement to Microsoft Excel for data visualization and regression analysis
• New and updated Learning the Basics questions and Applying the Concepts
problems that provide reinforcements, both at the end of the section and at the end of
the chapter, to test basic concepts and students’ ability to apply those concepts

Levine • Stephan • Szabat

Available separately for purchase with this book is MyLab Statistics, the teaching
and learning platform that empowers instructors to personalize learning for each
student. When combined with trusted educational content, MyLab Statistics
provides countless opportunities for practice—with the help of statistics-specific
resources and tools—that enhance a student’s experience and their comprehension.

CVR_LEVI8248_09_GE_CVR.indd 1 10/04/20 11:04 AM

About the Authors
David M. Levine, David F. Stephan, and Kathryn A. Szabat
are all experienced business school educators committed to inno-
vation and improving instruction in business statistics and related
subjects.
David Levine, Professor Emeritus of Statistics and CIS at Baruch
College, CUNY, is a nationally recognized innovator in statistics
education for more than three decades. Levine has coauthored
14 books, including several business statistics textbooks; textbooks
and professional titles that explain and explore quality management
and the Six Sigma approach; and, with David Stephan, a trade paper-
back that explains statistical concepts to a general audience. Levine
has presented or chaired numerous sessions about business edu-
Kathryn Szabat, David Levine, and David Stephan cation at leading conferences conducted by the Decision Sciences
Institute (DSI) and the American Statistical Association, and he
and his coauthors have been active participants in the annual DSI Data, Analytics, and Statistics
Instruction (DASI) mini-conference. During his many years teaching at Baruch College, Levine
was recognized for his contributions to teaching and curriculum development with the College’s
highest distinguished teaching honor. He earned B.B.A. and M.B.A. degrees from CCNY. and a
Ph.D. in industrial engineering and operations research from New York University.
Advances in computing have always shaped David Stephan’s professional life. As an undergradu-
ate, he helped professors use statistics software that was considered advanced even though it could
compute only several things discussed in Chapter 3, thereby gaining an early appreciation for the
benefits of using software to solve problems (and perhaps positively influencing his grades). An
early advocate of using computers to support instruction, he developed a prototype of a main-
frame-based system that anticipated features found today in Pearson’s MathXL and served as spe-
cial assistant for computing to the Dean and Provost at Baruch College. In his many years teaching
at Baruch, Stephan implemented the first computer-based classroom, helped redevelop the CIS
curriculum, and, as part of a FIPSE project team, designed and implemented a multimedia learning
environment. He was also nominated for teaching honors. Stephan has presented at SEDSI and DSI
DASI mini-conferences, sometimes with his coauthors. Stephan earned a B.A. from Franklin &
Marshall College and an M.S. from Baruch College, CUNY, and completed the instructional tech-
nology graduate program at Teachers College, Columbia University.
As Associate Professor of Business Systems and Analytics at La Salle University, Kathryn Szabat
has transformed several business school majors into one interdisciplinary major that better sup-
ports careers in new and emerging disciplines of data analysis including analytics. Szabat strives to
inspire, stimulate, challenge, and motivate students through innovation and curricular enhancements
and shares her coauthors’ commitment to teaching excellence and the continual improvement of
statistics presentations. Beyond the classroom she has provided statistical advice to numerous busi-
ness, nonbusiness, and academic communities, with particular interest in the areas of education,
medicine, and nonprofit capacity building. Her research activities have led to journal publications,
chapters in scholarly books, and conference presentations. Szabat is a member of the American
Statistical Association (ASA), DSI, Institute for Operation Research and Management Sciences
(INFORMS), and DSI DASI. She received a B.S. from SUNY-Albany, an M.S. in statistics from
the Wharton School of the University of Pennsylvania, and a Ph.D. in statistics, with a cognate in
operations research, from the Wharton School of the University of Pennsylvania.
For all three coauthors, continuous improvement is a natural outcome of their curiosity about the
world. Their varied backgrounds and many years of teaching experience have come together to
shape this book in ways discussed in the Preface.

7
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Brief Contents

Preface 21
First Things First 31
1 Defining and Collecting Data 46
2 Organizing and Visualizing Variables 68
3 Numerical Descriptive Measures 138
4 Basic Probability 182
5 Discrete Probability Distributions 206
6 The Normal Distribution and Other Continuous Distributions 228
7 Sampling Distributions 254
8 Confidence Interval Estimation 274
9 Fundamentals of ­Hypothesis Testing: One-Sample Tests 305
10 Two-Sample Tests 341
11 Analysis of Variance 382
12 Chi-Square and Nonparametric Tests 419
13 Simple Linear Regression 460
14 Introduction to Multiple Regression 508
15 Multiple Regression Model Building 556
16 Time-Series Forecasting 586
17 Business Analytics 630
18 Getting Ready to Analyze Data in the Future 648
19 Statistical Applications in Quality Management (online) 19-1
20 Decision Making (online) 20-1
Appendices A-H 655
Self-Test Solutions and Answers to Selected Even-Numbered
Problems 703
Index 743
Credits 750

9
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Contents

Preface 21 1.2 Collecting Data 49

Populations and Samples 49
Data Sources 50
First Things First 31
1.3 Types of Sampling Methods 51
Simple Random Sample 51
USING STATISTICS: “The Price of Admission” 31 Systematic Sample 52
FTF.1 Think Differently About Statistics 32 Stratified Sample 52
Statistics: A Way of Thinking 33 Cluster Sample 52
Statistics: An Important Part of Your Business Education 34 1.4 Data Cleaning 54
FTF.2 Business Analytics: The Changing Face of Statistics 34 Invalid Variable Values 54
“Big Data” 34 Coding Errors 54
FTF.3 Starting Point for Learning Statistics 35 Data Integration Errors 54
Statistic 35 Missing Values 55
Can Statistics ( pl., statistic) Lie? 35 Algorithmic Cleaning of Extreme Numerical Values 55

FTF.4 Starting Point for Using Software 36 1.5 Other Data Preprocessing Tasks 55
Using Software Properly 37 Data Formatting 55
Stacking and Unstacking Data 56
FTF.5 Starting Point for Using Microsoft Excel 38
Recoding Variables 56
More About the Excel Guide Workbooks 39
Excel Skills That Readers Need 39 1.6 Types of Survey Errors 57
Coverage Error 57
REFERENCES 40
Nonresponse Error 57
KEY TERMS 40
Sampling Error 58
EXCEL GUIDE 41 Measurement Error 58
EG.1 Getting Started with Excel 41 Ethical Issues About Surveys 58
EG.2 Entering Data 41
CONSIDER THIS: New Media Surveys/Old Survey Errors 59
EG.3 Open or Save a Workbook 41
EG.4 Working with a Workbook 42 USING STATISTICS: Defining Moments, Revisited 60
EG.5 Print a Worksheet 42 SUMMARY 60
EG.6 Reviewing Worksheets 42 REFERENCES 60
EG.7 If You Use the Workbook Instructions 42 KEY TERMS 61

TABLEAU GUIDE 43 CHECKING YOUR UNDERSTANDING 61

TG.1 Getting Started with Tableau 43 CHAPTER REVIEW PROBLEMS 61

TG.2 Entering Data 44 CASES FOR CHAPTER 1 62
TG.3 Open or Save a Workbook 44 Managing Ashland MultiComm Services 62
TG.4 Working with Data 45 CardioGood Fitness 63
TG.5 Print a Workbook 45 Clear Mountain State Student Survey 63
Learning With the Digital Cases 63
CHAPTER 1 EXCEL GUIDE 65
1 Defining and Collecting EG1.1 Defining Variables 65
Data 46 EG1.2 Types of Sampling Methods 65
EG1.3 Data Cleaning 66
EG1.4 Other Data Preprocessing 66
USING STATISTICS: Defining Moments 46
1.1 Defining Variables 47 CHAPTER 1 TABLEAU GUIDE 67
Classifying Variables by Type 47 TG1.1 Defining Variables 67
Measurement Scales 48 TG1.2 Data Cleaning 67

11
12 CONTENTS

2 Organizing and Visualizing EG2.3 Visualizing Categorical Variables 122

EG2.4 Visualizing Numerical Variables 124
Variables 68 EG2.5 Visualizing Two Numerical Variables 127
EG2.6 Organizing a Mix of Variables 128
USING STATISTICS: “The Choice Is Yours” 68 EG2.7 Visualizing a Mix of Variables 129
2.1 Organizing Categorical Variables 69 EG2.8 Filtering and Querying Data 131
The Summary Table 69
CHAPTER 2 TABLEAU GUIDE 131
The Contingency Table 70
TG2.1 Organizing Categorical Variables 131
2.2 Organizing Numerical Variables 73 TG2.2 Organizing Numerical Variables 132
The Frequency Distribution 74
TG2.3 Visualizing Categorical Variables 132
The Relative Frequency Distribution and the Percentage
Distribution 76 TG2.4 Visualizing Numerical Variables 134
The Cumulative Distribution 78 TG2.5 Visualizing Two Numerical Variables 135
TG2.6 Organizing a Mix of Variables 135
2.3 Visualizing Categorical Variables 81
The Bar Chart 81 TG2.7 Visualizing a Mix of Variables 136
The Pie Chart and the Doughnut Chart 82
The Pareto Chart 83
Visualizing Two Categorical Variables 85
3 Numerical Descriptive
2.4 Visualizing Numerical Variables 88
The Stem-and-Leaf Display 88 Measures 138
The Histogram 89
The Percentage Polygon 90 USING STATISTICS: More Descriptive Choices 138
The Cumulative Percentage Polygon (Ogive) 91 3.1 Measures of Central Tendency 139
2.5 Visualizing Two Numerical Variables 95 The Mean 139
The Scatter Plot 95 The Median 141
The Time-Series Plot 96 The Mode 142
2.6 Organizing a Mix of Variables 98 The Geometric Mean 143
Drill-Down 99 3.2 Measures of Variation and Shape 144
2.7 Visualizing a Mix of Variables 100 The Range 144
Colored Scatter Plot (Tableau) 100 The Variance and the Standard Deviation 145
Bubble Chart 101 The Coefficient of Variation 147
PivotChart 101 Z Scores 148
Treemap 101 Shape: Skewness 150
Sparklines 102 Shape: Kurtosis 150
2.8 Filtering and Querying Data 103 3.3 Exploring Numerical Variables 155
Excel Slicers 103 Quartiles 155
The Interquartile Range 157
2.9 Pitfalls in Organizing and Visualizing Variables 105
The Five-Number Summary 158
Obscuring Data 105
The Boxplot 159
Creating False Impressions 106
Chartjunk 107 3.4 Numerical Descriptive Measures for
a Population 162
USING STATISTICS: “The Choice Is Yours,” Revisited 109
The Population Mean 162
SUMMARY 109 The Population Variance and Standard Deviation 163
REFERENCES 110 The Empirical Rule 164
KEY EQUATIONS 110 Chebyshev’s Theorem 164
KEY TERMS 111 3.5 The Covariance and the Coefficient of Correlation 166
CHECKING YOUR UNDERSTANDING 111 The Covariance 166
CHAPTER REVIEW PROBLEMS 111 The Coefficient of Correlation 167

