2?ew f orfe Hntt QfoUege of Agrwultutc At CfocneU Iniaeraita atljara, 35f. 5. SItbrara Cornell University Library RC 76.C24 Physical diagnosis, 3 1924 003 515 297 Cornell University Library The original of this book is in the Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924003515297 Cabot— Physical Diagnosis ARGYRIA Silver Nitrate Poisoning with Slaty Blue Color of Skin {Painted from Life) PHYSICAL DIAGNOSIS BY RICHARD C. CABOT, M. D. PBOPBSSOR OP MEDICINE IN HARVARD U.VrVERSITT CHIEF OP THE WEST MEDICAL SERVICE AT THE MA.aSACHUSETT8 GENERAL HOSPITAL Seventh EOitlon REVISED AND ENLARGED, WITH 6 PLATES AND 263 FIGURES IN THE TEXT NEW YORK WILLIAM WOOD AND COMPANY • MDCCCCXIX Copyright, 1919 BY WILLIAM WOOD AND COMPANY THE MAPUE PRESS YORK PA FREDERICK C. SHATTUCK, M. D. FORMERLY JACKSON PROFESSOR OF CLINICAL MEDICINE IN HARVARD UNIVERSITY IN EVIDBNCB OF MT APPRECIATION OP THE EXAMPLE OF SINCEKITY, COMMON SENSE, AND ENTHUSIASM ESTABLISHED BY HIM IN THE TEACHING AND THE PRACTICE OF MEDICINE PREFACE TO THE SEVENTH EDITION. New experience gained by war service in France has served to modify especially my ideas on the Cardiac Signs of Nervousness, on Hilus Tuberculosis (peribronchial), on Goitre Heart, and on Empyema. New matter has been written on all these topics. I have further ex- pressed my growing scepticism as to the existence of rheumatic mitral regurgitation (without stenosis) , as to the diagnosis of chronic appen- dicitis, and of tricuspid stenosis. My beliefs about blood pressure and about arteriosclerosis have undergone considerable change, which is incorporated in the new text. A good many minor changes have been made. I Marlborough St., Boston, Richard C. Cabot. June I, 1919. PREFACE. This book endeavors to present an account of the diagnostic methods and processes needed by competent practitioners of the present date. It differs from other books on the subject in that it makes no attempt to describe technical processes with which the writer has no personal familiarity and gives no space to the descrip- tion of tests which he believes to be useless. To gain genuine familiarity with all the technical processes de- scribed in most books on physical diagnosis — such familiarity as makes one competent to use them with due regard for the sources and limits of error inherent in. them — needs more than the life-time of one man. But unless one has one's self used a technical process long enough to gain this sort of mastery over it, one cannot prop- erly describe it, far less recommend it to others. Because of my lack of personal acquaintance with such methods as cystoscopy, ophthal- moscopy, and laryngoscopy I have attempted no description of them, although I believe they should sooner or later be mastered by every internist. All that I have described I know by prolonged use. A book constructed on this basis should make obvious what its writer considers important and what unimportant, and reveal therein not only his opinions but his personal limitations. But I believe there is no longer a demand for books that attempt impartially to present all that has been or is now thought of value by some one. The personal equation cannot and should not be ignored. In diag- nosis as in therapeutics "What do you find valuable?" is the question that our contemporaries ask of any one of us, not "What has been recommended?" In the endeavor further to break down the false distinction be- tween clinical diagnosis and laboratory diagnosis I have described all the methods of getting at an organ — e.g., the kidney — in a sin- gle section. Palpation, thermometry, urinalysis are different proc- esses by which we may gather information about the kidney. The student should be accustomed to think of them and practise them in close sequence. VUl PREFACE For the same reason the most important methods of investigat- ing the stomach have been grouped together without any distinction of " clinical " and "laboratory " procedure. For the illustrations I owe many thanks to many persons, espe- cially to Drs. Frank Billings, A. E. Boycott, E. H. Bradford, E. R. Carson, J. Everett Button, R. T. Edes, Joel E. Goldthwait, J. S. Haldane, Frederick T. Lord, R. W. Lovett, H. C. Masland, S. J. Meltzer, Percy Musgrave, R. F. O'Neil, J. E. Schadle, William H. Smith, W. S. Thayer, and G. L. Walton; also to the editors of The Boston Medical and Surgical Journal, The St. Paul Medical Journal, American Medicine, The Journal oj Experimental Medicine, and The Lancet. My assistant. Dr. Mary W. Rowley, has helped me very much with the index as well as with other parts of the book. I Marlboro St., Boston. June, 1905. TABLE OF CONTENTS. CHAPTER I. DATA RELATING TO THE BODY AS A WHOLE. Pagb I. Weight I 1. Causes of Gain in Weight, .... i 2. Causes of Loss in Weight, 2 II. Temperature — Technique and Sources of Error, . . 2 1. Causes of Fever, 3 2. Subnormal Temperature, . i 3. Chills and Their Causes 3, 4 4. Night and Day Sweats, 4 CHAPTER II. THE HEAD, FACE, AND NECK. I. The Cranial Vault S I. Size, Shape S ■i. Fontanels 6 3. Hair, . 6 II. The Forehead, ... 7 III. The Face as a Whole . 8 IV. Movements of the Head and Face, . 13 V. The Eyes ... 14 (a) Ocular Motion, . .... i6- (6) The Retina . 17 VI. The Nose 17 VII. The Lips .19 VIII. The Teeth .... .21 IX. The Breath, 22 X. The Tongue . . 22 XI. The Gums, ..... . . .24 XII. The Buccal Cavity, . . . . . .' . . .25 XIII. The Tonsils and Pharynx, . 27 XIV. The Neck, . . 29 1. Glands 29 2. Abscess or Scars, -32 3. Thyroid Tumors . . 32 4. Torticollis . . -33 5. Vertebral Tuberculosis .... 34 6. Bronchial Cysts and Fistula;, . -34 7. Actinomycosis, 3S 8. Cervical Rib 35 9. Inflammatory or Dropsical Swelling of Neck 36 ix X TABLE OF CONTENTS CHAPTER III. THE ARMS AND HANDS; THE BACK. Page The Arms. I. Paralysis, .... 37 II. Wasting of One Arm, 39 III. Contractures 39 IV. CEdema 40 V. Tumors, 40 VI. Miscellaneous Lesions of the Forearm, 42 The Hands. I. Evidence of Occupation 43 II. Temperature and Moisture, 44 III. Movements, 44 IV. Deformities, $1 The Nails 56 The BAck. I. Stiff Back 57 II. Sacro-iliac Disease 57 III. Spinal Curvatures 58 IV. Tumors of the Back, 59 V. Prominent Scapula, 59 VI. Scaphoid Scapula . 60 VII. Spina Bifida 60 CHAPTER IV. THE CHEST. TECHNIQUE AND GENERAL DIAGNOSIS. Introduction. I. Methods of Examining the Thoracic Organs, 61 II. Regional Anatomy of the Chest, 61 Inspection. I. Size 64 II. Shape 64 1. The Rachitic Chest 65 2. The Paralytic Chest 65 3; The Barrel Chest 66 III. Deformities 67 1. Curvature of the Spine, 67 2. Flattening of One Side of the Chest, 68 3. Prominence of One Side of the Chest, 69 4. Local Prominences 69 TABLE OF CONTENTS xi Page IV. Respiratory Movements 70 1. Normal Respiration, 70 2. Anomalies of Expansion 71 (a). Diminished Expansion, 71 (6). Increased Expansion, 72 3. Dyspncea, 73 V. Relation of Dyspncea to Cyanosis 73 VI. The Respiratory Rhythm 74 1. Asthmatic Breathing 74 2. Cheyne-Stokes Breathing, 75 3. Restrained Breathing, . 76 4. Stridtdous Breathing 76 VII. Diaphragmatic Movements (Litten's Phenomenon),. 76 VIII. The Cardiac Movements, 78 1. Normal Cardiac Impulse 78 2. Displacement of the Cardiac Impulse 82 3. Apex Retraction 83 4. Epigastric Pulsation, 84 5. Uncovering of the Heart, 84 IX. Aneurism and Other Causes of Abnormal Thoracic Pulsation, . 85 X. The Peripheral Vessels,. 86 1. Inspection of the Veins 86 2. Arterial Phenomena, 88 3. Capillary Pulsation 90 XI. The Skin and Mucous Membranes 90 I. Cyanosis, . . .90 ■i. (Edema 91 3. Pallor 92 , 4.' Jaundice, 92 5. Scars and Eruptions 92 XII. Enlarged Glands 92 CHAPTER V. PALPATION AND STUDY OF THE PULSE. I. Palpation 94 1. The Apex Beat 94 2. Thrills, 9S 3. Tactile Fremitus, 96 4. Friction, Pleural or Pericardial 98 S- Palpable Rales, 99 6. Joint Frictions and Tendon Frictions 99 7. Local Muscular Spasm, 99 8. Tender Points 99 The Pulse, 100 I. The Rate loi ■z. Rhythm, . 102 3. Compressibility 102 xii TABLE OF CONTENTS Page 4. Size and Shape of Pulse Wave 102 S- Tension 103 6. Size and Position of Artery, 105 7. Condition of Artery Walls 105 III. Arterial Pressure and the Instruments for Measuring it, 107 1. Systolic or Maximum Pressure 108 2. Diastolic Pressure, .... . , 109 3. Normal Readings, . . . . ... no 4. Use of Data no CHAPTER VI. ARTERIOGRAMS, PHLEBOGRAMS AND ELECTROCARDIOGRAMS. I. Heart Block, . . . ... 114 II. Auricular Fibrillation, ... 116 III. Paroxysmal Tachycardia, ... 117 IV. Prernature Beats (Extrasystoles), 118 V. Coupling of Heart Beats and Alternation, 120 VI. Sinus Arrhythmia, ... . . 121 VII. Ventricular Preponderance, . 121 CHAPTER VII. PERCUSSION. l Technique, ... Mediate Percussion, . Immediate Percussion, . . . . Auscultatory Percussion, .... 3 . Palpatory Percussion II. Percussion-Resonance of the Normal Chest, . I. Vesicular Resonance z. Dulness and Flatness, .... 3. Tympanitic Resonance, . . . 4. Kronig's Isthmus, . . 5. Cracked-pot Resonance, , . 6. Amphoric Resonance, . 7. The Lung Reflex, . . III. Sense of Resistance . iVg CHAPTER VIII. AUSCULTATION. I. Mediate and Immediate Auscultation 130 II. Selection of a Stethoscope, 140 III. The Use of the Stethoscope 14^ 1. Selective Attention and What to Disregard 14^ 2. Muscle Sounds i-y 3. Other Sources of Error i^^g 122 122 128 129 130 130 132 133 133 136 137 137 TABLE OF CONTENTS xiii Page IV. Auscultation of the Lungs 150 1. Respiratory Types 150 (a) Vesicular Breathing, 151 (6) Tubular Breathing 153 (c) Broncho- vesicular Breathing, 154 (d) Emphysematous Breathing, 154 {e) Asthmatic Breathing, 155 (/) Cog-wheel Breathing 155 (g) Amphoric Breathing, 156 {h) Metamorphosing Breathing 156 V. Differences between the Right and the Left Chest 156 VI. Pathological Modifications of Vesicular Breathing, 156 1. Exaggerated Vesicular. Breathing, 157 2. Diminished Vesicular Breathing, . 157 VII. Bronchial Breathing in Disease 159 VIII. Broncho-vesicular Breathing in Disease, . . . . 159 IX. Amphoric Breathing, . . . . 160 X. Rales ... . 160 I. Moist, ... . . 161 .i. Dry, ... . 162 3. Musical 163 XI. Cough. Effects on Respiratory Sounds, 163 XII. Pleural Friction . . 163 XIII. Auscultation of the Voice Sound, . .... 165 1. The Whispered Voice, . . 165 2. The Spoken Voice 165 3. Egophony .... . . . 166 XIV. Phenomena Peculiar to Pneumo-hydrothorax, . . . . 166 1. Succussion, ... . .... 166 2. Metallic Tinkle, ... . ; 167 3. The Lung Fistula Sound, . . 168 CHAPTER IX. AUSCULTATION OF THE HEART. I. The Valve Areas, . . . 169 II. Normal Heart Sounds, 170 III. Modifications in the Intensity of the Heart Sounds, 172 1. Mitral First Sound .... . 172 (a) Lengthening, . . . 172 (6) Shortening, 173 (c) Doubling, . . ; ... 173 2. The Second Sounds. at the Base of the Heart 173 (a) Physiological Variations, 173 (6) Pathological Variations 175 Accentuation of Pulmonic Second Sound, 175 Weakening of Pulmonic Second Sound 176 Accentuation of the Aortic Second Sound 176 Weakening of the Aortic Second Sound, 176 xiv TABLE OF CONTENTS Page 3. Modifications in Rhythm of Cardiac Sounds and Doubling of Second Sounds, 177 4. Metallic Quality of the Heart Sounds 178 5. " Muffled " Heart Sounds 178 IV. Sounds Audible Over the Peripheral Vessels 179 CHAPTER X. AUSCULTATION OF THE HEART, CONTINUED. Cardiac Murmurs 180 I. Terminology, . . 180 II. Mode of Production 180 1. Place of Murmurs in the Cardiac Cycle, . 183 2. Area of Transmission, 183 3. Intensity, Quality, and Length, 185 4. Relation to Heart Sounds, 187 5. Effects of Respiration, Exertion, and Position, 187 6. Metamorphosis of Murmurs, 188 III. Functional Murmurs 188 IV. Cardio-Respiratory Murmurs .... 190 V. Arterial Murmurs 191 CHAPTER XI. ESTABLISHMENT AND FAILURE OF COMPENSATION IN VALVULAR DISEASE OF THE HEART. I. Compensation Not Yet Established • • I93 II. The Period of Compensation,. 193 III. Failure of Compensation, ... 194 IV. Hypertrophy and Dilatation . . 195 1. Causes . . 195 2. Results ... 196 3. Dilatation of the Heart 198 (a) Predominant Dilatation of the Left Ventricle 200 (J) Predominant Dilatation of the Right Ventricle, . . 201 CHAPTER XII. THE CLASSIFICATION OF CARDIO-VASCULAR DISEASES. Five Groups of Diseases Due to Circulatory Weakness 203 I. Rheumatic Heart Disease, 203 1. Acute Endocarditis, 205 2. Rheumatic Pancarditis of Children, 205 3. Mitral Endocarditis (Rheumatic Type) 206 (a) Early Stages 206 ib) Late Mitral Disease — Stenosis . 213 TABLE OF CONTENTS xv Page 4. Aortic Disease (Rheumatic Type), 221 1. Aortic Regurgitation, ... 221 2. Aortic Stenosis, ... 224 5. Diseases of the Tricuspid and Pulmonary Valves, . 230 1. Tricuspid Regurgitation, . . ... 230 2. Tricuspid Stenosis . 233 3. Pulmonary Regurgitation, . 233 6. Combined Valvular Lesions, . . 234 1. Double Mitral Disease, . .... 235 2. Aortic Regurgitation with Mitral Disease, . . 236 3. Aortic Regurgitation with Aortic Stenosis, .... 236 7. Pericarditis, 237 1. Dry or Fibrinous,. 237 2. Pericardial Effusion, . . 239 3. Adherent Pericardium, . . 244 CHAPTER XIII. SYPHILITIC HEART DISEASE. I. Syphilitic Aortitis with or without Aneurism, 247 1. Aortic Regurgitation (Syphilitic Type), 247 2. Physical Signs, ... .... 248 3. Capillary Pulsation, . 249 4. Palpation, .... 250 5. Percussion and Auscultation, . . 251 II. Complications, 253 CHAPTER XIV. ', - SYPHILITIC AORTITIS WITH ANEURISM. I. Inspection and Palpation, 255 1. Abnormal Pulsation, ... 255 2. Tumor . ....... 255 3. Thrill, . . . ........ 256 4. Diastolic Shock, 256 5. Tracheal Tug, . ..... 257 II. Percussion, .... ... . . 259 III. Auscultation, . . . ... , ■. 259 IV. Radioscopy, :.,.,. . -• ;. . ■. . 260 V. Diagnosis, ... .... . ,., / ..-,.. 261 CHAPTER XV. ' HYPERTENSIVE CARDIO-VASCULAR DISEASEt I. Physical Signs, II. Fatty Overgrowth, .... III. Fatty Degeneration, ...... IV. Senile or. Decrescent Arteridsclefosis, 266 269 269 269 xvi TABLE OF CONTENTS CHAPTER XVI. NEPHROGENOUS HEART DISEASE, GOITRE HEART, CONGENITAL MALFORMATIONS, MISCEL- LANEOUS CARDIAC LESIONS. Page I. Nephritic (or Nephrogenous) Heart Disease, . . . 270 II. Goitre Heart, . . . . . . 270 III. Congenital Heart Disease, . 271 1. Pulmonary Stenosis, . . 272 2. Aortic Coarctation, . . 272 3. Patent Ductus Arteriosus, .... 272 4. Defective Interventricular Septum, 273 5. Defective Interauricular Septum, . . 273 6. Transposition of the Arterial Trunks, 273 7. Hypoplasia of the Aorta, . . 273 IV. Other Diseases which Weaken the Heart, . 273 ' I. Acute Myocarditis, 273 V. Miscellaneous Affections of the Heart, 274 1. Tachycardia, ..... 274 2. Cardiac Symptoms of Nervousness, . 275 Post Infectious Tachycardia, Tobacco , Supposed Effect, Athlete's Heart, ... . 276 3. Bradycardia, . . 277 4. Heart Block, ... 277 5. Palpitation, . 277 CHAPTER XVII. DISEASES OF THE LUNGS. BRONCHITIS, PNEUMONIA, TUBERCULOSIS. I. Tracheitis 279 II. Bronchitis, . ... 279 1. Acute, . . 279 2. Chronic, . . ... . 282 III. Croupous Pneumonia, . . (o) Inspection, . (6) Palpation,. . (c) Percussion, (d) Auscultation, . (e) Differential Diagnosis, IV. Inhalation Pneumonia,. . V. Broncho-Pneumonia, VI. Pulmonary Tuberculosis, . 282 -283 283 .... . . . .284 285 .288 289 .... 290 • ■ ■ 292 I. Incipient Tuberculosis 292 X. Moderately Advanced Cases, . . 295 3. Advanced Phthisis 297 4. Hilus Tuberculosis, . . . ...... 301 5. Fibroid Phthisis, . ... 302 6. Phthisis with Predominant Pleural Thickening, 302 TABLE OF CONTENTS xvii Page 7. Emphysematous Form of Phthisis 303 8. Phthisis with Anomalous Distribution of the Lesions, . 303 9. Acute Pulmonary Tuberculosis, . . 303 CHAPTER XVIII. (DISEASES OF THE LUNGS, CONTINUED.) I. Emphysema . . . . . 304 1. Large-Lunged Emphysema, 304 2. Emphysema with Arteriosclerosis and Asthma, . . 307 3. Interstitial Emphysema, ... . 307 4. Complementary Emphysema, . . . 308 S- Acute Pulmonary Tympanites, . 308 II. Bronchial Asthma, ... . 308 III. Syphilis of the Lung, . 309 IV. Bronchiectasis 310 V. Examination of Sputa, . .311 1. Origin ... 311 2. Quantity, . 311 3- Odor .312 4. Gross Appearance, ... -313 5. Microscopic Examination, . . 313 CHAPTER XIX. DISEASES AFFECTING THE PLEURAL CAVITY. I. Hydrothorax, . 316 II. Pneumothorax, . . ... 316 III. Pneumohydrothorax or Pneumopyothorax, . 318 I. Differential Diagnosis, ... ... 320 IV. Pleurisy . . 321 1. Dry Pleurisy, . . ... 322 2. Pleuritic Effusion,. . . 323 (a) Percussion, . . . 324 (6) Auscultation, . . 329 (c) Inspection and Palpation, . . 330 (d) Interlobar Empyema, .... 332 3. Pleural Thickening 333 4. Encapsulated Pleural ESusions,. ..... . 334 5. Pulsating Pleurisyand Empyema Necessitatis, ... 335 6. Difierential Diagnosis of Pleural EfEusions, . . . . 335 7. Carcinoma of the Pleura, . . 338 8. Cancer of the Bronchi and Lung, 338 9. Echinococcus of the Pleura, 338 10. Actinomycosis of the Pleura, 339 V. Cyto-Diagnosis of Pleural and Other Fluids, . ... 339 I. Technique, - . 340 ■A. Interpretation of Results, . ,. . ■ . 340 xviii TABLE OF CONTENTS CHAPTER XX. ABSCESS, GANGRENE, AND CANCER OF THE LUNG, PUL- MONARY ATELECTASIS, CEDEMA, AND HYPOSTATIC CONGESTION. Page I. Abscess and Gangrene of the Lung, ... 342 IL Neoplasms of the Lung and Mediastinum, . 343 III. Atelectasis .... . . 344 IV. CEdema of the Lungs, . 345 V. Hypostatic Pneumonia, . . 346 CHAPTER XXI. THE ABDOMEN IN GENERAL, THE BELLY WALLS,, PERI- TONEUM, OMENTUM, AND MESENTERY. I. Examination of the Abdomen in General, . 347 1. Technique, ... . 347 (a) Inspection, . 347 (6) Palpation, . ... . . 349 2. What can be felt Beneath the Normal Abdominal Walls,. . 350 3. Palpable Lesions of the Belly Walls, . . . . -351 4. Abdominal Tumors, . . 352 (a) Percussion, . , . . . 354 II. Diseases of the Peritoneum, . . . 35 = I. Peritonitis, Local or General, , . ... 355 li. Ascites, . 356 3. Cancer and Tuberculosis, . . . 3^7 III. The Mesentery, . . . 353 Glands, . . . 358 Thrombosis, 358 . CHAPTER XXII. THE STOMACH, LIVER, AND PANCREAS I. The Stomach . 355 1. Inspection and Palpation, . . ". 355 2. Use of the Stomach Tube, :. - ; , . 360 3. Examination of Contents, . ." . 363 (a) Qualitative Tests 364 (fc) QuantitativeEstimationof Free HCl and of Total Acidity, 364 4. Bismuth X-ray Examination of the Stomach 366 5. Incidence and Diagnosis of Gastric Diseases, , . 368 II. The Liver, . ... ,69 1. Pain, . . . . . 370 2. Enlargement,. ....... 370 3. Atrophy,. . . ■ ■ ■ • 373 4. Portal Obstruction, .; . 37^ 5. Jaundice, .... 374 6. Loss of Flesh and Strength, . 376 TABLE OF CONTENTS XIX 7. The Infection Group of Symptoms, . 8. Cerebral Symptoms of Liver Disease, III. The Gall Bladder and Bile Ducts 1. Differential Diagnosis of Biliary Colic, 2. Enlarged Gall Bladder, . *. . 3. Cholecystitis, IV. The Pancreas, . . 1. Cancer, . . ... 2. Acute Pancreatic Disease, 3- Cyst 4. Bronzed Diabetes, Page ■ 376 ■ 377 ■ 377 378 378 378 ■ 379 379 379 380 380 CHAPTER XXIII. THE INTESTINES, SPLEEN, AND KIDNEY. I. The Intestines 1 . Data for Diagnosis, . 2. Appendicitis, ... 3. Chronic Appendicitis, 4. Intestinal Obstruction, . 5. Cancer, ' 6. Examination of Contents, 7. Parasites, . II. The Spleen 1. Palpation, ... ... .i. Percussion, ... 3. Causes of Enlargement, . 4. Differential Diagnosis of the Various Causes of Enlargement, III. The Kidney 1. Incidence and Data, . . 2. Characteristics Common to Most Tumors of the Kidney, (a) Malignant Disease, (6) Hydronephrosis and Cystic Kidney, (c) Perinephritic Abscess, (d) Abscess of the Kidney, .... (e) Floating Kidney, ... ... 3. Renal Colic and Other Renal Pain, 4. Examination of the Urine, . (a) Amount and Weight, . (6) Optical Properties {c) Significance of Sediments (Gross), 5. Pyuria 6. Haematuria, . . 7. The "Red Test," 8. Chemical Examination of the Urine,. (a) Reaction of Normal Urine, (6) Tests for Albuminuria, . (c) Significance of Albuminuria, . . , 381 381 383 385 385 386 386 388 393 393 394 395 396 397 397 398 398 398 399 399 400 400 401 402 402 403 404 405 406 406 406 407 408 XX TABLE OF CONTENTS Page (d) Significance of Albumosuria, . . 409 (e) Glycosuria and Its Significance, . 409 (/) The Acetone Bodies, ... 410 (g) Other Constituents, ... . . 411 9. Microscopic Examination of Ifrinary Sediments, .... 411 10. Summary of the Urinary Pictures Most Useful in Diagnosis, . 415 CHAPTER XXIV. THE BLADDER, RECTUM, AND GENITAL ORGANS. I. The Bladder . . .419 I. Incidence and Data, . 419 u. Distention,. . ..;.... . ■ . 419 3. The Urine as Evidence of Bladder Disease, . . . . . 421 II. The Rectum 422 1. Symptoms which should Suggest an Examination, . 422 2. Methods, . . ... 422 III. The Male Genitals, . 424 I. The Penis, . . . 424 2. The Testes and Scrotum, IV. The Female Genitals, . . J.. Methods,. . . ■z. Lesions, . (o) In the External Genitals, (6) In the Uterus (c) In the Fallopian Tubes, . (d) In the Ovaries, . . 425 427 427 427 427 428 429 429 CHAPTER XXV. THE LEGS AND FEET. I. The Legs, . . .... 432 1. Hip, . 432 2. Groin, . 432 3- Thigh,. . 433 4. Knee, . „ ,,. , 437 5. Lower Leg, . ■'..•■-■•-,..,-,> • 438 XL The Feet, . . "■' S'^^." :'■ . . 441 I. The Toes,.. ... CHAPTER XXVI. THE BLOOD. I. Examination of the Blood 1. Haemoglobin 2. Study of the Stained Blood Film, 3. Counting the White Corpuscles, . . , 4. Counting the Red Corpusclesi . . 443 445 445 447 453 454 J TABLE OF CONTENTS , xxi Page II. Interpretation of These Data, . 455 1. Secondary Anaemia, ... . 445 2. Chlorosis, . . 456 3. Pernicious Anaemia, . .'.... 456 4. Leucocytosis 457 5. Lymphocytosis, . 458 6. Eosinophilia, . . . 458 7. Leukaemia, ... . 459 III. The Widal Reaction, . . ... ... 460 IV. The Wassermann Reaction, ... . 461 v.* Blood Parasites 462 1. Malaria . . . . 462 2. Trypanosomiasis, . 462 3. Filariasis, .... . 463 CHAPTER XXVII. THE JOINTS. I. Examination of the Joints . . . 464 1. Methods and Data, . . . 465 2. Technique, . . . 465 II. Joint Diseases, ... . . 468 J.. Infectious Arthritis, .... . . 469 2. Atrophic Arthritis, . ... ... . 472 3. Hypertrophic Arthritis, . . . . 474 4. Gouty Arthritis 480 5. Haemophilic Arthritis . 480 6. Relative Frequency of the Various Joint Lesions, . 480 CHAPTER XXVIII. THE NERVOUS SYSTEM. I. Examination of the Nervous System, . .481 I. Disorders of Motion, .481 ■^. Disorders of Sensation, . . . . 484 3. Reflexes 485 4. Electrical Reactions, 489 5. Speech and Handwriting, ... . 490 6. Trophic Vasomotor Disorders, . 490 7. The Examination of Psychic Functions; Coma, ... 491 8. Examination of the Cerebro-Spinal Fluid . . 494 PHYSICAL DIAGNOSIS. CHAPTER I. DATA RELATING TO THE BODY AS A WHOLE. I. Weight. To weigh the patient should be part of every physical examina- tion, and every physician's ofHce should contain a good set of scales. 1. Gain in weight, aside from seasonal changes, the increase in normal growth, and convalescence from wasting diseases, means usually: (o) Obesity. (b) The accumulation of serous fluid in the body — dropsy, evi- dent or latent. The first of these needs no comment. Latent accumulation of fluid, not evident in the subcutaneous tissues or serous spaces, oc- curs in some forms of uncompensated cardiac or renal disease, and gives rise to an increase in weight which may delude the physician with the false hope of an improvement in the patient's condition, but in reality calls for derivative treatment (diuresis, sweating) . Obvious dropsy has, of course, the same effect on the weight and the same significance. (c) Myxoedema is occasionally a cause of increased weight, i.e., when the myxoedematous infiltration is widespread (see below, page 8). 2. Loss of Weight. — The aging process is so often associated with loss of weight that some writers speak of the "cachexia of old age." In some, a rapid loss of superfluous fat may occur at moderate age, e.g., at fifty-five, and may give rise to grave apprehension though the general health remains good and no known disease develops. Aside from this physiological change of later life, most cases of loss of weight are due to : (o) Malnutrition. (6) Loss of sleep (whether from pain or other cause) . (c) Infectious fevers and other toxsemic states. Under the head of malnutrition come the cases of oesophageal 1 2 PHYSICAL DIAGNOSIS stricture, chronic dyspepsia (with or without peptic ulcer) and gastric cancer, chronic diarrhoea, the atrophies of infancy, diabetes mellitus, and the rare cases of anorexia nervosa and of gall-stones. Loss of sleep is, I believe, the chief factor in the emaciation oc- curring in many painful illnesses as well as in various other types of disease. It is only in this way that I can account for the marked emaciation in many cases of thoracic aneurism and of gall-stones. Toxcemia is, I suppose, accountable for part at least of the ema- ciation in typhoid, cirrhotic liver, and tuberculosis. It is especially important to suspect tuberculosis and look for it in any patient who has lost weight without any obvious cause, for such a loss is often an early symptom of the disease. Accelerated or increased metabolism is present in Graves' disease and may be one of the earliest symptoms. Unless the patient takes more than his normal share of food he loses weight steadily. II. Temperature. The method of taking temperature is too familiar to need expla- nation, but the student should be aware of the fact that hysterics and malingerers can and often do raise the mercury in the bulb by various manceuvres, unless they are vigilantly watched. Dipping the bulb into hot water, shaking the mercury upward toward the higher degrees of the scale, and possibly friction with the tongue (?) are to be suspected. In comatose or dyspnceic patients and in infancy the temperature is best taken by rectum. In others we must be sure that the lips do not remain open during the test, so as to reduce the temperature of the mouth. I. Fever, i.e., a temperature above 99° F., has much more diag- nostic value in adults than in infancy and childhood. In the latter it is often impossible to make out any pathological condition to account for a fever. After childhood the vast majority of fevers are found to be due to : (a) Infectious disease or inflammation of any type. (6) Toxsemia without infection — a much less common and less satisfactory explanation. Graves' disease is an example. (c) Disturbance of heat regulation — as in sunstroke, after the use of atropine, and in nervous excitement, e.g., just after entering a hospital.' ' The latter event may also reduce (temporarily) a high fever to normal or below it. In coma from any cause (uraemia, cerebral hemorrhage, diabetic coma) fever often occurs TEMPERATURE 3 (d) After hsemorrhage there may be marked fever for which no cause is clear. Fdr such causes we search when the thermometer indicates fever. Types of fever often referred to are: (a) " Continued fever," one which does not return to normal at any period in the twenty-four hours, as in many cases of typhoid, pneumonia, and tuberculosis. (6) "Intermittent," "hectic," or "septic" fever, one which disap- pears once or more in twenty-four hours, as in double tertian mala- ria and septic fevers of various types (including mixed infections in tuberculosis) . A fever which disappears suddenly and permanently is said to end by "crisis," while one which gradually passes off in the course of several days ends by "lysis." Long-continued fevers — i.e., those lasting two weeks or more without obvious cause-^are usually due (in the temperate zone) to one of three causes : — Typhoid, tuberculosis, sepsis. In 1,000 "long fevers" (as above defined) the following causes were found in the medical records of the Massachusetts General Hospital : 926, or 92 .6 per cent. , or 7.4 per cent. Typhoid Fever 586 Tuberculosis 192 Pyogenic Infections 148 Epidemic Meningitis 27 "Influenza" 10 Infectious Artliritis ("rheumatism") 9 Leucaemia S Cancer 4 Sjrphilis 2 Miscellaneous 17 Since the last 7.4 per cent, here listed represent fevers whose cause is usually obvious, it is substantially true to say that any long obscure fever arising in' the temperate zones is due to typhoid, tuberculosis or sepsis. Under sepsis I include vegetative endocarditis ("benign" or "malignant"), all local inflammatory processes and generalized bacterial infections with or without a known portal of entry. 2. Subnormal temperature is often seen in wasting disease (can- cer), nephritis, uncompensated heart disease, and myxcedema. It is rarely of diagnostic value, but is a rough measure of the degree of prostration. It may be present in health. 4 PHYSICAL DIAGNOSIS 3. Chills (due usually to a sudden rise in temperature) are seen chiefly in: (o) Sepsis of any type; (b) Malaria; (c) Onset of acute infections; (d) "Nervous" states. After the passage of a catheter, after or during labor, and after infusion of saline solution, a chill is often seen, but not easily ex- plained. True chill, with shivering and chattering teeth, is distinguished from chilliness without any shivering. Chilliness is far less signifi- cant and often goes without fever; true chill rarely does. The cause of true chills can usually be determined by blood ex- amination (leucocytosis, malarial parasites) and by the general physical examination. Chills without any abnormal physical signs and with normal blood are most often due to sepsis in the liver or bile ducts. Fever without explanation is often from dental sepsis. 4. Night Sweats and Day Sweats. Sweating in disease seems to be conditioned by: (a) Fever (infec- tion) ; (6) Weakness; (c) Sleep. A phthisical patient who falls asleep in the daytime will sweat then and there, and the sweating will stop when he wakes. In ty- phoid fever and pneumonia sweating often begins in convalescence when the temperature is nearly or quite normal. In alcoholism, hyperthyroidism, and neurasthenic states we sometimes see sweating without fever. In France pretty much all dispensary patients com- plain of night sweats, perhaps because of their sleeping habits. Sepsis, acute rheumatism, and tuberculosis are the infections most often accompanied by sweating. In rickets the head sweats especially. CHAPTER II. THE HEAD AND FACE; THE NECK. THE HEAD AND FACE. Almost all that we can learn about the manifestations of disease on the head and face is to be learned by the use of our eyes, by inspec- tion, as the term is. Other methods — percussion, x-ray, palpation — yield but little. I shall begin at the top. I. The Cranial Vault. I . The Shape and Size of the Cranium. The shape and size of the cranium concern us, especially in children. (a) Abnornially sinall crania (microcephalia) are apt to mean idiocy, especially if the sutures are closed. (&) An abnormally large head is seen in hydrocephalus (see Fig. i), asso- ciated with enormous "open" areas uncovered by bone and a peculiar downward inclination of the eyes, which are partly covered by the eyelids and show a white margin above the iris. This condition is to be distinguished from the: (c) Rachitic head, which is flatter at the vertex and more protuberant at the frontal eminences, giving it a squarish outline, contrasted with the globular shape and rounded vertex of the hydrocephalic. In rickets there are no changes in the eyes. (d) In adult life an enlargement Fig- i.— Hydrocejihalus. of the skull, due to bony thickening, forms part of the rare disease, osteitis deformans (Paget's disease), associated with thickening and bowing of the long bones (see Fig. 2). (e) Myelomata of the skull may or may not be accompanied by a 5 6 PHYSICAL DIAGNOSIS leukfemic blood and a greenish staining of the tumor tissues. They are recognized by the concurrent presence of the Bence-Jones protein in the urine, by the :i;-ray, the negative AVassermann reaction and finalljr the histological examination of an excised node (see Figs. 3 and 4). H^rpernephromata may exhibit a cranial metastasis. With such a tumor the presence of hematuria and enlarged kidney is suggestive. 2. The Fontanels. The anterior and larger fontanel remains about the same size for the first year of life, then diminishes, and closes about the twentieth month. The posterior closes in about six weeks. In rickets, hydro- cephalus, hereditary syphilis, and cretinism, the fontanels and sutures remain open after the normal time limit. Fig. 2. — Paget's Disease. (Edes.) a, Before onset of hyperostosis cranii. of hyperostosis cranii. c, Later still. b, After onset (a) Bulging fontanels mean increased intracranial tension (hydro- cephalus, hemorrhage, meningitis, or any acute febrile disease with- out dyspnoea). (6) Depressed fontanels are seen in severe diarrhoea, wasting diseases, collapsed states, and acute dj^spnoeic conditions. 3. The Hair. (a) A rachitic child often rubs the hair off the back of its head by constant rolling on the pillow. (This is associated with profuse sweating of the head.) Patchy baldness occurs in the skin disease THE HEAD AND FACE 7 alopecia areata, and occasionally over the painful area in trigeminal neuralgia. (6) General loss of hair occurs normally after many acute fevers and with advancing age. Early baldness (under thirty-five) is often hereditary. Syphilis may produce a rapid loss of hair, local or general, and the same is true of myxaedema; but in both these diseases the hair usually grows again in convalescence. Fig. 3. — Multiple Myelomata. Fig. 4. — Multiple Myelomata. (f) Parasites (pediculi) are worth looking for in the dirtier classes and those associated with them (teachers). Their eggs adhere to the hairs and are familiarly known as "nits." An eczema or itching dermatitis and an adenitis often results. II. The Forehead. Scars, eruptions, and bony nodes are important. (a) Scars may be due to trauma or to old syphilitic periostitis. The epileptic often cuts his forehead in falling. (6) Eruptions often seen on the forehead are those of acne, syphilis, and smallpox. These may resemble each other closely, and are to be distinguished by the history, the presence of lesions on other parts of the body, and the concomitant signs (fever, prostration, etc.). 8 PHYSICAL DIAGNOSIS (c) Nodes may be the result of many bumps in childhood or may be caused by a syphilitic periostitis or neoplasms (see Figs. 3, 4, 5 and 7). The history must decide. [d) Evidence of frontal sinusitis may be found (see Fig. 9). III. The Face as a Whole. Very characteristic even at a glance is the face of (a) acrome- galia. A strong family likeness seems to pervade all well-marked cases (see Figs. 6 and 8). The huge, bony "whopper jaw" is the Fig. 5. — Syphilis of ttie Frontal Bone. (Curschniann.) most striking item, then the prominent cheek bones, and the ridge above the eyes. The nose and chin are very large. (&) Myxosdema (see Fig. lo) is not so characteristic and might easily be mistaken for nephritis or normal stupidity with obesity. The presence of dry skin, falling hair, mental dulness, and subnormal temperature, all supervening simultaneously within a few weeks or months, make us suspect the disease, especially at or near the meno- THE HEAD AND FACE ■H 9 BHpK^" * ^I^^^^^B pBfJf ;/"gl,.^^i,"?^j^^;" ^^^^.^- .--^ W^ ^HIP^^B^^r^ '^^'-'' '^IS'^^m^H '"-, ^^^^H ■••■M^^^Mm I9EIIH 1 "•?- I'^^W"^ ~" '^B ^H L, ■<■ ^^^H Fig. 6. — Acromegalia. 1 p v^ ^p H^ri^R ^' ^^^g Fig- 7- — Gumma Involving Frontal Bone. 10 PHYSICAL DIAGNOSIS Fig. S. — Typical Face in Acromegaly. Fig. g.— Frontal Sinusitis Fig. lo. — Myxcedema THE HEAD AND FACE 11 pause. Palpation shows that the puffiness of the face is not true oedema, as it does not pit on pressure. (c) Cretinism — the infantile form of myxoedema — can generally be recognized by sight alone (see Figs, ii and 12). Here the tongue is often protruded, and there are often pot-belly and deformed legs. (d) In adenoids of the naso- pharjmx the child's mouth is often open, the nose looks pinched, the expression is stupid (see Fig. 13). There is a history of mouth-breathing and Figs, ii and 12. — Cretinisii snoring, with frequent "colds," a high-arched palate, and perhaps deafness. (e) In paralysis agitans the "mask-like" face shows almost no change of expression, whatever the patient says or does. The neck is usually inclined forward, and so rigid that when the patient wishes 12 PHYSICAL DIAGNOSIS to look to right or left his whole body rotates like a statue on a pivot. In some cases tremor is absent and the characteristics just mentioned are then of great importance in diagnosis. (/) In Graves' disease (thyrotoxicosis) the startled or frightened look is characteristic, though the expression is almost wholly due to the bulging of the eyes and their quick motions (Fig. 14) . (g) In leprosy the general expression is of a superabundance of skin on the patient's face, reminding us of some animal ("leonine face") (Fig. 15). Fig. 13. — Adenoid Face. (Schadle.) {h) In early phthisis one often notices the clear, delicate skin, fine hair, long eyelashes, wide pupils — "appealing eyes." Pallor and a febrile flush (hectic) come later in some cases. (-i) After vomiting the face has often a drawn, pinched, anxious look, which has often been supposed to be characteristic of general peritonitis, intestinal obstruction, or other diseases accompanied by vomiting; but I do not recognize any single expression as charac- teristic of peritoneal lesions. ii) Chronic alcoholisin may be shown not only in a red nose, but oftener in a peculiar, smoothed-oui look, due, I suppose, to an extra but evenly distributed accumulation of subcutaneous fat. THE HEAD AND FACE 13 (k) An (Edematous or swollen face is much more easily noticed by the patient or his friends than by one who is not familiar with his normal look. It usually points to nephritis, but may occur in heart disease, and sometimes (especially in the morning) without any known cause. When combined with anaemia, the puffy face gives a peculiar "pasty" look (chronic glomerulo-nephritis) . . ^^ 'S f A Fig. 14. — Exophthalmic Goitre. (Meltzer.) Fig. 15. — Face in Leprosy. IV. Movements of the Head and Face. I. The Shaking Head. This occurs often in old age, occasionally in paralysis agitans (which oftener affects the hands), and in toxic conditions (alcohol, tobacco, opium). In some cases no cause can be found. 2. Spasms of the Face. Spasms of the face, i.e., sudden, quick contractions of certain facial muscles, such as winking-spasm, jerking of a corner of the mouth, or sniffing, occur chiefly: (a) As a matter of habit without other disease. This is chronic. (b) As a part of the acute infectious disease chorea, with similar "restless " motions of the hands and feet. We often see these spasms in school-children; occasionally in pregnant women. The disease is probably due to the same streptococcus which produces (simultane- 14 PHYSICAL DIAGNOSIS ously or at other times) the youthful types of polyarthritis (rheu- matic fever) and of endopericarditis. (c) By imitation, in schools and institutions, these spasms may spread like an epidemic. From habit spasms, which persist for months or years in one or two groups of muscles, true chorea is distinguished by its involvement of the hands, feet, and other parts, by its frequent association with tonsillitis, joint pain and endocarditis (see page 460) , and by its short course (eight to ten weeks on the average) . In hysterical conditions and hereditary brain defects, various other spasms occur (see below, page 472). V. The Eyes. I shall not attempt to deal with lesions essentially local (such as a "sty"), and shall confine myself to data that have diagnostic value in relation to the rest of the body. I. (Edema of the Lids. CEdema of lids, especially the lower, often accumulates in the night and is seen in the early morning, without known cause or after a debauch. In other cases it usually points to the existence of : (a) Nephritis (prove by urinary examination) . (6) Ancemia (prove by blood examination). (c) Measles and whooping-cough (eruption, paroxysms of cough). Rarer causes are trichiniasis, angioneurotic oedema, and erysipelas. Trichiniasis is recognized by the presence of fever, muscular ten- derness, and an excess of eosinophiles in the blood. In angioneurotic oedema there is usually a previous history of similar transitory swellings in other parts of the body. The acute onset, red blush, high fever, and general prostration distinguish the oedema of erysipelas. 2. Dark Circles under the Eyes may appear in any debilitated state, e.g., from loss of sleep, hunger, menstruation, masturbation, etc. 3. Conjunctivitis. This affection forms part of hay fever, measles, streptococcus in- fections, typhus, trichiniasis and yellow fever. ■ It also occurs as an independent infection. It follows overdoses of iodide of potash or arsenic. The whole conjunctiva is reddened, in contradistinction from the reddening about the iris seen in iritis. Phlyctenular conjunctivitis and keratitis occurs especially in ill- THE HEAD AND FACE 15 nourished children of poor and ignorant parents living in congested districts, i.e., under the conditions producing tuberculosis. Its cause is unknown. It produces a yellowish-red ulcerated streak growing in from the conjunctiva across the margins of the cornea. 4. Jaundice. Jaundice, the yellow coloration of the white of the eye by bile pigment, is easily recognized when well marked, and can be con- founded only with subconjunctival fat, which differs from jaundice in that it appears in spots and patches, not covering the whole sclera, as jaundice does. In mild cases only the posterior portions of the sclera are tinted yellow, while the anterior part around the iris may show a bluish-white tinge in contrast. This state of things is hard to distinguish from the appearances seen in the eyes of many apparently healthy people. The presence of bile in the urine often clears up the question. The skin, mucous membranes, urine, and sweat are also bile- stained in most cases, and the circulation of the bile in the blood often produces slow pulse, itching,^ and mental depression. Lack of bile in the gut leads to flatulence and clay-colored fatty stools. The commonest causes are: (a) Biliary obstruction (catarrh, stone or tumors obstructing the bile ducts, hepatic cirrhosis, or syphilis constricting them) . (&) Hemolysis (malaria, sepsis, icterus of the new-born, pernicious anaemia) . 5. Argyria. Since the prevalent use of silver salts in the treatment of ocular disease, a brownish staining of the conjunctiva and sclera not in- frequently results, even after moderate doses. Individual hyper- sensitiveness doubtless plays a part. 6. The Pupils. The normal reflexes to light are best tested with an electric flash light which produces a brisk and obvious contraction of the healthy pupil. To test the reaction to distance turn the patient away from the light and let him look at the farthest corner of the room. The pupil expands. Make him look at your finger a few inches distant from his eyes. The pupil contracts. Each pupil should be examined separately. The value of the pupils in diagnosis has been greatly overestimated. There are few conditions except tabes and paresis in which they yield us important diagnostic evidence, for, although they are very often ' In gall-stone cases one often finds itching without jaundice. 16 PHYSICAL DIAGNOSIS abnormal, the abnormalities are seldom characteristic of any single pathological condition and throw little light on the diagnosis. (a) The Argyll-Robertson pupil reacts to distance, but not to light. It is of great value as a factor in the diagnosis of tabes dorsalis and dementia paralytica. (6) Dilated pupils. — (a) Many phthisical patients show a more or less transient dilatation of one or both pupils. (6) Blindness or deficient sight (from any cause) may cause dilatation of the pupil. (c) Other common causes are distress or strong emotion from any cause, many fevers and comatose states, and the use of mydriatic drugs. (c) Contracted pupils are common in old age and in photophobia from any cause. Disease high up in the spinal cord (tabes, general paralysis, etc.) may produce contraction (spinal myosis) by paralyzing the sympathetic dilators. Aortic aneurism may produce in the same way contraction of one pupil (see below, page 266). (d) Contraction with irregular outline and sluggish reactions is often seen in iritis as a result of adhesions to the lens (posterior synechise), also in syphilis. 7. The Cornea. (a) Arcus senilis, a grayish ring at the circumference of the cornea is one of the classical signs of old age and arteriosclerosis, but is occa- sionally seen in normal young adults. (b) Syphilitic keratitis, usually seen in the hereditary form of the disease, produces an irregularly distributed haziness of the cornea, usually in both eyes and before the sixteenth year. Diagnosis depends on other evidences of syphilis. (a) Ocular Motions. (a) Ptosis, or dropping of the eyelid, is usually unilateral and dependent on paralysis of the third nerve. Its" most frequent cause is syphilis. The eye is usually drawn out by the action of the unparalyzed external rectus. Moderate, bilateral ptosis is common in hysterical and neurasthenic conditions. (6) Squint (strabismus) is called external if the eye turns out, internal if it turns in. Of its many types and causes I mention only the acute cases due to intracranial lesions, such as tuberculous and epidemic meningitis, syphilis, tumors. (c) Nystagmus is a rapid, usually horizontal oscillation of both eyeballs. It may be the result of albinism or of various local eye troubles, but is an important member of the symptom group char- acteristic of multiple sclerosis. It may, however, occur in other brain lesions and in health. Rarely the oscillation is vertical. THE HEAD AND FACE 17 (6) The Retina. The lesions of greatest interest in general medicine are: Retinal hemorrhage, arterio-sclerosis, optic neuritis, and optic atrophy. (a) Retinal hemorrhages, with or without other retinal changes, are important signs of nephritis, grave ancemias, and diabetes. (b) Arterio-sclerosis may appear earlier or more clearly in the retina than elsewhere. (c) Optic neuritis (usually bilateral) is of great value in the diagnosis of brain tumors, tuberculous tneningitis, and brain abscess. It also forms part of the lesions in many cases of nephritis and diabetes. {d) Optic atrophy may be the end result of any of the types of optic neuritis just mentioned, or in a primary form is important evi- dence of tabes dorsalis. Many cases occur without any known cause Fig. i6. — Syphilitic Depression of tlie Nasal Bones. VI. The Nose. I. Size and Shape. — ^The enlargement of all the tissues of the nose occurring in acromegaly has already been mentioned. In myxaedema the nostrils are sometimes thickened and the whole nose loses its delicacy of shape. A red nose is popularly and correctly associated with alcoholism, but in many cases identical appearances are produced 2 IS PHYSICAL DIAGNOSIS by acne rosacea or by lupus erythematosus, as well as by circulatory anomalies without any other disease. Falling in of the bridge of the nose may be due to syphihs of the nasal bones, especially when there are scars over the sunken portion, but is sometimes present without any disease. See Fig. i6. Perforation of the septum (syphilitic) is often unknown to the patient and may be important in diagnosis. Occasionallj' it is due to mild non-syphilitic inflammations of the septum. The habit of put- ting a hand electric flash light against the side of the nose in the routine of physical examination is valuable. The small, narrow nose associated with adenoid growths has already been mentioned. 2. The nostrils move visibly in many conditions involving dyspnoea (diseases of the heart and lungs, acute infections, etc.), and this is Fig. 17 -Epithelioma. sometimes useful in suggesting to the physician the possibility of pneumonia, hitherto unsuspected. Dried blood in the nostrils may be of value as evidence of recent nosebleed. 3. Nosebleed suggests especially trauma, vascular hypertension, infectious fevers (particularly typhoid and juvenile endocarditis) ; also hemorrhagic diseases (purpura, haemophilia, acute leuksemia). 4. A nasal discharge in a young infant ("snuffles") suggests hered- THE HEAD AND FACE 19 itary syphilis. In adults the familiar " cold in the head " may need a bacteriological examination to exclude the possibility of nasal diph- theria or to confirm a diagnosis of influenza. 5. A small, indolent, long-standing sore on the nose or near the corner of the eye should always suggest epithelioma (see Fig. 17) and tuberculosis. Microscopic examination may be necessary to determine the diagnosis. 6. The consideration of local disease within the nose does not fall within the scope of this book, but is suggested by local pain, dijfficulty in breathing through the nose, frequent "colds," and asthma. (For the examination of the ears, see below, p. 470.) VII. The Lips. 1. Pallor of the mucous membrane of the lips suggests, though it never proves, anaemia. No diagnosis of anaemia should be made without at least testing the haemoglobin (Tallqvist's scale) . One minute suffices. 2. Cyanosis, a purplish or slatey-blue color of the lips, occurs in some healthy persons from simple "weathering." When well marked, however, it should always suggest: — (a) Heart disease (especially mitral or congenital lesions) . — (6) Lung diseases (especially emphysema and pneumonia), (c) Polycythaemia. — {d) Poisoning by acetanilid or other coal-tar antipyretics, producing methaemoglobinsemia.^ The last is easily tested by noting the brownish (not red) tint of the blood when soaked into filter paper, as in performing Tallqvist's haemoglobin test; the test should be confirmed by the history. Disease of the heart or lung is identified by physical examination of the chest. 3. Parted lips, an open mouth, may be a mere habit or may be due to nasal obstruction (adenoids). Idiots and cretins are very apt to keep their mouths open, whether there is enlargement of the tongue or not. Dyspnoea may compel a patient to keep his mouth open so as to get more air. In cold weather a crack or fissure may appear, usually in the centre of the lower lip, and in poorly nourished individuals may persist for weeks. At the corners of the mouth fissures or cracks may be due to chapping or "cold-sores" (herpes), but if they persist for weeks in young children they are very suggestive of syphilis. White linear scars radiating from the corners of the mouth are presumptive evidence of healed syphilitic lesions, oftenest congenital. ' Cyanosis of intestinal origin occurs in connection with certain diseases involving excessive intestinal decomposition. (See Gibson, Quarterly Journal of Medicine, Oct. 1907, p. 29.) 20 PHYSICAL DIAGNOSIS 4. The mucous patches of syphilis — ^white, sharply bounded areas about the size of the little-finger nail — are often seen at the junction of the skin with the labial mucous membrane, especially at the corners of the mouth. 5. Herper ("cold sores ") is due to a lesion of the Gasserian ganglion with resulting "trophic" disturbances of the regions supplied by the trigeminal nerve. Appearing first as a cluster of vesicles ("water blisters") which break and leave a small sore near the mouth, herpes is to be distinguished by: (a) its distribution, near the terminations of some branch or branches of the trigeminal nerve ("herpes frontalis, nasalis, labialis ") ; (b) by its lasting but a few days; and (c) by the absence of similar lesions elsewhere. It may be connected with a "cold" (which is often a disease of the trigeminus), with pneumonia, malaria or meningitis, but it frequently occurs without any discover- able cause. Herpetic stomatitis ("canker sores") may accompany it. Fig. 18. — Epithelioma of the Lip. Fig. iq. — Chancre of the Lip. 6. Epithelioma^ of the lip and chancre should be suspected whenever a long-standing sore is discovered there. Epithelioma occurs almost always on the lower lip in a man past middle life (see Fig. 18). It lasts longer than chancre, is slower in producing glandular enlargement at the angle of the jaw, and is not associated with other syphilitic lesions. 7. Chancre of the lip is commoner in women and may occur at any age, especially under forty. The sore usually lasts but a few weeks, excites early enlargement of the glands, and is usually associated with other manifestations of syphilis (see Fig. 19). 8. Angioneurotic oedema appears as a sudden, painless, apparently causeless swelling of the whole lip (see Fig. 20), which may attain ' It does harm to call this lesion "cancer" because this term is so firmly associated in the lay mind with metastasis, recurrence, and death that unnecessary suffering may result when the patient or his family learns that he has "cancer." THE HEAD AND FACE 21 double its normal size. The diagnosis depends on the exclusion of all known causes (trauma, infection, insect bites) and on the history of similar swellings (on the lip or else- where) in the past. 9. The enlargement of the lips in myxoedema and cretinism has been mentioned above (page 19). ID. Hare-lip is a vertical slit (congenital deficiency) in the upper lip opposite to the nostril; it is often connected with an antero-posterior cleft through the hard palate ("cleft palate"). The lesion may be double, leaving a small island of tissue continuous with the nasal septum (intermaxillary bone) . Diagnosis is made at a glance. VIII. The Teeth. Fig. 20. — Angioneurotic CCdema o£ Lower Lip. The first set of teeth is fairly constant in its order and date of appearance. In Fig. 21 the number of the month when each tooth is most apt to appear is marked on the tooth. The second set (per- FiG. 21. — Diagram Showing tiie Month at which Each Tooth (of the First Set) Should Appear. Fig. 22. — Notched Incisors in Con- genital Syphilis. manent teeth) arrives (less regularly) between the sixth and the fifteenth year, except the "wisdom teeth," which appear about the twenty-first year. 22 PHYSICAL DIAGNOSIS 1 . Rickets or cretinism often delays dentition considerably. 2. Congenital syphilis may be associated with various deformities of the central incisors (permanent). The most constant is that shown in Fig. 22. 3. Teeth-grinding. — Nervous, delicate, oversensitive children often grind their teeth in their sleep. There is no foundation for the popular superstition that this act indicates "worms." IX. The Breath. Foul breath is oftenest due to local causes such as: (o) Foul teeth and gums (neglect, Riggs' Disease) . (&) Stomatitis of any variety. (c) FoUicular Tonsillitis with cheesy deposits in the crypts. (d) Nasal Disease. Rarer causes are abscess or gangrene of the lung, in which the breath may be intensely foul ; the source of the odor is made evident by the sputa. Acetone breath has a faintly sweetish odor, which has been com- pared to that of chloroform, new-mown hay, and rotting apples. It occurs not only in diabetes, but in various conditions involving starvation (vomiting, fevers), and especially, but not only, a lack of carbohydrates.' In urcemia a foul odor is often noticed, and an ammoniacal ("urin- ous") smell has been mentioned by many writers. In typhoid and in syphilis some persons seem to detect a characteristic odor, but the evidence is insufficient. Alcoholic breath is often of value in correcting the false statements of its possessor. In comatose persons we must remember that a drink may have been taken just before an attack of apoplexy or any other cause for coma, so that an alcoholic breath in comatose patients does not prove that the coma is due to alcohol. In poisoning by illuminating gas the gaseous odor of the breath may be noticed. X. The Tongue. The act of protruding the tongue may give us valuable information on the condition of the nervous system. (o) The hesitating, tremulous tongue of typhoidal states is very characteristic. Simple tremor is seen in alcoholism, dementia par- ' See Taylor: "Studies on an Ash-free Diet." University of California Publication, July 30th, 1904. THE HEAD AND FACE alytica, and weakness. A tongue protruded very far means usually a neurasthenic individual who is in the habit of examining it in a looking glass. (6) If the tongue is protruded to one side, it usually means facial paralysis as part of a hemiplegia; rarely it is due to lesions of the hypoglossal nerve or its nucleus (in bulbar paralysis or tabes) . (c) A coated tongue (due mostly to lack of saliva) is not often of much value in diagnosis, and there is no need to distinguish the varieties and colors of coats; but a few suggestions may be obtained from it. Many persons who seem otherwise perfectly healthy have coated tongues in the early morning. This is especially true in mouth-breathers, in smokers, and in those who keep late hours. In those whose tongues are usually clean the appearance of a coat is associated often with arrested digestion, constipation, or fevers. A clean tongue in a dyspeptic suggests hyperacidity or peptic ulcer. This point I have found of more value than any inference from a coated tongue. A dry, hrown-coated, perhaps cracked tongue goes with serious exhausted states and wasting diseases with or without fever. (d) Cyanosis and jaundice may be seen in the tongue, but better elsewhere. (e) Indentation of the edges of the tongue by the teeth occurs especially in foul, neglected mouths, but has no diagnostic value. (/) Herpes ("canker") often occurs on the tongue; it begins as a group of vesi- cles, but these rupture so soon that we usually see first a very small, grayish ulcer with a red areola. It heals in a day or two, i.e., more quickly than the syphiUtic mucous patch or any other lesion with which it is likely to be confounded. (g) Cancer, tuberculosis, and syphiUs may attack the tongue and form deep, long-standing ulcerations. Syphilis can usually be diag- nosed by the history, the presence of other syphihtic lesions, the Wassermann reaction, and the therapeutic test (see Fig. 23). Cancer and tuberculosis should be diagnosed by microscopic examination, though cancer is more commonly found in men (especially smokers) Fig. 23. — Syphilis of the Tongue. 