9 ^/^ €52--^*^ ^=^1^1, ?il21 4^7 /m- COLLEGE OF PHYSICIANS AND SURGEONS LIBRARY Casino Book C M. C. WYMAN, Manager, 1374 - 1376 Broadwaj New York.' I A CLINICAL TEXT-BOOK MEDICAL DiAaFOSIS PHYSICIANS AND STUDENTS BASED ON THE MOST RECENT METHODS OF EXAMINATION. BY OSWALD VIERORDT, M.D., PROFESSOR OF MEDICINE AT TUE UNIVERSITY OP HEIDELBERG, FORMERLY PRIVAT-DOCENT AT THE UNIVERSITY OP LEIPZIG ; LATER, PROFESSOR OP MEDICINE AND DIRECTOR OF THE MEDICAL POLYCLINIC AT THE UNIVERSITY OP JENA. AUTHORIZED TRANSLATION, WITH ADDITIONS, BY FRANCIS H. STUART, A.M.,M.D., MEMBER OF THE MEDICAL SOCIETY OF THE COUNTY OF KINGS, NEW YORK ; FELLOW OF THE NEW YORK ACADEMY OP MEDICINE, MEMBER OF THE BRITISH MEDICAL ASSOCIATION, ETC. THIRD REVISED EDITION. WITH ONE HUNDRED AND SEVENTY-EIGHT ILLUSTRATIONS, Many of which are in colors. PHILADELPHIA: W. B. SAUNDERS, 925 Walnut Street. 1894. 'lev Entered according to the Act of Congress, in the years 1891, 1893, by W. B. SAUNDERS, in the Office of the Librarian of Congress, at Washington. Press of W. B. Saunders, Philadelphia. VORWORT DES AUTORS ZUR ENGLISCHEN AUFLAGE. Es gereicht mir zur lebhaften Genugthuung, Herrn Francis H. Stuart, M.D., meinen Dank daftir auszusprechen, dass er es unter- nommen hat, meine Diagnostik in das Englische zu dbersetzen Ich bezweifle nicht, dass die Ubersetzung ihm gut gelungen ist, und gebe ihr den Wunsch mit auf den Weg, dass sie sich in der neuen Welt ebenso viele Freunde erwerben moge, wie die deutsche Ausgabe in Deutschland gefunden bat. Heidelberg, SOsten M'arz, 1891. Prof. Dr. 0. VIERORDT, Director der Poliklinik. (iii) TRANSLATOR'S PREFACE TO THE THIRD EDITION. The rapid sale of the second edition, which was quite large, has enabled the Translator to subject his work to another careful re- vision. For the correction of many slight errors and suggestions of improvement he is indebted to Professor George Dock of the University of Michigan, who was a pupil of the Author, and who uses the work as a text-book in his classes. The Translator desires to express his gratification that this valu- able work of Professor Vierordt has met in its English dress such universal welcome and appreciation. This generous reception by the profession has been a reward for his labor, and a stimulus to him to make the work still more Avorthy of its popularity. FRANCIS H. STUART. 123 JoRALEMON Street, Brooklyn, N. Y., TRANSLATOR'S PREFACE. The work of which a translation is here offered is one of the best that has yet been written upon the subject. When it first came into the hands of the translator he had no thought of ever using it except as a work of reference. But as he read it he became convinced that it had such merit that it would certainly be welcomed by a large class of readers if it were rendered into English. Accordingly, after com- municating with the author and his publisher, the work of translation was begun, and has been prosecuted at such intervals of time as could be secured from an active professional life. If the work shall com- mend itself to others as it has to him, the translator will feel amply rewarded for the effort he has made to put it into their hands. Here and there slight additions have been made, which the trans- lator trusts will increase the value of the work. A very full index has been prepared, which, it is believed, comprises a reference to every material statement in the book. The translation was almost completed when a copy of the second edition of the original Avas received from the publisher. The author has made numerous additions which have enhanced its value, and the translation has been made to correspond with this enlarged edition. It is gratifying to the translator to find that a second edition has so soon been called for, and that his own favorable opinion has been further confirmed by the fact that Italian and Russian translations of the work have been made. FRANCIS H. STUART. 123 JoRALEMON Street, Brooklyn, N.Y., March, 1891. (V) AUTHOR'S PREFACE TO THE SECOND EDITIO:^. IjST this edition the book has received, as I think, not incon- siderable additions and improvements. To mention only the most important ones : The section upon the examination of the contents of the stomach has been almost entirely rewritten, and so have some portions of the section on the examination of the organs of the senses, especially that of the" eye. The laryngoscopic examination of the larynx has been treated anew, and much more extensively than in the first edition. A short section, almost entirely new, has been added upon the enlargement of the vessels of the brain, and at the end of the book a concise presentation of those peculiarities of micro- organisms whose recognition and discrimination are made possible by cultures and inoculation. Finally, with the hearty cooperation of the publisher, the illustrations of the most important micro- organisms are printed in colors, and also some entirely new figures have been added. I am indebted to the friendly assistance of Professor Gartner in the department of bacteriology, of which I here make public acknowledgment. OSWALD VIERORDT. Jena, August, 1889. vi) PREFACE TO THE FIRST EDITION. The book which is here offered to the medical public was under- taken at the solicitation of a number of associates, and in view of the experience which I have acquired during more than four years of work as Teacher of Diagnosis in the Medical Clinic at the University of Leipsic. Originally I had in view a very extensive treatise com- prising a detailed explanation of normal and pathological anatomy and physiology as a foundation for diagnosis. But this plan I abandoned with a view to the convenience and general usefulness of the book. Regarding the principles which have guided me, and which I hope, particularly in the " Special Part," notwithstanding the brevity of the presentation, have been made plain, I may be permitted here to specify the following. I have here, as well as in my teaching, taken pains to emphasize that, besides availing ourselves of the constantly- increasing finer methods of diagnosis, the simple use of our senses, especially of the unaided eye, must not be forgotten. Still more the manifold labors with the microscope and in the laboratory ought not to permit the physician to forget that a preparation or a chemical reaction is not enough for a diagnosis, but that the whole organism must always be brought under consideration. In other words, in diagnosis as well as therapeutics this rule is imperative : We must individualize the case. Should the book to any extent antagonize the inclination of our time to theorizing, it would afford me especial satisfaction. OSWALD VIERORDT. Leipsic, June^ 1888. (vii) , CO:^TENTS. PART I, CHAPTER I. INTRODUCTION. rAGE Anamnesis ............ 18 Mode of Taking the Anamnesis 19 What the Anamnesis Comprises .20 Previous History of the Patient ... 20 The Present Disease . 22 CHAPTER II. EXAMINATION OF PATIENTS, What the Examination Comprises . 24 [Note by the Translator upon Keeping Records of Cases, and a Form for Recording the Results of a Medical Examination] ... 24 PART II CHAPTER III. GENERAL EXAMINATION I. The Psychical Condition of the Patient . II. The Position of the Patient III. The Structure of the Body and Nutrition IV. Skin and Subcutaneous Cellular Tissue . A. The State of Nutrition of the Skin . B. The Moisture of the Skin ; Perspiration 31 31 33 36 36 36 (ix) 5 CONTENTS. PAGE C. The Color of the Skin 38 1. The Pale Skin 39 2. Abnormal Redness of Skin 41 3. The Blue-red Skin, Cyanosis 42 4. The Yellow Skin, Icterus, Jaundice 45 5. The Bronze Skin 48 6. The Cray Skin of Silver Deposit ..... 49 D. Other Pathological Appearances of the Skin which are of General Diagnostic Value 49 1. Acute Exanthematous Diseases . . ... 49 2. Exanthemata from Poisons and the Use of Medicines . 50 3. Hemorrhages in the Skin 51 4. Scars 52 E. CEdema of the Skin and Subcutaneous Cellular Tissue (CEdema, Anasarca) ....... 52 F. Emphysema of the Skin 55 V. The Temperature of the Body. Fever 57 1. The Terms Used and the Method of Taking the Temperature 57 2. The Normal Temperature of the Body . . ... 59 3. Elevated Temperature. Fever . . . . . .60 4. The Subnormal Temperature . , . . . . .63 5. Diagnostic Value of the Temperature, especially of its General Course 64 6. Local Elevation or Lowering of the Temperature ... 71 PART III. CHAPTER IV. EXAMINATION OF THE RESPIRATORY APPARATUS. Examination of the Nose and Larynx 73 1. The Nose 73 2. The Larynx . 74 Examination of the Lungs . 76 Topographical Anatomy of the Lungs 76 The Anatomical Boundaries of the Lungs with Reference to the Thorax 77 Inspection of the Thorax 81 1. Normal Form of Thorax and Normal Respiration . . 81 2. Pathological Forms of Thorax 83 3. Anomalies of Respiration ... , ... 89 CONTENTS. xi PACE Palpation of the Thorax 100 1. Pain caused by Pressure upon the Thorax .... 101 2. Testing the Movement during Respiration .... 102 General and Preliminary Remarks Regarding Percussion . . 103 1. History and Methods 104 2. Qualities of Sounds 106 3. The Conditions that determine the Quality of the Sounds and their Production in the Body. The Feeling of Re- sistance .......... 109 4. Topographical Percussion : Determining the Parietal Bound- aries of Organs ......... 116 Percussion of the Thorax, Especially of the Lungs . . . 118 1. Methods 118 2. Normal Sound over the Lungs, Trachea, and Larynx. The Normal Boundaries of the Lungs 119 3. Abnormal Sound over the Lungs. Abnormal position of the Border of the Lungs 125 The Second Quality of Sound which is found over Diseased Lungs 130 Auscultation of the Lungs- 138 1. History. The Sphere of Auscultation at the Present Time 138 2. Methods of Auscultation 138 3. Auscultatory Signs in Normal Respiration .... 141 4. Pathological Sounds in the Respiratory Apparatus . . 144 Palpation of Vocal Fremitus (Auscultation of the Voice) . . 156 Exploratory Puncture of the Pleura 160 Methods of Measuring and Stethography 162 Measuring the Thorax 162 Spirometry, Pneumatometry, and Stethography .... 163 Cough and Expectoration 164 Expectoration, Sputum 167 1. General Characteristics of the Expectoration . . . 168 2. Foreign Substances in the Sputum which are Visible to the Unaided Eye 171 3. Microscopical Examination of the Sputum .... 175 CHAPTER V. EXAMINATION OF THE CIECULATOEY APPARATUS. Examination of the Heart 191 Anatomy of the Normal Heart 191 Preliminary Remarks necessary to Understand the Physical Phe- nomena of the Heart 193 xii CONTENTS. PAOB Inspection and Palpation of the Region of the Heart . . . 197 The Apex-beat 197 Alteration in the Width and Strength of the Apex-beat . . 200 The Neighborhood of the Heart in general .... 202 The Epigastrium 204 Percussion of the Heart 204 Normal Percussion Figure of the Heart 205 Methods of Percussion 205 Enlargement of the Area of Heart-dulness .... 208 Diminution or Loss of Heart-dulness 210 Displacement (dislocation) of the Heart-dulness . . . 210 Auscultation of the Heart 211 Method and Normal Condition 211 Pathological Changes in the Heart-sounds .... 216 Organic Endocardial Heart-murmurs 221 Inorganic, Anaemic Murmurs. (Synonyms : accidental, blood murmurs.) 229 Pericardial Murmurs. [Friction-sounds.] .... 230 Examination of the Arteries 234 I. The Pulse, its Palpation and Graphic Representation . . 234 Palpation of the Pulse 234 1. The Normal Pulse 234 2. Pathological Frequency of the Pulse .... 237 3. Want of Rhythm of the Pulse 241 4. Quality of the Pulse 241 6. Symmetry of the Radial Pulse . . . . . 245 II. Other Phenomena in Arteries 253 Examination of the Veins 260 Inspection and Palpation of Veins 260 1. Increased Fulness of Veins 260 2. Phenomena of Circulation in the Jugular Veins . . . 262 3. Phenomena of Circulation in Other Veins .... 267 4. Venous Thrombosis 268 Auscultation of Veins 268 Examination of the Blood 270 Preliminary Remarks 270 1. Color and Spectroscopic Character of the Blood . . . 270 2. Microscopic Examination of the Blood .... 273 CHAPTER VI. EXAMINATION OF THE DIGESTIVE APPARATUS. Mouth, Palate, and Pharyngeal Cavity 284 Examination of the CEsophagus . 291 CONTENTS. xiii PAGE Examination of the Stomach 297 Anatomy of the Stomach 297 Inspection and Palpation of the Stomach 299 Percussion of the Stomach . 304 Auscultation of the Stomach 307 Examination of the Intestines . ....... 308 Inspection and Palpation . . . . . . . . 308 Percussion of the Intestine 311 Auscultation of the Intestine 312 Examination of the Peritoneum . . . . . . . 312 Inspection of the Abdomen 313 Examination of the Liver \ . 319 Inspection of the Liver 320 Palpation of the Liver . 323 Percussion of the Liver 326 Examination of the Spleen 332 Inspection of the Spleen 334 Palpation of the Spleen 334 Percussion of the Spleen 336 Auscultation of the Spleen 339 Examination of the Pancreas, Omentum, Retro-peritoneal Glands . 340 Examination of the Contents of the Stomach 341 Examination of the Process of Digestion 342 Stomach-digestion and its Disturbances 342 Mode of Procedure in Examining the Stomach-digestion . 347 Vomiting, and the Examination of What is Vomited .... 358 The Vomit 359 Animal Parasites 377 CHAPTER VII. EXAMINATION OF THE URINARY APPARATUS. Examination of the Kidneys 392 Anatomy 392 Local Examination of the Kidneys 394 Pathological Conditions of the Kidneys 394 Examination of the Ureters and Bladder 398 Examination of the Urine 399 (A) Normal Urine 401 (B) Pathological Urine 406 Sediments of Organic Bodies, or Direct Products of These . 416 Inorganic Sediments 428 Examination of the Urinary Constituents in Solution . . 433 Bile-pigments and Bile-acids 442 The Urine as Affected by Medicines 460 xiv CONTENTS. CHAPTER VIII. EXAMINATION OF THE NEBVOUS SYSTEM. PAGE Anatomy ; Normal and Pathological Physiology ..... 452 1 . The Cortico-muscular Tract (the Pyramidal Tract, Flechsig) . 452 2. The Sensitive or Centripetal Tracts 459 3. Centres and Tracts of the Special Senses 460 4. Remarks upon the Vessels Supplying the Brain .... 461 Symptomatology and Methods of Examination 463 Examination of the Seat of Disease 463 The Spinal Column 467 The Peripheral Nerves and their Surroundings .... 468 Examination of the Condition of the Mind 469 Disturbances of Sensibility 472 1. Sensitiveness to Peripheral Irritation 472 [a) Sensibility of the Skin 473 [b] Deep Sensibility 479 The Knowledge of Form (Stereognosis) 481 2. Sensible Phenomena of Irritation and Pain from Pressure upon Nerves 482 1. Parsesthesia 482 2. Spontaneous Pain 482 3. Distribution of the Sensory Cutaneous Nerves .... 484 Disturbances of Motility 488 1. Paralysis 488 2. Disturbance of the Nutrition and Tone of the Muscles . . 489 3. The Reflexes 495 1. Skin Reflex 495 2. Tendon Reflexes (periosteal, fascial reflex) .... 497 4. Electrical Examination of the Nerves and Muscles . . . 501 Regarding the Physics, and the Instruments Employed '. . 501 Methods of Examination and their Physiological Results upon the Living Human Body . 505 General Methods, and Explanation of the Terms Employed in Galvanic Examinations 506 Method of Examination in Detail. Normal Condition . . 507 1. Points of Stimulation 508 2. Examination 510 (a) Faradic Examination . . ' . . . . 512 [b) Galvanic Examination 515 3. What to Observe in Determining the Electrical Re- action 516 Faradic Current 517 Galvanic Current 517 CONTENTS. XV PAGE 1. The Reaction of Degeneration (EaE) 619 (a) Complete EaR . . 619 [b) Partial EaR .619 Varieties of EaR 523 (e) Mixed Electrical Reaction 523 2. Myotonic Reaction (Erb) 524 3. Diagnostic Value of the Electrical Condition . . . 524 4. Mechanical Excitability of Muscles and Nerves . . . 526 5. Coordination and Ataxia 527 6. Spasms of the Voluntary Muscles ..... 530 7. Voluntary Muscles, their Innervation, their Function, and the Diseases that Disturb Them 536 Disturbances of Speech (Lalopathy) 548 I. Dysarthria and Anarthria 548 II. Aphasic Disturbances, Disturbance of Graphic Communica- tion (of Mimicking and Singing) 549 Mode of Procedure in Testing for Aphasic Disturbances . . 555 Sense Organs 561 Disturbances of the Vegetative System in Nervous Diseases . . . 575 1. General Phenomena 575 2. Disturbances of the Respiratory Apparatus . . . 575 3. Disturbances in the Circulatory Apparatus .... 576 4. Disturbances of the Digestive Apparatus .... 577 5. Disturbances of the Urinary Apparatus . ■ . . . 579 6. Disturbances of the Genital Apparatus .... 580 7. Disturbances of the Skin 581 Bones and Joints 583 The Diagnostic Value of the Symptoms in Nervous Diseases . 583 APPENDIX. 1. Laryngoscopic Examination of the Larynx 589 Paralysis of the Muscles of the Larynx 597 2. Examination with the Ophthalmoscope 600 3. Bacteria which come under Consideration in the Diagnosis of In- ternal Diseases 602 MEDICAL DIAGNOSIS. PART I. CHAPTER I. INTRODUCTION. The physician arrives at an opinion regarding his patient in two ways : by inquiry of the patient or of friends of the patient, and by his own objective examination. The result of the former is called the Anamnesis ; the latter reveals the Present Condition of the Patient. The notes which the physician makes from time to time in the course of his continued observation of the patient, and in which he records the changing phenomena of the disease, constitute the History of the Case. The judgment formed in this way is expressed by the Diagnosis. In a narrow sense such a judgment simply consists in giving a name to the disease that is found; or, if there are several diseases together, or special complications of one, names to several diseases. But in the wider sense, a diagnosis must always consist of something more than this. The physician must endeavor to form a clear conception, in a given case, as to how the whole organism has been affected from the beginning, what is the character of the disease, or what harm it has wrought already in the organism as a whole, as well as locally. If in the narrow sense the diagnosis is schematic, so that the disease can be classified, then the diagnosis is in a broader sense indi- vidualized. A complete, exhaustive presentation of the peculiarity and severity of the existing disease and of the patient's prospects •2 (17) J 8 MEDICAL DIAGNOSIS. (Prognosis) is presented only by this method. This alone is a sure guide in treatment. We attain to a diagnosis in this wider sense only by having our perception of the general behavior of patients quickened and by carefully combining with it the experience derived from previous examinations. Since the chief object of this work is the teaching of the examination of patients and the presentation of the methods of conducting it, we begin with but a very few words in regard to obtaining the Anamnesis. What is it necessary for the physician to know, beyond what his examination reveals, in order to recognize a given disease in itself and to form a critical judgment regarding the patient in a larger sense ? It is difficult to define this. Facts which appear insignificant in themselves in experience often exercise a decided influence upon the special diagnosis, and especially in forming a judgment regarding the constitution of the patient, or upon the timely recognition of a secondary disease. From having at hand clear knowledge of the symptoms of the different diseases, both of their remote or predisposing and of their directly exciting causes, the physician is constantly able to select what is essential from the past, and so to avoid too great prolixity. But it is always well for the beginner to secure as com- plete an anamnesis, or prior history, as possible, in order that he may allow nothing of importance to escape his attention. The anamnesis generally begins with and involves the question as to whether the disease is acute or chronic, what organs are affected, or are inclined to be diseased. This determines the examination to follow, in that certain organs are examined with greater exactitude than others. But the examiner must guard himself from too great influence or prejudice from the result of the anamnesis ; the objectivity of the objective examination must be kept in view ; and this, in turn, may give occasion for supplementing the anamnesis, by occasioning additional inquiries regarding certain occurrences and appearances, and thus a conclusion is finally reached. It is advisable for the student, under all circumstances, with all the patients he examines, and for the physician at least with his more important cases, to note INTRODUCTION. 19 down in regular order the results both of the anamnesis and of his examination. [See Translator's note, page 24 et seq.~\ Mode of Tahing the Anam^iesis. First, we always note the name, occupation, age, residence of the patient. Then we conduct, as simply as possible, a dialogue with the patient, or in the case of a child or of a person who is insensible, unconscious, or mentally disturbed, with his neighbors or relatives. How much we may allow them simply to tell, how much we must learn by asking questions, must depend upon the cultivation and intelligence of the person who is giving the information. We must particularly guard against asking the patient leading questions — that is, influencing his reply by the manner in which we put the questions. To the question : " Have you then really never had any pain in the bowels ?" or, " Did you never have any pain in the bowels?" we shall almost certainly receive an affirmative answer, either from indiiference, or from a desire to make his complaints as interesting as possible and enlarge upon them ; or, lastly, whether because he is of a very impres- sionable nature, and the mere calling to mind the question of pain suggests to him what in reality he has not had. On the other hand, we must exercise close scrutiny of what we learn, a scrutiny which it is generally best not to allow the patient to know of. This scrutiny may be made with reference to three points : (a) We must not accept without further inquiry the name the patient gives to a disease he has formerly passed through, since mis- chief is often done by the laity in the use of the names of diseases, as of diphtheria, typhus, etc. In any doubtful case we inquire its symptoms, and also what the physician who attended the patient had called the disease. (b) The simulation of a disease is common. This was confined in large part to the domain of hysteria ; but, now-a-days, from certain social reasons, it is much more frequent. Neuralgia, rheumatism, trembling, spasms, lameness, also pains in the bowels, asthmatic attacks, are the conditions which are most often simulated. The attempt to deceive is made not only with reference to the anamnesis, but also during the objective examination. ((?) The concealment of the appearances of disease is manifest with reference to the different sexual diseases, especially syphilis. Women, 20 MEDICAL DIAGNOSIS. moreover, often attempt to avoid all statements in regard to the sexual apparatus, even when it alone is diseased. Inebriates, and those who practise onanism, often confess their habits to the physician only with great reluctance. What the Anamnesis Comprises. The exact knowledge of the etiology and symptomatology of internal diseases is here the only correct guide, and, at the same time, gives us complete information respecting the cases which, under various cir- cumstances, come under consideration. We are content with indi- cating the essential point of view by the introduction of a few examples. We may divide every anamnesis into the following two parts : I. Previous history of the patient : This comprises all that it is important to know up to the beginning of the disease on account of which the patient consults the physician. II. The present disease : This relates to the exciting causes, the commencement, and the course to the present time. Previous History of the Patient. 1. Hereditary disease {heredity). This is of importance in so many diseases that in each and every case we have to inquire regard- ing the parents, brothers and sisters of the patient, and also very often regarding the brothers, sisters, and parents of the parents. There especially come into view in this connection, syphilis, tuberculosis, diseases of the brain, and certain general neuroses. Heredity, as regards rheumatism, carcinoma, and diseases of the heart, is of sec- ondary importance, yet not immaterial. These diseases are in part inherited as such, in part they confer upon the descendants only the organic foundation, the disposition to the new development of the same or related diseases. Different descendants are variously divided by heredity. Often individuals, or a majority, are wholly exempt. It also happens that one generation is entirely passed over, and the trouble reappears in the following generation (hence the question regarding the grandparents). Of the infectious diseases, smallpox and syphilis can, without INTRODUCTION. 21 doubt, be conveyed in utero; but the intra-uterine communication of tuberculosis from the mother to the child is extremely improbable. 2. The manner of life, habits, profession, occupation, residence, experiences as to fatigue^ other harmful influences to which they have been exposed, whether they have descendants, and, in the case of women, the number and character of their confinements, compose this group. Under the manner of life are considered the diet, character of dwelling, and the clothing. Injurious habits play a very important part in the manner of life, especially immoderate use of alcohol and tobacco ; so, also, venereal excesses must be taken into account. But it is important to remember that, at least within certain limits, the harmful limit of these things differs with the individual. Profession and occupation on the one hand affect the whole consti- tution, and on the other are often to be regarded as predisposing or exciting causes of disease ; finally, they may exert a favorable or an unfavorable influence upon the course of an existing chronic disease. Thus, for instance, stonecutters and polishers, by continually inhaling fine dust from the stone, are very frequently inclined to bronchial attacks and diseases of the lungs ; thus, too, the occupations that have to do with lead (type-setting, type-polishing, painting), or with mer- cury (making mirrors, etc.), frequently cause chronic poisoning by these metals. Persons who are engaged about sheep, swine, horses, or with the fresh skins and hair of these animals, are apt to have malignant pustule and other diseases. The place of prior residence is to be considered with reference to miasmatic (intermittent), endemic diseases, or epidemics which may have prevailed there at that time. With travellers, exotic diseases, which less frequently occur in their native places, as lepra, certain exotic animal parasites, etc., must be thought of As regards fatigue, army marches are to be regarded as particularly fruitful sources of disease ; so of exposure to harmful influences. A fall, slight, perhaps, but whose effects continue ; or a wound, without other immediate sequelae except that it does not heal — of these, account must be taken ; and also of very harmful momentary experiences, as sorrow, care, severe fright, anxiety. Where there is sterility we consider anomalies of the sexual apparatus of the man or woman, but especially the question of syphilis. The 22 MEDICAL DIAGNOSIS. puerperal period, even when it does not pursue an unfavorable course, may in various ways be a source of disease. 3. Diseases which one has had, not only acute diseases, but the temporary outbreak of a chronic disease ending in apparent or real recovery. Certain acute diseases may have as sequelae certain other diseases which either are directly connected with them, as paralysis following diphtheria, nephritis after scarlet fever; or which appear after a shorter or longer period, as valvular disease of the heart from endo- carditis in acute articular rheumatism, arising during scarlet fever. The outbreaks of a chronic disease are often spoken of by patients as diseases which they have gone through ; as, especially, the primary and secondary affections of syphilis, temporary manifestations of tuberculosis of the lungs, etc. This point is of special importance in two ways : 1. There are certain acute diseases which one does not easily have a second time, as scarlet fever, measles, typhoid fever. On the other hand, others readily occur again, as erysipelas, pneumonia, articular rheumatism, typhlitis. 2. Certain diseases of childhood are ' especially to be con- sidered — for example, scrofulosis as early indications of tuberculosis ; manifestations of hereditary syphilis ; frequent convulsions as an early sign of anomalous condition of the nervous system. The dis- eases ordinarily designated as "children's diseases" generally have no significance as to the future, but yet sometimes, unfortunately, they leave lasting suffering behind them, as emphysema after whooping- cough, etc. The Present Disease. 1. The possible exciting causes must be first considered. It is especially important for the early diagnosis of an infectious disease to inquire whether the patient has been exposed to infection. Many diseases are conveyed by a very short exposure, others require a longer, or even a personal contact. Also the period of incubation must be considered. This is the period from the moment of infection until the outbreak of the disease. With most transferable diseases this period is of a known, somewhat exactly defined duration. More- over, "taking cold," over-exertion, improper eating and drinking, taking of poison, etc., come under consideration. INTRODUCTION. 23 It is to be remarked that the laity often assume something as an exciting cause, thus especially "taking cold." 2. The first appearances and the course of the disease up to the time of examination. With chronic diseases the first appearances are sometimes at the beginning scarcely noticeable : they often consist only in a change from the previous behavior, unless the new condition in itself directly appears to be one of disease ; a person who previously had red cheeks becomes paler (all kinds of wasting diseases), a stout person without other reason becomes thin, one who always previously ate and drank little, all at once eats and drinks considerably (diabetes), a person formerly very orderly becomes disorderly, forgetful (disease of the brain, especially progressive paralysis). Even when they have made considerable progress, such gradually developing disturbances often are not at all noticed by ignorant and indiflferent people. CHAPTER II. EXAMINATION OF PATIENTS. The examination of the patient comprises : 1. A general examination, which takes into account certain phe- nomena of disease which concern the organism as a whole, and are the expression of a pathological change of the whole organism. 2. A special examination, which inquires into the different regions and organs, the secretions and excretions of the body. At the bed- side we generally proceed in such a way that, beginning at the head, we gradually go downward, in order to facilitate the investigation by examining contiguous organs. But in many cases it is better to group together organs that are functionally related, no matter what their anatomical location may be, since we thus quickly obtain a compre- hensive view of the way in which the affected organs or systems are disturbed. Thus, in diseases of the heart, the heart and bloodvessels, in diseases of the nervous system, the central and peripheral nervous systems are examined together. Sometimes, as in the case of very weak or very unruly patients, as children, the examination of the body must be very brief. Here the expertness of the physician espe- cially is put to the test to the utmost degree. It will best answer the purposes of study if the division of the subject throughout strictly conforms to the organ-systems, and hence the special part is divided into : I. Examination of the respiratory apparatus. II. Examination of the circulatory apparatus. III. Examination of the digestive apparatus. IV. Examination of the urinary apparatus, including also in part the sexual apparatus. V. Examination of the nervous system. [note by the translator upon keeping records of cases, and a form for recording the results of a medical examination. It is not practicable at the bedside to go through any set form for conducting the inquiry regarding the present illness. The most direct (24) EXAMINATION OF PATIENTS. 25 way of getting at it, and the one that will lead to the most satis- factory replies to our interrogatories, is to ask the question, What is your complaint ? How are you sick ? or some such direct question as this. In this way we get at once at the disease we are called upon first to diagnose and then to treat. As we proceed we will arrange the facts in our minds, and when we make the record, we shall place them in a natural and logical order. Having a regular form for keeping records of cases soon develops an order of procedure in accordance with it. Case-taking is a most valuable aid to the student in clinical study. 1. He learns to make a systematic examination of the patients he sees. He forms the habit of bringing before his mind each factor in the case in orderly succession. There are two advantages from this. First. He forms the habit of thoroughness in examining his cases. Second. He can readily compare one case with another — having arranged the factors of each in like order. While it is not necessary in making the examination to have or to follow strictly a printed form, yet it is desirable to have some regular form for making the record, so that cases that are similar can be readily compared. One case may require going over only a few points, in another it will be necessary to examine every organ in the body. 2. The memory is greatly strengthened. Memory depends upon attention and repetition. Case- taking cultivates both of these in an eminent degree. Facts and symptoms that else would escape notice entirely, or be only slightly noted, are brought prominently before the mind for consideration. Their value or bearing is weighed, and so they are strongly impressed upon the mind. 3. The mind is developed by this habit of carefully reflecting upon every feature of a case. Thought is both stimulated and made easy. Clearness and power of thought are increased. Independence of judgment is cultivated. Both knowledge and intellectual cultivation are acquired. " By knowledge is understood the mere possession of truths ; 5y intellectual cultivation, or intellectual development, the power, acquired hy exercise of the higher faculties, of a more varied, vigorous and protracted activity.'' (Sir William Hamilton.) 4. Ease and habit of writing are almost unconsciously acquired. This is most valuable. The great majority of physicians keep no records of cases. Many never record or publish important ones, 26 MEDICAL DIAGNOSIS. because they have not the facility of -writing which comes with prac- tice. Anything is easy to the 2^fCLcti^^d hand. " Who can estimate how much we have lost, from the fact that generations of men gifted with powers of acute and shrewd observation, have passed away without leaving one record behind them ? Think not that it is the hospital physician or surgeon alone who can advance the progress of medicine. There is not a practitioner who could not aid this great work. But he can only add to it with efficiency if he has faithfully recorded his observations., and does not trust to the general and vague impressions of unassisted memory. Therefore, on all grounds, per- sonal to yourselves and general for medical science, so engrain this habit within you that it becomes a second nature." (Coupland.) The Anamnesis. Personal and Previous History. Name, Address, Birthplace, ^ge> Sex, Family history — Heredity : Father, Mother, Brothers, Sisters, Other relatives. Manner of life, habits, occupation, residence, etc.. Previous diseases — character and results. (Note each one that was of such a character as to have any lasting eflfect upon the health or vitality.) Present Illness. Duration, Possible exciting cause. How began — suddenly or not ; prodromal symptoms, Course of the disease till the time of examination. EXAMINATION OF PATIENTS. 27 Examination of the Patient. General examination : Appearance, Psychical condition, Position in bed, Structure and nutrition. Skin and subcutaneous tissues, Temperature, Pulse. This covers the general features of every case. Attention has been directed, by what has been learned thus far, to some one or more of the special organs or systems of the body. It is usually best first to examine that, and to make this examination very full and thorough. Then the remaining organs of the body can be examined with greater or less fulness, according as they are found to be aifected by the principal disease, or as they are related to the one specially diseased. It is well to form the habit of following a certain order in examining each organ. One is much less apt to overlook any part ; and, too, as has already been pointed out, the records will be more easily con- sulted and compared. For this purpose, it is well to take the order of the text-book, so as to become thoroughly familiar with each subject. It is not of so much importance that this or that one is adopted, pro- vided it is a good one. But we have here a notable illustration of the truth and value of the Spanish proverb: " Beware of the man of one book." Presuming that those who use this work will follow the order laid down in it, the form now given conforms with the order in which the systems are treated. Special Examination. Examination of the respiratory apparatus : Nose, Mouth, Larynx. 28 MEDICAL DIAGNOSIS. Examination of the lungs : Inspection of thorax, Palpation of thorax, Percussion of thorax, Auscultation of lungs, Auscultation of voice, Measurement of thorax, Cough and expectoration. Examination of circulatory apparatus: Inspection and palpation of the region of the heart, Percussion of the heart, Apex-beat, Auscultation of heart, Examination of the arteries and veins, Examination of the blood. Examination of the digestive apparatus : Mouth, gums, and pharynx. Stomach, Intestines, Peritoneum, Liver, Spleen, Pancreas, Contents of the stomach and vomited matters, Feces. Examination of the urinary apparatus : Kidneys, Ureters and bladder. Examination of the urine: Amount in twenty-four hours, Reaction, Odor, Specific gravity, Sediment, Albumin, Blood, Bile, Sugar, Other constituents. EXAMINATION OF PATIENTS. 29 Examination of the nervous system : Disturbances of sensibility, Location of, Superficial or deep, Motor disturbances, Disturbances of speech, Condition of the organs of special sense. PART II. CHAPTER III. GENERAL EXAMINATION. This consists of a number of subordinate divisions, namely: we have to consider : I. The psychical condition of the patient. II. The position in bed. III. The general structure of the body and the nutrition. IV. The skin and the subcutaneous cellular tissue. V. The temperature and the pulse. I. The Psychical Condition of the Patient. From this — that is, from the clearness of his intelligence, his sus- ceptibility to external impressions, his power of thought, from the possible presence of depression or irritability — we may often obtain important points of diagnosis ; both for diagnosis in the narrower sense, certain diseases being accompanied with definite manifestations of this kind, and for diagnosis in a broader sense, since the severity of a disease, the possible turn for better or worse, often becomes manifest by the psychical condition of the patient. (Regarding this and the way in which the examination in this direction is conducted, see the section on " Examination of the Nervous System.") II. The Position of the Patient. This furnishes a very simple aid to diagnosis, because generally it can be determined by a single glance of the eye. From it conclusions in various directions may be drawn. People in health or only slightly sick usually assume the dorsal position, or a position upon one side, (31) g2 MEDICAL DIAGNOSIS. in a certain unconstrained comfortable position (the active dorsal or side position). On the contrary, patients who either are not wholly conscious, or who have become very weak, frequently are inclined to slide down toward the foot of the bed and sink into a heap there, a position which manifests weakness, and iii some respects, but espe- cially for breathing, is very unfavorable (the passive dorsal and side position). In acute infectious diseases, more than elsewhere, the passive dorsal position is specially noteworthy. It is particularly ^o when apathy and clouded intelligence are combined with great muscular weakness, as is frequently the case in typhoid fever, where such a condition of the patient is so frequently and sometimes early present that it may aid in the diagnosis. But in still another way the position in bed is sometimes charac- teristic. Patients with acute affections of the chest organs involving only one side (pneumonia, pleurisy, pneumothorax) generally lie upon the side, and for the most part upon the side affected. This may be due to various causes. The pain caused by breathing is generally in this way diminished, because by lying upon the side the motion of that side is very much lessened, while, on the other hand, the motion of the opposite side in breathing is greater than when the patient lies upon the back ; hence the sound side, when the patient lies upon the diseased side, can better compensate for the loss of the portion diseased. In exudative pleuritis frequently there is the further advantage in lying upon the affected side that the exudation least interferes by pressure with the healthy side.' Yet patients with pneumonia not infrequently lie upon the healthy side, because they have least pain in this position. That in diseases of the chest in general patients are inclined at the beginning of the disease to lie upon the sound side, and later upon the diseased side, I am not able to affirm. Difficult breathing, dyspnoea, if extreme, prompts one to assume the upright sitting posture in bed or in an easy chair — orthopnoea ; because in this attitude the action of the accessory muscles of respira- tion is more effective than when lying down. Orthopnoea may, there- fore, occur with all diseases which are accompanied with marked interference with respiration : as in narrowing of the air-passages in disease of the lungs (comparatively rare with phthisis — see under GENERAL EXAMINATION. 33 "Dyspnoea"), in diseases of the pleura, heart, pericardium, with large effusions into the abdominal cavity, which press the diaphragm up ; and in general dropsy with effusions into the cavities of the body. In the severest cases the patients may indeed be obliged to keep the sitting posture, even to sleep. The continued exertion of sitting and the diminished sleep obtained in this position, besides the great anxiety and excitement these patients generally have, usually quickly bring on exhaustion. Another group of characteristic situations and positions in bed refer to diseases of the brain and its membranes. Thus meningitis betrays itself often at the first glance by opisthotonus, with the head boring into the pillow, so-called contraction of the neck ; in circumscribed disease of the cerebrum the head is sometimes persistently inclined to be drawn forcibly to one side : forcible contraction of the head ; in affections of the cerebellum, also of the crus cerebelli, we not infre- quently see the whole body continually, as one lies in bed, drawn, sharply to one side, and, when turned over to the dorsal position, returning immediately again to this constrained position. These phenomena, however, are in part to be reckoned as convulsive con- ditions, which indeed bring about the greatest variety of characteristic positions and attitudes of the body. These latter, however, are gener- ally quite transitory. III. The Structure of the Body and Nutrition. The development of the skeleton determines the form of the body. Generally firm bones and broad, flat chest are characteristic of strong and enduring health : while those persons of delicate skeleton, espe- cially with slender ribs and narrow chest, are considered capable of both limited life and endurance. Yet this is only a general rule. We often see people of delicate build who are remarkably tough and enduring, both with reference to exertion and disease ; and not infre- quently we find robust people with little power of resistance, especially to acute diseases. Unusually small development of the skeleton is often observed in idiots and cretins ; and, in more rare cases, in dwarfs, without any other anomaly. The form of the thorax is of especial importance. With a slight 3 34 MEDICAL DIAGNOSIS. and narrow chest-cavity there is a proportionally frequent disposition to tuberculosis of the lungs ; and, on the other hand, a certain fulness carries with it a tendency to emphysema of the lungs. This will be more particularly spoken of under Respiratory Organs. The significance of the structure of the pelvis is manifest in the practice of obstetrics. The muscles, the subcutaneous tissues, and the skin furnish a means of judging of the nutrition, and also of the weight. In general, well-nourished and healthy persons have a certain volume and firm- ness of muscles. There is also a relation between the muscles and the skeleton. But even in perfectly normal persons there is a very marked difference in the volume of the muscles, which is not always explained by differences of occupation. By experience the eye grad- ually becomes quick in recognizing a suspiciously small muscular volume ; yet the firmness of the muscles' is a better guide to an opinion than their volume. The fat of the subcutaneous tissues may be very differently de- veloped in persons of good health. As a rule, it varies with the age, being greater for the first years of life up to the forty-fifth or fiftieth year. Beyond this it again, as a rule, becomes less. It also some- times varies in a shorter time without being caused by disease, as in women at about twenty years of age. It varies also, as a matter of course, with the kind and the richness of food, as well as with the occupation. Loose adipose tissue generally indicates a weak organization. A marked degree of leanness of the subcutaneous tissue is, under all circumstances, suspicious, and suggests an examination as to whether it may be caused by disease. In the same way the accumu- lation of fat beyond a certain degree becomes pathological. The measure or degree can only be established by experience. Of much greater importance is a commencing, even though a slight, wasting away of the subcutaneous fat, and eventually also of the mus- cles. As we have said, this is sometimes physiological. It can also take place, as among the poorer classes, from very poor nourishment. But in the majority of cases it is caused by disease, and it is, there- fore, important not to overlook it. This wasting can only really be learned by the physician when he has known the patient for some time. When this is not the case he must rely upon the statements of GENERAL EXAMINATIOX. 35 the patient and his surroundings, and, therefore, this subject properly belongs to the " previous history." When the emaciation is marked, its proof is furnished by the condition of the skin. In these cases the skin of the patient's whole body is loose, and can easily be taken up in folds. Excessive wasting is denominated ati'ophy, emaciation ; and when this is accompanied by general loss of strength and failure of function, marasmus or cachexia.. The weight of the body is an excellent index and one which is superior to all other signs of corpulence, and its increase or diminu- tion. The absolute value of the weight of the body in the different periods of life has no diagnostic imprest, for the reason that it varies within wide hmits. Likewise the relation of the weight of the body to the height and the circumference of the chest has scarcely any significance for our purposes. On the other hand, change in the body-weight wrought by disease is of the greatest importance. In chronic diseases this is an extremelv valuable means of determining whether the disease is increasing, standing still, or is being recovered from. Taking the weight regularly .(say, weekly) in cases of tubercu- losis is especially to be recommended, also in diseases of the digestive apparatus. In convalescence from acute diseases, following the weight of the body is also a very important aid, especially for the early recog- nition of the possibility of the disease becoming chronic, or of the presence of associated chronic diseases. Moreover, in all these cases we must remember that oedema (which see) produces a deceptive increase in the weight of the body. According to Bernhardt (cited by H. Vierordt), the relation of the weight of the'body, P, to the height, H (in cm.), and to the average circumference of the chest, C (measured at the level of the nipples, in cm.), for the average individual, may be reckoned as follows : i'=(i)k'i ^ ; kilograms. The weight of the body of the newly-born and its increase during the first months is of special significance. Regarding this subject, see works upon obstetrics and diseases of children, also Daten und Tabellen, by H. Vierordt. Diseases of the alimentary tract, more than others, produce emacia- 3g MEDICAL DIAGNOSIS. ♦ tion ; next, all febrile diseases, whether acute or chronic (of the latter especially tuberculosis), then severe forms of diabetes mellitus, and, finally, all malignant growths. A certain degree of emaciation can be produced by any disease of an internal organ. IV. Skin and Subcutaneous Cellular Tissue. In medical diagnosis the condition of the skin and subcutaneous tissue is considered with reference to the following points : A. The condition of general nutrition. B. The moisture of the skin ; perspiration. C. The color of the skin. D. Certain pathological appearances of general diagnostic value (characteristic eruptions, hemorrhages, scars, etc.). E. The presence of oedema. F. Possible emphysema of the skin. Skin diseases proper and certain acute infectious diseases, with special localization upon the skin (the co-called acute exanthematous diseases) are not considered in this work. A. THE STATE OF NUTRITION OP THE SKIN. In old age the nutrition of the skin is diminished over the whole body. This is physiological. In earlier years a noticeable general atrophy of the skin exists only where there is a very severe cachexia. The skin is then thin and generally dry. It loses its tone, and when taken up in a fold resumes its place slowly. The different forms of circumscribed atrophy of the skin which have been described do not interest us here. They belong to works upon skin diseases. B. THE MOISTURE OF THE SKIN ; PERSPIRATION. Physiology teaches us that the moisture of the skin, as well as the visible secretion of perspiration, is influenced by various circumstances. It is increased during active exertion, by increased temperature of the blood, by moist heat, by mental impressions, especially fear; finally, by certain ingesta, as hot tea, by pilocarpine, etc. GENERAL EXAMINATION. 37 In some of these cases there is at the same time an increase of heat of the body, which is overcome by the perspiration, cooling being caused by its evaporation. Perspiration is a regulator of the temperature of the body. The loss of water by evaporation (the greater part of the insensible perspiration) in health is, cceteris 'paribus, greater at night than during the day. It seems to alternate with the secretion of the urine. In healthy people the secretion of perspiration is in this way very changeable. But it is still more so in cases of illness. It may be increased to such a degree that the whole bed may be wet through (hyperidrosis). On the other hand, it may be so diminished (hyphi- drosis) that the skin is perfectly dry (anidrosis). Hyperidrosis of the whole body is called hyperidrosis universalis ; if confined to a part of the body, hyperidrosis localis. The latter may be unilateral (hemi- drosis). A general perspiration may take place in cases of illness : 1. When there are present conditions which are analogous to those which produce it in persons in a state of health, as in cases of strong tetanic convulsions by the increased muscular work and heart-action. On the contrary, in cases of epileptic, hysterical, and other convul- sions we have either no perspiration or at least none corresponding with the very great muscular exertion ; in all possible diseased con- ditions connected with great excitement, especially fear, or with severe pain ; and again, sometimes (not always, see below under Anidrosis) from a high degree of atmospheric heat, warm baths, moist warm pack, or sudorifics (pilocarpine, etc.). Morphine, also, with some persons, induces perspiration. 2. In difficult breathing — dyspnoea. This is generally connected with sweating. (In the same way sweating sometimes occurs with heart disease, accompanied by an engorged condition of the " greater" circulation ; also with all diseases of the respiratory organs and their surroundings, which interfere with respiration.) 3. In febrile diseases. Sweating usually occurs with the fall of the temperature in these diseases. The most important instances are (a) the critical sweat of a rapid definite decline of the fever especially frequent in pneumonia and febris recurrens [relapsing fever] ; (b) the sweat which regularly accompanies the fall of temperature in intermittent fever and pyaemia (diseases which manifest themselves by rapid rise 38 MEDICAL DIAGNOSIS. and fall of temperature), the night-sweats of the hectic fever of phthisis and the sweat of the remittent (hectic) fever of typhoid fever ; and (c) the cold sweat of collapse (that is, the sudden failure of strength in the death struggle). Acute articular rheumatism manifests itself by considerable perspi- ration, which may not depend upon a fall of temperature. Finally, there is always the inclination to perspiration in the commencement of convalescence from severe diseases and in parturient patients, when there is great weakness and the heart is easily excited. Local sweating occurs in various neuroses, also in organic diseases of the nervous system. There is very frequently sweating of the whole of one side (hemidrosis), or of the head alone, as in Basedow's disease, migraine, hysteria ; localized disease of the brain, and in mental diseases. Diminished secretion of stveat, even to complete anidrosis, is ob- served chiefly in high continued fever. It is, moreover, a peculiarity of all diseases which are accompanied with considerable loss of Avater by the bowels or the kidneys, of severe diarrhoea of any kind, con- tracted kidney, and diabetes. The anidrosis which exists with general dropsy, in consequence of the anaemia of the skin produced by the pressure and stretching, has a peculiar appearance. The anidrosis of high fever and general dropsy is very persistent, often resisting all therapeutic measures, both those acting directly upon the skin (moist heat, etc.) and the medicines already mentioned. Qualitative alterations of sweat exist sometimes in severe jaundice, when it contains the coloring-matter of bile and is yellow in color ; also, when the urinary secretion is greatly diminished or entirely sup- pressed, as in nephritis, diseases of the urinary tract, and cholera. It then contains considerable quantities of urinary products, which, by the evaporation of the perspiration, crystallize upon the skin (espe- cially upon the nose and forehead) in small white scales. This is called uridrosis, the scales giving the reaction of urinary ingredients. C. THE COLOR OF THE SKIN. As is well known, races differ in the color of the skin, but even in the Indo-Germanic race there are variations depending upon the stock, the climate (blonde, brunette). In some nations the pale, in GENERAL EXAMINATION. 39 others a more florid, complexion, especially of the face, prepon- derates. We know that there are differences depending on the mode of life; also that, even as regards the so-called healthy color of skin, considerable individual variations exist. But, after all, the hue of the skin stands in intimate relation to a large number of diseases of in- ternal organs. It is considered most suitable to judge from the color of the countenance, the portion of the skin most generally reddened ; and, since on every hand we have opportunity for practice, it is well to sharpen the eye for critically examining this part of the body. But the color of the countenance can sometimes deceive us (vide especially under "red skin "), and it is therefore advisable always to examine the mucous membrane of the lips, mouth, and throat,^ and, besides, to glance at the color of the skin of a part of the body usually covered by the clothing. We recognize the following abnormal colorations of the skin : 1. A pale skin. 2. The abnormally red skin. 3. The blue-red cyanotic skin. 4. The yellow skin of icterus. 5. The bronze skin. 6. The gray skin produced by nitrate of silver. 1. The Pale Skin. This can to a certain extent be physiological, especially in persons who spend little time in the open air. In these cases a glance at the mucous membrane gives further information. But one can be de- ceived regarding such persons, who, having exposed the face (also arms and hands) frequently to radiant heat, or to cold and heat in rapid succession, often have a local redness of face. This redness of face may arise from other causes (p. 41). Only experience can enable one to distinguish between physiological paleness and that produced by disease. The recognition of the latter is frequently aided in that it is associated with a grayish, yellowish color (see below). The color of the skin is produced by the fulness 1 The conjunctival mucous membrane is not included. It is not decisive, since many persons in whom the teguments are elsewhere pale, at times have the conjunctiva easily injected. 40 MEDICAL DIAGNOSIS. of its capillary vessels. The abnormal paleness may be dependent upon disturbance of the circulation (and in consequence of diminished force of the heart or active narrowing of the peripheral arteries), or by a lessening of the quantity of the blood constituents, chiefly of the haemoglobin. We distinguish : {a) Temporary paleness, which is partly physiological and partly pathological. It occurs with strong emotion, especially fright; in syncope or fainting; in the chill of fever, which ordinarily accompanies a rapid, considerable elevation of temperature ; and in spasm of the capillary vessels, (h) Paleness lasting a longer or shorter time. This comes on sometimes quite rapidly, at least in the course of a few moments, during profase hemorrhage and in sudden collapse — that is to say, in sudden failure of the heart as it occurs in acute, and sometimes chronic, diseases, and in acute poisoning. It is accompanied by a rapid and small pulse, increasing weakness, and, finally, loss of consciousness. Where there is external hemorrhage the condition is perfectly plain. But cases of seve^^e internal hemorrhage, especially of the stomach or bowels, of ruptured aneurism, hemorrhage from internal wounds of any kind, are declared only by this sudden paleness, sometimes even befoi'e the patients themselves, if quiet in bed, complain of weakness. In a case of endocarditis which I saw, the patient became pale, as one does from an internal hemorrhage, with increased frequency of pulse and stupor, within less than ten minutes. At the autopsy there was found a recent total rupture of an aortic valve. This paleness can develop more slowly, within a few hours or days, by considerable repeated hemorrhages ; as a symptom of weakening of the heart's activity in all acute and chronic diseases of the heart and pericardium ; also in diseases of parts adjacent to the heart, as pleurisy and abdominal affections, Avith much pressure upon the dia- phragm, in case they interfere with the action of the heart ; finally, in many acute diseases, especially in diphtheria, in heart-failure from diseases affecting the muscular structure of the heart ; and very often, and in a very striking way, in acute catarrh of the stomach (acute dyspepsia). Finally, paleness of the skin comes on in certain conditions gener- ally unnoticeable, insidious, and is a chronic condition : in the so-called special diseases of the blood and of the blood-making organs — indeed, most unfortunately, from a diminution of the haemoglobin; hence, in GENERAL EXAMINATION. 4X chlorosis, also in pernicious anaemia, leukaemia, pseudoleukaemia. In this list also probably belongs malarial cachexia. Paleness is a symptom of all slowly-developing secondary ayicemias (cachexia) as they occur in a large number of diseases, such as all chronic febrile diseases, especially tuberculosis ; in suppurations without fever ; in continuing slight hemorrhages, as in many tumors and in ankylosto- miasis [Egyptian chlorosis] ; in all chronic diseases of the digestive tract; in most aiseases of the female generative organs; in the dif- ferent forms of chronic nephritis, especially the large white kidney ; in chronic poisoning, especially by mercury and lead ; sometimes, also, in constitutional syphilis ; in malignant growths, especially in cancer proper ; and in chronic diseases of the hearty but especially in fatty heart and mitral and aortic stenosis. In most of these conditions there is, moreover, not only paleness of the skin, but its color has a still further characteristic appearance. In severe anaemias we often have a peculiar waxy appearance, which not rarely has a yellow tone. A striking, light white skin often exists with the so-called large white kidney, also in a certain proportion of the cases of lead-poisoning (which latter is often of a grayish white), of leukaemia and of tuberculosis. In chlorosis the skin has a greenish hue ; in diseases of the heart-muscle and in mitral insufficiency the skin is generally a smutty yellow, while in the cachexia of cancer it is often gray-yellow. In striking contrast is a large development of adipose tissue in cases of most marked paleness. This is very often so in diseases of the blood-making organs and in heart diseases. (It is not to be mistaken for oedema, vide under (Edema.) 2. Abnormal Redness of Skin. This is an expression of a superfluity of normal blood, since a genuine plethora does not necessarily give rise to such a condition. General abnormal redness of the skin exists as a sign of hyperaemia of the cutaneous capillaries in high fevers — especially in continuous fevers. It also is present during the perspiration following a warm bath. Finally, in poisoning with atropine, even in very mild cases, it is developed like the redness of scarlet fever. (The scarlet-fever redness, being connected Avith a disease of the skin, does not belong here.) 42 MEDICAL DIAGNOSIS. Local redness, depending upon a dilatation of the capillaries, exists very frequently in the face, and indeed is physiological in those who labor in the sun. It comes and goes quickly, as in blushing (rubor pudicitige), in nervously excitable persons in consequence of very slight psychical impressions, also not infrequently as a result of physical exertion. Moreover, we see redness of the face in fever ; finally, one-sided redness of face in the "paralytic" form of hemi- crania. Tuberculosis is characterized by a very marked variation in the fulness of the capillaries of the face : if the patients are entirely at rest and without fever they are generally pale, but under excitement or exertion, after eating, and, lastly, during fever, they exhibit a very striking, generally bright, redness of the cheeks, and often a sharply- defined spot (hectic redness). In the slight forms of anaemia, especially if it is associated with nervous irritability of heart (likewise Avith local vasomotor disturb- ances), there is sometimes intense redness of the face which may con- ceal the anaemia from the physician. For distinction of circumscribed hypersemia from hemorrhage in the skin, see under the latter. 3. Tlie Blue-red Skin, Cyanosis. This is most plain on the parts that normally are bright red, hence more than elsewhere on the mucous membranes, on the lips, cheeks, etc. ; also on the knees, the phalanges of the fingers, and under the finger-nails. A moderate degree of cyanosis, therefore, would only be discovered at these parts. A marked degree, on the other hand, exhibits a blue color spread over the whole body, while those parts, especially the mucous membrane, become black-blue. The cyanosis of the newborn, with heart-failure, is so striking to the experienced observer, that it is regarded by him as pathognomonic. One only sees anything like it in the death agony, and, exceptionally, in severe spasms with marked interference with breathing. The combination of cyanosis with great paleness is designated as " livid skin." Cyanosis arises from the blue-red color of the capillaries, and this, as is well known, is caused by an accumulation of carbonic acid and GENERAL EXAMINATION. 43 deficiency of oxygen — that is to say, by the venous or hypervenous character of the capillary contents. Carbonic acid in the blood (serum and red corpuscles) arises from : 1. Interference with the exchange of gases in the lungs. 2. From the slowing of the capillary circulation and the consequently dimin- ished gas-exchange in the tissues, that is to say, the diminished giving up of COg by the tissues to the blood. Cyanosis arises, therefore: 1. In disturbed respiration and circula- tion through the lungs ; 2. In disturbance of the " greater circulation," which may be general or circumscribed according as the stoppage maj be general or local. The two causes may be combined. Here belong to 1 : (a) All conditions which cause a narrowing of the larger air-^ jjassages or of a large number of small bronchi : inflammation of the neighborhood of the pharynx or entrance to the larynx ; retro- pharyngeal abscess, angina Ludovici ; very exceptionally a diphtheria of the throat. (In all of these cases the interference with respiration is either direct or dependent on oedema of the glottis.^) The following are enumerated : spasm of the glottis, paralysis of the dilator of the glottis (crico-arytenoideus post.), all acute and chronic inflammations of the larynx, but especially croup ; tumors of the larynx ; cicatricial narrowing of the larynx ; foreign bodies in the larynx (something swallowed or vomited) ; also foreign bodies, croup and scars in the trachea or one or both primary bronchi, compression of these from without by enlarged glands, aneurism of the aorta, etc. ; mediastinal tumors, etc. ; bronchial spasm ; anid severe diffuse bronchitis, espe- cially the acute croupous form. ib) All diseases of the lungs and diseases in the neighborhood of the lungs which hinder their expansion or wholly compress them: emphysema of the lungs ; all forms of consolidation ; pleuritic and great pericardial exudation, pneumothorax ; tumors in the chest- cavity ; abdominal diseases with marked upward pressure of the diaphragm. (c) Paralysis of the respiratory muscles : bulbar paralysis, periph- eral neuritis ; paralysis of diaphragm from peritonitis ; spasm of the 1 A very distressing case of suffocation from the lodgement of a large piece of meat in the pharynx, and the consequent closure of the entrance of the larynx, presented itself at the Leipzig medical clinic. 44 MEDICAL DIAGNOSIS. muscles of respiration, epilepsy, tetanus, but, on the other hand, very rarely hystero-epilepsy ; special muscular diseases : myopathic forms of progressive muscular atrophy, trichinosis, myositis ossificans. Disturbances of the circulation through the lungs occur in a number of the diseases which interfere with respiration. In emphysema a large number of capillary channels are closed, also in tuberculosis and other chronic lung affections ; a large pleural exudation not only compresses the lungs, but also the capillaries. This acts in the same way as a hindrance to respiration. (d) Diseases of the heart which result in obstruction of the pul- monary circulation. It is to be noticed that in the conditions named under (5) a disturbance of the respiration interferes with pulmonary cir- culation. Moreover, we must emphasize the fact that in several of these conditions (especially diseases of the pleura, of the peritoneum, in trichinosis of the diaphragm and intercostal muscles) the insufficient breathing, as well as the cyanosis, will be increased by the pain caused by the act of breathing. If the physician correctly recognizes the chain of events he will be able to bring relief by the use of narcotics. In persons very much wasted, especially from tuberculosis, cyanosis may be absent even in spite of the loss of a large part of the breathing surface of the lungs, since the remaining normal portion suffices for supplying the required quantity of oxygen to the diminished quantity of blood. Under heading 2 : Slowing of the hlood-current in the capillaries of the greater circula- tion is dependent upon stopping of the venous outlet. This can be general and caused by all the conditions of the first category, general cyanosis, or it can be occasioned by a venous stopping of an extremity or of the head, and so produce a local cyanosis. General venous damming occurs in diminished pumping power of the right ventricle (valvular deficiency, congenital stenosis of the pulmonary artery, diseases of the heart-muscle, large pericardial exu- dation with hindering of the heart's action, considerable emphysema of the lungs with excessive damming of the smaller circulation), and in the rare case of compression of a large venous trunk just before it enters the right auricle (tumors of the mediastinum). Local venous stasis is caused by closure or marked narrowing of a more or less large venous trunk. This closure may be produced by GENERAL EXAMINATION. 45 compression or by thrombosis of the vein (compression of tbe cava or the extremity of a venous trunk by tumors) ; compression of the cava inferior in connection with the common iliac artery by very large effusion in the peritoneum, or by tumors ; atrophic thrombosis of a vein of the extremity, especially the femoral. Not infrequently the collateral veins of the skin take up the conveyance of the blood of the venous stasis ; they then become enlarged and sometimes tortuous {vide examination of the veins). For the cyanosis produced by certain poisons, see Examination of the blood. 4. The Yellow Skin, Icterus, Jaundice. The jaundiced state of the skin exists in well-marked cases, with slight differences, almost equally over the surface of the whole body It is found especially in the conjunctiva, and in slight cases exclu- sively there and in the other mucous membranes, if the observer will render the spot angemic by pressure (best done by means of a micro- scopic slide pressed upon the everted lip or upon the tongue). Ac- cording to the intensity of the jaundice the tissues are but slightly tinged with yellow, or citron color, or yellow-green. Only in very severe cases (melas-icterus) does the skin become green or brownish- yellow. Jaundice cannot be detected by the ordinary means of illumination, since the yellow, artificial light does not enable one to distinguish between white and yellow. In slight cases it will first be detected in the conjunctiva. But this must not be confounded with the yellow fat that sometimes exists there, especially in elderly people. In persons with yellow or brown skin the jaundice is revealed by an examination of the mucous membrane. The yellow color of the skin after taking picric acid or santonine has no relation to jaundice. We distinguish this condition from jaundice by analysis of the urine {q. v?) and by the etiology of the former. Jaundice of the skin is the yellow coloration of almost the whole body by the coloring matter of the bile in the blood. Very much the most frequent form is the jaundice of simple engorgement, hepato- genous or mechanical jaundice, according to the old designation. It is occasioned by a primary biliary engorgement in the liver, resulting 46 MEDICAL DIAGNOSIS. from a purely local interference with the discharge of bile. This interference is at the ductus choledochus, the transverse fissure of the liver, or within the liver. But there are also so-called haematogenous forms of jaundice which have this in common, that at the first indication of the existence of jaundice there is hsemoglobinsemia, because haemoglobin is set free from the red blood corpuscles. In many of these cases (poisoning, see below), according to recent investigations, it is to be assumed that, from the decomposition of the red blood-corpuscles, there is secreted in the liver a very concentrated, thick bile, and that this cannot floAV through the ductus choledochus, thus producing engorgement and jaundice. It is still uncertain whether this explanation can be applied to all cases of jaundice which are not to be referred to primary biliary engorgement. It is not inconceivable (although more and more doubtful) that hsematoidin or bilirubin (these two being identical) is formed from the haemoglobin which has become free within the blood- vessels. This would be a purely " blood-jaundice " in the old sense. In all these cases the coloring-matter of the bile passes into the urine, although when the jaundice is very slight it may not do so (see particularly under 2 of this section). The occurrence of the bile- acids in the blood and its appearance in the urine can, of course, only take place in primary or secondary jaundice due to engorgement. Hence, these would be an infalhble indication as to whether the jaun- dice was due to engorgement, or was "blood-jaundice," provided there was, on the one hand, no trace of bile-acids in the normal urine ; or, on the other, if they very rapidly disappeared after passing into the blood. Thus, even in cases of undoubted engorgement- jaundice, the bile-acids might not appear in the urine. In very marked jaundice the coloring-matter of the bile is also found in the perspiration and in the saliva. It is to be remarked that by no means every case of haemoglobin- aemia results in jaundice ; sometimes it simply results in hsemoglobin- uria, sometimes also in urobilinuria. 1. Hepatic jaundice is almost always purely the result of a biliary stoppage. The cause of the penning-up of the bile may exist in the bowel; in gastroduodenal catarrh, with catarrhal swelling of the mucous membrane, and accumulation of mucus in the ductus choled- ochus ; in tumors which press upon the duodenal orifice of the ductus GENERAL EXAMINATION. 47 choledochus, and especially cancer of the head of the pancreas ; in ascarides, or round-worms {q. v.) which enter the ductus choledochus ; and also in gall-stones, which lodge there. There may be compression of the hepatic duct or of the large gall- duct at the entrance of the liver by tumors (carcinoma, echinococcus), or by scars, or by closure of the same by gall-stones. Closure of many small bile-ducts may be caused by so-called intra-hepatic gall- stones ; possibly also compression of these by marked damming in the branches of the veins of the liver from general venous stasis ; finally, catarrh of the smallest bile-ducts may possibly cause bile stasis and jaundice, as in phosphorus-poisoning. In case the flow of bile is much hindered or is wholly stopped, then, partly from the want of bile and partly from the fatty contents, the stools become light, perhaps entirely white or gray-white. The par- ticulars of this condition of the stools and of urine in jaundice are explained in the chapters devoted to these subjects. In some cases of severe jaundice there may be still other appear- ances : itching, various skin affections, minute cutaneous hemorrhages, slowing of pulse, or simple nervous manifestations. In very severe, long-standing jaundice, there may be marked heart disturbances, hemorrhagic diathesis may develop, or, finally, there may arise severe nervous manifestations (cholaemia, cholsemic manifestations). Moreover, hepatic jaundice may be produced by the sudden diminu- tion of pressure in the portal vein while the pressure in the bile-ducts remains the same, as at the moment of birth — icterus neonatorum (Frerichs). 2. Hsemato-jaundice, whose primary cause is to be regarded as a decomposition of the blood, takes place in certain acute infectious dis- eases (pyaemia, yellow fever, probably also sometimes in pneumonia) ; and from certain poisons (chloroform, ether, chloral, chlorate of potash, solution of arsenic, toluylendiamin). In this case, as well as in the jaundice of damming, there may be bile coloring-matter in the urine. Not infrequently, as in pyaemia, well-marked signs of bile coloring- matter may be wanting, and this has diagnostic value for the assumption that we have a case of hsemato- jaundice. It is very important to notice that in real blood-jaundice the flow 48 MEDICAL DIAGNOSIS. of bile into the intestine is not disturbed, and hence there is no altera- tion of the color of the stools. JJrohilin-icterus. In diseases of the liver, in prolonged hemor- rhages of whatever nature, also in the hemorrhagic diathesis, finally, in fever, a larger quantity of urobilin is removed by the urine (see Urine). Hence in rare cases a mild jaundice is observed : Uro- bilin-icterus (Gerhardt, Jaksch). The origin of urobilin is to be explained as follows : First hsema- toidin or bilirubin is formed, and then urobilin is formed from this by reduction in the tissues or in the bloodvessels. 5. The Bronze Skin. Unlike cyanosis and jaundice, this is a condition pertaining only to the skin and mucous membrane. We speak of the chief symptom, instead of the true anatomical seat, of the disease, viz., the supra- renal capsule — the so-called Addison's disease. (Very frequently it is tubercular.) [The association of this peculiar brown discoloration of the skin is not constant in Addison's disease. It is not so constant in cancerous, but is more common with cheesy, degeneration. The latter condition may be present without bronzing of the skin. On the other hand, the skin may be bronzed, just as "in Addison's dis- ease without the existence of cheesy degeneration or any other change in the supra-renal capsules. These facts have induced many observers to attribute the cutaneous discoloration rather to changes in the neighboring sympathetic nerves — the solar plexus and the semilunar ganglia.''] The bronze skin is characterized by a brown, gray to black dis- coloration, especially of the face and hands. There is also the common normal pigmentation of the skin in spots. The discoloration may gradually extend over the whole surface of the body, only the nails and cornea remaining clear. It is very important to notice that the same discoloration appears upon the mucous membrane of the mouth, and more rarely upon the ^ips, as very sharply circumscribed, frequently quite small, brown specks. The discoloration is caused by deposit of pigment in the rete ]Mal~ pighii. Of course, pressure with the finger does not at all diminish it. GENERAL EXAMINATION. 49 6. The G-ray Shin of Silver Deposit. After long-continued administration of nitrate of silver there may be deposits, in certain organs, of very fine black particles (metallic silver or silver albuminate ?), as in the kidneys, intestine, and also in the skin, and especially in the corium, the tunica propria of the sweat- glands. The skin of such persons, especially of the face and hands, is gray or blackish. The color is not changed by pressure. In severe cases we also observe corresponding gray specks in the mucous membrane of the mouth. In a strict sense this is not a diseased condition : these people are perfectly well. D. OTHER PATHOLOGICAL APPEARANCES OF THE SKIN OF GENERAL DIAGNOSTIC VALUE. 1. Acute Exanthematous Diseases. In some acute infectious diseases a characteristic eruption of the skin has so marked an appearance that these diseases are designated as " acute exanthemata." They are: Scarlet fever, measles, German measles, smallpox, and varicella. Here we may pass over these dis- eases, since they are closely connected with the complete description as they are taught at the bedside. On the other hand, there are certain other acute exanthematous diseases, less striking, but at the same time of great diagnostic im- portance. We may here briefly mention : {a) Roseola. This pres'ents a small, round, rose-red, slightly ele- vated spot. It is generally scattered, is found most frequently upon the abdomen and lower part of the back, more rarely upon the breast and extremi- ties in typhoid fever. It appears about the beginning, and generally fades at the end, of the second week. Now and then secondary roseolar spots appear later, which are connected with exacerbations of the disease (involving new portions of the intestine ?). Secondly, they appear in most cases of typhus fever. But, except in light cases, they are in this disease petechial — i. e., the location of small hemorrhages, which are slowly absorbed. 4 50 MEDICAL DIAGNOSIS. Further, they exist in some cases of acute miliary tuberculosis, and finally in animal poisoning. (h) Herpes facialis. This consists of a group of small vesicles upon a slightly red base. The vesicles contain at first clear water, then are cloudy, then yellow from pus contained in them. They may be con- fluent. After a few days they dry up and scale. Most frequently this exanthem is found in the neighborhood of the mouth — herpes labialis ; or of the nose — herpes nasalis ; it may also appear upon the cheeks or the ear. It makes its appearance at the beginning of some acute diseases and seems to be especially peculiar to very rapidly rising fever. Above all it accompanies croupous pneumonia, then epidemic cerebro-spinal meningitis (in this disease it is often quite extensive), finally, some- times in angina (angina herpetica), and a light febrile disease named in consequence, febris herpetica. An herpetic eruption also sometimes accompanies the development of intermittent fever and the chill of pycemia. (c) Miliaria or sudamina. These are small, remarkably clear vesi- cles, which reflect the light strongly, generally in large numbers, especially upon the abdomen. They appear if a patient, after long- continued anhidrosis, begins to sweat profusely, especially in acute, but also sometimes in chronic, diseases. It is necessary to mention them here only because the explanation of their diagnostic, and like- wise pathological, meaning ought to be made prominent. Still other exanthemata of diagnostic importance could be mentioned here, as the (rare) scarlet redness in the beginning of typhoid fever, the difierent eruptions of sepsis, pyoemia, and other diseases. 2. Exanthemata from Poisons and the Use of Medicines. These are of varied character, since they sometimes resemble those of acute diseases, viz., scarlet fever, measles, etc. They may, there- fore, easily cause an error in diagnosis. It is sufficient here to point out the diagnostic importance of these exanthemata. The particulars regarding them belong to works on diseases of the skin, and also to pharmacology and toxicology. GENERAL EXAMINATION. 51 3. Hemorrhages in the Skin. They arise chiefly by diapedesis, and take place particularly, but not exclusively, in dependent parts, especially the lower extremities. They may be of every size — from the smallest perceivable point to the size of the palm of the hand, or even larger. The small, puncti- form hemorrhages, eccliymoses or petechise, are most apt to appear at the hair-follicles. The color of fresh hemorrhages is like venous blood. During absorption they are brown-red, later becoming bright brown. A hemorrhage is distinguished from a circumscribed inflammatory redness of skin in that it does not disappear upon pressure. (The small ecchymoses in the hair-follicles, mentioned above, are easily confounded with the latter, especially in cyanosis ; further, petechise, in parts previously inflamed, as in measles, are easily overlooked.) Simplest test : Press a piece of glass, a microscope slide, upon the suspected spot. A hemorrhage is rendered more distinct, while the surrounding part becomes anaemic ; an inflammatory hyperaemia, on the other hand, disappears. Hemorrhages appear: 1. As evidences of a marked hemorrhagic diathesis. They are then generally extensive in the skin, and, moreover, occur in con- nection with hemorrhages from internal organs. They occur in scorbutus, purpura hemorrhagica; in severe acute infectious diseases, especially pysemia, smallpox, and scarlet fever ; in acute phosphorus- poisoning and acute yellow atrophy of the liver ; and in all severe cachexia. 2. Without internal hemorrhages., as a condition limited to the skin : in peliosis rheumatica [^'. e., purpura occurring with severe pain in the extremities] ; also as small petechioe ; almost constantly in typhus fever (see Roseola), often in measles, and scarlet fever ; more- over, on the legs when the convalescent patient first stands up, espe- cially after typhoid fever ; and in badly nourished persons where they have been bitten by pediculi. 3. In marked venous stasis, local as well as general (see Cyanosis). 4. As traumatic hemorrhages in and under the skin. They are sometimes of importance for determining the occurrence of an injury, especially upon the skull. 52 MEDICAL DIAGNOSIS. 4, Scars. These are often important marks for limiting or explaining the clininal history, which, by reason of the scars, can be confined to past local or general diseases, or to injuries received. Thus come under consideration "pock " (smallpox) marks and the scars which may remain after the difierent scrofulous and syphilitic diseases of the skin and deeper organs, especially the bones and glands. In internal medicine, scars from injuries have importance in many nervous diseases (injuries upon the head, the spine, in the course of peripheral nerves). Here also belong the scars of pregnancy, strice, upon the lower part of the abdomen and the upper part of the thigh. Exactly the same scars occur in marked oedema (see the following section), and also sometimes in very fat persons. E. (EDEMA OF THE SKIN AND SUBCUTANEOUS CELLULAR TISSUE ((EDEMA, anasarca). By these terms we designate an abnormal, marked saturation of the tissues with fluid, which fluid remains wholly or in part distributed in the cellular meshes and lymph-spaces, instead of a corresponding quantity of fluid existing in bulk, as its transudation takes place from the bloodvessels to be removed by the lymph-current. (Edema is recognized by puffiness of the skin causing increase of volume of the affected part, and hence, also, the normal contour, the prominences of the joints, as well as depressions, are obliterated, and, moreover, there is a tendency to an equal roundness. The skin is smooth, generally slightly shining, and hence very pale in conse- quence of the diminished circulation. It is very noticeable that the oedematous tissue loses its elasticity, so that a depression made by the point of the finger remains for a certain time, sometimes for hours. In general or widely extending oedema it is most manifest in de- pendent parts, or where the skin is tender and the subcutaneous cellular tissue is loose. Hence, in those persons who walk and stand it appears first at the ankles or on the dorsum of the feet (not on the soles and toes, since here the skin is too thick or closely attached ;) in bed-ridden patients, on the inner side of the thigh or in the scrotum GENERAL EXAMINATION. 53 and penis, where it is often enormous ; on the lower part of the back ; sometimes first of all, in the loose cellular tissue beneath the lower eyelid. One must examine all of these points if he would detect the first evidences of oedema. In very marked cases the deeper parts, especially the muscles, become oedematous ; the legs may then attain enormous proportions. Moreover, in marked general dropsy there are fluid accumulations in the cavities of the body, giving rise to hydroperitoneum or hydrops ascites, hydrothorax, hydropericardium. In long-continued oedema the skin of the legs and the lower part of the abdomen may become thickened, as in elephantiasis. We recognize three causes for dropsy of the skin (as for dropsy in general) : 1. Venous stasis (hydrops mechanicus). 2. Altered condition of the blood, particularly its becoming watery. 8. Inflammations. Hence, these corresponding diseases cause oedema : 1. All diseases, local or general, which hinder the return of venous blood to the right side of the heart, as those that have been already mentioned under Cyanosis (see p. 44). In local stasis the oedema is naturally confined to the roots of the corresponding veins, as, for example, thrombosis of the right crural vein, causing dropsy of the right leg, or compression of the vena cava inferior by an abdominal tumor, causing dropsy of both lower ex- tremities. 2. All forms of hydrgemia (ansemia), acute and chronic nephritis, in which the diminished excretion of water, on the one side, and the loss of albumin from the blood, consequent upon the albuminuria (which see), on the other hand, occasions the hydrsemia, which is the chief factor in the condition which permits frequent and often marked oedema. Yet the hydrsemia does not always explain the existence of the oedema (Cohnheim and Lichtheim ; see under Albuminuria). All other kinds of anaemia (hydrsemia, see Blood) come under this head when they appear as diseases of the blood or of the blood-making organs, and are secondary to the appearance of wasting diseases and severe acute diseases (as oedema of the ankles, when the convalescent patient first stands up). The anaemia caused by long-continued slight hemorrhages (as those 54 MEDICAL DIAGNOSIS. occurring in ankylostomo-ansemia) may also lead to moderate oedema, for here also we have hydreemia, in that the loss of blood is replaced by water in the blood. 3. (Edema, sometimes of considerable extent, occurs in the neigh- borhood of inflammation (" inflammatory oedema," "collateral oedema'"). This may be of great diagnostic importance, since it sometimes reveals a deep-seated inflammation. This is of more interest to the surgeon. To the physician it is important, for instance, in pleuritis with oedema of the chest- wall. It shoAvs, with tolerable certainty, that the pleuritis is purulent. Deep muscular abscesses in severe diseases, as in typhoid fever, may easily be overlooked, and may first be recognized by the appearance of oedema in the neighborhood, as along the femur. The oedema in these different, but so heterogeneous, cases does not have a uniform character : that from stasis is sometimes soft, some- times very elastic, the latter especially (in marked stasis) exists in the extremities, when it is often difiicult, and sometimes impossible, to leave the mark of the pressure with the finger ; moreover, in cases of nephritis, with a small quantity of urine and marked albuminuria, it is sometimes very considerable, but now and then softer. In the different anaemias the oedema is mostly slight — a scarcely noticeable pufiiness. Slight oedema disappears between morning and evening, or evening and morning, according to the change of position of the body. The question, Why does oedema result from venous stasis, hydrgemia, or inflammation ? has not in all respects been satisfactorily answered. Until recently it seemed to be proved that this is entirely to be ascribed in these three conditions to an injury of the endothelium of the vessels, and by this means occasioning increased transudation into the tissues (Cohnheim). Recently the view has been advanced, and it seems to me has become well established, that the loss of elasticity and the diminished squeezing-out of lymph from the tissues by their being relaxed plays an important, perhaps a chief, part in causing oedema (Landerer). This relaxation of the tissues might be caused by the stasis from the increased transudation, or by the hydraemia from the deficient nourishment of the tissues by the morbidly thin blood ; or, finally, it might be caused by inflammation excited in the neighborhood. GENERAL EXAMINATION. 55 In conclusion, we must not omit to mention that, in rare cases, oedema exists without any other possible morbid disturbance. Here belong the essential oedema of children and the oedema of the feet after forced marches. r. EMPHYSEMA OF THE SKIN. By emphysema of the skin is understood the entrance of air into the cellular tissue. It may be limited to one region of the body, as the neck or the upper part of the chest, or the upper part of the abdomen. But it may be spread over almost the whole of the body. It is a very rare condition. We recognize emphysema of the skin by the very pale skin over a region which is decidedly elevated above its surroundings. Indeed, on account of the loose fixation of the skin in certain parts, even de- pressions, as that over the clavicle, or the axillary space, or the inter- costal spaces, may he filled up, so that sometimes on a first glance at the part it seems like marked oedema. Sometimes at such places there may even be an elevation of the skin like a pillow. Upon pal- pation we find that the part is very yielding, like a soft pillow. Quite unlike oedema, however, the depression made by pressure immediately disappears. Moreover, upon palpating the part, we feel and hear an unusually fine crackling. The so-called spontaneous emphysema of the skin does not here concern us. It arises from decomposition of a blood extravasation, or abscesses with formation of putrid gases. The so-called emphysema of skin from aspiration arises from the entrance of air or gas into the subcutaneous tissue, either from without through a wound of the skin, or from within from an organ containing air or gas. {a) The entrance of air from without after a wound of the skin belongs to surgery. It is especially observed in wounds of the neck, of the breast, in the lower part of the face (so-called wounds of the mucous membrane). The wounds in question are sometimes remark- ably small. (h) Of much greater interest in themselves, as well as from a diag- nostic point of view, is emphysema from air or gas entering the cellular tissue from within. Under all circumstances it is occasioned by the 56 MEDICAL DIAGNOSIS. rupture, either spontaneously or traumatically, of the wall of an organ containing air or gas. Hence, emphysema^ from " aspiration ' ' may arise — 1. From any portion of the respiratory tract, from the larynx down. Deep-seated ulceration of the larynx or trachea may invade the walls of these organs, and thus the air may escape and enter the sub- cutaneous cellular tissue. Cavities of the lungs (after previous, repeated adhesions between the pulmonary and parietal pleura) may ulcerate into the chest-wall, until, jBnally, communication with the cellular tissue is established. Then the pressure of a severe paroxysm of cough may cause the air in large quantity to spread out quickly under the skin. Single pul- monary alveoli may burst from any very high intra-thoracic pressure, as severe cough, especially in children with whooping-cough, bronchitis, or emphysema ; sharp crying ; severe exertion, as blowing on wind- instruments, or women in childbirth ; and air may enter under the pleura or into the inter-alveolar tissue, reach the mediastinum, pass along the mediastinal space into the subcutaneous tissue of the neck, and so spread onward. Wounds of the lungs (as fracture of the ribs without external wound) may either directly cause emphysema of skin, or, passing the mediastinum as above, take the same course. 2. From the oesophagus, stomach, or intestines, and, indeed, from the oesophagus again through the mediastinum ; from the stomach or intestines by adhesions with the abdominal wall and invasion of the cellular tissue there; from traumatic rupture of the oesophagus, more frequently from ulceration, especially in connection with carcinoma of the oesophagus ; with any kind of deep-seated ulcerations of the stomach and bowels. Sometimes there occurs extensive decomposition of the cellular tissue, especially if emphysema of the skin is produced by gases from the intestinal canal (mixed with intestinal contents). Very often, however, the emphysema remains without such action. It may then spontaneously disappear. But at the same time, the emphysema is generally a final development, partly on account of the severity of the 1 The name " emphysema " is not quite accurate, since generally the air is driven in under pressure, as is shown by what follows. GENERAL EXAMINATION. 57 primary disease, and partly because it causes severe dyspnoea, as, for instance, that in the mediastinum, and hence is a very serious condition. From a diagnostic point of view, emphysema of the skin is of great importance, since it affords a conclusion regarding the diseases men- tioned. Under some circumstances it may aiford the first and only symptom, as in the affections of the oesophagus. V. The Temperature of the Body. Fever. It is a well-known peculiarity of warm-blooded animals that they, if the organization is otherwise sound, with remarkable constancy, maintain a certain internal temperature which is subject to very slight variations. If that peculiarity is lost, if the temperature departs from the normal, then, almost without exception, a morbid disturbance is present. A knowledge of this fact, and especially of the elevation of the specific heat in disease, attracted the attention of physicians to the temperature of the body from the earliest time. Recently, however, the measurement of the temperature has become of the greatest diag- nostic aid. In what way this is so will be explained at length. 1. The Terms Used and the Method of Taking the Temperature. Judging of the temperature by laying on of the hands is under all circumstances deceptive. Great errors cannot be avoided even if covered parts of the body are selected, while uncovered parts cool so rapidly as to furnish no standard. We measure the temperature with the Centigrade or Celsius's ther- mometer, with the scale divided into tenths, from about 30° to 45°. There is no need for a thermometer with indications below 30° (see below). In France the Reaumur scale is solnetimes used ; in England and America the Fahrenheit is generally used. To convert from one standard to another the following formula is used : 1° C. = f ° R. = (9 + 32)° Fahr. It is further to be remarked, that in Germany still, especially at the public baths, the baths are frequently measured and are prescribed accordins: to Reaumur standard. 58 MEDICAL DIAGNOSIS. Regarding the selection of the instrument, it concerns us to remember that there are many incorrect thermometers. Exact com- parison Avith a standard at the time of purchase, and at least every two years thereafter, is indispensable, since all thermometers register somewhat higher with age. Thermometers with a cylindrical column of mercury are to be preferred, since they are more reliable and like- wise easier to use. Maximal thermometers are strongly recommended, but the index must work exactly ; moreover, it is of course always to be remembered that every time before using the thermometer the index must be shaken down as far as (in certain cases below) the normal mark. When a comparison with a normal thermometer cannot be made, an approximate determination may be made by taking the temperature in the axilla of a healthy person upon say six different days an hour after breakfast. A thermometer which is correct in its reading must then give an average reading of 37° C. or a little less (Liebermeister). The temperature may be taken in the axilla, the rectum, or in the vagina. (Taking the temperature in the mouth, and especially from freshly-passed urine, is to be avoided.) Of the three places mentioned, the rectum or vagina would be preferred, since their temperature most nearly corresponds with that of the inside of the body, since the ther- mometer lies very equally in either of these situations, and because it requires less time, the maximum being there soonest reached. But from reasons of delicacy we only take the temperature there when it is not possible to take it in the axilla. Therefore, ordinarily, the thermometer is placed in the axilla (which should be first carefully wiped dry, if it is moist) as high as possible, and then the flexed arm should be pressed against the chest. [The maximum is indicated in from three to five minutes. Some thermom- eters accurately indicate it in one minute ; but these are so delicate as to require special care to avpid breaking. The thermometer is to be left in as long as the index continues to rise. One can easily ascertain how long a given thermometer requires by testing it in warm water at various temperatures.] If the' patient is unconscious the arm must be held. In cases of marked unconsciousness, of unruly persons, and of childrenj it is better to take the temperature in the rectum or vagina. If there are fecal accumulations in the rectum the result is unre- GENERAL EXAMIXATIOX. 59 liable. The thermometer is to be oiled and passed in to the depth of about 5 cm. The maximum is indicated in about five minutes. In. the rectum the temperature is usually about 0.2° C. = 0.36° F. higher than in the axilla. If the thermometer is not self-registering, it must, of course, be read before it is removed. iVfter using the thermometer in either the rectum or vagina it must, in every case, even "U"hen there is no infec- tious disease of either of these organs, be carefully disinfected. [Xo matter where the thermometer is used, it ought always to be imme- diately cleaned most thoroughly.] A single use of the thermometer may be of great value. But it is still more important, as will be shown below, to follow the state of the temperature progressively, and to ascertain its course. For this pur- pose it is necessary to measure it at stated intervals. How frequently this must be done in order to ascertain the course of the temperature, must be determined by the particular disease. The thermometer should be used at least twice in twenty-four hours (at about 8 A. M. and again at about 5 P. M.). In diseases with high fever, according to the rapidity with which the oscillations of the temperature are completed, the thermometer must be used every three hours, every two hours, or even hourly. Where the changes of temperature are very marked, it may be of interest to observe it every quarter-hour. It is to be understood that, where it is proper to do so, the use of the thermometer should, as far as possible, be suspended at night, in order not unnecessarily to disturb the patient's sleep. The record of the course of the temperature may be indicated by a curve. Charts suitable for this purpose of various kinds are to be had. They serve also for the record of the pulse and respiration. Now-a-days, in every case of severe fever, the physician ought to prepare such a fever- curve. In what folloAYS, the statements regarding the temperature refer to measurements taken throughout in the axilla. 2. Tlie Normal Temperature of the Body. The average temperature is 37° C, and varies from this about 1J°: from 36.25° to 37.5° C. The variations are of different kinds and have different causes. Of least interest, since they are only very insignificant, are those de- 60 MEDICAL DIAGNOSIS. pendent upon age (in children, except the day after birth, a few tenths higher than later; in old people, again, a little higher) ; an elevation after meals ; an elevation after severe exertion. But the periodic daily variations are more important. They follow the following course : In early morning, between two and six, the *' daily minimum " is reached, and then with considerable (not per- fect) regularity it rises to the "daily maximum," between 5 and 8 in the evening. From that point it again, during the night, declines. The difference between the minimum and maximum, the " daily dif- ference," is about 1° C. (in rare cases even nearly 2° C). After severe exertion, the temperature rises quite a considerable amount higher, especially in the sun (Obernier observed that in the case of a person running it rose to 39.6° C.)and in very warm baths. 3. Elevated Temperature. Fever. Every elevation of temperature which is not dependent in a marked way upon over-heating or severe exertion of the body, we call fever. The febrile elevation of temperature is generally for a certain dura- tion, but it may exist in single cases as a single short period, " a febrile paroxysm."' But it is here important to remember that fever does not alone consist of an elevation of temperature, but is a complex symptom, whose separate manifestations are occasioned partly by an increase of tissue-changes, partly by disturbance of the functions of certain organs. To it also belong the elevation of the specific heat ; also general feeling of being sick, relaxation, sometimes mental disturb- ances ; increased frequency of pulse and respiration with exhalation of CO2; loss of appetite, increased- thirst, disturbance of bowels. The urine is generally diminished in quantity, with increase of excretory products of the body, especially of urinary products, of uric acid and diminished chlorides. In case the fever continues there is notable wasting. Although a part of these appearances may be caused by over-heating of the organism, yet in febrile disease they are doubtless not to be regarded as simple results of high temperature. Hence it results, among other things, that the increased frequency of the pulse, ^ The definition of fever as " a continued elevation of temperature," therefore, is not suitable. GENERAL EXAMINATION. Q\ the mental manifestations, and the disturbances of the bowels, do not have a constant relation to the height of the temperature, but, on the contrary, have a markedly different expression according to the cause of the fever — that is, the nature of the disease. Nevertheless, the height of the temperature is a very practical index of the severity of the fever, and these two factors clinically become fully identified. But the physician must never forget to pay attention to still other manifestations of fever beside-. With reference to bodily temperature, Wunderlich has prepared the following table : I. Normal temperature, 37° to 37.4° C. II. Subfebrile temperature, 37.5° to 38° C. III. Febrile temperature, a, slight fever, 88° to 38.4° C; 6, moderate fever, 38.5° to 39° C. morning, and 39.5° 0. evening ;^ c, considerable fever, 39.5° C. morning, and 40.5° C. evening ; d, high fever, 39.5° C. morning, and 40.5 C. evening. [^Qoui'parison of Thermometric Scales: Cent. Fahr. 34° 93.2° 35 95 36 96.8 Normal temperature, 37 98.6 Normal temperature. 38 100.4 39 102.2 40 104 41 105.8 42 107.6 43 109.4] If the temperature reaches 42° 0. then we speak of hyperpyrexia, hyperpyretic fever. While the higher temperatures even of high fevers do not occasion direct danger to the organization, in hyperpyrexia the temperature is directly dangerous to life ; it generally leads to a fatal issue. 1 Regarding this difference between raorning and evening temperatures, see under Remission. 62 MEDICAL DIAGNOSIS. There is uncertainty regarding the highest temperatures that have been observed. Temperatures of 45° C. have been published as curiosities. One ease of injury to the spine, which resulted in re- covery, is reported by Teale to have repeatedly had a temperature of 122° r. = 50° C. The course of the temperature in twenty-four hours can vary much only in fever. Most fevers show distinct fluctuations, in that toward morning the temperature falls more or less, reviission, until it reaches the daily minimum, thence in the course of the day it rises, exacer^ba- iion, and toward evening reaches the daily maximum. The difference between the daily maximum and the daily minimum in fever is called, as in normal temperature, the daily difference. Ys^hile the course of the temperature in fever is analogous to that of health, not unfrequently the minimum and maximum come at quite a different time, as, for instance, the maximum may be at midday or at midnight ; a complete reverse may even take place so that the maxi- mum occurs in the morning and the minimum in the evening : typus inversus. From this it is seen how the temperature must be exactly measured every hour of the day and night if it is of importance to know whether a patient has fever or not. There have been cases when the persons were thought to be without fever until the physician thought of ascer- taining the temperature at night. The exacerbation of the fever is frequently connected with shivering. If the temperature rises very rapidly (it may rise several degrees in a single hour) generally there is a chill, that is, a decided feeling of chilliness with severe shaking of the whole body, chattering of teeth, when the high internal temperature of the body is then very quickly contrasted with the subjective feeling of chilliness. The skin is at first pale, livid, and generally cool ; toward the end of the chill, how- ever, it is regularly very hot. On the other hand, a rapid remission * of the temperature is generally accompanied with sweats. According to the amount of the daily difference we distinguish three types of fever: . Continued fever : daily difference not more than 1° C. (chiefly high temperature). Remittent fever : daily difference over 1° C. GENERAL EXAMINATION. 63 Intermittent fever : maximum very high, minimum within the normal (or even below). An important peculiarity of fever is that the temperature does not long remain at the same point, as it does in health. It is very chano^eable. Warm clothing, high temperature of the room, and sometimes the taking of nourishment, cause a very marked rise of the temperature in fever ; likewise also psychical influences, as fright or anger. On the other hand, a* cool room and (especially) a cool bath, also gradual loss of blood, as in menstruation, cause it to fall. It is absolutely necessary to know this if we wish to ascertain the cause of many remarkable variations of temperature in fever. Moreover, the sudden fall of the temperature is sometimes a sure indication of an internal hemorrhage. 4. The Subnormal Temperature. It begins at 36.25° C. ; the lowest observed temperature is 22° C. 1. It is observed in febrile diseases as an expression of two directly opposite conditions, namely : a. In a sudden fall of the high fever with an advance to recovery, the " crisis," the critical decline of the fever. In this case the tem- perature falls during perspiration sometimes to below 34° C, and only in the course of one, two, or three days again returns to the normal. We recognize the " crisis " by the simultaneous diminution of the frequency of the pulse and the respiration, and the feeling of comfort and returning health by the patient. h. In the so-called collapse. In this condition there is generally a very rapid fall of the temperature, and at the same time a sudden failure of the heart, with (as is the contrary in '• crisis ") increase of the frequency of the pulse, with paleness and general failure of strength. The condition of collapse may pass over, when there generally is an immediate rise of temperature again to the former point ; or it may pass on to a fatal termination. On the chart of the fever- curve the line of the falling temperature is crossed by the rising line of the line of the pulse-curve in a charac- teristic way (see Pulse). Sometimes, in a case of collapse ending fatally, the pulse-line sinks parallel with the temperature-line (see Pulse). 2. It occurs sometimes temporarily in severe hemorrhages, also 64 MEDICAL DIAGNOSIS. sometimes in all kinds of chronic diseases, especially in those of the heart and the lungs. If the temperature suddenly falls, accompanied by weakness of the heart and general prostration, then also we speak of collapse, 3. Continuing subnormal temperature, extending into a number of weeks, is very rare. It may exist in all severe wasting diseases and in diseases of the brain. 5. Diagnostic Value of the Temperature, especially/ of its G-eneral Course. Under certain circumstances a single, or, in other words, the first measurement of the temperature may be of the greatest diagnostic value. Of this a few examples may be given, 1. Frequently the elevated temperature, with some indistinctive complaints (or, in the case of children, abstinence from food with rest- lessness), is the only sign of a disease just commencing, or of one that has been going on for some time. Ascertaining the temperature is then of great service, in that it leads to a more careful examination and more extended observation, and to directing suitable care of the patient. A hi^h morning tempCTature points directly to an acute infectious disease." 2. In marked cachexia, without distinct organic disease, the exist- ence of temporary fever indicates tuberculosis with considerable probability. 3. A single chill accompanied with a rise of the temperature to about 40° C, may, in a given case, say of a disease which from expe- rience sometimes causes suppuration, lead to the diagnosis of suppura- tion, as in gall-stones, renal calculi, after injuries to the skull, as brain abscess ; also here belongs puerperal fever, or, under certain circum- stances, it may possibly be malaria. But the continued observation of the course of the temperature is of still greater importance. It advances medical knowledge in various ways : 1, The course of the fever in a number of diseases is so typical that from the temperature alone the diagnosis may often be made with great probability, sometimes with certainty. At any rate it is always, taken in association with other symptoms, an important aid in diagnosis. GENERAL EXAMINATION. 