ili 1111 Tral ^ --'•.'•:'' MWm hK5bw£^^> ■■■..■■■-■-•■ a- ■- §IS&R§ ■ Si§ ss&o&aag ■V: : . . .ut= I LIBRARY OF CONGRESS. Shelf ^,;4_ UNITED STATES OF AMERICA MANUAL Clinical Diagnosis Dr. OTTO SEIFERT and Dr. FRIEDRICH MULLER PRIVATDOCENT IN WURZBURG ASSISTENT DER II. MED. KLINIK IN BERLIN TRANSLATED FROM THE FIFTH GERMAN EDITION, ENLARGED AND REVISED, WITH THE PERMISSION OF THE AUTHORS, BY WILLIAM BUCKINGHAM CANFIELD, A.M., M.D. (Berlin) Fellow of the American Academy of Medicine ; Member of the Medical and Chirurgical Faculty of Maryland ; Visiting Physician to the Union Protestant Infirmary of Baltimore; Lecturer on Clinical Medicine, and Chief of Chest Clinic, University of Maryland. ?3 SECOND ENGLISH EDITION REVISED AND ENLARGED WITH FIFTY ILLUSTRATIONS AND ONE COLORED 1'LATK z c G. P. PUTNAM'S SONS NEW YORK LONDON 27 WEST TWENTY-THIRD ST. 27 KING WILLIAM ST., STRAND S^e IttHtkerbochcr. |jtt*s 1890 ^,-C/v .£**> COPYRIGHT. G. P. PUTNAM'S SONS Press of G. P. Putnam's Sons New York n TO HIS ESTEEMED FRIEND PROFESSOR PI. KNAPP THIS WORK IS DEDICATED BY THE TRANSLATOR PREFACE TO THE FIRST EDITION. The presentation of this manual to the public is due to the encouragement of our highly esteemed teacher and chef, Geheimrath Professor Gerhardt. We have endeav- ored to supply a want by giving in an epitomized form, the different methods of examination, as well as a con- venient collection of those data and figures which should always be familiar to the physician and student. These data, on account of their number and variety, cannot be remembered with the necessary exactness, and, on the other hand, are so scattered throughout numberless text- books and monographs, that it would be troublesome and time-wasting to search for them. In selecting and ar- ranging this material, we have been led by the experience gained in holding courses, and we have also endeavored to consider the practical needs of the student and physi- cian by noting only what is reliable, and omitting every thing self-evident and of secondary importance. THE AUTHORS. Wurzburg and Berlin, April, 1886. PREFACE TO THE THIRD EDITION. In preparing the third edition of this manual, I have endeavored to do justice to all the wishes expressed by the different critics, as well as to consider any wants which have become apparent since the last edition. Conse- quently, a number of improvements and additions have been made, and among them it seemed necessary to add some new illustrations, especially to the chapters on blood and urine. The illustrations of the leucocytes are from preparations of Professor Ehrlich, and those of the urinary sediment are, in part, taken from the physico- chemical atlas of Funke. The tables in the last chapter are intended to make the questions of diet and assimila- tion of practical use in the sick-room. In conclusion, I should like to thank all those gentlemen who have so kindly assisted us by their suggestions. Berlin, October, 1886. TRANSLATOR'S PREFACE. The favor with which this book has been received in Germany, and its eminently practical and concise man- ner of dealing with the different important points in diag- nosis, seem to justify its translation into English. It has been brought down to the latest acquisitions of science, thus representing the most advanced views. For the sake of clearness, the figures relating to weight, measure, length, etc., as well as the dose table at the end of the book, have been modified to conform to the system used in America and England. Translations from the original into French and Russian are now in press. The translator takes great pleasure in thanking in this place his friend Dr. Robert T, Wilson, for kind services and valuable suggestions rendered in the proof-reading and correction. W. B. C. ioio North Charles St., Baltimore,- September, 1887. TRANSLATOR'S PREFACE TO THE SECOND ENGLISH EDITION. The exhaustion of the first edition and the changes in the original call for a revision of this translation. The principal changes are certain additions in diseases of the heart and lungs, an entire revision of the ever- changing section on bacteriology, the correction of certain errors kindly pointed out by critics, and the addition of a handsomely executed chromo-lithograph of the micro-organisms. W. B. C. ioio North Charles St., Baltimore. November, 1890. CONTENTS. PAGE Preface to First Edition v Preface to Third Edition vi Translator's Preface vii Chap. I. — The Blood i Chap. II. — The Temperature S Measles 10 Scarlet-Fever ......... io Small-Pox ii Varioloid . . . . . . . . .11 Chicken-Pox ......... 12 Typhoid Fever ........ 12 Typhus Fever 13 Relapsing Fever ........ 13 Malaria .......... 14 Erysipelas . ........ 15 Pneumonia Crouposa . . . . . . .15 Chap. III. — Organs of Respiration 16 Topography of the Chest . . . . . . .16 Spirometry ......... 20 Percussion of the Thorax . . . . . . .21 The Normal Boundaries of the Lung . . . .21 Topography of the Different Lobes of the Lung . . 22 Auscultation ......... 27 The Breathing Sound ....... 27 Rales .28 Auscultation of the Voice . . ... 29 Chap. IV. — The Sputum 32 Morphological Constituents ...... 34 •Chap. V. — -Laryngoscopy and Rhinoscopy .. . - 37 Voice .......... 37 The Muscles of the Larynx ...... 38 ix CONTENTS. Nerves of the Larynx . Paralysis of the Vocal Cords Chap. VI. — Circulatory System Inspection and Palpation Percussion of the Heart . Auscultation of the Heart The Heart Murmurs Auscultation of the Blood-Vessels Chap. VII.— The Pulse Chap. VIII. — Digestive and Abdominal Organ The Teeth ..... The Saliva . (Esophagus ..... Stomach ...... Examination of the Stomach's Contents Liver ...... The Spleen . . Abdomen ..... The Faeces Chap. IX. — The Urine-Producing System The Genito-Urinary Organs The Urine ..... Normal Constituents of the Urine Inorganic Constituents of the Urine Pathological Constituents of the Urine Organic Sediments Chap. X. — Transudations and Exudations Chap. XL — Parasites .... i. animal parasites : Cestodes — Tape-Worms Nematodes — Round-Worms Trematodes — Flat-Worms Arthropodes .... Protozoa ..... ii. vegetable parasites : Hyphomycetes .... Yeast Fungi .... Schizomycetes or Bacteria PAGE 38 39 41 41 43 45 46 48 50 55 55 56 56 57 58 60 6 1 62 63 67 67 67 70 74 77 89 91 96 96 98 100 100 101 101 102 102 CONTENTS. XI Chap. XI. — The Nervous System Testing the Sensibility Testing the Motility Motor Symptoms of Irritation Diagnosis by Means of Electricity Reflexes ...... The Most Important Clinical Points the Nervous System . Brain and Spinal Cord . Cranial Nerves .... Spinal Nerves . Chap. XIII. — Analysis of the Pathologicai ments Urinary Concrements .... Concrements of the Intestine . Salivary Calculi Gall Stones Chap. XIV. — Metabolism and Nutrition Table of the Weights of the Human Body Dose Table ....... Appendix ....... Index ........ the Anatomy Concre PAGE 10S 1 08 in 112 113 121 124 124 127 129 132 132 134 134 134 136 143 144 163 175 Fie. 1 Fig. 2 -> ^ J *t l v w *~ J v. r , Pneumonococcus Bacillus Cholera Fig. 3 Fig.* V X 7/ ^ \ BacStus Anthracis <\r*J SpirHhurv Obermeiri Fig. 5 • ••• .f ' • :*•*• .• : " % •* . * Fig. 6 -.■ . StapTiflo coccus pyogenes aureus Streptococcus Brysipelatos Prmted TnrJF.Ba'(/marm. .Wiesbaden . Pig. 7 ** if PflTi"^ * >» ^ Bacillus Tuberculosis Fig. Fig. 9 Bacillus Leprae Bacillus Eqvimae Fig. 10 % ***** Fig. 11 Bacillus Typhosus LiLh . CJSrst Leipzig. CLINICAL DIAGNOSIS. CHAPTER I. THE BLOOD. The whole quantity of blood in the body of an adult is equal to about -^ of the weight of the body — that is, on an average, 5 kilograms [10 lbs.]. 1 The specific gravity varies in health between 1045 and i°75- The reaction of the blood is alkaline. The amount of hcemoglobin' 1 in the blood is about 14.57 grams [4 drachms] in men, and 13.27 grams [31 drachms] in women, in 100 ccm. [3 ounces] of blood. On heating, the haemoglobin is resolved into brown haematin and albumen. If some blood {e. g., that obtained from a blood stain on wood or linen), be heated to the boiling point with glacial acetic acid and a trace of common salt, and then slowly evaporated, there are formed brownish-yellow rhombic crystals of the muriate of hcematin, which is the same thing as hcemin or Teichmann's crystals. The prepara- tion should then be moistened with a little glycerine, and examined with a high power under the microscope. The red blood corpuscles measure in healthy individuals 1 That part enclosed in [ ] is by the translator. a The amount of haemoglobin is determined by the quantitative spectral analysis or by means of a hsemochromometer. 2 CLINICAL DIAGNOSIS. from 6.7 j.i to 9.3 /O The average size is 7.8 jn (Gram). Giant blood corpuscles (measuring from 10 to 15 yu) are found principally in the blood of the anaemic, and especially in those suffering from progressive pernicious anaemia. The dwarf Mood corpuscles measure from 2.2 to 6 //, and are like the normal ones, only slightly more bi- concave. These are also found frequently in anaemia. By Poikilocytes are meant those red corpuscles of irregular form (pear-, club-, or biscuit-shaped) which are seen in all anaemic conditions. Microcytes are small spherical bodies, generally very rich in haemoglobin, and Fig. 1. Nucleated red blood corpuscles. Poikilocytes. Dwarf (W) Mood corpuscles. >-—«______ c A normal red blood corpuscle* <-> r^n J y^) ^ Giant f^ ^7 M"~^-^ - blood corpuscles. Microcytes. are found in many cases of burning and poisoning. Still we must very often consider them as artificial products. It is uncertain whether red corpuscles with crenated edges (thorn-apple-shaped corpuscles) appear in normal blood or not. When seen, they are generally considered artificial products caused by evaporation. Notwith- standing this, they are observed to form more quickly and abundantly in many cachectic conditions than in normal blood. 1 /Li = the one-thousandth part of a millimetre, and is known as a THE BLOOD. 3 Nucleated red blood corpuscles are seen in all severe cases of anaemia but they can only be recognized in stained preparations. 1 Very large nucleated blood corpuscles (megalocytes) are seen in progressive per- nicious anaemia. Blood-plaques (Bizzozero 2 ) = Hcematoblasts (Hayern 3 ) are colorless flat round discs about one half the diameter of a red blood corpuscle. They change their shapes very quickly when outside of the blood-vessel. The elementary granular masses are small, often angular, colorless granules with a diameter of 1-2/i. They consist in part of fat, and are probably for the most part disin- tegrated products of the blood-plaques. Fig. 2. Fig. 3. Fig. 4. Fig. 5. V Lymphocytes. Large mononuclear Polynuclear Small size. Large size. cell. cell. The white blood corpuscles (Leucocytes) are divided according to Ehrlich into : (i) Lymphocytes, which are about the size of a red blood corpuscle or somewhat larger, with a large round nucleus, and a very small, often scarcely visible, protoplasm. We distinguish two forms, a smaller and a larger, which latter is only the former in a more progressive stage of development. The lymphocytes have their origin in the lymphatic glands. (2) Large mononuclear forms, with large round or oval nucleus and broad protoplasmic body. These are the earlier stages of development of the third. (3) The large polynuclear form, containing a nucleus very much divided and lobulated, and which may be deeply stained 1 Fortschritte der Medicin, 1884. 3 Bizzozero : Vi re how's Archiv., Bd. xc. 3 Hayem : Archive de Physiologie, iS 78-79. 