24 PHYSICAL DIAGNOSIS past middle life and on the side of the tongue. A local reaction after the injection of tuberculin may be of decisive importance. (h) "Simple ulcers" are due to irritation from a tooth or to trauma, and heal readily if their cause is removed. (i) Fissures of the tongue are usually due to syphilis, which is recognized in other lesions or by the Wassermann test. (y) Leukoplakia buccalis (lingual corns) refers to whitish, smooth, hard patches of thickened epithelium, usually on the dorsum of the tongue in smokers, running a chronic course without pain or ulceration, but important because epithelioma has been known (and not very rarely) to develop in them. (fe) Geographic tongue is a desquamation of the lingual epithelium in sinuous or circinate areas, which spread and fuse at their edges, while the central portions heal, giving a look something like the moun- tain ranges in a geographical map. It usually gives no trouble unless the patient's attention becomes concentrated on it. (/) Hypertrophy of the tongue has already been mentioned in connection with myxcedema and cretinism. It may occur independ- ently as a congenital affection. XI. The Gums. (a) A lead line should be looked for in every patient as a matter of routine, as it may not be suggested by anything in the patient's symptoms or history, yet may be the key to the whole case. The deposit of lead sulphide in (not on) the gums is not blue, but gray or black; and is not a line, but a series of dots and lines arranged near the free margin of the gums and about one millimetre from it. Where there are no teeth there is no lead line. In faint or doubtful cases a hand lens is of great assistance and shows up the dotted arrange- ment of the deposit very clearly (see Fig. 24). It is unfortunate that the term "blue line" has become attached to these gray-black dots. (6) A bismuth line — in poisoning from the injection of bismuth paste— may present all the appearances of a lead line, though in some cases the staining is more diffuse and occurs at some distance from a tooth as well as at the free margin of the gum. The analyses of the feces and the history of the case serve to distinguish it from a lead line. (c) Sordes, a collection of epithelium, bacteria, and food particles, accumulates about the roots of the teeth with great rapidity in febrile cases, but has no considerable diagnostic importance. -THE HEAD AND FACE 25 (d) Spongy and bleeding gums occur as part of the disease " scurvy," after overdoses of mercury or potassic iodide, in various debilitated states, and sometimes without known cause. The teeth are loosened and the flow of saliva is usually profuse. The stench from such cases is often intolerable. (e) Suppuration about the roots of the teeth (pyorrhoea alveolaris) is common in neglected mouths, and seems in some cases to injure digestion, but in most cases its effects appear to be wholly local. Fig. 24. — Lead-dots in the Gums. (/) Gumboil {alveolar abscess), is easily recognized by the familiar signs of abscess associated with a diseased tooth. Dental abscesses are an important cause of obscure fevers and joint pains. (g) "Epulis" is a word applied to various soft tumors springing from the jaw bone or occasionally from the gums themselves. Many of them are sarcomatous, but microscopic examination is necessary to distinguish these from fibroma, granuloma, and angioma. XII. The Buccal Cavity. I . Eruptions. (a) Koplik's spots in measles are of much importance. They appear chiefly in the inside of the cheeks, opposite the hne of closure of the molars, and consist of minute, bluish- white spots, each surrounded by a red areola and sometimes fusing into larger red areas. (fo) The syphilitic mucous patch (see above) should be looked for in suspicious cases, not only in easily accessible parts of the mouth, 26 PHYSICAL DIAGNOSIS but round the roots of the gums, where the cheeks or lips have to be pushed away to afford a good view. 2. Pigmentations. In Addison's disease brown spots or patches often occur on any part of the mucous membrane of the mouth. They may also occur in negroes without any disease and after ulcerations {e.g., from a tooth), so that they are not distinctive of Addison's disease. 3. Gangrene. Gangrene (stomatitis gangrenosa, "noma"), a rare disease of weakly children, starts as a hard red spot inside the cheek and usually not far from the corner of the mouth (see Fig. 25). There is a swell- FiG. 25. — Gangrenous Stomatitis ("noma"). ing of the whole cheek, especially under the eye. The odor of gan- grene is usually the first thing to make clear the diagnosis. Then the gangrene appears externally as a black patch on the cheek, surrounded by a red halo. THE HEAD AND FACE 27 XIII. The Tonsils and Pharynx. Method of Examination. — ^Place the patient facing a good light, natural or artificial. An electric flash light is especially convenient. Ask him to open his mouth without protruding the tongue. Ask him to say "Ah." Then gently press down and forward on the dorsum of the tongue (not too far back) with a spoon or tongue depressor,' until a good view of the throat is obtained. Look especially for : 1. Inflammations (redness, eruptions, spots, or membranes). 2. Ulcerations. 3. Swellings. 4. Reflexes. I. Inflammations. (a) General redness means a mild or early pharyngitis, but may precede severe diseases like diphtheria and scarlet fever. (6) Yellowish-white spots on the tonsils, more or less confluent, mean fol'.icular tonsillitis in the vast majority of cases, but only by culture can we exclude diphtheria with certainty. Fever and head- ache are usually present. (c) A membrane, continuous and grayish-white over one or both tonsils, especially if it extends to soft palate and uvula, means diph- theria in almost every case.^ Rarely a similar membrane is seen in streptococcus throats with or without scarlet fever. Cultures alone can decide. (d) The eruptions of smallpox and chickenpox may be distributed in the pharynx as well as over the rest of the respiratory tract. They are recognized by association with more characteristic skin lesions and constitutional signs. 2. Ulcerations. (a) Deep chronic, painless ulcerations of the tonsils or soft palate are oftenest due to syphilis. Improvement under treatment and the manifestations of syphilis elsewhere make the diagnosis possible. ' If the patient is especially nervous, it is sometimes well to let him press down his tongue with his own forefinger. ' Thrush, a rather rare disease of ill-nourished infants, due to a fungus of the yeast order, may produce on the pharynx, tongue, or in any part of the mouth, patches of white membrane. As the disease is almost wholly local and without constitutional manifestations, it is passed over briefly here. ' Streaks of mucus or bits of milk coagulum are sometimes mistaken for a membrane. 28 PHYSICAL DIAGNOSIS (6) Tuberculosis may produce similar deep ulcerations, easily- recognized by their association with tuberculosis of the lung or larynx. Occasionally smaller "miliary" tubercles, not unlike "canker sores," are seen in the tonsillar region. Tuberculous lesions are usually very tender, syphilitic lesions almost free from tenderness. The chronic course of pharyngeal tuberculosis and the presence of other tuber- culous lesions identify it. (c) Malignant disease (oftenest sarcoma) may attack the tonsil, and forms a painful, tender and finally ulcerating tumor. No other lesion of the tonsil grows so fast and invades surrounding parts so extensively except abscess; in abscess the pain, fever, and constitu- tional manifestations are far greater. 3. Swellings. (a) Chronic swollen tonsil (unilateral or bilateral) without fever or constitutional symptoms represents usually the residual hypertrophy following many acute attacks of tonsillitis or maybe part of the general adenoid hypertrophy so common in children's throats. Rarely it forms part of the leuksemic or pseudo-leukaemic process. (6) Acute swollen tonsil is usually part of foUicular tonsillitis (see above), but may occur without spots, and often accompanies scarlet fever. Swelling, pain in swallowing, and fever are the essentials of diagnosis. Our chief care should be to exclude: (c) Tonsillar abscess (quinsy sore throat). Here the swelling is usualy unilateral and greater than in follicular tonsillitis. The pain, which is often severe, is continuous and not merely on swallowing. Fever, constitutional symptoms, and swelling of the glands at the angle of the jaw are all more marked than in follicular tonsillitis. The voice is nasal or suppressed, and there is often salivation. The pillars of the fauces and the soft palate take part in the swelling and the throat may be almost blocked by it. The suffering increases until the abscess breaks or is opened. Fluctuation is often late and indefinite, but should always be sought for. (d) Retropharyngeal Abscess. — A swelling in the back of the pharynx near the vertebrae occurs not infrequently during the first year of life. A peculiar cry or cough, like the bark of a puppy or the call of a heron, is very often associated (the French " cri de canard"). The parents are often unaware that the throat is the seat of the trouble, and only digital, examination proves the presence of bulging and fluctuation, usually on one side of the posterior pharyngeal wall. THE NECK . 29 A similar abscess of chronic course may complicate cervical caries (see below, page 32). (e) Swollen uvula, with transparent oedema of its tip, often com- plicates a pharyngitis or any lesion with violent cough. Elongation of the uvula may bring it into contact with the tongue and by tickling excite cough. (f) Perforation of the soft palate or its adhesion to the back of the pharynx means syphilis almost invariably, and, as it may be the only sign of an old infection, it is a valuable piece of evidence. 4. Reflexes. (a) Lively or exaggerated pharyngeal reflexes, such that the patient gags and coughs as soon as one touches the dorsum of the tongue, are seen in many nervous persons and in many alcoholics without nervousness. It is this condition, combined with a smoker's pharyn- gitis, that leads to many cases of morning vomiting in alcoholics. (6) Diminished or absent reflexes (with paralysis of the palate) occur in postdiphtheritic neuritis and bulbar paralysis. Fluids are regurgi- tated through the nose and the voice has a peculiar intonation. To test for paralysis, ask the patient to say "Ah." In unilateral paralysis one side of the palate remains motionless; in bilateral paralysis the whole palate is still. (c) Diminished or absent gag-reflex is often seen (without palatal paralysis) in neurasthenic states, associated with corneal anesth|^sia and lively knee jerks. XIV. The Neck. Long, thin necks are often seen in phthisical individuals, and short necks in the emphysematous, but nothing more than a bare hint can be derived from such facts. The lesions oftenest searched for in the neck are: i. Enlarged glands (cervical adenitis). 2. Abscesses and scars. 3. Thyroid tumors. 4. Pulsations (see below, page 86). 5. Torticollis and other lesions simulating it. (6) Tuberculosis of the cervical vertebrae. Rarer lesions will be mentioned below. I . Chains of Enlarged Glands. radiate in all directions from the angle of the jaw — ^upward, in front of the ear and behind it, forward along the ramus of the jaw, and downward to the clavicle. The areas drained by the different groups overlap so much that it is not necessary to distinguish them. 30 PHYSICAL DIAGNOSIS The commonest causes of enlargement are: (a) Tonsillitis and other injiammations within or around the mouth (diphtheria, the exanthemata, "cankers," carious teeth, etc.) . Glandu- lar swellings due to these causes are usually acute and more or less tender; most of them disappear in a fortnight or less, but some persist (without pain) indefinitely. (6) Tuberculosis; long-standing cervical adenitis in children and young adults, with a tendency to involve the skin and to suppurate, Fig. 26. — Tuberculous Glands. is usually tuberculous. Certain diagnosis needs microscopic exami- nation, animal inoculation, the tuberculin test and the Wassermann. (c) Syphilis; small, non-suppurating glands, occurring in the neck and about the occiput in adults, often accompany syphilis, but the diagnosis depends on the presence of unmistakable syphilitic lesions elsewhere. Occasionally syphilitic glands are large and soft. (d) Hodgkin's disease; chronic, large, rarely suppurating glands in the neck, axillae, and groins, with slight splenic enlargement and nor- mal blood, suggest Hodgkin's disease, but microscopic examination is THE NECK 31 necessary to exclude tuberculosis. A superficial gland can be excised under cocaine, with very little pain. (e) Lymphoid Leukannia. No distinguishing characteristics can be found in the glands, but any nodular enlargement in the neck should lead us to examine a film specimen of blood, and the leuksemic blood changes to easily and quickly recognized. (/) Malignant disease (near by or at a distance) may enlarge the cervical glands. Cancer of the lip or tongue, sarcoma of the tonsil. m^^^m B^H WW?^^^L ^^^m ^H H ■ FT^ i 1 1 1 Hh m a I 1 B m H ^ 1 1 T h ^■■-■^ ■• '..^ 4 ■ i !.:■...■ ■..■m^ ^%t: .._.id Fig. 27. — Hodgkin's Disease, Si.x Months Duration. and, among distant lesions, cancer of the stomach and sarcoma of the lung have caused enlargement of these glands in cases under my observation. (g) If the parotid gland alone is swollen and there are fever and pain on chewing, the case is probably one of mumps, especially if there are other cases in the vicinity. Malignant disease may also attack the parotid. (h) German measles may be accompanied by swelling of the pos- terior cervical or occipital glands without the involvement of any other. 32 PHYSICAL DIAGNOSIS 2. Abscess or Scars. Abscess or scars in the sides and front of the neclc generally result from glandular tuberculosis; hence the presence of scars may be of value in the diagnosis of doubtful cases with a suspicion of tubercu- losis in later life. Aside from glandular abscesses (tuberculous or septic) it is rare to find any suppuration in the neck, except in the nape, where deep, septic abscess (car- buncle) and superficial boils are common. High Pott's disease may be complicated by abscess (see Figs. 28 and 29). Figs. 2S and 2g.— Cervical Abscess in Pott's Disease. (Bradford and Lovett.) 3. Thyroid Tumors occur chiefly in two diseases; (a) Simple goitre (unilateral or bilateral). (b) Goitre with exophthalmos, lachycardia, and tremor, sweating and loss of weight (Thj-rotoxicosis or Graves' disease). The tumor may look the same in these two diseases (see Fig. 30) ; it varies in outline and consistency according to the amount of gland THE NECK 33 Fig. 30. — Simple Goitre. tissue and fibrous or cystic degeneration that is present. Owing to its connection with the larynx it moves up and down somewhat when the patient swallows, but is not at- tached to any other structures in the neck. The enlargement is often unilateral or largely so. If very vascular, the tumor may vary greatly in size from moment to moment or at certain times (■i.e., menstruation, pregnancy). Since the normal thyroid can rarely be felt, atrophy of the gland (as in myxoedema) is un- recognizable. Cancer or sarcoma also oc- cur in the thyroid and may be difficult to distinguish from goitre. Malignant tumors are usually painful, grow fast, are accompanied by emaciation and anaemia, are often harder and more nodulated than benign goitres, and invade the neighboring tissues and lymphatics. His- tological examination should decide in doubtful cases. 4. Torticollis (Wry-neck) and Other Lesions Resembling It. (a) Spasm (tonic, rarely clonic) of the sterno-mastoid and trapezius may be due to irritation of the spinal acces- sory nerve by swollen glands, abscess, scar, or tumor, but more often occurs without known cause ("rheumatic" and "nervous" cases). The muscle is rigid and tender. (b) Congenital torticollis (a counterpart of club-foot) is due to shortness of the muscle without spasm- It is almost always right-sided and associated with facial asymmetry. Fig. 31. — Dislocation of the Cervical Vertebra:. (Walton.) 34 PHYSICAL DIAGNOSIS (c) Dislocation of the upper cervical vertebrce causes a distortion of the neck much Uke that of torticollis (see Fig. 31). The diagnosis depends on the history of injury, the absence of true muscular spasm, and the a;-ray picture. (d) Compensatory cervical deviations: (i) When there is marked lateral curvature of the spine, with or without Pott's disease, the head may be inclined so far to the opposite side that torticollis is simulated (see below, page 72) . (2) When the power of the two eyes is mark- edly different, as in some varieties of astigmatism, the head may be habitually canted to one side to assist vision. (3) In some cases due to none of the above causes, habit or occupation (heavy loads on one shoulder) seem to produce the condition. (e) Forced attitude from cerebellar disease may resemble torticollis. The diagnosis depends on the other evidences of intracranial disease. 5. Cervical Pott's Disease (Vertebral Tuberculosis) has the characteristics alluded to below in the section on joint tuber- culosis, viz., stiffness due to muscular spasm, malposition of the bones and of the head, and abscess formation (see page 32) . Diagnosis depends oh wry-neck with stiffness of the muscles of the back and neck and pain in the occiput — a very characteristic symptom- group. The chin is often supported by the hand. "Rheumatic" or traumatic torticollis, however, may present all these symptoms, and diagnosis may be impossible without the aid of time and ther- apeutic tests. 6. Branchial Cysts and Fistulce. These, due to persistence of parts of the foetal branchial clefts, are not very uncommon (see Fig. 32). A branchial cyst is a globular or ovoid fluctuating sac, hanging or projecting from the side of the neck or the region of the hyoid bone, painless and slow of growth. It may transmit the motions of the carotids and be mistaken for aneurism, but has no expansile pulsation and occurs in youth, when aneurism is practically unknown. Some such cysts may be emptied by external pressure.' Branchial cysts may contain serous, mucous, or sero-sanguineous fluid, or hair and sebaceous material, according as their lining wall ' A patient of mine can produce a gush of foul fluid in the mouth by pressure over a small cyst in the neck. THE NECK 35 Fig. 32. — Branchial Cyst. is derived from ectoderm or entoderm. Diagnosis depends on the position and consistency of the growth and on the results of aspira- tion. Branchial fistiilce (congen- ital) may open externally in the neck, and occasionally are complete from neck to pharynx. They may become occluded and suppuration result. 7. Actinomycosis. Actinomycosis, though it usually arises in the lower jaw bone, may appear externally in the neck. A dense infiltration with bluish-colored, semifluctuat- ing areas in it, but without any distinct lumps or sharp outlines, is strongly suggestive of actinomycosis, and should always lead to a microscopic examination of exci,sed portions or of the dis- charge. Fistulae may form, but are less common than in tuberculosis. 8. A Cervical Rib, springing from the seventh cer- vical vertebra and ending free or attached to the first thoracic rib, appears in the neck as an angular fulness which pulsates, owing to the presence of the subclavian artery on top of it. It rarely produces any symp- toms and is generally encoun- tered when percussing the apex of the lung. The bone can be felt behind the artery by careful palpation and demonstrated by Fig. 33. — Mediastinal Neoplasm with Cervical Metastases and Obstructed Vena Cava. radiography. Pain or wasting in the arm, and occasionally throm- bosis or gangrene may occur and may be cured by removing the rib. 36 PHYSICAL DIAGNOSIS 9. Inflammatory or Dropsical Swelling of Neck. Venous thrombosis, medistianal tumors and inflammatory exudates (see Fig. 33a) may produce oedema in the neck. Fig. 33a. — Anthrax Infection of the Neck. CHAPTER III. THE ARMS AND HANDS; THE BACK. THE ARMS. Most of the lesions of these parts are joint lesions and are dealt with in the section on joints. Others fall under the province of the neurologist or the dermatologist, but must be briefly mentioned here. I. Paralysis of One Arm. Paralysis of most or all the muscles of one arm occurs of tenest in : (a) Hemiplegia — with paralysis of the leg and often of the face on the same side, (b) Pressure neuritis — traumatic or from new growths. (c) Obstetrical paralysis — neuritis from injury during parturition. (d) Lead or alcoholic neuritis — extensors of wrist especially, and often in both arms, (e) Anterior poliomyelitis — infantile paralysis. (/) Hysteria and traumatic neuroses.'- Pressure Neuritis. — The history of the case is of the greatest im- portance. During surgical anaesthesia the brachial plexus or the musculo-spiral nerve may be compressed, and paralysis is noted as soon as the patient comes out of anaesthesia. In a similar way in deep sleep, especially drunken sleep with the arm, hanging over a bench or doubled under the body, the nerves may be injured. Pres- sure from a crutch or from the head of the humerus in fractures or dislocations, or even a violent fall on the shoulder without injury of bones, may result in a paralyzed arm. Diagnosis rests on the history, and on the fact that not only the muscles of the shoulder group and the extensors of the wrist are affected, but also the supinator longus, while in the toxic paralyses, especially lead^ the supinator longus is spared. To test the function of this muscle, grasp the patient's wrist with the thumb side upper- most, and resist while he attempts to flex the arm at the elbow. If the supinator is intact it will spring into relief on the thumb side of the forearm. ' Less common are paralyses due to lesions of the arm centre in tlie cerebral cortex (tumor, softening, cyst, abscess, hemorrhage, thromboses, or embolism) . 37 38 PHYSICAL DIAGNOSIS Obstetrical Neuritis. — In instrumental deliveries or when forcible traction on the child's arm has been necessary, with or without fractures, a paralysis of the arm often results, and, what is important, is often not noticed till some years later, and then thought to have just arisen ; thus it maj' be mistaken for anterior poliomyelitis or other lesions. Toxic Neuritis. — Lead or alcohol produces usually a weakness of both forearms, especially the extensors of the wrist ("wrist-drop"), but one side may be predominantly affected and other muscles are Fig. 34.— Wrist Drop, following Lead Neuritis. involved in most severe cases. The history, the other signs of lead poisoning, and the soundness of the supinator longus distinguish it from other paralyses. (See Fig. 34.) All these forms of neuritis are apt to be accompanied by pain, anesthesia, or parsesthesia, which helps to distinguish them from the cerebral and spinal paralyses next described. Acute Anterior PoliomyeHtts.~-Fara\ysis attacks a child suddenly and without apparent cause, usually after "a feverish turn." Either the upper arm group (deltoid, biceps, brachialis anticus, and supinator longus) or the lower arm group (flexors and extensors of wrist and THE ARMS 39 fingers) may be affected. The arm is flabby and painless, the muscles waste rapidly, and the electrical reactions show degeneration, often within a week. Hysterical and Traumatic Neuroses. — The history and mode of onset, the frequent association of sensory symptoms which do not fit the distribution of any peripheral nerve, spinal segment, or cortical area, the normal reflexes and electrical reactions distinguish most cases of this type, but diagnosis is sometimes impossible. Paralysis of both arms is much less common than paralysis of one arm, and occurs chiefly in poisoning by lead and in multiple neuritis. Rarely it is seen in the late stages of chronic diseases of the spinal cord. II. Wasting of One Arm. (a) Rapid atrophy occurs in all the types of neuritis mentioned above, as well as in poliomyelitis and progressive muscular atrophy. In the latter it occurs without complete paralysis, though the wasted muscles are, of course, weak. Progressive muscular atrophy usually begins in the muscles at the base of the thumb and between it and the index finger. Less often the disease begjns in the deltoid. In either case the rest of the arm muscles are later involved. In all the atrophies just mentioned a lack of the trophic or nourish- ing functions which should flow down the nerve is assumed to ex- plain the wasting {^'trophic atrophy"). From this we distinguish the atrophy due simply to disuse of the muscles without nerve lesions. (6) Slow atrophy of disuse occurs in the arm in hemiplegia, infantile or adult, and in other cerebral lesions involving the arm centre or the fibres leading down from it. (c) Cervical rib occasionally leads to wasting as well as pain in the corresponding arm. (d) The atrophy often seen in hysterical cases is probably due to disuse and is similar to that occurring in an arm that has been splinted after fracture or dislocation. III. Contractures of the Arm. After cerebral lesions involving the arm centre, and in almost any spinal or peripheral nerve lesion which involves one set of muscles and spares another, the sound muscles contract (or, overact) and permanent deformities result. In hysteria similar contractures occur. Contrac- tures have in themselves little or no diagnostic value, but indicate a late and stubborn stage of whatever lesion is present. 40 PHYSICAL DIAGNOSIS IV. CEdema of the Arm.^ Causes. — i. Thrombosis of axillary or brachial vein, usually from heart disease or from: 2. Pressure of tumors — aneurism, cancer of axillary glands, Hodgkin's disease, sarcoma of lung or mediastinum. 3. Nephritis, when the patient has lain long on one side. 4. Inflam- mation, usually with evidence of lymphangitis spreading up the arm from a septic wound on the hand. 5. Deep axillary abscess — an insidious painful septic focus, not depending on tuberculosis or on any form of adenitis, may burrow so deeply in the axilla that oedema of the arm (as well as pain) is produced. Leucocytosis and slight fever accompany it. The diagnosis is easily made from the above data provided we are aware of the existence of this uncommon but distinct clinical entity. The diagnosis of the cause of oedema is usually easy in the light of the facts brought out by the general physical examination (heart, urine, local lesions, etc.). The arteries of the arm (brachial and radial) are to be investigated for changes in the vessels (see page 88) and for the evidence given by their pulsations as to the wor-k of the heart (see page 100) . V. Tumors of the Upper Arm. In the upper arm we have: i. Fatty tumors. 2. Sarcoma of the humerus. 3. Ruptured biceps. 4. Syphilitic nodes on the humerus. 5. Tuberculosis of the humerus. 6. Gouty deposits in the triceps tendon. Fatty tumors are recognized by the history of long duration and very slow growth, by their superficial position, usually external to the muscles, and soft, lobulated feel. Sarcoma forms the only large tumor springing from the humerus. It is usually hard and obviously deep seated (see Fig. 35). Ruptured biceps. The lower half of the biceps projects sharply when the muscle is contracted, looking as if the biceps had slid down from its normal site. This appearance suddenly following a wrench or strain of the biceps is diagnostic. Syphilitic nodes are flattened elevations on the bone, usually about the size of a half-dollar, and feel like the callus after a fracture, but project only from one side of the bone. There is pain, especially at night, and moderate tenderness. A history or other and more ' Distinguished, like all cedema, by the fact that a dent made by pressing with the finger does not at once disappear when the pressure is removed. THE ARMS 41 characteristic lesion of syphilis or a Wassermann reaction may be necessary for diagnosis. Ttiberculous lesions'- are much more common on the forearm bones, but are occasionally seen on the humerus near the epiphyseal ends. They usually involve and perforate the skin, leaving an indolent, sup- purating sinus leading to necrosed bone. The evidence of tuberculosis Fig. 35. — Sarcoma of Humerus. in other organs and the slow, "cold" progress of the lesion assist the diagnosis. In doubtful cases the local reaction after the subcutaneous injection of tuberculin may be of distinct value. Pain, tenderness, oedema, redness and heat may appear or may be increased if already present. Gouty tophi are sometimes seen along the fascia covering the triceps tendon. They are hard and painless. The diagnosis depends upon ' Coccidioidal Granuloma^ a rare disease clinically identical with tuberculosis, but due to a wholly different organism, an animal parasite resembling a coccidium, has been described by Rixford, Gilchrist, Montgomery, and others. 42 PHYSICAL DIAGNOSIS the peculiar situation of the lesions and their association with other evidences of gout.' VI. Miscellaneous Lesions of the Forearm. Bowing of the forearm hones occurs in rickets and in Paget's disease (see Fig. 229). The lesions in the other parts of the body make the diagnosis clear. Local lesions of the bones of the forearm are chiefly tuberculous and syphilitic, both of which have been sufficiently described in the last section. Fig. 36. — Rachitic Epiphysitis. Fig. 37. — Sarcoma of Ulna. In the wrist bones we find ; 1. Rachitic enlargement of the epiphyses. In rickets the terminal epiphyses at the wrists take part in the general epiphyseal enlargement so common in the disease. The diagnosis is easy, for there is no other disease of infancy producing general enlargement of the epiphyses (see Fig. 36). 2. Hypertrophic pulmonary osteoarthropathy (Figs. 38, 39, and 40). An enlargement of the lower ends of the radius and ulna, with clubbing ' Bursitis over the olecranon ("niiner's elbow") produces a tender fluctuating swelling over the tip of the elbow. THE HANDS 43 of the fingers (see below, page 53) , is recognized by the ^-ray picture and by its association with pulmonary or pleural diseases of many years' duration (bronchiectasis, phthisis, empyema) . 3. Acromegalia (see page 8) affects chiefly the bones and soft tissues of the hand. The it-ray picture is characteristic. 4. Hypertrophic, atrophic, or tuberculous disease of the wrist-joint will be described below (see Examinations of the joints, page 456). 5. "Weeping sinew" or "ganglion" (tenosynovitis) forms a fluc- tuating, spindle-shaped swelling along one of the tendons of the wrist, slow and almost painless in its course. It may be tubercu- lous, in which case the sac is generally divided into several parts ("compound ganglion") ,~bacilli may occasionally be demonstrated in the exudate. 6. Neoplasms (see Fig. 37). Fig. 38. — Hypertrophic Pulmonary Osteo-arthropathy. (Thayer.) THE HANDS. L Evidence of Occupation. The horny, stiffened hands of the " son of toil," the stains of paint in house painters, the flattened, calloused finger-tips of the violinist, 44 PHYSICAL DIAGNOSIS the worn fingers of the sewing woman, afford us items of informa- tion which are sometimes useful and worth a rapid glance in routine examination. II. Temperature and Moisture. (a) The cold, moist hand is most commonly felt in "nervous" people under forty. It is almost never seen in heart disease, which its possessor often fears, and does not mean "poor circulation," but vasomotor disturbances of neurotic origin. (b) Cold, dry extremities — hands, feet, nose, ears — may mean simply fatigTie, exposure to low tempera- ture, or insufficient exercise; but in the course of chronic disease they usually mean weakness of the heart, and hence are serious. (c) Warm, moist hands are felt in Graves' disease (thyrotoxicosis) , and if the warmth and moisture are present most of the time and not only as a temporary phase — e.g. , after violent exercise — this disease is strongly suggested, and a search for tremor, rapid heart, goitre, and bulging eyes should be made. III. Movements of the Hands. (a) The manner of shaking hands gives us vague but useful impres- sions of the patient's temperament. The nervous, cramped, half-opened hand, which never really grasps and gets away as soon as possible; the firm, hearty grasp; the limp, "wilted" hand — furnish hints of character that every physician must take account of. In fevers or toxemic states (typhoid, alcoholism) there are two sets of movements which recur so often that names have been given them, viz.: i. Carphologia — picking and fumbling at the bed clothes. 2. Subsn/liis tcndinitm — involuntary twitching and jerking of the ten- FiG. 3<). — Radiographs of the Hand and Arm of a Case of Hypertroj)hic Pul- monary Osteoarthropathy (the left figure) compared with the hand and arm of a normal individual of the same height (the right figure). Note especially the thick- ening of the radius and ulna. (Thayer.) THE HANDS 45 dons in the wrist and on the back of the hand, usually associated with tremor and carphologia. (b) Tremor of the Hands. — To test for ordinary tremor, we ask the patient to extend and separate his fingers widely. The motions are then apparent. Causes; i. Nervousness, cold, or old age. 2. Fever and tox- aemia. 3. Alcohol (less often lead, tobacco, morphine, or other drugs). 4. Graves' disease. 5. Paralysis agitans. 6. Multiple sclerosis. 7. Hysteria. Fig. 40. — Radiograph of the Wrists in Hypertrophic Pulmonary Osteo-arthropathy. (v. Ziemssen's Atlas.) Most of these tremors need no comment. The mlenlion tremor of multiple sclerosis (sometimes seen also in hysteria) is exaggerated into coarse shaking movements when the patient tries to pick up a pin, drink a glass of water, or do any other act calling for the volitional coordination of the small hand muscles. In the presence of such a tremor we should look for nystagmus (see above, page 16), a spastic gait (see page 473), and a slow, staccato speech. This group of symp- toms suggests multiple (or insular) sclerosis. 46 PHYSICAL DIAGNOSIS In direct contrast with this is the piU-rolling tremor of paralysis agitans, which usually ceases during voluntary movements. The thumb and forefinger are near or touch one another, and move as if they were rolling a bread-pill. This tremor is usually associated with an immov- able expressionless face, a stiffened neck and back, and a peculiar attitude and gait (see below, page 474). Fig. 41. — Athetosis. Successive positions of the hands. (Curschmann.) The other varieties of tremor can usually be recognized by the history and associated symptoms. (c) Spasms or coarse twiichings of the hand due to : I . Jacksonian epilepsy — convulsive attacks which begin in and may remain confined to one set of muscles, often preceded by prick- ling or other paresthesia of the part aftected, but without loss of con- THE HANDS 47 scio%isness. These muscle spasms are due usually to an irritation of the corresponding motor area in the cortex cerebri (tumor, softening, chronic meningitis, etc.), but may also occur in urjemia and dementia paralytica. Coma and general spasms may follow. 2. Professional Spasm.— Writers, violin-players, and others who use one set of muscles continually are often attacked with paivfnl cramps in the muscles used ("writer's cramp"). Weakness and pain are usually far more promi- nent bhan spasm. 3. Chorea and Choreiform Move- ments. — True, acute, infectious chorea (Sydenham's) occurs chiefly in children between five and fifteen, generally in those who have joint troubles or heart disease, and ends in eight or ten weeks. The hands Fig. 42. — Tetany. (Masland.) Fig. 43. — Tetany. are usually affected first, and their movements are like those of restlessness and are quasi-purposive, i.e., movements that might have been made intentionally, though they are not. At first sight one would surely think the child was simply fidgety. Similar movements occur in pregnant women or sometimes after parturition, but the type is much severer and is apt to be associated with maniacal symptoms. Habit spasms or tics are much commoner in the face, throat and shoulders but also reach the hands occasionally. They constitute an 48 PHYSICAL DIAGNOSIS Fig. 44. — Tetany. Fig. 45.— Tetany. THE HANDS 49 independent chomic neurosis and may or may not be associated with mental or emotional disturbances. Winking and nodding movements are commonest. They have no relation to infectious chorea, to the joints or the heart. Fig. 46. — Tetany Fig. 47. — Atrophic Arthritis with "Flipper Hand." Post-hemiplegic chorea refers to similar movements in the paralyzed hands of hemiplegic cases (children or adults). Infectious chorea may also affect only one-half the body (hemichorea). 50 PHYSICAL DIAGNOSIS In hysteria or by a sort of psychic contagion similar movements are sometimes taken up in schools and institutions, and last till their cause is understood and removed. Chronic choreiform -nioveinents occur also in the rarer congenital forms of paralysis with or without idiocy. 4. Athetosis (see Fig. 41) means slow twisting and bending move- r Fig. 48. — Spade Hand in Myxcedema. ments of the fingers, quite involuntary and always secondary to organic cerebral lesions (hemiplegia, infantile cerebral paralysis) . 5. Tetany (see Figs. 42, 43, 44, 45 and 46)— a peculiar spasm of the hands (often of the feet as well), occurring in the course of diseases of the stomach and intestine in children, in nursing women, after THE HANDS gastric lavage, and after thyroidectomy, hours — ^rarely days. 51 usually lasting minutes or IV. Deformities of the Hands. I. "Claw hand" results from paralysis of the interossei and lumbri- cales with contractures, and occurs when the median or ulnar nerves are paralyzed, and in progressive muscular atrophy, syringomyeha, and chronic poliomyelitis. Fig. 49. — a. Acromegalic Hand, b, Normal Hand. 2. "Flipper hand" (see Fig. 47), a common result of the contrac- tures in late cases of atrophic arthritis. Other deformities of the fingers are common in this disease and in gout (see below, page 472). 3. " Hemiplegic hand," a result of the contractures following hemi- plegia from any cause. 4. Myxaedeina results in thickening and coarsening of the tissues of the hand (" spade hand ") without bony enlargement; but the spade hand is a fairly common type without myx oedema, and one needs to see ' When the parathyroid glands are accidentally removed. 52 PHYSICAL DIAGNOSIS it rapidly develop in connection with other myxoedematous lesions before it can have diagnostic significance. (The same is true of the myxcedematous face.) (See Fig. 48.) ^^^^^^^^^B^^^^^^^^^^^^^BiBBII^^^%....!.^\& w^ BH^Bp^^^ 1 ^ ps^ \y ^ ^BS^^^^S il&lil * ''Am ■ip Fig. 50. — Atrophic Arthritis. Fig. 51. — Clubbed Fingers. 5. Acromegalia produces general enlargement of the bones and other tissues of the hands and feet. 6. Pulmonary Osleo-arlhropathy.— Any long-standing disease of THE HANDS 53 the heart, lungs, or pleura may be followed by this peculiar hyper- trophic change in all the tissues of the extremities. Mild forms produce " clubbed fingers," a bulbous enlargement of the finger-tips Fig. 52. — Clubbed Fingers. Fig. 53. — Raynaud's Disease with double curvation of the nails, lateral and antero-posterior' (see Fig. 51). In severer forms the bones of the hand and wrist are also considerably enlarged (see Figs. 39 and 40). ' Clubbed fingers are occasionally seen in a variety of other diseases: e.g., hepatic abscess, nephritis; and even in apparently healthy persons. 54 PHYSICAL DIAGNOSIS 7. Heberdens nodes, later described under the head of hypertrophic arthritis, are here pictured (Fig. 54)- The distinction from gout has already been referred to (page 472). 8. Atrophic arthritis (Fig. 47) (further described on page 460) H^ ^K m fH^^H ^H^i^l Hl^ ^v ^ H^KiBH ^HP^^^H ^^M ^'^1^ pi ^^^^^B^'^s^Hb^I ^M 1 y ^ B Fig. 54. — Heberden's Nodes. Fig. 55. — Tuberculous Dactylitis. presents its most typical lesions in the hands and wrists. The con- striction line opposite the articulation is observed in late cases, but ordinarily multiple spindle- joints symmetrically arranged are all that we see. The boggy feel, the trophic disturbances, and the chronic course are usuall}' diagnostic; but x-ra}' examination is necessary to THE HANDS 55 establish the diagnosis which is important because of the unfavorable prognosis which it involves. 9. Syphilitic and tuberculous dactylitis (see Fig. 55), seen as a rule in young children, are not distinguished from each other by the physi- cal signs. Diagnosis rests upon the history, the course, the Wasser- mann reaction, the results of giving tuberculin or Salvarsan, and Fig. 56. — Morvan's Disease. the evidence of syphilitic or tuberculous lesions elsewhere. In either disease we have a chronic, almost painless, boggy, red enlargement of one phalanx, or more, due to an indolent inflammation which starts from the bone or periosteum and usually burrows to the surface, to produce a chronic discharging sinus or ulcer. ID. Raynaud's disease attacks the fingers more often than any 56 PHYSICAL DIAGNOSIS Other part. Osier distinguishes three grades of intensity: A. Local syncope ("dead fingers") following exposures to slight cold or emo- tional strain. The fingers become white and cold. The condition usually passes off in an hour or two. From similar causes we may have: B. Local asphyxia ("chilblains"), producing congestion and swelling with or without pain and stiffness and with heat or coldness of the part. C. Local or symmetrical gangrene. If local asphyxia persists, gangrene results. (See also under Erythromelalgia, p. 434.) 11. Morvan's Disease. — As a part of syringomyelia multiple arthropathies (atrophic arthritis) and painless felons may develop in the hands (see Fig. 56). The appearances may strongly suggest: 12. Leprosy, in which there is likewise anaesthetic necrosis of phalanges, but the two diseases can usually be distinguished by a study of the lesions and symptoms in other parts of the body. 13. Dupuyiren's contraction of the palmar fascia is commonest in adult men, and gradually produces a permanent, painless flexion of the little finger in one or both hands. A tense band is felt in the palm. The ring finger ma}' also be affected; less often the others. If burn and felon are excluded, the diagnosis is obvious. THE NAILS AND FINGER TIPS. 1. The nutrition of the nails suEers in chronic skin diseases, in myxoe- dema, in many nerve lesions (neuritis, hemiplegia, syringomyelia, etc.), de- mentia paralj'tica; also in atrophic arthritis. 2. A transverse ridge and groove on the nails often form when their growth is resumed after an acute illness. The movement of this ridge from the matrix to the free edge is said to take about six months (see Fig. 57). 3. Hang-nails possess a certain medical interest, because in some individuals they become sore when the general condition is below par, and constitute a rough index of the degree of resistance to infection They may become infected and lead on to suppuration (paronychia) . 4. Indolent sores around the nail should rouse the suspicion of tuberculosis or s\'philis, esijcciall}' in a child. Fig. 57. — Grooved Nails after Acute Illness. THE BACK 57 5- (o) Cyanosis, the slatey or purplish-blue color of venous con- gestion, can be well seen in the nails. (6) Ancemia, if well marked, blanches the tint of the tissues seen through the nail, but the diagnosis should invariably be confirmed by a haemoglobin estimate. 6. Incurvation of the nails has already been referred to as a part of the condition knovra as "clubbed fingers" (page 52). 7. Capillary pulse (see below, page 90) . 8. Tender finger ends not infrequently occur in septic endocarditis and may help in the diagnosis of that disease. Minute ecchymoses are occasionally present as well. Both phenomena are, I suppose, embolic. THE BACK. The evidences of spinal tuberculosis, spinal curvature, and of the spinal form of infectious and of hypertrophic arthritis will be described later (pages 459 and 466). I. Stiff Back. "Stiff back" may be due not only to the joint troubles just meur tioned, but also and more commonly to lumbago, a painful affection of the lumbar muscles without known pathologic basis. Clinically it is characterized by pain when the muscles are used, as in bending forward to tie one's shoes and in recovering the upright position. There is no bony soreness, no involvement of the sacro-iliac joints, and sideways bending is usually freer than in hypertrophic arthritis. The pain of lumbago does not radiate around the chest or down the legs, and is not especially aggravated by coughing or sneezing, but it some- times extends down low into the fascia of the lumbar muscles over the sacrum. The age of the patient (usually over thirty) distinguishes most cases of lumbago from spinal tuberculosis. "Stiff neck" often accompanies or precedes it and some relation to meteoric conditions can often be traced. The disease is self limited and should end in a few days or at most a few weeks. Cases of longer duration are prob- ably due to spinal arthritis or tuberculosis. Metastatic cancer of the vertebrae often follows cancer of the breast producing a stiff, painful spine. The at-ray picture is usually charac- teristic. II. Sacro-iliac Disease. Tuberculosis of this joint has long been known and calls attention to its presence by pain, psoas spasm, and a limp. If the wings of the S8 PHYSICAL DIAGNOSIS ilium are forcibly pressed together, the pain in the joint is much increased. Abscess formation is often the first distinctive sign. The motions at the hip-joint are not restricted and the local signs of verte- bral caries are absent. The duration of the disease, the local reaction after tuberculin injection and the formation of abscess distinguish it from other lesions of the sacro-iliac joint. Goldthwait' has recently shown that the sacro-iliac joint is subject to most of the diseases of other joints, and that some (e.g., hypertro- phic arthritis) are not at all uncommon there. Many of the pains in the back complained of by women during menstruation or in pelvic disorders are referred precisely to the sacro-iliac articulation and are probably due to lesions of that joint. Many cases diagnosed as "lumbago" are probably due to one or another sacro-iliac lesion, strain, sprain or subluxation. The diagnostic points are — on the positive side: (o) Pain or tenderness directly over the joint. Such pain may be elicited by raising the leg while the knee is kept stiff. It is also referred in many cases to the course of the sciatic nerve so that many, perhaps most, cases of so-called sciatica are due in fact to sacro- iliac disease. It is often worse at night. (6) Abnormal mobility of the sacro-iliac joint, (c) A tendency to lean the trunk away from the affected side when standing, (d) Limitation of lateral bending of the spine to one side or the other when the patient stands with the knees stiff. On the negative side the absence of limitation in the motions at the hip-joint, the negative x-tslj, the free forward bending (when the patient sits during the test), the absence of fever, leucocytosis and abscess formation are important. A strong nervous element is present in many cases. III. Spinal Curvatures. Diagnosis is not difficult, provided we are led to examine the back at all. (a) Kyphosis or backward convexity of the spine, if sharply an- gular, means Pott's disease (tuberculosis) . If the curve is gentle and gradual it may be due to "round shoulders," to hypertrophic arthritis, to emphysema, Paget's disease, or rickets. The rachitic curve is flaccid, is due simply to muscular weakness, and is associated with other evidences of rickets. In emphysema and Paget's disease the kyphosis goes with the other signs of those diseases. In hypertrophic arthritis the curve is rigid, irreducible, and usually painless. " Round ' Go ldthwait: Boston Medical and Surgical Journal, March 9th, 1905. THE BACK 59 shoulders" can be straightened by muscular exertion, and represent a habit of posture. (b) Lordosis, an exaggeration of the normal forward convexity of the lumbar spine, is seen in tuberculosis of the hip or spine, in paralysis of the dorsal or abdominal muscles (especially muscular dystrophy), axid in abdominal tumors (pregnancy), which need to be counter- balanced by backward bending. (c) Scoliosis is a combination of lateral curvature with twisting of the spine. In slight or doubtful cases the tips of the spinous processes should be marked with a colored pencil, which makes the deviation easily visible. Severe cases cannot be mistaken. IV. Tumors of the Back. (a) Aneurism of the descending aorta may point in the back near the angle of the left scapula (see below, page 270). It is the only pulsating tumor of this region. (6) Perinephritic abscess usually points between the crest of the ilium and the twelfth rib, a few inches from the spine (see page 391). (c) Tuberculous abscess ("cold abscess"), originating in vertebral tuberculosis, may point in the same region, though more often it fol- lows down the sheath of the psoas and points near Poupart's ligament. "Cold abscess," starting from a necrosed rib, is often seen in the back. The probe leads to dead bone at the end of the sinus. Microscopic examination of excised pieces is the only way of excluding actinomycosis, though this disease is less apt to form sinuses. (d) Sarcoma of the scapula, the only tumor of the scapula that is often seen, occurs in children and rarely after the second decade- With a solid, nearly painless tumor of this bone in a child, sarcoma should always be suspected. Benign exostoses are possible, but usually occur later in life. Histological examination will decide. (e) Epithelioma, arising from the skin of the back, presents the ordinary evidences of this form of cancer. (/) The multiple subcutaneous abscesses due to glanders ("farcy buds") are more common on the extremities, but may be found on the trunk as well. Flattened, oval, fluctuating nodes with slight tender- ness are suggestive. Bacteriological examination of the purulent contents settles the diagnosis. V. Prominent Scapula. This is due usually to: (a) Lateral curvature of the spine (see above) . 60 PHYSICAL DIAGNOSIS (6) Serratus paralysis, recognized by the startling prominence of the scapula if the patient pushes forward with both hands against re- sistance ("angel-wing" scapula). VI. Scaphoid Scapula. In congenital syphilis the median or vertebral border of the scapula is sometimes markedly concave. VII. Spina Bifida. A congenital, saccular tumor, connecting through a bony defect with the interior of the spinal canal at any point between the occiput and the sacrum ; nine-tenths of all cases occur in the lowest third of the ^■j ^^^m'i' -^^IH V Otker effects of coughing upon physical signs will be mentioned later ^-pp-. 278, 285). XII. PLEoiAt Friction. The surfaces of the healthy,; pleural icavity g,re lubricated wilii sufficient serum to make thein pass noiselessly over each other during the movements of respiration. But when the tissues become abnoir- mally dry, as in Asiatic cholera, or when the serous surfaces are roughened by the presence, ofcia fibrinousnexudation, a-s in ordinary pleurisy, the rubbing of the two pleural surfaces against one another produces peculiar and very characteristic sounds known as "pleural 164 PHYSICAL DIAGNOSIS friction sounds." The favorite seat of pleural friction sounds is at the bottom of the axilla, i.e., where the lung makes the widest excursion and where the costal and diaphragmatic pleura are in close apposition (see Fig. 82). In some cases pleural friction sounds are to be heard altogether below the level of the lung. In others they may extend up several inches above its lower margin, and occasionally it happens that friction may be appreciated over the whole lung from the top to the bottom. Sometimes friction sounds are heard only at the apex of the lung in early tuberculosis. The sound of pleural friction may be closely imitated by holding the thumb and forefinger close to the ear, and rubbing them past each other with strong pressure, or by pressing the palm of one hand over the ear and rubbing upon the back of this hand with the fingers of the other. Pleural friction is usually a catchy, jerky, interrupted, ir- regular sound, and is apt to occur during inspiration only, and particu- larly at the end of this act. It may, however, be heard with both respiratory acts, but rarely if ever occurs during expiration alone. The intensity and quality of the sounds vary a great deal, so that they may be compared to grazing, rubbing, rasping, and creaking sounds. They are sometimes spoken of as "leathery." As a rule, they seem very near to the ear, and are sometimes startlingly loud. In many cases they cannot be heard after the patient has taken a few full breaths, probably because the rough pleural surfaces are smoothed down temporarily by the friction which deep breathing produces. After a short rest, however, and a period of superficial breathing, pleural friction sounds often return and can be heard for a short time with all their former intensity. They are increased by pressure exerted upon the outside of the chest wall. Such pressure had best be made with the hand or with the Bowles stethoscope, since the sharp edges of the chest-piece of the ordinary stethoscope may give rise to considerable pain; but if such pressure is made with the hand, one must be careful not to let the hand shift its position upon the skin, else rubbing sounds may thus be produced which perfectly simulate pleural friction. In well-marked cases friction can be felt if the hand is laid over the suspected area; occasionally the vibrations are so coarse that they can be heard and felt by the patient himself or by those around him. I have already mentioned F. T. Lord's^ ac- count of a sound a good deal like pleural friction, often heard over the scapulae when examining patients whose arms are folded across the chest with each hand on the opposite shoulder. The sound ap- 'F. T. Lord: Boston Med. & Surg. Journal, Oct. 21, 1909 AUSCULTATION 165 parently starts in the shoulder- joint on one side or both sides — usually both. It is less jerky and irregular than pleural friction, can often be abolished by shifting the position of the arms, and causes no pain. XIII. Auscultation of the Spoken or Whispered Voice Sounds ^ The more important of these is: I. The Whispered Voice. The patient is directed to whisper "one, two, three," or "ninety- nine," while the auscultator listens over different portions of the chest to see to what degree the whispered syllables are transmitted. In the great majority of normal chests the whispered voice is to be heard only over the trachea and primary bronchi in front and behind, while over the remaining portions of the lung little or no sound is to be heard. When, on the other hand, solidification of the lung is present, the whispered voice may be distinctly heard over portions of the lung relatively distant from the trachea and bronchi; for example, over the lower lobes of the lung behind. The usefulness of the whispered voice in the search for small areas of solidification or for the boundaries of a solidified area is great, especially in pneumonia when we wish to save the patient the pain and fatigue of taking deep breaths. Whispered voice sounds are practically equivalent to a forced expiration and can be obtained with very little exertion on the patient's part. The in- creased transmission of the whispered voice is, in my opinion, a more delicate test for solidification than tubular breathing. The latter sign is present only when a considerable area of lung tissue is solidified, while the increase of the whispered voice may be obtained over much smaller areas. Retraction of the lung above the level of a pleural effusion causes a moderate increase in the transmission of the whispered voice, and at times this increased or bronchial whisper is to be heard over the fluid itself, probably by transmission from the compressed lung above. Where the lung is completely solidified the whispered words may be clearly distinguished over the affected area. In lesser degrees of solidification the syllables are more or less blurred. 2. The Spoken Voice. The evidence given us by listening for the spoken voice in various parts of the chest is considerably less in value than that obtained through the whispered voice. As a rule, it corresponds with the 166 PHYSICAL DIAGNOSIS tactile fremitus, being increased in intensity by the same causes which increase tactile fremitus, viz., solidification or condensation of the lung, and decreased by the same causes which decrease tactile fremitus— namely, by the presence of air or water in the pleural cavity, by the thickening of the pleura itself, or by an obstruction of the bronchus leading to the part over which we are listening. In some cases the presence of solidification of the lung gives rise not merely to an increase in transmission of the spoken voice, but to a change in its quality, so that it sounds abnormally concentrated, nasal, and near to the listen- er's ear. The latter change may be heard over areas where tactile fremitus is not increased, and even where it is diminished. Where this change in the quality of the voice occurs, the actual words spoken can often be distinguished in a way not usually possible over either normal or solidified lung. " Bronchophony," or the distinct transmission of audible words, and not merely of diffuse, unrecogniz- able voice sounds, is considerably commoner in the solidifications due to pneumonia than in those due to phthisis; it occurs in some cases of pneumothorax and pulmonary cavity. iO 3. Egophony. l^mong the least important 'of the classical physical signs is a nasal or squeaky quality of^ the sounds which reach the observer's ear when the patient speaks in a natural voice. To this peculiar quality of voice the name of "egophony". has been given. It is most frequently heard in cases of moderate-sized pleuritic effusion just about the level of the lower angle of the scapula and in the vicinity of that point. Less often it is heard at the same level in front.' It is very rarely heard in the Upper portion of the chest and is by no. means constant either in pleuritic effusion or in any other condition. A point at which it is heard corresponds not, as a rule, with the upper level of the accumulated fluid, as has been frequently supposed, but often with a point about an inch farther down. The presence of egophony is in no way distinctive of pleuritic effusions and may be heard occasionally over solidified lung. XIV. Phenomena Peculiar to Pneumohydrothorax and Pneumo- PYOTHORAX: I. Succussion Sounds. Now and then a patient consults a physician, complaining that he hears noises inside him as if water were being shaken about. One AUSCULTATION 167 such patient expressed himself to me to the effect that he felt "like a half -empty bottle." In the chest of such a patient, if one presses the ear against any portion of the thorax and then shakes the whole patient strongly (succussion) , one may hear loud splashing sounds due to air and fluid within. The sound itself is often miscalled "succussion." Such sounds are absolutely diagnostic of the presence of both air and fluid. Very frequently they may be detected by the physician when the patient is not aware of their presence. Occasionally the splashing of the fluid within may be felt as well as heard. It is essential, of course, to distinguish splashing due to the presence of air and fluid in the pleural cavity from similar sounds produced in the stomach, but this is not at all difficult in the majority of cases. It is a bare possibility that succussion sounds may be due to the presence of air and fluid in the pericardial cavity, or in the stomach or gut escaped into the thorax through a ruptured diaphragm. In accident cases this possibility must be remembered. It is important to remember that splashing is never to be heard in simple pleuritic effusion or hydrothorax. The presence of air, as well as liquid, in the pleural cavity is absolutely essential to the pro- duction of succussion sounds.' 