65 2. Moreover, during the progress of a febrile disease, the tempe- rature not infrequently gives notice, by its unusual behavior, of the occurrence of an unusual event. Hence, not infrequently, we first become aware of an exacerbation or of a complication in a given dis- ease by a specially high rise of the temperature. A sudden fall of the temperature may give notice of collapse, or a change to a fatal issue, or an internal hemorrhage, as of the bowels in typhoid fever. In the following the moi^t important typical courses of fever are briefly set forth : 1. Continued fever exists especially in two diseases : Typhoid fever and croupous pneumonia ; also in typhus fever, sometimes in erysipelas and miliary tuberculosis. In a case of severe fever, with the diagnosis doubtful, a fever continued through several days points with proba- bility to typhoid fever ; and next to acute miliary tuberculosis. In abdominal typhus [typhoid fever] the fever rises for several days by equal steps, "initial period''; reaches the summit, at which it remains as a continued fever one, two, or more weeks ; then it, as a rule, gradually becomes a remittent fever, of such a character that at first the daily maximum remains high, with the minimum going lower ("the double stage" ["the long-continued paroxysm"] — the mini- mum may even go below the normal) ; then the defervescence begins, Fis. 1. Day of illness : 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 40° 37 Br;KBBBBBSBBBBBBBBBBB8SSBBSaBBBBB7BS'£BV«B |aBSBgSBSSS8BSSSBBBSBBBSBBSSSBSifiLaffl7i^^ SSBBBBBBBS8888B88aSBB8BBSSBBB|BS8BBBSSB —■■■■■—■■■■■■■■■■■■■■■■■■■■■■■■■—■■■■■ Initial period. Acme. Defervescence. Fever-curve of a regular mild typhoid fever. (Wundeelich.) the maximum declining; this usually reaches the normal in a few days. The remittent and defervescent stages may be protracted for 5 66 MEDICAL DIAGNOSIS. some time, even as much as a week : " slow typhus." Moreover, the temperature may, after it has somewhat declined, again rise : " recur- rence"; or the disease, after the temperature has reached the normal, may begin anew, in the same manner as at first : "renewing" (see regarding these points Figs. 1, 2, 3). Fig. 2. Day of illness : 13 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 Long-continued paroxysm of typhoid fever. There are all manner of variations from this behavior of the tem- perature in typhoid fever, so that a single case seldom really pursues a typical course. Particular variations partly declare themselves by Fig. 3. 40° 39 38 37 36 SSSSnSSS&SBmnSSHSBSSSBSSSSSSraSSSSSij fas^s;ansssB»Kags»BssaBB9B»:BBRSj ■.IMBBVAWrill ■■I aj.'B.f.siis;7ABr&vi!iB;iB';»'; !■■■ ■ ■■■ !■■■ ■Ha ■i! Defervescence. Typhoid fever, with recurrence of fever. Second attack. the earlier change of the temperature to the changeable character, mentioned on page 67 ; but the fever-curve will especially be affected GENERAL EXAMINATION. Ql by the administration of antipyretics.^ But, particularly, every exacerbation of the temperature should cause the physician to think of complications, and a fall of the temperature, of collapse, and also of possible intestinal hemorrhage. In pneumonia (see Figs. 4 and 5) the temperature rises very rapidly ("initial period," lasting a few hours), often accompanied by chill, then remaining as a high continued fever. From this it may decline, also very rapidly — in a few hours — to or below the normal, with a simultaneous decline of the pulse and the respiration, and generally with severe sweating. Or the defervescence may be some- Fig. 4. Day of illness: 1234 5 6 7 8 niO ■■■■■■■■■■■■■■■■■■H HHHHHHHHIHHHHHIHHHHHH HHHMHHHHHHHHHHHHHHIBi 4( o ■■VAnHHHHrAlHr^HHBHaBH ■MMBHFilHBiamHMnHHHBHH ■ KrjH.VllHKKHiWflllHBHBBH ■■■■WBMHMHkVBRMBHHHH ■■■■riBWMHVMIIHHBHHH "Vi ■■■■HBHMHBMmiHBHHHH ■■■■■■■ a55BE!S999BB ■!■■■■■■ ■■■BBIBBHHHH Cto ■MBHBBnaBBBHBIBHBHgg ■(■■■BailiBBBBBWBBBBBB ■{■■■BMIU ■BBBHIBBBBBB o8 ■IBBBBHI'I ■■■■■■■BBBB IIBBBBBB BBBBBBHBBBB IIBBBBBH ■■■BBBHBBBB IIBBBBBB BBBBBlHBBBBB 0*7 6i iSSSSBSB SSSbbISBbbbb BBBBBBB BBBBBMBBBBB BBBBBHH ■BBBBMBStlBfiiiri BBsalss SSsSbbBBs 36 Pseudo-crisis. Fever curve of croupous pneumonia. (Strumpell.) what slower, occupying one or two days. The former way is called " crisis " (critical sweat), the latter "lysis"; midway between these two is " protracted crisis." Sometimes the day before the crisis the temperature suddenly falls very rapidly, and then again rises — " pseudo-crisis " (distinguished 1 The antipyretic treatment, especially with internal remedies, has, no doubt, the result of rendering the course of the fever untypical, and so destroying its diagnostic value. Therefore, until the diagnosis has been established in a case of febrile disease, the internal antipyretic treatment ought, if possible, to be suspended* 68 MEDICAL DIAGNOSIS. from collapse by the pulse and the general condition, as referred to under "the subnormal temperature"). Or there is exacerbation of the temperature just before the crisis, rising from, say, 40° to 41° C. — " critical perturbation." Day of illness: 2 Fig. 5. 3 4 5 Fig. 6. itna — — SSSBSIS BBSS iSwif iSii'j HBL ■■■»■!■■■ ——-■■■■■wBg SSB Pseudo-crisis and crisis in pneu- monia. (WUNDERLICH.) Remittent and intermittent fever (catarrhal pneumonia). (Wunderi.ich.) 2. Remitteiit fever is often met with. It may exist some time during the course of any febrile disease. While the temperature of continued fever is generally high — about 40° — the fever may remit whatever its height. If the maxima are low, the minima may easily be normal — a behavior which, strictly speaking, must be considered as intermittent fever. Remittent fever belongs especially to chronic tuberculosis. Fig. 7. 40© 37 ■■■■SSSllSnBBiiBfiEfSaiiBRHHfiiiiHHn ■■■iiiBiliBSBHB'iiHr>a'ii.Hri«iiB,'£l!lS9B" Hectic fever in tuberculosis of the lungs. If the maximal points of the curve are high, the temperature often falls pretty I'apidly, accompanied with chills and night-sweats {hectic fever). Similar conditions are observed in the fever of pus-formation. GENERAL EXAMINAJ'ION. 69 3. Intermittent fever, in a general sense, occurs in combination with remittent fever (see Fig. 7). The hectic fever mentioned above as accompanying remittent typlius [relapsing fever], is often also an intermittent, in which the minimum may even be subnormal. Fig. 8. 2 3 41° 40 39 38 37 ■I ■■■■■■■■■■■ ■iiiHBHHgagBBB alVBBRBSBSr^ law ■!!■■■■■ ■■■■lilllllllll ■■■ ■IIHIIANIir ^iniiiinifJ ■ni'iilii' ■■■iviniiii «ni ■iiiiiraHatI ■illHWMB*" ■■■IIIBBI MM B'I ■IIIBIIHBBI HIHIIHHW ■■■UBtlMBBBBH ■■■■■■■■■■— Pysemia with rapidly fatal course. (WUNDERLICH.) Fig. 9. S ^^ Mi^ ^^ ^^ i^BH ■■■■■■■■■■■ ■■ ■■■■■■■■■ llH.BH ■■■■■ ■mizzz ■IIIHIIBI ■IIIHI|BIII ■IIIBUHII BlilBIIIBni SI 41° 40 39 38 37 36 Quotidian intermittent fever. (WUNDERLICH.) ■UHHIBni ■IIHI ■U»l ■■■ hSISbS ■■lira iiiiiBBBg ■■■I'B ■■■■{■■■n IIW y.ll A peculiar form of intermittent fever is observed in pyaemia, where the temperature during chill may rise two, three, or more times in twenty-four hours, and soon fall, with sweat and great exhaustion, Fig. 10. Fig. 11. 41° 40 39 37 SSBBilBBSBSSSSS ■ lllBBBfllgl WW BB ■ [■■■■■aiBBIKIB MBB W ■ IIIBBaillBIIBBI«BflB ■niBHBUBniggaHag ■ IIIBBIIIIHIIBBlBBBg ■ BIBHIHIHIBBUHBg ■MiBBiniHiiHHnnnB IB'BBimailHHIIH'AV ■■v^'iiaiiBramaKw^HM ■■nauBwaBBwafati ■■BBBBBBHiBIBBg B ■■■■»!■ HnMBBB BBBBriBBMBBBB Tertian intermittent fever. (WUNDERLICH.) 40° 39 38 36 S '9ES5SSB B IBBSeSBSB ! lESBEB BBM (■■■■■■Bl BBBB ■■■BBBBI B BSBB 8BBBBBB IBBBBB 8BB7.BBS fj BB « IB. ■■ IIBBIi liKM ■■■ BBSIKIB'^ffillBB 8BB BBSi;&.^8ffi.'BB BSIB BHBBAJBBBBB BBB Quartan intermittent fever. (WUNDERLICH.) then again rising. The pulse is generally very fi'equent, and the patient often gives the impression, by the great prostration during the 70 MEDICAL DIAGNOSIS. sweating stage, of going into collapse ; in fact, a condition of collapse sometimes exists with the fall of the temperature (see Fig. 8). In a narrower sense, however, we designate as intermittent fever the course of temperature of a special form of malaria. In this there is a continual alternation between times without fever (apyrexia) ; a quick, high rise, and, after a short time, again, a rapid fall of tem- perature (often below normal) — "fever paroxysm." Severe chills and perspiration accompany these attacks of fever. The attacks recur with great regularity, either every twenty-four hours (quotidian), or forty-eight hours (tertian), or seventy-two hours (quartan). Some- times the attacks recur one or more hours earlier on successive days (anticipating), or they may recur later each time (postponing). In these forms of fever the diagnosis is made certain by the fever-curve (see Figs. 9, 10, 11). Fig. 12. 420 41 40 39 38 37 86 B ■■■■■■■■■■■■ ■■■■■■■■■■■I -wmxwmwmmmmmmwn miivfMwtmmmummmi _IMIIlirwnBBHHBHI BnirmrAWBiaaBHi ■JMBUHWIlHiaaHHI ■■■ItlHIII ■■■■■■III ■■■llWill ■■■rflniiii iravHitiii ■■■niMaii rgifjHwaii ■ ■IflBBBII g ■!■■■■ II ■■■■■■■■■n ■■■■■■■■■■■ ■■■■■■■■■■■ ■■■■■■■■■■■ SSSSSSSBSSSSSSSS5SSSS5SSSSS "" BBB9BBBSS!B'"'"9!SBBBSBSB!J*""""i'*""^&nMSB ■■■■■WBBHn ■■■■■■■I ^rJIWaaHMHHHHH _. ■iail'iliaHl*!S?HBIHHHMMI ■laBanaaHHiiir.iHv^anHi ■I mmm ■■■■avAwraoriHi ■{■■I ■■■■I ui ■■■iHaiBriH.viHi BBSS: BS9B'9BBi'9^'""B*BBi BS5SSBB SBBS>"'''l!"i BB9S BBB'l'B vtf vjLTiai ■■■■■^•'^■•^■■■■■■■■■'■■■riBi^MiW mSSSBSS8S8SSBS8SSSSSi 1. Apyrexia. 1. Febris recurrens. (Wundeelich.) Compare p. 2. Apyrexia. 4. Recurrent fever only exists as a renewal of a febrile disease, or a disease known as relapsing fever. There is an attack of fever very like that of pneumonia, with sharp transitions and very severe sweating, the temperature falling often to 34° or 35° C, and apyrexia; then a relapse after five to eight days, with a chill, followed by a high continued fever, which, in turn, ends in five or six days by a critical GENERAL EXAMINATION. 71 sweat ; new apyrexia, fresh relapse ; and so, over and over again, but each new attack with less fever and of shorter duration. 5. Not infrequently a quite irregular fever will he met with. Its course is such that sometimes one cannot speak of any daily remission — at least, the lowest daily temperature comes at a variable hour of the day or night. But this fever may be of diagnostic value. In acute meningitis a continuing irregular movement of the temperature speaks against tuberculosis and against ordinary purulent meningitis, but, on the contrary, for epidemic cerebro-spinal meningitis. Again, a pronounced irregular fever in an acute disease in general speaks against any of those diseases which manifest themselves by any typical fever. 6. Local Elevation or Lowering of the Temperature. 1. Elevation of the temperature. In internal medicine this is seldom of diagnostic aid. We meet it where there is any kind of inflammation which is near the surface, as in surgery. In unilateral pneumonia, also, a careful measurement shows an elevation of the temperature in the axilla of the aifected side. In recent paralysis of any sort the temperature of that side is somewhat higher for a short time ; then the temperature usually falls. Rare cases of hysteria exhibit a one-sided elevation of temperature with redness of the skin and perspiration. 2. Lowering of the temperature. This is the expression of local disturbance of the circulation. In heart-failure, also in collapse and near-approaching death, the extremities and also the nose become cool. Coolness of the aff'ected limb is observed in venous thrombosis, in paralysis of long standing in consequence of diminished venous blood-current, and in arterial embolism and thrombosis. PART III. SPECIAL DIAGNOSIS. CHAPTER lY. EXAMINATION OF THE RESPIRATORY APPARATUS. Examination of the Nose and Larynx. 1. The Nose. Inspection of the nose sometimes reveals diseased conditions which concern the bony structure, and, therefore, belong to surgery : defor- mities, fistulse, ulcers, with deeply- seated destructive process at the root of the nose. Only one of these conditions has interest for us as physicians : the so-called saddle nose, arising from necrosis and removal of a part of the bony framework of the nose, is an almost infallible sign of consti- tutional syphilis. Swelling and redness of the nostrils indicate inflammation of the nasal mucous membrane. Not infrequently we also see traces of a muco-purulent or purulent, sometimes an ill-looking bloody, serous secretion ; the latter is sometimes offensive in odor. Patients with obstructed nose (with severe catarrh or tumors) breathe through the mouth. On the other hand, in severe dyspnoea [q. V.) there is likewise motion of the alae nasi. JEpistaxis shows itself most plainly by the flow of blood from the nose. However, when persons are entirely unconscious or healthy persons are asleep upon the back, the blood flows backward into the pharynx or even into the stomach. Then the hemorrhage may be overlooked, or the first symptom of epistaxis may be vomiting of blood. (73) 74 SPECIAL DIAGNOSIS. In all important diseases of the nose it is necessary to make use of the nasal speculum. (For the use of this in examinations, see the Appendix.) Palpation of the interior of the nose may be necessary (see works upon Surgery). Acute muco-purulent and purulent catarrh of the nose is symp- tomatic in measles, diphtheria, and equinia. Chronic catarrh is a common symptom of scrofula (in which disease the whole nose is often swollen) and of syphilis. In the former disease there is sometimes an inflammatory thickening of the whole nose, particularly of its lower walls. Inflammation of an acute form, with very foul-smelling and ill-looking secretion, most frequently indicates diphtheria of the nose and pharynx. 2. The Larynx. The larynx is examined with reference to its functions (voice, cough, breathing) and the local appearances ; the latter includes the external and internal examination (see also under Sputum). (a) The Function. — The voice is changed in all afiections of the larynx. It may be muflied, rough, hoarse, even to the entire loss of voice — " aphonia." In severe diseases it may have a whistling or sibilant (strident) quality : This indicates stenosis of the larynx ; or it is very hoarse and deep : this points to deep-seated ulceration. In diseases of the larynx the cough is hoarse, loud, or barking. In extensive destruction and in certain paralyses of the crico-aryte- noid muscles, cough is either more difficult or is impossible, since the power to close the glottis preceding the cough, as is normally the case, is wanting (see Cough). Breathing is obstructed in all conditions that narrow the larynx, as in inflammation resulting in hypertrophy, in new formations, in scars with contraction. Then there is an inspiratory and expiratory dyspnoea (which see), and a peculiar noise of stenosis, " stridor laryn- geus." In marked stenosis, especially when the thorax is weak, as in children, there is a drawing-in of the lower part of the thorax in front, in the region of the insertion of the diaphragm (see the chapter on Anomalies of Respiration). Stenosis only in inspiration, causing inspiratory dyspnoea, is ob- EXAMINATION OF THE RESPIRATORY APPARATUS. 75 served in paralysis of the crico-arytenoid muscles, the dilators of the larynx. Laryngeal stenosis is distinguished from tracheal stenosis at the first glance, in that in the former condition the larynx moves up and down with each breath, and the neck is stretched to the fullest extent, while in the latter the larynx remains quiet and the head is always somewhat bent forward. (h) Local Examination.- — The external examination is made with reference to pain, to deformities revealed to the sight or touch (these are very rare, resulting from destruction by periostitis), and laryngeal fremitus. Laryngeal fremitus is a trembling of the thyroid cartilage during speech. It is stronger or weaker on one side in unilateral paralysis. It has no special diagnostic value. The internal examination. By great care, and in the case of patients who have themselves under good control, sometimes the entrance to the larynx and the tissues even as far as the glottis can be touched. This method, however, has now little value, since it has been entirely superseded by the examination with the laryngeal mirror, which is the best means of examining the larynx. (Regarding its use see the Appendix.) In inflammatory conditions, patients complain of pain in speaking, but sometimes, even with severe disturbances, there is no pain ; now and then there is dyspnoea, especially on exertion. Pain in sivallow- ing in chronic diseases of the larynx frequently indicates serious con- ditions : extension of new formation (carcinoma) toward the oesophagus, or destructive suppuration. The leading symptomatic indications of diseases of the larynx with reference to other possible internal diseases, are as follows : acute laryngitis, with manifestations of an acute infectious disease, points especially to measles, croup (and also to smallpox). Chronic laryn- gitis points to tuberculosis and syphilis ; to constriction by scars, to syphilis. Of paralyses, paralysis of the recurrent nerve is of special diagnostic importance, since it often arises from pressure upon nei'ves, especially upon the left side from aneurism of the aorta, carcinoma of the oesophagus, tumors of all kinds in the mediastinum. Certain paralyses indicate hysteria. 76 SPECIAL DIAGNOSIS. Examination of the Lungs, topographical anatomy of the lungs. For localizing the surface of the chest with reference to height and depth Ave make use partly of anatomical prominences and partly (for determining the breadth) of certain local lines which we think of as drawn upon the surface of the thorax. Upon the front side of the thorax are the important anatomical regions : the fossa supraclavicularis (above the clavicle and bounded by the sterno-cleido-mastoid and trapezius muscles) and the fossa in- fraclavicularis. The latter has no distinct lower boundary. We under- stand it as the region immediately below the clavicle, about as far as to the second rib. From the second rib downward we designate the height by the ribs and intercostal spaces : as above the fourth, under the fourth rib, the fourth intercostal space. The number of the par- ticular rib is determined by counting from the second rib downward. It is always easy to find this rib : it is in articulation with the sternum exactly where the manubrium and corpus sterni unite, ordinarily forming a very slight angle (angulus Ludovici), and this place is plainly to be felt, and often seen, as a cross-line or prominence. We feel for this prominence and find the second rib to be its prolongation. "We count the ribs from that downward, feeling somewhat obliquely outward as we go down. Morenheim's depression [the outer part of the infraclavicular depression] and the so-called Sibson's furrow (the under border of the pectoralis major) are sometimes, although not very practically, useful as points for locating internal organs. For determining the breadth the vertical lines now to be mentioned are useful (the subject is supposed to be standing) : the middle line, drawn through the sternum ; the two sternal lines, drawn parallel along the sides of the sternum ; the mammillary lines, drawn through the male nipple ; and the parasternal lines, drawn midway between the sternal and the mammillary lines. On the two sides we determine the height by the ribs, which we count in front ; and the breadth by the middle axillary line (drawn through the middle of the axilla, the arm being extended sidewise), the anterior and posterior axillary lines (drawn perpendicularly from EXAMINATION OF THE RESPIRATORY APPARATUS. 77 the points where the pectoralis major and latissimus dorsi muscles leave the thorax, with the arm raised sidewise to the horizontal). Upon the back, we name the fossa supraspinata ; above that, the suprascapular space ; the fossa infraspinata ; the interscapular space, between the two scapulae ; the infrascapular space, under the shoulder- blades. Exact determination of height is made by counting the ribs, which, however, are difficult to count, especially in fat persons. They can be determined by three methods : (a) By counting the vertebral prominences from the vertebra prominens (the seventh cervical). (h) By counting from the lower angle of the scapula ; this over- hangs the seventh rib in the average person when the shoulders hang comfortably and the arms rest against the chest with the fore- arms folded lightly. ((?) By the point of the twelfth rib, which is easily felt (the best way for the lower ribs). Moreover, we have the scapular line, which is drawn upon the two sides of the spine through the lower angle of the scapulae (at the point already mentioned under (5)), It is to be observed that some of the vertical lines are not deter- mined exactly. This is true regarding the mammillary line (always very important) more than any other. In women it is generally very variable. On this account it is always to be thought of as drawn upon a male thorax. But even in the male the nipple is an uncertain point. By much practice the eye is cultivated so as to recognize what is to be regarded as the average location of the nipple in the male, and by this we must always correct the mammillary line. The attempts to substitute other lines for this one have not been accepted. The designation " infrascapular space " is little used. The expres- sions, " right, left ; behind, below," correspond to it, and are much to be recommended : behind or below the right, the left, scapula. THE A^'ATOMICAL BOUNDARIES OF THE LUNGS WITH REFERENCE TO THE THORAX. In front the lungs reach to the sixth, and behind to the tenth, rib, and are almost everywhere directly in contact with the chest-wall. They afe not in contact with the chest-wall in the neighborhood of the heart nor behind a small portion of the upper part of the sternum. 78 SPECIAL DIAGNOSIS. The accompanying figure exhibits the anatomical boundaries of the lungs. They project with their summits into the fossa clavicularis from three to five cm. above the clavicle, and with their inner anterior borders converging downward, so that behind the angulus Ludovici, not exactly behind the middle of the sternum, but a little to the left, they come to lie very close to each other ; then they continue parallel Fig. 13. Position of the thoracic viscera, of the stomach and of the liver, from in front. The portions of the heart and liver which are drawn with unbroken hatched lines represent the parietal portions of those organs. The portions that are not in contact with the chest- wall, but are covered by the lungs, are represented by broken (clear) hatched lines. The line ef, border of the right lung; g h, border of the left lungj dotted lines ( ) a h and c d, the boundaries of the complementary pleural space ; i, the boundary between the right upper and middle lobes; k, the boundary between the right middle and lower lobes of the lung; I, boundary between the left upper and lower lobes; w, greater curvature of the stomach. (Weil-Luschka.) downward to the insertion of the fourth rib. From there the inner border of the right lung proceeds still further downward to the top of the insertion of the fifth rib, then gradually bends toward the right so that it follows along the sixth rib, on the upper border of which it meets the mammillary line. Then it continues approaching the hori- EXAMINATION OF THE RESPIRATORY APPARATUS. 79 zontal (in the upright posture) so that it lies, in the middle axillary line, upon the seventh or eighth rib, in the scapular line upon the tenth rib (this location on the dead body is about one cm. higher than in quiet respiration in the living subject). On the left side, the border of the lung bends sharply round from the fourth rib to give place to the heart, continues behind the fourth rib as far as the left Fig. 14. Position of the lungs, liver, spleen, and kidneys, seen from behind. The liver and spleen are represented by the same hatching as in Fig. 13. a h, the lower border of the lungs J cd{ ), complementary space; i (dotted line) (broken line), border of the liver; ef (dotted line), boundary between the upper and lower lobes of the lungs; g, boundary between the upper and middle lobes of the right lung. (Weil-Luschka.) parasternal line, then bends vertically downward, making a small bow, which converges toward the right; then sharply bending again behind the sixth rib so as to pass the mammillary line under the sixth rib (hence, somewhat lower than on the right side), it passes the axillary line between the seventh and eighth, and the scapular line at the tenth, rib. The boundaries of the lungs are different according to age, as well as in individuals. (See section on Percussion of the Lungs.) 80 SPECIAL DIAGNOSIS. The boundaries of the pleural sacs — that is, the lines on which the pleura costalis (sternalis) leaves the wall of the thorax and bends inward — agree in reality with the course of the inner borders of the lung. But along the lower borders of the lungs and at the cardiac concavity the pleural space extends considerably beyond the border of the lungs (in quiet breathing), making the sinus phrenico-costalis and the comple- mentary pleural sinus The size of these corresponds with the form. The largest is the complementary pleural sinus in the two axillary lines. This is there about ten cm. high. The pleural sinuses are therefore important, since into them extend the lungs at every deep inspiration and also in the pathological, chronic inflation, emphysema pulmonum; and also, because in them fluid eff'usions into the pleural cavity ordinarily first accumulate. The under surface of the lungs rests directly upon the diaphragm. The diaphragm in the dead body rises at its highest part, as a dome, about as high as the insertion of the fourth rib, a little higher upon the right than the left side. The average situation of the dome of the diaphragm in life, during quiet breathing, is a little lower. Finally, it is necessary to mention the course of the boundaries of the lobes of the lungs, since they sometimes have an important part in diagnosis: at the back, near the spine, the boundary between the upper and lower lobes is at the height of the lower angle of the scapula ; upon the left it gradually slopes forward and outward in such a way that in the axillary line it stands at the fourth rib, and meets the lower border of the lung (that is, at the sixth rib) in the mammil- lary line. On the right side the boundary-line divides near the outer border of the scapula into two diverging lines : the line between the upper and middle lobes and that between the middle and lower lobes. The former proceeds at first behind the third rib, and terminates at the inner border of the lung at the insertion of the fourth rib ; the latter meets the lower border of the lung somewhat within the mammillary line, and, therefore, behind the sixth rib. Hence, in front upon the right side, we have the upper lobe; about at the third intercostal space, from there downward really the middle lobe; in front on the left side, for the whole distance we really have the upper lobe ; on the side at the right, we have the middle lobe above and the lower lobe below ; on the side at the left, we have the lower EXAMINATION OF THE RESPIRATORY APPARATUS. gl lobe ; behind we have only the apices, formed by the upper lobes ; all the rest is lower lobe. INSPECTION OF THE THORAX. The examination of the thoracic organs must always begin with the inspection of the thorax. Nothing is more faulty than to take up some other method of examination first. Inspection of the thorax is important because a very large number of the diseases of the lungs and pleura manifest themselves in the form of the chest cavity and a change of the respiration. Certain diseases of the internal organs have a causal relation to changes in the form of the thorax. In other cases, as it appears, a given form of thorax accompanies a "disposi- tion " of the lungs to certain diseases (emphysema, phthisis). It is very probable, although it is difficult positively to establish, that sometimes the thorax by its form either causes or favors the develop- ment of the given disease. Moreover, we know that there are deform- ities of the chest which in other ways injure or render useless the thoracic organs ; there are such, also, as have no influence upon the lungs or heart. Method of procedure. During inspection (as in all examinations of the thorax) attention must be given to having the patient straight, but without undue muscular tension. The light should fall symme- trically upon the front or back, whichever is under examination ; the eyes of the examiner should, if possible, be directly before the middle line of the body. The general structure of the thorax (and neck) should first be considered, next possible peculiarities, then the motions of respiration, first during quiet, then deeper, respiration. 1. Normal Form of Thorax and Normal Respiration. In a well-constructed thorax we expect, first, perfect symmetry (this is departed from almost always normally, in that there is a very slight curvature of the dorsal vertebrge toward the right). Moreover, the clavicular depressions may only be indicated ; the angulus Ludo- vici [also called the angle of Louis] (the angle formed by the junction of the manubrium and corpus sterni) may just be recognizable; the true ribs should so leave the sternum that from the top downward there 6 g2 SPECIAL DIAGNOSIS. is increasing obliquity, making the angle formed by the two opposite bendings of the ribs, " the epigastric angle," almost a right angle ; the thorax should be well developed ; the scapulae should, in the upright position, lie flat upon it ; the intercostal spaces should be visible only at the lower ribs ; finally, the dimensions of the chest and the size of the body should have a certain relation to each other. Very seldom does the normal thorax correspond to this ideal, and there are many de- partures from it in persons who are perfectly sound. Such " physio- logical " departures may be mentioned; a slight asymmetry in a gradually-acquired spinal curvature or a deformity of the ribs self- established ; further, a peculiar form of thorax, where the upper part is somewhat shallow, but the lower of increasing depth, so that the lower aperture of the thorax is very large ; also more marked angle of Louis (Braune) ; again, in a shorter thorax, a more acute epigastric angle may sometimes be observed in healthy persons (hence, also, without signs of emphysema, see below)- The supra-clavicular de- pressions are often both deepened, with the apices of the lung entirely normal (unequal deepening of them is, however, very suspicious of tuberculosis, see below) ; single ribs, more frequently the second, third, also the fourth, sometimes on account of greater curvature, project more in front ; on the other hand, the lower ribs will often be found pressed into the side and from there flattened forward, and other variations. The boundary between the unsymmetrical and the path- ological form of chest is much confused ; it can only be recognized in the individual case by attention to the location and function of the thoracic organs. Normal breathing takes place in this wise : inspiration only is active, that is, is accomplished by muscular action ; expiration, on the contrary, is produced wholly by the elasticity of the lungs, the weight of the chest wall, and the pressure of the abdominal organs upon the diaphragm. The number of respirations to the minute in the newborn is about 44 ; at five years, about 26 ; from the twentieth year, about 16 to 20. It is very easily influenced by a number of con- ditions : in sitting and standing it is somewhat higher than in lying ; it is increased by bodily activity and psychical impressions. There- fore, it can only be determined during perfect quiet, with the atten- tion withdrawn from the examiner, or during sleep. For counting EXAMIXATIOX OF THE RESPIRATOR T APPARATUS. 83 it, it is generally most advantageous to lay the hand lightly upon the chest (or upon the epigastrium). The breathing is generally regular, and the single breaths of equal strength ; but under the influence of the shghtest psychical disturbance it easily becomes irregular and unequal. Many persons of sound health, as snorers in sleep, often breathe irregularly or unequally deeply. Breathing is either exactly or very nearly symmetrical, though the left side frequently inclines to breathe a trifle stronger. The inspiratory enlargement of the thorax is occasioned by the elevation of the ribs and the sternum, and the simultaneous drawino- of the former upAvard and outward (intercostales extern! and interni muscles — '■^ costal breathing''); moreover, by the contraction of the diaphragm, and, hence, flattening of its dome. The latter movement, at the same time, draws down the intestines, and so with every inspira- tion the whole anterior wall of the abdomen projects, but especially the epigastrium (diaphragmatic, or abdominal, breathing). The com- bination of costal and diaphragmatic breathing varies in the two sexes in that in the male the latter, and in the female the former, preponderates. But in aged females, with firm thoracic walls, dia- phragmatic breathing increases ; while, on the other hand, male as well as female children incline to the costal type of breathing. From this it seems that the degree of flexibility of the thorax influences the kind of breathing. In the costal breathing of women, even in quiet respiration, the scaleni muscles (elevators of the first and second ribs) take a part ; w^hile in men these muscles belong to the auxiliary muscles of respira- tion (see below), 2. Pathological Forms of Thorax. (a) The inflated or emphysematous thorax. This refers to a chronic symmetrical expansion in all directions, conforming somewhat to the form of the chest during inspiration (the inspiratory position). The antero-posterior (the sterno-vertebral) diameter is increased. In many cases it appears as if the thorax became enlarged, especially at about the height of the middle of the sternum, making a barrel-shaped chest; however, this may be entirely wanting. The ribs are generally strong, and are at right angles to the sternum, hence the epigastric 34 SPECIAL DIAGNOSIS. angle is larger than normal ; the thorax is generally short. Fre- quently the angle of Louis is very prominent. The supra-clavicular depressions may vary very much ; sometimes they are deepened, again, shallow or even projecting like pillows (the latter condition obtaining in emphysema of the upper part of the lungs). The lower intercostal spaces are sometimes drawn in during inspiration. In the emphysematous thorax the breathing is so changed that the expiration is both slower and imperfect in consequence of the diminished elasticity of the lungs ; it is prolonged, and, in marked emphysema, it is assisted by muscular action, especially by the transversus abdominis and the quadratus lumborum. We can then plainly see the abdominal wall energetically flattened, and we are directly impressed with the idea that the thorax is forcibly expanded. But the inspiration is also altered in consequence of the rigidity of the chest-wall ; ordinary costal breathing is wanting ; it is very im- perfect ; and in its place we notice that the front of the chest, as a whole, has been drawn up by the powerful action of the sterno-cleido- mastoidei muscles. Consequently, in emphysema we have the breathing rendered difficult ; in severe cases it may become so to a high degree (see Dyspnoea). The typical emphysematous thorax points almost with certainty to emphysema, and hence its name ; however, we must guard against the mistake of calling every short chest an emphysematous one. On the contrary, also, we not infrequently find a general emphysema of the lungs in a chest that has no trace of the " emphysematous " form. Active expiration, expiratory dyspnoea, is much more characteristic than the form of the thorax ; besides emphysema, it exists in no other condition except certain diseases of the larynx (see Dyspnoea). (5) The paralytie or phthisical thorax. This is the direct opposite of the preceding : it is flat, especially in the upper part ; is often also narrow ; the intercostal spaces are wide ; the ribs are generally delicate, are sharply inclined downward from the sternum, and, hence, must be bent at a sharp angle again in order to come back to the vertebrae. This sloping from the sternum makes the epigastric angle very sharp ; the chest, as a whole, chiefly in consequence of the course of the ribs, is long. The angle of Louis is often very marked. EXAMINATION OF THE RESPIRATORY APPARATUS. 85 The depressions are generally deep. The shoulder-blades frequently stand out like wings. Quiet breathing may be almost normal ; by exertion it is generally immediately very much increased in frequency ; it is shallow ; even in women the costal type is often wanting, especially at the upper part of the chest. This form of chest corresponds with that of tuberculosis. A well- marked paralytic thorax, 'except where phthisis of the lungs has early developed, is very infrequently seen ; but yet this disease occurs very often Avhere the phthisical thorax is wholly absent — indeed with an emphysematous thorax. In a paralytic thorax, with phthisis already developed, by means of the latter the form of the thorax and the breathing will become essentially and variously changed. See above under {a) and below under {d). But one must be very careful not to conclude that a thorax narrow from great emaciation, and especially one that appears flat, is a paralytic one. For example, a beginner is apt to find that a patient convalescent from typhoid fever has a paralytic chest. Strictly speaking, also, every plain or flattened thorax is not to be called a paralytic one. Moreover, emaciation and flattening of the upper parts of the chest, in cases of developed phthisis, frequently render the thorax paralytic, which it originally was not. (c) One-sided exjMJision of the thorax, a relatively infrequent affection, occurs in disease, or functional loss, of the opposite lung. The dilated side is then the seat of the so-called " vicarious em- physema " of the lung. This is distinguished from true emphysema by the absence of expiratory dyspnoea. The dilated side is much more frequently the diseased one. The widening of the chest-cavity is more plainly seen from the front than from behind. Very frequently the mamma and the scapula are further removed from the median line than upon the normal side. The intercostal spaces are level or are projecting; in contrast with this, the diseased side drags after the other — that is, in inspiration it rises later and less than the sound side, and it may even not rise at all. Hence, the spinal column is sometimes bent toward the diseased side. Marked expansion is met with in pneumothorax and in extensive pleuritic exudation ; while the development of the latter usually first gg SPECIAL DIAGNOSIS. manifests itself by expansion and lagging behind at the posterioi- and lower part of the chest. A very slight expansion of one half of the chest is^ moreover, sometimes seen in croupous pneumonia of the "whole of the affected lung. Circumscribed forward expansion of the chest occurs especially with tumors of the pleura, and is sometimes humped, and, again, uniform ; empyema which inclines to breaking through, pushes the affected region prominently forward, and, at the same time, the skin is generally oedematous. Encapsulated pleuritic exudations or circum- scribed pneumothorax seldom cause expansion, yet the first causes a smoothing out of the neighboring intercostal spaces, besides lagging behind. Local projections, moreover, occur not infrequently from inflammatory affections of the ribs or the subcutaneous cellular tissue. Local expansions of the thorax are seen in cases of enlargement of other organs. The cardiac region may be bulged out in enlargement of the heart or distention of the pericardium (see under Examination of the Heart) ;. a marked enlargement of the liver may press out the lower ribs on the right side, and enlargement of the spleen on the left ; and sometimes, especially in children, a very marked expansion of the whole lower part of the thorax, an enlargement of the lower aperture of the chest, is observed in cases of considerable expansion of the whole, or the upper part, of the abdomen (meteorismus, ascites, peritonitis, tumors). Then the upper part of the chest seems quite small in comparison with the lower part ; the whole trunk is, hence, shaped like a bee. From the drawing up of the diaphragm there results interference with diaphragmatic breathing, and generally there is severe dyspnoea. It is very important to remember that the expansion of the chest, especially that caused by pleuritic exudation, varies with the flexibility of the thoracic wall. If the wall is soft, as is the case with children, the expansion is very pronounced; if rigid, as in subjects of em- physema, sometimes a very large pleuritic exudation causes no noticeable expansion. Therefore, Avhile we expect in general that an extensive pleuritic exudation will manifest itself by an enlargement of the affected side of the chest, yet, where the walls are rigid, we must not conclude from the absence of expansion that there is no exudation. {d) Drawing-in or shrinking of one side. This is seen more or less frequently as a symmetrical drawing-in of the whole side, so that EXAMINATION OF THE RESPIRATORY APPARATUS. g'J the affected side is altogether smaller than the other; the ribs are close together, and in the lower part they may even overlap, like shingles on a roof. The shoulder of that side hangs down ; the mamma and scapula are nearer the median line. The spinal column is curved with its convexity toward the healthy side ; hence, the whole carriage is affected. There is diminished breathing, or no breathing at all, on the side drawn in ; on the healthy side, there develops a vicarious emphysema. This condition is observed in recovery from extensive pleuritic exudations, and in long-continued contraction of the lungs. In pleurisy, it is the loss of elasticity and thickening of the pleura, with adhesions of pleural surfaces, in shrinking of the lungs, and the development of connective tissue in the lungs, which not alone hinder the lungs from following the inspiratory expansion of the thorax, but from the tendency to contract, as in scars of the skin, draws in the chest-wall. This inward traction, however, does not concern the thorax alone: the mediastinum, heart, and diaphragm are pulled toward the sunken side. Hence, there is displacement of the heart toward the diseased side, and the diaphragm is high in the chest. More frequently there is an unequal degree or a partial shrinking on the affected side ; with it also is always connected a more or less marked lagging. It is most frequently observed above in front, here sometimes noticeable at the first commencement as a deepening of the supra-clavicular depression (an important symptom of contraction of the apex of the lung from tuberculosis). Again, a partial drawing-in is often seen, most frequently low down posteriorly, after the disap- pearance of a small pleuritic exudation. But there may be shrinking of any part of the chest-wall, as after gangrene and abscesses of the lungs. One must be careful not to confound a deformity of chest from disease of the thoracic organs with deformities that are dependent on a primary bending of the spine and thorax. Concerning these, see the following section. A repaired fracture of the ribs may also cause deformity ; a fracture of the clavicle which has healed with an angle forward may deepen the supra- and infra-clavicular depressions, and so deceive one ; one- sided defect or atrophy of the pectoralis major, of course, flattens that side. All of these cases may be excluded by a more careful examina- tion. gg SPECIAL DIAGNOSIS. ie) Expansion or retraction of the chest hy primary deformity of the skeleton. Kyphosis, or bending backward, and scoliosis, the bending sidewise of the spine, but, still more, the combination of both, kypho- scoUosis, occasion sometimes deformities of the chest that are enormous. Most frequently one side is smaller in front, while the other side appears as if enlarged ; and the picture of one-sided contraction of pleura or lung is more complete from the dragging-after of the smaller side. In consequence of a peculiar twist of the spine and its effect upon the course of the ribs, the back is generally very crooked. This is spokert of more particularly in works upon surgery. Whether we have to deal with a primary deformity of the chest or with a contraction of the lung or pleura is generally made clear by the ex- amination of the spine ; in rare cases, however, this, and even the minutest examination of the thoracic organs, does not give a positive diagnosis. Moreover, the thoracic organs are almost always much displaced ; the lungs are in part functionally very much disturbed. These patients have short breath on the least exertion ; and in case of disease of the chest organs, especially in acute infectious diseases, are more in danger than others. The distinction of the different kinds of spinal curvature and their origin belongs to surgery. RhacMtis is frequently the cause of such deformities, but it may also cause all other possible bendings of the chest. Of these espe- cially characteristic are : 1. The rhachitie chest, a thickening of the point of transition from the cartilage to the bony ribs. The several prominences arising from it form on both sides of the sternum a line passing as aa arch outward and downward. 2. The pigeon-chest. The chest seems to be compressed sidewise and pressed forward. The ribs run sharply backward from the front, so that the sternum stands forward like the keel of a ship, the sterno-vertebral measurement being much increased. 3. A circular draioing4n in the neighbor- hood of the costal attachment of the diaphragm. The ribs, as is well known, form a fixed point for the diaphragm ; if, as in rhachitis, the chest is abnormally yielding, it is drawn inward by the contraction of the diaphragm, and this especially is the case if there is increased action of the diaphragm — that is, if from any cause there is difficulty of breathing. Funnel-breast (Fig. 15). This deformity consists in a sinking-in of the sternum, especially of the lower portion of it ; it may be EX A MIXA TION OF THE R ESP IRA TOR Y A PPA RA TUS. g 9 very considerable (as much as seven cm.). The aifection is generally congenital, and, according to our experience, in very marked cases it may prove a hindrance to respiration. Shoemakers' -bf-east exhibits a sort of acquired funnel-breast, caused by pressure of tools against the lower part of the sternum and the xiphoid cartilage ; the depres- sion never becomes very great, and involves only the cartilage ; it ' has no pathological significance. Fig. 15. J'unnel-breast. (Ebstein.) According to recent experience, the funnel-breast sometimes is observed in several branches of a family. In individual cases it occurs as a sign of degeneration, with other errors of development, or associated with neuropathic or psychopathic disease or hereditary taint. 3. Anomalies of JRespiration. In the preceding section the anomalies of breathing which accom- pany thie several pathological forms of thorax have been briefly referred to. But these require a further separate description. In 90 SPECIAL DIAGNOSIS. giving this it will not be possible to avoid a partial repetition of what has already been said. {a) Anomalies of the manner of breathing. The type of breathing which, as has been mentioned above, in the normal human being is typically different in the two sexes, and is denominated costal and costo-abdominal, may be influenced by a number of different pathological conditions. 1. The activity of the diaphragm, from some cause or other, may be restricted or entirely stopped ; it may then be replaced by increased thoracic breathing ; this causes the costal type peculiar to women to be still more prominent, while the male type is reversed ; instead of the abdominal predominating, the costal becomes predominant or entirely prevails — that is, may take on the female type Such a restriction or prevention of the action of the diaphragm is occasioned by pain, or mechanical restraint, or by Aveakness or paralysis of the diaphragm. Such is the action of all inflammations of the abdominal or pleural cavities in case they involve the corresponding serous covering of the diaphragm, markedly impairing diaphragmatic breathing ; they often act so because they are painful ; but also some- times, especially in inflammation of the diaphragmatic peritoneum, actual paralysis of the diaphragm quickly develops, which is recog- nized by the entire disappearance of abdominal breathing (see above, p. 83). This takes place quite commonly in diffuse peritonitis ; it is, however, also sometimes the only symptom of a beginning local "sub- phrenic" peritonitis. Marked distention of the abdomen by tumors, fluid, and accumulations of gas in the intestines, hinder diaphragmatic breathing in a high degree. Finally, there occurs paralysis of the diaphragm in organic diseases of the nervous system (bulbar paralysis ; neuritis of the phrenic nerve in the various forms of multiple neuritis), as well as a manifestation of functional neurosis (hysteria). The action of the diaphragm is recognized, as has frequently been mentioned, by the protrusion of the epigastrium during inspiration. Of course, this does not take place when there is no contraction. In complete paralysis the diaphragm is sometimes even completely sucked into the thorax ; in hysteria, during inspiration, the epigastrium sometimes sinks in extraordinarily deep. One-sided failure of action of the diaphragm may also occasionally be made out. (See Palpation.) 2. But sometimes, also, hindered thoracic breathing may be replaced EX A MINA TIO N OF THE RESPIRA TORY A PPARA TVS. 9 1 by increased diaphragmatic breathing ; hence, in such a case, if the patient is a female, the type of breathing is changed — that is, ab- dominal breathing predominates instead of costal. Therefore, in very rigid thorax (emphysema), sometimes also in women, diaphragmatic breathing predominates. Here belong paralysis of the muscles of inspiration (bulbar paralysis), and myositis ossificans (rare), since it causes a rigid condition of the thorax. A peculiar disease of the skin, schleroderma, may, if located upon the thorax, also entirely abolish thoracic breathing. It has been shown above, under emphysematous thorax, how, in lieu of the peculiar costal breathing, this may in part be replaced by the movement of the thorax as a whole by the (auxiliary) muscles — the sterno-cleido-mastoidei. 3. Asymmetry of breathing, which is occasioned as follows : the whole side, or the upper or lower part of one side, either (very rarely plainly) expands somewhat later than the opposite side, or (most fre- quently) expands less strongly or not at all — which condition has already been mentioned several times. Such a lagging may be caused by a unilateral painful affection of any kind ; moreover, by all diseases of the thoracic organs which interfere with respiration upon one side. This "lagging behind" is a valuable symptom, especially in phthisis (lagging in the infra- clavicular depression), also in the beginning of pneumonia and pleurisy^ when other symptoms are wanting. (See Palpation of the Thorax.) (h) Anomalies of breathing as regauds frequency and RHYTHM. Diminished frequency of breathing may take place in all severe diseases of the brain and its meninges, hence in large hemor- rhages, tumors, etc., and in all forms of meningitis; thereby exists always more or less dulness of intellect ; the slowness of breathing may sometimes pass into the Cheyne-Stokes respiration (see below). Further, in acute infectious diseases, with marked mental dulness, the respiration may be slower ; finally, it is generally so in the death agony. A very important form of diminished frequency of respiration is observed with stenosis of the upper air-passage ; this belongs in the section on Dyspnoea. Increased frequency of respiration as a patho- 92 SPECIAL DIAGNOSIS. logical manifestation belongs, without exception, to a large group, which will also be discussed in the next section. It has already been mentioned that we meet with temporary irregu- larity of breathing in healthy persons. It is of pathological, and generally of grave, import in all cases of marked mental dulness (as in apoplectic, urgemic, and the coma of severe typhus), and very especially in the death-agony. The so-called Cheyne-Stokes breathing is a very peculiar form of breathing, which is periodically repeated. It is unequal and arhyth- mic: in typical cases one or two quite superficial breaths are followed by four or five that are successively deeper and more noisy, with strong action and snorting or snoring, sometimes also a sort of deep sighing ; then the resnirations are ag-ain regular, become also sometimes some- what slower ; the fourth or fifth from the acme is even hardly notice- able ; then follows a pause of variable length without any breath (" apnoea ") ; this may last as much as a minute; then the course as above described is repeated. Frequently, also, there is a regularly recurring apnoea alternating with ordinary deep breaths. Very remarkable cases, of which I have seen a few, but of which others have observed many, are those in which patients, ordinarily unconscious, become conscious regularly with each return of the deep breathing ; they open the eyes, raise the head a little, and may pos- sibly even ask questions ; but, with the return of the apnoea, the patient again sinks into unconsciousness. In individual cases this form of breathing occurs with patients 'who are almost entirely conscious. The Cheyne-Stokes respiration is observed in all forms of meningitis and in hemorrhages, tumors, etc., of the brain ; likewise, in heart- failure in consequence of heart-disease of whatever sort, but especially from fatty heart (Stokes), in uraemia (uraemic coma) ; finally, in poisoning by opium or morphine. Besides, it may occur occasionally in any deep coma. It is very difficult to explain the significance of this phenomenon, in that it is not always a fatal one. We have seen it frequently without fatal result in uraemia, also in one case of apoplexia cerebri, and once in a case of acute diifuse peritonitis of the vermiform ap- pendix. In heart diseases it seems at any rate to indicate approaching EXAMINATION OF THE RESPIRATORY APPARATUS. 93 death. It may last Lours and days ; it is said to have even been observed to continue for ahmost seven months. It is, without question, dependent upon a disturbance of the function of the respiratory centre in the medulla oblongata. But we are in want of any exact description of the nature of this disturbance. A simple diminution of the irritability of these ganglion-cells cer- tainly must, from the blood containing CO2, have eventually, as a less frequent result, deep or superficial (possibly irregular) breathing, as is seen in the death-agony. To ascribe a different degree of irritability to particular cells or groups of cells, as some have done, is at least a great refinement. In short, we have no clear explanation of this phenomenon. Moreover, the peculiar change of consciousness, and the other manifestations that have sometimes been observed to accom- pany it (the contracted pupils in apnoea, jerking of the muscles at the close of the apnoea), do not throw any clear light upon the subject.^ (a) Difficult breathing, dyspncea. We have to designate that form of dyspnoea as physiological which results when the respiratory centre is supplied with blood which contains less than the normal quantity of 0, or an increased amount of COg. The pathologist and the clinician speak of dyspnoea if the respiration is labored, whether the number of respirations be normal, or prolonged, or more frequent. Finally, in all cases of increased respiration, if rapid and labored breathing are combined, dyspnoea is caused by all those conditions that interfere in any way with the exchange of gases in the lungs (see Tinder Cyanosis). But there is another condition which manifests itself by an increased formation and giving off of COj; that condition is fever. Labored respiration with normal or diminished frequency takes place in stenosis of the upper air- passage — that is, of the larynx and trachea. Intra-tracheal tumors, foreign bodies, inflammations (espe- cially croup), cicatricial strictures (generally syphilitic), granulations, also, compression from without, and lastly paralyses of certain laryngeal muscles (see under Inspiratory Dyspnoea), produce narrowing of the air-passage. 1 Recently, Mosso points out that there is a like oscillation in the sleep of healthy- persons, and explains it by the assumption of a " breathing luxus" ; he considers the Cheyne-Stokes phenomenon simply as a pathological example of the same phenomenonj but the condition is not explained by this. 94 SPECIAL DIAGNOSIS. Strictly speaking, this form of dyspnoea often occurs in diseases of the brain (also see above, page 91). At the acme of respiration in Cheyne-Stokes breathing we must speak, too, of there being dyspnoea. Increased Frequency of Respiration Occurs : (a) In fever. Here it is often simply increased frequency, the breaths being deeper, but sometimes, also, we notice that they become somewhat labored (without its being a question of complication of the thoracic organs). The amount of quickening of the respiration varies very much, according to the nature of the disease and with the indi- vidual. Nervous persons often breathe remarkably rapidly in fever ; with children, respirations as high as sixty or more to the minute have often been observed. Nevertheless, in fever every case of marked increase in frequency of breathing must lead to an especially careful examination of the thoracic organs. The cause of fever- dyspnoea is, moreover, not alone the increased formation of CO^, but is also the result of the irritation of the respiratory centre by the warmer blood. Fever-dyspnoea may be increased by association with that caused by diseases of the respiratory apparatus. (&) In all conditions that are connected with pain in breathing. Here belong all diseases of the pleura or the lungs in connection with the pleura (especially croupous pneumonia), inflammatory affections of the diaphragm (trichinosis), of the peritoneum (especially the diaphragmatic peritoneum), fracture of ribs, and severe rheumatism of the muscles of the thorax. Rightly to explain this form of dyspnoea is often of the greatest therapeutic value ; it may sometimes (not always) be relieved by a narcotic. (c) In diseases of the bronchial tubes, which narrow or close the tubes by the secretion or exudation. Here belong all forms of bron- chitis, and also bronchial asthma. In the latter disease there is much less swelling and exudation than from bronchial spasm of neurotic origin, which chiefly causes the dyspnoea. No doubt spasm of the diaphragm is associated with this sometimes, which causes a prolonged inspiratory expansion of the lungs, and, of course, this increases the dyspnoea. Where there is bronchial asthma and croupous bronchitis in addi- tion to laryngeal croup, there is generally very severe dyspnoea with quicker and very forced respiration. Simple catarrh of the bronchial JilXAMIXA TIOX OF THE RESPIRA TOR Y A PPA RA TUS. 9 5 tubes generally leads to quickening of the respiration without the breaths being deeper ; for a complete closure of the bronchial tubes cuts off a large section of lung, and so breathing is entirely lost in this section, as in capillary bronchitis, especially in children. The consideration of this condition properly belongs to the next section, in that it results in the lung-tissue itself becoming diseased. ((?) In all conditions in which the breathing surface of the lungs is diminished or the volumetric variation of the lungs, which is necessary for respiration, is disturbed. These are : All diseases of the lungs : the different forms of pneumonia, oedema of the lungs, infarction, tuberculosis, emphysema (this not only on account of the diminished breathing surface, but also the loss of elasticity, and hence diminished contraction of the lungs during expiration) ; the different forms of pleurisy with exudation, pneumo- thorax ; tumors in the chest-cavity which diminish its capacity ; abdom- inal affections which push up the diaphragm ; marked kyphoscoliosis with the resulting deformity of the chest and consequent unfavorable condition for breathing ; paralysis of the muscles of respiration ; and also tonic and clonic spasm of the muscles of the chest, as in tetanus and epilepsy, which may occasion the most severe dyspnoea. As is evident, these diseases differ widely from one another. Those that diminish the chest-cavity, if they are inconsiderable, sometimes merely restrict the inspiratory expansion of the chest, and so affect the lungs ; but, if they are marked, then they directly compress the lungs, and hence diminish their breathing-surface. It has been already stated that in a number of these conditions the need of oxygen may be met by a substitution of diaphragmatic breathing in place of the diminished costal breathing, and vice versa. It is, of course, very calamitous when there is a combination of several causes of dyspnoea, as, for example, when a subject of kypho-scoliosis has an abdominal affection which presses up the diaphragm, or has inflammation of ^^^ lungs. Accommodation, adaptation, plays an important part in many chronic diseases which occasion dyspnoea. This becomes most strikingly evident if we compare the terrible dyspnoea of beginning pneumo-thorax with the relatively comfortable condition of patients who have continually at their disposal for breathing only one lung, or even only a part of a lung. In many of these cases it is 96 SPECIAL DIAGNOSIS. easy to understand this accommodation ; chronic cases, especially phthisical patients, who here come prominently into view, are generally anaemic, and therefore require, at least when quiet, only a very small interchange of gases in the lungs ; but every effort at muscular exer- tion immediately causes dyspnoea. On the other hand, " lung dys- pnoea" is generally considerably increased in one who has an acute disease, by the fever. Likewise, there are cases where we cannot dispense with the idea, which formerly was not clear, of an "accom- modation." Dyspnoea further occurs : (e) In diseases of the heart which cause stasis of blood in the lung circulation. These are mitral insufficiency or stenosis of the left auriculo-ventricular opening; also heart-failure, which may occur in all diseases of the heart. It is evident that slowing of the capillary circulation of the lungs diminishes the interchange of gases in the whole quantity of the blood ; but generally we have, beside this, a diminution of the alveolar lumen, from the capillaries being swollen, especially in the so-called brown induration of the lungs. Increased and forced resjnration. Forced respiration may at any time be associated with rapid breathing by increase of dyspnoea. The only exceptions to this are those cases that arise from pain and paralysis, both from reasons that are easily intelligible. Mechanism of forced^ respiration. This is, in the most charac- teristic way, different from normal breathing, namely, that while the muscles of ordinary inspiration and the mechanical conditions of ex- piration no longer suffice, inspiration and expiration are assisted by the action of the auxiliary muscles of respiration. The auxiliary muscles of inspiration are : the scaleni muscles in the male (in the female they act even in quiet breathing), as elevators of the two first ribs ; the sterno-mastoidei draw up the sternum when the head is fixed; the pectoralis major and minor, thelevatores costarum, the serratus post, super., all of which act as elevators of the ribs, the first named when the upper arms are fixed. In more severe dyspnoea the trapezius, the levator scapulae, the rhomboideus, are brought into action to elevate the scapula; in severest dyspnoea the extensors of the neck assist also, and then we notice the expansion of the alae nasi (see under Nose) ; when the mouth is open the soft palate is EXAMINATION OF THE RESPIRATORY APPARATUS. 97 seen to be drawn up during inspiration ; and, finally, even those mus cles that dilate the mouth and depress the larynx may be brought into action. The muscles have very varying degrees of importance, the greatest being the work of lifting up the ribs, the sternum, and the shoulders. The expansion of the al^e nasi as a symptom is not unimportant, but really does not at all assist in breathing. In expiration the following muscles act in assisting respiration : Of first importance are the broad muscles of the abdomen, especially the transversus, which compress the abdominal contents, thus pressing up the diaphragm ; further, the quadratus lumborum and serratus post, infer., which draw down the lower ribs. It is easy to distinguish the moderate drawing-in of the thorax and epigastrium which occurs in normal passive expiration from the active expiration of dyspnoea, by the energy of the act in consequence of muscular contraction. Moreover, the contraction of the broad mus- cles of the abdomen is plainly to be seen. • Patients with forced respiration exhibit still other appearances which partly stand in direct relation to the increased energy of the breathing. That the thorax may be entirely easy and that the auxiliary mus- cles may be able to act better, patients prefer the upright posture to lying down (Orthopnoea, p. 32) — indeed, in very severe dyspnoea, they may not be able to lie down at all ; the arms are fixed in order that the upper arms and shoulders may furnish a fixed point for the auxiliary muscles ; and, in order that the sterno-cleido-mastoidei may act most efficiently in assisting respiration, the neck is stretched and the face somewhat elevated. Not infrequently the breathing is audible ; in forced respiration, it is panting, groaning. In stenosis of the larynx or trachea we hear the before-mentioned hissing — stridor laryngeus vel trachealis. The voice is weak, often suppressed ; the patient speaks with short, un- natural pauses ; broken speech. Here belongs the so-called inspiratory " drawing-in." Even in healthy people we sometimes notice with forced respiration that the lower intercostal spaces in the beginning of inspiration sink in some- what (a simple flattening-out takes place from the contraction of the intercostal muscles). Drawing-in that is more marked and is pro- 7 98 SPECIAL DIAGNOSIS. longed during the whole of inspiration, under all circumstances is pathological ; with very yielding thorax (children), even the ribs and the lower part of the sternum may share in the condition. It shows that the lungs do not follow the motion of the thorax — that, there- fore, the air is prevented from entering the alveoli. Hence, all forms of stenosis of the larynx (especially frequent with croup) and of the trachea (likewise both bronchi) cause inspiratory drawing-in of both sides, most markedly of the lower part of the sternum, the lower ribs, and intercostal spaces ; if the stenosis is very marked, the condition is extended to the upper ribs and intercostal spaces, as far as the jugular and supra-clavicular spaces. Stenosis of a bronchus causes inspiratory drawing-in of one side when the breathing has a certain degree of force, beside "lagging" of the affected side. Bronchitis of the smaller tubes (especially in children) may occasion inspiratory drawing-in in a more circumscribed way, as only the lower part upon one side. But we may also sometimes see an extended, very marked drawing-in with extensive capillary bron- chitis (with atelectasis, broncho-pneumonia) in children. There are two reasons why stenosis of the upper air-passage causes the drawing-in to be greatest at the lower part of the chest, and which may also affect the ribs of this part : first, the air entering the lungs, reaches the lowest part, as being the furthest removed, last ; secondly, if the thorax is yielding, it is drawn in by the contraction of the dia- phragm ; for if the diaphragm cannot descend when it contracts, since the lung does not follow it, then the dome of the diaphragm becomes a fixed point, and the thorax in the neighborhood of the insertion of the diaphragm is drawn inward and upward. Also, expiratory bulging sometimes takes place in the supra- clavicular depression, especially in marked emphysema of the upper part of the lung, as, for example, after whooping-cough (see p. 76) ; or in the upper intercostal spaces, when large cavities are adherent to the chest-wair, as in pulmonary phthisis. With this appearance there is a strongly-marked pressure in the thorax ; hence it is observed only in very forced expiration, and especially in strained coughing. Very frequently we find in cases of lung-cavities with expiratory bulging — especially frequent in the second intercostal space — the affected intercostal muscles very much shrunken, sometimes fatty degeneration of them. EXAMINATION OF THE RESPIRATORY APPARATUS. 99 Finally, the picture of such an unfortunate will be completed by the expression of subjective anxiety; sometimes of the most fearful agony ; by the peculiar expression of the eyes, the consequence of the dilatation of the pupils which always exists in dyspnoea (see Nervous System) ; lastly, by the cyanosis and frequent cold sweat [q. v.). According as inspiration or expiration, or both, are difficult, or the auxiliary muscles of respiration are brought into action, we distinguish an inspirator^/ (pure or preponderating), an expiratory (pure or pre- ponderating), a mixed, dyspnoea. Purely inspiratory dyspnoea exists with paralysis of the posterior cricoarytenoid muscles (dilators of the glottis); here expiration is free, since the escaping current of air presses the vocal bands apart ; on the other hand, the in-rushing air brings them, like valves, in contact, and hence inspiration may be hindered even to threatened suffocation. Tumors and foreign bodies may, moreover, be sometimes so located as, by valve-like closure, almost completely to preclude inspiration. Further, inspiratory dyspnoea occurs with increased activity of other muscles when certain respiratory muscles are para- lyzed (as, for example, in paralysis of the diaphragm, increased thoracic breathing is accomplished by the auxiliary muscles). Purely expiratory dyspnoea is observed with movable tumors situated below the glottis ; the out-going air pushes them against the rima glottidis, but in expiration they are drawn to one side. Moreover, a preponderating expiratory dyspnoea is peculiar to bronchial asthma (in addition to the always present inspiratory). Probably we correctly assume that the smallest tubes, spasmodically narrowed, are still more compressed by the pressure in the thorax during expiration. The disease that most frequently causes expiratory dyspnoea is emphysema of the substance of the lungs ; the diminished power of expiration is chiefly from the loss of elasticity of the lung-tissue, the contracting force of the lungs ; generally there is, besides, diminished thoracic breathing — since, if the thorax is too rigid to expand during inspiration, then it is also not conti-acted, either by virtue of its own elasticity or the traction of the lungs. Bronchial asthma of long duration always causes emphysema of the lungs ; then, of course, there is a twofold cause of expiratory dyspnoea. 1(30 SPECIAL DIAGNOSIS. In genuine emphysema of the lungs there is always also well-marked inspiratory dyspnoea, on account of the atrophy of lung-tissue and capillaries of the lung, and hence diminished breathing-surface. More- over, it will be understood that whenever there is expiratory dyspnoea, if the difficulty of expiration is not equalized by forced or prolonged expiration, there must result a simultaneous inspiratory dyspnoea ; there is a diminished interchange of gases in the lungs resulting from the incompleteness of the act of expiration ; there is a demand for oxygen, and hence forced inspiration. There is no expiratory dyspnoea with vicarious emphysema of the lungs. Mixed dyspnoea — that is, where it is manifest in equal degree in inspiration and expiration — is by far the most frequent. It accom- panies all the diseases of the respiratory organs not mentioned here, also diseases of the heart, and fever. Palpation of the Thorax. This method of examination has, on the one hand, an independent value, and on the other it confirms and, with sufficient practice, even adds to the results of inspection. It is, therefore, very wrong to omit it. It is indispensable on account of its simplicity, and because, like inspection, it quickly furnishes a result in a general way ; moreover, its result is often decisive in diiferential diagnosis, in a certain direc- tion, relative to vocal fremitus. Palpation of the thorax, with reference to the respiratory organs, is made for the purpose of ascertaining : 1. Possible pain upon pressure. 2. The respiratory movements of the thorax, especially as to symmetry, 3. Any friction-sounds or rS,les that may be felt. 4. Vocal fremitus. In addition, there are some rare appearances that are not unim- portant in differential diagnosis. The examination with reference to the first and second points may be combined with inspection ; the trial of the third point may suitably be settled during auscultation, either before or after. Ordinarily we test the vocal fremitus after the completion of percussion and auscul- EXAMINATION OF THE RESPIRATORY APPARATUS. IQl tation, hence we conclude the physical examination of the thoracic organs by noticing the vocal fremitus. We pause here, in the course of the examination, and only speak of the first and second points ; the two others will be introduced under the heads of Percussion and Auscultation. 1. Pain caused by Pressure upon the Thorax. In diseases of the chest pain is common, accompanying the diseases or elicited by pressure. In case it resjlly refers to an internal organ, and not to the chest-wall, it indicates disease of the pleura or compli- cation with the pleura. By carefully feeling the intercostal spaces with the tips of the fingers, the region that is tender on pressure may be very exactly defined ; it is generally less extensive than the terri- tory of spontaneous pain, since the latter ordinarily "radiates." This tenderness sometimes exists with, exudative pleuritis, but in this disease it is often wanting ; more frequently it is seen in croupous pneumonia which involves also the pleura, and also in phthisis. In the latter disease it generally depends upon callous thickening of the pleura. It is very important, but also frequently difficult, to distinguish between pleuritic pains produced by pressure from those arising in the soft parts of the chest-ioall or the ribs. Phlegmonous inflam- mations and abscesses of the chest are, of course, easily recognized. Pain proceeding from a rib is generally characteristic ; quite circum- scribed, it occurs only when pressure is made upon the affected rib (caries, periostitis, over fractured ribs, slight pressure) ; also, rheu- matism of the chest-muscles occasions no great difficulty, at least when it is in the superficial muscles ; the muscle is ordinarily sensitive if pressed between two fingers. On the other hand, it is often not easy to distinguish between pleuritic pain and intercostal neuralgia ; the latter can sometimes be distinguished by Valleix's points of tender- ness, which stand wholly out of relation to deep breathing or cough. (See Nervous System.) It is important to remember that neuralgic intercostal pain may be present in affections of the pleura, as in tubercular thickening of the pleura in the lower part of the thorax. In short, we ought, in the absence of other indications which point to a disease of the internal thoracic organs, to refer a pain produced 102 SPECIAL DIAGNOSIS. })j pressure upon the thorax rather to something else than to the pleura ; only continuous pain, always at the same places, over the upper sections of the lungs, arising either spontaneously or from pressure, is suspicious ; this may indicate irritation of the pleura from tuberculosis of the apices. Structures of the ribs are recognized by crepitation, and also by dislocation of the fragments ; also, often by the fact that pressure at any part of the broken rib causes pain at the seat of fracture. Moreover, fracture of the rib may cause pleurisy. Caries of the rib may also excite pleurisy. Then, in recognized pleurisy, caries may be proved to be the cause by the circumscribed pain elicited by pressure upon the rib. It must also be mentioned that if a purulent pleuritis breaks out- wai'd (empyema necessitatis), it causes peripleural inflammation, and with this there is pain upon the slightest pressure, besides swelling, redness, heat, oedema of the skin, and, lastly, fluctuation. To the above-mentioned conditions revealed by palpation of the thorax must be added 'pulsations of the heart felt through a portion of infiltrated lung lying over the heart, and also in the so-called empyema pulsans (empyema pulsatile). This occurs when there is an accumulation of pus lying over the heart, almost always upon the left side, to which the pulsation of the heart is communicated. In some cases it is very difficult to distin- guish it from aneurism of the aorta. It can only be done by taking a comprehensive view of the case. (We must be on our guard in puncturing or in making an exploratory puncture.) Sometimes pulsa- tions are even found on the left lower posterior portion of the thorax. Usually several causes combine to produce the pulsation : paresis of the intercostal muscles, higher pressure of the exudate, direct contact with the heart, lastly, as indispensably necessary, powerful action of the heart. 2. Testing the Movement during Respiration. With special reference to symmetry, with some practice, palpation is a most excellent method. It gives more exact results than inspec- tion, and makes the further examination easier, in that it directs the EXAMINATION OF THE RESPIRATORY APPARATUS. 103 attention immediately to the diseased side or the region of the thorax affected. The respiration is examined by placing the two hands alike upon the two sides of the chest. In order to test the breathing of the upper divisions of the lungs, place the hands flat in front, gradually diverging below^ so that the tips of the fingers reach to the lower border of the clavicle. For examining the lower parts, spread out the hands with the thumbs extended so that the thumbs rest upon the angle of the ribs. Behind, only the respiration of the lower lobes will be tested by laying the flattened hands, with the thumbs extended, upon the surface in such a way that the points of the fingers reach about to the middle axillary lines. For exact examination, it is necessary, if possible, for the physician to be exactly before or behind his patient ; the latter position espe- cially is often difficult when the patient sits in bed ; it is best, then, to have the patient slide somewhat down toward the foot of the bed. When palpation is well performed, "lagging" over the apex in beginning phthisis, or the " lagging " of the lower part of one side in pneumonia, pleurisy, infarction, etc., is recognized with great exact- ness ; this is of great importance, because, as I have already said, " lagging " may be in many diseases for some time the only symptom. We may also test the action of the diaphragm with reference to its symmetry by palpation. We place the hands so that the finger-tips cover the epigastrium ; in this way may be detected the lack of con- traction upon one side (pleuritis diaphragmatica, local peritonitis, paralysis of one phrenic nerve). Failure to contract upon both sides is, of course, seen at once. GENERAL AND PRELIMINARY REMARKS REGARDING PERCUSSION.^ In daily life we learn on every hand that bodies of different physical structure give forth different sounds when struck. We also sometimes strike an object in order to determine from the sound it gives forth what its physical condition is — that is, whether it is hollow or solid. 1 In this chapter the author follows in many ways, but not entirely, the Tiews and methods of presentation of Weil, whose personal pupil he was for ten years and whose teachings, in the courses upon percussion which the author has conducted for four years, were in many respects a rule of conduct to him. 104 SPECIAL DIAGNOSIS. This is the principle upon which percussion is practised on the human body; from the sound elicited by the blow, we judge of the physical condition of the part which lies beneath the covering of the body within the sphere of our percussion-stroke. Hence, percussion gives direct information regarding organs or parts of organs which lie approximatively near to the surface of the body ; in general, by this method, we penetrate only to the depth of five, or, at most, seven cm. 1. History and Methods. The honor of the discovery of percussion belongs to a physician of Vienna, named Auenbrugger ; the paper in which he made known his method appeared in 1T61 under the title, Inventum novum ex percussione thoracis humani ut signo ahstrusos interni pectoris morhos detegendi. For almost half a century Auenbrugger's discovery was, on the one hand, declared to be without importance, and, on the other, was ridiculed, until the year 1808, when Corvisart, body physician to Napoleon I., emphatically revived and largely improved it by a translation into French, with a commentary. Then the truth began really to prevail, especially by the influence of Piorry in France and Skoda in Vienna. The former was the founder of topographical percussion. During fifty years the method gradually became common professional property. Further, and up to the most recent time, it experienced improvement and explanation of every kind, especially by Wintrich, Traube, Biermer, Gerhardt, and Weil. For several years, especially since the labors of Veil, it appears that a degree of certainty has been reached in regard to this proceeding. In the course of the development of percussion several methods of striking the body have been discovered, most of which still have value to-day. Auenbrugger struck directly upon the thorax with the tips of the fingers : direct or immediate percussion. Piorry discovered indirect or mediate percussion., in that he placed under the percussing finger a small plate of ivory — a pleximeter. Wintrich introduced the percussion-hammer, which had already been sometimes used by Laennec and Piorry, in place of striking with the fingers. EXAMINATION OF THE RESPIRATORY APPARATUS. 105 But finally, in more recent times, the method of indirect percussion, without instruments, has very widely prevailed. The index- or middle finger of the left hand is used as the pleximeter, which is placed upon the spot to be percussed, and it is struck with the index- or middle finger of the right hand (finger-percussion). Of these methods, that of Auenbrugger, the direct, has been dropped as being less practical, while now-a-days the three in use are all examples of the indirect method : I. Finger-percussion. II. Finger-pleximeter percussion. III. Hammer-pleximeter percussion. All three are practised and taught by good teachers of percussion ; all three, in reality, yield equally exact results; the secret of their value lies in their application. One who thoroughly understands finger-percussion can very quickly acquire a knowledge of the two other methods. Hence, I am most heartily in accord with those who, in their teachings and writings, emphatically recommend their students at first to practise the finger method of percussion exclusively. I think it superfluous for me here to go into particulars regarding the technique ; these can only be made clear in the clinic; but I must remark that the greatest difficulty in finger-percussion is in holding the percussing finger crooked, like a hammer, and, at the same time, having the wrist-joint move quite freely. Also, the numerous forms of percussion-hammers and pleximeters (the latter of glass, ivory, hard rubber, and wood, in different forms) cannot be described here. It appears to me that the hammer with a wooden handle and a metal head, not too heavy, is rather to be recommended; likewise, a medium-sized oblong ivory pleximeter, about two cm. wide, and the so-called double pleximeter of Seitz. Even to those who practise finger-percussion this last is recommended for percussing the supra- clavicular depressions. There is one point of great importance : that the individual should, as much as possible, be homogeneous in his method and in accord with it throughout : in percussing, if the finger method is used, he should always strike upon the index- or always upon the middle finger of the left hand ; the pleximeter, if that is used, should always be used in exactly the' same way, etc. Nothing is worse than frequently to change methods or instruments, be the 106 SPECIAL DIAGNOSIS. change ever so slight. But if physicians, as is true of many, are accustomed at certain parts of the thorax where it is difficult to use finger-pei-cussion, regularly to employ a pleximeter, or both pleximeter and hammer, there is no objection to this twofold method ; only he must be master of the two methods which he employs. It is well, also, always to repeat the same method upon the same parts of the body. 2. Qualities of Sounds. By our striking upon the body we cause a sound. This percussion sound differs according to the condition of the part of the body which is shaken by our percussion blow. Two principal sentences contain the foundation of percussion ; 1. When we strike upon a solid portion of the body entirely free from air we elicit a toneless sound of the least possible intensity and duration; it is designated as "absolutely deadened," or as a "thigh sound," since it is like that caused by striking upon the thigh. [Deadness : I have frequently used this word and its derivations as giving a useful and accurate discrimination from the familiar English terms, flatness, dulness. Deadness is more than dulness.] 2. If organs containing air lie in the range of our percussion blow, then these give forth a sound of a certain intensity, duration, and tone ; this sound is designated as " clear." The clear sound of organs containing air may have only a different degree of intensity or clearness. Its intensity depends upon : 1. The length of the oscillation. It is, therefore, stronger, the stronger the blow; and, moreover, the nearer the organ containing the^ir is to the percussing finger — that is to say, the less the per- cussion-stroke is weakened by the tissue, as fat, muscles, bones [also clothing], intervening between it and the air-cavity. 2. By the volume of the parts of the air-containing tissue set in motion. Hence, with equal strength of percussion, we have in different parts of the body different intensity and different clearness of sound, according to the greater or less amount of air which the tissues contain, or according to the nearness or distance of the air-cavity from the surface of the body — that is, from the percussing finger. It is according to the change of these conditions in the human EXAMINATION OF THE RESPIRATORY APPARATUS. 107 body that we obtain the different clear sounds ; we may meet every grade from absolute deadness to a very clear — the peculiarly clear — sound. These intervening grades are designated as " relative dull- ness" (that is, in comparison with a real clear sound it is dull). Fig. 16. Fig ir. Fig. 18. Luttff Lrni^ Fig. 16. — Diagrammatic representation of the difference between weak and strong percussion under circumstances that are otherwise alike. The length of the arrows corresponds with the strength of the percussion; the size of the triangle designates the volume of the portion of lung affected by the blow, and, at the same time, the intensity of the sound. Fig. 17. — Eepresentation of the difference of result with a percussion-stroke of equal strength, but when the thickness of the covering of the body varies. Clear sound, relatively dull sound, no resonance — that is, absolutely dull sound. Fig. 18. — Eepresentation of the effect upon percussing over a thick covering of the body. Over the apex and border of the lung the sound is less intense than over the rest of the lung, on account of the diminished volume of lung-tissue, the percussion- stroke having the same force, and this tolerably strong. Absolutely dead or dull sounds differ according as they proceed from muscle, bone, etc. We cannot wholly ignore these differences, as if not existing. On the other hand, the clear sounds fall into the two following important divisions : 1. Tympanitic sound (the name is from tympanon; the kettle- drum or tymbal, not exactly, but very nearly, produces it). This approaches a musical note, so that we can exactly define its place on the musical scale, and it is actually shown formed from regular oscil- lations in the rotating reflected image of the sensitive gas-flame. It shows, also, according to the different conditions to be described later, sharply definable differences of pitch. A tympanitic sound such as is frequently met with in the body can easily be produced if one strikes 108 • SPECIAL DIAGNOSIS. upon his own cheeks, which have been inflated, but not too strongly stretched. 2. The clear sound called non-tympa7iitic, also more briefly "lung- sound" — a very practical designation. This has no sound definable by its pitch, but yet it may be known in general as " high " or "deep." Hence, both the tympanitic and the non-tympanitic sound have a certain intensity and duration; but, while the latter only approxi- matively may be designated as high or deep, the pitch of the tone brings it toward the tympanitic. Both occur in a very high degree of clearness and in all degrees of relative dulness ('•' relative dullness " or " dull tympanitic sound"), even to an often unnoticeable transition to absolute dullness. 1. In the foregoing, we give those designations which, in late years, we have without exception employed in our instruction on per- cussion. Regarding the large number of other terms for qualities of sound which the older teachers of percussion have introduced, but which, to the great advantage of clearness of mutual under- standing, have more and more disappeared from the literature of the subject, we refer to the classical work by Weil on Topographical Percussion. We have in fact, as will be seen, followed the nomen- clature proposed by Weil, with only one exception ; the term dull is avoided, and in place of it we have employed the expression (which, it is true, is somewhat circumstantial) "absolutely smothered," or " thigh- sound." This was done because, over and over, we found that pupils were reminded of the "dull sound of the kettle-drum," '' dull roaring," etc., and, hence, were confused ; in short, because the expression does not grammatically designate what is intended in teaching percussion. "Absolute smothered sound " has this advantage — that, to the beginner, it is a new association of words ; it cannot, therefore, so easily occasion confusion. Moreover, the expression alwaya summons one to a more exact testing as to whether, at the particular place, there is really absolute or only relative dullness; and every teacher of percussion knows how much this is needed — that, for instance, in percussing the lower part of the right mammil- lary line the so-called relative liver-dullness is spoken of as absolute dullness. 2. For the sake of brevity and clearness, we also have really not EXAMINA TION OF THE RESPIRA TOR Y A PPA RA TUS. 109 gone into the many ideas and the manner of explaining them pre- sented by others, on this subject, which was formerly quite confused, and is even yet diflficult. But we cannot abstain from citing here the three fundamental sentences from Skoda : {a) All fleshy parts, not containing air (except tense membranes and filaments), also fluid accumulations, give an entirely dead and empty, scarcely distinguishable percussion-sound, which can be demon- strated by striking upon the thigh. (h) Only bones and cartilage when directly struck give a peculiar sound. {c) Every sound which we elicit by percussing the thorax and abdomen, and which diff"ers from the sound of the thigh or bone, comes from air or gas in the chest or abdominal cavity. 3. The acoustic character of the clear, and that of the relative or absolutely dull, sound is clearest expressed if we say : the dull sound is a very slight noise of short duration ; the clear, non-tym- panitic sound is a noise louder and of longer duration, Avith a trace of being a note ; this latter, however, is so little apparent that it either cannot at all be recognized, or only in general, as to its being high or deep. In the tympanitic sound, with the discordant mingling of tones, a tone predominates of such a character that it is plainly heard and its musical pitch distinguished. The Qonditions that determine the Quality of the Sounds arid their Production in the Body. — The Feeling of Resistance. The tympanitic sound exists : 1. Over cavities that contain air or gas, if they are surrounded by walls moderately smooth and capable of reflexion, and if they com- municate with the external air through an opening, the walls being stiiF or yielding. The intensity of the tympanitic sound thus pro- duced depends upon the conditions (mentioned on page 107) influ- encing the intensity of clear sounds in general. The musical pitch of the sound is determined by : (a) The size of the communicating opening ; the larger it is the higher the tone. (6) The volume of the cavity containing the air ; the larger, the deeper the tone. 110 SPECIAL DIAGNOSIS. (c) If the walls are yielding, membranous, by their tension; lax membranous walls make the tone deeper. 2. Over air-eontaining cavities with yielding, membranous walls, if the cavities are closed — that is, do not communicate with the external air ; only the walls, and with them the enclosed air, must not be too tense. Here the pitch is determined only : (a) By the volume of the air-cavity. (See above under h) (b) By the tension of the wall. (See above under c.) But if the tension of the wall (and with it the enclosed air) of a closed cavity reaches a certain degree, then the percussion-tone be- comes clear and non-tympanitic. Likewise, cavities that are closed on all sides by stiff walls give a non-tympanitic sound. The tympanitic sound mentioned under 1 is called "open," that under 2 "closed;" the former has a much more pronounced tym- panitic character — that is, the pitch of the tone appears more dis- tinctly than the latter. When the cavities are cylindrical, communicating outward by an opening, the pitch of the tone is determined by the length of the cylinder; the longer it is, the higher the tone. Some experiments, illustrating what has been said, are easily performed and are strongly recommended to beginners : Take an empty Florence flask and percuss upon its mouth, either directly or hold the pleximeter lightly over its mouth, then diminish the quantity of air by partly filling the bottle with water; if possible, also compare the differences of pitch which are produced by different lengths of the neck of the bottle, other con- ditions remaining the same. Percuss a rubber gas-bag which is at first only moderately inflated, then more tensely, with air. In this way one can very easily illustrate the most important of the laws that have been mentioned. 3. Finally, tympanitic sound occurs under quite other conditions, namely, in certain conditions of the lungs which have this in common — that they probably accompany a Avant of tension of the lung-tissue. Referring to what was said above under 1, we add that the open tympanitic sound occurs in the human body, under normal relations, when the mouth., larynx, and trachea are percussed; pathologically, when percussing lung-cavities which are in open communication with the air-passages ; further, if in consequence of shrinking of the apices of the lungs, the trachea, or in consequence of shrinking or thickening EXAMINATION OF THE RESPIRATORY APPARATUS. HI of the lung where it covers a fissure, a primary bronchus, wouhl be reached by the percussion-stroke, and would, therefore, be itself per- cussed ; and, finally, the open tympanitic sound sometimes occurs with opeyi 'pneumothorax. Herewith we notice a peculiarity of this sound, which truly stands iu a certain (although still not altogether clear) relation to the laws above enunciated regarding the pitch of the open tympanitic sound: the sound is higher with the mouth open, deeper with the mouth closed. If this occurs when percussing a lung-cavity (or, also, in open pneumothorax) it is called Wintrich's change of sound; if on percussion of the trachea or a primary bronchus, then we speak of Williams's tracheal tone. In addition to what was said above under 2, we remark that in the human body the closed tympanitic sound is heard over the stomach and bowels ; in rare cases over closed pneumothorax ; and, finally, in pneumopericardium. Now, while it is difficult to apply the rules regarding the change of pitch to the open tympanitic sound, since the cavities of which we are speaking are of most extremely complicated form and have very dif- ferent walls, the influence, on the one side, of the volume of the cavity, and on the other, the influence of the tension of a membranous wall, are shown over the stomach and intestines. A greater volume, as in the stomach and colon in comparison with that of the small intestine, deepens the sound ; while increased tension heightens it, and even renders it non-tympanitic. We add to what was said above under 3, that the normally clear, non-tympanitic sound over the lung becomes tympanitic if the tension of the lung-tissue diminishes — i. e., if the lung, following the pull of its elasticity, is able to retract. This is true in all cases where the pleural cavity is diminished, hence, especially in exudative pleuritis. The tympanitic sound is found where the retracted lung lies against the thorax. All the other changes of the thoracic and abdominal cavities, working in the same way which have been before mentioned, occasion these phenomena. Probably, for the same reason — i. e., in consequence of the relaxa- tion of the lung-tissue — a tympanitic sound is heard in croupous pneumonia during the stages of engorgement and of resolution ; in oedema of the lungs ; and, finally, in the neighborhood of thickened 112 SPECIAL DIAGNOSIS. parts of the lungs. In the latter relation the tympanitic sound over the apices of the lungs in the beginning of tuberculosis, where lung- tissue containing air is situated between groups of small tubercular masses, is of some diagnostic importance. In these cases we must assume that the lung-tissue has become loose and ductile, and has, therefore, lost its power of stretching. It has not yet been established that this explanation is correct. Metallic sound. We thus designate such a variety of tympanitic sound by which a metallic character, produced by a very high over- tone, either occurring with the sound itself, a peculiar metallic tone, or it is produced afterward, metallic after-sounds. The metallic sound exists over not too small, very smooth-walled, regular cavities, both open and closed. Hence, we find it sometimes over the normal stomach, intestines, amd sometimes over lung-cavities, in pneumothorax, pneumo- pericardium. It is best brought out in percussing with the so-called rod pleximeter, or in percussion-auscultation (Heubner). (See later.) The clear non-tympanitic sound occurs where, " within the sphere of action of acoustics, there is found tissue containing air, but whose capacity for vibration is more diminished than in those cases in which the tympanitic sound occurs" (Weil, Handbook of Topographical Percussion, 2d ed., p. 35). It is heard over the normal lungs — a remarkable fact, since a lung that has been removed from the body, even if it is inflated to a volume corresponding with the condition during life, gives a sound that more nearly approaches the tympanitic than the non-tympanitic. Why a lung in the thorax loses wholly the tympanitic character of its sound is not entirely clear ; but we cannot help thinking that, in some way or other, the chest-wall is the cause. The intensity of this lung-sound is sufficiently explained by the rules given above ; its pitch, only approximately recognizable, is chiefly influenced by the tension of the lung-tissue. We have men- tioned above that retracted and relaxed lung-tissue gives a tympanitic sound ; if the tension is only slightly diminished, then there is only a very deep (and abnormally clear) non-tympanitic sound. This occurs, also, in emphysema of the lungs, but sometimes in exudative pleurisy, and also in pneumonia in the air-containing, infiltrated adjacent sec- tions of the lungs. The transition from the non-tympanitic to the tym- panitic sound over the lungs may be thus summarized : According to the diminution of the normal tension of the healthy lungs, there takes EXAMINATION OF THE RESPIRATORY APPARATUS. 113 place in the thorax a change of the clear non-tympanitic sound to an abnormally clear and deep, and, in very marked relaxation, to a tympanitic sound. To the above corresponds the fact that in very deep respiration, at the height of inspiration, at many points of the thorax, the respiratory sound is distinctly higher, Avhile in deep expiration it is deeper (" change of respiratory sound," Friedreich). Moreover, we hear the lung-sound over the stofnach and bowels, if they are very much inflated with gas, where gas, as well as wall, is under marked tension ; finally, in entrance of air into the cavities of the body, in case their walls are thereby made tense ; this especially happens in most cases of prieumothorax (except that open pneumo- thorax frequently gives a tympanitic sound). (See above.) The deadened sound. Absolutely deadened or thigh-sound is met with " if only structures that are free from air lie within the sphere where the percussion-stroke acts acoustically " (Weil). Since this, at best — i. e., with the strongest percussion — reaches only to the depth of six to seven cm., and not so much as this in a lateral direction, therefore, in case of only strong percussion, absolutely deadened sound Fig. 19. Entirely deadened : >J Clear : ^^^ " Covering of the body : Diagrammatic representation of percussion over a thick covering of the body. The short arrow indicates weak, the long one strong, percussion. "With weak percussion we have absolutely deadened resonance; with strong percussion a clear, although less intense, sound (indicated by the hatched triangle). would, after all, be found where we percussed over airless structure of sufficient size, in case an organ containing air was not directly in contact with it. If we percuss still less strongly, we should, as a matter of course, the sooner receive an absolutely deadened sound. In the human body we have next to consider the internal organs not containing air, called " parietal " if they lie in contact with the wall of the body ; and, also, the coverings (subcutaneous fat, muscles, 114 SPECIAL DIAGNOSIS. bones) if they are of sufficient magnitude. Thus, frequently, in the neighborhood where the heart is parietal, and, further, where the liver also is, even with strong percussion there is absolutely deadened sound. Not infrequently, however, especially over the heart, absolute deaden- ing does not exist, since the structures containing air lying under or near by may be reached chiefly through transmission by the chest- wall, though it may be only by its vibration, and may give the clear sound belonging to the air-containing structures. As regards the skeletal coverings, in abnormally fat persons, and in oedematous diseases, these sometimes attain such proportions that even strong percussion yields an absolutely deadened sound ; in normal, moderately fat persons it is only the fossa infraspinata that very frequently gives absolutely dull sound. But, further, parietal tumors, and especially Jluid accumulations in the pleura and peritoneum (more rarely, thickening of the lungs), occasion absolutely deadened sound in case they, together with the skeletal covering, possess sufficient depth and breadth. Moreover, over ribs markedly bowed, as over the point of sharpest bending-out of the thorax in kypho-scoliosis, absolutely deadened sound may take the place of the lung sound; also, here, often a peculiar change of the lung (aplasia) plays some part. Relatively dull sound occurs where air-containing structures of only small size are percussed, or where structures containing air are made to vibrate only slightly by percussion, or where these two con- ditions are met with together. Thus, a relatively dull sound is ob- tained with feeble percussion of air-containing structures, while strong percussion of the same yields a clear sound ; the blow reaches only a small volume of the air-containing organ, and it moreover causes in it oscillations of only moderate amplitude. Likewise, where the volume of lung-tissue is small, as over the apices and just over the lower border of the lungs, the sound is relatively dull, and this is true even with strongest percussion, since there is here only a small portion of air- containing material to be acted upon. Finally, every layer of airless tissue which lies over an air-containing tissue or space causes a deadening of the percussion-sound of the latter — i. e., a rela- tively deadened sound — if the overlying layer is not so thick as to cause an absolutely deadened sound. Subcutaneous fat, muscles, bones, parietal tumors, thickening of lungs, layers of fluid, callosities EXAMINATION OF THE RESPIRATORY APPARATUS. II5 — all these, as overlying airless masses, deaden the sound in proportion to their size. A special description is required both of parietal and of deeply seated airless 'parts which normally contain air, such as appear Fig. 20. Clear : - _ ^L No differenca __ Belatively dull : — *^^ clearness in I W ,s:j ^1 Lunff H^ liVJitf Weak percussion. Strong percussion. Diagrammatic representation of the value of gentle percussion in determining parietal condensation in the lungs. The length of the arrow indicates the strength of the per- cussion, the size of the hatched triangle the extent of the vibrations in breadth and depth. We notice that weak percussion is better, because it gives a deadened sound over the thickening, while over the lung it gives a clear sound. especially in the lungs as aoute and chronic pneumonic thickenings, infarction, and tumors For ascertaining such solidifications it is necessary not to percuss too strongly ; then we shall plainly make Fig. 21. Clear : ■ Absolutely dull ; • Less difference in clearness : Lung fii J^^ Lung Strong percussion. Weak percussion. Diagrammatic representation of the value of strong percussion in determining con- densation in the lungs lying at some distance from the surface. The strength of the percussion-stroke is indicated by the length of the arrows. The hatched triangle shows the extent of the oscillations in breadth and depth. out the place where there is air by the diiference in sound, if the given patch of thickening measures as much as about five cm. in 11(5 SPECIAL DIAGNOSIS. breadth and two cm. in depth (see Fig. 20). Deposits which are located at about three to four cm. in depth, if they are correspond- ingly large, may be detected, but only by very strong percussion; then we elicit a relatively deadened sound in the midst of what is quite normal, as is shown by Fig. 21. Sensation of Resistance. — We introduce here the description of this symptom, although it really belongs under Palpation, but in truth it is most intimately connected with Percussion. With the percussing finger (less distinctly with the hammer) the examiner forms an opinion of the degree of resistance, or, to express it better, concerning the degree of capacity of the "parts lying beneath it to vibrate. This feeling of resistance is strongest, the power to vibrate least conceivable, where it is absolutely deadened, the sound identical with the "thigh sound"; hence, normally, where we strike upon thick muscle, also bones and muscles ; pathologically, it is especially distinct over large pleuritic exudations, very thick pleura, solid parietal tumors of the chest; over large solid abdominal swellings ; and in extremely rare cases, in extensive thickening of lungs, where the bronchi are completely stopped (as in the so-called " massive pneu- monia " of the French. When the percussing hammer is used, to ascertain the feeling of resistance the index-finger is placed upon the head of the hammer. This has always seemed to me a very poor substitute for finger- percussion. Other authors, as Weil, find a marked feeling of resistance only over massive layers of fluid. I have often convinced myself of the presence of marked resistance in the cases above mentioned. 4. Topographical Percussion : Determining the Parietal Boundaries of Organs. Only of a part of the internal organs can we determine the bound- aries by percussion on the surface of the body. The conditions of such determinations are these : (a) That the given organ be parietal. [b] That it yield a sound differing from, its surrounding tissues. Hence we can mark off the boundaries of a parietal organ that gives an absolutely deadened sound from one that gives a clear (tympanitic EXAMINATION OF THE RESPIRATORY APPARATUS. WJ or non-tympanitic) sound, as the liver from the lung or stomach, the heart from the lung; of a parietal organ that gives a tympanitic sound from one that yields a non-tympanitic sound, as the lung from the stomach or the intestine ; of parietal organs with tympanitic sounds of different pitch, as the stomach from the intestines ; and also, though very seldom, two organs of non-tympanitic sound, in case they are of very different pitch, as pneumothorax from lung lying against the opposite side. But we can never recognize the boundaries between two organs giving deadened sound (heart and lungs), nor between the heart and fluid effusion in the pleura (see below). Method of Determining the Boundary. — Generally we percuss from an organ that yields a clear sound toward that which gives a deadened sound and upon the line which stands perpendicular to the expected boundary-line (hence the pleximeter or the pleximeter-finger is placed parallel to the boundary-line). We proceed by long stages upon this perpendicular (striking it at intervals of about 3 cm.), until the sound has so distinctly changed that we are convinced that we are over another organ. Then we define the boundaries by placing the pleximeter at shorter and shorter intervals until we have defined the boundaries as sharply as possible. This is traced by means of a blue pencil. After the boundaries have been determined at various points and they have been thus marked, then the points are united in a line, which is the boundary-line of the particular organ. TJte rule most important to observe is to percuss very lightly along the border of the organ ive are trying to locate. It is easy to see the reason for this : 1. By strong percussion, as of the liver close to the lower border of the lungs, we should at the same time disturb the adjacent lung and so would elicit a noticeable clear sound, and we should then easily think that we were still over the lung. In the same way, in determining the lower border of the liver, by strong percussion we disturb the intestine which here lies under the thin portion of the liver, and so get a tympanitic tone. 2. The ear perceives the very slight differences of sound which exist upon the border-line (we remember the lower border of the lung, how the clear sound yielded by it must have slight intensity) better if the sound is itself slight. For those who are trained, the simplest method may be recom- 118 SPECIAL DIAGNOSIS. mended, that on approaching the boundary between the two organs one should successively percuss the more lightly. After this indispensable explanation of the general rules for per- cussion, we again take up in succession the methods of examination of the respiratory organs. PERCUSSION OF THE THORAX, ESPECIALLY OF THE LUNGS. 