CASES FOR CHAPTER 2 116 3.6 Descriptive Statistics: Pitfalls and Ethical Issues 171
Managing Ashland MultiComm Services 116 USING STATISTICS: More Descriptive Choices,
Digital Case 116 Revisited 171
CardioGood Fitness 117 SUMMARY 172
The Choice Is Yours Follow-Up 117 REFERENCES 172
Clear Mountain State Student Survey 117 KEY EQUATIONS 172
CHAPTER 2 EXCEL GUIDE 118 KEY TERMS 173
EG2.1 Organizing Categorical Variables 118 CHECKING YOUR UNDERSTANDING 173
EG2.2 Organizing Numerical Variables 120 CHAPTER REVIEW PROBLEMS 174
 CONTENTS 13

CASES FOR CHAPTER 3 177

Managing Ashland MultiComm Services 177
5 Discrete Probability
Digital Case 177 Distributions 206
CardioGood Fitness 177
More Descriptive Choices Follow-Up 177 USING STATISTICS: Events of Interest at Ricknel Home
Clear Mountain State Student Survey 177 Centers 206
CHAPTER 3 EXCEL GUIDE 178 5.1 The Probability Distribution for a Discrete Variable 207
EG3.1 Measures of Central Tendency 178 Expected Value of a Discrete Variable 207
EG3.2 Measures of Variation and Shape 179 Variance and Standard Deviation of a Discrete Variable 208
EG3.3 Exploring Numerical Variables 179 5.2 Binomial Distribution 211
EG3.4 Numerical Descriptive Measures for a Population 180 Histograms for Discrete Variables 214
EG3.5 The Covariance and the Coefficient of Correlation 180 Summary Measures for the Binomial Distribution 215
5.3 Poisson Distribution 218
CHAPTER 3 TABLEAU GUIDE 181
TG3.1 Exploring Numerical Variables 181 5.4 Covariance of a Probability Distribution and its
­Application in Finance 221
5.5 Hypergeometric Distribution 221
4 Basic Probability 182 USING STATISTICS: Events of Interest …, Revisited 221
SUMMARY 222
USING STATISTICS: Probable Outcomes at Fredco REFERENCES 222
Warehouse Club 182
KEY EQUATIONS 222
4.1 Basic Probability Concepts 183 KEY TERMS 222
Events and Sample Spaces 183
CHECKING YOUR UNDERSTANDING 222
Types of Probability 184
CHAPTER REVIEW PROBLEMS 223
Summarizing Sample Spaces 185
Simple Probability 185 CASES FOR CHAPTER 5 225
Joint Probability 187 Managing Ashland MultiComm Services 225
Marginal Probability 187 Digital Case 225
General Addition Rule 188 CHAPTER 5 EXCEL GUIDE 226
4.2 Conditional Probability 191 EG5.1 The Probability Distribution for a Discrete Variable 226
Calculating Conditional Probabilities 191 EG5.2 Binomial Distribution 226
Decision Trees 193 EG5.3 Poisson Distribution 226
Independence 194
Multiplication Rules 195
Marginal Probability Using the General
Multiplication Rule 196
6 The Normal Distribution
4.3 Ethical Issues and Probability 199 and Other Continuous
4.4 Bayes’ Theorem 199 Distributions 228
CONSIDER THIS: Divine Providence and Spam 200
USING STATISTICS: Normal Load Times at MyTVLab 228
4.5 Counting Rules 201
6.1 Continuous Probability Distributions 229
USING STATISTICS: Probable Outcomes at Fredco
Warehouse Club, Revisited 201 6.2 The Normal Distribution 230
Role of the Mean and the Standard Deviation 231
SUMMARY 201
Calculating Normal Probabilities 232
REFERENCES 202
KEY EQUATIONS 202 VISUAL EXPLORATIONS: Exploring the Normal
Distribution 236
KEY TERMS 202
Finding X Values 237
CHECKING YOUR UNDERSTANDING 202
CONSIDER THIS: What Is Normal? 240
CHAPTER REVIEW PROBLEMS 203
6.3 Evaluating Normality 242
CASES FOR CHAPTER 4 204
Comparing Data Characteristics to Theoretical Properties 242
Digital Case 204
Constructing the Normal Probability Plot 243
CardioGood Fitness 204
The Choice Is Yours Follow-Up 204 6.4 The Uniform Distribution 245
Clear Mountain State Student Survey 204 6.5 The Exponential Distribution 247
CHAPTER 4 EXCEL GUIDE 205 6.6 The Normal Approximation to the Binomial
EG4.1 Basic Probability Concepts 205 Distribution 247
EG4.2 Bayes’ Theorem 205 USING STATISTICS: Normal Load Times …, Revisited 248
SUMMARY 248
14 CONTENTS

REFERENCES 248 8.2 Confidence Interval Estimate for the Mean

KEY EQUATIONS 249
KEY TERMS 249
CHECKING YOUR UNDERSTANDING 249
CHAPTER REVIEW PROBLEMS 249
CASES FOR CHAPTER 6 251
Managing Ashland MultiComm Services 251
CardioGood Fitness 251
More Descriptive Choices Follow-Up 251
Clear Mountain State Student Survey 251
Digital Case 251
CHAPTER 6 EXCEL GUIDE 252
EG6.1 The Normal Distribution 252
EG6.2 Evaluating Normality 252
7 Sampling Distributions
USING STATISTICS: Sampling Oxford Cereals 254
7.1 Sampling Distributions 255
7.2 Sampling Distribution of the Mean 255
The Unbiased Property of the Sample Mean 255
Standard Error of the Mean 257
Sampling from Normally Distributed
Populations 258
Sampling from Non-Normally Distributed Populations—The
Central Limit Theorem 261
VISUAL EXPLORATIONS: Exploring Sampling
Distributions 265
7.3 Sampling Distribution of the Proportion 266
7.4 Sampling from Finite Populations 269
USING STATISTICS: Sampling Oxford Cereals,
Revisited 269
SUMMARY 270
REFERENCES 270
KEY EQUATIONS 270
KEY TERMS 270
CHECKING YOUR UNDERSTANDING 270
CHAPTER REVIEW PROBLEMS 271
CASES FOR CHAPTER 7 272
Managing Ashland MultiComm Services 272
Digital Case 272
CHAPTER 7 EXCEL GUIDE 273
EG7.1 Sampling Distribution of the Mean 273
(σ Unknown) 280
Student’s t Distribution 280
The Concept of Degrees of Freedom 281
Properties of the t Distribution 281
The Confidence Interval Statement 283
8.3 Confidence Interval Estimate for the Proportion 288
8.4 Determining Sample Size 291
Sample Size Determination for the Mean 291
Sample Size Determination for the Proportion 293
8.5 Confidence Interval Estimation and Ethical Issues 296
8.6 Application of Confidence Interval Estimation in
Auditing 296
8.7 Estimation and Sample Size Determination for Finite
Populations 296
8.8 Bootstrapping 296
254 USING STATISTICS: Getting Estimates at Ricknel Home
  Centers, Revisited297
SUMMARY 297
REFERENCES 297
KEY EQUATIONS 298
KEY TERMS 298
CHECKING YOUR UNDERSTANDING 298
CHAPTER REVIEW PROBLEMS 298
CASES FOR CHAPTER 8 301
Managing Ashland MultiComm Services 301
Digital Case 302
Sure Value Convenience Stores 302
CardioGood Fitness 302
More Descriptive Choices Follow-Up 302
Clear Mountain State Student Survey 302
CHAPTER 8 EXCEL GUIDE 303
EG8.1 Confidence Interval Estimate for the Mean (s Known) 303
EG8.2 Confidence Interval Estimate for the Mean (s Unknown) 303
EG8.3 Confidence Interval Estimate for the Proportion 304
EG8.4 Determining Sample Size 304
9 Fundamentals of ­Hypothesis
Testing: One-Sample Tests 305
USING STATISTICS: Significant Testing at Oxford
Cereals 305
9.1 Fundamentals of Hypothesis Testing 306
The Critical Value of the Test Statistic 307
Regions of Rejection and Nonrejection 308

8 Confidence Interval Risks in Decision Making Using Hypothesis Testing 308

Z Test for the Mean (σ Known) 310
Estimation 274 Hypothesis Testing Using the Critical Value Approach 310
Hypothesis Testing Using the p-Value Approach 314
USING STATISTICS: Getting Estimates at Ricknel Home A Connection Between Confidence Interval Estimation and
Centers 274 Hypothesis Testing 316
8.1 Confidence Interval Estimate for the Mean Can You Ever Know the Population Standard Deviation? 317
(σ Known) 275 9.2 t Test of Hypothesis for the Mean (σ Unknown) 318
Sampling Error 276 Using the Critical Value Approach 319
Can You Ever Know the Population Standard Deviation? 279 Using the p-Value Approach 320
 CONTENTS 15