2. Metallic Tinkle or Falling-Drop Sound. When listening over a pleural cavity which contains both air and fluid, one occasionally hears a liquid, tinkling sound, due possibly to the impact of a drop of liquid falling from the relaxed lung above into the accumulated fluid at the bottom of the pleural cavity, but probably to riles produced in the tissues around the cavity. It is stated that this physical sign may in rare cases be observed in large sized phthisical cavities as well as in pneumohydrothorax and pneumopyothorax. It is well for the student to try for himself the following experiment, which I have found useful in impressing these facts upon the attention of classes in physical diagnosis: Fill an ordinary rubber hot-water bag to the brim with water. Invert it and squeeze out forcibly a certain amount (perhaps half) of the contents, by grasping the upper end of the bag and compressing it. While the water is thus being forced out, screw in the nozzle of the bag. Now shake the whole bag, and it vnll be found impossible to produce any splashing sounds owing to the fact that there is no air in the bag. Unscrew the nozzle, admit air, and then screw it in again. Now shake the bag again and loud splashing vsdll be easily heard. 168 PHYSICAL DIAGNOSIS 3. The Lung-Fistula Sound. When a perforation of the lung occurs below the level of the fluid accumulated in the pleural cavity, bubbles of air may be forced out from the lung and up through the fluid with a sound reminding one of that made by children when blowing soap-bubbles. CHAPTER IX. AUSCULTATION OF THE HEART. I. " Valve Areas." In the routine examination of the heart, most observers listen in four places : (i) At the apex of the heart in the fifth intercostal space near the nipple, the "mitral area." (2) In the second left intercostal space near the sternum, the "pulmonic area." (3) In the second right intercostal space near the sternum, the "aortic area." Aortic area Tricuspid area, r' Pulmonic area. Mitral area. Fig. 125. — The Valve Areas. (4) At the bottom of the sternum near the ensiform cartilage, the "tricuspid area." These points are represented in Fig. 125 and are known as "valve areas." They do not correspond to the anatomical position of any one of the four valves, but experience has shown that most of the sounds heard best at the apex can be proved (by post-mortem ex- amination) to be produced at the mitral orifice. They are probably transmitted through the papillary muscle whose base or insertion is near the apex region. Similarly sounds heard best in the second left intercostal space are proved to be produced at the pulmonary orifice; 169 170 PHYSICAL DIAGNOSIS those which are loudest at the second right intercostal space to be pro- duced at the aortic orifice;' while those which are most distinct' near the origin of the ensiform cartilage are produced at the tricuspid orifice. II. The Normal Heart Sounds. A glance at Fig. 126, which represents the anatomical positions of the four valves above referred to, illustrates what I said above; namely, that the traditional valve areas do not correspond at all with the anatomical position of the valves. If now we listen in the " mitral area," that is, in the region of the apex impulse of the heart, keeping -^ Pulmonic valve. Tricuspid valve. — Fig. 126. — Anatomical Position of the Cardiac Valves. at the same time one finger on some point at which the cardiac impulse is palpable, one hears with each outward thrust of the heart a low, dull sound, and in the period between the heart beats a second sound, shorter and sharper in quality.^ That which occurs with the cardiac impulse is known as the first sound; that which occurs between each two beats of the heart is known as the second sound. The second sound is generally admitted to be due to the closure of the semilunar valves. The cause of the first ' For the exceptions to this rule, see below, page 214. ' The first sound of the heart, as heard at the apex, may be imitated by holding a linen handkerchief by the corners and suddenly tautening one of the borders. To imitate the second sound, use one-half the length of the border instead of the whole. AUSCULTATION OF THE HEART 171 sound has been a most fruitful source of discussion, and no one expla- nation of it can be said to be generally received. Perhaps the most commonly accepted view attributes the first or systolic sound of the heart to a combination of two elements — (a) The contraction of the heart muscle itself. (b) The sudden tautening of the mitral curtains. Following the second sound there is a pause corresponding to the diastole of the heart. Normally this pause occupies a little more time than the first and second sounds of the heart taken together. In disease it may be much shortened. The first sound of the heart is not only longer and duller than the second (it is often spoken of as "booming" in contrast with the "snapping" quality of the second sound), but is also considerably more intense, so that it gives us the impression of being accented like the first syllable of a trochaic rhythm. After a little practice one grows so accustomed to this rhythm that one is apt to rely upon his appreciation of the rhythm alone to identify the first of systolic sound. This is, however, an unsafe practice and leads to many errors. Our impression as to which of the sounds of each cardiac cycle corre- sponds to systole should always be verified either by sight or touch. We must either see or feel the cardiac impulse and assure ourselves that it is synchronoiis with the heart sound which we take to be systolic' This point is of especial importance in the recognition and identification of cardiac murmurs, as will be seen presently. So far, I have been describing the normal heart sounds heard in the "mitral area," that is, at the apex of the heart. If now we listen over the pulmonary area (in the second left intercostal space) , we find that the rhythm of the heart sounds has changed and that here the stress seems to fall upon the "second sound," i.e., that corresponding to the beginning of diastole; in other words, the first sound of the heart is here heard more feebly and the second sound more distinctly. The sharp, snapping quality of the latter is here even more marked than at the apex; and despite the feebleness of the first sound in this area we can usually recognize its relatively dull and prolonged quality. Over the aortic area {i.e., in the second right interspace) the rhythm is the same as in the pulmonary area, although the second sound may be either stronger or weaker than the corresponding sound on the other side of the sternum (see below, p. 172). ' When the cardiac impulse can be neither seen nor felt, the pulsation of the carotid will generally guide us. The radial pulse is not a safe guide. 172 PHYSICAL DIAGNOSIS Over the tricuspid area one hears sounds practically indistinguish- able in quality and in rhythm from those heard at the apex.' When the chest walls are thick and the cardiac sounds feeble, it may be difficult to hear them at all. In such cases the heart sounds may be heard much more distinctly if the patient leans forward and toward his own left. Such a position of the body also renders it easier to map out the outlines of the cardiac dulness by percussion if we allow for the swing of the heart to the left. In cardiac neuroses, thyrotoxicoses and during excitement or emo- tional strain, the first sound at the apex is not only very loud but has often a curious metallic reverberation {" cliquetis metallique") corre- sponding to the trembling, jarring cardiac impulse (often mistaken for a thrill) which palpation reveals. III. Modifications in the Intensity of the Heart Sounds. It has already been mentioned that in young persons with thin, elastic chests, the heart sounds are heard with greater intensity than in older persons whose chest walls are thicker and stiffer. In obese, indolent adults it is sometimes difficult to hear any heart sounds at all, while in young persons of excitable temperament the sounds may have a very intense and ringing quality. Under diseased conditions either of the heart sounds may be increased or diminished in intensity. I shall consider I, The First Sound at the Apex (sometimes Called the Mitral First Sound) . (a) Increase in the intensity of the first sound at the apex of the heart occurs in any condition which causes the heart to act with unusual degree of force, such as thyrotoxicosis, exertion, or rexcite- ment. In the earlier stages of infectious fevers a similar increase in the intensity of this sound may sometimes be noted. Hypertrophy of the left ventricle sometimes has a similar effect upon the sound, but less often than one would suppose, while weakening of the left ventricle, 1 A third heart sound (or reduplication of the second sound) is audible on careful auscultation in a considerable proportion of healthy young individuals— especially if they lie on the left side. Barie described it in 1893 (Semaine med., 1893, xiii, 474), and Thayer (^Boston Med. &• Surg. Journ., May 7, 1908) has recently recalled it to notice, believing it due to "the sudden tension of the mitral and perhaps at times tricuspid valves occurring at the end of the first and most rapid phase of diastole." This is probably identical with the double second sound of mitral stenosis and with one of the types of gallop rhythm. No diagnostic significance is as yet clearly associated with it. AUSCULTATION OF THE HEART 173 contrary to what one would suppose, is not infrequently associated with a loud, forcible first sound at the apex. In mitral stenosis the first sound is usually very intense, and is often spoken of as a " thump- ing first sound" or as a "sharp slap." (6) Shortening and weakening of the first sound at the apex. In the course of continued fevers and especially in typhoid fever the granular degeneration which takes place in the heart muscle is manifested by a shortening and weakening of the first sound at the apex, so that the two heart sounds come to seem much more alike than usual. In the later stages of typhoid, the first sound may become almost inaudible. The sharp "valvular" quality, which one notices in the first apex sound under these conditions, has been attributed to the fact that weakening of the myocardium has caused a suppression of one of the two elements which go to make up the first sound, namely, the muscular element, so that we hear only the short, sharp sound due to the tautening of the mitral curtains. Arterio-sclerosis, or any other change which tends to enfeeble the heart wall, produces a weakening and shortening of the first sound similar to that just de- scribed. Simple weakness in the mitral first sound without any change in its duration or pitch may be due to fatty overgrowth of the heart, to emphysema or pericardial effusion in case the heart is covered by the distended lung or by the accumulated fluid. Among valvular diseases of the heart the one mdst likely to be associated with a diminution in intensity of the first apex sound is mitral regurgitation. (c) Doubling of the first sound at the apex. It is not uncommon in healthy hearts to hear in the region of the apex impulse a doubling of the first sound so that it may be suggested by pronouncing the syllables "turrupp" or "trupp." In health this is especially apt to occur at the end of expiration. In disease it is associated with many different conditions involving an increase in the work of one or the other side of the heart. It seems, however, to be unusually frequent in the weakened heart of nephritis and arterio- sclerosis. 2. Modifications in the Second Sounds as Heard at the Base of the Heart. (a) Physiological Variations. The relative intensity of the pulmonic second sound, when com- pared with the second sound heard in the conventional aortic area, varies a great deal at different periods of life. Attention was first 174 PHYSICAL DIAGNOSIS called to this by Vierordt,' and it has of late years been recognized by the best authorities on diseases of the heart. The work of Dr. Sarah R. Creighton, done in my clinic during the summer of 1899, showed that in 90 per cent, of healthy children under ten years of age, the pulmonic second sound is louder than the aortic. In the next decade (from the tenth to the twentieth year) the pulmonic second sound is louder in two-thirds of the cases. About half of 207 cases, between the ages of twenty and twenty-nine, showed an accen- 100%- 90% ■ Bo'/o- 70/„- 30%- 20%- 10%-. 0-9 10-19 20-39 DECADES. 30-39 140-49 50-59 '60-69 70-79 1 \ \ \ V • \ \ \ \ V ^ V ^ —100^ — 90% -80"/ —'Ofo —60% — 50/„ — 40»/„ —30°^ —20"/ ■— -10"Z Fig. 127. — Showing the Per Cent, of Accentuated Pulmonic Second Sound in Each Decade. Based on 1,000 cases. tuation of the pulmonic second, while after the thirtieth year the number of cases showing such accentuation became smaller with each decade, until after the sixtieth year we found an accentuation of the aortic second in sixty-six out of sixty-eight cases examined. These facts are exhibited in tabular form in Figs. 127 and 128, and appear to show that the relative intensity of the two sounds in the aortic and pulmonic arteries depends primarily upon the age of the individual, the pulmonic 'Vierordt: "Die Messung der Intensitat der Herztone" (Tubingen, 1885). See also Hochsinger, " Die Auscultation des kindUchen Herzens " ; Gibson, " Diseases of the Heart" (1898); Rosenbacb, "Diseases of the Heart" (1900) ;.Allbutt, "System of Medicine." AUSCULTATION OF THE HEART 175 sound predominating in youth and the aortic in old age, while in the period of middle life there is relatively little discrepancy between the two. It is, therefore, far from true to suppose that we can, obtain evi- dence of a pathological increase in the intensity of either of the second sounds at the base of the heart simply by comparing it with the other. Pathological accentuation of the pulmonic second sound must mean a greater loudness of this sound than should be expected at the age of the patient in question, and not simply a greater intensity than that of the DECADES. m%- 90°/-- snV 0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 innV r^ -- -—100^ --90°/ --80% / r / T0°/— / --TO"/ 60°/ '"/" / / m o m / / / Ar.^1 nycosis of the Pleura. There are no characteristic physical signs. These diseases may be suspected if an empyema perforates the chest or is associated with chronic pulmonary suppurating. Diagnosis depends on the micro- scopic examination of the fluid. V. Cyto-Diagnosis of Pleural and Other Fluids- Only such methods as can be carried out without a thermostat will be here described. Hence the examination of diphtheria swabs, blood cultures, and pus are excluded. We have left the fluids obtained by tapping the pleura, the peritoneum, and the spinal cord. The first is the most important. / • • Fig. 194. — Lymphocytosis in Pleural Fluid. Primary tuberculous pleurisy. (X750 diameters.) (Musgrave.) Pleural Fluids. — A fluid withdrawn from the pleura by puncture may be a mechanical transudate (hydrothorax) , may be evidence of tuberculous pleurisy (primary or associated with phthisis), or, rarely, an exudate of septic or cancerous origin. To investigate these fluids we note: 1. Color. Bloody fluids suggest cancer, but occasionally occur in pneumonia and tuberculosis. 2. Weight.^ Dropsical fluid is generally helow 1.015 in specific ' The amount of albumin usually runs parallel with the weight of the fluid. 340 PHYSICAL DIAGNOSIS gravity. Exudates are usually in the vicinity of 1.020. An ordinary specific-gravity bulb is used. 3. The cells of the sediment (cytodiagnosis) . I. Technique of Cytodiagnosis. Pour fluid into tubes of a centrifuge and centrifugalize five minutes. 2. Pour off the supernatant fluid and stir up the sediment with a platinum loop, so as to suspend the sediment in the few remaining drops. 3. Spread a drop of the mixture on a clean cover glass with the platinum loop and let the smear dry without heating it. 4. Stain like a blood film (see below, page 441) with the foUowing mixture ;! Wright's modification of Leishman's stain, 3 parts; pure methyl alcohol, i part. •t «t ■•■■*k. « k 1 m Fig. 195. — Polynuclears and Large Lymphocytes in Pleural Fluid from a Case of Trau- matic Acute Infectious Pleurisy. (X 750 diameters.) (Musgrave.) 5. After staining, wash very gently, using a dropper (else the whole film may be pushed off) , and dry in the fingers over a Bunsen or alco- holic flame. Do not blot the preparation. 6. Mount in Canada balsam and examine with an oil-immersion lens. 2. Interpretation of Results, (a) In tuberculous pleurisy, lymphocytes make up from seventy to 'Suggested by Musgrave: Boston Med. and Surg. Journ., vol. cli., p. jrg, 1904. DISEASES AFFECTING THE PLEURAL CAVITY 341 ninety-nine per cent — usually over ninety per cent — of all the cells found in the smear^ (see Fig. 194). (6) In septic cases due to the streptococcus, staphylococcus, or pneumococcus the majority of the cells are polymidear leucocytes (see Fig. 195). (c) In transudations (dropsical) the predominating cell is a large mononuclear type, apparently endothelial in origin and often occur- ring in sheets or "plaques" (see Fig. 196). Exceptions occasionally occur, but in the main these rules are sufficiently exact to be of value in diagnosis when taken in connection with all the facts in the case. Fig. 196. — Pleural Fluid in Hydrothorax due to Cardiac Disease. Endothelial plaques and cells. (X 750 diameters.) (Musgrave.) In peritoneal fluid the use of cytodiagnosis has not as yet furnished information of any considerable diagnostic value. In cerebrospinal fluid obtained by lumbar puncture the predomi- nance of lymphocytes is not so often associated with tuberculosis as it is in the pleura, but usually means chronic cerebrospinal irritation such as is produced by dementia paralytica and tabes. As excess of polynuclear cells is usually due to acute meningitis, — epidemic or sporadic. 2 This rule, however, does not work both ways. Tuberculosis produces lymphocytosis, but so do other chronic irritations. The lymphocytosis is a mark of chronicity and only suggests tuberculosis, but there are no other common causes for chronic pleural irritation. CHAPTER XX. ABSCESS, GANGRENE, AND CANCER OF THE LUNG, PULMONARY ATELECTASIS, (EDEMA, AND HYPOSTATIC CONGESTION. I. Abscess and Gangrene of the Lung. I consider these two affections together because the physical signs, exclusive of the sputa, do not differ materially in the two affections. In some cases there may be no physical signs at all, and the diagnosis is made fronl the character of sputa and from a knowledge of the etiology and symptomatology of the case. In loo cases studied by Lord at the Massachusetts General Hospital, 22 were due to pneumonia. Inhalation of septic material (as dtiring tonsil operations), extension from the pleura, bronchi or subdiaphragmatic region, septic emboli and trauma are the next most frequent causes. The right lower lobe close beneath the pleura is a favorite site. In 25 of Lord's 38 cases there were multiple abscesses. Acute ab- scess may be single. Chronic infections are generally multiple. The pleura is firmly adherent in only one-third of the cases. The symptoms are of sepsis with cough and purulent, foul, sometimes bloody sputa, containing elastic tissue. In most cases we find nothing more than a patch of coarse rales or a small area of solidification, over which distant bronchial breathing, with increased voice sound and fremitus, may be appreciated. Usually there is some' localized dulness on percussion. One may find the signs of cavity (amphoric breathing, cracked-pot resonance, and gurgling rales), but this is unusual. Pulmonary abscess is often simulated by the breaking of an em- pyema into the lung and the emptying of the pus through a bronchus. Large quantities of pus are expectorated in such a condition, and ab- scess of the lung is suggested, but the other physical signs are those of elastic fibres is the crucial point in the diagnosis of intrapulmonary abscess, whether due to the tubercle bacillus or to other organisms. Tuberculous abscess (cavity) is usually near the summit of the lung, and other varieties of abscess are near the base, but often there are no physical signs by which we can distinctly localize the process. 342 ATELECTASIS 343 II. Neoplasms of the Lung and Mediastinum. Neoplasms of the lung are usually secondary to tumors of the di- gestive tract, bones, uterus or breast, and are recognized chiefly by the presence of ill-defined pulmonary symptoms in patients known to have previously suffered from neoplasms elsewhere in the body. Primary neoplasms, 87 per cent of which start in the bronchi, may be quite without physical signs. The recognizable cases fall into two groups: 1. The lung type. 2. The mediastinal pressure type. In the pulmonary type neoplasms reaching near to the pleural surface of the lung may produce a diminution or loss of percussion resonance, breath sound, voice, and fremitus. Diagnosis is impossi- ble unless there are tumor fragments in the sputa. The disease is usually mistaken for lung abscess, bronchiectasis or tuberculosis. In the mediastinal type the diagnosis of mediastinal tumor is usually made. Metastatic glandtdar masses produce pressure signs like those of primary mediastinal neoplasms. I. Mediastinal Neoplasms. According to Christian' the mediastinal neoplasms which are neither so rare nor so obscure as to make diagnosis practically impos- sible are: (i) Sarcoma (including lymphosarcoma, leucaemic growths, and Hodgkins' disease) ; (2) Teratoma and cyst. 2. Mediastinal Sarcoma. Starting in the local lymph nodes, in the thymus or in the connec- tive tissue, occurring at any age and chiefly in males, the growths com- prise neighboring structtures and thus produce dyspnoea, cough, and pain, sometimes dysphagia and hoarseness. The physical signs are: (a) prominence or bulging of the regions near the manubrium ; (b) distension of the veins of the neck and upper thorax, cyanosis and localized oedema from pressure on the cava or its branches; (c) metastatic tumors in the neck which may push the trachea to one side; (d) percussion dulness on each side of the manu- brium with diminished vocal and tactile fremitus. Auscultation rarely yields characteristic results, though there may be noisy strident breath- sound from pressure on a bronchus, (e) Evidence of pleural effusion, (f) X-ray shadows of characteristic irregular shape. 'Christian: Osier's Modem Medicine, vol. iii, p. 893. 344 PHYSICAL BIAGNOSIS 3. Differential Diagnosis. Our chief business is to exclude aneurism. This is usually possible by studying the shape of the x-ra.j shadow, the course and history of the case, the Wassermann reaction, and the pressure symptoms which with tumors are far more apt to include venous distension, oedema, and cyanosis than is the case with aneurism (see also p. 261). 4. Cysts of the Mediastinum. Christian {loc. cit.) has collected sixty-four cases of dermoid cyst or teratoma of the mediastinum. Most cases occur before the thirtieth year. The course is very chronic. The cyst may exist for years with- out producing any symptoms and then be accidentally discovered in the course of an x-ray examination undertaken for some other pur- pose. When it grows large enough to produce pressure symptoms it may give rise to dyspnoea, pain, and cough. In eleven of Christian's cases hair was expectorated as a result of communication between the cyst and a bronchus. Bulging of the chest wall near the manubrium with dulness on percussion, diminished breathing, and vocal sounds, and an often characteristically spherical ovoid x-ray shadow, are the most constant physical signs. III. Atelectasis. (a) Areas of atelectasis or collapse of pulmonary tissue are often present in connection with various pathological processes in the lung (such as tuberculosis or lobular pneumonia) , but are usually too small to give rise to any characteristic physical signs; nevertheless (6) In most normal individuals a certain degree of atelectasis of the margins of the lungs may be demonstrated in the following way: The position of the margins of the lungs in the axillae, in the back, or in the precordial region are marked out by percussion at the end of expiration. The patient is then directed to take ten full breaths, and the pulmonary outlines at the end of expiration are then percussed out a second time. The pulmonary resonance will now be found to extend nearly an inch beyond its former limits, owing to the distention of previously collapsed air vesicles. If one auscults the suspected areas during the deep breaths which are used to dispel the atelectasis, very fine rales are often to be heard at the end of expiration, disappearing after a few breaths in most cases, but sometimes audible as long as we choose to listen to them. These ATELECTASIS 345 sounds, to which Abrams has given the name of "atelectatic crepita- tion," are in my experience especially frequent at the base of either axilla. The same writer has noticed an opacity to the a;-rays over such atelectatic areas. Forcible percussion may be sufficient to distend small areas of collapsed lung, or at any rate to dispel the dulness previously present (see above, p. 135, the lung reflex). (c) When one of the large bronchi is compressed (as by an aneu- rism) or occluded by a foreign body, collapse of the corresponding area of lung may be shown by diminished motion of the affected side, dulness on percussion, and absence of breathing, voice sounds, and tactile fremitus. In new-born babies whose lungs do not fully expand at the time of birth, similar physical signs are present over the non-expanded lobes. The right lung is especially apt to be affected. In the differential diagnosis of extensive pulmonary collapse, the etiology, the suddenness of the onset, the absence of fever and of displacement of neighboring organs enable us to exclude pneumonia and pleuritic effusion. In distinguishing small areas of solidification from similar areas of atelectasis, Abrams finds the "lung-reflex" (see page 135) of value. Atelectatic areas expand if the skin overlying them is irritated. Solidified areas show no change. IV. (Edema of the Lungs. (a) Chronic Form. — In cardiac or renal disease one can often dem- onstrate that the lungs have been invaded by transuded serum as a part of the general dropsy. More rarely pulmonary oedema exists without much evidence of oedema in other organs or tissues. The only physical sign characteristic of this condition is the presence of numerous rales in the dependent portions of the lungs; that is, throughout their posterior surfaces when the patient has been for some time in a recumbent position; or over the lower portions of the axillae and the back if the patient has not taken to his bed. The rales are always bilateral (unless the patient has been lying for a long time on one side), and the individual bubbles appear to be all of the same size, or nearly so, differing in this respect from those to be heard in bronchitis. Squeaking or groaning sounds are less often heard. The respiratory murmur is usually somewhat diminished in intensity. Dulness on percussion and modification of voice sounds are not 346 PHYSICAL DIAGNOSIS present, unless hydrothorax or hypostatic pneumonia complicate the oedema. (b) Acute Form. — In hypertensive cardio-vascular disease the lungs may suddenly fill with fluid " out of a clear sky" and with such urgency that pinkish frothy serum pours from the mouth or is very rapidly expectorated. The patient may die in the first attack, more often in later attacks. The physical signs are coarse bubbling riles throughout the lungs with feeble heart. V. Hypostatic Pneumonia. In long-standing passive congestion, the alveoli of the dependent portions of the lungs may become so engorged with blood and alveolar cells as to be practically solidified. Under these conditions examina- tion of the posterior portions of the lungs shows usually: (a) Slight dulness on percussion reaching usually from the base to a point about one-third way up the scapula. At the very base the dulness is less marked and becomes mixed with a shade of tjrmpany. (b) Feeble or absent tactile fremitus. (c) Diminished or suppressed breathing and voice sounds. The right lung is apt to be more extensively affected than the left. Occasionally the breathing is tubular and the voice sounds are in- creased, making the physical signs identical with those of croupous pneumonia, but as a rule the bronchi are as much engorged as the alve- oli to which they lead, and hence no breath sounds are produced. Rales of oedema or of bronchitis may be present in the adjacent parts of the lungs. The fact that the dulness is less marked at the base of the lung than higher up helps to distinguish the condition from hydrothorax. The diagnosis is usually easy, owing to the presence of the under- lying disease. Fever, pain, and cough such as characterize croupous pneumonia are usually absent. CHAPTER XXI. THE ABDOMEN IN GENERAL, THE BELLY WALLS, PERITONEUM, OMENTUM, AND MESENTERY. I. Examination of the Abdomen in General. Our methods are crude and inexact compared to those applicable to the chest. Auscultation, despite Cannon's brilliant foundation studies,' is of practically no use. Inspection is helpful in but few cases. Palpation, our mainstay, is often rendered almost impossible by thickness, muscular spasm, or ticklishness of the abdominal walls. Percussion is of great value in some cases, but yields no useful results in the majority. I. Technique. The knack of abdominal examination, and especially that part of it whereby the skilled diagnostician gets his most yalued information, is difficult even to demonstrate and almost impossible to describe. Hence the account of it in this and other books is very brief when compared with the space allotted to the methods of examining the chest. ^ The table or bed on which the patient lies during most abdominal examinations (excluding gynaecological work) should be at least three feet high, narrow, and^rw. Most beds are too low, too wide, and too soft; but, on the other hand, the patient must not be made uncom- fortable by the hardness or coldness of the surface on which he lies. A comfortable pillow should be provided. (a) Inspection. We need a tangential light, such as accentuates by shadows every unevenness of the surface. If the patient is examined in the ordinary dorsal decubitus, the light from any single window, except one overhead, is satisfactory. If one inspects the abdomen ' Summarized in his "Mechanical Factors of Digestion:" Longman's, 1911. ' I have heard a physician in a leading American city say that when palpation of the spleen in typhoid fever was first introduced, there was but one physician in the city who had the knack, and that his colleagues were very sceptical about the possibility of accom- plishing the feat at all. I have seen a similar uncertainty regarding the palpation of the normal but slightly displaced right kidney. 347 348 PHYSICAL DIAGNOSIS with the patient upright, he should stand with his side to the light, not facing it. By inspection we seek information on : (o) The general contour of the abdomen. (6) The surface of the belly walls, especially the skin and the navel. (c) Respiratory movements, their limitation or absence. (d) Peristaltic movements (gastric or intestinal in origin) . (e) The presence of local prominence or (rarely) depression. Inspection of the Belly Wall. — i. The surface of the belly wall is often searched most carefully for the rose spots of typhoid fever, which are hypersemic, very slightly elevated spots, about the diameter of a large pin head (2-4 mm.). They disappear on pressure. Pimples are usually larger, better defined at the edges, and more highly colored, contrasting with the very pale red of most rose spots. They are by no means confined to the belly and may be found exclusively on the back. Having been at the outset somewhat sceptical of their value in diagno- sis, I have become thoroughly convinced by greater experience and more careful examination. Richardson' has shown that they often contain bunches of typhoid bacilli. The spots are present in about three-fourths of all cases, and, while they also may occur in any dis- ease when the blood contains bacteria (e.g., sepsis), they are common- est in typhoid. 2. Distended and tortuous veins on the abdomen are seen in dis- eases obstructing the portal circulation (rarely in cirrhotic liver) or the inferior cava (see Fig. 77). 3. Striae, or linear markings on the skin of the abdomen, follow the subsidence of any long-standing trouble that stretches the skin — pregnancy, obesity, tumors, etc. They are red, are angry when first produced, but later turn white {linece alhicantes). 4. Scars of old wounds or operations may be of great diagnostic value in comatose or delirious cases. 5. Projection or levelling of the normal depression at the navel is evidence of distention, usually by fluid, within the belly. Respiratory movements of the belly walls are limited or cease in painful diseases within the peritoneum (peritonitis, lead colic) or when the diaphragm is pushed up by a large tumor, ascites, or meteorism. Peristaltic waves creeping along beneath the belly walls are seen with chronic stenosis and obstruction at the pylorus or at some point in the colon and occasionally in thin but healthy persons. Hernia and local and general prominences will be discussed in connection with abdominal tumors (page 344) . ' M. W. Richardson: Pennsylvania Medical Journal, March 3, 1900. THE ABDOMEN IN GENERAL 349 (6) Palpation.^ With the patient on the back upon a suitable bed or table, ^ the head on a comfortable pillow, and the abdomen exposed, run the palm of the hand (warm) lightly over the whole surface, to accustom the muscles to its presence. ' Then try whether better relaxation of the belly walls is obtained when the patient's knees are drawn up. Some patients relax better in this position ; others when the legs are extended. If the muscles of the abdomen remain contracted and stiff even when the patient is comfortable and has become accustomed to the presence of the physician's hand, we may try to induce relaxation: (a) By getting the patient to take a series of deep breaths. (b) By diverting his attention through conversation of otherwise. If these means fail and it is important that we should thoroughly investigate the abdomen, we have left two further ways of producing relaxation, viz.: (c) By putting the patient into a warm bath. (d) By anaesthesia (ether or chloroform) . The movements of the physician*s hand should never be sudden or rough. He should avoid digging into the skin with his nails or pressing strongly on a small spot with the finger-tips. If any spot be suspected to be tender, that should be palpated last, after going over the rest of the abdomen. If it is necessary to make deep pressure at any point, it is best to lay the fingers of the left hand loosely over the spot and then exert pressure upon them with the fingers of the right "^hand. The passive hand is more sensitive. To reach a deep spot, put the hands in this position over it, ask the patient to take a long breath, and, as the belly falls in expiration, follow it down with the hands. Then hold what you have gained, and with the next full expiration you may be able to get in still deeper, until after a series of deep breaths the desired spot is reached. Naturally this cannot be done if there is much tenderness, but pure nervous spasm may sometimes be overcome in this way. To make use of the relaxation secured by a hot bath, we need an unusually long tub, so that the patient can lie almost flat when his knees are slightly drawn up. If he is doubled up with his knees and ' Special methods of palpating a diseased kidney, spleen, or liver are described in the sec lions on those organs. ' It is essential that the physician as well as the patient should be comfortable during an abdominal examination, else' his attention is not wholly on his work. Hence the impor- tance of a high, narrow bed, or table, so that the physician need not stretch or stoop to reach the patient. 350 PHYSICAL DIAGNOSIS head in close proximity, nothing can be accomplished. The patient gets into the tub with the water comfortably warm, and its tempera- ture is then raised to between i io° and 120° F. by pouring in very hot water. The greatest relaxation is usually attained after about ten minutes' immersion. When women are examined the water can be rendered opaque by adding milk or soap suds. This method is far less inconvenient than etherization, and is especially. valuable when the recti are well developed and form rounded, tumor like masses as soon as ordinary palpation is attempted. If we suspect that a tumor-like mass may be one of the bellies of the rectus, it is well to grasp the mass with the hand and then ask the patient to raise his head. The mass will harden suddenly if it is the rectus. 2. What' can be Felt Beneath the Normal Abdominal Walls. No part of the normal intestine, including the appendix, can, in my opinion, be felt through the abdominal walls. The same is true of the stomach, spleen, left kidney, pancreas,' bladder, and pelvic organs. All that we can make out in most normal cases is : 1 . The abdominal aorta. 2. The spinal column, near and above the umbilicus. 3. Part of the liver (occasionally, if the costal angle is sharp and the belly walls are thin and lax) . 4. The tip of the right kidney (in many young persons) . 5. Gurgling and splashing in the stomach or colon. 6. The ilio psoas muscle and sometimes the beginning of the iliac arteries in thin people. The aorta is too deep to be felt at all in some persons, but, on the other hand, it is astonishing how close under the belly wall it is in others, i.e., in those whose dorsal spine projects sharply forward. In such persons the aorta may be almost taken in the hand, and its course, calibre, and motions are so startlingly evident that it is often mis- takenly supposed to be the seat of an aneurism, especially as a sys- tolic murmur and thrill can be appreciated over it if a little pressure is exerted, so as to produce an artificial stenosis. Behind and beside the aorta we can sometimes feel the bodies of the vertebrae, and on them trace the division of the aorta into the com- mon iliacs. The liver cannot be felt at all in the great majority of normal per- » Leube believes that in very thin subjects the head of the pancreas may occasionally be THE ABDOMEN IN GENERAL 351 sons, but occasionally the costal angle is so sharp that a small portion of the organ is palpable in the epigastric region. Bimanually (see below, page 391) the tip of the normal right kid- ney may often be caught between the hands at the end of a long inspira- tion, especially in thin people with lax belly walls. If the stomach or colon contains fluids, the palpating hand often elicits sounds corresponding to the movement of these fluids. Their only importance in diagnosis will be mentioned on page 352. Very deceptive often are muscular bundles in the external oblique, which seem distinguishable as sausage-shaped tumors, and doubtless give rise to some of the legends about feeling the normal appendix. 3 . Palpable Lesion of the Belly Walls. The occurrence of lesions, to be recognized mainly by inspection and percussion, has been discussed (page 339). Besides these we search for : I. Hernice, epigastric or umbilical (see Fig. 197). The diagnosis rests on the presence of an impulse on coughing, with or without a reducible tumor. Omental herniae do not bulge with cough. Fig. 197. — Epigastric Hernia. 2. Separation of the Recti. — When the patient, lying on the back, lifts his head and shoulders, a longitudinal wedge bulges out along the median line of the belly from the gastric to the suprapubic region. 3. Abscess of the abdominal walls usually represents a stitch abscess or the external vent of pus burrowing from the appendix, the pelvis, or the prevesical space. But in about one-third of the cases no such cause can be found. An infected hsematoma due to trauma or without known cause explains some cases, and occasionally tuberculosis or 352 PHYSICAL DIAGNOSIS actinomycosis occurs. The latter conditions are recognized by the microscopic examination of the pus and of the abscess wall. 4. Sarcoma of the belly wall is rather rare, and can be recognized with certainty only by microscopic examination; without this I have known it to be confused with lipoma and with tuberculosis. 5. Thickening or inflammation at the navel occurs in some cases of cancerous or tuberculous peritonitis. The diagnosis rests on the further evidence of cancer or tuberculosis within the peritoneal cavity and on the microscopic examination of a piece excised for the purpose. Palpation of the Spleen (see page 386). Palpation of the Liver (see page 364). Palpation of the Kidney (see page 391). 4. Study of Abdominal Tumors. One should notice : Size, contour, consistency, mobility with pressure and with respiration, tenderness, pulsation, peritoneal crepitus, adherence to the skin or to the abdominal wall, relationship to any abdominal organ (also dulness or resonance on percussion, see below, page 346) . Most of these points need no comment. To ascertain whether the tumor involves the skin, one lifts up a fold of skin crossing the mass. If the skin dimples markedly over the tumor, i.e., fails to rise at that point while on all sides of the mass it can easily be picked up, the skin is adherent. Tumors in the abdominal wall can usually be gathered up along with the lat.ter when we grasp a large fold with both hands. To determine the relationship of a tumor with the liver or spleen we note: (a) Whether a groove or interval can be made out, by palpation or percussion, between the mass and either of those organs. (b) Whether its respiratory mobility is as great as theirs. (c) Whether there are other facts in the case suggestive of hepatic or splenic disease (jaundice, ascites, leuksemic blood). (d) The effect of inflation of the colon (see below). Tumors con- nected with the spleen are forced forward and do not become resonant when the colon is inflated. To determine the degree of respiratory mobility, hold the fingers of one hand in contact with the lower edge of the mass and allow them to descend with it while the patient takes a full breath. To make sure that an actual descent occurs, one must sight the mass (and the hand) against some motionless object in the room beyond, else one may be decieved by the movement of the abdominal walls over the tumor, THE ABDOMEN IN GENERAL 353 while the tumor itself remains motionless or nearly so. Tumors con- nected with the stomach, omentum, liver or spleen move about two inches with a forced inspiration. Kidney tumors move less, seldom as much as an inch. Pancreatic and retroperitoneal tumors have scarcely any mobility. Those connected with the intestine vary con- siderably in respiratory mobility, according to the presence and degree of adherence to other parts, but their excursion is rarely an inch. Peritoneal crepitus is a grating, rubbing sensation experienced on light palpation, and due — supposedly — to the presence of a plastic, peritoneal exudate similar to that which produces the friction sounds Fig. 198. — Diastasis recti. in pericarditis. Over an enlarged spleen (e.g., in leukaemia) peritoneal crepitus may be due to local perisplenitis, and in perigastritis, peri- hepatitis, and perienteritis similar crepitus occurs. Dipping refers to a sudden displacement of the abdominal wall and whatever lies close beneath it, by a swift poke of the finger tips, which may succeed thereby in touching a solid organ or tumor which gentle, gradual palpation misses. Thus one may reach and mark out an enlarged liver through a layer of ascites which would prevent ordinary palpation. 23 354 PHYSICAL DIAGNOSIS (a) Percussion. Abdominal percussion is less valuable than thoracic. A lighter blow is used, and the distinction between dulness and tympany is easy. It is of value chiefly to determine the presence of fluid free in the peritoneal cavity, and to ascertain whether a tumor is due to or cov- ered by gaseous distention. (a) Free fluid (ascites, peritonitis, hsemoperitoneum, ruptured cyst), gravitates to the flanks and suprapubic region, while the intes- tines float up and occupy the epigastric and umbilical space. Hence there is dulness in the flanks and over the pubes, with resonance in the epigastric and umbilical regions. But the crucial and ever-necessary test is the shifting of this area of dulness when the patient turns on his side; then the uppermost flank should become resonant and the lower half of the belly — including part of the umbilical region — dull. With- out this test the mere marking out of dull areas in the flanks is not conclusive evidence of free fluid there. Occasionally one is deceived by the shifting of a distended colon or a mass of small intestines con- taining fluid. Still less reliable is the "fluctuation wave," which can be transmitted as an impulse palpable to the hand laid flat on one flank, by sharply snapping the other flank. Similar impulses can be transmitted through the fat of the belly wall, despite all efforts to check them by pfessure upon the latter. (6) Percussion is our final test in the diagnostic procedure that begins with inflation of the colon. Air is forced into the rectum with an ordinary Davidson syringe, and, as the colon becomes prominent and hyperresonant, we note whether its tympany covers up the tumor- mass under investigation, or whether the mass lies anterior to and remains dull over the inflated colon. Kidney tumors lie behind the inflated colon; splenic tumors remain dull in iront of it. Auscultatory percussion, for identification or demarkation of ab- dominal tumors and organs, has never been successful in my hands nor in those of most of the observers in whose results I have confidence. Hence I omit further description of it. Percussion of the stomach and spleen (see below, pages 351 and 387). Percussion of Traube's semilunar tympanitic space (the small area bounded on the right by the splenic and on the left by the hepatic dulness, above by the free edge of the left lung, and below by the lower edge of the ribs) is, in my experience, of very little value in diagnosis. This tympanitic area is obliterated in many pleuritic effusions (not in all), but many other causes (full stomach or gut, obese omentum) may produce similar dulness. .THE ABDOMEN IN GENERAL 355 Before describing the signs of the different diseases to which the abdominal organs are subject it seems to me best to introduce here a list of the commoner abdominal tumors found in the study of 4876 such tumors at the Massachusetts General Hospital. Relative Frequency of Abdominal Tumors. I. Congested liver 1288 :i. Uterine fibromyoma 766 3. Hernia 488 4. Ovarian cyst 382 5. Gastric cancer 285 6. Displaced kidney 227 7. Cirrhotic liver 153 8. Cancer of liver 151 9. Cancer of colon ' 90 10. Abscess of abdominal vsrall 79^ 11. Splenic tumor in cirrhosis of the liver 60 12. Leukaemic spleen 58 13. Malignant tumor of the ovary 43 14. Tuberculous kidney 41 15. Tumor as part of tuberculous peritonitis 33 16. Cancer of the pancreas 32"= 17. Neoplasm of the kidney 27 18. Sarcoma of abdominal wall > 27 19. Enlarged spleen of unknown cause 26 20. Omental cancer 18 21. Intussusception 17 II. ■ Diseases of the Peritoneum. 1. Peritonitis — ^local or general. 2. Ascites. 3. Cancer and tuberculosis. I. Peritonitis. I. Local peritonitis gives evidence of its presence by (a) pain, (6) tenderness, (c) muscular spasm, (d) tumor, and (e) constitutional manifestations. The pain may be at first diffuse, later localizing itself at the site of -the lesion; or it may be felt first where the peritonitis begins and spread with the lesion if the general peritoneal cavity becomes involved. The character and intensity of the pain vary greatly. ' Some of these were so small as hardly to deserve classification as tumors. ' Rarely produces a palpable tumor but is here mentioned for convenience. 356 PHYSICAL DIAGNOSIS Tenderness is the important sign in diagnosis, and helps us to exclude the various colics and other causes of pain which are often relieved by pressure. Local muscular spasm of the belly muscles to guard the tender le- sion be:(>eath is of great value in pointing our attention to the spot affected, though the muscles may be so rigid as to prevent palpation through them. [Psoas spasm is described in the section on Appendi- citis, see page 377.] The iumor is apt to consist of intestine or other organs matted together by adhesions about the site of the process. The constitutional manifestations are those of infection, viz., fever, leucocytosis, anorexia, constipation, often albuminuria and albumosuria. The commonest causes of local peritonitis are: 1. Appendicitis. 2. Pus tube. 3. Gall-bladder inflammation. Less common is cancer or ulcer of the stomach or intestine. 2. General Peritonitis. — The belly may be generally swollen and tympanitic or retracted and hard. General tenderness is the most im- portant sign. In advanced cases, free fluid in the flanks may be demon- strated, as explained on page 346. Faeces and even gas cease to move, as the intestines are paralyzed. Vomiting is the rule, and soon be- comes very foul (stercoraceous) . There is fever, with a rapid and very weak pulse. The mind is clear, alert. The facial expression is not peculiar and may be normal. If there is persistent vomiting the facies of that condition appears, viz., a drawn, pinched, anxious look, with dark circles under the eyes. The nausea and the rapid loss of fluid by vomiting account for these appearances. The leucocyte count is generally elevated, but in the most viru- lent cases remains normal or subnormal. 2. Ascites. The commonest causes are: (i) Dropsy, from cardiac, pericardial, or renal disease. (2) Portal stasis, usually from cirrhosis of the liver. (3) Tuberculous peritonitis. (4) Cancer of the peritoneum. (5) Solid ovarian tumors. The methods of diagnosis of ascites have been explained above. THE ABDOMEN IN GENERAL 357 The diagnosis of its cause depends on the history, the results of punc- ture, and the general physical examination. The contour of the belly is often that pictured in Fig. 199. 3. Cancer and Tuberculosis oj the Peritoneum. In connection with cancer or tuberculosis of some abdominal or pelvic organ, the disease may become spread throughout the perito- neum with deposits in the omentum and mesentery. The signs are: I. Tumor masses scattered here and there, sometimes at the navel. 2. Ascites. 3. Emaciation and anaemia. The diagnosis of cancer depends on the recognition of multiple, hard, nodular tumors in the abdomen of a patient known to have cancer of some abdominal organ. Somewhat similar masses, usually due to loops of intestine matted together by adhesions, may be felt in tuberculous peri- tonitis, but here they are larger, fewer, and not so hard. Cancer appears in late life, tuberculous peritonitis usually in early life. The emaciation and anaemia are less marked in tuberculosis, and fever is more marked. The history or present evidence of tuberculosis elsewhere — lung, pleura, glands, pelvis, testis — favors the diagnosis of tuberculous peritonitis. Cytodiagnosis and the tuberculin test may be of value in diagnosis. Subphrenic Abscess. — There are two common types — the one near the liver, the other near the spleen. (a) The perihepatic type is recognized, as a rule, chiefly by its etiology (perforated gastric ulcer, appendix-abscess), by the constitu- tional signs of concealed pus (fever, chills, leucocytosis), and to a less extent by physical signs, none of which, however, serves to distinguish perihepatic from intrahepatic pus. Pain in the hepatic region, promi- nence of the right lower ribs or right hypochondrium, increased area of percussion dulness over the lower ribs in front and behind (whence empyema or pneumonia is often suspected) , and the results of x--ray examination are the data from which we must reason. (See Fig. 193.) (6) The perisplenic type of abscess follows a general peritonitis, Fig. 199. — Cliaracterislic Shape of Belly in Ascites. 358 PHYSICAL DIAGNOSIS which has been treated by drainage and recumbency. The pus becomes pocketed near the spleen instead of gravitating toward the pelvis as it does if the patient's trunk is kept upright. Pain, sometimes tenderness, the history of the case and the consti- tutional evidence of concealed pus are the facts on which a conjecture may be hazarded. The Mesentery. 1. Enlarged glands — tuberculous, cancerous, or lymphomatous — can occasionally be felt in very thin patients. Their recognition as glands would depend on more obvious evidence of their cause in other parts of the body. 2. Mesenteric thrombosis produces all the signs of intestinal ob- struction (see below, page 378), from which it can rarely be dis- tinguished without operation or autopsy, except when it occurs as a complication of mitral stenosis, when we are on the watch f6r em- bolism of the brain, extremities and mesentery. CHAPTER XXII. THE STOMACH, LIVER, AND PANCREAS. I. The Stomach. The best methods of examining the stomach are : 1. Inspection and palpation of the epigastrium and the neighbor- ing portions of the abdomen. 2. Bismuth — a;-ray examination. 3. Examination of the stomach contents: (a) fasting; (b) after a test meal. By combining the results of these three methods of examination with the results of our general examination of the body — emaciation, anasmia, etc. — and with the data obtained by a careful history, we ob- tain all the information about the stomach which it is possible for us to make use of at the present time. I . Inspection and Palpation of the Epigastrium. (a) Tenderness. — ^The normal stomach cannot be seen pr felt, nor can anything certain be learned in regard to it by percussion or auscul- tation. Tenderness in the epigastrium is so common that we can attach no significance to it. In a small proportion of cases cutaneous tenderness in the back (lower dorsal or upper lumbar region) can be elicited in cases of peptic ulcer, but this has no value in diagnosis. (6) A tumor in the epigastrium (see Fig. 200) is of far greater impor- tance than any other local evidence. If it occurs in an emaciated and anaemic person past middle life, is hard and nodular, and does not disappear after catharsis, it is almost invariably due to cancer of the stomach. Such a tumor may also be due to a mass of adhesions about a gastric ulcer. Tumors of the pancreas much less often reach the surface in this region; tumors of the liver are generally larger, and their connection with this organ can generally be demonstrated by percussion, palpation, and by their greater respiratory mobility when compared with gastric cancer. Epigastric hernia usually shows an impulse on coughing, is soft and doughy in feel, and presents none of the other symptoms and signs of gastric cancer. 359 360 PHYSICAL DIAGNOSIS Tubercular deposits in the omentum are almost always associated with ascites, fever, and other evidences of tuberculosis either in the examination of other organs or in the history. (c) Visible gastric peristalsis means stenosis of the pylorus (cancer, ulcer, adhesions, or muscular spasm). The contraction wave passes from left to right across the epigastrium, and is seen by means of the shadow cast by a tangential light with the patient in a recumbent position. If the peristalsis stops it can sometimes be reexcited by briskly snapping the epigastric region with the finger. Fig. 200. — Epigastric Tumor in Gastric Cancer. (d) The normal splash sound can usually be heard if sudden, quick pressure is made in the epigastrium within three hours after a meal. If splashing can be elicited more than three hours after a meal, and especially if it is present before breakfast, it is evidence of gastric stasis and usually of dilatation. (e) Hypogastric bulging due to dilated stomach is occasionally seen in cases of marked dilatation when the patient stands up, and is exam- ined in profile (see Fig. 201). 2. V se 0} the Stomach Tube. (a) The passage of the tube. The standard red rubber ttibc gener- ally in use in this country' comes in two sizes. Personally I prefer the larger, with a lateral as well as a terminal opening at the lower end, although the smaller size i^-oduccs somewhat less discomfort. The i3aticnt should be covered by a rubber sheet and the clothing removed from the abdomen. So prepared, he should sit in a straight- backed, wooden chair, with a good-sized foot-tub between his feet THE STOMACH, LIVER, AND PANCREAS 361 and a towel in his hand ready to wipe awaj^ the profuse secretions of the mouth and pharynx. He should then be warned that the process of passing a tube, although entirely free from danger, is very disagreeable, both on account of the nausea which it produces and because it often seems to the patient as if he were choking and could not get his breath. This, in fact, is not the case, and if the patient will persist in drawing long, deep breaths throughout the process of passing a tube, the worst of it is over in twenty seconds. Fig. 20I. — Outline of Abdomen in Dilatalion of the Stomach, due to cancer at the pylorus. The tube is moistened with water and pushed straight down through the pharynx without any attempt to direct it, beyond keeping the median line. There is no danger of entering the trachea and no use in trying to avoid it. On its way down the tube is arrested now and then by muscular spasm of the oesophagus, but after a few seconds the spasm relaxes and allows us to push the tube on until the twenty- two-inch mark reaches the teeth. The lower end of the tube is then in the stomach,' and we are ready to extract the gastric contents (in 'Unless there is gastric dilatation or gastroptosis; then the tube must be pushed in several inches farther, the distance depending on the position of the lower gastric border, as determined in previous examinations. 362 PHYSICAL DIAGNOSIS case a test meal has been previously given) , to wash out the organ, or to distend it with air or water. Since the passage of the stomach tube is the means whereby we become sure of the existence of such diseases as cardio-spasm, diverticulum of the gullet and cancerous stricture of the gullet, some account of the diagnosis of these diseases will be given here. Cardio-spasm with Dilatation of the CEsophagus. — ^Plummer has reported 40 cases seen in the Mayos' clinic within two and a quarter years. Hence the disease cannot be a rare one though there are less than 200 more cases on record. The patient complains that food sticks, causing discomfort at the lower end of the sternum and later regurgitating unmixed with acid juice. The cases usually begin at so early an age (29 is the average) and are usually chronic enough when seen to exclude a cancerous stricture, but as a rule the first reliable evidence on this point is obtained when we find that : 1. A stomach tube will not pass while a large sound properly guided by a thread (see below) passes fairly easily. 