1. Methods. It is best first to percuss patients who are out of bed in the stand- ing posture, and later, if necessary for the front of the chest, lying down. Upon bedridden patients the examination of the chest is con- ducted with the patient in the dorsal position ; for percussing the back, we have the patient sit up. We must then take care that the patient sits in a symmetrical position, but with the least possible ten- sion of muscles ; the head is held exactly straight, and especially in percussing the supraclavicular depressions it must not be turned ; in the dorsal position the arms lie quietly by the side of the thorax. Both in sitting and standing the patient bows the back a little, in- clines the head slightly forward, allows the shoulders to hang and folds the forearms across the chest. Every contracting muscle in- creases the thickness of the covering by its swelling and increases the impression of dulness ; hence contraction of the muscles of the thorax must as much as possible be prevented. In finger-percussion of the front of the chest with the patient in the dorsal position, we approach the bed if possible so as to stand on the left side of the patient. From the other side it is not possible to place the finger of the left hand, used as a pleximeter, symmetrically (see below) upon the two sides in both supraclavicular spaces. We proceed in such a way as to compare at every situation the percussion-note of points that are symmetrically located. We must take particular care to strike exactly upon symmetrical points, other- wise the "comparative percussion" has no value. Moreover, since we wish to make an exact comparison throughout, we take care also not only to percuss at symmetrical points, but to percuss with equal strength, and somewhat moderately. We first percuss the supraclavicular depressions, first on the right. EXAMINATION OF THE RESPIRATORY APPARATUS 119 then on the left, wliereby, in cases where it is of special importance, we determine the upper boundaries of the apices of the lungs ; then, in the same way, the infraclavicular spaces are percussed ; on the two sides in finger-percussion we must, if possible, hold the pleximeter band in such way as always to have the wrist toward the middle line of the thorax and the pleximeter finger pointing outward. Then we percuss the third intercostal space right and left, then downward only on the right, and usually only in the intercostal spaces. We do not further compare it with the left side, since the heart lies here, which is percussed by itself Then follows the deter- mination of the right lower border of the lungs according to the rules given above regarding the determination of parietal organs. We percuss upward, comparing the two sides of the thorax, again in the intercostal spaces. When we wish to percuss high in the axillae, the arms are to be abducted. Then follows the determination of the boundaries of the rio;ht and left borders of the lungs in the middle axillary lines. Sometimes it is valuable also to percuss from the infraclavicular spaces sideward and downward upon a line which is at right angles with the course of the ribs. In percussing the back we first compare the sound over the apices of the lungs, thus completely defining their upper boundaries ; then we percuss on the right and the left, comparing corresponding intercostal spaces as we proceed downward to the lower borders of the lungs. Then we percuss on the sides of the spine below the angles of the scapulae, comparing symmetrical points. The boundaries of the lungs are best determined in the scapular lines. In this way the thorax is generally to be percussed. But the presence of pathological conditions that require one to be especially careful in the examination of certain parts may give the preference to special methods of examination. These have been in part already mentioned in the general division. They follow directly from what was said there. They will be again mentioned in the description of percussion in pathological conditions of the lung. 2. Normal Sound over the Lungs, Trachea, and Larnyx. The normal boundaries of the lungs. It is shown that in percussion of the lungs in general over the normal lung there is elicited a non-tympanitic sound. But this sound 120 SPECIAL DIAGNOSIS. as regards its intensity is individually very different in diiFerent persons, also, in each single chest it is not alike throughout, but exhibits individual regional differences. The individual variations arrange themselves first according to the amount of fat. Very fat bodies give a less clear thoracic sound, or in order to yield a clear sound they must be percussed more strongly, requiring perhaps the use of the hammer ; but it is evident, as we have said, that this is unfavorable for determining the boundaries, for which the rule is to employ very light percussion. Farther, the percussion-note of the chest differs according to age : with children, having a more elastic thorax, as well as with aged per- sons with thin structural coverings and somewhat lax or rarefied lungs, it is higher in pitch than in persons in middle life. But also in the individual thorax the different regions normally give .different clearness of sound In other words, one region com- pared with another yields a relatively deadened sound, and according to the two chief points of view previously mentioned, namely, accord- ing to the varying thickness of the covering and according to the size of the lungs. Hence we remark the following facts : {a) Over the apices of the lungs, even with strong percussion, the sound is not very intense ; for though the covering is thin, the volume of the lung tissue is small. (J) In the infraclavicular spaces, and still more in the second inter- costal spaces, the sound is very intense (covering thin, more lung tissue). ((?) Farther down, not only in the male, but in still higher degree in the female, the sound is deadened by the pectoral muscle or by this and the mamma ; in the female the sound may be absolutely deadened over the mamma ; and this notwithstanding the fact that the lung- tissue is here very considerable. (d) Upon the back, the apices yield a sound of very slight inten- sity, since here there is a very small volume of lung and a very thick body of muscle. Over the scapuloe there is likewise a very deadened sound, at the spine, and directly below, even a thigh-sound. In the interscapular spaces the sound is clearer. (g) Below the scapuloe and at the sides of the chest the sound is very intense. EXAMINATION OF THE RESPIRATORY APPARATUS. 121 (/) Strictly speaking, here also belongs the description of the so- called ^'•relative heart and liver deadeyiing." (See page 124.) Now, it is further very important to know which similarly situated points on the thorax normally give the same kind of sound, since it is especially by comparative percussion that we seek to ascertain the presence of disease on one side. We may say that in healthy people marked dissimilarity of sound at symmetrical parts of the chest on the right and left sides exists only : In tlie neigJihorhood of ,the heart, as compared with the corre- sponding part on the right. At the two sides: on the left side normally the sound, almost as far back as the spine and forward in front at varying height as far some- times as the fourth rib, is often clearer than on the right, and of some- what tympanitic tone (combining with the sound of the stom.ach or colon). In addition, there is a slight inequality sometimes posteriorly over the apices. In right-handed persons, the sound on the right side at that location may sometimes be met with a little less clear, because the muscles are somewhat more developed. On the left side, in left- handed persons, the case is reversed. Lastly, it is necessary to mention a point of greater importance — that over the whole sternum there is a clearer, non-tympanitic sound, even where there is no lung-tissue at all, as at the upper part of the manubrium (trachea) and over the left half of the lower part of the corpus sterni. The sternum acts as an unusually thick pleximeter, and yields therefore throughout, and in equal strength, the sound of the lung lying in contact, spread out over its inner surface. The larynx and trachea in the neck in front give the tympanitic sound of a hollow cavity with smooth walls. This has the peculiarity of being higher and more plainly tympanitic with the mouth open than with it closed (Williams's tracheal tone, tracheal change of sound). The cause oi this phenomenon is not quite clear; the explanation given by Neukirch, and accepted by Weil, is based upon the assump- tion of the resonance of the mouth changing with its opening and closing. This will be referred to later. Normal Percussion-boundaries of the Lungs. — It is not possible to define the boundaries of the lungs perfectly by percussion. Moreover, by percussion we can only establish : 122 SPECIAL DIAGNOSIS. 1. The apices so far as they rise above the clavicle : they are dis- tinguished by their clear sound in comparison with the deadened sound of their surrounding soft parts. 2. The boundaries of the left lung at the incisura cardiaea : the lung sound from the absolutely deadened sound of the heart — the lung-heart boundary. 3. The lower borders of the lungs, this especially at the lower border of the right lung : the lung sound marks the boundary of the absolutely deadened sound of the liver — the lung-liver boundary. Fig. 22. Boundary of the lungs as determined by percussion in front. (After Weil.) g h, the extent of the lung upward; ef, the lower limit of the lungs; h d, the relations of the lung and heart at the incisura cardiaea. The strongly-hatched surface represents the portions of the heart and liver which are parietal ; the lighter hatching shows the so- called relative heart and liver deadness. (See below.) At the lower border of the left lung, first about from the mam- millary to the middle of the middle axillary line, the lung sound marks the boundary of the tympanitic sound (stomach, or more rarely also intestines) — lung-stomach boundary ; next, the lung sound from the deadened sound of the spleen — lung-spleen boundary; and, EXAMINATION OF THE RESPIRATOR V APPARATUS. 123 lastly, from the deadened sound of the kidney — the lung-kidney boundary. It is difficult to determine the boundaries of the lungs, since the difference of sound is often slight, especially as the tympanitic sound of the stomach often mingles with the lung sound higher up than the anatomical border of the lower limits of the lung; moreover, the lower boundaries of the lungs close up to the spine on both sides, because of the thick layers of the erector spinge, require strong per- cussion, and this is unfavorable for determining the boundaries. (See above.) Fig. 23. Boundary of the lungs as determined by percussion upon tlie back. (After Weil.) a h, the upper limits of the lungs; c d, lower limits. We cannot determine by percussion the front borders of the lungs behind the sternum. This is the case because the lungs lie close to each other for some distance there, and also because the sternum, like a firm bone, yields a uniform sound and it is not possible to recognize a difference of sound in what lies beneath it : it yields throughout a clear sound, very like the lung resonance over the ribs. 124 SPECIAL DIAGNOSIS. Hence, it may also be explained that the lower part of the anterior border of the right lung, which behind the sternum is limited by the heart, cannot be defined by percussion ; we much more receive, in- stead of the actual boundary of the right lung, one that is apparent — where the uniform sternal sound is exchanged for the absolutely deadened sound of the heart at the left border of the sternum. In front the base of the right lung does not extend so far down as the left — the right coming as low as the inferior border of the fifth rib, while the left corresponds with the superior border of the sixth rib. Relative heart- and liver-dullness. The determination of the lung- heart and the lung-liver boundaries is made more difficult by the peculiar circumstance that, on account of the small volume of lung- tissue at the border of the lungs, the resonance of the lungs imme- diately over the borders has very slight intensity, a relatively deadened sound. We percuss from the lung toward the liver with strong or mod- erately strong strokes, and find, say in the mammillary line at the fifth rib, a strong relatively deadened sound which the beginner is inclined to regard as absolute liver-dullness. But this, as has been said, corresponds with the thinning of the lungs at the lower border. In this way a zone of relative dullness manifests itself over the whole of the lower border of the right lung, except close to the spine behind, and in a similar but somewhat smaller zone the heart-dullness bows round and to the left ; this is the (incorrectly) so-called relative liver- and relative heart-dullness, as indicated by the light shading in Figs. 22 and 23. Also, sometimes, there is such a relative dullness over the lung-spleen boundary. It does not exist over the lung-stomach boundary, because here, by moderate percussion, the coincident sound of the stomach causes a low tympanitic sound. These zones are diagnostically important only in isolated cases, and they have nothing to do with enlargement of the heart, liver, or spleen. In order to avoid deception by these conditions, when determining the boundaries it is necessary to take care : 1. To percuss lightly in determining the boundaries of the lungs. 2. To mark the lung-heart and the lung-liver boundary, that is the border of the lungs where the relative dullness passes into abso- lute dullness, or, in other words, where, in percussing from the lungs toward the heart and the liver, the dullness begins to be so marked that it no longer increases. EXAMINATION OF THE RESPIRATORY APPARATUS. 125 On the average, that is, in middle life, we thus find (compare Figs. 22 and 23) : the lung-liver boundary in the mammillary line at the sixth, in the middle axillary line at the eighth, in the scapulary line at the tenth rib ; tlie lower border of the left lung : in general as high as the right only in the mammillary line at the lower border of the sixth rib ; the lung -heart boundary : at the fourth rib and more or less just without the parasternal line ; the upper limits of the apices of the lungs: three to five cm. above the clavicle. Differences by reason of age. In children, the lower border of the lungs is from a half to a whole intercostal space higher ; in old per- sons, it is that much lower (Weil). There is a like difference as regards the lung-heart boundary. That is, the lungs increase with the years, as compared with other organs. Displacement of lower border of the lungs is manifest by percussion : 1. In deep inspiration and expiration (active mobility) : in the mid- dle axillary line the lower border sinks with deepest inspiration about three to four cm. ; in the mammillary and scapular lines about two to three cm. ; in deepest expiration it rises up not quite so much above the average location (Weil). With deep inspiration, at the incisura cardiaca the lung moves so as quite to cover the heart ; and it may even entirely obscure the heart dulness. 2. In change of position (passive mobility) : when lying upon one or the other side the lower border of the lung of the opposite side moves down as much as three to four cm. (Grerhardt, Salzer, Weil). 3. Abnormal Sound over the Lungs. Abnormal position of the border of the lungs. A. Dullness : Deadened Resonance. — In order not to overlook slight deadening we must remember what was said upon comparative percussion on page 124 ; if the comparison with the opposite side is inadmissible, as when both sides are diseased, then the comparison is made with the adjacent parts upon the same side, bearing in mind the normal regional differences of intensity of sound. Thus, in disease of both apices we sometimes recognize the dead- ness of the apex to be less affected by comparing the resonance over the latter with the percussion-resonance a little lower down ; remem- bering that normally the resonance over the first and second inter- 126 SPECIAL DIAGNOSIS. costal spaces must be clearer than in the supraclavicular space, and clearer than over the third intercostal space. But also, without further consideration, we must not designate every deadness as due to an internal organ, but consider the deadening influence of a sharply-bowed rib, etc. Slight deadening^ without any other pathological evidence, especially over the apices, is to be given value with very great caution. (a) Resonance is deadened by the development of airless tissue in the lungs either by condensation or by solid new formations in them. In croupous ^pneumonia the lung-tissue in the height of the disease is in the stage of hepatization. Generally in a large region it is completely deprived of air through the filling of the alveoli with inflammatory exudation. An intense deadening is coextensive with this condition. It seldom becomes absolutely deadened like the thigh-sound, but there can generally be recognized a slight tympanitic tone. The feeling of resistance is generally likewise correspondingly increased, but not so much as is the case with a pleuritic exudation, Thigh-dulness and very marked feeling of resistance may exist Avith croupous pneumonia if, besides the lung-tissue, the bronchial tubes of that part of the lung are likewise completely filled with the exudation ("massive pneumonia "), or if the croupous pneumonia is complicated with a large pleuritic exudation, which is then almost always behind and low in the chest. The extent of the deadening in croupous pneu- monia very frequently corresponds with a lobe of the lung, because of its being a lobar pneumonia, or there is evidence of an enlargement of the lobe in all directions (the inflammatory exudation spreads out to a considerable extent). Often, therefore, in this disease we may recognize the boundaries of the lobe in the figure of the area of dead- ening, or the boundaries which correspond to the tracing of the lobe enlarged in all directions. The infiltrated part of the lung may, how- ever, be also smaller, especially on the surface of the lungs, occupying so small an extent as not to cause any recognizable deadening. Auscultation (which see) here leads to a conclusion sooner than per- cussion. In the neighborhood of an infiltration the resonance is generally abnormally loud and deep, even slightly tympanitic (compare what is said of croupous pneumonia under B. Tympanitic Sound). Since the infiltrated lobe of the lung is somewhat larger than EXAMINATION OF THE RESPIRATORY APPARATUS. 127 normal, sometimes in pneumonia of the whole lower lobe deadness will be found posteriorly as far up as the apex without the apex being involved. Percussion upon the front of the chest then yields a very loud, deep sound over the upper part of the upper lobe. Further, for the same reason, in pneumonia of the left lower lobe the lower borders of the deadness may overstep the region of the normal boundaries of the lungs, as the marking out of the lung-stomach boundary then shows that the so-called " halfmoon-shaped space" is somewhat smaller. (See under Digestive Apparatus.) Also in catarrhal or lobular pneumonia and tuberculosis (in the so-called infiltrated tuberculosis of a larger part of the lungs) there may be an extended thickening and a corresponding deadening. Often, indeed, there are pathological deposits so small that their presence is not revealed by percussion ; but though widely scattered, they are interspersed with points still containing air and hence give a clear sound. Then, because the tissue of the parts still remaining normal is somewhat lax, the resonance is often tympanitic. Or, the latter sound is mingled with that of deadness from the infiltrated parts — the tympanitic deadened sound. In tuberculosis of the apices of the lungs there is, at the beginning, in very slight measure, a mingling of thickened parts with tissue con- taining air, but relaxed ; hence the resonance in the beginning over the diseased apex is very often tympanitic or tympanitic-deadened, in comparison with the healthy apex. Moreover, there is early retraction of the upper boundary of the apex upon the afifected side. (See under Diminution of the Boundaries of the Lungs.) Large hemorrhagic infarctions and sections of the lungs compressed even to the point of not containing any air, as from pleuritic exuda- tions, tumors, and large pericardial exudations, may likewise give a deadened sound. Finally, it is conceivable that solid tumors of the lungs (sarcoma, carcinoma) produce the same effects in case they lie upon the surface or attain to a certain size. (6) Resonance is deadened by the presence of a deadening medium over the lungs — that is, between it and the percussing finger. Most important of these is pleuritic exudation. Generally, this first appears low down posteriorly in the complementary space and above it, and if it amounts to as much as 400 cubic cm. it may even be recognized by light percussion. Corresponding with the increase of 128 SPECIAL DIAGNOSIS. the exudation the area of deadness will gradually become more extensive ; its limits ordinarily correspond with a fluid surface which, while the patient is in the posture most frequently assumed, is somewhat horizontal ; that is to say, in bedridden patients the fluid levels itself high up on the posterior wall of the thorax, and the limits on the sides and in front drop off sharply ; while with people who are much out of bed, or may still be at work, the fluid stands equally high in front and at the back of the chest. When the efi'usion is very large the deadness may extend even to the apex, both anteriorly and posteriorly. It quickly becomes, with considerable effusion, an absolute deadenino; and with the most marked feelino; of resistance. Corresponding with the increase of the fluid the lung becomes lax in an ever-increasing area, since it may then follow its elastic trac- tion ; immediately over the fluid it gives deadness, and when there is a large exudation, where at least there is ordinarily left a district with clear sound, namely, high in front, it yields an abnormally loud and deep, or a tympanitic sound, sometimes cracked-pot sound (see page 134). A very large exudation may even compress the lung to such a degree as to expel all air. When there is a certain amount of exudation its weight presses upon the diaphragm, increases the affected pleural cavity toward the side, presses out the side of the thorax (see above), and pushes the mediastinum and the heart over toward the sound side (see Displace- ment of the Heart). The downward pressure of the diaphragm in cases of pleurisy of the right side is recognized by the liver being lower (see Percussion of the Liver). In pleurisy of the left side, it may directly be made out by locating the upper boundary of the so- called " halfmoon-shaped space." When the pleural surfaces directly over the exudate are glued together, then in change of position of the patient the pleuritic exuda- tion is not movable, and the boundaries of the deadness are therefore not changeable ; not infrequently the exudation is entirely " capsu- lated ' ' by the adhesion of the pleural surfaces. If the exudation is reabsorbed, then the evidences of expansion and of displacement, on the one hand, and the deadness (and, indeed, according to its extent, likewise its intensity), on the other hand, steadily disappear. Often EXAMINATION OF THE RESPIRATORY APPARATUS. ] 29 the upper border of deadness then shows as a bowed line with its convexity upward (Damoiseau's curve). If a new pleuritic exudation takes place between pleural surfaces already adherent from a former attack, then, of course, it remains confined within the space thus prepared — "■ encapsulated, circumscribed pleurisy." The boundaries of the exudation may, in these cases, take a very varying course. Hydrothorax practically gives rise to similar appearances ; but it is generally on both sides, yet not infrequently with a very different amount upon the two sides. Further, hydrothorax always shows in change of position, although only after a certain time, a change of its relation to the thorax in such a way that it tends to take possession of the part of the thorax that, for the time being, is the lowest; accordingly, there is what may be called a passive mobility of the boundaries of deadness. Serous or purulent, or ichorous, effusion into the pleural cavity com- plicating pneumothorax (sero-, pyo-pneumothorax) is distinguished from the above by its mobility with the change of posture. It be- haves like the water in a bottle when the position of the latter is changed ; in every situation the fluid maintains a horizontal surface, and occasions at the same time, Avith every change of place or location of the thorax, a prompt variation of the upper boundaries of the deadness. . Further, a deadening of the resonance is occasioned by the thick- ening of the "pleura, which either remains after an exudative pleuritis or in conjunction with processes slowly going on in the lungs. The latter is the case very frequently in tuberculosis of the apices of the lungs ; marked deadening, appearing early in the beginning of the disease, is generally caused by pleural thickening. The intensity of the deadness is determined by the amount of the thickening ; it may even become like thigh-deadness. The feeling of resistance is generally very markedly increased ; with very thick deposit this is positive. Tumors, as a matter of course, likewise cause deadening. This latter deadening generally exhibits an irregular boundary, if it is not, as is rarely the case, complicated by pleuritic exudations. It is sometimes very difficult to distinguish between a thickened pleural surface and a portion of pleural exudation left behind with moderate thickening ; this question often especially arises where the 130 SPECIAL DIAGNOSIS. deadness is low down posteriorly. In arriving at a decision the first thing to consider is whether there is expansion or contraction, or whether there is a deep or a high position of the diaphragm. But here, as well as in the often very diificult differential diagnosis between pleural exudations and tumors, as of the lungs, pleura, or chest-wall, the application of the explorative puncture is the best means of deciding. Finally, the resonance of the thorax is deadened by all processes in the chest-wall which lead to its being thickened — tumors, peri- pleuritis, oedema. The second quality of sound tvhich is found over diseased lungs is B. Tympanitic Sound. — (a) It occurs, pathologically, if the lung is in a state of elastic equilibrium : we know that this condition is a consequence of retraction of the lung : with large pleuritic exudation as well as shrinking in connection with pleurisy ; further, in all other affections of the chest which decrease its capacity. Hence tympanitic resonance exists over the lungs in the neighborhood of tumors of all kinds ; sometimes in the neighborhood of the heart in exudative pericarditis, more rarely in hypertrophy and dilatation of the heart ; lower in the thorax : in diaphragmatic pleurisy ; in high position of the diaphragm from subphrenic tumors, abscesses, etc.; and in general peritonitis, general distention of the abdomen from ascites, tumors, etc. We may also think of the same condition of approaching equilibrium of elasticity as arising from relaxation of the lung-tissue (Weil) ; and this will explain the tympanitic resonance that exists with croupous pneumonia in the stage of engorgement and resolution ; over many small catarrhal-pneumonic and tubercular deposits., since the inter- vening tissue containing air has become lax ; and finally, in oedema of the lungs. {b) In consequence of marked shrinking and thickening of the lung, in strong percussion of the supraclavicular fossa, it arises from the trachea, while in percussing the first or second intercostal space it arises from this or the primary bronchus, directly from the percus- sion-blow, and so the broncho-tracheal column of air is put in vibra- tion ; thus arises a peculiar change of sound in the trachea, the EXAMINATION OF THE RESPIRATORY APPARATUS. l^i sound with the mouth open being more distinctly tympanitic and higher (Williams's tracheal tone). {c) Over cavities within the lungs, caverns (vomicce). We may have here, according as the cavity does or does not com- municate with the outer air by means of a pervious bronchial tube, the open or the closed tympanitic resonayice. In the former case the sound is under all circumstances more distinctly tympanitic and also more intense ; in the latter case, on the other hand, much less distinct and weaker, all the more since we must assume that the cavities, because they lie in the thorax, have more or less stiff walls, and since the rigidity of the wall with the cavity closed hinders the condition that causes the tympanitic sound. How large the cavity must be in order to give a tympanitic sound it is not possible exactly to state, since besides the size, the situation of the cavity (whether parietal or deep), the amount of fluid secretion it contains, its walls (whether smooth and vibratory), the condition of the surrounding lung-tissue, and finally the vibratory capacity of the given thorax must also be taken into consideration. Generally, cavi- ties occurring in the apices from tuberculosis exhibit more distinct ph^'sical characteristics than cavities in the lower portions of the lungs, which frequently are of the nature of bronchiectasis, since the former, even when of moderate size, must reach to the surftice of the lungs, and generally have tliickened walls. Cavities as large as a walnut in the upper parts of the lungs generally give a distinctly tympanitic resonance. If the cavity is very large with relatively smooth walls a metallic tone is added to the tympanitic resonance. If the cavity is covered by thickened lung-tissue or with thickened pleura (this very frequent) then the sound becomes tympanitic-dead- ened ; if by a very thick layer of airless tissue, absolutely deadened. Temporarily marked filling of the cavity with secretion deadens the tympanitic sound also, sometimes even to absolute deadening; further, the sound becomes temporarily indistinctly tympanitic and deadened- tympanitic if a bronchus connecting with it, otherwise open, becomes closed (with secretion or from dipping belovf the fluid contents of the cavity). Under different conditions tympanitic sound over a cavity may change its pitch : 132 SPECIAL DIAGNOSIS. 1. The so-called simple Wintrich's change of sound. The tym- panitic sound becomes louder, more distinctly tympanitic, and higher, if the patient opens the mouth wide (and, what is desirable, at the same time protrudes the tongue a little). This can only occur over those cavities that freely communicate with the broncho-tracheal column of air. We percuss, not too strongly, while the patient lies ■ or stands quietly and alternately opens and closes the mouth ; but it is neces- sary for the patient to breathe as superficially as possible, or we must compare the sound in the same stage of the breathin.g, since the sound also sometimes changes its pitch according to the stage of the breath (compare under 4. Respiratory change of sound). The explanation of this symptom, as of the tracheal change of sound which is exactly similar, is that it is from the change of con- sonance of the mouth-throat cavity. This Wintrich's change of sound may also occur over cavities in such a way that the sound with the mouth closed is markedly deadened, with only a trace of tympanitic sound (especially with marked callous formations over the cavity), and only with the mouth open does the sound become tympanitic (at the same time becoming louder and noticeably higher). I would hke, therefore, in opposition to Weil, to insist that we ought, if there is only a slight possibility of the existence of a cavity, and also in the case of tympanitic sound slightly distinct, even indistinct, with dulness, to apply the test of Wintrich's change of sound. It is very easy to confound the simple Wintrich's change of sound with Williams's tracheal tone. We should take notice : (1) Whether there is very marked contraction, when it is much more likely to indi- cate change of sound than Williams's tracheal tone. (2) Whether in order to cause the change of sound only weak percussion (cavity) or strong percussion (trachea or bronchus) is required. (3) Whether there are other symptoms of a cavity. Simple Wintrich's change of sound points with greater probability to a cavity. But its value as an indication is diminished by the above-mentioned possibility of being confounded with Williams's tracheal tone. 2. Interrupted Wintrich's change of sound (Gerhardt, Moritz). It EXAMINATION OF THE RESPIRATOR}' APPARATUS. 13-3 is distinguished from the simple in that in some positions of the bodj it is plain, in others it is indistinct or is wanting. The explanation of this is that in one position the bronchus leading to the cavity is open, while in the other it dips into the secretion in the cavity and so is closed. In this way the tracheal change of sound cannot possibly be interrupted This change of sound is very rarely met with, but it is to be regarded as a positive sign of a cavity. 3. Gferhardt's change of sound. A tympanitic sound changes its pitch if the patient changes his posture (upright, dorsal, side position); and sometimes, if the patient changes from the dorsal to the upright Fig. 2-i. Oerhardt's change of sound — Schematic rejiresentation of the behavior of the contents of a cavity with a change of position of the body of the patient. position, the sound becomes deadened-tympanitic or absolutely dead- ened over the lower part of the cavity, because in this position the fluid contents of the cavity come into contact with the chest- wall. Gerhardt's change of sound may take place over communicating, as well as over closed, cavities. The change of pitch, in case the cavity is open, may have very different causes, which we will not discuss here. In closed cavities it is really due to a change in the tension of the chest (and cavity ?) wall, perhaps also to a change in the size of the part of the cavity containing air — a change caused by different loca- tion of the secretion. (See Figs. 24 and 25, from WeiVs Handbook.) Gerhardt's change of sound is in every form an almost certain symptom of a cavity, but, like the former, it is very rare. 4. Friedreich's or the respiratory change of sound: the sound 134 SPECIAL DIAGNOSIS. l)ecomes higher at ihe height of a deep inspiration. This occurs not alone over cavities, but may be observed in any case of tympanitic sound over the lungs. It depends upon the increased tension during inspiration of the chest-wall and lung-tissues, likewise of the wall of the cavity. It does not have diagnostic significance. But it is important to know it in order that we may not be misled by it in the examination of other changes of sound ; therefore, we ought in testing this to observe the rule to percuss during very superficial breathing, or still better always to percuss at the same stage of the breathing, as has been said above. {d) Finally, the tyinpanitic sound occurs in very rare cases in pneumothorax and sometimes entirely in cases that have permanent and completely-open fistulse ; this " open " pneumothorax is generally circumscribed. In pneumothorax the tympanitic sound may some- times exhibit Wintrich's change, since the physical conditions upon which it depends are also present, as in large communicating cavities : open communication of an air-space with the broncho-tracheal column of air. Here we have also metallic tone (see p. 135). Oracked-ijot sound (britit de jyot fele). It seems that this is the most suitable place to describe this phenomenon, which, Avhile very surprising and remarkable, is of very subordinate diagnostic sig- nificance. It consists of a peculiar click (" clinking of coin " or "trembling"), which sometimes accompanies the clear sound and indeed generally the tympanitic, more rarely the clear, nun-tympanitic. It corresponds to the noise which occurs when wo strike a cracked plate or pot, or when we hold the palms of the hands together lightly and then strike them upon the knee. It occurs in the thorax if an instantaneous current of air of a given force is driven from the lungs against the larynx by the percussion-stroke, or if during expira- tion a stream of air flowing outward is for a moment suddenly sharply arrested. This symptom requires strong percussion, yielding thorax, and thin covering (generally in front superiorly, and also below posteriorly). It occurs sometimes in normal cases, especially in children. Pathologically it occurs: 1. Over large parietal cavities, here often remarkably intense. 2. In pneumothorax with open fistula, especially if circumscribed. EXAMINATION OF THE RESPIRATOR V APPARATUS. 135 3. Ov&c pnemaonic deposits. 4. Over retracted lung tissue, especially above large pleuritic exuda- tions (high in front), rarely in the neighborhood of thickened portions of lung. This phenomenon is always more distinct if we percuss during expiration ; very often, especially in case of cavity and open pneumo- thorax, it becomes louder by opening the mouth. As above remarked, this symptom has almost no diagnostic meaning, since it is present with such varying conditions. The noise is caused by a swift current of air striking at a narrowed point; this happens at the glottis, in a cavity at the mouth 'of a bronchus, and at the puncture in the pleura in case of pneumo- thorax. Sometimes a rattling sound is mingled with the trembling (" the moist cracked-pot sound"). C. Abnormally Loud and Deep Sound.- — This occurs : 1. In severe emphysema of the lungs, designated as " band-box note" (Biermer). 2. In decreased tension of lung tissue above a pleuritic exudation : a zone of this abnormal sound lies just above the line of deadness pro- duced by the exudation in the neighborhood of pneumonic thickening — as anteriorly in pneumonia of a whole lower lobe ; sometimes in the neighborhood of the heart in pericarditis exudativa, but also with dilatation and hypertrophy ; likewise, and especially, in the neighbor- hood of encroaching tumors, and with a high position of the diaphragm consequent upon abdominal affections. As was said before, in most of these cases, if the tension of the lung-tissue is very considerable, tympanitic resonance may arise (see p. 130). 3. With pneumothorax. Here the sound, in consequence of the strono" tension of the chest-wall, is almost always non-tympanitic, loud and deep. Only (a rare case) in open pneumothorax, especially if it be circumscribed, is tympanitic sound sometimes met with (see p. 134). This abnormally loud and deep, even tympanitic sound of pneumo- thorax gives almost regularly the metallic sound, only seldom recog- nizable, however, by the ordinary methods of percussion, but very admirably by the rod-pleximeter percussion described by Heubner. 136 SPECIAL DIAG-NOSIS. 3Iode of application. Rod-pleximeter percussion is best conducted bj two examiners. One strikes with the handle of the percussion- hammer, or with a pencil upon a pleximeter; the other auscults the thorax. If both manipuhite over a pneumothoracic cavity the second hears the strokes as the finest metalHc, generally a silvery, clear rino;ino;. This, moreover, is sometimes also observed with very large and smooth-ivalled cavities with tliin covering. With pneumothorax accompanied with fluid (pyo-, seropneumothorax) the metallic sound, almost without exception, changes its pitch with the change of posi- tion ; in sitting up it is generally deeper, but sometimes also higher (Biermer's change of sound). If the effusion is so large as entirely, or almost entirely, to fill the pleural cavity of course the metallic sound disappears. It will be mentioned in the appropriate sections that this metallic ringing in pneumothorax not only accompanies such an artificially created noise, but also may be present with rhonchus, respiratory sound, and heart-sound. D. Changed Condition (and Diminished Power op Displace- ment) OF THE Boundaiues OF THE LuNGS. — (a) Extension of the boundaries of the lungs takes place in emphysema: the lower borders usually move sidewise and deeper, both front and back, in the most marked cases. The raammillary line will be at the eighth rib, the axillary line at the tenth, the scapular line at the eleventh or twelfth. Heart deadness may also or quite disappear, from the expanded lung lying over it from the side. At the apices of the lungs some- times a slight enlargement of the lungs may be made out ; in rare cases even expansion of the apices may likewise take place (as after whooping-cough in children). "Relative 1 iver- dullness " and "heart-dullness" is very small ; simultaneously with the expansion, the lung loses its power of displacement, both active and passive, even past recognition. One-sided downward movement of the boundary of the lung occurs in vicarious emphysema, but the capacity to change its boundaries is preserved in this case. Apparent one-sided expansion of the boundary— tha,t is to say, the appearance of a clear sound upon one side quite beyond the normal boundary of the lung — takes place in diffuse pneumothorax : the EX A MIX A TION OF THE RES PI R A TOR V A PPA RA TUS. 1 3 7 lower border of the clear sound is sometimes met with even deeper than in emphysema ; this border is immovable, and always very sharply defined. The side of the thorax is expanded, the heart and also liver are displaced, or the tympanitic sound of the " half-moon- shaped '' space is replaced by the sound of pneumothorax. Displace- ment of the mediastinum in right-sided pneumothorax is generally distinctly recognized by the change of sound between it and the left lung (the boundary-line lies to the left of the upper part of the sternum). {h) Diminished volume of the lungs is shown by the lower boundaries of the lungs being higher than normal on both sides, by the diaphragm being pressed up from below or from its being paralyzed ; one-sided diminution, by shrinking from disease of the lung or a past pleurisy. The motility of the borders is thus diminished or destroyed. The liver stands correspondingly higher (see Liver), or the " half- moon- shaped " space is enlarged. Sometimes diminution in size of an apex in phthisis manifests itself by the deeper position of the upper border of the lung upon one side. (c) Diminution of the motility alone, especially during respiration, without change of the average condition of the borders, sometimes exists low down posteriorly as the^rs^ symptom of pleurisy, and also as the only sign of a past pleurisy, in which case it is noticed along the whole lower border of a lung or a part of the same, as at the heart ; here, also, it is a residuum of pericarditis externa. (See Examination of the Heart.) Retraction of the lungs in the neighborhood of the heart by shrinking permits the latter to come in contact with the chest-wall to a larger extent than normal ; there is displacement of the heart- border of the lung to the left and upward, and, hence, hypertrophy or dilatation of the heart may at first be mistaken for the real condition, (See Heart.) On the other hand, diseased conditions in the neck (tumors, scars, etc.) may influence the position of the apices, and thus at first may deceive the inexperienced in leading him to conclude that there is one-sided shrinking of the lung. 138 SPECIAL DIAGNOSIS. AUSCULTATION OF THE LUNGS. 1. History. The Sphere of Auscultation at the Present Time. ' It now appears to us very strange that the idea of percussing the body was only so lately brought into medical practice. It is yet more difficult to understand that methodical auscultation of the body is only a child of the most recent time. It is true that Hippocrates heard what he named a succussion-sound, and also, no doubt, rattling and rubbing sounds ; but to the two latter he did not attach any great importance, and in all the centuries from the Greek physician to the time of Laennec no real attention was given to the audible phenomena of the healthy and diseased body. Only a few voices — that of the often-mentioned Hooke more than any other (second half of the seventeenth century) — were timidly raised, and these Avere not heeded. Only in consequence of the discovery and general consideration of the value of percussion was auscultation developed, and this by Laennec, the discoverer of the stethoscope. His epoch-making work is called TraitS de V Auscultation mediate et des Maladies des Poumons et du Coeur. After him, Skoda, by critical sifting and by his own efforts, which traced the new phenomena to their physical causes, rendered imperishable service to this branch of knowledge. But up to the present time the work has still been going on, which, in part, has made new discoveries, and, in part, has investigated the nature of what was already known. The sphere of auscultation — of listening — in its widest sense extends to all that we are able to take note of by the ear, hence, in the first place, to the voice, cough, noises caused by breathing, by mucus in the upper air-passages, which may often be heard in the furthest corner of the sick-chamber. But, strictly speaking, ausculta- tion concerns only those phenomena which the ear perceives, either by direct application to the body or which are brought to it by an instrument, as a stethoscope or an ear-trumpet. These, so far as they refer to the respiratory apparatus, form the subject of the following section, 2. Methods of Auscultation. Nowadays we employ both immediate (direct) and the mediate (indirect) auscultation. In the first, the ear is directly applied to the EXAMINATION OF THE RESPIRATORY APPARATUS. I39 person to be examined ; in the latter, we employ a stethoscope or ear- trumpet. While, as will be referred to later, we employ almost ex- clusively the indirect method in examining the heart and vessels, both methods are applied in the examination of the respiratory apparatus, and particularly of the lungs. In applying both, where it is possible, we must endeavor to have the body bare ; in no case should the cover- ing be more than a single thickness, and that should be as thin as possible, and must be perfectly smooth, [By the use of a solid — a wooden or hard-rubber — stethoscope it is not absolutely necessary to remove the clothing ; by pressing the instrument firmly against the chest with the fingers friction of the clothing is prevented ] The application of the ear to the body consists simply in laying the ear lightly over the particular part to be examined. In order to place the ear exactly over the spot which we wish to auscult, it is well to place the tip of the index-finger at the point and keep it there until the ear is placed at the point indicated, when the finger is withdrawn. For stethoscopic auscultation, almost universally used in Germany at the present time, preference is given to the simple hollow stethoscope, the tube being about twelve to eighteen* cm. long, with a not too small ear-plate. No doubt the plate has this disadvantage — unless the examiner is sufficiently careful — that it does not lie smoothly upon the outer ear; but, nevertheless, it is the most suitable form, since the stethoscope with hollowed ear-pieces, especially those recently devised, which, embracing the head of the auscultator, lie over the whole outer ear, for most persons have a most disturbing roar — a disadvantage which quite outweighs the advantage that, by increasing the resonance, it so well conducts the noises from the body ; and the cone-shaped ear-pieces which are inserted into the outer ear, in the short stetho- scopes with stiff tubes, cannot long be borne by the examiner. These stethoscopes may have the further peculiarity that the end that rests upon the body measures, on the average, not more than two to five cm.; hence they conduct to the ear impressions of sound from a much smaller region than will be heard from by direct auscultation. They are made of various material (wood, hard rubber, ivory), but this is of small importance. The flexible stethoscopes (rubber tubing instead of the stiif tube, and ear-cones instead of the ear-plate) come less into use because it is difficult, at least in the beginning of their use, to exclude the marked noises that are associated with them. Of 140 SPECIAL DIAGNOSIS. the double stethoscopes I only mention that of Camman, since it is decidedly very useful ; hut it is a complicated instrument. In general the use of the stethoscope resembles the practice of percussion in that everyone, especially while learning, ought always to use the same kind of instrument, in order that he may learn to judge correctly of the auditory impressions which his instrument furnishes. In my teaching I have always found that those students who each time they wished to make an examination had to borrow an instrument from their fellows did not hear anything. There are a large number of forms of stethoscopes, especially of the hollow stiff ones, the separate models of which it is not possible to describe. It may be remarked that the microphone has recently been employed. P. Niemeyer's solid stethoscope with ear-cones (acuoxylon) is deci- dedly not to be recommended; it has not proved practical, nt)r are the theoretical grounds of its construction sound. It is very important in the beginning not to make pressure with the stethoscope. Hence it is advisable to steady the instrument with two fingers, and not to hold ifin place Avith the head. As was said above, it is decidedly to be recommended in the exam- ination of the lungs to employ both direct and indirect auscultation. The former is here preferable, since by it we can generally listen at one time to a large region of the lung ; hence it is on the one hand more comprehensive, and on the other hand furnishes collectively louder sounds. Moreover, in the examination of the chest posteriorly of very sick patients it cannot be dispensed with, since by its compre- hensiveness it furnishes the means of conducting the examination with the necessary quickness. On the other hand the stethoscope is employed ; 1. Where the ear cannot be applied, as over the supraclavicular spaces. 2. If we wish to listen quite separately to noises existing in a narrow limited space. 3. Sometimes from reasons of delicacy, as over the female breast. 4. If the physician wishes to avoid being soiled, the risk of receiv- ing or getting parasitic insects, or infections. In a general examination it is well to auscultate after percussing. After percussing the front of the chest, auscultate over the same EXAMINATION OF THE RESPIRATORV APPARATUS. 141 region and then percuss and auscult the back. Generally the patient should breathe deeply ; it is not at all preferable to have him breathe very hard and quickly. Not infrequently we hear best with mode- rately deep breathing. Where it is possible, as in percussion, sym- metrical parts should be compared. The particular points where it is necessary to take care are described in the following section. 3. Auscultatory Signs in Normal Respiration. 1. Sound of bronchial 'breathing. If we auscult the larynx or trachea of a healthy person during inspiration and expiration we hear a loud aspirating sound which corresponds somewhat exactly with that we can make with the mouth when we put it in position to pronounce "h" or " ch " and then inspire or expire. We designate this sound as the laryngeal and tracheal, or by the collective expression, bron- chial breathing sound. Its peculiarity is its more or less pronounced sharpness {eh or h sound) and moreover a somewhat rising pitch ; again, it is ordinarily somewhat louder (and deeper) in expiration than during inspiration. The sound is formed in the glottis by the eddies which are here formed in the current of air by the sudden narrowing; it is louder in expiration, because the rima glottidis is narrower then than during inspiration. The strength and rapidity of the breathing have a great influence upon the loudness of the sound. Besides over the throat in front, where the larnyx and trachea lie superficially, we hear this sound over the vertebra prominens at the back of the neck in healthy persons during moderately strong breath- ing; also, sometimes, over the upper part of the sternum; very frequently, too, in the interscapular space, and more plainly upon the right than to the left of the median line (region of the bifurcation). Bronchial breathing may be noticed at other parts of the thorax at a varyinof distance from the above regions durino; strons; breathing, especially with violent, coughing expiration. It is heard earliest over the upper sections of the chest. There may be great individual differences and yet be within the limits of the normal, Confounding bronchial breathing with the diseased conditions to be mentioned later will be avoided by noting the approximate symmetry of this breathing- sound, the condition in feeble breathing, and also the result of the further examination. 142 SPECIAL DIAGNOSIS. A noise which arises in the pharnyx and at the lips of the person examined not infrequently disturbs or deceives the beginner ; closing the free ear is here recommended. 2. Vesicular breathing. In healthy persons this is heard -wherever the lungs lie in contact with the chest wall (with the exception of in the interscapular space ; see above). It is of a very slight shuffling character, resembling the sound we may produce by placing the lips in position to say '-f " or "v." The pitch of this sound can only be approximately recognized (like the clear non-tympanitic sound). This sound can only be heard in inspiration, and most plainly at the end of inspiration. In a sound lung expiration has a very slight breathing sound which may be said to be of bronchial character. Not infrequently it is wholly imperceptible ; sometimes, however, we find inspiration which is simply like a very much weakened vesicular inspiratory sound. The force of vesicular breathing varies very much. It is most determined by the strength of the breathing ; in very strong respiration it is often so loud that it is also heard over the organs adjacent to the lungs, as over the heart, liver, and stomach. In the majority of healthy persons the vesicular murmur is louder upon the left side than upon the right (Stokes). Otherwise the strength of this breathing sound is determined by the loudness of the pulmonic sound; over thin portions of the lung, as the apices, it is very slight, and likewise it may be weakened by the thickness of the covering even to such a degree as not to be heard at all. Moreover, there are individual differences which depend chiefly upon the differences in the width of the glottis, also on the elasticity of the chest on the one hand and on that of the lungs on the other. Puerile breathing (Laennec). The vesicular murmur in children is remarkably different from that of maturity ; the former up to about the twelfth year of age exhibits a remarkably distinct, loud and sharp vesicular breathing sound, which approaches bronchial breathing, especially also in that often it is nearly as strong in expiration as in inspiration. Generally, also, women have a stronger vesicular murmur than men. Origin. Vesicular breathing sound is nothing more than the bronchial breathing sound as it is heard over the trachea or larynx. EXAMINATION OF THE RESPIRATORY APPARATUS. 14^ as it is formed at the rima glottidis (see above), but changed by being prolonged into the air-containing lung. It is the air-containing lung which causes that sharp sound, having a musical pitch, to reach our ears so changed in character. Any tissue not containing air, and, indeed, the lung-tissue that has been deprived of air by the products of disease, as "will be shown below, conducts tl^c bronchial breathing unchanged from the large tubes in which it forms to the surface of the chest, and so to the ear; and, on the other hand, a piece of animal lung inflated, placed upon the neck, when auscultated changes the laryngeal breathing sound to a vesicular. (Penzoldt.) In our opinion, this explanation is probably correct. Moreover, it has this decided preference — that it forms a good foundation for com- prehending almost all the pathological appearances. Hence, we do not mention other ways of explaining vesicular breathing here, but remark that very excellent authorities, particularly Dehio, prefer other explanations. Thus far, positive proofs have not been produced for any of the assumed methods of producing vesicular breathing. Sometimes there are special peculiarities of vesicular hreathing sound quite tvithin the normal, which may easily mislead the beginner. We may see during inspiration interrupted or jerking respiration in persons who, at discretion, take deep breaths imperfectly, in a jerking manner ; and, further, in whining children, who half suppress their sobs. This kind of jerking breathing exists over all portions of the lungs alike. Moreover, in the portion surrounding the heart, and as far up as to the apex of the left lung, the vesicular murmur exhibits interruptions exactly corresponding to the action of the heart (systolic vesicular breathing, depending upon the unequal entrance of air into this portion of the lung in consequence of the changed condition of the heart, and, hence, often especially plain in disturbed heart's action). To learn to distinguish between the bronchial and vesicular breathing is, for the beginner, among the most difficult things in diagnosis. For the comprehension of the latter sound it is strongly recommended always to auscult directly, since the sound is then louder and its nature can thus be more clearly recognized. More than this, it is well to place the ear frequently, for comparison, upon the patient's neck, so as there to hear the bronchial sound. 144 SPECIAL DIAGNOSIS. 4. Pathological Sounds in the Respiratory Apparatus. The following are enumerated : {a) Certain changes in the vesicular breathing. (h) Broi/bhial breathing, in place of vesicular breathing. (c) The so-called indefinite, transition, breathing [broncho- vesicular] . (d) Dry rales. (e) Moist rales. (/) Crepitant rales. {g) Friction-sound of the pleura, (/i) Succussion-sound of Hippocrates. From this enumeration, and still more from what follows, it is evident that the number of pathological sounds to be heard with the diseases of the respiratory apparatus is not small. The chief difficulty is that very often different ones are to be heard at the same time, so that one sound conceals another. It is urgently recommended that the beginner at first practise in such a way that, in auscultating, he endeavor always in the first place to learn to recognize only the breathing sound, and that he then endeavor to direct his attention to other possible so-called accessory sounds (rales, friction-sounds). One can acquire the power to exclude one sound in order to be able more exactly to pay attention to another — to acquire a certain dexterity which very much facilitates auscultation. {a) Alterations of Vesicular Breathing. — 1. The vesicular breathing sound may be increased in inspiration, or sharpened. This takes place whenever the respiration is increased, as in active deep breathing : in the acme of Cheyne-Stokes breathing ; in certain forms of dyspnoea, as of diabetic coma ; and Avhere one section of lung is vicariously nerforming; the work of others which have been shut off. Moreover, it forms a very important sign in bronchitis, here occa- sioned by the local narrowing of small bi'onchial tubes in consequence of swelling of the mucous membrane and accumulation of mucus. Not infrequently beginning tuberculosis of the apex is revealed solely by sharpened vesicular breathing in comparison with the sound side, as evidence of accompanying catarrh of small bronchial tubes. Here the one-sidedness of the sharpened vesicular breathing is of the greatest importance ; two-sided sharpened breathing of the upper portion of both lungs almost never has this signification ; not infre- EXAMINATION OF THE RESPIRATORY APPARATUS. I45 quentlj it exists in tightly-laced women, also in children who breathe poorly with the lower portions of the lungs in consequence of a high position of the diaphragm, due to abdominal affections. 2. Vesicular breathing may be diminished, either in 67"owcA/aZcahite corpuscles becomes about equal. At any rate, the number of red corpuscles is always diminished: Jaksch found the average ,of a number of cases to be two to three million cells (red and white) in a cubic millimetre of blood. The size of the white corpuscles usually remains normal; but very often re- markably large leucocytes are found, some of which have strikingly large nuclei. Moreover, we sometimes find nucleated red corpuscles (probably transition forms from the white to red). The red corpuscles often have the forms of poikilocytosis. Ehrlich found a«-emarkable behavior of leucocytes — that is, their protoplasmic granules — in the presence of certain aniline colors. His most important result is the dis- covery that only in leuktemia are there found in the blood white cells called eosinophile — that is, that are distinctly colored with eosin. In doubtful cases this fact would seem to be useful in diagnosing leukaemia.^ Ehrlich dries a preparation upon a covering glass, as thin as possible, in the air or exsiccator, heats it for ten to twelve hours in a drying chamber at 1'20°-130° C, and quickly stains it with eosin-glycerin. Then he washes it with water, and mounts it dry in Canada balsam. Opinion is divided as to whether it is possible to recognize the different pathological, anatomical, or clinical forms of leuksemia^-Jjy the condition of the blood — that is, to discriminate whether the leu- kaemia exists by participation with lymph-glands, the spleen, medulla of the bones (lymphatic, splenic, myelogenic leukaemia). It seems true that the above-mentioned transition-forms between red and white blood-corpuscles point to alterations in the medulla of the bones. Moreover, many think that the small cells are more connected with the lymph-glands and the large ones with the spleen. In extremely rare cases of leukaemia, crystals are found in the blood (Charcot): they are colorless, shining, long octahedral, like Charcot's crystals found in the stools and expectoration, or they are identical with them. 1 According to the investigations of Jliiller and Rieder, tlie eosinophile cells sho\v that in leukseniia the boae-iuaiTOW is primarily affected. — TRANSLATOR. "280 SPECIAL DIAGNOSIS. 4. Abnormal additions to the blood. Of these we first mention melaneemia and lipsemia. Melancemia occurs directly after severe attacks of malaria and in malarial disease. We sometimes find, swimming free in the blood, brownish -black or yellow-brown lumps and granules, or, also, white blood-corpuscles filled with such granules. They result from breaking up of red corpuscles. By lipcemia we understand the occurrence of extremely fine drops of fat in the blood, as in drunkards, in diabetes, and in chyluria ; but they are also sometimes seen in health. In recent times we have learned to recognize microorganisms as most important additions to human blood. They are exclusively schizomycetes. Fig. 78. Anthrax bacilli in the arterial human blood (fuchsine-staining. Ziess's homogeneous immersion lens xj. eye piece 4, camera lucida, magnified about 1000 diameters). The white line in the middle of the bacilli indicates only reflections. Prepared by Dr. Freimuth in Danzig. Anthrax bacilli in the blood have been repeatedly found in infec- tion by anthrax, although always in moderate quantity. The defect in the microscopical proof does not exclude, however, a general in- fection : a test by inoculating mice may, however, succeed. We may often have single bacilli of anthrax occurring together, not threads ; spores may be entirely wanting. The bacilli are recog- EXAMINATION OF THE CIRCULATORY APPARATUS. 281 nized, without staining, as tolerably thick rods, as long as, or twice the diameter of, a red blood-corpuscle. below. Regarding staining, see c8o^oR# o o .QV Spirillum recurrens in the blood. (After Jaksch.) The first microorganisms that were seen in the blood were the spi- rillum recurrens (Obermeier). We find them during an attack of recurrent fever. They disappear shortly before the decline of the fever. By careful examination they can always be demonstrated, although sometimes there are only a few of them. In a fresh drop of blood they appear (Hartnack 8, Zeiss F) as extremely fine threads, about five times as long as the diameter of a red corpuscle, with extremely active spiral, serpentine motion. They occur either singly or several close together, sometimes lying together like a group of rats' tails. I have very often first seen them near white blood-corpuscles. The white or red corpuscle against which it lies is usually set slightly in motion by the microbe, and hence we find them there first. Moreover, there often occurs in the blood slight leukocytosis ; also, we sometimes meet with shining granules (elemen- tary granules ? spores ?). As to staining, which, after a little practice, is not necessary, see below. Tubercle bacillus exists in the blood as evidence of miliary tuber- culosis. But in this disease we may lack this proof. With the exception of one case observed by Jacksch, it always occurs quite isolated. A special treatment is required for obtaining this microbe. We arrange a thin layer of blood upon the glass cover just as we do a preparation of sputum (see Sputum). Typhus abdominalis bacilli have in several cases been found in the 282 SPECIAL DIAGNOSIS. blood as short (one-third the diameter of the red corpuscle), thick clubs, rounded at the end. See examination of the Stools (for stain- ing, see below). The bacilli of glanders are, in general, a little longer than the pre- ceding, but considerably slimmer. They have likewise been found a number of times in the blood of this disease. It is necessary to stain them (see below). [Since the publication of the first edition of this work the Plas- modium malarice (Laveran) has been studied by many observers (Marchiafava, Colli, Canalis, v. Jaksch, Osier, Shattuck, Dock, and many others). All concur in stating that certain organisms are found in the blood in every genuine case of malarial fever. Doubtful cases can be differentiated by examining the blood for them, and a pos- itive diagnosis made from their absence or presence. Corresponding with the different clinical features of malarial fevers, there are found three different types of malarial parasites : those of tertian, of quar- tan, and of the atypical and irregular fevers.] They are protoplas- mic bodies, within [and without] the red corpuscles, which can be stained by methylene-blue. No cultures of them have yet been obtained. The greatest care and cleanliness are necessary in arranging a preparation of blood for microscopic examination for microorganisms, although the minutiae of disinfection and sterilization, as in preparing for culture, are not required. In malignant pustule and/e&m reeurrens staining can be dispensed with. When it is necessary to stain a preparation, it is prepared by drying a small drop of blood which has been spread out and made as thin as possible by pressing two covers together. Then they are separated, allowed to dry in the air, and afterward passed two or three times through the flame of a spirit-lamp or a Bunsen's burner. If, now, we wish to examine for tubercle bacilli, a special treatment is necessary, as has already been described under Sputum. For other microorganisms we stain with basic aniliiie colors (vesuvine, fuchsine, particularly methylene-blue, etc.), and then carefully rinse and examine in water, or, after drying, in Canada balsam. The staining is much more beautiful if we first briefly dip them in gentian-violet-aniline water (see al)Ove under Sputum), and then stain them a few minutes in Gram's iodine-iodide-of-potassium solution EXAMINATION OF THE CIRCULATORY APPARATUS. 283 (iodine 1 part, iodide of potassium 2 parts, aq. destil. 300 parts), then in absolute alcohol. Finally, we briefly refer to two animal parasites which are met with in the blood, though they do not belong in this book : the filaria san- guinis hominis, which causes haematochyluria (in British India and Brazil), generally only found in the blood at night-time, and distoma hcematohium (Bilharz), which causes a kind of haematuria, chiefly occurring in Egypt. (See under Urine.) Fig. 81. Distoma ha?matobium with eggs. (After Jaksch.) Filaria sanguinis hominis. (After Jaksch.) Chemical Examination of the Blood. — We content ourselves with a few hints regarding this department, since it lies almost entirely outside of the limits of diagnosis. Recently, in certain diseases, the degree of alkalescence of freshly- drawn blood has been determined by various methods, and it has been found that in severe anaemia, fever, and diabetes (Jaksch) the alkalescence is considerably diminished. Uric acid in unusual quantity has been found in the blood in gout. The quickness with which blood coagulates after it has been with- drawn varies in diff"erent diseases. In health, coagulation takes place in about nine minutes. It is slower than this where the nutrition is chronically disturbed. (H. Vierordt.) CHAPTER YI. EXAMINATION OF THE DIGESTIVE APPARATUS. Mouth, Palate, and Pharyngeal Cavity. The inspection of these parts requires good illumination, and for a portion of them, in many cases, a quick view. Bright daylight is better than artificial light. The mouth is to be opened widely, the tongue protruded, and not only put out, but, for inspecting its borders, turned from side to side. (For examining it with reference to paralysis, see Nervous System.) In order to inspect the mucous membrane of the mouth, v^c turn out the upper and lower lips with the finger, the mouth being closed ; then, the mouth being opened, we carefully lift the mucous membrane of the cheeks from the back teeth with a mouth-spatula (made of ivory, hard rubber, horn, or metal). The gums are examined by opening the mouth as Avidely as possible and holding the tongue down carefully with a tongue-depressor (a teaspoon serves very well). The back of the mouth is best brought into view by having the patient say distinctly "se" (full elevation of the soft palate). The patient should be required to drink some water, also to clear the throat thoroughly before it is examined. If we meet with opposition, especially in children, it is sometimes necessary to hold the nose, and thus compel them to open the mouth. When a child cries, we are able to see very well It is often useful to cause the sensation of strangling by putting the tongue-depressor far back, and thus we are able to see the tonsils better — of course, only for an instant. [One learns, by practice, to take a very perfect and com- plete view of the whole cavity of the mouth and pharynx in this instant of strangulation, and then can carry the mental picture long enough to note all its particulars.] But we must guard against being too harsh or rough with children with diphtlieria^ or with any very sick patient. In diphtheria, imme- (284) EXAMINATION OF THE DIGESTIVE APPARATUS. 285 diate death may follow an effort at examining the throat. With those who are unconscious, it is necessary to cause gagging in order to inspect the posterior part of the mouth. In marked cases of this character, it is often impossible to obtain a view at all. Palpation is only rarely employed for examining the tongue, floor of the mouth (making counter-pressure from without), the tonsils, or the back part of the pharynx. We employ the index, or this and the middle fingers, which have been carefully washed in the presence of the patient. The odor from the mouth is, in many cases, important. A foul odor — -foetor ex ore — results from imperfect cleansing of the teeth, caries of the teeth, or dyspepsia. From this odor we distinguish the stale, and at the same time foul, fetor from considerable old deposit in the mouth of patients who are very ill. If the sense of smell is acute, one can also distinguish a slight cadaveric odor upon patients who are very sick, even if the mouth is quite clean, and sometimes it precedes death. Of much more diagnostic value are the different odors which we meet with in poisoning from prussic acid, phosphorus, alcohol, and chloroform ; but the two former, even in recent cases, may possibly be wanting. Lastly, we mention the odor of fruit, wrongly called "acetone" odor, very like fresh apples, which sometimes occurs with the so-called chloride of iron reaction of the urine (see) in diabetes, especially before or during the onset of diabetic coma. The lips. With regard to their color (pale, cyanosed, etc.), we can refer to what has already been said when speaking of the mucous membrane. Dryness of the lips is seen in connection with dryness of the tongue (which see). There is marked dryness in severe febrile diseases, with a dirty looking crust adherent to the mucous membrane, which easily bleeds when this is removed (fuliginous deposit). Small cracks (rhagades, crevices) are, in themselves, without significance. On the contrary, in children, rhagades are an important, generally a positive, sign of hereditary syphilis. The teeth and gums. We must take both into consideration, and, besides, as to whether the teeth are sound. In small children we notice whether the first teeth have all come ; in the later years of childhood, the change to the permanent set. There is often marked caries of the teeth in diabetes meUitus, 286 SPECIAL DIAGNOSIS. though it is very common without this disease. A circular excavation of the lower edge of the upper middle incisor teeth of the second dentition [Hutchinson's teeth] is usually a positive, almost pathogno- monic, sign of congenital syphilis (with catarrh of the middle-ear and parenchymatous keratitis, the whole forming the infallible Hutchin- son's triad). Imperfect and diseased teeth, interfering with mastica- tion, are often the chief cause of dyspepsia. Loosening of the teeth, and the gums discolored bluish-red, receding from the teeth, easily bleeding, and even inflamed, are important symptoms of scorbutus. Loose teeth, with moderate swelling, is a sign of chronic poisoning with mercury. A grayish deposit upon the teeth, and a gray line along the dental border of the gums, results from chronic lead-poisoning. In poisoning by copper, we have sometimes the same condition, only the color is greener. The eruption of the first teeth is a source of much disturbance in the mouth of the little patients. Occasionally it gives rise to serious disturbances — diarrhoea in rare cases, epileptiform attacks (eclampsia of children, infantile convulsions, spasms of dentition), also spasm of the glottis. Second dentition and the eruption of the wisdom-teeth are not infrequently accompanied with limited or general oral dis- turbances, sometimes likewise the cause of abscess. To the red border upon the gum, observed by Fredericq-Thompson, which in young subjects is said to be a very suspicious sign of tuberculosis, we have given careful attention for a long time, and conclude that it has no significance. The tongue. For paralysis and neurotic atrophy of the tongue, see under, the Nervous System. Enlargement of the tongue, if slight, is only to be determined from the indentations on its borders by the lower teeth. This occurs with the various forms of stomatitis. Marked enlargement of the tongue may be caused by parenchymatous glossitis, tumors, and also by severe angina, which produce venous engorgement of the tongue. Moreover, there are very great individual variations in the size of the tongue. Circumscribed swelling and hardness, or the latter alone, are the first evidences of carcinomatous or syphilitic formations of the tongue. It is extremely difficult to make the very important differential diag- EXAMINATION OF THE DIGESTIVE APPARATUS. 287 nosis between these new growths, and usually it can only be made by microscopically examining a small piece, which can easily be removed from it. (See, regarding this, in works upon surgery.) Wounds and the resulting scars, sometimes accompanied with swelling, are frequent appearances after epileptic attacks, and result from biting the tongue (see Scars). We nevei- see the tongue bitten in hystero-epilepsy. If the tongue trembles when it is protruded, or if it does so when within the mouth, it is a valuable sign of chronic alcoholism. This is also the case in severe fevers, and especially early in typhus abdomi- nalis [typhoid fever]. In these cases, when there is marked herbetude, the patient often will not draw in his tongue after protruding it unless he is directed to do so. The color of the tongue is affected by that of the blood : cyanosis affords the most marked instance of this. It is quite common to find local redness with febrile conditions. It often goes side by side with the febrile redness of the cheeks. Mulberry tongue is one in which there is a decided redness with swelling of the papillse, and is an important sign of scarlet fever, which, in individual cases, may develop before the cutaneous eruption. Very often the coating of the tongue conceals the color of the mucous membrane. When the saliva is glutinous or diminished it causes the tongue to be sticky or dry. In connection with dryness of the throat, febrile diseases cause thirst. When the fever is very high, the dryness is often increased by the patient keeping his mouth constantly open. Then the surface of the tongue, if free from coating, first becomes horny, then quickly very smooth, and soon rough and cracked. Coating of the tongue, as a thin white layer, is often constant in health. When a tongue which previously was clean becomes coated, especially if thickly coated, it indicates dyspepsia. There is very marked coating of the tongue in severe acute and chronic diseases of the stomach and with the dyspepsia of fever. With the latter, it is often discolored brownish-red from small hemorrhages of the mucous membrane. When there is great dryness of the tongue, it becomes crusty and adheres so closely that when removed the mucous membrane bleeds. Articles of diet may cause temporary coating, or they may color the coating that is already there (milk, cocoa, coffee, etc.). A thick white — often, also, a discolored — coating on the tongue may depend upon the development of thrush (Oidium albicans). In 288 SPECIAL DIAGNOSIS. very pronounced cases it forms separate small tufts about the size of a millet-seed which spread out and coalesce. It is cheesy and tolerably adherent. It may cover the surface of the tongue, the soft and hard palate, the mucous membrane of the cheeks ; it may even extend down into the oesophagus ; occasionally, we see the whole surface of the mouth and throat covered with it. Small children have it quite often ; adults only in cases of severe illness when the care of the mouth is neglected, especially in fevers, diabetes, tuberculosis, etc. Whenever there is a thick coating in the mouth we must think of this growth, because its early recognition is very important. The diagnosis is promptly made by the aid of the microscope (see below). For scars from biting of the tongue during an attack of epilepsy, see above under Wounds. Dense, often depressed, scars upon the surface of the tongue indicate healed syphilitic ulcers. When there is a suspicion of syphilis, the mucous membrane of the mouth must be examined with the greatest care (scars, ulcers [mucous patches]) ; also, when there is a possibility of poisoning with strong mineral acids or alkalies, corrosive sublimate, carbolic acid (superficial gray color and under it marked injection of the mucous membrane, raw patches). It may also be the seat of catarrhal ulcers as well as of the develop- ment of thrush (see above). Cancrum oris (Noma) usually begins with a circumscribed bluish-black discoloration of the mucous mem- brane of the cheek or an ulcer with this condition around it and with a thick, inflammatory infiltration of the cheek. It is a kind of spontaneous gangrene with a decivded reactive inflammation in poor, wasting; children. It is a rare disease. We examine the floor of the mouth by palpation from within and without. It may be the seat of very dangerous inflammation (angina Ludwigii). Salivary glands and saliva. Of the former we notice only the parotid gland. When it is inflamed there are pain and swelling, and if it proceeds to the formation of an abscess, there are also redness and fluctuation above the angle of the jaw. The saliva is increased (salivation, ptyalism) by all kinds of irrita- tion that affect the mucous membrane of the mouth : physiologically by eating, pathologically by all inflammatory conditions of the mouth (ulcers, inflammation of the gums in connection with affections of the EXAMINATION OF THE DIGESTIVE APPARATUS. 289 teeth, dental abscess, etc. ; corrosive action of acids, alkalies in the mouth and throat) ; also, in chronic mercurial poisoning, and, lastly, sometimes in disease of the medulla oblongata (see Bulbar Paralysis). The saliva is diminished in febrile diseases, in diabetes, in severe diarrhoea (cholera). Thus far the chemical examination of the saliva has been of no diagnostic value. It is of interest that in nephritis it may contain urea, and also that thus far there has never been discov- ered in it any coloring matter from the bile nor any sugar. Many substances, like iodide of potassium, after they have entered the stomach appear remarkably quickly in the saliva. Microscopic examination of the contents of the mouth. Normally we find flat epithelial cells from the upper layer of the mucous mem- brane of the mouth, separate vrhite blood-corpuscles, and likewise micrococci, bacilli, and spirochgeta (especially a microbe like the cholera bacillus and one like the recurrens spirilla). Among these microdrganisms, no doubt, there are some which may become patho- genic for the individuals in whom they occur. In the coating of the teeth we find these microorganisms very abundantly, and besides the leptothrix buccalis (long bacilli, often forming long threads, which are colored blue-red by iodide of potassium, see Fig. 82). Fig. 82. Leptothrix buccalis, 1000 : 1 (after Flugge). There is an unusually large quantity of the different schizomycetes, especially cocci, in any case where the contents of the mouth are decomposed (scorbutus, severe chronic mercurial poisoning, in any severe disease where there is difficulty in swallowing, especially if the mouth is not carefully cleaned). We also usually find an abundance of red and also white blood-corpuscles. 19 290 SPECIAL DIAGNOSIS. In the common white coating of the tongue there are abundant flat epithelial cells and fungi ; these, together with a quantity of brawn detritus, as well as red corpuscles, are found in the coating when discolored. It is easy to recognize the thrush fungus under the microscope by the characteristic, tolerably broad, light fungus-threads (they are more than half as broad as a white blood-corpuscle) and by their roundish- oval, clear granules. Suppurations in the mouth proceeding from the inferior maxilla are, in rare cases, caused by actinoinyces. Whenever there is a dis- charge of pus into the mouth we must remember the characteristic granules (see p. 175 ; Microscopic Examination, see p. 189). Of the soft palate, we are chiefly interested in the tonsils. We take note of their size and the appearance of their surface. Large tonsils with deep, empty lacunae indicate frequent attacks of tonsillitis; prominent white scars, syphilis. If active disease be present, we are to notice whether there are plugs in the lacunae (^follicular tonsillitis) ; whether there is a deposit upon the tonsils, and, in case there is, whether it is confined only to the tonsils and lacunae (in both cases, angina necrotica) ; v/hether it extends over upon the arches (diph- theria) ; Avhether it is loose or adherent, testing it with the spatula, and whether we find beneath it a necrosis of the tonsil going on. Dijjhtheria may cause a deposit upon the arches of the pharynx, the uvula, all of the soft palate, and even a part of the hard palate. We recognize an abscess of the tonsil by its [usually] being on one side only, with swelling of the anterior arch, by the fluctuation (which is felt with the finger). Lor ^--continued ulcers of the tonsils and soft palate are generally syphilitic; more rarely, tubercular. In the latter case there is often a broad, reticulated, purulent discoloration of the mucous membrane, which reminds one of slightly-inflamed pleura covered with a fine fibrinous exudate. (Paralysis of the Throat, see Nervous System.) In the pharynx, we look for possible chronic or acute inflammation and ulcers ; in children who, for some unknown reason, swallow badly - and have distress in breathing, for possible swelling of the posterior pharyngeal wall (retropharyngeal abscess, the fluctuation in which may be detected by palpation). We must always examine the lymphatic glands in the neck in con- EXAMINATION OF THE DIGESTIVE APPARATUS. 291 nection with the examination of the throat. In all acute inflammations of the latter they swell, most markedly in diphtheria, also in chronic inflammations, especially syphilis. In diseases of the palate and pharynx the microscope gives very little assistance. It is chiefly useful in tuberculosis. When there is a suspicion of a tubercular ulcer, we scrape a little directly from the surflice of the ulcer, but yet we cannot be certain that we have not taken some tubercular sputum which has adhered there. Long- standing plugs from lacunae (often quite free from irritation) frequently contain leptothrix (pharyngomycosis leptothricia). The important differential diagnosis between diphtheria and benign necrosis of the tonsils cannot, with our present knowledge, be made by the aid of the microscope. Pharyngomycosis leptothricia (algosis faucium leptothricia) may, as has been observed in individual cases, extend from the tonsils, par- ticularly to the follicular glands at the root of the tongue, or even still further into the trachea itself. They manifest themselves as a number of distinct, elevated, yellowish-white specks. The nature of these deposits is easily recognized under the microscope, especially after the addition of iodine (see preceding page). Examination of the (Esophagus. Preliminary anatomical remarks : The oesophagus begins at the level of the cricoid cartilage of the larynx (= the lower border of the sixth cervical vertebra), and extends to the stomach, at about the height of the base of the xiphoid process. At first it lies immediately in front of the vertebrae, then it comes a little forward, and, at about the seventh dorsal vertebra, it bends a little to the right, then again to the left, to reach the oesophageal opening in the diaphragm. In adults, the oesophagus is about twenty-five cm. long. When we employ an oesophageal sound, we estimate the distance from the incisor teeth to the stomach at about seventeen cm., in the newly born, while with adults it is about forty cm. In the latter, the distance from the incisor teeth to the bifurcation of the trachea is about twenty-two cm. The oesophagus does not have the same diameter throughout: its narrowest points are at the commencement, and the point where it perforates the diaphragm. The neighboring organs with which it has 292 SPECIAL DIAGNOSIS. important relations in different diseases are : the trachea for the upper seven to eight cm. of the oesophagus, the bronchial glands, the pleura, the pericardium, the aorta from the bifurcation of the trachea down- ward, lastly, the recurrent nerve from the bifurcation upward. It is only in the neck that the oesophagus can be felt from without. Below the neck, we cannot employ the usual methods of examination. Characteristic difficulties almost always occur with certain diseases of this organ, namely, with those conditions which result in stenosis (stricture) : there are more or less deeply-seated difficulties in swal- lowing ; the patient, after taking food, has a feeling of pressure, or even of pain, in the neck or the chest — a feeling that what has been taken cannot be passed down. According to the place or degree of the stenosis, the patient experiences difficulty only after taking large, slightly comminuted bites of food, or even after swallowing soup or fluids, either immediately after the former or only after many bites or swallows. Moreover, the food may be regurgitated, wholly or in part, some time after it has been taken. Then we distinguish it from vomiting by the absence of odor, of acid reaction, and of muriatic acid. Pain in swallowing, without stenosis, occurs with inflammation of the mucous membrane of the oesophagus or in its near neighbor- hood (mediastinum). Examination of the oesophagus is almost confined to direct palpa- tion from within by means of the sound, excepting that, in the cervical portion, we can employ inspection and palpation from without. Auscultation furnishes little, percussion no, aid. But it is very important in many cases to examine the neighborhood, particularly the thorax. Only in exceptional cases do inspection and palpation of the cervical portion yield any result, because the great majority of diseases of the oesophagus are located quite below the bifurcation of the trachea. We can feel a carcmomf ^ the cervical portion (likewise swelling of the glands of the neck; , we can feel, and often also see, pulsating diverticula when they are full — that is, after the patient has eaten. Carcinoma of the lower end of the oesophagus can be felt from the abdomen, if the cardiac end of the stomach is encroached upon. Pain from pressure in the neck occurs in the conditions above named and in inflammations, as after swallowing acids and alkalies. EXAMINATION OF THE DIGESTIVE APPARATUS. 2'93 Direct Palpation; Examination with the Sound. — For diagnostic sounding of the oesophagus we employ either a whalebone or English oesophageal sound. The former consists of a thin staff with an olive-shaped ivory knob screwed upon one end. We have knobs of different sizes, in order to determine and measure the decfree of the stenosis (see below). Before using, we are to make certain that the bulb is secure upon the staff, and also that the staff is perfectly smooth, so as not to catch anywhere and thus mislead us. This sound furnishes the most positive information, and yet it requires the greatest dexterity and caution in using it. The English oesophageal sound is a cylindrical India-rubber tube, tolerably stiff when cold, with its end slightly smaller and closed, but having two openings at the side. Before using, it must be somewhat softened by dipping it in warm water. We must have at hand several such sounds of different sizes. The end should always be rounded and perfectly smooth, so as not to produce a rupture. Before introducing it, we are to moisten only the knob of the whalebone sound, but the Avhole of the English sound with glycerin or white- of-egg (not with olive oil, nor with water). The patient sits upon a chair or the edge of the bed with the chin somewhat elevated. The index and middle fingers of the left hand are introduced into the mouth, and with them we slowly feel as far as the root of the tongue. Then we seize the sound with the right hand, like a pen-holder, and slowly push it along the tongue under the two fingers. As soon as it passes beyond the ends of the fingers, we press its end somewhat downward with the tip of the fingers, and at the same time elevate the right hand, so that the sound may not strike against the back of the throat. The sound is then with gentle pressure pushed on, always holding it as if writing. The left hand is now withdrawn. Special precautionary measures, such as placing a cork between the teeth, or anything to hold the jaw, are usually not necessary, since this operation is not performed upon unwilling or unconscious patients (see Sounding the Stomach). Only with children are we sometimes obliged to use the cork. Many patients bear a skilfully-performed sounding very well, but others can only become accustomed to it from considerinsr its beneficial results. If the motions of strang-lino- are not severe, we need not be disturbed by them, but if there is vomiting we must at once withdraw the sound in order that there may 294 SPECIAL DIAGNOSIS. be no choking. A slight spasm of the glottis and momentary arrest of breathing have no significance, yet attention is called to the second paragraph below. We sometimes meet with a resistance which is not pathological : 1. At the posterior wall of the throat, but only with unskilful intro- duction of the sound (see above). 2. Sometimes, if the cricoid cartilage of the larynx overlaps the oesophagus somewhat, from the point of the sound striking against it ; this is easily passed by withdrawing it a little, and then pushing it on again. 3. By spasm of the oesophagus, caused by the sound, which disappears soon by waiting. Two occurrences may endanger the life of a patient : 1. The intro- duction of the sound into the trachea, which very rarely happens. At any rate, as soon as there is marked diflSculty in breathing the sound is to be withdrawn. If the patient is able to pronounce "a" clearly, moreover, if the portion of the sound introduced is longer than the trachea, then we know that it has not entered the trachea. Other signs are deceptive. 2. A still greater danger is that the wall of the oesophagus may be injured or ruptured. This results from narrowing of the canal, if it has become thin and fragile from a crumbling new formation, or by an ulceration, or when an abscess or aneurism near the oesophagus is thus perforated. The results of these are either ichorous mediastinus or pleurisy with fatal termination, or if an aneu- rism, with immediately fatal hemorrhage. We must never employ force if the sound meets with resistance. If we can confirm the suspicion of an aneurism by examining the chest, we are always to omit using the sound. Examination with the sound gives information in the following ways : 1. Sometimes a deep-seated pain occurs after the examination has been made several times, although the sound has only been introduced a certain distance. It may depend upon inflammation in that neighbor- hood (for determining its height, see under " Stenosis"), upon an ulcer, a carcinoma not causing stenosis, a purulent oesophagitis, or perioeso- phagitis. 2, The sound meets with resistance. Then the patient, in many cases, is sensible of pressure, or has a sensation of pain ; sometimes there is severe strangulation. We move the sound back and forth, and endeavor to advance it with very slight pressure. We mount a smaller knob upon the whalebone sound, or take a thinner rubber one. But EXAMINATION OF THE DIGESTIVE APPARATUS. 295 the smaller the sound the greater the danger, and hence greater caution is required in using it. If we are at length able to advance it further, then we feel resist- ance just so long as the knob is in the stenosed portion. After passing the narrowed part, it again passes easily, but, of course, meets with resistance at the same point as it is withdrawn. We obtain information regarding the situation of a stricture, by- bearing in mind the rules given when referring to the anatomy of the parts. We introduce the sound as far as the stenosis, note the loca- tion, starting from the incisor teeth (by seizing the sound accurately Avith the fingers), draw it out and measure it. Regarding the degree and length of the stenosis : we learn the former by the thickness of the sound that will just pass the stricture: the length of the stricture will best be ascertained by employing whale- bone sounds, in that we can mark the place where the incisor teeth touch the sound when it enters the stenosis, and as it passes through the stenosis. Also, if there is a double stenosis, it is indicated (see Fig. 83). We can learn almost nothing regarding the nature of the stenosis, unless we should catch in the fenestrum of an India-rubber sound a shred of tissue which would enable us to diagnose a carcinoma, or unless we should meet Avith the condition described in the next sec- tion (3). Fig, 83. Diagrammatic representation of sounding the cesophagus whcu there id a short, long, and a double stenosis. 3. By repeated introductions of the sound, we are sometimes able to pass it through, but if again we meet with an insuperable obstruc- tion we must be very careful : this points to a diverticulum, though 296 SPECIAL DIAGNOSIS. Fig. 84. not indeed with absolute certainty, since it may be met with in other kinds of stenosis, 4. In a case of stenosis which we have repeatedly examined, we suddenly find ourselves unable to get the smallest sound through, where it has frequently passed easily. This may indicate an obstruction by a foreign body, as was the case in one instance under my observation, which ended fatally, where a cherry stone was found in the stenosis. 5. The end of the sound may meet with opposition upon one side and not upon the other. This indicates a dilatation of the oesophagus (generally above the stenosis). Stenosis may be caused by scars resulting from swallowing a corrosive fluid some time before (Anamnesis), or by carcinoma of the oesophagus, or by diverticula (see above under 3) ; these are generally high up in the oesoph- agus; or by compression of the oesoph- agus. Congenital stenosis (difiiculty in swallowing from birth), and stenosis caused by thrush, are both very rare. Examination of the neighborhood of the oesophagus, that is of the neck and thorax, is of the greatest importance. We are thus able to discover compressing tumors, or to exclude them with probability. We may aid the diagnosis by giving attention to the larynx, and observing whether there is a recurrent paralysis, which may exist even though the voice be quite clear. Compression of the recurrent nerve sometimes occurs in carcinoma of the oesophagus, with aneurism of the aorta (particularly the left nerve). Moreover, we take into considera- tion the examination of the chest, especially whenever there is any evidence of a rupture, as in pleuritis, gangrene of the lungs, rupture into the trachea or bronchus, with coughing up of particles of food; pericarditis, and emphysema of the skin (see). Percussion of the oesophagus itself can be of almost no aid. Large diverticula in the neck may show dulness, provided they are full. Exceptionally, a dilatation above a stenosis in the thoracic portion may, if full, also produce dulness. a. Sounding the oesopha- gus when the diverticulum is full; b. sounding when the diverticulum is empty. EXAMINATION OF THE DIGESTIVE APPARATUS. 297 Auscultation of the oesophagus is of very subordinate value. It can be employed as far as to the seventh thoracic vertebra at the left of the spine, in examining the lower part of the oesophagus ; or we may listen over the spine or to the right of it. Ir^ health, when fluids are being swallowed, we can hear a gurgling in the whole extent of the oesophagus. When there is stenosis, we sometimes notice that the gurgling ceases just at that point. The sounds of swallowing which we hear at the stomach are less certain signs than this phenomenon ; in health, there is sometimes heard a sound six or seven seconds after an act of swallowing, as of something being pressed through, and some- times preceding this is a sound of squirting (Kronecker and Meltzer, B. Frankel). (Esophagoscopy (illuminating the oesophagus with an electric light) has not yet attained a position as a recognized method of examination. Examination of the Stomach. Topography of the abdomen. This is represented in the accom- panying figure. We form the different sections by prolonging the mam- millary lines (or a line which passes from the middle of Poupart's ligament upon each side) ; also by lines which, in the upright position, are drawn through the ends of the eleventh ribs, and through the anterior superior spines of the ilei. By these latter lines, the section lying between the mammillary lines is divided into the epigastrium, mesogastrium, and hypogastrium. It is further to be added that the region, directly over Poupart's ligament, which extends inward toward the symphysis pubis, and outward somewhat over the middle of the ligament, is called the inguinal region, and the territory below the ends of the ribs, the hypochondrium. So far as the abdominal contents are parietal, their relations to the separate regions of the abdomen are plainly indicated in the accompanying figure. ANATOMY OF THE STOMACH. ' Only a little more than the pyloric portion [one-sixth] of the stomach lies in the right half of the body, the rest [five-sixths] being on the left of the median line. It slopes obliquely from the left downward toward the right, so that the cardia is about behind the 298 SPECIAL DIAGNOSIS. Sternal insertion of the seventh rib, the pylorus between the right sternal and parasternal lines, on a level with the apex of the xiphoid cartilage. The fundus — the portion situated the highest, clinging to the left side of the dome of the diaphragm — rises as high as the fourth Fig. 85. Might mammillary line.' CJir E.J'1 ,Left mammillary line. -EJla. -CD. Position of the abdominal contents. (M. Ascending colon. CD. Descending colon. iiJ"- C. Ileocecal region. i?J". Inguinal region. RHs. Left hypochondriam. EE. Epigastrium. RU. Umbilical region. H. Hypogastrium. intercostal space. The lesser curvature forms a bow with its con- vexity arranged obliquely downward toward the left. It, with the cardia and pylorus, which it connects, lies more posteriorly, covered by the liver, while the greater curvature extends forward toward the abdominal wall ; so that a line drawn from the lowest point of the EXAMINATION OF THE DIGESTIVE APPARATUS. 299 lesser, to the lowest point of the greater, curvature would incline forward and downward. The situation of the greater curvature varies very much with the degree of distention of the stomach. In health, it only very exceptionally extends to the umbilicus. The fundus of the stomach is adjacent to the diaphragm, the spleen, and the left kidney ; its greater curvature, and also the lower part of its posterior surface, to the transverse colon ; the pylorus, lesser curvature, and that portion of its anterior surface which is near to these, to the left lobe of the liver. Behind and above the stomach, situated at the upper part of its posterior surface, is the sinus of the peritoneal cavity, the bursa omentalis (pathologically not unimportant), and also the pancreas. When the stomach is moderately distended, a part of the anterior surface, and the greater curvature, are parietal, so far as they are not prevented by the lung or heart from above, or by the spleen on the left, and by the left lobe of the liver on the right. That part of the parietal surface of the stomach which is covered by the left lower portion of the ribs comprises the important region to which Traube gave the name of " halfmoon-shaped space." We see from this description that, with moderate distention, only a small part of the healthy stomach can be directly examined. The most important parts, the cardia and pylorus, are bent deeply in. But we have a favorable moment for examining the latter in certain pathological conditions, where it is desirable to be able to judge of it, it being often pushed down with the lesser curvature below the liver. INSPECTION AND PALPATION OF THE STOMACH. There is scarcely any place where inspection and palpation are so closely connected as at the abdomen, and especially the stomach. The patient is placed so as to lie comfortably, with the upper portion of the body moderately raised. We look at the region of the stomach with the greatest care, illuminating it from all possible directions ; then palpate with the tips of the first, second, and third fingers, and thus notice first the tenderness (always at first proceeding very cautiously), then the objective condition, finally completing the palpa- tion with inspection, or vice versa. The result of the two methods of examination will be affected by 300 SPECIAL DIAGNOSIS. several factors — by the size, sharpness of the boundaries, and density (resistance) which we discover in the abdominal wall, and its condition. As regards the latter, it is important for the examiner to avoid causing contraction of the abdominal muscles, by having the patient in the recumbent posture, cautioning him to keep the muscles lax, and by proceeding slowly with the palpation, the hands being warmed. Contraction of the recti abdominis, with their short tumor-like sec- tions of muscle, may very much disturb, or even deceive, one in making an examination. As to the general thickness of the abdominal walls in chronic diseases of the stomach, especially if very severe, this is very much lessened by wasting — a condition favorable for making an examination. The normal stomach cannot at all distinctly be recognized or defined through the abdominal wall. It can only exceptionally be done when there is extreme emaciation. I remember two cases where, in extremely wasted females Avith very lax walls, the greater curvature and peristalsis of the anterior wall of the stomach could be clearly seen. In both cases the stomach was very slightly distended, and in both cases the autopsy showed a normal condition of the stomach. On the other hand, the healthy stomach, distended with food or gas, sometimes enables us to imagine its condition by the projection in the epigastrium, and still more by a high halfmoon-shaped space — that is, by tympanitic resonance over the left lower lobe of the lung in the side (see under Percussion). We can sharply bound a healthy stomach only in individual cases when it is inflated with gas (see method of procedure, p. 301). Thus, it has been found that the greater curvature of a normal stomach, when very greatly distended, may reach as far as the umbilicus. Of course, we cannot ascertain the location of the lesser curvature. Moreover, the distensibility of the healthy stomach varies very much with different persons, so that on trial one person earlier, and another later, has difficulty, especially oppression, which marks the limit of distention. The chief pathological signs furnished by the stomach are, its dis- tention or displacement, its thickness, and amount of peristaltic action of its walls, also signs of circumscribed tumors in its walls. Other important signs are to be added to those already mentioned. Pain upon pressure during palpation requires a special description. EXAMINATION OF THE DIGESTIVE APPARATUS, 301 Distention is more or less distinctly made out bj inspection and palpation, according to its extent and the thinness of the abdominal walls. But it may also entirely elude examination. In favorable cases, we can see and feel (easily when looking down from the patient's head) the greater curvature. To a varying extent it moves down, often below the umbilicus, more rarely nearly to the symphysis, and in so doing it shows the bend toward the left. The position of the greater curvature, of course, varies with the degree of fulness of the stomach, but usually, unless artificially emptied, as by emesis or the stomach-pump, it does not come up above the umbilicus. Thus, the pyloric portion behaves peculiarly, in that it influences the situation of the stomach and renders the pylorus, as well as the lesser curva- ture accessible for examination. When the stomach is, for the time being, distended by a large quantity of food, in the upright position of the patient, it pulls the pylorus forward from under the liver, and with it, under some circumstances, the lesser curvature. This, in rare cases, is seen in the upper epigastrium, in a line convex down- ward (when the light falls from the foot of the bed), when it may even be felt. Also the portio pylorica, and the pylorus itself, may be felt (see under Tumors). In consequence of this displacement of the pylorus, the whole stomach slopes more strongly downward toward the right. In rare cases, the pylorus stands as low down, without there being any dilatation of the stomach. The condition is congenital, or caused by strong adhesions (Kussmaul). As has already been mentioned, the distinctness with which the figure of the stomach can be made out is largely influenced by the extent of its fulness. Hence, for the purpose of making the examina- tion, we must artificially distend it (Frerichs). Until very recently, this was always done with carbonic acid, by giving the patient as much as two teaspoonfuls of tartaric acid and bicarbonate of soda dis- solved in a little water. The gas quickly develops in the stomach, and demonstrates clearly the situation and size of the organ, rendering the examination of its walls easy (see under Peristalsis and Hyper- trophy). But this procedure sometimes gives rise to a feeling of oppression, and even of symptoms of collapse ; and recently there has been devised a method of inflating the stomach which is much more to be recommended, because the amount of gas for distending the 302 SPECIAL DIAGNOSIS. stomach can be regulated exactly, and, if necessary, it can be emptied out in an instant. A Nelaton stomach-sound is introduced (just as in sounding the oesophagus), and then the stomach is inflated with air through the sound by means of an India-rubber ball, introducing as much as is necessary, or as the patient can bear. At any time the air can immediately be let out through the sound. By inflating the stomach, Eichhorst has several times easily recog- nized the so-called hour-glass stomach (twice it was formed by a scar which strictured it in the middle). In the same way, we can discover that the pylorus does not close, by the fact that the gas blown in does not distend the stomach, but immediately enters the small intestine. Ziemssen still gives the preference to distention with carbonic acid. In his last communication he gives the proportions for adult men as seven grammes of bicarbonate of soda and six grammes of tartaric acid, for adult women, one gramme less of each. The sound may be employed in the same way as with the oesophagus to determine stenosis at the eardia, due to cancer. (The employment of an English oesophageal sound for ascertaining the size of the stomach [Leube] requires the greatest caution. The sound is intro- duced into the stomach and pushed on until it meets resistance at the greater curvature, and then we ascertain where the end of the sound is by palpation from without.) Regarding palpation by striking and the resulting splashing, see under Auscultation. In the neighborhood of the stomach we may have epigastric pulsation (see p. 204), liver-pulse (see p. 266), lastly it may be communicated from the aorta or from aneurism of the abdominal aorta. With tumors of the stomach, the pulsation from the aorta is usually very distinctly transmitted. Increased resistance; peristaltic motions. The former occurs simultaneously with the general distention of the stomach in conse- quence of the hypertrophy of the muscular portion, which generally accompanies dilatation of the stomach. Hence, it is an indirect sign of dilatation. If it is found within a limited area, as in the right half of the epi- gastrium, even if it is not sharply defined, it may indicate carcinoma. We must be careful not to confound it with contraction of one of the bellies of the rectus abdominis. Peristaltic motions which can be felt as well as seen are very important, being often the first signs of EXAMINATION OF THE DIGESTIVE APPARATUS. 303 a hypertrophy, and, thus, a dilatation. By their situation and extgit, they may also indicate the size of the stomach. It is very rare for them to occur without dilatation — in nervous " peristaltic unrest " of the stomach (Kussmaul). Generally it extends in the normal direc- tion from the fundus to the pyloric region. But sometimes it is reversed (marked pyloric stenosis, Kussmaul) — antiperistalsis. It will often be excited or increased by gentle strokes, and by faradization ; sometimes by irritation, of the skin, as by simply uncovering it. With very lean persons, we must think of the possibility of it being, under some conditions, intestinal peristalsis. Tumors in the region of the stomach are often only to be felt, not seen. They cannot be demonstrated if connected with a part of the stomach that is not parietal : cardia, lesser curvature, posterior wall of the stomach, commencing cancer of the pylorus. These tumors are most frequently cancer of the stomach (more rarely a dense scar from ulcer), and are most often located to the right of the middle line, because they belong to the portio pylorica or to the pylorus itself. In the latter case, they can generally only be felt when the pylorus is pushed downward, as has already been mentioned. Carcinoma usually feels uneven and dense. Less frequently it is smooth, and can then easily be overlooked, or be mistaken for a belly of the rectus (see above, under Resistance). Projection of the stomach during deep breathing, as a result of the movements of the diaphragm, usually does not take place at all, for the reason that the stomach is not a solid body. We observe a slight, or possibly a marked, respira- tory displacement when there is adhesion of the distended pylorus and the liver (see), or if there is a tumor which extends from the sub- phrenic region to a parietal portion of the stomach. Dense scars from ulcers and the infrequent hypertrophy of the pylorus, also solid bodies that have been swallowed, may feel like tumors. Mistaking them for scybala in the transverse colon (see Intestine) is not likely to happen. In all diseases of the stomach, pain upon pressure during palpation may be wanting. It is absent least frequently with ulcer of the stomach. If there is pain, it may vary very much : in acute catarrh of the stomach, also som-etimes in chronic, it is dull and quite diiFuse ; with ulcer, it is often very much circumscribed, limited to a spot the size of a dime, extremely severe, often shooting through to the back 304 SPECIAL DIAGNOSIS. (especially toward the left) ; in carcinoma, there is sometimes a marked insensibility, sometimes a more diffuse, sometimes a narrowly-defined, pain of various intensity. PERCUSSION OF THE STOMACH. This applies to that portion of the anterior wall of the stomach which lies against the abdomen and the anterior (left lower) wall of the thorax. It yields, in much the greater majority of cases, a very deep tympanitic sound ; and sometimes, when there is marked tension Fig. Percussion boundary of the lungs in front. (Weil.) ff,h. the upper boundary of the lungs; e,f, the lower boundary of the lungs; 6, c?, boundary between the lung and heart at the incisura cardiaca. The dark hatched surface represents the portions of the heart and liver that are in contact with the chest-wall; the light hatching, the so-called relative heart- and liver deadness (see later), m, spleen-deadness ; n, the average position of the lower boundary of the stomach. of the stomach, a clear non-tympanitic sound. If the stomach con- tains a considerable amount of food it may, in part (especially in standing), have an absolutely dull sound. But we hardly ever find it dull throughout the whole extent of that portion of the stomach that EXAMINATION OF THE DIGESTIVE APPARATUS. 