Checking the Normality Assumption 321 USING STATISTICS: Differing Means for Selling …,
9.3 One-Tail Tests 324   Revisited 370
Using the Critical Value Approach 324 SUMMARY 371
Using the p-Value Approach 326 REFERENCES 372
9.4 Z Test of Hypothesis for the Proportion 328 KEY EQUATIONS 372
Using the Critical Value Approach 329 KEY TERMS 372
Using the p-Value Approach 330 CHECKING YOUR UNDERSTANDING 373
9.5 Potential Hypothesis-Testing Pitfalls and Ethical CHAPTER REVIEW PROBLEMS 373
Issues 332
CASES FOR CHAPTER 10 375
Important Planning Stage Questions 332
Managing Ashland MultiComm Services 375
Statistical Significance Versus Practical Significance 333
Digital Case 375
Statistical Insignificance Versus Importance 333
Sure Value Convenience Stores 376
Reporting of Findings 333
CardioGood Fitness 376
Ethical Issues 333
More Descriptive Choices Follow-Up 376
9.6 Power of the Test 333 Clear Mountain State Student Survey 376
USING STATISTICS: Significant Testing …, Revisited 334 CHAPTER 10 EXCEL GUIDE 377
SUMMARY 334 EG10.1 C
 omparing the Means of Two Independent
REFERENCES 334 Populations 377
KEY EQUATIONS 335 EG10.2 Comparing the Means of Two Related Populations 379
KEY TERMS 335 EG10.3 Comparing the Proportions of Two Independent
Populations 380
CHECKING YOUR UNDERSTANDING 335
EG10.4 F Test for the Ratio of Two Variances 381
CHAPTER REVIEW PROBLEMS 335
CASES FOR CHAPTER 9 337
Managing Ashland MultiComm Services 337 11   Analysis of Variance 382
Digital Case 337
Sure Value Convenience Stores 338
USING STATISTICS: The Means to Find Differences
CHAPTER 9 EXCEL GUIDE 339 at Arlingtons 382
EG9.1 Fundamentals of Hypothesis Testing 339 11.1 One-Way ANOVA 383
EG9.2 t Test of Hypothesis for the Mean (s Unknown) 339 F Test for Differences Among More Than Two Means 386
EG9.3 One-Tail Tests 340 One-Way ANOVA F Test Assumptions 390
EG9.4 Z Test of Hypothesis for the Proportion 340 Levene Test for Homogeneity of Variance 391
Multiple Comparisons: The Tukey-Kramer Procedure 392
11.2 Two-Way ANOVA 397
10   Two-Sample Tests 341 Factor and Interaction Effects 397
Testing for Factor and Interaction Effects 399
USING STATISTICS: Differing Means for Selling Streaming Multiple Comparisons: The Tukey Procedure 403
Media Players at Arlingtons? 341 Visualizing Interaction Effects: The Cell Means Plot 404
10.1 Comparing the Means of Two Independent Interpreting Interaction Effects 404
Populations 342 11.3 The Randomized Block Design 409
Pooled-Variance t Test for the Difference Between Two 11.4 Fixed Effects, Random Effects, and Mixed Effects
Means Assuming Equal Variances 342
Models 409
Evaluating the Normality Assumption 345
USING STATISTICS: The Means to Find Differences at
Confidence Interval Estimate for the Difference Between Two
Means 347 Arlingtons, Revisited 409
Separate-Variance t Test for the Difference Between Two SUMMARY 409
Means, Assuming Unequal Variances 348 REFERENCES 410
CONSIDER THIS: Do People Really Do This? 349 KEY EQUATIONS 410
10.2 Comparing the Means of Two Related Populations 351 KEY TERMS 411
Paired t Test 352 CHECKING YOUR UNDERSTANDING 411
Confidence Interval Estimate for the Mean Difference 357 CHAPTER REVIEW PROBLEMS 411
10.3 Comparing the Proportions of Two Independent CASES FOR CHAPTER 11 413
Populations 359 Managing Ashland MultiComm Services 413
Z Test for the Difference Between Two Proportions 359 PHASE 1 413
Confidence Interval Estimate for the Difference Between PHASE 2 413
Two Proportions 363 Digital Case 414
10.4 F Test for the Ratio of Two Variances 366 Sure Value Convenience Stores 414
10.5 Effect Size 370 CardioGood Fitness 414
16 CONTENTS

More Descriptive Choices Follow-Up 414

Clear Mountain State Student Survey 414 13   Simple Linear Regression 460
CHAPTER 11 EXCEL GUIDE 415
EG11.1 The Completely Randomized Design: One-Way ANOVA 415 USING STATISTICS: Knowing Customers at Sunflowers
Apparel 460
EG11.2 The Factorial Design: Two-Way ANOVA 417
Preliminary Analysis 461
13.1 Simple Linear Regression Models 462
12   Chi-Square and 13.2 Determining the Simple Linear Regression Equation 463
Nonparametric Tests 419
The Least-Squares Method 463
Predictions in Regression Analysis: Interpolation Versus
Extrapolation 466
USING STATISTICS: Avoiding Guesswork About Resort Calculating the Slope, b1, and the Y Intercept, b0 467
Guests 419
VISUAL EXPLORATIONS: Exploring Simple Linear
12.1 Chi-Square Test for the Difference Between Regression Coefficients 469
Two Proportions 420
13.3 Measures of Variation 471
12.2 Chi-Square Test for Differences Among More Than Computing the Sum of Squares 471
Two Proportions 427 The Coefficient of Determination 473
The Marascuilo Procedure 430 Standard Error of the Estimate 474
The Analysis of Proportions (ANOP) 432
13.4 Assumptions of Regression 475
12.3 Chi-Square Test of Independence 433 13.5 Residual Analysis 476
12.4 Wilcoxon Rank Sum Test for Two Independent Evaluating the Assumptions 476
Populations 439 13.6 Measuring Autocorrelation: The Durbin-Watson
12.5 Kruskal-Wallis Rank Test for the One-Way ANOVA 445 Statistic 480
Assumptions of the Kruskal-Wallis Rank Test 448 Residual Plots to Detect Autocorrelation 480
12.6 McNemar Test for the Difference Between Two The Durbin-Watson Statistic 481
­Proportions (Related Samples) 449 13.7 Inferences About the Slope and Correlation
12.7 Chi-Square Test for the Variance or Standard Coefficient 484
Deviation 449 t Test for the Slope 484
F Test for the Slope 485
12.8 Wilcoxon Signed Ranks Test for Two Related
Confidence Interval Estimate for the Slope 487
Populations 450
t Test for the Correlation Coefficient 487
USING STATISTICS: Avoiding Guesswork …, Revisited 450
13.8 Estimation of Mean Values and Prediction
REFERENCES 450 of Individual Values 490
SUMMARY 450 The Confidence Interval Estimate
KEY EQUATIONS 451 for the Mean Response 491
KEY TERMS 452 The Prediction Interval for an Individual Response 492
CHECKING YOUR UNDERSTANDING 452 13.9 Potential Pitfalls in Regression 494
CHAPTER REVIEW PROBLEMS 452 USING STATISTICS: Knowing Customers …, Revisited 496
SUMMARY 497
CASES FOR CHAPTER 12 454
REFERENCES 498
Managing Ashland MultiComm Services 454
PHASE 1 454 KEY EQUATIONS 498
PHASE 2 454 KEY TERMS 499
Digital Case 455 CHECKING YOUR UNDERSTANDING 499
Sure Value Convenience Stores 455 CHAPTER REVIEW PROBLEMS 500
CardioGood Fitness 455 CASES FOR CHAPTER 13 503
More Descriptive Choices Follow-Up 455 Managing Ashland MultiComm Services 503
Clear Mountain State Student Survey 455 Digital Case 503
CHAPTER 12 EXCEL GUIDE 457 Brynne Packaging 503
EG12.1 Chi-Square Test for the Difference Between Two CHAPTER 13 EXCEL GUIDE 504
Proportions 457 EG13.1 Determining the Simple Linear Regression Equation 504
EG12.2 Chi-Square Test for ­Differences Among More Than Two EG13.2 Measures of Variation 505
Proportions 457 EG13.3 Residual Analysis 505
EG12.3 Chi-Square Test of Independence 458 EG13.4 Measuring Autocorrelation: the Durbin-Watson Statistic 506
EG12.4 Wilcoxon Rank Sum Test: A Nonparametric Method
EG13.5 Inferences About the Slope and Correlation Coefficient 506
for Two Independent Populations 458
EG13.6 Estimation of Mean Values and Prediction
EG12.5 Kruskal-Wallis Rank Test: A Nonparametric Method
of Individual Values 506
for the One-Way ANOVA 459
CHAPTER 13 TABLEAU GUIDE 507
TG13.1 Determining the Simple ­Linear Regression Equation 507
TG13.2 Measures of Variation 507
 CONTENTS 17

Testing the Quadratic Effect 560

14   Introduction to Multiple
Regression 508
USING STATISTICS: The Multiple Effects of OmniPower
Bars 508
14.1 Developing a Multiple Regression Model 509
Interpreting the Regression Coefficients 509
Predicting the Dependent Variable Y 511
14.2 Evaluating Multiple Regression Models 513
Coefficient of Multiple Determination, r 2 514
Adjusted r 2 514
F Test for the Significance of the Overall Multiple
Regression Model 515
14.3 Multiple Regression Residual Analysis 517
14.4 Inferences About the Population Regression
Coefficients 519
Tests of Hypothesis 519
Confidence Interval Estimation 520
14.5 Testing Portions of the Multiple Regression Model 522
Coefficients of Partial Determination 525
14.6 Using Dummy Variables and Interaction Terms 527
Interactions 533
CONSIDER THIS: What Is Not Normal? (Using a Categorical
Dependent Variable) 538
14.7 Logistic Regression 539
The Coefficient of Multiple Determination 563
15.2 Using Transformations in Regression Models 564
The Square-Root Transformation 565
The Log Transformation 566
15.3 Collinearity 568
15.4 Model Building 570
The Stepwise Regression Approach to Model Building 571
The Best Subsets Approach to Model Building 572
15.5 Pitfalls in Multiple Regression and Ethical Issues 577
Pitfalls in Multiple Regression 577
Ethical Issues 577
USING STATISTICS: Valuing Parsimony …, Revisited 577
SUMMARY 578
REFERENCES 579
KEY EQUATIONS 579
KEY TERMS 579
CHECKING YOUR UNDERSTANDING 579
CHAPTER REVIEW PROBLEMS 579
CASES FOR CHAPTER 15 581
The Mountain States Potato Company 581
Sure Value Convenience Stores 582
Digital Case 582
The Craybill Instrumentation Company Case 582
More Descriptive Choices Follow-Up 583

14.8 Cross-Validation 544 CHAPTER 15 EXCEL GUIDE 584

EG15.1 The Quadratic Regression Model 584
USING STATISTICS: The Multiple Effects …, Revisited 545
EG15.2 Using Transformations in Regression Models 584
SUMMARY 545
EG15.3 Collinearity 585
REFERENCES 547
EG15.4 Model Building 585
KEY EQUATIONS 547
KEY TERMS 548
CHECKING YOUR UNDERSTANDING 548 16   Time-Series Forecasting 586
CHAPTER REVIEW PROBLEMS 548
CASES FOR CHAPTER 14 551 USING STATISTICS: Is the ByYourDoor Service Trending? 586
Managing Ashland MultiComm Services 551 16.1 Time-Series Component Factors 587
Digital Case 551
16.2 Smoothing an Annual Time Series 589
CHAPTER 14 EXCEL GUIDE 552 Moving Averages 589
EG14.1 Developing a Multiple Regression Model 552 Exponential Smoothing 591
EG14.2 Evaluating Multiple Regression Models 553
16.3 Least-Squares Trend Fitting and Forecasting 594
EG14.3 Multiple Regression ­Residual Analysis 553 The Linear Trend Model 594
EG14.4 Inferences About the Population Regression The Quadratic Trend Model 596
Coefficients 554
The Exponential Trend Model 597
EG14.5 Testing Portions of the Multiple Regression Model 554 Model Selection Using First, Second,
EG14.6 Using Dummy Variables and Interaction Terms 554 and Percentage Differences 599
EG14.7 Logistic Regression 554 16.4 Autoregressive Modeling for Trend Fitting
and Forecasting 603
Selecting an Appropriate Autoregressive Model 604
15   Multiple Regression Determining the Appropriateness of a Selected Model 605