4 CLINICAL DIAGNOSIS. with aniline colors. They form by far the greatest number of the leucocytes, and are found almost exclu- sively in pus. Ehrlich designates as eosinophile cells those leucocytes in whose protoplasm a quantity of coarse, fatty, shining granules are seen, which are colored an intense red on staining a preparation of dried blood with a one-per-cent. watery solution of eosin. These cells have their origin in the marrow of bones, and are present in normal blood in small quantities only. In myeloge- netic leucaemia they are seen in large numbers. In lymphatic leucaemia it is principally the small lympho- cytes which are increased in number In order to examine the blood, it is generally sufficient to cleanse and dry the finger, and, with a needle or lancet, to make a quick and deep puncture in the tip. The drop of blood should then escape without squeezing the finger, and be dropped on a clean cover-glass, which is, in turn, dropped on the slide in such a way that the blood is spread out in a thin film. In order to see the blood-plaques, a drop of a one-per-cent. osmic-acid solution is applied to the finger, and the puncture is made through this drop. Instead of the osmic acid, which is simply a conservative fluid, a thin watery solution of methyl violet with 0.6 % of common salt may be used, which colors the blood-plaques and the nuclei of the nucleated red blood- corpuscles. In finer examinations of the blood, it is better to color a dried preparation {vid. Chap. xi. for preparation) with the follow- ing solution : IJ Hematoxylin, 2 grams [30 grains]. Alcohol, Glycerine, Distilled water, aa 100 grams [3 ounces]. Glacial acetic acid, 10 grams \2.\ drachms]. Alum in excess. This mixture should stand 3 weeks in the light, and a few granules of eosin should be added to it. The dry preparations remain from 6-12 hours in the staining fluid, and then are to be washed off with water and examined. The nuclei of the nucleated red blood- corpuscles will be found to be stained intensely black. (Ehrlich.) THE BLOOD. 5 The number of red blood corpuscles is, on an average, in men, in the normal condition, 5 million ; in women, 4j- million, to a cubic millimetre [a millimetre equals ^ of an inch]. The number of white blood corpuscles varies between 5,000-10,000, and is temporarily increased after a hearty meal. The number of blood-plaques is about 200,000 to the cubic millimetre. The proportion between white and red blood corpuscles is, in healthy individuals, 1-500 to 1-1,000. A proportion which is more than 1 to 400 must be considered as a pathological increase in the number of white corpuscles. Welker and Moleschott considered the proportion of white to red corpuscles to be 1:330 and 1.357. Dupe'rie found 5.500,000, red to 5,000 white, or 1:1100 ; Malassez, 1:1200 ; Hayem, Bouchut, Du- brisay found, on an average, 1:500—1,000 ; Halla, 1:422-811. Laache and Otto found, on an average, for men 4.97 and 4.99 million, and for women 4.43 and 4.58 million red blood corpuscles. In order to count the corpuscles, a deep puncture is made into the finger-tip, and the escaping drop is sucked up into the me'langeur until it reaches the mark 1. The point of the instrument is then wiped off, and the diluting fluid 'is sucked up to the mark 101. This mixture of blood and diluting fluid 1 is well shaken and introduced into the counting chamber, and covered by the cover-glass, which should be lightly pressed on, and then the corpuscles are counted in each square, which is etched on the cover-glass. If a thousand cor- puscles have been counted in one square, the amount of corpuscles in a cubic millimetre can be calculated, since the dilution of the blood (1:100) and the depth of the chamber are known. By using the chamber of Thoma-Zeiss (depth ^ mm., 1 square = ^-J-^ cubic millimetre), the average number of corpuscles in a small square 1 This fluid may be either a 3 % solution of common salt, or a 5 % solution of Glauber's salt, or Hayem's solution, which is corrosive sublimate, 0.5 grams [7 grains], Glauber's salt, 5.0 [1^ drachms], common salt, 2.0 [4 drachm], distilled water 200.0 grams [6 ounces]. 6 CLINICAL DIAGNOSIS. is multiplied by 400,000 — that is, the whole number of corpuscles is to be divided by the number of squares which have been counted. It is more convenient to count the four small squares in one col- umn and calculate the average result of a large number of counts. This number, which is the number of blood corpuscles in any four squares, is then multiplied by 100,000. In using the chamber of Malassez or Hayem, which has a depth of \ mm., the average num- ber which is in a large rectangle (=20 small squares) is to be multi- plied by 10,000. If the blood dilution is 1:200 instead of 1:100, i. e. (up to mark 0.5 of the melangeur), the result should be multiplied by 2. Leucocytosis, that is, an increase of the leucocytes in proportion to the red corpuscle, is observed in numerous acute diseases (typhus abdominalis, erysipelas, etc.), also in cachectic conditions (cancer). This increase of leucocytes is often very great, and may even reach as high as 1 to 60 red corpuscles. In Leuccemia, the amount of red corpuscles as well as of haemoglobin is generally considerably decreased, so that the number of leucocytes is very considerably increased, and almost equals that of the red corpuscles ; indeed it may equal or exceed it. In the first stages of the disease, when the increase of the white corpuscles is often less than in severe leucocytosis, the diagnosis of leucaemia can be certain only when, in its further course, a rapid increase of leucocytes makes it very evident ; or when the proportion of white to red exceeds 1:50. In myelogenetic leucaemia, there are numerous eosinophile leucocytes, and also nucleated red blood corpuscles to be seen. Ly?nphatic leucaemia is characterized by an increase of lymphocytes. In pseudoleuc&mia there is a slight decrease in the number of red corpuscles, and in the amount of haemoglobin, and no increase of the leucocytes. In the first few days after heavy loss of blood, the amount of red corpuscles as well as of the haemoglobin sinks markedly to over 50 % of the normal, whereas the number of leucocytes increases. In the period of convalescence, the amount of red corpuscles increases more quickly than that of the haemoglobin. In the secondary ancsmice, after typhus abdominalis, tuberculosis, malaria, lead poisoning, ankylostomiasis, nephritis, cancer, etc., the number of red cor- puscles as well as the amount of haemoglobin is diminished, and the amount of white blood corpuscles increased (leucocytosis). THE BLOOD. 7 In chlorosis the amount of haemoglobin is very greatly decreased, whereas the number of red corpuscles is often very little or not at all increased. These are therefore very pale. The amount of white corpuscles is normal. In progressive pernicious anamia, the number of red corpuscles is enormously reduced, often to T V of the normal, whereas their size, and above all things, the amount of haemoglobin is increased. An increase in the number of red corpuscles is observed in thicken- ing of the blood in cholera, as well as in many heart affections. After long-existing malaria, pigment-containing leucocytes are at times seen in the blood. Micro-organisms are also observed in the blood— e. g., tubercle bacilli in miliary tuberculosis, bacilli lepra, bacilli anthracis, and the spirilla of relapsing fever. The latter can be seen with medium power, and are best recognized from the fact that when they come in contact with the red blood corpuscles, they impart to them a jerking motion ; or they can be recognized by coloring them as a dried prep- aration,' with a watery solution of gentian violet, as in the case of the bacilli anthracis. 1 1 v. Appendix. CHAPTER II. TEMPERATURE. The temperature of the body is generally taken either in the axillary space or in the rectum [and under the tongue]. In the rectum it is about 0.5 — 1° higher than in the axilla. The temperature of the healthy individual measures 1 in the axilla between 3 6.2 C.[97.i°F.] and 37. 5 C.[99.5°F.]. The highest temperature is late in the afternoon, and the lowest, very early in the morning. An elevation of tem- perature can temporarily occur in consequence of bodily exertion, taking food, hot-baths, etc. A continuous ele- vation of temperature occurs in fever. According to Wunderlich we have : The temperature of collapse, 36 C. [96. 8° F.]. Sub-febrile temperature 37.5°-38° C. [99. 5 F.-100.4 F.]. Slight fever 38°- 3 8.5° C. [ioo. 4 °-ioi.3° F.]. Moderate fever 39 C. [102.2 F.] morning ; 39. 5 [103. i° F.] evening. Considerable fever 39.5 C. [103. i° F.] morning ; 40.5 C. [io4.9°F.] evening. High fever over 39-5°C. [103. i° F.] morning; over 40. 5 C. [104.9 F.] evening. 1 In order to convert from one scale to the other, the following formula may be used : N° C = I n° R = f n° + 32 F. TEMPERA TURE. 9 Hyperpyrexia, or fever over 41. 5 C. [106. 7 ]. Also in fever there is usually a morning remission and an evening exacerbation. Exceptionally, especially in phthisis, we have the reverse — typus inversus. The difference between the highest and lowest tempera- ture decides its type of the fever, thus : Febris continua = a daily difference of not more than i° C. [i.8° F.]. Febris remittals = a daily difference of not more than 1.5° C. [2.7° F.]. Febris intermittens = in the course of the day the high temperature is varied by a period of no fever. In the course of a fever we distinguish : I. Stadium incrementi = a quick rise of temperature, generally accompanied by a chill or a slowly rising temperature. II. Fastigium = ora stage of highest temperature. Its transition to the next stage is known as the amphibolic stage. III. Stadium decrementi. The fever fall can follow either slowly, in course of several days, in which case we have lysis ; or quickly, the crisis. At the actual crisis the temperature falls rapidly (in one day) until it goes below normal. This fall is generally accompanied by a profuse perspiration. A high rise of temperature often precedes the crisis, which is called perturbatio critica. In acute infectious diseases we distinguish the stage of incubation — that is, the time between the moment of con- tagion and the outbreak of the disease. Also in acute exanthematous diseases there is the prodromal stage, or stage of the first morbid appearances, /. e., before the outbreak of the eruption. IO CLINICAL DIAGNOSIS. Morbilli— Measles. Incubation, ten days. Prodromal stage, three days, characterized by affections of the mucous membranes. Fig. 8. Temperature chart in Morbilli, It begins with chill and high fever ; and on the second or third day there is a slight fall of temperature. At the appearance of the eruption (on the face) the temperature rises again, and reaches its highest point when the erup- .6 tion is most widely dissemi- 9 <5_ 8 nated. This is the stadium Prodromes. Eruption. Defervescence. floHtionis, and lasts three tO four days. The critical fall of temperature occurs on the sixth or seventh day of the disease, after which des- quamation begins. Scarlatina — Scarlet-Fever. Incubation, four to seven days. Prodromal stage, one to two days. It is characterized by angina. It begins with a chill and quick rise of temperature. At the end of the first or second day there is an outbreak of the c ° eruption (on the breast), and 41,* as it spreads the tempera- 40 ture rises. Defervescence begins on fourth to seventh day of the disease, and comes 3 ' to an end slowly, with the 37 paling of the eruption in 3 6, three to six days later. Desquamation then follows. Fig. 9. Temperature chart in Scarlatina. 