305 is parietal, because it almost always contains considerable gas as well as food. The tympanitic, as well as the non-tympanitic, stomach- sound frequently has a metallic quality. The boundaries of the stomach are determined by topographical percussion (see Fig. 86). On the side toward the liver, there is a dull sound; it is often difficult to make out, because the border of the liver is thin (see Per- cussion of the Liver). On the side toward the lung, theie is a non- tympanitic, clear sound. Here it is often difficult to mark sharply the boundary line, on account of the thinness of the border of the lung and the similarity of the two sounds. Sometimes we have to distinguish a boundary of the stomach from the heart, should its apex reach further toward the left than the liver; sometimes from the spleen, if the stomach should be stretched out somewhat. We can separate it from the large and small intes- tine, both of which give a tympanitic sound. Except these last named, the boundary lines are all dependent upon the situation and size of the surrounding organs. Therefore, and because there are no true boundary lines for the stomach, except its parietal boundaries, we do not employ percussion for the stomach. The only real boundary is that on the side toward the intestine, which gives the situation of the greater curvature. But it is almost always very difficult to determine this line (there being a tympanitic sound on both sides of it, with only a difference in pitch). We can hardly even maintain its correctness without the aid of inspection and palpation. Thus, percussion of the stomach, for the great majority of cases, has an extremely doubtful value. On the whole, we get the best results from percussion in health, and particularly when the stomach has been artificially dilated. With the former, we then find that the greater curvature usually is somewhat above the umbilicus, sometimes reaching to it. When the stomach is moder- ately full, it commonly stands about midway between the apex of the xiphoid process and the umbilicus. If the stomach is dilated, the boundary is lower down (see Inspection, Palpation). Likewise, should the lesser curvature be lower down, it can be made out by the aid of percussion. . Another procedure, but one which is not always successful, is first to empty the stomach as much as possible (see Emesis), then to percuss 20 306 SPECIAL DIAGNOSIS. the abdomen, the patient being in the standing position. Usually we do not find any boundary for the stomach. Then we have the patient drink freely, and again percuss while he is standing. In the lower part of the stomach, hence above the greater curvature, about in the middle line, we shall find a dulness which indicates the situation of the greater curvature, and thus a possible dilatation may be recognized (modified after Penzoldt). This dulness may sometimes be directly proved, without any preliminary procedure, if the stomach is partly filled with fluid. The dulness disappears when the patient lies down. There is distinct dulness with tumors of the stomach (strong per- cussion) only when they are very thick, and this is not often the case. Hence they usually give stomach-resonance. But tumors of the liver and spleen, on the other hand, almost always are dull because they are larger. Yet this diiference is not an entirely sure sign. Rod-2Jleximeter-2yercuss{on (see p. 136) over the stomach usually gives a beautiful silver tone.' It is employed for determining the boundary, under the supposition that in this way the person who is listening over the stomach must hear the high silver tone just so long as his assistant percusses over the stomach ; but the result of this pro- cedure is hardly ever positive enough to give it value. That part of the left lower lobe of the lung is designated as the "circular stomach-lung space," where a tympanitic sound may be heard with strong percussion (Ferber). We may likewise speak of a '^ circular stomach-liver space," sometimes even of a "stomach-heart space " (see page 206). None of these have any value for determining the size of the stomach. The Half-moon-shaped Space (Traubb\ — It is that portion of the lower left part of the thorax which lies below the lung (or heart) between the liver and spleen, and, as a rule, in health gives a tympa- nitic sound, most frequently a stomach sound, but not infrequently also an intestinal sound, or both. It is discovered by gentle per- cussion. Occasionally, in health, we here find dulness instead of tympanites', and then only when the stomach is decidedly full, or when the full transverse colon is here parietal, or when the greater omentum is unusually loaded with fat (Weil). In enlargemeyit of the liver., of the left heart, and of the spleen, this space will always be found correspondingly smaller. But its behavior in certain conditions of the left lung, or of the left pleura, is EXAMINATION OF THE DIGESTIVE APPARATUS. 307 of especial diagnostic interest. Exudation in the left pleura usually causes dulness correspondingly early in the upper portion of this space, in that it first collects in the complementary pleural sinus. As the exudation increases, the half moon-shaped space diminishes more and more, the dulness sometimes extending as far as the bend of the ribs, depending upon the amount of downward pressure of the diaphragm (unless there are pleuritic adhesions in the pleural sinus, in which case we do not have the space diminished). As the pleuritic exudation is absorbed, the space resumes its normal proportions, and if there is shrinking after the absorption, it becomes greater than normal, for the reason that the lower border of the lungs does not again come down to its former place, and, on the other hand, the diaphragm stands higher. Rarely, -with pneumonia of the whole left lung, or its lower lobe, the half-moon-shaped space becomes very slightly smaller, as a result of the enlargement of the lung during hepatization, and also, probably, from a small pleuritic exudation. It is to be observed that in an acute disease of the left half of the chest, an early distinct diminution of the half- moon- shaped space is made manifest by a certain degree of dulness ; a marked diminution of the space indicates very plainly a pleuritic exudation ; and if there is extensive dulness in the left half of the chest, if the diiferential diag;- nosis between pneumonia and pleurisy is uncertain (see p. 158), then a decided diminution in the size of the space speaks with strong emphasis in favor of the latter. AUSCULTATION OF THE STOMACH. This has value in only one direction, but that is not to be under- valued. When palpation is made by strokes upon the region of the stomach, striking more or less strongly, according to the sensibility of the patient, very short blows with the tips of the fingers, we some- times hear a splashing which is loud enough to be heard at a distance. This results from a certain relation between the fluid and the gas in the stomach even in health, but very much more frequently in dilata- tion. Hence, in making a careful examination of the stomach, we must always employ it. In itself it does not indicate anything, even though it is often found when the examination is frequently repeated. If we apply the ear when the stomach is inflated with carbonic acid 308 SPECIAL DIAGNOSIS. we shall hear a loud seething. We can recognize the same thing, but less distinctly, in dilatation of the stomach with fermentation of its contents. It is evident from the above that very often anatomical diseases of the stomach exist without any physical signs. This is almost always the case in the different forms of nervous dyspepsia, which are accom- panied with marked subjective symptoms. Hence, in most cases of affection of the stomach, the examination of its contents gives much more important conclusions than the local examination. Therefore, especial attention is called to the former. Examination op the Intestines, inspection and palpation. In employing the former, there must of course be illumination. The patient being in the dorsal position, we inspect the trunk as a whole, from a distance ; in detail, close at hand, palpating with a warm hand. Then, carefully grasping a part, we notice always first as to the amount of tenderness, when, if there is any suspicion of simula- tion or exaggeration, it is best not to ask whether we are causing pain, but simply to notice the result of a moderate and also stronger pres- sure. After completing the first examination, which gives one the bearings of the case, inspection and palpation go very closely, hand in hand, together ; for this reason, we speak of them together. Pain produced by pressure [Tenderness]. A difi"use dull pain often occurs with intestinal catarrh. A like diffuse, but generally an extremely severe, pain is observed with acute general peritonitis. Circumscribed tenderness is • especially frequent in the right iliac fossa. It is often quite marked in ahdoyninal typhus [typhoid fever], often more severe in intestinal tuberculosis, moderately severe in typhlitis and affections of the vermiform appendix, in both the last-named diseases generally (not always), in connection with other local signs (which see). Pain in the left iliac fossa is connected with the descending colon (especially dysentery). Very circumscribed severe pain shifting about, may occur with a circumscribed affection of the small intestine, as invagi- nation (see Palpation, Intestinal Tuberculosis). The seats of hernia EXAMINATION OF THE DIGESTIVE APPARATUS. 309 require very especial attention. (Works upon surgery are to be con- sulted regarding these). It is to be further remarked that pain in the abdomen, according to its location, may come from any of the organs contained in its cavity, and also from its walls ; from the anterior abdominal wall (abscess) ; pain in the inguinal region, from psoas abscess in the iliac regions, from the sacral spines (inflammation, tumors). The general extent of the abdomen may be increased by a layer of fat, by gas in the intestines (intestinal meteorism, tympanites), as it occurs continually, scarcely pathologically, after hearty eating, often with a large development of fat : but we may also have it in every variety of degree as a pathological condition : in acute and chronic catarrh of the intestine, intestinsjl stenosis, in acute and chronic perito- nitis, and in abdominal typhus [typhoid fever], where it is often of diagnostic value. According to the amount of distention, the abdomen is more or less full, which changes its normal soft condition to one of marked resistance. When there is marked meteorism, the liver and diaphragm are pressed upon, and by the latter the lungs and heart are pressed upward. In a case of typhus abdominalis [typhoid fever] I once saw an ex- tensive inflammatory undermining of the abdominal wall, which very closely simulated meteorism by considerably distending the abdomen, which proved to be an abscess in the abdominal muscle. For distention of the abdomen with fluid and air in the peritoneal sac, see Peritoneum. There may be circumscribed distention of the abdomen from a great variety of causes : most frequently from some condition in the peri- toneum (which see, and also the next page under Tumors). Diminished volume of the abdomen (drawing-in, sinking-in) results from an insufficient amount of nourishment from any cause (especially from diseases of the oesophagus, pyloric stenosis, any cachexia — in short, from any disease that requires, or results, in restricted diet. Usually this condition is more especially manifested by the absence of fat and wasting of the abdominal muscles. A particularly marked — the so-called "scaphoid" — drawing-in, probably related to an active contraction of the abdominal muscles, occurs in meningitis, particularly basilar, and in lead-colic. Intestinal peristalsis exceptionally can be seen when the abdominal wall is very thin and lax. It occurs almost exclusively in women 310 SPECIAL DIAGNOSIS. who have had children (particularly if there is a separation of the recti muscles). It is to be distinguished from its similarity to what is described as pathological peristalsis only by the absence of other phenomena, and by the narrowness of the intestinal figure. Peristalsis that is pathological is an important visible and palpable ^ign of stenosis of the intestine, and occurs in the portion of intestine above the stenosis. We observe a round projection, with the slow motions of a worm, now disappearing and often immediately reappearing in a spot not far distant, so that we have the phenomenon of peristalsis. The intestine, as it becomes prominent, is moderately resistant, and is often distinctly distended. [During the instant of greatest disten- tion the prominence is more distinctly tympanitic] The resistance may become greater in chronic stenosis of the intestine with hypertrophy. Sometimes the last swelling — that is, the one just above the point of stenosis — is the largest, and subsides with a loud cooing or bursting sound. This phenomenon may have a very great variety of manifes- tations, generally with a pressing, choking pain, and it may manifest itself under gentle blows, with faradization, or even by merely ex- posing the surface to the air. It is usually very difficult to draw any conclusion regarding the portion of the intestine involved by the location of the phenomenon or the direction of the peristalsis. On account of its thickness, we are apt to mistake a dilated loop of small intestine for a portion of the colon. Circumscribed tumors of the intestine are always felt before they can be seen. They may be : 1. Balls of feces, scybala, in the large intestine, often recognized by being arranged in a circular form, by their location (which is often deceptive), or by their retaining an indentation. Sometimes we are only able to be positive regarding their nature by their disappearance after free purgation. 2. Tumors of the intestine are either new formations, which are generally very firm, uneven, or, from invagination of one portion of the small intestine into another or into the large intestine, which are round vermiform tumors. The former are entirely fixed, the latter may suddenly disappear. Both may be connected with signs of stenosis of the intestine. If they belong to the small intestine, they usually more or less change their location. (For distinguishing these tumors from those of the other abdominal organs, of the peritoneum, and of the abdominal wall, see below. For inflammatory tumors of the intestine, perityphlitis, etc., see Peritoneum.) EXAMINATION OF THE DIGESTIVE APPARATUS. 311 Tumors of the rectum cannot be recognized from the abdomen (see for these, below). Those at the point of union between the transverse and the descending colon are often recognized late, because they lie concealed. They may easily be confounded with tumors of the spleen or with the kidneys (which see). In this connection we must bear in mind the phenomena of stenosis. (For peritoneal friction-sounds, see Peritoneum ; for cooing-sounds that can be felt, see Auscultation of the Intestine.) Palpation of the rectum. The rectum must be examined with the finger if the movement of the bowels or the character of the stools indicate disease of this organ, or if disease in the neighborhood (as the wall of the true pelvis, the prostate in men, the uterus and its annexae in Avomen) is suspected. In making the examination, we first obtain a view of the anus externally (as to varices, pedunculated new forma- tions, which sometimes come into view at the anus from above the flexure, an external rectal fistula). Sometimes it is also necessary to obtain a thorough emptying of the bowel beforehand. The index- finger is to be oiled and introduced with the patient either lying on the side or back. (For examining during narcosis by introducing the whole hand, see works upon surgery.) When the rectal sound is employed, in order to reach a stenosis beyond the reach of the finger, the greatest care is necessary. It is best to employ a sound open at the end, so as to throw in some lukewarm water by means of an irrigator, so that any obstruction to the passing of the sound may be gotten out of the way. Sometimes a large quantity of water is thus employed, as recommended by Hegar (see also the works upon surgery for the employment of the mirror in making the examination). Distending the descending colon by inflating it with air introduced from the anus through the sound, if carefully done, is not dangerous, and is very strongly recommended for determining the location of the colon with reference to other organs, tumors (see spleen, kidneys), the figure and condition of the colon itself PERCUSSION OF THE IXTESTUSTE. Generally the intestine gives a tympanitic sound ; with meteorism with great tension, it may become clear non-tympanitic. Over large intes- tinal loops, and also over the stomach (with like tension), the sound is 312 ■ SPECIAL DIAGNOSIS. deeper than over narrow portions ; over lax portions, it is deeper than over those under strong tension. But we can hardly ever determine as to the width of any portion of intestine by the resonance, chiefly because of the influence of tension, which, for a single loop of intestine, we cannot at all control. Hence, we cannot with certainty determine by percussion the boundary between the colon and small intestine, a dilatation above a stenosis from another portion, or intestine from the stomach. At most, we can only determine the boundary of the descending colon by artificially inflating it. (For determining by percussion the boundaries of the abdominal organs that do not contain air, see under the different ones.) Intes- tinal tumors do not always become so large as to give dulness. In percussing them, we first press tolerably deeply with the finger used as pleximeter, and if we do not find dulness we press still deeper, in order that we may push aside any fold of intestine that may lie over the tumor ("deep percussion," Weil). AUSCULTATION OF THE INTESTINE. Borhorygmi and splashings, which may often be heard at a distance, and are in themselves very troublesome (especially in women who have had children), do not have any further significance. A loud cooing is not without diagnostic value, if it occurs at the close of an attack of pain like strangulation. Even if we cannot see any intes- tinal peristalsis, we must remember the possibility of stenosis of the intestine. Although formerly too much importance was attached to it, yet there is some diagnostic value in the cooing, which is more fre- quently felt than seen in the ileo-csecal region in typhoid fever (ilio- caecal gurgling). Examination of the Peritoneum. Pathological conditions of the peritoneum are, in part, of such a character that they aff"ect the outer layers, the coverings of the other abdominal viscera, hence possible anomalies of the peritoneum may be overlooked in the direct examination. Thus, very many diseases of other abdominal organs are combined with those of the peritoneum. This fact and the anatomical interrelations of the diaphragm and certain other organs make it very difficult to give a separate descrip- EXAMINATION OF THE DIGESTIVE APPARATUS. 313 tion of its physical diagnosis. In what follows we mention what may be learned in peritoneal diseases by the separate methods of examina- tion, but Ave call attention to the point that the examiner ought to learn to give his attention to all the abdominal organs, by inspection, palpation, etc., at the same time. INSPECTION OF THE ABDOMEN. In diseases of the peritoneum, this may reveal distention of the abdomen, which may be quite considerable, and quite like intestinal meteorism. Meteorismus peritonei — that is, escape of air into the abdominal cavity from the intestine or stomach — is a very serious condition, which always results in peritonitis. (See below.) There is general, though often unequal, distention when there is freely-movable fluid in the peritoneal cavity: ascites. Such a fluid effusion collects in the most dependent part of the abdominal cavity, first in the true pelvis ; then, as the amount increases, it rises higher, reaching the abdominal wall, where its level may stand at different heights. The abdominal organs that contain air float upon the top of the fluid so far as the peritoneal fold permits. In consequence of the increased internal pressure, the abdomen is broader, and the lower part contains the fluid, while the intestine, containing air, lies at the upper part, and is in contact with the abdominal wall. But the fluid, since it is freely movable, occupies always the most dependent part with every change of position of the body, and, if the tension of the abdominal wall is not too great, there often results an unequal disten- tion of the abdomen which varies with the position of the body. In the dorsal position, it is quite toward the sides ; when lying upon the side, it is over the inguinal and lumbar regions upon each side ; while in the sitting posture, it fills the dependent abdominal sides, the upper portions being empty ; and in standing, the lower part of the abdomen projects. If there is so large an effusion as to fill the abdo- men very full there is no change in the distention, and it is also more regular, like that we have with marked meteorism. (Regarding the high position of the diaphragm, when there is distention of the abdo- men, see Respiratory Organs and Liver.) If the skin is examined when there is marked effusion it will not at all look as it usually does : on account of the tension, it is smooth, 314 SPECIAL DIAGNOSIS. shining, and shows, especially in the dependent parts, a peculiar bluish shimmer. When the tension is of long standing, there are colorless streaks or strise which are formed in the skin by the con- tinuous stretching, as in tlie scars resulting from pregnancy, so-called from their chief cause. The umbilicus may be obliterated or even project. In marked ascites, the cutaneous veins of the abdomen are found enlarged, since, as collateral veins, they must take up the over- flow of the intra-abdominal veins, which are compressed. Under some circumstances, there may be oedema of the legs from compression of the iliac veins. (Regarding the caput medusae and the abdominal veins in general in cirrhosis of the liver, see under Liver.) Ascites that moves about generally results from transudation into the abdominal cavity from stasis, being rarely, except in the beginning of a disease, dependent upon inflammatory exudations. In the former case, it is either a partial indication of general dropsy, and connected with oedema (see), or entirely the result of obstruction of the portal vein (cirrhosis of the liver, compression, and thrombosis of the vein). In the latter case it is a sign of peritonitis. (See under Palpation, Percussion.) Circumscribed distention of the abdomen, where there has been little or no change in posture, may be due to inflammatory fluid exudations, which are enclosed between adhesions of the intestine to itself or the abdominal wall, or by any kind of tumor in the abdominal cavity; and also by tumors or abscess in the abdominal wall itself. Circum- scribed distention, Avith inflammatory redness, indicates a discharge outward of an abscess, either fecal or some other collection of pus in the abdominal cavity, or of the abdominal wall. In diseases of the peritoneum, palpation gives very important signs : Pain in all inflammatory affections. It is usually very severe in a,c\xte peritonitis, sometimes so great that the slightest motion, or even the lightest covering upon the abdomen, cannot be borne. This sensi- bility is an important indication of peritonitis, especially in distinguish- ing the ordinary intestinal meteorism from the intestinal meteorism with peritonitis, sometimes also in distinguishing inflammatory ascites from dropsical ascites. Circumscribed pain may indicate a circumscribed peritonitis, as it occurs more particularly over tumors, abscess of the stomach and intestine. In chronic peritonitis, especially in tubercu- losis, sometimes there is entire absence of tenderness. EXAMINATION OF THE DIGESTIVE APPARATUS. 315 Now and then, in chronic peritonitis there is a general, more or less symmetrical, hardness of the abdominal wall — that is to say, it feels as if it were thickened. This is to be distinguished from the general increased resistance from tension due to marked distention of the abdomen from meteorism and ascites. Thus, there is a marked differ- ence between the resistance of fluid and that of meteorism in a fold of intestine. The latter has more the feeling of an air-pillow, the former is more like a material substance. But we recognize fluid with much more certainty by the feeling of fluctuation, undulation. A hand is laid flat upon the surface of the abdomen, and then the abdominal wall is tapped lightly with one or two fingers, just as in direct percussion. If both hands are used, fluctuation is found in a place where there is an accumulation of fluid, and the stroke of the wave is felt with every tap of the fingers. In this way the presence of even a small amount of fluid in the abdominal cavity can be made out with great certainty. When there is great effusion under high pressure this sign may fail. On the other hand, we may be deceived in the case of persons who have a large accumulation of fat in the abdomen by the trembling of the layers of fat, and possibly, also, by the fat in the abdominal cavity, in the omentum especially. Very much increase of resistance, and thus an indistinct fluctuation, generally occurs when the peritoneal fluid is encysted. Circumscribed hard resistance, now like a round ball and again cord-like, occurs with extremely great variations in chronic peritonitis, not alone of the tubercular variety, but also in the so-called simple peritonitis from in- flammatory new formations ; nevertheless, the former is usually the much more frequent condition. Particularly often in this, although sometimes also in simple chronic peritonitis, we feel above the navel a dense transverse string : the omentum is shrunken and thickened by inflammatory products. Besides there are usually, but not always, the signs of encysted or even of free fluid in the peritoneal cavity. Exactly the same phenomena are present in carcinoma and sarcoma of the peritoneum. There occurs in an acute way resistance in the neighborhood of the caecum in typhlitis and perityphlitis. Here there is generally a cir- cumscribed globular, or flattened globular, tumor, usually immovable, which, at first at least, is extremely tender. It indicates a fixed mass of feces in the caecum, or an inflammatory deposit upon the serous side 316 SPECIAL DIAGNOSIS. of the caecum, or both. In inflammatory cases, there remains for a long time, or even permanently after recovery, a dense spot (a scar from shrunken inflammatory new formation in the peritoneum). In inflam- mation of the vermiform appendix, we can seldom affirm that there is a tumor. Palpation of the peritoneum through the vagina in order to dis- cover whether there are tumors, exudations in Douglas's space and anywhere in the neighborhood of the uterus, especially the different forms of peritonitis, belongs to gynecology. It is not necessary to measure the circumference of the abdomen for establishing a diagnosis, but yet it is valuable for the purpose of observing the course of an abdominal affection, and particularly for ascertaining the increase and diminution of fluid exudations. It is generally suSicient to measure the abdominal circumference across the navel and the lower lumbar vertebrae. It is better also to measure the distance between the xiphoid process and the symphysis pubis. Percussion gives valuable information regarding the peritoneum, as to whether there is fluid eff"usion in the peritoneal cavity, its location and nature. By percussing with some force at what we suppose to be the boundary line, we can easily determine the boundary between the dulness of fluid and the tympanitic resonance of the intestine ; but we can never distinguish it from that of those organs that do not con- tain air, as the liver, spleen, etc. The superior surface of a freely- movable effusion is always horizontal, and hence its upper boundary line must correspond to a section of a horizontal plane drawn through the abdomen, in whatever position the patient may assume. When- ever the patient changes his position, immediately the eff"usion changes its relations to the abdominal cavity (see above, under Inspection). Hence the result of percussion changes with the position of the body : if the patient lies upon the right side, then the portion of the abdo- men which is now lowest gives a deadened sound, while the upper boundary is horizontal ; in the left half of the cavity, there is tympan- itic resonance ; if the patient turns upon the left side, this is now dull, and the right is tympanitic. This is an important sign, not only that the fluid is movable, but often that there is fluid present. Small effu- sions, which rarely rise only a little above the pelvis, will hence be first recognized by percussing when the patient stands upright. If there is then dulness above the symphysis pubis, it immediately disappears EXAMINATION OF THE DIGESTIVE APPARATUS. 317 when the patient lies upon the back. Very large eflfusions may fill the abdomen so full that the intestines, on account of a short mesen- tery, cannot float, and hence cannot come in contact with the abdom- inal wall. Then the strongly-distended abdomen gives a dull sound throughout, and we sometimes notice a change of the boundary of dul- ness only in the position on the side, Avhen the upper portion gives a clear sound. When the fluid moves about with difficulty, slowly and incompletely changing its location with the change of position of the body, and still more if it is entirely immovable, inflammatory exudation with glueing or adhesion of the intestines together and to the abdominal wall is indicated. If the fluid does not move it is said to be en- cysted. But not infrequently even inflammatory exudation, at least in the beginning of its efiusion, is freely movable. Percussion may be an important aid in recognizing meteorismus peritonei in so far that in many cases, if adhesions have not already been formed before the occurrence of perforation, it gives a perfectly uniform tympanitic or, if the tension is great, a non-tympanitic sound over the whole abdomen, also over the region of the liver and spleen, and besides, on account of the diaphragm being arched high up, as far as the fifth, or even the fourth, rib. Not infrequently in this way we obtain Heubner's rod-pleximeter phenomenon (see p. 112). Subphrenic peritonitis, pyopneumothorax subphrenicus (Leyden), subphrenic abscess. We understand by this an ichorous-purulent, sacculated peritonitis below the diaphragm. From paralysis (partly also from destruction), the diaphragm is pushed very high into the thorax, causing a marked retraction or compression of the lung of that side. That half of the thorax is broadened, and by the presence of pus and gas in the cavity, one is apt to mistake the condition for pyopneumothorax. Peritonitis of this character usually begins at the stomach as an ulcer, or at the intestine, especially at the vermiform appendix and caecum. In making a diff"erential diagnosis, we observe whether, in the status proesens or in the previous development, there were indications of disease of the lungs or, on the other hand, of the abdomen, and also whether the luug of the diseased side still performs the motions of respiration. During puncture, it has frequently been found that the pressure rises during inspiration in a subphrenic cavity, 318 SPECIAL DIAGNOSIS. while it falls, of course, in a pleural cavity. This can be recognized by the varying rapidity of discharge from the aperture made by the needle, or by introducing a manometer into the cavit3^ The presence of air which has escaped into the peritoneal cavity is shown in m^tny cases by the clear, metallic ringing, intestinal sound in the upper part of the abdominal cavity, sometimes even a metallic, transmitted breathing sound, which it yields to auscultation. More- over, with the inflammatory deposits upon the reduplications of the peritoneum, especially over the liver and spleen, there occurs syn- chronously with breathing a peritoneal friction sound, exactly corre- sponding to the pleuritic friction sound. It is very rarely produced by peristalsis over the intestines. If the friction sound is pronounced, it can also be felt. When it is advisable, as a therapeutic measure, to draw off fluid from the peritoneal cavity by puncture, it may be of diagnostic value in two ways : 1. It is then possible to examine the organs in the abdominal cavity, which previously were concealed by the ascites. Not only does the fluid prevent the examination of the organs more or less completely covered by it, but the folds of the intestine floating upon it also do so, in that they crowd in between certain parts, especially the liver and spleen, and the anterior abdominal wall. When the abdomen has been emptied, its wall, which before was tensely stretched, is very lax, and this renders the examination extremely easy. Hence we can now usually very easily discover the diseases which caused the effusion (cirrhosis of the liver, tumors, which press upon the portal vein ; cancer of the stomach, ovarian tumor, etc.), or certain results of peri- tonitis (bands of scar tissue, which compress the intestine, swollen mesentery, etc.). 2. The fluid that has been drawn off can be examined. It is as important to do this as to examine pleural fluid (which see, p. IGO). The ordinary hypodermic syringe, holding one gramme — not the one recommended for puncturing the pleura — is to be employed for puncturing the abdomen. Exploratory puncture., by means of a large hypodermic syringe, is useful in distinguishing encysted peritoneal fluid from the solid and fluid contents of certain tumors (see Abdominal Tumors). Chylous ascites has been observed in some cases of compression of EXAMINATION OF THE DIGESTIVE APPARATUS. 319 the thoracic duct ; the ascitic fluid is, to a varying extent, milk-like in appearance. It contains molecules of fat and a ferment that forms sugar. Examination of the Liver. Anatomy. — -The liver, covered by the peritoneum, lies close to the diaphragm — within its arch — and is held in place by the suspensory ligament and by the intra-abdominal pressure exerted upon its lower Fig. 87. Location of thfi thoracic contents, of the stomach, and of the liver, from in front. ("Weil-Ltjschka.) The unbroken hatched lines represent the portions of the heart and liver that are in contact with the thoracic wall. The portions of these organs that are not in parietal contact and are covered by the lungs are represented by the light hatch- ing. ef{ ), border of the right lung; g h { ), border of the left lung; a6, andc«Z (. . . .), boundary of the complementary pleural sinus; i, boundary between the upper and middle lobes of the right lung; k, boundary between the middle and lower lobes; I, boundary between the upper and lower lobes of the left lung; w, stomach (greater curvature). surface. About three-fourths of it is in the right side of the body, and one-fourth in the left. With reference to its superficial topog- raphy, a larger portion of it belongs to the right hypochondrium, 320 SPECIAL DIAGNOSIS. extending into the epigastrium, and with a small portion into the left hypochondrium. Usually it does not extend so far to the left as the apex of the heart. Above, the lungs and heart glide over it, and it glides over the stomach (see Fig, 13, p. 78). The extent to which its surface is in contact with the thoracic wall is determined by the relation of its upper surface to the diaphragm. Hence, during expiration it rises in the right half of the body as high as the fourth intercostal space, and with its extreme left end to the fifth rib. The lower border, in the scapular and middle axillary line, stands about at the eleventh rib, in the mammillary line, just at the border of the ribs, then proceeds obliquely upward toward the left, through the epigastrium, under the left border of the ribs, and almost to the apex of the heart. In the middle line, it stands about midway between the xiphoid process and the umbilicus. The gall-bladder lies just where the lower border of the liver passes under the right border of the ribs, hence close within the right mammillary line. The organs that border upon the liver are the lungs, heart, and the diaphragm above, and the right kidney, colon and stomach below. That portion of its upper convex surface which is not covered by the lungs or heart is parietal. This parietal portion is very small behind. As it comes forward, it is much broader, and is, for the most part, covered by the chest-wall, except in the epigastrium, where it is free from its bony covering. With children, the liver is in all dimensions proportionally larger, so that its lower border is in the axillary line below the border of the ribs. Normally, the liver, strictly speaking, only moves in connection with the diaphragm. INSPECTION OF THE LIVER. This is made with the body in the dorsal position moderately elevated. In the healthy condition, in adults, absolutely nothing can be made out. The right and left hypochondriac regions are exactly alike. In small children, we can sometimes notice a moderate projection of the right hypochondrium. EXAMINATION OF THE DIGESTIVE APPARATUS. 321 Projection of the right hypochondrium,' or also of the epigastrium and the region below the right border of the ribs, indicates enlarge- ment of the liver. This must be pretty well marked, in order to be noticed in this way. Where the thorax is very stiiF, the ribs do not usually project; but when the ribs are very flexible (children, young females), where it can relatively easily take place, the projection of the abdominal wall is plainer if the abdomen is a little full and the covering thin. Fig. Location of the lungs, liver, spleen, and of the kidneys, from behind. (Weil-Luschka.) The liver and spleen are represented by the same liind of hatching as in Fig. 87. ab ( ), lower border of the lungs; cd (. . . .), complementary space; i ( ), border of the liver; e/(. . . .), boundary between the upper and lower lobes of the lungs; g, boundary between the upper and middle lobes of the right lung. If the projection is entirely of the portion of the abdomen below the border of the ribs, it points more to a displacement of the liver downward. There may be very marked distention when an enlarged liver is so displaced. It is very rare to see or to feel the lower border of the liver. But it may be, if, on account of enlargement or displacement, or both, it 21 322 SPECIAL DIAGNOSIS. is located low down, and if* the abdominal wall is thin. We can then also observe how the border of the liver moves downward with the motion of the diaphragm in deep inspiration. For observing this the light must come from the head of the bed. When the wall is very thin, tumors on the surface of the liver in contact with the abdominal wall, or on the lower surface of the border, and also a distended gall-bladder, can be seen. With deep breathing, they follow the motions of the diaphragm, and they transmit the motions to tumors of the stomach or omentum, which may be adherent to them, or, like them, visible. Finally, arterial or venous liver-pulse may be visible, especially the latter, which always accompanies enlargement of the liver. Enlargement of the liver may be dependent upon different diseases of this organ. In engorgement of the liver, especially in mitral defects and in emphysema, in fatty or amyloid liver, or when it is due to obstruction of the gall-bladder, and in diffuse hepatitis, in certain acute infectious diseases, the enlargement of the liver is tolerably uniform, its form being retained. It manifests itself by its lower border moving down into the abdomen, but, on the other hand, the diaphragm is pressed upward only when the liver is very greatly enlarged, or when the general abdominal pressure is increased (espe- cially in ascites) The liver is irregularly enlarged in carcinoma, echinococcus, generally in syphilis, and in abscess. To what extent it is noticeable depends upon the location of the swelling, whether anterior, inferior, or superior, with displacement of the diaphragm. Downward displacement or dislocation of the liver occurs generally with depression of the diaphragm, with severe emphysema, with pleurisy or pneumothorax of the right side. Left-sided pleurisy or pneumothorax, pericarditis, though generally only to a slight degree, press the point of the left lobe of the liver downward, and thus the lower border of the liver in the epigastrium is horizontal. Moreover, under some circumstances the liver is pressed downward by sub- phrenic abscess (see above), which at the same time pushes up the diaphragm. Lastly, here belongs the "wandering" liver, due to relaxation of the suspensory ligament (occurring in women who have borne children). It is only in the two conditions last named that it is not in contact with the diaphragm. EXAMINATION OF THE DIGESTIVE APPARATUS. 323 It is to be observed that the lower border of the liver moves down- ward not only when it is enlarged, but also when it is displaced. These two conditions will be distinguished chiefly by palpation and percussion, and the consideration of the accompanying conditions of the organs in the chest and abdomen. Displacement of the liver upward, can, of course only take place when the diaphragm is higher than normal, as in retraction of the lungs, pressure from belo^v, inflammatory or neurotic paralysis of the diaphragm. PALPATION OF THE LIVER. In every relation, this is the most important and certain method of examining this organ, and hence must be most diligently practised by the beginner. It is best to have the patient in the dorsal position, and the abdominal wall as relaxed as possible. We first seize, with the warm hands, the whole abdominal sac, have the patient open the mouth and breathe quietly. Drawing up the limbs is of little aid and disturbs the examination. We very frequently make use of deep breathing, because in this way the parts hidden under the ribs move deeper, and the border or any small unevenness, etc., can be felt more distinctly as it moves against the examining fingers; and lastly, because the liver can be distinguished from other organs (kidney, colon, omentum, often stomach, abdominal wall) by its motions during deep breathing. By striking palpation we understand a brusque stroke with the tips of the fingers. We employ it in meteorism and ascites in order to push aside for the moment a layer of intestine lying over the liver or fluid, and thus be able to reach the liver with the tips of the fingers. (See, moreover, what is said on page 318 regarding palpation of the abdomen after puncture.) Normally, in the adult, with the ordinary thickness of abdominal wall, we can feel scarcely anything of the liver. If there is a thin lax wall (especially in women), we not infrequently feel the edge of the liver in the mammillary line at the border of the ribs, seldom also in the epigastrium, particularly if it is pressed down in deep inspira- tion. In children it is often very distinct. For example, we take a condition bordering on the normal, the so-called constricted liver, a disease almost without significance. It occurs in women who have laced themselves very tightly for a long 324 SPECIAL DIAGNOSIS. time. Corresponding to the anatomical condition of the liver, we can feel a tongue-like prolongation of the right lobe, which prolongation is separated from the mass of the liver by a constricting furrow close under the border of the ribs. Sometimes the constricted liver is sensi- tive on pressure. In ascertaining the pathological conditions of the liver by palpation a series of points of view come under consideration : 1. The existence of tenderness. There is no tenderness with the fatty, amyloid, cirrhotic liver, with echinococcus (if there is no forma- tion of pus), nor engorged liver (infrequent), if it has been for a long time uniformly engorged ; the syphilitic liver is usually not tender, but sometimes it is so. Generally, in the beginning of cirrhosis the liver is sensitive, also in biliary engorgement. According to the extent to which the peritoneum is involved, carcinoma of the liver may be entirely without tenderness, or it may be very sensitive, also, when engorgement of the liver has rapidly developed, it may be very tender. When an abscess of the liver is parietal, possibly involving the peri- toneum, there is a circumscribed area of great tenderness ; with deep- seated abscess, there is no pain. Tenderness of the liver may, besides, be caused by chronic (often tubercular) peritonitis, without there being any trouble with the liver itself. 2. The size and form. Depression of the lower border, without change in form, indicates uniform enlargement, but possibly also dis- placement. Unless there is considerable enlargement, it is often difficult to distinguish between these two conditions. If there is simultaneously tenderness and hardness (see below), or if there are conditions of other organs which make enlargement of the liver prob- able, as valvular disease of the heart with engorgement, a disease causing an amyloid condition, then we are very seldom wrong in the supposition that there is an enlargement. On the other hand, for example, the existence of pleuritic exudation, dextra, etc. (see above), makes displacement more probable. There also may be at the same time enlargement and downward displacement. But it must be remem- bered that, when a liver is markedly displaced downward, the impres- sion is easily made that it is also enlarged, because, by traction about its transverse axis, it becomes parietal to a larger extent. When a downward- displaced liver is distinctly movable by pressure with the finger, in such a way that in the dorsal position it can be EXAMINATION OF THE DIGESTIVE APPARATUS. 325 brought back to its normal position, then we have a "wandering" liver. The form of the liver is recognized with varying distinctness, accord- ing to the increased extent to which it lies against the abdominal wall, when it may be enlarged. It has already been mentioned under what conditions the liver retains its form. Tumors of all kinds (espetjially carcinoma, gummata, echinococcus) and scars (syphilis) change its form. Whole portions of the parenchyma of the liver may often, not always, be marked off by the scars of syphilis if they are very deep: "lobulated liver." 3. Again, the surface of the liver can be judged by the portion of the upper surface or the lower border which is accessible to palpation, and we can do this best by moving the finger-tips with the abdominal wall back and forth over the liver. In individual cases it is only possible to feel a portion of the lower surface. In engorgement of the liver, in fatty liver, in amyloid liver, in a portion of the first stage of cirrhosis, and in the so-called hypertrophic liver, the surface will be found to be smooth ; also, in echinococcus, carcinoma, and syphilis of the liver, if we palpate a portion entirely free from tumor or scars. Small inequali- ties, generally to a certain extent uniform over the whole palpable portions of the surface, sometimes so fine that if the abdominal wall is thick it is difficult to feel them, are the characteristic signs of ordinary cirrhosis of the liver (interstitial hepatitis, granulated liver) toward the end of the first stage and into the second. Here, for two reasons, it is usually very difficult to reach the liver with the fingers: first, because in the second stage it is smaller, and hence is to a less extent parietal, and second, because the disease is commonly associated with ascites. For this reason, what has been said regarding "stroking palpation " and examination after puncture, applies especially hei'e. It is further to be remarked that the surface of the liver in chronic, and especially in tubercular peritonitis, may feel tuberculated in conse- quence of inflammatory growths upon the serous coat, and this without there being any cirrhosis (although not infrequently this exists at the same time). Large rough tumors, from the size of a cherry to that of an apple, often mingled with small knots, are the usual appearances with carcinoma of the liver. We can sometimes recognize upon the top of these carcinomatous knots a depression, the cancer navel ; but they are of neither positive nor negative diagnostic weight. More 326 SPECIAL DIAGNOSIS. smooth, flat projections, especially if, besides, we can feel scar-like depressions, indicate the presence of syphilitic gummata. Echino- coccus causes smooth tumors which, according to their location, are flat or elevated, or they may even stand out prominently from the surface of the liver; thus also abscess of the liver causes smooth promi- nences of diff"erent sizes and elevations. 4. The consistence of the liver is uniformly, and generally markedly, increased in amyloid disease, engorged liver, and in ciiThosis. Car- cinoma manifests itself, as elsewhere, usually by great density. Abscess of the liver and echinococcus bladders may distinctly fluctu- ate ; the latter often, if tightly full, feel dense as well as elastic,-and we can sometimes recognize by quick, short strokes of the opposing hands a peculiar whizzing — the hydatid thrill. In many cases exploratory puncture will be indicated, as in order to recognize or exclude echinococcus or abscess. (Regarding the condition when there is echinococcus, particularly of the effects, see pp. 322, 325.) Moreover, it is necessary to compare the results of palpation, in the broad sense of the word, with the accom- panying appearances of other organs, which belong to the individual diseases of the liver. These may stand in a causal relation (constitu- tional syphilis, primary cancer of the stomach, etc.), or they may be results (ascites in cirrhosis of the liver or pressure from tumors, scars of the portal vein, rigors in abscess of the liver, etc.). The gall-hladder. If this is normal, it is only in cases of extreme emaciation that it can occasionally be felt. This is much sooner possible when it is abnormally full of fluid, as in biliary engorgement, hydrops vesicce fellece, suppuration, or when it is distended with gall- stones. In biliary engorgement and catarrhal icterus it is possible to diminish the gall-bladder by carefully compressing it, and expelling the contents into the ductus choledochus and the duodenum. When there are gall-stones, if the abdominal wall is thin, we sometimes get the distinct impression of a sac filled with angular stones rubbing against one another. A dense, rough tumor indicates carcinoma of the gall-bladder. PERCUSSION OF THE LIVER. Wherever the liver is in contact with the thoracic or abdominal wall, we, of course, have dulness, and this is an absolutely deadened EXAMINATION OF THE DIGESTIVE APPARATUS. 327 sound where the liver receives the whole of the percussion-stroke, and the stroke is not permitted to reach to an underlying air-containing organ, as the intestine or stomach. A relative dulness, with tympanitic associated sound, occurs when a thin layer of liver lies over the stomach or intestine, as is the case in the neighborhood of the lower border of the liver. To a certain extent it depends upon the strength Fig. Percussion boundary of the liver in front (Weil). g h, the upper limits of the lungs; ef, the lower limits of the lungs; b d, the boun- dary between the lung and heart at the incisura cardiaca. The darkly-hatched surface represents the portions of the heart and liver that are in contact with the chest- wall; the light hatchings the so-called relative heart and liver deadness; m, spleen deadness; n, the average position of the lower border of the stomach. of the percussion-stroke whether we have a relative or an absolutely deadened sound (see p. 117) : the weaker the stroke, the sooner do we have absolute dulness. The varying thickness of the covering of the liver is confusing — consisting partly of ribs and partly of abdominal wall. Still more confusing for exact examination is it that the border of the arch of the ribs, at the most important point in the mammillary line, normally exactly corresponds with the lower border of the liver. 328 SPECIAL DIAGNOSIS. The difference in sound which is caused by this change in the covering alone obscures the exact examination of the liver at this point. The limits of tbe liver, so far as they are determined by percussion, are ascertained by gentle percussion at the right lower border of the lung, by the transition from the clear lung-sound (or relative liver- dulness) to the absolutely deadened sound. Thus, the upper boundary of the parietal part of the liver is easily found, with the exception of a small portion, whore the liver lies against the heart (see Fig. 87). Here we cannot determine the boundary by percussion, because the heart-dulness and liver-dulness cannot be distinguished. The lower border of the liver near the spine cannot be pointed out, because it joins the kidney (see Fig, 88), but everywhere else its sound could be very easily distinguished from the tympanitic sound of the stomach and intestine if its anterior part were not too sharp — that is, if the liver were not here too thin. For this reason, even with the most gentle percussion in the epigastric region, it is usually found too high. Often no distinct liver-dulness can be perceived in any portion of the epigastrium. Moreover, we must guard against being deceived by the dulness of one of the bellies of the rectus abdominis (lax abdominal wall). The relative liver-dulness lying above the absolute does not corre- spond to the anatomical size of the liver, which lies much further back than this, as is shown by a comparison of the anatomical figure Avith the boundary as determined by percussion. This is because the lung becomes thinner at its lower border ; moreover, it is only anteriorly and at the side that it is always distinctly present. It usually fails between the scapular line and the spine, owing to the thick wall and the diminished sharpness of the edge of the lung. Mode of procedure : We percuss strongly or lightly down a known vertical line on the thorax, for determining the beginning of relative liver-dulness, and thus fix the lung-liver boundary — that is, the transi- tion from the relative to the absolute liver-deadness. Then we percuss downward, through the extent of liver-dulness, until by the gentlest percussion, we get the entirely pure tympanitic sound. From this point we go again upward till we get the first indication of relative dulness. We determine the exact boundary lines by exclusion (see p. 117). EXAMINATION OF THE DIGESTIVE APPARATUS. 329 The average boundary-lines of the liver, as determined by percus- sion, are about as follows : The upper, the lung-liver boundary : Middle line, base of the ensi- form cartilage ; mammillary line, sixth rib ; middle axillary line, eighth rib ; scapular line, tenth rib. The heart-liver boundary cannot be determined by percussion, but it lies near the apex-beat. The lower, the liver-stomach (intestine) boundary : Left of the middle line, toward the half-moon-shaped space, ascending obliquely to about the sixth rib in the parasternal line ; middle line, not lower — often higher — than midway between xiphoid process and the umbili- cus ; mammillary line, at the bend of the ribs ; middle axillary line, the tenth rib ; scapular line, the eleventh rib. But from these there, is frequently a considerable departure, even normally. Throughout, the lower boundary has been found much higher, this being caused by a fold of intestine lying over the liver and thus diminishing the extent to which it is parietal. This is par- ticularly the case with the ugly, but not pathological, form of the thorax where it is short and its lower aperture is quite wide ; also, in persons who have a full abdomen. In this way the liver-dulness may sometimes be entirely wanting : at the upper boundary of the half- moon-shaped space we pass, in percussing, from lung-sound into tympanitic resonance. Extreme elevation of the liver-dulness, although very variable within normal limits, is not at all applicable in diagnosis. Mobility of the boundaries of the liver. In deep breathing, there is a more marked active displacement of the upper boundary (corre- sponding to the respiratory excursion of the border of the lung) than of the lower, which displacement is the expression of the movement of the dome of the diaphragm. As regards passive movement, we only notice that in the left-side position both boundaries move down- ward, the upper distinctly so (see Lungs) ; the lower, very little. Pathological Relations. — 1. The upper boundary of dulness is found higher. The cause of this can first of all be found in the pleural cavity : pleural exudation, tumors of the pleura, of the lungs, pneumonia ; or in the chest wall : tumors, peripleuritis. Then, of course, it is not possible to distinguish the dulness of what lies above the liver from that of the liver itself, since two media that on per- 330 SPECIAL DIAGNOSIS. cussion give dulness cannot be distinguished from one another. If there is exudative pleuritis upon the right side, the diaphragm is deeper and the liver moves down, causing its lower boundary of dulness to be lower, and thus in this disease there may be an extensive dulness, reaching from high in the thorax to far below the border of the ribs — dulness of the exudation plus liver- dulness. If the conditions just named are excluded, then we may have {a) Displacement of the liver upward, with high position of the diaphragm. Then, at the same time, the lower border of the liver is higher, and indeed the latter is displaced upward further than the former, because the liver, as it moves upward, in a sense turns on its axis — that is, the lower border turns up, so that it is to a less extent parietal — the square position of Frerichs. (For the conditions which displace the liver, see above.) (6) A tumor, of the convexity of the liver, as a new formation, an abscess, echinococcus, when the upper boundary of dulness pur- sues an irregular course, according to the form of the tumor ; or a subphrenic abscess. In these cases, the liver is usually displaced downward, often very markedly so ; hence, the lower boundary of the liver at the same time stands deeper. (e) A simultaneous general enlargement of the liver. This is rare, occurring only when the liver is very large. Here also the lower boundary of dulness is considerably deeper. It is often very difficult to distinguish, and then only by inspection (projection) and palpa- tion of the surface and consistence of the liver, and other evidences of disease referred to under (6). 2. The upper boundary of dulness is found deeper. This occurs : (a) With a simultaneous normal position of the lower boundary, in slight substantive, and in vicarious, emphysema. Although in this case the lung moves down into the complementary space, and thus covers the liver somewhat more than is normal, yet the dome of the diaphragm does not become deeper. [h) With simultaneous downward displacement of the lower boun- dary : low position of the diaphragm with the liver : marked emphy- sema with low position of the diaphragm ; pneumothorax. We can have the same percussion result with considerable emphysema and en- largement of the liver. Finally, there may be low position of both boundaries resulting from the low position and enlargement of the EXAMINATION OF THE DIGESTIVE APPARATUS. 33I liver, as is a frequent occurrence in severe emphysema, because of the existing eno;ora;ement of the liver. When the liver is displaced downward it easily gives the impression of being enlarged without such being the fact, because it is often parietal for a larger area than is normal. Also, for this reason, the liver-dulness is higher than it is normally on the average; especially in pneumothorax is it often distinct. 3. The behavior of the lower boundary when the upper is displaced has in general been already mentioned. It remains to be noticed that, when the liver is pushed down by a thoracic affection on the right side [pleurisy, pneumothorax), it stands obliquely, that is, the right lobe is deeper than the left, hence the depressed lower boundary of dulness stands steeper than normal, sloping from the right toward the left. On the other hand, when we have a pleurisy or pneumothorax upon the left side, or marked pericarditis exudativa, since the left end of the liver (loh. sinistra) is then alone pressed down, the lower line of dulness is found more horizontal. With a normal upper border, the lower boundary stands deep and reaches further into the half-moon- shaped space when the liver is en- larged; on the other hand, it is higher than normal, under some circum- stances even until the liver dulness completely disappears in the following conditions : (a) If the liver is smaller, as in cirrhosis, acute yellow atrophy, here occurring rapidly. (5) As happens much more 'frequently than (a), in case the liver, though perfectly sound, is less parietal than normal, or is not at all so, as in those who are on the whole well, in meteorism, ascites, entrance of air into the peritoneum. In this way even an enlarged liver may elude examination. In yet two Other rare cases is the liver dulness entirely wanting ; in situs inversus viscerum and in cases of "wandering liver." With the latter, sometimes a portion of the upper surface of the liver will be found in contact with the abdominal wall further down. Apparent low position of the lower border occurs when there is an airless mass below the liver, as with a full colon, or a large tumor of the colon, of the omentum, or of the stomach, although these are rare. The form of the lower border departs from the normal when there is unequal enlargement of the liver (see above) ; also sometimes in marked enlargement of the gall-bladder, seldom determined by per- 332 SPECIAL DIAGNOSIS. cussion. (For the different kinds of enlargement, see under Palpa- tion.) 4. Relative liver-dulness is diagnostically of little interest. It is relatively high, if the diaphragm rises steeply upward and inward from the thoracic wall, and very low, if the diaphragm goes off per- pendicularly from the thoracic wall, as in severe emijliysema, but especially in pneumothorax. All in all, percussion of the liver, when rightly performed and cor- rectly interpreted, is of very great value. But where palpation can be employed, as is usually the case whenever the inferior border of the liver is lower than normal, it must yield to the latter method of examination, which is more anatomical and hence more exact. If the border of the liver can be felt, then we note its course upon the body by the results of palpation and not of percussion, and proceed with the diagnosis in accordance with this position. Examination of the Spleen. Anatomy. — The spleen, a long, generally almost oval, organ, lies in the left hypochondrium, between the ninth and eleventh ribs, in such a way that its long diameter in the dorsal position of the body lies almost exactly behind and parallel to the tenth rib. Its posterior end lies about two centimetres from the tenth dorsal vertebra ; its anterior end, normally, scarcely reaches to a line drawn from the tip of the eleventh rib to the left sterno-clavicular articulation {linea costo-articularis), at any rate does not pass beyond it. The upper (anterior — upper ^) of the two borders of the spleen exhibits one or two notches. The spleen lies close to the under surface of the diaphragm, in the periphery of that portion which rises sharply upward, and toward its inner lower end it covers a small portion of the upper part of the left kidney, also the colon and stomach. Topographically, with reference to the thorax, its location is as follows : Its upper third, during moderate respiration, is covered by the lung. The lower two-thirds are in con- 1 In what follows I designate the two borders of the spleen as " upper " and " lower," because from the topographical standpoint that always seems to me the most natural. We speak of an upper and lower border of all the ribs, even of the lower ones, which are oblique. I cannot understand why one of the two ends of the spleen should be called the " upper" and the other the " anterior," as is done by Weil. EXAMINATION OF THE DIGESTIVE APPARATUS. 333 tact with the thoracic wall, but it changes its relation somewhat with the position of the body by reason of the passive mobility of the border of the lung (which see). Its upper border follows the ninth rib, forms the outer boundary of the "half-moon-shaped space," and Fig. 90.. € S A Se M S \ Position of the spleen. (Weil.) M, the middle line of the back; A, B,C, the axillary lines; >S'c, the scapular lines; abed, spleen; abc' d, unusual rhomboidal form of the spleen; efg, outer boundary of the kidney ; I b c, the spleen-lrng and dh g, the spleen-kidney angle; n m, the lower border of the liver. stands at a sharp angle with the lower border of the lung (see figure), called the spleen-lung angle, whose apex, in the upright position, is about at the posterior axillary line, but when in the right-side position, in consequence of the movement downward of the lower border of the lung, it moves somewhat forward, even as far as the anterior axillary line. Its lower border follows the eleventh rib, and for the most part bounds the left kidney. The spleen is in parietal contact only in its lower two-thirds, but it cannot be reached by the finger except sometimes by turning the abdominal wall under the border of the ribs. 334 SPECIAL DIAGNOSIS. INSPECTION OP THE SPLEEN. In the normal condition, and even when greatly enlarged, inspec- tion of the spleen gives no result. A very considerable enlargement causes a projection of the left hypochondrium. and of the abdominal region obliquely inward and downward from it. When the abdominal wall is thin, the border of the enlarged organ or a circumscribed swelling on its parietal surface may be seen. Then if the upper end of the spleen has not left its place close to the diaphragm (see below), it usually plainly descends with deep inspiration. PALPATION OF THE SPLEEN. Palpation is very much the most important method of examination, because its results are much more reliable than is the case with per- cussion. Ordinarily, in order to employ palpation, it is necessary for the patient to assume what is called the diagonal position on the right side, that is to say, a position midway between the dorsal and the right- side position, and also for the reason that percussion can be practised very much better in this position, and because the unity of the position is useful for comparing the results of the two methods of examination. When the patient is very sick, it is better to palpate in the dorsal posi- tion. When the spleen is of very considerable size, this is also best (then, too, it is preferable for percussion). If it is difficult to find the spleen, then we try the right-side position, because this more fully relaxes the left side of the abdominal wall. If we have the patient take several deep inspirations, a slight swelling of the spleen can usually be made out by feeling the anterior end of the organ close to the border of the ribs, at about the tenth rib, where it comes in contact with the tip of the finger. Without further investigation we cannot refer a simple increase of resistance at the edge of the ribs to the spleen ; but we must further seek to feel its border. The spleen can be felt : 1. In individual cases in health, when the abdominal wall is very lax ; also, sometimes, in persons with deformed chest (kypho-scoliosis). 2. If it is enlarged. It may be enlarged and yet retain its form. ■ It is uniformly enlarged in certain acute infectious diseases, as in ty- phoid, exanthematous and recurrent fever ; in scarlet fever, usually in EXAMINATION OF THE DIGESTIVE APPARATUS. 335 severe smallpox ; malaria, here relatively very large ; in erysipelas, here often very little enlarged ; in sepsis and pyaemia ; sometimes in acute miliary tuberculosis ; in engorgement of the spleen, especially in cirrhosis of the liver ; in occlusion of the portal vein ; in general venous engorgement ; in amyloid disease of the spleen ; in leuksemia (greatest enlargement), and in splenic angemia ; sometimes, in infarc- tion of the spleen (heart disease) ; and also in tubercular peritonitis. We must here also mention the apparent enlargement of the spleen where there are thick peritoneal deposits (perisplenitis). It may also be unequally enlarged by new formations, especially by carcinoma, and by echinococcus and abscess. 8. It may be felt if it is displaced, with low position of the dia- phragm (rare); the " wandering " spleen. In palpating we take notice of: Pain. Tenderness, probably always from the peritoneum, some- times occurs in acute infectious diseases, in suddenly developed engorge- ment, in infarction of spleen, new formations, abscesses. There may sometimes, in abscesses and infarction, be tenderness to pressure upon the ribs in the neighborhood of the spleen. Size. The largest tumors of the spleen, often reaching into the right side of the abdomen, occur in leukgemia. On the other hand, in the acute infectious diseases, we have moderate enlargement of the spleen, which does not come below the border of the ribs. In other diseases the splenic tumor varies very much in size. Pulsating splenic tumor has been observed now and then in cases of aortic insufficiency. Consistence. As a rule, the consistence increases with the size, and is more dense in chronic, than in acute, cases. Generally, the consistence is not a guide in diagnosis. Form, surface. It has already been mentioned in what diseases the spleen is uniformly, and in what unequally, enlarged. In diseases- of the first group, we can almost always, and in the latter sometimes, feel distinctly the notches in the upper border, if the spleen projects far enough beyond the border of the ribs. In carcinoma, the surface shows hard, uneven tumors ; in echinococcus, they are round, tense, elastic. But in leukaemia, the surface is not always uniform, for it may sometimes exhibit flat elevations. Mohility. We have already mentioned the downward movement of the spleen with deep inspiration. I have seen cases of very great 336 SPECIAL DIAGNOSIS. enlargement of spleen where this did not take place, because the spleen had pushed the diaphragm high up on the left side (see Percus- sion), and hindered its contraction. Wandering spleen, having dimirfished respiratory movement, but passively movable, and sometimes even showing displacement down- ward with change of posture, occurs only in women. The spleen may wander astonishingly far from its place, even into the true pelvis, and it has been found in the abdominal cavity entirely free from its attach- ments ; but usually there is only slight displacement. Tumors of this kind are recognized as wandering spleen by their form and by the notches. Often, it is at the same time enlarged. A spleen displaced by the low position of the diaphragm can seldom be felt. (See farther regarding displacement, under Percussion of the Spleen.) Relation of the colon to the spleen. Enlarged and wandering spleen lies in front of the colon. We can best prove this by inflating the colon with air in connection with palpation and percussion. PERCUSSION OF THE SPLEEN. Percussion is limited to that portion of the spleen which is not covered by the lung (Weil). It is bounded above by the lung ; toward the front superiorly, we have the upper border, inferiorly, the anterior end, and a portion some distance behind (inferior border), against the stomach and intestine; further back, against the kidney. But this latter portion cannot be defined, there being dulness against dulness. When we can only percuss with the patient in one position, as with very sick patients, we do so in the right diagonal posture. But if we wish to be very exact, and the patient can bear it, it is best also to percuss in the upright posture. Let it be repeated, that palpation generally, even though the physician be skilful in per- cussion, gives a much more certain result. But percussion must never be omitted. When the spleen is very much enlarged, we may examine the patient in the dorsal position. The diagonal posture is only required to determine whether, and how much, the spleen pushes up the diaphragm. ' In both the diagonal and the upright posture, we begin by determining the lower border of the left lung. It is normally in the upright position : EXAMINATION OF THE DIGESTIVE APPARATUS. 837 Fig. fll. — <2 mammillary line, sixth rib; middle axillary line, eighth rib; scapular line, tenth rib. In the diagonal position, it varies from the seventh to the eleventh rib. From here, if we percuss in the vertical line, over the border of the lung downward, and, in the diagonal position, about in the anterior or middle axillary line, below the border of the lung, we will meet dulness instead of the tympanitic sound of the half-moon- shaped space : spleen-dulness. The place at the border of the lung where the dulness is met with is the apex of the spleen-lung angle (see anatomy, p. 333). We now per- cuss vertically downward, through this angle beyond the deadened sound, till we come to a tympanitic (intestinal) resonance : the boundary line is the lower border of the spleen. Then we percuss from the half-moon-shaped space and from the abdomen, upon lines which cross what we suppose to be the area of spleen-dulness, and thus ascertain where the tympanitic stomach or intestinal resonance changes to dulness. This marks the line of the spleen. If we mark these points, and connect them, we obtain the figure of the parietal portion of the spleen, which we can complete by determining the lower border of the spleen in the posterior axillary line, or in a vertical line between this and the scapular line. In the upright position, the conditions are altered in such a way that the border of the lungs, and with it the lung-spleen boundary, stands somewhat higher (see above), and hence we find the apex of the lung-spleen angle in the middle or posterior axillary line. As has already been said, the size of the spleen-dulness, with careful percussion and under favorable conditions (see below), cor- responds to the parietal part of the spleen. From this we must estimate the size of the spleen. In measuring it, we have only two points of departure : the height of the spleen-dulness in the vertical 22 jhape of the spleen-deadness. 338 SPECIAL DIAGNOSIS. line passing through the apex of the spleen-lung angle, and the rela- tion of the anterior end of the spleen to the liyiea costo-articularis. The average in health has been found to be (Weil) : In the diagonal posture, the height of the spleen is 5.5 to 7 cm., the anterior end at most reachino; to the linea costo-articularis. In the upright position, the height is 4,5 to 6 cm., the anterior end under some circumstances passing a little beyond the linea costo- articularis: the spleen-lung angle more pointed — that is, the spleen is a little more horizontal. We are interested in the mobility of the spleen-dulness in deep inspiration only so far as it affects the boundary between the spleen and lung (see what has been said regarding active mobility of the border of the lung). Weil, in his work upon Topographical Percussion, has sufficiently explained why we must forego the determination of the portion of the spleen which is covered by the lung. In the first place, we percuss tolerably strongly. If in that way we obtain no result, we then percuss very lightly. With strong per- cussion over the spleen, we very seldom get resonance; also, with moderately strong, only rarely absolute deadness. Also, we must often be satisfied, by gentle percussion, with a relative dulness, asso- ciated with tympanitic accompaniment. Departures from what has been called the "average" in health : (a) The dulness of the spleen is only approximated as regards size or intensity: a very frequent occurrence when it is covered by intestine, or the spleen is thin and the intestines nea,r it are distended by gas. (5) The area of spleen-dulness is larger, while its form is retained or is changed : this occurs when the stomach is overloaded with food, when there are fecal masses in the neighboring colon, when there is corpulence (the greater omentum loaded with fat) ; but, also, some- times without these conditions being present. We must guard against deception as respects the stomach and intestine by repeated examina- tions, especially with abstinence from food and after free purgation. When there is obesity, we ought not, on the whole, to draw any con- clusion from a large area of spleen-dulness. But, at any rate, we must never, by a single examination, diagnos- ticate a spleen-tumor from percussion alone. Pathological Relations. — As mentioned above, diminution of spleen-dulness is often met with in health. In sickness, it occurs from EXAMINATION OF THE DIGESTIVE APPARATUS. 339 overlapping of the spleen from above by the lung : this happens with emphysema of the lung, when the lung spreads into the comple- mentary space ; sinking down of the lower border of the spleen and its anterior end, as evidence of displacement downward by flattening of the diaphragm, but in emphysema this cannot be proved. There is always diminution of spleen-dulness (even to complete disappear- ance) Avhen it is displaced upward, as in shrinking after pleurisy, contraction of the lung,' high position of the diaphragm. Here, generally, there is no spleen-dulness at all, on account of the intestine lying over it. Mnlargertient of spleen-dulness. If we make out such a condition we ought to call to mind the sources of error mentioned above. We should never make the diagnosis of enlarged spleen from a single percussion, without the support afforded by palpation. We must notice whether the enlarged dulness shows the relations of the figure of the spleen ; if it does, then it is quite probable that the spleen is enlarged ; likewise, if the examination in the diagonal and the standing position shows a similar result, with change of dulness that distinctly corresponds with the changed position of the border of the lung and the spleen. Enlargement of the spleen is to be assumed when the vertical measurement of dulness is as much as 9 cm. or more ; also, if the area of dulness extends considerably beyond the linea costo-articularis ; and, lastly, if the dulness is very decided, with moderately strong percussion absolute. When there is considerable enlargement of the spleen, the area of dulness upward is larger, and, hence, the diaphragm, and with it the border of the lung, moves higher in the chest. More- over, in every upward enlargement of the spleen-dulness it is to be remembered that it may be merely apparent, being caused by pleuritic exudation, infiltration of the lungs, or pleural tumor. When there is a decided enlargement of the spleen, it considerably diminishes the half-moon-shaped space. If there is, simultaneously, tumor of spleen and liver, the space may be entirely deadened. AUSCULTATION OF THE SPLEEN. In rare cases, auscultation enables us to recognize peritoneal friction-, sounds should there be inflammatory deposits upon the serous coat of the 340 SPECIAL DIAGNOSIS. spleen and the parietal portion of the peritoneum opposite to it^ if the diaphragm is not paralyzed by the peritonitis or the spleen has not become adherent. Peritoneal friction-sound over the spleen (and over the liver) seems to me to have greater weight as evidence that the first of the two last-named conditions is wanting, than as the sign of peritonitis, for the latter usually appears to be plainer from other symptoms. It may easily happen that we find it difficult to distin- guish whether we really have peritoneal, rather than pleuritic, friction- sound. Auscultating with the stethoscope enables us to localize the sound more exactly. We must also take into consideration the whole picture of the disease. Examination of the Pancreas, Omentum, Retro-peritoneal Glands. The pancreas is accessible for examination, and even to palpation, if it is the seat of new formation, as of carcinoma, especially of the caput pancreatis, and hence is larger and harder than normal : we have a roundish tumor in the right epigastrium which does not move during respiration, about midway between the point of the xiphoid cartilage and the umbilicus, hence, directly under the border of the liver ; or a somewhat longer tumor across the epigastrium. Unless there are characteristic associated symptoms (compression of the ductus choledochus and pancreaticus, biliary engorgement, and change in the character of the stools), the diagnosis of tumor of the pancreas can scarcely be made from such a tumor, which may also belong to the omentum, but especially to the retro-peritoneal glands. The omentum, also, is only perceptible when it is thickened by inflammation or new formations, or by both. It frequently shrinks up to a transverse band which lies close above the umbilicus, as in tuberculosis, but doubtless also in "simple" chronic peritonitis. Car- cinomatous knots in the omentum are best to be distinguished from similar deposits in the anterior wall of the stomach, by examining the latter, both when empty, and full, or inflated. Sometimes it is very . difficult to distinguish them from carcinoma of the liver, especially if the omentum, from adhesion with the liver, moves with each respira- tion. Echinococcus of the omentum is quite rare. Enlargement of the retro-peritoneal glands generally occurs in EXAMINATION OF THE DIGESTIVE APPARATUS. 34I secondary carcinoma as firm, immovable bunches, which are located in the cavity of the abdomen, about on the level with the umbilicus ; but sometimes they reach even deeper. They may compress the side of the inferior vena cava or the iliac vein. This may easily be con- founded with aneurism of the aorta, especially if it is a round tumor and propagates pulsations, and it may also even communicate a hum- ming murmur of stenosis from the aorta. We must again call attention to the importance of always emptying the intestines and bladder in all cases of this character where the diagnosis is difficult. This is not the place to explain the differential diagnosis of a large number of other affections of the abdomen, especially tumors of the uterus, ovaries ; also, pregnancy. (We refer for these to works upon Gynaecology and Obstetrics.) Examination of the Contents of the Stomach. In general we may obtain the contents of the stomach for examina- tion in two ways : when the patient vomits, or when, by emptying the stomach by means of an oesophageal catheter, we remove a portion of its contents. The catheter may be introduced for therapeutic purposes, or only for the purposes of diagnosis. The latter way of obtaining some of the contents of the stomach, it is readily seen, is the more exact for making a diagnosis, because we regulate the time for doing it by the object we have in view. First, with reference to the most important problem in the diagnosis of the contents of the stomach, namely, the examination of the stomach- digestion and the secretion of gastric juice, it is only necessary to empty the stomach to obtain the object required. At the same time, it is to be remembered that, in many cases, the examination of vomited matters or the fluid employed in rinsing out the stomach (especially in cases of poisoning) is of very great importance, and is, then, not to be overlooked. Artificial emptying of the stomach or removal of some of its contents for the purposes of diagnosis is, as has been said, the only method which enables us to form a reliable opinion regarding the gastric secretion and the process of digestion, for the reason just given, that such an opinion can usually only be formed when the contents of the 342 SPECIAL DIAGNOSIS. stomach have been obtained in a pure state and at a definite time after partaking of a meal. Vomiting can make the artificial emptying of the stomach unnecessary only when it occurs at exactly the time desired, and when the material vomited does not contain bile and not too much mucus (see below). Induction of emesis is contra-indicated when there is a tendency to hemorrhage, and in poisoning, where we have reason to think the poisons, as acids and alkalies, have caused erosion of the oesophagus or stomach. Sounds, even soft ones, are to be employed with the greatest caution if there has ever been any hemorrhage of the stomach, and also when there is any suspicion of an ulcer of the stomach or of a carcinoma that is eating through the walls. , Knowledge regarding the secretion of gastric juice and stomach- digestion is important really in three directions, because, by means of it, certain diseases may be recognized early, before inspection, palpa- tion, etc., are of any value, or where these methods do not in any way give any result. And even where other methods of examination have led to a positive conclusion, the diagnosis is not only made still more definite by this knowledge, but likewise the effect of a disease of the stomach upon its functions is determined. Lastly, there is sometimes a flat contradiction between the severe complaints of the patient regarding the stomach and a perfectly normal gastric digestion. In this case, the examination of the contents of the stomach immediately furnishes an explanatibn, as in some forms of "nervous" dyspepsia. EXAMINATION OF THE PROCESS OF DIGESTION. Stomach-digestion and its Disturbances. 1. After partaking of a meal which contains albumen and starch (fat does not come under consideration, because it is not digested by the stomach), there first occurs, under the influence of the ptyalin of the saliva, the amylolytic period of digestion : the starch contained in the food taken gradually disappears, and dextrine takes its place (achroo- and ery thro- dextrine) and there is a slight amount of grape- sugar ; any cane-sugar that has been taken is inverted, that is, is partly transformed into grape-sugar. These processes go on tolerably rapidly. Moreover, under the influence of microorganisms that excite fermenta- EXAMINATION OF THE DIGESTIVE APPARATUS. 34.3 tion, there occurs a partial lactic-acid fermentation of the grape-sugar, and hence lactic acid is formed (lactic-acid fermentation). This amylolytic period varies in length according to the size of the meal ; on the average, it lasts three-quarters of an hour. As a matter of course, it is entirely absent if only meat is eaten ; then, also, there is no lactic acid. Immediately after food is taken, the mucous membrane of the stomach begins to secrete muriatic acid and pepsin, and the stomach-juice mixes with the alkaline chyme. But at first the muriatic acid is in combi- nation, and we do not have free muriatic acid in any quantity until, on the average, one-half to three-quarters of an hour ; thus the amylo- lytic period is brought to a close, because the diastatic action of the saliva cannot go on in an acid solution. Instead, there begins the peptonizing action of the secretion of the stomach upon the albuminous bodies. The lactic acid disappears, and after the first hour none, or only a trace of it, can be detected. The stomach now contains an increasing amount of free muriatic acid, and this reaches its maximum, 0.2 per cent., or less, according to the size and character of the meal, from two to five hours after the time it was eaten. From now on there appear peptones and their precursors (syntonin and propeptone). Simultaneously with the free muriatic acid, the [milk-curdling ferment] rennet-ferment appears, under whose action the casein of the milk that has been taken is coagulated. The pepsin and rennet-ferment are not secreted as such by the mucous membrane of the stomach, but are formed by their zymo- gens [Q^firi, ferment], propepsin and rennet-zymogen. Both, under the influence of the muriatic acid, become transformed into pepsin and rennet-ferment. The lactic acid, although in very much larger quantity, has this effect upon the zymogens also. This second or muriatic-acid period of stomach-digestion, now shows the very important peculiarity that, during its course, under the influ- ence of the 0.2 per cent, of free muriatic acid, we have the antiseptic action of the gastric juice, by which the greater proportion of the microorganisms swallowed with the food and drink, particularly those that excite fermentation and putridity, as well as certain pathogenic ones, as the cholera bacillus, are destroyed. During the progress of stomach-digestion the food is mixed by peris- talsis, and partly by the aid of the ferments is comminuted and reduced 344 SPECIAL DIAGNOSIS. to a homogeneous mass. A small portion of the fluid resulting from_ digestion is absorbed ; but besides, at the pyloric end of the stomach, a continuous separation of the solid and fluid portions is going on, and the latter, during the whole period of digestion, passes little by little into the duodenum. 2. About six hours after a mixed meal of moderate quantity (much sooner after a smaller one), the stomach has become entirely empty, or at most contains only small particles of food. In the interval until the next meal, in the great majority of healthy persons, it appears that the stomach contains a very scant amount of clear fluid, with a neutral reaction, but no muriatic acid or pepsin. The stomach-digestion of nurslings has as yet been very little studied. According to Leo, the fasting stomach of a nursling almost always contains free muriatic acid, while during digestion free muriatic acid cannot at all, or only after an hour, be demonstrated ; this is not because there is none secreted, but because it is neutralized by the milk. Leo always found rennet-ferment, excepting in one case where there was rennet- zymogen. After half an hour, the greater portion of the milk has passed into the intestine, and in one, or at most two hours, the stomach is empty. Leo also thinks that the peptonizing of the milk in the stomach is a subordinate process. He regards the stomach as really a milk-reservoir, and perhaps as oifering a barrier to patho- genic micro5rganisms. 3. The chief points in regard to the eff"ect of pathological disturb- ances of the gastric secretion, of the motions of the stomach upon digestion, and the sterilization of the food and its further transporta- tion into the intestine, are as follows : Diminished secretion of muriatic acid (subacidity, hypacidity) interferes with the digestion of albumen and the power of the stomach to prevent decomposition and fermentation. When the muriatic acid is increased (superacidity, hyperacidity), free acid is present earlier, and thus there is interference with the digestion of the starches, because this only goes on while the contents of the stomach have an alkaline reaction ; likewise, the albuminous bodies are either normally, or more rapidly, peptonized, but in some cases it is remarkable that they are more slowly peptonized. Diminution of the muriatic acid generally appears to go parallel •with a diminution of the pepsin. On the other hand, this parallelism EXAMINATION OF THE DIGESTIVE APPARATUS. 345 is generally not present when there is superacidity ; with increase of the muriatic acid, there even appears to be an absence of pepsin. At least, this latter condition alone explains those cases where the pepto- nization of the albuminous bodies is prolonged, although the free acid is increased. Hence, with subacidity (inacidity) not only are the albuminous bodies imperfectly digested, but under the influence of the unrestrained development of microorganisms there occurs an abnormal decomposi- tion, and particularly of fermentation with formation of lactic acid in excess of the normal time and amount, as well as of other organic acids. This abnormal chemical activity in turn produces a paralvsis of peristalsis and muscular tone. The removal of the food stops for this reason, and probably also because the pylorus does not readily allow material to pass into the duodenum which is in an abnormal chemical, and in part physical, condition. The food remains too long in the stomach, and hence the stomach-digestion is prolonged. Lastly, if the condition persists, there is ectasia or dilatation of the stomach. It is to be remarked that by the word dilatation alone is always meant permanent dilatation, in contradistinction from temporary dilatation, which occurs after every meal. Quite similar in its final results is the efiect of a hindraiice to the emptying of the stomach, as is particularly frequent with pyloric stenosis ; only here the disturbance is on the whole much more marked. In stenosis of the pylorus, the difficulty in expelling the food is at first overcome by an hypertrophy of the muscular coats of the stomach ; but gradually there becomes manifest a disproportion between the strength of the stomach and the narrowed passage. Part of the con- tents of the stomach remain behind at the time of the next meal, and so the stomach becomes more and more dilated. There is an accumu- lation of material (peptones, albuminates, muriatic and phosphoric acid salts) ; and the muriatic acid, though free, is yet so interfered with that it no longer exerts its peptonizing and antifermentative action. There is no further digestion, but in place of it the food accumulated in the stomach takes on fermentation, with formation of a great amount of lactic acid, butyric acid, acetic acid, and alcohol. Through this abnormal chemical action, peristalsis and the muscular tone are still more weakened: there results a true eir cuius vitiosus of the motor and chemical phenomena. 346 SPECIAL DIAGNOSIS. 4. The chief points in the symptomatology of a distended stomach are the following : Subacidity or inacidity may be recognized by the diminished per- centage of muriatic acid or its absence. Further, there are signs of abnormal fermentation, of which the most important is the unusual duration and amount of lactic acid. Digestion is usually prolonged: the stomach is not empty after seven hours ; it still contains un- changed particles of meat, discernible microscopically or even macro- scopically. If we institute experimental digestion with the gastric juice in an incubator (see below), we find that it is diminished, or that it has lost its power to digest albumen. Superacidity during digestion shows an increased amount of free muriatic acid : usually the free acid makes its appearance too early ; the amylolytic period is thus shortened, and there is unchanged starch (microscopically and chemically demonstrable). Albuminous digestion in the incubator may be quickened. Increased difficulty in conveying the food from the stomach (especi- ally when due to stenosis of the pylorus) is connected with diminution or absence of free muriatic acid. Thus, the secretion of acid may be normal or even increased; but the muriatic acid is loosely connected with the bulky remaining albuminates, peptones, and salts, and hence is without chemical or antiseptic action on the one hand, and, on the other, its presence is " concealed," or cannot be established by the ordi- nary reactions. The great amount of lactic acids (butyric and acetic acids) is shown by the amount of fermentation. The diminished digestion of all kinds of food shows this plainly. In the incubator the albumen is not digested. 5. A peculiar anomaly as respects the gastric secretion consists in the fact that even Avhen the stomach is empty, muriatic acid, pepsin, and rennet-ferment, or propepsin and rennet-zymogen, are secreted (supersecretion, hypersecretion). A very considerable amount of this gastric secretion may be accumulated in the stomach ; and this is still more increased by the fact that, generally, the presence of an acid fluid in the stomach stimulates the secretion of saliva. The saliva swallowed is not, however, sufficient to neutralize the acid fluid. Schreiber has recently found that, even in persons who are in per- fect health, there is a small quantity of acid gastric secretion in the fasting stomach. This is in direct contradiction of the statements of EXAMINATION OF THE DIGESTIVE APPARATUS. 347 former authors. We will again enter (p. 355) upon the question of the gastric secretion in the fasting stomach. Mode of Procedure in Examining the Stomach- Digestion. The action of the stomach is divided into the chemical effect of its secretion and the assistance furnished by mechanically mixing the food and reducing it to small particles; the passing-on of the digested or sterilized material, and the absorption of a portion of it. Com- pared with that which is passed along, the amount absorbed seems to be small. These processes imply, as has been shown above, a certain length of time, which, in health and when a meal of moderate size is eaten, takes place within tolerably definite limits. Thus, the examination of the action of the stomach is connected with the determination of the' duration of digestion, the examination of the chemical action during digestion, lastly, the relation of the onward movement and absorption. I. Duration of digestion. Since the duration of digestion very much depends upon the kind and size of the meal, in making the examination, it is indispensably necessary to arrange similar conditions artificially. This requirement will be met by Leube's experimental meal, consisting of a plate of water-gruel, an ordinary piece of beef- steak, and white bread. After partaking of this meal, the patient takes nothing until seven hours from the time it was eaten, when the stomach is to be emptied by means of an oesophageal catheter. When the digestion is normal, the stomach after this space of time is empty, or contains only a few particles of the remains of the food. The stomach is emptied or washed out by means of an oesophageal catheter and a siphon, or exceptionally by employing a stomach- pump. We employ a soft N^laton's oesophageal catheter of at least 0.6 cm. internal diameter, to which we attach a piece of rubber tubing, 1 m. to 1.20 m. in length, with a short piece of glass tubing inserted along its course ; on the other end of the tubing is a glass funnel. The catheter is introduced without a guide ; in short, like any other oesophageal sound (see p. 293). After it has been used several times, the patient learns to introduce it himself, which he does by a sort of swallowing motion. Care must be taken lest the sound goes clear down, as has more than once happened. 348 SPECIAL DIAGNOSIS. If the stomach is quite full, then immediately after the catheter is introduced its contents well up through it, even if the rubber tube and funnel have not been attached. If the stomach is only moder- ately full, then it is often simply necessary to press the patient in order to bring up the contents of the stomach through the catheter. If, in this way, we do not receive anything, then, if there is no reason to suspect an ulcer or a carcinoma that will bleed easily, we may carefully aspirate with a stomach-pump. If, even then, we do not get anything, we must wash out the stomach with a small, but measured, amount of water, so as to see whether there are still some remaining particles of food. For this purpose we fill the tube and a part of the funnel with lukewarm water, before connecting it with the catheter, and then we pour more water into the funnel, hold it high and allow the water to run into the stomach. Next, before it is quite empty, we lower the funnel quickly into a vessel standing ready upon the floor : the tubing and funnel act as a siphon, and suck out the contents of the stomach. By filling and emptying it several times, the stomach will generally be completely emptied. If, in this way, we cannot obtain sufficient siphon-action, we can increase the suction power of the apparatus by placing the funnel in a vessel of water, extending the rubber tube, and then lifting the funnel a little in the water. If the rinsings of the stomach after seven hours contain at most only a few remnants of food, in most cases the digestion is normal. At any rate, if it is tolerably certain that there is diminution of gas- tric juice, we can almost certainly conclude that the power of the stomach to empty itself is unimpaired. But it is possible that there is superacidity, and, as a matter of course, supersecretion. If this is the case, we repeat the experiment, except that the catheter is introduced one or two hours sooner. In this way we determine the duration of digestion. If, after seven hours, the stomach still contains considerable por- tions of food, then digestion is prolonged : subacidity, or there is inter- ference with the physiological emptying of the stomach : stenosis of the pylorus, diminished peristalsis, or dilatation. Digestion of a simple meal (see above) lasting longer than seven hours is, in health, only observed in menstruating women. II. The chemistry of digestion. We may again employ Leube's experimental meal for investigating the chemistry of digestion. Some- EXAMINATION OF THE DIGESTIVE APPARATUS. 349 times we may make use of what we obtain while determining the dura- tion of digestion — that is, if seven hours after the meal we find the stomach yet full. If it is empty, then we repeat the experimental meal, and make the trial five hours after it. If we then find it empty (which, normally, is not seldom the case), we go back to four hours. In such cases, at any rate, where there is free muriatic acid, we endeavor to examine the contents of the stomach at the height of the muriatic- acid digestion — that is, at, the time when the muriatic acid has its chief value. This is usually about an hour before the close of the period of gastric digestion. Ewald has introduced an important simplification of this examina- tion. He gives a test-breakfast, consisting of a dry roll and luke- warm water or dilute tea, which are taken fasting. The period of digestion is thus so shortened that one hour after digestion has reached its highest point. In regard to the dispute as to which is preferable, the experimental meal or the experimental breakfast, we take the ground that the latter is decidedly to be preferred for settling the important points we are seeking, particularly for the practising physician, who is not able to control his patients, and hence must choose the experiment lasting one hour rather than the other, where he is obliged to be away from his fasting patient from four to six hours. But, on the other hand, we must, with others, emphasize the fact that the experimental breakfast makes too slight a demand upon the stomach to permitof a nice judgment as to what it can do. Hence, our experience leads us to believe that the experimental breakfast may mislead us in two diametrically opposite directions — in many cases, by the digestive power of the stomach seem- ing greater than it is ; or, in other cases, that it does not appear to be as strong as it really is, because it is too little stimulated (in certain nervous dyspepsias, also in many cases of chronic catarrh, as alcoholic catarrh). The greater "cleanliness" of his experiment, as Ewald maintains, cannot be recognized as regulative ; after filtration, in all cases, we obtain after the experimental meal a perfectly clear fluid, which responds very well to the reactions presently to be described. Jaworski gives as the experimental meal the albumin of two boiled eggs with 100 gm. of water — a simplification which we do not think useful or necessary. It is an unnatural experiment, as the well-known instinctive disgust for food of pure albumin proves. 350 SPECIAL DIAGNOSIS. The following procedure is recommended for making the examina- tion : 1. We satisfy ourselves whether there is any bile, blood, or pus in the contents of the stomach (see Vomit). If there is not, then we filter a portion for further examination. 2. We carefully examine the residuum upon the filtering-paper with the naked eye. If an experimental meal has been given, then we observe how thoroughly the masses of meat have been macerated, especi- ally whether the maceration is uniform ; further, we notice whether there are any unchanged particles of bread. (Regarding certain things seen under the microscope, see Vomit.) 3. We test the reaction of the fluid-filtrate with litmus (paper or tincture). An acid reaction may be due to muriatic acid or organic acids, or both. 4. Then follows the qualitative examination for free muriatic acid and lactic acid. For testing for free muriatic acid we recommend the test with tropaolin-paper.^ W^e moisten the paper with a drop of the filtrate, then place the bit of paper in a watch-glass and heat it. If there is free HCl, the tropaolin-paper first becomes brown, then, as it dries, lilac color. Approximately equivalent is the test with a saturated alcoholic solution of 00-tropaolin, which has been mixed with a double quantity of the filtrate in a small porcelain dish, distributed by whirling. After pouring ofi" the surplus, it is to be slowly heated : free HCl yields a lilac-red reflection. Lactic acid gives no reaction, even when tolerably concentrated (0.6 per cent.). It is very distinct when the solution of HCl is pure — about 0.05 per cent. In the pres- ence of albumin, peptones, phosphates, it is much less distinct. Still more certain and much more distinct, while its distinctness is much less affected by other substances, is the phloroglucin-vanillin test. The reagent consists of phloroglucin 2 parts, vanillin 1 part, to absolute alcohol 30 parts. Of this, one or two drops are placed in a shallow por- celain dish, with an equal amount of the filtrate, and carefully heated. Free HCl gives a deep red, or, if the quantity is small^ a bright rosy-red deposit; if there is no HCl, then the deposit is brown-red or brown. It is distinct — even to 0.05 per thousand. It is very 1 Filter-paper soaked with a saturated solution of 00-Tropaolin. EXAMINATION OF THE DIGESTIVE APPARATUS. 351 nearly absolutel}'^ certain ; its only drawback is that the reaction takes place also in the presence of sulphuretted hydrogen (hence, after tainted eggs have been eaten). This test very much surpasses all others. It is sufficient to employ this only. Of the numerous other tests we only mention : The reaction with methyl-violet, which is applied as follows : two reagent-glasses are half-filled with a transparent solution of methyl-violet, and to this some of the filtrate is added. Free HCl colors methyl-violet blue. The reaction is not very distinct, nor is it very reliable; it can be imitated by table-salt, and it may be concealed by albuminate, pep- tone, etc. There are also to be named : congo-paper, blue ultramarine, and, lastly, resorcin, recently recommended by Boas (resorcin 5 parts, sugar 3 parts, dilute spirit to 100 parts). The examination for lactic acid is conducted in the way suggested by Uffelmann : to about 100 gm. of a 2-per-cent. solution of carbolic acid we add one to two drops of a solution of chloride of iron, when the mixture becomes steel-blue. To this we add some of the stomach- fluid. If lactic acid is present, the solution is discolored and becomes yellow or yellowish-green ; on the other hand, if there is only HCl, the solution becomes clear, like water. Butyric and acetic acids give it a more yellowish-red color ; moreover, they are recognized by their odor, at any rate after shaking up some of the stomach-fluid with ether and evaporating the ether. The test is a very delicate one, and shows 0.01 per thousand of lactic acid. Its certainty is somewhat detracted from by the fact that lactic-acid salts give the same reaction. It is more important that alcohol, sugar, and acid salts cause the solution of chloride of iron and carbolic acid to assume a straw-yellow color. For this reason, in case there is no pronounced greenish-yellow, but a straw-yellow coloration, we must employ a more certain method : we simply agitate some of the filtrate with ether in a reagent-glass, pour off the ether, and then evaporate the residue over hot water, not a flame. We dissolve the deposit in water, and apply Uffelmann's reaction by the addition of a few drops of the reagent (Ewald). 5. The quantitative examination of the muriatic acid has a certain value in subacidity, but still greater when there is a suspicion of superacidity. Let it be once more remarked that the latter may be the case not only when the duration of the digestion of albuminous 352 SPECIAL DIAGNOSIS. material is diminished, but also when it is normal, or even when its duration is prolonged. Two methods may be employed, in both of which the supposed time of greatest amount of HCl is selected. Pus, blood, bile, a large amount of saliva must be excluded. Repeated examination is necessary. If the quantity of HCl exceeds 0.3 per cent., it may certainly be regarded as pathological. As much as 0.6 per cent, of free acid has been found. First method : The determination of the total acidity is made by neutralizing it with a normal solution of soda. Of course, this will be understood to have value only in case there are no organic acids present, or not an appreciable amount of them. It is treated with a 1 to 10 normal solution of soda and litmus or phenol-phtallein ; 1 c.c. of the 1 to 10 soda solution neutralizes 0.0365 HCl. Second method : As suggested by Giinzburg, we can employ the phloroglucin- vanillin reaction for an approximative quantitative de- termination of HCl, by remembering that the reaction still positively takes place in the presence of 0.05 per thousand of HCl. Hence we have to dilute the stomach-fluid with a definite quantity of distilled water so long as the reaction is produced sufficiently to be recognized. Since Giinzburg's reaction is not disturbed by lactic acid, the simul- taneous presence of lactic acid does not interfere with this method. It is still very desirable that there should be an exact revisional proof of this method. 6. Examining the digestion in an incubator. The examination of the digestive power of the gastric juice is of especial value for demon- strating pepsin. At any rate, experience shows that when there is free muriatic acid, pepsin is usually present ; on the other hand, when muriatic acid is absent, no pepsin is present, for the reason that the mucous membrane of the stomach does not secrete pepsin itself, but secretes its zymogen, propepsin, and because muriatic acid has the exclusive, or at least the chief, power to form pepsin out of propepsin. For these reasons, it may suffice, in most cases, to examine for muri- atic acid alone. But the thorough examination is of the greatest value for arriving at a complete judgment. We test the digestive power of the gastric juice upon a piece of the white of a hard-boiled egg. A piece about a centimetre square and a millimetre thick placed in a reagent-glass full of normal stomach-fluid should be dissolved in about an hour. If the solution is delayed, or EXAMINATION OF THE DIGESTIVE APPARATUS. 353 does not take place at all, it proves that there is a deficiency in the normal amount of pepsin only when we are able to determine that there is also a deficiency in muriatic acid. For this reason, \t is best to conduct the examination simultaneously in two reagent glasses, to one of which a few drops of HCl have been added. The coagulating eff"ect of the gastric juice — that is to say, of the rennet-ferment — upon the casein of milk is proved by the fact that, at the temperature of the body, neutralized stomach-filtrate with neutral (or amphoteric) milk is coagulated ; in fifteen to thirty minutes, if the rennet-ferment is present, there is coagulation of the casein. This test, it seems, can generally be omitted if it concerns nurslings, in whom it is of special interest : for it has been shown that when free HCl and pepsin are present, the rennet-ferment is never absent; even in most cases of absence of both the others, rennet-ferment indeed seems not to be met with, but rennet-zymogen, which requires muriatic acid in order to transform it into rennet-ferment. In order to prove the presence of rennet-zymogen in gastric juice which is deficient in HCl and rennet-ferment, we supply the deficiency by adding HCl and then allow it to stand in an incubator for two hours, after which we apply the test for the ferment mentioned above. In atrophy of the mucous membrane of the stomach, there is entire absence of rennet-zymogen, as well as of HCl and pepsin. Of the somewhat difficult methods of examining the products of digestion we can here mention the two following : 1. The transforma- tion of the starches into erythro- and achro5-dextrin can be quali- tatively followed by means of dilute Lugol's solution (iod. 1 part, iodide of potash 2 parts, aq. dest. 200 parts); it colors starch blue; erythro-dextrin, purple-red; achro5- dextrin remains colorless or be- comes yellow. A mixture of starch and dextrin with the first drops of the iodine solution becomes colorless, but upon further addition it becomes red and then blue. 2. Peptone and propeptone in alkaline solution, upon the addition of a solution of sulphate of copper, give a beautiful purple color ; albumin makes it a blue- violet ; hence, on account of this similarity of colors, it is often extremely difficult to distinguish albumin from peptone, particularly if the stomach-fluid is turbid. III. The effijrt has been made in various ways to ascertain what part the movements of the stomach play in digestion. No method 23 354 SPECIAL DIAGNOSIS. that has thus far been devised meets the requirement ; hence, we only mention them very briefly. The peculiarity of salol that it splits up into salicylic acid and phenol only in the intestine, whereupon the appearance of salicylic acid in the urine is easily proved, has been employed by Ewald to determine the rapidity of the passage of food from the stomach into the intestine. Salicylic acid is recognized in the urine after the addi- tion of chloride of iron by the violet reaction in the urine. In order to recognize the first traces, we must make the test upon an ethereal extract [of the urine. (Compare what is said later regarding the Urine after the Administration of Medicines. y\. Ewald found that in health the first positive reaction took place one- half to one hour after it had been taken ; when the process of transportation from the stomach had been interrupted, it was later. However, the results of this procedure seem to be quite variable. The same thing must be said of the use of pills of iodide of potash coated with keratin, which very evidently are preferable, because we do not need to employ the urine in proving the absorption of the iodide, but we can make use of the saliva. But Stintzing has found that these pills are sometimes dissolved in the stomach. Finally, Klemperer has attempted a method, which, from a purely technical standpoint, is very exact, but is decidedly impracticable. He introduces into the empty stomach 100 grammes of olive oil, and, after a certain interval, washes the stomach out. From healthy stomachs he found that, in two hours, 70 to 80 grammes of the oil had been discharged into the intestine, while in cases of catarrh of the stomach about half, and in one case of atrophy a quarter, of that amount had in the same time disappeared from the stomach. This method is less objectionable, because the oil is sometimes not borne in the patient's stomach — it may even be rejected. But it is much more so because it does not sufiiciently irritate the stomach. Lastly, the absorptive power of the stomach has been frequently the object of examination. Penzoldt gives 0.2 iodide of potassium in gelatin capsules, and then at once tests the saliva to see whether the capsule was close and free from iodide of potassium upon its outer surface. For this purpose we have the patient, moment by moment, spit upon a piece of filter-paper saturated with a solution of starch, upon which we place a trace of EXAMINATION OF THE DIGESTIVE APPARATUS. 