Model Building 556 16.5 Choosing an Appropriate Forecasting Model 612

Residual Analysis 612
The Magnitude of the Residuals Through Squared
USING STATISTICS: Valuing Parsimony at WSTA-TV 556 or Absolute Differences 613
15.1 The Quadratic Regression Model 557 The Principle of Parsimony 614
Finding the Regression Coefficients and Predicting Y 558 A Comparison of Four Forecasting Methods 614
Testing for the Significance of the Quadratic Model 560
16.6 Time-Series Forecasting of Seasonal Data 616
18 CONTENTS

Least-Squares Forecasting with Monthly

or Quarterly Data 616 18   Getting Ready to Analyze
16.7 Index Numbers 622 Data in the Future 648
CONSIDER THIS: Let the Model User Beware 622
USING STATISTICS: Is the ByYourDoor Service Trending? USING STATISTICS: Mounting Future Analyses 648
Revisited 622 18.1 Analyzing Numerical Variables 649
SUMMARY 622 Describe the Characteristics of a Numerical Variable 649
REFERENCES 623 Reach Conclusions About the Population Mean
or the Standard Deviation 649
KEY EQUATIONS 623
Determine Whether the Mean and/or Standard ­Deviation
KEY TERMS 624
Differs Depending on the Group 650
CHECKING YOUR UNDERSTANDING 625 Determine Which Factors Affect the Value of a Variable 650
CHAPTER REVIEW PROBLEMS 625 Predict the Value of a Variable Based on the Values
CASES FOR CHAPTER 16 626 of Other Variables 651
Managing Ashland MultiComm Services 626 Classify or Associate Items 651
Digital Case 626 Determine Whether the Values of a Variable Are Stable
Over Time 651
CHAPTER 16 EXCEL GUIDE 627
18.2 Analyzing Categorical Variables 651
EG16.1 Smoothing an Annual Time Series 627
Describe the Proportion of Items of Interest
EG16.2 Least-Squares Trend Fitting and Forecasting 628 in Each Category 651
EG16.3 Autoregressive Modeling for Trend Fitting and Reach Conclusions About the Proportion of Items
Forecasting 628 of Interest 652
EG16.4 Choosing an Appropriate Forecasting Model 629 Determine Whether the Proportion of Items of Interest Differs
EG16.5 Time-Series Forecasting of Seasonal Data 629 Depending on the Group 652
Predict the Proportion of Items of Interest Based
on the Values of Other Variables 652
17   Business Analytics 630 Cluster or Associate Items 652
Determine Whether the Proportion of Items of Interest
Is Stable Over Time 652
USING STATISTICS: Back to Arlingtons for the Future 630
USING STATISTICS: The Future to Be Visited 653
17.1 Business Analytics Overview 631
CHAPTER REVIEW PROBLEMS 653
Business Analytics Categories 631
Business Analytics Vocabulary 632
CONSIDER THIS: What’s My Major If I Want 19   Statistical Applications
to Be a Data Miner? 632
Inferential Statistics and Predictive Analytics 633
in Quality Management
Microsoft Excel and Business Analytics 634 (online) 19-1
Remainder of This Chapter 634
17.2 Descriptive Analytics 634 USING STATISTICS: Finding Quality at the
Dashboards 635 Beachcomber 19-1
Data Dimensionality and Descriptive Analytics 636 19.1 The Theory of Control Charts 19-2
17.3 Decision Trees 636 The Causes of Variation 19-2
Regression Trees 637 19.2 Control Chart for the Proportion: The p Chart 19-4
Classification Trees 638
19.3 The Red Bead Experiment: Understanding
Subjectivity and Interpretation 639 Process Variability 19-10
17.4 Clustering 639 19.4 Control Chart for an Area of Opportunity:
17.5 Association Analysis 640 The c Chart 19-12
17.6 Text Analytics 641 19.5 Control Charts for the Range and the Mean 19-15
17.7 Prescriptive Analytics 642 The R Chart 19-15
Optimization and Simulation 643 The X Chart 19-18

USING STATISTICS: Back to Arlingtons …, Revisited 643 19.6 Process Capability 19-21
REFERENCES 643 Customer Satisfaction and Specification Limits 19-21
Capability Indices 19-22
KEY TERMS 644
CPL, CPU, and C pk 19-23
CHECKING YOUR UNDERSTANDING 644
19.7 Total Quality Management 19-26
CHAPTER 17 SOFTWARE GUIDE 645
19.8 Six Sigma 19-27
SG17.1 Descriptive Analytics 645
The DMAIC Model 19-28
SG17.2 Predictive Analytics for Clustering 646
Roles in a Six Sigma Organization 19-29
Lean Six Sigma 19-29
 CONTENTS 19

USING STATISTICS: Finding Quality at the Beachcomber, A.3 Rules for Algebra: Exponents and Square Roots 656
Revisited 19-30 A.4 Rules for Logarithms 657
SUMMARY 19-30 A.5 Summation Notation 658
A.6 Greek Alphabet 661
REFERENCES 19-31
KEY EQUATIONS 19-31 B. Important Software Skills and Concepts 662
B.1 Identifying the Software Version 662
KEY TERMS 19-32
B.2 Formulas 662
CHAPTER REVIEW PROBLEMS 19-32 B.3 Excel Cell References 663
CASES FOR CHAPTER 19 19-35 B.4 Excel Worksheet Formatting 665
The Harnswell Sewing Machine Company Case 19-35 B.5E Excel Chart Formatting 666
PHASE 1 19-35 B.5T Tableau Chart Formatting 667
PHASE 2 19-35 B.6 Creating Histograms for Discrete Probability
PHASE 3 19-36 Distributions (Excel) 668
B.7 Deleting the “Extra” Histogram Bar (Excel) 668
PHASE 4 19-36
PHASE 5 19-36 C. Online Resources 670
Managing Ashland Multicomm Services 19-37 C.1 About the Online Resources for This Book 670
C.2 Data Files 670
CHAPTER 19 EXCEL GUIDE 19-38
C.3 Microsoft Excel Files Integrated With This Book 676
EG19.2 Control Chart for the Proportion: The p Chart 19-38 C.4 Supplemental Files 676
EG19.4 Control Chart for an Area of Opportunity:
D. Configuring Software 677
The c Chart 19-39
D.1 Microsoft Excel Configuration 677
EG19.5 Control Charts for the Range and the Mean 19-40
D.2 Supplemental Files 678
EG19.6 Process Capability 19-41
E. Table 679
E.1 Table of Random Numbers 679

20   Decision Making (online) 20-1

E.2
E.3
The Cumulative Standardized Normal Distribution 681
Critical Values of t 683
E.4 Critical Values of x2 685
USING STATISTICS: Reliable Decision Making 20-1 E.5 Critical Values of F 686
20.1 Payoff Tables and Decision Trees 20-2 E.6 Lower and Upper Critical Values, T1, of the Wilcoxon
Rank Sum Test 690
20.2 Criteria for Decision Making 20-6
E.7 Critical Values of the Studentized Range, Q 691
Maximax Payoff 20-6
E.8 Critical Values, dL and dU, of the Durbin-Watson Statistic, D
Maximin Payoff 20-7 (Critical Values Are One-Sided) 693
Expected Monetary Value 20-7 E.9 Control Chart Factors 694
Expected Opportunity Loss 20-9 E.10 The Standardized Normal Distribution 695
Return-to-Risk Ratio 20-11
F. Useful Knowledge 696
20.3 Decision Making with Sample Information 20-16 F.1 Keyboard Shortcuts 696
20.4 Utility 20-21 F.2 Understanding the Nonstatistical Excel Functions 696

CONSIDER THIS: Risky Business 20-22 G. Software FAQs 698

G.1 Microsoft Excel FAQs 698
USING STATISTICS: Reliable Decision Making,
G.2 PHStat FAQs 698
Revisited 20-22
G.3 Tableau FAQs 699
SUMMARY 20-23
H. All About PHStat 700
REFERENCES 20-23
H.1 What is PHStat? 700
KEY EQUATIONS 20-23 H.2 Obtaining and Setting Up PHStat 701
KEY TERMS 20-23 H.3 Using PHStat 701
CHAPTER REVIEW PROBLEMS 20-23 H.4 PHStat Procedures, by Category 702

CASES FOR CHAPTER 20 20-26

Digital Case 20-26 Self-Test Solutions and Answers to
CHAPTER 20 EXCEL GUIDE 20-27 Selected Even-Numbered Problems 703
EG 20.1 Payoff Tables and Decision Trees 20-27
EG 20.2 Criteria for Decision Making 20-27 Index 743
Credits 750
Appendices 655
A. Basic Math Concepts and Symbols 656
A.1 Operators 656
A.2 Rules for Arithmetic Operations 656
This page intentionally left blank
 Preface

A
s business statistics evolves and becomes an increasingly important part of one’s business
education, which topics get taught and how those topics are presented becomes all the
more important. As authors, we think about these issues as we seek ways to continuously
improve the quality of business statistics education. We actively participate in conferences and
meetings sponsored by the Decision Sciences Institute, American Statistical Association (ASA),
and INFORMS, the Institute for Operations Research and the Management Sciences. We use the
ASA’s Guidelines for Assessment and Instruction (GAISE) reports and combine them with our
experiences teaching business statistics to a diverse student body at several universities.
When writing a book for introductory business statistics students, four learning principles
guide us.
Help students see the relevance of statistics to their own careers by using examples from
the functional areas that may become their areas of specialization. Students need to learn
statistics in the context of the functional areas of business. We discuss every statistical method
using an example from a functional area, such as accounting, finance, management, or market-
ing, and explain the application of methods to specific business activities.
Emphasize interpretation and analysis of statistical results over calculation. We empha-
size the interpretation of results, the evaluation of the assumptions, and the discussion of what
should be done if the assumptions are violated. We believe that these activities are more impor-
tant to students’ futures and will serve them better than emphasizing tedious manual calculations.
Give students ample practice in understanding how to apply statistics to business. We
believe that both classroom examples and homework exercises should involve actual or realis-
tic data, using small and large sets of data, to the extent possible.
Integrate data analysis software with statistical learning. We integrate Microsoft Excel into
every statistics method that the book discusses in full. This integration illustrates how software
can assist the business decision-making process. In this edition, we also integrate using Tableau
into selected topics, where such integration makes best sense. (Integrating data analysis soft-
ware also supports our second principle about emphasizing interpretation over calculation.)
When thinking about introductory business statistics students using data analysis software,
three additional principles guide us.
Using software should model business best practices. We emphasize reusable templates and
model solutions over building unaudited solutions from scratch that may contain errors. Using
preconstructed and previously validated solutions not only models best practice but reflects
regulatory requirements that businesses face today.
Provide detailed sets of instructions that accommodate various levels of software use and
familiarity. Instruction sets should accommodate casual software users and as well as users
keen to use software to a deeper level. For most topics, we present PHStat and Workbook
instructions, two different sets that create identical statistical results.
Software instruction sets should be complete and contain known starting points. Vague
instructions that present statements such as “Use command X” that presume students can figure
out how to “get to” command X are distracting to learning. We provide instruction sets that have a
known starting point, typically in the form of “open to a specific worksheet in a specific workbook.”