39 TEMPERA TURE. II Variola— Small-pox. Incubation, nine days (nine to sixteen days), at the end of which time there is general disturbance of func- tions. The prodromal stage (two to five days) begins with a chill, with sudden rise of tern- c perature, and 41 often on the 4<3 second or 39 third day the . 38 first signs of the eruption 37 are observed. 3 6 With the be- ginning of the pustulation there is a quick fall of tem- perature. Then comes a second and in the beginning a slight febrile movement, which reaches its climax on about the ninth day (fever of suppuration), preserves a remittent type for some time, and after a varying length ends in lysis (period of desquamation). About the six- teenth day the stadium decrustationis begins. Variolois — Varioloid. Fig:, to. Temperature chart in Variola. lllllllplllllll iiiiiiiiiiitll! I mmmmmmm Iliigglilliigl F° 105.8 104. 102.2 100.4 98.6 96.8 Prodromes. Eruption. Fever of suppuration. Desquamation. Fig. tt. Temperature chart in Variolois. iiDHIIil HHHiiHH iiUmiHIIilllin JSMyiiHHiiliH The incubation et° and prodromal stag- 8 es are the same as in variola vera, only much lighter. The second period of [ °°' 4 fever (fever of sup- 98.6 puration) is want- 968 ing. The period of 12 CLINICAL DIAGNOSIS. desquamation often begins as early as the ninth or tenth day, and is generally accompanied by slight rise of temperature. Varicella— Chicken-pox. The prodromes ase generally wanting. The eruption " j. S ? 5 " of the vesicles begins with slight fever. The vesicles dry up after three or four days. Typhus Abdominalis— Typhoid Fever. Incubation, seven to twenty- one days. The prodromal stage lasts several days to a week, and is accompanied by general disturbances. In the first week of the disease the temperature rises by degrees, accompanied by slight chills, and reaches, on the fourth or seventh day, its highest point. This continues as a febris con- tinua until the third week in the milder forms, and until the fifth week in the more severe forms. Then the morn- ing temperature begins gradu- ally to fall, while the evening temperature still remains high, until gradually lysis results, which in mild cases is in the fourth week. There is also TEMPERA TURE. 13 tumefaction of the spleen in the second half of the first week of the disease. Roseola occurs on the sixth to ninth day of the disease. Typhus Exanthematicus — Typhus Fever. Incubation varies from a few days to three weeks. The prodromal stage is not marked. The disease begins with a chill and rapid rise of temperature, and then it remains febris continua until the thirteenth to the seven- Fig. 13. Temperature chart in Typhus exanthematicus. j ^j^ ^i|r||M5 KinlJa &^fc^ 41.0 40.0 39-° 38.0 37-o 36.0 jmmmmmmmmk ■HBBBH iSilQHilliMiiesiii iiigiiiiliiliHiiiii Illll UJl J I fl F° 105.8 104. 102.2 100.4 98.6 96.8 Eruption. teenth day. There are often remissions at the end of the first week. There is then a critical fall of tempera- ture, at times with transitory perturbatio critica. The eruption appears on the third to the sixth day after an inflammation of the mucous tracts. Febris Recurrens— Relapsing- Fever. Incubation five to seven days. The prodromal stage is not clearly marked. The fever begins with violent chill and a (high) sudden rise of temperature, which con- tinues as in febris continua until the fifth or seventh day, and then critically falls. After a period of apyrexia, last- ing about a week, there is again an attack of fever as at 14 CLINIC A L DIA GNO SIS. first, but not lasting so long. Often, after a period of seven days, there is a third attack, lasting one to two days. Fig. 14. Temperature chart in Febris recurrens. Malaria — Febris Intermittens. Incubation seven to twenty-one days. Prodromal stage is not marked. There is a chill, and the tempera- ture rises to very great height, and then sinks after a few hours to or below the normal. There is also strong per- Fig. 15- Temperature chart in Febris intermittens LIS According occurs every lllblllili "lUUHIIINHIJ fl&E&sasisBSSssas:: S!!SS!i3!5iiS5S5S:!SiiSg5£3S;3f HIIHIBIHr' spiration. the fever day, or every second and third day, it is called quo- tidian, tertian, and quar- tan intermittent fever. Febris intermittens dupli- cata is that type in which two attacks occur in quick succession in the course of the same day. Febris inter- mittens anteponens and post-ponens is that type in which the new attack of fever does not generally occur at the same hour of the day as the preceding attack, but sooner or later 11IB1IHI11 36 Febris quotid ; tertiana ; quartana. 100.4 98.6 96.8 TEMPERA TURE, 15 Fig. 16. Temperature chart in Erysipelas. Erysipelas. Incubation one to eight days. It generally begins with a chill and high temper- ature. On the first or second day an inflammation of the c skin is observed. The tern- perature continues high as ilssani^BwiRsi long as the morbid process 4 °'° fillip j iliilfs!! spreads, and quickly falls as 39 '° |ig|[ isfill soon as the erysipelas ceases 38, ° f|g| 11110111 spreading. With the spas- 37.0 §§§||||§|§ f||| modic spread of the erup- 36o 11511111 105.8 104. 102.2 100.4 98.6 96.8 tion there is often found a remittent or intermittent fever. Pneumonia Crouposa. It begins with a chill and sudden rise of temperature. There is a continued fever during the spread of the peneumonic infiltration. On the fifth to the seventh day, and at times later, the crisis occurs, generally very Fig. 17. Fig. i3. Temperature charts in Pneumonia crouposa. suddenly, with strong perspiration, and, at the same time, a decrease in the frequency of the pulse and respiration. There is often a pseudo-crisis (v. Fig. 18) one or two days before the real crisis, but here the pulse and respira- tion remain high. CHAPTER III. ORGANS OF RESPIRATION. Topography of the Chest. The vertebral column has a normal curvature at the cervical, dorsal, lumbar, and sacral regions. A patho- logical curvature of the vertebral column convexly back- ward is called cyphosis. The same deformity, not curved but angular in character, is called gibbus. A curvature forward is called lordosis, and a lateral curvature scoliosis. A deforming curvature both laterally and backward is called cypho-scoliosis. The sternum in the adult is about 16-20 cm. [6-S inches] long. The angular prominence between the manubrium and body is called the angulus Ludovici. A bending inward of the xiphoid process, and of the lower part of the body, is called funnel breast. This latter shape of the thorax is acquired, and is seen in some occupations, e. g., in cobblers who press their instru- ments against the breast (cobbler's breast). When the costal cartilages in rachitis are pressed in by lateral com- pression, and the sternum has a keel shape, it is called pectus carinatum or chicken breast. The clavicle has a supra- and infra-clavicular groove in it. The external part of the latter is called Mohren- heim's groove. The scapula covers the second to seventh or third to eighth rib, and is provided with a fossa supraspinata and t5 ORGANS OF RESPIRATION. 1 7 a fossa infraspinata. Between the inner border of each scapula is the inter-scapular space. In order to determine the height of the thorax in front, we must follow the ribs by beginning to count at the second ; and behind the landmarks are the spinous pro- cesses, beginning with the seventh cervical, the vertebra prom in ens. The Harrison furrow has a horizontal direction at the level of the xiphoid process, and corresponding to the •normal attachment of the diaphragm. The region be- low this furrow to the angle of the ribs is called the hypochondrium. In order to determine the breadth of the thorax, we make use of the following perpendicular lines : (i) The median line. (2) The parasternal line, drawn half-way between the border of the sternum and the nipple. (3) The mammary line, drawn through the nipple, which, in healthy adults, lies between the fourth and fifth ribs, 10 cm [4 inches] distant from the border of the sternum. (4) The anterior, middle, and posterior axillary line ; the former drawn through the anterior, the latter through the posterior, boundary of the axilla. (5) The scapular line, drawn through the lower border of the scapula. The costo-articular line is a line drawn from the sterno- costal articulation to the tip of the eleventh rib. Size of the Thorax. The sterno-vertebral diameter of the thorax measures, in healthy men, 16.5 cm. [6J inches] above, and 19.2 cm. [7J inches] below, and in women it is somewhat smaller. The broad diameter of the chest is, in men, at the height of the nipple, 26 cm. [10 inches]. 1 8 CLINICAL DIAGNOSLS. The circumference of the chest at the height of the nipple measures, in healthy men, 82.0 cm. [32J inches], after deep expiration, and 90 cm. [36 inches] after deep inspiration — that is to say, the maximum excursion of the thorax in respiration is 8.0 cm [3 inches]. In those who are right-handed, the circumference of the right half of the chest is 0.5 to 2.0 cm [J- to 1 inch] larger than the left. In left-handed persons the left side is slightly larger. Enlargement of one side of the chest is observed in pneumothorax, in effusions into the pleural sac (occasionally in pneumonia), often in mediastinal tumors, and in emphysema. In the latter disease there is, in severe cases, a barrel-shaped chest, while all the diameters, but especially the sterno-vertebral diameter, are enlarged, so that there results a permanent position of inspiration. Enlargements, especially of the lower opening of the thorax, occur with tumors and effusions in the peritoneal cavity. A narrow thorax may be congenital or acquired. A congenital narrowing of the thorax, in which it is long, small, shallow, while the intercostal spaces are broad and the sterno-vertebral diameter is especially smaller, is called a paralytic shape of the thorax, and is most frequent in phthisis pulmonum. An acquired narrowing of the thorax may be caused by an ab- sorption of a pleuritic exudation and shrinkage of the lungs, as in phthisis and cirrhosis pulmonum. The number of respirations in the healthy adult is from 16 to 20, and in new-born children 44, a minute. The normal relation between the frequency of respiration and pulse is as 1:3 J to 4. The inspiratory enlargement of the thorax takes place in the male, principally by a deep descent of the abdo- men, and partly by the raising of the ribs by the scaleni and intercostal muscles — typus costo-abdominalis. In women, the inspiration is carried on more by raising the ribs — typus costalis. ORGANS OF RESPIRATION. 