355 fuming nitric acid ; the appearance of the iodide in the saliva Avill be recognized by the red and blue coloration of the paper. In health, the iodide will make its appearance, if it has been taken upon an empty stomach or three hours after eating, in from six and a half to eleven minutes ; if directly after a meal has been eaten, after twenty to forty-five minutes. In cases of dilatation, if taken upon a fasting stomach, its earliest appearance is after fifteen to thirty minutes. It also seems to, be delayed in carcinoma, chronic catarrh, and in fevers. The question is, whether we can draw a conclusion as to the absorption of the products of digestion from the behavior of the iodide. The examination of the fasting stomach has for its object the determination of the behavior of the gastric secretion after the com- pletion of stomach-digestion. Hence, it is conducted with reference to the diagnosis of a possible hypersecretion. Method. Recent investigations upon this subject show that it is very important to avoid making use of the secretion of the stomach which results from any mechanical irritation. Hence, we must be very cautious and proceed very rapidly. We recommend a Nelaton's sound, without an eye, but, instead, a number of fine openings at the end, which is to be introduced into the stomach some hours after we have washed it out in order to make sure that it was empty. Or, still better, we first determine the duration of digestion, then we allow the stomach to be quiet after the expiration of the last meal. Then a stomach- pump is quickly introduced ; aspirate, withdraw the sound, and empty it into a vessel. Next we examine the fluid thus obtained as to its reaction, and, if acid, for muriatic acid ; further, as to its digesting qualities. For passing judgment upon the results of this procedure and its diagnostic significance, see the following pages. Finally, on account of its historical interest, we mention here the method given by Leube, but superseded by his experimental digestion. He introduced ice-water into the empty stomach and then aspirated it, in order to obtain for examination the gastric secretion pure — that is, diluted with water. Results of the examination of stomach- digestion : their value. 1. If the examination of the duration of digestion shows that it is not prolonged, then, as a rule, the process of digestion is normal ; but 356 SPECIAL DIAGNOSIS. the period of digestion may be shortened, and this sometimes is the case when there is superacidity. If the period of digestion is pro- longed, this must be further investigated. 2. Free muriatic acid, which belongs to the time when normal digestion is at its height, may be completely wanting (inacidity, anacidity). This almost uniformly occurs when there is complete destruction (corrosion) of the mucous membrane of the stomach, when it is atrophied, or has undergone amyloid degeneration. Further, inacidity is almost always present in carcinoma ventriculi with dilata- tion, more rarely, although also yery frequently, in all other kinds of dilatation. Of these we must mention especially that which occurs with chronic gastric catarrh. The dilatation produced by the scar of an ulcer (at the pylorus), or accompanying an ulcer, is associated with diminution or absence of free HCl. Subacidity, or even inacidity, is further observed in severe anaemia of all kinds and with fever, and, lastly, in certain cases of nervous dyspepsia. Accompanying this condition is the more or less markedly increased formation of lactic acids (butyric, acetic acids, alcohol) — a sign of abnormal fermentation. In very severe cases it may result in fetid decomposition of the contents of the stomach. Moreover, for an unusual length of time or continuously, there may be undigested masses or fine particles of meat. For reasons that are readily understood, the behavior of the stomach in cases of phthisis has been very much studied ; the results vary in a very remarkable degree. The general conclusion from these examinations (Liebermeister, Hildebrand, Brieger) seems to be that in cases of severe phthisis with continued fever, very often no free HCl, sometimes even no rennet-zymogen, is found, but that free muriatic acid is also sometimes wanting in remittent fever. At any rate, the ex- amination of the stomach-digestion in phthisis for prognostic and therapeutic reasons is to be recommended in every single case. 3. Increased amount of HCl at the height of digestion, shortening of the time (normal maximum of one hour) during which lactic acid is present, are signs of superacidity. Thus the period of digestion is shortened, or normal, or sometimes even prolonged. As evidence of disturbed amylolysis, we have unchanged starch during the whole period of digestion. EXAMINATION OF THE DIGESTIVE APPARATUS. 357 Superacidity is present in the majority of cases of ulcer, also in certain nervous dyspepsias (gastroxynsis, pyrosis liydrochlorica), lastly in acute and sometimes in chronic gastric catarrh. It is also observed in the forms of insanity accompanied with depression. 4. It has been shown by recent investigations (Schreiber, and par- ticularly E. Pick), regarding the significance of the presence of acid- secretion of the stomach, that a positive conclusion from the examina- tion can only be drawn AVith caution, because the irritation of the sound seems to stimulate the stomach to pour out its secretion very rapidly. We can only diagnosticate supersecretion (hypersecretion), Avhen by a rapid, careful procedure at least about 200 c. c. of acid gastric secretion are obtained. Supersecretion occurs in the gastric crisis of tabes and certain neuroses, as hysteria and nervousness. It is sometimes also observ^ed with ulcus ventriculi, in individual cases of carcinoma, and in acute and chronic catarrh. Emptying the stomach for therapeutic purposes, or Avashing it out, must be undertaken, in the first place, in cases of recent acute poisoning, and frequently for the purpose of diagnosis. This is the case in almost all cases of poisoning, where the poison has been swallowed. But it must be remembered that in poisoning with substances that are corro- sive, as acids and alkalies, on account of the danger of perforation of the oesophagus or stomach, the sound must be used with the greatest caution, or even not at all. The detection of the kind of poison in the contents of the stomach belongs to toxicology. Some poisons entirely escape detection. What has been said above regarding the examination of the con- tents of the stomach, explains the therapeutic use of washing out the stomach when it is diseased, in that it can be employed for observing the course of the disturbance of digestion in diseases of the stomach. For instance, it is evident from what has been said that it is not without value occasionally to institute a daily washing out of the stomach, in case it is diseased, to determine whether it contains lactic acid many hours after the last meal was taken. Also, frequent micro- scopical examination of the sediment of the rinsings of the stomach (in sarcina ventriculi, etc., see Vomit) is of undoubted value. 358 SPECIAL DIAGNOSIS. Vomiting, and the Examination of what is Vomited. The act of vomiting consists of one or several strong forcible contrac- tions which occur simultaneously in the oblique abdominal muscles and the diaphragm. In this way the stomach is compressed, and, by the simultaneous opening of the cardiac orifice, its contents escape upward. Otherwise the stomach takes no active part in expelling the food. From the not infrequent presence of bile in the last portions that are vomited toward the end of a severe effort at vomiting, it is evident that the pylorus also sometimes does not entirely close. In this connection Ave do not include the vomiting, or rather the expulsion of food from dilated parts of the oesophagus when there is stenosis or diverticula. (See Examination of the CEsophagus.) Vomiting may occur in a great variety of ways, and in diseases which differ greatly in character. We suppose that the so-called vomiting- centre is situated in the oblongata. This may be stimulated from the periphery, chiefly through the sensory portion of the vagus, and so give rise to reflex vomiting. Moreover, it may be stimulated directly or by impressions from other portions of the brain (central vomiting). Children generally vomit easier than adults. There are also indi- vidual differences. Clinically, we distinguish : 1. Vomiting occasioned by reflex influences from the stomach. It occurs in all diseases of the stomach, but also in irritation of the mucous membrane of the stomach by different poisons, certain emetics, etc., and also by overloading the stomach. 2. Reflex vomiting caused by other abdominal organs, as from the female sexual apparatus in menstruation, pregnancy, diseases of the sexual apparatus ; from inflammation of the peritoneum ; also, in renal and biliary colic, etc. Likewise, vomiting may be caused by irritation or tickling of the fauces. Probably here also belongs vomiting which occurs at the end of a severe fit of coughing, as in whooping-cough and phthisis. 3. Central vomiting. It may result from irritation of the brain of various kinds : as different evident diseases of the brain, especially tumors ; in the different forms of meningitis ; in neuroses, particularly hysteria ; and from uraemia. Vomiting occurs also in the beginning of certain acute infectious diseases, as pneumonia, scarlet fever, small- pox, erysipelas, [remittent fever]. EXAMINATION OF THE DIGESTIVE APPARATUS. 359 Vomiting is almost always accompanied by certain other phenomena: previous malaise, often severe sweating, quickening of the pulse; exhaustion, with the feeling of relief, but also evidences of collapse. In diseases of the brain, it sometimes occurs without any preliminary indisposition, even quite suddenly and unexpectedly. As regards the time when the vomiting begins, in diseases of the stomach, it often (not always) follows eating. Also in peritonitis, vomit- ing is often excited by th,e taking of food ; but here also it takes place quite independently of this. The vomitus matuiinus of drunkards, as a rule, regulacly occurs early in the morning, when the stomach is empty. Also in certain nervous dyspepsias there are apt to be attacks of vomiting when the stomach is empty. When there is severe vomit- ing without phenomena of stomach or other abdominal disturbances, we must take into consideration the other conditions named above — acute infectious diseases, disease of the brain, uraemia, hysteria — according to the circumstances. The frequency of vomiting is extraordinarily variable, and is of little moment in diagnosis ; only that it might be mentioned that in very marked dilatation of the stomach, from pyloric stenosis, vomiting occurs remarkably infrequently, but in most cases tolerably regularly, at intervals of several days (but then very profusely). There may be eructation in all the conditions in which vomiting occurs. It is observed, especially, in slight and severe diseases of the stomach of all kinds. The odor of the eructation corresponds to that of the contents of the stomach, as a matter of course. (See under Odor of the Vomit.) In individual cases, combustible gases have been observed (marsh gas, and probably also other gases). There occur ■with nervous persons very distressing and entirely odorless eructa- tions. The Vomit. "When we examine the vomit, we notice the quantity, the macro- scopical and microscopical appearance, the odor, and the reaction. The chemical examination can probably occasionally enable us to judge of the character of the stomach-digestion. This is especially the case in those diseases which we cannot include in a methodical investigation, as, particularly, inclination to hemorrhage, etc. (See above.) Of course, we must consider the relation of the vomiting to 360 SPECIAL DIAGNOSIS. the time of the last meal, and what this meal consisted of. The points of view are to be taken from what has been said above regard- ing experimental digestion. Wnere there are macroscopical appear- ances of blood and coloring matter of bile, we must farther apply the chemical tests for these substances. The quantity vomited. Here we must consider the time and fre- quency of the vomiting, as well as the amount of food taken. When there is vomiting from an empty stomach, there is usually only a little mucus, seldom much mucus or saliva that has been swallowed {vomitus matutinus potatorum), or more or less pure gastric juice (hypersecre- tion). In acute infectious diseases, diseases of the brain, uraemia, sometimes scarcely anything at all is vomited. A vomiting which seems to result from the ingestion of food, but the amount of which considerably exceeds the quantity of food and drink last taken, is an almost mathematically sure proof of dilatation of the stomach. Here the contents of the stomach may accumulate for a number of days and then be thrown off en masse, to the amount of several litres. The macroscopical appearance. This will naturally depend very much upon the food taken. It was mentioned above, when speaking of the experiments with digestion, that under some circumstances we can form a conclusion regarding digestion by the comminution of the food. Some foods, as coffee, cocoa, red wine, huckleberries, etc., markedly color the vomit, and may sometimes give rise to mistake, if it is superficially examined, by causing one to think that there has been hsematemesis (the laity being not infrequently thus deceived, and hence we must be very careful in accepting the anamnesis). When preparations of iron have been taken, the vomit is black ; but it is also sometimes black in acute lead-poisoning. Apart from the food, we can, from some prominent constituents (when the contents of the stomach are abnormal), make certain important distinctions in what is vomited, just as in the sputum. Watery, watery-mucous, mucous vomit. The first and the second named may ordinarily have two very different meanings. In both cases we have a somewhat turbid fluid, resembling saliva or fluid mucus, which is vomited from a fasting stomach. It has an alkaline reaction, and usually indicates chronic gastric catarrh. The fluid consists of mucus from the mucous membrane of the stomach, and of EXAMINATION OF THE DIGESTIVE APPARATUS. 3(51 saliva that has been swallowed. In this way the frequently men- tioned "water-brash" of drunkards {vomitus matutinus potatorum) especially manifests itself in the early morning, immediately after rising. Also such vomiting occurs (rare) in nervous dyspepsia. If the fluid smells sour, and has an acid reaction, and if it shows the muriatic acid reaction and power of digestion, then we have gastric juice secreted by the empty stomach : hypersecretion. This gastric juice is often over-acid — hypersecretion with hyperacidity (over 0.3 per cent.). This occurs in certain kinds of nervous dyspepsia (gas- troxynsis, gastroxia ; also hysteria ; tabes), but also in dyspepsia fol- lowing healed ulcer, and acute and chronic gastric catarrh. In these cases the quantity vomited may amount to several hundred grammes. A special form of watery-mucous vomit is peculiar to Asiatic cholera. In this disease there is often vomited a great quantity of alkaline, stale-smelling fluid, like rice-water (very like the stools of cholera) (which see). The small flocks, like rice, are mucous flocks. It is not possible to separate mucous from watery-mucous vomit. Sometimes a great quantity of mucus is observed in chronic catarrh of the stomach. Vomiting of bile. As previously mentioned, bile may be mixed with every vomit, and this is especially apt to be the case in very severe efforts at vomiting, so that toward the end almost pure bile is ejected. The vomit looks yellowish-green or green, and smells decidedly bilious. It exhibits the reaction of the coloring matter of the bile. (See Urine.) A grass-green bilious vomit, occurring with tolerable uniformity, with every act of vomiting whether violent or not, is a not unimpor- tant peculiarity of peritonitis, and of marked obstruction of the bowels. Bloody vomit, vomiting of blood (haematemesis). Blood from the nose, throat, and oesophagus may become mixed with the vomit in the act of vomiting. Small quantities, in streaks, are usually of no sig- nificance. Large hemorrhages from the oesophagus, as in varices of the lower portion of the oesophagus, and in cirrhosis of the liver, usually after it has run down into the stomach, cause severe haemate- mesis. Also blood from the nose, and even from the lungs, may reach the stomach and be vomited up (see p. 170). We must be careful not to confound such an occurrence with hemorrhage of the 362 SPECIAL D/AGNOSIS. stomach. In doubtful cases the anamnesis is of less value than the examination of the stomach, nose, and lungs. (See p. 170 for further particulars regarding the distinction of hemorrhage of the lungs from that of the stomach.) Small points of blood and streaks in the vomit, moreover, even if they come from the stomach, according to our experience, are generally without significance ; that they are from the stomach is proved by the presence, not infrequently, of bloody suffusion of the mucous mem- brane of the stomach at the autopsy. Streaks of blood frequently recurring, whose source the autopsy proves to be the stomach, are not at all uncommon in cirrhosis of the liver. Bloody vomit, from hemorrhage of the stomach, takes place in ulcer of the stomach, carcinoma ventriculi, portal engorgement from cir- rhosis of the liver, closure of the portal vein (rarely in general venous stasis), in severe lesions of the mucous membrane of the stomach by corrosive poisons, also in general hemorrhagic diathesis (see cutaneous hemorrhages), in yellow fever, melsena neonatorum ; in the last-named cases there usually occurs simultaneous hemorrhage of the bowels. Very decided, and sometimes fatal, hsematemesis is chiefly peculiar to ulcus ventriculi (also melsena). In carcinoma we notice very fre- quently repeated, but always moderate, hemorrhages. Moreover, in all these conditions the vomiting of blood may be entirely wanting, either because there is no escape of blood into the stomach, or because the blood is nqt vomited. When we suspect hemorrhage of the stomach, which is not vomited, we are to examine the stools (which see). Sometimes, in ulcer of the stomach, the patient becomes suddenly pale, may collapse, or may even die from a hemorrhage of the stomach, Avithout there being any vomiting of blood. In order to observe exactly an ulceration of the stomach, it is particularly necessary to observe uninterruptedly the stools. Pure blood is seldom vomited, unless there is a great quantity of it, or it is vomited directly after or during the hemorrhage. Moreover, it is never of so clear an arterial color as in hemorrhage of the lungs. The blood is almost always more or less changed by the gastric juice : it is very dark, black -brown, and has an acid reaction. If it has been in the stomach for some time, as is quite often the case in carcinoma with dilatation, because the hemorrhages are usually small and there EXAMINATION OF THE DIGESTIVE APPARATUS ggg are long pauses between the hemorrhages, under the influence of the acids, by the breaking-up of the red corpuscles and the haemoglobin, and the appearance of hsematin, it becomes coffee-brown and also of the consistence of coffee-grounds. Then, in case it is abundant, it is easy, with some experience, to recognize it ; yet it is easy to confound it with other substances, as coffee, cocoa, etc. (See above.) For this reason, and because here the microscope is deceptive, it is prefer- able, in this case, always^ to make a special test of the blood. Testing the blood: 1. Very correctly, the haemin test is generally employed, because it is certain and distinct. The following is the best way to make it : Some of the coffee-grounds material is filtered ; a Fig. 92. o \^ Crystals of hsemin. Zelss's apochromatic lens No. 8, eye-piece No. 8, camera lucida. Magnified about 300 diameters. little of this is to be evaporated in a watch-glass. Scrape off some of the dried material, mix it with a trace of finely-pulverized salt, place the dried mixture upon an object-glass, cover it with a glass cover, and allow one or two drops of glacial acetic acid to flow under it ; then the acetic acid is again evaporated very slowly, and, after it is thor- oughly dry, one or two drops of distilled water are allowed to flow under to dissolve any crystals of salt that may be present. Under the microscope, there can be seen crystals of hsemin (hydrochlorate of hsematin) in coffee-brown or reddish-brown crystals in rhombic plates, which must be considerably magnified, as the crystals are very small. 364 SPECIAL DIAGNOSIS. The following method (an adaptation to the vomit of Heller's test for blood-coloring material in the urine, which see) leads to a result more quickly : We place some of the filtered stomach-fluid in a reagent-glass, with a like quantity of normal urine, make it strongly alkaline with liquor potassse, and heat it. The urine-phosphates are precipitated and carry with them the coloring-material of the blood, and when blood is present, we have a cloudy, flocculent, reddish-brown deposit. Vomiting of pus. Pus, as a macroscopically visible constituent of the vomit, is somewhat unusual, and is only observed in isolated cases of phlegmonous gastritis or of abscess of a neighboring organ, breaking into the stomach. Probably it can then only be observed when it pours into the stomach in such quantities and so quickly that it makes the contents of the stomach alkaline, for only thus will it avoid immediate digestion. Regarding separate white corpuscles, see below. Fecal vomiting (miserere, ileus). In this condition, either there are considerable quantities vomited which do not look distinctly feculent, probably coming rather from the stomach or the upper portion of the small intestine, and the fecal addition is betrayed by its odor, or there are distinctly fecal masses, even balls of excrement. This kind of vomit occurs in severe diffuse peritonitis and in serious occlusion of the bowels (see Inspection and Palpation of the Abdomen). It indicates an extremely serious and, in most cases, fatal condition ; yet it does not by any means have the absolutely fatal significance which was formerly ascribed to it. As visible admixtures which can be seen with the naked eye, are still to be mentioned : Round worms, which come from the small intestine, probably brought into the stomach by the first efforts at vomiting, and are afterward seen in the material vomited up. It is a startling appear- ance, but in itself has no significance. Also : Membranous rags of echinococcus, in case one should break into the stomach from the liver or spleen. In these cases, the microscope sometimes shows the scolices and hooks of the parasite (see illustration, p. 183). Moreover, in individual cases, there are found in the vomit, also, oxyuris, anchylostomse, trichinae (see these under Stool). Microscopical examination. This is of very little independent EXAMINATION OF THE DIGESTIVE APPARATUS. 365 value in determining the processes of digestion. In vomiting which takes place during digestion, we, of course, expect to find portions of food in very varying condition, according to the time the vomiting- occurs. Starch-grains in considerable quantity, for the time when the amylolytic digestive period ought to be past, indicate incomplete amylolysis, as is almost always produced by hyperacidity (in conse- quence of the too early appearance of free muriatic acid). Mucous corpuscles are found in watery and mucous vomit; epithe- lium, from the mouth, throat, oesophagus, also sometimes from the stomach, is observed ; unchanged red blood-corpuscles are very rare ; in hemorrhage of the stomach, the microscope generally is useless, because the red blood-corpuscles are broken up. Also, it is rare to find white blood-corpuscles that are well-preserved. Vomited material (Jaksch). a, Muscular fibre; 6, white blood-corpuscle; c,c!,c", flat and cylindrical epithelium; d, starch-corpuscles; e, fat-globules; f, sarcina ven- triculi ; g, yeast-ferment; h, i, cocci and bacilli (those near h were once found by Jaksch in a case of ileus, hence arising from the intestine); k, fat- needles, connective tissue; I, vegetable cells. Sarcina ventriculi (schizomycetes) and torula cerevisiae (yeast-fun- gus) are not entirely without value, as indications that the stomach retains its contents for a long time, as, especially, in dilatation. 366 SPECIAL DIAGNOSIS. Of the two fungi, the sarcina is the more important. If it is not macerated or deformed by pressure with the covering-glass, it is generally easily recognized, when strongly magnified, by its peculiar resemblance to a ball wrapped with a string crossing at right-angles. It is stained a reddish-brown by a weak solution of iodine, or iodide of potassium. Torulse of diiferent kinds and sizes (the latter very much like a small white blood-corpuscle, generally smaller) are easily distinguished as small bodies strung along together, sharply defined, which refract the light and are egg- or elliptical-shaped. Isolated ones are observed in the contents of the stomach with normal digestion. When the quantity is considerable, it shows that it has been a long time in the stomach, whose contents have undergone alcoholic fermentation. Other different kinds of bacilli and cocci, which have only recently been carefully studied, are found in the vomit, but as yet they have no diagnostic value. Also, there are found in the vomit aphthae (probably originating in the oesophagus, see above) and favus fungus, achorion Schonleinii. Reaction of the vomit. This is usually acid from muriatic or organic acids (see above, under Digestion). It may be alkaline when a considerable quantity of blood is vomited, as in water-brash, the watery vomit of Asiatic cholera ; also, rarely, in putrid vomiting, as in ulcerating cancer of the stomach, and in the vomiting of kidney- disease (see below, under Odor). Moreover, oesophagus-vomiting manifests itself by being always alkaline (see under Examination of the (Esophagus). Odor of the vomit. In many respects this is very important. Thus, particularly the pi'esence of fatty acids is recognized wath great certainty by their characteristic pungent odor. The odor is very important in many poisons, as with phosphorus (odor of garlic), bitter almonds, or nitro-benzole (odor of bitter almonds), ammonia, carbolic acid, etc. There is fecal odor with ileus, cadaveric odor in ulcerating car- cinoma, also in fresh hemorrhage of the stomach. The odor is ammoniacal in nephritic patients, especially when there is uraemia. It is thought to result from the separation of urea by the mucous membrane of the stomach, by the urea in the stomach changing into carbonate of ammonia. examination of the digestive apparatus. 367 Examination of the Feces. As in examining the contents of the stomach, the inquiring physician must pursue his task from two points of view : On the one hand, he is to draw a conclusion from the character of the intestinal discharges as to the intestinal digestion, and any pos- sible disturbances of it from the abnormal chemical changes, and also an opinion regarding the present disease. On the other hand, he is to form a diagnosis directly from the occurrence of certain products of disease, or even of substances generated by disease, as intestinal parasites or microorganisms found in the stools. Unfortunately an explanation from the point of view first mentioned is difficult for sev- eral reasons : first, because we have to do with the last step of an extremely complicated process, and then, in many respects, we do not sufficiently understand this process itself, or its pathological variations. With reference to the other point, and especially regarding organic exciting causes of disease, we have only a few sure principles, part of which are old, and part have only recently been acquired. We have to consider : The intestinal discharges, with reference to their frequency and their possible, usually subjective, accompanying symptoms The more particular examination of the stools : quantity, consist- ence, or form, color, odor. In addition, there are the admixtures which are visible by the naked eye, and those to be seen only by the aid of the microscope. As yet, it is not possible to form an estimate of the intestinal diges- tion by the character of the intestinal fluid. It is well known that sometimes (especially by evacuating the fasting stomach) there enters into the stomach a fluid mixed with bile which is to be regarded as a mixture of pancreatic and intestinal fluids, since with an alkaline reac- tion it digests albumin, starch is changed into dextrine and maltose, and fat is split up. But this occasional occurrence has not yet been employed for consecutive examinations. Boas recently, after carefully rinsing out the stomach with soda and having it tightly squeezed, has endeavored, by employing an oesophageal sound, to obtain the intestinal juice. But his results have not yet been completely published ; hence it is not possible to form an opinion as to what assistance his method will be for the purposes of diagnosis. 368 SPECIAL DIAGNOSIS. Intestinal discharges. In health their frequency varies individu- ally very much. Ordinarily, at all ages, excepting nursing children who have three or four movements a day, there is one stool in twenty- four hours ; hut many persons regularly have a movement twice in the twenty-four hours, while others only have one in two or three days, or even at longer intervals, without experiencing any inconveni- ence [or disorder]. But in scarcely any other way do physiology and pathology so much encroach upon each other's limits as with reference to the frequency of the intestinal discharges, for sometimes a move- ment even once in two days may be troublesome, and the physiological habitual constipation, in many cases, cannot in any way be distin- guished from the pathological condition. Constipation, or, better, pathological constipation, is called obstipa- tion ; the expression obstruction (severe obstruction) is often inten- tionally used for constipation in a serious sense. The opposite to this condition is looseness, diarrhoea. The frequency of the discharges is directly connected with the quantity of food taken ; hence a person who is fasting is always constipated. This point must often be thought of The character of the food, too, has an influence upon the frequency of the discharges, and upon the passage of food through the intestinal canal. (See under "quantity.") Thus rapid peristalsis causes diarrhoea, slow peristalsis, obstipation. Hence, any mechanical obstruction in the alimentary canal brings on constipation. Diarrhoea is the most important sign of intestinal catarrh. This is brought about by errors of diet, by cold, by infectious causes, as the intestinal catarrh of typhus, dysenteric inflammation of the large intestine, and also many intestinal catarrhs which were formerly referred to the cause first mentioned. In this condition, the stools are always thin (see the second section below and Consistence of the Stools) ; their frequency may be increased, even to occurring hourly, or yet oftener. Moreover, medicines or poisons may increase the peristalsis alone, or intestinal catarrh, and thus result in diarrhoea. In all these cases the increased peristalsis increases the fluidity of the intestinal contents, even causing effusion from the intestinal wall into the intestinal cavity (cholera), until we have the condition of diar- rhoea. (See below.) EXAMINATION OF THE DIGESTIVE APPARATUS. 359 Obstipation may be a disease which is relatively harmless, although very troublesome, becoming habitual. But it is of much greater diag- nostic significance, however, as an early sign of peritonitis from paralysis of the intestine. Of still greater importance is severe ob- struction in all forms of stenosis of the intestine, as fecal accumulation, particularly in the caecum ; strangulation, invagination, intussuscep- tion of the intestine : new formations, scars in the intestinal wall, compressing tumors external to the intestine ; constrictions, bends produced by peritoneal exudations. In many cases of chronic intes- tinal occlusion, as in chronic peritonitis, constipation alternates with diarrhoea. But the condition of obstipation or diarrhoea is still more affected by a possible increased or diminished abstraction of fluid from the intestinal contents ; the more fluid there is, the quicker it passes through the bowel. Now, if the intestinal contents part with much fluid when there is slow peristalsis, as a result of prolonged retention, they become dry and hard, hence are carried forward with difiiculty. If the peristalsis is quicker, the contrary exists. The effect of slow or quick peristalsis is felt in the transit [of the intestinal contents], caus- ing either obstipation or diarrhoea. The severest diarrhoea occurs in cholera Asiatica, because in this disease there is great eff'usion of fluid from the intestinal wall into the lumen of the intestine. 1. It is to be understood that an ordinary constipation and severe obstruction are to be sharply distinguished from each other, for a quite ordinary obstipation may be very obstinate. Here the decision is made by considering other phenomena, as vomiting, pain, and par- ticularly by examining the abdomen. This can never be omitted in any sudden attack of obstipation, special attention being given to the hernial orifices and the caecum. 2. Persons who eat little or. nothing, whom many things either strangle (stenosis of the oesophagus), or cause vomiting, as in diseases of the stomach, but especially pyloric stenosis, in which case there is infrequent but considerable vomiting at a time, cannot have frequent stools; hence they must be obstipated. Such cases are easily over- looked, particularly if the patients complain a good deal of obsti- pation. 24 370 SPECIAL DIAGNOSIS. The special peculiarities which precede the examination of the bowels are of diagnostic importance : Pain with the movements. There will be pain at the anus or at the lower portion of the abdomen in all kinds of inflammatory affec- tions of the anus, the rectum, or their neighborxiood. We have severest pain when the lower portion of the rectum is compressed by a large inflammatory (purulent) exudation, especially in the exudation of peri- and para-metritis ; also in fissure of the anus and abscesses from peri-proctitis (see Surgery). Likewise, in carcinomatous, syphilitic, gonorrhoeal stenosis of the rectum, but also in the usually harmless hemorrhoids, the pain at stool is characteristic. Sometimes in all these conditions, and particularly in all inflammations of the large intestine, but most pronounced in dysentery, there is usually painful straining at stool, and pain after it — tenesmus. Whenever there is pain at stool there must be a careful inspection of the anus and pal- pation of the rectum. Involuntary discharges of the bowels, incontinentia alvi, are most frequently dependent upon the cloudiness of intelligence which ac- companies any severe disease ; but they may result from paralysis, particularly in diseases of the spinal cord. If the stools are thin, then incontinence occurs with less loss of intelligence than if they are firm. Slight incontinence manifests itself sometimes by the fact that the patient must hasten to go to stool as soon as he has the impulse. Incontinentia is opposed to retentio alvi as regards its neurotic origin. (See Examination of the Nervous System.) Physical and chemical peculiarities of the feces. Assuming an unobstructed passage, the amount of the stools is determined by the quantity and quality of the food taken. In the latter respect it depends upon how much of the food is digested and taken up ; hence, all vegetable foods make copious stools. Also, the quantity of the stools is increased in diarrhoea, because too little of the fluid portion of the intestinal contents is taken up. The greatest increase occurs in cholera, from the eff"usion of quantities of fluid into the intestine. Enormous quantities of firm, solid stools may be passed after pro- longed obstipation or serious obstruction. We may form an estimate from the amounc of the stools, or of their weight, of the resorption of food, if we know how much of resorbable EXA MINA TION F THE DIG ES TI VE A PPA RA TUS. 371 substances the food taken contains, and if we can decide that a par- ticular stool comes from the food taken within the period of observa- tion, by the admixture of substances which give a distinctive color. However, Ave neglect the addition made to the feces during digestion from the digestive juices. On the one side, there is a too rapid move- ment of the food along the alimentary canal, and, on the other, dis- turbance of the resorption of the food. We learn from the recent investigations of F. Miiller, that in mild enteritis and in mild amyloid degeneration only the fat, but in severe cases of disease of the mucous membrane all the nutritive material, is poorly resorbed ; further, that a deficiency of pancreatic juice makes no special disturbance; defi- ciency of bile and tuberculosis of the lymphatic glands disturb the absorption of fat (see below) ; finally, that absorption is only slightly disturbed by accumulation in the intestinal canal. Consistence^ or form of the stool. Normally, it is firm or mushy. The fact has already been stated, and the reason given, why in diarrhoea the stool is more or less thin, or like thin soup. The stool may really be watery, as in cholera Asiatica, but also in all severe acute cases of enteritis, also in dysentery. The dried fecal balls which are passed with or after obstipation are very hard. The form of firm feces does not have any independent value. Especially the stool which is like the stool of sheep (small, hard balls, about the size of a cherry) is not characteristic of stenosis of the rectum, because it also occurs in ordinary constipation. Band-like flat scybala rather indicates stenosis, more especially compression of the rectum antero-posteriorly. ' Here may be mentioned the arrangement in layers of the thin and the mushy stools which not infrequently are met with. In these the firm portions settle so that the upper part of the stool consists of a clear watery layer. This is the kind of stool we have in typhus abdominalis [typhoid fever], but we also have it in other thin stools, and it is very commonly a result of the admixture of urine. Odor of the stools. The variations from the normal fecal odor not infrequently have distinct diagnostic value. In nursing children a slightly sour odor is normal. The alcoholic stool is offensive, but does not always really have a foul odor. An odor like fatty acids (and acid reaction from acid fer- mentation) is peculiar to the slight forms of infantile diarrhoea. A 372 SPECIAL DIAGNOSIS. decidedly foul smell (putrid albumin, alkaline fermentation) belongs to severe forms of this disease. The stools of cholera and dysentery often smell flat, like semen (cadaverin, Brieger). Cadaverous, foul, stinking stools characterize gangrenous dysentery, carcinomatous or syphilitic ulceration of the rectum. When blood or pus is mixed with the stool in considerable quantities the fecal odor may be masked and replaced by a mild, stale odor. Often the stool is ammoniacal, from admixture Avith urine which has decomposed. Reaction of the stools. Only iu children, particularly nurslings (in whom it is normally slightly acid) is the reaction diagnostic, and gives important indications for treatment. Decided acid reaction is observed in acid fermentation in the intestinal canal ; alkaline reac- tion in alkaline fermentation with putrid albumin. In both condi- tions there is intestinal catarrh. Color, constituents, admixtures of the stools (so- far as they can be recognized by the naked eye). The normal color of the stools varies from bright- to blackish-brown. It is in part due to the addition of bile (that is, products of decomposition of the coloring matter of the bile, particularly hydrobilirubin), and partly to the food. By the latter, the stool may be unusually colored, as by huckleber- ries, which color it black, and may be confounded with blood. In the normal stool, portions of food can be recognized with the naked eye, if things that cannot be digested — like cherry-stones, particles of wood, etc. — have been swallowed. We also see grape- seeds, the skin of many kinds of fruit, etc. Large fibres of con- nective-tissue, undigested portions of grains, mushrooms, etc., may sometimes be met with in the stools, if the patient has eaten rapidly or has swallowed his food in quantities. With the naked eye, we can see fibres and pieces of undigested substances, the old designa- tion for which was lientery, like portions of muscle, flocks of casein, in the stools of children ; sometimes somewhat friable, perhaps slimy ; or even portions of starch. All of these indicate disturbance of" digestion in the small intestine, or also in the stomach, as is seen in intestinal catarrh, or catarrh of the stomach, or in the dyspepsia of fever, with increased peristalsis. In the rare condition of communication between the stomach and colon (perforating ulcer of the stomach), we find the coarsest admix- ture of digestible portions of food in the stool. EXAMINATION OF THE DIGESTIVE APPARATUS. 373 Occasionally, extraordinary forms of remains of vegetables (orange- like, etc.) have given rise to mistake. With children, hysterical persons, and imbeciles, we must be prepared for all sorts of pre- posterous foreign bodies in the stools. The stools of nurslings and of adults who live upon milk illustrate the appearance of the stool when colored only by bile-pigment. Firm stools are generally darker than thin ones, because more concentrated. In severe diarrhoea, but especially in cholera, dysentery, also severe enteritis, after the first evacuations have swept out the intestinal con- tents, the stools always become brighter, afterward grayish-white and watery, or, in dysentery, colored by blood, etc. When there is diminished flow of bile into the intestine, as occurs in hepatogenous icterus, the stools are lighter. If the bile is cut off, they are grayish-white, clayey, and faintly glistening. This is due not alone to the want of the transformation of the bile-pigment, but also, it would seem, chiefly to the large amount of fat in the so-called acholic stools. The increased amount of fat, in turn, shows dimin- ished digestion of the fat, due to the deficiency of bile. We designate as bilious stools those which contain the coloring- matter of the bile unchanged. A quick passage of the contents of the intestine, and profuse diarrhoea, always bring about this kind of stool. We see it most frequently in acute intestinal catarrh, especi- ally in children ; perhaps there is here also an increased effusion of bile. The bilious stool is bright-yellow, green-yellow, or green, and has the reaction of the coloring-matter of the bile. We filter it, and treat the filtrate as we do when testing for bile in the urine (which see). Mucous stool. When mucus can be distinctly recognized in the evacuations of the bowels, it always indicates catarrh of the mucous membrane of the intestine, and hence something pathological ; though in many cases the disturbance in the intestines may be regarded as without significance. There are unnoticeable transitions from the normal secretion of mucus by the intestine to a decided stimulation by chemical or mechanical irritation, even to a true enteritis. Nothnao-el considers that small, visible particles of mucus interspersed in firm stools belong to a normal condition. Larger masses of mucus, in the form of more or less thick shreds, always indicate with greater probability a catarrh of the large intestine. 374 SPECIAL DIAGNOSIS. Certain small, roundish particles of mucus, like sago granules, are said to come usually from this portion of the intestine. Catarrh of the large intestine then can be definitely diagnosed from the stools, if firm fecal balls are passed which are covered with mucus. Sometimes we find spread over the scybalaa layer of thick, tough mucus. An abundant admixture of mucus in thin stools occurs, especially in acute intestinal catarrh, if the large intestine is also aifected, and in catarrhal dysentery. We designate as intestinal infarction cylindrical tubes which consist entirely of mucus (or partly of fibrine), and which form casts of the large intestine. In rare cases they occur in chronic catarrh of the large intestine, and are usually passed with great pain (mucous colic). If there are fine and equal portions of mucus in solid fecal balls, we then think of catarrh of the small intestine. But, also, mucus occurring in thin stools may have its origin in the small intestine. Then it is usually finely divided, and is soft. In cholera Asiatica (also in cholera morbus) the stools are watery, and contain particles of mucus which look like boiled rice (rice-water stools). Nothnagel utters a warning against regarding all small, slimy-look- ing particles in the stools as mucus. They may come from the food. The chemical reaction determines in a doubtful case. Watery stools. To these we have already referred repeatedly. They occur in severe acute intestinal catarrh, in dysentery, and in cholera Asiatica, and express profuse diarrhoea, by which the intestinal contents are completely expelled. Even bile, or its transition products, are not usually found in watery stools. Fatty stool. This is usually recognized by its slightly glistening, and its greasy look. When there is much fat, the stools are clayey- looking, or whitish, even Avhen the bile is not cut off from the intes- tine. When the stool contains considerable fat, moreover, it has the peculiarity of becoming softer and more glistening with the eleva- tion of the temperature of the body. For further regarding fatty stool and its occurrence, see under Microscopical Examination. Bloody stool. This has an extremely variable appearance, dependent upon the more or less change in the blood, and whether it is not at all, or is intimately, mixed with the feces. When firm scybala are covered over with blood, it indicates hemor- rhage of the rectum, or large intestine. If the blood does not look EXAMINATION OF THE DIGESTIVE APPARATUS. 375 at all changed, it is from the rectum or anus. When there is an admixture of blood with thin stools, if the blood retains its color, and is not intimately mixed with feces, mucus, or pus, it points with tolerable certainty to the large intestine or anus. However, there may be intimate mixture of blood even in hemorrhage from the large intestine, and in watery stools, as in meat-juice stools in dysentery, and in severe catarrh of the large intestine in children. Hemorrhage of the large intestine occurs most frequently with hemorrhoids in the lower portion of the rectum, carcinomatous ulcera- tion, again chiefly from the rectum, and in other ulcerations of the large intestine of any kind, as in dysentery. When the blood is intimately mixed with the feces, it indicates hemorrha";e from the small intestine or from the stomach. Besides, in this case the blood is usually more or less changed, brownish-red, even deep-black, the color of tar, from breaking up of the red corpuscles and of haemoglobin (formation of sulphate of iron ?). The degree of change which the blood undergoes depends upon the length of time it has been in the intestinal canal, and the way in which it is mixed with the feces. There is the least change, the blood sometimes remaining red, with preservation of the red corpuscles, when a large quantity of blood from the lower part of the ileum passes quickly into the colon, because of existing diarrhoea. This happens with the profuse hemorrhage of the bowels in typhus abdominalis. Blood which comes from the stomach, duodenum (in ulcer of the stomach, ulcus duodenale) becomes as black as tar before it is evacu- ated, because of its slow transit and the usual absence of diarrhoea. Moreover, with gastric hemorrhage, the blood may appear in the stool like coifee-grounds (see above, p. 363). In most cases, in order to prove the existence of blood, it does not suffice merely to examine with the naked eye. Then we employ the microscope to make out the red blood-corpuscles, and if they are bi'oken up, then it is necessary to test for hsemin. (See above, p. 363.) 1. We have already repeatedly spoken of the importance of giving continued attention to the stools whenever there is a suspicion of hemorrhage in the alimentary canal. This obtains particularly with ulcer of the stomach or duodenum. 2. It is evident that any blood which reaches the stomach, having its origin in the oesophagus, or coming from farther up and being swallowed, 376 SPECIAL DIAGNOSIS. may appear in the stools (see examination of the nose, expectoration, oesophagus). Purulent stools. A considerable quantity of pure pus is not so very rare, happening as a sign of a rupture somewhere of a collection of pus (generally of a parametric exudation) into the intestines, especially the rectum. Therefore, whenever there is a febrile affection of the abdomen, where the formation of the pus is either made out, or at least is thought to be possible, we ought always, but especially if there has been a sudden decline of the fever, carefully to examine the stools as well as the urine (which see). Moreover, dysenteric, catarrhal, syphilitic, and carcinomatous, ulcera- tions of the large intestine produce some, or possibly considerable, accumulation of pus, according to their extent ; likewise, periproctitic abscesses. Gall-stones, enteroliths. The former come either from the galL bladder or the intrahepatic gall-passages (intrahepatic stones, much smaller than the others, rare) through the ductus choledochus, and, as they come into the intestine, often produce severe colic and jaundice. Whenever there is abdominal colic, particularly if it is connected with jaundice, and generally whenever there is jaundice, we must look out for gall-stones in the stools. In rare cases, if there is suppuration of the gall-bladder, they come from the gall-bladder, there being adhesion with the colon, into which they break, and thus directly reach the intestine. When we are looking for gall-stones the stool must be passed through a sieve. If it is formed or mushy, it must be broken up by pouring a stream of water upon it. The gall-stones are generally very easily recognized by their shining appearance, smooth surface, and many angled (facets) form. Small, especially intrahepatic, stones' may not have facets, and be more crumbling. They consist chiefly of cholesterin, and also contain coloring matter of the bile. Enteroliths are rare. They usually come from the vermiform appendix, and their centre commonly consists of solid, undigested portions of food, as a cherry-stone, around which have been deposited some lime or magnesium salts. Portions of tissue from the intestinal canal. In very rare cases, when there is invagination of the intestine, the whole of the portion that is turned in sloughs off, the intestine forming new adhesions, EXAMINATION OF THE DIGESTIVE APPARATUS. 377 and thus life is preserved. This entire piece may appear in the stool. Shreds of mucous membrane from the large intestine in dysentery, portions of tissue of carcinoma, or other new formations, may appear in the stools. Animal Parasites. In what follows it will be shown that some of the animal parasites that exist in the human alimentary canal have no pathological signifi- cance ; others, on the other hand, are very important factors as excitors of disease. The examination for these latter or for their eggs cannot be made too frequently, or too carefully. An examination of the stools for parasites must be undertaken not alone when there are complaints or symptoms which directly indicate intestinal parasites, or in general Avhen there are evidences of intestinal catarrh, but in any case of anaemia, when there is any general nervous depression, in certain other phenomena of the nervous system (see works upon pathology), if the cause of the particular complaint does not appear to be clear. The cases are numberless where, after long fruitless search elsewhere, the discovery of a joint of a tapeworm, for instance, leads to the correct apprehension and treatment of the patient. In order not to separate what belongs together, we collect here all that is to be said regarding the occurrence of intestinal animal para- sites and their eggs in the stools, whether in the examination we employ the naked eye, the simple or the compound microscope. Tape-worm {eestodes). Its habitat is exclusively the small intes- tine. It gives rise to very great pathological disturbances (intestinal catarrh, anaemia, nervous manifestations of varying severity). It consists of a very small head and neck, and a ribbon of flat joints (proglottides), several meters long, which constantly push oif at the end of the worm, and grow again from above. It clings to the wall of the intestine by its head. It can be recognized by a single joint, which can easily be seen with the naked eye, or by the presence of eggs in the stools (micro- scopical examination). 1. Tcenia solium. This is 2 or 3 meters long. Its head is the size of the head of a pin, glistening gray ; the jest of the worm is white, or yellowish-white. Upon the head ai'e four pigmented suck- ing cups (to be seen with a simple microscope), which surround ;? crown of chitin hooks. '' crown of hooks." The ripe proglottides — 4l\ SPECIAL DIAGNOSIS. that is, those on the lower end of the worm — are about 10 mm. long, •5 or 6 mm. broad, and are like gourd-seods (but are smaller). From the peculiarity of these ripe joints, which are continuously thrown off and passed with the stool, we are able to make the differential diagnosis Fig. 94. Fig. 95. Fig 94. — TaBnia solium, head enlarged. (Heller.) Fig. 95. — Taenia solium. Ripe joint, magnified C times. (Heller ) Fig. 96. — Egg of taenia solium. (Heller.) between this and the other tape-worms. The joints show a longitu- dinal canal (the uterus), from which, toward both sides, as many as a dozen branches go off which ramify like the branches of a tree. The eggs of T. solium (which require the use of a moderate micro- scopic power in order to find them, stronger to examine them care- fully) are round, and, if they are ripe, have very thick shells (which show radiating lines, and which, with a little pressure upon the cov- ering glass, break into hard pieces. In the finely granular contents we often see a few chitin hooks. 2. The Taenia mediocanellata, seu sagiyiata, grows to 4 or 5 meters. The head is somewhat larger than that of the solium, is also more strongly pigmented. It has no crown of hooks, but four sucking cups, which are much stronger than those of the solium. On the whole, the rest of the worm, as respects its individual joints, is fatter and thicker than the first-named. The ripe proglottides are passed, not only by the stool, but wander independently from the anus, having strong, very energetic, independent movements. They are distin- guished from the T. solium in that the uterus gives off more and finer branches on each side, which divide dichotomously. EXAMIXATIOX OF THE DIGESTIVE APPARATUS. 379 The egg of the T. mediocanellata looks extremely like that of the T. solium, except that on the average it is some"n"hat larger. Fig. 97. Fig. 9S. Fig. 99. Fig. 97. — Tisuia mediocanellata. Head darkly pigmented. (Heller.) Fig. 98. — Tffinia mediocanellata. Eipe joint, magnified 6 times. i^Heller.) Fig. 99. — Egg of twnia mediocanellata. (Heller.; 3. Bothriocephalus lata (sinus head) is found in Germany, only in the neighborhood of the North and East Seas, of Lake Geneva, and in Northwestern Russia [Sweden, Poland, Belgium. Holland. Fig. 100. Fig. 101. Fig. 102. Fig. 103. Fig. 100. — Head of bothrioceplialus latns. (Heller.) Fio-. 101.— Ripe joint of botlirioeephalus latus enlarged six times. (Heller.) Fig. 102. — Egg of bothriocephalus latus. (Heller.) Fig. ] 0.3.— Egg of bothriocephalus latus. with developed embryo. (LErcKARX.) ''Low-lying damp regions near the borders of seas and lakes are those in which it is most often abundant."] It is the largest of the tape- 380 SPECIAL DIAGNOSIS. worms, and reaches to 7 or 8 meters in length. Its head is elongated, and has two narrow, long-drawn out sucking cups. The illustration shows its form and the shape of the uterus. The ripe joints are not given off singly, but a large piece of the worm is always passed at one time, and then, after a long interval, another ; most frequently in the spring and fall. For this reason we here refer to the finding of the eggs (which are always present in the stools). They are oval (see Fig 102), and much larger than those of two other kinds of tape-worm. The shell is bright brown, relatively thin, and, on one end of the oval, has an opening which is closed with a cover of exactly the same kind. The contents of the egg are granular. As has recently become known, the bothriocephalus gives rise to severe anaemia, with changes in the blood like those in severe per- nicious anaemia ; for this reason, and because there are no joints thrown off, this tape-worm is very easily overlooked for a long time. 4. Taenia cucumerina, 5-20 cm. long, 2 mm. wide; the head is somewhat long, and has sixty hooks;, the last joints are reddish, and have the form of pumpkin seed. Six to fifteen of the eggs lie together in the so-called cocoon. It occurs in dogs, cats, and not infrequently in men, especially children (Leuckart). Its pathological significance is not known. (See Fig. 104.) Fig. ] 04. Taenia cucumerina (BtRCH-HiRSCHFELD). a, joint, natural size ; b, enlarged 12 times; c, cocoon, enlarged 290 times. Round worms — Ascaris lumbricoides. This is easily recognized from its likeness to the common earth-worm. Its habitat is the small intestine. Very frequently it gives rise to little or no complaint, but it sometimes, and especially in children, causes very uncomfortable phenomena of all sorts, particularly of the nervous system. Occa- sionally, when there is severe vomiting [and sometimes when there EXAMINATION OF THE DIGESTIVE APPARATUS. 381 has not been any vomiting at all], it gets into the stomach and is then vomited. Moreover, it may crawl into the ductus choledochus, and thus cause obstinate jaundice. These worms appear in the stools ; and sometimes, in sleep, they will crawl out of the anus. They are said sometimes to come out of the mouth and nose while the person is sleeping. The fresh eggs of the ascaris lumbricoides have a very peculiar appearance, since its chitin capsule is covered wdth an uneven, as it were, humped albuminous envelope. (See Fig. 105.) Fig. 105. Fig. 108. Fig. 105. — Ascaris lumbricoides (Jaksch). a, -worm natural size; b. head- c, egg. Fig. 106. — Oxyuris vermicularis. Natural size. 1, female; 2, males. Fig. 107. — Egg of oxyuris vermicularis (enlarged). Fig. 108.— Oxyuris vermicularis, enlarged, a, ripe, but unimpregnated female; b, male ; c, female containing eggs. 382 SPJECJAL DIAGNOSIS. Oxyuru vermieuJaris is a small, -white -R-orm (Fig. 106) found particularly in the large intestine. It may wander from the anus into the Tagina. It has very slight pathological significance. It appears in the stools, and also it is not infrequently found by itself in the neighborhood of the anus. When first passed, it has usually ver\" lively peculiar movements. The eggs are commonly unsymmetrical. (See' Fig. 107.) Anchylostoma diwd^nale, very like the last in form, but often longer, even twice as long : usually inhabits the upper part of the small intestine, especially the duodenum. Formerly it was only observed in other countries [discovered by Dubini in 1838. in northern Italy], more recently also in Switzerland (first during the building of the St. Gothard tunnel), and finally it was noticed among brickmakers. Because it continually sucks blood from the wall of the intestine, it causes severe, sometimes fatal, anaemia (anchylostomiasis, formerly "Egyptian-chlorosis,"' Griesinger). It is difficult to discover the worms in the stools unless some vermifuge is ■Qsed, but, on the other hand, the tolerably characteristic eggs are always present. They are as large as, or perhaps a little larger than, those of Fig. 109. Anchylostoma duodenale (Jaksch). a. male: b, female, natural size ; e, male; d. female, slightly magnified: e, head; /, egg. the oxyuris. They have a thick covering, and contain two or more segmentation globules. By allowing the stool to stand for several EXAMISATIOX OF THE DIGESTIVE APPARATUS. 333 days in a warm place, we can see the embryos develop in the eg^s. In this very serious disease the stools often contain blood. Besides the intestinal parasites already mentioned, there are the following, part of which are pathologically unimportant, and others 'are very rare : Tricocepliahis dkpar. Its habitat is the colon, especially the caecum. It is of no importance. Both the worms and eggs are highly characteristic in form. (See Figs. llU and 111.) Fig. 110. Fig. 110. — Trichoeephalus dispar, natural size. (Hellee.) Fig. lll.^-Egg of triehocephalus dispar, moderatelv enlarged. TricJiina spiralis. It very rarely occurs in the intestine, but some- times in the first stage of the trichinosis, the stomach-stage, with intestinal phenomena, it is found in the stools. Since the early recog- nition of trichinosis is of the greatest importance, in a suspicious case the stool is to be examined with the greatest care, best after the adminis- tration of an aperient. The appearance of the intestinal trichina is shown in Fig. 112. It is onlv one-third as lonsr as the o-Tviiris, and hence cannot be seen with the naked eye. Distoma Jiepaticum and D. lanceolatum, two rare, but pathologi- cally important, parasites, which inhabit the gall-passages of the liver, sometimes make themselves known by their eggs, which, passing out into the intestine with the bile, appear in the stools. The egg of the D. hepaticum is much larger than the other parasites previously men- tioned, about three times as large as thos^ of ascaris lumb. The egg of the D. lanceolatum is somewhat smaller than that of the oxyuris. For its other characteristics see Fig, 114. Infusoria of very gi'eat variety of species are found in the stools of all kinds of diarrhoea: in acute and chronic intestinal catarrh, in 384 SPECIAL DIAGNOSIS. typhoid fever, in tuberculosis of the intestine. Immediately after the evacuation of the bowels they manifest very active movement. Their pathological and diagnostic significance are both negative. Fig. 112. Fig. 113. Fig.'112. — Adult intestinal trichina, human. Male, female, and two embryos slightlv magnified. (Biech-Hirschfeld.) Fig. lis. — Trichina (Jaksch.; a, male; h, female intestinal trichina; c. muscle trichina. Fig. 114. — Eggof distoma hepaticum and distoma lanceolatum. (Heller.) EXAMINATION OF THE DIGESTIVE APPARATUS. 385 Microscopic examination of the feces. Thin, or thin-mushy stools, are examined without making any addition to them. To thick, mushy, or solid stools, about a half per cent, of solution of salt is added ; and the solid portions must, of course, be broken up. Somewhat of a selec- FiG. 115. Monads from the feces (Jaksch). a, tricomonas inlestinalis; b, cercomonas intes. ; c, Amoeba coli ; d, param^secium coli ; e, living monads ; /, dead monads. tion must be made from the different portions of the stool, according to the object of the examination. In what follows are presented the details. The amplification also varies with the object of the exami- FiG. 116. Microscopical constituents of the stools (partly from Jaksch ). a, vegetable fragments ; b, muscular fibres ; c, white blood-corpuscles ; d, saccharomyces ; e, microorganisms ; y, crystals of triple phosphate ; g, fatty acid crystals. nation. In general, we employ the dry method. When looking for parasites (which have already been described), it is better, on the other hand, to make use of a tolerably strong amplification. 25 386 SPECIAL DIAGNOSIS. 1. Undigested portions of food. These may be found in every stool, and in varying quantities, according to the kind of food eaten. We mostly meet with coverings of vegetable cells, elastic fibres, etc. 2. Portions of digested food. Although these, if visible with the naked eye, indicate disturbed digestion in the small intestine, yet microscopical particles of these substances are seen in small quantities in normal stool, as well as small portions of muscular fibre, with the transverse striations, shreds of connective tissue, starch granules, and fat. But considerable quantities of the substances named always indicate disturbed digestion either in the small intestine or the stomach, and hence have the same significance as the occurrence of larger pieces, which can be seen without being magnified. When the microscopical particles are colored a bright-yellow, as we commonly see small por- tions, particularly of muscular tissue, but sometimes almost all the solid portions of the stools, it shows that there is unchanged bile in the stool, and catarrh of the small intestine. Fat, in the shape of polygonal glassy lumps, of needle-shaped crystals, and also in the form of drops, is a very frequent constituent of the stools. The glassy lumps occur very frequently in health, and are often colored yellow or yellowish-red. They are recognized as fat, fatty acids, or soap, by their transformation upon the addition of sulphuric acid, and, when warmed, into drops of fat (Mliller). Drops of fat occur in the stools with milk-diet (hence, particularly in those of children), when taking cod-liver oil, likewise castor-oil, and, if there is intestinal catarrh, then in very considerable amount. The needles of fat have pathological significance. They sometimes occur .singly, and, again, in bundles and druses. They are changed by simply warming them, or by the addition of acid and then warm- ing, into drops of fat, and this takes place whether they consist of fatty acids or (lime-) soap. When there are great numbers of fat-needles, it is a pathological sign of disturbance of the resorption of fat, as may result from shutting oiF of the bile from the intestine, from any form of enteritis, of tuberculosis, amyloid degeneration of the intestine, and, lastly, from disease of the mesenteric glands. The increase of the fat in the stool is not, as was formerly assumed, cbaracteristic of a want of pancreatic juice (disease of the pancreas, EXAMINATION OF THE DIGESTIVE APPARATUS. 387 closure of the ductus Wirsungianus). As a matter of fact, the absence of pancreatic juice does not seem to hinder the resorption of fat (Miiller). Detritus. With respect to detritus in the stools little needs to be said, because we cannot determine separately a great number of the kernels, husks, etc. 3, Additions to the stools from the alimentary canal. A micro- scopical quantity of mucus occurs in the stools of persons in health. Small glassy lumps of mucus may also be present, which come from the cells of plants. Usually the examination with the naked eye is sufficient to determine whether there is a pathological admixture of mucus. It is necessary only to mention that a firm stool, abundantly inter- spersed with small light lumps of mucus, is observed with intestinal catarrh (Nothnagel). In these cases, we can generally discover the mucus, if we carefully examine, without any artificial aid. Epithelium. Some cylindrical cells, often in mucous metamorpho- sis, are a frequent occurrence. If the quantity is large, it indicates intestinal catarrh. Very abundant cylindrical epithelium occurs in chronic catarrh of the large intestine, especially in mucous colic, in this case caused by mucous "infarction." It has already been men- tioned that regular shreds of mucous membrane are found in the stools, also portions of tissue. Red and white blood-corpuscles. These are present in quantities in fresh bloody, and in purulent, stools. When seen but once, they do not have significance. 4. Crystals. Except the fat crystals mentioned above, there are almost no crystals which are brought into requisition for the purposes of diagnosis. Crystals of ammoniaco-magnesian phosphates (see these under the examination of the urine), no doubt, occur in the stools in enteritis and abdominal typhus. But they may also be found in any other stools, if they are not kept separate from the urine and stand for a long time. Lime-salts of all kinds, partly with inorganic, partly with organic, acids, in the form of wedges, dumb-bells, needles, etc., sometimes colored an intense yellow by the bile in the stool, have no diagnostic import. Charcot's crystals, in appearance and probably also chemically 388 SPECIAL DIAGNOSIS. entirely agreeing with the Charcot-Leyden crystals of asthma, are observed in rare cases of dysentery, typhus abdominalis, intestinal tuberculosis, anchylostomiasis. 5. Vegetable parasites. We may divide the large number of vegetable microorganisms which we find in the stools, from the stand- point of clinical diagnosis, into two classes : (a) Those which, primarily, for clinical diagnosis are only of sub- ordinate significance, because we do not know that they have any definite connection with any diseases. Here, also, we class those which are indirectly harmful — that is, they cause abnormal decom- position of the intestinal contents. This class is extremely numerous, and great numbers of one kind or another are present in every stool. The knowledge of the different kinds has recently been greatly extended by the important labors of Nothnagel, Bienstock, Escherich, and others. But the point has not yet been reached which makes them as available, for clinical diagnosis, as the other peculiarities of the stools. For this reason we will treat of them only very briefly here. Of the fungus-spores we have (very rarely) that of thrush in children who are suffering from thrush in the mouth. Yeast fungus, and, indeed, the different kinds of tortula cervisiae (see Fig. 116, c?), occasionally occur in all stools, especially in the milk-stools of children. In intestinal dyspepsia with acid fer- mentation they are generally more abundant than in normal diges- tion. But the schizomycetes belong to the numberless micro- organisms which are seen in every microscopical preparation of the stools, whether normal or pathological. Of chief importance are the micrococci and bacilli. A very large part of these are colored yellow or brownish with iodine and iodide of potassium ; others are colored by the same reagent blue or violet (Nothnagel). These latter, according to Jaksch, are increased in intestinal catarrh. We are already able to conclude that the knowledge of these intestinal bacteria furnish diagnostic indications of anomalies in intestinal digestion, and that the different kinds of bacilli possess extraordinary biological peculiarities. Some require for their rapid development a neutral or slightly alkaline reaction, while others an acid reaction, of the intestinal contents ; some are aerobiotic, others- EXAMINATION OF THE DIGESTIVE APPARATUS. 389 anaerobiotic ; and while some have the power to transform starch into sugar, others cause the decomposition of albumin. (5) Pathogenic fungi. These we are able to isolate, and from them diagnosticate the disease they cause, as the tubercle-bacillus in the sputum. Here, also, belong ih.e pathogenic schizomycetes. These are : Koch's cholera bacillus, the bacilli of typhus and tubercle. Cholera bacilli (comma bacilli) are the pathognomonic sign of Asiatic cholera. They are short, more or less crooked rods, which are sometimes connected one to another in such a way as to form "spirals," like a screw. The curve may be very slight, even want- ing: or marked, even semicircular. In general, they are shorter, but thicker, than the bacilli of tubercle. Fig. 117. ^«%rvvy Comma bacillus, pure culture (prepared by Prof. Gartner). Zeiss's immersion lens one-twelfth, eye-piece No. 2, camera lucida. Magnified about 600 times. - i jJVfjil Cholera dejections upon a damp sheet. (Two days old. ) a, S-form bacilli, 600 : x. (Koch.) Sahitat : mode of preparation. They are particularly found in the free mucous floccules of rice-water stools, also very abundantly upon the linen soiled by the dejections, and, indeed, here after two or three days, provided the linen has been kept moist. A mucous floccule (or a drop of the stools), or some of the deposit on the linen, is placed upon a covering-glass. First dry it in the air, then pass it 390 SPECIAL DIAGNOSIS. two or three times through the flame of a spirit-lamp, and stain it with methylene-blue or fuchsin by warming it one to five minutes. These bacilli have been found, we may say, constantly in the stools of Asiatic cholera by a great many other examiners besides Koch, and they are found in no other stools. They must, therefore, diagnostically be of pathognomonic value to even those who doubt Koch's teachings concerning their pathogenic character. Fig. 119. Covering-glass preparation of a mucous floccule in Asiatic cholera. Zeiss's homogeneous immersion one-twelfth, eye-piece No. 2, drawn by a camera lucida. Magnified about 650 diameters. But since the morphological peculiarities of the cholera bacillus in the microscopical preparation do not furnish an absolutely certain recognition, and, on the other hand, since there is no specific reaction (as with the tubercle-bacillus), in order to determine an isolated case, it is indispensably necessary to establish a pure culture. (See, regarding this, the works upon bacteriology.) Comma bacilli are also, in individual cases, found in the vomit of Asiatic cholera. Morphologically, but not biologically, they are like Finkler and Prior's spirals of cholera nostras, which possibly stand in the same relation to this latter disease that the comma bacillus does to Asiatic cholera. They are positively distinguished from the bacilli of Asiatic cholera by pure culture. EXAMINATION OF THE DIGESTIVE APPARATUS. 391 A bacillus which is morphologically like the comma bacillus occurs in tooth-mucus (Lewis and Miller), and just such an one, also, in old cheese (cheese-spirals, Deneke). Biologically, they diiFer from Koch's comma bacillus and from each other. Typhus abdominalis bacillus. These bacilli are regularly found in typhus abdominalis, in the diseased portion of intestine, in the mesen- teric glands, the spleen and liver, in the kidneys, and also frequently in the blood (which see). They have also frequently been found in Fig. 120. Fig. 121. vse- -S^-jfpj-^,^''. Spirillum (Finkler and Prior), 700 : 1. Typhus abdominalis bacillus in pure cul- (Flugge.) ture. Zeiss's homogeneous immersion lens one-twelfili, eye-piece No. 2, drawn with camera lucida. Magnified about 650 times. the stools of typhus. But since they are neither distinguished by their form (just at the end they are rounded ; are about as long as the tubercle bacillus, but are much thicker — about one-third as thick as long) nor by a specific color-reaction from the other bacilli which occurs in the stools, their microscopical proof is extremely uncertain. Pure cultures are here much more necessary for the positive deter- mination, and even then are uncertain. The typhus abdominalis bacillus is best stained with methylene- blue or fuchsine in a dry preparation upon the glass cover. Tubercle bacillus. These are frequently found in tuberculous ulcers of the intestine. It is not yet sufficiently established whether they are always present, chiefly because not infrequently tubercular ulcers of the intestines do not have any symptoms, and particularly : do not cause diarrhoea ; and so, often enough, the firm stools are not I examined for bacilli. On the other hand, in phthisical patients, the tubercle bacillus is sometimes observed in the stools without there being any intestinal tuberculosis. They come from swallowing tuberculous sputum.^ 1 Amoeba coli is a protozoa which has been found by Koch, Osier, Dock, and others in the stools of patients suffering from severe chronic enteritis and dysentery. — Translator. CHAPTER YII. EXAMINATION OF THE URINARY APPARATUS. This comprises the examination of tlie urinary organs themselves and the examination of the urine. Indeed, in very many eases, the latter examination only is made, or it forms the chief part, whether in its relation as being the secretion of the kidneys, or whether it be in reference to admixtures or alterations of the urine, which occur in the course of its transit through the urinary passages. The local examination of the urinary organs is now not often required, but if it is, the result of the examination generally confirms the diagnosis. This direct examination, therefore, oui2;ht never to be neglected Moreover, where the kidneys themselves are diseased there come into consideration certain resulting phenomena in the different organs of the body. Examination of the Kidneys. Anatomy. The kidneys, about 10 to 12 cm. long, about 5 cm. broad, of well- known form, lie upon the two sides of the spinal column, upon the anterior surface of the quadratus lumborum muscle and the lumbar portion of the diaphragm, and reach from the level of the twelfth dorsal vertebra to the level of the second or third lumbar vertebra. The lower portions diverge somewhat downward, and hence lie with their lower ends somewhat further from the median line of the body (about three fingers' breadth) than the upper ends (about two fingers' breadth). The right kidney is a little lower down than the left. The upper half of both kidneys is covered by the eleventh and twelfth ribs, the extreme upper portion also by the complementary pleural sinus (see Fig. 122); hence, the lower border of the lungs does not extend as low down as the kidneys. It is very important to note that the outer border of both kidneys corresponds tolerably exactly (392) EXAMINATION OF THE URINARY APPARATUS. 393 -with the outer border of the thick fleshy hiyer of the sacro-spinalis muscle. The left kidney at its upper end, rather by its suprarenal capsule, is in contact with the spleen; the right kidney, with the under surface of the liver. Both organs encroach upon the upper end of the kidney of their respective sides, like the tiles of a roof (see Fig. 122). The figure also furnishes information regarding the so-called spleen-kidney and liver-kidney angle. Fig. 122. Anatomical situation of the kidneys. (Weil.) a. d, borders of the lungs; c, e, limits of the pleural sacs; f, angle between the spleen and kidney; g, angle between the liver and kidney. The superior surface of each kidney is covered by the parietal peritoneum, and in front of it lies the ascending or descending colon. The anterior inner border of the right kidney is not far from the ductus choledochus and the duodenum. In the rare condition known as horseshoe-kidney, the lower ends of 394 SPECIAL DIAGNOSIS. the two kidneys are connected by a transverse band consisting of kidney-parenchyma. This transverse portion passes, like a bridge, across the aorta and the spine, about on a level with the second lumbar vertebra. Local Examination of the Kidneys. In every respect its result is almost negative. The normal kidney, of course, cannot be inspected. In remarkably exceptional cases we may, by employing bimanual palpation, with the legs drawn well up (one hand being placed behind in the lumbar region and the other pressing deeply in front), get some information, provided tKe abdominal covering is very unusually lax and thin, and the stomach is empty. Of late, percussion of the kidneys has very rightly come more and more into discredit. It must be perfectly evident to every one that it is impossible to point out the normal kidneys, or even moderately enlarged ones, if he remembers that the kidney is less voluminous than the spleen ; that, moreover, it lies much less favorably ; and, besides, if he takes into consideration how often the normal spleen is with difficulty, or cannot at all, be made out. The kidney is unfavorably located for percussion, because the sacro-spinalis muscle (of considerable mass) lies over it, but especially for the reason that its lateral border almost exactly corresponds with the convex border of the kidney. So we cannot with certainty determine whether the kidney lies under the muscle, nor where its limits are. Individual exceptional cases, where very thin or atrophic sacro- spinalis muscles permit of percussion of the kidneys, may nevertheless occur, as the cases mentioned above, where the normal kidneys can be felt. But we cannot consider the result of percussion of the kidneys as of great value. Pathological Qonditions of the Kidneys. Inspection. The kidney can only be inspected when it is very much enlarged, or enlarged and displaced. Tum.ors of the kidney may make their appearance in the lumbar region, in the side, and in the lateral anterior portion of the abdomen, near the border of the ribs. According to their nature, they are smooth, roundish, irregular, EXAMINATION OF THE URINARY APPARATUS. 395 or uneven (see Palpation). They do not move with respiration. Their appearance may strikingly vary, but not necessarily so, with the changes of position of the body (the dorsal position, lying down). If the tumor is very large, then it generally presses the colon, ascending or descending, toward the anterior abdominal wall, and then the colon, according to the amount of its distention, may lie up against the abdominal wall (see Palpation). If the kidney is the seat of a tumor, it very often departs from its place high up against the diaphragm, and becomes the so-called wandering kidney. In this case it is much easier seen from in front. A normal kidney wandering so much as to be visible, is a curiosity (Bartels). A roundish, symmetrical swelling, located in the dorsum in the region of the kidney, or somewhat sidewise from it, points to purulent perinephritis. Sometimes it extends upward in the abdominal cavity, from the diaphragm being pushed up. Often there is oedema of the skin at the spot (deep formation of pus, see p. 62), or there may be inflammatory redness. Moreover, abscess, due to the congestion accompanying caries of the spine, may break here. Also, large peri- nephritic abscesses have been seen as tumors above the border of Poupart's ligament in the iliac region. Palpation. This is most important in the local examination of the kidneys. We employ it in the dorsal position with the knees well drawn up, but sometimes also in the abdominal position. In both cases, we always first examine bimanually, one hand being upon the region of the kidney and the other upon the abdomen. Tenderness upon pressure occurs : sometimes in acute, almost never in chronic, nephritis ; also in tumor of the kidney, stone in the pelvis of the kidney, in case it excites inflammation ; in inflammatory hydronephrosis, and in perinephritis (here there is often very great sensibility). When the kidney is enlarged from engorgement, amyloid disease, or nephritis (large white kidney), it is never perceptible to palpation oxcept it leave its place (wandering kidney), or we have one of the exceptional cases in which even a kidney of normal size and location can be felt (see above. Local Examination of the Kidney). Very large new formations, as carcinoma, sarcoma, hydro- and pyo-nephro- sis, echinococcus, and perinephritis, only are palpable. The tumor 396 SPECIAL DIAGNOSIS. can be felt in one side of the lumbar region, or at one side of the anterior abdominal region. With new formations it is usually uneven ; in hydronephrosis, smoothly round, more or less tense, under some circumstances fluctuation can be distinctly made out. Echinococcus is usually smooth and tensely elastic; it may show hydatid vibration (see above, p. 326). It is important to remember that tumor of the kidney is only very rarely movable upon pressure (for if it descends, then we have a wandering kidney). We have never seen a case where one moved with respiration ; but it seems that in some cases there is this move- ment. At any rate, the absence of respiratory movement points to the kidney, and especially against the spleen or a tumor fixed to the liver. In a considerable number of cases it will be found that the ascend- ing and descending colon is in front of the kidney-tumor and pressed by it against the abdominal wall. In these cases, tliis fact has great value for differential diagnosis. In other cases, the tumor will be found lying exactly in the median line, and then it is of significance for differential diagnosis, especially from ovarian tumor. The location of the colon, moreover, is usually only made out with certainty Avhen it can be felt, and particularly when it contains air. It is, therefore,, advisable to inflate it (see p. 311). Wandering Mdney ; movable hidnei/. By this we understand- downward dislocation of the kidney, whether much or little. Almost always only one is dislocated, and this is usually the right one. In these cases the kidney is commonly of normal size, but it may be enlarged, and this is most frequently due to hydronephrosis caused by the bending of the ureter, or also because it is the seat of a new formation. It is generally very easy to recognize a kidney that is very much out of place, but when it is still high up, near the liver or the spleen, it is often very difficult to do so. The diagnosis is based upon the bean-shaped form of the kidney, eventually, upon its being of the appropriate size, and upon its mobility by pressure, which is almost never wanting; also, sometimes, Avith the changes of position of the body. Not infrequently the kidney can be perfectly replaced. In some cases dyspeptic symptoms, even dilatation of the stomach, also jaundice from engorgement, have been observed when the right EXAMINATION OF THE URINARY APPARATUS. 397 kidney was displaced (from compression of the duodenum or of the ductus choledochus). Those cases are rarities where the pulse can be felt in the renal artery. Percussion. We employ percussion to establish the existence of tumors of the kidney which give a deadened sound, on account of their solidity ; but they are almost always clearly made out by palpation. Its value in determining dislocation of the kidney was formerly very much over-rated. It Avas thought that we were able to prove one-sided dislocation of the kidney, because, when the patient was lying upon the abdomen, the resonance of the two sides in the neighborhood of the kidneys Avas found to be dilFerent : clearer upon the side of the wandering kidney, in contrast with the absolute dulness of the normal side. In our opinion, even in the most favorable cases, such a con- dition cannot be employed for deciding the diagnosis. But, on the other hand, percussion may be of the greatest value, either to determine the relation of a tumor in one side of the abdomen to the colon, or to determine the course of the colon over a tumor of the kidney (see above). In such a case, distending the colon Avith air is of the greatest assistance. Further, it might possibly occur that a considerable enlargement of the kidney could be made probable (never certain) by an area of dulness upon the back, extending from the region of the kidneys toward the side. Differential diagnosis of tumor of the kidney. The positive evi- dence of tumor of the kidney has just been spoken of. We may have to make a differential diagnosis between a right kidney which is not very much displaced downward and a distended gall-bladder, or an echinococcus located upon the lower surface of the liver. If there is respiratory mobility, this speaks against it being the kidney, but if the tumor can be replaced, so that it may even disappear, then it speaks for it being the kidney. Both wandering kidney and a pe- dunculated echinococcus may be easily movable upon pressure. It may often be impossible to determine exactly the form of a tumor situated close under the liver. A wandering left kidney is distinguished from a wandering spleen by the form, which is made out by percussing the neighbor- hood of the region of the spleen : in wandering spleen, we may find notches ; if it is the kidney, Ave may feel the pulse at the hilus. We distmguish tumor of the left kidney from tumor of the spleen by the 398 SPECIAL DIAGNOSIS. form and relation to the colon. Sometimes respiratory mobility decides in favor of the spleen ; but with this it may also be wanting ; while notches on the upper border of the tumor may speak with prob- ability for the spleen, yet in one case, where they could be very dis- tinctly felt, they led us to a false diagnosis ; it was found to be a carcinoma of the kidney. We know of one case where a movable tumor of the left side of the abdomen was, by a recognized master of percussion, pronounced a wandering kidney on account of the tympanitic resonance in the region of the left kidney. It was operated upon ; it proved to be a Avandering spleen. It was extirpated with permanently favorable result. Examination op the Ureters and Bladder. Simon, by introducing the hand into the rectum, has repeatedly felt of the ureters (see works upon Surgery). Recently Heger- Kaltenbach and Sanger have proposed, in the case of women, to palpate them jjer vaginam. We can feel their lower ends where they come down on either side of the neck of the uterus and enter the lower side of the bladder. With some practice often even a normal ureter, but still more one that is thickened, can be felt in the lateral and anterior fornix vagince and the anterior vaginal wall close to the middle line. In this way it is not difficult to recognize thickening or tenderness of one or both ureters. Both occur in cystopyelitis and in tubercu- losis of the urinary apparatus ; thickening and distention may some- times be observed also in pyelitis calculosa (renal calculus). The bladder lies behind the symphysis pubis, when ordinarily dis- tended, it rises above it, but only when it is excessively full, as in paralysis of the bladder, spasm of the sphincter, stone in the bladder,, stricture of the urethra, does it swell so much as to be noticed (rarely) by inspection; but especially by palpation and percussion, as a roundish tumor, which, of course, is dull in sound. In men it can also be felt from the rectum. We are able to decide with certainty whether a tumor in the hypogastrium is a distended bladder or not by drawing off the urine with a catheter. It may be confounded with a pregnant uterus, and also with other swellings. Always before undertaking an examination of the abdomen, we must see that the bladder is empty, partly to avoid confounding the distended bladder EXAMINATION OF THE URINARY APPARATUS. 399 with something else, and partly because, if the bladder is full, it inter- feres with the examination of the abdomen. Anomalies located in the wall of the bladder can usually be felt best when the bladder is full. The external examination is made |:>er var/incon, per rectum, and sometimes bimanually. Surgery and gynecology teach the complicated methods of examining the bladder and ureters. With reference to the examination of the male urethra, we refer to works upon Surgery. Examination of the Ukine. Under normal conditions and when free from admixture, the urine, as it issues from the orifice of the urethra, exhibit? the renal secretion in a state of purity, since, in its transit through the urinary passages, it receives scarcely any additions from the mucous membrane that are worth mentioning ; and further, since, at the time of its discharge from the body, and for some time after, its physical and chemical conditions are the same as at the moment of secretion. In a number of pathological conditions, also, the urine is the pure and unaltered secretion of the kidneys ; while, in a second series of diseases, it is changed by its exit from the body, and, indeed, by admixtures from the urinary passages, or by decomposition of its constituents in the bladder. To the first series belong the anomalies of the secretion itself; to the second, the diseases of the urinary passages. In women the urine may be contaminated by admixture of material from the vagina or uterus, and of these the most frequent and impor- tant is the menstrual fluid. In order to avoid this contamination, we are sometimes obliged to draw off the urine with the catheter. It is usually contaminated by fecal material only from carelessness of the patient or of the attendant. But sometimes it results from commu- nication of the intestine with the urinary passages, as of the rectum with the bladder or with the vagina. Recent investigations by Lustgarten and Mannaberg show that the former assumption that the urine is normally free from bacteria must be given up. The urine of healthy persons contains a number of microorganisms which have their origin in the urethra. The most important are a large streptococcus, a diplococcus which resembles the gonococcus, also like that in epithelium, but, of course, it is not found 400 SPECIAL DIAGNOSIS. in pus-corpuscles, and lastly, a bacillus which morphologically and in its color- reactions agrees with the tubercle bacillus, and which probably is the smegma bacillus, which also occurs in the preputial sac. This latter may give occasion for the erroneous supposition that there is tuberculosis. But that it has its origin in the urethra is shown by the fact that it is observed even when the preputial sac has been most carefully cleaned previous to urination, though it is only found in individual cases, while in cases of tuberculosis it is always abundantly found iu the urine. Sometimes inoculation must decide (see Appen- dix). We may avoid the urethral bacillus by drawing the urine with a catheter, but then also, sometimes, possible tubercle bacilli from the prostate or genital apparatus may be found in the urine. In case of disease of one kidney or pelvis of the kidney, the question may arise as to what part of the urine passed is from the right, and what from the left, kidney. If one kidney fails, the other acts vicari- ously. In tuberculosis of the urinary passage and in pyelitis, it may happen that for a time one ureter is stopped ; the urine comes only from the other kidney, and it may be quite normal. Then, suddenly, the character of the urine will change, showing considerable white blood-corpuscles, seed-like particles, tubercle bacilli, or calculi, and blood. The quantity of urine is, for the time being, increased ; for the closed side has again opened. In certain diseases of the urinary apparatus, the manner of passing the urine shows characteristic peculiarities ; but in many of the conditions under consideration, the urine is passed in a perfectly normal way. Painful strangury, frequent urination, a feeling of burning in the urethra while passing the urine, may result from the urine being much concentrated, such as is passed when there is engorgement of the kidneys, and in the majority of cases of acute nephritis. Very pronounced tenesmus of the bladder — that is, painful urgency, ex- tremely frequent, very painful urination, in which only a small quantity of urine is passed at a time — indicates cystitis. We must mention here, further, retention and incontinence of urine, nocturnal enuresis (regarding these, see under Examination of the Nervous System). In regard to the mode of procedure in examining the urine, let it be here remarked, in the first place, that we should take care that the urine is received in vessels that are perfectly clean — if possible, in EXAMINATION OF THE URINARY APPARATUS. 401 glass vessels ; and, also, that forjudging of certain general character- istics, it is necessary to examine the mixed urine passed during twenty-four hours, or that passed during the day and during the night, separately. For certain examinations it is necessary to separate, in the most careful way, the urine passed each twenty-four hours. In the warm season of the year, the urine ought to be examined as soon as possible after it is passed. In order to examine the sediment, the upper portion of the urine is to be carefully poured off, and the re- maining cloudy portion is put into a conical glass, in which it is allowed to stand till the sediment is deposited ; then we take up a few drops from the bottom of the glass with a pipette. When there is unconsciousness or difficulty in passing the urine, we must employ the catheter. The artificial emptying of the bladder, for the purposes of examination, must never be omitted in any case of unconsciousness. We briefly describe the characteristics of the normal urine. (A) Normal Urine. 1. Amount. In twenty-four hours, with healthy persons, it amounts on the average to about 1500 grms. But its variations within physi- ological limits are very considerable, since every increase in the amount of water taken increases the amount of the urine, and every increase in the amount of water disposed of in other ways diminishes the urine. In the latter respect, in health we have to consider the loss of water by respiration and by perspiration, from heat and from active bodily exertion. It is superfluous in the cases just referred to to specify the maximal and minimal figures for the amount of the urine; only when those conditions are wanting, must a departure from the average quantity of urine given above cause us to think of a pathological condition. Within the twenty-four hours, the least urine is passed at night, or in the early morning, very much the greater portion being passed during the course of the day. Usually, the amount of urine passed increases about an hour after taking fluid. Emotional excitement, especially anxiety, sometimes temporarily increases the secretion of urine. 2. Color ; transparency. In health, the color is usually dark straw- color to reddish-yellow. Generally, the greater the amount of urine 26 402 SPECIAL DIAGNOSIS. the clearer it is. In this respect as well as in the quantity, with physiologically exceptional cases, it shows marked variations from the average ; from being almost as clear as water, after a great amount of fluid has been drunk, to a decidedly dark reddish-yellow (concentrated urine), after severe sweating. The coloring-materials which give the normal color to the urine are not yet all exactly known. The most important pigment seems to be urobilin ; moreover, indican interests the clinician. Both coloring-materials may, in disease, be pathologi- cally increased. (See Pathological Colors of the Urine.) Urine freshly passed is, in health, always perfectly clear and transparent ; but in these respects it may change some time after it has been passed. (a) In almost all normal urine, after standing a short time, there is formed a slight cloud of mucus. This is from the urinary passages, chiefly from the bladder. {h) It not infrequently happens, with healthy persons, that the urine, if somewhat concentrated, is cloudy when it becomes cool from the separation of the uric-acid salts. Gradually, the salts sink down and form a sediment of clear brick-dust red or flesh- color (associated coloring-matter of the urine, brick-dust sediment, lateritious sedi- ment). It has the pecrdiarity — by which it is likewise recognized — that it is again immediately dissolved as soon as the urine is warmed. After a long march in the heat, this sediment occurs very regularly, because the urine is then concentrated ; but it also is observed in urine that is not so very dark, if it is allowed to stand in a cool place. (See further regarding the Urinary Sediments, p. 428.) (c) Urine that stands exposed for a long time, both clear and dark, likewise sometimes becomes cloudy, because it undergoes ammoniacal fermentation. The urea is changed into carbonate of ammonia, which makes the urine alkaline, whence there is a deposit of phos- phates (ammonio-magnesian phosphates or triple-phosphates, also phosphate of lime). Urate of ammonia also is formed and deposited. These separations and numerous bacteria render the urine cloudy and gradually form a whitish sediment. In hot weather this ammoniacal fermentation takes place within a few hours after the urine is passed ; in a cool place, it does not begin before 36 to 48 hours, or not at all. For a more particular account of the condition when there is ammo- niacal fermentation of the urine, see p. 413. EXAMINATION OF THE miNARV APPARATUS. 403 3. Specific gravity. In health it usually varies between 1015 and 1020. It depends upon the amount of solids held in solution by the urine, hence, on the one hand, upon the absolute quantity of the solids, and, on the other, of the amount of the watery portion of the urine, or the quantity of the urine. The abundant urine which follows drinking a great amount of water is always of low specific gravity, and, therefore, clear. A scanty urine, from the loss of water in other ways, is always of high specific gravity, and hence is dark. Then, also, in health the specific gravity, under some circumstances, temporarily oversteps very considerably the figures given above, from as low as 1008 to as high as 1025, or even higher. In the absence of "physiological causes," these figures are always of pathological significance. Mode of procedure : We measure the specific gravity of the urine by means of an areometer graduated for taking the specific gravity of tlie urine (that is, from 1000 to about 1040, " urometer"). We take a portion of the urine which we wish to weigh (generally a mixture of that which has been passed during the previous twenty-four hours) and pour it into a not too narrow cylindrical glass until the column of urine is longer than the urometer. With filter-paper or a pipette, we remove any air-bubbles from the surface, and then introduce into it a perfectly clean and dry urometer; wait until it has become quiet, and then observe the figure that stands opposite the lower border of the meniscus of the fluid. None of the simple medical instruments is so often useless as the urometer. We shouM never use one until its accuracy has been tested. It is always desirable to have a urometer upon which is given the temperature for which its scale is arranged ; not that we must always have the urine at this temperature, but because the absence of this declaration from the instrument shows very certainly that it has been prepared without care. 4. Reaction : In general, this is always acid, chiefly from the presence of acid urates and phosphates, The degree of acidity varies individually ; moreover, it is a constant quantity in every individual case of health, and when the food is approximately alike. But in the twenty-four hours the reaction varies considerably, so as to be even alkaline, and yet physiological. The variations proceed in such a way that, after every meal consisting of a mixed diet, the 404 SPECIAL DIAGNOSIS. acidity declines until, after about two hours, it becomes alkalescent — but this quickly passes so as to give place again to an acid reaction (Gorges). These variations have been referred by many to the loss by the body of acids and alkalies in stomach and intestinal digestion. Hence it is assumed that the separation of HCl in the stomach in- creases the alkalescence of the blood, and hence the urine becomes less acid, or alkaline. But, according to recent investigations by Xoorden, this increased alkalinity of the blood does not exist. By a graphic representation of the reaction of the urine during twenty-four hours we obtain the so-called " acid-curve." This, Avith some healthy persons, and under like conditions (as to time and quality of food), is tolerably constant, but with other healthy persons it varies consider- ably. Sometimes the reaction of the urine is amphoteric — that is, it colors red litmus blue, and at the same time colors blue litmus red. The neutral or alkaline urine of health at the time of passing is usually clear. But it quickly becomes cloudy from the withdrawal of the phosphates, which gradually form a sediment. The cloudiness does not disappear upon the application of heat, but becomes more marked ; on the other hand, the urine again becomes clear upon adding acetic acid, which dissolves the phosphates. 5. Odor. The normal aromatic odor of urine is well known ; it is changed by certain foods. Most frequent and most striking is the stench of urine after eating asparagus ; garlic gives its odor to the urine. During alkaline fermentation we may have the development of ammonia, which gives its known pungent odor. 6. Sediments. With reference to the cloudiness, the urate sediment of the acid, and the phosphatic sediment of the alkaline urine, have been mentioned on p. 402. (Regarding the microscopical condition of the sediment, see p. 430.) Whenever there is a sediment it is not unimportant to remember that different things may have been mixed with the urine after it was passed ; see above, p. 390. 7. The portions in solution. The constituents of normal urine, which, from our present knowledge, are of importance to the clinician, besides the coloring materials, are the following : urea, uric acid, kreatinin, oxalic acid, chloride of sodium, sulphates, phosphates, carbonates. EXAMINATION OF THE URINARV APPARATUS. 405 Urea ■{ COmu^ > passed in tweuty-four hours amounts in the '2 adult to about 30 grammes (men somewhat more, women somewhat less). However, the amount of urea varies within wide limits : it is dependent upon the amount of albuminous material in the food taken, and, on the other hand, it is almost independent of the amount of muscular exertion. Uric acid, like urea, is a product of the metabolism of albu- min ; in man the quantity is much smaller than the former, being in proportion to the urea about as 1 : 45 ; but it is to be remarked that great variations take place, chiefly under the influence of the food ; and this in such away that albuminous food increases the acidity of the urine. With reference to clinical diagnosis, the uric acid as well as the kreatinin is chiefly of interest, because they may place difficulties in the way in examining the urine for sugar, in that they sometimes simulate the reaction of sugar. Sometimes, on the other hand, they hinder the reaction of sugar (see under Sugar in Urine). Qhloride of sodium, the most important of the inorganic con- stituents, in health corresponds in amount with tolerable exactness to the amount of salt in the food taken. On the average, it usually is proportioned to the urea as 1 : 2 to 1 : 3. Exceptionally, in health, there is found in the urine : Albumin, the so-called physiological albumin. There is still great difference of opinion regarding this subject; while it is doubted by some, others maintain (Senator, recently Posner) that traces of albu- min exist in the urine in every healthy person. It occurs in very small quantity (about one per cent.) after severe exertion or hearty eating. The urine of the newly-born not infrequently contains some albumin. Sugar (grape sugar) is observed in individual cases in very small quantities. After partaking freely of cane sugar, this may appear in the urine. Bile acids are likewise observed in very small quantities in normal urine. Fat is recognizable generally only in microscopical drops (or only in ether extract), and is found when the food has contained a great abundance of fat, as of cod- liver oil. 406 SPECIAL DIAGNOSIS. (B) Pathological Urine. Anomalies in the Quantity. Increased amount (polyuria) is observed. 1. In a watery condition of the blood, in the different forms of anaemia or hydrsemia. The increase here is never very great: 2000 grammes or less ; there may be no increase, and if the heart is weak (see below) it may even be diminished. 2. In the different forms of contracted kidney, and this in conse- quence of the accompanying hypertrophy of the left ventricle, which causes increased pressure in the whole arterial system, and thus also in the renal arteries (here even to 3500 grammes or more). Here the chief cause of the polyuria is the increased arterial pressure from the increased action of the heart (see below). 3. When the exudation or transudation in the serous cavities of the body, or the fluid in the cellular tissues (oedema), is resorbed, the daily excretion of urine sometimes amounts to four thousand grams or more. The increased arterial pressure from quickening of the action of the heart, which occurs at the same time, is also a prominent factor in producing polyuria. 4. In diabetes. Both diabetes insipidus and mellitus (mellituria) manifest themselves by the increase, often an enormous amount of urine: 4000 to 10,000 grammes, and more. Sometimes in diabetes mellitus there is only a moderate polyuria, or, for a time, in this dis- ease there is even complete absence of polyuria (diabetes decipiens). (See under Specific Gravity and Sugar in the Urine.) 5. As a necessary consequence of abnormal thirst, polydipsia, as it is sometimes particularly observed in hysteria. In this connection we must further mention the quite temporary polyuria which sometimes occurs in nervous persons after great mental excitement. - Finally, there is the polyuria which occupies a place by itself, resulting from an obstruction somewhere in the urinary pas- sages, where the urine is held back, and then the passage again becomes free (see under Obstruction). Finally, we must briefly refer to some drinks which temporarily increase the amount of the urine, as coffee, beer, and wine, which increase the quantity of urine more than the amount of water repre- sented. Likewise there are to be mentioned certain articles of diet which have the same effect, partly in that they increase the blood- EX A MINA TION OF THE URINA RY A PPA RA TVS. 407 pressure by affecting the action of the heart, partly in that they stim- ulate the secreting action of the kidneys. In the above pathological conditions, where we do not have a removal from the organism of water that has accumulated there, then the polyuria must be made up, of course, by imbibing an increased amount of drink (polydipsia). Whether we have the increased thirst from increased loss of water, or whether the polyuria is the result of the polydipsia, is not entirely clear, especially in many cases of dia- betes insipidus. In diabetes mellitus the polyuria is probably only a purely secondary result of the polydipsia, which, in turn, is to be regarded as the consequence of the gluktemia (Cohnheim), Diminution in the amount of urine, under some circumstances even to the extent of not passing any (anuria), occurs : From diminution in the secretion of urine : 1. In the loss of water in other ways : in severe sweating (see, also. Normal Urine) ; in any kind of severe diarrhoea, particularly in Asiatic cholera, where for days together there is continuous anuria. Thus, also, during the formation of a pleuritic or peritoneal exuda- tion, where fever is to be taken into account as a cause (see below). 2. In fever, and largely in consequence of the loss of water in other ways ; by increased perspiration and the greater loss of water by the lungs. 3. By reduced blood- pressure resulting from the diminished work of the heart ; hence, in diseases of the heart-muscle : incompensation in valvular disease, in weakening of the hypertrophic heart of con- tracted kidney, in emphysema, in all the diseases, frequently men- tioned, which harmfully affect the action of the heart. In these conditions the amount of the urine is the chief means of forming a judgment of the course of the disease, and furnishes the indications for treatment. 4. In acute nephritis, subacute and chronic nephritis, except con- tracted kidney (regarding which see also under 3). In these diseases, also, the amount of the urine is a symptom which indicates the severity of the case. In acute nephritis there not infrequently is, for a time, anuria. 