21
22 PREFACE

What’s New in This Edition?

This ninth edition of Statistics for Managers Using Microsoft Excel features many passages
rewritten in a more concise style that emphasize definitions as the foundation for understanding
statistical concepts. In addition to changes that readers of past editions have come to expect,
such as new examples and Using Statistics case scenarios and an extensive number of new end-
of-section or end-of-chapter problems, the edition debuts:
• Tabular Summaries that state hypothesis test and regression example results along with
the conclusions that those results support now appear in Chapters 10 through 13.
• Tableau Guides that explain how to use the data visualization software Tableau Public as
a complement to Microsoft Excel for visualizing data and regression analysis.
• A New Business Analytics Chapter (Chapter 17) that provides a complete introduction
to the field of business analytics. The chapter defines terms and categories that introductory
business statistics students may encounter in other courses or outside the classroom. This
chapter benefits from the insights the authors have gained from teaching and lecturing about
business analytics as well as research the authors have done for a forthcoming companion
book on business analytics.

Continuing Features That Readers Have Come to Expect

This edition of Statistics for Managers Using Microsoft Excel continues to incorporate a num-
ber of distinctive features that has led to its wide adoption over the previous editions. Table 1
summaries these carry-over features:
TABLE 1
Distinctive Features Continued in the Ninth Edition

Feature
Using Statistics
case scenarios
Emphasis on interpretation of
the data analysis results
Software integration and
flexibility
Unique Excel workbooks
Details
Each chapter begins with a Using Statistics case scenario that presents a business
problem or goal that illustrates the application of business statistics to provide
actionable information. For many chapters, scenarios also provide the scaffolding for
learning a series of related statistical methods. End-of-chapter “Revisited” sections
reinforce the statistical learning of a chapter by discussing how the methods and tech-
niques can be applied to the goal or problem that the case scenario considers.
In this edition, seven chapters have new or revised case scenarios.
Statistics for Managers Using Microsoft Excel was among the first introductory busi-
ness statistics textbooks to focus on the interpretation of Microsoft Excel statistical
results. This tradition continues, now supplemented by Tableau (Public) results for
selected methods in which Tableau can enhance or complement Excel results.
Software instructions feature chapter examples and were personally written by the
authors, who collectively have more than one hundred years of experience teaching
the application of business software.
With modularized Workbook, PHStat, and where applicable, Analysis Toolbook
instructions, both instructors and students can switch among these instruction sets as
they use this book with no loss of statistical learning.
Statistics for Managers Using Microsoft Excel comes with Excel Guide workbooks
that illustrate model solutions and provide template solutions to selected methods and
Visual Explorations, macro-enhanced workbooks that demonstrate selected basic con-
cepts. This book is fully integrated with PHStat, the Pearson statistical add-in for Excel
that places the focus on statistical learning that the authors designed and developed.
See Appendix H for a complete description of PHStat.

TABLE 1 Distinctive Features Continued in the Ninth Edition (continued)
Feature
In-chapter and
end-of-chapter reinforcements
End-of-chapter cases
Answers to even-numbered
problems
Opportunities for
additional learning
Highly tailorable content
Chapter-by-Chapter Changes Made for This Edition
Because the authors believe in continuous quality improvement, every chapter of Statistics
for Managers Using Microsoft Excel contains changes to enhance, update, or just freshen this
book. Table 2 provides a chapter-by-chapter summary of these changes.
TABLE 2
Chapter-by-Chapter
Change Matrix
PREFACE 23
Details
Exhibits summarize key processes throughout the book. A key terms list provides
an index to the definitions of the important vocabulary of a chapter. “Learning the
Basics” questions test the basic concepts of a chapter. “Applying the Concepts” prob-
lems test the learner’s ability to apply statistical methods to business problems. And,
for the more mathematically minded, “Key Equations” list the boxed number equa-
tions that appear in a chapter.
End-of-chapter cases include a case that continues through most chapters and several
cases that reoccur throughout the book. “Digital Cases” require students to examine
business documents and other information sources to sift through various claims and
discover the data most relevant to a business case problem. Many of these cases also
illustrate common misuses of statistical information.
The Instructor’s Solutions Manual provides instructional tips for using cases as well
as solutions to the Digital Cases.
An appendix provides additional self-study opportunities by provides answers to the
“Self-Test” problems and most of the even-numbered problems in this book
In-margin student tips and LearnMore references reinforce important points and direct
students to additional learning resources. In-chapter Consider This essays reinforce
important concepts, examine side issues, or answer questions that arise while studying
business statistics, such as “What is so ‘normal’ about the normal distribution?”
With an extensive library of separate online topics, sections, and even two full chap-
ters, instructors can combine these materials and the opportunities for additional
learning to meet their curricular needs.
Using Estimated
Statistics Problems
Chapter Changed Changed Selected Chapter Changes
First n.a. Updates opening section.
Things Retitles, revises, and expands old Section FTF.4 as
First ­Section FTF.4 and new Section FTF.5 “Starting Point
for Using Microsoft Excel.”
Expands the First Things First Excel Guide.
Adds a First Things First Tableau Guide.
1 50% Old Sections 1.3 and 1.4 revised and expanded as new
Section 1.4 “Data Preparation.”
Adds a Chapter 1 Tableau Guide.
2 • 57% Uses new samples of 479 retirement funds and 100
restaurant meal costs for in-chapter examples.
Includes new examples for organizing and visualizing
categorical variables.
Uses updated scatter plot and time-series plot examples.
Adds new Section 2.8 “Filtering and Querying Data.”
Adds coverage of bubble charts, treemaps, and
(Tableau) colored scatter plots.
Revises and expands the Chapter 2 Excel Guide.
Adds a Chapter 2 Tableau Guide.
24 PREFACE

TABLE 2 Using
Chapter-by-Chapter Statistics Problems
Change Matrix (continued) Chapter Changed Changed Selected Chapter Changes
3 • 52% Uses new samples of 479 retirement funds and 100
restaurant meal costs for in-chapter examples.
Adds a Chapter 3 Tableau Guide.
4 • 41% Uses the updated Using Statistics scenario for in-chapter
examples.
5 32% Adds a new exhibit that summarizes the binomial
distribution.
6 31% Uses new samples of 479 retirement funds for the nor-
mal probability plot example.
7 • 43% Enhances selected figures for additional clarity.
8 36% Presents a more realistic chapter opening illustration.
Revises Example 8.3 in Section 8.2 “Confidence
­Interval Estimate for the Mean (s Unknown).”
9 29% Adds a new exhibit that summarizes fundamental
hypothesis testing concepts.
Revises Section 9.2 “t Test of Hypothesis for the Mean
(s Unknown)” example such that the normality
assumption is not violated.
Revises examples in Section 9.3 “One-Tail Tests” and
Section 9.4 “Z Test of Hypothesis for the Proportion.”
10 52% Uses the new tabular test summaries for the two-sample
t test, paired t test, and the Z test for the difference
between two proportions.
Includes new Section 10.1 passage “Evaluating the
­Normality Assumption.”
Uses new (market basket) data for the paired “t test
example.
Enhances selected figures for additional clarity.
Contains general writing improvements throughout
chapter.
11 • 46% Presents an updated chapter opening illustration.
Uses revised data for the Using Statistics scenario for
in-chapter examples.
Uses the new tabular test summaries for the one-way
ANOVA results.
Presents discussion of the Levene test for the homoge-
neity of variance before the Tukey-Kramer multiple
comparisons procedure.
Revises Example 11.1 in Section 11.1 “One-Way
ANOVA.”
12 37% Uses the new tabular test summaries for the chi-square
tests, Wilcoxon rank sum test, and Kruskal-Wallis
rank test.
Category changes in text of independence example.
Uses revised data for Section 12.4 and 12.5 examples
for the Wilcoxon and Kruskal-Wallis tests.
Contains general writing improvements throughout
chapter.
Another random document with
no related content on Scribd:
know, there is no proof that it possesses any virtue in meningeal
tuberculosis. It has the high authority of Charles West,14 however,
who thinks the remedy is more encouraging than any other, and who
mentions one instance in which recovery took place under its
employment. He recommends that two grains be given every four
hours to a child three years old, the bowels being kept free. Most
authorities recommend much higher doses, such as ten or fifteen
grains, three or four times daily.
14 Op. cit., p. 102.

Counter-irritation to the head or back of the neck was formerly much

employed, but is now generally abandoned, as giving rise to much
discomfort without obvious beneficial effect. In the cases reported by
Hahn, already alluded to under the head of Prognosis, recovery is
attributed to the energetic application of tartar-emetic ointment to the
scalp, producing extensive ulceration, which in one of them lasted
more than ten months before cicatrization took place. A careful
examination of the reports of these cases satisfies me that but two
out of the seven were really examples of tubercular meningitis. How
far the recovery in the successful cases is to be attributed to the
treatment is very doubtful. Small blisters applied to the vertex or
back of the neck are alluded to favorably by West, but he quotes no
observations in which they were followed by benefit.

Tubercular Meningitis in the Adult.