1 9 The expiratory narrowing of the thorax is, under nor- mal conditions, caused only by the elasticity of the chest, without muscular assistance. Inspiration and expiration are generally of the same duration, and follow each other without the intervention of a pause. The lungs perform no active movement during respira- tion, but passively follow the movements of the chest wall and the diaphragm. In healthy individuals at rest, infre- quent and superficial respirations are sufficient to change the air in the lungs, but as soon as the amount of carbon- ic acid gas becomes too great in the lungs, the respira- tion becomes more frequent and deeper. This is seen in bodily exertion and fever, and also in disturbances of the circulation in consequence of heart troubles, and in all diseased conditions of the respiratory tract itself. If the blood is overloaded with carbonic acid gas to too great an extent, difficulty of breathing, i. e., dyspnoea, sets in. In inspiratory dyspncea, in which long-drawn inspirations are car- ried out with great muscular exertion, while the expirations follow more easily, the accessory muscles come into play. The sterno- mostoidei, scaleni, levatores costarum, serratus posticus superior, ser- ratus anticus major, pectoralis major and minor, levator scapulae, trapezius, rhomboidei major and minor, the extensors of the vertebral columns, the dilators of the nasal and oral cavities as well as of the larynx. This kind of dyspncea is observed in narrowing of the air passages — e. g., of the larynx, the trachea, and the bronchi, as well as in many diseased conditions of the lungs where there is a decrease of the respiratory surface. In severe inspiratory dyspncea, there is an inspiratory drawing in in the region of the xiphoid process and the lower border of the ribs. In expiratory dyspnoea, in which the narrowing of the chest is ren- dered difficult, and the length of the expiration is increased in pro- portion to that of the inspiration, the abdominal muscles and the 20 CLINICAL DIAGNOSIS. serratus posticus inferior and the quadratus lumborum come into play as the accessory muscles of respiration. Expiratory dyspnoea is ob- served in cases of laryngeal polypus, more especially in emphysema and bronchial asthma. The mixed form of dyspnoea is made up of the inspiratory and expiratory dyspnoea. Changes in the Frequency of Breathing. Increase in respiratory frequency takes place : 1. From nervous causes, in all affections of the mind, and in hysteria. 2. From accumulation of carbonic acid gas in the blood, from bodily exertion, in fever, and in many forms of heart disease. 3. In most diseases of the respiratory tract, such as pneumonia, phthisis, pleurisy, emphysema, accumulation of fluid and liquid in the pleural cavity, and finally, in all diseases of the abdomen — e. g., in peritonitis, tumors, ascites, which hinder the movements of the diaphragm. The relation between the frequency of the pulse and respiration may thus be changed from 1:4 to 1:1. Retarding of the respiration is observed in stenosis of the upper air- passages, and in cerebral diseases (as in hemorrhages, tumors, etc.). The Cheyne- Stokes respiration is a kind of breathing in which periods of complete cessation from breathing (apncea) are varied with periods of slowly rising respiratory movements, which become gradually deeper, and then, in turn, fall. This phenomenon is observed in many severe cerebral diseases, in heart disease, and uraemia. Spirometry. The total capacity of the lungs, i. . Chapter XL). For the analysis of the urinary concrements see Chapter XIII. CHAPTER X. TRANSUDATIONS AND EXUDATIONS. The different serous transudations have a very different specific gravity according to their origin. They are in the order of their specific gravity ; hydrocele, hydro- thorax, ascites, anasarca, and hydrocephalus. The serous (inflammatory) exudations have a greater specific gravity than the simple transudations of conges- tion, and indeed it may generally be taken for granted that a fluid, be its origin what it may, is the product of an inflammation when its specific gravity exceeds 1018 (pleurisy, peritonitis), and that it is simply a transudation due to congestion when its specific gravity in hydrothorax is less than 1015, " ascites " " " 1012, " anasarca " " " 1010, " hydrocephalus" " " 1008.5. Now since the amount of ash, extractive matter, etc., contained in exudations and transudations varies very slightly and the amount of albumen varies very greatly, we conclude that the specific gravity is principally de- pendent upon the amount of albumen contained in these fluids. Therefore from the specific gravity the amount of albumen may be approximately determined according to the formula of Reuss, E = | (S- 1000) -2.8, 92 TRANSUDATIONS AND EXUDATIONS. 93 in which E denotes the amount per cent, of albumen sought and S the specific gravity. Accordingly in a spe- cific gravity of 1018, 3.95 almond-shaped with ciliated ex- tremities. Balantidium or Paramceciiim coli, pear-shaped, 70-100 ju [|— |- inch] long, ciliated, with an inverted mouth. Besides these protozoa, there are found in the vaginal secretion, trichomonas vagi- nalis, and in other secretions other protozoa. Vegetable Parasites. Hyphomycetes or Moulds. Achorion Schoenleinii, ox f amis fungus, is in the shape of worm-like filaments, which are provided with septa and lateral elevations, and in their ends are round or oval, brightly shining spores (conidia). The Tryclwphyton tonsurans is the fungus of herpes tonsurans and circinatus, as well as of acne mentagra (sycosis parasitaria). The mycelium consists of curved and branching filaments provided with septa. The fila- ments have partly at their ends shining spores (conidia) with double contour. In the epidermis the fungus fila- ments are found, while in the hair and hair-sheath the spores (conidia) are found. The Microsporon furfur, or fungus of pityriasis ver- 102 CLINICAL DIAGNOSIS. sicolor, is found in the yellowish epidermis scales in large numbers as a dense network of curved, more or less branched filaments, with heaps of shining spores (conidia) within. The Microsporon minutissimum is a very fine non- branching filamentous fungus without the formation of spores, and is found in erythrasma, but whether in causal relation or not is doubtful. The oidium albicans, or thrush fungus, is found in the mouth cavity as well as in the oesophagus and the stomach. It consists of branching filaments, with shining, round or oval spores (conidia) at the points of bifurcation. The Aspergillus glaucus and niger are often found in the sputum of consumptives or imbeciles, and may cause a peculiar kind of pneumonia called pneumonomycosis as- pergillina. They are filaments more or less branched, with double contour and with many brown pigmented spores. In order to make the filamentous fungus visible, the preparation (from a scraped tongue, epidermis scales, hair, etc.) is allowed to stand for a few minutes in a 10 % caustic potash solution, which makes the albuminous substances and epidermis more translucent, and the fungus thereby all the more distinct. Yeast fungi are frequently found in fermenting condi- tions of the stomach. Schizomycetes or Bacteria. ' Morphologically we distingnish (a) The Coccus (spherical or oval), and according as the cocci are single, in twos, in chains, or in a racemose conglomeration, they are called monococcus, diplococcus, streptococcus, and staphylococcus. (b) Bacillus or rod. (c) Vibrio, or curved rod, fragments and developing form of spirilla as comma bacilli. 1 v. Appendix. PARASITES. I03 (d) Leptothrix forms. Filiform. (e) Spirillum. Spiral form. To the Cocci belong also the micro-organisms of erysipelas (round streptococci) and of puerperal fever, of gonorrhoea (bean-shaped dip- lococci which are found in clumps, partly in the leucocytes of the gonorrhceal pus), of croupous pneumonia and the pus-producing cocci, staphylococcus pyogenes aureus, the coccus of acute osteo- myelitis, and staphylococcus pyogenes albus, etc. To the Bacilli belong the micro-organisms of tuberculosis, of lepra (syphilis), of anthrax, malleus (glanders), typhoid fever, diphtheria, malignant oedema. As comma bacilli, are to be mentioned the cholera bacillus and the bacillus of Finkler-Prior. To the Spirilla belong the Spirochseta Obermeieri, in recurrent fever, and the Spirochseta buccalis and others. Figs. 45-53. 3l Fig. 45- Bacillus mallei. Fig. 49- » Fig. 46. Bacillus typhosus (Eberth). Fig. 47- Bacillus leprae (Hansen). 4 \«p J '& •?:• Fig. 48. Bacillus tuberculosis (Koch). \ si" Fig. 50. Fig. 51. Fig. 52. Fig. 53. Bacillus anthracis. Spirillum of spirochasta Bacillus (s. spiril- Gonococcus Streptococcus Obermeieri lum) choleras Neisseri. erysipelatis. (relapsing fever). Asiatics (Koch). Clinically, the coloring of the micro-organisms in a dried preparation is almost exclusively used. 1 1 The preparation and the staining of the sections, as well as the methods of bacteria culture, are subjects too extensive to be taken up here. They may be better studied in the " Proceedings of the Royal Board of Health" (Berlin); Cornil et Babes: " Les Bac- teries " ; Friedlaender : " Microscopical Technique " ; Hueppe : " The Methods of Bacterial Investigation." 104 CLINICAL DIAGNOSIS. A small drop or particle of the substance (blood, pus, sputum, tissue juice, etc.) to be examined is spread with a platinum needle upon a clean cover-glass, or two glasses are rubbed together so that a thin film of the matter is deposited on each. The cover-glasses are then to be protected from the dust and left until dry. Then the glass, with the preparation side turned upward, is passed three times moderately quickly through the spirit flame. Dry preparations of blood should be heated a few hours at a temperature above ioo° C. (212 F.), in order to fix the hemoglobin, and the best way to accomplish this, according to Ehrlich, is to put the glass on a metal plate, to one corner of which the heat is applied. The dried preparation may then be colored. In clinical examinations aniline colors are principally used, and among them the following : (a) The acid aniline colors : Eosine, picric acid (prin- cipally in blood examination). (b) The basic aniline colors : Fuchsin (muriate of rosaniline), methyl blue, methyl violet, and gentian violet, vesuvin (Bismarck brown), and malachite green. 1 Of these colors it is well to have on hand either a concen- trated, watery filtered solution, or, what is better in the case of fuchsin, a concentrated alcoholic solution. The coloring of the dried preparations is carried out either by dropping with a glass rod some of the concen- trated watery solution on the preparation, or, if the object is to let the color work in for a longer time, by letting the cover-glass float, with the preparation down- ward, on the surface of the staining fluid in a watch-glass. In using methyl violet, gentian violet, or malachite green 1 These colors may be obtained from W. Konig, Berlin, N. W. Dorotheenstrasse, 35. PARASITES. I05 in a concentrated watery solution J-i minute is long enough to color ; in the case of fuchsin and methyl blue it is well to use more diluted solutions for several minutes until the proper tinge is obtained. This latter has the advantage over the other stains in not over-coloring, but in staining the nuclei and bacteria distinctly and causing no precipitate (Ehrlich). Vesuvin (Bismarck brown) should be used in a concentrated watery solution for several minutes. When the preparation is sufficiently colored it should be washed off carefully with water. Then the cover-glass is pressed between folds of .filter paper and finally dried by holding it over the flame, and then examined in Canada balsam (dissolved in turpentine) or in cedar oil. The fundamental principle in examining stained bac- teria preparation is to remove the diaphragm from the microscope stage, and, if possible, then use the Abbe illuminating apparatus [condenser] without the dia- phragm, making the contour of the preparation more indistinct, and thus causing the colored objects to be more prominent. But in all other microscopical exami- nations in which the endeavor is to have the clearest possible outline in an uncolored preparation — e. g, } in looking for hyaline casts, the narrowest diaphragm ad- missible should be used. Almost all micro-organisms except the tubercle bacil- lus may be colored in dry preparation according to the above methods. The staining of tubercle bacilli as done according to Ehr- lich. Aniline water is prepared by shaking up one or more