5. From suppression of urinary secretion due to nervous causes, especially in a still indistinct reflex way in trauma, as from operations affecting the abdomen. Also, there may be a less quantity of urine from difficulty in mic- 408 SPECIAL DIAGNOSIS. turition ; from a very narrow stricture of the urethra (surgery) ; from retention in the bladder; from obstruction in the ureters. In regard to the latter, when one kidney is cut oif, the other generally vicari- ously performs the work of both ; but there may also be anuria when one ureter is closed, as from stone in the kidney, and this, in fact, from a kind of reflex suppression in the other kidney (see Shock). The great zeal in using the catheter in recent times has given us as a result, among other things, the knowledge of the fact that in health with every urination the bladder is completely emptied, even to a few drops. If a certain amount of urine remains in the bladder (residual urine) there is a pathological cause for it. This may be a purely mechanical hindrance to the emptying of the bladder, as stricture, hypertrophy of the prostate, urinary calculi ; or it may result from the mechanical hindrance, atony of the bladder ; or there may be primary nervous paresis of the detrusor, as occurs in tabes and in all diseases of the lumbar cord. The amount of residual urine is said to be tolerably constant ; it is measured by having the patient pass his urine, and then use the catheter immediately afterward. Color and Transparency of the Urine in Disease. Primarily, the color varies according to the degree of concentration, in the same way as in normal urine; and as in health, so also in general in disease, it stands in a certain relation to the amount of the urine : the greater the amount the clearer the urine. But, like the variations of quantity from the average, the changes in the color of the urine are also much more significant in disease than is the case in normal urine. The scale of colors of the urine passes from the almost colorless to the straw-yellow, reddish, red-brown, even brown- black. It is not necessary to have a very exact determination of the color of. the urine by comparing it with those of a table of colors, as was proposed by Vogel, because it could only have a value in deter- mining the degree of concentration, and generally for this the specific gravity is much more exact (see). Patients with cirrhosis (without icterus, which see) sometimes pass urine that, in proportion to its amount, is very dark. Anaemic (chlo- rotic) persons, on the other hand, often pass remarkably clear urine. In fever the urine is relatively dark — reddish or brownish-red (see below, IJrobilin, EX A MINA TION OF THE URINA R Y A PPA RA TVS. 409 In diabetes melUtus there is a peculiai'ity in the very striking con- tradiction between the clear color and great amount of the urine on the one side, and its high specific gravity upon the other, which is of diagnostic importance. As special pigments of the urine, the following are to be men- tioned : 1. Color due to the increase in the normal pigments. Two of these come into consideration herfe : Indiean., occurring in increased amount may sometimes give to the urine a bluish or bluish-black color, if it has been decomposed in the urinary passages and changed into indigo-blne ; but very often we do . not recognize that the urine contains more indican, because indigo has not yet been formed. Hence, when there is a suspicion of indican, or if we wish to make use of its possible presence for the purposes of diagnosis, even when the urine appears to be perfectly normal, we must examine it with reference to this substance. When urine containing indican has been standing for some hours, it can generally be recognized by the bluish shimmer of the residuum, from the drops of urine from the upper part of the urine-glass sprinkled and spread out as thin as possible, and sometimes, also, by a bluish film upon the surface of the urine. Besides, all of the urine is some- times blackish-blue, and this is most markedly the case when the urine putrefies (for its chemical reaction, see below). Indican urea — that is increase of the indican — occurs : when there is accumulation of the intestinal contents, especially of the con- tents of the small intestine, hence in occlusion of the intestine from any cause, as peritonitis or obstinate obstipation; likewise, in all forms of severe cachexia, as well as in Asiatic cholera ; lastly, in individual cases in health. Urobilin, if it exist in considerable quantity in the urine, colors it a decided red or brownish-red. The foam of the urine sometimes looks yellowish-red or yellowish-brown. While there is only a small quantity of it in health, it is abundant in febrile diseases and where there is at any time resorption of large effusions of blood. When there is a marked separation of it which continues for some time, a brownish discoloration of the skin is observed in the so-called urobilin-icterus, though, there is still dispute as to its nature. Proof of the increase of indican : The following reaction establishes 410 SPECIAL DIAGNOSIS. the presence of indican in increased amount, because it does not operate in the presence of the small quantity found in normal urine. We mix equal parts of urine and fuming nitro-muriatic acid in a reagent glass ; into this we drop two to three, or at most four, drops of a concentrated solution of chlorinated potash ; immediately, or after a few seconds, there is formed just beneath the surface a blue-black cloud — indigo-blue. By stirring the solution of potash in the urine we obtain, according to the quantity of indigo formed, a more or less dark coloration of the whole fluid. If, then, we add a few drops of chloroform and agitate (not shake) the reagent-glass several times, we have the blue color at the bottom from the settling of the chloroform (it becomes green if too much of the solution of chlorinated potash has been added, from the further oxidation of the indigo-blue). Proof of urobilin. 1. Spectroscopic : Absorption bands in green- blue, between Frauenhofer's lines b and F (sometimes it is necessary to dilute the urine with water, in order to be able to make the exami- nation). 2. Chemically : We add ammonia to the reddish urine in the reagent-glass. If there is much urobilin there, it gradually becomes a clear green ; it is then filtered ; and, sometimes, upon the addition of a few drops of a watery solution of chloride of zinc, there appears the rose-red-greenish fluorescence that is peculiar to urobilin. 2. Discoloration of the urine from the presence of the coloring- matter of the blood, and of the bile. That of the blood colors the urine variously according to the amount that is mixed with the urine, also whether it is fresh or has been changed, and according to the original <;olor (concentration) of the urine : flesh-red or blood-red with green- ish shimmer with the light passing through it, corresponding to the •dichrotic behavior of the blood ; or an untransparent brown, even Mackish. Frequently the bloody color is easily recognized ; but, generally, the reaction-test for blood coloring-matter is necessary (see Coloring Matter of the Blood). Colorinsj-matter of blood occurs in the urine : 1. In hsematuria, and this in the sediment. It is circumstantially described in the section on Admixture of Blood with the Urine. 2. In hsemoglobinuria. In this condition the haemoglobin is found entirely dissolved or in granular lumps, but no red blood-corpuscles, or very few, are found in the urine. This results from heemoglobingemia (see p. 271), and this condition may arise from very different causes : from poisons (chlorate of potash, mineral acids, arsenical solutions, pyrogallic acid, EXAMINATIOX OF THE JRINARY APPARATUS. 411 Tiaplithol, poison of the edible musliroom, helvella esculenta ; after transfusion of animal blood, as of lamb's blood) ; in infectious diseases (as scarlet fever, abdominal typhus, malaria, syphilis) ; after extensive burns ; lastly, Ave have to mention a form of hsemoglobinuria which occurs as an independent disease — paroxysmal lisemoglobinuria. Coloring matter of the bile exists in the urine in icterus (icteric urine). Such urine is most frequently a beer-brown, sometimes brown- green, or even black. If the urine of icterus, as is very seldom the case, is very thin, then it may have a golden-reddish tone. The foam that forms when it is shaken is then highly characteristic : from clear to dark yellow, green-yellow, even brownish. (Regarding the chemical tests for bile coloring-matter, and more particularly regard- ing its presence and that of the bile acids in the urine, see section on Coloring Matter of the Bile.) 3. Staining of the urine from medicines. It is very important to recognize these changes in color, so that one may be on the guard against deception by confounding them with the coloring matter of the bile and the blood. The chrysophanic acid contained in rhubarb and senna passes off hy the urine. It colors the urine slightly, making it at most a little brownish, if it is normally acid ; but if it is alkaline, or is made so, then it becomes a purplish-red. After taking logwood, alkaline urine also becomes reddish or violet. Santonin colors the urine yellow or greenish-yellow, with a yellow foam ; upon the addition of an alkali the color changes to red. Picric acid makes the urine yellow, but there is no change in color after changing the reaction. Carbolic acid, naphthalin, creasote, and other preparations of tar, as well as the infusion of the leaves of uvse ursi (arbutin) produce a greenish or greenish-black color of urine. Brownish or blackish discoloration of the urine after standing for some time in the air is observed in patients with melanotic tumors, because the pigment which forms the coloring matter of the blood in those tumors passes off by the urine. A similar behavior of the urine is found in the presence of an abnormal amount of pyrocatechin, an extremely rare occurrence. Transparency of the urine. A loss of transparency by turbidness may take place even in normal urine when it has been allowed to stand (see above). Urine that is turbid when passed is always pathological. 412 SPECIAL DIAGNOSIS. This is the case, first of all, in nephritis, in consequence of the pres- ence of organized constituents ; in all diseases of the urinary passages, for the same reason (here particularly on account of mucus) ; but especially in severe cystitis, because the urine in this condition is alkaline when it is passed (alkaline fermentation in the bladder), and hence, besides the organic constituents, contains a deposit of phos- phates. Admixture of blood and pus always makes the urine turbid to some extent. The most striking, and, at the same time, the rarest kind of turbidness is that caused by fat in the urine, chyluria. Here the urine is milky, as if mixed with pus (galacturia) from the emulsi- fied fat; or it contains large drops of fat or fat-bubbles swimming upon its surface (lipuria). By shaking the urine up with ether it becomes clear. But when it is allowed to stand, part of the fat settles as a sediment, and part forms a cream-like layer on top. (See further regarding Chyluria.) Tlie Specific Q-ravity of the Urine in Disease. The specific gravity of the urine may vary from a little over 1000 to over lOGO (in diabetes mellitus). Apart from certain special admixtures (we mean particularly sugar, which increases the specific gravity without changing its color, and the special pig- mentary admixtures, which, on the other hand, darken the color without essentially adding to the specific gravity), almost always in disease, as in health, a scanty, dark urine has a high specific gravity ; an abundant, clear urine, a low specific gravity. According to Hsesef and Neubauer, from the specific gravity we can obtain an approxima- tion to the amount of solid constituents of the urine by multiplying the last two figures of the specific gravity by 2.33. This product represents the quantity of solid constituents in 1000 grammes of the urine. If we have 1200 grammes of urine with a specific gravity of 1021, then 1000 grammes of this contains 21 X 2 33 = 48.93 grammes of solids, and the whole amount = 58.7 grammes. But not much has been said regarding the change of material upon which it chiefly depends, because the different solid constituents of the urine have very different specific gravity, particularly urea, which, as compared with chloride of sodium is as 2 to 3. Hence, we can never draw defi- nite conclusions from the specific gravity alone, and even where we can exactly determine the solids, as by examining the various material EXAMINATION OF THE URINARY APPARATUS. 413 changes, the quantitative determination of the urea or of the nitrogen is indispensably necessary. The chief value in the determination of the specific gravity with reference to diagnosis consists in the following : 1. High specific gravity with clear and abundant urine points to diabetes mellitus. We may even say that a specific gravity of 1040 and over, the urine being clear, can only be caused by sugar, and hence is pathognomonic of diabetes. 2. Repeated or continued examination of the urine in general engorgement is of value, because this, as well as the quantity of the urine, measures the labor of the heart. It is not unimportant to know further : 3. A low specific gravity, when there is a small amount of urine which is often high colored, occurs in nephritis from diminished excre- tion of urea, also in severe diarrhoea and vomiting. Reaction of Urine in Disease. For the reasons previously given (under Reaction of the Normal Urine), the reaction of the urine is reliable only a short time after it has been passed. Neutral or alkaline reaction of the urine is met with in sickness : 1. Under the same conditions that make it neutral or alkaline in health. 2. When there is resorption of transudates and exudation in the cavities of the body, also from large eS"usions of blood, especially in the pleura and peritoneum. 3. With dilatation of the stomach, and particularly if the contents of the stomach must frequently be brought up, either by vomiting or artificially. The reason given is that the blood and the organism lose their acidity because free HCl is not again resorbed (?) (See above, under Reaction of the Normal Urine.) 4. Considerable admixture of blood or pus. In the cases of alka- line urine previously mentioned the urine is clear, or is turbid from the deposit of phosphate ; it contains no bacteria, or only a few. 5. With alkaline fermentation of the urine in the bladder. This accompanies severe forms of cystitis. Here the urine is turbid, because of the presence of pus-corpuscles, abundant bacteria, deposit of triple-phosphates, urate of ammonia, carbonate and phosphate of lime and magnesia. Sometimes it has a peculiar, urinous smell, and is 414 SPECIAL DIAGNOSIS pungent from the free ammonia. By this latter a strip of red litmus- paper, just held free over the fluid, is colored blue. Further regarding the formed constituents of simple alkaline urine, and that which has been the subject of alkaline fermentation, see under Sediment. The acidity of the urine may be determined by a simple, but really not very accurate, method : Prepare a 10-per-cent. solution of caustic soda (1 of soda to 9 of distilled water), and pour this from a burette into the urine until a piece of very sensitive litmus becomes blue. 1 c.cm. of the soda solution corresponds to 0.0068 of oxalic acid. Works upon analysis of the urine teach the more exact methods. Pathological Odor of the Urine. Here we must mention as worthy of recognition the pathological departures from the odor of normal urine. A urinous, more or less pungent, ammoniacal odor, in cases of severe cystitis, shows ammo- niacal fermentation in the urine that is passed. Then there is the feculent odor Avhen the urine is mixed with feces, whether the admix- ture takes place after the urine is passed (see Contamination, p. 399), or whether it has taken place from communication between the bladder and the intestine, with discharge into the bladder. The most notable, and at the same time diagnostically important, odor of the urine is the fruity (apple-odor), or like chloroform. The substance which has this peculiar odor seems to be acetone (Fetters) [compare what is said later regarding Acetone]. The urine Avhich has this odor, upon the addition of chloride of iron, sometimes gives a burgundy-red reaction (" chloride-of-iron reaction," Gerhardt), which shows the presence of acetoacetic acid (see further below). Usually the odor of apples is more noticeable in the breath of the patient even than in the urine, and it may be noticed in the breath alone. The apple-odor is observed in individual cases of diabetes mellitus. It especially occurs in diabetic coma or as the precursor of this con- dition, but it also exists, and, indeed, often for a long time, without the occurrence of coma. Unusual odors may be imparted to the urine by medicines : after taking turpentine, violet odor; after cubebs and copaiva, the aromatic odor of these drugs. Foul, albuminous urine, but especially urine that contains pus. develops, as the result of certain organisms, sulphuretted hydrogen : EXAMINATION OF THE URINARY APPARATUS. 415 hydrothionic urine. Sometimes this fermentation, with the develop- ment of sulphuretted hydrogen, seems to take place in the bladder (cystitis). On the other hand, if the urine, when first passed, is clear, and upon being promptly examined is found to contain sul- phuretted hydrogen, it is probable that there has been resorption of SH2 into the blood or into the bladder from the intestine, or from a depot of pus in the neighborhood of the bladder ; under which circum- stances the general symptoms of poisoning have recently been observed. Urinary Sediments. We are to call to mind the sediments, previously mentioned, which may occur in normal urine. On the other hand, these same sedi- ments may sometimes be observed as pathological signs, as is shown in Avhat follows : All formed constituents which separate when the urine is allowed to stand are reckoned as "sediments," whether they can be recog- ni-zed with the, naked eye or only under the microscope, or whether they are organized or are really "deposits." As previously men- tioned, in order to examine the sediment it is desirable carefully to pour off from the vessel containing the urine the upper part ; the lower turbid or already settled portion is to be put into a glass with a pointed bottom, and again allowed to settle. Then follows the examination with the naked eye and with the microscope. For the latter, we take up some of the sediment with a pipette by introducing it closed by one finger upon the upper end to the bottom of the pointed glass, when it is to be opened again for a moment, then it is withdrawn and carefully wiped off, and a drop of its contents allowed to flow upon an object-glass. [A slide with a depression in the centre making a shallow cell is very convenient, since a larger drop can be examined at each time.] Upon this we place a glass cover, and examine it with a magnifying power of about 400 diameters. If the sediment is very scanty, we are to focus the microscope so as first to examine the edge of the covering-glass. It may happen that the sediment is so scanty that we cannot see anything at the bottom of the glass with the naked eye, but by carefully removing a drop from the bottom of the glass and placing it under the microscope we may possibly make out formed constituents, as a few casts (contracted kidney). It is necessary to color the urinary preparations only when examining for certain microorganisms (see below). 416 SPECIAL DIAGNOSIS. 1. Sediments of Organic Bodies or their Direct Products. Mucus. Physiologically this exists only in small quantities. It is increased in all diseases of the urinary passages, but especially in cystitis, and also in fever. Some mucous forms are characteristic : In the form of minute roundish floccules, the size of a millet-seed or the head of a pin, they are tolerably characteristic of mild cystitis. Under the microscope they show white blood-corpuscles lying closely to one another, and they are apparently conglomerations of white corpuscles. In the form of threads, one to two centimetres long — gonorrhoeal threads — sometimes more purely mucous in character, and, again, containing abundant pus-corpuscles: they occur in chronic gonorrhoea or as the residuum of a past attack. Finally, we find microscopical mucous threads, cylindroids (see Fig. 123, p. 417), which may be confounded by the inexperienced with tube-casts. The origin and diagnostic significance of these is not clear. They are found in nephritis by the side of the casts, in cystitis, but also in health. They are distinguished from the urinary casts by their usually being of considerable length, their mucus-thread texture, their very varying thickness (as fine as threads, especially at the end), and their tape-like appearance. Chemical proof of mucus in solution : The addition of acetic acid makes a flocculent precipitate, which is not again dissolved by an excess of acid, nor is it again dissolved by heat, as is the case with a precipitate of urates produced by acetic acid. In Avomen mistakes may arise from the admixture of vaginal mucus with the urine. Blood, or red blood-corpuscles. The appearance of the urine varies very remarkably in hsematuria. Sometimes there is a considerable bloody sediment, not infrequently partly coagulated ; again, only a fine deposit of red blood-corpuscles spread out evenly : and lastly, sometimes, a more brown-red, clear, or dark -brownish sediment. The red blood-corpuscles may be so scanty as to escape detection with the naked eye. This distinction pertains to the amount of the blood and its having been for a longer or shorter time in the urine — that is, with reference to the location of the hemorrhage. (Regarding the color of the urine, see p. 401.) EXAMINATION OF THE URINARY APPARATUS. 417 Fig. 123. Hcematuria occurs : (a) In diseases of the kidneys — that is to say, in acute and chronic hemorrhagic nephritis, in embolic hemorrhagic infarction of the kidney (valvular disease of the heart), in septic hemorrhage of the kidneys (acute en- docarditis), in marked engorgement of the kidney, with new formations, and, lastly, in injuries to the kidney. {h) In certain diseases of the urinary passages, and also of the pelvis of the kidney (nephrolithiasis, tumors), of the hladiler (severe cystitis, tumors, stone), of the urethra (gonorrhcea with parasites of the urinary canal ; see below). Moreover, hgematuria has symptoma- tic significance for recognizing diseases of other kinds. Thus it occurs in scor- butus, morbus Werlhofii, haemophilia, and, lastly, in the rare hemorrhages of the kidney or urinary tract that are due to leukaemia. From the appearance of the sediment and the way it is passed, a conclusion with i-eference to the location of the hemorrhage and the kind of disease Avill be made from the following points of view : A small amount of blood, or, at least a not too abundant quantity of blood, uniformly mixed with the urine, the color of the blood being retained, or, more frequently, changed into a brownish color, points to a hemorrhage of the kid- ney. That this is its source can be more certainly proved by the microscope showing blood-casts (see below). Where there is renal hemorrhage, the blood-corpuscles are always more or less discolored, as rings or shadows. Cells and casts, if present, are stained brown by the coloring-matter of the blood. A brown color of the sediment 27 CyIindroids{seep. 416). (Jaksch.) 418 SPECIAL DIAGNOSIS. and of tlie urine indicates acute hemorrhagic nephritis. The sudden occurrence of bloody urine, with valvular disease of the heart, points to renal infarction. Individual red blood-corpuscles occur in very concentrated urine in renal engorgement. In hemorrhage of the pelvis of the kidney, especially that caused by stope, the urine usually alternates between being bloody and free from blood, and this, either because there are temporary hemorrhages or because the ureter of the diseased side is for the time being stopped, and then the urine that is passed only comes from the sound side. The blood may for a time escape very freely; in rare cases it may be passed in the form of vermiform coagula (casts of the ureter), which give great pain as they are passed. Cystic hemorrhages, especially in villous tumors, may be so free as to be fatal. The urine is not intimately mixed with blood, especially if the patient lies quietly in bed ; at first there is little or no blood at each urination ; but then, again, pure blood is sometimes passed. On the other hand, in hemorrhage from the urethra, blood comes only at the beginning of the urination. Here, sometimes, there is an escape of blood between the urinations. Works upon surgery treat more at length of hemorrhages of the bladder and urethra. Microscopical examiyiation. In every respect this is the most valuable method for recognizing hsematuria, especially from the following points of view: 1. Because the separate red blood-corpuscles can be discovered where neither the fluid portion of the urine nor the sediment shows the color of blood, and where, also, the fluid portion does not show the reaction of the blood-pigment (see below). 2. Because it alone establishes the differential diagnosis between hsema- turia and hsemoglobinuria. 3. Because, from the condition of the red bloo^-corpuscles, from the presence of possible blood-casts (see Casts), we can sometimes determine that there is renal hemorrhage. In haematuria we find more or less abundance of red corpuscles. In decided hemorrhage, especially from the lower portion of the urinary tract, these are only slightly changed. If retained for some time in the urine, and particularly if they are scanty, us in renal hemorrhage, they are smaller, have granular contents, or are more or less markedly discolored. If they are very pale, then we have the so-called rings. If there are no red blood-corpuscles in a urine that is bloody and certainly contains haemoglobin (see Examination of the EXAMINATION OF THE URINARY APPARATUS. 419 dissolved portion), or if they are very scanty in a urine that contains a good deal of haemoglobin, then we have htemoglobinuria (which see). Besides red blood-corpuscles, we frequently find in the sediment, according to the disease present, still other formed constituents : in cystitis, first of all, white blood-corpuscles, phosphate crystals ; in nephritis, casts and white blood-corpuscles. A considerable amount of blood in the urine makesit somewhat albuminous. With women, we must remember the possibility of beino- deceived by the menstrual blood. Hcemoglohin. In hsemoglobinuria there is usually a brown or brown-black sediment, which consists of brown flakes and fine granular detritus. A few red blood-corpuscles are likewise found. If casts and epithelium are present, they are often colored brown. Pus, or white blood- corpuscles. It is rare that a considerable amount of pus is passed by the urethra. It happens if a neighboring depot of pus breaks into the urinary canal : in perinephritic abscess with discharge into the pelvis of the kidney, but particularly in ab- scesses of all kinds in the neighborhood of the bladder. Here the discharge of pus takes place suddenly, and after a short time the urine becomes normal again. But the discharge of pus into the urinary passage may continue for some time, or it may indicate cystitis. Sediments of pus or white blood-corpuscles are more frequent, being caused by inflammation of the mucous membrane of the urinary tract, or by nephritis. In the latter case they are less abundant than in the former. The sediment is yellow to white, in nephritis; in catarrhal cystitis it is sometimes very like phosphatic sediment (which see). In inflammation of the urinary tract, generally the sediment becomes a peculiar compact jelly, from mucus; in alkaline urine, it is due to the mucous swelling of the white blood-corpuscles (see above); in nephritis, it is quite spongy. The microscopical examination shows the white blood-corpuscles more or less changed according to their' amount, the length of time they have been in the urine, and the reaction of the latter. In alka- line urine they are very clear and much swollen. Of the diseases of the kidneys, acute hemorrhagic nephritis, and sometimes the sub- 420 SPECIAL DIAGNOSIS. chronic (chronic parenchymatous) nephritis, show a relatively abundant amount of pus-corpuscles. To a slight degree, pus makes the urine albuminous ; a considerable amount of albumin in the urine is always due to renal albuminuria. When the quantity of albumin in the urine is slight, the question may arise whether we have nephritis, either as a separate disease or as a complication of cystitis or pyelitis. This can only be answered by the infallible sign of nephritis — that is, easts in the urine. Fat-drops. The fat accompanying chyluria may, as was previously mentioned, exist in the urine as a sediment, but also as a cream-like or swimming layer, or in the form of large drops. We must remember that it may be due to impurities, as the use of an oiled catheter. The microscope shows minute particles of fat or large drops, which markedly refract the light. In the first case the fatty character of the sediment may be most quickly recognized by the grease-spot formed upon paper by the sediment. We may also shake it up with ether, and then allow the ether to escape by evaporation. The occurrence of fat-drops free and attached to casts, adipose Avhite blood-corpuscles, is very important in diagnosing large white kidney. EpitheUum. We find in the urine the epithelium of the urinary passages and the epithelium of the renal urinary channels [urinary tubules]. In addition, in women we have very frequently, but espe- cially when there is leucorrhoea, flat epithelium from the vulva. The epithelial cells in transition are everywhere very similar. But renal epithelium is usually easily recognized as such. While in normal urine only individual flat epithelial, and some- times, caudate cells occur, we meet a large quantity of the three species of cells named in inflammation of the urinary passages. Usually, they are well preserved. It is misleading to form a conclu- sion from the kind of cells as to the location of the inflammation (especially Avhether of the pelvis of the kidney or of the bladder). The vulva being excluded, a large quantity of flat epithelium points to the bladder. Abundant caudate, but especially overlapping, " tile- like," roundish cells with large nuclei, were formerly often regarded as characteristic of inflammation of the pelvis of the kidney ; but more recently this view has come into discredit. EXAMINATION OF THE URINARV APPARATUS. 421 Renal epithelia occur in considerable numbers only in affections of the kidney, and especially in nephritis. If their form is well pre- served, they are recognized without difficulty as polygonal or round- cornered cells of peculiarly sharp contour, with large oval nuclei and a decidedly granular, often yellowish-looking, protoplasm. They are small — not larger than white blood-corpuscles, sometimes smaller. In acute hemorrhagic nephritis they are often coarsely granular, brownish in color; in the large white (butter) kidney, but sometimes also in the first disease, we not infrequently see them in all stages of fatty degeneration. Fig. 124. Epithelium from the urine, a, h, epithelium from the bladder, from the pelvis of the kidney; c, caudate epithelium (pelvis of the kidney?); d, renal epithelium, partly changed into fat. Regarding cylindrical epithelium, see under Casts. Shreds of tissue. Shreds of connective-tissue ^nd " caseous crumbs " are found in tuberculosis of the urinary apparatus. Particles of carcinomatous tissue are separated in carcinoma, but are more frequently found in carcinoma villosum of the bladder. Only particles which distinctly show the structure of carcinomatous tissue are of importance here. Single, or, also, several pretended " cancer-cells " lying close to one another have no diagnostic value. Si^ermatozoa. After every discharge of semen these aro seen in the urine. Hence, they arc not unimportant for detecting masturba- tion. They also occur in spermatorrhoea. Lastly, sometimes they are found after epileptic attacks ; also, now and then with severe diseases of all kinds, as in typhoid fever patients. Casts. The so-called urinary casts (Henle, 1842) are incontestably the most important form-elements in pathological urine. They are 422 SPECIAL DIAGNOSIS. found with renal albuminuria. Aside from quite individual excep- tional cases, they occur without simultaneous albuminuria only in one condition : hepatogenous icterus. Here they have no diagnostic interest further than that, from their occurrence, we may suspect the presence of bile-acids in the urine. They are intensely stained with the bile-pigment. We concern ourselves only with the occurrence of casts with albu- minuria. By their presence these not only permit a conclusion that there is a disease of the kidneys which causes albuminuria, but, by their quantity and character, also enable us to diagnose the exact nature of the disease. Regarding their numbers the casts are scanty, and then usually hyaline (see below), in engorgement of the kidneys, in fever, in physiological albuminuria ; and, lastly, they are tem- porarily present in contracted and amyloid kidney. There is often here a sediment which is scarcely, or not at all, visible. In making a preparation we must, with the greatest care, take a few drops from the bottom of the urine-glass and examine the preparation with great thoroughness. It is advantageous, but not indispensable, to stain any casts that may be present by the addition of a little gentian- violet solution placed upon the edge of the covering-glass. The casts are very abundant in acute, and frequently also in chronic, nephritis. In these diseases they may form the principal portion of a tolerably abundant sediment. Variation in the quantity of the casts is to be observed in all the diseases named. Sometimes it seems as if, after a period of stagna- tion, the casts are passed in greater abundance. This is not very rare in amyloid nephritis, also in acute attacks of nephritis. In size and form the casts vary greatly. We will speak further regarding this. As to their nature, we distinguish the following kinds of casts : Hyaline casts. These are of great variety as to length and breadth ; sometimes not so broad as a white blood-corpuscle (thin hyaline casts), and, again, five or six times as broad (thick or medium casts). In length they may be as much as one millimetre. They are homogeneous and clear as water, with a very fine outline, hence often very difficult to see ; the ends look as if broken off", rounded, or even clubbed (for aggregation of substances within them, see below). They occur in company with other forms in all diseases of the kidney. EXAMiyATIOy OF THE URINARY APPARATUS. 423 Exclusively hyaline casts occur most frequently in contracted and amyloid kidney, also in fever and with [renal] engorgement. A special kind of hyaline casts are the waxy, so named from their dull lustre and usually yellowish color. Sometimes they show the amyloid reaction with iodine and iodide of potassium — brown, then violet with sulphuric acid. We cannot form a conclusion from them as to the nature of the disease of the kidney ; certainly they Fif._ 126. are not pathognomonic of amy- loid kidney. Additions to the hyaline, and also to the waxy, casts fre- quently occur in the form of liili red and white blood-corpuscles, renal epithelium, crystals, gran- ular masses, which, in turn, may show urates, phosphates, Fifi. 125. Hyaline easts (narrow and tolerably broad ones). Waxy casts. (Jaksch.) 5, a cast containing crystals of oxalate of litne. albuminous or fat granules, and, lastly, bacteria. Among these additions those of special significance are red blood-corpuscles, as in hemorrhagic nephritis, possibly adipose renal epithelia, white blood- corpuscles (granular spheres), and free fat-granules. These adipose elements, if abundant, are important for the diagnosis of large white or fatty kidney. In some cases of pyelonephritis we have seen hyaline casts which 424 S FECI A L D I A GNOSIS. were split like a pair of trousers. These might possibly have their origin in collective tubes (?). Casts that are coarse or finely granular are generally hyaline, with additions to their contents, as above. But, especially in acute nephritis, conglomerate casts of albumin in lumps and granules also occur ; sometimes stained or mixed with hsematoidin. Blood easts are conglomerations of red blood-corpuscles held together by coagulation. They are important as indisputable signs of renal hsematuria. Epithelial casts are either hyaline casts with the addition of renal epithelium (recognized by their sharp outline and distinct large nuclei), or they are true epithelial tubes. In both cases they have the same significance — the free desquamation of renal epithelium, especially as it occurs with acute hemorrhagic nephritis. Fig. 127. Fig. 128. Fig. 129. Fig. 127.— Granular casts. (Jaksch.) Fig. 128. — Red blood-corpuscles, partly as " rings'' and cast of red blood-corpuscles. (ElCHHORST.) Fig. 129. — Epithelial cast. (Jaksch.) Casts of lumps of haemoglobin in hsemoglobinuria, urate-casts in the newly born (uric acid infarction in connection with ammonium urate), and casts of bacteria in pysemia (?) are very rare occurrences. We may confound casts with cylindroids (see p. 416), also with threads of linen or other adventitious materials in the urine. Practice in examining and cleanliness guard one from mistake Animal Parasites. Uehinococcus. Shreds from echinococcus bladders, scolices, are met with in the urine if an echinococcus of the kidney oi from the ^EXAMINATION OF THE URINARY APPARATUS. 425 neighborhood of the urinary apparatus breaks into the urinary passage. The passing of urine is often attended with severe pain, especially by attacks of colic during its transit through the ureters. They may be preceded by anuria from obstruction of the urethra, obstruction of one ureter, and "reflex" suppression of secretion upon the sound side (or reflex spasm of the sphincter vesicae). Distoma hcematobium, an exotic from Egypt, located in the roots of the portal vein, also particularly in the plexus vesicalis, causes h^ema- turia. The eggs of the parasite make their appearance in the urine. Strongylus gigas located in the pelvis of the kidney causes pyuria and hsematuria. Filaria sanguinis, an exotic from East India, Japan, China, and Australia, located in the large lymph-vessels, among other things causes engorgement of the lymph-vessels of the bladder : chyluria (and likewise galacturia, see) and hsematuria (peach-red urine). Besides, the urine contains embryo filaria, round worms of delicate structure, lying in a fine sheath, with lively motion. Its width is about that of a red blood-corpuscle ; its length, two to three millimetres. Oxyuris vermicidaris, trichomonas vaginalis (an infusorium), and, in one case under my observation, the larva of a fly, musca vom- itoria (!), may become mixed with the urine from the vagina. Vegetable Parasites and Fungi. Normal fresh urine, free from impurities, is not entirely free from fungi (see p. 399). A number of bacilli and cocci colonize in urine that has been standing for some time, of which those of special interest are the ones which cause alkaline fermentation, changing the urea into carbonate of ammonia (see p. 402). The micrococci and bacilli of alkaline fermentation, and, with them, the signs of this fermentation — alkaline urine, crystals of triple- phosphate and carbonate of ammonia (see below) — however, occur in fresh urine in severe cystitis, particularly as the result of the use of a catheter that is unclean, in cases of weak or paralyzed bladder; but this is no doubt also caused by paralysis of the bladder alone, and the spontaneous entrance of fungus germs through the urethra. The fungi produce cystitis by the fermentation they set up, and this, in turn, favors the development of the fungi. If these schizomycetes are very numerous they may form the greater part of the abundant 426 SPECIAL DIAGNOSIS. sediment. Under the microscope we see ciiiefly the chain-coccus (micrococcus urese, micrococcus urese liquifaciens) and bacilli (chiefly bacillus urese, Leube), not so long, but thicker than the bacillus tuberculosis; all these forms of fungi being in the most lively motion. It is the presence of these fungi that distinguishes simple alkaline urine (see p. 413) from urine that is alkaline from fermentation. Tubercle bacilli in the urine are an absolutely sure sign of ulcer- ating urogenital tuberculosis. But in this disease, especially when there is tuberculosis of the pelvis of the kidney or of the kidney of only one side, the ureter of that side is temporarily or permanently stopped. In regard to the occurrence of single bacilli having the form and the color-reaction of tubercle bacilli, compare what has been said regarding smegma bacilli, p. 400. If tubercle bacilli appear at all in the urine, they are generally abundant, not infrequently even Fig. 130. Pure culture of tubercle bacilli in the urine in tuberculosis of the genito-urinary apparatus. Zeiss's homogeneous immersion one-twelfth eye-piece No. 4. Drawn with a camera lucida. Magnified about 1100. Author's observation. in masses and with an arrangement which reminds one of a pure culture. Fig. 130 exhibits an excessive dev^elopment of this kind (personal observation). In purulent urinary sediment they can be demonstrated just as distinctly as in the sputum. If there is decided anaemia, wasting, and continued fever, as well as in cases of long- continued gleet, every purulent urinary sediment should be examined for tubercle bacillus. EXAMINATION OF THE URINARV APPARATUS. 427 Gonococci(Neisser) occur in the pus of recent gonorrhoea in clusters, in epithelial cells, and in pus-cells. The latter circumstance is char- acteristic of gonococci, and distinguishes them from other bacteria which resemble them. Gonococci are chiefly met with as diplococci, and since the individual coccus seems to be divided into two by a bright transverse band, it often makes the so-called roll-form. In gleet and in pervsons who have formerly had gleet, but have for years Fig. 131. Gonococci iu the pus from the urethra. Zeiss's homogeneous immersion one-twelfth, eye-piece 'No. 2 Drawn with a camera lucida. Magnified about 650. been free from any symptoms, we find a diplococcus which resembles the gonococcus. But by recent investigations it has been discovered that even in the urethral secretion of persons in health, who have never had gonorrhoea, there occurs a diplococcus, free as well as enclosed in epithelia (although, of course, not in pus-corpuscles). This diplococcus hns a form very much like the gonococcus (Lust- garten and Mannaberg). The gonococcus is to be stained with gentian-violet or methylene-blue, or fuchsin, and then rinsed in water. Pathogenic fungi which circulate in the blood are, in individual cases, found in the urine : thus, tubercle bacilli in acute miliary tuberculosis, equinia, erysipelas cocci in erysipelatous nephritis (Fehleisen), spirillum recurrens in complicating hemorrhage of the kidney (Kanncnberg), pus-micrococci in pysemia and endocarditis (Weichselbaum). Also, casts of micrococci are described in septic processes (Litten and others). Lastly, in cases of acute nephritis, bacteria have recently been found in the urine and in the kidney, which have been regarded by different authors as the specific excitants of the nephritis. These cases are too much isolated to permit us to form a definite conclusion as yet. 428 SPECIAL DIAGNOSIS. A small form of sarcina is found rarelj in alkaline fermentation in the urine. It, as well as the other fungi named, is regarded as the cause of the transformation of the urea. Leptothrix buccalis occurs as a foreign substance, as from the preputial sac (Huber). The occurrence of the yeast fungus, saccharorayces, in urine con- taining sugar is not unimportant. Here it causes acid fermentation. In urine that does not contain sugar, some yeast-cells are found occa- sionally, but they do not increase. 2 Inorganic Sediments. These consist of materials which are ordinarily found in the urine in a state of solution, but which, for various reasons, are absent, chiefly because the urine is very much concentrated, or because its reaction has changed. These bodies show the forms of more or less pure crystals ; they may be crystalline, or amorphous, but neverthe- less often have a peculiar symmetrical form. Here we really consider the finer urinary sediments ; urinary calculi, which belong to surgery, will be mentioned at the end and only very briefly. (a) The more frequent inorganic sediments. From acid urine there are deposited: Uric acid, uric acid salts (sodium, lime), oxalate of lime. From the faintly acid, neutral (amphoteric), alkaline urine there are deposited: Ammonio-magnesian phosphates, phosphate of lime, carbonate of lime, urate of ammonia, and sometimes uric acid. All these substances may occasionally be deposited from healthy urine (see p. 402) Uric acid. As is stated above, we find this as a deposit not only in acid, but sometimes in neutral and alkaline, urine. It can often be recognized with the naked eye in the form of yellowish-red, glittering granules, which are located upon the side of the urine-glass, or in the form of a yellowish-red powder at the bottom of the glass. Uric acid deposited from the urine always has this yellowish-red color, while the chemically pure uric acid is colorless. Under the microscope it shows the greatest variety of crystal forms and crys- talline figures (see Fig. 132). The basis form is the rhomboidal plate. But this is rare. More frequently we have derivatives of EXAMINATION OF THE URINARY APPARATUS. 429 this, the so-called ''whetstone " (with a cross or in druses), ''barrel- shaped,'' also peculiar bundles of prisms, lastly, amorphous lumps and clubs with separate, shining, smooth surfiices — all easily recognized by their distinct color. AVe may artificially produce a separation of uric acid deposit by adding to the urine some concentrated solution of salt and allowing it to stand for twenty-four hours. Ordinarily, chemical reaction is not necessary. Fig. 132. Fig. 133. Urie acid iind urates. (Funke.) Oxalate of lime. (Laachk. The occurrence of uric-acid crystals in the urine only shows that uric acid is not exactly Avanting in the urine, and nothing more. It is said that the frequent separation of amorphous forms indicates urinary calculi (Ultzmann). Urate of soda and lime. When concentrated urine cools there is often a very abundant sediment, colored a flesh-red by the urinary pigment, "brick-dust sediment," or sedimeiifiim lateritium. When cooled to zero, C, we can obtain it from any urine. It will be most easily recognized by the fact that it immediately completely dissolves when the urine is warmed (not boiled, because then there is a phos- phatic cloudiness, and also coagulation of albumin, if present). Under the microscope the urates of soda and of lime are seen as very fine grains. . They incline to settle upon the casts, and especially upon mucus threads. Uric-acid crystals form about half an hour after the addition of some muriatic acid. From concentrated urine the lateritious sediment is deposited at 430 SPECIAL DIAGNOSIS. the ordinary temperature of the room, especiallj in engorgement of the kidneys, in attacks of diarrhoea, in fever, and also in health (see p. 402). We should never conclude from its presence that there is increased separation of uric acid. AVe can only determine this by ascertaining the amount of uric acid and urate separated in twenty- four hours. Oxalate of Iwie. Single crystals of this may appear in any urine that has been standing for some time. The crystals are almost always tolerably small, sometimes minute regular octahedra, which are con- spicuous by their perfect form and strong refraction of light (envelope- form). They are rarely hour-glass- and dum.b-bell-shaped. The crystals are insoluble in Avater, and are thus distinguished from chloride of sodium. Fig. 134. Fig. 135. Triple-phosphates ; urate of ammonia. (Laache.) Phosphate of lime. (Laache.) These crystals occur in the urine in great abundance after eating certain fruits and vegetables, as apples, pears, cauliflower, and the different kinds of sorrel; and also in diabetes mellitus, catarrhal icterus, hypochondria. Moreover, we cannot conclude, without further evidence than the mere occurrence of a somewhat large amount of these crystals, that there is increased separation of oxalic acid (oxaluria). The disease described by English physicians (and Can- tani) as oxaluria does not seem to be a unity. This oxaluria occurs in cachexia (tuberculosis, cancer). EXAMIXATION OF THE URINARV APPARATUS. 431 Amiiioiuarn-iiiagnesian jjliospliate (triple-phosphate) is found in urine that is simply alkaline and that is undergoing alkaline fermenta- tion. Sometimes it forms the principal portion of the Avhitish sedi- ment. The basis form is the rhombic prism ; it is well formed in the "coffin-lid crystals," often also of various other forms, and is then more difficult to recognize. The triple-phosphates are all perfectly colorless, 'and soluble in acetic acid, thus contrasting with oxalate of lime. Phosphoric acid as a basic salt occurs in amorphous grains in alkaline fermentation of the urine. It is soluble in acetic acid, but not by heat. As a neutral salt it occurs in simple alkaline urine in the form of long Avedgos or knife-blades. These disappear in alkaline fermentation. Fig. 136. Fig. 1.37. ' Carbonate of lime. (Laache.) Leucin and tyrosin. (Laache.) Carbonate of lime, in the form of spherules or crossed drum-sticks, seldom occurs in alkaline urine. [" In highly alkaline urine, in which the alkalescence is caused by carbonate of ammonia set free by decomposition of urea, carbonate of lime occurs in small quantity, but in an amorphous form. This is the only form in which I have yet seen carbonate of lime in human urine." — Beale.] It is dissolved by the addition of muriatic acid, with eifervescence. The so-called phosphaturia is a condition in which phosphates and carbonates ai-e precipitated before or immediately after the urine is passed. But there is no increase in the phosphoric acid. The 432 SPECIAL DIAGNOSIS precipitation is probably produced by the alkalinity of the urine. Phosphaturia occurs in neurasthenia, hypochondria, chronic articular rheumatism. Urate of ammonia accompanies triple-phosphate in alkaline fer- mentation. The characteristic form is that of the thorn-apple (grayish-yellow or brownish opaque balls, from which fine needles project). When muriatic acid is added, there develop under the covering-glass uric-acid crystals. (5) 3Iore rare inorganic sediments. Hsematoidin is exceptionally found in the forms of needles and plates mentioned before (p. 180). Sometimes we see white blood-corpuscles which contain hsematoidin needles, which project through the cell-membrane. Leucin and tyrosin (see Fig. 137). The characteristic forms of these substances, which almost always appear together, are sometimes found in the sediment, more often only when we have evaporated the urine in a water-bath to the consistence of syrup, or until we slowly boil down a drop of urine upon an object-glass until it is almost dry. Leucin appears in the form of faintly shining spheres, which some- times, if they are large, show radiating lines and concentric rings. Tyrosin crystallizes in very fine needles, which commonly form druses and bundles. Leucin and tyrosin are products of the decomposition of albumin. They do not occur in normal urine. Diseases in which they are found and for which they may have diagnostic value, are acute yellow atrophy of the liver and acute poisoning by phosphorus. They are also seen in variola and typhus abdominalis [typhoid fever], as well as in pernicious anaemia (Laache). Cystin sometimes occurs in the urine in health. Large quantities of cystin in the urine may cause the formation of cystin-calculi and excite cystitis, and are thus a pathological condition in themselves. According to recent investigations (Baumann, Brieger) there seems to be a connection between the occurrence of ptomaines and cystin in the urine. Brieger assumes that by the presence of certain ptomaines in the intestinal canal (hence, in mycotic enteritis) the cystin forms a combination with the ptomaines in the intestine, which overflows into the urine. There the compound decomposes, and cystin is again set free. Sometimes this does not take place, and so calculi are formed. The ptomaines, in turn, may cause inflammation, especially cystitis. EXAMINATION OF THE URINARY APPARATUS. 433 Cystin, besides occurring in the urine in the form of calculi, is seen in the form of extremely thin, six-sided, and very perfectly formed colorless plates. (c) Concretions in tlie urine. We are interested only in the con- cretions that arise in the pelvis of the kidney, as in nephrolithiasis, pyelitis calculosa. Those that form in the bladder belong to surgery. The former are named, according to their size, renal sand, renal gravel, renal calculi. If they attain a certain size, they cause severe attacks of pain in their transit through the urethra (renal calculi colic). Most frequently the concretions consist chiefly of uric acid and urates. They are then brown or brown-black, and tolerably smooth on the surface. Stones of oxalate of lime are densely hard and have a rough surface (mulberry calculi) ; they are dark brown. A combination of layers of uric acid and oxalate of lime is likewise met -with. Phosphatic calculi are tolerably soft, but not iiifrequently they contain a kernel of the first-named substances (phosphate de- posited upon the stone from the alkaline urine of cystitis [excited by the original stone]. Finally, we must mention stones of cystin and (extremely rare) xanthin. All these stones, with the exception of the phosphatic calculi, are formed in acid urine. For the exact chemical examination of the concretions we refer to the text-books upon Urinary Analysis. Examination of the Urinary Constituents in Solution. 1. Anomalies in the Quantity of tlte Normal Constituents. In disease the normal constituents of the urine are variously increased or diminished. These quantitative variations, however, can only excep- tionally be made use of for the diagnosis of disease. But they are important for determining the change of material and the removal of material that can be carried oil by the urine in various diseases. This requires throughout an exact quantitative analysis, for the different " approximative methods " have no value at all. We cannot here go into an explanation of the exact methods, but must refer to the hand- books upon urinary analysis. However, w^e mention briefly the most important anomalies which belong here. Wo have already mentioned the quantities of the normal constituents of the urine, p. 404. Urea. This is increased in fever, either absolutely, as in pneu- 28 434 SPECIAL DIAGNOSIS. monia, or relatively — that is, in relation to diminution in the amount of food taken. It is also increased in diabetes. We find it diminished in all forms of nephritis, but especially in uraemia ; in cachexia of all kinds, especially if there is dropsy ; and, lastly, sometimes in acute yellow atrophy of the liver. The very decided increase in the amount of excretion of urea which takes place immediately after the crisis in pneumonia is designated as post epicritical. It is probably con- nected with the increase in the amount of water secreted by the kidney. Sehrwald has recently {Milnchen med. Wochenschrift, 1888, No. 46) devised a simplification of Knop-Hiifner's method of determining the amount of urea, which seems to us to be very practical and rela- tively exact. We have not yet had an opportunity to test thoroughly the method. At least, we recommend that it be tried. Uric acid is usually increased in fever parallel with the urea. Besides, it is increased in leukaemia and pernicious anaemia (with the first, often very markedly), also in all diseases which afiect the inter- change of gases in the lungs ; and, lastly, with the uric-acid or gouty diathesis, apart from attacks of gout, during which it is often dimin- ished. The total amount of nitrogenous material in the urine, the most important for determining the metamorphosis of tissues, approximately afrrees with the amount estimated from the urea, because the uric acid, kreatinin, and xanthin bodies are insignificant in amount com- pared with the urea. Besides, the most practicable method for the quantitative determination of the urea (Liebig's) is really a determina- tion of the total amount of nitrogen, expressed as urea (C. Voit, Salkowski, and Leube). When determining both nitrogen and urea, of course, it must be done apart from any possible albumin — that is to say, the latter must first be removed. Chloride of sodium is pathologically increased during the resorp- tion of transudations and exudations, and also in intermittent fever, from the destruction of red blood-corpuscles (Kast). It is diminished in fever, nephritis, and in many cachectic conditions. [In pneumo- nia, during the stage of exudation and until resolution begins, the chlorides are diminished or disappear from the urine. While the dis- appearance of the chlorides from the urine is not characteristic of EXAMINATION OF THE URINARY APPARATUS. 435 this disease alone, it shows that exudation is still going on, or that resolution has not yet commenced.] Sulphuric acid interests us chiefly with reference to the associated ethylsulphuric acid (phenol-, indoxyl-sulphuric acids). It is found with increased separation of indican and carbolic acid. Reo-ardino- the former, see p. 409. The latter occurs with the internal and external use of carbolic acid. It has been found that the phosphates are diminished in rhachitis, also in acute yellow atrophy of the liver. In nephritis they are not infrequently diminished. 2. Abnormal Constituents. Albuynin. Except in the rare cases of physiological albuminuria already mentioned, any separation of albumin in the urine is patho- logical. This is always so if it continues. The albuminous substances, which in the conditions reckoned as albuminuria in the narrow sense can be separated, are serum-albumin and serum-globulin. Their amount varies from a trace to one-half per cent. — very exceptionally more. Generally, it remains below one-half per cent. The secretion of hemialbuminose is very rare, and thus far has not been found to have special diagnostic significance. Of late, we are not accustomed to regard peptonuria as albuminuria. It will be considered at the close of this chapter. Albuminuria occurs : 1. As true renal albuminuria, in all forms of acute and chronic nephritis, in amyloid kidney, in f ngorgement of the kidneys ; in hydremic conditions of the blood, as anaemia, ieuksemia ; in fever, and in acute poisoning ; in these two cases, especially in the latter, there occur, besides all the transitions to nephritis ; lastly, after epi- leptic attacks, apoplexy (transitory albuminuria). Besides, there has recently been discovered a peculiar form of albuminuria which is distinguished from other forms by the absence of all pathological signs in the urine, especially of cylinders : cyclic albuminuria. See, regarding this, p. 437. 2. Further, albumin in solution in the urine may also pass over into the urinary passages when blood and pus are mingled with the urine in the bladder. The amount of albumin, however, is always small. Qualitative tests for albumin. We select a few from the great number of tests for albumin, which have the tolerably uniform approval 436 SPECIAL DIAGNOSIS. of authors (see, regarding them, Penzoldt's Old and New Urinary Tests), and which, according to our experience, have the preference. The preliminary condition is that the urine be not contaminated, as by menses or leucorrhoea, and that it be clear. The latter is the more necessary in proportion as the amount of the albumin is small. In order to be able to discover it when only a very little is present, it is necessary to filter the urine until it is perfectly clear. (a) Addition of acetic acid and ferro-cyanide of potassium. By the acetic acid the urine is rendered distinctly acid, and then the cold urine is mixed Avith a few drops of a watery solution of potas. ferro- cyanide. Even with a very small amount of albumin, very fine floccules are formed, often almost milky cloudiness, though when there is only a very small quantity of albumin it is somewhat delayed. This very certain and distinct test is strongly recommended for use at the house of the physician. (h) Boiling and the addition of nitric acid. If the urine is neutral or alkaline, acetic acid must be added to it to render it acid before boiling. If there is cloudiness, it can only be due to one of two causes : albumin or phosphates. To determine which of these it is, we add about ten drops of nitric acid, when the phosphatic deposit is immediately dissolved ; but if the deposit is of albumin, it is made more distinct, When the albumin is somewhat abundant, the deposit can be immediately recognized by its floccular appearance. The test is a sharp one, showing even 0.005 to 0.01 per cent, of albumin, and, being tolerably certain, is in general to be recommended. (c) Picric-acid test. We add to the urine a few drops of a con- centrated watery solution of picric acid : if it immediately becomes cloudy, it shows albumin ; but cloudiness appearing later shows nothing (Johnson, Penzoldt). It is a certain and sharp test, not less to be recommended than the others. As portable tests for albumin, we can proportionally recommend the following as best : (d) Geisler's albumin test-papers.^ These consist of a piece of filter-paper saturated with a concentrated solution of citric acid, and of another saturated v/"ith a three-per-cent. solution of iodide of potas- sium added to a twelve or fifteen-per-cent. solution of corrosive subli- [1 They may be obtained of Parke, Davis & Co., and other manufacturing chemists.] EXAMINATION OF THE URINARY APPARATUS. 437 mate. We first put one of the strips of the first into the urine — if very alkaline, more than one — then one of the second papers, and shake it. Cloudiness due to albumin appears pretty promptly. Pep- tone is also precipitated, which, in many cases, can cause deception (see Peptonuria). In concentrated urine, urates are also precipitated, but these can afterward be dissolved by heat. Deception from the .solution of particles of paper making a cloudiness is not possible, if it is carefully examined. As a preliminary test at the sick-bed, this method is to be recommended. But we ought not to be satisfied with its result, and should always afterward employ one of the tests pre- viously mentioned. If we examine the urine a number of times in twenty-four hours, and find that there is a periodic presence and absence of albumin, we designate this condition as cyclic albuminuria.^ It never occurs after rest at night ; the albumin is generally separated after exertion. In case this condition is suspected, we are to examine the urine several times during the day, and especially toward evening, also directly after rising; in the morning. Klemperer has made a very clear demonstration of the course of the separation of the albumin. He places about five com. of the urine, passed at different times during the day, in a series of reagent- glasses, and then boils them with the addition of nitric acid. The height of the deposit in the glasses, as they are arranged in a row, may be regarded as a direct delineation of the "albumin curve." Quantitative test for albumin. Here, as in all quantitative de- terminations, the urine of exactly twenty-four hours must be mixed, and a portion from this mixture examined. The urine for exactly twenty-four hours can be obtained if we have the patient urinate early, say shortly before seven o'clock, and then keep all the urine that is passed till the next morning at exactly the same hour, passing his urine again at seven o'clock. It is possible to make an exact quantitative determination only by completely separating the albumin from a measured quantity of urine. Filter, wash the residue upon the filter-paper, dry, and weigh it. (For particulars regarding these processes, see text-books upon Urinary [1 In the British Medical Journal, January 31, 1891, p. 218, Dr. Herringham gives a valuable and careful study of a case of Cyclical Albuminuria which was under his care at the West London Hospital. — Translator.] 438 SPECIAL DIAGNOSIS. Fig. 138. t^^ytM Analysis.) This examination can only be conducted in a laboratory. There is no mode of procedure Avhich is more simple, nor one that is so nearly exact as this. The polarizing method is only applicable when there is a considerable amount of albumin. A substitute for the exact quantitative determination is quite com- monly found by endeavoring to estimate the amount of deposit which results from the qualitative determination, especially by the boiling nitric-acid test : we wait along time — till it. settles in the reagent- glass — and then we speak of one-half, one-quarter, or the whole being albumin, by comparing the volume of albu- min that can be seen with the whole amount of urine in the reagent-glass. It may be assumed that one-half the volume of albumin, if the reagent-glass has stood for one hour, corresponds to about 0.2 to 0.6. This estimate is extremely unreliable, being chiefly dependent upon the size and thickness of the flakes of ajlbumin. But, if we always employ the same test for albumin, it is certainly not valueless forjudging of the variations in the separa- tion of albumin in the course of disease. More exact is the method with Esbach's albuminometer, although it acts upon the same principle, and so is only approximative. What exactness it has depends in reality upon the employment always of the same reagents, mix- ing them with an equal amount of urine, and always allowing the same time for the deposit of the precipitate. Tlie albuminometer — a graduated thick reagent-glass — is filled with urine to the mark U, from there to R with the reagent. This reagent consists of 10 grammes of picric acid and 20 grammes of citric acid to 1000 of distilled water.^ The glass is then closed with a rubber cork, turned upside down ten times, and allowed to stand undis- turbed for twenty-four hours, best in a special stand. After this period of time we notice at Avhat mark of the scale on the glass the albuminous deposit stands. The marks each give one-tenth per cent, of albumin. As the scale only goes as far as 0.7 per cent., urine that Esbach's Albuminom eter. 1 The exact amounts of both acids (chemically pure and dry) are to be dissolved in 1000 grammes of water, made hot, and, after cooling, any deficit in the amount of fluid is to be made up .by the addition of water to 1000 grammes. EXAMINATION OF THE URINARY APPARATUS. 439 is strongly albuminous must be diluted in a definite way before the test. We must avoid producing air-bubbles, because these cause the precipitate, or a part of it, to swim, and for this reason we are not to shake the glass. If there are air-bubbles, they mast be removed with a pipette. In most cases the method is tolerably exact (an error of one-tenth to two-tenths of albumin), but in individual cases, and often without any recognizable cause, the precipitate does not sink down as Avell as it usually does. Nevertheless, it is to be recommended as an improve- ment upon the simple, rough " volumetric " estimate. [The apparatus is not at all expensive. It c:in be obtained in New York of Eimer & Amend.] Rare Forms of Albumin. Peptone (von Jaksch, Maixner, and others). This never occurs in healthy urine. Pathologically, it occurs sometimes in ordinary albu- minuria, and, again, independently — peptonuria. It occurs in a great number of very different conditions : in large abscesses, in emphy- sema, sometimes in pneumonia; likewise in acute rheumatism, scor- butus, phosphorus- poisoning; also, in carcinoma ventriculi, in puerperal fever, in typhus abdominalis [typhoid fever], etc. Hence, this very remarkable substance has no value for diao;nosis. Its determination, even qualitative (biuret reaction), is, for various reasons, diflBcult. Hem^ialhumose (hemialbuminose, propeptone) very rarely exists in the urine (albumosuria). There must arise a suspicion of these albuminous bodies, which, according to the latest researches, show a mixture of four albuminous substances (Kiihne, K., and Chittenden), if there is a precipitate in the urine after it has been subjected to the boiling and nitric-acid test. For demonstrative tests, see the text- books upon the subject. Hitherto this substance has had no diag- nostic significance. Kahler has recently observed hemialbumose in multiple primary lymph o-sarcoma of the spinal cord. Fibrin occurs in the urine in hsematuria, in deep-seated inflamma- tion of the urmary passages, in tuberculosis, in poisoning with can- tharides, and in chyluria. It is recognized by the fact that it coagulates spontaneously in the urine, although sometimes only after the urine has stood for some time. The coagula are then to be further examined. 440 SPECIAL DIAGNOSIS. In this place are to be mentioned two phenomena that occur in those diseases of the kidney that stand in close relation to albumin- uria: dropsy and ursemia. The dropsy of Iddacu disease manifests itself, very frequently, first in the skin of the face, especially at the eyelids. "With contracted kidney the oedema is very fugitive, often changing its place ; in a large number of cases, it is entirely wanting during the entire course of the disease. With large white kidney it is more decided and stable ; there is often a very soft, doughy oedema. In this respect acute nephritis varies very much. In all forms of Bright's disease, from its association with heart- weakness, a new factor may come into play for the development or increase of the oedema and effusion into the cavities of the body (dropsy of engorgement). With reference to the cause of the dropsy in kidney-disease, no doubt the most important element is the diminished elimination of water by the kidneys. This retention of water often, especially if excessive, has the effect that even a slight, perhaps a scarcely notice- able, dropsy of the skin and subcutaneous tissue considerably disturbs the excretion of water by perspiration. At any rate, it is certain that the dropsy of kidney-disease is, in many cases, not explained by the retention cf water ; but neither is Cohnheim's hypothesis, that the walls of the vessels are abnormally pervious, at all generally accepted. This whole matter is still an open question. Uraemia is an association of nervous manifestations which, at least in the majority of cases, is dependent upon the retention in the blood of urinary products (especially uric acid). In individual cases of " ursemic " manifestations, however, this explanation is not correct, and the nature of such cases is not yet clear (oedema of the brain (?), Traube; sometimes anatomical changes in the brain (?), Striimpell, etc.). We coincide with Striimpell's view, that ui'semia is a multi- farious condition — a number of conditions, which by their presence and their phenomena seem to belong together, are in reality different. • Slight ursemic symptoms may last, with slight changes, for weeks, even months, as somnolence, restlessness, headache, malaise, vomiting, dyspnoea (ursemic asthma), indications of Cheyne-Stokes respiration, slight transitory disturbances of vision. The more severe symptoms are : decided cloudiness of intelligence, even to coma or delirium ; maniacal conditions ; convulsions, from single convulsive movements EXAMINATION OF THE URINARY APPARATUS. i4l to pronounced epileptic attacks ; and temporary amaurosis. There may be slowness of the pulse, with acceleration later, and fever. In individual cases there occur evident symptoms of cerebral congestion; convulsions, paraesthesia, paralysis of an arm or of one side of the body, and aphasic manifestations. Mucin. It has already been mentioned when this appears in the urine. When the mucin is dissolved, its presence can be established by the addition of acetic 'acid : it forms a flocculent, thready pre- cipitate in cold urine, which is not again dissolved by an excess of acetic acid. Coloring-matter of the blood. The occurrence of this body has also been previously mentioned (p. 410). Here we have to refer to testino; for hsemoo-lobin, or hsematin in solution. First, it must bo mentioned that, of course, the urine shows the presence of albumin in both hasmaturia and heemoglobinuria. The amount of albumin is always small, provided there is no albuminuria besides. Blood-Figment will be shown to be present by the following pro- cedures : (a) Heller s test. A portion of urine is made decidedly alkaline with caustic potash, and boiled in a reagent-glass : the phosphates are precipitated as very delicate floccules, which look like mucus, and slowly sink to the bottom. They accompany the blood-pigment, and hence look brown or red-yellow. When the urine is concentrated, we dilute it, after boiling, by filling the reagent-glass with water, because the color of the floccules is easily concealed. Urine that is poor in phosphates, as in nephritis, gives no phosphatic deposit. Such urine must be mixed with some that has the normal amount of phosphates, before making the test. The color described as belonging to the phosphatic deposit occurs nowhere else, except with urine containing chrysophanic acid, but this latter is recognized by its changfe in color after the reaction. This test is very simple, certain, and, with clear urine, is tolerably distinct. (b) Test with tincture of guaiac. The reagent consists of tinct. guaiac, ol. terebinth, ozonisat., aa 10 parts. A small portion of this, placed in a reagent-glass, is carefully covered with urine : when the coloring-matter of the blood is present, there is, besides the dirty white deposit of resin, an indigo-blue ring. When shaken up, the 442 SPECIAL DIAGNOSIS. whole contents of the glass become a non-transparent bright blue. The test is a very distinct one. (c) Test for hcemin. This is made with a large drop of urine or urinary sediment, exactly in the same way as has been described already (p. 363) for finding it in the material vomited. The test is more distinct than the preceding, particularly if we boil it down in a porcelain dish and then apply the reaction. (d) Spectroscopic examination. This gives the absorption-bands of methsemoglobin, namely, in yellow, green, and red. Of course, this is an extremely distinct test. Bile-'pigments and Bile-acids. G-mellins test for hile-pigments. We pour a small quantity of nitric acid into a reagent-glass and add to it one or two drops of fuming nitric acid, forming a trace of an admixture of nitrous acid. To this mixture we very cautiously add a layer of urine, by permitting it to flow from a pipette, down the side of the glass held obliquely. When the bile-pigment is abundant, if the fluids are kept carefully distinct, there is a ring of green (blue), violet, and red. The first named constitutes the test. There is no reaction when there is only a small amount of bile-pigment. RosenhacK s modification is decidedly more distinct. Filter some urine, not too little (about 200 c.cm.), through a medium-sized filter, and pour upon this the mixture of nitric and nitrous acids. The colored rings form upon the filtrate. Still sharper is Gmellin's test, if, after acidulating the urine with acetic acid, we shake it up with chloroform, pour off the urine, and then with the chloroform, colored yellow by the bile-pigment, make a layer with the nitric-acid mixture. Penzoldt recommends a filtrate prepared as in the Gmellin-Rosen- bach test (allowing a good deal of urine to flow through), over which acetic acid is poured, and this is allowed to flow into a broad glass vessel, so as to have it in a shallow, but broad, layer. The acetic acid becomes yellow-green, gradually becomes green (quicker, if it is warmed), even bluish-green. Penzoldt declares that this test is very distinct. Pettenkofer s test for bile-acids: glycocholic, taurocholic, and EXAMINATION OF THE URINARY APPARATUS. 44.3 cholal acids. This test is based upon the fact that the addition of a Aveak solution of cane-sugar (1 to 500) and a trace of concentrated sulphuric acid to urine causes a violet-red color. We must be care- ful not to have the resulting elevation of temperature too high, at most not higher than about 50° C. For various reasons this last reaction is uncertain. Its result is reliable only when the bile-acids, if present, have been isolated. At any rate, the bile-acids have only a slight diagnostic value : a trace sometimes occurs in normal urine, while we find in undoubted cases of jaundice due to engorgement of bile, often none, or only a trace, because frequently in the transmission it becomes broken up in the blood. Hence, Ave cannot account for the absence of the bile-acids in the urine in cases of icterus by the assumption that it is not an hepatogenous icterus. On the other hand, an abundance of bile-acids in the urine proves that the jaundice is due to engorgement of bile. Moreover, it is clear that if we Avish to explain " hepatogenous " icterus by the idea of engorgement of bile in the liver, logically, we must assume an increase of the bile-acids in this jaundice also. As a matter of fact, this is found to be the case in toxic " hemato-hepato- genous'' icterus (arseniuretted hydrogen, toluylendiamin, Stadelmann). Grape-sugar. Pathologically, grape-sugar occurs in the urine : 1. In diabetes mellitus, usually in considerable quantity — as much as tAvo to five per cent, (minimum one-half, maximum ten per cent.). The urine is increased in amount, is bright and clear, of higher specific gravity, as has already been mentioned. 2. As glycosuria (Frerichs), usually in small quantity. It is almost always temporary after poisoning Avith carbonic oxide, curare, amyl nitrite, turpentine ; sometimes with mercury, morphia, chloral, prussic acid, sulphuric acid, alcohol; again, in acute infectious dis- eases (typhus, scarlet fever, diphtheria, etc. ; in diseases of the oblongata (but here it is more lasting) ; and from other neurotic causes, as excessive mental exertion, neuralgia, injuries to the central nervous system, concussion of the brain, etc. ; also, after epileptic convulsions and apoplexia cerebri. It is to be remarked that the urine is always to be examined for sugar when it has a decidedly high specific gravity ; but particularly if it is clear and abundant, and, at the same time, has a high specific gravity. 444 SPECIAL DIAGNOSIS. ■ Qualitative Tests for Sugar. Bismuth test (with Nylander's modification). For this purpose, we employ Nylander's reagent: 2 parts basic nitrate of bismuth and 4 parts soda tartrate, to 100 parts of an 8-per cent, solution of caustic soda. Of this we take 1 part to 10 of urine, and boil them together. After a few minutes, if there is only a little sugar — sometimes only after it has cooled — it becomes black from the reduction of the contents of the reagent-glass with the formation of the oxide of bismuth, if the urine contains as much as one per cent, of sugar. It is evident that this is a very distinct test. It is only uncertain when there is albumin in the urine (arising from the black sulphuret of bismuth) ; here it had better not be employed. Trommer s test. To a given quantity of urine we add about one- third as much liq. potassae, and to this, drop by drop, of a 10-per-cent. solution of the sulphate of copper, as long as it is held in solution by mixing ; then it is heated. A precipitate of yellowish-red hydrated cupric suboxide, which may appear even before the fluid has been boiled, shows the presence of sugar with the greatest probability. The yellow color of the liquid, or a precipitate that takes place later, may be caused by a very small amount of sugar, but also by uric acid and creatinin. Thus, the test is uncertain when the quantity of sugar is small ; hence, in brief, it is not a sharp one. Pheyiyl-hydracin test (von Jaksch). About two grains of muriate of phenyl-hydracin and three of acetate of soda are put into a reagent- glass which is filled half-full of Avater. After heating, the glass is to be filled with the urine to be tested. It is allowed to stand for fifteen or twenty minutes in boiling- water, then it is put into a beaker- glass filled with cold water. When there is a large amount of sugar,, there is formed a macroscopically visible deposit. With a small amount of sugar, after standing, there is a deposit, which can be seen with the microscope, of yellow needles, single and in druses — phenyl- glucosazon. Yellow plates and brown balls prove nothing. Albumin that may be present must previously be removed by boiling the urine. Jaksch urges this test because it is a very exact one. Its difficulty consists in this, that the needles of phenyl-glucosazon are sometimes not alike clearly characteristic in distinction from the yellow plates, etc., whi^h prove nothing, these latter not being crystallizable in alcohol. Nevertheless, the test seems to be a very sharp one. EXAMINATION OF THE URINARY APPARATUS. 445 Of the other very numerous tests for sugar we only mention the following : Moore s Uq. pctassoe and boiling test, which causes urine that con- tains sugar to become brown — not a very certain and sharp test ; and the test with diazo-benzol-sulphuric acid and potash, recommended by Penzoldt. One test, of great importance and highly recommended on account of its absolute certainty, is somewhat troublesome : Fermentation test. This rests upon the peculiarity that yeast has of separating sugar into alcohol and carbonic acid (succinic acid, etc.). The test may be made in a simple way, as follows: Three perfectly clean reagent-glasses are filled about two-thirds full of mercury. The first is then to be filled with some of the urine to be tested and a little yeast ; the second is to be filled with normal urine and some yeast ; the third with a thin, watery solution of sugar and yeast. It is Avell to add to each a drop of a solution of tartaric acid. All three tubes are now placed upside down in a tray of mercury, by covering the opening with the thumb as we invert them. The second tube should not show any development of carbonic acid, but if it should do so the yeast was not perfectly free from sugar, and the experiment must be repeated with yeast that is perfectly pure. The third glass should show the development of carbonic acid, otherwise the yeast has become inactive. The first tube shows carbonic acid or not, accordino; to the state of the urine under examination in respect to its containing sugar. The development of carbonic acid is recognized by the existence of gas in the upper part of the inverted tube. Its presence is made certain by its being absorbed when potash-lye is introduced into the tube. Fermentation-tubes are very helpful in employing the fermentation test (see Salkowski-Leube, Penzoldt). Quantitative Determination of Sugar. This is indispensable, if a case of diabetes is to be carefully observed, particularly for determining its severity, its course, especially the effect of treatment. From the qualitative examination we cannot draw satis- factory conclusions as to the amount of sugar, except by a comparison of the specific gravity of the urine with its quantity. We make use of the urine that is passed in exactly twenty-four hours. 446 SPECIAL DIAGNOSIS. 1. Estimating it tvith Fehling's solution (after Salkowski-Leube,. Penzoldt). The principle is that in Trommer's test, the oxide of copper in an alkaline solution of grape-sugar is reduced to a lower state of oxidation : five parts of anhydrous grape-sugar will reduce 34,639 parts of pure sulphate of copper to protoxide. The problem is to determine how much of a specimen of urine is necessary to reduce a certain amount of sulphate of copper. Solution I. 34,639 grammes of pure sulphate of copper are, by warming, dissolved in about 100 grammes of water, and the solution is then diluted to 500 c.c. It is to be set away well corked. Solution II. 173 parts of tartrate of soda and 100 parts of officinal solution of caustic soda of the specific gravity of 1034, dissolved in water to 500 parts. This is to be kept in a well-stoppered bottle \. but it must not be allowed to become too stale. Mode of procedure: Equal parts of I. and II. are mixed together. The mixture (Fehling's solution) must not, when boiled, separate any oxydul. 10 c.c. of the mixture and 40 c.c. of water are placed in a deep porcelain saucer. Thoroughly mixing the urine of twenty -four hours, we take a portion of this and dilute it with 9 parts of water (urine 1, water 9), and with this we fill a burette. The mixture in the saucer is brought to the boiling-point, and into this the urine in the burette is allowed to flow : there occurs a separation of oxydul and oxydul-hydrate, and the blue color of Fehling's solution disap- pears. The instant when the fluid (if we incline the saucer) first loses its color, shows the completion of the reduction. We allow the amount of urine necessary to complete the reduction to flow from the burette. Calculation: Since 0.05 gramme of grape-sugar reduces 10 c.c. of Fehling's solution, therefore the quantity of the mixture which has escaped from the burette contained 0,05 gramme of grape-sugar We represent that quantity of the mixture by " ^, " then the mixture in 0.05 X 100 5 the burette contains = - per cent, of sugar. And, q q since the mixture of urine was diluted tenfold, the urine itself contains 5 X 10 50 = — per cent, sugar — that is, 5 times the amount diluted, divided by the quantity of the mixture in the burette that was used. EXAMINATION OF THE URINARY APPARATUS. 447 The dilution of the urine is to be varied according to the amount of sugar it contains. 2. Determining "the sugar by circumpolarization. This depends upon the property of sugar to turn the plane of polarization to the right. Recently, the method has come somewhat into discredit, or it has been shown to be exact only when Ave exclude oxybutyric acid and any levulose that may be present (which, according to Kulz, some- times occurs in severe forms of diabetes). Regarding complicated methods (complete fermentation, etc.), see hand-books upon Urinary Analysis. We do not give a description of the method by polarization, as a description of its use always accompanies the different apparatus sold. (We recommend particularly the simple apparatus made by Zeiss.) Other Soluble Constituents of the Urine. Levulose sometimes occurs in the urine, in addition to grape-sugar, in cases of diabetes mellitus. It gives the chemical reaction of the latter, and for this reason it cannot, without complicated methods, be recognized, chiefly on account of a striking difference between the quantitative determination by Fehling's solution, on the other side, and the polarizing apparatus on the other. Levulose turns it to the left; but Ave must be on guard with reference to oxybutyric acid. Lactose, occurring in puerperal patients, inosite in diabetes in- sipidus, albumin, can only be demonstrated in the urine when they are isolated. Lipuria, as has been already mentioned, occurs in chyluria. It has, in one instance (Ebstein), been found in pyonephrosis; small quantities of fat occur, with large Avhite kidney (see Sediments), in poisoning by phosphorus, and in diabetes mellitus, but also in health after taking very much fat, as cod-liver oil. The proof is by shaking it up Avith ether. Lapaciduria (fugitive fatty acids in the urine) has recently been much studied, but thus far, from the standpoint of diagnosis, Avithout significance. Diaceturia, resulting from acetoacetic acid in the urine (Jaksch), never occurs under physiological conditions. It is observed (always Avith a simultaneous abundance of acetone, see below) in diabetes, and especially in the severe forms, which then some- times end in coma ; also in fever and as an independent dis- ease (Jaksch) ; and both are apt to occur in children. Diaceturia 448 SPECIAL DIAGNOSIS. is o-enerally, especially if it occurs in adults, associated with severe symptoms, particularly nervous, -wliicli are to be regarded as signs of auto-intoxication [poisoning] ; hence it may result in deep coma and be the direct precursor of death. As to its significance when it occurs in children, Jaksch, by recent investigations, arrives at the supposition that the convulsions which so frequently occur with them in acute diseases are explained by diaceturia. Test. Some solution of chloride of iron is slowly added to the urine ; sometimes there occurs a precipitate of phosphates, which must be removed by filtration ; then more iron chloride must be added. If glacial acetic acid is present, the urine becomes a Bordeaux-red. Then the test must be repeated v/ith urine that has been boiled. Further, a poition of urine must be mixed with sulphuric acid, ex- tracted with ether and repeated with the extract ; lastly, it must be examined for acetone (see below). Diaceturia is present if, in the presence of the chloride-of-iron reaction of the fresh urine, 1, tbe boiled urine shows no, or only a slight, chloride of-iron reaction ; 2, if the ether extract shows a chloride-of-iron reaction which fades in the course of twenty-four hours at the longest ; 3, if acetone is present at the same time (Jaksch). Acetonuria, in contradistinction from the preceding, is, it seems, in most cases a phenomenon without significance. It occurs in health (a trace), in fever, in diabetes, with inanition, but also Avithout these in carcinoma, in psychoses. There also seems to be an auto-intoxication [poisoning] with acetone (v. Jaksch), which accompanies symptoms of cerebral irritation (also epileptic convulsions), states of depression. The cases hitherto observed have ended in recovery. Thus, an abundance of acetone is found in the urine, but no glacial acetic acid (see above). The exact test is complicated. Several methods have been given, which, if one wishes to be certain, it is best to employ simultaneously : 1. Distil the urine with some phosphoric acid. Several cubic centi- metres of this distillate are mixed with a few drops of solution of iodine and iodide of potassium ; an immediate precipitate of iodoform- crystals proves acetone (Lieben). 2. We add to the urine some freshly-prepared oxide of mercury, obtained by mixing :in alcoholic solution of potash with chloride of mercury. Filter it, and cover the filtrate with sulphate of ammonium : a black ring of sulphate of mer- cury shows acetone (Reynolds). Legal (cited by Jaksch) has devised EXAMINATION OF THE URINARY APPARATUS. 449 a test for acetone which is a useful preliminary one : Several cubic centimetres of urine are treated with a few drops of a concentrated solution of sodium nitroprusside and somewhat concentrated liquor potassae. If acetone be present, a bright red color is seen, which quickly fades, but upon the addition of some acetic acid changes to purple or violet-red. Acetone is a product of normal decomposition of albumin. If this body is abundant in the urine it indicates an increased decomposition of albumin. It is worthy of note that acetic acid easily breaks up into acetone and carbonic acid, and that acetic acid, in turn, is a product of oxidation of /3-oxybutyric acid. This acid is found in diabetic coma, as it seems, exceptionally in very large quantities in the urine (Stadelmann, Minkowski) ; and it becomes more and more probable that it, in union with other fatty acids, must be regarded as the cause of diabetic coma, as the pupils of Naunyn, mentioned above, have for years maintained. Hence, in diabetic coma we have to deal with an acid-intoxication of the organism, in which it is to be assumed that the given acids only as acids are poisonous — that is, by the withdrawal of alkalies from the blood. In close relation with the withdrawal of the acids stands (according to Hallervorden, Stadelmann) the separation of a substance with which the organism, as long as possible, attempts to neutralize the pernicious acids : the separation of ammonia in the urine. We cannot go into the subject here, for the reason that the quantitative deter- mination of ammonia does not come within the province of this work. [The Translator adds here a summary of Stadelmann's observations upon "Diabetic Coma," as given in i\\e American Journal of the Medical Sciences, taken from Deutsch. med. Wochenschrift, 1889, No. 46 : " 1. Diabetic coma, apart from accidental coma due to other causes, occurs only in the case of diabetic patients whose urine contains oxybutyric acids. " 2. Almost equivalent in value with the recognition of oxybutyric acid is the determination of the amount of ammonia in the urine ; while it is also far easier of performance. " 3. Diabetic patients with an excretion of ammonia of more than one and one-tenth grammes per day, are in danger of becoming severe cases of the disease. 29 450 ■ SPECIAL DIAGNOSIS. " 4, Patients excreting two, four, six, and more grammes of am- monia daily, need constant watching by the physician, and are in constant danger of passing into diabetic coma. "5. If the determination of the presence of oxy butyric acid, or the estimation of the amount of ammonia, cannot be carried out, at least the chloride-of-iron test should be made. If this gives a more positive reaction, oxybutyric acid is present in the urine, and the cases answer to the statements made in the third and fourth conclusions. The converse of this, however, is not always true, for there are cases of diabetes with oxybutyric acid in the urine, and even suffering from diabetic coma, the urine of which does not give the chloride-of-iron reaction."] Regardmg the occurrence of the two compounds of sulphuric acid or of the products of their decomposition (here also belong indican, which has been previously mentioned, indoxylsulphuric acid), also of ptomaines, ferments (especially pepsin), see the various special works upon these subjects. The Urine as Affected hy Medicines. The determination as to whether a medicine has been taken or not may often be of diagnostic importance. A number of medicines may be directly detected in the urine; to those not easily, or not at all, demonstrable to a slight extent, according to Penzoldt's recommenda- tion of a particular case, we can add one easily demonstrable. If we find in the urine the reaction of demonstrable medicines that have been given, then we can naturally assume that any other which was mixed with it has been taken. Iodide of potassium. Add a couple of drops of red fuming nitric acid and about one-quarter as much chloroform as there is of urine ; shake it ; the chloroform gradually settles down, colored reddish- violet. Bromine. The same method ; chloroform colors it brown-yellow. Salicylic acid. The urine is made a blue-violet by the chloride of iron (not Burgundy-red, see Diaceturia). When the amount of sali- cylic acid is small, we shake up the urine (to which some sulphuric acid has been added) with ether and then apply the test. Rhubarb and senna, see p. 411. EXAMINATION OF THE URINARY APPARATUS. 45I Carbolic acid, also yiaphthalin, resorcin, etc. Upon standing, the urine becomes olive-green to brown-black, even black (hydrochinon). Exact determination requires particular methods. Salol. Urine containing this, as well as carbolic acid, becomes green to black, and, at the same time, responds to the tests for sali- cylic acid. Antifehrin. Add one-fourth volume of a concentrated solution of hydrochloric acid in a reagent-glass ; boil for a few minutes ; cool ; add a few c.c. of a three-per-cent. solution of carbolic acid and a drop of dilute solution of chromic acid. The mixture becomes red ; after the addition of ammonia up to an alkaline reaction, a beautiful blue. (After Miiller.) Antipyrin, thallin. Red coloration with chloride of iron; more- over, thallin urine is green-brown. Works upon Chemical Analysis and Toxicology give further information. CHAPTER YIII. EXAMINATION OF THE NERVOUS SYSTEM. Anatomy; Normal and Pathological Physiology. Only a sketch of what is most important can be given here. For further particulars, see the special text-books upon the subject. 1. THE CORTICO-MUSCULAR TRACT (tHE PYRAMIDAL TRACT, FLECHSIG). It has its origin in the so-called psycho-motor centres of the cortical substance of the cerebrum. These lie in the motor- cortical Fig. 139. ^^.X^-obuhis paracsTifralis Lateral view of the brain. (Combined from Ecker.) Gyri and lobuli marked with, antique type, the sulci and fissures with italic type. (452) EXAMINATION OF THE NERVOUS SYSTEM. 453 Fig. 140. Diagram of the motor tracts of tbe facial nerve and of the nerves of the extremities. (Edinger.) At a, B, C, are ind.cated supposed local diseases. ^^ lesion of the left side of the internal capsule, causing right hemiplegia on the right sidej B, lesion of the left half of the pons, touches the pyramidal tract of the extremities of the right side and of the left facial, causing crossed paralysis; C, shows the rare condition of uncrossed facial paralysis and paralysis of the extremities from lesion in the pons. 454 SPECIAL DIAGNOSIS. Fig. 141. region, which includes the anterior and posterior central convolutions and the lobus paracentralis of each hemisphere. It has been found that the centre for the lower portion of the face (the countenance, exclud- ing the forehead), and the tongue, is from the lower section of the anterior rather than the posterior central con- volution. The centre for the arm is in the middle portion of the anterior central convolution. The centre for the leg is in the lobus paracentralis and the upper section of both central convolutions. Thus, the centres of the cortex lie tolerably wide apart. The tracts course from there, and next converge in the corona radiata, in a fan-shape, to the internal capsule, Avhere they lie close together in its anterior segment, hence between the lenticular nucleus and optic thalamus. They lie close behind a point midway between these [but do not connect with them]. From thence they go to the foot of the crus cerebri, passing about in the middle of it. In the pons, the pyramidal tracts are split up by transverse fibres. They unite again to form pyramids at the an- terior portion of the medulla ob- longata, and here the pyramidal tracts of the two sides lie very close together. [From the circumstance that they form the anterior pyramids of the medulla, they receive their name, " pyramidal tracts,"] At the lower end of the medulla the right Diagram of the innervation of the muscles. (Partly from Edinger.) The radiation of the Py-tracts varies at different portions of the cortex (see p. 452). JPy-H, pyramidal tract for the cervical spinal cord ; Py-L, pyramidal tract for the lumbar por- tion of the cord ; H, cervical cord ; L, lumbar cord; Py-Fis omitted. Notice that down to the lumbar por- tion of the cord Py-L passes in the lateral column. EXAMINATION OF THE NERVOUS SYSTEM. 455 and left pyramidal tracts interlace, so that very mucli the larger part of the fibres go to foi"m the lateral column of the opposite side of the spinal cord (lateral pyramidal tract). Only a small part of the fibres [of the external aspect of the pyramids], without crossing to the opposite side, pass to the anterior column of the spinal cord [forming the columns of Tiirck]. (Anterior pyramidal tracts, Pi/- V.) At different levels of the cord, from the lateral pyramidal tracts, fibres continually pass to the ganglion cell-groups of the same side, and from these ganglion cells arise the anterior roots of the [nerves of the] spinal cord. These unite with the posterior, and form with them the mixed peripheral nerves. In these the motor tracts pass to the muscles. The tracts for the motor cranial nerves separate successively in the pons and oblongata from the pyramidal tracts, decussate and, at the floor of the fourth ventricle, enter the grey nuclei of the pons and oblongata, which consist of ganglion cells, perfectly analogous to the anterior horn ganglia. Fig. 142. Tsir. m. w. Location of the nuclei of the cranial nerves. fEoiNGER.) The oblongata and pons are represented as transparent. The nuclei of sensation are red, the motor are black. The centres of the cortex are those of voluntary motion ; the centres of the anterior horns simply convey these to the peripheral nerves. Moreover, they are the reflex spinal centres, in that they receive sensible irritation from the posterior roots of the spinal cord 456 ■ SPECIAL DIAGNOSIS. (see below) and transpose them into motor stimuli, which they convey to the anterior roots. But both central apparatuses also have trophic influences — that is, they preside over the nutrition of a certain section of the cortico- muscular tract. The cortical centres preside over the nutrition of the fibres until they enter the ganglia of the anterior horn. These latter control the nutrition of the peripheral nerve-fibres and of the muscles. Paralysis is produced by any lesion (local disease : hemorrhage, softening, inflammation, tumor) at any point in the cortico muscular tract which disturbs the central ganglia or interrupts the course of the tract. According to the location of the lesion, this paralysis shoAvs difierent characteristics ; and these may primarily be studied from three points of view : 1. If the lesion is located in the cortex, or afiects the tracts above the point of decussation, then the paralysis is upon the opposite side of the body ; on the contrary, lesion below the decussation produces paralysis of the same side. If located in the pons, it may happen, for example, that besides the pyramidal tract, which as yet has not decussated, it affects the fibres of the facial, which have already crossed over (see above), it then causes paralysis of the opposite side of the body and of the same side of the face, hence these two cross each other — hemiplegia cruciata seu alter ans. 2. If the lesion affects a cortical centre, or a point in the pyramidal tract in the brain, the pons, the oblongata, the spinal cord above the point of entrance of the particular tract into ganglia of the anterior horn (or the analogous gray nuclei of the oblongata or of the pons), then, because the trophical influence of the cortical centre from above ceases at that point, the affected tract degenerates just up to the cor- responding cells of the anterior horn, while these and the peripheral nerves and the muscles do not desienerate. This degeneration of the pyramidal tract does not in itself cause any further clinical phe- nomena. On the other hand, if the lesion is in the anterior horn, or downward from there in the motor tract, there is degeneration downward of the nerves and muscles supplied by the portion which is the seat of the lesion. In the latter case, we have the clinical evi- dences of degeneration (rapid diminution in volume, diminution or loss of electrical reaction, and other signs of degeneration, see below). EXAMINATION OF THE NERVOUS SYSTEM. 457 3. Since the centres and tracts in the different sections in some instances lie wide apart and in others close together, a certain extent of lesion, according to its location, will cause a paralysis widely different in its extent : (a) A lesion of" considerable extent located in the cortex, or in the corona radiata, just under it, generally affects the centre for one-half of the countenance, or an arm, or a leg (monoplegia). {h) If located in the internal capsule, then the lesion need not be so very large in order to produce a paralysis of the whole of the opposite side of the body — hemiplegia. This points to the crus cerebri. (c) If the lesion is in the cord, where the motor organs and all the other nervous organs of the body lie close together, it easily causes paralysis of both sides : thus, lesion of the dorsal portion of the cord produces paralysis of both lower extremities, or paraplegia inferior ; lesion of the cervical portion of the cord sometimes causes paralysis of both arms and both legs, or only the former — paraplegia superior seu brachialis. To the above statements we may add still another : (d) If the lesion is in the pons and oblongata, it may easily affect to a considerable degree the centres that are very essential to life, as the respiratory-centre, vagus-centre for the heart, and death may soon follow. Often, if there is hemorrhage or softening, it may take place immediately. A local disease at the base of the brain injures the cranial nerves wliich go off from that point. If it is located in the anterior cranial fossa, the olfactory nerve will be affected ; if in the middle cranial fossa, it may cause disease of the opticus, oculomotorius, trochlearis, abducens, sometimes also the olfactorius ; if in the posterior fossa, the trochlearis, abducens, facialis, acusticus, glosso- pharyngeus, vagus, accessorius, come under consideration. The disease may be bilateral. See the illustration, which shows how the different nerves come together at the base of the skull. From simultaneous injury to the crus cerebri, pons, and oblongata, the pyramidal tracts may become affected, and paralysis of the extremi- ties results. In basilar affections, this is generally less marked than is the paralysis of the cranial nerves. 458 SPECIAL DIAGNOSIS. The foregoing contains only the introduction to the points of diagnosis in these directions. "We must refer for particulars to the Fig. T43. Points of exit of the cranial nerves from the skull. (Henle.) The Roman figures indicate the cranial nerves; Vi,V2, V^, fi.rst, second, and third branches of the tri- geminus; V*, Gasserian ganglion. clinical text-books. AYc refer here to text-books upon clinical medi- cine, and particularly to the second edition of Edinger's book on the EXAMINATION OF THE NERVOUS SYSTEM. 459 Struetnre of the Central Organs of the Nervous System, the second edition of which has just appeared. 2. THE SENSITIVE OR CENTRIPETAL TRACTS. The tract of the sensibility of the skin of the trunk and of the extremities passes from the sensitive terminal fibres of the skin in the mixed nerves, then into the posterior root to the cord. From there it, for the most part, enters the posterior horn (it is doubtful whether a small portion may not enter the lateral column) ; it decussates soon after its entrance into the cord — how, we do not know. Above the cord we do not know the behavior of this tract till it reaches the tegumentum cruris cerebri, into Avhich it passes. Then it enters the inner capsule behind the pyramidal tract — that is, in the posterior third of the posterior peduncle. Beyond this, we do not exactly know its course. The tract of deep sensibility (usually called the muscular sense) probably has the same course as that we have just described. Most probably it ends in the motor cortical zone of the central convolutions and the lobus paracentralis. An important centripetal, but not in the strict sense a sensitive, tract, are the columns of Goll, which likewise arise from the posterior roots, which, moreover, only from the upper part of the dorsal portion of the cord, and above that point, form a compact bundle in the median portion of the posterior column. We know nothing positive of their function. Also, the lateral column of the tract of the cere- bellum is centripetal, which, in the upper portion of the cord, springing from the columns of Clarke, goes into the cerebrum. Its function, also, is not entirely clear ; probably it is of service in preserving equilibrium. Severe lesions, or complete interruption of the tract of sensibility of the skin in the peripheral nerves, or in the cord, or in the internal capsule, cause total anaesthesia of the skin. If the lesion is not severe, there is diminution of the sense of touch or a partial loss of sensibility — a partial paralysis of sensibility, as the sense of pain — and this latter is frequent, especially in disease of the spinal cord. Anaesthesia from local disease of the internal capsule, or of the spinal cord, manifests itself upon the opposite side. 460 SPECIAL DIAGNOSIS. 3. CENTRES AND TRACTS OF THE SPECIAL SENSES. (a) Sight. This tract passes from the retina in the eye to the chiasm. Here occurs a peculiar partial decussation (semi- decussation), which is reproduced in Fig. 144 : the optic nerve-fibres belonging to the outer half of the retina do not cross, those belonging to the inner half do. Then it passes in the optic tract to the anterior corpus quadrigeminum, and from there in the posterior third of the posterior limb of the internal capsule entering into relation with the pulvinar of the optic thalamus and the corpus geniculum ext., and then spreads out obliquely backward and upward in the cortex of the occipital lobe. The most important points in relation to this nerve are the following : Fig. 144. Diagram of the optic nerve-fibres in the chiasm. 1. That pathological processes at the base of the brain, and lesions in the posterior end of the inner capsule (causing a simultaneous hemi- ansesthesia), of the pulvinar of the optic thalamus, or of the occipital lobe, produce disturbances of vision. 2. That every complete destruction of the cortical centres in the occipital lobes, as well as of the tract from there to the chiasm, cuts off the impressions of sight from the outer half of the retina of the same side and the inner half of the opposite side, thus from synony- mous halves of the two retinae. Thus, hemiopia and hemianopsia are produced (see under Eye). (b) Hearing. The acoustic nerve passes, together with the facial, EXAMINATION OF THE NERVOUS SYSTEM. 4(U to the oblongata, to the acoustic ganglion, in regard to which, we cannot here enter into further detail. In its central course it comes into relation with the cerebrum, and then appears, probably, in the most posterior, sensitive portion of the internal capsule, whence it spreads out in the cortex of the temporal lobe (see Word-deafness). ((') Smell. Of the olfactory nerve perhaps nothing more is to be said than that its centripetal tract seems to pass through the posterior portion of the internal capsule. (d) Taste. The sense of taste is located [chiefly] in the glosso- pharyngeus nerve, distributed to the palate and the posterior third of the tongue, by which nerve it is conveyed to the oblongata. The course for the anterior two-thirds, however, is complicated: as the chorda tympani, it first passes in the lingual nerve, but leaves tliis and goes to the facial, leaves this again at the geniculate ganglion, and probably extends, as the greater superficial petrosal nerve, Vidian, and the sphenopalatine ganglion, to the trigeminus (second branch), going toward the centre with this. We again meet the fibres of taste in the posterior portion of the inner capsule. It is very important to note the participation of the sense of taste at the anterior portion of the tongue in peripheral paralysis of the facial, and also (according to Erb and others) in disease of the tri- geminus situated high up, as well as in lesions of the posterior portion of the inner capsule (hemisesthesia). Until we come to the symptomatology, we delay speaking of all other points regarding localization of the brain, especially regarding aphasia and the phenomena associated with it, and regarding the origin of certain forms of convulsions, of vertigo, coordination, etc. 4. REMARKS UPON THE VESSELS SUPPLYING THE BRAIN. The brain is supplied with blood from the two internal carotids and from the vertebral artery. The right and left vertebral unite at the basilar surface of the pons to form the basilar artery ; this, again, divides at a point corresponding to the anterior inferior border of the pons into the two posterior cerebral arteries, which, by the posterior communicating arteries, form a connection with the carotids (the circle of Willis). Besides the ophthalmic and the posterior communicating, the carotid gives off the anterior communicating, which, with its opposite fellow, completes the circle of Willis. There also arises from 462 SPECIAL DIAGNOSIS. the carotid the middle cerebral, the [hirgest, and] most important vessel of the brain. Of tliese vessels the greatest interest attaches to those which supply the pons and medulla, and the most important part of the cortex and the internal capsule. The pons and medulla are chiefly supplied by the basilar and vcrtebrals. The branches of these are terminal arteries — that is, they do not anastomose with each other, or with other branches in their neighborhood. Hence, thrombosis or emboli of such branches, or, for instance, of a part of the basilar, immediately produces arrest of func- tion, and, besides, unless the stoppage is again removed, produces anaemic necrosis of the affected portion of the pons or medulla. The region of next importance is that supplied by the middle cerebral artery (the artery of the fissure of Sylvius). This, as well as the regions of the cerebrum supplied by each of the two other arteries supplying portions of the cerebrum, divides distinctly into two parts, which do not anastomose Avith each other, into an inner and a cortical portion. The inner region, supplied by the middle cerebral artery and its branches, embraces the internal capsule, with the exception of its posterior section (sensory tract),- the lenticular nucleus, the greater part of the caudate nucleus, and a part of the optic thalamus. This internal region of the middle cerebral artery (artery of the fossa of Sylvius) is sharply distinguished from the neighboring regions of the other arteries of the brain : there are no anastomoses ; hence, con- tinuous occlusion of this vessel at its root must inevitably result in softening of the above-named central portion of the brain. The cortical region of the middle cerebral artery extends over the third frontal convolution, the anterior central convolution (with the excep- tion of the upper portion, which belongs to the anterior cerebral artery), the posterior central convolution, the superior and inferior parietal lobes, the whole region in the neighborhood of the fissure of Sylvius, lastly, the second and third temporal convolutions. This cortical portion of the artery of the fossa of Sylvius seems to anasto- mose, in individual instances, with the neighboring cortical regions in a great variety of ways ; for this reason, occlusion of the artery in only a part of the cases results in softening of this cortical portion of the brain. The optic centre of the occipital lobe, the corpora quadrigemina, EXAMINATION OF THE NERVOUS SYSTEM. 