2. Great and long-continuing relief is obtained by dilating the stricture a few times with water pressure inside a silk covered rubber bag. Radiography of a bismuth meal and the use of the cesophagoscope are supplementary aids to diagnosis. If there is any difficulty in reaching the stomach, a silk thread six yards long is swallowed. After the lower end has passed into the gut the upper end can be pulled taut and on it as a guide a sound and subsequently a dilator can be passed. Diverticulum of the CEsophagus. — Most diverticula are so high up in the gullet that they are easily recognized by radiography and sounding. The rarer diverticula low down in the oesophagus can also be recognized in most cases by radiographing a bismuth meal or by the silk thread method above described. The thread guides the sound past the opening of the diverticulum. Cancer of the (Esophagus. — The age of the patient and the duration of symptoms usually differentiate cancer of the gullet from cardio- spasm. In doubtful cases the fact that sounds even when accurately guided do not pass much more easily than the soft rubber tube favors the diagnosis of cancer. (6) Extracting the Gastric Contents. — One hour after a test meal the tube is passed and the patient is then asked to lean forward, press with his hands upon his stomach, and strain down as if he were going to have a movement of the bowels. In most cases this suffices to force THE STOMACH, LIVER, AND PANCREAS 363 the gastric contents out through the tube and into a basin, which is held ready. If the gastric contents cannot be extracted either in this way by having the patient lie down or by moving the tube in the pharynx so as to excite nausea, we should make sure first that the eye of the tube is not plugged. This may be ascertained by disconnecting the funnel and blowing through the tube, which usually suffices to discharge any obstacle from the eye of the tube. If still the gastric contents do not flow out, we may use suction by connecting a Politzer air-bag with the end of the tube in place of the funnel. For the analysis of the contents so obtained, see below, page 356. (c) Washing the Stomach (Lavage). — -Though not of much use this procedure may be briefly mentioned here. After introducing the tube as above described, about a pint of water is poured in, through the funnel, and, just before the water disappears in the vortex of the funnel, the latter is rapidly lowered so as to enipty by siphonage into a vessel oh the floor. This process is repeated until food and mucus cease to come out and the water runs clear. To remove the tube at the end of any of the procedures just de- scribed, we have only to pinch it tightly just outside of the patient's teeth and pull it rapidly out. 3. Examination of Gastric Contents. 1 . The contents of the fasting stomach are best obtained by passing the tube before breakfast, and should consist of no more than a few cubic centimetres of clear fluid containing free hydrochloric acid. If any food is present, gastric stasis is proven. If more than 50 c.c. of fluid without food are present, hypersecretion is indicated. 2. Gastric Contents after a Test Meal. — The best test meal is that of Ewald, and consists of a slice of bread (or its equivalent in crackers or cereal) with a glass and a half of water. After this meal not more than 100 c.c. should be found in the stomach at the end of an hour. Occasionally the stomach has emptied itself even within the hour, and we have then to reduce the period. After extracting the gastric contents as above described and noting the quantity, we should investigate also their color, odor, and general appearance, (a) Small streaks of blood are of no consequence. Considerable quantities of blood (fresh) suggest ulcer. Small quanti- ties of dark-brown substance resembling blood should be investigated by the guaiac test. If this is positive, gastric cancer is suggested. The guaiac test is best performed as follows : Chip off the oxidized 364 PHYSICAL DIAGNOSIS outer shell of a lump of gum guaiac and prepare a fresh tincture by shaking a few chips of the inner non-oxidized guaiac with a few cubic centimetres of alcohol. Add about lo drops of this tincture and 2 c.c. of hydrogen peroxide to an ethereal solution of the gastric contents prepared by extracting 10 c.c. of gastric contents with 2 c.c. of glacial acetic acid and 15 c.c. of ether (shake 5 minutes). On adding the guaiad to the ethereal solution of gastric contents a blue color indicates the presence of blood. (b) For acetic and butyric acids we test merely by our sense of smell. Whenever stasis or fermentation has occurred, we are apt to get a characteristic odor of these acids mingled with that of yeast. (c) The general appearance of the contents tells us little that is important. In cases of marked dilatation they often separate into three layers — the upper frothy, the middle a thin, turbid liquid, and the lower a flocculent sediment of partially digested food. Mucus is not of any considerable clinical significance unless it is so abundant that the whole stomach contents will slide in one lump from one beaker to another. When absolutely no digestion has taken place, as in the rare cases of achylia gastrica, the contents consist simply of unaltered bread and water. (a) Chemical Tests of Gastric Contents. 1 . Dip a piece of blue litmus in the contents; if no reddening occurs, no further tests need be made. 2. If the contents are acid to litmus, test with Gunzburg' s reagent (phloroglucin, 2 gm. ; vanillin, i gm. ; alcohol, 30 gm.) , by mixing two drops of it with an equal amount of gastric contents (unfiltered) upon a white porcelain plate or dish, and evaporating slowly over a flame.' If free HCl is present, a bright rose pink appears. In the absence of free HCl, the color is a dirty yellowish-brown. If this test is positive, we need make no further tests except the following: {h) Quantitatiue Estimation of free HCl and of Total Acidity. To 10 c.c. of unfiltered gastric contents add four drops (about) of Topfer's reagent (dimethyl-amido-azo-benzol : 0.5 per cent alcoholic solution) in a beaker; a carmine-red color results. Fill a graduated burette with decinormal NaOH solution, and let it run out into the ' The same test may be performed on a glass slide which is subsequently put upon a piece of white paper to bring out the color. THE STOMACH, LIVER, AND PANCREAS 365 beaker, a few drops at a time, until the carmine-red color disappears. While titrating stir the mixture constantly with a glass rod. Note the number of cubic centimetres of NaOH that have run out.^ To estimate the quantity of free HCl, multiply the number of cubic centimetres of NaOH used in the titration by 0.0365; the result is the percentage of free HCl. Normal free HCl varies from 0.07 to 0.2 per cent, or from 2 to 6 c.c. of decinormal NaOH for 10 c.c. of gastric contents. The estimation of combined HCl and of the acid salts is seldom of importance. Total acidity is determined by adding to the same beaker of contents in which the free HCl has just been neutralized two or three drops of a one-per-cent solution (alcoholic) of phenolphthalein, and continuing the titration with the NaOH solution (and constant stirring) until a permanent red color appears. By multiplying the number of cubic centimetres of NaOH used from the beginning of the first titration up to the point when the red color reappears by 0.0365, we obtain a figure I presenting the percentage of total acidity. The normal range of total acidity is from 0.15 to 0.3 per cent, and we usually find that we have used from 4 to 8 c.c. of the NaOH solution in the process of neutralizing 10 c.c. of gastric contents. Lactic acid is to be tested for only when HCl is absent. The test must be made at once, since lactic acid soon develops in stomach contents which are kept in a warm place. To perform the test, we dilute a solution of FeCl (strong aqueous) with water until a faint yellow color barely remains. Then fill the concavities of two test tubes with this solution, using one for comparison. If, on adding a few drops of stomach contents to the other, a considerable intensifica- tion of the yellow color occurs, lactic acid is almost certainly present. A negative test rules out lactic acid. The sediment need not be examined. It is true that sarcinae and various bacteria (Boas-Oppler bacillus and others) are often found in cases of gastric stasis, but they add little if anything to the other evi- dence of stasis more easily obtained — i.e., the symptoms mentioned on page 362, the presence of splashing more than four hours after a meal, ' An ordinaxy medicine-dropper may be substituted for the burette if we get an apothe- cary to mark with a file upon it the point to which a (previously measured) cubic centimetre of water rises when sucked into the dropper. The half-centimetre point can be similarly marked. Decinormal NaOH solution is then sucked into the dropper and expelled, one- half centimetere at a time, into the beaker containing the Tbpfer's reagent and gastric contents. 366 PHYSICAL DIAGNOSIS the evidence of dilatation or gastroptosis as given above, and the find- ing of organic acids. In my own practice I have discarded the use of test meals and chemical analysis. History, physical examination and x'-ray are suffi- cient for all the diagnosis that we can use. The minor variations in the chemistry and physics of the stomach are not in my opinion sig- nificant. vStill I am not prepared yet to omit all description of these methods. 4. X-ray Examination of the Stomach. From two to four ounces of barium sulphate suspended in milk or gruel are taken on an empty stomach (say at 5 a. m.). Six hours later the patient is radiographed in the upright position. There should G G G G Fig. 202a. — Radiograph of Normal Stomach After Bismuth. B. First Portion of Duodenum. P. Pyloric Ring. C, C. Normal Contraction Rings. G, G, G, G. Bismuth in Gut. be then no bismuth residue in the stomach. The presence of any such residue is strong evidence that stasis and, therefore, some of the causes of stasis, — gastric cancer, peptic ulcer (gastric or duodenal), adhesions or ptosis, are present. Immediately after this test for stasis, a second bismuth meal is given and the patient is then radiographed at frequent intervals there- THE STOMACH, LIVER, AND PANCREAS 367 after in search of departures from the normal shape assumed by the bismuth shadow under these conditions and corresponding to the outline of the stomach's interior during peristalsis. If the patient is radiographed lying down, great care should be taken to avoid pressure upon the stomach through the abdominal wall. By such pressure the gastric shadow may be so deformed as to simulate hour-glass stomach and other abnormalities. The tube is to be focussed in all cases upon the third lumbar vertebra, and neither this focus nor the Fig. 202b. — Radiograph of Stomach After Bismuth-Meal. P. Pylorus. A. Loss of outline proved at operation to be due to cancer of the greater curvature and anterior wall. D. Duodenum. patient's position must change; great distortion of the picture and many false inferences result from failure to follow these rules. In a satisfactory picture of the stomach one should be able to make out the unbroken outline of the organ indented only by one or two contraction waves. The pyloric sphincter and portion of bismuth just beyond it in the duodenum (the "Bishop's cap") should be visible (see Fig. 202a) . If these are not to be made out, or if there is a marked interruption of the normal outline of the stomach shown in the same place in all the plates taken, cancer or ulcer may be suspected (see Fig. 202b). The changes to be found in peptic ulcer are a filling, defect or irregu- larity in outline and a bismuth residue are visible at the end of six hours. These facts, together with the history and physical examina- tion suffice for diagnosis in almost every case. 368 -PHYSICAL DIAGNOSIS 5. Incidence and Diagnosis of Gastric Diseases. In the wards of the Massachusetts General Hospital the number of cases apparently of gastric disease treated between 1870 and 1905 was as follows: Cancer 403 Ulcer S36 Dilatation, cause not determined 170 Dyspepsia' ^1°°^ Total 2. Ill The data at our disposal are as follows: 1 . The history (most important of all) . 2. The local and external examination of the epigastric region. 3. The estimation of the size and motor power of the stomach. 4. The examination of the gastric contents. (a) In advanced cancer of the stomach we have pain, emaciation, anaemia, symptoms of fermentation (see page 362), often dilatation and motor insufficiency due to pyloric stenosis, sometimes absence of HCl in the gastric contents (only eighty out of six hundred and fifty cases reported from the Mayos' clinic by Graham and Guthrie showed no HCl), and in about two-thirds of the cases the presence of digested blood ("coffee grounds") in the gastric contents and occult blood (guaiac) in the faeces^ X-ray usually shows stasis and a defect in the normal outlines. But without the presence of an epigastric tumor all these facts are insufficient for diagnosis. Even the tumor itself may deceive us, as the adhesions around a gastric ulcer may present a similar mass to the palpating hand. The age of the patient is of great importance, especially if during the earlier decades of life he has been totally free from gastric symp- toms. Any type of dyspepsia, any sort of genuine gastric trouble,'^ occurring in a person over forty who has never had any such trouble before, is strongly suggestive of cancer. (6) Peptic Ulcer, gastric or duodenal. — Physical examination usually shows us very little. The diagnosis rests upon the history. Contrary to the usual belief HCl is normal or subnormal in nearly three-fourths of the cases. Occult blood is occasionally found and the stomach may show stasis. The vomiting of blood is infrequent (about twenty-five per cent.). X-ray evidence is very helpful. '■I.e., cases of painful digestion including anomalies of motion, sensation, secretion "gastritis" and "gastric catarrh," but without evidence of ulcer or cancer. ^We must exclude angina pectoris and nephritis as well as gall stones and their effects. THE STOMACH, LIVER, AND PANCREAS 369 (c) Pure functional hyperacidity is not common but may produce symptoms indistinguishable from those of ulcer. (d) Hypoacidity and achylia gastrica are not characteristic of any gastric disease. They are common in alcoholism, in all types of anaemia, in tuberculosis, diabetes, and nephritis, as well as in gastric cancer. (e) Gastric dilatation, when considerable, is almost always second- ary to pyloric obstruction (due to cancer, ulcer, or adhesions) . Sjmip- toms suggesting it are the vomiting at one time of a large quantity — a quart or more — of stomach contents, often containing fragments of food eaten more than eight hours previously. Such attacks of vomit- ing occur usually not after every meal, but at longer intervals. It is to be positively diagnosed by passing a tube and distending the stomach with air or water. (/) Gastric stasis occurs with more or less constancy in almost every disease of the stomach and in many general constitutional diseases (tuberculosis, ansemia, general debility) . It constitutes what is usually referred to by patients as "indigestion," "dyspepsia," or "sour stomach." Fermentation of stomach contents too long retained is the essential point. This results in a sense of weight and pressure in the epigastrium, eructations of gas and of sour or burning fluids, loss of appetite, nausea, and vomiting. The tongue is generally furred and the bowels are constipated. Headache, vertigo, and depres- sion of spirits often accompany it. II. The Liver. The Massachusetts General Hospital records (1870-1905) show the following figures bea ing on the incidence of diseases of the liver: Pa=si e congestion 1,288 Portal cirrhosis 234 Biliary cirrhosis (Hanot' .) o Cancer of the liver 184 Sarcoma of the liver 2 Abscess of the liver 51 Leukaemic infiltration 46 Pseudoleukaemic infiltration 10 Amyloid infiltra ion 9 Fatty infiltration 6 Hydatid cyst 8 Syphilis 8 "Simple cyst" 6 Actinomycosis 3 Acute yellow atrophy 2 Tuberculosis i Total 1,858 24 370 PHYSICAL DIAGNOSIS Diseases of the Gall Bladder and Bile Ducts. Cholelithiasis 457 Acute cholecystitis "o Catarrhal jaundice 125 Cancer of gall-bladder or ducts 47 Cholangitis 9 Total 701 The evidences of liver disease may be either local or general. Local signs include: (a) Pain and tenderness in the hepatic region, (6) Enlargement of the organ, symmetrical or irregular, (c) Atrophy of the organ. The general signs which assist in the diagnosis of liver disease are: {d) Portal obstruction, (e) • Jaundice, including changes in the color of the skin, mucous membranes, and excretions. (/) Loss of flesh and strength, (g) Evidences of infection (fever, leucocytosis, chills, sweats, anorexia). Qi) Cerebral symptoms (headache, vomiting, depression, delirium, convulsions, coma). The various attempts to test the liver functions by chemical examination of urine and faeces have not as yet been successful; hence all diagnoses of liver disease must be built up of the above eight groups of data. I. Hepatic Pain. This forms little or no part of many cases of liver disease, since it occurs only when the capsule is stretched or its nerves are involved in a perihepatitis. Many cases of hepatic, abscess, for example, run their course without pain or become painful only when the pus burrows to the surface and stretches the capsule. Besides this capsule pain in liver disease, we have shoulder pain referred to the right shoulder or to the region of the right scapula, less often to other parts of the back. Capsule pain is most noticeable in cancer of the liver; shoulder pain in abscess. Tenderness is present in the same cases which are painful, i.e., those in which there is perihepatitis or stretching of the capsule by rapidly increasing tension from within. The latter condition is commonest in passive congestion, but is not characteristic of any single disease. 2. Enlargement of the Liver. Tumors behind the liver, pushing it forward and down, are often overlooked, because they bring the liver so prominently into the fore- THE STOMACH, LIVER, AND PANCREAS 371 ground and fasten our attention on what is mistaken for an enlarge- ment of the organ. Wherever the cause of a supposed enlargement of the liver is not obvious, retroperitoneal sarcoma or some other deep- seated tumor should be suspected. I have already alluded to the possibility of mistaking the enlarged liver for empyema, and vice versa (see above, page 329). We are sure of an increase in the size of the liver only when we can feel its edge below the ribs and can determine by percussion that its upper border is not depressed.^ To feel the edge of the liver, hook the fingers of both hands around the margin of the right ribs and ask the patient to take a deep breath. At the height of inspiration an edge may be felt to descend against the fingers and to push its way beneath them. Unless an edge, either sharp or rounded, is felt, one cannot be sure of hepatic enlargement, for percussion of the lower edge of the liver is notoriously unreliable. Dulness below the costal margin is frequently found in cases without hepatic enlargement, and should never be relied on unless the liver can be felt. The long, smooth edge of the liver descending one to two inches with full inspiration is rarely mistaken for anything else, but if the edge is irregular and the surface nodular (see below) it may be hard to distinguish liver from stomach or possibly kidney. If ascites is present, the presence and dimensions of an enlarged liver beneath the fluid can sometimes be made out by dipping (see above, page 345). If this is impossible, the ascites may be tapped, after which it is usually easy to feel any enlargement that is present, as the belly walls are very flaccid. The causes of hepatic enlargement (in adults^), arranged approxi- mately in the order of frequency, are : , I. Passive congestion (later stages of uncompensated heart dis- ease) . 2. Obstructive jaundice (from any cause). 3. Cirrhosis. 4. Fatty liver, including "infiltration" and "degeneration." 5. Malignant disease. 6. Syphilis of the liver (congenital or acquired). ' A normal liver may be pushed down by air, water, or solid tumors in the lung and pleura, so as to be palpable below the ribs; but the evidence of a cause and the low position of the upper border usually make diagnosis easy. ' In infants, rickets, anaemia, and gastro-intestinal disturbances often produce hepatic enlargement, though the splenic enlargement is usually much greater. (The infant's liver is normally \ inch below the ribs in the nipple line.) 372 PHYSICAL DIAGNOSIS 7. Abscess of the liver. 8. Leuksemia and pseudoleuksemia. 9. Cholangitis. 10. Amyloid. 1 1 . Hydatid cysts. The largest livers are found in malignant disease, biliary cirrhosis, and abscess. In passive congestion the liver is very tender, and the presence of uncompensated heart disease^ usually makes the diagnosis easy. The surface of the organ is smooth and firm. In cirrhosis a distinction must be drawn between (a) latent or compensated cases, wholly without symptoms, and (b) uncompensated cases, in which diagnosis depends on the chronic enlargement without any considerable increase under observation, associated with evidence of portal or biliary obstruction {or both) and without much pain or irregularity of the liver. Eighty per cent of the two hundred and thirty-four cases recorded at the Massachusetts General Hospital showed enlargement, and only twelve per cent showed pain (cf. Malignant Disease, below). The fatty liver is soft and smooth in feel. The presence of phthisis or alcoholism makes us suspect this diagnosis, which depends largely on excluding other causes of enlargement. Malignant disease of the liver (cancer or sarcoma) is usually sec- ondary to new growth elsewhere. The liver grows rapidly under observation, is usually painful (80 per cent of 168 Massachusetts Hospital cases) and nodular. Jaundice and irregular fever are present in over one-half of the cases (54 and 62 per cent respectively) , and the loss of flesh and strength is marked. Obstructive jaundice (due to stone, stricture, catarrh, or tumor of the bile ducts, or to any other cause) often produces an enlarged liver. Diagnosis depends on the evidence of a cause for the obstruction and the absence of hepatic nodules, pain, or a rapid increase in the size of the organ. Syphilitic liver may be distinguishable from cirrhosis or from malignant disease only by the Wassermann test and therapeutic test. The history or present evidences of alcoholism or of syphilis are important factors in diagnosis, but, since syphilis may simulate the nodular liver of malignant disease or the general enlargement and portal stasis of cirrhosis, it is essential to give antisyphilitic treatment in all doubtful cases of liver disease. ' Either primary or resulting from chronic bronchitis and emphysema. THE STOMACH, LIVER, AND PANCREAS 373 Abscess of the liver produces enlargement, pain, fever, leucocytosis, and chills in typical cases, but any of these symptoms may be absent and diagnosis is often difficult. Pain is usually absent. The presence of a possible cause (amoebic dysentery, appendicitis) is important evidence. The enlargement is more apt to be upward and to the right than in other liver diseases, since the pus usually starts in the right lobe and bturrows upward. Hence many cases are mistaken for empyema (see above, page 329). Should swelling or fluctuation ap- pear externally the diagnosis is usually obvious, but in most cases this does not occur. Whenever fever, leucocytosis and dulness in the right lower back appear after an appendix operation with drainage, after a dysentery, or after long continued biliary obstruction (gall stone) , hepatic abscess should be suspected. As a rule the diagnosis is made on the etiology rather than on physical signs. Soft new growths and syphilis may be almost indistinguishable from abscess by local signs, but jaundice is much commoner in malig- nant disease and the liver of syphilis is often irregular. The history is of value. Suppurative cholangitis, subphrenic abscess, and pylephlebitis give us practically the same symptoms as hepatic abscess. Amyloid liver is recognized by the presence of an appropriate cause (chronic suppuration or syphilis) and the evidence of amyloid in other organs (enlarged spleen, albuminuria, diarrhoea). The liver is smooth, not irregular as in hepatic syphilis. The leukcemic liver is recognized by blood examination; the pseudo- leukaemic liver by the normal blood and the histological examination of the glandular enlargements which always accompany it. Hydatid cyst is rarely to be diagnosed by physical signs. The history of a residence in Australia, Iceland, certain parts of Germany or of the British Isles, is important evidence, since the disease has never been known to originate in North America. Physical examina- tion may enable us to make out that the hepatic enlargement is due to a cystic tumor, tense and elastic, with notable absence of constitutional disturbances (Rolleston) and often an eosinophilia. 3. Atrophy of the Liver. Diminution in the size of the liver can hardly ever be demonstrated satisfactorily during life, since we must rely upon percussion for our evidence, and percussion of the upper and of the lower border of the liver may be rendered difficult by distention of the lung (emphysema) 374 PHYSICAL DIAGNOSIS or of the colon. Atrophy may be recoguized in a small proportion of the cases of hepatic cirrhosis and in acute yellow atrophy, but is rarely recognized in either condition. The rapidly fatal course of the latter disease with jaundice and a "typhoidal state" contrasts with the prolonged portal stasis characteristic of cirrhosis. 4. Portal Obstruction. A characteristic group of signs manifest the presence of an obstacle to the flow of blood through the portal system. This group includes: 1. Hffimatemesis and dyspepsia. 2. Ascites' (see page 348). 3. Splenic enlargement.' 4. Collateral dilatation of the abdominal veins (rarely seen in life) . Hmmatemesis is usually due to rupture of dilated oesophageal veins, occasionally to gastritis. Splenic enlargement is more marked in the rare cases associated with chronic jaundice {biliary cirrhosis) and without ascites. The cause of portal obstruction is: i. Cirrhosis, in ninety-five per cent of the cases. The remaining five per cent is made up of: 2. Obliterations of the portal vein, usually by thrombosis or tumors. 5. Jaundice. The yellow staining of sclera, skin, and mucous membranes, with or without changes in the color of the urine and fsces, is known as jaun- dice. I have classed it as a general rather than a local sign of liver disease, because it may occur from toxaemia and independent of any lesion of the liver; for instance, in septicaemia, malaria, yellow fever, and pernicious anaemia. It is true, nevertheless, that all jaundice is due ultimately to obstruction in the path of the bile stream. In the toxaemic cases the obstruction is due to inflammation of some of the small ducts within the liver. In the cases due to stone or cancer the obstruction is in the larger bile ducts, usually the common duct. Causes of Jaundice. — The four types most often seen are: 1. Jaundice of the new-born (occurs in from thirty to eighty per cent of all children) . 2. Catarrh of the bile ducts ("catarrhal jaundice"). 3. Gall stones, especially in the common duct. 4. Cancer (pancreas, glands, liver, gall bladder, or bile ducts) . ' Ascites and splenic enlargement are not purely mechanical phenomena. Toxsemia and sometimes chronic peritonitis or cardiac failure contribute. THE STOMACH, LIVER, AND PANCREAS 375 Less common are the cases due to 5. Cirrhosis of the liver. 6. Syphilis of the liver. 7. Infectious disease or toxaemia. Rare causes are : 8. Acute yellow atrophy, with or without phosphorus poisoning. 9. Weil's disease and other types of infectious jaundice. 10. Congenital obliteration of the bile ducts. 11. Family hemolytic jaundice. The results of jaundice upon the body are chiefly the following: (a) Slow pulse (often below 60) . (6) Itching of the skin, (c) Mental depression, (d) Hemorrhagic tendency (which renders operation dangerous) . In mild cases there is no bile in the urine; in severe cases it is almost .always present. The stools are gray or clay-colored when the obstruc- tion is in the larger bile ducts outside the liver, but in the toxaemic forms of jaundice abundance of bile passes into the intestine and the stools are of normal color. Diagnosis of the cause of jaundice depends on the following con- siderations : 1. If it occurs during the first four days of life without any other symptom and passes off within a few weeks, we call it simple jaundice of the new-horn. 2. If the attack is preceded by gastro-intestinal disturbances, usually in a young person, if pain and hepatic enlargement are slight or absent, and if the jaundice passes off within six weeks, we term it " catarrhal jaundice" (though the pathology of this and of the preceding condition is unknown) . 3. If there have been attacks of biliary colic (see below, page 370), intermittent fever with intervals of good health, and no considerable or progressive enlargement of the liver or gall bladder, stone in the common duct is probably the diagnosis. 4. Cancer of the pancreas, duodenal papilla, gall bladder, bile ducts, or of the glands at the hilus of the liver, produces enlargement of the gall bladder, and a jaundice usually painless but of the intensest type known. Loss of flesh and strength is rapid. Cancer of the liver itself gives a rapidly enlarging, nodular liver often with pain, and, in fifty per cent of cases, jaundice. 5. In ordinary portal cirrhosis the jaundice is less intense and permanent, portal stasis is usually evident, and there is generally a moderate enlargement of the liver. 376 PHYSICAL DIAGNOSIS 6. Enlargement of the liver with jaundice lasting for years in young people is probably due to biliary cirrhosis, or family hemolytic jaundice. In some of the cases of this group the red cells can be shown to possess an exaggerated vulnerability, and the blood serum may have unusual autohemolytic powers. Several such cases may occur in a single family. 7. Hepatic syphilis produces jaundice in a small percentage of cases, and under these conditions is so apt to be mistaken for cancer that I think in all cases supposed to be cancer in or near the liver a Wassermann reaction should be tried and a course of antisyphilitic treatment given. Other lesions or symptoms of syphilis will naturally influence us. 8. The jaundice secondary to septicaemia, yellow fever, malaria, and pernicious ahsemia is usually slight and rarely shows in the uxine or bleaches the stools. The evidence of the anaemia or of an infection makes evident the nature of the jaundice. 9. Acute yellow atrophy, when in addition to jaundice and a small liver, we have rapid failure of strength and somnolence and other mental disturbance leading to death. The urine is rarely char- acteristic. 10. Weil's disease is the term applied to some or all of the groups of infections of unknown origin which are accompanied by jaundice. From catarrhal jaundice it is to be distinguished during life only by convincing evidence of general infection. 6. Loss of Flesh and Strength in cases presenting other signs of liver disease is commonest in uncom- pensated cirrhosis and in malignant disease, but may occur in gall- stone disease, syphilis, or abscess. I have known a physician greatly alarmed at his own rapid emaciation, though his symptoms (jaundice and colic) pointed to stone in the common duct and operation proved this diagnosis correct. 7. The Infection Gron^p of Symptoms. These symptoms — viz., fever, chills, sweats, leucocytosis', disturb- ances of digestion and sleep — are oftenest seen in: i. Cholangitis. 2. Hepatic abscess.' 3. "Ball-valve" or "floating" stone in the ' With or without pylephlebitis. THE STOMACH, LIVER, AND PANCREAS 377- common duct. In the last disease jaundice is usually present; in the others usually absent. In cancer of the liver, fever and leucocytosis are often present, but the other signs of infection are rarely seen. 8. The Cerebral Symptoms of Liver Disease. These vary from simple depression and apathy to delirium, con- vulsions, and coma. Severe symptoms are oftenest seen at the end of uncompensated cirrhotic cases; eighty-two per cent of our fatal cases showed during the last days of life symptoms indistinguishable from uraemia. Identical disturbance occurs in acute yellow atrophy. III. The Gall Bladder and Bile Ducts. (o) Biliary colic, and. (6) enlarged gall bladder, with or without tenderness and pain, are the data on which (with the evidence of local or general infection, cachexia, intestinal obstruction, and jaundice) our knowledge of gall-bladder disease is built up. In some cases puzzling digestive symptoms closely resembling those of duodenal ulcer are present. I . Differential Diagnosis of Biliary Colic. Biliary colic, due to impaction of a gall stone in the cystic or common duct, is a sudden pain in the gastric or hepatic region, radiat- ing thence in all directions, but especially to the right shoulder, scapula or back, with fever, chills, and vomiting. In most cases the attack lasts from three to twelve hours (RoUeston) unless relieved by morphine. The pains may be of any degree of severity, and are often accompanied and followed by tenderness over the hepatic region and right hypochondrium. The liver or gall bladder is seldom palpable. Jaundice precedes or follows the attack in about one-half of the cases. Renal colic differs in that it usually starts over the kidney (in the back) and radiates down the ureter, while the urine is apt to be bloody but free from bile. Floating kidney with kinTsed ureter may produce pains which cannot in themselves'be distinguished from biliary colic. The palpa- tion of the floating kidney may be all that makes us suspect that organ to be the cause of suffering. Peptic ulcer (gastric or duodenal) may produce sharp, paroxysmal pain, but this usually comes several hours after a meal, can be relieved by food, vomiting, lavage, or alkalies, and produces no fever, chill, or 37S PHYSICAL DIAGNOSIS sweat. Hyperchlorhydria may produce similar pain at night (the commonest time for biliary colic), but is relieved by food or alkali. Lead colic is almost always associated with lead dots in the gums and stippling of the red corpuscles (see pages 24 and 444). The history of work as a painter or plumber and the absence of tenderness assist the diagnosis. Gastric Crises in Tabes are often operated on under a false diag- nosis of gall stones. Study of the reflexes prevents such a mistake in most cases but lumbar puncture is occasionally necessary for diag- nosis. 2. Enlarged Gall Bladder. An enlarged gall bladder cannot be felt unless it is stretched tight by its contents; a very tense gall bladder may be palpable without much enlargement. Probably most enlarged gall bladders are not tense, and so cannot be made out without operation. When palpable the organ presents as a smooth, rounded, pear-shaped tumor at the margin of the ribs in the nipple line. The causes of enlargement are : (a) Stone in the cystic duct, at the neck of the gall bladder. (h) Cancer of the pancreas or other tumor obstructing the common duct from without.' (c) Cholecystitis. In the first of these jaundice is rarely present (ten to fifteen per cent — RiedeP) , and colic with or without palpable tumor is our guide to diagnosis. In cancerous obstruction there is intense and permanent jaundice. In cholecystitis there is usually no jaundice, but all the signs of local and general infection — pain, tenderness, leucocytosis, and fever — are present. In acute cases the symptoms, however, may be indis- tinguishable from those of appendicitis, since the pain may be referred to the navel or even to the appendix region. Many mistakes of diagnosis between appendicitis and acute cholecystitis occur, and must occur until our present diagnostic resources are increased. 3. Results of Cholecystitis. (a) Adhesions about the gall bladder may involve the duodenum or pylorus, and produce kinking and consequent dilatation of the stomach and chronic dyspepsia. ' Courvoisier has shown that if the common duct is obstructed by a gall stone the gall bladder is very rarely enlarged. ' Riedel: BerUn. klin. Woch., 1901, No. 3. THE STOMACH, LIVER, AND PANCREAS 379 (b) Intestinal obstruction (see below, page 378) is occasionally produced by the ulceration of a large gall stone from the gall bladder into the intestine, usually the small intestine or duodenum. IV. The Pancreas. Diseases of the pancreas can very rarely be diagnosed by our present methods. If greatly enlarged (tumor, cyst, hemorrhage) it may become palpable as a deep epigastric tumor, but we are rarely able to differentiate such tumors from those of the retroperitoneal structures. Indirect and uncertain information is afforded by the presence in the urine of sugar or fat-splitting ferments^ and in the stools by the appearance of an abnormal amount of muscle fibre or of fat not other- wise to be accounted for (i.e., in the absence of jaundice, diarrhoea, tuberculous peritonitis, or large meals of fat) . 1. Cancer of the pancreas may sometimes be suspected on account of its pressure effects. Intense and painless jaundice with enlarged (perhaps palpable) gall bladder and liver is often due to the pressure of cancer in the head of the pancreas upon the common bile duct. Ascites and swelled legs may be produced by compression of the inferior vena cava. But the diagnosis can rarely be more than a suspicion, for cancer of the gall bladder, ducts, duodenal papilla or retroperitoneal sarcoma may produce similar pressure effects. Should these pressure effects coincide with a glycosuria and the presence of a deep-seated, almost immovable tumor, the suggestion of. pancreatic disease becomes more plausible. 2. Acute pancreatic disease, hemorrhagic or suppurative, is not rec- ognizable until it is seen at an operation undertaken for the relief of some grave, acute lesion of the upper abdomen. Perforated gastric ulcer and intestinal obstruction may give identical symptoms, viz., sudden, intense, epigastric pain and tenderness, with vomiting and collapse. One or two days later a tender epigastric tumor may appear, but this presents no characteristic peculiarities. 3. Pancreatic cyst presents a very slaw-growing, possibly elastic, deep-seated epigastric tumor, which usually produces little in the way 'The suspected urine is neutralized with potassium hydroxide and one portion of it boiled to destroy any ferment that may be present. To tlus and to the unboiled portion sthyl butyrate is added. In twenty-four hours an add reaction may appearin the unboiled epedmen if it contains a ferment, wliile the other specimen shows no considerable change in reaction. 380 PHYSICAL DIAGNOSIS of pressure effects, and may be associated with glycosuria and fatty stools. 4. Bronzed Diabetes. — The association of diabetes with bronzing of the skin and enlargement of the liver is strongly suggestive of chronic fibrous pancreatitis. In any doubtful case the possibility of pancreatic disease is in- creased: (a) If improvement follows the adminstration of pancreatic preparation; (6) if glycosuria follows the administration of 100 gm. of glucose (alimentary glycosuria) . (a) Incidence of Pancreatic Disease. The following table is from the Massachusetts General Hospital records (1870-1905): Cases Cancer of the pancreas" 55 Acute pancreatitis 13 Chronic pancreatitis 10 Cyst of the pancreas 3 Total 61 Cabot — Physical Diagnosis. PLATE I. Fig. I. — Trichomonas hominis. (Leuckart.) Fig. 2. — Balantidium coli. ('Leuckart.) Magnified about 150 diameters. Fig. 3. — Lamblia intestinalis. (Leuckart ) CHAPTER XXIII. THE INTESTINE, SPLEEN, KIDNEY. I. The Intestines. Incidence of Intestinal Disease (excluding diarrhoea and constipation) at the Massachusetts General Hospital, 1870- 1905. ±. Appendicitis 3,314 2. Acute obstruction 142 3. Cancer (above the rectum) i c - 4. Dilated colon 6 5. Tuberculosis 2 6. Faecal impaction (above the rectum) 2 Total. 3,621 I . Data for Diagnosis. The data on which are based all our conclusions regarding intes- tinal disease are obtained from the following sources : 1. Pain (colicky or steady) and tenderness, tenesmus. 2. Gaseous distention and the noises and sensations produced by gas. 3. Diarrhcea or constipation. 4. Muscular rigidity of the belly wall protecting^ an intestinal lesion. 5. Tumor, palpable or visible, and believed to be connected with the intestines (together with the effect of catharsis on such tumor). 6. Visible or palpable peristalsis (see page 340). 7. Digital or visual examination of the rectum, (see page 415). 8. Examination of the intestinal contents, fsecal and other (see page 379). 9. Inflation of the colon through the rectum (see page 346) . 10. Indicanuria — rarely of value. 11. Constitutional manifestations, such as fevers, vomiting, leu- cocytosis, emaciation. Some of these data need ftuther comment. Intestinal Pain. — Many pains associated with intestinal disease ppendicitis, cancer) are due in fact to irritation of the peritoneum. Which of the numerous pains referred to the belly should be inter- 381 382 PHYSICAL DIAGNOSIS preted as intestinal in origin? Those especially which (a) shift rapidly from place to place; (6) accompany the noises and sensations of the passage of gas and feeces through the intestine; (c) accompany diar- rhoea or constipation. Tenderness is usually a symptom of peritoneal rather than intes- tinal irritation. With true intestinal pain (colic) there is often relief by pressure — the precise opposite of tenderness. Yet so close is the asso- ciation of intestine and peritoneum that in appendicitis, intestinal ulcera- tion, tumors, and even in simple gaseous distention of the gut, there is often local or general tenderness. When extreme and associated with constitutional manifestations — fever, leucocytosis, collapse — it always sug- gests peritonitis. When there are no constitutional manifestations, a purely local pain or tenderness has little diagnostic value. Tenesmus. — The desire to pass another stool as soon as one has been evacuated, together with local burning and straining, means always rectal irritation (inflammation, ulcer). It is one of the most definite and reliable symptoms known. Gaseous distention of the intestine is proved by an increase of the normal tympanitic note over part or all of the belly, together with a prominence of the overlying belly wall. It is chiefly and most frequently the colon that produces distention. The significance of distention is vague and depends largely on the associated data. In acute gastro-intestinal "catarrh" the diarrhoea and absence of severe constitutional manifestations make us put little stress on the associated distention. In typhoid fever distention results from atony of the intestinal walls and is "to some extent a measure of the intensity of the local lesions " (Osier) . In intestinal obstruction distention may be extreme if the stoppage is low down (in the colon), less marked if the lesion is high up. Fig. ;o3.- -Congenital dilatation of colon. Cabot — Physical Diagnosis. PLATE II. Distoma buski. Ascaris lumbricoide ,f '-'J f Uncinaria americana. Ancliylostoma duodenale. wj^^.^,<-j»?-. '.■-',■ >- .C'" ' c '^■■t W."^ , 'f^^0 '*'- - M^. m '■,1 > Ky.iJ^''^ ^S -Kf^ ■-'.. \^>-.^ W^- "'i » "-» \^^ yl"'-" , :^-^^j.^: i^'*- Trichuris trichiura. Uibolhriocephalus latus. Taenia solium. EGGS OF INTESTINAL PARASITES. All are magnified 250 diameters. Tienia sasinala. I. Intestinal disease. THE INTESTINE, SPLEEN, KIDNEY 383 Distention which continues despite free purgation is very often due to chronic intestinal obstruction. In starvation, children often get very large bellies, owing to muscu- lar atony of the gut and the resulting gaseous accumulation. But in no case is the distention of itself of much diagnostic value. The associated symptoms give it significance. In congenital dilation of the colon (Hirschsprung's disease) a huge belly is associated with obstinate constipation. The colon can be measured and shown to be dilated through the use of bismuth suspen- sions (by rectum) and x-ray. (See Fig. 203.) Diarrhcea, the passage of more and looser stools than is normal for the individual, is, like distention, a result of many causes both within and outside the intestine. The most important are : (a) Indigestion (acute and chronic). (6) Ulceration (some cases only). (c) Cancer of the colon or rectum. (d) Intussusception. (c) Infectious diseases (cholera, dysentery, typhoid). (/) Intestinal parasites. {{a) Nervous causes (emotion, Basedow's disease, etc.). (6) General infections (sepsis), (c) Cachectic states (anaemias, nephritis, etc.) . By a search for these causes, as well as by the use of the data obtained by examination of the stools, we arrive at an understanding of the diagnostic significance of diarrhcea. Aside from symptomatic diarrhoea, constipation, and dysentery, which produce no physical signs beyond those described — distention, borborygmi, pain, tenderness, tenesmus, and constitutional mani- festations — there are but three important^ diseases of the intestines : I. Appendicitis. II. Intestinal obstruction. III. Cancer of the bowel. 2. Acute Appendicitis J 1. The local signs are pain, tenderness, muscular spasm, and tumor. 2. The general or constitutional signs are fever, chill, rapid pulse, vomiting, constipation, frequency or cessation of micturition, and leucocytosis. (a) The pain may be at first epigastric (pylorospasm ?) or general, ' Tuberculous enteritis and pericaecal tuberculosis will be briefly referred to later. 384 PHYSICAL DIAGNOSIS later localizing itself in the right iliac fossa, less often near the navel, the gall bladder, or in any other part of the belly. (6) The tenderness is more important in diagnosis; indeed, without tenderness diagnosis is rarely possible. It is usually greatest near a point half-way from the anterior iliac spine to the navel. Occasionally a tender point in the pelvis may be reached by rectal or vaginal examination, but this is not at all a reliable sign. (c) Muscular spasm over the appendix region is present in most cases, and, while it renders accurate palpation impossible, it is in itself so characteristic of the disease that we do not regret it. Psoas spasm occurs in a minority of cases. The patient leans his body forward and toward the right in walking, or, if recumbent, draws up the right thigh to relax the spasm. (d) Tumor — about the size and shape of a lemon, ill-defined and tender — is felt in the right iliac fossa in many cases. It may be con- siderably larger and better defined if abscess has existed for several days, or it may be smaller and more sausage-shaped. Fluctuation and bulging can sometimes be made out by rectum or vagina. (e) The constitutional signs may or may not be marked, according to the duration of the process, its virulence, and the degree of infection of the peritoneal cavity. The fever is usually moderate, under 1022° F.,' with corresponding elevation of the pulse. Vomiting comes at the outset if at all, and is usually over by the second day. A leucocyte count which rises or remains elevated (above 16,000) accompanies the active and advancing stages of the disease. In cases that are very mild or tightly walled in by adhesions, and in cases with virulent general peritonitis, the leucocytes may be normal or subnormal. Diagnosis can hope only to establish the existence of a local inflam- matory process in the abdomen; acute cholecystitis and acute pus tube may present signs indistinguishable from those of appendicitis, though the site of tenderness often sets us right. Non-inflammatory processes, such as lead colic, tabes, biliary and renal colic, floating kidney, and acute gastro-intestinal upsets, can usually be excluded, since they do not show so much local tenderness, fever, and leucoc3rtosis. In those who are familiar with the symptoms of appendicitis, a vivid imagination may conjure up a set of sensations that are difficult for the physician to distinguish from those of the actual disease. Even tenderness may be simulated, but, by distracting the patient's atten- tion while we palpate, we may be able to press hard over the appendix without eliciting complaint. The absence of leucocytosis, the age and sex of the patient, also help us to exclude appendicitis. Cabot— Physical Diagnosis. PLATE III. Heterophyes heterophyes. Distoma sinense. Fasciola hepatica. Distoma buski. Disloma felineum. Dictocoelium lanceolatum. Taenia solium Billiarzia Diplogonoporus Bilharzia liaematobium. grandis. hctmatobium. Tienia saginala Dibothrio- Bilharzia cephalus lalus. iia^matobium. Ascaris lumbricoides. Oxyuris vermicularis Paragonimus westermani. Tsnia nana. Ascaris lumbricoides. Anchylostoma duodenale. Uncinaria americana Strongyloides stercoralis. DRAWINGS OF EGGS OF INTESTINAL PARASITES. All are magnified 250. (After Looss.) THE INTESTINE, SPLEEN, KIDNEY 385 3. Chronic Appendicitis. A disease which can be diagnosed by the iCTays alone. There are no symptoms or signs characteristic of it and in most cases it repre- sents only a harmless historical landmark, a shrivelled appendix. 4. Intestinal Obstruction. (a) Acute Obstruction. — A person may have had no fsecal discharge for a week or even considerably longer and yet present all the evidences of good health. It is only when vomiting, severe paroxysms of pain, and distention of the belly ensue that we suspect obstruction. In the acute cases tumor is noted in only about fifteen per cent. In the chronic cases, usually due to stricture or cancer, a faecal tumor can often be felt and diarrhoea be the chief symptom or may alternate with constipation. By physical signs alone I do not believe that general peritonitis and acute intestinal obstruction can always be distinguished. Fever is not distinctive of general peritonitis, for it occurred in eighty-four out of one hundred and twenty-two cases of acute obstruction in the Massachusetts Hospital records, and in forty-three of these cases free fluid in the peritoneal cavity was demonstrated as well. Stercoraceous vomiting may occur in general peritonitis; it was absent in three- fourths of the Massachusetts Hospital cases of obstruction. Weak, rapid pulse, cold extremities, and a drawn, anxious face are common to both diseases. Tenderness is more general and more marked in general peritonitis than in simple obstruction, yet some tenderness was complained of in fifty-six out of the one hundred and twenty-two cases of obstruction just cited. On the whole, the differential diagnosis of these two diseases seems to depend far more on the history and the etiology than on physical signs. (6) Chronic Obstruction. — Here the diagnosis is simpler. There is usually a history of increasing constipation sometimes interrupted by occasional attacks of diarrhoea.' Tumor is palpable in fifty-eight per cent of cases. Visible peristalsis was recorded in seventeen per cent of the Massachusetts Hospital cases. Distention is gradual and late, but often persists or recurs despite purgation. Cancer, usually at the sigmoid or caecum, is the commonest cause. Stricture, except cancerous stricture, is rare, but syphilis occasionally produces it. (c) Acute Obstruction by a Chronic Lesion. — Cancer of the sigmoid often exists for months almost latent, or produces only moderate con- ' The latter combination occurred in six per cent of the Massachusetts Hospital cases. 25 386 PHYSICAL DIAGNOSIS stipation, so that the patient considers himself well. Such cancers may present an annular growth, hardly bigger than a signet-ring, practically an annular stricture. This stricture may be suddenly "shut down" during an acute gastro-intestinal attack, and we are then confronted with all the signs of acute obstruction. Only the seat of the lesion, the age of the patient, and possibly the appearance of peristaltic waves can lead us aright in our diagnosis of the cause of obstruction. 5. Cancer of the Bowel. The signs are those of chronic intestinal obstruction (see last section) . Occasionally the tumor may not produce much obstruction, and we have simply pain and a tumor which we find by examination is not attached to the liver, spleen, kidney, or stomach, and usually is about the size of a hen's egg. If faeces have accumulated behind such a tumor, we may feel larger masses. In my experience palpable tumors due to faecal impaction alone, without organic stricture or cancer, are very rare, except in the rectum; if found above this region they are almost invariably dependent on stricture or cancer of the bowel. 6. Examination of Intestinal Contents. 1. Weight. — With the average diet of the adult "Anglo-Saxon," the weight of the daily stool is from 100 to 250 gm. (about 25 to 70 gm. dry) but Chittenden has shown that with a low proteid diet of 2,000-2,750 calories value, the weight of the stool may be less than half this amount.' 2. Color. — (o) White or light yellow — milk diet, bread and milk diet. (6) Black — blood, bismuth or iron (medicinal), blackberries, huckleberries, red wine. (c) Green; some normal infants' stools after standing; fermented infant's stool if green when passed; green vegetables, calomel. (d) Gray — absence of bile (jaundice), sometimes after cocoa or chocolate. (e) Bloody red— if in small amount and fresh, usually due to hemorrhoids; in large amounts it may also be due to hemorrhoids or to any of the causes of intestinal ulceration (typhoid, cancer, dysen- tery, etc.). 3. Odor.— In adults of no great significance. In infants foul stools suggest albuminoid decomposition, and strongly soiu- stools suggest acid fermentation. ' "Physiological Economy in Nutrition," 1904, p. 42. THE INTESTINE, SPLEEN, KIDNEY 387 4. Abnormal Ingredients. — (a) C/wdigerfed/ood in small quantities is present in normal stools, but when digestion is faulty larger quan- tities easily recognized by the naked eye may occur. Pieces of meat, flakes of casein (especially in typhoid patients overfed with milk), fragments of starchy food, and lumps of fat (steatorrhcea) may be seen. The natiu-al inference from the presence of these substances is that the gastro-intestinal tract is not at present dealing with them satisfactorily. Fatty stools are present in jaundice, tuberculosis, or amyloid of the intestine, and even in simple catarrh. Though often associated with pancreatic disease, fatty stools are by no means char- acteristic of it. (6) Mucus. — Small shreds of mucus adherent to faeces are of no importance and cause much unnecessary worry among anxious mothers. Larger amounts, if intimately mixed with the stool, point to catarrh of the small intestine; if mucus thickly coats or makes up the bulk of the stool, the trouble is in the colon. The latter is by far the commonest condition. Anything from a very mild to a severe catarrhal condition is accompanied by mucus. Large periodic discharges of mucus and shreds mean usually the neurosis "colica mucosa." (c) Fresh Blood. — ^Piles are by far the commonest cause of bloody stools, and the amount of blood may be trifling or may be large enough to produce in time a severe anaemia. Enteritis (the mild follicular or the severe ulcerative form) often produces bloody stools. The associated symptoms, diarrhoea, mucus, and pain, together with the etiology (dietetic error, typhoid fever, amoeba histolytica), must determine the nature of the enteritis. In cancer of the rectum or sigmoid (rarely higher up in the bowel) , small quantities of blood, fresh or altered, are almost always passed sooner or later. The infrequent, ofifensive, and painful stools and the results of digital examination usually reveal the source of the blood. In intussusception the association of bloody stools with the sudden appearance of a painful abdominal tumor (usually in the caecal region) , vomiting, and severe constitutional manifestations suggest the diagnosis. In hemorrhagic diseases (purpura, scurvy, acute leukaemia) blood may come from the intestine as well as from the other mucous mem- branes. Other rare causes for blood in stools are a ruptured aneurism, thrombosed mesenteric artery, rectal syphilis, or fissiu-e. {d) Altered blood (tarry stools, melsena) follows the pouring out of blood — a pint or more — ^in the upper gastro-intestinal tract, and occurs 388 PHYSICAL DIAGNOSIS in hepatic cirrhosis, gastric or duodenal ulcer, after severe nose-bleed, and occasionally from other causes. Occult blood, recognizable by the guaiac test, often occurs in cancer or ulcer of the stomach, and forms an important link in the chain of evidence on which the diagnosis of those diseases is based. (e) Pus is not of great diagnostic value. Large amounts mean the breaking of an abscess (appendix, pus tube) into the rectum. Small amounts occur in ulcers or even from catarrh. (/) Shreds of tissue point to ulceratiou. (g) Gall Stones. — In suspicious cases break up the fseces in a sieve with plenty of water. The peculiar, facetted shape of most gall stones is easily recognized. 7. Intestinal Parasites. Bacteria. — Only the tubercle bacillus can be recognized without culture methods, which do not fall within the scope of this book. For the identification of tubercle bacilli the following method is to be recommended: "Dilute the stool with ten volumes of water, mix thoroughly, and let it stand in a wide-mouthed bottle for twenty-four hours. The narrow layer between the thin supernatant liquid and the solid sediment contains the bacilli. Remove this with a pipette, spread it on a cover slip, evaporate slowly to dryness, and proceed as with sputum " (" Harvard Outlines of Medical Diagnosis," 1904, p. 29). Animal Parasites. — The most important are: I 1. Amoeba histolytica. T c • J ti 1 f C*^) Uncinaria americana. I. Serious < 2. Hook-worm („(.,, , , I ■ [ {b) Anchylostoma duodenale. 3. Bilharzia haematobium. 4. Balanlidium coli. 5. Tape-worms; the beef-worm (Taenia saginata) is very common; the pork- worm (Taenia solium) is rare; the miniature tape- worm (Tsenia nana) and the fish-worm (Dibothriocephalus latus') are fairly common. Several other forms occur in foreign countries. 6. Strongyloides intestinalis. 7. Ascaris lumbricoides (round-worm). 8. Oxyuris vermiculaxis (thread- worm; pin- worm). Q. Trichiuris trichiura (whip-worm). 10. Trichomonas intestinalis. 