ccm. of aniline oil with 20 ccm. [5 drachms] of dis- stilled water, and allowing it to stand a short time, and then filtering. To the clear filtrate, which may be heated 106 CLINICAL DIAGNOSIS. to boiling in a test-tube to hasten the coloring, 5-10 drops of a concentrated alcoholic solution of diamond fuchsin are added in a watch-glass until the fluid begins to opalesce. Instead of this solution, which should be prepared fresh every time, the following of Weigert-Koch may be used, which can be kept 10-12 days. Saturated aniline water 100 ccm. [3 ounces], a con- centrated alcoholic solution of fuchsin or methyl violet II ccm. [2| drachms], absolute alcohol 10 ccm. \l\ drachms]. The preparations, smeared on a cover-glass, are al- lowed to float on the solution 3-12 hours (if the solution be heated, 5—20 minutes are long enough), then taken out with the forceps, dipped for a few seconds into diluted nitric or hydrochloric acid (1:3 water), then at once thoroughly washed with water. If the preparations have a red color the procedure should be repeated until this color disappears. All bacteria are decolorized by the acid except the tubercle bacillus (and lepra bacillus). This preparation should then be colored by a drop of concentrated watery solution of malachite green or methyl blue, again washed thoroughly with water, dried, and examined in cedar oil or Canada balsam. The tu- bercle bacilli will then be found to be colored red, while every thing else present is green or blue. The tubercle bacilli may be recognized with a power of 350 diameters. The isolated method of staining micro-organisms accord- ing to Gram. The preparations are first colored for 1-3 minutes in a solution of aniline water which has been saturated with gentian violet, and then put into a solu- tion of iodine in iodide of potash, 1 and then in absolute 1 Iodine 1.0 [15 grains]. Iodide of potash 2.0 [30 grains]. Distilled water 300.0 [9J ounces]. PARASITES. I07 alcohol until the preparations are decolorized. The prep- aration is then to be stained with vesuvin and examined in water, or dried and examined in cedar oil or Canada balsam. The micro-organisms are colored bluish black. In order to stain the pneumonococci of Friedlander, and their capsules, there may be made, either a solution of gentian violet in aniline water, or the solution which Ehrlich uses to stain the plasma cells. 1 The preparation should remain twenty-four hours in the solution, and then put in \ - z g S s s s s~ t^ s~ % s s f^. Nervus obturatorius. Nervus peroneus. Nervus tibialis. 1H d 3d 119 120 CLINICAL DIAGNOSIS, closed connection only, from the anode to the cathode (Volta's alter- native), and even this may be entirely extinguished. A qualitative change in the electric irritability, is called the reaction of degeneration (EaR). When a motor nerve is diseased or cut off peripherally from its trophic centre (the anterior horns of the spinal cord, or the gray matter of the cervical nerves), or if the trophic centre itself be diseased, a motor paralysis appears, the nerve becomes degenerated, and the degeneration (degenera- tive atrophy) reaches to the muscle supplied by it. The electric irritability of the nerve diminishes for the fara- dic, as well as for the galvanic current, and is destroyed after about two weeks, i. e., the nerve ceases to conduct the electric current as well as the will. Also the direct faradic irritability of the muscle is diminished and dis- appears ; on the contrary, in the 2d or 3d week there is an increase of the direct muscular irritability for the galvanic current, the contractions occur with the weak- est current, but are long drawn out and slow, and the formula of contraction is changed. The AnSZ occurs with the same or weaker current, as the KaSZ, and the KaOZ becomes like the AnOZ. In one or two months the galvano-muscular irritability diminishes, and disap- pears in a few months. If recovery take place the muscular tonus and voluntary motion appear, but the electric irritability returns only gradually to the normal. This " complete reaction of degeneration " only occurs in grave lesion of the nerves (transverse rupture, se- vere rheumatic facial paralysis); when the conditions of degeneration are not so grave, there is often an incom- plete, or even no " partial reaction of degeneration." In the latter case, the irritability for the nerves is retained, and also the direct faradic muscular irritability. In di- THE NERVOUS SYSTEM. 121 rect galvanic irritation of the muscles, there are neverthe- less, hyperexcitability, and change of the formula of contraction (AnSZ > KSZ), and a slow contraction. The latter is the actual characteristic of EaR. The reaction of degeneration is present in peripheral lesions of the motor nerves, of a traumatic, rheumatic, neurotic, or diphtheritic nature, also in disease of the gray matter of the anterior horns of the spinal cord, and of the gray nuclei of the medulla, e.g., in in- fantile paralysis and lead paralysis ; also sometimes in progressive muscular atrophy, bulbar paralysis, amyotrophic lateral sclerosis, myelitis, etc. The EaR is absent, however, in all cerebral paralyses (apoplexies), and in those spinal paralyses which have a central cause from the trophic centre, and also in pure myopathic paralysis (pseudo-hyper- trophy of the muscles). The trophic behavior of the paralyzed muscles is en- tirely analogous to the electric behavior. In disease of the gray matter of the anterior horns, as well as in lesions of the motor nerves peripherally from themselves, a degenerative atrophy occurs, while in paralysis whose cause lies in the motor tract central from the gray mat- ter of the anterior horns, a slight atrophy of the para- lyzed muscle takes place, but not until after a long time (atrophy of inactivity). In degenerative atrophy of the muscles, there are often fibrillary contractions observed in them. Reflexes. We distinguish skin (superficial) and tendon (deep) reflexes. It is not certain whether the latter are actually reflex or not. They do not behave alike, and may be often completely different. Among the skin reflexes which are more or less present in health, are : 122 CLINICAL DIAGNOSIS. Reflex of the sole of the foot : In exciting the sole of the foot by tickling, stroking, sticking, touching it with ice, there is dorsal flexion of the foot, and when the irri- tation is strong, the leg is drawn up against the body. Cremaster reflex : In exciting the inner surface of the thigh, the corresponding testicle rises- up. Reflex of the abdominal walls, gluteal and scapular re- gions : In irritating the skin in these regions, the corre- sponding muscles contract. Tendon Reflexes. Patellar reflex : If the patellar tendon be percussed while the leg is crossed and completely relaxed, and the patient's attention be withdrawn, there is a contraction of the quadriceps and the leg is extended. Patellar clonus : If the patella be pushed quickly down and held there firmly, there is a rhythmic contraction of the quadriceps. Reflex of the te?tdo Achillis ; In percussing the tendo Achillis, there is caused a contraction of the calf muscles. Foot clonus : If the foot be seized by the ball of the great toe, and be pressed quickly upward while the knee is slightly bent, there is a rhythmic plantar-contraction of the calf muscles. In health the patellar reflex is constant, and the reflex of the tendo Achillis frequent. The presence of the remaining tendon reflexes, also of the upper extremities (biceps, triceps, flexors of the hand etc.), is considered as a diseased reflex irritability. In order that the conditions of reflex tendon may occur, it is, above all things, necessary that the reflex circidt be entire. This reflex circuit is formed by the sensory nerve tracts, which go from the muscle or tendon or fas- THE NERVOUS SYSTEM. I 23 cia, to the spinal cord and motor tracts which descend to the muscles, as well as to that part of the spinal cord connecting both. The reflexes are extinguished when the reflex circuit is interrupted in any part of its course, i. W \JL /ito^mi&\^ Antero-lateral inner capsule the motor f JMfJfk "\ tract ' ... [ ^ ® / \ Lateral pyramidal tracts pass through the ^fg| ^^ tract. . , , Cerebellar lateral pes cruris cerebri (the ^WJm \\ -__ . , .. Posterio r / ^-^K"^ Tract of Burdach. sensory through the teg- root - * \ „ 3 O & Tract of Goll. mentum cruris cerebri) into the pons. The motor fibres, after their exit from the pons into the medulla, form the pyramidal bodies, and here, for the most part, cross. The crossed fibres in the lateral tract of the spinal cord pass downwards (lateral pyramidal tract, Fig. 59) ; only a small part of the motor fibres remains uncrossed, and passes down in the middle part of the anterior tract (anterior pyramidal tract). A destruction of any part of this motor tract produces, not only a paralysis of the muscle concerned, but also de- scending degeneration of the pyramidal tracts, inasmuch as their trophic centre is situated in the cerebrum. The motor fibres pass out of the pyramidal tracts into the anterior cornu of the gray matter, whose great ganglion 126 CLINICAL DIAGNOSIS. cells form the trophic centre for the peripheral motor nerves and the muscles ; and from there they pass through the anterior roots to the periphery of the body. Injuries of the motor nerves beyond the gray anterior cornua, or a morbid condition of them, produce a degen- eration of the nerves, as well as paralysis and atrophy of the muscles, with the reaction of degeneration. These paralyses are characterized as peripheral, in distinction from central paralyses, which are caused by a lesion of the motor tracts proximal to the gray anterior cornua. Inasmuch as in the cerebral cortex the motor centres of the single muscular regions lie far apart from each other, a lesion in that particular place generally produces monoplegia, i. e., a paralysis of one member or of one group of muscles alone, which is often connected with paroxysmal cramps in the paralyzed portion (cortical epilepsy, Jackson's epilepsy). Lesion of the inner cap- sule generally produces total hemiplegia, as well as affec- tions of the crus cerebri and the pons. (In case of dis- eased condition of the crus cerebri, there is often with it a crossed paralysis of the oculomotorius ; when the pons is diseased, there is crossed paralysis of the facialis.) All these paralyses affect the opposite side of the body, while affections of the spinal cord before the pyramidal decus- sation cause paralyses of the same side. As most lesions, however, affect the spinal cord on both sides alike, para- plegia is the principal form of spinal paralysis (myelitis, compression of the spinal cord by spondylitis or tumors). Injuries of the anterior roots, of the plexus, and of the nerves, produce paralyses of single groups of muscles. The sensory nerves, whose trophic centre is situated in the intervertebral ganglia, enter the spinal cord through the posterior roots, cross shortly after their entrance THE NERVOUS SYSTEM. \2*J (deep decussation), and ascend through the posterior columns to the brain, so that the inner columns (of Goll) contain the long, ascending bundles of fibres, while the outer columns (of Burdach) are made up of short bundles which run to the gray posterior cornua. Besides that, long bundles in the lateral column of the cerebellum pass upward. In cases of transverse section of the spinal cord, the columns of Goll and cerebellar lateral columns degenerate upward from the point of injury, and the pyramidal column downward. In case of a lesion of one side of the spinal cord, there appears a motor paralysis of the same side, and anaesthesia of the other side ; besides this, a narrow anaes- thetic belt around the body at the height of the lesion (Brown-Sequard). In case of tabes dorsalis the posterior columns are diseased, and in spastic paralyses the lateral columns (tabes spastica). In amyotrophic lateral scle- rosis the anterior cornua and lateral columns are dis- eased, and in infantile paralysis and progressive muscular atrophy the gray anterior cornua are diseased. In dis- eases of the gray nuclei of the medulla oblongata (bulbar paralysis) there are disturbances of speech and degluti- tion caused by paralysis and atrophy of the lips, soft palate, muscles of deglutition, and larynx. Cranial Nerves. 