4(33 and the posterior portion of the internal capsule are supplied bv the posterior cerebral artery. The prominence of the middle cerebral artery consists not only in the fact that it supplies the most important portion of the cerebrum, but also because it is within this region that both hemorrhaores and emboli most frequently occur. These two disturbances chiefly aifect the internal region of the artery — the hemorrhages, probably, because the pressure is highest in 'the branches that go directly off from its root, or that here is felt most strongly the rapid changes in the power of the heart; but emboli much more frequently disturb the inner territory than the cortical, because, as was mentioned before, there are no anastomoses in the former region, while in the cortical there are. In the relation of the left carotid to the aorta (going off at a very acute angle) seems to lie the explanation as to why emboli are much more frequent in the left middle cerebral artery than in tha right. Symptomatology and Methods of Examination.. examination of the seat of disease. We learn from the physiological properties of the nervous system that when affected by disease there is little or nothing to be seen at the seat of the disease, while the symptoms are manifest at other por- tions of the body often quite distant from it. Besides, the brain and spinal cord are almost entirely removed from the possibility of beino- examined, on account of their bony casem'ents. Lastly, very often a local disease of the nervous system, although it causes pronounced phenomena, is locally very indistinct. For all these reasons, the local examination of the nervous system, in a number of its diseases, is quite subordinate. Still, we place its consideration first, because in a systematic examination it belongs there, and because the expression of our opinion cannot at all affect the value which it, nevertheless, in many respects possesses. The Skull. — The majority of the diseases of the brain and its coverings run their course without any manifest effect upon the skull ; indeed, there is no disease of that organ in which it may not more or less frequently happen that alterations in the skull were entirely wanting. If there are such alterations in a portion of the cases, 464 SPECIAL DIAGNOSIS. they are secondary in their nature, dependent upon disease on the inner surface ; in other, more rare cases, the alterations of the skull are the cause of the disease of the brain. As methods of examination, we mention inspection, palpation, and measuring or tracing the shape of the cranium upon paper. The Size of the Cranium. — Generally this is determined by the circumference of the head over the glabella and the occipital protu- berance, and by estimating the relation between the brain-case proper and the face. This latter can be measured simply by the eye. In the newly born the circumference of the head is 39 to 40 cm. (accord- ing to others somewhat less). In the course of the first year it increases to about 45 cm., and from then to the beginning of the twelfth year to 50 cm. ; in adults it amounts to about 55 cm. (in women it is generally somewhat less than in men). Marked enlargement of the cranium, macrocephalus (to 80 cm. and more in circumference), occurs with hydrocephalus, if the fontanelles have not yet closed. Then the frontal bones particularly project; the countenance is proportionally too small, the eyes are directed down- ward, the expression is often peculiarly staring ; the fontanelles are very large and remain open for a long time ; the cranial bones are thin. Hydrocephalus which occurs later, when the skull has already closed, causes little or no enlargement of the head. Moreover, a somewhat considerable macrocephalus is peculiar to the rhachitic skull, and is here dependent upon thickening of the bones of the skull. But it is generally somewhat angular (caput quadratum). There is no notable recession of the bones of the face as in the former; the bones give the impression of being dense, only the occipital bone is sometimes very thin, even as paper, sometimes upon pressure crackling like parchment (be careful !). Here, too, the fontanelles remain open abnormally long — sometimes into the third year. The distinction from hydrocephalus is made in the first place by an examination of the nervous system, which in this disease is almost always injuriously affected (as respects its psychic, intel- lectual, and motor functions), while in rhachitis it is normal; also the evidences of rhachitis are to be sought at other points (the infe- rior maxilla, the thorax, the bones of the extremities). Moreover, we may have a combination of hydrocephalus and rhachitic thickening of the cranium. EXAMINATION OF THE NERVOUS SYSTEM. 465 Abnormally small skull, microcephalus, is naturally connected Avith. abnormally small brain, thus necessarily with idiocy (see). Form of the Skull. — Departures from the typical form. Here belong dolichocephalus, brachycephalus, and other forms of head which are often met with without any pathological condition of the brain, but also in congenital malformation of the brain, as in idiots. Asym- metry of the skull likewise occurs with this condition, but also not infrequently with persons who are perfectly healthy and intelligent. We discover the asymmetry of the skull by viewing it from above or by tracing it upon paper : measuring the sagittal and the large trans- verse diameters of the cranium with the calipers, and making an outline with a strip of lead as was described upon page 163, in the examination of the form of the thorax. Circumscribed projections and depressions have much greater path- ological significance, the latter, however, very frequently not with reference to disease of the brain but as signs of a general disease. Projections occur in disease of the cranial walls and of the dura mater ,^ and these are chiefly syphilitic gummata, carcinoma, and sarcoma. Sinking-in, depressions, impressions, may be traumatic. If there is defect of the bony wall the defect may feel like a fontanelle. Soft and slightly depressed [or depressible] round spots are sometimes present in carcinoma of the cranial vault. Very important, lastly, are scar-like, round depressions over which the scalp is adherent, and which often contain an actual scar : these occur as the result of healed syphilitic gummata or deep ulcerations. All these appearances, but especially the traumatic and syphilitic depressions, are of the greatest diagnostic importance. When the skull is thickly covered with hair they may be easily overlooked, if we do not examine it with the greatest care by feeling all points. In making the examination of the cranium, it is of the greatest importance that we should have a clear conception of the location of the brain and its different parts with reference to its bony casement. We cannot here go into particulars, but attention is called to Fig. 145, from which we especially learn the relation of the so-called motor cortical regions of the temporal and occipital lobes to the cranium. 1 The knowledge and significance of tumors of the cranium caused by meningocele and cephalocele are taught in works upon surgery. 30 466 SPECIAL DIAGNOSIS. The most important point is that the motor cortical region lies just in front of a vertical line drawn through the external orifice of the auditory canal. Fig'. 145, Explanation of the topographical relation between the surface of the brain and the skull, c, fissure of Eolando; ^Cand VC, posterior and anterior central convolu- tion; S, S, 8, fossa of Sylvius; P, P, upper and lower parietal lobes; 0, occipital lobe; C 6, cerebellum ; T, temporal lobe ; J?'. Frontal lobe. (Strumpell from Ecker.) Sensibility of the Cranium to Pressure. — This is ascertained by pressure with the finger or by gentle stroke with the tip of the finger or the percussion hammer. General sensibility to pressure occurs in nervousness, especially nervous pain in the head. We also sometimes meet with circumscribed sensibility to pressure in nervous- ness, also in hysteria ; but sometimes the latter corresponds with a circumscribed meningitis, as this may be caused chiefly by tumors, abscess of the brain, etc. If there are other signs of a disease of this character present, then its topical diagnosis may be aided by palpation and percussion ; by itself its results must be received with caution. Regarding the significance of dilatation of the veins of the skull, see page 260. EXAMINATION OF THE NERVOUS SYSTEM. 467 Suppuration of the ear and nose (the latter seldom) plays an im- portant part as causes of meningitis and abscess of the brain. THE SPINAL COLUMN. Form. The significance of the expressions scoliosis, kyphosis (lateral and posterior curvature of the spine) and kyphoscoliosis have already been referred to on page 88. Lordosis is an abnormal cur- vature forward. If these curvatures are obtuse-angled, none of them have a deleterious effect upon the spinal cord, or at least only excep- tionally. Acute-angled kyphosis (gibbous), as is usually caused by caries of the vertebrae, also by fracture of a vertebra, is of much greater importance, [causing] compression of the cord. It is to be remarked that in order to recognize slight lateral curvature it is desirable to mark the s^jines of the vertebrse, without moving the skin, with a blue crayon, aid then to observe carefully the line that is thus formed. Anj weak less or paralysis of the muscles of the spine on one or both sides may lead to secondary curvature of the spine, espe- cially to scoliosis and lordosis ; see still further regarding this under Function of the Muscles. Dimmished mobility of the spinal column, if it occurs with respect to the whole length in persons of mature years, is often not patho- logical. Complete general stiffness occurs, also, in arthritis deformans. If the stiffness is limited to a certain portion, while the rest of the vertebrae have free motion, this is of pathological significance (almost always due to caries, and here we sometimes have stiffness without curvature of the spine). Forcible bending is then generally painful. The spinal column is abnormally mobile when there is weakness or paralysis of its extensor or flexor muscles in young persons. This is especially marked in juvenile muscular atrophy, often in connection with habitual curvature. Sensitiveness of the vertebral column to pressure (especially of the spines of the vertebrae) may have a great variety of significance. There may be palpable disease, especially caries, but also tumors of the vertebrae, of the spinal meninges, spinal meningitis, or tabes; but it may likewise occur with spinal irritation (particularly in the neck and between the shoulder-blades), as well as in hysteria, and here it may be excessive. We discover this sensibility by strong pressure, 468 SPECIAL DIAGNOSIS. or by striking the spines of the vertebrae. Often, but by no means always, there is at the same time painful sensibility when a hot sponge or the cathode of the galvanic current is passed over it. Here, also, belongs the rigidity of the neck in meningitis, particu- larly basilar — an important sign of this disease ; also, the rigidity of the whole spinal column in spinal meningitis. With the former, by the contraction of the cervical extensors of the head, the latter is often bent back to a marked degree, " boring into the pillow." Backward bending of the vertebral column — opisthotonus — likewise occurs with attacks of tetanus ; with epileptic, and especially hys- terical, convulsions. With the latter, as the " arc de cercle," there are sometimes incredible distortions. The anatomical relation of the cord to the spinal column is as follows : the cervical enlargement of the cord corresponds about with the third cervical or the first dorsal spine, the lumbar enlargement about on the level with the ninth dorsal to the first lumbar vertebral spine; the conus terminalis begins at the first or second lumbar vertebra. THE PERIPHERAL NERVES AND THEIR SURROUNDINGS. The nerves, as the seat of disease, come into consideration in all peripheral paralyses and in neuralgias (also among others, in reflex epilepsy). In order directly to examine a nerve-trunk, an exact knowledge of its course is necessary, and also of the organs that surround it, from Avhich an injurious efiect upon the nerve may proceed. By the examination of a nerve we learn its anatomical condition : any possible symmetrical thickening, with neuritis or perineuritis, unequal thickening or tumors in the nerve, with neurofibroma, neuroma; also any possible sensibility to pressure, as occurs with neuritis along the whole length of the diseased nerve, although this may be entirely absent. Finally, here belong the sensitive points in neuralgias (see below). Moreover, a special examination must be made of certain points, which, from any cause whatsoever, may easily be the starting-point of a disease of a peripheral nerve. These are : (a) those points Avhere a nerve is especially exposed to traumatism, because it lies near the EXAMINATION OF THE NERVOUS SFSTEM. 469 surface of the body (especially if it at the same time lies over a bone). These situations essentially coincide, in part, with the electro-motor points to be mentioned later. Severe injuries, deep punctures, etc., of course, may destroy a nerve at any point. They are : (5) neigh- borhoods where a nerve may be exposed to injury from other organs. Here belongs compression by development of callus about the seat of fracture, especially of the bones of the extremities ; also com- pression and sometimes inflammatory irritation from glandular tumors (axilla, neck, etc.), aneurism, hernia (crural nerve) ; lesion of the facial nerve caused by caries of the petrous portion [of the temporal bone], etc. Indeed, in case of lesion of a peripheral nerve we are frequently able to find the seat of the disease in this sense ; but in every single case it must be looked for. An extremely instructive case from the standpoint of diagnosis of the locus morhi was observed by Erb, Avhich was reported by the author. It was a case of ulnar neuritis resulting from exposure of the ulnar nerve from the fracture of the internal condyle of the humerus. The author has recently seen a similar case : both internal condyles of the humerus projected; the sulcus ulnaris was broad and shallow. In the first case there was a unilateral, in the second a bilateral, ulnar neuritis resulting from frequent injury to the nerve at its exposed point. EXAMINATION OF THE CONDITION OF THE MIND. In this section, which touches upon a territory foreign to this work, — the mental state — we must, of course, limit ourselves to a brief mention of what is necessary in making a medical examination. Mode of examination. An attentive observation of the behavior of the patient in bed, the expression of his countenance, his position, the reaction to external impressions, give many disclosures regarding the faculty of perception, and of his sensibility [or well-being]. By engaging the patient in conversation (taking the anamnesis,. page 18), we are able to discover more regarding these points, and to judge of the intellectual activity : memory, imagination, possible delusions, the ability to think logically. In testing the memory, we take notice of the recollection of things that are long past, as well as of more recent events, or of what has taken place during the present illness. The 470 SPECIAL DIAGNOSIS. test of the power of thought and of the imagination is made by more or less simple arithmetical problems and by questions which are suit- able to the social position and the occupation of the patient. We observe the great difference which various degrees of education pro- duce in patients affected with the same disease, and we also take into consideration the age of the patient. We observe any possible diminution or increase of action, both instinctive, as the taking of food, or sexual indulgences, and of actions with conscious purpose. This expresses in general terms the course of the examination. To be sure, we shall very frequently be obliged, in order to recognize the first traces of a mental disorder, to take into consideration whether the patient has changed in his nature or behavior. Thus, for example, if a person becomes suddenly forgetful, careless, and disorderly, this Avill have quite a different significance than if he had always from his youth been so. Of course, in regard to these things we must chiefly rely upon the statements of his relatives. In what follows is given the explanation of the terms that have been adopted in the medical clinic, and the phenomena that accom- pany the several conditions : Disturbances of consciousness are designated, according to their severity, as : stupor, also somnolence (sleepiness, lethargy, from which the patient can easily be awakensd) ; sopor, in which the patient can only be awakened by decided appeals to his senses ; coma^ or complete loss of consciousness, in which the patient cannot be awakened in any way. The slightest degree of obtunded conscious- ness manifests itself in the scarcely noticeable trouble which it costs the patient to collect himself in order to answer a question, or by his indifference with respect to being sick — a subjective sense of well- being. Further, there is an indication given by the sensibility to pain, and the arbitrary or involuntary voidance of the stools and urine. In this respect, the sensibility to pain often does not coincide with the other manifestations of consciousness. .Disturbance of consciousness occurs : in acute infeciious diseases ; especially in typhoid fever (see more below), where the early mani- festation of dulness has diagnostic value ; but it may accompany any infectious disease, and may pass into deep coma; in acute poisoning of various kinds, especially from narcotics; as ursemic, diabetic, carci- nomatous coma; as epileptic, apoplectic coma; in meningitis; in the EXAMINATION OF THE NERVOUS SYSTEM. 47 1 most varying diseases of the brain, especially in tumors of the brain and its meninges. In the different forms of meningitis, however, consciousness may be retained for a remarkably long time. In tumors of the brain there is often for a long time a slight obscuration. It occurs also in injuries and concussion of the cranium ; in large hemor- rhages ; in all chronic cachexia at the end of life, at any rate in the last moments. A patient who is in deiep coma when he comes under the eye of the physician always causes great difficulty in diagnosis, the greatest when he can make no inquiry in regard to the patient. Systematic examination of the whole body is to be made: of the cranium for wounds; of the heart and vessels; for evidences of apoplexy, menin- gitis; for signs of poisoning; of the urine, which is to be drawn with the catheter (for sugar, reaction for chloride of iron, for albumin, casts; for certain poisons or as evidence of certain poisons, haemo- globin) ; lastly, of the stomach by evacuation (poisons). SPECIAL PHENOMENA OF OBTUNDED CONSCIOUSNESS. Delirium, that is, talk and gesticulations arising from delusions. It may follow any disturbance of consciousness, but it occurs especially frequently with acute infectious diseases ; with severe cachexia, often as the end of life approaches; finally, as delirium tremens seu potatorum, in chronic alcoholic poisoning. The latter manifests itself by talkative- ness, restlessness, rapid alternations between passion and great anxiety, fear, hallucinations of sight (small black animals, especially mice, etc.), loss of sensibility to pain and cold ; besides alcoholic trembling (see). The expression " muttering delirium " is used to designate a low murmuring with profound disturbance of consciousness. It is always a serious indication of great weakness and occurs particularly with typlioid fever. Hysterical delirium forms a transition to the true psychoses, which cannot be treated here. Spasms, vomiting, see below. Loss of consciousness, which quickly passes off, occurs as " syn- cope," "dizziness." This may be very benign, as in ansemia and chlorosis, nervousness, great excitement, or severe pain. But it may have a serious significance in elderly people as precursors of apoplexy, or as slight epileptic attacks (petit mal) ; lastly, it occurs in all possible chronic diseases of the brain, but especially in progres- 472 SPECIAL DIAGNOSIS. sive paralysis. All of these conditions must be thought of when attacks of dizziness occur frequently in the same individual. Dizziness, vertigo. In many respects this is to be looked upon as a slight, temporary loss of consciousness, or connected with it (see above). But it only indicates a disturbance of the sense of equilibrium and occurs as such most purely as a swimming of the eyes in diplopia (see Eyes) from deception regarding the location of objects in space and regarding the level of the floor. It also occurs in affections of the ear (vertigo ab aure Isesa) ; in tumors of the brain, especially of the vermiform process of the cerebellum ; in multiple sclerosis ; with diseases of the stomach (vertigo a stomacho laeso) ; in anaemia, and in cerebral neurasthenia. Pathological depreciation of the power of the mind to perform its functions is designated as imbecility. It occurs in all gradations from moderate diminution in the perceptive faculties, to a complete animal condition. Congenital imbecility is designated idiocy., when accompanied with certain physical manifestations as cretinism. As an acquired condition it occurs as dementia senilis, also in organic diseases of the brain, especially tumors, apoplexy, multiple sclerosis ; but also, as a temporary condition in convalescence from severe dis- eases, there is a slight imbecility. Imbecility with delusions of great- ness is a tolerably characteristic sign of progressive paralysis. Of disturbances of volitional impulses are to be mentioned : abulia (hypochondria, drunkenness, indulgence in morphia) ; loss of desire for food : anorexia ; certain forms of pathological excesses : boulimia (a morbidly great and unnatural appetite for eating all sorts of things), nymphomania and satyriasis (abnormal sexual desires). Disturbances of Sensibility. 1. sensitiveness to peripheral irritation. The determination of the sensibility which a patient has for irrita- tions applied from the periphery (by the physician) is made difficult by the fact that the estimation of them must rest with the patient, who is the subject of the experiment. Subjective sensibility, especially to pain, without doubt varies with individuals: with "torpid" persons EXAMINATION OF THE NERVOUS SYSTEM. 473 and with the aged it is depreciated. Moreover, in a varying degree, it is diminished with persons who are unconscious to the point of entire loss of sensation. Further, it will be influenced, when the irri- tation is slight, by the attentiveness of the person examined. The report of what is discovered in such examinations depends wholly upon the sincerity and good-will of the patient. We must always think of the possibility of simulation and concealment, and the absence of favorable intention. Very little weight must be given to the statements of the patient as to his capacity to feel. The most brief examination is best, as securing the most exact answers, for we very often meet with erroneous conceptions of the condition of the sensibility of the skin. Whenever we are testing the sensibility, it is advisable to prevent the patient from seeing what we are doing. If the disease is uni- lateral, it is desirable to make use of this circumstance to compare the diseased with the healthy side. How we are to guard against decep- tion by simulation, see below. Finally, it is most emphatically recommended that the individual should employ the utmost similarity possible in the methods of making his examinations ; for only in this way is it possible con- stantly to sharpen his own judgment. Moreover, every record of an examination should contain a statement of how the result was ob- tained. Passing over the higher senses, the sensibility to peripheral irrita- tion is divided into (a) cutaneous sensibility, (5) the so-called deep sensibility. {a) Cutaneous Sensibility. This again is divided into a number of qualities whose relation to each other and distinction one from the other is not yet entirely clear. We avoid any discussion of disputed points, and treat the qualities from the stand-point of clinical interest. 1. The sense of touch, sensibility to contact. We test this by gently touching the skin with the tip of the finger, the patient keeping his eyes closed, and whenever he feels the touch saying "now" ; it is better if he will also say " on the hand," or on the given finger, etc. Thus we approximately test the sense of locality (see below). And it is also recommended, in order to shorten the examination, to test the 474 SPECIAL DIAGNOSIS. Jatier immediately more exactly by having the patient designate with the tip of the finger the spot that is touched. If he is able to do this then his sense of touch and of locality is normal ; if he cannot, there may be several reasons for his inability, as disturbance of the sense of touch and of locality, sometimes of the muscular sense (see below). Then we must endeavor to separate the sense of touch from the sense of locality. In many cases of slight disturbance the patient is able to feel the contact, but it is duller and different from what it is in normal places. Then we often obtain more exact information if we touch him with rough and soft materials, and the like. In other cases this procedure is unnecessary. 2. The local sense, the power of localization, is tested by having the patient tell exactly where he has been touched. A healthy per- son can tell this with different degrees of accuracy, according to the portion of the body which is touched. This about corresponds with the distances on the body which the related sense of space has been found to give. (See below.) Testing the sense of space (only required when from any reasons the sensibility must be tested with the greatest exactness) is best done with Sieveking's aesthesiometer : by means of two sliding points we are able to measure the shortest distance at which the two points can be recognized as two separate objects. In health the minimal dis- tance, on the average, is as follows : At the tip of the finger In the palm of the hand On the back of the hand The forearm and the leg The back . The upper arm and thigh 2.5 to 5 mm. 8 to 12 " 31 " about 40 " 40 to 70 " about 75 " Analogous, although in its results not wholly corresponding to those of the above-mentioned method, is that of testing the sensation of movements (Leube) : it relates to the power to distinguish points and the shortest lines that can be drawn upon the skin. 3. The sense of pressure residing in the skin is tested by the ability of the patient to determine the smallest differences between weights EXAMINATION OF THE NERVOUS SYSTEM. 475 placed npon the skin. The limb must lie firmly, so that the muscular sense (see) is excluded. It is best to take blocks of wood of the same size (instead of metal), but made of different weight by being loaded with lead. The healthy person perceives differences of weight which are equal to about -2^ to -3^ of the absolute weight of the bodies employed. Partial paralysis of the sense of pressure is frequently observed, especially in tabes. 4. The sense of warmth and cold. This is most quickly and simply tested by breathing and blowing upon the skin. Healthy persons distinguish the first from the second perfectly well. This method, however, is entirely unsatisfactory, because the finer disturb- ances of the sense of cold and heat are not revealed by it. Somewhat more exact is the test made by means of two test-tubes filled with water at different temperatures. We must select a difference of tem- perature which we ourselves distinctly recognize, as, for instance, by passing the hand over them. If, with one of these methods, we find a disturbance of one of the two temperature-senses, then we can more exactly determine the degree of this disturbance by employing tem- peratures which vary still more ; hence, very low or very high (ice, hot water). At the same time we can thus determine the temperature at which cold- or heat-pain begins. A finer test of the sense of heat is made by the aid of the thermses- thesiometer We recommend Nothnagel's — two cylindrical wooden vessels, with metal bottoms, into each of which is dipped a thermom- eter to test the temperature of the water that is poured into them. In a very imperfect way we may make a substitute for this thermaes- thesiometer by using two reagent glasses half filled with water. In these are placed thermometers surrounded by pledgets of wadding. The temperature of the glasses is varied by dipping them into vessels of cold or hot water. The thermgesthesiometer enables us to deter- mine exactly the fineness of the sensibility to heat and cold. The normal fineness of the sensibility to heat differs with the absolute height of the temperature which we select. The temperatures between 27° C. and 33° C. are most delicately distinguished. Here the recognizable differences in health average 5° C, except over the legs, where the number may be somewhat larger, and on the back, where it is about 1° 0. On the cheeks it is about 0.25° C. 476 SPECIAL DIAGNOSIS. Fig. 146. 5. Sensihility to pain} We recommend to test exclusively by pinching a fold of skin between two fingers, because in this way, with some practice — it depends very much upon the size of the fold of skin that is taken, and it is recommended always to press the rounded portion of the skin — we can best attain some uniformity in regard to the amount of irritation employed each time. (Regarding pain caused by faradization, see below.) With patients who are unconscious it very often happens that the sensibility to pain is the only quality of sensation that is accessible to examination. When there is very decided uncon- sciousness we are made aware of it by the possible distortion of the counte- nance on account of pain or even a withdrawing of an extremity (not to be confounded with reflex of the skin, see below). 6. Electric sensibility. By the galvanic as Avell as the faradic current we can develop an obj ectively- visible as Avell as subjectively- painful sensibility of the skin. We confine ourselves to the descrip- tion of the farado- cutaneous sensibility. It is best obtained by employing Erb's electrode for testing farado- cutaneous sensibility (made by St5hrer, in Leipzig), which is a cable of insulated copper wires cut at right angles with its axis. We mount this electrode upon the cathode of the opening current of a Dubois's induction-coil (the other electrode may stand anywhere upon the body), and notice the distance of rotation when the point of the skin under examination becomes sensitive (minimum of sensation), and also where it stands Avhen pain is produced. Then, besides, we are to test the galvanic resistance at each point tested (see under Elec- trical Examination for Motility), in order to have an approximate guide as to how sti'ong a current, furnished by Dubois's apparatus, is Erb's electrode fortesting the sen- sibility of the skin, a, tube of hard rubber; b, free surface of the elec- trode. (Erb.) ^ Corresponding with the mode of procedure in making an examination, this is included here, although it properly belongs with common sensation (which see). EXAMINATION OF THE NERVOUS SYSTEM. 477 exhausted by the resistance of the body (or of the skin) at the indi- vidual points ; hence, how much of it is used up each time in produc- ing the irritation of the skin. The following table gives the average figures of health as found by Erb, but we remark that the figures change according to the strength and construction of the induction apparatus employed, and also that the deviation of the needle (for testing the galvanic resistance) was attached to an old galvanometer without absolute divisions. For both of these reasons the relation of the figures from each other, rather than the absolute variation of the needle indicated by them, is of value : Points of resistance. Cheeks . Minimum. 200-220 Pain. 130 Deviation of the needle with 8 elements ; con- duction resistance 150. 26° Neck 180-200 120 22° Upper arm . Forearm 200 190 120 115 21° 18° Back of the hand . 175 110 15° Tip of the finger . 125 90 2° Abdomen 190 120 20° Thigh . 180 115 21° Lower leg Back of the foot . 170 175 110 110 19° 10° Sole of the foot 110 80 5° The method is further liable to error, regarding which we cannot speak here. Farado-cutaneous sensibility does not go entirely parallel with any other quality of sensibility. Most frequently, but not always, the sensations of pain produced by pinching, and the minimal sensations of pain produced by the faradic current, correspond with each other (this is especially the case in tabes). The method has not yet been sufficiently studied to be of independent diagnostic significance, and particularly to have a value for special diagnosis. Its application is chiefly to be recommended in unilateral slight disturbance of sensi- bility, from the possibility of making a comparison with the sound side, which cannot be quite certainly established when there is normal irritability of the skin. (Regarding stereognosis, see p. 481.) Now, if by testing the sensibility we find it diminished, we speak of hypcesthesia, often incorrectly spoken of as anoesthesia. If none is found — that is, if the strong or maximal irritation employed, which 478 SPECIAL DIAGNOSIS. is always to be stated as accurately as possible, meets with no response — then we speak of loss of sensibility, or anaesthesia. Heightened sensibility is hypercesthesia, or sensibility to variations of temperature and to pain. In many cases, especially in diseases of the peripheral nerves, the sensibility is equally altered in all its qualities ; in others, and especially in diseases of the spinal cord, in cerebral anaesthesia, and not infrequently in hysteria, there exists a partial paralysis of sensibility. Of this, the most frequent form is the diminution or absence of sensibility to pain — analgesia. When sensibility is slowly conducted {^'■delayed sensibility "), it is recognized by requiring the patient, with his eyes closed, to call out " now " the instant he has a sensation. Sometimes, the pause can be measured by seconds (ten seconds, and more). This phenomenon is most frequently observed with reference to pain, as in tabes and in peripheral paralysis. If we take hold of the skin, to pinch it. the patient will often call out "now" twice, because he felt the touch, and then, later, the pinch: there is double sensibility. For this reason, it is best to take up the skin first, without pressing it, and then suddenly to pinch it. Gradual increase of the sensibility to pain, when inflicted, so that just at the moment of being pinched it is inconsiderable, and, later, the pain increases markedly, appears by its phenomena and occurrence to be related to delayed communication of the pain. Perverse sensibility to changes of temperature (Striimpell) consists in cold being experienced as heat. According to our recent views of the complete opposition of the sensibility to heat and the sensibility to cold, this disturbance is not, as yet, explicable. Yet it has an analogy in those rare anomalies of sensibility where a gentle touch is felt as cold. After- sensibility (Naunyn) is a term used to describe a pain that, when first inflicted, immediately subsides, but for some time after returns, and, indeed, with increase of intensity. Pulycestliesia (Fischer) : when one point of the sesthesiometer is placed upon the surface, it feels as if there were two. AllocMria (Obersteiner) : when the right extremity is touched, it is referred to the left, and vice versa, as in tabes, myelitis, hysteria, multiple sclerosis. Local manifestations of disturbed sensibility. Of course, these EXAMINATION OF THE NERVOUS SYSTEM. 479 are to be determined as accurately as possible. This is very easily done when the disturbance of sensibility is sharply bounded ; how- ever, not infrequently the region of disturbed sensibility of the skin passes very gradually and indistinctly into the normal portion. Total anaesthesia is a curiosity. Unilateral anaesthesia, or hemiancesthesia, not passing beyond the middle line of the body, sometimes affecting the head, trunk, and extremities (including the raucous membrane), in a similar way, occurs with certain deposits in the internal capsule (in the posterior third of its posterior limb), and in hysteria. In the latter, and (it is said) also in the first case, there is simultaneously exact unilateral disturbance of all the higher senses. Para-ancesthesia is anaesthesia of both lower or both upper limbs. A zone of dis- turbed sensibility, a territory of any extent, may exist in all imagin- able parts of the body. If it is small, it may easily be overlooked, unless the search for it is very carefully made; this is particularly apt to be the case in the extremities. Here, especially (but also on the trunk), we must carefully determine whether the anaesthesia cor- responds with the region of distribution of a cutaneous nerve, or of a mixed nerve-trunk (see p. 484), or whether it is not confined to such a territory — that is, " diffuse " or " washed out." In the first case it "would indicate an isolated disease of that particular nerve. Anaes- thesia (analgesia) affecting an extremity which is limited to the por- tion distributed about a joint (say, as far as the wrist, or up as far as the elbow-joint, etc.), has been met with in certain functional neuroses, especially of the so-called hystero-traumatic neuroses of the French. It may happen — indeed, it very frequently does — that an anaesthetic territory does not really comprise the limits of a nerve of the ex- tremities, but the inner half of it is wanting. Thus, in a radial paralysis, there may be an anaesthetic zone (easily overlooked) con-, fined to a small part of the dorsal side of the forearm. This results, either because the nerve is not interrupted throughout its whole trans- verse section, or because we have that^ very puzzling phenomenon, the "vicarious" participation of a neighboring nerve. {b) Deep Sensibility. This is divided into the less important categories of the dynamic sense, the sensation of spasm of the muscles, and the important 480 SPECIAL DIAGNOSIS. so-called muscular sense, which is a generic name for a series of sensations. Dynamic sense is the capacity to recognize the weight or the difference of weight between different bodies which one lifts. It may- be exactly tested only with the upper extremities, and even here it is not wholly separable from the pressure-sense of the skin. Different weights are placed in a cloth-sling pulled over the hand on to the wrist. A healthy person will recognize differences of one-tenth. Sensation of spasm is the unpleasant sensation or pain which is experienced in very strong contraction of the muscles, as in cramp in the calf of the leg, or strong faradic muscular stimulus with anaesthesia of the skin. Muscular sense. By this we understand the ability to recognize, with the eyes closed, the position a limb is in (conception of location), and the active and passive motions of a limb. It is due to the sensi- bility of the muscles, joints, and their ligaments, by the feeling of varying tension of the skin in flexion and extension of a joint, by the impressions of touch which come from portions of skin being in con- tact, as in the axilla and elsewhere. We test the sensation of location and of motion in the arm (with the eyes closed), in persons with uni- lateral disease very simply : we place the diseased arm in different positions, and have the patient with the sound hand take hold of the wrist of the diseased arm. The same method may be employed in unilateral disease of the leg. Besides, it is well, when there is disease of the legs and bilateral affection of the arms, to have the patient describe the positions in which they are placed or the passive motions of the joint that are made. We can also have the patient describe and represent numbers in the air with his hands. Romberg's symptom. The patient places his feet close together, and as soon as he closes his eyes he begins to reel, sometimes he may fall down. The phenomenon is dependent upon anaesthesia of the soles of the feet and disturbance of the muscular sense of the legs, which is no doubt increased by the existing ataxia (which see), because in this condition the motions to correct the swinging are too violent ; this is especially characteristic of tabes dorsalis. [But something of this symptom may be present in health, owing to the lack of vision to correct incipient lateral movements. This may be made clear by closing the eyes and then attempting to stand on one foot.] EXAMINATION OF THE NERVOUS SYSTEM. 481 A finer test of the muscular sense may be made by placing before the patient a table with numbered squares like a chess-board, each square measuring about 10 cm. on a side, and having him point them out with the eyes open until he has them all in his head, and then with closed eyes to touch them with the hand ; or, on the other hand, the patient moves his hand about the squares and names the fields as he comes to them. With the legs, the same test may be made with cubes measuring 10 cm. on a side, placed one on top of another and then side by side. This test, however, requires a certain degree of intelligence on the part of the patient. Oonception of space ("finding one's position in space") can be tested by placing substances of different thicknesses between his thumb and forefinger to ascertain the smallest perceptible differences of thickness. In testing the conceptions of active motions, we see that it is very much disturbed in paralysis, ataxia, and chorea ; regarding these, see below. The Knowledge of Form (Stereognosis). We recognize the form of bodies partly by the sensibility of the skin and partly by deep sensibility. The former is employed more for very small bodies (which we are able to grasp with the hand ; here, indeed, the hand is the chief means), the latter more for large substances. Thus far only the recognition of small bodies has been sought, especially in an exact way by Hofimann. To make this test he selected a ball, half-ball, segment of a ball, a cone, a three-cornered pyramid, a regular octahedron, and a dodec- ahedron — all of a size for the hand to grasp. He chiefly tested the hand of persons in health and sick people as regards their ability to recognize these bodies (to which popular names were given). Hoffmann and others have found that the recognition of small bodies was principally made by the skin and sense of space and of pressure of the skin, and to a less degree by the sense of motion in the joints and the power of determining the location in space. Also, that the active to-and-fro motion of the body in the hand, for a dif- ferent reason, comes into consideration : if the active motion is want- ing, then the stereognosis is hindered, but not abolished. Formerly the examination of stereognosis did not have an inde- 31 482 SPECIAL DIAGNOSIS. pendent value ; testing the separate qualities of sensation is superior to it. According to our experience, the most important result of Hoffmann's examination is the knowledge that the separate factors of stereognosis may very perfectly act one for another when there are pathological disturbances. 2. SENSIBLE PHENOMENA OF IRRITATION AND PAIN FROM PRESSUEE UPON NERVES. 1. JParcesthesia. This occurs as a subjective sensation of touch, like fur, creeping of ants, creeping of insects, falling asleep; also as a subjective sensa- tion of pain, as a fine stinging or pricking, and also a severe pain ; lastly, as a subjective sensation of cold and heat or painful burning. The so-called feeling of constriction, which occurs most frequently upon the trunk in the region of the thoracic vertebra, especially in tabes, but also in local disease of the spinal cord and its meninges, belongs here. Generally it is a sensation of tension, but it also occurs in all stages of transition to genuine neuralgic pains, when it is deeply located (see Neuralgia). 2. S-pontaneous Pain. Headache (cephalalgia). This, according to the manner of its occurrence as well as its significance, may be extremely varied in its character. Its chief forms are : (a) Headache produced by palpable disease of the meninges in the different forms of meningitis; in all those diseases of the cranium and the brain which accompany meningitis. If the affection is circum- scribed, the headache may likewise be so, and it then sometimes indicates the location of the disease; but, also, often enough in this case it is not located. Related with this are the nocturnal headaches of syphilis. (h) The headache of neurasthenia is quite various in its onset. Sometimes it appears as a painful pressure in the head, sometimes as extremely severe pain ; again it is diffuse, then localized, especially at the crown of the head. There is the hysterical headache, not infre- quently circumscribed at the crown (clavus hystericus). EXAMINATION OF THE NERVOUS SYSTEM. 483 ( CaSC. {h) Partial EaR. Faradic : nerves : diminution of I, muscles : diminution of I ; Galvanic : nerves : diminution of I, muscles : EaR as above. For more ready comprehension we add here two curves from Kast, which graphically exhibit the normal muscular reaction and the EaR. Fig. 160. Diagrammatic representation of the normal galvanic muscular reaction. Healthy young girl. Stimulation of the muscles in the region of the peroneus. 33 cells. Ka = CaSC; An = AnSC. (After Kast.) 520 SPECIAL DlAGNOSm. Fig. 161. Diagrammatic representation of the reaction of degeneration (EaR). (After Kast.) Case of poliomyelitis anter. chronic. Same muscles as above. 40 cells. Contractions tardy, AnSC > KaSC. Course of JEaR. EaE, is the pathognomonic sign of those changes which take place in muscle, or motor nerves and muscle, when they cease to stand under the peculiar trophic influence of their anterior horn ganglia — those alterations we designate as degenera- tion of the nerves and muscles. This degeneration can be most beau- tifully studied by the electrical phenomena if a nerve trunk is, at some place, suddenly interrupted throughout its whole transverse section. Whenever there is such an interruption there is manifest a complete separation of the portion of the nerve of the muscles located peripherally from the anterior horn, which must inevitably lead, not only to paralysis, but also degeneration of the portions cut off, and with it EaR. But now the case can either proceed so far that there is a permanent interruption at the injured spot, which results in com- plete atrophy of the nerves and muscular fibres, or, after a time, the conduction at this place may be restored ; and in the latter case there is a return of the tissues of the nerves and muscles to the normal con- dition — that is, there is regeneration of them. Now, according as the degeneration of the nerve (muscle) results in atrophy [i. e., transfor- mation into connective tissue), or again regenerates and returns to its normal condition, the EaR shows a definite result as such, and also in its temporary behavior with reference to the ability to use the muscles. This result of EaR may, of course, be made use of in drawing a conclusion as to the condition of the nerves and muscles. Erb has investigated these facts in regard to rheumatic facial paral- ysis, and by experimental examinations, in a classical manner. He has given representations for the course of rheumatic facial paralysis, which we here insert. Fig. 162 gives a representation of complete EaR with reference to motility, and faradic and galvanic irritability of the nerves and muscles; EXAMINATION OF THE NERVOUS SYSTEM. 521 and over it are given the designations of the simultaneous histological changes. The line of galvanic muscular irritability is wavy so lonfl^ as the qualitative changes (slowness of contraction and preponderance of AnSC) continued. 1. Paralysis with relative early return of motility. The first trace of motility appears at a time when there is still complete EaR. One week later the faradic and galvanic irritability of the nerves reappears ; Degeneration of nerves. Fig. 162. Atrophy, etc. of muscular fibres. Regeneration. Cirrhosis ' 3. ' 1. 2. 4. 5. 6. 7. 8. 9. 10. 11. 24, Weeks. Motility Complete EaR with reference to motion. Faradic and galvanic stimulation of the nerves and muscles. Paralysis with early return of motility. (Erb.) hence there now is partial EaR ; three weeks later, the slowness of the contractions begins to disappear. Diminished irritability of the nerves and motility continues a still longer time. 2. Paralysis with later return of motility. Temporarily the condition is like that in Fio:. 162. Here, also, there is for some Fig. 163. Degeneration of Atrophy, etc., nerves. of muscles. Cirrhosis. Regeneration. 1. 2. 5. 6. 10. 15. 20. 25. 30. 35. 40 45. 50. 55. Weeks, Motility Paralysis with later return of motility. (Eeb.) 522 SPECIAL DIAGNOSIS. time a partial EaR. All the evidences of regeneration return again later. 3. Permanent paralysis. Motility, irritability of the nerves, and faradic muscular irritability do not return. The galvanic muscular Degeneration of nerves. Fig. 164. Atrophy ; nuclear proliferation ; cirrhosis Total atrophy. 1. 3. 10. 20. 30. 40. 50. 00. 70. 80. 90. 100. Weeks. Motility Irremediable paralysis. (Erb.) irritability in the course of some months becomes nil; the contractions, so long as they are still possible, are slow. Fir.. 165. Degenerative atrophy of muscular fibres, r Kegeneration. 9. Weeks. Paralysis in which there is only partial EaR. (Erb.) 4. Paralysis in which there is only partial EaR. The faradic and galvanic irritability of the nerves and faradic irritability di- minishes only to a slight degree. Motility returns again quite early. EXAMINATION OF THE NERVOUS SYSTEM. 523 Varieties of JEaR. (a) Partial EaR is necessarily accompanied with slowness of con- tractions (which are also indirect — Erb). Not only the contractions which occur with direct galvanic irritation of the muscles, but all contractions, including those, also, which occur with galvanic and faradic stimulation of the nerves and faradic stimulation of the mus- cles, are slow in their character. [" The faradic excitability of the paralyzed muscle undergoes a diminution corresponding to that of the nerve, but the galvanic excitability of the muscles manifests the quantitative and qualitative changes which are characteristic of the severer forms of the reaction of degeneration."] (5) The AnSC of the nerves is slow, the CaSC is not (Lowenfeld), or, the muscle has a slow faradic reaction, while the nerve does not respond at all (Stintzing) ; or, the muscle has a slow, the nerve a prompt faradic reaction, etc. Stintzing, with the greatest pains, has recently undertaken to bring order out of this confusion with remarkable, although with few, results. Probably it is well to allow the material to still further accumulate before we undertake to interpret it, diagnostically or pathologically. (e) Mixed JElectrieal Reaction. We thus designate those electrical reactions which occur when a muscle is partly degenerated and partly normal, and a corresponding portion of the nerves is also sound and another portion degenerated. Then we find a diminution, but never a loss, of faradic and galvanic excitability of the nerves and of faradic excitability of the muscles. But the direct galvanic muscular reaction causes the greatest difficulties : the contractions are not exactly short, not altogether slow, AnSC=CaSC, here and there also shorter : it is hard to discover its significance. All of this is not easy to understand, because normal contractions are mixed with EaR ; especially difficult is it, if, as is almost always the case, the excitability is lowered. The object is sometimes attained by making repeated, indeed, daily tests (when it seems that EaR often becomes more distinct), by thorough examination of every part of the mus- cular system with weak as well as with moderately strong currents, frequently changing the location of the indifferent electrode (which must always be done in such a way as to avoid exciting the nerves). A 524 SPECIAL DIAGNOSIS. single clearer manifestation of EaR in one muscle, or in a bundle of muscular fibres, will usually serve as an indication of the whole disease as degenerative atrophic paralysis. It is true that EaR has twice been found in myopathic muscular atrophy in single muscles (Schulte and Zimmerlin). We (with Erb) do not share the opinion of Wernicke that this mixture is the single cause of every case of partial EaR. 2. Myotonic Reaction (Erb). Myotonia congenita occurs in the very powerful (hypertrophic) muscles which always exist with this disease : they show increased irritability and continuance of the contraction with the faradic cur- rent ; with the galvanic test, likewise, there is increased irritability, but only contractions as the current is closed, and then extremely slow and continuing contractions with peculiar formation of furrows and depressions. Stable acting currents (the stimulating electrode placed not upon the muscle, but on the vasti, for instance, near the patella) produce rhythmical, wave-like contractions from the cathode toward the anode. The relation of EaR to the so-called mechanical EaR is not unim- portant. (See, regarding this, on p. 526.) 3. Diagnostic Value of the JElectrieal Condition. The reaction of degeneration (EaR) occurs : 1. In all paralyses produced by disease of the ganglion cells of the gray anterior columns of the spinal cord, or of the motor nerves of the bulb. 2. In all paralyses produced by disease of the anterior roots and of the periph- eral nerves, where the trophic influence of the anterior horn ganglia fails on account of the interruption of the conduction, peripherally, in the nerve and muscle. The reaction of degeneration (EaR), therefore, is closely connected with degenerative atrophy of the muscles. Thus, it occurs : in polio- myelitis acuta, chronica, spinal progressive muscular atrophy, amyo- trophic lateral sclerosis, lesions of a section of the gray anterior horns from hemorrhage, tumors, etc. ; bulbar paralysis ; in traumatic lesion of the peripheral nerves; in neuritis of all kinds; in "rheumatic" paralyses ; in primary multiple neuritis ; in toxic paralyses, and those that occur after infectious diseases. EXAMINATION OF THE NERVOUS SYSTEM. 525, The presence of EaR points directly in opposition to : cerebral paralysis, paralysis from lesion of the pyramidal tract in the spinal cord ; further, against myopathic paralysis ; lastly, against functional or hysterical paralysis. Of course, the EaR. is to be regarded as contra-indicating the diseases last named, only with the reservation that there is no com- plication with the conditions first named. Of this character we, with others, consider also the condition of EaR found by Schulte and Zimmerlin with myopathic progressive muscular atrophy [see previous page]. In harmony with the above principles, partial EaR has exactly the same significance as complete. It occurs : 1. In slight afiections (as slight forms of rheumatic facial paralysis, slight paralysis of the arm from pressure). 2. In atrophic paralysis, which only affects a portion of the bundles of the muscular fibres, it is disseminated (especially frequent in spinal progressive muscular atrophy, amyotrophic lateral sclerosis, multiple neuritis), and, hence, as a mixed reaction. (See above, p. 523.) When EaR is absent, sometimes it does not strictly show that there is no affection of the anterior horns or of the peripheral nerves — that is to say, it does not do so if we have to do with a disseminated disease (see Mixed Reaction). EaR may be wanting when there is an existing peripheral paralysis, if it is very slight (very slight pressure-paralysis of the N. radialis, which heals in three to four weeks). EaR in muscles that are not paralyzed is seen by itself in lead- paralysis and traumatic paralyses. Lessened excitability, especially of nerves, without EaR, occurs chiefly in myopathic muscular atrophy (dystrophia muse, Erb), in muscular atrophy from disease of the joints, and in lesions of the spinal pyramidal tracts, especially if recent and very severe. More- over, it is observed with multiple neuritis., arsenic-paralysis, alcohol- paralysis, bulbar paralysis, amyotrophic lateral sclerosis, etc., and here it is probably to be counted as mixed reaction. An intermitting general paralysis at intervals of one to four weeks, which lasts for twenty-four hours, with complete or almost complete loss of all electrical reaction, has been observed by Westphal. Its nature is very problematical. 526 SPECIAL DIAGNOSIS. Increased excitability as manifested by early occurrence of CaSC and CaSTe, occurrence of AnOTe, is an extremely important sign of tetanus. Slight increase is observed in cerebral, spinal, recent neuritic paralyses, in progressive muscular atrophy of spinal origin (here a more considerable increase, and this in muscles that are still performing their function). The increase of galvanic excitability of the muscles with EaR, as well as of the faradic and galvanic irritability of the muscles with myotonic reaction, does not belong here. (For myotonic reaction, see above, p. 524.) 4. Mechanical Exeitahility of Muscles and Nerves. 1. Upon striking a muscle with a percussion-hammer, we see that a short contraction occurs, like a CaSC with a tolerably weak current. We find these contractions increased and usually quite decidedly slow in those muscles which show electrical EaR : " mechanical EaR." If distinctly present, this shows the same thing as the electrical EaR ; but, often enough, it either fails or is not distinct, while the electrical examination proves the existence of EaR. Increased mechanical excitability with energetic, but slowly de- clining and prolonged contractions (to as much as thirty seconds, Erb), are peculiar to myotonia congenita. [See p. 524.] For those who are experienced, mechanical excitability is not with- out its value as a preliminary starting-point. But it cannot be a substitute for the electrical test. 2. Idiomuscular contractions are transverse prominences which appear locally at the spot where the muscle is struck — thus far without any diagnostic significance. 3. Mechanical excitability of the nerves (striking upon the trunk of the nerve at the point of electrical stimulation) has individual differences. In many healthy persons mechanical irritation does not cause any contraction at all. The mechanical excitability of the nerves — but not of the muscles — is very much increased in tetanus (especially in the branches of the N. facialis). 4. Charcot has discovered that a peculiar form of over-excitability of the nerves and muscles is characteristic of the lethargic stage of hypnosis in very hysterical persons: pressure upon the nerve or muscle causes contracture. EXAMINATION OF THE NERVOUS SYSTEM. 527 We mention here, further, the peculiar and obscure phenomenon of paradoxical contractions (Westphal) : In passive dorsal flexion of the foot there occurs a tetanic contraction of the tibialis anticus which lasts from a few seconds to several minutes ; the tendon of the muscle becomes prominent, the foot — even when it is no longer held — remains dorsally flexed. It frequently occurs in connection with increased tendon reflex. 5. Coordination and Ataxia. In all motions there is necessarily a more or less complicated concurrent action of a number of muscles. For example, in order to seize anything with the hand, not only are a series of muscles of the arm, hand, and finger moved, but at the same time, or a minimum of time before, the scapula, as a fixed point for the arm, must be steadied ; moreover, from the free attitude of the body, the shifting of the centre of gravity, brought about by the motion of the arm, must be equallized by the contraction of the muscles of the trunk and legs, and the equilibrium must be maintained — a proceeding which, it is evident from what has just been said, cannot be sharply defined. Hence, in order that the hand may attain its object, and in order that it may attain it in the shortest way and with a steady motion, a very exactly defined number of muscles must contract at the right instant and with the finest adjustment of energy. This correct selection of muscles, and their regula- tion as to time and gradation of activity, is called coordination. It is acquired by practice by means of conscious and unconscious direc- tion of our motions ; and it is preserved by an oversight which is continually becoming less conscious and more unconscious, and which all our motions acquire. Children at first are ataxic in grasping things as well as in walk- ing. The acquired coordination in walking can be partly lost again from long-continued severe sickness. The processes for acquiring and for maintaining coordination are certainly very diversified. Coordination will be acquired by the cor- rections which will be suggested by sensible irritations of all kinds, caused by the motions that are made and conducted to the central organs : the eye sees, the ear (as of the violinist and others) hears — the motion itself or its efl"ects, the sensibility of the skin, the whole 528 SPECIAL DIAGNOSIS. totality of deep sensibility furnishes information — and the correc- tion depends upon the sense of power of the muscles, which gives unconscious information regarding the intensity of the work accom- plished each time by the muscle. In this acquisition of coordi- nation the conscious will participates in many ways : in maintaining coordination it recedes very extraordinarily, and gives place to an unconscious influence of the motions by centripetal influences. But, if necessary, it may at any moment take hold, and even with a con- trary effect to that intended, in that the unusual, new agent of the regulation of the will disturbs the co5rdination which went on suc- cessfully before unconsciously. A person says, " I will make it par- ticularly beautiful," and just at that instant he becomes awkward. This happens, not only with nervous and embarrassed people, but also with those who are very calm : under the control of the will, they suddenly perform a motion which has long been automatically made. Now there is scarcely any doubt as to the nature of the centripetal influences, but where and how they bring their influence to bear upon the motor tract is very far from being clear. Voluntary motions certainly proceed to a certain extent from regulation derived from the cortex (where the complex motions, like those for speech, must exist), but certainly still other portions of the brain, which prob- ably act as reflex centres, have an influence upon this regulation (thus especially the cerebellum for the motions of the trunk and legs) ; and lastly, no doubt the gray anterior horns have a part in directing the continuity of motion : they preside over the tonus of the muscles, the antagonizing tension constantly in action during activity; they are the seat of tendon ,and skin reflexes. That all these things have an influence upon the continuity of motion seems to us (as well as to many others) cannot be doubted. But, likewise, there is no doubt that the various centripetal influences upon coordination, to a very great extent, may act vicariously for one another : when there is the loss of the conscious skin and muscular sensibility, in the disappearance of centripetal stimulation, they call forth the muscular tonus, the more attentive regulation of the cor- tical innervation (with the assistance, for example, of the eyes) replaces the loss of constancy ; that, on the other hand — for instance, in the case of the blind — the exquisite superficial and deep sensibility (conscious as well as unconscious) must become prominent. But now. EXAMINATION OF THE NERVOUS SYSTEM. 529 if coordination can no longer be maintained, then with its disturb- ance there occurs ataxia. It is clear from the foregoing that ataxia may exist at the same time with perfectly normal vigor ; indeed, it has nothing whatever to do with native strength. Ataxia shows itself according to its degree only with delicate, or it may even with gross, functions. It usually occurs as an excess of innervation in the sense of directing motion, or as a want of restraint (tabes).: swing of the legs in walking, putting the feet down as if stamping, or only a clumsy way of moving the feet when turn- ing around (as in closing the door of one's room) ; thus, on account of the uncertainty, the legs are spread out in standing and walking ; impossibility of describing a circle with the foot when lying in bed, inability to exactly place the heel upon the knee of the other leg ; when endeavoring to take hold of anything, the hand misses it, as in the effort to take hold of one's own nose, in executing with the hand the finer movements of all kinds. In other kinds of ataxia there are other kinds of uncertainty, without this character of missing the mark, or the 'ataxia of the legs and trunk manifests itself by reeling. The control of the eyes sometimes diminishes the ataxia, sometimes not ; the first is often the case in tabes. Most ataxic patients accord- ingly show a noticeable inward consciousness with every ordinary voluntary motion (as walking), quite in contrast with persons in health [see p. 480]. Ataxia occurs : {a) In cerebral affections, and particularly those of the cortex ; here with paresis, confined to a limb or one-half of the body ; with lesions of the vermiform process of the cerebellum, of the crura cerebelli, and of the pons and the corpora quadrigemina ; and lastly, in individual cases in ordinary hemiplegia, if there is slight spasm, [h) Especially in tabes, where ataxia is the most impor- tant symptom, sometimes after disease involving the whole thickness of the spinal cord. ((?) Rarely, and generally to a slight degree, in diffuse peripheral neuritides. {d) Rarely as a highly developed dis- turbance after acute infectious diseases. On the contrary, traces of ataxia after long confinement to the bed, especially after acute dis- eases, are not at all rare. Co5rdination is then temporarily and only partly lost. For details regarding the different theories of ataxia, especially those in regard to tabes dorsalis, see the different special works. It is our 34 530 SPECIAL DIAGNOSIS. opinion that only one source of coordination has always been assumed, in a somewhat one-sided way, by the advocates of the several views. 6. Spasms of the Voluntary Muscles. We gather together under this designation all those pathological motions existing outside of the influence of the will, so we must go very much beyond the popular literal idea of "spasms." But this cannot very well be avoided unless we purposely wish to divide the subject very minutely. First, then, a few general remarks : Tonic spasms are those lasting some time — from minutes to days and weeks — and are symmetrical. Clonic spasms are contractions of short duration, followed by relaxation of the affected muscles. All, with the exception of some forms of trembling, are phenomena of irri- tation derived from the nervous system ; and, in fact, chiefly from the cortex, pyramidal tracts, the anterior horns of the spinal cord, some probably also from the peripheral nerves (also from the muscles themselves : paralysis agitans, contractions of fibrillse). The patho- logical irritation is probably generally a direct one, but certainly also partly reflex ; and, indeed, there is no doubt that the same kind of spasm may be caused by direct as well as reflex influences — as partial traumatic and reflex epilepsy. Many kinds of spasm consist of motions that are always similar — many combined from a few, and sometimes from a great many. Spasms are partly the intrinsic element of the given disease, the thing of which the disease consists ; partly they are a symptom ; and then again they may be a local sign, that is, they may point directly to the seat, or point of origin, of the disease. Often we must deter- mine other phenomena (as paralysis, etc.) for the purpose of dis- covering the point of origin. With certain spasms, especially those that are paroxysmal and general, the condition of self-consciousness at the time of the attack is of great diagnostic importance. Also we often have to consider the general mental condition, for many cases of convulsions lead us over into the territory of psychiatria. We now only mention the diflerent kinds of spasm : Trembling (tremor) consists of unproductive motions, often only to \>% seen by close observation, rapidly following one another. We EXAMINATION OF THE NERVOUS SYSTEM. 531 recognize them partly by observing the limb when at rest, partly when the hand is stretched out, or is holding a glass of water, and also by the handwriting. Graphic representation shows that the different forms of tremor differ in the form, frequency, and rhythm of the contractions. Trembling is physiological with bodily exertion, and with mental excitement, and it is sometimes constant, even with persons in good health. Upon the borders of the normal stand the tremors of the aged, tremor senilis. Alcoholic tremor, especially of the extremities and tongue, occurs with the passing away of the effects of the indulgence, or when it is declining; the tremor saturninus, the tremor which affects morphia- habitues when they abstain from it, that with morbus Basedoivii (generally very fine, rapid movements, sometimes also coarser con- tractions), and the tremors of nervous individuals, are the finer kinds of tremors. The tremor of paralysis agitans (especially of the extremities, but also of the head) manifests itself by a symmetrical rhythm, by a very characteristic position of the hand and fingers (" pill-maker "). It ceases when voluntary motions are made, especially if vigorous, but sometimes even when writing. On the other hand, the intention tremor occurs only with voluntary motions, in that toward the end of the motion it becomes stronger ; it stops as soon as the patient is quiet. It is an important symptom of multiple sclerosis ; it occurs, however, as tremor mercurialis. In many cases it is difficult to distinguish it from ataxia (which see). Between "tremor" and "clonic spasms " it is not possible to draw a precise distinction. The designation shaking-spasm is used for the transition forms of both. The prominent transition forms of this kind of tremor are those shiverings which begin with fine tremors, becoming constantly coarser with cooling off, and with rapidly-rising fever ; with hysteria there are conditions that resemble tremor. Likewise is to be mentioned the quaking which occurs with marked active spasm of the legs, as especially takes place sometimes after mechanical irri- tation ; foot clonus, particularly, often shows these transition forms very beautifully. In the foregoing we have not distinguished between the tremors of spasm and those of paralysis, because in regard to most kinds of tremors it is not yet clear to which of the two classes they belong. 532 SPECIAL DIAGNOSIS. For further points regarding this subject, see the several special works. Fibrillary contractions are contractions in individual coarse or fine bundles of muscular fibres which do not produce motion in the limb. In individual cases, however, we can observe a very diminutive motor effect. They are easily recognized by observing the muscle. In health they are often excited (with great individual differences) by the cooling of the skin ; but they also occur with atrophic paralysis, and very abundantly, and hence are not without diagnostic value, in spinal, progressive muscular atrophy. Clonic spasms rarely occur by themselves, but they more frequently accompany epileptic and other attacks of convulsions (see below). We sometimes observe them isolated in local affections of the cortex of the brain (see below, Partial Epilepsy) ; but also in other localized cerebral diseases, and in myelitis transversa, as single brusque bending motions of the legs, generally both legs together — probably of reflex origin. Tonic spasms, by themselves, occur most frequently in the form of active spasms (see above, p. 494), in lesions of the pyramidal tracts, and with hysteria. Moreover, they occur in tetanus, and in these forms : as masseter spasms in trismus ; this latter also by itself; as rigidity of the face, risus sardonicus ; extension of the vertebrae with rigidity of the neck and opisthotonus, and in spasms of the legs in the state of extension. Moreover, tonic spasm of the muscles occurs when first moving them after long rest, and as a prolonged condition after voluntary contractions in myotonia congenita; also, occasionally, as bending and adduction spasms of the arm and hands in tetanus ; as the tonic form of writers' cramp, although seldom purely as such, generally with slight contractions mixed with tremor ; and in the first stage of epileptic attacks (see below). Epileptic spasms, in genuine epilepsy, generally pursue a typical course : after certain subjective warnings (aura), or without these, there is a sudden loss of consciousness, ushered in with a cry, and imme- diately the patient falls down. Then there is a short tonic spasm of all of the voluntary muscles (more especially of the extensors of the arms, legs, vertebrae, but the hands are closed and the thumb is grasped by the fingers) ; then there is clonic spasm, with frightful vigor, of all the muscles of the body, including the muscles of the eyes, tongue, etc. ; after a few minutes there follows, either gradually or EXAMINATION OF THE NERVOUS SYSTEM. 533 suddenly, a period of relaxation with continued loss of consciousness — post-epileptic coma. During the attack, the tongue is often bitten, involuntary discharges take place, and, from the interference with respiration, marked cyanosis often occurs. It is very important to make a differential diagnosis between genuine epilepsy and symptomatic, which often very much resembles the ■former. Tiie latter occurs in all manner of anatomical diseases of the brain (regarding partial epilepsy in disease of the cortex of the brain, see below), as traumatic and reflex epilepsy, as epileptiform spasms in uraemia, these latter also as eclampsia gravidarum. There occur in children, upon slight provocation, epileptiform or eclamptic attacks during dentition, from intestinal irritation from worms, in the beginning of acute infectious diseases, as scarlet fever, measles, pneumonia, and in the beginning stage of acute poliomyelitis and encephalitis. It is generally very difficult to form an opinion regarding spasms from the anamnesis. Here we must be very cautious in arriving at a diagnosis. Partial epilepsy (Jackson's or cortical). In this there are epilepti- form convulsions which are limited to an extremity or to the facial mus- cles of one side. They are an almost infallible sign of disease located in a corresponding part of the cortex of the brain, and also are connected with or followed by paresis, increased tendon reflex, and sometimes by disturbance of the sensibility of the affected limb (monoplegia). The convulsions may be unilateral or even general, but they manifest themselves as originally partial epileptic, by beginning in the affected limb. Hysterical convulsions (attacks of hystero-epilepsy) sometimes have a great likeness to epilepsy ; yet almost always the motions may be distinguished in that they are more wide-reaching [and tumultuous], and more than all by the fact that they partly manifest coordinated motions, or remind one of them. Motions such as we see made by a person senselessly furious, or an unruly child, are not at all infre- quent ; especial manifestations are flits of laughing, shouting, weeping, coughing. Tbe most important mark of difference between hysterical and epileptic spasms, in doubtful cases, is that in the former there is almost never an entire loss of consciousness ; very often it remains quite 534 SPECIAL DIAGNOSIS. intact; and the absence of involuntary discharges (urine, stool, in males also of semen), as is not infrequent with genuine epilepsy ; lastly, the tongue is not bitten, and there is reaction of the pupil during the attack. G-ross [severe] hysteria. The attack of hystero-epilepsy may pass into a second stage ["phase des grand mouvements " of the French] of contortions, and excessive movements — among others, especially' that of the "arc de cercle " (head bent backward, boring into the pillow; the trunk bent as in opisthotonus) — -which may last for hours, are characteristic manifestations ; then there may follow a third stage, which is either quiet or may be excited (delirium) — tho stage of hal- lucinations and of emotional attitudes. The stages may occur singly. Besides what has already been described, it is important for diag- nosis that there should be present hysterical signs (stigmates hys- t^riques), manifested by the patient in the form of sensory anaesthesia, especially a concentric limitation of the field of vision ; also, hemi- ansesthesia; hysterogenous zones — that is, hypersesthetic regions of the body (ovaries, testicles, circumscribed portions of the skin), the irritation of which by pressure sometimes causes an attack or is asso- ciated with one. Constrained positions and motions, ^o the former belong the drawing of the head or trunk to one side, so that the patient assumes the side position in bed (sometimes with the eyes fixed: deviation conjugee occurs with the other manifestations); to the latter belong the involuntary forward, backward, and movement in a circle (manegegang). Both phenomena indicate a lesion of the vermiform process ot the cerebellum or of the median crus cerebri. With the constrained motions, or the " coordinated spasms," are also to be reckoned the gross motions previously mentioned under hysteria, as laughing, screaming, etc. Chorea minor. This is the designation given to the very rapid, lightning-like, entirely irregular muscular contractions, which, on the one hand, produce restlessness of the limbs and of the face ; and, on the other, disturb and divert the regular voluntary motions. They afiect the head (face, tongue, masticating muscles) of the trunk, espe- cially of the shoulders and legs, and sometimes the glottis. They occur in all degrees of severity, from single weak jerks to the most extravagantly confused strong movements (folie musculaire). If the EXAMINATION OF THE NERVOUS SYSTEM 535 subject is embarrassed, especially if observed, frequently the contrac- tions are increased. During sleep (but there may be difficulty in getting to sleep), the convulsions entirely disappear, excepting in par- ticularly severe cases. Chorea minor is not often purely one-sided, or hemichorea. Hemi- chorea may occur either as the forerunner or as the result of hemi- plegia, when it indicates a lesion of the posterior section of the inner capsule or of the optic thalamus. Especially frequent are choreic or athetose motions (which see), with declining acute encephalitis in children (poliencephalitis, Striimpell) in the paralyzed limbs. Quite recently, Flechsig has found both internal segments of the lenticular nucleus diseased in several cases of severe general chorea with delirium. Athetosis [described by W. A. Hammond]. This designates pecu- liar, slow, and at the same time tolerably energetic motions, particu- larly of the hands, arms, shoulders, but also anywhere else. If the motions are somewhat quicker than, but resembling, those of chorea, they then form a transition to the latter. Athetosis, as well as chorea, is a disease in itself; hemiathetosis is observed in the same cerebral locations as hemichorea (which see). In the cerebral paralyses of children it is more frequent than hemichorea. Associated movements are abnormal involuntary motions, which take place with the performance of voluntary motions by the contrac- tions of muscles in regions which have nothino- to do with the motions desired. We find them especially in cerebral, but also in spinal, and even in peripheral, paralyses ; hence they cannot be made use of as an aid in diagnosis. Sometimes we see them in muscles of the same limb as that put in motion. Particularly frequent is a dorsal flexion of the foot when the leg is drawn up to the abdomen, as in hemiplegia, spastic spinal paralysis (Striimpell), or in unilateral affections, as synonymous associated movements of the sound side with those of the diseased side, or of the diseased side with the sound side. Catalepsy, cataleptic rigidity, fiexibilitas cerea, is a peculiar in- crease of the tonus of the voluntary muscles, of such a character that the limbs not only off"er only a very slight or feeble resistance in passive motion, but also remain in a given position, even when it is opposed to gravity, and this sometimes for an hour and more at a 536 SPECIAL DIAGNOSIS. time. Catalepsy very rarely occurs in anatomical diseases, as tumors of the brain and meningitis ; more frequently in hysteria, especially in hypnosis, and in certain psychoses, as in melancholia attonita. 7. Voluntary Muscles, their Innervation, their Function, and the Diseases that Disturb Them. 1. Muscles of the eye (see Examination of the Eye). 2. Muscles of the face, supplied by the N. facialis : M, frontalis draws up the brow and causes wrinkles across the forehead. M. corrugator supercil. draws the skin of the forehead over the roots of the nose into folds. M. orbicularis palpebrarum closes the eyes. M. depressor nasi seu dilator narium dilates the nostrils. M. levator lab. super, (propr.) and M. levator anguli oris lift up the upper lip and the corner of the mouth. M. zygomaticus major raises up and draws out the angle of the mouth. M. buccinator makes the cheeks tense, holds open the pouch of the cheek when eating, prevents the distention of the cheeks when blowing or when whistling (to a slight extent supplied by the trigeminus ?). M. orbicularis closes the mouth ; is the chief factor in whistling, pronouncing the consonants b, f, m, p, v, w, the vowels o, u (greatly assisted by the levator menti). Paralysis of the facial: The forehead is smooth and remains so upon the affected side when the effort is made to wrinkle it ; the eye remains open and cannot be closed (lagophthalmus) ; the naso-labial furrow is obliterated ; the angle of the mouth hangs down ; the mouth, and often also the tip of the nose, are drawn toward the sound side ; the effort to expose the teeth, as in cleansing the teeth, makes very plain the defective elevation of the upper lip and distortion of the mouth. When blowing, the affected cheek is distended ; on attemptr ing to whistle, the lips are drawn to the sound side ; if the paralysis is unilateral, the labials are generally, except in recent paralyses, pro- nounced distinctly ; if bilateral, they cannot be. (See further. Soft Palate, Hearing, Taste.) 3. Muscles of mastication, tongue, soft palate, pharynx. Mm. temporalis and masseter (N. trigeminus branch III.) draw up the lower EXAMINATION OF THE NERVOUS SYSTEM. 537 jaw and press the teeth together. Mm. pterygoidei eifect the side- ways movement (rotation) of the lower jaw. Paralysis of these muscles will be recognized by the absence, upon one or both sides, of these motions; bilateral paralysis of the temporalis and masseter, by the dropping down of the lower jaw. Palpation below the zygoma detects possible paralysis arid atrophy of the mas- seter ; above the zygoma, paralysis and atrophy of the temporalis by its laxity. We pass over the complicated arrangement of muscles which draw down the lower jaw, because their paralyses have not yet been suffi- ciently studied. The tongue is stretched out — that is, it is drawn forward by the two Mm. geniohyoglossi, which act somewhat convergently, and is •drawn back chiefly by the two Mm. styloglossi ; M. hypoglossus principally draws it down. These, and the inner lingual muscles, produce the changes in the form of the tongue. Unilateral hypoglossal j^aralysis : When the tongue is protruded it deviates toward the paralyzed side, because the genioglossus of the sound side pushes it that way. Bilateral paralysis (generally atrophic) causes diminution of all the motions, even to their complete oblitera- tion ; difiiculty in mastication and swallowing ; and in the formation •of the consonants c, d, g, k, 1, n, r, s, sch, x, z, and of the vowels i [e], e [a]. Unilateral paralysis produces all these disturbances to a slight degree, and they become less with habit. Atrophy, seldom unilateral, will be recognized by diminution in the volume, by wrinkles, and sensible thinness. The soft -palate derives its principal innervation from the spheno- palatine ganglion (N petrosus superfic. maj., and from the ganglion geniculi of the facial nerve. The fifth and the tenth and eleventh ganglia also take part). Examination: by inspection and phonation — i. e., by observing the voice and inspection, and by the swallowing of fluids. Unilateral paralysis of the soft palate in paralysis of the facial located high up, shows deviation of the uvula toward the healthy side and depression of the arch of the paralyzed soft palate, both more distinctly in phonation. In the passive state, the relaxed uvula may hang to one side, even when there is no paralysis. Sometimes the speech is nasal, and fluids may escape from the nose in attempting to 538 SPECIAL DIAGNOSIS. swallow. Both symptoms are due to ineiFectual closure between the nose and the mouth : pharyngeal space. In bilateral paralysis, espe- cially with bulbar paralysis and as diphtheritic paralysis, the soft palate hangs down without any power to contract ; and nasal utter- ance and the difficulty in swallowing are increased. The 'pliaryngeal muscles (N. X.-XI.), with the aid of the tongue, accomplish the act of swallowing. When they are palsied, this act is disturbed, and, from the lack of vigor and promptness in passing the food along, it easily enters the larynx : thus, there is coughing in connection with swallowing. But if the patient is unconscious, or there is at the same time disturbance of the sensibility of the larynx (N. laryngeus super, vagi), there may be no cough. 4. Laryngeal muscles. The muscles supplied by the laryngeus super, vagi are : depressors of the epiglottis ; Mm. thyreoepiglott., aryepiglottici (paralysis : difficulty in swallowing), and the M. crico- thyreoides, tensors of the vocal cords by movement of the thyroid cartilage toward the cricoid cartilage (paralysis : hoarse voice). N. laryngeus inferior (recurrent branch of the N. X.-XI.) : Mm. crico arytsenoid. postici dilate the glottis (bilateral paralysis: inspi- ratory dyspnoea, sometimes of the severest kind, with the voice unchanged or very slightly impure). Mm. thyreo-arytsenoidei are the most important tensors of the vocal cords (paralysis : loss of voice »and hoarseness). Musculi arytaenoidei transversi et laterales : they narrow the pos- terior portion of the glottis (in isolated paralysis : the voice is very hoarse, as in catarrh, hysteria). Mm. crico-arytsenoidei laterales : in connection with the preceding they narrow the glottis. Complete paralysis of the recurrent : [a) unilateral (compression by aortic aneurism, carcinoma of the oesophagus, mediastinal tumors ; bulbar paralysis) : voice hoarse, easily changing to the falsetto, or little or even not at all altered ; (h) bilateral (rare) : complete aphonia, inability to cough. (Regarding the laryngoscopic examination, see Appendix.) 5. Muscles of the throat and neck. M. sterno-cleido-mastoideus (N. XI.) draws the head and face toward the opposite side and looking upward ; both together somewhat bend the neck and push the head forward : or, if the head is the fixed point, they lift up the sternum or the clavicles, as in emphysema. The test of their function and EXAMINATION OF THE NERVOUS SYSTEM. 539 recognition of their paralysis and spasm is easy. When both are paralyzed, the neck, and with it the head, incline backward. The muscles that stretch, bend, twist the neck or the head (nervi cervical. I.-IV.), maintain the head in the upright position. If they are weak or paralyzed, it is impossible to hold the head up : it falls forward, if it is not exactly balanced. This happens, if the head is too heavy (hydrocephalus). Defective mobility of the head is more frequently caused by spasm or inflammation (stiff-neck, caries of the cervical vertebrae), than by paralysis. 6. Muscles of the trunk. Muscles that move the vertebrae (inner- vated by Nn. dorsales and lumbales). Lumbar extensors and extensors of the lower vertebrae : M. erector trunci (sacro-lumb. et longissim.) with bilateral action. Bending forward : the abdominal muscles. Bending of the lower vertebrae sideways : quadrati lumborum. Twisting the trunk : semispinalis and multifidus. Paralysis of the erector trunci : (a) bilateral : the body is bent backward (lordosis of the lumbar, kyphosis of the upper thoracic, vertebrae, in such a way that the latter overhangs the sacrum ; a plumb-line held from it falls behind the sacrum) ; the pelvis is tilted up, the knees are bent, (h) Unilateral : in standing, a scoliosis of the lower vertebrae is convex toward the diseased side ; on the other hand, there is a compensatory scoliosis of the thoracic vertebrae. Paralysis of the abdominal muscles : marked lordosis of tte lumbar and lower thoracic vertebrae, compensatory kyphosis of the upper thoracic vertebrae, but these are exactly vertical over the sacrum. There is marked inclination of the pelvis. In paralysis of the extensors, it is impossible to place the bent trunk in an unsupported upright position ; it is accomplished by placing the hands upon the knees and thighs. If, in addition, there is paralysis of the glutei, especially of the gluteus maximus, then the patient can only rise from the floor by first getting down on " all fours," then pushing himself up with the hands from the floor, in order immediately to put them upon the knees and thus further support the body: this is his way of standing up. In paralysis of the flexors, it is impossible to sit up from the dorsal position without assistance. Opistliotonus is produced by spasm of the extensors, emprosthotonus 540 SPECIAL DIAGNOSIS. by spasm of the flexors ; unilateral spasm of the extensors causes scoliosis, convex toward the diseased side. 7. Muscles of the thorax., diaphragm^ and abdomen. Here belongs most of what has already been said upon p. 81fF. There we learn regarding the ordinary and the auxiliary muscles of inspiration and the auxiliary muscles of expiration. Paralysis of the diaphragm (phrenic nerve, chiefly from the fourth nerve of the. [deep] cervical plexus) in perfect quiet, may be entirely compensated by the thoracic muscles of inspiration ; but otherwise every increased requirement for breath produces marked dyspnoea ; and this is exactly the case with, respect to the vicarious action of the dia- phragm when there is defective thoracic breathing. It will be under- stood, then, that paralysis of the auxiliary muscles of respiration has only a bad outlook for the breathing when it comes to such a pass that they must be called upon (see p. 96). Tonic and clonic spasm of the thoracic muscles of inspiration in tetanus and epilepsy at once cause severe cyanosis; in the first disease it may be fatal ; also tonic spasm of the diaphragm interferes very much with breathing and may be dangerous to life. Clonic spasm of the diaphragm (singultus, hiccough), in a mild form, is not infre- quently seen ; if it continues for hours and days, as it sometimes does in abdominal and cerebral afi'ections, then from the disturbance of the rest, and severe pain along the line of insertion of the diaphragm, it may bring about a serious condition. By the contraction of the abdominal muscles the anterior abdominal wall is flattened, and thus the abdominal cavity is lessened ; by the simultaneous contraction of the diaphragm there arises " the abdominal pressure," which is important in defecation and emptying the bladder, and the expulsion of the child in labor. The role of the rectus and obliquus externus, as flexors of the vertebral column (when those of one side act alone, the trunk is bent laterally forward over on one side), has been already mentioned, as v/ell as their function in active expi- ration. 8. Muscles of the upper extremity. (a) Muscles which move the shoulder-blade or fix it : M. trapezius (N. accessorius for the most part) rajses the shoulder-blades and draws them toward the middle line, both of these by the middle and posterior par.ts. The former chiefly lifts up the acromion, the latter the inner EXAMINATION OF THE NERVOUS SYSTEM. 541 upper angle. With its anterior clavicular portion it inclines the head obliquely backward and at the same time lifts up the acromion. Paral- ysis of the trapezius permits the scapula to drop down, to be drawn away from the middle line, and at the same time to turn round so that its apex moves toward the spinal column (because the levator scapulae holds up the upper inner angle). The shoulder sinks downward and forward ; there is diflficulty in raising the upper arm, because the scapula is not so perfectly fixed, and shrugging of the shoulders is restricted. From what has been said the test of its function is easy. M. levator anguli scapulae (N. dorsalis scapulae from the cervical plexus) lifts up the scapula by its inner upper border, with the ten- dency to turn the right scapula in the direction of the hands of the clock, and the left in the opposite direction. Its paralysis can only be recognized when the trapezius is paralyzed at the same time, by the complete inability to lift the shoulder. Mm. rhomboideus major et minor (N. dorsalis scapulae) draw the shoulder-blades toward the spinal column, and thus lift them in the same way as t^e levator scapulae and turn them in such a way that the lower angle of the scapula is nearest the spinal column. They fix the scapulae, especially in backward motions of the arms and legs, and when lifting weights. Paralysis [of these muscles] moves the scapula, and particularly its lower angle, away from the spinal column. Moreover, it is difficult to detect paralysis of these muscles when the trapezii are normal. M. serratus anticus (N. thoracicus longus seu posterior, Henle, from the brachial plexus) turns the scapula in such a way that the lower angle moves outward, draws it somewhat away from the spinal column, and presses it against the thorax : it is an important fixation-muscle of the scapula when the arms are lifted. When the scapula is fixed (by the rhomboidei) it is a muscle of inspiration. Paralysis of the serratus, in the condition of rest, causes a slight elevation and rotation of the scapula, so that the lower angle stands out a little from the thorax and is (slightly) drawn toward the spinal column. The arm can be lifted up to the horizontal sideways : this moves the inner border of the scapula close up to the vertebral column. It can only be raised higher by fixing the scapula in the same way as would be accomplished by the serratus. When the arm is moved forward, the inner border of the scapula stands out like a wing. 542 SPECIAL DIAGNOSIS. (b) Muscles of the trunk and of the scapula [attached] to the upper arm : M. deltoides (N. axillaris at the infraclavicular portion of the brachial plexus) ; the middle portion extends the arm outward from the body, the anterior portion raises it obliquely forward, the posterior por- tion obliquely backward. It raises it as far as the horizontal, beyond which, the arm being fixed by the deltoid against the scapula, it is raised by the rotation of the scapula. Paralysis is easily recognized : If the muscle is relaxed, there is subluxation of the humerus, par- ticularly if at the same time the supraspinatus is paralyzed ; if the deltoid is atrophied, the contour of the bones at the shoulder shows plainly. M. supraspinatus (N. suprascapularis from the supraclavicular por- tion of the brachial plexus) assists the deltoid in raising the arm out- ward toward the front, rolls it inward, it is also said to hold the head of the humerus in its socket when the arm is raised. Mm. infraspinatus (N. suprascapularis) and the teres minor (N. axillaris) roll the upper arm outward. M. subscapularis (N. subscapularis from the brachial plexus) is a rotator inward. Paralysis of a rotator allows the arm to rotate in the opposite course ; in testing, we first make passive rotation, and letting the arm fall, allow it actively to do the same thing, while we oppose the rotation. M. pectoralis major (N. thoracic, anti. of the brachial plexus) ad- ducts the upper arm ; when the arm is raised up, it moves it forward in the horizontal plane, draws the arm down when it is raised. Test: Have the upraised arm moved forward in a horizontal plane while we offer resistance. M. latissimus dorsi (N. thoracico-dorsalis from the brachial plexus) draws down the arm when it is raised up in exertion, [it depresses it], and draws it backward. When the arm hangs down it draws it back- ward and inward [toward the buttock]. Test: The arm is raised to the horizontal and the effort is made to lower it while the movement is opposed. The teres major materially assists the latissimus ; it is at the same time a rotator inward. Mm. coraco-brachialis (N. musculo-cutaneous of the median) and anconeus longus (cap. long, tricipitis ; N. radial.), when the arm is EXAMINATION OF THE NERVOUS SYSTEM. 543 drawn down by the latissimus and pectoralis, hold the head of the humerus up and firmly in its socket. (c) Muscles from the upper arm to the forearm : M. triceps (N. radialis) is an extensor of the forearm. M. brachialis internus (N. musculo- cutaneus) is a simple flexor. M. biceps (N. rausculo-cutaneus) flexes and supinates. M. supinator longus (N. radialis) flexes and pronates. This is proved by having the modeVately pronated forearm flexed while the movement is resisted. If it is healthy, it rises up like a hard roll on the outer side of the elbow-joint. We here next mention the pronators : the pronator teres (it is at the same time a flexor) and quadratus, both supplied by the median nerve. (c?) Muscles which extend from the condyles of the humerus and the bones of the forearm to the hand and fingers, and the small mus- cles of the hand : ^ The extensor carpi radialis longus and brevis (N. rad.) + extensor carpi ulnar. (N. rad.) are elevators of the hand. The flexor carpi radialis (N. median) + flexor carpi ulnaris (N. ulnar.) are volar flexors of the hand ; the palmaris longus (N. median.) assists in this action. The extensor carpi radialis longus -{- flexor carpi radialis adduct the band in the direction of the radius. Extensor carpi ulnaris + flexor carpi ulnaris adduct the hand on the ulnar side. If the exten- sor carp. rad. long, acts alone, it raises the hand obliquely on the radial side, as the ext. carp. uln. does on the ulnar side. Paralysis of the extensors of the hand (or especially lead-paralysis, also sleep-paralysis of the N. radialis) allows the hand, when the fore- arm is pronated, to hang loosely down. Paralysis of the abductors and adductors and also paralysis of the extensores c. radial, long, and carpi ulnaris alone, produces oblique position of the hand [paralysis from the former giving a position opposite to that of the latter]. We test the individual movements by successively opposing them. M. extensor digitorum (communis indicator, exte. digiti V,, all from the N. radial) extend the first phalanges. M. flexor digitor. coram, sublim. (N. median.) flexes the middle phalanges; M. flexor digitor. coram, prof. (N. media, the two ulnar bellies from N. ulnar.) flexes the terminal phalanges. Mm. inteross. dors, 4- volares (N. ulnar.) and Mm. lumbricales (N. med. and ulnar.) 544 SPECIAL DIAGNOSIS. flex the first phalanx and at the same time extend the middle and terminal phalanges. Mm. inteross. dors, alone abduct (spread apart), volares alone adduct the (middle : third) finger. Movements of the thumb : extensor pollic. long. (N. rad.) is essen- tially an extensor of both phalanges ; extens. poll. brev. (N. rad.) is an extensor only of the first phalanx. Adductor poll. long. (N. rad.) abducts the metacarpus. Flexor poll. long. (N. med.) flexes the term- inal phalanx. At the thenar are the opposing muscles — abductor poll, brevis, outer head of the flexor brevis, and the opponens poll, (all from the N. med.). Adductors: adductor poUicis and the inner deep head of the flex. brev. (both N. ulnar.) These two and the abductor brev. flex the first and extend the terminal phalanx. The adductor, flexor, and opponens act at the hypothenar, their names indicating their action. All are innervated by the N. ulnaris. Chai'acteristic positions of the hand and fingers : 1. In paralysis of the ulnar there is the clawing, clutching hand, 7nain en griff e : the first phalanges are extended, the middle and terminal ones flexed (paralysis of the interossei), the thumb hangs helpless over the hand (paralysis of the adductor) ; the fingers are easily spread out (action of the extensores digit.). Thus the interosseal spaces on the dorsum are deepened, likewise the groove between I. and II. metacarpal bones (atrophy of the adductor pollicis, deep head of the flexor brevis and inteross. dorsi I ). The hypothenar is atrophic. 2. In paralysis of the thenar (deep median paralysis) there is the ape-hand : the thumb does not stand out opposing, but is parallel with, the other fingers. Paralysis of the extensors of the hand causes apparent weakness of the long flexors of the fingers, because the origin and insertion of the flexors are brought near together by the flexion of the hand at the wrist. Hence, we must passively extend the wrist and then test the flexion of the fingers. For the same reason it is necessary, when there is paralysis of the long extensors of the fingers, to passively extend the first phalanx before testing the flexion of the middle and terminal phalanges. Examination. We observe the position of the hand for possible atrophy. Then we test extension, flexion, abduction and adduction at the wrist — sometimes all of these — by resisting these motions ; then the extension of the fingers; next the long flexors by "hooking" of EXAMINATION OF THE NERVOUS SYSTEM. 545 the fingers ; then let the patient make the separate motions of the interossei muscles ; flex the first phalanx with the middle and end phalanges extended ; then spread out and close the fingers ; test the muscles of the thenar and hypothenar by bringing the thumb and little finger into contact ; lastly, the examiner places his own index finger in the saddle between the thumb and the second metacarpus, while the patient makes simple adduction of the thumb, thus testing the power that is manifested. Pressure of the hand is a very prac- tical way of making a general test of the long flexors and the small muscles of the hand. For such paralyses as are not wholly diffuse, but rather confined to individual muscles or gr6ups of muscles, peripheral and certain spinal paralyses, it has value only as a preliminary examination. For various reasons we consider the dynamometer as an unnecessary apparatus and one that does not accomplish its purpose. It cannot be sufficiently insisted upon that in order to establish the diagnosis exactly in the upper extremity, and particularly in the hand, beside a clear conception regarding the location and physiological action of the muscles, there must be a knowledge of their innervation. We observe, especially, how the ulnar and median are distributed in the small muscles of the hand. The former innervates the hypothenar, interossei, the two ulnar lumbricales, and the adductors of the thenar, adductor pollicis, and the deep head of the flexor brevis ; the latter, the remaining muscles. In the hand, the radial only supplies branches to the skin. 9. Muscles of the lower extremity. (a) Muscles from the pelvis to the thigh : M. ileo-psoas (N. crural from the lumbar plexus) flexes the hip- joint ; it is assisted (and in the sense of pure flexion) by the action of tensor fasciae latse (N. gluteus super, from ischiadic plexus). In paralysis of the psoas, or of this and the tensor fasciae, it is not pos- sible to flex the thigh either in walking or in bed ; paralysis of the tensor fasciae alone permits the pure psoas action to take place : flexion with rotation outward. M. gluteus max. (N. glut, inferior or plexus ischiad.) extends the thigh ; when the thigh is fixed, it brings the pelvis to the horizontal position, and thus the trunk to the vertical (into the upright from the stooping posture, standing upright, etc.). When it is paralyzed, there 35 546 SPECIAL DIAGNOSIS. is the peculiar kind of action in rising from the floor described on page 539, with paralysis of the extensors of the trunk. M. gluteus medius (N. glut. sup. from the plexus ischiad.), abduc- tor ; M. gluteus minim, (same nerve) rotates the thigh inward. The three glutei are the most important supporters of the pelvis. M. piriformis (plex. isckiad.), M. obturator, int. (N. ischiad.), M. gemelli (N. ischiad.), M. obturator exter. (N. obturat., plex. lumbal.), M. quadrat, femor. (N. ischiad.), are all, in reality, out-rotators. M. adductor long., brev.,magn., pectineus and gracilis (N. obturat., plex. lumb.), are, for the most part, adductors, at the same time partly flexors. The eff"ect of their paralysis is clear. (5) Muscles from the pelvis and the femur to the leg : M. quadriceps (N. crural.) extends the leg; its long head, the rectus, arises from the pelvis (anter. infer, spine), and hence acts with more power when the thigh is in a position of extension with reference to the pelvis. In paresis of the quadriceps, the leg (or pos- sibly both legs) in walking are frequently set forward, flexed more markedly at the knee-joint (the leg during the forward movement of the limb hangs vertically down), and this is true also when it is set down quickly, so that there is a sort of snapping of the knee-joint into the position of extension. The examination is best made by endeavoring to flex the limb when it is actively extended. M. sartorius (N. crural.) is probably chiefly an inward rotator of the flexed leg. Mm. biceps fem., semitendinos., and semimembranos. (N. ischiad.) flex the knee-joint ; the first rotates the flexed leg outward, the second inward. If the limb is powerfully extended by the quadriceps, then these flexors, as well as the gluteus max., act: they place the pelvis in the horizontal position (important in walking). (c) Muscles from the leg (or the condyles of the femur) to the foot and toes : M. gastrocnemius, soleus, plantaris (N. tibial.) are extensors ; that is, are plantar flexors of the foot, and, at the same time, adductors of the extended foot. Mm. peroneus long, and brev. (N. peroneus) are extensors (chiefly the first) and adductors of the foot, lift up the outer border of the foot. In paralysis of the peronei muscles (by " peroneus-paralysis " we mean paralysis of the whole peroneus nerve : see below, under M. tibialis EXAMINATION OF THE NERVOUS SYSTEM. 547 antic.) ; the foot in extension, as well as flexion, stands in the position of adduction and the outer border of the foot is deeper ; the foot becomes flat. It is not easy to test the activity of the peronei : we must first show the patient the movements of abducting and lifting up the outer border of the foot by passive movements, and then have him repeat them ; besides, we have the patient extend the foot : in paralysis of the peroneus longus decided adduction then takes place. M. tibial, ant. (N, peroneus) flexes ; that is, dorsally flexes and adducts the foot ; M. extensor digit, comm. and extens. halluc. long. (N. peron.) flexes and adducts the foot, extends the toes. Paralysis of the dorsal flexors causes the point of the foot to drop when the foot is lifted from the floor. If the peronei are likewise paralyzed (pero- neal paralysis ; that is, paralysis of the peroneus nerve), then the foot is lax at the ankle-joint ; the point of the foot hangs down, with inclination to adduction. In walking we observe that the foot, as it is raised from the floor, makes a peculiar shuffling motion inward, and it is set down in a fumbling manner. Persons with unilateral, isolated peroneal paralysis are always inclined to take a longer step with the disabled limb in order to obtain the sweeping motion required for the awkward placing of the foot upon the floor. M. tibial, postic. (N. tibial.) is an adductor. Mm. flexor digitor. comm. long, and brev. (N. tibial.) are flexors of the middle and terminal phalanges of the toes ; Mm. interossei externi interni (N. tib.) are flexors of the first, extensors of the middle and terminal phalanges — interossei externi. [The outer three muscles are abductors of the second, third, and fourth toes, respect- ively, Avhile the first is an adductor of the second toe, and assists the plantar interossei.] Paralysis of the interossei causes a peculiar kind of claw-position exactly analogous to that of the fingers (see p. 544). M. extensor halluc. longus (N. peron.) extends the first phalanx of the great toe ; Mm. adductor, flexor brevis, abductor hallucis (N. tib.) act essentially in accordance with their names : they produce simul- taneously flexion of the first and extension of the terminal phalanx. Paralysis of the flexor of the great toe hinders one in walking, but especially in springing. 548 SPECIAL DIAGNOSIS. Disturbances of Speech (Lalopathy). I. Dysarthria and Anarthria. Bj these expressions we understand those disturbances of speech in which we see it altered in the same way as the activity of a joint is distributed as to its motility : by paresis, paralysis, trembling, spasm, and even ataxia of the vocal muscles. Unilateral paralysis of the muscles of speech occurs in unilateral affections of the pyramidal tract above the medulla oblongata, or of the cortical centre of the motor speech muscles ; likewise in peripheral paralysis of the hypoglossus and facial nerves. At first the speech is decidedly disturbed ; if these affections continue, there occurs a considerable improvement in the speech, as if it were re-acquired by practice. Bilateral paralyses generally occur from the bulbus of the oblongata (bulbar paralysis), and are then, if they are ganglion paralyses, degenerative-atrophic. It is rare to have bilateral speech paralysis from bilateral cortical or pyramidal lesion (pseudo-bulbar paralysis). We also rarely have a bilateral paralysis of the hypo- glossus or facial nerves of peripheral origin. For the muscles that produce speech and their innervation, see above, pp. 536 and 537. Depending upon which muscles are paralyzed, the disturbance of speech may vary with different letters, as mentioned at the above-named place. We recognize slight anarthritic disturb- ances of speech by requiring the patient to pronounce difficult words quickly, especially such as contain many consonants. Simultaneously with this disturbance of speech, the voice, from paralysis of the palate, is often nasal (or also a kind of " clod-voice "), or the voice has a monotone, or it is inclined to change to a falsetto. (Regarding swal- lowing, see p. 537.) Scanning speech : sounding like the speech of a rider of a horse that is trotting ; there are sharp changes of rhythm, unnatural pauses, sudden, " explosive," and then, again, snapping pronunciation of words. It is particularly characteristic of multiple sclerosis. Hysterical dumbness is a complete loss of speech and generally also of the voice, which occurs suddenly, and generally after an attack of hysteria, which lasts anywhere from days to years, and may suddenly disappear. The mobility of the tongue is normal. EXAMINATION OF THE NERVOUS SYSTEM. 549 II. Apliasic Disturbances, Disturbance of Graphic Communication {of Mimicking, of Singing). In order to understand these conditions it is necessary to make some explanations regarding the acquisition and use of speech, of writing, etc. Speech and its related functions have their foundation in the culti- vated memory, which is acquired by much practice, and for the mother tongue in childhood. We acquire such a development of the memory : 1. For speech in the narrow sense, and it comprises: (a) Cultivation of acoustic memory, acquaintance with the sound of words by hearing letters, words, and sentences spoken by others. (b) Cultivation of the motor memory, the complex motions used in speaking words, by imitating what we hear, trying to produce the same by correcting what the organs of speech produce until we attain the desired degree of perfection, and we treasure up [in the memory] the complex motions which are required for accomplishing what is desired. 2. The memory for writing comprises the cultivation of the optic memory, the acquisition of writing, and the complex motor writing- motions — again by imitating what we see. Likewise, we develop the comprehension and reproduction of music, a very individual faculty ; of mimicry, and of gestures, varying according to the nationality. Simultaneously with speech, or always somewhat later than imita- tion of what is heard, ideas develop — the concrete first; upon the foundation of the concrete, the abstract. Now, we suppose that the cultivation of the sound of words, and of their /orm, also the complex motions for speaking as well as writing them, these four to be accumulated each at its own place in the brain- cortex ; but that, presiding over all, yet not concentrated at one place, but as the result of innumerable functions, with numberless tracts connected with the cells of the brain- cortex, is the mind — intelli- gence. The representations of memory, and the complex motions (which are likewise representations of memory), can only functionate the nervous tissue — that is, can only be represented as tones, chords, a series of tones and chords of a violin. And in fact they can be innervated : 550 SPECIAL DIAGNOSIS. 1 . From the representations of the sound of words : these come from the periphery through the sense of hearing. If we hear the mother tongue (or any other language which we know), from the con- ception, we inwardly pronounce the words. 2. From the written representation : from the periphery — that is, from the organ of sight, if we read in a known language ; and from the conception, if we inwardly represent to ourselves the printed or written word. 2>. From the complex motions of speech : from the centre repre- senting the sound of words by virtue of the imitative instinct — repeti- tion ; and from the mental conceptions — independent utterance of thought. 4. From the complex motions of writing : from written words, by virtue of our imitative instinct — copying ; from mental conceptions — writing out the thought. But still, this is not all : the impulse to produce the complex motions of speech may come from the written or printed representation — we read aloud. On the other hand, the impulse to make the complex motions of writing may come from what is heard — we write from dic- tation. Further, while we are speaking or writing, there comes along the muscular sense an innervation (going in a centripetal direction) of the complex motions of speech or writing. We can make this clear if, with the eyes closed, we have someone else move our hand, as if writing a word : by this means, without other assistance, we can recog- nize simple words. In a still higher degree, also, in the active motions of writing and speaking the report of what is written or spoken — that is, the contractions of the muscles taking part in these acts, and the motions produced by them, go centripetally to the brain. The conceptions of musical notes seem to coordinate those of word- sounds, while the complex motions for producing speech and those which produce music (melody and rhythm) — that is, for singing — are co- ordinated with the larynx and mouth. The conceptions of musical sounds are intimately connected with those of word-sounds, and the com- plex motions required in singing are connected with those required in speaking. The intimateness of this association appears very distinctly in the fact that when a melody happens to come to mind we hum the words belonging to it; or, if the words come first, then we hum the EXAMINATION OF THE NERVOUS SYSTEM. 