Tubercular meningitis may occur at any age, but after the period of
childhood it is most frequent between the ages of sixteen and thirty
years. About 75 per cent. of the patients are males, and 25 per cent.
females.15 The disease does not differ essentially in its course and
symptoms from that in children. A family history of tuberculosis is
common, or the patient may be already suffering from phthisis,
scrofulous glands, cheesy deposits in various organs, caries of the
bone, syphilis, or other constitutional affections. According to Seitz,
in 93.5 per cent. out of 130 cases with autopsies chronic
inflammatory conditions or caseous deposits were found in various
organs of the body. Many cases are examples of acute tuberculosis
in which the brunt of the disease has fallen upon the brain rather
than the other organs.
15 Seitz, op. cit., p. 9.

When cerebral symptoms supervene upon acute disease, such as

typhoid fever, pericarditis, acute rheumatism, pneumonia, the
exanthemata, etc., the diagnosis between tubercular and simple
meningitis is important, because the latter is not necessarily fatal,
while the former is almost never recovered from. If the patient were
previously healthy and presumably free from tubercular disease, the
chances would be in favor of the simple form. A rapid course of the
disease would also speak for acute meningitis, and recovery would
almost certainly preclude tubercular meningitis. In some cases the
diagnosis is difficult or impossible in the beginning.

In cases beginning without acute antecedents—in adults as in

children—there is no pathognomonic symptom, but the combination
and succession of the phenomena are usually sufficient for the
diagnosis. Headache, depression or irritability of temper, delirium,
half-closed eyes, ptosis of one lid, squinting, inequality and
sluggishness of the pupils, moderate fever, sunken belly, vomiting,
constipation, slow and irregular pulse, sopor gradually deepening to
coma, with occasional convulsions or paralysis of the limbs, followed
in the course of two or three weeks by death, especially if occurring
in a patient who has already presented signs of tuberculosis in other
organs, point almost unmistakably to tubercular meningitis. Some of
the symptoms may not be strongly pronounced, one or two may be
absent, but the general picture will suggest no other disease.
According to Seitz, tubercle of the choroid is rare in tubercular
meningitis of the adult. It is usually associated with tuberculosis of
other organs, the pia being free. The subjoined cases are
illustrations of the disease in adolescence and adult life:
Case I.—A lad sixteen years old, always somewhat delicate, with a
cough and morning expectoration of some months' standing, exerted
himself immoderately in gymnastic exercise on the afternoon of
Sept. 24, 1875. That night he was awakened by cough and
hæmoptysis. Signs of consolidation were found at the apices of both
lungs. In three months there were swelling, induration, and
suppuration of one testicle. Some months later, pain in the right arm,
stiffness of the shoulder-joint, and an abscess communicating with
the joint, from which small spicula of bone were discharged. He was
about, and even attended school, for more than a year from the time
of the attack of hæmoptysis. About Jan. 1, 1877, he began to
complain of severe pain in the forehead, with nausea (but no
vomiting) and constipation. Jan. 27th he took to his bed, complaining
chiefly of pain in the forehead and eyes. Feb. 1st he was drowsy,
irritable, and delirious. Feb. 3d incontinence of urine and constant
delirium. Up to this time the pulse had not been above 76 in the
minute, and on this day it was 64. The next day, Feb. 4th, he was
wholly unconscious; pulse 96, pupils dilated. Feb. 5th, left hand in
constant motion; pulse 112. From this time the pulse steadily
increased in frequency. Feb. 6th he swallowed food, notwithstanding
his stupor. Feb. 7th he answered questions; there was oscillation of
the eyeballs, and epistaxis from constant picking of the nose. He
died Feb. 9th, the pulse being 144 and the respirations 60 in the
minute for several hours previous. The temperature never rose
above 101.7° F. There was never any vomiting. The duration of the
case was thirteen days, in addition to the prodromic period of twenty-
seven days.—Autopsy by R. H. Fitz: The pia of the base of the brain
from the medulla to the optic thalamus contained a large number of
gray miliary tubercles, old and recent, and the same condition was
found in the surfaces of the fissure of Sylvius. Ventricles distended
with fluid, ependyma thick and translucent. A moderate-sized cavity
in the apex of the left lung, with cheesy contents. Both lungs
contained an abundance of hard, gray, miliary tubercles. Left kidney
contained a wedge-shaped, cheesy mass of the size of a walnut,
with numerous tubercles. Left testicle contained a cheesy mass of
the size of a walnut; both epididymes were cheesy. The mucous
membrane of the bladder contained tubercles near the neck. The
vesiculæ seminales contained softened cheesy masses with
openings into the urethra. There was a fistulous opening into the
right shoulder-joint.

Case II.—Emeline K. L——, 32 years old, single, nurse, had become

much exhausted by taking care of a difficult case, and entered
Massachusetts General Hospital March 6, 1883, complaining since
four days of a little cough, slight expectoration, and chilliness, but no
rigor. She seemed hysterical. There was complaint of severe pain in
the head, chest, and abdomen. A slight systolic murmur was found
at the apex of the heart, and a few moist râles at the base of the
chest on both sides behind. The urine was normal. Temperature,
103° F. Three weeks after entrance she began to be delirious,
especially at night. April 13th, five weeks and three days after
entrance, she was semi-conscious, but would put out her tongue and
open her eyes when requested to do so; the abdomen was
distended, the pupils were dilated and unequal; there was twitching
of the muscles of the right side of the face. Careful examination only
disclosed occasional fine râle at the base of right chest. She died
April 16th, having been completely unconscious for twenty-four
hours. There was no vomiting throughout the case. The temperature
was very irregular, ranging between 100° and 103° F., and once as
high as 104° F.; it was usually one or two degrees higher at night
than in the morning. Pulse, generally from 100 to 110; it rose steadily
during the last few days to 160 at the time of death.—Autopsy: Pia
mater of brain œdematous, slightly opaque; its lower surface,
especially at the base of the brain, showed numerous minute gray
tubercles; enlarged cheesy glands at the base of the neck; small,
opaque, gray tubercles scattered rather sparsely throughout both
lungs. There was also miliary tuberculosis of the liver, spleen, and
kidneys.
CHRONIC HYDROCEPHALUS.
 BY FRANCIS MINOT, M.D.

SYNONYMS.—Dropsy of the brain, Dropsy of the head.

DEFINITION.—A gradual accumulation of serous fluid in the brain,

occupying either the ventricles or the cavity of the arachnoid, or both,
occurring chiefly in infants or very young children.

The term hydrocephalus, which was applied by the older writers to

accumulations of serous fluid both within and also without the
cranium, termed distinctively internal and external hydrocephalus, is
now restricted to dropsical effusions either between the meninges or
within the ventricular cavities. These may be acute or chronic, and
they arise from the same conditions which are followed by the
effusion of serum in other parts of the body; that is to say, from an
alteration in the serous membrane lining a cavity, from an obstruction
in the capillary circulation with increased tension in the larger
vessels, from an altered condition of the blood, etc.

Chronic hydrocephalus is almost entirely confined to young children,

and is probably due to an arrested development of the brain, as
shown by its being usually congenital, by the dwarfed intellectual
condition of the patient, and by its frequent association with spina
bifida. The pathogeny of the disease is, however, still obscure.
Whether the abnormal accumulation of serous fluid is to be ascribed
to a chronic alteration of the ventricular walls or of the choroid
plexuses, allied to inflammation, such as occurs in the pleura, for
example, causing an increased secretion, or to a closure of the
communication between the ventricles and the spinal cavity, as
suggested by the late John Hilton, resulting in dropsy by retention, or
to some other cause, is not yet determined. Hilton says:1 “In almost
every case of internal hydrocephalus which I have examined after
death I found that this cerebro-spinal opening [between the fourth
ventricle and the spinal canal] was so completely closed that no
cerebro-spinal fluid could escape from the interior of the brain; and,
as the fluid was being constantly secreted, it necessarily
accumulated there, and the occlusion formed, to my mind, the
essential pathological element of internal hydrocephalus.” Sieveking,
commenting upon Hilton's theory, says:2 “While giving these facts
due weight, it must be pointed out that we are yet far from
understanding either how the fluid is poured into the cerebral cavities
or how it is removed, and that we do not positively know that the
spinal canal has any better means of getting rid of an excess of fluid
than the cerebral cavities have.” An arrest of the growth of the brain
is supposed by some pathologists to account for ventricular as well
as arachnoidal dropsy by the creation of a vacuum in the cavity of
the cranium, which is filled by exudation of the more fluid portion of
the blood from the vessels or of lymph from the lymphatics.
1 John Hilton, Lectures on Rest and Pain, etc., 2d ed., New York, 1879, p. 22.

2 Jones and Sieveking's Pathological Anatomy, 2d ed., London, 1875, p. 248.

ETIOLOGY.—That chronic hydrocephalus in young children is in a

large proportion of cases an hereditary disease is shown by the fact
that it is frequently congenital, that more than one child in a family is
occasionally affected by it, and that while one child is hydrocephalic
others may be idiotic. A scrofulous taint in the family history is
noticeable in many cases, the evil effect of which is frequently
enhanced by unfavorable sanitary conditions of life, especially by
residence in dark, damp, ill-ventilated, and badly-drained apartments
and by insufficient or unwholesome food. Hence the disease is more
frequently met with among the poor than in the well-to-do classes of
society. There is a difference of opinion as to whether it ever arises
in consequence of external violence, such as a blow on the head, or
of some strong impression, like fright or grief, acting on the mother of
the child during pregnancy. The probability is that such causes would
not be efficient except in cases where a predisposition to
hydrocephalus had already existed. West3 mentions the case of a
healthy child five months old who fell out of the arms of her nurse,
and was taken with a fit the same day. She apparently recovered,
but when a year old had frequent returns of convulsions. At the age
of fifteen months the head began to enlarge, and it continued to
increase in size until she was three years old, when she was
attacked by measles, and died in a few days with convulsions and
coma. The symptoms, both bodily and mental, were typical of
hydrocephalus, and the diagnosis was fully confirmed by the
autopsy.
3 Op. cit., p. 127.

The causes of chronic hydrocephalus in older subjects and in adults

are, in addition to the above mentioned, chiefly mechanical. Any
lesion which hinders the exit of venous blood from the cranium may
be followed by dropsy of the arachnoid cavity or ventricles. The
principal ones are tumors of the brain or its membranes, the effusion
of lymph in the neighborhood of veins, thrombosis of the cerebral
sinuses, compression of numerous small vessels by tubercular
granulations, obstructions outside the cranium, including tumors of
the neck, aneurisms, obstructive disease of the heart, emphysema
and cirrhosis of the lungs, besides diseases giving rise to general
dropsy, as the different forms of nephritis, marasmus, the various
cachexiæ, etc.