1. Olfactorius. The testing of the sense of smell is accomplished by holding before the nose odoriferous and irritating substances, such as volatile oils, asafoetida, musk, etc. 2. Opticus. Test the sharpness and field of vision, and sense cf color, and then examine with the ophthalmoscope. 3. Oculomotorius supplies the levator palpebrae superioris, rectus superior, internus, and inferior, obliquus inferior, and sphinctor pu- pillse. In paralysis, there is ptosis, diplopia, dilatation, and absence of pupillary reaction, and disturbance of accommodation. 128 CLINICAL DIAGNOSIS. 4. Trochlearis supplies the obliquus superior. 5. Trigeminus. The motor part supplies the muscles of mastica- tion, the masseter, temporalis, pterygoid, mylohyoid, and the ante- rior belly of the biventer. The sensory part supplies the skin of the face and head as far as the ears. The first branch goes to the skin of the forehead, of the top of the head, of the upper eyelids, and of the bridge of the nose. The second branch supplies the upper half of the cheek and upper lip, and the third branch, the lower half of the cheek, the skin in the temporal region, and the chin. Besides this, the trigeminus supplies the cornea and conjunctiva and the mu- cous membrane of the mouth and nose, and the dura mater with sen- sory fibres. The lingualis from the trigeminus is the nerve of taste for the anterior two thirds of the tongue. 6. The abducens supplies the abducens muscle. When it is para- lyzed, the eyeball cannot be turned outward. 7. The facialis supplies all the mimic muscles of the face, and the stylohyoideus, and the posterior part of the biventer. From the re- lation of the facialis to the petrosus superficialis major nerve, and to the chorda tympani, it is clear that in a lesion of this nerve, proximal to the ganglion geniculi, the soft palate on the same side is paralyzed and hangs lower, and that in a lesion between the ganglion geniculi and the passage of the chorda tympani, disturbances of taste occur in the anterior two thirds of the tongue, with decrease of the salivary secretion. In central paralysis of the facialis, only the lower half of the face is usually paralyzed ; in peripheral paralysis, only the upper part. 8. Actisticus. The power of hearing should be tested, and oto- scopic examination made. 9. Glossopharyngeus. The nerve of taste for the posterior third of the tongue supplies the palate with sensory fibres. The test is to apply quinine, sugar, salt, or vinegar to the part. 10. The vagus supplies the larynx, pharynx, and oesophagus with motor and sensory fibres, and sends fibres to the contents of the chest and abdomen. Irritation of the vagus causes slowing of the pulse ; and paralysis of the nerve, a quickening of the pulse and slowing of the respiration. 11. The accessorius supplies the sterno-cleido-mastoid and the trapezius. 12. The hypoglossus, the motor nerve of the tongue, supplies the THE NERVOUS SYSTEM. I2Q genio-glossus, hyo-glossus, stylo-glossus, the innermost muscles of the tongue, the genio-hyoidcus, omo-hyoidcus, sterno-hyoideus, hyo- thyroideus, and sterno-thyroidcus. In paralysis of the hypoglossus, the tongue turns toward the paralyzed side. Spinal Nerves. 1. Plexus cervicalis (ist-4th cervical nerve) supplies the post-occi- pital region behind the ear, neck, and shoulders with sensory nerves ; the deep cervical muscles and the scaleni, with motor nerves. From the fourth cervical nerve the phrenic branches, and forms the motor nerve of the diaphragm. 2. Plexus brachialis (5th-8th cervical nerve, ist and 2d dorsal nerve). In lesion of a certain part of this plexus, there is a motor paralysis of the deltoid, biceps, brachialis internus [anticus], supin- ator longus, infraspinatus (paralysis of Erb). The nervi ihoracici anterioj'es supply the musculus pectoralis major and minor. The iiervus thoracicus longus supplies the musculus serratus anticus major [serratus magnus]. The iiervus dorsalls scapuhc supplies the musculi rhomboidei, levator [anguli] scapulas, and serratus posticus superior. The nervus suprascapularis supplies the musculus supraspinatus and infraspinatus. The nervus subscapulars supplies the musculus subscapularis, teres major, and latissimus dorsi. The nervus axillaris supplies the musculus deltoideu-, teres minor, and sensory fibres go to the skin of the outer side of the upper arm. The nervus cutancus medius and medialis supply the skin of the median (inner surface) side of the forearm. The nervus musculocutaneus supplies the musculus biceps, coraco- brachialis, brachialis internus [anticus], and the skin on the radial side of the forearm. The nervus medianus supplies the musculus flexor carpi radiahs, pronator [radii] teres and pronator quadratus, flexor digitorum com- munis superhcialis and profundus (in part), palmaris longus, flexor pol- licis longus and brevis, abductor and opponens pollicis ; the skin of the palmar surface of the hand from the thumb to the middle of the third [ring] finger ; and the dorsal side of the ungual phalanx of the first and second finger. I30 CLINICAL DIAGNOSIS. In paralysis of this nerve, pronation and flexion of the hand is al- most entirely impossible, and flexion and opposition of the thumb and flexion of the finger in the last two phalanges, is impossible ; on the contrary, the first phalanges can be flexed by the interossei. With the last three fingers, whose flexor profundus is partly supplied by the nervus ulnaris, the power of grasping is still retained. The nervus ulnaris supplies the museums flexor carpi ulnaris, flexor digitorum profundus for the last three fingers, the muscles of the ul- nar side of the hand, the interossei, lumbricales, adductor pollicis ; the skin of the ulnar side of the hand on the palmar side as far as the middle of the third [ring] finger, and on the dorsal side to the middle of the second finger. In paralysis of this nerve there is diminished power of lateral move- ment towards the ulnar side as well as loss of power to flex the last three fingers : further, also, there is loss of motion of the little fin- ger in flexion of the first phalanges and extension of the last pha- langes of the four last fingers, and loss of power to spread the fingers out and draw them together. In paralyses which have existed a long time we have the claw-like position of the hand, in which case the first phalanges are flexed towards the dorsal surface and the end phalanges towards the palmar surface. This is caused by atrophy of the interossei. The nervus radialis supplies the extensors of the arm,, hand, and fingers, the musculus triceps, supinator longus and brevis, all the muscles on the posterior surface of the forearm, namely, the extensor carpi radialis longus and brevis, extensor carpi ulnaris, extensor digi- torum communis, extensor indicis and digiti minimi, extensor pol- licis longus and brevis, abductor pollicis longus. The cutaneous branches go to the posterior surface of the upper arm and forearm, to the dorsal surface of the thumb, and the skin as far as the middle of the second finger. In paralysis of this nerve there is inability to extend the relaxed muscles of the hand and fingers, as well as to extend and abduct the thumb. The outstretched arm cannot be supinated (but on flexion of the arm the forearm can be supinated by the biceps). Such a paraly- sis is observed in lead paralysis, except that the supinator longus is generally exempt. The sensory disturbances in paralysis of the nerves of the arm may be inferred from the above description of the distribution of the sensory branches, but the symptoms are generally less distinctly marked. THE NERVOUS SYSTEM. 131 3. The dorsal nerves supply the skin and muscles of the thorax and abdomen. 4. The plexus lumbalis (12th cervical to ist-4th dorsal nerve) goes to the skin of the lower abdominal region, of the anterior surface of the thigh, and of the inner surface of the leg. The motor branches sup- ply the internal pelvic muscles. The nervus cruralis supplies the musculus quadriceps femoris, sartorius, pectineus ; the nervus obtur- atorius supplies the musculus obturator, adductor magnus, longus, and brevis, and gracilis. 5. The plexus sacralis (5th lumbar to ist-5th sacral nerve) supplies the bladder, rectum, sexual organs, perineum, and nates with motor and sensory branches. The nervus ischiadicus [sciatic nerve], which supplies the skin on the posterior surface of the thigh, on the outer side of the leg, and on the foot as well as the musculus biceps, semitendinosus and semi- membranosus, divides half way down the thigh into the nervus tibialis and peroneus, the former of which supplies the muscles on the pos- terior surface of the leg (calf muscles) and of the under surface of the foot, the latter going to the muscles on the anterior surface of the leg and foot (see Figs. 58 and 59). CHAPTER XIII. ANALYSIS OF THE PATHOLOGICAL CON- CREMENTS. Urinary Concrements. — The concrement should be rubbed to a fine powder, and a part of it heated red hot on a platinum spatula or on a porcelain crucible top. If the concrement be completely destroyed, or if only a small amount of ash remain behind, then it con- sists of organic substance, /. e., uric acid, urate of am- monia, xanthin, or cystin. Uric Acid is tested for with the murexide test, by moist- ening some of the powder on a crucible lid with a drop of nitric acid and slowly evaporating it. If uric acid is present an orange-red mark is left, which turns purple on being moistened with ammonia. Uric acid calculi are generally reddish-yellow and hard. Ammonia is tested for by dissolving the powder with dilute hydrochloric acid, filtering and making the filtrate alkaline with caustic potash, and heating it in a test tube. A smell of ammonia is developed, and moist red litmus paper, held over the opening of the tube, turns blue from the vapor ; and a glass rod moistened with muriatic acid and held over the opening of the tube causes a vapor of chloride of ammonia. If uric acid and ammonia are de- tected the calculus contains urate of ammonia. Such stones are generally white and crumbly. If the murexide test does not succeed, the xanthin is 132 PATHOLOGICAL CONCREMENTS. 