11. Lamblia intestinalis. ' Fish tape-worms may produce a severe anosmia, but in probably the great majority of all cases ihey do not do so. II. Relatively mild. III. Usually harmless. THE INTESTINE, SPLEEN, KIDNEY 389 Tape-worms, round- worms, pin-worms, and the strongyloides are to be recognized in their adult form (see Figs. 204, 205, 206, 207, 208). They are usually noticed by the patients themselves and brought to the physician for examination. If the worm has the look of a common earth-worm, but a length of five to nine inches, it is safe to call it the "round- worm" (Ascaris lumbricoides) ; if the worm is about one-half an inch long and as thick as a pin, it is in all probability a " pin- worm " (Oxyuris vermicularis) . The Amosba histolytica is to be searched for in fresh stools passed into a warm vessel, after MgS04 has been given. A bit of mucus from such stools or a little obtained by passing a rectal tube is put upon a warmed slide with a drop of water, covered with a cover glass, and ex- a b Fig. 204. — a. Head of Tsenia saginata, much magnified; b, uterine canal of same, twenty branches on each side. About amined at once with a high-power dry lens. The organism is rec- ognized as an amoeba by the presence of distinct amoeboid movements. When dead it assumes a round shape, but one should not attempt a positive diagnosis until live amoeboid parasites are present. Apparently there is a harmless variety of amosba coU to be obtained from the stools of many normal persons by purgation. This is distinguished from the amoeba histolytica by the foUowing criteria (Vedder). The dysenteric or tissue-destroying amoeba is larger more actively motile, has an easily distinguished refractive ectoplasm which can also be made out in the pseudopods which are themselves relatively large and easily seen. Especially characteristic of the amceba histolytica is the presence of numerous vacuoles and usually of ingested red corpuscles which hide the nucleus. 390 PHYSICAL DIAGNOSIS The other parasites are identified, as a rule, by the finding of their eggs in the stools. The technique of this operation is described below, as exemplified in the search for the egg of uncinaria— at present the egg most important for Americans to recognize. Eggs of parasites catch the eye in the examination of stools, first of all, by the clean-cut, mathematical symmetry of their oval, when com- pared with the irregular, shapeless masses which usually appear in slide and cover preparations from the fseces. Secondly, the size of parasitic eggs is greater than that of most of the objects seen in the faeces; and, thirdly, they are for the most part dark brown, stained with bile (the uncinaria is an exception) . Fig. 205. — a, Head of Tsenia solium (note crown of hooks) ; b, uterine canal in two segments. Only five to seven branches on each side. The differences between individual species will be described later. In Plates II. and III. the most important eggs are pictured and catalogued. The Uncinaria americana or its European equivalent {Anchylos- toma duodenale) is recognized most easily by the identification of its eggs in the stools. These eggs are characteristic (see Plate II.), and " the only thing liable to be confounded with them is the ovum of Ascaris lumbricoides stripped of its heavy, bile-stained outer shell (see Plate II.) ; but this has a double contour and contains a shapeless mass of granular matter not differentiated" (as most uncinaria eggs THE INTESTINE, SPLEEN, KIDNEY 391 are) "into clear segments.'" The greater size of the American hook- worm's egg compared to that of the European worm is shown in Plate II. " Free embryos are rarely if ever found in intestine. When free (worm-like) embryos are seen in the stools, they are generally those of the Strongyloides intestinalis " (see Fig. 208). The ova of uncinaria catch the eye in a rapid examination, first, because they are "not generally bile-stained, but clear, whereas those of the commonly associated intestinal parasites are of a yellow to deep amber or brown color." They are dis- tributed quite evenly throughout the entire fsecal mass; hence, in searching for them, the following method is advisable : Technique of Microscopic Exami- nation. — "A bit of faeces the size of a match head is removed with a tooth- pick and placed on a glass slide. Fig. 206. — Taenia nana (Dwarf Tape-worm), o,- Hooklet; b, head, greatly enlarged; c, whole worm, magnified about 10 times. Upon this is placed a cover glass and pressed down so as to give a clear centre to the specimen. Do not add water. Examine with a one-third to two-thirds objective, a No. 4 ocular, and a partially closed ' All the quotations in this sertion are from the " Report of the Commission for the Study and Treatment of Aneemia in Porto Rico," by Ashford, King, and Igaravidez (December ist, 1904), a study of 5,490 cases. 392 PHYSICAL DIAGNOSIS diaphragm. If too much light is admitted the delicate ovum will be passed over." The following interesting table (from the studies of Ashf ord, King, and Igaravidez in Porto Rico) shows, roughly, the relative frequency (in a tropical climate) of the common intestinal parasites recognizable Fig. 207. — Segments of the Dibothriocephalus latus (Fish Tape- worm). shaped uterine marking. Note the rosette- by their e^gs. In the examination of the stools of 5,490 cases of uncin- ariasis they found as well: Ascaris lumbricoides in 1,408 (many others seen but not noted). Trichuris trichiura in 326 (many others seen but not noted). Strongyloides intestinalis in 36 (the embryo worms, not eggs). Bilharzia haematobium in 21 (frequently no careful search was made for this egg) . Balantidium coli in 14 Oxyuris vermicularis in 3 Amoeba coli in 3 Taenia saginata in 2 Tsenia solium in 2 Newton Evans {Southern Medical Journal, Nov., 191 1) examined the stools of 122 children in public institutions of Tennessee and found worms in 60 children, or nearly 50%, though no symptoms were present. The order of frequency was as follows : 1. Hook worm (39 cases). 2. Round worm. 3. Whip worm. 4. Dwarf tape worm. 5. Pin worm. Ascaris lumbricoides has usually a thick, wavy ("mammillated") shell; but this is not always seen, and in its absence the egg is dis- THE INTESTINE, SPLEEN, KIDNEY 393 tinguishable from Uncinaria americana chiefly by the absence of the segmentation usually seen in the egg of the latter (see Plate II., 6). Trichuris trichiura (also called Tricocephalus dispar) has a thick shell, very dark-stained, and apparently pointed and perforated at each end, instead of curving evenly over as the uncinaria egg does (see Plate II., c). Bilharzia eggs are not at all uncommon in the faeces, though more often described in the urine, in connection with hsematuria. In the urine the terminal spine at one end is their most characteristic feature (see Plate III). In the faeces the spine is usually at one side (see Plate III). The other eggs are briefly described in the explanatory text accompanying Plate II. II. The Spleen. Diseases of the spleen (abscess, malignant disease, cyst) are almost never recognized during life. It is for evidence of splenic enlargement as a factor in the diagnosis of diseases origi- nating elsewhere that we investigate the splenic region as part of the routine of abdominal examinations. Splenic enlargement is detected chiefly by palpation. Percussion plays a minor r61e in the determination of the organ's size, and should never be relied on in the absence of palpable evidence. Palpation is easy, provided the organ is enlarged sufiiciently to project beyond the ribs without forced respiration, but much prac- tice is needed when the enlargement is slight, as in, for example, most cases of typhoid fever. I . Palpation of the Spleen. The co-operative action of both hands is as Fig. 208. — Strongy- loides stercoralis. Mag- nified about 250 diame- ters. (After Thayer.) essential as in vaginal examination, and each hand must do the right thing at the right moment. The patient should be on his back, his head comfortably supported and his knees drawn up. The left hand, placed over the normal situation of the spleen, (a) draws the whole splenic region downward and inward 394 PHYSICAL DIAGNOSIS toward the expectant finger-tips of the right hand; (&) at the same time the left hand should slide the skin and subcutaneous tissues over the ribs and toward the right hand (see Fig. 209), so as to leave a loose fold of skin along the margin of the ribs and give the palpating fingers a slack rather than a taut covering to feel through. The right hand lies on the abdominal wall just below the margin of the ribs, and the fingers should point straight up the path down which the spleen is to move, i.e., obliquely toward the left hypo- chondrium. With the hands in this position ask the patient to draw a full breath. Keep the hands still and do not expect to feel Fig. 20g. — Position of the Hands in Palpation of the Spleen. anything until near the end of inspiration. Then draw the hands slightly toward each other and dip in a little with the right finger- tips, so that if the spleen issues from beneath the ribs its edge will meet the finger-tips for an instant and spring over them as they rise from diving into the soft tissues (see Fig. 209) . Some physicians have the patient lie on the right side, and, stand- ing behind him, hook their fingers over the ribs in the left hypo- chondrium. In this way we may be able to feel the spleen at the end of a long inspiration, but I have seldom found this position as useful as that described above. A hard, fibrous spleen (malaria) is much easier to feel than a soft one (typhoid) . 2. Percussion of the Spleen. Only when the edge of the spleen has been felt is it worth while to try to define its upper border by percussion. Normally there is dulness in THE INTESTINE, SPLEEN, KIDNEY 395 the midaxillary line from the ninth to the eleventh ribs, corresponding to that part of the spleen that is most superficial. Its lower and posterior borders cannot be defined; its anterior edge is approxi- mately in the midaxillary line (see Fig. 59). If this small area of dul- ness is enlarged upward and forward, and if the edge has been felt below the ribs, it is probable that the increased area of dulness corre- sponds to an enlargement of the organ. 3. Causes of Splenic Enlargement. Slight enlargement of the spleen can often be detected in : 1. Rickets and other debilitating conditions of childhood with or without anaemia. 2. Malaria. 3. Typhoid fever. Fig. 210. — Splenic leuGcmia. In other acute infections slight enlargement can usually be made out post mortem, but not during life. In a series of 100 cases of marked splenic enlargement studied in the Massachusetts General Hospital I found the following types: 396 PHYSICAL DIAGNOSIS 1. Leucaemia — 35 cases. 2. Hepatic cirrhosis — 30 cases. 3. Malaria — 8 cases. 4. Hodgkin's disease — 6 cases. 5. " Splenic Aneemia" — 4 cases. 6. Syphilis — 2 cases. 7. Polycythsemia — 2 cases. 8. Amyloid — i case. 9. Unknown Cause — 13 cases. Rarer causes are abscess, tuberculosis, malignant disease, perni- cious anaemia, hydatid, and Leishman-Donovan disease. Differences Between a Large Spleen and Tumors (of the kidney or other organs). — A large spleen is easily recognized after a little practice. As it enlarges it keeps its shape and advances obliquely across the belly toward the navel or (in marked cases) beyond it. It is always hard and smooth of surface, although the edge near- est the epigastrium shows one or more notches which are very char- acteristic. The edge is sharp, never rounded, and the whole organ is very superficial, being covered only by the belly walls, so that if we inflate the colon (by forcing air into the rectum with a Davidson syringe) , it passes behind the spleen and does not obliterate its dulness. Tumors of the kidney fill out the flank, and an impulse can be transmitted to the lumbar region by bimanual palpation. They have no sharp edge or notches, are often irregular of surface, and not so superficial. The inflated colon passes in front of a tutnor of the kidney and obliterates the dulness due to it. All these differences hold for any other tumors likely to be con- fused with an enlarged spleen. 4. Differential Diagnosis of the Various Causes of Splenic Enlargement. In children splenic enlargement without fever or leuksemic blood changes is to be classed as a manifestation of general debility. It has no special connection with any type of anaemia, though anaemia is often seen with it. In typhoid the fever with the Widal reaction and blood culture are generally sufficient to make clear the cause of the splenic enlargement; in active malaria the blood parasites are always demonstrable, and in chronic cases the history and the locality are significant. Hepatic cirrhosis (and Banti's disease) should show evidences of portal stasis (ascites, jaundice, haematemesis) . THE INTESTINE, SPLEEN, KIDNEY 397 Splenic anaemia means simply an anaemia of unknown origin associated with an enlarged spleen. |fet Leukcemic enlargement of the spleen is easily recognized by the characteristic blood picture. Hodgkin's disease (lymphoma) shows enlarged glands in the neck, axillas, and groins, with normal blood. Histological examina- tion of an excised gland is necessary for diagnosis. Amyloid can be suspected if there is a history of syphilis or chronic suppuration (hip abscess, etc.). III. Diseases of the Kidney. I. Incidence of Renal Disease {Massachusetts General Hospital, 1870-1905). Acute nephritis 200 Chronic glomerulo-nephrilis 41'] Chronic interstitial nephritis 250' Amyloid nephritis 9 Floating kidney 227 Stone in the kidney 145 Malignant disease 42 Tuberculous kidney 41 Renal sepsis (pyonephrosis, pyelitis and suppurative nephritis) . . 54 Perinephritic abscess 35 Hydronephrosis 19 Cystic kidneys 10 Total J.449 We get evidence of diseases of the kidney in four ways -.^ 1 . By external examination of the region of the kidney. 2. By examination of the urine. 3. By cystoscopy and the ureteral catheter. 4. By study of the constitutional symptoms — ^fever, leucocytosis, anaemia, uraemia, dropsy, blood pressure and cardiac hypertrophy. Local examination acquaints us with the presence of tenderness and tumor. (a) Tenderness is often present in renal abscess (tuberculous or non-tuberculous), pyelitis, and perinephritic abscess, less often in connection with nephrolithiasis, occasionally in hydronephrosis and malignant disease. A floating kidney may have an exquisite and ' Seven hundred and seventy-five other cases of "nephritis" not further specified. 2 A fifth, blood examination by Folin's test for non-protein nitrogen, is still under trial, its clinical value not yet determined. 398 PHYSICAL DIAGNOSIS peculiar sensitiveness to pressure, which differs from ordinary tenderness. (&) Tumor in the kidney region may occur in abscess in or around the kidney (including tuberculosis of the kidney and pyonephrosis), malignant disease, hydronephrosis , and cystic kidney. The latter members of this list afford examples of the largest tumors associated with the kidney. 2. Characteristics Common to Most Tumors of the Kidney. Renal tumors are best felt bimanually, one hand in the hypo- chondrium and the other in the region of the kidney behind, with the patient in the recumbent position. In this way the tumor may often be grasped and an impulse transmitted from hand to hand. It is usually round and smooth, often very hard, less often fluctu- ating. It descends slightly with inspiration. If the colon is in- flated by forcing air into the rectum with a Davidson syringe, res- onance appears in front of the tumor; this serves to distinguish it from tumors of the spleen which are pushed forward by the inflated colon as it passes behind them. Tumors of the kidney never pre- sent a thin and sharp edge, like that of the spleen. Occasionally they are irregular and nodulated — a condition almost never found in the spleen. It must be remembered that an enlarged kidney may be the sound kidney hypertrophied in compensation for disease on the other side. (a) Malignant disease of the kidney, usually a hypernephroma, makes up with cystic kidney the great bulk of the large abdominal tumors occurring in childhood, but is also not uncommon in adults. The characteristics of the tumor are those already described, except that in advanced stages the tumor pushes forward from its position in the loin until it may reach the umbilicus or even fill the abdomen. Nodular irregularities can usually be felt. There is usually pain, hsematuria, emaciation, and anaemia, sometimes leucocytosis, but small tumors at some distance from the renal pelvis are symptomless and unrecognizable. Metastases — especially bone metastases — are often the first evidence of the disease. (b) Hydronephrosis and cystic kidney may be indistinguishable from each other unless the hydronephrosis is intermittent and dis- appears with a great gush of urine, or unless the cystic kidney is bilateral — as, indeed, is usually the case. In both diseases a smooth, round tumor forms in the loin and hypochondrium, usually without THE INTESTINE, SPLEEN, KIDNEY 399 much constitutional disturbance and very frequently with a urine like that of contracted kidneys (see below) (see Fig. 211). Pain and tenderness are slight. In many cases the tumor is astonish- ingly hard and often gives no sign of fluctuation. With cystic kidney it may be coarsely lobulated. Like other tumors of the kidney it de- scends slightly on inspiration. Cystic kidneys are often congenital, but usually produce no symptoms until the}^ have attained a consid- erable size, and hence are often overlooked or discovered accident- ally- In hydronephrosis the diag- nosis may be assisted by etiological hints, such as an abnormal degree of mobility of the kidney on the affected side, a history of renal colic with or without haematuria, or a prostatic obstruction. Comparatively slight degrees of dilatation or distortion of the renal pelvis and their relation to kinking of the ureter may be made out by the use of coUargol-radio- graphic plates. Braasch, from the Mayos' clinic, considers this method of practical value in the diagnosis of hydronephrosis, pyonephrosis, pyelitis (which shows dilatation of the pelvis) , renal tuberculosis and tumors, cystic kidney, hydro-ureter and ureteral ob- struction, and for other purposes. I have no experience with this method, but it sounds promising. (c) Perinephritic abscess usually works its way to the surface in the back, between the crest of the ilium and the twelfth rib. This was the situation of the external tumor in 25 out of 35 cases recorded at the Massachusetts General Hospital. A tender swelling appears at the point just described, sometimes with redness and heat, and almost always with fever, chills, leucocytosis, and some emaciation. The urine may show nothing abnormal or may show the evidence of cys- titis, of concomitant nephritis, or, rarely, of an abscess within the kidney itself. Perinephritic abscess often remains latent for weeks or months, and the amount of pus accumulated may be a quart or more. ((f) Abscess of the kidney, including tuberculous, suppurating kid- neys and pyonephrosis, usually produces a smooth, round tumor in Fig. 211. — Left Hydronephrosis. A, Area of dull irregular resistance. 400 PHYSICAL DIAGNOSIS the hypochondrium and loin. It has the characteristics common to most renal tumors (see last page), but is usually distinguishable by: 1. The etiology (cystitis, stone in the kidney, tuberculosis, pyae- mia). In acute cases, however, there is often no discoverable cause. 2. The presence of renal pyuria (see below, page 396). 3. The presence of fever and leucocytosis. Persistent urinary frequency, especially nocturnal, in a young adult suggests renal tuberculosis. Animal inoculation with the urinary sediment ob- tained by ureteral Catheter is essential to confirm diagnosis. Bladder irritation is usually the first symptom of renal tuberculosis. (e) Floating Kidney; Displaced and Movable Kidney, — The tip of the right kidney is palpable in most thin persons with loose belly walls. If the whole organ is palpable but not movable, we speak of it as displaced. If the range of mobility is relatively great we call it floating; if relatively slight we call it movable. With bimanual palpation (as described above) we exert pressure just at the end of a deep inspiration and maintain it. During expiration something smooth and round may then be felt to slip upward between our hands toward the ribs. If the kidney "hides" behind the ribs, have the patient sit up, cough, and breathe deeply; then repeat the bimanual palpation as he lies on his back. Very movable or floating kidneys may be found far from their normal home, and are then recognized by : I. Their size, shape, and slippery feel. 2. The sickening pain pro- duced by pressure. 3. The possibility of replacing them. 3. Renal Colic and Other Renal Pain. Typical renal colic is paroxysmal, like all colics; that is, an attack begins suddenly, ends suddenly, and lasts but a few hours or less. The pain usually begins in the back, over the kidney, and follows the course of the xureter to the groin. During an attack the testicle on the affected side may be tender and drawn up tightly by contrac- tion of the cremaster. When associated with hsematuria or pyuria, with or without sud- den stoppage of water during an attack and without any generalor constitutional symptoms between attacks, renal colic is suggestive of stone in the pelvis of the kidney; but similar attacks may occur with other surgical diseases of the kidney, with tuberculosis, neo- plasm, with kinking of the ureter, and very often without any cause discoverable at operation. From biliary colic it may be distinguished by the (a) different THE INTESTINE, SPLEEN, KIDNEY 401 situation of the pain, (b) by the presence of blood or pus in the urine, and (c) the absence of jaundice in this or a former attack. In intestinal colic the pain shifts its position frequently and is associated with noises produced by wind in the bowels, or with diar- rhoea or constipation. Renal pain, not colic, occurs in almost any disease of the kidney except nephritis, and is characterized by its situation over the ana- tomical seat of the kidney and by the lack of any connection with muscular movements (lumbago), with spinal movements (hypertro- phic arthritis), or with the sacro-iliac joint. I have now described what seems to me most important in the local external examination for kidney disease, and have mentioned, along with the different lesions producing tumor, the general con- stitutional manifestations which are of assistance in diagnosis. Aside from the local and the constitutional evidence of renal disease (high blood pressure and enlarged heart), we have only the evidence afforded by the urine, to which I now pass on. 4. EiC'amination of the Urine. The urine as passed per urethram is a resultant and reflects the influence of many different organs and surfaces. Thus disturb- ances of metabolism, such as diabetes, intoxications (lead, arsenic), 'diseases of the heart, liver, and intestine, febrile conditions, infec- tive or malignant disease of any part of the urinary tract (kidney, ureter, bladder, or urethra) , as well as the different types of nephritis, all affect the urine, though hardly any of them produce pathognomonic changes in it. In this section I shall consider the urine as a piece of evidence in the diagnosis of kidney disease, and only in contrast with this will its characteristics in extrarenal troubles be mentioned briefly. The most essential features of the urine in the diagnosis of kid- ney disease are : 1. The amount passed in twenty-four hours, measuring sepa- rately the portions passed at night (8 p.m. to 8 a.m.) and in the day- time (8 A.M. to 8 P.M.). 2. The specific gravity. 3. The looks (optical properties). 4. The "red test" (see page 399). 5. The reaction to litmus. 6. The presence of blood, pus, or tubercle bacilli. 7. The presence or absence of albumin and sugar. 26 402 PHYSICAL DIAGNOSIS Much less important than these is the presence or absence of casts, cells, crystals, etc. (a) The Amount and Weight of the Urine. The twenty-four-hour amount concerns us chiefly in diabetes, the different types of nephritis, and in cardiac decompensation. Polyuria occurs in health after the ingestion of large quantities of water, and sometimes in conditions of nervous strain. In dis- ease it characterizes both forms of diabetes, contracted kidneys {■pn- mary, secondary, or arterio-sclerotic) , and is seen during the con- valescence from acute nephritis and from various infectious diseases. It also occurs in the early stages of renal tuberculosis or when con- tinuous drainage (catheter) is established in cases of prostatic obstruc- tion. In diabetes of either form several quarts or even gallons may be passed. In contracted kidneys the increase of urine occurs very largely at night, so that the amount may be double that passed in the day-time, just reversing the conditions of health. Oliguria or scanty urine occurs in health when the amount of water ingested is small or when water is passed out of the body abundantly through the skin or by the bowels (diarrhoea). In dis- ease oliguria or absolute suppression of urine {anuria) occurs at the beginning of acute nephritis and as a result of occlusion of one or both ureters by stone or malignant disease.'- Remarkable examples of anuria also occur in hysteria. Infectious fevers and cachectic states often diminish the secretion of the urine by one-half or more. The specific gravity is usually low with polyuria and high with oligturia, but in diabetes mellitus the presence of the sugar gives us polyuria with high specific gravity. Total Urinary Solids. — By multiplying the last two figures of the specific gravity by the number of ounces of urine passed in twenty- four hours and the product by i.i, we get a figure representing the total urinary solids in grains, with acctiracy sufiicient for clinical diagnosis. Thus if 30 ounces of urine are passed in 24 hours and the gravity is i .020, then 20X30X1.1= 660 grains. (b) Optical Properties. Color. — Dilute urines (polyuria) are generally pale, and concen- trated urines (oliguria) high in color. A dark or brownish tint in ' It is a remarkable but well-attested fact that when one ureter is suddenly blocked both kidneys may stop secreting for the time. Yet when one kidney is gradually destroyed as in tuberculosis, the other hypertrophies so as to assume the function of both. THE INTESTINE, SPLEEN, KIDNEY 403 the urine is generally produced by bile, by blood pigment, or as a result of certain drugs — carbolic acid, coal-tar preparations, and salol. If the color is due to bile, a bright canary yellow appears in the foam after shaking up a little of the urine in a test tube. No other tests for bile are necessary. Urines darkened by blood pig- ment show abundant blood corpuscles in the sediment;* when the color is due to drugs we can usually learn this fact from the history. Turbidity in alkaline urine is usually due to the presence of bac- teria. In acid urine it is produced in a great majority of cases by amorphous urates, and disappears on heating the urine, while the turbidity due to bacteria is unaffected by heat. Normal urine may be turbid and alkaline, -owing to the presence of insoluble carbon- ates and phosphates, but clears on the addition of acetic acid. Hence tiurbidity, not removed by heat or acetic acid, is almost always due to bacteria and pus, i.e., to cystitis, pyelonephritis, or both. Shreds seen floating in the urine and found to be composed mostly of pus are presumptive evidence of urethritis, and practically always of gonorrhoea. The gross sediment as seen by the naked eye amounts in health to nothing more than a slight cloud, which settles in the lower part of the vessel containing the urine. This cloud is somewhat denser in women than in men, owing to the presence of vaginal detritus. When the gross sediment amounts to anything more than this, it is almost invariably made up of (a) pus, (b) blood, or (c) urates. The latter are dissolved on heating. Pus has usually its ordinary yellow color and general appearance. Blood may be somewhat lighter or somewhat darker than under ordinary conditions, but is usually recognized without difficulty. (a) Significance of these Sediments. A urate sediment means nothing more than a concentrated urine standing in a cold room. In the winter-time patients often bring us, in great alarm, a bottle of milky or fawn-colored and turbid urine, which is not in any way abnormal. The urates have been precipi- tated over night by the low temperature of the bedroom. Pyuria, or gross pus in the urine, is oftenest seen in cystitis and less often in pyelonephritis and renal suppurations, tuberculous or pyogenic. The pus occurring in gonorrheal urethritis is usually much less in quantity than that coming from the bladder or kidney, and can be distinguished by the local signs of gonorrhoea. Leucorrhoeal pus can be excluded by withdrawing the urine by catheter. The rupture ' Except in some cases of haemoglobinuria. 404 PHYSICAL DIAGNOSIS into the urinary passages of an abscess from the prostate or any part of the pelvis may produce a profuse but transient pyuria. After excluding gonorrhoea, leucorrhoea, and abscess, which can usually be done with the help of a good history and a catheter, we have left cystitis and renal suppurations, which it is very important and sometimes difficult to differentiate. In both we have the fre- quent and painful passage of small quantities of a urine which is in no way remarkable except in containing large amounts of pus and bacteria. Cystoscopy is often essential. In the vast majority of cases "cystitis" is secondary to some other disease above or below the bladder — e.g., to prostatic obstruction, renal tuberculosis, etc. In many cases the differentiation may be accomplished as fol- lows: Have the patient save for twenty-four hours the urine voided at each passage in a separate bottle (all of the bottles being of uni- form size) , and mark each bottle with the hour at which it was filled. Then arrange the specimens in a row, beginning with that passed earliest and ending with that passed last. Now if the case is one of cystitis without involvement of the kidney, the amount of pus that settles is practically the same in each bottle (allowing for differ- ences in the amount of urine in the different bottles). But if the pus comes from the kidney, it is almost always discharged inter- mittently, and hence some of the bottles will be almost free from sediment, while in a group of the others the amount of pus increases as we pass along the line, reaches a maximum in one or two bottles, and decreases again in those representing the later acts of micturition. Pus from the bladder is generally alkaline, although in tubercu- losis it may be acid; pus from the kidney is generally acid. When both organs are involved, as is frequently the case, we have a mixture of the characteristics of both types of pjoiria, and cystoscopic ex- amination with or without catheterization of the ureters is usually necessary. S- Pyuria. In renal pyuria ' we often have local signs in the renal region (tumor and tenderness), a history of renal colic, and decided con- stitutional symptoms. In vesical pyuria we have vesical pain, often tenesmus, no renal pain or tumor, and usually slighter constitutional symptoms. The amount of squamous epithelium (see below) is sometimes larger in cystitis than in renal suppurations, but no reliable inferences can be drawn from the size or shape of the cells. THE INTESTINE, SPLEEN, KIDNEY 405 To determine whether pus from the bladder or the kidney iy tuber- culous or non-tuberculous in origin, we usually inject- the sediment into a guinea-pig, which develops tuberculosis or not according to the nature of the pus injected. This method is much more reliable than the bacteriological examination of the sediment, for besides the tubercle bacillus other bacilli which retain fuchsin and resist decolorization by strong mineral acid and by alcohol occasionally occur in the urine. 6. Hmmaturia. In searching for the source of the blood we must be sure to exclude the female genital organs. Menstrual blood and uterine bleeding from various other causes often contaminate the urine, and must be excluded by using a catheter. The causes of true hsematuria, arranged approximately in the order of frequency! are : 1. Acute nephritis and acute hemorrhage in chronic nephritis. 2. Stone in the kidney (less often vesical stone). 3. Tumors of the kidney or bladder. 4. Tuberculosis of the kidney or bladder. 5. Early cystitis. Less common causes are: floating kidney, hydronephrosis and cystic kidneys, animal parasites in the urinary passages, poisons (turpentine, carbolic acid, cantharides) , hemorrhagic diseases (pur- pura, scurvy, leukaemia), trauma and renal infarction. In nearly one-fourth of all cases no cause can be found. In cystitis there are bladder symptoms — pain, tenesmus, fre- quent and painful mictm-ition. The blood is mixed with pus and epithelium, and is especially abundant in the urine passed near the end of the act of micturition. If the bladder is irrigated it is hard to get the wash-water clear. Cystoscopy demonstrates or upsets the diagnosis and also serves to show some other disease to which the cystitis is secondary. Distrust all diagnoses of "primary cystitis." In renal stone there are no bladder symptoms to speak of, the blood is pure and thoroughly mixed with the urine, and if the bladder is washed out the final wash-water is clear. There is often renal colic (see p. 392) and sometimes the passage of stones or gravel by urethra. X-ray evidence is usually conclusive. In acute nephritis the blood is rarely fresh, generally dark choco- late in color. The twenty-four-hour amount of urine is small, and albumin and casts (see below) are abundant. General oedema is 406 PHYSICAL DIAGNOSIS common. Local symptoms in the kidney or bladder' are absent. Most cases of '-' acute nephritis" in adults turn out, on careful study, to represent acute exacerbations of chronic nephritis. In renal tumor and especially in renal tuberculosis we have often pyuria and the local and constitutional evidences above described (page 390) , with marked and early bladder symptoms {even when the bladder is not diseased) . Tumors of the bladder need cystoscopy for diagnosis. In the diagnosis of the rarer forms of hsematuria we rely chiefly on the history (trauma, poisons ingested) and on the evidences afforded by cystoscopy and general physical examination. 7. The "Red Test" (Phenolsulphonephthalein) for Renal Function. Of the many "functional" kidney tests introduced in recent years that of Rowntree and Geraghty is by far the most useful for clinical purposes. One cubic centimeter of the standard sterilized solution of phenolsulphonephthaleinHs injected subcutaneously into the back or thigh. Two hours later the patient passes urine which is then made alkaline with sodic hydrate and diluted up to i liter. The degree of red color in the resulting fluid is then compared in a test tube with a scale of standard test tubes representing 90 per cent., 80 per cent., 70 per cent., etc., of the amount of coloring matter originally injected. Such a scale of test tubes can be cheaply made by any one who has access to a Dubose colorimeter. The scale can also be bought for a few dollars from Joseph Godsoe, Massachusetts General Hospital, Boston. If there is prostatic obstruction or urethral stricture the patient should be catheterized when the "red" is injected and at the end of 2 hours. Normal young adults excrete 65 per cent, to 90 per cent, of the color injected- within 2 hours. In nephritis and decompensated heart disease the color output may fall to 5 per cent, or to zero. In elderly people confined to bed 40 to 50 per cent, may be considered normal and does not indicate nephritis. Allowing for age and activ- ity the test is a valuable measure of the kidney's general excretory function. 8. Chemical Examination of the Urine, (a) The Reaction of the Urine. The reaction of normal urine is acid to litmus, except temporarily 1 Any dealer in medical supplies can furnish it. THE INTESTINE, SPLEEN, KIDNEY 407 after large meals. Its acidity becomes excessive in fevers or occasionally without any known cause. Alkaline lurine has generally an ammoniacal odor and suggests cystitis. As a result of decomposition and bacterial fermentation all urine becomes alkaline (ammoniacal) on standing exposed to air.* Occasionally we find urine alkaline from fixed alkali and without known cause. The value of the litmus test is chiefly as prima-facie evidence of stasis in the bladder and cystitis. Occasionally tuberculous cystitis and the first stages of any variety of cystitis are associated with acid urine, but in most cases lasting over a week am- moniacal fermentation and alkalinity appear. ' "i|i ifi t (6) Albuminuria and the Tests for It. Serum, albumin is the only variety of clinical im- portance, and for this but two tests are necessary: (i) Nitric-acid test; (2) test by boiling. The nitric-acid test is best performed in a small wine- glass. After filling this half full of urine, insert a small glass funnel to the bottom of the urine and gently pom- in concentrated nitric acid. If albumin is present, a white ring forms at the junction of the acid with the urine, either immediately or in the course of ten minutes. If carefully performed this test is delicate enough for all clinical purposes, but since some of the albumoses give a similar precipitate, the boiling test should be used as a control whenever a positive reaction is obtained with nitric acid. None of the other rings, observable above or below but not at the junction of the acid with the lurine, is of any clinical importance. The Boiling Test. — ^To half a test tube full of urine add three or fotu^ drops of dilute acetic acid, and boil the upper three-quarter inch of the urine. If albumin is present a white cloud appears. If the Bence- Jones body is present a white cloud appears on heating, dis- appears on boiling, and reappears on cooling. In per- forming this test the addition of acetic acid as above Esbach's Albu- described is absolutely necessary to prevent error. menometer. ' Simultaneously a dark-brown color rarely appears: alkaptonuria, a fact at present of no clinical significance except that such urines reduce Fehling's solution and may be mis- takenly supposed to contain sugar. 41i Fig. 212. 408 PHYSICAL DIAGNOSIS For the detection of albumin no other tests are needed. For its approximate quantitative estimation, Esbach's method is the best. Esbach's Method.— A special tube (see Fig. 212) is employed. Urine is poured in up to the mark "U," and then Esbach's reagent' up to the mark "R." The tube is then corked, inverted about half a dozen times, and set aside for twenty-four hours. A precipitate falls and the amount per mille is then read off on the scale etched upon the tube. If the urine is not acid it must be made so with dilute acetic acid, and unless its specific gravity is already very low it should be diluted once or twice with water so as to bring the gravity below 1.008. After such a dilution we must, of course, multi- ply the result obtained by a figure corresponding to the dilution. The method is not accurate, but is probably accurate enough for prac- tical purposes, if all tests are made at approximately the same tem- perature. (c) Significance of Albuminuria. It is important to realize that albuminuria very often o curs with- out nephritis and that nephritis occasionally occurs without albu- minuria. Among the more important types not due to kidney disease are the following: (i) Febrile albuminuria; (2) albuminuria from renal stasis; (3) albuminuria due to pus, blood, bile, or sugar in the urine; (4) toxic albuminuria. Besides these, there are a good many cases of albuminuria occur- ring in diseases of the blood, after violent exertion, after epileptic attacks, and without any known cause. Many of the latter group occur only when the patient is on his feet and are absent as long as the patient lies down {orthostatic albuminuria) ; others occur irregu- larly or at regular intervals (cyclic albuminuria). Most of these cases appear at adolescence and pass ofiE without any nephritis ever developing. Nearly one in ten college freshmen shows this harmless albuminuria. Exclude fever, circulatory disturbance, anaemia, poisons — such as cantharides, turpentine, carbolic acid, and arsenic — and deposits of blood or pus in the urine, before deciding that a case of albuminuria is due to nephritis. In general, it is a good rule not to attribute albuminuria to nephritis unless there is other and more convincing evidence in the physical characteristics of the urine and in the other organs of the patient. If the 2-hour amount and the gravity are approximately normal, and if there is no oedema, no increased blood pressure, no cardiac hypertrophy, no uraemic manifestations, and ' Esbach's reagent: Picric acid, 10 gm.; citric acid, 20 gm.; distilled water, 1,000 c.c. THE INTESTINE, SPLEEN, KIDNEY 409 nothing alarming in the sediment of the urine, we should not diag- nose nephritis. I shall discuss this point further in the section on the examination of the sediment (see page 404). It will be noted that practically all the types of albuminuria not due to nephritis are transient, while, with the exception of certain stages of chronic inter- stitial nephritis, the albuminuria of nephritis is as permanent as the nephritis itself. On the other hand, many cases of nephritis (so proved by autopsy) show no albuminuria for long periods. They are then to be recognized by the evidence of high blood-pressure and by its results. {d) Significance of Albumosuria. The Bence-Jones body is very constantly present in the urine of cases of multiple myeloma. It has no known importance in any other disease. Deuteroalbumoses have no clinical significance. (e) Glucosuria and Its Significance. For glucose in the urine we need but one qualitative and one quantitative test, viz., Fehling's test and the fermentation test. 1. Fehling's Test. — Mix in a test tube equal parts of a standard solution of copper sulphate' and a standard solution of alkaline tar- trates,^ and add to this mixture an equal amount of urine. Mix and heat nearly to boiling. The amount of error entailed by boil- ing is slight and unimportant, but the only advantage of boiling is a slight saving of time. If sugar is present a yellow or reddish- yellow precipitate occurs, either at once or (if the amount of sugar is very small) after the urine has cooled. Fehling's solution may also be used for quantitative estimation of sugar, but it is more con- venient to use : 2. The Fermentation Test.— Take the specific gravity of the urine as carefully as possible, and acidify it if necessary with acetic acid. Pour six or eight ounces of urine into a wide-mouthed vessel and crumb into it half a cake of fresh Fleischmann's yeast. Set the flask aside in a warm place, and after twenty-four hours test the super- natant fluid with Fehling's solution as above; if sugar is still present fermentation must be allowed to go on twenty-four hours longer. As soon as a negative reaction to Fehling's has been secured (whether in twenty-four or forty-eight hours), the specific gravity of the fil- ' Made by dissolving 34.64 gm. pure CuSOj in water and then adding enough water to make 500 c.c. ' Made by dissolving 173 gm. Rochelle salts and 60 gm. sodic hydrate each in 200 c.c. of water, mixing the two solutions, and adding water to make 500 c.c. 410 PHYSICAL DIAGNOSIS tered urine is again taken. ^ It will be found lower than before the fermentation, and for every degree of specific gravity lost we may reckon that 0.23 per cent of sugar has been fermented out of the urine. Thus if the reading was 1.040 before fermentation and 1.020 afterward, we multiply the difference between these readings, 20, by 0.23, giving 4.6 per cent — the percentage of sugar. Fehling's test should be a.pplied to every urine examined; it takes but a minute or two. When it shows a yellow or red precipitate, the fermentation test should also be tried; and if both tests are positive we shall run but a negligible risk in saying that glucose is present. From the result of the fermentation test and the twenty-four-hour amount of urine, we can estimate the daily output of sugar through the urine. Permanent glucosuria means diabetes mellitus. Transitory glu- cosuria may be due to a great many causes, among which are: (i) Diseases of the liver; (2) diseases of the brain, organic or functional, especially the latter; (3) infectious fevers; (4) poisons, especially narcotics (alcohol, chloral, morphine) ; (5) pregnancy; (6) exoph- thalmic goitre. Experimental ("alimentary") glucosuria or levulosuria can be produced in many of these same diseases by giving the patient 100 gm. of glucose or levulose in solution. The differential diagnosis of the cause of glucosuria depends on the recognition of one of the above conditions. The other sugars occasionally found in the urine (levulose, lactose, pentose, etc.), are of no clinical importance. (/) The Acetone Bodies. Acetone, Diacetic and Beta-Oxybutyric Acids. 1. Test for Acetone. — To about one-sixth of a test tube of urine add a crystal of sodium nitroprusside, and then NaOH to strong alkalinity. Shake and add to the foam a few drops of glacial acetic acid. A purple color shows acetone. 2. Test for Diacetic Acid. — A Burgundy red color when a strong aqueous solution of ferric chloride is added to fresh urine {not pre- viously boiled) in a test tube. If this reaction is well marked beta- oxybutyric acid is probably also present, but we possess no clinical test for the latter substance. Significance of the Acetone Bodies. — -Diminished utilization of carbohydrate food by the body is usually the cause of the appear- ance of these bodies in the urine. This may occur: (a) Because suf- I The room temperature must be approximately the same as at the time of the previous reading. THE INTESTINE, SPLEEN, KIDNEY 411 ficient carbohydrates are not eaten (starvation, rectal alimentation, feyers, etc.). (6) Because they are not absorbed (vomiting, diar- rhoea, etc.). (c) Because they are not assimilated (diabetes), and rarely for other reasons. (g) Other Chemical Tests. The information to be derived from testing for indican, for the amounts of urea, uric acid, chlorides, phosphates, and sulphates, does not seem to me sufficient to justify the time spent. The same is true of the diazo reaction. The guaiac test for blood , described above (see p. 356) in connection with the examination of gastric contents and fevers, is also of value in the urinary examination. Simon's lucid arguinents for the value of the indican test have not been borne out by my experience with it in diagnostic puzzles. The tests for urea and uric acid are of value only when we possess a knowledge of all the factors governing their excretion, knowledge which in clinical work we almost never have. Diminution or ab- sence of the urinary chlorides in pneumonia is not constant, and occurs in many other infections (typhoid, scarlet fever, etc.). The diazo reaction is nearly constant in typhoid, but is occasionally found in so many other febrile and cachectic states that most clini- cians have ceased to rely on it. Its value in the prognosis of phthisis is slight. I believe that the general abandonment of the tests for the sulphates and phosphates will soon be followed by the abandon- ment of the tests for urea, uric acid, indican, and the chlorides. The use of these tests gives the appearance of accuracy and scientific method in diagnosis — the appearance, but not the reality. 9. Microscopic Examination of Urinary Sedim,ents. Methods. — A centrifuge is convenient, but not necessary. The sediment should be allowed to settle in a conical glass (see Fig. 213), whence a drop of it -can be transferred to a slide by means of a pointed glass pipette. Close the upper end of this with the forefinger and introduce the pointed end into the densest portion of the sediment; next very slightly relax the pressure of the forefinger until urine and sedi- ment flow into the lower one-half or three-fourths inch of the pipette. Then resume firm pressure with the forefinger, withdraw the pipette, wipe the outside of it ^'°',^i^~ ° . . . ,. , J . Conical Glass dry, put Its point upon a microscopic shde, and again ^^^ urinary slightly relax the pressure of the forefinger so as to let a sediments. small drop of urine and sediment run out upon the slide. 412 PHYSICAL DIAGNOSIS Cover this drop with a seven-eighths inch cover glass, and examine it with a Leitz objective No. 5 or Zeiss DD. The arrangement of the light is most important. The iris dia- phragm should be closed until one can just distinguish the outlines of the cells and other objects in the field. If more light is admitted the pure hyaline casts will be invisible. Results. — The objects most often sought for in the sediment are : (o) Casts ; (6) cells ; (c) crystals ; id) animal parasites or their eggs. I. Casts. ^ — Casts, or moulds of the renal tubules, may be homo- geneous and transparent (hyaline, Fig. 214, i) or may have a,ttached to this matrix a variety of granules, cells, crystals, or fat drops. Ac- cording to the variety of passengers carried down from the kidney on the casts, we call them granular, hrbwn- granular, cellular, blood, fatty, or crystal-bearing casts (see Fig. 214, 2 and 3, and Fig. 215, i, 2, 3, and 4). Dense or highly refractile casts, colorless or straw colored, are occasionally seen, and are often given a variety of names quite un- justified by any knowledge of their composition (e.g., "waxy,"^ "fibrinous," etc.). From strands of mucus, foreign bodies, and other sources of error, true casts may be distinguished by the following traits : (a) Their sides are parallel. (6) One end is rounded; sometimes both ends. Red corpuscles and other cells upon casts are to be recognized — the former by the size, shape, and, if fresh, by their color (pale straw) ; the latter by the presence of a nucleus. Fat drops are spherical and very highly refractile, so that they seem to have a black line at their per- iphery. Crystals can be recog- nized by their angles. They ' Though I have here described casts first I believe that the finding of blood or pus in the sediment is of far more frequent and more considerable importance. ^ Some dense, refractile casts give the amyloid reaction, but this does not indicate amyloid kidneys and has no known clinical significance. Fig. 214. — Casts, i. Hyaline casts; 2 and 3, hyaline casts with cells and blood adherent; 4, " cylindroids." THE INTESTINE, SPLEEN, KIDNEY 413 Fig. 215. — Casts, i, Blood-casts; 2, fatty casts; 3, granular casts; 4, cellular casts. are very rarely of importance. When showers of oxalate crystals in large masses are associated with attacks of hsematuria not otherwise explained, the crystals may be of some etiological significance. Other bodies on casts are called granules. Significance of Casts. — Casts may occur in health (un- less we choose to class muscular fatigue as disease) as well as under any of the conditions giv- ing rise to albuminuria (see page 400). They are usually more numerous in acute nephritis and in the acute exacerbations of chronic nephritis than in most other conditions. Any type of cast may occur in any type of nephritis, but Cellular,^ blood, and brown-granular casts are most often found in acute nephritis. Fatty, highly refracting, or dense casts most often predominate in chronic glomerular nephritis ("diffuse" or "parenchymatous" nephritis) . Hyaline and granular casts may occur in any type of nephritis ^ and in many other conditions (fatigue, renal stasis, r y^ (^ etc.) . In the urine of persons over fifty years of age ) JP ^VC\ the presence of a few hyaline and granular casts has /^ no known clinical significance, and may probably be / \P considered physiological. \y ^ I I Periods occur in the course of many cases of f]--^ Q y chronic contracted kidney when no casts can be found. If any occur they are usually of the hyaline and fine granular types. 2. Free Cells in Urinary Sediment. A. Recogni- tion. — The presence of macroscopic pus or blood already alluded to may be verified by the microscope. (o) Fresh red cells, lately freed from the blood-vessels, preserve their straw-yellow color. Their presence points to the recent effu- sion of blood, probably from the bladder, urethra, or renal pelvis. ' "Cellular" is a better term than "epithelial," since we have no marks for recognizing renal epithelium or for distinguishing a renal cell from a lymphocyte. U^ ; Fig. 216 Spermatozoa. 414 PHYSICAL DIAGNOSIS (6) Abnormal blood, decolorized and shadowy red discs, can be recognized with practice by their size and shape. We may infer that they have remained some time in the urine and have probably come from the kidney. (c) Pus is easily recognized as a rule by the presence of the fa- miliar polymOTphous nucleus in most of the cells. Should doubt arise, a drop of dilute acetic acid allowed to run under the cover glass will sharpen the outlines of the nuclei and facilitate their recog- l|SS,s' j^^^J nition. (d) Spermatozoa (see Fig. 216) are often seen in the urine after coitus or nocturnal emissions. They are of no importance, ex- cept that when appearing in the urine of females they may afford valuable medico-legal evidence. They are easily recognized by their size and shape. (e) Other varieties of cells need not be differentiated, since almost any of the varieties usually described (squamous, spindle-shaped, caudate, etc.) may come from Fig. 217. — Crystals of Triple Phosphate (prisms) and Ammonium Urate (small spheres with spines.) Fig. 218.— Crystals of Uric Acid (whet- stone-shaped) with Calcic Oxalate (small octahedral) and Amorphous Urates. any part of the urinary tract. Renal cells are not recognizable by our present methods of ex- amination. Any of the urinary cells may contain fat drops, but these have no special diagnostic significance. B. Interpretation. — The sig- nificance of large quantities of blood or of pus in the urine has already been discussed (page 396). When recognizable only by the microscope they have no diagnostic value. The presence of large num- bers of cells not coming from the e " ^ 4>° D CD ■^ 0. a' C D THE INTESTINE, SPLEEN, KIDNEY 415 blood-vessels (squamous, " spindle-shaped, etc.) is usually associated with cystitis, provided the accidental admixture of vaginal detritus is excluded. Pyelitis and renal suppurations may fill the sediment with similar cells, and only by other methods of examination (cystos- copy, ureteral catheterization) and by taking account of all the facts in the case can the differentiation be made. 3. Crystals in Urinary Sedi- ments (see Figs. 217, 218, and 2 19). — The varieties oftenest seen are: i (a) Triple phosphate (ammoniacal urine, cystitis); (6) ammonium urate; (c) uric acid; {d) calcic oxalate. ^ All of these varieties are color- _y^ less except the uric-acid crystals, which are usually light or dark •\/ „ ^» yellow or yellowish-brown. . ^ ■.-, ji ii 1 , . Fig. 210. — Calcic Oxalate Crystals. None of these have much sig- nificance in diagnosis. The first two merely confirm the evidence of urinary decomposition (usually from cystitis) afforded by the re- action, turbidity, and odor of the urine. Uric-acid crystals, if present in great numbers in the urine when passed, suggest the search for macroscopic masses (gravel) and for other evidence of renal stone, but as a rule they are of no importance. The same may be said of calcium oxalate. Oxaluria is one of the most persistent bugbears of the medical profession, but it is utterly harmless except in the rare cases in which it accompanies hsematuria (see above) or gravel. 4. Animal parasites or their eggs are occasionally found in the urine, with or without hsematuria and evidence of cystitis (see Figs. 220 and 221). 10. Summary of the Urinary Pictures Most Useful in Diagnosis. Aside from polyuria, oliguria, hcematuria, and pyuria, which have already. been discussed, the most important conditions in which the urine gives valuable diagnostic evidence are: I. Cystitis. — Urine passed frequently, painfully, and in small amounts. Turbid, ammoniacal, and offensive (after the earliest stages). Much pus and many other cells are found in the sediment, 416 PHYSICAL DIAGNOSIS with bacteria, triple phosphate crystals, and amorphous debris. It must be remembered that cystitis is usually but one element in the diagnosis; bladder stone, obstructing prostate, tuberculous kidney, or other diseases may be its cause. Fig. 220. — ^Vinegar Eels in Urine. (Billings.) o, Protruded hooks of male; 6, top- shaped oesophageal enlargement. The Strongyloides stereoralis (see above, Fig. 208, page 393) has also been found in the urine. 2. Acute Nephritis (or acute exacerbations in chronic cases). — Scanty, heavy, highly albuminous urine, often bloody and containing in the sediment much blood and many cells, free or on casts. Other varieties of casts occur, but are not characteristic. In convalescence the urine becomes abundant and of light weight, and the other abnormalities gradually disappear. THE INTESTINE, SPLEEN, KIDNEY 417 3. Chronic Glomerular Nephritis ("parenchymatous" or "dif- fuse"). — The urine is rather scanty, pale, and light (1.012-1.018), with a varying amount of albumin and, in the sediment, much fat — free, in cells, and on casts. Also found, but not characteristic, are all the other varieties of casts. If death does not ensue within eight- een months, the urine is apt to assume the characteristics of the : 4. Contracte'd kidney (primary, secondary, or arterio-sclerotic) , with polyuria (often several quarts; urine especially abundant at night), low specific gravity (1.014 or less). Traces of albumin and Fig. 221. — Bilharzia Eggs in the Urine, with Blood, Calcic Oxalate, and a Hyaline Cast. (O'Neil.) a few hyaline and granular casts occur steadily or intermittently. High blood pressure is nearly constant. 5. Pyelitis and acute hcematogenous renal suppurations are dis- eases much more commonly recognized since 1904 than previously. The presence of bacteria (usually colon bacilli) and pus without many cells of other types in acid urine should always lead to bacteriological and cystoscopic examinations. This condition of the urine may at times be the only sign of the disease. The presence of pain, tender- ness, or tumor in the region of the kidney (usually the right kidney) and the occurrence of fever and leucocytosis support the diagnosis. 418 PHYSICAL DIAGNOSIS especially in little girls and in women near parturition. To dis- tinguish pure pyelitis from pyelitis complicating a renal infection is at present impossible. This disease should be borne in mind : (a) In all cases of unexplained fever without obvious local cause — especially in girl babies and in women a short time before or after parturition (subacute or chronic renal infection). (6) In acute abdominal emergencies when appendicitis, chole- cystitis, intestinal obstruction, perforating peptic ulcer, and pan- creatitis are being considered. With these consider also acute infection of the kidney, for in some cases the pain is in the right hypochondrium and no complaints suggesting the kidney are uttered. CHAPTER XXIV. THE BLADDER, RECTUM, AND GENITAL ORGANS. I. The Bladder. I. Incidence of Bladder Disease. (Massachusetts General Hospital, 1 870-1 905.) Cystitis 829 cases. Stone 538 cases. Cancer 57 cases. Papilloma 20 cases. Tuberculosis 43'cases. (a) Data. Distention, tumor, the urine, and the results obtained by cystos- copy, by catheterization, by rectal and vaginal examination, by the x-ray, and by sounding for stone furnish most of our direct evidence in bladder disease. Pain in the bladder or near the end of the penis, and frequent, painful micturition -with vesical tenesmus or straining, are common symptoms in various lesions of the organ, and direct our attention to it, though they do not indicate the nature of the trouble. 