SYMPTOMS.—When the disease is already somewhat advanced

before birth, the head is often abnormally large, the cranial bones
are separated, the fontanels are distended and fluctuating, and it
occasionally happens that delivery of the distended head can only be
effected after the fluid has been evacuated by puncture. Even when
there is no abnormal increase in the size of the head, indications of
cerebral disturbance are sometimes apparent from birth, such as
strabismus or convulsions recurring with more or less frequency,
along with signs of failure of the general health. In the course of
some weeks, or, it may be, months, the attention of the parents is
attracted to the prominence of the child's forehead, strongly
contrasting with the comparatively diminutive size of the face. Soon
an enlargement of the fontanels is perceived, the sutures between
the cranial bones become broader, and the head assumes a globular
shape from the pressure of the contained fluid. The separation of the
bones at the vertex of the skull causes the os frontis to protrude
forward, the parietals backward and outward, and the occipital
backward and downward. The orbital plates of the frontal bone yield
to the pressure of the fluid behind them, and from a horizontal
position tend to assume a vertical one, protruding the eyeballs,
which have a peculiar downward direction. The sclerotica is visible
above the iris, and the latter is partially covered by the lower eyelid.
The enlargement of the head is progressive, though not uniformly so,
there being pauses of weeks or months during which it is arrested. If
it be considerable, the cranial bones are usually thinned, so that the
skull becomes translucent when opposite a bright light. When there
is a wide separation of the bones there is an unusual development of
ossa triquetra in the sutures.

In cases in which the ossification of the cranium is considerably

advanced before the beginning of the disease, the enlargement of
the head is apt to be correspondingly less. If all the sutures are
consolidated, there may be no increase in size, and this is especially
true of the mechanical dropsy of adult life. The dropsical effusion,
which is then moderate in amount, finds room through compression
of the brain-substance, and part of it escapes into the spinal canal.

The size of the hydrocephalic head varies considerably. Where there

has been an early arrest of the disease it may be but slightly above
the normal. On the other hand, the dimensions are sometimes
enormous. In the Warren Museum of Harvard University is a cranium
which measures 27½ inches in its greatest circumference, and 20½
inches from one auditory foramen to the other over the top of the
head. Its internal capacity is 257 cubic inches. The patient, who died
at the age of three years, was never able to sit up and support the
head, or even to turn it from the left side, on which she continually
lay; she never spoke, and seemed to have no intelligence. The skull
of the celebrated James Cardinal measured 32¼ inches in its largest
circumference.4 Even more remarkable instances are on record. The
dimensions of the fontanels, particularly the anterior, usually
correspond with those of the skull in general. During any strong
muscular effort on the part of the patient the membrane covering
them is seen to be bulged out by pressure from the fluid beneath.
The enlargement is not always uniform; it may be in part or wholly
confined to one side, owing to consolidation of the sutures of the
opposite side, or because only one of the lateral ventricles is
affected. The scalp is traversed by numerous distended veins. The
hair is very scanty. The head has a soft, fluctuating feel, and the
walls sometimes seem to crackle beneath the fingers, like
parchment.
4 Reports of Medical Cases, etc., by Richard Bright, M.D., London, 1831, vol. i. p.
431.

In cases of moderate severity there may be few or no symptoms of

active cerebral disturbance, such as convulsions or paralysis, but the
child does not learn to talk, to walk, or to control the sphincters even
at the age of three or four years, and the signs of imperfect mental
development are evident. He is apt to be irritable or mischievous,
and even when not actually idiotic is very backward in evincing signs
of intelligence. There are, however, not a few exceptions to this, and
some children with large hydrocephalic heads are intelligent and
amiable. The cranium of a girl who died at the age of sixteen years is
preserved in the Warren Museum. It measures 24¼ inches in
circumference and 17¼ inches from one auditory meatus to the
other over the vertex, and the bone is in no place more than one-
eighth of an inch in thickness. The child was an inmate of a house of
industry, where she was instructed in the usual branches of
knowledge taught in our common schools, until at length, such was
her capacity, she was entrusted with the teaching of the other pauper
children, and she had an excellent character for intelligence and
moral worth. She died of phthisis. On post-mortem examination “the
brain was found floating, as it were, in a large collection of water.” As
in other chronic diseases, there are often pauses, from time to time,
of variable duration, in which there is some improvement in the
condition of the patient, as well as a temporary arrest in the
enlargement of the head. The growth of the child in stature is often
retarded, and when life is prolonged the individual is more or less
dwarfed. In some cases there is a considerable increase in the
amount of adipose tissue, and the appetite is often voracious. L.
Fürst reports5 the case of a hydrocephalic girl, sixteen years old,
whose height (or, rather, length, for she was unable to stand) was 81
centimeters (nearly 32 inches), corresponding to the stature of a
child between three and four years old. The periphery of the head
measured 511/5 centimeters (20¼ inches). The anterior fontanel was
still open. The age was verified by reference to the registry of birth at
the police-office.
5 “Exquisite Wachsthumshemmung bei Hydrocephalus chronicus,” von Dr. Livius
Fürst, Virchow's Archiv, June, 1884.

The symptoms of cerebral disturbance in chronic hydrocephalus are

much less striking than one would expect, doubtless because the
increase of pressure upon the brain is so gradual. Actual paralysis,
especially of the limbs, is rare, but convulsions are not infrequent, as
is the spasmodic constriction of the glottis known as laryngismus
stridulus or spasmodic croup. A general state of uneasiness and
restlessness is common. Vision is often impaired and sometimes
wholly lost. Strabismus is frequently present, or there may be an
involuntary rolling movement of the eyeballs. The pupils are often
dilated and insensible to light. In consequence of the increased
weight of the head, the child is unable to support it, and in most
cases is compelled to keep the bed. Vomiting is common. The
digestive functions are disturbed. Constipation is an almost constant
symptom, and the sphincters are relaxed in the advanced stages of
the disease. Although in some cases, as already stated, the child
may grow fat, the reverse of this is the rule; there is usually
progressive emaciation, especially of the lower extremities.

The duration of the disease varies much in different cases. The

earlier the characteristic symptoms manifest themselves the more
rapid is its course. Most children born hydrocephalic survive but a
few days or weeks. In cases which are more slow in their
development the patient may live some years, and in rare instances
attain adult life. But his feeble vitality usually makes him an easy
prey to the ordinary complaints of childhood, and a large proportion
of cases succumb to inflammation of the lungs or of other organs, to
diarrhœa, whooping cough, or the eruptive diseases. Most of those
who escape these intercurrent maladies perish from defective
nutrition, the result of malassimilation of food, or else are cut off by
acute cerebral inflammation, with convulsions, etc.

PATHOLOGICAL ANATOMY.—It is rarely that a large amount of serum is

found in the cavity of the arachnoid unless a free communication has
been established between it and the ventricles by the destruction of
cerebral tissue. In the pia the quantity may be more abundant than
normal, filling the subarachnoid spaces, separating the convolutions
from each other, and occasionally forming little sac-like elevations on
the surface of the membrane; but it should be borne in mind that a
certain amount of serous infiltration of the tissue of the pia is by no
means rare in cases of death from various diseases, owing to the
obstruction to the circulation during the last hours of life, and should
not be considered pathological unless it exceed the usual limits. The
amount of effusion into the ventricles varies between very wide
limits, from some ounces to two or three pints. It may be transparent,
or turbid from particles of cerebral tissue or epithelial or pus-cells,
and is occasionally slightly tinged with blood. Its specific gravity is
nearly identical with that of water, and it contains a trace of albumen.
The effusion usually occupies the two lateral and the middle
ventricles. Less frequently the dropsy is unilateral, in consequence,
apparently, of an obliteration of the foramen of Monro. The tissues
composing the walls of the ventricles are compressed and hardened.
The ependyma of the walls and of the plexus is thickened and
roughened by the formation of minute elevations, which the
microscope shows to be composed of proliferated and sclerosed
connective tissue. The brain in cases of large effusion is reduced to
a membranous sac, flattened, with hardly any trace of its original
structure at first sight apparent. In the case of James Cardinal,
before alluded to, Bright says, “The brain lay at its base [of the skull]
with its hemispheres opened outward like the leaves of a book.”
Closer inspection shows that all the parts are present, although
atrophied by pressure. The convolutions are flattened and the brain-
substance is pale and softened. The cranial nerves are often
softened and flattened.

In the dropsy of the head in adults which is the result of mechanical

pressure or of cachexia the appearances are widely different. The
effusion may occupy the cavity of the arachnoid, and even the space
between the dura and the skull, as well as the ventricles. The
amount of fluid is much less than in the chronic hydrocephalus of
children. The ventricular walls present no signs of inflammatory
changes.

DIAGNOSIS.—Chronic hydrocephalus is usually recognized without

difficulty. The chief points of diagnostic importance are the
progressive enlargement of the head, the separation of the cranial
bones, with their peculiar change of position, as already described,
and the evident signs of arrested intellectual development. If the
head be but little enlarged, the case might be mistaken for that of
chronic hypertrophy of the brain, but this is a very rare disease, and
is not accompanied with defective mental development.

PROGNOSIS.—The elements of prognosis include the size of the head

at birth, its rate of enlargement, the general condition of the child,
both physically and intellectually, his hereditary antecedents, and the
hygienic influences to which he may be subjected. A large proportion
of children born hydrocephalic live but a short time; a few survive
one or more years. The number of those who reach adult life is
extremely small. The favorable indications are a tardy appearance of
the dropsy and its slow progress, without marked evidence of
defective mental and bodily development.

TREATMENT.—The treatment of chronic hydrocephalus is general and

local, the first being the most important, although in many cases it is
difficult to enforce it, from lack of intelligence and of means on the
part of those in charge of the patient. Proper ventilation, good
drainage, and cleanliness are essential. The child should be bathed
daily, and should be protected against changes in temperature by
suitable clothing. If his strength allow, he should be taken into the
open air daily in fine weather. A wet-nurse should be provided for
infants whose mothers are unable to suckle them. Older patients
should take milk, cream, animal broths, farinaceous substances,
etc., with wine or brandy. Tonics, especially cod-liver oil,
hypophosphite of lime, and some preparation of iron or of the iodide
of iron, are important, the choice being determined by the effect
apparently produced. The internal and external employment of
mercurial preparations, once in vogue, is now almost entirely
abandoned by the best authorities. The evacuation of the fluid by
puncture, followed by compression of the head by bandaging, has
been occasionally resorted to, and in a few instances with success,
but the cases in which it is indicated are rare. Thomas Young
Thompson6 reports a case in which puncture was followed by
recovery. The child, fourteen days old, fell, apparently without ill
effects, but three weeks afterward a protuberance appeared on the
crown of the head which continued to enlarge, and the signs of
chronic hydrocephalus were unmistakable. In three months the
circumference over the parietal eminences measured 20 inches, and
a year afterward 24½ inches. In spite of energetic internal and
external treatment the enlargement continued to progress, until the
head was punctured, and about three hundred grammes of a clear,
transparent fluid, free from albumen, were evacuated. Five weeks
later a second puncture was made, and sixty grammes of a milky
fluid withdrawn. The child recovered, and two years later was in
good health, the head not being disproportioned to the rest of the
body. West considers the cases in which the effusion is apparently
external—that is, confined to the arachnoid cavity, rather than
ventricular, and in which there are no indications of active cerebral
disease—to be the most favorable for the operation. The proper
situation for the puncture is the coronal suture, about an inch or an
inch and a half from the anterior fontanel. A few ounces of fluid only
should be withdrawn at a time, and compression should be carefully
applied both during the escape of the fluid and afterward.
6 Med.-Chir. Transactions, vol. xlvii., 1864.
 CONGESTION, INFLAMMATION, AND
HEMORRHAGE OF THE MEMBRANES OF THE
SPINAL CORD.