133 tested for by dissolving the powder in dilute nitric acid, and evaporating it slowly on a porcelain crucible top. If a lemon-colored residue is left which is unchanged on moistening it with ammonia, but turns red on adding caustic potash, then what remains is xanthin. Xanthin calculi are generally of a cinnamon-brown color, moder- ately hard, and take on a waxy lustre on being rubbed. Cystin is detected by dissolving the sediment with heat and ammonia. After evaporating, the filtrate may be recognized microscopically as regular hexagonal crystals of cystin. Cystin calculi are generally smooth, yellow, and not very hard. If the concrement is not completely consumed, but made black only, then it consists of inorganic substances, or of compounds of organic acids (uric or oxalic acid), with alkalies or alkaline earths. A little of the sediment is put into a test tube, and dilute hydrochloric acid is added. If effervescence take place, it is proof of the presence of carbonic acid. If the substance be not completely dissolved on heating, then the residue may consist of uric acid (to be detected by the murexide test). It should then be filtered, the fil- trate made alkaline with ammonia, and then made slightly acid with acetic acid. If then a white powdery precipitate, insoluble with heat, be left, it consists of the oxalate of lime. It should then be filtered, and oxalate of ammonia added. A white precipitate shows the pres- ence of calcium monoxide. This is heated and filtered, and ammonia added, and if a precipitate (ammonio- phosphate of magnesia) be formed after standing, it shows the presence of magnesia and phosphoric acid. If no precipitate be formed, the fluid is divided into two parts, and to one part phosphate of sodium and to the 134 CLINICAL DIAGNOSIS. other sulphate of magnesium is added. The appearance of a precipitate in the first shows the presence oimagnesia; in the second, of phosphoric acid. Phosphoric acid may be detected in the fluid by adding acetate of uran after the acetic acid, and a yellow-white precipitate shows the presence of the phosphate of uran. Sulphuric acid may be detected by adding chloride of barium after the muriatic acid, and a white precipitate of the sulphide of barium results if sulphuric acid be present. Calculi of the oxalate of lime are generally very hard, of a mulberry shape, and are colored dark with the col- oring matter of the blood. They are not dissolved by acetic acid ; but are dissolved without effervescence by the mineral acids. Calculi of the phosphate of lime and of ammonio- phosphate of magnesia are generally white, soft, and friable. Calculi of the carbonate of lime are white, chalky, and effervesce on adding acids. The concrements of the intestine (faecal calculi) consist partly of organic substances of different kinds, and partly of inorganic salts, such as the phosphate of calcium, the ammonio-phosphate of magnesia, the sul- phates of the mineral alkalies. They should be dissolved in muriatic acid, and examined in the customary manner. Salivary calculi generally consist of carbonate of lime. Gall stones consist principally of cholesterine and bilirubin, in combination with calcium. To detect cholesterine the powdered concrement should be dis- solved in hot alcohol, and filtered, and after cooling the cholesterine crystallizes out of the filtrate in slender PATHOLOGICAL CONCREMENTS. 135 plates. If the cholesterine be then dissolved in chloro- form and concentrated sulphuric acid be added, a beau- tiful cherry-red color is formed, which changes later to blue and green. To test for bilirubin the residue of the concrement is made slightly acid with muriatic acid and extracted with chloroform in a warm place. On adding fuming nitric acid to the chloroform the Gmelin reaction appears. CHAPTER XIV. METABOLISM AND NUTRITION. In order that the human organism shall retain its proper amount of albumen, fat, ashy residue, and water, there must be a sufficient amount and proper proportion of these substances in the daily food. Since the water and ashy residue are generally abundant, the principal question is of giving those nutritious substances which prevent the body from losing albumen and fat. These substances are the albuminous and fatty matters and the carbo-hydrates. In order to see whether an organism keeps up the proper amount of nourishment or not, it is not sufficient to consider the weight alone ; for the weight can remain the same, or even increase, while the nourishment de- creases, as in cases of hydrsemia, even without visible oedema. Albwiien is also set free 1 from the organism in hunger. In order that the body shall not lose its proper amount of albumen, a certain quantity should always be given with the food, which can be substituted by no other food. The smallest amount of albumen with which the body can be kept up to its standard is called the diet of sus- tenance. This for a medium-sized adult is about 85 grams 1 In long-continued complete inanition, about 4.26 grams [63 grains] of nitrogen, equivalent to 210 grams [6| ounces] of muscle, are split up and set free daily. 136 METABOLISM AND NUTRITION. 1 37 [2 J ounces] (Voit '). If more albumen be given more is decomposed, and the body soon sets it free and quickly regains its nitrogenous equilibrium, /. f oz.] [11 oz.] An idle man (priso- 87 22 305 ner) [2| OZ.] [f oz.j [9 oz.] The need of food for growing individuals (children) is less than for adults, but greater in proportion to the weight of the body. The composition of the most important kinds of food is given in the table opposite. The nutritive substances are not completely absorbed in the intestinal canal, but a part of them is always passed out unused with the faeces. Under normal con- ditions animal albumen (meat, eggs, cheese, etc.) is very thoroughly used up, while vegetable albumen (bread, legumes, vegetables) are less thoroughly absorbed. The 1 According to Pfltiger and Bohland the amount of albumen con- verted is in adults (of 62 kilo [T24 lbs.] ) equivalent to 96.467 grams [1447- grains]. metabolism and nutrition. Composition of Foods. 141 ^ x^ \r be M CO 53 •fcs. O Adonidine .... gr. f<; to i 0.06 to 0.02 gm. Aloe gr. ii to v 0. 10 to 0.30 gm. Aloe et canella gr. v to xxx 0.30 to 2.0 gm. Aloinum gr. j to iij c.06 to 0.20 gm. Alumen (expectorant ) gr. iij to x 0.20 to 0.60 gm. " exsiccat. gr. v to xxx 0.30 to 2 gm. Ammonii benzoas gr. x to xx 0.60 to 1.2 gm. " bromid. gr. v to xxx 0.30 to 2 gm. " carb. gr. iij to x 0.20 to 0.60 gm. " chlorid. gr. xv to xxx 1 to 20 gm. " iodid. gr. iij to xv 0.20 to 1.0 gm. ' ' phosph . gr. v lo xx 0.30 to 1.2 gm. " picras gr. itoi 0.15 to 03 gm. " sulph. gr. iij to xv 0.20 to 1.0 gm. " valer. gr. iij to xv 0.20 to 1.0 gm. Amyl nitris TTL ij to V 0. 10 to 0.30 gm. Anthemis 3 ss to 3 j 2.0 to 4.0 gm. Antimonii et pot. tartr. (diapli.) g r - tV to h 0.004 to 0.01 gm. " et pot. tartr. (emetic) gr. j to ij 0.05 to 0.10 gm. " oxid. gr. j to ij O.05 to 0. 10 gm. oxysulphurct. gr. i to ii 0.03 to 0.10 gm. sulphid. . gr. i to ij 0.03 to 0.01 gm. " sulphuret. gr. -i- to n 03 to 0. 10 gm. Antipyrine gr. v to xv 30 to 1.0 gm. Apomorph. hydrochlor. g'-- ifo to T V 0.002 to 0.005 gm. Aqua ammoniae TTL VJ tO XXX 0.40 to 2 ccm. " amygd. amar. f 3 ij to xv 8.0 to 16.0 ccm. ' ' camphorse f \ ss to ij 15 to 60 ccm. " chlori f 3 j to iv 4 to 15 ccm. " creasoti . f 3 j to iv 4 to 15 ccm. " laurocerasi Tfyvj to xxx 0.40 to 2 ccm. Argenti iodidum gr. \ to ij 0.03 to 0.10 gm. " nitras . g'-. \ to A 0.01 to 0.02 gm. " oxid. . gr. -J to ij 0.03 to 0.10 gm. Arnica gr. v to xx 0.30 to 1.20 gm. Arsenici iodidum g r - 6T tO T V 0.001 to 0.005 gm. Asafcetida gr. v to xx 0.30 to I.20 gm. Atropina gr. T ^ to J 5 0.005 to 0.002 gm. Atropinae sulph. gr . y |- to 5*2 0.005 to 0.002 gm. 146 CLINICAL DIAGNOSIS. Dose expressed in teims of Dose Remedies. apothecaries' expressed in weights metric terms. and measures. Auri et sodii chlorid. gr. 3L to T V 0.002 to 0x04 gm. Belladonnas folium . g r - j 0.05 gm. Bismuthi citras gr. iij to xv 0.20 to 1.0 gm. " et ammon. citr. gr. j to xv O.05 to 1.0 gm. " sub-carb. . gr. vj to xxx 0.40 to 2 gm. " sub-nitr. gr. vj to xxx 0.40 to 2 gm. " tannas gr. vj to xxx O.40 to 2 gm. 4 ' valer. gr. j to iij 0.05 to 0.20 gm. Brucina . g r - -h lo iV 0.001 to 0.004 gm° Buchu gr. xx to xxx 1.20 to 2.0 gm. Caffeina . gr. j to v 0.05 to 0.30 gm. Caffeinse citras gr. j to v O.05 to 0.30 gm. Calcii bromidum gr. v to xxx 0.30 to 2.0 gm. " carb. gr. xv to Ix 1 to 4 gm. " hypophosphis gr. iij to xv 0.20 to 1 gm. " iodidum gr. j to iij 0.05 to. 0.20 gm. 84 phosphas gr. xv to xxx 1 to 2 gm. Calumba gr. x to xxx 0.60 to 2.0 gm. Calx sulphurata g r - -3- to j 0.02 to 0.05 gm. Cambogium gr. 1 to iv 05 to 0.25 gm. Camphora gr. iij to x O.20 to 0.60 gm. Camph. monobrom. gr. ij to v 0.10 to 0.30 gm. Cantharis gr. \ to ij 0.03 to 0.10 gm. Cardamonum . gr. v to xxx O.30 to 2 gm. Castoreum gr. vj to xv 0.40 to I gm. Catechu . gr. xv to xxx 1 to 2 gm. Cerii nitras gr. j to iij 0.05 to O.20 gm. " oxalas gr-'j to iij 0.05 to 0.20 gm. Chinoidinum . gr. iij to xxx O.20 to 2 gm. Chloral hydrat. gr. iij to xv 0.20 to 1 gm. Chloroformum TTLJ to V O.05 to 0.30 ccm„ Cinchona gr. xv to lx I to 4 gm. Cinchonidina and its salts gr. j to xxx 0.05. to 2 gm. Cinchonina and its salts gr. j to xxx 0.05 to 2 gm. Cinnamonum . gr. vj to xxx 0.40 to 2 gm. Codeina . gr. | to ij 0.03 to 0.10 gm. Colchici radix . gr. ij to vj 0.03 to 0.40 gm. " semen gr. ij to vj 0.03 to 0.40 gm. Colocynthis gr. v to xv 0.30 to 1.0 gm. Confectio opii . gr. x to xx 0.C0 to i.co gm. DOSE TABLE. H7 Dose expressed Remedies. in terms of apothecaries' weights and Dose expressed in metric terms. measures. Confectio sennse .... gr. j to ij 0.5 to 0.10 gm. Conii fol. gr. 11 j 0.20 gm. Coniina and its salts gr. J3- to & 0.001 to 0.002 gm. Copaiba . TT[ xv to lx 1 to 4 ccm. Creasotum Til j to iij 0.05 to 0.20 ccm. Creta prsepar. gr. xy to Ixxv 1 to 5 gm. Croton chloral gr. j to x 0.05 to 0.60 gm. Cubeba . gr. xv. to lx 1 to 4 gm. Cupri acetas g r - \ to vj 0.03 to 0.40 gm. " sulphas . gr. \ to x 0.03 to 0.60 gm. Cuprum aramon. g r - i to j o.oi to 0.05 gm. Curare g 1 "- T2 tO_i 0.002 to 0.01 gm. Decoct, aloes comp. f 1 ss to ij 15 to 60 ccm. " chimaphilge fjij 60 ccm. " citron se flij 60 ccm. " sarsap comp. f I ij to vj 50 to 200 ccm. Digitalinum gr. fo to 3L 0.001 to 0.002 gm. Digitalis . gr. \ to ij 0.03 to 0. 10 gm. Duboisina and its salts g 1 "- ih to eV 0.0005 to O.ooi gm. Elaterinum, U. S. P., 1880 g r - -arV to re 0.001 to 0.004 g m - Elaterium " 1870 gr. tV to \ 0.004 t0 °-°3 g m - Emetina and salts, (emetic) gr- f to i 0.008 to 0.016 gm. " and salts, (diaph.) gr. j^js to ¥ V 0005 to 0.002 gm. Ergot a ..... gr. xv to lx 1 to 4 gm. Ergotinum .... gr. ij to viij 0.10 to 0.50 gm. Eserinse and its sails gr- 6T to Ffr 0.001 to 0.004 gm. Extr. absinthii fl. TT[ xv to XXX 1 to 2 ccm. " aconiti fol. (Engl.) . gr. 3 to j 0.02 to O.05 gm. " aconiti fol., U. S. P., 1870 gr- i to ij 0.03 to 0.10 gm. " aconiti fol. fluid. TTl i to V 0.05 to 0.30 ccm. " aconiti rad., U. S. 1'., 1880 gr- tV to i 0.005 to 0.015 gm. " aconiti rad. fluid m i to ijss 0.03 to 0.13 ccm. " agaric fl. .... Tit v to XX 0.30 to 1.20 ccm. " aloes aquos. .... gr. \ to iij O.03 to 0.20 gm. " anthemidis .... gr. ij to x 0. 10 to 0.60 gm. " anthemidis fl. ... TTT, XXX to lx 2 to 4 ccm. " arnicse flor. .... gr. iij to viij 0.20 to 0.50 gm. " arnicse fl. .... TTL v tO XV 0.30 to 1 ccm. " arnicae rad. . ... gr. ij to v 0. 10 to 0.30 gm„ " arnicae rad. fl. TTL v to xv 0.30 to 1 ccm. 148 CLINICAL DIAGNOSIS. Dose expressed in terms of Dose Remedies. apothecaries' expressed in weights metric terms. and measures. Extr. aromat. fl. . . TIL xxx to lx 2 to 4 ccm. " aurantii. cort. fl. f 3 i to ijss 1 to 10 ccm. " bellad. fol. (Engl.) gr- *tof 0.01 to 0.04 gm. " bellad. alcohol gr. . P., 1870 gr. 1 to li 0.05 to 0.08 gm. DOSE TABLE. 