2. Distention of the Bladder. In both sexes, distention is often wholly unknown to the patient, and may be accompanied by frequent acts of urination, especially in prostatic obstruction, in acute infections, and after operations. A distended bladder is readily recognized by palpation as a smooth, round, firm, symmetrical tumor in the median line, above the pubes. The tumor is dull on percussion, and in slight degrees of distention this dulness above the pubes may be the only physical sign obtainable. In well-marked cases, which are most common in males, the distended bladder may reach to the navel or even above it, and the beginiier is usually astonished at its dimensions and its firm, resistant surface (see 419 420 PHYSICAL DIAGNOSIS Fig. 222). Diagnosis rests on the infrequency of other tumors of this region in men and on the result of catheterization or suprapubic aspiration. In females a history of failure to pass urine almost invariably makes the diagnosis obvious, though occasionally after operations distention of the bladder and dribbling of urine may go together in women, as they so frequently do in men. The commonest causes of distended bladder are : (i) Prostatic obstruction, (2) Old strictures of the urethra. Less common are : (3) Spasm of the urethra in gonorrhoea. (4) Acute prostatitis. Fig. 2: -Distended Bladder Reaching Above the Navel. (5) Paralysis of the bladder, from di.5ease or injury, after opera- tion, and in fevers. (6) Tumor or stone near the neck of the bladder. The diagnosis of the cause of distention rests on the history, the result of attempts at catheterization, the rectal examination, the condition of the urine, and the physical signs in other parts of the body. A long history of frequent micturition, especially at night, in an old man, an obvious enlargement of the prostate felt by rectum, THE BLADDER, RECTUM, AND GENITAL ORGANS 421 and the passage of ammoniacal urine suggest prostatic obstruction. The information obtained during the passage of a catheter usually clinches the diagnosis. Acute retention, with no previous history of frequent micturition or foul-smelling urine in a young or middle-aged man, who has had gonorrhoea and may or may not have noticed a diminution in the size of the stream of urine passed, suggests a urethral stricture. The catheter decides. Spasm of the urethra may occur in acute gonorrhoea, and pro- duces a retention which may often be overcome by hot poultices and enemata. The history and the effects of treatment suggest the cause of the retention. Acute prostatitis, as a cause of retention following gonorrhoea, is suggested by pain and tenderness in the perineum, painful defe- cation, fever, perhaps chills, and a hot, tender prostate felt by rectum. Abscess may form and discharge by urethra or rectum. Paralysis of the bladder, as a cause of retention, is usually obvi- ous from the history and from the evidence of disease of the spinal cord, or of operation and semicomatose states (as in fevers and shock) . 3. The Urine as Evidence of Bladder Disease. This has been described above (page 408). Cystitis, acute or chronic, usually gives characteristic evidence of itself in the urine, and suggests as its cause the possibility of gonorrhoea, of vesical stone, of prostatic or other obstruction to the outflow, and of vesical or renal tuberculosis. When a urine like that described in contracted kidney occurs with chronic prostatic obstruction, the relief of the obstruction is necessary if we are to prevent progressive development of cirrhotic kidney from back pressure. Frequent micturition is much commoner and less significant in women than in men. All sorts of "nervousness" and emotional strain produce this symptom in women, independent of any demon- strable source of irritation in the urinary tract. Aside from these conditions the symptom is of tenest met with in : (o) Cystitis, from any cause, including stone and renal tuberculosis, or without known cause, with characteristic changes in the urine. (6) Prostatic obstruction, with evidence of retention. (c) Gonorrhoea, with evidence of this disease. (d) Paralysis of the bladder (see above) . (e) Over concentration of the urine {estimated by the color and . specific gravity) . 422 PHYSICAL DIAGNOSIS ///. Stone in the Bladder. — Pain near the end of the penis, espe- cially at the end of micturition and aggravated by jolting or active motion, frequent urination, especially in the daytime, sudden inter- ruption of the stream of urine, and hsematuria at the end of micturi- tion, are the most frequent symptoms of stone, especially if they occur in boys. In old men stone may be wholly without character- istic symptoms, and at any age the symptoms can never do more than suggest the possibility of stone and the advisability of search- ing for it systematically with a sound or a cystoscope. IV . Tuberculosis of the Bladder. — Cystoscopy and the recogni- tion of tubercle bacilli by animal inoculation are the only reliable means of diagnosis. A chronic cystitis in a young or middle-aged person, especially with an acid urine, is suggestive. V. Tumors of the bladder are suggested by intermittent hsema- turia with vesical irritation, and confirmed by cystoscopic examination. II. The Rectum. I. Symptoms. It is not and should not be a part of routine physical examina- tion to examine the rectum. The commonest conditions which call for such investigation are : (a) Hemorrhage at stool. (6) The protrusion after defecation of something which is not easily returned ("piles"). (c) Painful defecation or pain in the region of the rectum at other times. (d) The presence of an ulcer or sinus near the rectum. (e) Habitual constipation, not explained by lesions elsewhere. (/) Intestinal obstruction. (g) All subacute diarrhoeas of elderly persons (cancer) . . Qi) Suspected appendicitis, prostatitis, prostatic cancer or ob- struction, or diseases of the seminal vesicles. (i) Pelvic symptoms in women with tight hymen. The diseases of the rectum which we are especially on the look- out for are: (i) Hemorrhoids; (2) fissure of the anus; (3) ischio- rectal abscess; (4) fistula in ano; (5) cancer of the rectum. Less common are: (6) pruritus ani; (7) prolapse of the rectum; (8) ulcera- tion or stricture of the rectum. 2. Methods. For most examinations the finger suffices. It should be covered THE BLADDER, RECTUM, AND GENITAL ORGANS 423 by a thin, rubber finger-cot, greased with vaseHne, and should be introduced slowly and gently while the patient strains down as dur- ing defecation. The examining finger should note the presence of abnormal prominences or resistance (piles, tumors) in any part of the rectum, of tender spots (ulcer, abscess), and strictures. The shape and size of the prostate gland, its consistence, and the presence or absence of tenderness in it are of importance. The normal seminal vesicles can be felt if distended. If they are hard and nodular, tuberculosis should be suspected. By milking the vesicles and massaging the prostate, pus containing gonococci may be pressed out through the urethra. This process is often of value both in diagnosis and in treatment. High up on the right one may touch a tender spot if an inflamed appendix is near the pelvic brim (often a fallacious sign) . In women the uterus, especially if retroverted, may be easily felt, and most of the other details of pelvic examination (see below, page 420) can be more or less clearly made out. For higher and more thorough examination a cylindrical specu- lum and a head mirror should be used. Hemorrhoids. — The diagnosis of external hemorrhoids, which can easily be brought outside the anus, is made at a glance. Internal hemorrhoids are best seen with a rectal speculum, and may resemble the external or may consist of "bright red, "Spongy, granular tumors, rarely larger than aten-cent piece, and situated high up in the rectum. " Fissure of the anus is often connected with a small ulcer and with cedematous folds, which resemble an external pile but are much more tender. On separating these folds the fissure comes into sight. It usually produces severe pain during and after defecation. Ischio-rectal abscess presents near the anus the ordinary signs of abscess with pain radiating through the pelvis, but may open either within or outside the rectum and results in Fistula in ano, a sinus beside the rectum, opening internally, externally, or in both directions. It may be very tortuous. Tu- berculosis is always to be suspected in such fistulse. Cancer of the rectum is suggested by the occurrence of rectal pain during defecation, with blood in the stools and either diarrhoea or constipation, usually with some pallor and emaciation, in persons past middle life. Owing to neglect of a thorough examination many cases are at first mistaken for piles. The examining finger reaches a hard, ulcerating mass high up. 424 PHYSICAL DIAGNOSIS as a rule, in the rectum. It may be easier to reach if the patient stands or squats and strains down during examination. From tuberculous or syphilitic stricture with or without ulcera- tion, and from benign villous growths, it may be impossible to dis- tinguish cancer without histological examination of an excised piece. Cancer of the prostate is felt on the anterior wall of the rectum and makes the prostate hard, fixed, sometimes nodular. It is often very difficult to recognize. III. The Male Genitals. Routine examination of the male genitals includes investigation of the penis for the presence of : (a) Urethral discharge and its consequences. (6) Chancre. (c) Chancroid. (d) Balanitis. (e) Phimosis or paraphimosis. (/) Periurethral abscess. (g) Malformations. (h) Cancer. In the testes and scrotum we look for : (o) Epididymitis (gonorrhceal or tuberculous). (b) Orchitis (traumatic, syphilitic, tuberculous, after mumps and other infections). (c) Tumors of the testis (cancer or sarcoma). (d) Hydrocele and haematocele. (e) Varicocele. (f) Scrotal hernia. (g) Absence of one or both testes. I. The Penis. Urethral discharge, if not obvious, may often be brought to light by "stripping" the urethra forward from the prostatic region to the meatus. If Gram's stain brings out an intracellular, decolorizing diplococcus in the exudate, there is no reasonable doubt of the pres- ence of gonorrhoea. Chancre ("hard sore"), the primary syphilitic lesion, is a super- ficial, painless, indolent ulcer with an indurated base and a scanty serous discharge. It is usually round or oval and sharply demarked from the surrounding tissue by elevated edges. It is rarely multi- ple. Painless, hard, non-suppurating buboes accompany it. The THE BLADDER, RECTUM, AND GENITAL ORGANS 426 glans and the inner surface of the prepuce are the commonest sites. The Treponema pallidum can often be identified in stained smears or by the dark field illumination. In a certain percentage of cases a positive Wassermann reaction may be obtained. Chancroid ("soft sore") is like any other painful, superficial ulcer without induration, irregular in shape, often multiple, and with abundant discharge. A single, painful bubo accompanies it in about one-third of all cases. Balanitis (inflammation of the surface of the glans penis), usu- ally gonorrhceal, has the ordinary signs of inflammation; it often spreads to the inner surface of the prepuce. Phimosis is a contraction of the orifice of the prepuce, so that it cannot be retracted to uncover the glans. May be hereditary or the result of gonorrhoea. In paraphimosis the prepuce is caught behind the glans penis so that it cannot be brought forward. Great oedema of the neighbor- ing parts usually results. Peri-urethral abscess, usually a complication of gonorrhoea, ap- pears as a small, tender swelling on the under surface of the urethra. Malformations are chiefly hypospadias or congenital deficiency of some portion of the lower wall of the urethra, and epispadias (rare), a similar deficiency in the upper wall. A short, downward curved penis is often associated with hypospadias. ^Cancer of the penis attacks the foreskin or the glans, and has the usual characteristics of epithelioma elsewhere. 2. The Testes and Scrotum. Acute epididymitis, usually a complication of gonorrhoea, appears as a hot and tender swelling behind the testis, often preceded by tenderness along the sperihatic cord. Acute hydrocele may accom- pany it. Chronic epididymitis, usually tuberculous, is painless and insid- ious in onset, and produces a hard, irregular enlargement low down behind one or both testes, to which, however, the process is apt soon to spread. Caseation and involvement of the skin later produce a suppurating sinus, which is often the first thing to bring the patient to a physician. Acute orchitis is often due to a blow, to gonorrhoea, or to mumps. The testis is symmetrically swollen and . tender, but suppuration rarely follow^. Chronic orchitis, often syphilitic, is slow, painless, and may be 426 PHYSICAL DIAGNOSIS accidentally discovered as a slightly irregular induration of the testes with little if any increase in size. Ulceration and fistulae are rare in the syphilitic form, common in the tuberculous. Cancer of the testis may appear at any age. It is soft, almost fluctuating, and grows very rapidly, soon involving and perforat- ing the skin, so as to produce an offensive, fungous, granulating out- growth which easily bleeds. The inguinal glands are involved. Sarcoma of the testis, commonest at puberty, produces a painless, uniform enlargement, and may reach great size. It may resemble hydrocele or haematocele and be mistaken for the latter, especially for an old effusion in a thickened sac (see below) . Diagnosis depends on rapid growth, the entire absence of trans- lucency, the tendency to adhere to the skin and to present unequal resistance in different portions (Jacobson). Incision should be made in all doubtful cases. Hydrocele, an accumulation of serous fluid in the tunica vagi- nalis, may depend on trauma or on an acute epididymitis or orchitis, but is usually chronic and of unknown cause. It may be congenita and communicate with the peritoneal cavity or form part of a general dropsy in heart or kidney disease. Examination shows a smooth, tense, fluctuating tumor, without impulse on cough, usually without pain, tenderness, or any sign of inflammation, and, above all, translucent if examined with a hydro- scope tube or in a dark room with a candle. If the fluid is opaque or bloody, or if the tunica is thickened, there may be no translucency and diagnosis may be impossible without puncture. The testis lies behind the effusion and near its lower end. Hcematocele usually follows injury and produces a heavy, opaque, non-fluctuating tumor, which may closely resemble sarcoma unless the history and evidence of trauma are clear. Incision or puncture should decide. Varicocele, a usually harmless enlargement of the veins about the spermatic cord, is easily recogjiized as a mass of tortuous vessels, generally in the left side. It often complicates hypernephroma. Scrotal hernia is usually reducible, tympanitic on percussion and gives an impulse on coughing. If it consists largely of omen- tum it will be dull on percussion. The history of the case and the progression of the tumor from above downward usually make its origin clear. Absence of one or both testes from the scrotum should direct our search upward to the inguinal canal, since a retained testis may be THE BLADDER, RECTUM, ANT) GENITAL ORGANS 427 the seat of troublesome inflammation or of malignant disease. (For examination of the seminal vesicles, see the Rectum, page 416.) IV. The Female Genitals. I. Methods. Inspection of the external genitals is easy if the parts are properly exposed by a satisfactory position and a good light. Intravaginal inspection needs a speculum (Sims' or bivalve) and usually an assistant to hold it. Palpation should always be bimanual, the left forefinger in the vagina (or in the rectum if the hymen is narrow), the right hand above the symphysis pubis. The proper co-operation of the hands is hard to describe and depends on practice. The pressure of the external hand helps to bring the pelvic organs within reach of the examining finger in the vagina. Unless the organs can be thus grasped or balanced between the outer and inner hands, no satisfac- tory examination is possible. Tenderness may prevent this or render an anaesthetic necessary, but gentleness and the avoidance of any sudden or rapid motions do much to facilitate the examination. The left hand, in making its way into the upper parts of the vaginal vault, should press only on the perineum, avoiding the region of the clitoris. It is astonishing how much pressure can be borne without pain, provided it is exerted gradually and upon the peri- neum only. Many examiners find it advantageous to rest the left foot upon a stool, with the left elbow on the knee. 2. Lesions. I. In the EXTERNAL GENITALS oue looks for some of the same lesions already described on page 417, viz., chancre, chancroid, local inflammations, and tumors. Only the commonest and most' impor- tant lesions will be mentioned here. (a) In young children a suppura:ting vulvo-vaginitis, usually gonorrhoeal, but often non-venereal, is easily recognized by the abun- dant purulent discharge. (6) Local eczema, often red and angry, is commonly the result of the irritation of diabetic urine or a leucorrhoeal discharge. (c) Varicose veins and oedema of the vulva are common in preg- nancy and occasionally result from large pelvic tumors. (d) Ruptured perineum, with more or less protrusion of the vaginal walls, carrying with it the bladder (cystocele) or rectum (rectocele), is readily recognized if the normal anatomy of the parts is familiar. 428 PHYSICAL DIAGNOSIS (e) The hymen may be imperforate with retention of menstrual fluid, or tender, irritated remains of it after rupture may cause pain and need removal. (/) Urethral caruncle (a small vascular papilloma at the entrance of the urethra) is a bright red excrescence, usually the size of a split pea or smaller. It may cause no symptoms or may produce irritation, especially during micturition. (g) Small abscesses, of the glands within or around the urethra may cause pain in coitus or during micturition. II. The Uterus. — Only the commonest lesions will be dealt with here, viz. : 1. Laceration and "erosion" of the cervix. 2. Malpositions of the organ. 3. Endometritis. 4. Cancer of the uterus. 5. Fibro-myoma of the uterus. 1 . (a) Lacerations of the cervix following childbirth are very common and frequently produce no symptoms. They are readily recognized by inspection and palpation, and are often combined with: (6) "Erosions," an ulcerated, raw surface at and around tlie os uteri, with or without the formation of small cysts. At times the OS assumes a warty, irregular appearance, suggesting cancer, from which it can be distinguished only by histological examination of an excised piece. 2. (a) Malpositions (backward or forward) may involve the whole organ (ante- or retroversion) or represent a bending of the organ upon itself (ante- or retroflexion). These lesions may be variously combined and frequently exist without producing any symp- toms. Indeed, it is doubtful whether there is any single "normal" position for the uterus. Its position is recognized by bimanual pal- pation, which should also determine whether the uterus is freely movable or whether it is bound in place by adhesions, such as are very often found with backward displacements. (b) Prolapse of the uterus toward the vaginal outlet is often a result of pelvic lacerations unrepaired. When the uterus is outside the vaginal outlet, we call the condition procidentia. (c) Lateral displacement of the uterus by pressure of tumors or traction by old adhesions is less common. 3. Endometritis may present no definite physical signs except a muco-purulent discharge (leucorrhcea, "whites") and perhaps un- duly frequent, profuse, or prolonged menstruation. The slightest THE BLADDER, RECTUM, AND GENITAL ORGANS 429 touch of a uterine sound may produce bleeding. It often accom- panies disturbances of digestion and neurasthenic conditions, usually as part of a general prostration. 4. Cancer of the uterus usually attacks the cervix, and in marked cases is easily recognized by sight and touch as a " cauliflower "- like, /ungating mass on the cervix. In its early stages it may be confounded with "erosions" and papillomatous growths, and only microscopic examination can satisfactorily determine its nature. Profuse hemorrhage, especially in a woman about the period of the menopause, and the offensive odor of the discharge suggest the diag- nosis. The vaginal wall is soon involved in the growth, and irrita- bility or obstruction in bladder or rectum may result. Cancer of the fundus is suspected from the finding of enlargement or a suspicious discharge, but confirmed only by the histological examination of bits removed by curetting. 5. Fibro-myoma of the uterus is by far the commonest tumor of that organ. It produces hemorrhages at or between the menstrual periods, and anaemia results. Otherwise its effects are those of pressure on the bladder and rectum, or on neighboring nerves or vessels (pain, oedema). Bimanual palpation determines, first of all, the fact that the growth is connected and moves with the uterus. This determined and cancer excluded by the absence of any involvement of the cervix or of the vaginal wall, the chief difficulty may be in distinguishing the growth from a pregnant uterus. Usually its irregular shape, the persistence of menses, and the lapse of time settle the question. Lengthening of the uterine canal is an important confirmatory sign of fibromyoma, but sounds should never be passed to determine this fact unless pregnancy is definitely impossible. III. Fallopian Tubes. — Salpingitis (acute or chronic) and tubal pregnancy are the most important diseases of the tubes. (o) Salpingitis is usually gonorrhoeal, occasionally tuberculous, sometimes of unknown origin. A painful, tender swelling or in- duration in the region of the tube, with or without fever, chill, or leucocytosis, constitutes the evidence for diagnosis. From pelvic peritonitis of the tubal region diagnosis is impossible. From tubal pregnancy diagnosis may be very difficult, and sus- picions are rarely aroused until rupture occurs {vide infra). If the signs and symptoms of pregnancy are absent and tenderness is marked, the condition is usually called salpingitis; but even then mistakes often occur, as the menses may persist in tubal pregnancy 430 PHYSICAL DIAGNOSIS and the foetal tumor may be tender. Only when pregnancy can absolutely be excluded is diagnosis sure. (6) Tubal pregnancy, as just explained, is rarely to be diag- nosed until the growth of the foetus ruptures the tube — an event which usually occurs between the third and the twelfth week of pregnancy.^ Sudden pelvic pain with tenderness, vomiting, and evidence of internal hemorrhage {i.e., pallor, fainting, weak, rapid pulse, thirst, air hunger) suggest the diagnosis, especially if a tumor in the tubal region can be detected bimanually. IV. Ovaries. — A prolapsed ovary is often felt during a vaginal examination, being recognized by its size, shape, and relation to the uterus. Ovaritis, enlargement, and tenderness of one or both ovaries is usually part of tubal disease and not sharply to be distinguished from it before operation. In other cases it is associated with cyst for- mation, and the cysts may be palpated bimanually. Abscess of the ovary is not commonly diagnosed, but is met with in operations for pus tubes. Ovarian Tumors. (a) Small Tumor. — In their earlier stages these growths pro- duce symptoms only when complications arise, i.e., suppuration or twisting of the pedicle. Sm,all, suppurating cysts give practically the same signs as those of a pus tube, and are recognized only at operation or autopsy. Twisted pedicle gives rise to symptoms and signs often indistin- guishable from those of perforative peritonitis or intestinal obstruction. Only the recognition of the tumor as ovarian can suggest that the acute symptoms may be due to twisting of its ped'cle. (6) Large ovarian tumors have been confused in my expe ience with pregnancy, fibroid of the uterus, ascites, and tuberculous peri- tonitis. From these we may usually distinguish an ovarian tumor by its history, its origin from one side of the belly, by the shape of the belly, the area of percussion dulness, and the pelvic examination. By the history we should attempt to exclude disease of the heart, kidney, and liver, and tuberculosis of any organ, should inquire into the position of the tumor in the earlier stages of its growth, and establish the presence or absence of the ordinary signs of preg- nancy and of uterine hemorrhages such as occur with fibroids. ' If disturbances of menstruation, morning nausea, changes in the breasts, and cyanosis of the vagina are combined with an extra-uterine tumor and an unusually slight uterine enlargement, the diagnosis of tubal gestation may be suspected prior to rupture. THE BLADDER, RECTUM, AND GENITAL ORGANS 431 In ascites or tuberculous peritonitis the flanks often bulge (see Fig. 199, page 349), whereas in ovarian disease the bulging is central and greatest just below the navel (see Fig. 223). If by the history or by palpation and percussion we can deter- mine that the tumor is fluctuant and springs from one side of the abdomen, it is in all probability ovarian. High psoas abscess some- times presents identical signs, but is associated with evidence of spinal tuberculosis (see below, p. 459). Moderate ascites or tuber- Fio. 223. — Huge Ovarian Cyst. culous peritonitis leaves an oval, resonant area about the navel, which is absent with large ovarian tumors; but if the amount of free fluid is large, percussion and palpation may give results identical with those found in ovarian disease. Vaginal examination may exclude fibroid by showing that the uterus is not directly connected with the tumor and by demonstrating with a uterine sound that the uterine canal is not elongated. Solid tumors of the ovary, carcinoma, sarcoma, or fibroma are rarely recognizable before operation and are often mistaken for pedun- culated uterine fibroids. They are apt to be associated with ascites. CHAPTER XXV. THE LEGS AND FEET. I. The Legs. I. Hip. The examination of the hip will be discussed later (see page 458). 2. Groin. In the groin we look for evidences of : 1. Enlarged or inflamed lymphatic glands and scars of previous inflammation. 2. Hernia and hydrocele of the cord. 3. Psoas abscess. Less common are : 4. Retained testis. 5. Filarial lymphatic varix. 1. Inguinal Glands. — Two sets of inguinal glands are distin- guished — one arranged along the lower half of Poupart's ligament; the other lower down, around the saphenous opening. (a) The "Poupart's group" are acutely enlarged in lesions of the genitals ("bubo" of gonorrhoea,' syphilis, chancroid) and peri- neum; chronically enlarged in malignant disease of the penis, uterus (late) , and other genitalia. (6) The saphenous group is enlarged in response to lesions of the thigh, leg, and foot (cuts, wounds, ulcers, eczema, etc.). (c) Either or both groups may be enlarged in leukaemia, Hodg- kin's disease (see above, page 30), infectious arthritis, and various obscure fevers. In many cases no cause for enlargement can be found. 2. Hernia is diagnosed by the presence of a soft, resonant, fluc- tuating, usually reducible tumor with an impulse on coughing. Hy- drocele of the cord gives also an impulse on coughing, but usually shows a distinct limit above. On pulling the cord the swelling moves too. 3. Psoas abscess (see Fig. 224) presents the ordinary signs of pus and is associated with vertebral tuberculosis (dorsal or lumbar) . ' The bubo of gonorrhoea often suppurates; that of syphilis rarely. Hence a scar in the inguinal region suggests an old gonorrhoea. 432 THE LEGS AND FEET 433 4. Retained testis should be suspected whenever an inguinal tumor is present and only one testis is found in the scrotum. 5. Filarial lymphangiectasis is generally mistaken for hernia and operated on as such, although it gives no impulse on coughing and cannot be completely reduced. The history of residence in the tropics should always suggest an exami- nation of the blood (at night) for filariae. 3. The Thigh. The records of the Massa- chusetts General Hospital show that (i) epiphysitis and osteo- myelitis (septic or tuberculous) are almost ten times as common as any other serious lesion of the thigh, except fracture. The cases are to be divided into acute septic cases and chronic, usually tuberculous, cases. The acute septic cases begin with severe pain, tenderness, fever, chill, and leucocytosis. Later an induration and finally fluctuation appear, and the abscess, if not incised, will break ex- ternally. General, sometimes fatal, septicaemia may take place. The chronic tuberculous cases first consult the physician, as a rule, for sinus, which proves when explored to lead to dead bone, as do most of the sinuses from septic cases. The diagnosis of the acute cases depends chiefly on excluding arthritis of any type. Careful examination with testing of joint motions will usually demonstrate that the pain and tenderness are in the bone and not in the joint. The leucocyte count is but slightly elevated in most cases of arthritis, but is decidedly high, 20,000 or more, in most cases of acute osteomyelitis. The same is true of the temperature. Monarticular arthritis — the only variety likely to be considered in such a diagnosis — is rare in youth, when most cases of acute osteomyelitis and epiphysitis occur. Whether the disease starts in the shaft of the bone or in the ep physis is to be determined by the seat of pain and tenderness. Fig. 224- -Psoas Abscess. and Lovett.) (Bradford 434 PHYSICAL DIAGNOSIS Tuberculous cases can be recognized only by the histological ex- amination. Old cases may be suspected by the presence of a scar, but (2) Multiple white scars should always suggest, though they are far from proving, syphilis, for chronic ulcer above the knee is often due to gumma. (a) Tumors of the Thigh. (i) Sarcoma of the femur is the commonest and largest tumor of the thigh. Among one hundred and thirty-three tumors of the thigh recorded at the Massa- chusetts General Hospital, sixty-six were sarcoma. A hard, spindle-shaped growth encircles the femur ; the lower end is the commonest site, but any part of the bone may be affected (see Fig. 225). (2) Osteoma, or exostosis, occurred eleven times in the one hundred and thirty-three cases just mentioned. It is much smaller and of slower growth. The last trait usually serves to distinguish it from sarcoma; a;-ray should decide. (3) Metastatic cancer of the upper half of the femur may occur after cancer of the breast, but rarely gives rise to symptoms unless spontaneous fracture occurs — an event which always should suggest cancer. Epithelioma of the thigh is not very rare (twelve cases in the one hundred and thirty-three above referred to). Its traits are those of epithelioma elsewhere. Tuhercidosis of the knee may simulate sarcoma of the lower end of the femur, but sarcoma grows more rapidlj^ The tuberculin test or an exploratory incision may be necessary to decide the diagnosis. (4) Psoas abscess or hip- joint abscess (see Fig. 224) may burrow down so as to point on the thigh. The evidence of disease in the hip or vertebrae is usually sufficient to make clear the diagnosis. I. Sciatic pain and tenderness more or less clearlj^ confined to the distribution of the sciatic nerve may be due to (a) Sacroiliac disease (strain, looseness, displacement). Fig. 225. — Sarcoma of the Femur. THE LEGS AND FEET 435 (6) Spondulitis. (c) Unknown cause (neuritis). {d) Prostatitis, prostatic abscess or neoplasm. (e) Pelvic tumors or abscesses (including psoas abscess. (6) Miscellaneous Lesions of the Thigh. (2) Phlebitis with thrombosis of a vein, usually the saphenous, is a common cause for swollen thigh (and leg) with pain and tender- ness, especially over the inflamed vein, where a cordy induration can often be felt. Typhoid fever and the puerperal state are the usual causes, but it also occurs after tonsillitis and other infections, and sometimes without any known cause. Diagnosis depends on the presence of these signs and causes and the absence of any other de- monstrable cause for inflammation. (3) Meralgia parcesthetica means the presence of a patch of anaes- thesia, partesthesia, or hyperaes- thesia (tenderness) , with or without pain, on the anterior and upper surface of one or both thighs (the area of the external cutaneous nerve) . (4) Paget's disease (osteitis de- formans) presents usually its most marked lesions in the legs and head, though most of the other bones are also affected. In the leg the most characteristic lesions are forward bowing of the femur and tibia with outward rotation of the whole limb (see Fig. 226). The a;-ray shows marked thickening of some areas, with thinning of Fig. 226. — Paget's Disease (Osteitis De- formans). Note the outward and forward (s) Intermittent Claudication and bowing of legs and arms. (Robin.) ' ' Cramps. ' ' — Insufficient circula- tion through the arteries of the legs may give rise to sudden "giving way" of one or both during running or walking, the power returning after a short rest. In patients at rest the frequent recurrence of painful cramps in the muscles may be the only manifestation of the 436 PHYSICAL DIAGNOSIS disease. In other cases there are various forms of paresthesia such as numbness, prickling, and "hot feet at night." Obliteration of the dorsalis pedis (or larger arteries) by arterio- sclerosis is often found, but there is reason to believe that local anaemia, due to vasomotor disturbances or other causes, may produce similar cramps (e.g., those seen in football players during a hard run and in pregnant women) . (c) Paralyses. (i) Paralysis of one leg, occurring in children, is usually due to anterior poliomyelitis; in adults it usually forms part of a hemiplegia or is of hysterical origin. Neuritis, due to alcohol, lead, arsenic, or diphtheria, may affect one leg predominantly, but both are usually involved. Cerebral monoplegias, due to cortical lesions of the leg area, are rare. Chorea may be associated with a limp, half-paralyzed condi- tion in one leg, usually with some involvement of the arm on the same side, and the characteristic motions (see above, page 47) make the diagnosis clear. The differential diagnosis of the other varieties of monoplegia is usually easily made with the aid of a careful history and a thorough .examination of the other parts of the body. (2) Complete paralysis of both legs (paraplegia) is commonest in diffuse or transverse myelitis {e.g., in spinal tuberculosis or metastatic cancer with pressure on the cord), in multiple sclerosis, spastic para- plegia (hereditary or acquired), and in late tabes. Hysteria also may produce a spastic paraplegia, though monoplegia is commoner in this disease. (3) Partial paralysis of both legs is oftenest due to neuritis, resulting from the causes mentioned above. The extensors of the foot are especially affected and toe-drop results, so that in walking "the entire foot is slapped upon the ground like a flail" (Osier). Differential Diagnosis. — (a) In diffuse or transverse myelitis, whether or not the trouble be due to pressure, there are increased reflexes, anaesthesia, usually loss of control of the sphincters (involun- tary urine and faeces) , and often bed-sores. (6) In spastic paraplegia of any type the legs are stiff and the reflexes increased, but sensation and the sphincters are normal and there is no atrophy or bed-sore formation. (c) In multiple sclerosis there are usually no disturbances of sensa- tion or of the sphincters, and the paralysis is associated with nys- tagmus, intention tremor, and slow, .staccato speech. THE LEGS AND FEET 437 (d) Tabes dorsalis shows ataxia but no paralysis until late in its course. The paralytic stage is preceded by a long period characterized by lightning pains, bladder symptoms, Argyll-Robertson pupil (see page 1 6), and loss of knee-jerks. (e) Hysteria may take on almost any type of paralysis and may deceive the very elect, but as a rule the other evidences of hysteria guide the diagnosis. 4. The Knee. (a) Tuberculosis, atrophic, hypertrophic, and infectious arthritis, and traumatic synovitis are the commonest diseases, but will be described with other diseases of the joints (see page 458). Fig. 227. — Prepatellar Bursitis ("Housemaid's Knee"). (6) Housemaid's knee is a bursitis of the prepatellar bursa (see Fig. 227). Fluctuation, with or without heat and tenderness, and limited to the prepatellar space, is diagnostic. 438 PHYSICAL DIAGNOSIS (c) Bow-legs and knock-knee are so easy of diagnosis that I shall simply mention them here. 5. The Lower Leg. 1. Varicose veins, with their results (eczema and ulcer), are the commonest lesions of the lower leg. The soft, twisted, purplish eminences are easily recognized. Hardness in such a vein usually means thrombosis. It should be remembered that pregnancy and pelvic tumors may produce varicose veins in the legs. 2. Chronic ulcers of the lower leg, especially those in front, are usually due to varicose veins and the resulting malnutrition of the tissues. The}^ leave a brown scar after healing. Syphilitic ulcers Fig. 228. — Syphilitic Periostitis ("Saber Shins"). usually leave a white scar; they may occur in the same situation, but are more common above the knee or on the calf. 3. Syphxlitic periostitis is common on the shaft of the tibia, and gives rise to pain (worse at night) with tenderness and some swelling. Later hony nodes are sometimes formed, similar to those already pictured on the frontal bone. In doubtful cases of syphilis in other THE LEGS AND FEET 439 parts of the body we may sometimes secure convincing evidence by radiography of the tibiae. Periosteal thickening, not otherwise recognizable, may be thus brought to light and may help our diagnosis of a cardiac arthritis or hepatic lesion. 4. Osteomyelitis (septic, tuberculous) often starts on the head of the tibia, with intense pain, tenderness, fever, and leucocytosis (if acute); "rheumatism" is often falsely diagnosed; there results a general septiceemia or a local sinus leading to dead bone. Fig. 229. — Angioneurotic OLdema of One Leg. 5. Sarcoma not infrequently attacks the upper end of the tibia or fibula, producing lesions similar to those described in the femur. 6. CEdenia of the legs^ is oftenest due to: (a) Uncompensated heart lesions, primary or secondary from lung disease. {h) Nephritis. ' It is notable tliat cedema is usually greatest in the/ro»t of the leg and in the back of the thigh. 440 PHYSICAL DIAGNOSIS (c) Cirrhotic Liver. (d) Anaemia. (e) Neuritis (alcoholic, beri-beri, etc.). (/) Varicose veins. (g) Obesity, flat-foot, and other causes of deficient local circu- lation. In some cases no cause can be found ("angioneurotic" oedema, "essential" and "hereditary" cedema). Diagnosis of the cause of Fig. 230. — Sporadic elephantiasis. (Non-lilarial.) uedema depends on the history and the examination of the rest of the body. In one leg oedema may be due to thrombosis of a vein (see page 429), to pressure of tumors in the pelvis (pregnancy, etc.), to hemi- plegia, elephantiasis (see Figs. 230 and 231) or to inflammation. THE LEGS AND FEET 441 7. Tenderness in the lower legs frequently accompanies oedema from any cause. It may also be due to neuritis or trichiniasis, and, of course, to any local inflammation. II. The Feet. I. The varieties of club-foot are: (a) Equinus, the heel drawn up. (fo) Varus, the ankle bent outward, (c) Valgus, the ankle bent inward and the foot outward, {d) Calcaneus, the foot turned outward and upward. P'lG. 231. — Elephantiasis. The affection is usually congenital. 2. Flat-foot is a breaking down or weakening of the normal arch of the foot. There may or may not be changes in the sole-print. There may be pain and tenderness near the attachment of the liga- ments and often higher up on the leg, but many cases are symptom- less and should not be treated. 3. Tenosynovitis of the Achilles tendon often produces pain in the tendon, increased by use and sometimes associated with palpable creaking or crepitus over it. 442 PHYSICAL DIAGNOSIS 4. Enlarged {rachitic) epiphyses are seen at the lower end of the tibia and fibula just above the ankle-joint in about forty per cent of rachitic cases. There may also be bending of the bones (see Fig. 233). The other signs of rickets in the child make diagnosis easy. 5. Tuberculosis is especially apt to attack the ankle bones in young persons. It is recognized by the usual evidences of joint tuberculosis (see below, page 463). 6. Epithelioma of the ankle has the characteristics of epithelioma elsewhere. 7. Erythromelalgia, or red neuralgia of the extremities, is common- est iv the feet. The toes (or fingers) are red, hot, tender, and painful. Fig. 232. — Flat-foot. (Bradford and Lovett.) In Raynaud's disease the digits are cold and painless or anaesthetic. The attacks are aggravated by heat and not (like those of Raynaud's disease) by cold. Such attacks are probably akin to the condition of " hot feet" often seen in the arteriosclerosis of elderly people. The patient kicks off the bed clothes from his feet at night on account of the burning sensations in them. Other evidence of insufficient arterial blood supply {e.g., clubbing, intermittent claudication, cramps, gangrene) may coexist. 8. "Judaische Kranldieit," an obliterating thrombosis of veins and arteries in the extremities, chiefly the feet, confined practically to the Jewish race, and usually resulting, after months of pain, in gangrene. THE LEGS AND FEET 443 I. The Toes. Many of the lesions already mentioned in the fingers are found also in the toes (e.g., atrophic and hypertrophic arthritis, acromegaly, pulmonary osteoarthropathy, tuberculous or syphilitic dactylitis, tremors, spasms, and choreiform movements). Other lesions, such as ingrowing toe-nail, bunion, hallux valgus, policeman's heel, are too purely local to deserve description here. Excluding these we have left: Fig. 233. — Rachitic deformity of leg bones. 1 . Gout, which is especially prone to attack the metatarso-phalan- geal joint of the great toe, producing all the classical signs of inflammation and in chronic cases tophi (see page 41). 2. Gangrene is usually the result of arteriosclerosis (see Fig. 234) 444 PHYSICAL DIAGNOSIS with or without diabetes mellitus, but may result (as in the fingers) from arterial spasm or local asphyxia (Raynaud's disease) . 3. Perforating Ulcer. — In diabetes and sometimes in tabes a trophic or nutritional ulcer may develop in the toe or tarsus as a result of nerve influences similar to those which produce Charcot's joint or herpes zoster in the diseases just mentioned. It is called "perforating ulcer" because of its stubborn progression despite a plan of treatment that checks ordinary infectious abscesses. Actual per- foration is not often seen. Fig. 234. — Arteriosclerotic gangrene. 4. "Tender toes" after typhoid fever result from an infectious neuritis. 5. "Morton's disease" (metatarsalgia) means pain in the tarsus at a small spot near the distal end of one of the three outer toes, always associated with compression of the foot by tight boots and probably due to pinching of the external plantar nerves between the metatarsal bones. It is relieved by proper shoes. CHAPTER XXVI. THE BLOOD. I. Examination of the Blood. The essentials of blood examination as a part of physical diagnosis are as follows : I. Hemoglobin test (Tallqvist) in all cases. II. Study of a stained blood film in most cases. III. Total leucocyte count (Thoma-Zeiss) in many cases. IV. Count of red corpuscles and Widal reaction in a few cases. I will now give a brief account of each of these methods and of the interpretation of the data obtained by them. I. Hcemoglobin. (a) The Tallqvist scale consists of ten strips of red-tinted paper corresponding to the tint of a filter paper of standard quality when saturated with blood containing ten per cent, twenty per cent, thirty per cent, etc., haemoglobin up to one hundred per cent. To perform the test we puncture the lobe of the ear with a glover's needle (not with sewing needle) , saturate ^ strip of the filter paper which is bound up with the scale, in the blood of the patient to be examined, and compare the tint of this strip with the different standard tints in the scale. Let the blood dry until the gloss has disappeared. Hold the blood spot beside not behind the scale. Ignore the perforations in the latter. Do not blot the blood spot, and do not delay in making the comparison after the humid gloss has disappeared. Stand with the light behind you or at one side of you; use daylight always. The test is not accurate within ten degrees, but a degree of accm-acy greater than this is very rarely required for any purpose of diagnosis, prognosis, or treatment. In rare cases, when a more accurate reading is needed, we may use the instrument of Gowers as modified by Sahli. (6) Sahli's instrument (see Fig. 242). must be obtained from one of the firms recoipmended by him,' else the standard solution is likely to ' Holtz or Biichi of Berne. 445 446 PHYSICAL DIAGNOSIS be inaccurate in color. To use the instrument we first put a few drops of decinormal HCl solution into the empty tube (Fig. 235, B), so as to fill it to the mark 10; then suck up blood with the pipette (Fig. 235, C), until the mark i is reached. Wipe the point of the pipette and imme- diately blow out the blood into the solution at the bottom of the tube (B) . Suck this mixture of blood and water back into the pipette and blow it out again twice to cleanse the pipette. Next add water from the dropper (D) , a few drops at a time, until the tint of the mixture of the blood and water is the same as that of the standard solution, when both are looked at with trans- mitted light. After each addition of water close the end of the tube with the thumb and invert it twice, then scrape the thumb on the edge l^^lllll^^S^^^^MJ of the tube so as to rub ofi' any l^^ffillal i^^^^^^^BIl moisture deposited there during the ^^^imLjffi8^ik?-.-_-gjpll-| ' ', process of inversion. As the tint of the mixture of blood and water approaches that of the standard solution, add the water two drops at a time, and close the eyes for a few seconds between each two at- tempts at reading. When the colors in the two tubes seem to be identical, read off the figure cor- responding with the meniscus of the column of fluid in the tube. The resulting figure represents the percentage of haemoglobin . (c) The Color Index. — The data to be obtained b}^ these instru- ments stand for the amount of the coloring matter in a given unit of blood when compared with the amount in a similar unit of normal blood. When the haemoglobin percentage is low, antemia is always present, and the degree of anaemia is measured by the amount of reduction in the haemoglobin per cent. But the percentage of hsemo- globin is not a measure of the number of corpuscles present in a given unit of blood, for if the corpuscles are large and contain each of them a relatively large amount of haemoglobin, they may be considerably diminished in number and yet furnish a normal bulk of haemoglobin, as tested by either of the instruments described. Thus in pernicious anaemia the corpuscles are often so large that they contain nearly one- third as much again as a normal corpuscle, so that even though their number is considerably diminished they may carry a normal amount of haemoglobin. This condition is known as a "higli color index." On Fig. 235. — Sahli's Haemoglobinometer. B Diluting tube; C, pipette; D, dropper. THE BLOOD 447 the other hand, the number of red corpuscles may be normal, yet each corpuscle so deficient in haemoglobin that the haemoglobin in a given quantity of blood is as low as forty or fifty per cent. This state of things is often found in chlorosis or in any form of secondary anaemia (see below, page 447). When the diminution in the number of red corpuscles is greater than the diminution of haemoglobin, we say that the color index is high, meaning that each corpuscle carries more haemo- globin than normal. Thus if we have a red count of two millions and a half of red cells, and each cell contained the normal amount of haemo- globin, the haemoglobin percentage would be fifty, representing a re- duction in haemoglobin proportional to the reduction in the red cells; but if with the same count we had a haemoglobin percentage of seventy- five, this would mean that each corpuscle contained half as much again as compared with the haemoglobin in normal red cells. Here we should say that the color index is 1.5. Five miillion red cells and one hundred per cent, of haemoglobin give a color ndex of o. i. Four million red cells with forty per cent, haemoglobin, represents a color index of 0.5 ; three million red cells with 40 per cent, haemoglobin, represents a color index of 0.58. The diagnostic significance of the color index is briefly this: Any diminution in hcBmoglobin means anamia, but a diminution in hemoglo- bin with a high color index suggests, though it does not prove, pernicious ancemia, while a low color, index points to chlorosis or secondary ancemia of any type. Normal color index, despite anaemia, is most often found immediately after hemorrhage. Achromia shown in the stained film is the best obtainable evidence of low color index. When the film contradicts the hemoglobin measurement always believe the film. 2. Study of the Stained Blood Film. To recognize the presence and the degree of anaemia one needs only the hcemoglobin test, but to determine the kind of anaemia, to study the leucocytes, or to search for parasites we need the stained blood film. Two processes are now to be described: 1. Preparing the film. 2. Staining. I. Blood films may be spread on slides or on cover glasses. The first method is the easier; the second gives better preparations. To prepare blood films on slides, dip two slides in water and rub them clean with a towel or handkerchief. Puncture the lobe of the ear {not the finger) with a bayonet pointed Glover's needle or surgical 448 PHYSICAL DIAGNOSIS needle. Put a drop of blood near one end of one slide, put the other slide against the drop, and rest it evenly upon the first, as shown in Fig. 236, so that the drop will spread laterally across the face of the "spreader." Next draw the upper slide along horizontally, so as to spread the drop over the whole surface of the lower slide. The process may then be repeated, reversing the slides and using as a "spreader" the one on which the film has already been prepared. Both slides are then allowed to dry in the air without touching each other. This method is so simple that one can usually succeed with it at the first attempt, but the corpuscles are not spread quite so evenly as in cover- glass preparations and it is somewhat more difficult to get a perfect stain. The cover-glass method requires a much greater degree of cleanliness and manual dexterity than the slide method. Cover glasses must be washed in water and then thoroughly polished with a silk (not cotton ^tAXjf/t^If '''S^ffae/ <^€^ Fig. 236. — Method of Spreading Blood Films. Fig. 237. — Proper Method of Holding a Cover Glass. or linen) handkerchief. The success of the whole process depends upon the thoroughness of the polishing. Every part of the glass must be thoroughly gone over, taking care not to omit the corners. This is rather tedious and often drives us to use slides, which can be much more quickly prepared. With cover glasses we must remove not only all dirt and grease, but also every speck of dust or lint which may settle upon them. The use of silk as a polisher reduces this difficulty to a minimum. Having prepared the cover glasses in this way, the next point is to keep them both clean and dry during the process of spreading the blood. We must always hold them as in Fig. 237, and never touch any part of their surfaces with the fingers. Any one whose fingers tend to get moist must handle the cover glasses with forceps, but most of us will always use our fingers, despite the warnings of our Teutonic THE BLOOD 449 brethren. Holding a cover glass as in Fig. 237, touch the centre of it with the tip of a drop of blood as it issues from a puncture, taking care not to touch the skin of the ear itself; then drop this cover glass (blood side downward) upon a second cover glass in such a position that their comers do not match. If the covers are quite clean and free from dust, the blood drop will at once spread so as to cover the whole surface of the glasses. The instant it stops spreading, take hold of the upper cover glass by one comer and slide it rapidly off without lifting it or tilting it at all. This needs some practice, and some men never learn it; hence the use of slides. Films so prepared will keep for a long time without deteriorating, especially if the air is excluded. 2. Staining. — The introduction of the Romano wsky method of staining (Nocht's, Ziemann's, Jenner's, Leishman's, Wright's) enables us to dispense with all other blood stains and greatly shortens the time of the process. Wright's stain is identical with Leishman's except in the method of preparation, which Wright has considerably simplified, and as either of these mixtures can be obtained ready made of any of the larger dealers in physicians' supplies, I shall not describe the method of making it. Reliable stains can always be obtained from the Massachusetts General Hospital in Boston. An ounce bottle will stain hundreds of specimens. To stain a cover-glass film, grasp it with Cornets's forceps, rest the forceps on the sink so that the film side is upward and is approximately horizontal. Draw a little of Wright's or Leishman's stain into a clean medicine-dropper and squeeze out upon the film enough to flood its surface. (a) Allow the stain to act for one minute; during this time the methylic alcohol contained in it fixes the film upon the cover glass. (6) Next add distilled water from a clean medicine-dropper until a greenish metallic lustre appears like a scum upon the surface of the stain. Usually about six or eight drops of water are needed if we are using a seven-eighths-inch cover glass. The stain, so diluted with water, should remain upon the cover glass about two minutes. The exact time does not matter. (c) Next wash off the stain with water cautiously and let the film remain in clean water for about a minute more or until it takes on a light pink color. Dry gently with blotting paper and mount in Canada balsam. This whole process can be- completed inside of five minutes, and I know of no other staining method at once so rapid, so reliable, and so 29 450 PHYSICAL DIAGNOSIS widel}' applicable. It brings out all the minutiae of the red corpuscles, leucocytes, and blood parasites, and for clinical work no other stain is needed. Appearance of Films so Stained. — i. The normal red corpuscles appear as round discs with pale centres. Their color depends upon the length of time that we continue the washing with clear water after the staining mixture has been poured off, and varies from brown through pink to golden yellow. (a) Poikilocytosis means the appearance in the blood of red cells variously deformed, sausage shaped, battledore shaped, oblong, pear shaped, etc. It is always associated with ahnormalities in the size of ■ the corpuscles, so that dwarf forms and giant forms appear. (6) Polychromasia (or polychromatophilia) refers to abnormal staining reactions in the red corpuscles, whereby isolated individuals take on a brownish or purplish tint, sharply contrasted with the pink or yellow of the corpuscles around. If this brownish or purplish tint occurs in all the corpuscles, it has no pathological significance, but merely means that the staining has been incorrectly performed. (c) "Stippling" refers to fine, dark-blue dots scattered over the pink surface of a red corpuscle, as if a charge of fine shot had been fired into it. All the abnormalities just de- scribed are to be found in any of the t3^pes of severe ansemia, whether primary or secondary, but stippling may also be found without ancemia in some cases of lead poisoning, and is therefore useful as a confirmatory sign in cases of this disease. Nucleated red corpuscles are divided into two main varieties: (i) normoblasts, which are of the size of normal corpuscles; and (2) mega- loblasts, which are larger than normal corpuscles (see Fig. 245). The nucleus of the normoblast is generally small and deeply stained, navy blue. In the megaloblast the nucleus may have the same character- istics or may be much larger and paler, with a distinct intranuclear net- work. The protoplasm of both varieties is often discolored, murky, gray, or even blue, and sometimes stippled, so that by beginners the Fig. 2 3 8 .—Nucleated Red Cells, m, m, Megaloblasts; n, normoblast; s, stippled cell. THE BLOOD 451 cell may be mistaken for a leucoeyte. The mistake may be avoided, however, after some experience. In the protoplasm of nucleated cells there are often concentric rings like the layers in an oyster shell, and their outline is usually more irregular than that of any leucocyte. Further points of differentiation must be learned by practice. 2. Leucocytes. — In normal blood four main varieties may be dis- tinguished; (o) Polynuclears or polymorphonuclear neutrophiles. (b) Lymphocytes (including endothelial cells). (c) Eosinophiles. (d) Mast cells. (o) Polynuclears. — The deeply stained, markedly contorted nucleus assumes a great variety of shapes in different cells, and is surrounded by a pinkish protoplasm studded with spots or granules just large '^ ¥t^ ^ M Fig. 239. — a, Leucocytosis (40,000); sixteen polynuclears in a field. 