BY FRANCIS MINOT, M.D.

Congestion of the Spinal Membranes.

The blood-vessels of the spinal membranes communicate freely with

the general circulation, and there is less opportunity for their
obstruction than in the case of the meninges of the brain.
Hyperæmia of the dura and pia mater is therefore seldom met with,
except in connection with disease of the cord; and, indeed, but little
is known on the subject, which is only alluded to as possible by
authorities of the present day, although the affection was formerly
supposed to be a common one, giving rise to various symptoms,
such as numbness and formication of the extremities, muscular
weakness, and even paraplegia—symptoms which are now known
to be caused by structural diseases of the cord only. As Erb1
remarks, “It is hardly possible that any considerable hyperæmia of
the meninges should exist without a similar condition existing in the
cord also, as the vascular supply of both is the same.”
 1 “Krankheiten des Rückenmarks,” von Wilhelm Erb, in Ziemssen's Handbuch,
Leipzig, 1876; Am. trans., vol. xiii. p. 99.

ETIOLOGY.—Hyperæmia of the spinal membranes is found after death

from convulsions, especially in cases of tetanus, hydrophobia,
eclampsia, strangulation, poisoning from narcotics, etc., in which the
effect is evidently due to asphyxia. An interesting case of extensive
hyperæmia of the spinal membranes, as well as of those of the
brain, complicating mania, is reported by M. R. G. Fronmüller.2 A girl
of eighteen years, previously well, being accused of theft, fell into a
state of melancholia, passing into mania, with frequent convulsions,
screaming, etc. There was no spinal tenderness. The urine
contained no albumen. The temperature was never elevated. No
opisthotonos. The sphincters became relaxed, and she died at the
end of about three weeks. The dura was found to be normal, but the
pia mater of the brain, cerebellum, medulla oblongata, and cord was
strongly injected. The brain and cord were normal; no ventricular
effusion. Here the meningeal hyperæmia was doubtless caused by
asphyxia resulting from the convulsions.
2 See Schmidt's Jahrbücher, 1883, No. 7.

Congestion of the spinal membranes has been attributed to sudden

suppression of the menstrual flow or of hemorrhoidal bleeding, and
to portal obstruction, but the evidence of this is very meagre.
Exposure to cold and wet, as from sleeping on the damp ground, is
an alleged and plausible cause.

The SYMPTOMS attributed to hyperæmia of the spinal membranes are

pain in the back extending to the legs, with numbness and tingling of
the toes, sensation of weight in the limbs, muscular weakness,
appearing suddenly without fever and usually of transient duration.
There is no evidence that it gives rise to paralysis. Considering that
temporary congestion of the membranes must occasionally happen
from convulsions, as in epilepsy, etc., it is remarkable that no
symptoms attributable to it have been observed under these
circumstances.3
 3 See Epilepsy and other Chronic Convulsive Diseases, etc., by W. R. Gowers, M.D.,
London, 1881, p. 106.

MORBID ANATOMY.—We must be careful not to mistake post-mortem

staining of the tissues from imbibition of the coloring matter of the
blood—the result of decomposition aided by the position of the body
—for true congestion. The latter is recognized by fine vascular
arborization covering the surface of the dura or pia, often
accompanied with small punctate hemorrhages. More extensive
extravasations in the connective tissue, surrounding and between
the membranes, are sometimes found. The spinal fluid is usually
increased in amount, and often tinged with red. On account of the
free vascular connection between the membranes and the cord the
latter almost always partakes of the congestion.

DIAGNOSIS.—From what has been said it follows that simple

hyperæmia of the spinal membranes can hardly be distinguished
from that of the cord. (See the article on DISEASES OF THE SUBSTANCE
OF THE BRAIN AND SPINAL CORD.) When the symptoms are
unaccompanied by fever, are of very moderate severity, and of short
duration, we may perhaps infer that the lesion is confined to the
membranes.

The TREATMENT is the same as that for congestion of the spinal cord.

Acute Inflammation of the Spinal Dura Mater.

SYNONYM.—Acute spinal pachymeningitis.

Acute inflammation of the spinal dura mater is chiefly confined to the

outer surface of the membrane (peripachymeningitis), and is almost
always consecutive to either injury or disease of the vertebræ
(fracture, dislocation, caries), to wounds penetrating the spinal
cavity, or to suppurative disease in neighboring organs or tissues,
which makes its way into the peridural space through the
intervertebral openings. The symptoms are complex—in part caused
by the original disease, and in part by the pressure of the products of
inflammation exercised upon the nerve-roots, and even upon the
cord itself. Pain in the back, corresponding to the seat of the
disease, is rarely absent, and all movements of the trunk are
extremely painful. When the exudation is sufficient to compress the
nerve-roots, the pain will extend to the trunk and the limbs, and other
signs of irritation, such as a feeling of constriction by a tight girdle,
and tingling, numbness, and cutaneous hyperæsthesia in the limbs,
will be observed, varying in situation according to the seat of the
lesion. In some cases the compression of the cord may be sufficient
to cause paraplegia. General symptoms will vary according to the
complications of the case. Severe injury or extensive disease of the
vertebræ will be accompanied with high fever; but if the external
inflammation be moderate and the meningeal complication be limited
in extent, the fever may be subacute.

MORBID ANATOMY.—The connective tissue between the dura and the

bone is the seat of inflammatory exudation, usually purulent, of
greater or less extent, and more abundant in the posterior than the
anterior part of the spinal cavity, owing to the position of the patient.
A more or less abundant exudation, either of pus or of dry caseous
matter, is found upon the outer surface of the dura or infiltrating the
connective tissue between it and the bony walls. The dura is
thickened, and sometimes the exudation is seen upon its inner walls,
but the pia is seldom involved in the inflammation. The cord may be
compressed or flattened when the amount of exudation is large, and
may in consequence show signs of inflammation in its vicinity. The
spinal nerves likewise are sometimes compressed, atrophied,
softened, and inflamed. The disease rarely occupies the cervical
region, on account of the close union of the dura with the bones of
that part; hence there is an absence of pain in the neck and of
retraction of the head.

DIAGNOSIS.—The diagnosis is founded on the presence of general

symptoms of spinal disease—pain in the back, but not extending to
the neck, increased by movements of the trunk; cutaneous
hyperæsthesia, tingling, or numbness in various parts of the surface
of the body; paresis or paralysis of the lower extremities in severe
cases; along with a history of vertebral disease or injury or of
suppurative disease in the neighborhood of the spine. The history of
the case will generally be sufficient to exclude myelitis, tetanus, or
muscular pain (rheumatism, lumbago). From acute leptomeningitis
the diagnosis must also be made by the history, but it should be
borne in mind that the pia may be involved at the same time with the
dura.

PROGNOSIS.—In complicated cases the prognosis is grave if the

spinal symptoms are well marked and severe, especially when there
is evidence of much pressure on the cord (paraplegia). If the signs of
spinal irritation were moderate, the danger would depend upon the
nature and extent of the external lesion.

TREATMENT.—This would be addressed mainly to the primitive

disease. For the spinal symptoms the treatment would not differ
materially from that of inflammation of the spinal pia mater.

Chronic Spinal Pachymeningitis.

This affection generally coexists with chronic inflammation of the pia.

Like the acute inflammation of the dura, it is seen in connection with
disease or injury of the vertebræ, and it may also arise from tumors
of the membrane (chiefly syphilitic) and from myelitis. It is frequent
among the chronic insane, and in them is sometimes associated with
hemorrhagic effusions analogous to the hæmatoma of the cerebral
dura mater. Chronic inflammation of the spinal dura is of unfrequent
occurrence, and but little is known of its history and pathology. In a
case reported by Wilks4 the membrane was thickened to nearly its
whole extent, and in the cervical region presented numerous bony
plates. The pia was also thickened at this part and adhered closely
to the dura. The symptoms, which seemed chiefly due to disease of
the cord from compression, were retraction of the lower limbs and
violent jerking from excessive reflex action.
4 Transactions of the Pathological Society of London, vol. vii., 1856.

A special form of the disease, occupying chiefly the cervical region,

was first described by Charcot.5 The membrane is thickened by a
deposit of successive layers of fibrin, compressing the cord, which is
flattened from before backward and inflamed. The nerve-roots are
also more or less compressed. The course of the disease may be
divided into two stages: First, that of irritation of the spinal nerves,
with pain in the back part of the neck, extending to the head and
along the upper limbs. The pain is permanent, but liable to
exacerbations, and is accompanied with stiffness of the neck and a
feeling of numbness and tingling, with muscular weakness of the
arms. Sometimes the skin of the arms is the seat of trophic changes,
as shown by the presence of bullæ or pemphigus. The second
period is that of extension of the disease to the cord. The pain
ceases, and is followed by paralysis or muscular atrophy, especially
in the domain of the ulnar and median nerves, resulting in extension
of the hand on the forearm, with flexion of the fingers toward the
palm, giving rise to a claw-like appearance (main en griffe). In some
cases an upward extension of the disease implicates the root of the
radial nerve, and the hand then assumes a prone position from
paralysis of the extensor muscles. The lower portion of the cord may
also become involved, with similar results in the lower extremities.
Although the disease is generally progressive, it is not always so,
and Charcot cites one case in which great improvement took place in
the course of some years, though not apparently in consequence of
any special treatment.
5 Leçons sur les Mal. du Syst. nerv., par J. M. Charcot, Paris, 1875, vol. ii. p. 246.
See, also, Maladies du Syst. nerv., par A. Vulpian, Paris, 1879, p. 127; and Clinique
méd. de l'Hôpital de la Charité, by the same.