149 Dose expressed in terms of Dose Remedies. apothecaries' expressed in weights metric terms. and measures. Extr. eon. (fr.)alc, U. S. P., 1880 . gr-itoj 0.02 to 0.05 gm. ' conii fol. fl. . TTJ, iij to XV 0.20 to 1 ccm. ' con. (fr.) fl. U. S. P., 1880 TT^ l| tO V 03 to 0.30 ccm. ' convallariae rad. fl. . TTL XV to XXX 1 to 2 ccm ' cubebse fl. VI XV IO XXK 1 to 2 ccm. ' damianae fl. f 3 ss to ijss 2 to 10 ccm. ' delphinii fl. TTi j to iij 0.05 to 0.20 ccm. ' digitalis . gr. i lo i 0.01 to 0.03 gm. 1 digitalis fl. Hi 1 to vj 0.05 to 0.40 ccm. ' duboisiae gr- i to | 0.015 to 0.03 gm. ' duboisiae fl. TTJ, v tO X 0.30 to 1.20 ccm. 1 dulcamarae gr. v. to xv 0.30 to 1 gm. ' dulcamarae fl. f 3 j to ij 4 to 8 ccm. 1 ergotae . gr. iss to viij 0.08 to 0.5 gm. ' ergotae fl. TTI, xv to Ix 1 to 4 ccm. ' erythroxyli fl. f 3 ss to ij 2 to 8 ccm. ' eucalypti fl. TTI, xv to lx 1 to 4 ccm. ' euonymi fl. TTI XV tO lx I to 4 ccm. ' eupatorii fl. TTX XXX tO lx 2 to 4 ccm. ' euphorb. ipec. fl. TTj, V tO XXX 0.30 to 2 ccm. 1 ferri. pom. gr. iij to xv O.20 to I gm. 1 frangulae fl. f 3 ss to ijss 2 to 10 ccm. 1 fuci vesiculos. V\ xv to XXX 1 to 2 ccm. ' gallae fl. f 3 ss to ij 2 to 8 ccm. ' gelsemii . TTj, ij to viij 0.10 to 0.50 ccm. ' gelsemii fl. TTI j to viij 0.05 to 0.50 ccm. 1 gent. fl. . TTL XXX to lx 2 to 4 ccm. ' gent. comp. fl TTj, XXX tO lx 2 to 4 ccm. ' geranii fl. TTX XV tOO XXX 1 to 2 ccm. 1 gossypii fl. TTi XV tO xlv 1 to 3 ccm. 1 granati. rad. cort. fl f 3 ss to ij 2 to 8 ccm. 1 grind, rob. fl. TTj, XXX tO lx 2 to 4 ccm. 1 guaiaci ligni fl. TTi XXX tO lx 2 to 4 ccm. ' guaranae fl. TT1, XV tO XXX 1 to 2 ccm. ' haematoxyli gr. v to xxx 0.30 to 2 gm. ' haematoxyli fl. Til XXX tO lx 2 to 4 ccm. 1 hamamelid fl. . ttl xxx to xc 2 to 6 ccm. c helieb. nigris . gr. i to iij 0.03 to 0.20 gm. 1 helieb nigris fl. TTj, V tO XV 0.30 to 1 ccm. 1 humuli . gr. iij to xv 0.20 to I gm. i5o CLINICAL DIAGNOSIS. Dose expressed in terms of Dose RemedieSo apothecaries' expressed in weights metric terms. and measures. Extr. humuli fl. TTj, iij to XV 0.20 to 1 ccm. ' hydrangeas fl. TTJ, xxx to Ix 2 to 4 ccm. ' hydrastis gr. iij to x 0.20 to 1.20 gm. ' hydrastis fl. . n^ v to xxx O.30 to 2.0 ccm. ' hyoscyami (Engl.) . gr. j to iv 0.05 to 0.25 gm. * hyoscyami ale. gr. j to ij 0.05 to 0.10 gm. ' hyoscyami fol. fl. TT[ iij to xv 0.20 to 1 ccm. ' hyoscyami sem. fl. . TTj, ij to viij 0.10 to 0.50 ccm. ' ignatiae . gr. i to ii 0.02 to 0.65 gm. ' ignatiae fl. m j to vj 0.05 to 0.40 ccm. ' ipecac fl. VI iij to lx 0.20 to 4 ccm. ' iridis versicol. gr. iij to vj 0.20 to 0.40 gm. ' iridis versicol fl. TIL «xv too xxx 1 to 2 ccm. ' jalapse, U. S. P., 1870 gr. v tox 0.30 to 0.60 gm. ' jalapse ale. gr. iij to vj 0.20 to 0.40 gm. ' jalapae fl. TT[ xv to lx 1 to 4 ccm. ' junip. fl. TTJ, xxx to lx 2 to 4 ccm. ' kamala fl. Til, xxx to lx 2 to 4 ccm. ' kino liquid Til, xv to xxx 1 to 2 ccm. ' kramarise gr. v to xv 0.30 to 1 gm. 1 lactucse fl. TH, xv to lx 1 to 4 ccm. ' lactucarii fl. TIX v to xxx 0.30 to 2.0 ccm. ' leptandrse gr. iij to x O.20 to 0.60 gm. ' leptrandrae fl. TTL XXX to lx 2 to 4 ccm. ' lobeliae fl. TTi j tO V 0.05 to 0.30 ccm ' lupulini fl. TTj, V to XV 0.30 to 1 ccm. ' matico fl. TTi, xxx to lx 2 to 4 ccm. ' myricae fl. TTj, xxx to lx 2 to 4 ccm. ' nectandrae fl. f 3 j to iv 4 to 16 ccm. ' nuc. vom. gr. i to i| 0.02 to 0.08 gm. ' nuc. vom. fl. ttl 1 to iv 0.05 to 0.30 ccm. ' opii gr- £ to | 0.01 to 0.03 gm. * papaveris gr. i to ij 0.03 to 0.10 gm. ' papaveris fl. TT], XV tO xlv 1 to 3 ccm. 1 pareirae fl. TTj, xxx to lx 2 to 4 ccm. 4 petroselini fl. f 3 j to ij 4 to 8 ccm. ' physostigmce gr. tV to I 0.004 to 0.01 gm. ' physostigmae fl. TTI j to iij 0.05 to 0.20 ccm. 4 phytolaccae baccar. fl. TT[V tO XXX 0.30 to 2 ccm. ' phytolaccae rac I. gr. j to iij 0.05 to 0.20 gm. DOSE TABLE. 151 Dose expressed in terms of Dose Remedies. ■ apothecaries' expressed in weights and metric terms. measures. Extr. phytolaccae rad. fl. . TT^v to XXX 0.30 to 2 ccm. ' pilocarpi fl. TTl,XV tO lx 1 to 4 ccm. ' pimentae fl. TTLxv to xlv 1 to 3 ccm. ' piper nigr. fl. . TIL xv to xlv I to 3 ccm. ' podophylli gr. £ to i£ 0.03 to 0.08 gm. ' podophylli fl. . TTLv to XXX 0.30 to 2.0 ccm. ' polygoni fl. TTLxv to XXX I to 2 ccm. ' polygonati fl. . TILV tO XV 0.30 to I ccm. 1 prun. virg. fl. . TTLxxx to lx 2 to 4 ccm. 1 quassias . gr. j to v 0.05 to O.30 gm. ' quassiae fl. TTLxxx to lx 2 to 4 ccm. ' quebracho fl. . TTLX tO lx 0.60 to 4 ccm. ' quercus fl. TTLxxx to lx 2 to 4 ccm. ' rhamni cath. ft. fl. TTLxxx to lx 2 to 4 ccm. 4 rhamni pursh. cort. fl. TTLxxx to exx 2 to 8 ccm. ' rhei gr. v to xv 0.30 to 1 gm. « rheifl. . TTLxv to xlv 1 to 3 ccm. ' ricini fol. fl. . f 3 ss to ij 2 to 8 ccm. ' rutae fl. . TTLxv to xxx I to 2 ccm. ' sabinae fl. TTLv to XV 0.30 to 1 ccm. ' sanguin. fl. TTLV tO XV 0.30 to 1 ccm. ' santali citr. fl. f 3 j to ij 4 to 8 ccm. ' santonicae fl. . TTLxv to lx 1 to 4 ccm. ' sarsap. fl. f 3 ss to ij 2 to 8 ccm. ' sarsap. comp. fl. f 3 ss to ij 2 to 8 ccm. ' sassafras fl. f 3 ss to ij 2 to 8 ccm. ' scillae fl. . TTLV to XXX 0.30 to 2 ccm. ' scillae comp. fl. TTLV tO XXX 0.30 to 2 ccm. ' scoparii fl. f 3 ss to j 2 to 4 ccm. ' senegae fl. TTLV tO XV 0.30 to 1 ccm. ' sennae fl. f 3 j to iv 4 to 16 ccm. ' serpent, fl. TTLxxx to lx 2 to 4 ccm. ' simarubae fl. TTLxv to XXX 1 to 2 ccm. ' spigeliae fl. TTLxv to lx I to 4 ccm. 1 spigeliae et sennae fl f 3 ss to ij 2 to 8 ccm. ' stillingiae fl. . f 3 ss to ij 2 to 8 ccm. 1 stillingiae comp. f 3 ss to ij 2 to 8 ccm. 1 stramonii (Engl.) gr. i to j 0.03 to 0.05 gm. * stramonii fol. ale. gr. i to 1 0.02 to 0.04 gm. ' stramonii sem. gr. i to i 0.01 to 0.03 gm. i=;2 CLINICAL DIAGNOSIS. Dose expressed in terms of Dose Remedies. apothecaries' expressed in weights metric terms. and measures. Extr. stramonii fl. . TT^j to vi 0.05 to 0.40 ccm. " sumbul fl. TTJ,XV to lx 1 to 4 ccm. " taraxaci . gr. v to xv O.30 to I gm. " taraxaci fl. f 3 ss to ij 2 to 8 ccm. " toxicodendri fl. Taj to v O.05 to O.30 ccm. " trifol. prat. fl. f 3 j to ij 4 to 8 ccm. " urticse rad. fl. . v\v to xv 0.30 to I ccm. " ustilag. maid. fl. TTIXV to lx 1 to 4 ccm. " uva? ursi fl. TT^xxx to lx 2 to 4 ccm. " valer. gr. v to xv 0.30 to I gm. " valer. fl. TTlxxx to lx 2 to 4 ccm. " veralr. vir. fl. TT[ij to viij 0.10 to O.50 ccm. " verbense fl. TT[XV to lx I to 4 ccm. " viburni opuli fl. i 3 j to ij 4 to 8 ccm. " viburni [prunifol] fl i 3 j to ij 4 to 8 ccm. " yerbse santae fl. i 3 i to 3 j 1 to 4 ccm. " zingiberis fl. TI[v to XXX 0.30 to 2 ccm. Ferri arsen. gr. ¥ V to i O.003 to 0.03 gm. " benzoas . gr. j to v 0.05 to 30 gm. " bromid. . gr. j to v 0.05 to 0.30 gm. " carb. sacch. gr. iv to xv 0.25 to I gm. " chlorid. . gr. j to iij 0.05 to 0.20 gm. " citr. gr. v to x 0.30 to 0.60 gm. " et ammon. citr. gr. v to x 0.30 to 0.60 gm. " et ammon. sulph. gr. v to x 0.30 to 0.60 gm. " et ammon. tartr. gr. v to xv 0.30 to I gm. " et cinchonid. citr. gr. v to x 0.30 to 0.60 gm. 1 ' et pot. tartr. . gr. xv to lx I to 4 gm. " et quin. citr. . gr. v to x 0.30 to 0.60 gm. " et strychnin, citr. gr. j to xv 0.05 to I gm. " ferrocyanid. gr. iij to v 0.20 to 30 gm. 44 hypophosphis . gr. v to x 0.30 to 0.60 gm. 44 iodidum . gr. j to v 0.05 to O.30 gm. " iodidum sacch. gr. ij to x 0. 10 to 0.60 gm. " lactas gr. j to iij 0.05 to 0.20 gm. 44 oxalas gr. j to iij 0.05 to 0.20 gm. " oxid. hydrat. . I ss to ij 15 to 60 ccm. " oxid. magnet. gr. v to x 0.30 to 0.60 gm. " phosphas gr. j to v 0.05 to 0.30 gm. " hypophosphas gr. j to v 0.05 to 0.30 gm. DOSE TABLE. 153 Dose expressed in terms of Dose Remedies. apothecaries' expressed in weights metric terms. and measures. Fcrri sub-carb. .... gr. v to xxx 0.30 to 2 gm. " sulphas . gr. j to iij 0.05 to 0.20 gm. " sulphas exsiccat. gr. \ to \\ 0.03 to O.08 gm. " valer. gr. j to iij 0.05 to O.20 gm. Ferrum ammoniat. . gr. v to x 0.30 to 0.60 gm. " dialys. THj to XV 0.05 to I ccm. " redact. gr. j to v 0.05 to 0.30 gm. Filix mas 3 j to ij 4 to 8 gm. Fuchsine . gr. j to iij 0.05 to 0.20 gm. Galla gr. x to xx 0.60 to 1.20 gm. Gambogia gr. ij to iij 0.10 to O.20 gm. Gentiana gr. x to xxx 0.60 to 2 gm. Guarana . gr. v to xxx 0.30 to 2 gm. Hydrarg. c. creta gr. v to x 0.30 to 0.60 gm. " chlor. corros. gr. ci- to jV O.OOI to 0.005 gm. " chlorid. mite gr. \ to vnj O.oi to 0.50 gm. " cyanid. gr- h to £ 0.004 to O.03 gm. " iodid. flav. g r - \ to j o.oi to O.05 gm. " iodid. rubr. g r - h to £ 0.004 to 0.03 gm. " iodid. vir. g r - \ to j 0.01 to 0.05 gm. " oxid. flav. gr- tV to £ 0.004 to 0.03 gm. " oxid. nigr. gr- iV l0 J 0.005 to 0.05 gm. " oxid. rubr. gr- iV to £ 0.004 to 0.03 gm. " subsulphas flav. gr. i to j 0.015 to 0.05 gm. " sulphuret. nigr. gr. v to x 0.30 to 0.60 gm. " sulphuret. rub. gr. v to x 0.30 to 0.60 gm. " c. magn. . gr. v to x 0.30 to 0.60 gm. Infusum brayeroe 1 1 ij to viij 60 to 250 ccm. " buchu f§ij 60 ccm. " digitalis f 3 ij to iv 8 to 16 ccm. " eupatorii f Iij 60 ccm. " sennce comp. f 1 j to ij 30 to 60 ccm. " ulmi . Ad libitum-. Ad libitum. Iodinum . gr. i to j 0.015 to O.05 gm. Iodoform urn gr. j to iij 0.05 to 0.20 gm. Ipecacuanha expect. gr- I to j 0.01 to 0.05 gm. emet. . gr. xv to xxx 1 to 2 gm. Jalapa gr. xv to xxx 1 to 2 gm. Juniperi baccce 3 j to ij 4 to 8 gm. Kairine . rr. ij to x 0. 10 to 0.60 gm. 154 CLINICAL DIAGNOSIS. Dose expressed in terms of Dose Remedies. apothecaries' expressed in weights metric terms. and measures. Kino ...... gr. x to xxx o.6o to 2 gm. Krameria ..... gr. x to xxx o.6o to 2 gm. Lacto-peptine ..... gr. x _ o.6o gm. Lactucarium ..... gr. iij to x 0.20 to o.6o gm. Liq. ammon. acet. .... f 3 ij to viij 8 to 25 ccm. " acidi arseniosi .... TTlij to vij 0. 10 to 0.50 ccm. ' ' arsen. et hydr. iod. (Donovan's sol.) niij to vij 0. 10 to 0.50 ccm. " ferri chloridi .... TT^ij to X 0. 10 to 0.60 ccm. " ferri dialys. .... TT[j tO XV 0.05 to 1 ccm. " ferri nitrat. .... V\y to XV 0.30 to 1 ccm. " pepsini ..... f 3 ij to iv 8 to 16 ccm. " potassse ..... TT[v to XXX O.30 to 2 ccm. " potassii arsenit. (Fowler's solution) Til iij to vij 0.20 to O.50 ccm. " potassii citrat. f 3 ij to iv 8 to 16 ccm. " sodse ..... TT[v to xxx O.30 to 2 ccm. ' ' sodii arseniatis (Pearson's solution) TT[iij to vij 0.20 to 0.50 ccm. Lithii benzoas ..... gr. ij to v 0.10 to 0.30 gm. " bromid. . . . . . gr. i to iij 0.05 to 0.20 gm. " carb. ..... gr. ij to vi . 0.10 to 0.40 gm. " citr gr. ij to v 0.10 to 0.30 gm. " salicylas .... gr. ij to viij o.to to 0.50 gm. Lobelia ...... gr. v to x 0.30 to 0.60 gm. Lupulinum ..... gr. v to x 0.30 to 0.60 gm. Magnesia ..... gr. xv to Ix 1 to 4 gm. Magnesii carb. .... gr. xv to lx 1 to 4 gm. " citr. gran. 3 j to viij 4 to 32 gm. " sulphas .... 3 j to viij 4 to 32 gm. " sulphis .... gr. v to xxx 0.30 to 2 gm. Manganesii oxid. nigr. (binoxid.) gr. ij to x 0.10 to 0.60 gm. " sulphas .... gr. ij to x 0. 10 to 0.60 gm. Manna ...... I i to ij 30 to 60 gm. Massa copaiba? .... gr. v to xxx 0.30 to 2 gm. *' ferri carb. .... gr. v to xv 0.30 to 1 gm. " hydrarg. .... gr. i to xv 0.05 to 1 gm. Mist ammoniaci . . . . f 3 iv to viij 15 to 30 ccm. " asafoetidse .... f 3 iv to viij 15 to 30 ccm. " chloroformi .... f 3 iv to viij 15 to 30 ccm. " cretae ..... f 1 j to ij 30 to 60 ccm. " ferri comp. . f § ss to ij 15 to 60 ccm. " ferri et ammon. acet. f | ss to j 15 to 30 ccm. DOSE TABLE. 155 Dose expressed in terms of Dose Remedies. apothecaries' expressed in weights metric terms. and measures. Mist glycyrrh. com p. f 3 j to iv 4 to 16 ccm. " magnes. et asafcet. f 3 j to iv 4 to 16 ccm. " potassii citr„ f § ss to ij 15 to 60 ccm. " rhei et sodae f | ss to j 15 to 30 ccm. Morphiae murat. gr- i to | 0.01 to 0.03 gm. ' ' sulph. gr- ¥ to i 0.008 to 0.03 gm. acetat. gr. i to $ 0.01 to 0.03 gm. " sulph. liq. . f 3 j to iv 4 to 16 ccm. " sulph. liq. (Mag< ;ndie TTLij to XV 0.10 to 1 ccm. Moschus . gr. v to x 0.30 to 0.60 gm. Myrrha .... gr. x to xx 0.60 to 1.20 gm. Napthalin gr. j to ij 0.05 to 0.10 gm. Narceina . gr. £ to ij 0.01 to 0.10 gm. Nicotia . gr-