6, Lymphatic leu- kaemia . p, Polynuclear; m, megaloblast; e, eosinophile. Twenty-one lymphocytes in this field. enough to be distinguished under the oil immersion and slightly deeper in tint than the protoplasm around them. These cells make up about two-thirds ififly to seventy per cent) of all the leucocytes present in the blood (see Fig. 239, a). (b) Lymphocytes . — The smallest variety is about the size of a red cell, and consists of a round nucleus stained deep blue and surrounded by a very narrow rim of pale, bluish-green protoplasm. In the larger forms (endothelial cells) the nucleus occupies less space, is often less deeply stained, and may be indented. The latter variety is sometimes 452 PHYSICAL DIAGNOSIS burdened with the useless name of "transitional cell," a term which in my opinion should begiven up, since all lymphocytes are transitional. In the protoplasm of the larger varieties of IjTnphocyte one often sees a sprinkling of fine pink granules. From thirty to fifty per cent (or about one-third) of all leucocytes belong to the lymphocyte group — classing all sizes together (see Fig. 239, b). (c) Eosinophiles. — The nucleus is irregularly contorted and attracts very little notice, owing to the very brilliant pink color and relatively large size of the granules in which it is immersed. The outline of the cell is more irregular than that of any other leucocyte, and its granules often become broken away and scattered in the technique of spreading the blood. The eosinophiles make up approximately one per cent of the leucocytes of normal blood. (d) Mast Cells. — The shape of the nucleus can rarely be made out, and the main characteristic of the cell is the presence of large dark granules, stained bluish black or plum color, and arranged most thickly about the margin of the cell. Mast cells are very scanty in normal blood and make up not more than one-half of one per cent of the leucocytes. Other varieties of leucoc3rtes which appear in the blood only in disease will be mentioned later. 3. Blood Plates. — In the normal blood film, stained as directed above, one finds, beside the red corpuscles and the different varieties of leucocjrtes, a varying number of bodies, usually about one-third the diameter of a red corpuscle, irregularly oval in shape, staining dark red or blue and tending to cohere in bunches. Occasionally larger forms occur, and in these a vague network and some hints of a nucleus may be traced. These bodies which are probably derived from one or more species of leucocytes have at present no considerable importance in medicine, although they not infrequently lead to mistakes, because, when lying on top of a red corpuscle, they bear a slight resemblance to a malarial parasite. They are usually increased in secondary anaemia and dimin- ished in pernicious anaemia. (a) The Differential Count of Leucocytes. A film stained as above directed is moved past the objective of the microscope either with a mechanical stage or with the fingers, and every leucocyte seen is classified under one of the heads just described until from 200-400 leucocytes have been thus differentiated. The percentages are then reckoned out. Cabot — Physical Diagnosis. PLATE IV. Fig. I. — Young Tertian Parasites. (Stained witli Wriglit's modification of Leishman's stain.) Fig. 2. — Mature Tertian Parasites. (Eosin and methylene blue.) Fig. 3. — Segmenting Tertian Parasites. (Eosin and methylene blue.) THE BLOOD 453 The points most often looked for are : 1 . Increase in the per cent of polynuclears. 2. Increase of eosinophiles. 3. Increase of lymphocytes. 4. Presence of myelocytes and other abnormal forms (see below) . 5. Changes in the red cells noted simultaneously. 3. Counting the White Corpuscles. The instrument used all over the world at the present day is the pipette of Thoma-Zeiss, in which the blood is diluted either ten or twenty times. The diluting solution is one-half of one per cent glacial acetic acid in water. This diluting solution often accumulates spores and becomes cloudy. As soon as this happens a fresh bottle should be prepared. After a rather deep puncture blood is sucked up to the point marked .5 on the pipette, which is then immersed in the diluting solution and suction exerted until the mixture is drawn up to the point marked 1 1 . This gives a dilution of one to twenty. By drawing blood up to the point marked i, instead of to the point marked .5, we obtain a dilution of one to ten. After this the ends of the pipette can be closed with a rubber band, and the blood, so shut in, can be kept or transported without loss or change. When we are ready to make the count, the rubber band is removed and the pipette rolled in the fingers rapidly back and forth for about one minute, to mix up the contents of the bulb thoroughly and evenly. Next blow out three drops, in order to get rid of the pure diluting solution which is in the shank of the pipette. Then put upon the circular disc of the counting chamber a drop of the mixture from the bulb of the pipette. This drop must be of such a size that when the cover glass (see Fig. 241, B) is let doAvn upon it' the drop will cover at ' To avoid air bubbles lower the cover glass with aid of a needle as in mounting micro- scopic specimens. This must be done as quickly as possible after the drop has been adjusted on the counting disc. Fig. 240. — ^Indicating an Order in which the Squares may be Counted. 454 PHYSICAL DIAGNOSIS least nine-tenths of the circular disc and not spill into the moat around it. The size of this drop can only be learned by practice. After about five minutes the leucocytes will have settled upon the ruled space which occupies the centre of the floor of the counting chamber, and the count can then be begun, using preferably a No. 5 objective of Leitz or a DD of Zeiss. The whole ruled space should be counted, and after a little practice this takes not more than five minutes. I usually begin my count in the left upper corner of the ruled space and proceed in the direction indicated by the serpentine arrow in Fig. 247. In normal blood one finds from thirty to fifty leucocytes in the whole ruled space. The number of leucocytes per cubic millimetre is obtained by multiplying this figure by 200. Thus if the number of Fig. 241. — Thoma-Zeiss Counting Slide. A, Ruled disc; B, cover-glass; C, moat. leucocytes counted is 35, the number in a cubic millimetre of blood is 35X200 = 7,000. If great accuracy is needed, a second count with a fresh drop should be made and the average of the two taken; but in ordinary clinical work this does not seem to me necessary, for the amount of error, although considerable, is not such as to affect our diagnostic inferences. 4. Counting the Red Corpuscles. Perhaps once in every twenty-five or fifty cases that one sees it is well to know the number of red corpuscles. They can then be counted with the Thoma-Zeiss pipette which is made for the purpose, and so arranged that the blood may be diluted one to two hundred. The technique is exactly that described in the last section, except that we need less blood and use a different diluting solution. I am accustomed to use a mixture suggested by Gowers, made up as follows : Sodium sulphate gr. cxii. Dilute acetic acid 5i. Water giv. Blood is sucked up to the mark 0.5 and then Gowers' solution to the mark loi. After the drop has been adjusted in the counting chamber and the corpuscles have settled upon the ruled space, we usually count a field of twenty-five small squares at each of the four THE BLOOD 455 corners of the whole ruled space. The figure so obtained is multiplied by 8,000. The result is the number of corpuscles per cubic millimetre. II. Interpretation of the Results so Obtained. I. Secondary Ancemia. The haemoglobin is usually reduced more than the count of red corpuscles, giving a low color index. In mild cases the haemoglobin may fall as low as forty per cent before the red corpuscles show any considerable diminution. In severe cases the red cells fall to 3,000,000, 2,000,000, and occasionally even to 1,000,000 or below it; but the haemoglobin usually suffers even more severely. The leucocytes may be normal, increased, or diminished, depending on the cause of the anaemia. Thus in anaemia due to chronic suppura- tive hip-disease the leucocytes are often increased to 20,000 or 30,000, while in malarial anaemia the leucocytes are often subnormal. There are no characteristic changes in the differential count, which varies with the underlying disease. The changes seen in the red cells in the stained blood film are briefly: Achromia; sometimes polychromasia, stippling, poikilocy- tosis, and the presence of nuclei either in normal-sized corpuscles (normoblasts) or in giant corpuscles (megaloblasts) . Achromia or abnormally great pallor of the centres of the cells is the most important point in the recognition of secondary ancemia and the exclusion of pernicious anamia. An occasional normoblast or rarely a megalo- blast can be found. The commonest causes for secondary or symptomatic anaemia are as follows : (a) Hemorrhage — gastric, hemorrhoidal, traumatic, puerperal, etc. (6) Malaria, more rarely sepsis or other infections. (c) Malignant disease. (d) Chronic suppurations. (e) Chronic glomerulo-nephritis. (/) Cirrhosis of the liver. (g) Poisons, especially lead. {h) Chronic dysentery, (i) Intestinal parasites. It is important to remember that insufficient food or even starva- tion does not produce anaemia, and so far as we know no form of bad hygiene has any notable effect upon the blood. Persons may grow 456 PHYSICAL DIAGNOSIS very pale under bad hygienic conditions, but their blood is usually not affected unless one of the diseased conditions mentioned above is present. 2. Chlorosis. The blood is practically identical with that just described, though the color index is sometimes lower, poikilocytosis less marked, and nucleated red cells fewer. The pallor of the centres of the cells ("achromia"), is often very marked. The leucocytes are generally normal and the differential count practically so, although the percent- age of polynuclear cells is often low with a corresponding relative increase of lymphocytes. 3. Pernicious Ancemia. The number of red cells is usually below 2,000,000 when the case is first seen. The color index is high and the leucocyte count sub- normal. In the stained specimen the essential point is the prevalence of big non-achromic red cells; there are also very marked deformities and abnormal staining reactions in the red cells. A few of the large reds contain nuclei (" megaloblas.ts ") , and a smaller number of normal-sized cells also contain nuclei ("normoblasts"). The polynuclears are absolutely diminished, with a corresponding relative increase in the lymphocytes. In the remissions which form so important a feature of the course of pernicious ansemia, the blood is generally transformed until it contains approximately 100 per cent, of haemoglobin, although the red cells seldom get above 4,000,000 unless splenectomy has been performed. The abnormally large and deeply stained red cells still prevail in most cases and make diagnosis possible though difficult. (a) Interpretation of the Results of the Leucocyte Count and Differential Count. By combining the facts obtained by the total white count and the differential count, we can estimate the number of each variety of leucocyte contained in a cubic millimetre of blood. Thus with 10,000 white corpuscles, 70 per cent of which are polynuclear (as seen in the stained film), we have 7,000 polynuclear cells per cubic millimetre, which may be considered the upper normal limit. Any number greater Cabot — Physical Diagnosis. PLATE V. Fig. I.— Two Young .Estivo-autumnal Parasites. (Wright's mocliiication ofLeishman': stain.) Fig 2. — ^Estivo-autumnal Parasites. Ring body at tire left; crescent at tlie rigiit. Stained like Fig. i. Fig. 3. — Ovoid in yEstivo- autumnal Malaria. Fig. 4. — Crescent in ^^stivo-autumnal iMalaria. THE BLOOD 457 than this should be considered as a leucocytosis. In a similar way we can say that any number greater than 3,500 is above thenormal limit for lymphocytes and constitutes a lymphocytosis, while eosino- philia is present whenever the number of eosinophiles is more than 400 per cubic millimetre. It is much better to use these absolute numbers than to rely upon percentages. If we say, for example, that 3 per cent of eosinophiles is within normal limits, we shall make an error now and then in cases of myelogenous leukaemia, in which, with a total count of 500,000 leucocytes, 3 per cent of eosinophiles would amount to a total of 15,000 per cubic millimetre, or nearly thirty times the normal number. Errors are also common in the opposite direction. For example, in typhoid, with a total leucocyte count of 3,000, the lympho- cytes may reach 60 per cent and yet be well within the normal limits, for 60 per cent of 3,000 is only i ,800. In this case the apparent lymph- ocytosis is due to an absolute decrease in polynuclear cells. For the reasons here given it seems to me best to use the following definitions: 1. Leucocytosis is an increase in the polynuclear cells beyond the normal — 7,000. 2. Lymphocytosis is an increase of lymphocytes beyond the normal upper limit — 3,500. 3. Eosinophilia is an increase of eosinophiles beyond the normal upper limit — 500 per cubic millimetre. 4. Occurrence of Leucocytosis. Leucocytosis, like fever, occurs in a great variety of conditions, of which the following are the most important : 1. In infectious diseases — except typhoid, typhus, malaria, uncom- plicated tuberculosis, measles, smallpox (prior to the pustular stage) , mumps, German measles, and influenza (most cases). 2. In a variety of toxcemic conditions, such as ursemia, hepatic toxaemia, diabetic coma, rickets, and poisoning by illuminating gas. 3. In a minority of cases of malignant disease, especially sarcoma. 4. After violent muscular exertion, including parturition, after cold baths or massage, haemorrhage and apoplectic seizures. There is in all probability no constant leucocytosis in pregnancy or during digestion. Leucocj^osis is most often of value in the differential diagnosis between typhoid fever or malaria on the one hand, and pyogenic infections (meningitis, appendicitis, sepsis, pneumonia) on the other. 458 PHYSICAL DIAGNOSIS A leucocyte-chart is often of value in judging whether a local suppura- tive process, such as appendicitis, is advancing or receding, or whether pus-pocketing has taken place. By a leucocyte-chart is meant series of leucocyte counts at short intervals — ^twelve, twenty-four, or forty-eight hours. When taken in connection with the other clinical data, a leucocyte chart is often of the greatest value, especially in follow- ing the course of any disease; to a less extent in diagnosis. Sondern {Med. Record, N. Y., March 25, 1905) considers that the higher the per cent of polynuclears, the severer the infection, while the body's resistance is mirrored in the height of the total leucocyte count. By noting both these facts, therefore, we have a prognostic guide of some importance. Most subsequent observations have tended to verify Sondern's theory. In internal medicine leucocyte counts are especially useful in febrile conditions, in the great majority of which they assist the diagnosis. Certain exceptions to the rules above given must be remembered: 1. Quiescent, thickly encapsulated collections of pus, in which the bacteria have died or lost their virulence, usually produce no leucocyto- sis. In this group come some of the abscesses of the liver or about the kidney, and a few cases of appendicitis. 2. The most virulent and overwhelming infections are apt not to be accompanied by leucocytosis. Thus, for example, the most virulent cases of pneumonia, diphtheria, or general peritonitis often run their course without leucocytosis. 5. Lymphocytosis. Only in three diseases does well-marked lymphocytosis of ten occur : I. Lymphatic leukaemia. 2. Whooping-cough and its complications (many cases). 3. Acute sepsis especially tonsillitis with or without glandular enlargement may produce a lymphocytosis which, but for the etiological factor, would be alarmingly like lymphoid leukaemia. Occasionally lymphocytosis occurs in rickets, hereditary syphilis, and anything that produces debility in children. Lymphocytosis is of value chiefly in the differentiation of lymphatic leukaemia from other causes of chronic glandular enlargement. 6. Eosinophilia. The eosinophiles are increased chiefly in: I. Bronchial asthma. THE BLOOD 459 2. Chronic skin diseases. 3. Diseases due to animal parasites (trichiniasis, uncinariasis, filariasis, hydatid disease, Bilharzia disease, trypanosomiasis, and with most of the intestinal worms) . 4. Myelogenous leukemia. There seems to be also some vague connection between eosinophilia and diseases of the female genital tract (except cancer and fibromyoma of the uterus). 7. Leiikcemia. Two forms are distinguished, though the distinction is chiefly a clinical one: (a) Myeloid and (&) lymphoid. (a) Myeloid Leukcemia. The leucocj'tes are usually about 250,000 per cubic millimetre when the case is first seen, but often run much higher, and sometimes lower. There is no anemia in the earliest stages; later moderate secondary ansemia develops. The differential count shows an extraordinary variety of types, including many not seen in normal blood (see Fig. 242). The majority of the leucocytes are polynuclears, but many of these are atypical in size or in the shape of their nucleus. From 20 to 40 per cent of the leuco- cytes are 'myelocytes (or mononu- clear neutrophiles) , the "infantile" form of the polynuclear cell. Lym- phocytes are absolutely normal or increased, but their percentage is low, on account of the greater in- crease of the other forms. Eosino- philes are absolutely much in- creased, though the percentage is not much above normal. Mast cells are more numerous than in any other disease (i to 12 per cent, out of an enormous total increase). Normoblasts are usually very numerous ; megaloblasts scanty. Under the influence of intercurrent infections or after rt-ray treat- ment the blood may return to normal. Fig. 242. — Myelogenous Leukasmia. m, Myelocytes; p, polynuclear; 6, mast cell; normoblast. 460 PHYSICAL DIAGNOSIS (b) Lymphoid Leukmmia. The total increase of leucocyt.es is usually much less than in the other type of leuksemia — 40,000 or 80,000 — or less in average cases. The differential count shows an overwhelming proportion of lymph- ocytes — 90 to 99.9-per cent as a rule. In the acute forms of the disease the large lymphocytes predominate; in chronic cases the small forms. Tonsillar infections and whooping-cough must be excluded before diagnosing lymphoid leucaemia from the blood film. III. The Widal Reaction. (a) Technique. Among the numerous agglutinative reactions between the serum of a given disease and the micro-organism producing that disease, only one has yet attained wide use in clinical medicine, viz., the so-called Widal reaction in typhoid fever. There are many ways of performing this reaction, but in my opinion the following is the best : Measure out iii two small test tubes ten drops and fifty drops respectively of a highly motile twelve- to twenty-four-hour bouillon culture of typhoid bacilli, in which the bacilli have no tendency to adhere spontaneously to each other. Carry these tubes and a micro- scope to the bedside, puncture the patient's ear as usual, and draw a little blood into a medicine-dropper of the same size as that used in measuring out the typhoid culture. Expel one drop of blood into each of the tubes containing typhoid culture, and examine a drop of each mixture between a slide and cover glass with a high-power dry lens. If within fifteen minutes clumping has taken place in the i :io mixture, or if within one hour clumping has taken place in the i :50 mixture, the reaction may be considered positive. By clumping I mean an agglutination of the bacilli into large groups and the complete or nearly complete cessation of motility. If it is inconvenient to carry the culture and the microscope to the bedside, ten or twenty drops of blood may be milked out of the ear and collected in a test tube (a three-inch test tube of small calibre is best). After clotting has taken place, if the edges of the clot are separated from the glass with a needle or a wire, a few drops of serum will exude, and this serum can be mixed with the bouillon culture in the manner already described. Less reliable, in my opinion, is the use of blood dried upon glass or glazed paper in large drops and subsequently dissolved in the culture itself. THE BLOOD 461 (b) Interpretation. A positive reaction occurs at some period in the course of ninety-five per cent of all cases of typhoid fever, but the proportion of cases in which the reaction occurs early enough to be of diagnostic value varies greatly in different epidemics. In most epidemics about two-thirds of the cases show a positive Widal reaction by the time the patient is sick enough to consult a physician. In the early daj's of the fever the Widal is often used but it is just at this period that we so often find typhoid bacilli by blood culture. Thus the two tests supplement each other. IV. The Wassermann Reaction. I shall attempt no description of the technique of this most valuable and important test, because its performance is so difficult and delicate Fig 243. — Trypanosoma in Human Blood. (By permission of Dr. J. Everett Dutton and the London Lancet.) that only one who is constantly doing it is reliable. A positive reaction done by a reliable expert is very important evidence of syphilis. Negative reactions do not exclude syphilis. The reaction is of especial value in cases of aneurism, aortic regurgitation, visceral and cerebral syphilis, doubtful cutaneous and arthritic and osseous lesions. Also in tabes and dementia paralytica. 462 PHYSICAL DIAGNOSIS V. Blood Parasites. I. The Malarial Parasite (see Plates IV. and V.). In films stained as above directed the malarial parasite appears blue against the pink background of the corpuscle. A crimson- stained dot should appear in some portion of the blue-stained organism; the protoplasm of the red corpuscle around it is often studded with pink dots. The stained specimen is preferable to the fresh blood in the search for malarial parasites, for the young, ring-shaped, or "hyaline" forms often escape notice altogether in fresh specimens. Tertian organisms are distinguished from the asstivo-autumnal variety by the following tests: Fig. 244. — The Filaria Sanguinis Hominis The head, curled up, is seen to the right of the cut, the tail to the left. Instantaneous photomicrograph. Four hundred diameters magniiication. (a) Tertian parasites make the corpuscle to which they are attached larger than its uninfected neighbors. ib) Segmenting forms are rare in the peripheral blood of a^stivo- autumnal fevers. (c) "Crescents" (see Plate V.) never occur except in asstivo- autumnal fevers. 2. The Trypanoso))iiasis. In Central Africa (and presumably in other tropical countries) the blood or gland juice of many persons contains the organism shown in Fig. 243, which has long been known as a parasite of the blood of horses and of many of the lower animals. Human trypanosomiasis — a chronic debilitating malady — becomes " sleeping sickness " when the trypanosoma enters the cerebrospinal canal. THE BLOOD 463 3. Filariasis- In the blood of many inhabitants of tropical countries there is found (with or without symptoms) the parasite shown in Fig. 244. The species most often found is present in the peripheral blood only at night; hence the blood should be examined after 8 p. m. A fresh drop is spread between slide and cover and examined with a low-power lens (No. 5 objective Leitz). CHAPTER XXVII. THE JOINTS. I. Examination of the Joints. I. Methods and Data. I. By inspection and palpation we detect : 1. Pain, tenderness, and heat in, near, or at a distance from the joint. 2. Enlargement: (a) Hard, probably bony. (&) Boggy, probably infiltration or thickening of capsule and periarticular structures. (c) Fluctuating, probably fluid in the joint. 3. Irregularities in contour: (a) Osteophytes or "lipping" (attached to the bone). (6) Gouty tophi (not attached to the bone) . (c) Constriction-line opposite the articulation. {d) Protrusion of joint-pockets in large effusions, filling out of natural depressions. 4. Limitation of motion: (o) Due to pain and effusion. (6) Due to muscular spasm. (c) Due to thickening or adhesions in the capsular and periarticular structures. (d) Due to obstruction by bony outgrowths or gouty tophi. (e) Due to ankylosis. 5. Excess of motion (subluxation). 6. Crepitus and creaking. 7. Free bodies in the joint. 8. Trophic lesions over or near a joint (cold, sweaty, mottled, cyanosed, white, or glossy skin, muscular atrophy) . 9. Sinus formation, the sinus leading to necrosed bone, to gouty tophi, or abscess in or near the joint. 10. Distortion and malposition, due to contracttu-es in the muscles near the joint, to necrosis, to exudation, or to subluxation. 464 THE JOINTS 465 II. Telescoping of the joint with shortening (limb, toe, finger, or trunk) . II. By radio.yco/'j' we investigate : 1. Bony outgrowths, their shape, extent, and position. 2. Necroses and atrophies of bone, their extent and position. 3. The structure of the bones in and near the joints. 4. The presence of lesions in the articular cartilages. 5. Free joint bodies, their presence and position. III. Indirectly we may gain valuable information about the joints by noting : 1. General constitutional symptoms, their presence or absence. These include fever, chills, leucocytosis, glandular enlargement, albuminuria, and emaciation. 2. Tuberculin reaction and Wassermann reaction, perhaps gono- coccus fixation test, — their presence or absence. 3. Disease of other organs, their presence or absence, i.e., syphilis, tuberculosis, tabes, and other chronic spinal-cord lesions, endocarditis, haemophilia, various acute infections (gonorrhoea, influenza, scarlatina, septicaemia) , and skin lesions (psoriasis, purpura, hives) . 4. The course of the disease and the results of treatment. 2. Technique of Joint Examination. (a) Enlargement is generally unmistakable, but when there is much muscular atrophy between the joints the latter may seem en- larged by contrast, when in fact they are not. (6) Fluctuation is obtained in most joints, as in any part of the body, by pressing a finger on each of two slightly separated spots in the suspected area, and endeavoring to transmit through the inter- vening space an impulse from one finger to the other. Fat or muscle will also transmit an impulse, but less perfectly than fluid. In the knee we test for "floating of the patella" over an effusion by surrounding the joint with the hands, which are pressed slightly toward each other to limit the escape of fluid in either direction, and then suddenly making quick pressure on the patella with one finger. If we feel or hear the patella knock against the bone below and rebound as we release the pressure, fluid in abnormal quantity is present. (c) Irregularities of contour are easily recognized, provided the normal contour is familiar. (d) Bony outgrowths may be obvious (as in Heberden's nodes) , but if within the joint they may be recognized only by the sudden arrest of 30 466 PHYSICAL DIAGNOSIS an otherwise free joint motion at a certain point. In many cases radio- scopy is necessary. (e) Gouty tophi are identified positively by transferring a minute piece to a glass slide, teasing it in a drop of water, covering with a cover glass, and examining with a high-power dry lens and a partly closed diaphragm. The sodium biurate crystals are characteristic. Fluid or semi-fluid exudates in joints may fill up and smooth out the natural depressions around the joint, or, if the exudate is large, may bulge the joint pockets; in the knee-joint four eminences may take the place of the natural depressions, two above and two below the patella. (/) Limitations of motion due to muscular spasm are seen with especial frequency in tuberculous joint disease, but may occur in almost any form of joint trouble, particularly in the larger joints. Fig. 245, — Testing for Psoas Spasm. (Bradford and Lovett.) (i) Hip-joint, two forms of spasm are important; (i) That which is due to irritation of the psoas alone (psoas spasm) ; (2) that in which all the muscles moving the joint are more or less contracted. In pure psoas spasm the thigh is usually somewhat flexed on the trunk, though this may be concealed by forward bending of the latter. Very slight degrees of psoas spasm may be appreciable only when, with the patient lying on his face, we attempt hyperextension (see Fig- 245)- The other motions of the hip — rotation, adduction, abduction, and flexion — are not impeded. General spasm of the hip muscles is tested with the patient on the back upon a table or bed (a child may be tested on its mother's lap) and the leg flexed to a right angle, both at the knee and at the hip. THE JOINTS 467 Using the sound leg as a standard of comparison, we may then draw the knee away from the middle line (abduction) , toward the past and middle line (adduction), and toward the patient's chest (flexion). Rotation is tested by holding the knee still and moving the foot away from the median line of the body or toward and across it. (2) Spinal column. Muscular spasm of the muscles guarding motion in the vertebral joints can be tested by watching the body attitude (a stiff, "military" carriage in most cases), and by efforts to bend the spine forward, backward, and to the sides. In most cases we can make out limitation of these motions by asking the patient to stand with knees and hips stiff and then bend Fig. 246. — Rigidity of Spine in Pott's Disease. his trunk (of course, naked) as far as he can in each of the four direc- tions. If we are familiar with the average range of motility in each direction and at the different ages, this test is usually easy and rapid. Backward bending is the least satisfactory, and in doubtful cases the patient should be on his face, while the physician, standing above him, lifts the whole body by the feet (see Fig. 246). (3) In the joints of the shoulder, knee, elbow, wrist, ankle, toes, and fingers, there is usually no difficulty in testing for muscular spasm, and no special directions are needed. To distinguish '>nuscular spasm from bony outgrouith as a cause of limited joint motion, we should notice that bony outgrowths {e.g., in the hip) allow perfectly free motion up to a certain point ; then motion is arrested suddenly, completely, and without great pain. Muscular spasm, on the contrary, checks motion a little from the outset, the 468 PHYSICAL DIAGNOSIS resistance and pain gradually increasing until our efforts are arrested at some point, vaguely determined by our strength and hard-hearted- ness and by the patient's ability to bear the pain. Motions limited by capsular thickening and adhesions are not, as a rule, so painful after the first limbering-up process is over. There is no sudden arrest after a space of free mobility, but motion is limited from the first and usually in all directions, -though the muscles around the joint are not rigid. The possibility of more or less limbering-out after active exercise (or passive motion) distinguishes this type of limitation. In true ankylosis there is no motility whatever. (g) Excessive motion in a joint is recognized simply by contrast with the limits furnished us by our knowledge of anatomy and of the physiology of joint motion at different ages. When the bone and cartilage appear normal or are not grossly injured, we call the excessive motility of the joint a subluxation, but excessive motility may also be due (as in Charcot's joint) to destruction of bone and other essentials of the joint. {h) To detect crepitus and creaking we simply rest one hand on the suspected joint, and with the other put it through its normal motions, while the patient remains passive. (i) Most free joint bodies are not palpable externally, and are rec- ognized only by their symptoms, by the a;-ray, and by operation. (;') Shortening of a limb as evidence of joint lesions is tested by careful measurements. The vast majority of such measurements are ^ made with reference to the hip-joint. The tip of each anterior superior iliac spine is marked with a skin-pencil, and likewise the tip of each inner malleolus. Then, with the patient lying at full length on a flat table, the distance from anterior superior spine to inner malleolus is measured with a tape on each side. The method of obtaining the other data tabulated on page 458 needs no explanation, except the radioscopic technique — a subject which I am not competent to discuss. II. Joint Diseases. I shall use the classification proposed by Goldthwait and divide joint diseases as follows : 1. Infectious arthritis: (a) Tuberculosis. (6) Other infections. 2. Atrophic arthritis: (a) Primary. (6) Secondary to organic nerve lesions (Charcot's joint). 3. Hypertrophic arthritis. THE JOINTS 469 4. Gouty arthritis. 5. Hsemophilic arthritis. I. Infectious Arthritis. Under infectious arthritis are included all varieties of articular "rheumatism" and the joint troubles symptomatic of gonorrhoea, of streptococcus infections (including scarlet fever), influenza, syphilis, typhoid, and other fevers. As tuberculosis is an infection we must include it in this group, although the disease begins usually as an osteitis and involves the joint secondarily by extension. I. Tuberculous Arthritis. — The characteristics of joint tuberculosis are: (a) Slow progress, with gradual enlargement and disabling of the joint. (6) Muscular spasm, especially in disease of the hip or vertebrae. (c) Evidences of low-grade inflammation (moderate heat, swelling, pain, and tenderness) . (d) Abscess and sinus formation. (e) Malpositions {e.g., shortening of one leg in hip-joint disease, angular backward projection in spinal disease, subluxations in the knee-joint). (/) Bone necrosis, as shown by a;-ray. The order of frequency in the different joints is as follows: spine, hip, knee, wrist, shoulder (tuberculous dactylitis is described on page 55)- In the deep-seated hip-joint, diagnosis has to depend largely on shortening and on the presence of limitation of all the hip motions by muscular spasm (see above, page 458), unless the disease is of long standing and manifests itself by abscesses burrowing to the surface. Usually these abscesses point in the upper anterior thigh, but they may open behind the great trochanter, below the gluteus maximus, or at any point in the vicinity of the hip. Besides muscular spasm, shortening, and abscess formation, we get some aid from the general and vague joint symptoms present in this as in many other joint lesions. Such are enlargement (felt as thickening about the great trochanter), muscular atrophy, pain, ten- derness, and crepitus. In spinal tuberculosis (Pott's disease) the distortion of the bones with formation of a knuckle in the back is often obvious and practically diagnostic. In other cases we depend on muscular spasm or abscess formation. The muscular spasm gives a stiff back and often psoas con- traction (see below) . The abscess is peculiar, in that it usually works 470 PHYSICAL DIAGNOSIS along in the sheath of the psoas and points in the groin below Poupart's ligament (see Fig. 224); less often it appears in the back or in the gluteal region, and rarely it may invade almost any part of the body (lung, gullet, gut, peritoneum, rectum, hip-joint, etc.). Psoas spasm, which is common both in hip and spinal tuberculosis, is by no means peculiar to these diseases, and it is worth remembering that it may be due to various other lesions, such as : (a) Hypertrophic arthritis of the spine. (&) Appendix abscess, (c) Perinephritic abscess. In the peripheral joints (shoulder, elbow, wrist, finger, knee, ankle) the diagnosis of tuberculosis rests on the chronic enlargement and disability, with abscess and sinus formation. Hysterical or acute traumatic lesions (with or without neurosis) may present symptoms and signs identical with those of tuberculosis. Decision is aided most by: (a) The lapse of time and the effects of treatment. (6) Z-ray examination, (c) The predominance in func- tional and traumatic cases of pain and tenderness rather than muscular spasm or malposition. II. Acute Infectious Arthritis. — All varieties are distinguished from the other types of arthritis by: (o) The absence of any marked bone lesions^ in most cases, (b) The tendency to recovery in the great majority of cases. The milder forms, whose cause is unknown, we have hitherto designated as "rheumatism." The others are distinguished as gonor- rhceal, pneumococcic, syphilitic, influenzal, dysenteric, etc., according to the organism producing them. Between this group and those known as "rheumatism," there is no clear pathologic distinction. Mild infection with streptococci may leave a sound joint. Virulent infections may lead to crippling through fibrous adhesions. On the other hand, arthritis of "rheu- matic" {i.e., of streptococcic) origin may end in suppuration, crip- pling the joint with adhesions, though in most cases it leaves a sound joint. All the members of the infectous group of joint lesions present the local signs of inflammation and the constitutional signs of infection. All may be complicated by endocarditis, but in those of streptococcic origin ("rheumatic") this complication is especially common. There is no bony hypertrophy, bone destruction, » sinus formation, or marked 1 Exceptionally, virulent infections (especially those due to pneumococci or gonococci) may destroy cartilage and bone and end in true bony ankylosis. THE JOINTS 471 irregularities of contour. A general enlargement (more or less spindle shaped, owing to periarticular thickening and muscular atrophy) is Fig. 247. — X-ray, showing Hands in Atrophic Arthritis. the rule. The joint motions are limited chiefly bj^ pain and effusion; muscular spasm is not prominent. 47i PHYSICAL DIAGNOSIS One or many large or small joints may be affected in any of the varieties of infectious arthritis, though the gonorrhceal virus is apt to lodge in few joints (oftenest the knee or ankle) and the "rheumatic" virus in many joints, while the typhoid poison has a predilection for the spine. 2. Atrophic Arthritis. Two types must be recognized: (a) A monarticular form, second- ary usually to tabes or syringomyeUa ("Charcot's joint," "neuropathic Fig. 24S. — a, Charcot's Joint with Loose Bodies; 6, Pulmonary Osteo-arthropathy. (\'. Ziemssen's Atlas.) joint"), and other diseases of the spinal cord. (6) A polyarticular primary form ("rheumatoid arthritis" or "anchylosing arthritis"). In both, the distinguishing characteristic is atrophy and destruc- tion of cartilage, bone, and joint membranes — a process which in the early stages can be identified only by the x-ray (see Fig. 247). Later the disintegration of the joint is usually evident, and is followed by distortions, contractures, and ankjdosis. (a) The monarticular form, is generally easy to recognize on account of its rapid, painless course, with semifluctuant swelling, secondary to a well-marked cord lesion, such as locomotor ataxia. A large joint is almost always affected, oftenest the knee, less often the hip, shoulder, or elbow. The joint shows abnormal mobility and the bones can often be felt to grate (see Fig. 248). THE JOINTS 473 Fig. 249. — Atrophic Atrophic Early stage. Fig. 250. — Atrophic Arthritis. (Goldthwait.) 474 PHYSICAL DIAGNOSIS (b) The primary polyarticular form usually begins in the fingers, and is very apt to occur symmetrically, i.e., in corresponding joints of both hands at the same time (see Fig. 249). The joints are enlarged, boggy, spindle shaped (owing to the rapid atrophy of the interossei), often abnormally white, apparently fluctuant, and show trophic skin lesions (glossy skin, sweating, mottling) (see Fig. 250). The terminal finger- joints are rarely swollen. Late in the course of the disease a ring of constriction often marks the line of articulation (see Fig. 251). Pain is not severe until motion is attempted or unless the joint is jarred and stirred up by some traumatism. Fig. 251. — Atrophic Arthritis. Late stage with constriction ring at the joint line. (Goldthwait.) The changes progress slowly and attack new and larger joints, moving centrally from the periphery. At any stage the process may become arrested, but usually not until ankylosis or contractures have occurred in one or many joints. Some of the "ossified men" of dime museums are in the ankylosed stage of this terrible malady. Flexion of fingers with hyperextension of the terminal joints and deflection to the ulnar side are common deformities. 3. Hypertrophic Arthritis. This is a degenerative type of disease in which osteophytic spurs are the distinguishing feature. It occurs mostly in elderly persons. The new bone is deposited round the edges of the articular cartilage, forming an irregular ring ("ring bone" in horses) or "Up" near the THE JOINTS 475 joint. The attachments of the Hgaments (e.g., the anterior lateral ligament of the spine or the cotyloid ligament in the hip-joint) furnish another favorite site for the bony deposits. There is no ankylosis and motion is limited only by the collision of bony spurs in joint margins. (o) In the terminal finger-joints {" Heberden's nodes") the process may remain for years without extending to any other articulation and without producing any discomfort (Figs. 54 and 252). (b) The disease may be limited to the hip-joint ("morbus coxae senilis") or to any other single joint, producing purely mechanical Fig. 252. — Hypertrophic Arthritis with Heberden's Nodes. disturbances by limitation of motion. There is no considerable muscular spasm, and motion is quite free up to a certain point, at which it is suddenly "locked" by the interference of the bony out- growths. The situation, size, and shape of these outgrowths can be shown, as a rule, by the a;-ray alone. Pain and swelling are slight or absent, unless traumatism (internal or external) stirs up the joint and produces a synovitis. The chief complaint is of stiffness. (c) Several joints may be affected, and there may result much pain because nerves pass through or over the new-formed bone and are compressed by it. This form is most often seen in the spine ("spon- 476 PHYSICAL DIAGNOSIS dylitis deformans," "osteoarthritis"), where a portion of the front and side of the vertebral column is "plastered over" with new- formed bone (see Fig. 253), which later invades the intervertebral cartilage and produces (see Fig. 254) finally either a straight "ramrod" spine or a forward curved spine. Fig. 253.— H\-|ierlrophic Arlhritis of Spine. (Goldthwait.) Non-tuberculous disease of the sacro iliac joint has already been referred to on page 58. In the early stages the disease is recognized by: THE JOINTS 477 (a) Nerve pain, running round the body or down the legs,' as the intercostal and spinal nerves are pressed on. Fig. 254. — Hypertrophic Arthritis (Spine) of Spine with Ankylosis. (Goldthwait.) Fig. 255. — Showing Normal Flexibility of Spine. (Goldthwait.) (6) Limitation of Motion. The process is usually unilateral, wholly or predominantly; hence the patient can usually bend much better to one side (see Figs. 255 and 256) than to the other. Motion is also more or less limited in other directions, but forward bending is fairly ' Many neuralgias and sciaticas are due to this disease- 478 PHYSICAL DIAGNOSIS well performed as a rule, in sharp contrast with "lumbago," which renders forward bending and the subsequent recovery almost impossible. Fig. 256. — Hyperlrofililr ArthviLis of Spine. ^Tolion to left limited. (Goldthwait.) I'"'"'- -si- — Gouty Toplius in ihe Ear. (c) Coughing or s>icczing often gives great pain, probably because the costo- vertebral joints are involved in the new growth; if ankylosis of these joints occurs later, the respiratory movements of the chest are interfered with. THE JOINTS 479 Fig. 25S. — Gouty Arthritis. Fig. 259, — X-ray of Hand in Gouty Arthritis. (Goldthwait.) 480 PHYSICAL DIAGNOSIS 4. Gouty Arthritis. The deposits of urate of sodium in the soft structures around the joint are, like those in the ear (see Fig. 257), close beneath the skin or perforate it, and hence are recognizable (as above explained) by microscopic examination. They somewhat resemble the nodes of hypertrophic arthritis, but are not attached to the bone and can be moved about in the soft structures over it. X-ray examination shows that there is often con- siderable destruction of bone in the vicinity of the tophi (see Figs. 258 and 259). 5. Hcemophilic Arthritis. A chronic stiffening and enlargement of the joint, resembling in many respects the joint of hypertrophic arthritis, but often accom- panied by the formation of fibrous adhesions, ensues in some cases of haemophilia, presumably as a result of frequent hemorrhages and serous oozings in the joint. The diagnosis depends on the evidence of haemophilia, the youth of the patient, and the absence of infection as a causative factor. 6. Relative Frequency of the Various Joint Lesions.^ The following table was prepared by Dr. Vickery^ from the records of the Massachusetts General Hospital (1893-1903) : Infectious arthritis. >873 Acute rheumatic arthritis 591 Subacute rheumatic arthritis 193 Gonorrhceal arthritis 86 Typhoid arthritis (spine) 3 Hypertrophic and atrophic arthritis 43 Gout 9 Chronic villous arthritis ("dry joint") is a purely local process and therefore recieves no further mention. 'Boston Med. and Surg. Jour., November 17, 1904. CHAPTER XVIII. THE NERVOUS SYSTEM. I. Examination of the Nervous System. The outlines of neurological diagnosis depend on knowledge of; I. Disturbances of motion. II. Disturbances of sensation. III. Disturbances of reflexes (including sphincteric and sexual reflexes). IV. Disturbances of electrical excitability. V. Disturbances of speech and handwriting. VI. Disturbances of nutrition ("trophic"). VII. Psychic disorders. VIII. Changes in the spinal fluid. I shall attempt no topical diagnosis of nerve lesio;ns, no diagnosis, that is, depending on memorizing the brain areas, cord levels, or skin- and-muscle areas corresponding to particular nerve lesions. The general practitioner for whom this book is intended will not attempt to carry such points in his head, but will refer to specialists or special text-books when the case confronts him. The general methods most often employed are all that I attempt to describe. I. Disorders of Motion. 1. Gaits. 2. Paralyses. 3. Spasms and tremors. 4. Ataxia. I. Gaits. — The most important gaits are: (a) The spastic, {b) The ataxic. (c) The gait of paralysis agitans. (d) The toe-drop gait. (e) The gait of simple weakness. With the spastic gait there is rigidity of the legs, making it difficult to lift the feet; hence the patient scuffs along, usually with bent knees and as if his feet were fastened to the ground. ' ' The cross-legged gait is a spastic gait in whicli the adductors of the thighs are so contracted that the feet tend to be crossed. This gait is oftenest seen in the congenital spastic paralyses. 31 481 482 PHYSICAL DIAGNOSIS The ataxic gait is difficult to describe. The patient is not muscu- larly weak, but does not know where his feet are or where the ground is; hence he flounders and throws his feet about irregularly. The gait of paralysis agitans is an exaggeration of the old man's gait, such as we often see on the stage. The whole body is bent for- ward and rigid (see Fig. 260), and, if progress is accelerated by a push given from behind, the patient may be unable to stop himself. In the toe-drop gait the foot is raised high and slapped down upon the ground with a flail-like motion. 2. Paralysis or Paresis. — No detailed account can be given here of the method of testing individual muscles for loss or impairment of power. In general, a knowledge of the origins and attachments of muscles enables us to work out for ourselves a series of tests that will bring any desired group into con- traction. It is convenient to class paralyses according to their origin as follows: (a) Brain paralysis: usually hemiplegta (arm and leg on same side, with or without the face). (b) Cord paralysis: usually par- aplegia (both legs, rarely both arms) or monoplegia (one extremity) . (c) Cranial nerve pralysis: usually one or jnore eye muscles. (d) Peripheral nerve paralysis: special muscle groups, oftenest the extensors of the wrist or foot, the shoulder muscles, and those supplied by the facial nerve. (e) Hysterical paralysis: no strict anatomical distribution, oftenest monoplegia (one extremity) . Peripheral nerve paralyses are especially apt to be accompanied by sensory symptoms, electrical changes, and wasting. Brain paralyses have relatively few sensory symptoms (sometimes par^sthesise, see Fig. 260. — Altitude Characteristic of Paralysis /\gitans. THE NERVOUS SYSTEM 483 -below, page 478) and relatively slight wasting. Mental changes, coma, or convulsions often precede or follow them. Cord paralyses may or may not show these associations, but are often accompanied by disorders of the bladder and rectum. 3. Spasm, Tremor, and Fibrillary Twitching. — (a) Spasm means involuntary muscular contraction. The familiar "cramp" is a good example of the type of spasm known as tonic spasm. In contrast with this is the clonic spasm, in which flexors and extensors contract alternately to produce a motion like that of our forearm when we shake up a fluid in a test tube, or like the ankle clonus (see below) . Spasms may be general or local, i.e., involve few or many muscles. In strychnine poisoning the whole body may be thrown into rigidity or general tonic spasm. At the beginning of an epileptic seizure the body stiffens out (tonic spasm), then becomes "convulsed" {general clonic spasm). Local tonic spasm is exemplified in the ordinary "cramp." The spastic gait, above described, is another common example of tonic spasm limited mainly to one group of muscles. The contractures which so often affect the sound muscles in a partially paralyzed limb (see above, page 476) are also examples of local tonic spasms. Athetosis, a special variety of local tonic spasm, has been described on page 50. Local clonic spasm is not common. It may be due to irritation of a small portion of the cerebral cortex by various lesions (" Jacksonian epilepsy"), and sometimes precedes or alternates with the general spasms of ordinary epilepsy. It also occurs in hysteria. Artificially a momentary or prolonged clonic spasm of the foot muscles is often produced in testing for the ankle clonus (see below, page 481). ' (6) Tremor may be defined as a clonic spasm of short excursion. Its causes and varieties have already been discussed (see page 45) . (c) Fibrillary twitchings means the brief repeated contraction of small bundles of muscle fibres. It is seen in patients who are cold or nervous, in many debilitated and neurasthenic conditions, and often in muscles affected by progressive muscular atrophy. (d) Choreic and choreiform movements have already been described (page 47). 4. Ataxia. — Inco-ordination of the various muscles which normally act together to produce a well-directed movement is called ataxia. All young infants exhibit ataxia in their more or less unsuccessful grasping movements. Alcoholic intoxication often produces typical ataxia, 484 PHYSICAL DIAGNOSIS and it is also exemplified in the gait o] tabes dorsahs. There is no lack, of muscular contraction — often too much — but it is disorderly and ill-directed. Deficiency in the power to balance in standing or walking is perhaps the commonest type of ataxia, and may be due not only to the causes just mentioned, but also to cerebellar disease and ear disease. In these types there is often a tendency to stagger in one particular direction, e.g., to the right, and the ataxia is associated with vertigo and with other evidences of brain tumor or of ear disease. In tabes dorsalis and other diseases we test the power to balance by asking the patient to bring his feet together (toe to toe and heel to heel) and to close his eyes. If he is unable to preserve his balance his failure is known as "Romberg's sign." 2. Disorders of Sensation. The following are the most important types : 1. AncBsthesia (or insensibility to pain, to touch, to heat and cold, and to muscle sensation). 2. HypercBsthesia (or oversensitiveness) . 3. Parcesthesia (abnormal, false, or disordered sensation). 4. Pain. 5. Disorders of special sense. These disturbances may all be seen in different stages or types of lesions of the spinal cord or peripheral nerves. They are less common in brain lesions. I. Tests of anaesthesia are time-consuming and difficult, because we depend for our data on the patient's intelligent answer to the question, "Do you feel that?" As a rule, we cover the patient's eyes and then touch the suspected parts — first lightly, then more strongly — questioning him to see if he feels the touch, can judge the nature of the touching object (finger, pencil, pin), and tell where he is touched. A pin-prick is oftenest used to test pain sense, and test tubes filled, one with hot, one with cold water, are convenient for trying the temperature sense. Finally, we try whether the patient can recognize familiar objects placed in his hand and can tell the position in which you may put his arms or legs. Failure to make these discriminations is known as astereognosis , and occurs oftenest in brain lesions affecting the temporal lobes. Dissociation of sensation — the preservation, for example, of sensa- tions of touch with loss of those of pain and temperature — occurs oftenest in syringomyelia. THE NERVOUS SYSTEM ' 485 Delayed sensation and mistakes regarding the point touched in testing are commonest in tabes dorsalis, which disease presents a great variety of sensory disorders not here catalogued. The distribution of anaesthesia depends, like the distribution of paralysis, on the lesion. HemiancBsthesia is seen oftenest in hysteria and organic brain lesions. Cord lesions, such as transverse myelitis or compression of the cord, usually produce anaesthesia in the area supplied by the spinal nerves below the lesion. Peripheral nerve lesions may produce anaesthesia of the skin areas supplied by the nerve in question. Areas of hysterical ancesthesia (with hyperaesthesia and paraesthesia) usually do not correspond to the distribution of any set of nerves or centres, and are distinguished by this fact. 2. HypercBsthesia is most often recognized as hyperaesthesia for pain (tenderness) or in the special senses (sensitiveness to light or noise). It is commonest in peripheral nerve lesions and in hysteria. The tests are the same as those for anaesthesia. 3. ParcBsthesia is commonest' in the form of the familiar prickling and tingling felt when one's arm or leg has "gone to sleep." Sensa- tions as of crawling insects are not uncommon; the "hot feet" of many elderly persons (with arterio-sclerosis) and the "burning hands" of many washerwomen are other familiar examples. Local parcesthesia is not uncommon in lesions of the cerebral cortex, and constitutes the preliminary "aura" with which many attacks of epilepsy are ushered in. Well-developed tabes dorsalis shows many curious or distressing varieties of paraesthesia, as do many other varie- ties of peripheral neuritis. 3. Reflexes. We may distinguish : 1. Pupil reflexes. 2. Deep reflexes (tendon reflexes). 3. Superficial reflexes (skin reflexes). 4. Sphincteric reflexes. 5. Sexual reflexes. 1. Pupil reflexes have been described on page 15. 2. Tendon Reflexes. — Among the most important of these is the knee-jerk (quadriceps tendon); less important are the ankle-jerk (Achilles tendon) and ankle clonus, the wrist, elbow, and jaw reflexes. To test the knee-jerk many methods are used; the following seems to me the best : The patient sits with his knees flexed at a blunt angle. The physician lays his left hand on the front of the thigh and strikes 486 ' PHYSICAL DIAGNOSIS the tendon of the quadriceps, just below the patella, with the finger tips of the right hand or with a rubber hammer. The left hand feels the sudden contraction of the quadriceps whether the foot jerks or not. If no contraction is obtained we should try what is known as "reen- f or cement of the knee-jerk." The essence of this is concentration of the patient's attention on a voluntary muscular contraction in another part of the body. We may accomplish this by asking the patient to hook the fingers of his hands together, and at a given signal to give a quick piill upon them and then let go. The physician gives the signal (often the word "now") and strikes the patella tendon at the same moment. The knee-jerk is often wanting or feeble in young infants. It varies a great deal in persons of different temperament ; in high-strung or oversensitive persons and in the Jewish race very lively knee-jerks are often seen without disease. Absence of knee-jerk is oftenest found in: (o) Peripheral neuritis (alcoholic, diphtheritic, lead, etc.). (6) Tabes dorsalis. (c) Anterior poliomyelitis (on the paralyzed side) . {d) In the deepest coma from any cause. (e) In complete severing of the spinal cord. Given a case without knee-jerks: Neuritis is suggested by the history (alcohol), by the presence of marked sensory symptoms (pain, tenderness), and the absence of symptoms pointing to the brain or cord. In tabes the Argyll-Robertson pupil, the disturbance of the sphinc- ters and sexual power, the "lightning pains," here and there, the changes in the spinal fluid (see page 488), and later the ataxic gait are important confirmatory signs. Anterior poliomyelitis presents a flaccid paralysis, usually of one extremity, coming on suddenly in a young child and wholly without sensory symptoms. Comatose patients, if the coma is due to cerebral hemorrhage and is not of the profoundest type, often show increased knee-jerks on the paralyzed side; but in very profound unconsciousness all reflexes are lost. Partial destruction of the cord often increases the reflexes, but total division usually abolishes them. Increased knee-jerk is found in : (a) Cerebral paralyses (infantile, apoplectic, dementia paralytica, etc.). THE NERVOUS SYSTEM 487 (6) Spastic paraplegia and the amyotrophic forms of lateral sclerosis. (c) Many cord lesions, localized above the lumbar enlargement (transverse or pressure myelitis) . (d) The earliest stages of peripheral neuritis. (e) Multiple sclerosis. (/) Some forms of chronic arthritis. Differential diagnosis of cases with increased knee-jerks: Cerebral paralyses usually manifest their place of origin by the presence of psychic symptoms (coma, idiocy, dementia) and by con- vulsions. The paralysis is usually hemiplegic and involves no wasting beyond the atrophy of disuse. Spastic paraplegia is readily recognized by the gait (see page 475) and the absence of marked sensory or sphincteric symptoms. Its pathology is not known. If marked wasting of the muscles occurs it is termed "amyotrophic lateral sclerosis." Transverse or diffuse cord lesions above the lumbar enlargement produce usually anaesthesia below the level of the lesion and relaxa- tion of the sphincters. Such cases are often syphilitic. The earliest stages of peripheral neuritis are usually recognizable, despite a lively knee-jerk, by the predominant sensory symptoms and the etiology. Multiple sclerosis presents, in typical cases, intention tremor (see above, page 45), nystagmus (page 16), and staccato speech. In atypical cases diagnosis is difficult and cases are often mistaken for hysteria. Almost any chronic joint disease, except tuberculosis, may be associated with increased reflexes. Diagnosis depends on the absence of other causes for the increase. Other Deep Reflexes. — The Achilles reflex is best obtained by having the patient kneel on the seat of a well-padded chair, with his feet unsupported, while we strike the Achilles tendon. The significance of its absence or increase is practically the same as that just given for the knee-jerk, but, since it represents a slighty lower position in the spinal cord, it may be affected earlier than the knee- jerk in any cord disease which begins at the bottom of the cord and travels up. Thus in tabes I have known the Achilles reflex absent when the knee-jerk still persisted. Ankle clonus occurs in spastic conditions of the legs or in any disease which increases the other leg reflexes. It is obtained by supporting the patient's leg in a state of such relaxation as can be 488 PHYSICAL DIAGNOSIS obtained, then suddenly and quickly forcing the foot up as far as it will go toward the shin, and holding it in this position. A clonic spasm results, which in true ankle clonus persists as long as we choose to hold the foot in this position. Spurious clonus is obtained when only a few contractions occur, the muscle then relaxing. This spurious clonus can often be obtained in neurasthenic and hysterical states, and has not the significance of true clonus. Kernig's sign is a reflex hypertension of the ham-string muscles, when we flex the thigh on the trunk at a right angle (as in the sitting position) and then try to extend the lower leg. Its motion is arrested about half way between the right angle and full extension. This reflex is of some value in the diagnosis of meningitis, though allowance must be made for the stiffness of old age. The sign is by no means pathognomonic, but is of some confirmatory value. The precise opposite of Kernig's sign, viz: a great slackness oj the hamstrings (hypotonus) is often a valuable confirmatory sign in tahes dorsalis. The deep reflexes of the arms (wrist, biceps, and triceps tendon) are obtained by snapping these tendons sharply with the finger. Decrease in these reflexes we cannot perceive, since they are only obtainable when increased. Such increase may* occur in the diseases which increase leg reflexes; also in chronic joint troubles. The jaw-jerk is obtained by asking the patient to let the lower jaw drop fully, placing a finger on the chin and percussing that finger as in percussion of the chest. It can be elicited only when increased. 3. Superficial Reflexes. — A "ticklish" person is one whose super- ficial reflexes (skin and muscles) are very lively. Among pathological reflexes of this type: (a) The Babinski reflex is the most important. It is a modifica- tion or reverse of the normal plantar reflex, which crumples up the toes toward the sole of the foot if the skin of the foot is tickled. To obtain the Babinski reflex, bare the patient's foot and draw the blunt end of a pencil along the inner side of the sole from heel to toe with moderate pressure. If the great toe cocks up toward the shin, Babinski's reflex is present. Sometimes several other toes spread laterally and follow the great toe. Squeezing the calf or drawing the finger along the outer tibial surface or various other ways of irritating the lower leg may also bring out the Babinski reflex (Gordon's sign, Oppenheim's sign, etc.). The reflex is obtained on the paralyzed side in hemiplegia and other lesions involving the motor tract. THE NERVOUS SYSTEM 489 (b) The cremasteric reflex draws the testis tight up against the body (as after a cold bath) when the skin and muscles on the inner side of the thigh are gathered up and firmly grasped in the hand. (c) The abdominal and epigastric "tickle reflexes" are excited by lightly and quickly stroking the skin of these parts with a pencil point or something of the sort. The presence of cremasteric, abdominal, and epigastric reflexes indicates that the portion of the spinal cord in which they are rep- resented (upper lumbar and lower dorsal regions) is functionally sound. The absence of these reflexes, however, signifies nothing, for in many healthy persons they cannot be excited. (d) The reflex of winking excited by the ordinary stimuli signifies the approximately normal conductivity of the fifth and seventh nerves (trigeminal and facial) . 4. Sphincteric Reflexes. — The sphincters of the bladder and rectum are kept closed in the normal adult by reflex contraction, normally of moderate degree, but excited by the presence of urine and faeces. If there is no awareness of faeces at the anus or of urine at the neck of the bladder, owing to destruction of the conducting nerves or spinal nerve-centres, involuntary urination and defecation occur. This is the case in transverse, diffuse, or compression myelitis above the segment (fourth and fifth sacral) where the centres for bladder and rectum are represented;' also in tabes dorsalis, dementia paralytica, and less often in other chronic spinal diseases. Periph- eral neuritis and brain lesions rarely affect the sphincters. In deep coma from any cause (epilepsy, cerebral hemorrhage) the sphincters may be relaxed, owing to the abolition of sensation. 5. Sexual Power. — Sexual power may be regarded as a reflex in the presence of a particular stimulus, and is diminished or lost in chronic cord diseases involving the first and second sacral segments (lumbar enlargement) or the nerves leading to them, e.g., in tabes, some cases of myelitis and dementia paralytica, etc. Temporary increase of power may precede the diminution. 4. Electrical Reactions. ■ In health a sharp contraction occurs if a faradic current is applied to a nerve or over a muscle, and a similar contraction can be obtained ' It must be remembered that these nerves arise from the cord at the level of the first lumbar vertebra, though they do not issue from the spinal column till the fourth and fifth sacral foramina are reached. 490 PHYSICAL DIAGNOSIS with the galvanic current just when the circuit is closed or broken, but not when the current is passing. In contrast with these conditions is the reaction of degeneration. When this is present we obtain no muscular twitching with the faradic current and none over the nerve with the galvanic; but with the galvanic over the muscle a slow, worm-like contraction occurs, and the response to the positive pole is as good as to the negative, or better, whereas normally there is far better response to the negative. This is the complete reaction of degeneration; in partial reactions of degeneration all the normal reactions may be present, but diminished in intensity. Reaction of degeneration occurs in all diseases affecting the anterior motor horns of the cord or their prolongations downward in the per- ipheral nerves; for example, in anterior poliomyelitis, progressive muscular atrophy, transverse or pressure myelitis, and all severe forms of peripheral neuritis. In brain lesions this reaction rarely occurs. In prognosis a reaction of degeneration persisting after six to twelve weeks is unfavorable for recovery of the use of the muscles in which it occurs. If reaction of degeneration is absent or partial from the start, the prognosis is for relatively speedy recovery, i.e., in weeks rather than months. 5. Speech and Handwriting. Aphasia, the loss of the power to speak or understand speech, despite normal hearing and muscular powers, occurs in lesions affecting the third left frontal and first left temporal convolutions of the brain.' The lesions producing aphasia may be permanent anatomical changes following hemorrhage or tumor, or they may be transitory, as in uraemia and migraine. The power to write or read letters is lost {agraphia) when the angular and supramarginal convolutions are destroyed. Degeneration of the handwriting, as compared with the standard of former years, is often a helpful bit of evidence in the diagnosis of dementia paralytica^ but may occur temporarily in various fatigue states. 6. Trophic or Vasomotor Disorders. Trophic lesions of the joints, muscles (atrophy), skin, and nails have already been exemplified (pages 466 and 54) . They blend with ' In some left-handed persons the centres are on the right side of the brain THE NERVOUS SYSTEM 491 and are by some explained as the results of vascular changes (vaso- motor). Herpes labialis ("cold sore") and herpes zoster ("shingles") certainly seem to give every evidence of being due to nutritive dis- orders in the ganglia and not to vascular changes. The acute bedsores which form in myelitis, the "angioneurotic" local swellings which appear here and" there in certain persons, and the local syncope or asphyxia which sometimes lead to Raynaud's form of gangrene, seem to need both nerve and vessel changes to explain them. In brain lesions these trophic and vasomotor changes are much rarer than in disease of the cord and peripheral nerves. 7. The Examination of Psychic Functions. The diagnosis of the mental factors of disease forms an important part of the study not only of neurology, but of all diseases wherever situated ; but as it cannot be called physical diagnosis, it falls outside the scope of this book, except in so far as loss of consciousness, coma, may be considered under this heading. {a) Coma. The causes of coma are nearly identical with the causes of con- vulsions. Almost every disease which causes the one may cause the other; hence all that is here said on the diagnosis of coma applies equally well to the diagnosis of convulsions. Either or both may result from : 1. Cerebral compression (skull fractures). 2. Apoplexy (including cerebral hemorrhage, embolism, and thrombosis) . 3. Alcohol. 4. Epilepsy. 5. Cerebral concussion (stun). 6. Uraemia and hepatic toxaemia. 7. Diabetes. 8. Syncope (fainting). 9. Opium. 10. Hysteria. 1 1 . Gas poisoning. 12. Sunstroke. 13. Stokes- Adams' syndrome. 492 PHYSICAL DIAGNOSIS Apoplexy is the probable diagnosis when an elderly person who has shown no previous signs of ill-health becomes suddenly and deeply comatose within a few seconds or minutes. If hemiplegia is present (with or without aphasia) and if we can exclude the other causes above mentioned, the probability of apoplexy is increased. To determine hemiplegia in a comatose patient, try the following tests : (a) Lift the arm and then the leg, first on one side and then on the other, and let go. The supported member falls more limply on the paralyzed side. (6) Pinch or prick the limbs alternately. The sound limb may be moved, while the other remains motionless. Pressure over the supraorbital notch may bring out a similar difference in the response of the two sides. (c) Try the knee-jerks. On the paralyzed side the jerk may be increased. (d) Try Babinski's reaction. It may be present on the paralyzed side or on both sides. UrcBmia. — The diagnosis between apoplexy and uraemia is some- times impossible, since uraemia may produce hemiplegia and the urine in the two conditions (as obtained by catheter) may be iden- tical. In practically all cases, however, the uraemic patient has pre- viously shown obvious signs of nephritis — oedema, headache and vomiting, long-standing oliguria, or polyuria with albuminuria. "Acute uraemia" suddenly appearing in a person apparently healthy is almost always a false diagnosis. The cases turn out to be skull fracture, apoplexy, arterio-sclerosis, etc. Convulsions more often precede or follow the coma of uraemia than that of apoplexy. Retinal hemorrhages or albuminuric retinitis, if recognized by ophthalmo- scopic examination, point strongly to uraemia. The hepatic toxaemia in which many cases of cirrhosis and acute yellow atrophy die is distinguishable from uraemia only if the previous history of the case is known to us and the signs of liver disease (ascites, jaundice, enlarged spleen) are evident Diabetic coma is usually recognized with ease, because the evidences of advancing diabetes lead gradually up to it. Like uraemia and unlike apoplexy it very rarely appears "out of a clear sky." The emacia- tion of the patient, the sweetish odor of the breath, the presence of sugar, and especially the evidences of acetone and diacetic acid in the catheter-urine, are the essential factors in diagnosis. Dyspnoea ("air hunger") precedes the coma in about one-third of the cases. THE NERVOUS SYSTEM 493 Concussion (or stun) after a blow usually clears up in a few minutes and so presents no difficulty in diagnosis. If the coma lasts on for hours or days (as it sometimes does) the suspicion arises that we are dealing with Compression. For this the evidences are: Focal symptoms, con- vulsions, slowing of the pulse, and signs of depressed fracture. To determine the latter fact may be impossible without trephining, since the inner table of the skull may be broken, while the outer is intact. The focal signs to be looked for are paralyses (ocular or peripheral). Syncope (or fainting) is usually over in a few minutes and so betrays its nature, but it must not be forgotten that a slight convulsion may occur just as the patient comes out of coma. No suspicions of epilepsy need be aroused thereby, but if there have previously been signs of hysteria we may be in doubt whether the fainting fit is not of hysterical origin. The history of the case, the circumstances at the onset of the attack, and the presence or absence of hysterical behavior during it usually guide us aright. Opium poisoning produces a coma from which the patient can usually be more or less aroused. Contracted pupils and slow respi- ration are the most characteristic signs. A laudanum bottle or a subcutaneous syringe found near the patient often assist the diagnosis. Alcoholic coma is rarely complete. The patient can be aroused. The circumstances under which he is found, the odor of alcohol on the breath, the absence of paralysis, fever, small pupils, or urinary abnormalities are the main supports in diagnosis. There is no char- acteristic pulse and the pupils show no constant changes, though in many cases they are dilated. Hysterical coma usually occurs in young women who have pre- viously shown signs of hysteria. In falling they never hurt them- selves. The eyelids are contracted, often tremulous, and when 'forcibly pulled open often expose eyeballs rolled up so that the whites alone are seen. The hands are apt to make grasping motions, and there are irregular, semipurposive movements of various parts of the body. A startling word may arouse the patient, but anaesthesia to pain (over one-half or all the body) is often complete. Postepileptic coma is usually recognized with ease, because of the convulsions which precede it and which are usually known to have occurred at intervals before. The scars of previous falls may be found on the head. Gas poisoning rarely presents any diagnostic difficulties, because the circumstances under which the patient is found make clear the cause 494 PHYSICAL DIAGNOSIS of his condition. An odor of gas may hang about his breath for some hours. Sunstroke is recognized by the state of the weather and the presence of a very high temperature (io6°, i io°, 1 15° F., or even more) . There is no other characteristic sign. This condition is to be distinguished from heat exhaustion in which there is no fever and no coma. The Stokes-Adams' Syndrome (see above p. 114) produces coma and convulsions with a very slow radial pulse and a quicker venous pulse (visible or traceable polygraphically) in the neck. 8. Examination of the Cerebrospinal Fluid. In cerebro-spinal syphilis (including tabes and paresis), and in all types of meningitis, the character of the fluid obtained by lumbar puncture is of great diagnostic value. In all comatose and paralytic states it is also useful . To obtain spinal fluid a hollow needle is inserted between the spines of the vertebrae in the median line at the level of a line carried round the back from the crest of one iliac bone to the other. The needle is pushed straight on until fluid begins to flow through it. This usually occurs when the needle point is about two inches from the surface. If the spinal fluid is under tension it may spurt through the tube but usually it falls drop by drop into the test tube, which is held in position to receive it. The most important tests are: i. The cell count. 2. The differ- ential cell count. 3. The Wassermann test. 4. The Lange colloidal gold test. To count the cells one puts a drop of the well shaken fluid on the counting disc of the Thoma-Zeiss blood counter and proceeds ex- actly as in dealing with blood. Normal cerebro-spinal fluid contains from I to 10 (usually i to 5) cells per cm. In syphilis from 20 to 200 or more cells are often found. In meningitis and pneumonia there are often several hundred. In leucaemia the count rises into the thousands. The differential count shows in most chronic inflammations of the canal, i.e. in tabes, paresis, and tuberculous meningitis, 90 to 100 per cent, of lymphocytes. In acute irritations such as epidemic meningitis and pneumonia the cells are largely polynuclear. The Wassermann reaction is often positive in the spinal fluid when it is negative in the blood, e.g. in tabes. Its value is therefore obvious. The Lange gold test depends on a color change produced by certain spinal fluids in a solution of colloidal gold. INDEX Abbott, Maud E., 270-273, Abdomen, contour of, 348 distended and tortuous veins of, 348 examination of, 347-352 free fluid in, 354, 356 inspection of, 348 organs palpable in, 350 palpation of, 349 projection or levelling of navel, 348 respiratory movements of, 349 rose spots on, 348 . strise of, 348 tumors of, 352 tumors of, frequency of, 355 tumors of, respiratory mobility in, 352 Abdominal distention, 386 reflexes, 489 wall, abscess of, 351 wall, inflammation of, 352 wall, lesions of, 355 wall, movements of, 348 wall, sarcoma of, 352 wall, thickening of, 352 Abscess, alveolar, 25 axillary, 40 cervical, caries in, 29 cervical in Pott's disease, 32 cold, 59, 70 glandular, 32 in tuberculous arthritis, 469 ischiorectal, 423 of abdominal wall, 351 of hip-joint, 58 of liver, 357 of lung, breath in, 22 of urethra, 428 peri-urethral, 425 Abscess, perihepatic, 357 perinephritic, 59, 398 perinephritic, psoas spasm in, 472 perisplenic, 357 psoas, 435 pulmonary, 301, 342 pulmonary, sputa in, 311 retropharyngeal, 28 subphrenic, 357 tonsillar, 28 tuberculous, 59 Acetone breath, 22 Achilles reflex, 487 Achromia of red cells in chlorosis, 456 Achylia gastrica, stomach contents in, 369 Acne rosacea, nose in, 18 Acromegalia, 8 arm in, 43 hands in, 52 nose in, 8, 17 "whopper jaw" in, 8 Actinomycosis, 59 of belly-wall, 352 of neck, 3 5 of pleura, 338 Addison's disease, 106 disease, buccal patches in, 26 Adenitis, 29, 92, 93 Adenoid growths, 64 growths, nose in, 18 Adenoids, ii lips in, 19 Adherent pericardium, 84, 205, 263 Agraphia, 490 Albuminuria, 406 in peritonitis, 356 significance of, 348 with nephritis, 408 495 496 INDEX Albuminuria, without nephritis, 408 Albumosuria, significance of, 408 Alcoholism, 371, 486 breath in, 22 coma in, 493 face in, 12 hands in, 44, 45 in myocarditis, 247 nose in, 17, 18 pharyngeal reflexes in, 2g skin in, 100 tongue in, 22 Alkaline urine, 406 AUbutt, Sir Clifiord, 210, 223, 248, 266 Alopecia areata, patchy baldness in, 7 Alternation, 113, 121 Altitude, effect on heart action, 275 Amoeba coli, 389 histolytica in feces, 389 Amyloid disease, of liver, 373 disease, spleen in, 397 Amytrophic lateral sclerosis, 488 Anaesthesia, hysterial; 486 neuritis after, 37 tests of, 482 Anatomy of chest, 61 Anemia, capillary pulsation in, go functional heart murmurs in, 189 hsgmoglobin test in, 447 hypertrophy and dilatation in, 195, 197 in heart disease, 270 in hypoplasia of aorta, 273 interpretation of blood count in, 456 lips in, 19 mitral stenosis in, 221 murmurs in, 252 nails in, 57 oedema of legs in, 459 oedema of lids in, 14 pallor in, 91 pernicious, 106, 189, 269 pulse in, 248, 250 retinal hemorrhage in, 17 splenic, 397 secondary causes of, 455 Aneurism, 34, 59, 70, 82, 85, 86, 242, 266, 336, 343 Aneurism, aortic, 195, 204, 227, 229, 247, 253 aortic, pupils in, 16 auscultation in, 259 cardiac, 217 diagnosis of, 273 diffuse and saccular, 255 distinguished from aortic steno- sis, 274 distingmshed from diffuse dilata- tion of the arch, without rupture of coats, 274 distinguished from empyema necessitatis, 275 distinguished from mediastinal tumors, 275 location of, 272 oedema of arm in, 40 of aorta, 234 percussion signs in, 259 pulsation in, 255 pupils in, 269 radial pulse in, 269 radioscopy in, 271 saccular, 249 seat of, 261, 262 thrill in, 256 tracheal tug in, 256 tumor of, 255, 256 Angina pectoris, 195, 254, 267, 321 Angioneurotic oedema, 14, 20, 491 oedema of legs, 441 Ankle clonus, spasm in, 483. clonus, test for, 487 Ankylosis, 468, 476 Anorexia in local peritonitis, 356 nervosa, malnutrition in, 2 Anterior poliomyelitis, 438 poliomyelitis, acute, paralysis in, 38 poliomyelitis, knee-jerk in, 486 poliomyelitis, reaction of de- generation in, 488 Anus, fistula of, 423 fissure of, 423 Aorta, hypoplasia of, 273 small, 196 Aortic aneurism, see Aneurism arch, dilatation of, 222, 229 INDEX 497 Aortic arch, roughening of, 234, 242 coarcuation, 271 dilatation, 211, 234 insufficiency, 219 obstruction, see Stenosis regurgitation, see Regurgitation second sound, 174, 175, 176 stenosis, see Stenosis aortic valves, roughening of, 229 Aortitis, syphilitic, 204, 220, 221, 247 with aneurism, 255-265 Apex retraction, 83 Aphasia, 250, 490 Aphonia, 242, 258 Apnoea in Cheyne-Stokes breathing, 74 Apoplexy, breathing in, 76 coma in, 491 distinguished from uraemia, 492 Appendicitis, 383 cause, of peritonitis, 354 leucocytosis in, 457 local and constitutional signs, 384 muscular spasm in, 384 psoas spasm in, 384, 470 simulated, 384 tenderness in, 384 tumor in, 384 Arcus senilis, 16 Argyll-Robertson pupil, 16, 486 Argyria, 15 Arms, atrophy of, 39 contractures of, 39 contractures of, in cerebral lesion, 39 contractures of, in hysteria, 39 cyanosis of, 269 deep reflexes of, 488 fatty tumors of, 40 gouty deposits in, 41 in acromegalia, 43 in acute anterior poliomyelitis, 38, 39 in osteoarthropathy, 43 in Paget's disease, 42 in rickets, 42 oedema of, 40 32 Arms, oedema of, causes of, 40 oedema of, in aneurism, 40 oedema of, in cancer, 40 oedema of, in Hodgkin's disease, 40 oedema of, in nephritis, 40 oedema of, in sarcoma of medi- astinum, 40 oedema of, in sarcoma of lung, 40 CEdema of, in thrombosis, 40 pain in, 35, 269 paralysis of, 37 sarcoma of bone of, 40 tuberculosis of bone of, 41 tuberculous lesions of, 41 Arrhythmia, 216 absolute, 267 causes of, 102 "nervous," 221 sinus type, 268 Arsenic poisoning with conjunctivitis, IS Arterial embolism, 218 murmurs, 191, 192 phenomena, 88-89 pressure, 107 tension, 104, 106 trunks, transposition of, 272 walls, calcification of, 106 walls, condition of, 105 walls, stiffening of, 105, 106 Arteries, calcification of, 106 changes in, 40 diseases of, 89 in nephritic heart disease, 270 inspection of, 88 position of, 105 pulsation in, see Pulsation stiffening of, 89 Arteriograms, 113 Arterio-sclerosis, 82, 89, 105, 107 III, 191, 194, 195, 196, 221 228, 247, 248, 262, 266 cornea in, 16 decrescent, 266 gangrene of toes in, 444 heart sounds in, 175 hypertrophy in, 200 498 INDEX Anterio-sclerosis, pulse in, 103 senile, 266 Arterio-sclerotic heart; disease, 266 269 Arthritis, 434 acute, 205 acute infectious, distinguished from other types, 470 acute infectious, endocarditis in, 470 atrophic, 54, 472 atrophic, monarticular form, 472 atrophic, of sacro-iliac joint, 475 atrophic, primary polyarticular form, 474 atrophic, symmetrical involve- ment of joints in, 474 atrophic. X-ray of hand in, 472 gouty, 480 haemophilic, 480 hypertrophic, features of, 474 hypertrophic, Heberden's nodes in, 474 hypertrophic, limitation of mo- tion in, 477 hypertrophic, nerve pain in, 477 hypertrophic, of sacro-iliac joint, S8 hypertrophic, psoas spasm in, 470 hypertrophic, with kyphosis, 58 infectious, 469 rheumatic, 213 spinal, s 7 tuberculous, characteristics of, 469 Ascaris lumbricoides, 389, 392 Ascites, 210, 219, 245, 431 causes of, 356 Asphyxia, local, in Raynaud's disease, 55 Astereognosis, 484 Asthma, 280 breathing in, 155 bronchial, 279, 308 bronchial, eosinophilia in, 458 thymic, 309 As-Vs interval, 114, 267, 270 -Vs interval, in mitral stenosis, 217 Ataxia, 483 Romberg's sign in, 484 Atelectasis, 271, 280, 290, 336, 344 crepitant rMes in, 162 pulmonary, 337 Athetosis, 50 Atrophic arthritis, see Arthritis Atrophy, acute yellow, 376 following fracture or dislocation, 39 of disuse, 39 in hysteria, 39 muscular, claw hand in, 5 1 muscular, reaction of. degenera- tion in, 490 optic, 17 progressive muscular, fibrillary twitching in, 483 Auricle, dilatation of, 201 hypertrophy of, 201 Auricular fibrillation, 117, 218 Auscultation, difierences between two sides of chest, 156 importance of, 138 in aneurism, 259 in pneumohydrothorax, 167 in aortic regurgitation, 225 in croupous pneumonia, 285 in mitral stenosis, 213 in myocarditis, 248 mediate versus immediate, 138, 139 of heart, 169 of lungs, 150 of muscle sounds, 147 of voice sounds, see Vocal Frem- itus see also Breathing, Murmurs, Rdles, Heart sounds sources of error in, 148, T49 technique of, 139 Austin Flint murmur, 219, 234, 254 Auto-intoxicatioji, 274 Babinski reflex, test for, 488 Bacilli influenza, 307, 313, 315 pneumococcic, 313 tubercle, 313, 388 INDEX 499 Bacilli tubercle, identification of, 388 Back, 57-60 aneurism pointing in, 59 dermoid cyst of, 60 epitheliomaof, 59 in lumbago, 57 nodes in, 59 spina bifida of, 60 stiffness of, 57 tumors of, 59, 60 Balanitis, 425 Baldness, 7 patchy, in alopecia areata, 7 Barie, 216 Basedow's disease, 383 Bathycardia, 84 Bence-Jones' body, 408 Biceps, rupture of, 40 Bigeminal pulse, 120, 218, 252 Bile ducts, 376 ducts, incidence of diseases of, 370 Bilharzia disease, blood in, 458 eggs, 393 Biliary colic, 377, 393, 400 obstruction, 15 Bismuth line, 24 X-ray examination of stomach, 366 Bladder disease, incidence of, 419 disease, percussion in, 419 disease, urine in, 421 distention of, 419 pus in, 404 stone of, 422 tuberculosis of, 422 tumor of, 406 Blindness, dilatation of pupil in, 16 Blood, altered, 387 color, index of, 446 counting red corpuscles of, method of, 454 counting white corpuscles, method of, 453 cover-glass preparation of, 447 eosinophiUa in, 452, 458 examination of, 445 filaria in, 463 films, appearance of stains, 450 Blood films, preparation of, 447 films, staining of, 449 films, stains used, 449 haemoglobin test, 446 in bilharzia disease, 458 in chlorosis, 456 in feces, 387 in filariasis, 458 in hydatid disease, 458 in lymphoid leukasmia, 458, 459 in myeloid leukaemia, 459 in pernicious anemia, 456 in secondary anemia, 455 interpretation of result of leuco- cyte count and differential count, 454 in trichiniasis, 458 in trypanosomiasis, 458 in uncinariasis, 458 in urine, 413 leucocytes in, 451 lymphocytes in, 451 normoblasts distinguished from megaloblasts in, 450 nucleated red cells in, 450 occult, 388 parasites in, 461 plates, 452 poikilocytosis, 450 polychromasia, 450 polynuclears in, 451 pressure, see Pressure stippled red cells in, 450 trypanosoma in, 463 Wassermann reaction, 461 Widal reaction, 460 see also Anemia Body, as a whole, i Bone, necrosis of, in tuberculous arthritis, 469 Bowel, cancer of, 385 Bradycardia, 274 Brain, abscess of, optic neuritis in, 17 defects, spasms in, 14 lesions, astereognosis in, 484 lesions, hemiansesthesia in, 485 lesions, nystagmus in, 16 paralysis of, 482 tumor, optic neuritis in, 17 500 -INDEX Bramwell, 219 Breast, funnel, 65 pigeon, 6s Breath, 22 acetone, 22 alcoholic, 22 causes of foul, 22 in gastric fermentation, 22 in poisoning by illuminating gas, 22 in Rigg's disease, 22 in stomatitis, 22 in tonsillitis follicular, 22 in urasmia, 22 Breathing, amphoric, 160, 299, 319 asthmatic, 74 bronchial, 153, 159, 160 bronchial or tracheal, 152, 153 broncho-vesicular, 154, 156, 159, 160, 285, 297 catchy, 75 cavernous, 160, 299, 318 Cheyne-Stokes, 75, 247 cog-wheel, 154, 155, 293, 294 compensatory, 157 differences between two sides of chest, 156 difficult, 72 emphysematous, 72, 154, 306 exaggerated vesicular, 157 in apoplexy, 75 in asthma, 72, 155 in hysteria, 77 interrupted, 154, 155, 294 metamorphosing, 156 ■ normal, 70, 73 rapid, 72, 73 shallow, 76 "sharp," 297 sighing, 76 stertorous, 76 stridulous, 76 tubular, 150, 242, 285 types of, 72, 73, 74, 150 vesicular, 150, 151, 152, 279 vesicular, diminished, 157 see also Respiration Bronchi, cancer of, 327 dilatation of, see Bronchiectasis spasm of, 308 Bronchial asthma, see Asthma breathing, see Breathing pneumonia, see Pneumonia Bronchiectasis, 284, 302, 303, 310 sputa in, 311 Bronchitis, acute, 276, 279, 291 chronic, 282, 310 tuberculous, acute, 303 Bronchophony, 166 Broncho-stenosis, 309 Buccal cavity, see Mouth Bulbar paralysis, see Paralysis Bundle of His, 114, 251 Bursitis, prepatellar, 438 Cachexia, 279 of old age, i Calcaneus, 442 Cancer, 275 age of patient in, 368 anemia in, 455 gastric, advanced, symptoms, 368 gastric, bismuth X-ray examina- tion in, 366 gastric, malnutrition in, 2 gastric, statistics of, 368 gastric, tumor in, 359 gastric, with absence of hydro- chloric acid, 368 glands in, 3 1 jaundice in, 375 metastatic, of femur, 435 oedema of arm in, 40 of bowel, 386 of bronchi, 327 of esophagus, 264, 361 of lip, 20 of liver, 372 of lung, 327 of pancreas, jaundice in, 379 of penis, 425 of peritoneum, 357 of pleural, 328, 337, 338 of rectum, 424 of rectum, stools in, 387 of sigmoid, 385 of stomach, 368 of testis, 426 of tongue, 22 INDEX 501 Cancer of tonsil, 28 of uterus, 429 of vertebrae, 57 tongue in, 23 "Canker sores," 20 Cardiac compensation, see Compen- sation cycle, see Heart cycle disease, diuresis in, i disease, sweating in, i disease, weight in, i disease, see also Heart dulness, 134, 197, 281, 295, 319, 327 impulse, 94, 95, 317, 330 impulse, character of, 79-81 impulse, displacement of, 62, 68, 82, 199 impulse, maximum, 79 impulse, normal, 78 impulse, position of, 79 incompetence, 180 insufficiency, 180 murmurs, see Murmurs neuroses, 81, 249 obstruction, 180 space, 130 Cardio-hepatic angle, 241, 244 Cardio-spasm, 361 Cardio-vascular disease, 204-247 hypertensive, 263 Caries of vertebrae, abscess in, 29 Carphologia, 44 Casts in urine, 471 Catarrhal pneumonia, see Pneu- monia Cavity, pulmonary, 300, 310 Cerebro-spinal fluid, examination of, 496 Cervical rib, an accessory, 35, 39 Charcot's joint, atrophic arthritis in, 470 Chest, abnormal pulsation in, 255 anatomy of, 61 barrel shaped, 66 diminished expansion of, 71 examination of, 61 flattening of, 68 in adenoid disease, 65 increased expansion of, 71 Chest, in phthisis, 65, 66, 67, 68 inspection of, 64 landmarks of, 62, 63 local prominences, 69 palpation of, 94 percussion of, 122 prominence of one side, 69 rachitic, 65 shape of, 64 size of, 64 tenderness in, 99 tumor of, 70 wall, nutrition of, 67 Cheyne-Stokes breathing, 75, 267 Children, splenic enlargement in, 396 Chill, cause of, 3 true, cause of, 4 Chilliness distinguished from chill, 4 Chlorosis, blood in, 456 visible pulsation in, 84 Cholangitis, 373 Cholecystitis, signs of, 377 results of, 377 Chorea, 205, 213 hands in, 47 leg in, 437 post-hemiplegic, 49 spasms in, 13 Sydenham's, of hands, 47, 203 true, to difierentiate, 14 Choreiform movements, 47, 49, 50 Cirrhosis of liver, see Liver of lung, see Pneumonia, chronic interstitial portal, jaundice in, 375 Claudication, intermittent, 436 "Cloudy swelling," 273 Club-foot, varieties of, 442 Coarctation, aortic, 271 "Cold sores," 19 Colic, biliary, 377 intestinal, 401 lead, 377 renal, 377 Collargol radiographs in kidney dis- ease, 399 Colon, congenital dilation of, 383 inflation of, in diagnosis of abdominal tumors, 354 palpation of fluid in, 354 502 INDEX Coma, alcoholic, 493 causes of, 491 in Stokes-Adams syndrome, 494 knee-jerk in, 486 lumbar puncture in, 494 postepileptic, 493 sphincteric reflexes in, 489 Compensation, 283 cardiac, establishment and fail- ure of, 193-^:95 failing, 207, 209, 230 tests of, 195 Compression, coma in, symptoms of, 493 of lung, 290 Concussion, coma in, 492 Conjunctivitis, causes of, 14, 15 following arsenic, 14 following iodide of potash, 14 with hay fever, 14 with measles, 14 with yellow fever, 14 Constipation, 387 :, in intestinal obstruction, 386 tongue in, 23 Contractures following atrophic ar- thritis, 476 hemiplegic, hand in, 51 of arm, 39 of the interossei and lumbricales, claw hand in, 51 Cor bovinum, 245, 248 Cornea, 16 Corrigan pulse, 103, 220, 250 Cough, 163 ,195, 220, 242, 258, 276, 290, 292, 301, 310, 329 with sputa, 315 Cranium, size and shape, 5 Cremasteric reflex, 488 Crepitation, atelectatic, 282 Crepitus in monarticular atrophic arthritis, 472 in perigastritis, 353 in perihepatitis, 353 in perisplenitis, 353 in peritonitis, 353 peritoneal, 353 Cretinism, ii lips in, 19, 21 Cretinism, teeth in, 22 tongue in, 24 "Croup," breathing in, 76 Curvature of spine, 34, 58, 59 ■■- facial, tongue in,. 23 in acute anterior poliomyelitis, 37. 437 in chorea, 437 in diseases of spinal cord, 437 infantile cerebral, athetosis in, in hemiplegia, 49, 437 in hysteria, 39, 437, 482 in lead-poisoning, 37, 38, 437 in myelitis, 437 in neuritis, 37, 437 in tabes, 430, 437 in toxic neuritis, 430, 437 in traumatic neurosis, 39 ' of arm 37 516 INDEX Paralysis of brain, 482 of cord, 482 of cranial nerve, 482 of dorsal or abdominal muscles, 59 of legs, 437 of interossei and lumbricales, claw-hand in, 51 of muscles of respiration, 158 of peripheral nerve, 482 pharyngeal reflexes in, 29 pupils in, 16 serratus, scapula in, 60 with contraction of pupil, 15 Paraphimosis, 425 Paraplegia, 482 paralysis of leg in, 437 spastic, 437, 487 Parasites, animal, diseases due to, 458 in feces, 388 in hair, 7 intestinal, eggs of, 390 malarial, 440 Paravertebral triangle, 327 Paresis, 482 lumbar puncture in, 494 Paronychia, 56 Parotid gland, cancer of, 3 1 gland, enlargement of, 31 Parturition, leucocytosis in, 457 Patent ductus arteriosus, 272 Patella, floating of, test for, 465 Pectus carinatum, 65 Pediculi in hair, 7 Penis, 424 cancer of, 425 chancre of, 424 chancroid of, 425 discharge from, 424 inflammation of glands of, 425 malformations of, 425 Peptic ulcer, 368, 370, 377 Percussion, auscultatory, 127 dull areas in, 130, 134 force of, 125, 131 importance of symmetrical, 133 in aneurism, 259 in aortic regurgitation, 225 in croupous pneumonia, 283 Percussion in enlarged heart, 131 in syphilitic heart disease, 251 lung reflex in, 137 mediate and immediate, 121 note, modifications of, 134 of heart, 202 of lung borders, 135 palpatory, 128 resonance, amphoric, 136 resonance, cracked-pot, 135, 277, 300 resonance, dull, 130 resonance of chest, 129 resonance, tympanitic, 132, 317, 325 resonance, varieties of, 136 signs in phthisis, 300 technique of, 121, 137 Peribronchitis, tuberculous, acute, 302 Pericardial friction, see Pericarditis Pericarditis, 237 acute, 205 dry, 237 effusion, 240 effusion, distinguished from pleu. ritic, 243 fibrinous-, 237 friction in, 98, 237 tricuspid stenosis after, 220 and endocarditis, 239 and pleurisy, 244 distinguished from hypertrophy and dilatation of heart, 243 Pericardium adherent, 84, 195^ 221, 244 diseases of, 237 Perihepatitis, 370 Perinephritic abscess, 59, 399 abscess, psoas spasm in, 470 Perineum, ruptured, 428 Periostitis, syphilitic, 439 Peripheral nerve lesions, hemianaes- thesia in, 485 nerve lesions, hyperaesthesia in, 485 neuritis, reaction of degenera- tion in, 490 Peristalsis, visible gastric, 359 INDEX 517 Peristalsis, visible, in intestinal ob- struction, 385 Peritoneum, cancer of, 356 diseases of, 354 tuberculosis of, 356 Peritonitis, causes of, 355 general, 355 local, 354 respiratory movements of belly in, 348 with thickening or inflammation of navel, 352 Peri-urethral abscess, 425 Pernicious anemia, see Anemia Pharyngeal reflexes in alcoholism, 29 reflexes in paralysis, 29 reflexes in postdiphtheritic neuri- tis, 29 Pharyngitis, 27 Pharynx, 27 eruptions of, 27 examination of, 27 Phenolsulphonephthalein test for renal function, 307 Phimosis, 425 Phlebitis, 436 Phlebograms, 113, 250 Photophobia, 16 Phrenic wave, 76 Phthisis, 77, 99, 250, 292, 309, 322 advanced, 298 advanced, sputa in, 311 bronchial breathing in, 159 chest in, 65, 66, 67, 68 cracked-pot resonance in, 136 face in, 12 fibroid, 83, 84, 265, 302 fibroid with pleural thickening, 298, 302 hilus, 301 pulse in, 224 pupils in, 16 sweating in, 4 with pleural thickening, 302 see also Tuberculosis of lung Pigmentation in Addison's disease, 26 in negroes, 26 Pin-worm, in feces, 388 Platelets in blood, 452 Pleura, actinomycosis of, 330 cancer of, 334, 338 diseases of, 316 echinococcus of, 337 Pleural adhesions, 77 cavity, fluid in, 157 effusion, 77, 82, 86, 230, 283, 292. 316, 319, 323 effusion, absorption of, 332 effusion, cytodiagnosis in, 339 effusion, distinguished from peri- cardial, 243 effusion, distinguished from pneu- monia, 289, 336 effusion, egophony in , 166 effusion, encapsulated, 334 effusion, percussion signs in, 323 fluid, examination of, 338 friction, 98, 163, 285, 316, 322 friction, distinction from peri- cardial friction, 257 friction, seat of, 164 thickening, 298, 302, 324, 333 Pleurisy, 68, 83, 99, 263, 316 and pericarditis, 244 auscultatory signs in, 331 breathing in, 77 clubbed fingers with, 53 dry, 322 Grocco's sign in, 327 plastic, 322 pulsating, 86, 335 purulent, 86 sub-crepitant riles in, 162 Plumbism, 39 anemia in, 455 lead line in, 24 paralysis in, 37, 38, 435 respiratory movements of belly in, 348 Pneumococcus infection, 283, 470 Pneumonia, 78, 237, 242 aspiration, 289 bronchial breathing in, 159 broncho-, 276, 281, 282, 290 broncho-pneumonia, chronic, 292 catarrhal, 290 central, 282 characteristic signs of, 291 518 INDEX Pneumonia, chronic interstitial, 84, 310 complications of, 288 crepitant r&les, in, 162 croupous (or lobar), 282, 310, 335 distinguished from pleuritic effu- sion, 289 distinguished from tuberculosis, 290 fibrinous, 282 hypertrophy in, 200 hypostatic, 346 inhalation, 290 leucocytosis in, 457 lobar, 282, 342 lobular, 290 lumbar puncture in, 494 massive, 282 nostrils in, 18 resolution of, 288 sputum in, 312 surgical, 283 tuberculous, 302 wandering, 288 Pneumohydrothorax, 167 Pneumopyothorax, 318 Pneumoserothorax, 318 Pneumothorax, 69, 82, 157, 306, 316 closed, 319 open, 319 Poikilocytosis in blood smears, 450 Poisoning by gas, coma in, 493 by illuminating gas, breath in, 22 by mercury; gums in, 25 by potassic iodide, gums in, 25 lead, see Plumhism silver nitrate, 15 opium, coma in, 493 Poliomyelitis, (acute) anterior, 38 reaction of degeneration in, 39 atrophy in, 39 chronic, hands in, 5 1 Polychromasia in blood smears, 450 Polynuclear cells in blood, 451 Polyuria, 402 Portal cirrhosis, jaundice in, 375 obstruction, causes of, 373 stasis, ascites in, 356 Postepileptic coma, 493 Potain, 211 Pott's disease, 32, 34, 58-68, 469 Precordial region, 69 Pregnancy, choreiform movements in, 47. 49, 5° glucosuria in, 409 lordosis in, 59 spasm in, 13 tubal, 429 Pressure, 258 arterial, 102, 103, 107— 112 arterial, methods of measuring, 107 blood-, 194, 228, 268; see also Hypertension by pericardial exudation, 242 high pulse, 228 in aneurism, 258, 260' in pulmonary artery, 234 diastolic, no, 112 high systolic blood-, in instruments for measuring, 107, 108 low systolic blood-, 1 1 1 mediastinal, 307 normal blood-, no systolic, 108, 109, no Presystolic murmur, see Murmurs Procidentia, 428 Progressive muscular atrophy, fibril- lary twitchings in, 483 muscular atrophy, reaction of degeneration in, 489 Prostate, hypertrophy of, distended bladder in, 420 Prostatitis, acute retention of urine in, 421 Pseudo-leukaemia, tonsils in, 28 Psoas abscess, 435 spasm, 470 spasm of hip, 466 Psychic functions, examinations of, 471 Ptosis, 16 bismuth X-ray examination in, 366 Pulmonary abscess,- 342 disease, mitral stenosis in, 220 INDEX 519 Pulmonary disease, see Lung hemorrhage, 292, 311 regurgitation, 250 oedema, sputa in, 311 osteoarthropathy, 42, 44, 47 stenosis, see Stenosis tuberculosis, see Tuberculosis of lung tympanites, 308, 320 Pulmonic area, 169 second .sound, 174, 200, 208, 241 sound in mitral stenosis, 216 Pulsation, abnormal, 85, 99, 255, 258 capillary, 89, 90, 234, 237, 246, 249 epigastric, 84, 198 in liver, 231 in pleurisy, 86 of arteries, 88, 89, 248 presystolic, 87 systolic, 249 venous, 87, 210 visible, 84, 199 Pulse, 100 alternating, 113, 122. 267 anacrotic, 103 bigeminal, 120, 218 bounding, 103 capillary, 244 compressibility of, 102, see also Arterial pressure Corrigan, 103, 220, 234 coupling of, 218 in aortic stenosis, loi, 230, 271 in misplaced artery, 105 in mitral stenosis, 216 irregular, 102, 117, 207 method of feeling, i o i paradoxical, 242 radial, in aneurism, 269 rapid (tachycardia), 273 rate, loi, 102, 274 rhythm or regularity, 102 slow (bradycardia), 15, 102, 274 tension, 103, 104, 106 trigeminal, 252 unequal. 258 Pulse, value of, 100 value of tracings, 113 waterhammer, 250 wave, dicrotic, 103 wave, recording of, 113 wave, size and shape of, 102, 103 see also Arrhythmia, Artery walls, Pressure, arterial Pulsus celer, 250 rarus, parvus, tardus, 226 Pupil, IS Argyll-Robertson, 16 contraction of, 16 dilatation of, 16 in aneurism, 269 inequality of, 258 irregularity of, 16 reflexes, 15 value of, in diagnosis, 15 Purpura, nosebleed in, 18 Purulent and pleuritic effusions, serous, 332 Pus in feces, 388 in kidney, 404 in urine, 403, 413 tube, cause of peritonitis, 356 Pyelitis, urine in, 417 Pylephlebitis, 373 Pylorus, stenosis of, gastric peristal- sis in, 359 Pyonephrosis, 399 Pyorrhoea alveolaris, 25 Pyuria, 403 vesical, 404 Quinsy, sore throat, 28 Rachitic rosary, 65 Rachitis, 58, 64 arm in, 42 epiphyses in, 42 hair in, 6 head in, 5 splenic enlargement in, 495 teeth in, 2 2 Radioscopy, 35, 61, 263, 265 examination in spinal tubercu- losis, 470 520 INDEX Radioscopy, examination of stomach, bismuth, 366 in adherent pericardium, 245 in aneurism, 260 in aortic stenosis, 234 . in bismuth X-ray examination of stomach, 367 ■ in diaphragmatic movements, 77.78 in interlobar empyema, 333 of joints, 464 Riles, bubbling, 160, 276, 278, 339 consonating, 295 crackling, 161, 209, 282, 292 crepitant, 161, 285 moist, 211 musical, 163 palpable, 99 squeaking, 155, 276 varieties of, 160 Raynaud's disease, 55, 441, 491 Reaction of degeneration, 489 Recti, separations of, 351 Rectocele, 428 Rectum, abscess of, 423 cancer of, 423 cancer of, stools in, 387 fissure of, 423 fistula of, 423 hemorrhoids of, 423 irritation of, in intestinal dis- ease, 382 methods of examination, 422 symptoms which suggest exami- nation, 422 Red test for renal function, 407 Reflex Achilles, 487 Babinski, 488 Reflexes, 485 deep, 488 of pupil, IS, 485 pharyngeal, 29 pharyngeal, in post-diphtheritic neuritis, 29 sexual, 489 sphincteric, 489 superficial, 488 tendon; 485 Regurgitation, 180 aortic, 90, 181, 191, 193, 197, 221, 228, 247 aortic, diagnosis of, 224, 228 aortic, diastolic murmur in, 251 aortic, Duroziez's sign in, 252 aortic, with mitral disease, 235 aortic, with stenosis, 235 pulmonary, 233 tricuspid, 211, 230 , with mitral stenosis, 2 18 Renal calculus, 398, 400, 406 colic, 400 disease, diuresis in, i disease, sweating in. i pyuria, 405 suppuration, 405 suppuration, urine m 417 tuberculosis, 406 tumor, 406 see also Kidney Resonance, see Percussion resonance, hyper-, 305, 308, 338 Respiration, see Breathing, 70 Respiratory movements, 264 Retina, 17 hemorrhage of , 17 see also Neuritis, optic, and Atrophy, optic Retinitis in heart disease, 270 Retraction causes, lung, 265 of thorax, 71, 72 systolic, 244, 249 Retropharyngeal abscess, 28 Rheumatism, 204, 237 acute articular, 273 Rheumatoid arthritis, 468, 470 Rhythm, disturbances of, 177, 216, 221, 264, 267, 270 gallop, 267, 270, 275 modifications in cardiac, 177 presystolic gallop, 178 protodiastolic gallop, 178 Rib, cervical, 35, 39 Rickets, see Rachitis Romberg's sign, 484, 486 Rosary, rachitic, 65 Rose spots, diagnosis of, 348 INDEX 521 Rosenbach, 194, 209, 220, 235 Round-worm in feces, 388 Sacro-iliac joint, see Hip-joint, 57 Sahli's test for haemoglobin, 466 Salpingitis, 429 Sansom's sign, 216, 253 Sarcoma, glands in, 31 of abdominal wall, 352 of arm, 40 of kidney, 399 of legs, 440 of liver, 372 of lung, oedema of arm in, 40 of mediastinum, 342 of mediastinum, oedema of arm in, 40 of scapula, 59 of testis, 426 of thigh, 435 of tonsil, 28 toxemia in, 457 Scapula, prominent, 59 sarcoma of, 59 Scarlet fever, pharynx in, 27 fever, tonsils in, 27 Scars, 92 from syphilitic ulcers on leg, 437 of forehead, 7 Sciatica, 58 Sclerosis, multiple, nystagmus in, 16 multiple, paraplegia in, 437 Scoliosis with twisting of spine, 59 Scrotum, hernia of, 426 hydrocele of, 426 "Scurvy" in gums, 25 Senility, tremor of hands in, 45 Sensation, delayed, 485 disorders of, 484 dissociation of, 484 Sepsis, leucocytosis in, 457 lymphocytosis in, 458 terminal streptococcus, 237 Septicaemia, 273 with jaundice, 15, 375 Septum, defects in, 242, 254 Serratus paralysis, scapula in, 60 Sexual power, 489 Sigmoid, cancer of, 385 Silver nitrate poisoning, 1 5 Situs inversus, 83 Skin diseases, chronic, blood in, 458 in jaundice, 376 in leprosy, 12 in myxoedema, 8 in phthisis, 12 inspection of, 90 lesions of, trophic, in atrophic arthritis, 474 roughness of, 100 temperature of, 100 tumor of, 351 Skull, enlargement of, 5 Sleep, loss of, 2 Small-pox, eruptions on forehead in, 7 throat in, 27 Smith, William H., 244 Snuffles, syphilitic, 18 Sordes, 24 "Soufile," 180 Sound, falling drop, 167, 318 lung-fistula, 168 splashing, 318, 352, 359 succussion, 167 see also Heart sounds Spade-hand, 51 Spasm, 328 cardio-, 361 eclamptic, 106 psoas, 57, 470 psoas, in appendicitis, 384 clonic, 483 habit, 14, 47, 49 Spasms, in chorea, 13 in hereditary brain defects, 14 in hysterical conditions, 14 in torticollis, 33, 34 laryngeal, 282 muscular, 384, 467, 483 of bronchi, 308 of face, causes of, 13 of glottis, 76, 309 of hands, 47, 50 of hip, 466 tonic, 483 of urethra, 422 Speech, loss of, 490 522 INDEX Sphincteric reflexes, 489 Spirochsetes, 146 Sphygmograph, 113 Sphygmomanometer, in Spina, bifidia, 60 Spinal column, muscular spasm in, 467 cord, paralysis of arms n diseases of, 39 curvature, 34, 58, S9i 67 curvature, cardiac impulse in, 83 myosis, 16 twisting, 68 Spine, chronic diseases of, sphincteric reflexes in, 489 hypertrophic arthritis, 475, 487 tuberculosis of, 58, 59 Spirometer, 78 Spitzenstoss, 81 Spleen, abscess of, 357 diseases of, 63, 393 enlarged, distinguished from tumors, 396 enlarged, types of, 395 enlargement of, 374, 393 palpation of, 393 percussion of, 132, 394 tumor of, 352 Splenic anemia, 397 Spondylitis deformans, 475 Sputa, artificially obtained, 294 appearance of, 311 bloody, 311 examination of, 311 staining of, 305, 313 obtained from children, 311 odor of, 311 origin of, 311 pneumonic, 312 purulent, 310 qualities of, 312 quantity of, 311 Squint, 16 Starvation, acetone breath in, 22 intestinal distention in, 383 Statistics on bladder, 419 on gall-bladder and bile-ducts, 371 Statistics on diseases of the intestine, 381 on diseases of liver, 369 on gastric diseases, 368 on joint lesions, 480 on kidney, 397 on pancreatic disease, 380 on thigh disease, 434 on thigh tumors, 435 Status lymphaticus, 196 Steell, Graham, 234 Stenosis, 180 aortic, 220, 224, 234, 254, 263, 271 aortic, with regurgitation, 234 mitral, 116, 182, 208, 213, 220, 233. 234 of a bronchus, 309 pulmonary, 229, 270 tricuspid, 219, 233, 237, 240 Stethoscope, in heart block, 1 16 in pneumonia, 288 selection of, 139 use of, 143 Stokes-Adams syndrome, 116, 251 syndrome, coma in, 494 Stomach, bismuth X-ray examina- tion of, 366 cancer of, 368 cancer of, glands in, 31 cancer of, statistics, 368 contents, acetic acid in, 364 contents, acidity of, 364 contents, blood in, 364 contents, examination of, 363 contents, fermentation of, 369 contents, free hydrochloric acid in, tests for, 365 contents, in achylia gastrica, 369 contents, in hyperacidity, 369 contents in stasis, 363, 366, 369 contents, lactic acid in, 365 contents, mucus in, 364 contents, nitric acid in, 364 dilatation of, 369 dilated, 359 distention of, methods, 362 hyperacidity, 369 INDEX 523 Stomach, hypoacidity, 369 hypogastric bulging of, 359 inspection and palpation, 358 lavage of, 363 methods of examination, 358 normal outline of, 367 normal splash sound in, 359 position of normal, 362 secretory and motor power of. 359 tube, passing of, 360 ulcer of, statistics of, 368 use of, 352 visible peristalsis in, 369 washing of, method, 372 see also Gastric Stomatitis, breath in, 22 gangrenous, 26 herpetic, 20 Stools in gastric ulcer, 368 in jaundice, 15, 374 in pancreatic disease, 379 Strabismus, 16 in meningitis, 16 in syphilis, 16 in tumors, 16 Streptococcus infection, 27, 204, 205, 213. 237 Stridor, 258 Strongyloides intestinalis, 388 Strychnine poisoning, spasm in, 483 Subphrenic abscess, 357 Subsultus tendinum, 44 Succussion, 167 Sugar, see Glucosuria Sunstroke, 2, 493 Suppurations, chronic, anemia in, 455 of gums, 25 renal, 404 Sweating in jaundice, 15 in phthisis, 4 night and day, causes of, 4 Sydenham's chorea, 203 Syncope, 267, 274, 493 local, in Raynaud's disease, 56 Syphilis, 204, 228 breath in, 2 2 chancre of penis in, 424 (congenital), teeth in, 22 cornea in, 16 Syphilis, coryza in, 18 dactylitis in, 55 enlarged glands in, 93 eruptions on forehead in, 7 florid, 247 glands of neck in, 30 hereditary, delayed closure of fontanels in, 6 inguinal glands in, 433 jaundice in, 377 keratitis in, 16 lip chancre, 20 lip scars in, 19 loss of hair in, 7 lumbar puncture in, 489 mucous patches in, 19, 25 nose in, 18 of lung, 309 orchitis in, 425 palate in, 29 ptosis in, 16 strabismus in, 16 teeth in, 22 tongue in, 23 ulcerations of tonsils in, 27, 28 Wassermann reaction in, 461 Syphilitic aortitis, 195, 244, 247 aortitis, with aneurism, 255 heart disease, 247 liver, 373 periostitis, 439 Syringomyelia, changes of nails in, 56 claw-hand in, 51 felons in, 56 Morvan's disease in, 56 with atrophic arthritis, 472 Systole, 183 Systolic murmur, see Murmurs retraction, 223 Tabes dorsalis, ataxia in, 483 dorsaUs hypotonus in, 488 dorsaUs, knee-jerk in, 486 dorsalis, lumbar puncture in, 494 dorsalis, optic atrophy, 17 dorsaUs, paraesthesia in, 485 dorsalis, paraplegia in, 437 reaction of pupil in, 16 524 INDEX Tabes dorsalis, Romberg's sign, 484, 486 dorsalis, sexual power in, 489 dorsalis, sphincteric reflexes in, 489 dorsalis, ulcer of toe in, 444 dorsalis with atrophic arthritis, 472 Tachycardia, 273 paroxysmal, 118, 267 Tactile fremitus, 96, 242, 283, 287 fremitus, diminution of, gS fremitus, increase of, gS Tffinia nana, 381, 384, 388, 391 saginata, 381, 382, 388, 389 solium, 381, 383, 388, 390 Tallqvist's test for heemoglobin, 19, 446 Tape-worm in feces, 388 Teeth, 21 carious, 25 grinding of, 22 in congenital syphilis, 22 in cretinism, 22 in rickets, 22 order of appearance, 2 1 second, 21 Temperature, 2 in hysterical patients, 2 in osteomyelitis, acute, 427 method of taking, 2 significance of, 2 sub-normal, 3 Tenderness in general peritonitis, 356 in intestinal diseases, 356 Tenesmus in intestinal disease, 382 Tenosynovitis, 43 of Achilles tendon, 442 Tension of pulse, 103, 104 Test, Lange colloidal gold, 494 "red" (phenolsulp h o n e p h - thalein), 307 tuberculin, 24, 41, 58, 292 Wassermann, 494 Widal, 494 Testes, 425 absence of one or both, 427, 434 cancer of, 426 haematocele of, 426 Testes, sarcoma of, 426 Tetany, spasm in, 50 Thayer, W. S., 216 Thigh, 434 cancer of, metastatic, 435 diseases of, statistics on, 434 intermittent claudication of, 434 meralgia, parsesthesia of, 434 osteoma or exostosis of, 433 sarcoma of, 433 tumors of, statistics, 433 Thoma-Zeiss blood counter, 451 Thoracic aneurism, see Aneurism deformities, 65, 67-70 disease, 201 disease, methods of diagnosis in, 61-192 pain in, 158 Thorax, paralytic, 65 tender points on, 99 Thrill, gs, 254 in aneurism, 257 in aortic stenosis, 227 in cardiac neurosis, gs in mitral stenosis, 219 in patent ductus arteriosus, 272 in pulmonary stenosis, 254 presystolic, 95, 216 systolic, 210, 264, 267 Thrombosis, 219 mesenteric, 357 oedema of arm in, 40 venous, 36 with cervical rib, 35 Thrush, 27 Thyroid gland, see Glands tumor, causes of, 32 Tinnitus, 271 Toes, 443 lesions of, 444 perforating ulcer of, 444 tender, after typhoid fever, 445 Tongue, 22-24 cancer of, 23 cyanosis of, 23 geographic, 24 herpes of, 23 hypertrophy of, 24 in fever, 23 INDEX 526 Tongue, leukoplakia buccalis, 24 "simple ulcers" of, 24 syphilis of, 23, 24 tremor of, 22, 23 Tonometer, Gaertner's, 107 Tonsillitis, acute, septic, 203 follicular, 22, 27, 28, 205, 213 glands in, 30 Tonsils, 27-28 abscess of, 28 enlargement of, 28 examination of, 27 in adenoids, 28 in diphtheria,- 2 7 ' inflammation of, 27 in leukasmia or pseudo-leukaemia, 28,31 in pharyngitis, 27 in scarlet fever, 28 in streptococcus infection, 27 malignant disease of, 28 membrane on, 27 sarcoma of glands in, 3 1 swollen, 28 ulcerations of, 27, 28 yellowish- white spots on, 27 Topfer's reagent, 365 Tophi, gouty, diagnosis of , 4 1 , 42, 466, 480 Torticollis, 33, 34 congenital, 33 rheumatic, 33, 34 traumatic, 34 with spasm, 33, 34 Toxemia, cause of jaundice, 15 fever in, 2 in hepatic cirrhosis, 2 in tuberculosis, 2 in typhoid, 2 leucocytosis in, 457 lymphocytosis in, 457 shaking head in, 13 tremor of hands in, 45 Tracheal tug, in aneurism, 256, 258 Tracheitis, 277 Traube's semilunar space, 133, 324, 328, 354 Trauma, nosebleed in, 18 Traumatic neuroses, paralysis in, 348 Tremor, 483 Tremors, intention, 45 Trichiniasis, blood in, 458 oedema of lids in, 14 tenderness of leg in, 442 Trichomonas intestinalis, 388 Trichuris trichiura, 393 Tricuspid stenosis, see Stenosis regurgitation, see Regurgitation Trigeminal pulse, 252 Trophic disorders, 490 disturbances, 54 Trypanosomiasis, blood in, 463 Tuberculin, 24, 41, 58 injection, 292 Tuberculosis, 106, 275, 311 arthritis in, 469 dactylitis, 55 emaciation in, 2 epididymitic, 425 glandular, 30, 32 hilus, 301 in ankle bone, 443 incipient, 292 in nose, 19 of bladder, 422 of bone of arm, 41 of joints, 469 of knee, distinguished from sar- coma, 435 of lung, 213, 264, 277, 292-302, 316, 321, 330 of lung, acute, 291, 295, 303 of lung, acute miliary, 303 of lung, advanced, 297 of lung, cavityformation, 299, 341 of lung, cog-wheel breathing, 294 of lung, cough in, 293 of lung, examination for, 293 of lung, fever in, 291 of lung, hemorrhage in, 292 of lung, hoarseness in, 292 of lung, Litten's sign in, 293 of lung,moderately advanced, 295 of lung, percussion in, 301 of lung, rales in, 393 of lung, tuberculin in, 393 of lung with emphysema, 303 of lungs, see also Phthisis of omentum, 351, 358 526 INDEX Tuberculosis of peritoneum, 457 of sacro-iliac joint, 5 7 of spine, 58, 59, 469 of spine, lordosis in, sy of spine, paraplegia in, 437 pharyngeal, 28 renal, 406 stiff back in, 57 tongue in, 23 ulceration of tonsils in, 28 vertebral, 34 vertebral, abscess in, sg Tug, tracheal, 268 Tumor, abdominal, 352 abdominal, respiratory move ments of belly in, 348 abdominal, spine in, 59 alveolar, 25 aneurismal, 82, 267 below diaphragm, 78, 82 distinguished from enlarged spleen, 396 epigastric, 358 "epulis," 25 Huctuatioii in, 99 in appendicitis, 384 in intestinal obstruction, 385 mediastinal, 36. 82, 264 motility of, 352 of aneurism, 255 of arm, 40 of back, 59, 60 of bladder, 405 of chest, 70 of liver, 351 of spleen, 351 of thigh, 433 renal, 397, 404 Tympanites, pulmonary, 308 Typhoid fever, breath in, 22 fever, distinguished from malaria, 457_ fever, distinguished from pyo- genic infections, 457 fever, hands in, 44 fever, heart in, 269 fever, intestinal distention in, 382 fever, nosebleed in, 18 fever, pulse in, 250 fever, rose spots in, 348 Typhoid fever, splenic enlargement in, 395 fever, tender toes after, 445 fever, tongue in, 22 fever, toxaemia in, 2 fever, Widal reaction in, 460 Ulcer, duodenal, 368 gastric, 368 in tuberculous dactylitis, 55 peptic, 368, 370, 377 peptic, bismuth X-ray examina- tion in, 366 ' perforating, of- toe, 443 "simple," of tongue, 24 of tonsils, 27, 28 Uncinaria americana, 394 Utaemiai 274 aphasia in, 490 breath in, 22 distinguished from apoplexy, 492 in heart disease, 270 Urate of sodium in gouty deposits, 480 Urethra, abscess of, 428 caruncle of, 428 spasm of, 414, 421 Urine, acetone in, 409 albumin in, boiling test, 407 albumin in, Esbach's test for, 407 albumin in, significance of, 407 albumin in, tests for, 406 albumin in, nitric acid tests of, 407 albumose in, 408 alkaline, 399, 406 amount of, 402 animal parasites in, 415 blood in, 405 casts in, 411. chemical examination of, 406 diacetic acid in, 410 examination of, 401 excessive, 402 glucose, fermentation test for, 402 glucose in, 408 glucose in, Fehling's test for, 408 in acute nephritis, 416 in cystitis, 416 in jaundice, 15 INDEX 527 Urine, in kidney disease, 417 litmus test of, 406 optical properties of, 402 overconcentration of, 421 pus in, 403 scanty, 402 sediment of, 403 sediment of, crystals in, 413 sediment of, free cells in, 411 sediment of, microscopic exami- nation of, 411 sediments, significance of, 403 shreds in, 403 specific gravity, 402 spermatozoa in, 413 total solids in,. 402 turbidity of, 403 Uterus, cancer of, 429 endometritis of, 429 erosions of cervix, 428 fibro-myoma of, 429 laceration of cervix, 428 malpositions of, 428 prolapse of, 428 Uvula, 29 Valgus, 442 Valve areas, 62 Valvular heart lesions, 182, 193, 204- 246 lesions, chronic, 205 lesions, combined, 234 Varicocele, 426 Varus, 442 Vascular phenomena, 86, 490 phenomena in aortic regurgi- tation, 228 tension, 104 Vaso-motor disorders, 490 Veins, abdominal, 88, 348 cervical, 244 inspection of, 86 pulsations in, see Pulsation varicose, 439 Venous stasis, 194, 202 Ventricle, dilatation of, 200, 221 hypertrophy of, 196, 202, 213 Ventricular preponderance, 120 Vertebrae, cervical, dislocation of, , 34 Vertebrae, deviations of, 34 when palpable, 350 Vocal fremitus, 165, 261, 287, 298, 329 fremitus in pulmonary tubercu- losis, 292 fremitus, spoken, 166 Voice sounds, see Vocal fremitus Vomiting, face after, 12 in appendicitis, 385 in gastric cancer, 368 in gastric ulcer, 368 in general peritonitis, 356 in intestinal obstruction, 385 Vomitus, "coffee-ground," 368 Vulva, eczema of, 427 oedema of, 427 varicose veins, 427 Vulvo-vaginitis, 427 Warthin, 247 Wassermann reaction. 247, 461, 494 Wasting diseases, 6, 205 Weeping sinew, 43 Weight, gain in, i in infectious fevers, 2 in insomnia, 2 in malnutrition, i, 2 in myxcedema, i in old age, i in toxasmic states, i loss of, I, 292, 369, 375 physiological changes in, 2 Weil's disease, jaundice in, 375 Whooping-cough, 76 lymphocytosis in, 458 oedema of lids in, 14 Widal reaction, interpretation of, 460 reaction, technique of, 460 Winking reflex, 488 Wrist, enlargement of bones in pul- monary osteoarthropathy 42, 44, S3 -drop, in lead poisoning, 38 Wry-neck, 33 X-RAY, see Radioscopy Yellow fever with conjunctivitis, 14