55X melody. Sometimes this humming is a purely automatic act, for both the text and the melody are articulated involuntarily together. But, again, sometimes the internal re-sounding follows the articulation or act of listening, and from this internal impression the articulation is first produced. Now, to these innervations there belong tracts of communication. Those conducting from the periphery to the " sensory " centres, leading to the centres for conceptions of sound and writing, we under- stand very well — the acoustic and optic nerves. Further, there must exist very manifold combinations between the conception and the four different centres themselves [mentioned on p. 550], but it is very difficult to obtain an exact presentation of these combinations. For instance, Kussmaul supposes that the tract from the centre of ideas to that for the complex motions of speech goes through the portion which takes note of the sound of the word ; hence he assumes no direct innervation of the centre of the complex motions of speech from that of ideas. Likewise, there is a dispute whether there is a direct communication from the written representation, or whether there is a communication with the centre for the complex motion of writing, etc., only through another centre. We will only bring forward one instance, for the sake of illustration. The following acts, done without understanding by persons in health as well as by sick persons — repeating, reading aloud, copying, or writing from dictation — make it plausible that direct communication exists between the sensory and motor centres, which, therefore, do not go through the centre for ideas. But there is no doubt that, in regard to this, there are very considerable individual differences, particularly dependent upon the degree of cultivation and the intelligence. Of course, we also understand the tracts which peripherally lead from the "motor speech- and writing-centres " — they go through the pyramidal tracts, the bulbar nucleus, to the individual motor nerves; and, finally, we have a general presentation, at least, of the tracts which pass centripetally from the muscles and joints. These very different qualities, acquired by practice, may each singly or several together be lost. When the organ of hearing remains per- fectly intact, the innervation from the periphery of the conception of the sound of words — that is, the ability to understand the words of one's native tongue — may be lost : there is word-deafness [" inability to 552 SPECIAL DIAGNOSIS. understand spoken words, although they are heard as sounds, while printed or written words are understood" — Billings], loss of intellectual perception of sounds. Even when the muscles of speech are perfectly normal, the ability to employ language, to express one's ideas through the innervation which results in the complex motions necessary to make use of the appropriate word in the native language, may be lost : motor or ataxic aphasia (or, as Kussmaul designates it, "the purest form of ataxic aphasia"). The arm may be in perfect condition, and yet we may not be able to write ; or the eyes may be intact, and yet we cannot read — agraphia, alexia. But since the different capacities under consideration — the understanding and formation of words, the understanding and production of writing — are in a very manifold way connected with^ each other, these disturbances almost never occur singly, but as a complex of disturbances. The expressions — '•'•acoustic amnesia'' for word- deafness, ^^ visual amnesia" for loss of intellectual perception of sounds — seem to us to be very useful, more so than the German designations formed upon a different principle. The only objection is that these expressions may be confounded with the idea of amnesia discussed later on (p. 554). The study of these things has proceeded from the observations of the disturbances of speech in the narrowest sense, that is, of speaking (Boilliaud, M. Dax, Broca). For this reason, and because all dis- turbances that come under consideration apply to speech in the broader sense (spoken and written speech, with reference to its comprehension and production), we class together, not at all incorrectly, all the conditions under consideration, by the designation of aphasia, aphasie disturbances. We only mention now those two manifestations which may be most sharply distinguished, while for all the details we refer to the special works (see, also, the "schema" of Lichtheim). 1. Word-deafness (Kussmaul), sensor?/ aphasia (Wernicke). The two ideas are not wholly identical. Special works show this more at length. The patient hears every word, but it sounds to him as any healthy person hears a word that belongs to a language which is wholly strange to him. The mother tongue, so far as the under- standing of the hearer is concerned, has become a foreign, unknown tongue ; also, ability to repeat and to write from dictation is wanting. EXAMINATION OF THE NERVOUS SYSTEM. 553 But, again, sometimes the understanding of writing may fail {alexia), and with it the ability to read aloud (see p. 558). But, in opposition to this, the power of volitional writing and to copy written characters, and further, volitional speech, is preserved. Nevertheless, we generally observe a disturbance in this also : very often the wrong words are used, because words that are related by sense or sound are, from unrestrained association, pronounced and strung together [parajjhasia) ; or, it may be distinctly noticed that the correct words are employed, but they are distorted by repetition of syllables, dropping of syllables, transposition of letters or syllables {literal ajyhasia, syllable- stumbling). Moreover, both conditions some- times have relation with amnesia ('' amnestic ojphasia,'' see p. 556). 2. Atactic ajyhasia (Broca's aphemia, Wernicke's, motor aphasia) consists in this, that the patient is unable to communicate his thoughts by words: he cannot name objects presented to him, although he promptly shows that he recognizes what they are in that he knows how to use them correctly ; at the same time there is dim- inution of the power to voluntarily write, or to write down what is heard (or write from dictation) : agraphia, with the exception of the ability to transcribe from copy, which is usually retained. Thus, in pure cases, there is perfect understanding of what is said and also of what is written, and hence there is neither word-blindness nor word- deafness. But in one respect the condition of most patients of this character is still somewhat obscure : with reference to the question whether they are able to produce the sound of the word mentally, to conceive of its sound, i.e., to mentally sound the word. According to Lichtheim, it is probable that in most or in all such cases this capacity has also been completely lost. But regarding this point it is very diflficult to form a positive opinion Avith respect to these patients. We cannot refrain from dwelling a little upon this question. (For further regarding the examination of patients with aphasia, see below.) We must confess that, in these cases, we have found that the method employed by Lichtheim, though it is ingenious, is very uncertain. Lichtheim, in order to determine whether the word which designates the given object is mentally correctly sounded, requires the patient to tell how many syllables there are in the word, or to press the hand as many times as it contains syllables. It is assumed that when an object 554 SPECIAL DIAGNOSIS. is presented to a patient there arises in his mind a conception of the sound. What designation does he think of ? I hold up a knife before him — does he think ''a pocket-knife" or "knife?" — a drink- ing-glass: " a drinking-glass " or a "glass?" — "handkerchief" or a "sackcloth?" I admit that there are substances about which there is no doubt, but one would be easily inclined to hold that the number of syllables was wrong, and yet the patient thought he had understood and had spoken correctly. Slighter forms of atactic aphasia manifest only a slight defect in the command of lano-uao-e : single words are omitted or sino;le words are defectively pronounced: "doltor," "dolner," for doctor; "lit," for lip; I am "benter," for better, etc. — that is, there is a literal ataxia, syllable-stumbling. But often the patient dwells upon only a few words, or only one, or even a single syllable, which is constantly employed for everything, as was the case with a patient reported by Striimpell, and whom we have watched for years, who could only say, "bibi, bi-bi-bi-bi-bi." We also have cases of paraphasia. An atactic-aphasic patient who, before becoming affected, was a good singer, may lose the power of singing as well as of speaking, and yet the "ea,r" may be retained: he hears Avhen he himself or some one else sings a false note. But though the speech may be lost, he may still retain the power to sing the melody of a song, and then it may happen that with the melody he may automatically articulate the words to which it belongs, although he cannot articulate them without the melody. In connection with this the reader is referred to p. 550 for what was said regarding the connection between the complex mo- tions of speaking and singing. There is another disturbance which plays an important part in all forms of aphasia and which presents a special group of symptoms : it is amnesia, amnestic aphasia. The patient presents a perfect picture of a person who is endeavor- ing to speak a foreign language which he only slightly or very imper- fectly understands. An object is held up before him : he is not able to name it ; he repeats it without understanding it, or he remarks : ^•Yes, certainly, that is the word;" or he hits upon the correct word through association, as upon the number of fingers held up before him by counting — "One, two, three, four — correct: four." . This amnesis manifests itself only with reference to certain kinds of words, as for EXAMINATION OF THE NERVOUS SYSTEM. 555 proper names, or chiefly for those representing the most concrete ideas (Kussmaul). Amnesia can be mixed with the different forms of aphasia ; the former may be very indistinct — even for a time, or continuously, may predominate over the aphasia ; but it also occurs in all possible conditions that do not at all belono; here : senile dementia, disease of the brain of all kinds, in convalescence from any very severe illness, etc. With Lichtheim we do not count these cases as aphasia. Localization of the aphasic disturbances. The exact localization of the two important centres of the understanding and use of language is one of the greatest attainments of recent times. The centre for the complex motions employed in the formation of words, the motor speech-centre, is located in the left third frontal con- volution (Broca) ; lesion of this point causes atactic aphasia. The centre for the formation of sounds, the centre for acoustic recollec- tions, is located in the left anterior central convolution (Wernicke). The right hemisphere has nothing to do with speech, except when the left side is mutilated, when it contains these centres instead of the left. Further, it is extremely probable, though it cannot be regarded as certain, that the centre for the conception of writing is to be looked for in the optic portion of the cortex of the occipital lobe (both sides or only the left ?), and the motor centre for writing in the left second frontal convolution. Hence, all these centres could lie within the given motor and sen- sory portions of the cortex : what relation they sustain to these we do not exactly know. We may always conceive of them as groups of cells which are brought into connection by tracts especially "smoothed" by repetition — that is, tracts with peculiarly slight resistance. Mode of Procedure in Testing for Aphasic Disturbances. We look for any possible aphasic symptoms whenever there is disease of the brain, but especially with any patient who has had an attack of apoplexy, and particularly when there is right-sided hemiplegia. It is evident that the examination of these patients is often inter- fered with, either because of their mental hebitude — dimness of 556 SPECIAL DIAGNOSIS. perception — or the inability to think, and the loss of memory which they exhibit. Those patients can only be exactly examined in whom the general effect of the injury has passed oiF; and the most interesting cases are those where, after the indirect collective symp- toms (see, respecting this, the last section of this chapter) have disappeared, an aphasic assemblage of symptoms remains behind as a unilateral disturbance. In the first place, we ascertain whether there is amnesia : if the patient can, we have him count, but further we test him by requiring him to name objects placed before him. If he fails to do this, we give him the name of the object and have him repeat it. If he can do so (either with or without apparent understanding), he is not atactic- aphasic, but amnesic. It is to be remarked that occasionally amnesia may simulate all : atactic aphasia, word-deafness, word-blindness, agraphia. We now proceed to test for possible word-deafness : by conver- sation, by requiring the patient to do something, as to touch his nose, or by directing him to take something in his hand — a knife, pocket- handkerchief, etc. We must be careful to avoid making any kind of gesture, also looking in the direction of the object named. Hereupon we look for signs of atactic aphasia : requiring him to speak and to repeat ; further for evidences of paraphasia, literal aphasia. If the patient is atactic-aphasic, then we must always make the effort to discover whether he has the internal sense of words (see above). After these things, we conclude the test by having him read (that is, read with understanding), read aloud, have him write, compose, write from dictation, copy. With persons who were formerly known to have had a musical ear, or could sing, it will be well to inquire whether they retain or have lost these powers, or, especially, what is the relation of the singing of the air and hearing the music to the understanding and speaking of the words that belong to it. The diagrams serve to display the mutual relations of the four cen- tres to each other and to the so-called " centre of perception." Many forms have been prepared, of which we mention those of Wernicke, Kussmaul, Charcot, Lichtheim. These diagrams are very useful for studying this subject (and we especially recommend Lichtheim's). They are a very excellent guide EXAMINATION OF THE NERVOUS SYSTEM. 557 for examination, for the clear understanding of the different functions, and as a stimulus to independent thought. But they do not exhibit the actual facts. As a rule, these can never be represented ; the individual differences are too great. Charcot rightly distinguishes persons as those in Avhom either the conception of sound or the con- ception of writing, or even the mechanical representation of speech or of writing, whichever may, be predominant, serves as a guide for speech and writing (and likewise for understanding as well as the production of them). We assume that in speaking as well as writing Fig, 166. Lichtheim's diagram of aphasia. A, centre for conception of the formation of sound (a A, conducting tract) ; 0, centre for conception of written characters (o 0, conducting tract); M, centre for the motions of speech {Mm, the centrifugal motor tract); E, cen- tre for the motions of writing [Ee, the corresponding motor tract) ; B, centre for con- ception of ideas. The arrows indicate the direction of innervation. the mental conception causes an innervation of the centre for sound first, and then this innervates the centre for the complex motions re- quired in producing the effect [of speech or writing] ; and further, that, when writing is seen, it must first innervate the centre for sound. Thus there results the understanding of the writing, and hence we can form a conception of what is the significance, to such a person, of the loss of the centre for the conception of sound : a lesion of the temporal lobe. Hence, in our opinion, if we add to Charcot's diagram the centre of cognitions, with its manifold relations, it is the most plausible : it includes all tracts that can possibly exist, and in most 558 SPECIAL DIAGNOSIS. cases of aphasia we must assume that in each individual, while in health, some of the tracts did not exist. Hence, it follows that, from the character of the disturbance, whose location we can know nothing of without an autopsy, much less locate simply from the symptoms, we must draw a conclusion regarding the tract from that one which the patient has made use of in health for the purposes of speech (in its widest sense) ; and further, from this we must ascertain what centres or tracts are now cut oif. It is plain from this how difficult it often is to judge of these things in an individual case. First we give Lichtheim's and then Charcot's diagram. After Lichtheim's we add his brief summary of the possible disturbances and their phenomena. This summary does not by any means give an idea of Lichtheim's work upon aphasia. Attention is here urgently called to the special works, particularly to the classical writings of Charcot, Wernicke, Kussmaul, or their pupils, and Lichtheim. 1. Interruption in M^ the centre for the conceptions of motion or the motor speech-centre (atactic aphasia). Lost : (a) volitional speech ; (h) ability to repeat ; (c) " to read aloud ; (d) " to write volitionally ; {e) " to write from dictation [e [in the figure], the internal conception of the word-sounds). Retained : (/) understanding of speech ; {g) " of writing ; Qi) ability to write from copy. 2. Interruption in A, the centre for the conceptions of the sounds of words (sensory aphasia). Lost : (a) understanding of speech ; (6) " of writing ; {p) ability to repeat after one ; {d) " to write from dictation ; (g) " to read aloud. Retained : (/) " to write volitionally ; {g) " to write from copy ; ^ (A) " to speak volitionally. EXAMINATION OF THE NERVOUS SYSTEM. 559 3. Interruption of 31 A. Intact : {a) understanding of speech ; (l>) " of writing ; ((') ability to write from copy. But there is (a) paraphasia ; (6) paragraphia (the same disturbance in voluntary writing) ; disturbance of the same kind in — (/) i"epeating after one ; ((/) reading aloud ; (A) writing from dictation. 4. Interruption of 3fB : modification of motor aphasia. Lost : {a) power of voluntary speech ; (5) " " writing; — as in atactic aphasia. But intact are not only (c) understanding of speech ; (t^) " of writing ; (g) ability to write from copy ; but besides (/) " to repeat what is said; (g) " to write from dictation ; (A) " to read aloud. 5. Interruption of Mm : modification of motor aphasia. Lost : All speech ; everything else intact. 6. Interruption of A B. Lost : (a) understanding of speech ; {h) " of writing. Disturbed : {c) volitional speech : paraphasia. Retained: [d) " writing; (e) ability to repeat what is said ; (/) " to read aloud*; [g) " to write from dictation. 7. Interruption of A a. Lost : (a) understanding of speech ; (h) ability to repeat what is said ; (c) " to write from dictation. Retained : (d) power of volitional speech ; (ej " " writing; 660 SPECIAL DIAGNOSIS. (/) understanding of writing ; {g) ability to read aloud ; (A) " to write from copy. We now introduce Charcot's diagram without further explanation. Apply Lichtheim's Case 1 to it : it will be seen that in those cases which show that representation of symptoms perfectly (Broca's aphasia), it must be assumed that Ji^is diseased; but further, that in Fig. 167. Mouth ? ' C 1!1 Charcot's diagram of aphasia. Drawn by Marie {Prog, med., 1883). The designa^ tions are the same as in Lichtheim's diagram. Tlie centres are represented as being in those centres of the cortex where they are to beloolied for; the light hatching around A and indicate the general acoustic and optical field in the cortex. Notice the double arrows upon all connecting lines between A, 0, E, M. Also notice the arrows pointing centripetally toward Mm and Ee, where the stimulation going to M and E cause the motions of speech and writing. In our opinion there is to be added the centre for ideas, which should have a twofold connection with A, 0, E, M. health the connection had passed from E to A only through M ; and still further, that for arbitrary innervation of -E' it must have previously gone from M, or from A through M. EXAMINATION OF THE NERVOUS SYSTEM. 561 As an addendum, we add here a few remarks upon the diagnostic value of the character of the writing : {a) Writing is the expression of thought, and in so far as this is the case it is a very fine test for recognizing psychical disturbances of all kinds. (See the text-books upon Psychiatria.) (h) As was mentioned above, agraphia belongs to the group of aphasic symptoms, and, in fact, it occurs in those forms which are completely analogous to disturbances of speech in the narrow sense : as total, as partial agraphia, as paragraphia, or literal agraphia. Likewise, it Avas previously stated that a sharp distinction was to be made between volitional writing, writing from dictation, and copying. Also, the loss of the capacity to form strictly grammatical sentences, to make a correct sequence of words (agrammatismus, akataphasia), shows itself in the writing also, or still better than, in speaking. (c) Motor disturbance of the right upper extremity manifests itself in many cases in a very characteristic way in the handwriting : the lifferent kinds of trembling, ataxia, the different varieties of writers' cramp. It is also worthy of note that patients with paralysis agitans very frequently write naturally because, as is well known, their trembling ceases when making intentional motions. The value of the handwriting for diagnosis here consists chiefly in the fact that we may recognize early slight disturbances (the contour wavy) : ataxia manifested by the strokes going beyond bounds, especially by the imperfections of the large letters. In paralytic dementia the writing, as well as the speech, is ex- tremely copious. This shows the psychical disturbances : delirium with exaltation or dementia ; there is agrammatismus, akataphasia, paragraphia, especially literal paragraphia in an extraordinarily high degree; lastly, there may be motor disturbances of the upper ex- tremities, trembling, ataxia. Sense Organs. The Eye. — In considering the relations of the diseases of the eye to internal diseases, those in connection with the diseases of the nervous system are of very much the greatest importance. We find the eyes, or the function of sight, sympathetically affected in diseases of the nervous system in a great variety of ways. We 36 562 SPECIAL DIAGNOSIS. observe disturbances which exhibit the more or less direct results of disease of the nerves or of the brain. They are : paralyses (less frequently spasms) of the outer and inner muscles of the eye ; dis- turbances of the different qualities of vision itself, from lesion of the sensory tract at any point from the optic nerve to the cortex ; neuritis optica (choked disk), which, on the other hand, may itself cause dis- turbance of vision. Other conditions, which are coordinate to the diseases in which they occur, oppose these conditions. They are of extremely varied character. We mention, as examples : atrophy of the optic nerve in tabes dorsalis, multiple sclerosis, embolus of the central artery of the retina with simultaneous embolus of the fossa of Sylvius, syphilitic iritis or retinitis in syphilis of the brain. Likewise, the disturbances of the apparatus of vision, occurring with any other internal diseases, may be either coordinated conditions or sequent phenomena of those diseases. Of the former category we name as examples : choroidal tuberculosis in acute miliary tuberculosis, retinal hemorrhage in general hemorrhagic diathesis (sepsis, pernicious anasmia), the various manifestations of syphilis, etc. As a sequent phenomenon we have embolus of the retinal artery in endocarditis aortse or mitralis, possibly cataract with diabetes mellitus, etc. We give these instances in order to show in how great a variety of ways the disturbances of vision may occur as symptoms of other dis- eases. In what follows we cannot classify the subject matter according to the points of view mentioned above. We rather proceed in accord- ance with the course of an examination of the eye. 1. Movements of the eye. — As is well known, these take place, in part at least, in a very complicated way, by the co5rdinate action of the muscles of the eye. Paralysis or spasm of the outer muscles of the eye causes a defective motion of the eye and disturbs its binocular motion, which we designate as strabismus. If the strabismus is due to spasm, it is present in all positions of the eye ; but if dependent upon paralysis, then it has a different relation. In slight paralysis (paresis) of a muscle, strabismus only occurs when a motion of the eye is made which is in a considerable degree dependent upon the co- operation of the muscle paralyzed ; on the other hand, in more marked paralysis, strabismus may be almost always present. It is only absent when the eyes. are brought into a position which cor- responds with an especially marked relaxation of the paralyzed muscle. EXAMINATION OF THE NERVOUS SYSTEM. 563 In long-continued paralysis of one or more muscles of the eye, con- tracture of the antagonizing muscles also takes place ; in consequence of which condition, strabismus is always, or almost always, present. Lateral strabismus is designated as divergent or convergent, according as there is a divergence, or an abnormal convergence, of the axis of vision. The direct result of strabismus is double-vision, or diplopia. This results from the fact that, in fixing an object whose image only falls upon the macula of the normal eye, it falls, in the one whose muscle or muscles are paralyzed, to one side of the maculp^, and at varying distances from it, according to the degree of the strabismus and the distance of the fixed object from the eye. In consequence of the double image, the determination of the position of an object in space, and with it the judgment of the patient with reference to his own position, is disturbed. Hence, primarily there is difficulty in taking hold of objects and in walking; there is dizziness (vertigo of the eye), and this is most marked when there is diplopia in looking downward (paralysis of a rectus inferior, of an obliquus superior). But after long-continued strabismus double vision disappears, for the patient learns to voluntarily shut out the abnormal eye. If it happens to be a case where there is paralysis or spasm of the muscles of both eyes which efi'ect the conjugate motions of the eyes (as the rectus internus of the right and the rectus externus of the left eye), then we speak of paralysis of the conjugate muscles of the eyes (or spasm of these muscles) ; for the position of the eyeball we employ the designation conjugate deviation. Paralysis of all or of almost all of the muscles of an eye results in protrusion of the ball — exophthalmus paralyticus. Marked or total paralysis of the oculomotorius produces, beside the paralysis of the eye (see below), also ptosis (depression of the upper lid), dilatation of the pupil, paralysis of accommodation (paralysis of the levator palp, sup,, of the sphincter of the iris, of the muscle of accommodation). Deviation of the eye in which the paralysis or spasm is located is termed the primary deviation. In cases of paralysis there occurs in the normal eye a so-called secondary deviation, if we have the patient cover the normal eye and then have him look with it at an object which has been fixed by the diseased one. (Upon this subject, see "works upon the Eye.) 564 SPECIAL DIAGNOSIS. We employ our own individual judgment in determining a paralysis of the muscles of the eye, by controlling the position of the eye of the patient while he is looking at a distant object and from the accom- modation, also, especially by motions of the ball sideways, upward and downward ; moreover, we test the patient by having him look at objects in different directions, and then question him as to double vision and in what relation the objects stands to one another. Mode of procedure in determining double vision. We hold up a finger about a metre from the patient, move it up and down, to the right and then to the left, and hold the finger steadily in the position in which the patient has a double image, and then have that position described by him. Then we suddenly close one eye : the patient now declares which image has disappeared. In this Avay we determine to which eye each one of the double image belongs. Or, we take a lighted candle as the object of vision, and alternately cover an eye with a piece of colored glass, and then, of course, the image presented to this eye is colored. (For further regarding this subject see works upon the Eye.) In regard to the significance of double vision, it is first to be stated that when the balls diverge the images are crossed ; when there is abnormal convergence, they are on the same side (on the side of the convergence). All the rest follows from what will now be said where we collate the function of individual muscles of the eye and the effects of paralysis. M. rectus externus (N. abducens), rolls the eye outward. Its paralysis, according to its degree, produces convergent strabismus, which is manifest either in looking straight ahead, or in looking only toward the side whose external rectus is affected. The double vision is also upon that side. M. rectus internus (N. oculomot.), rolls the eye inward, antagoniz- ing the preceding. When it is paralyzed the in-rotation of the ball is imperfect ; there is divergent strabismus, crossed double vision. M. rectus super. (N. oculomot.), rolls the eye upward and at the same time a little inward. Rectus super. + obliq. infer, together cause upward motion of the ball. Paralysis of the rectus sup., limits the motion upward ; the abnormal eye stares downward and a little outward : there is double vision when looking upward ; the image of the paralyzed eye is superimposed upon that of the other. EXAMINATION OF THE NERVOUS SYSTEM. 565 M. rectus inferior (N. oculomot.), rolls the ball downward and slightly inward ; acting with the obliq. sup., there is simple down- ward motion. Paralysis of the rectus infer. : in looking down, the paralyzed eye does not move, but remains directed upward and a little outward ; there is double vision, with one image above the other, the lower being that of the abnormal eye. M. obliq. infer. (N. oculomot.), if it is paralyzed, in looking up- ward we have the action of the rectus sup. alone : the eye turns some- what inward. There is double vision upon the same side, one image is above the other or they are side by side, particularly in looking upward. M. obliq. super, (N. trochlearis), if this is paralyzed, then in look- ing down the rectus inferior acts alone, turning the eye somewhat inward. There is double vision upon the affected side, especially when looking downward. Some of these paralyses, if they occur singly, can be easily recog- nized, and this is especially true of those of the recti. But when -several are combined, particularly if the obliqui are involved, there is often the greatest difficulty in making out the exact lesion. A com- bination which may occur frequently is a paralysis of all the muscles supplied by the oculomotorius, with which we may then also have the internal muscles of the eye involving the levator palp. sup. With this total paralysis of the oculomotorius the eye is rotated outward (the action of the abducens), there is some exophthalmia, the pupil is dilated and remains so in the presence of light, and there is absence of power of accommodation. By nystagmus, or oscillation of the eyeball, we understand very slight clonic jerking motions of the ball. They are generally conju- gate. If they take place in a horizontal direction, then we speak of horizontal nystagmus. It is often most distinct in fixing the eyeball, but particularly with marked rotation movements of the balls side- ways or in a vertical direction. The diagnostic significance of paralysis of the muscles of the eye varies very much : paralysis of several muscles of only one eye always points with considerable probability to the base of the brain, or to the orbital fissure and orbit, and this is particularly apt to be the case if, at the same time, there is evidence of a lesion of the optic nerve (dis- turbance of vision, unilateral choked disc). Progressive paralysis of 566 SPECIAL DIAGNOSIS. the muscles of both eyes, sometimes ending in total paralysis of these muscles, indicates a progressive nuclear paralysis (ophthalmoplegia externa). It is difficult to estimate the symptomatic value with refer- ence to the topical diagnosis of conjugate deviation. When it is present we should always first think of the possibility of a lesion of the posterior corpus quadrigeminum or its neighborhood ; but aside from this, conjugate deviation occurs with all kinds of local disease of the brain, especially if recent. Hence, if the deviation is due to paralysis, we infer that the line of vision is toward the same side, but if it is a conjugate spasm, the line of vision is toward the opposite side. In the latter case the head is very often drawn to that side. Paralysis of the oculomotorius of one side and of the extremities of the opposite side (crossed paralysis) points with great certainty to a lesion of the crus cerebri, and this corresponds with paralysis of the third nerve. We can immediately understand this fact if we recollect that the N. oculomotorius dexter passes to the right crus cerebri at its base — that is, it passes alongside of the pyramidal tract belonging to the left side of the body. 2. The pupils. — We do not concern ourselves with those changes of the pupil which belong wholly in the province of diseases of the eye (especially in connection with iritis). We are to consider the size, or the changes in the size, which result from certain circumstances. When the iris is normal, the size is regulated by the action of two antagonizing muscles : the sphincter pupillae (N. oculomotorius) and the dilator pupillse (N. sym- patheticus). [a) The size of the pupil. Contracted pupil, mi/osis, occurs in health during sleep, likewise in old age. Otherwise myosis is always a sign which must awaken suspicion, and indeed is especially frequent in tabes dorsalis (see below, Reflex rigid pupil) ; and, also, although more rarely, in progressive paralysis. The degree of the illumination also has a marked effect upon the size of the pupil (if from reflex action it is not rigid, see below under c). Hence, it is to be examined under moderate illumination. Dilatation of the pupil, mydriasis., occurs with marked disturbances of consciousness, severe pain (see below under c), with atrophy of the optic nerve, paralysis of the M. oculomotorius ; lastly, sometimes with tabes and progressive paralysis. EXAMINATION OF THE NERVOUS SYSTEM. 5tj7 Effect of poisons. Atropine, duboisin, cocaine, dilate the pupil ; eserine, pilocarpin, morphia, contract it. These eiFects upon the pupil are, in connection with other symptoms, employed for diagnosis in cases of poisoning with any of these substances. (b) Inequality of the pupils sometimes occurs with persons in health, also in people Avith unequal refraction in the two eyes (with myopia : mydriasis ; in hypermetropia : myosis) ; but, otherwise, inequality of the pupils is a suspicious symptom. It occurs in uni- lateral aifections of the brain of all kinds (thus, especially with lisematoma of the dura), with unilateral paralysis of the oculomotorius, of the opticus (dilatation), and in tabes ; besides, it frequently occurs in attacks of migraine (irritation, paralysis of the sympathetic of the aifected side). (e) Reflex changes in the size of the pupil. The pupil contracts in the presence of light from the contraction of the sphincter (the reflex arc [composed as follows] : (a) the optic nerve ; (b) optic tract ; (c) probably the anterior corpus quadrigeminum ; {d) oculomotorius). The test is made either in a light room by covering the eye with the hand and then suddenly withdrawing it, or in a room with a dim light by quickly going to the light (more certain). In either case the patient must not employ any accommodation, hence must look at a distant object (see below, converging motion). It is best to test each eye singly by alternately closing one. Sometimes there is an indica- tion for testing the crossed (" consensual ") reaction : we observe the changes in the pupil of the right eye, while we vary the light which enters the left, and vice versa. (Regarding hemiopic pupillary reaction, see below.) In old age the reaction of light is physiologically slow. Pain, as painful irritation of the skin (pinching, Faradic brush), dilates the pupil through the action of the dilator. The reaction is slower and less marked than from light. Absence of reaction is the term used for "reflex rigid pupil " (Erb), both " to light " and " to pain.'' This absence of both reactions often goes hand-in-hand, especially in tabes, where Erb in 84 cases found 59 instances (= 81.5 per cent.) of absolutely rigid pupils, or (moi-e rarely) very feeble reaction. At the same time there was always reflex rigidity with reference to pain ; and, further, in 37 cases (= 52 per cent.) simultaneous myosis. Reflex rigidity is less frequent in progressive paralysis ; but there rai-cly over occurs any other abnor- 538 SPECIAL DIAGNOSIS. mality of the pupils (myosis, mydriasis, inequality, slow reaction of rigidity) in this condition. The reaction of light also fails in atrophy of the optic nerve, and in complete paralysis of the oculomotorius. But it does not fail in central blindness, hence not in cortical hemianopsia. Moreover, when testing in this case, the light from the side where the field of vision is defective must be brought nearer, so that it may only fall upon the half of the retina which is cut oif from the centre (see p. 569). Reaction of light takes place in the diseased eye in unilateral optic atrophy when the normal eye is illuminated ; on the other hand, reaction of light is not retained in the diseased eye in unilateral com- plete paralysis of the oculomotorius, as is evident from the course of the reflex arc. {d) Contraction of the pupil in convergence of the eyes, or from accommodation, may not take place in paralysis of accommodation (this most frequently after acute diseases, particularly diphtheria), but it may also be retained. This contraction of the pupils during accommodation has its chief diasrnostic significance in the fact that it must be avoided when testing for the reaction to light or pain — that is, it is generally retained with reflex rigidity of the pupils. 3. Testing for the central sharpness of vision, the color-sense, and the field ofvisioyi. (a) We test the shai'pness of vision by means of Snellen's plates, which contain test-letters of diff"erent sizes, the number of which is represented by the distance in metres at which a normal eye can read the type. After correcting any possible anomaly of refraction in either eye, they are placed at a distance at which it can read the test- letter X. The sharpness of vision is expressed by a fraction whose denominator is the number on the plate, and whose numerator is the distance at which it can be read. According to the above, in normal vision the denominator and numerator must be alike ; the fraction then is always equal to 1 (f, f, etc.) ; instead of this [the sharpness of vision represented by] SV. = f , in case the eye is diseased we have SV. = f, etc. (For particulars, see text-books on the Eye.) As a matter of course, if we discover a diminution in the sharpness of vision, before we conclude that it is due to a disease of the nervous system we must exclude any disease of the refractive apparatus. (Here, also, the reader is referred to special works upon the Eye.) EXAMINATION OF THE NERVOUS SFSTEM. 539 (h) Testing the field of vision, FV., tlie "peripheral sight." The most exact way to do this is to employ a perimeter. A substitute for this expensive instrument, which can be recommended to one who is not a specialist, is the field-of-vision chart, which has six straight lines intersecting each other at a point making angles of 45 degrees. Starting from the point of intersection, these lines are divided into centimetres. At the point of intersection a rod of definite length stands perpendicular to the chart (it is screwed into the chart) ; upon this upright is a hoop into which the person to be examined places his head. It is used in the same way as a perimeter. The normal size of the field of vision for three or four healthy persons, with a definite length of the upright, is placed upon the chart, (It will be shown that on the outer side the field of vision is endless, because the angle is less than 90 degrees to the direction of the line of sight — but of this no account is taken.) The pathological result is drawn upon a diagram which represents the chart and the normal field of vision on a smaller scale. We recognize very decided disturbances by steadily holding a finger about a half metre from and in front of the eye, and then moving the other hand, or a light held by it, in every direction in the field of vision. Of course, in this case, as in all others, we are to test each eye singly. The great difficulty is in having the patient hold the eye fixed immovably. Concentric narrowing of the field of vision rarely occurs in organic diseases of the brain. It oftener occurs with multiple sclerosis, usually from atrophy of the optic nerve (see below), more frequently in neuroses ; and it is an especially important symptom in hysteria, *' traumatic hysteria," but also in " railroad neurosis," which is closely related to this. With atrophy of the optic nerve there likewise occurs narrowing of the field of vision, which is concentric, more rarely in the form of a sector. Central scotoma occurs particularly in alcohol- and tobacco-amblyopia. The result of semi-decussation of the optic in the chiasm is the peculiar symptom known as homonymous hemianopsia — a defect in the field of vision, involving about half of it, upon the same side of the body in both eyes. Fig, 168 explains this condition: a complete interruption of the optic tract or of the path centrally from it, or, lastly, a total destruction of the sight- centre in the cortex of the 570 SPECIAL DIAGNOSIS. occipital lobe, from which there must result hemianopsia ; and, too, the centripetal conduction of the half of the retina corresponding to the side of the lesion will be interrupted, consequently the half of the field of vision opposite the lesion will be defective. Thus, homonymous hemianopsia indicates a lesion which affects the tract of sight between Fig. If ^^^^^ Schematic drawing for explaining the relation of the eyes to Tision, and representing hemianopsia. The direction of vision of the two eyes BR is very nearly parallel (the eyes being fixed upon a distant object), ikf, macula lutea; C/i, chiasm; Rr, Ml, r\gh.\, and left cortical field of sight (occipital cortex). ITotice a kind of semi-decussation in the chiasm, the division of the fibres in the retinae, and the character of the images as they appear in the cortex. S, a local disease behind the chiasm ; it causes hemianopsia. The portion of the fieldof vision which disappears, and the cortical field which does not perceive the object, are hatched. The corresponding tracts are represented by a wavy line. the chiasm and the cortex. Without doubt, this tract also passes through the posterior portion of the posterior crus of the inner capsule, and with equal certainty is in relation with the anterior corpus quadri- geminum of the affected side, for from here also hemianopsia may arise, or, when there is lesion of the corpora quadrigemina of both sides, there is blindness. Lesion of a tract as far as to the affected corpus EXAMINATION OF THE NERVOUS SYSTEM. 57 1 quadrigeminum causes hemianopsic rigidity of pupil with respect to light (see above, Hemianoptic reaction of the pupils — Wernicke). Hemianopsia is sometimes made manifest by the patient not notic- ing Avhen some one comes to his bed from that side ; by his not being startled when a light is quickly brought near him from the affected side ; or, in writing, he does not see what he has written upon one side of a sheet of paper, etc. A bilateral dropping out of the nasal half of the retina, with bilat- eral temporal (hence, not homonymous) hemianopsia, may be caused by a tumor which is situated close in front of or behind the chiasm. In this case the two eyes in some degree may compensate, by mutual action, for the defect, though, of course, very imperfectly — for binocu- lar sight is no longer possible. There occur other difficulties whose description does not belong here. Subjective sensations of vision occur in severe diseases of the eyes of all kinds, but especially in anaemia (flimmering), with nervous sub- jects. Temporary partial amaurosis has great significance : a strong shining, generally pronounced unilateral subjective sensation of light, which, in some of the cases, is markedly present in migraine {migraine ophthalmique)^ sometimes, during the attack, passing into hemianopsia. (c) The color-sense. The central perception of color is tested by means of skeins of woollen yarns of as pure colors as it is possible to obtain. The color-sense within the limits of the field of vision — in other words, the size of the field of vision for the individual colors — is ascertained in the same way as that of pure white (see above). It is not without importance (see text-books upon diseases of the Eye). [d) The results of the ophthalmoscopic examination which are here of interest to us will be found in the Appendix. The diasrnostic value of the electrical reaction of the retina cannot be determined, hence we pass it over here. Hearing. — Functional test. We ascertain the distance at which a whisper can be heard (a healthy person in a closed room can catch it at a distance of about twenty-five metres). We also employ the tick of a watch, which has previously been tested upon healthy persons, to ascertain the distance at which it can be heard. As a matter of course each ear is to be examined separately, and the ear not being examined is to be closed. To this also extends the testing of the behavior of the conductivity of the bones : a normal person does not at all or 572 SPECIAL DIAGNOSIS. only barely hears a watch held near to the closed ear, but hears it distinctly when it is brought in contact with the skull in the neigh- borhood of the ear. Persons with disease of the outer ear-passage and of the middle ear are in the same condition as those with normal ears when more or less completely closed : at a distance they hear poorly or not at all, but by the conduction of the bones they can hear excellently well. On the other hand, when the acoustic nerve or its terminations in the tympanic cavity are diseased (nervous deafness), hearing at a distance and through the bones are both alike diminished. The examination with the ear-mirror cannot be described here. It naturally comes into consideration for the differential diagnosis of nervous deafness and of aifections of the middle ear or of the external ear passages. (Regarding this and its detailed use, see the text-books upon diseases of the Ear.) We call especial attention, from the funda- mental scientific points of view, to the important electrical examination of the acoustic nerve (Brenner) ; it is true that, in its diagnostic rela- tions, it has no independent significance. Apart from the special aural point of view, the determination of a disease of the ear or of the sense of hearing is of importance for vari- ous reasons : (a) for recognizing constitutional afi"ections (caries of the petrous bone in scrofula, tuberculosis, middle-ear catarrh in syphilis ; see p. 286) ; (h) for recognizing any other local disease of the cranium, or within the cranium (at its base), or of the brain, which injures the acoustic nerve or the central conduction of hearing ; lastly, with ref- erence to further resulting phenomena of a disease of the ear or the petrous bone, if they exist : purulent (sometimes, also, tuberculous) meningitis, abscess of the brain, and facial paralysis. It is further to be mentioned that, on the other hand, in a normal condition of the hearing apparatus a functional disturbance may be caused by a rheumatic facial paralysis, if it is located high up : from paralysis of the stapedius muscle, supplied by the facial, and predominant development of the tensor tympani, there may arise a morbid acuteness of hearing, especially for deep tones. Subjective sensibility of hearing (tingling, ringing, buzzing, roaring in the ear, etc.) occurs in anaemia, nervousness ; further, in diseases of this organ of any kind ; but, lastly, also in palpable nervous dis- eases. The latter are then generally affections of the acoustic nerve, EXAMINATION OF THE NERVOUS SYSTEM. 573 as compression or neuritis, or of its terminations in the labyrinth. Subjective auditory sensations, as signs of disease of the acoustic nucleus of the oblongata, or of the auditory tract in its central course, or of the auditory centre of the cortex in the temporal lobe, are very rare, if not unreliable. It is very worthy of note that tinnitus aurium may sometimes introduce an attack of migraine, apoplexy, or, as an aura, an epileptic attack. Tinnitus aurium may occasionally be combined with dizziness (nervus vestibularis) ; this is much the most pronounced in Meniere's disease. Marked ringing in the ears ma}^ become the source of psychical disturbance. In order to make a diagnosis of word-deafness, or of sensory aphasia, it is, of course, necessary, as a preliminary condition, to determine whether the hearing is good. Lastly, attention must be especially called to the fact that a uni- lateral disturbance of the hearing may have entirely escaped the attention of the patient. Smell. — Testing its function. For this purpose we may employ camphor, petroleum, perfumed spirit, and, as disgusting material, asafoetida ; but not ammonia or acetic acid, because even a very slight amount of the vapor of these substances may irritate the trigeminus. We first test one side and then the other. We do not here describe the examination of the nose with the nasal speculum. Anosmia [loss of the sense of smell] of neuropathic origin is not very frequent. It occurs in processes in the anterior cranial fossa and the anterior portion of the brain which lead to compression of the olfactory, as from tumors, meningitis, hydrocephalus; and here it is also due to compression of the olfactory. Unilateral anosmia has been observed as an associated phenomenon of total hemiansesthesia in lesion of the posterior portion of the internal capsule — of course, on the side opposite to that diseased. But in exactly the same way we may have unilateral anosmia with hysterical hemiansesthesia. It is rare to have anosmia from lesion of the nerves passing off from the bulb in the ethmoid bone, when this bone is fractured. But it is always to be remembered that the most frequent cause of loss or diminution of the sense of smell is disease of the nasal mucous membrane. It is further to be noticed that in old age anosmia some- 574 SPECIAL DIAGNOSIS. times occurs without any notable pathological cause (atrophy of the olfactory). In very isolated cases the disturbance is to be referred to paralysis of the trigeminus ; that is, to the dryness of the nasal mucous mem- brane due to the paralysis. Hyperosmia and osmic parsesthesia (parosmia) occur in hysteria and insanity, and as an aura in genuine epilepsy. Regarding the significance of the nose as a point of departure in disease within the cranium, compare further, pp. 358-9. Taste. — Testing its function. We test it for the recognition of salt, sugar, vinegar, and quinine. We also make a test by retaining the same order of succession of all these substances when suitably diluted. Then follows the testing of a circumscribed portion of the tongue, as first one and then the other half of the tongue, then the anterior two-thirds as compared with the posterior one- third, because the former portion is supplied by the chorda, the latter by the glosso- pharyngeus. For this purpose we wipe the tongue somewhat dry, apply to it a very little of the [test] fluid with a glass rod, remove any surplus and have the tongue simply drawn back, but without any further motion. Although this method is somewhat doubtful, since a portion of the hard and soft palate, which cannot be exactly defined, also possesses the sense of taste, yet it seems practicable, as follows from its positive results in certain cases of facial paralysis. The more exact method of not drawing the tongue back into the m®uth after the test substance has been put upon it, thus to eliminate the assistance of the palate, has the disadvantage that then even persons in health can only imperfectly taste. Ageusis [loss of the sense of taste] on one side of the tongue is observed with total hemianaesthesia. Unilateral ageusis of the anterior portion of the tongue occurs also from peripheral chordal paralysis, and this is the case whether it involves injury of the branch of the trigeminus as far as the Gasserian ganglion, or of the second branch from there to the spheno-palatine ganglion, or of the facial between the geniculate ganglion and the point where the chorda is given off, or of the commisural portion between the fifth and seventh nerves, the N. petrosus superf. major. Total ageusis points to hysteria. Moreover, the fineness of the taste, as well as of smell, varies much with the individual. examination of the nervous system. 575 Disturbances op the Vegetative System ix Nervous Diseases. We must here limit ourselves to a brief enumeration of the most important points. 1. G-eneral Phenomena, The apoplectic habit (short, thick neck, red face, full chest, abun- dant layer of fat) decidedly predisposes to hemorrhage of the brain, but this also occurs very frequently even in very lean and anaemic subjects. In other respects the general habit does not predispose individuals to diseases of the nervous system. Nervous diseases affect the nutrition in a great variety of ways, sometimes, for a long time, not at all, and again very decidedly. It depends chiefly upon the accompanying vegetative disturbances : fever, decubitus (which see) and the various disturbances of individual internal organs to be mentioned. A tuberculous nature of a local disease of the brain, or of a menin- gitis may be suspected (aside from possible tuberculosis of the lungs, scrofula, hectic fever) when the nutrition is decidedly poor. The same thing is true with respect to carcinoma. Fever occurs in diseases of the nervous system : (a) if the disease itself is of an inflammatory or infectious nature ; {h) if it causes vegetative disturbances, as decubitus, cystitis, etc., which in turn give rise to fever ; {c) in many cases where the elevation of the tem- perature is supposed to be of a neurotic character : in progressive paralysis, in injury of the cervical spinal cord, which is not fatal (here, according to Naunyn and Quincke, the increase in the produc- tion of heat rises to 44 C. [=112° F.]), in tetanus, in severe epileptic attacks. Diminution of temperature is likewise seen in progressive paralysis, and with injuries of the cervical spinal cord. 2. Disturbances of the Respiratory Apparatus. Nose. Certain affections of the nose (nasal polypi, enlargement of the turbinated bones, chronic catarrh) stand in a peculiar, often causal relation to various neuroses, especially to bronchial asthma, to nervous affections of the heart. The nose, through the ethmoid bone, may be 57G SPECIAL DIAGNOSIS. the gate of entrance for meningitis or abscess of the brain ; also, it is to be mentioned that the nose comes especially under consideration in the diagnosis of syphilis. Larynx. The larynx may be paralyzed. When there is anaes- thesia of the larynx we investigate its nerves and their centres in the bulb ; further, hysteria sometimes comes into consideration. See some additional remarks regarding the larynx in the Appendix. We have a nervous cough from simple nervousness, also in hysteria. Laryngeal spasm is an attack of nervous cough, which may occur in decidedly varying severity from slight irritative cough to attacks resembling whooping-cough of the severest character. It is produced by irritation of the vagus by tumors of the bronchial glands, or it occurs in tabes and hysteria. Dyspnoea : see what was said regarding asthma in connection with the nose. It occurs also in uraemia, and is sometimes the most promi- nent symptom in chronic uraemia, and in diabetes. Lastly, dyspnoea is caused by functional and true paralysis of the respiratory muscles. With the latter we take into consideration the tracts of the nerves, the nerve centres, especially the respiratory centre in the bulb. Dys- pnoea is caused also by tonic and rapidly recurring clonic spasms of these muscles. In hysteria there is great disturbance of the breath- ing : extremely rapid superficial, or labored, deep, panting breathing, and temporary fixation of the diaphragm. (Regarding Cheyne- Stokes phenomenon, see p. 92.) The condition of the lungs and the character of the sputum are chiefly regarded from two points of view : the determination of a tuberculosis ; and, because a connection between fetid bronchitis, abscess or gangrene of the lungs, emphysema, and purulent menin- gitis and abscess of the brain has recently been recognized. 3. Disturbances in the Circulatory Apparatus. Heart. This has most important relations to hemorrhages and em- bolic softening of the brain: hypertrophy of the left ventricle favors the occurrence of hemorrhage (contracted kidney) and valvular endo- carditis. In case of weak heart, thrombi existing within the heart (the auricular appendix), may cause emboli. Atheroma of the vessels likewise may cause hemorrhage, emboli, and local thrombosis of the EXAMINATION OF THE NERVOUS SYSTEM. 577 vessels of the brain. But often aneurism of the minute arteries of the brain causes hemorrhages without there being any atheroma of the vessels of the body. Whenever there is loss of consciousness, but espe- cially in every case of apoplexy, and of paralysis, which is to be referred to the brain, the heart and vessels are to be most carefully examined. Palpitation and pain (angina pectoris) occur in organic disease of the heart, in simple nervousness (heart neuroses), in hysteria, in Base- dow's disease, and in nicotine poisoning. Hence these phenomena may have great diversity of significance. Much has already been said (p. 237if.) regarding the anomalies of frequency of the pulse. Temporary, seldom continuous, quickening of the pulse occurs in neuroses ; but, besides, paralysis of the vagus or the vagus nucleus (neuritis, bulbar paralysis) quickens the pulse, often, also, causes a gallop-rhythm (see p. 220). The vasomotor disturbances are extremely manifold and interesting, but, according to our present knowledge, are seldom of diagnostic im- portance. There must be mentioned the unilateral paleness or redness of the head in many cases of migraine (hemicrania, sympathetica spastica and sympathetica paralytica) ; unilateral paleness in hysteri- cal hemiansesthesia. We observe cyanosis, coldness, oedema, especially frequently in cerebral, sometimes also in spinal (poliomyelitis acut.) and in peripheral paralyses, and in hysteria. Sensations of heat of the skin in Basedow's disease — perhaps, also, in paralysis agitans — are to. be referred to vasomotor influences. Regarding the secretion of per- spiration, see p. 36f. Local asphyxia (cyanosis, coldness) and spontaneous symmetrical gangrene is observed in general neuroses, peripheral neuritis, but also in acute infectious diseases, diabetes, and ergotism. 4. Disturbances of the Digestive Apparatus. Very much has already been said upon this point, hence reference is made to p. 284fF. Anaesthesia of the pharynx may, exceptionally, be evidence of a palpable disease ; it is a much more frequent and important symptom of hysteria. Increase in the secretion of saliva occurs in psychoses, idiotism, also in bulbar paralysis ; in all three cases — in the first from inattention, 37 578 SPECIAL DIAGNOSIS. in the latter from simultaneous paralysis of the lips, tongue, and mus- cles of deglutition — the secretion sometimes runs out of the mouth. But, for the same reason, in bulbar paralysis the secretion escapes from the mouth, although it is not increased in amount. Diminished secretion of saliva is seen chiefly in facial paralysis (secretory fibres in the chorda tympani). We are also to bear in mind the nervous dyspepsias, Avhich may be divided into psychical disturbances, as dyspeptic difiiculties with per- fectly normal digestion, and nervous disturbances of secretion or of the motor function of the stomach. The diagnosis is to be determined by an examination of the contents of the stomach. As was previously mentioned, vomiting takes place in all kinds of disease of the brain, especially in those that develop rapidly ; further, very especially in the course of diseases of the cerebellum. It is also to be mentioned that there is vomiting with migraine and hysteria. Gastric crises are attacks of very severe, often widely-radiating cardialgia, associated with vomiting (hyperacidity) ; they are a pecu- liarity of tabes, and not infrequently they are for a long time misun- derstood. Intestinal crises (attacks of colic), and those involving the rectum (severe tenesmus), are rare occurrences in tabes. With a number of nervous disturbances, especially in children, we must think of intestinal parasites. They may cause nervous agitation, marked nervousness, attacks like migraine, and spasms. It is not unimportant, although very infrequent, that the taenia solium may infect the subject who has it with cysticercus [cellulosae] : thus, some- times, cysticerci may develop in the brain, in the eye. Habitual constipation is especially frequent in all kinds of diseases of the spinal cord. Marked retentio alvi is very often dependent upon weakness or paralysis of the abdominal muscles, perhaps from abdominal pressure. Incontinentia alvi is partly the result of inattention on the part of idiots, the insane, those who are unconscious; on the other hand, it is evidence of paralysis which either only manifests itself by the fact that the stool cannot be retained long after the first sense of desire, or that only the fluid stool cannot be held back ; lastly, that solid as well as thin stool passes each time. This disturbance may occur from inter- ruption of the reflex arc centripetally from the rectum to the lumbar portion of the spinal cord, and thence again to the sphincter muscles. EXA MINA TION F THE NER VO US SYSTEM. 579 or by interruption of the tracts, centripetal and centrifugal, between the lumbar cord and the brain (voluntary defecation). Involuntary discharge of the stool likewise takes place, particularly in spinal diseases both of the lumbar cord and of the portion above it. In the latter case the discharge seems to be regulated by the absence of reflex, but without the influence of the will ; on the other hand, in destruction of the lumbar cord, the reflex as well as the voluntary influence is annulled : the sphincter is relaxed, the scybala escape as they are carried down from the intestine. The same thing is also observed in very great prostration. 5. Disturbances of the Urinary Apparatus. Oliguria, anuria, also polyuria, may temporarily affect hysterical patients. Polyuria (diabetes insipidus) and also glucosuria are ob- served temporarily or continuously with local diseases of the oblongata, for a very short time in tabes, and when there is considerable increase of the intracranial pressure. On the other hand, in genuine diabetes mellitus there are observed a number of nervous disturbances : neural- gia, neuritis, deep disturbances of the nutrition of the skin and the subcutaneous cellular tissue, and coma which appears either slowly or suddenly like apoplexy. Cystitis, from the slightest to the most severe form, is observed when there is difficulty in emptying the bladder (which see), and espe- cially (but not exclusively) after the use of the catheter. It is par- ticularly an important and frequent complication of myelitis transversa and of tabes. Further particulars regarding the condition of the urine are given in connection with the urinary apparatus itself Involuntary passage of the urine occurs in the insane, with idiots, an the state of unconsciousness, in severe diseases of any sort ; fur- ther, as a special form of disease in enuresis nocturna. Retentio et ineontinentia urince, however, have an especial role. With the former, the patient, when urinating, must press or wait a little, when the urine gradually comes in the ordinary way, or else it escapes very slowly in a small stream, or the bladder cannot empty itself at all and the catheter must be used. Incontinence often first manifests itself as under reflex control, but the urine is passed inde- 580 SPECIAL DIAGNOSIS. pendently of the will, or simultaneously with retention there is an after-trickling, or an escape of the urine while laughing, coughing, or in severe cases, as ischuria paradoxa : the bladder is not completely emptied, sometimes remains always abnormally full, but from time to time some of its contents escape ; in the most severe cases the urine trickles continually from the constantly-full bladder. In the latter cases there is complete paralysis of the bladder (generally of the detrusor as well as of the sphincter). An involuntary passage of urine which is under reflex control re- quires an intact reflex arc : (a) healthy mucous membrane of the bladder ; (b) sensitive muscle ; {c) nerves ; {d) lumbar spinal cord ; (e) muscles of the bladder — hence it occurs with an intact lumbar cord, but one which is cut off" from the brain : myelitis transversa dorsalis, cervicalis, or traumatic and other spinal transverse lesion. We meet with complete paralysis of the bladder chiefly in lesions of the lumbar cord. All kinds of bladder disturbance occur, from the slightest to the most severe, in tabes. Differential diagnosis comes chiefly into consideration from the fact that disturbances of the bladder are absent in multiple neuritis (as against tabes) ; further, in amyo- trophic lateral sclerosis, polio- myelitis (as against myelitis). We have still to mention the [frequent, but not invariable] invol- untary passage of urine in attacks of genuine epilepsy ; it is wanting in hystero-epilepsy, and so it is important for differential diagnosis. Bladder crises (painful tenesmus) are observed in tabes. Lastly, it is to be cited that the most varied conditions of irritation of the penis (especially phimosis) may lead to enuresis, pollution, other nervous disturbances of various kinds. 6. Disturbances of the G-enital Apparatus. The various anomalies of the male genital function may be almost entirely (with the exception of azoospermia and aspermatism) func- tional and organic, and in the latter case again may rest upon a ner- vous as well as some other form of disease. From the standpoint of diagnosis of nervous diseases the decline of the genital function is chiefly of importance in tabes, as against chronic multiple neuritis. On the other hand, differential diagnosis from neurasthenia spinalis is often necessary, and it is to be remembered that in the latter disease EXAMINATION OF THE NERVOUS SYSTEM. 581 there may also be long-continued marked functional disturbance of the activity of the sexual function. Of the female genital apparatus very little needs to be said here. An energetic reaction has taken place against the etiological relation, formerly very strongly claimed, between anatomical disturbances and hysteria, which reaction, in turn, is going too far. In our opinion, there is no doubt that in women diseases of a sexual character may cause hysteria, certainly more than other conditions which tend to weaken the nervous system do. The so-called painful ovary or ovarian hypergesthesia, sensitiveness of the hypogastric region, especially on the left side, to pressure upon this spot (which has nothing to do with the ovary) is not unimportant in hysteria and sometimes causes an hysterical spasm ; also [pressure] sometimes arrests an existing attack [Charcot]. Similar hystero- genous zones may exist in other regions of the body in hysterical subjects. 7. Disturbances of the Skin. A number of diseases of the skin, apart from the special province of dermatology, rest upon a neurotic basis, as herpes, sometimes prob- ably also pemphigus ; further, the so-called glassy skin ; at any rate, each of these may be regarded as a disease of the peripheral nerves. Herpes zoster, especially when it involves the intercostal nerves, has a special significance : it has its origin in compression of the spinal cord, in tabes, meningitis spinalis (here probably entirely from the roots of the nerves), in disease of the spinal ganglion, and in peripheral neuritis, in all these cases generally associated with neuralgic pains. But herpes also occurs in the region of any other nerves, as the tri- geminus. Regarding herpes labialis, etc., see under acute general diseases, p. 50. In all diseases of the nervous system we must search carefully for any evidences of syphilis, not only upon the skin but also in the other organs which come under consideration. Regarding local perspiration (see p. 38) we sometimes, although rarely, have local anidrosis. Among the laity the loss of perspiration of the feet plays an important part as the supposed cause of a number of diseases, particularly spinal, as tabes ; it is probably a con- secutive, and in itself an indiflferent, phenomenon of this disease. 582 SPECIAL DIAGNOSIS. Hemorrhages of the skin occur spontaneously in hysteria, as curi- osities ; punctiform ecchymoses may be observed upon the face, chiefly in the neighborhood of the eyes after epileptic attacks. Here, also, we more frequently have hemorrhages in the conjunctiva. Hemor- rhages into the subcutaneous tissues take place after injuries received during an epileptic attack. The significance of hemorrhages into the skin and subcutaneous cellular tissue of the head (especially about the eyes, and of the nose in fracture of the base of the skull), is treated of in the works upon Surgery. Decubitus is an ulceration of the skin, then of the subcutaneous tissue and sometimes of the deeper tissues, and even of the bone itself. It occurs in dependent portions of the body upon which the patient's weight rests, and particularly where the skin covers bony prominences, as the sacrum, the heels, the scapulae. Want of clean- liness, and lying upon the sacrum, especially when there is inconti- nence of stool and urine, are very marked exciting causes. 1. Decubitus acutus (malignus). It at first manifests itself as an erythema exudativum, then vesicles are generally formed, whose bases become necrotic, from which the destruction proceeds rapidly both in area and depth. Pressure and filth are marked causes, but pressure alone may produce the ominous exudative erythema, as on the inner sides of the knees when pressed together in cases of adduction con- tracture, where we once saw an enormous decubitus acutus form in a few days. Decubitus acutus has been seen by Charcot in hemiplegia upon the posterior portion of the paralyzed side two to four days after an attack of apoplexy. We have observed it only in severe diseases of the spinal cord. 2. Ordinary decubitus occurs only when the body lies so that pres- sure is made upon one place and with the concurrence of uncleanness ; it may be entirely prevented by proper care. It also begins as an erythema, or in the form of a few pustules, or a cutaneous hemor- rhage. It occurs in all organic paralyses, also in any kind of cachexia, if care is not taken to prevent it. Mai perforant [perforating disease of the foot] is a destruction of the skin and deeper parts of the foot, especially of the heel [sole ?]. It occurs in tabes, in progressive paralysis, also in diabetes. Recently ulcerations of the skin, or subcutaneous tissues in syringo-myelitis of the cervical cord have been observed (Schultze). EXAMINATION OF THE NERVOUS SYSTEM. 583 Growth of hair is a very notable anomaly dependent upon a neu- rosis. But these changes have no independent diagnostic signifi- cance. The nails readily become claw-like, angular and brittle in long-con- tinued severe peripheral paralysis. 8. Bpnes and Joints. We observe the arrest of growth of bones after severe' central paral- ysis during the period of childhood, and, likewise, after polio-myelitis acuta it is generally more marked than after encephalitis. Abnormal brittleness of the bones is frequently seen in tabes. In severe syringo- myelitis of the cervical cord, there are severe trophic disturbances of the bones, as fractures, periosteal inflammations with separation of sequestrum. Arthropathia of all kinds are to be observed in diseases of the nervous system : 1. Oi'ganic arthropathia, seldom in recent hemi- plegia, occurring more frequently as stiffness of the joints, is easily confounded with stiffness and sensibility from contracture. It occurs in old hemiplegias, and is also to be observed as serous effusion with periarticular swelling or as severe deforming arthritis, also causing new formation ; both the latter occur in tabes. 2. Joint neuroses occur as painful, occasionally exacerbating affec- tions of the joint, sometimes with points of pressure, stiffness, and contracture, the two latter disappearing under narcosis, but without any sign of organic disease. Under the name of acromegalia, Marie has recently described a peculiar disease, which consists in a giant-like enlargement of the feet, hands, nose, inferior maxilla, and certain parts of the skeleton, dependent entirely or chiefly upon hypertrophy of the bones. THE DIAGNOSTIC VALUE OF THE SYMPTOMS IN" NERVOUS DISEASES. In diseases of the nervous system the individual phenomena combine to form complexes of symptoms in so manifold a way (much more than in the diseases of any other organ-system), that the representation of only the most important possible combinations would very much ex- ceed the limits of a brief work upon diagnosis. Moreover, for the introductory study of individual diseases, we must confess that we 584 SPECIAL DIAGNOSIS. think the method of special pathology which compactly presents the picture of disease on the lines of etiology, anatomy and symptoms is far preferable to the introduction of such minutiae into a text-book upon diagnosis, as, if this and that phenomena is present, then the disease is so-and-so ; but if we have this and that other phenomena, then it is some other disease. For this reason we add here only a few general remarks. In diseases of the nervous system much more than in those of the rest of the organism, the impression stands out distinctly that we in reality have to estimate the phenomena found in a patient in twa ways. We must ask ourselves : (a) What are the portions of the nervous system whose disease^ judged by their nature and location, has caused or can cause the pres- ent phenomena ? This proceeds upon our knowledge of the anatomy, physiology and pathological physiology of the nervous system, which we must acquire as perfectly as possible. (5) Does the picture formed by all the symptoms correspond with any disease with which we are now acquainted ? Then comes the further question : (c) What light does the etiology, development, and course of the disease throw upon its nature, and sometimes also upon its location ? The lines of thought designated by (a) and (5) closely interlock ; generally both are employed in a single case. In certain diseases, indeed, we are wholly or almost wholly directed to the latter, (5), which is, so to speak, unscientific, particularly in certain general neuroses or functional diseases (regarding which, see below). On the other hand, we are fortunately able, in local diseases of the brain, of the spinal cord and of the peripheral nerves, to proceed upon an almost purely anatomico-physiological basis. In order to make a diagnosis of the location of a local disease, besides the special knowledge requisite for such a discrimination, one must have a certain amount of practice in making combinations, of which the ability to keep in mind the topography must form the basis. (Let it be here once more repeated that our preliminary anatomical remarks do not, by any means, contain all that has been positively determined and is interesting to know, but are rather for the purpose of instruction in topographical thinking). We advise the beginner, who wishes to train himself in this department, to begin EXAMINATION OF THE NERVOUS SYSTEM. 535 "With the study, for instance, of peripheral facial paralysis, the different combinations of paralysis of cranial nerves at the base of the brain, and then to study the group of symptoms in the cerebral centres. In order to arrive at a conclusion regarding the location of a local disease it is recommended, as the result of experience, that we should always attempt to trace the diiferent phenomena back to a focus ; but it is evident that sometimes there will be several foci. Moreover, the probability that there is only one focus varies with the supposed nature of the disease ; thus, for instance, a glioma almost always occurs as a single tumor, while metastatic cerebral abscesses are generally, and thrombotic foci of softening very often, multiple. In regard to local diseases of the brain we are to distinguish between the general phenomena as respects the brain, and the local symptoms. The general brain symptoms are essentially those relating to increased intracranial pressure, and may comprise : (a) Psychical disturbances (affecting the clearness of consciousness, of inteUigence, the subjective condition). {U) Pain in the head; dizziness; rigidity of the pupils; spasms; certain phenomena of organic life, as diminution of the pulse, vomit- ing, etc. Affections that develop rapidly and are of limited extent, espe- cially hemorrhages, also other disturbances occuring suddenly, as emboli, usually produce the most pronounced general phenomena. We call the sudden loss of consciousness, sometimes combined with one or other of the phenomena mentioned above, an apoplectic attack. The local symptoms are divided into direct and indirect: the former are dependent upon disturbances of the centre and the tracts which are regarded as irremediable, the latter are caused by all sorts of disturbances (commotion, "collateral oedema," anaemia, etc.) in the neighborhood of the elements that are really injured — disturbances which may again disappear, and which, after a hemorrhage or emboli, always disappear in the course of months, so that only the direct local symptoms caused by the disturbance itself then remain. With local growths which develop slowly, as tumors, these indirect local symptoms may often change, or they may permanently remain. In the spinal cord, when there are local diseases, the general phenomena do not usually play such an important role, and we may not here be able sharply to separate the direct and indirect local symptoms. 586 SPECIAL DIAGNOSIS. But in all diseases of the nervous system all possible disturbances in the rest of the organism contain diagnostic points, and come espe- cially under consideration in local diseases of the brain and spinal cord for forming a judgment as to the nature of the local trouble. We compare what was said upon this point in the chapter on vegetative disturbances ; but, especially, we must never fail, in every disease of the brain and spinal cord, to take into consideration the possibility of the syphilitic nature of the disease {when there is the slightest sus- picion of syphilis the treatment is to conform to it). Under the anatomical diseases of the nervous system, in every respect the so-called systemic diseases have a special place. In these conditions the disease in the nervous substance is, with more or less regularity, always concerned only with certain elements, which sys- tematically (in Fiechsig's sense, see below) belong together, while other portions, even lying very close to the diseased ones, remain entirely healthy : the disease does not lay hold of the entire region, and thus it stands in sharp distinction from the inflammatory diseases and all new formations. But even though the systemic disease lays hold upon ele- ments of the same function (and indeed always the symmetrical por- tions of the two sides ; and these are generally, although not always, of the same severity upon both sides), it always produces, at least in its main features, a like combination of symptoms. If several systems are affected with disease at the same time, then we speak of the combined system-disease. Amyotrophic lateral sclerosis furnishes the most clear picture of a combined system-disease which may affect the whole cortico -muscular conducting tract from the cortex to the mus- cles, but always leaves all the rest entirely intact. We advise every one to begin the study of the system-diseases with this remarkable one. Recently, aside from the systematic nerve-trunk degenerations, we speak, also, of systematic nuclear degeneration, in that we have somewhat modified the idea of the system which was employed by riechsig only for the bundles of fibres which showed similarity by the point of time when their medullary sheath was formed (and which " appeared to be intercalated between apparatus having objects of equal value"). Hence, and not incorrectly, we designate the disease itself as systematic when it involves " apparatus having objects of equal value." EXAMINATION OF THE NERVOUS SYSTEM. 5^7 In conclusion, we make a few further remarks regarding the differ- ential diagnosis of functional and anatomical diseases of the nervous system ; this differential diagnosis is often so extremely easy that the question does not arise at all, but sometimes it is extremely difficult. The points of departure for the differential diagnosis are arranged in four categories : 1. The first question always is whether the general picture entirely corresponds with a local disease, or an anatomical or functional disease. It is to be remarked, however, that hysteria may sometimes exactly simulate a local disease of the brain. 2. There are certain symptoms of palpable disease that are entirely unmistakable. These are : the reaction of degeneration (or rapidly developed and very decided atrophy and laxness of the paralyzed muscles (compare, further, what was said on p. 493 regarding atrophy in hysterical paralysis) ; choked disc and reflex rigidity of pupils are also symptoms. Not absolutely certain, although pointing quite decidedly to a palpable disease, are : absence of tendon reflex ; in unilateral affections, the unilateral absence of abdominal reflex, and very marked disturbance of the bladder. 3. There is one almost certain sign of functional disease : a sudden return to a perfectly normal condition after long persistence of a dis- eased condition, or the sudden occurrence of new and different phe- nomena with the disappearance of those previously existing. There are other signs of functional (hysterical) diseases which, in combina- tion, cannot mislead ; these are the stigmates liysteriques (Charcot) : hysterical hemiansesthesia, concentric limitation of the field of vision, characteristic spasms, sometimes hysterogenic zones. 4. As regards cerebral symptoms, marked development, or, on the other hand, the absence, of a disturbance of the sensorium and the in- telligence, decides the question. Also, continuous fever and rapid decline of strength indicates an anatomical disease. APPENDIX. We present here a very brief sketch regarding the examination of the larynx with the mirror and the revelations of the ophthalmoscope, so far as they are related to internal diseases, especially to the diseases of the nervous system. Lastly, there follows a review of the life his- tory of those pathogenic bacteria which have any part in the diag- nosis of internal diseases. We pass over entirely the examination, with the mirror, of the nose and ears, because these pertain chiefly to the diseases of these organs themselves, and are very rarely of significance for recognizing any other diseases. Besides, with reference to the latter view, we have already (pp. 573 and 575) referred to the diseases of the nose and ears which do sometimes come under consideration. 1. Laryngoscopic Examination of the Larynx} Instruments and sources of light. Tiirck's reflector with a head- band is most frequently recommended for illuminating the throat. As the laryngeal mirror we employ a round mirror, with a diameter of 20 to 25 mm., fixed to a stafi" at an angle of 120 to 125 degrees. The staff" is fixed to a handle or it is screwed into a handle prepared for it. For a source of light we may employ any sufficiently powerful oil- or gas-lamp. The lamp is placed close to the head of the person to be examined, so that the light from the reflector is thrown at the smallest possible angle into the throat of the person being examined. If it can be had, sunlight is better than artificial light. It is employed either in such a way that the patient sits, with his eyes closed, facing the sun, and the light is allowed to fall directly into the throat or so that the sunlight is thrown by the reflector into the throat. If the 1 Let it be distinctly understood that the above only contains the most essential points which are of use in the examination itself. They cannot and should not take the place of the study of these subjects in a medical course. (589) 590 APPENDIX. sunlight is glaring, we employ a special mirror with a longer focus (or a plane mirror), because the ordinary reflector would make a too glar- ing light, and sometimes even produce an uncomfortable sense of heat in the throat. Electric, magnesium, and other lights are at present too expensive to take the place of sunlight. In making the examination we sit directly in front of the patient, have him open his mouth, set the reflector at the proper angle, then warm the laryngeal mirror a little over a spirit-lamp (testing its tem- perature by placing it against the back of the hand), have the patient put out the tongue, seize it with a napkin or handkerchief and draw it out [as far as possible. It is well to have the head thrown quite well back.]. Holding the mirror as one would a pen, it is to be slowly and carefully introduced into the mouth, and then the patient required to distinctly pronounce " ge," at the same time giving the proper direc- tion to the mirror as it is pushed as far back as possible into the phar- yngeal cavity, slightly pressing up the soft palate. The parts are now brought into view by elevating the mirror, depressing it, turning it Fig. 169. Laryngoscopic view of the larynx during quiet breathing (after Heitzmann), double size. now to the right, then to the left, and revolving it, both during quiet respiration and phonation. The mirror must be most scrupulously cleaned with every examina- tion. It is not necessary to employ a special mirror with patients who are manifestly syphilitic. Irritability of the pharynx (strangling, vomiting) may, with prac- APPENDIX. 591 tice, be avoided. In very obstinate cases we can employ cocaine. (See the special text-books regarding other obstacles and the ways of meeting them.) In the laryngoscopic image the parts that are anterior appear as the posterior ; on the other hand, what is upon the right hand of the pa- tient remains upon the right ; the examiner has, of course, the right vocal cord of the patient upon his left side. We observe (see Fig. 169) : 1. The base of the tongue, the glosso- epiglottic ligaments, the epiglottis, lig. aryepiglottica with the carti- lages of Wrisberg. 2. The arytenoid cartilage, or the cartilage San- torini, the false vocal cords, the sinus Morgagni. 3. The ligamenta glottidis vera, with the vocal process of the arytenoid cartilage. 4. The region between the arytenoid cartilages, pars interarytsenoidea (the posterior wall of the larynx) ; the subcordal region, or the fore- shortened trachea. The illumination must be strong. It is advisable for those who have had but little experience to first fix the landmarks by the shining white prominent true vocal cords, and from thence to examine the individual parts of the laryngeal picture one after the other. The examination with the laryngeal mirror is directed to three things : the form and the color of the parts of the larynx, and the position, or motion of those that move. As to the form of the several portions of the inside of the larynx it is to be remembered that the representation given in Fig. 169 is, of course, only schematic. Repeated examinations of normal larynges will show the variations and fix them in mind. The form of the epi- glottis varies very much ; this is also true of the arytenoid cartilage and the false vocal cords or the opening of the ventricle of the larynx. The color of the mucous membrane of the larynx, with the excep- tion of the true vocal cords, is tolerably uniform and corresponds some- what with that of the hard palate. Very often the upper border of the epiglottis, and sometimes its upper surface, is lighter, even yellow- ish-red. Above the arytenoid cartilages, the color of the mucous membrane varies considerably : sometimes it is exactly like the other parts, sometimes darker, again lighter, and then yellowish. The true vocal cords are shining white ; in individual cases, with the function perfectly normal, they are slightly rosy. At the vocal process there is a circumscribed yellowish spot. 592 ' APPENDIX. f We must be on guard against being misled by deposits of mucus or of pus from the lungs. These deposits may be superficial, or may conceal deep ulcerations, loss of substance, croupous deposits. If in doubt, require the patient to cough. If still uncertain, have the patient inhale the vapor of steam for a few minutes, and then repeat the examination. I»[ormally the positions and movements of the portions of the larynx are perfectly symmetrical, although it is to be remarked that if the mirror is not properly held in position, the parts may easily appear to be unsymmetricai. During quiet respiration, the rima glottidis is tol- erably widely opened — at least so that the whole breadth of the true vocal cords is visible ; the arytenoid cartilage (cartilage of Santorini) can be seen between the pars interarytsenoidea (posterior wall of the larynx) ; with active deep inspiration, the vocal cords separate from each other still more, so that they almost or quite disappear under the false vocal cords (which likewise stand apart. During phonation, the vocal cords come so closely together that either no slit between them, or scarcely any, can be seen. Generally their median edges form a perfectly straight line. But in individual cases, only the pares liga- mentosse close so sharply, and posterior to the process, vocales (that is, the pars cartilaginea), the vocal cords remain somewhat more apart, leaving a triangular space between them. When the glottis is closed the arytenoid cartilages come near to- gether and the pars interarytsenoidea disappears ; on the other hand, the false vocal cords leave a tolerably broad space between each other, through which we see the true vocal cords. Patliological conditions. Since we here come upon a subject that has already been frequently referred to, in what follows we bring forward only those conditions which have relations to other internal diseases, and treat of them in the briefest way. We do not meet with paleness of the mucous membrane of the larynx as a local condition. Also, it is no longer of importance in the recognition of a general anaemia, because this is much easier deter- mined by the paleness of the skin, lips, etc. Only one circumstance needs mention, that tuberculous infiltration and ulceration, in contrast with other kinds, as syphilitic, often accompanies a very striking gen- eral paleness of the mucous membrane of the larynx. Abnormal red- ness of the mucous membrane of the larynx, without other changes, APPENDIX. 593 occurs in febrile liypersemia of all the mucous membranes and in gen- eral or local engorgement (the latter caused by pressure upon the larynx by tumors, from engorgement in the region of the cava supe- rior). Also, whenever there is any redness of the larynx it must, as a matter of course, lead us to examine most carefully for any possible other changes (ulcerations, swellings, etc.). Redness, swelling, and sometimes secretion, are the signs of catofrrli. Acute, as well as chronic laryngeal catarrh may involve various loca- tions : for example, it may attack the upper portion of the larynx, leaving the glottis free ; it may also attack only the glottis. A simple catarrh is always symmetrical. Acute, as well as chronic catarrh may cause motor disturbances : on the one side this may be due either to the swelling of the mucous membrane (especially of the incisura inter- arytsenoidea, preventing the closure of the glottis), or, to paralysis of the tensor of the vocal cords or the adductors. Acute laryngitis, especially in children, may give rise to apparent stenosis by reason of the swelling. It is to be especially remembered that chronic and recurrent acute catarrh, and likewise, no doubt, simple catarrh, are very frequent in all chronic diseases of the lungs and especially in tuberculosis. It is, further, important to remember that behind a chronic catarrh a tuber- culous or syphilitic (or lupous) new formation may for some time be concealed. A swelling which is limited to or elects the interarytsenoid region is always very highly suspicious of tuberculosis. Laryngitis hypoglottica (von Ziemssen) is an especially severe form of acute, as well as chronic, catarrh. In this disease we see beneath the vocal cords some- ^'^' ' times merely a soft rosy border, which can only be seen during inspiration ; sometimes a firm, grayish-red, smooth or uneven lump (see Fig. 170). It is almost always present upon both sides. These subcordal swellings appear to Swelling below the vocal vary a good deal as to their nature : sometimes '"^'"'^^ ^''"'^ laryngitis hy- ■,.-,-, T .1 poglottica chronica (after they are simply due to oedema ; m other cases, ziemssen). to a simple catarrh ; in still others, to submu- cous infiltration. Further, such a subcordal laryngitis may be or may become tuberculous in its nature ; more rarely it is syphilitic. From the condition of the larynx alone it is extremely difficult to make the 38 594 APPENDIX. diiFerential diagnosis of these specific diseases from simple catarrh, as well as between syphilis and tuberculosis. There may, however, be other alterations of the larynx present, or unquestionable signs in other organs, which throw light upon the matter. The serious character of laryngitis hypoglottica is manifested by the fact that very frequently, and sometimes very suddenly, it causes severe stenosis. Marked swelling of the whole larynx or of certain portions of it indicates oedema or phlegmon — that is, severe submucous inflammation which ends in abscess. Both of these will chiefly be distinguished by the color of the mucous membrane, which is pale when there is non- inflammatory oedema, even yellowish and often shaking like jelly, while in phlegmonous inflammation it is deep red. Midway between these two conditions stands inflammatory oedema, which pathologico- anatomically and genetically cannot be sharply distinguished from phlegmonous infiltration. Severe phlegmon may lead to decided dis- figurement of the larynx (see Fig. 171). This may also be true of oedema, as is shown in Fig. 172. Circumscribed laryngitis phlcg- monosa usually results in the formation of abscess, or it may occasion a submucous or perichondrial formation of pus. Fig. 171. Fig. 172. Phlegmonous laryngitis, with phthisi- cal ulcer, a, epiglottis; h, left aryepi- glottic fold ; c, left pyriform sinus. (From ZiEMsSEN after Turck.) Extensive phthisical ulceration of the larynx, marked stenosis of the larynx from oedema. a, right aryepiglottic fold ; h, anterior portion of the right cord. (From Ziemssen after Tueck.) Both these conditions are extremely dangerous, because they very easily result in stenosis, and sometimes, if they are acute, with re- markable suddenness. Phlegmonous laryngitis sometimes results in the formation of pus in the larynx (especially perichondritis), or its neighborhood (as angina Ludovici). Laryngeal catarrh very seldom terminates as a phlegmon ; foreign bodies, and substances that irritate chemically and as escharotics, may produce it ; and lastly, it occurs in APPENDIX. 595 various acute infectious diseases, either resulting in catarrhal or ulcer- ative processes, or, it would seem, as independent metastatic diseases. Inflammatory oedema may be the result in all of these cases, besides or instead of phlegmon. Simple oedema is rare and chiefly occurs with general dropsy of all kinds, and in local obstruction (as in struma, mediastinal tumors). Ulceration seldom occurs in the larynx with simple catarrh, more * frequently in acute infectious diseases, especially in typhus abdominalis [typhoid fever] and variola, but most frequently in syphilis and tuber- culosis. We limit ourselves to a description of the two last-named forms. Syphilitic ulceration in the larynx occurs almost exclusively in connection with pharyngeal syphilis. It, by preference, attacks the upper section of the larynx, but it may appear in the glottis. In the majority of cases a single ulcer is observed. The ulcers have reddened edges, with a more or less shallow, whitish deposit upon a vocal cord, or the epiglottis, or there is a very deep crater-like cavity with a whitish deposit and sharp or swollen border. By the absence of knotty ele- vations of the border they are sharply distinguished from carcino- matous ulcers. On the other hand, it is often difiicult to distinguish them from tubercular ulcerations. Here the differentiation is made by other signs of syphilis or tuberculosis that may be present. Regarding gummata of the larynx, see below. Syphilitic infiltra- tion without ulceration and without other associated signs of syphilis are very difficult to diagnose. These slighter syphilitic changes, moreover, very seldom come under examination, because they do not usually cause any inconvenience. See special Avorks regarding them. Tubercular ulceration develops from tubercular infiltration The principal location to be mentioned is the region of the interarytsenoid space. The regions next most frequently attacked are the arytaenoid cartilages and the false vocal cords. Tuberculous ulcers, with the excep- tion of those upon the glottis, are more frequently multiple than are syphilitic. They are either very superficial and yellowish in color, or deep with swollen edges, sometimes, especially in the interarytsenoid space, with papillomatous mucous proliferations. Although not path- ognomonic (Grottstein), the latter form is in the highest degree char- acteristic of tuberculosis. Further, a pale oedematous condition of the rest of the mucous membrane points to tuberculosis. The most im- portant factor is the discovery of tubercle bacilli in the sputum. These 596 APPENDIX. may come from the larynx or from the lungs, which latter are always, or almost always, the first to be attacked. Deep ulcerations may lead to perichondritis laryngea. The most frequent form is perichondritis arytsenoidea. Perichondritis causes a very marked swelling and redness, generally over quite a large area. It very easily passes from this condition of swelling or collateral oedema into stenosis. If it ruptures into the larynx, then the necrotic pieces of cartilage will be coughed out, and sometimes, when examining with the laryngeal mirror, we see them lying loose. Scars are found in the larynx, as elsewhere, after healing from loss of substance. Those that chiefly interest us are the syphilitic. These, more than others, are inclined to retract, and hence they not infre- quently result in stenosis. We either find a partial adhesion of the vocal cords or extensive cicatricial adhesions of the true and false vocal cords, with a funnel-shaped narrowing downward, etc. It is generally impossible to form any conclusion as to the nature of the antecedent processes from the scar. Only this, further, is to be said, that most laryngologists now agree that tubercular ulcers may cicatrize. Excepting the syphilitic gummata, new formations in the larynx have only a local significance. Gummata are either solitary nodules or a group of individually small nodules, at first red in color, with a crinkled contour. They are inclined to .break up rapidly, and then to be replaced by deep ulcers. Fig. 173. Fig. 174. Pedunculated fibroma upon the under surface of the left vocal cord; position during inspiration (Ziemssen). Epithelial carcinoma of the right vocal cord (Ziemssen). The other new formations may be divided into benign and malig- nant. Of the former, very much the most frequent are the papilloma ; more rare are the fibroma. Both, but especially the latter, are gen- erally located upon the vocal cords. Papilloma are sometimes fiat, APPENDIX. 597 wart-like, sometimes regular papules, often multiple, cauliflower-like. The fibroma are genei'ally pedunculated; the surface is usually- smooth, while that of the papilloma is uneven or villous. All the other benign new formations (lipoma, cysts, etc.) are extremely rare. The malignant new formations are, in the great majority of cases, carcinoma. They, like the papilloma, generally develop from the vocal cords ; next in frequency, from the false vocal cords. They manifest great inclination to necrosis and ulceration. The difieren- tial diagnosis of carcinoma, so long as there is no ulceration, is to be made from papilloma, after the occurrence of ulceration from tubercu- losis and syphilitic ulceration : generally this is not easy. For par- ticulars, we must refer to special works. Sarcoma of the larynx is much more rare than carcinoma. In reference to the more unusual diseases of the larynx, like lupus and lepra, we refer to special works. Spasms of the muscles of the larynx are, for the most part, not at all, or only exceptionally, observed with the laryngoscope. We here only mention phonic and inspiratory functional spasm of the glottis in adults. The former takes place at the instant when the efibrt at phonation is made, when a decided closure of the glottis takes place, as can be recognized with the laryngoscope ; on the contrary, in the latter the vocal cords close at the instant of inspiration, hence, at the time when they ought to separate. During expiration the glottis is normal, or almost normally open, in opposition to paralysis of the [crico-aryteenoidci] postici muscles (see below), in which they are very close together during expiration also. As disturbances of coordination, both of these conditions will be understood from their analogy to the neuroses caused by certain occu- pations affecting the upper extremity (writers' cramp, etc.), and are to be accounted for by over-strain. Paralysis of the Muscles of the Larynx. Paralysis of all the muscles that close the larynx (the crico-arytse- noideus lateralis, arytaenoideus transversus, thyreo arytsenoideus ext. et internus — all supplied by the recurrent nerve) : during phonation the vocal cords do not come close together, but remain in the position of inspiration. Complete aphonia is thus produced. The paralysis 598 APPENDIX. is generally bilateral, and is almost always due to hysteria as a basis. Hence, it is often combined with anaesthesia of the larynx. Paralysis of the arytsenoideus transversus : during phonation the most posterior portion of the glottis (the pars cartilaginea) does not close. As a result we have hoarseness, even to complete aphonia. It not infrequently occurs with acute laryngitis. (See Fig. 175.) Paralysis of the thyreo-arytsenoideus intern., one or both sides, causes imperfect closure of the glottis ; when both sides are paralyzed there is a very narrow, symmetrical oval fissure (see Fig. 176) ; with Fig. 175. Fig. 176. Paialysis of the arytsenoideus lu acute laryngitis (after Zibmssen). The poste- rior portion of the glottis remains open during phonation. Paralysis of both thyreo-arytaenoidei interni, resulting from acute laryngitis (Ziemssen). Position during phonation. unilateral paralysis, a correspondingly narrow, unsymmetrical fissure. It occurs in laryngitis, but, also, often in hysteria. Paralysis of the crico-arytsenoidei postici muscles, the openers of the glottis (recurrent nerve) ; posticus paralysis : the vocal cords in bilateral paralysis, during expiration, stand near together, and during inspiration still closer, sometimes in apposition ; phonation may be quite normal. Hence, there is inspiratory dyspnoea, with inspiratory stridor. The dyspnoea may increase until there is asphyxia. In unilateral posticus paralysis the paralyzed vocal cord is motionless and lies near the middle line, while upon the sound side there are normal motions. In its etiology, posticus paralysis is in many cases obscure. Some- times it forms the beginning of a bilateral recurrent paralysis ; in other cases it seems to have a muscular origin (gumma in the muscle, laryngitis with atrophy, etc.). Recurrent paralysis — that is, paralysis of all the muscles supplied by the recurrent nerve — causes the vocal cords to assume the so-called APPENDIX. 599 cadaver position — the position with reference to each other that they have during quiet breathing. In severe paralysis, the vocal cords are entirely stationary in this position. In incomplete paralysis, they still make slight motions outward and also show an inclination to assume the position of adduction, for which there is, as yet, no undis- puted explanation. When the paralysis has continued for a long time the vocal cords become atrophied. Bilateral recurrent paralysis produces bilateral cadaver-position of the vocal cords, and thus complete aphonia, with inability to cough. Fig. 177. Fig. 178. Bilateral complete posticus paralysis (paralysis of the crico-aiytsenoidei pos- tici, dilatation of glottis) at the moment of inspiration (-Ziemssen). Position during inspiration in paral- ysis of the left vocal cord, or recurrent conduction paralysis (after Ziemssen). Position and immobility of the left vocal cord, as in the cadaver. This is caused by compression of both recurrent nerves from aneu- rism of the aorta, carcinoma of the oesophagus, and enlarged glands. It will be readily understood that this bilateral paralysis from periph- eral causes is much more rare than unilateral. Complete or incom- plete bilateral paralysis of the recurrent nerve has been observed with bulbar paralysis, tumors, softening of the medulla, and compression of the vagi after their exit from the medulla. Unilateral recurrent paralysis is much more frequent. It may be easily overlooked, because the voice is often clear, although weak, for the reason that the sound vocal cord during phonation reaches beyond the middle line. The paralyzed vocal cord during quiet breathing stands in the cadaver-position, the sound one in the position of rest — that is, somewhat more widely abducted than the other. During phonation the necessary closure of the glottis takes place, because the healthy vocal cord overreaches; but then the glottis is necessarily askew. Unilateral paralysis of the recurrent nerve is almost always due to compression of the nerve in the neck or as it passes into the thorax ; 600 APPENDIX. this will be brought about by the same causes as bilateral peripheral recurrent paralysis. Thus, recurrent paralysis may be an important corroborative symptom of aneurism, of carcinoma of the oesophagus, or of any other kind of mediastinal tumor. When there is a suspicion of one of these conditions, we may almost regard a recurrent paralysis as decisive ; at any rate, the existence of a recurrent paralysis has often given the first suggestion that led to a discovery of an aneurism or of carcinoma of the oesophagus. Paralysis of the tensor of the vocal cords (crico-thyreoidei muscles, superior laryngeal nerve) is very seldom observed, and then it is always combined with anaasthesia of the mucous membrane and paral- ysis of the epiglottis. It is a tolerably dangerous condition, because of the accompanying difficulty of swallowing and the risk of degluti- tion-pneumonia. The glottis is not exactly steady, but oscillating. In unilateral paralysis the normal vocal cord stands higher. Paralysis of the tensor of the vocal cords takes place most frequently in diphtheria, but then it is always accompanied with paralysis of other muscles. 2. Examination with the Ophthalmoscope. . This method of examination strictly belongs in the province of ophthalmology. Therefore we limit ourselves simply to its use for the purpose of diagnosis, where we observe a connection between certain changes of the fundus oculi and an internal disease. («) Changes in the fundus oculi in nervous diseases. All diseases which lead to a general increase of the intracranial pressure may cause choked disc (neuritis optica). It is then always bilateral. At the same time choked disc may be absent in all these conditions, but its presence is of the highest diagnostic significance, and particularly in tumors and meningitis. Hydrocephalus is more rarely, and abscess of the brain very rarely combined with choked disc. Unilateral choked disc is only caused by local pressure (a tumor, etc.) upon one optic nerve. The extent to which vision is disturbed when we have choked disc varies very much ; there may be none, or almost none. Disturb- ance of vision in choked disc usually occurs very early and markedly if the disease-process causes pressure upon the chiasm or the begin- ning of the optic nerve, as in tumors of the hypophysis cerebri, or if APPENDIX, 601 there is hydrocephalus which presses inward upon the third ventricle (Wernicke). There must, of course, be disturbance of vision if the choked disc is followed by atrophy. Pronounced choked disc is very easily recognized (only take care : neuro-retinitis Brightii is exceptionally very much like it) ; but the exact recognition of a slight neuritis optica is very difficult. When- ever there is such a possibility an ophthalmologist should always be called in. It seems that neuro-retinitis is particularly apt to be present in meningitis when there is a basilar exudation. Neuro-retinitis is said to occur also with encephalitis. Primary atrophy of the optic nerve takes place (by the intraocular portion of the nerve changing into a white disc with a sharp boundary) especially in tabes, then sometimes in multiple sclerosis, dementia paralytica ; lastly, it occurs from pressure upon the chiasm. [The capillary circulation ceases, and hence the disappearance of the nor- mal rosy hue.] Finally, it is to be mentioned that retinal apoplexy has been observed as the forerunner of cerebral hemorrhage, emboli of the cen- tral retinal artery as the precursor of cerebral embolism. Regarding the changes of the fundus oculi in syphilis, see below. We hardly ever find choroidal tubercle in tubercular meningitis. (But with reference to acute general milliary tuberculosis, see below.) (h) Changes in the fundus oculi in other internal diseases. Betinitis or neuro-retinitis albuminurica, with white specks, often arranged as radiating lines around the macula, sometimes confluent, thickening of the walls of the vessels and hemorrhages, occurs partic- ularly frequently in contracted kidney, also often in subchronic and chronic nephritis, but very seldom in acute nephritis. The dis- turbance of vision is greater or less according as the macula is attacked or not. Ursemic amaurosis has nothing to do with this con- dition, but as a matter of fact this form of retinitis often occurs in uraemia (and this is important for the diagnosis). In constitutional syphilis (hence also in syphilis of the brain) we sometimes observe syphilitic changes in the fundus oculi : retinitis syphilitica, retinitis pigmentosa, choroiditis syphilitica. We not infrequently find tubercle of the choroid in acute general 602 ■ APPENDIX. tuberculosis, especially in the region of the macula ; the tubercular deposits are generally very difficult to see. In diabetes there occurs a peculiar so-called diabetic neuro-retinitis and atrophy ; in leucaemia, hemorrhages and whitish exudate ; in per- nicious anaemia, but also in simple, severe anaemia, hemorrhages (generally easily seen). Further, retinal hemorrhages are not unimportant diagnostic signs of pyaemia, particularly pyaemic endocarditis. They are not an abso- lutely fatal sign, as I myself saw in one case of puerperal pyaemia : this undoubted case of pyaemia, where besides the hemorrhages there were chills and slight icterus, recovered and the effused blood disap- peared, leaving clear specks behind. We have still to mention : Pulsation of the retinal arteries in aortic insufficiency, embolus of the central artery in endocarditis (also frequently observed in chorea); lastly, after severe hemorrhages (particularly of the stomach, also of the intestine, and uterus) there occurs sudden amaurosis, not infre- quently at first without any ophthalmoscopic condition, afterward usually with distinct atrophy of the optic nerve. Alcoholic amblyopia shows a negative condition, or else hyperaemia, neuritis, atrophy ; tobacco amblyopia shows a normal fundus optica, or atrophy ; in amblyopia or amaurosis saturnina either there is nothing, or else there is hyperaemia and neuritic atrophy. 3. Bacteria which come under Consideration in the Diagnosis of Internal Diseases. The object of the following sections is to summarize the notable peculiarities of the different microorganisms which have already been mentioned in different parts of the work. But this pertains not only to the characteristics of the different organisms and their appearances when stained, but also to the much more important phenomena of their growth in cultures and under animal experimentation. In regard to the methods of procedure we must refer to the text-books upon bac- teriology, and particularly to the instruction in the bacteriological courses. Staphylococcus pyogenes consists of small round cells which are usu- ally found in irregular masses, but are never arranged in chains. The APPENDIX. . 603 spores of this, as of all other micrococci, have not yet been discovered. It grows upon gelatin even without much air, in the temperature of the room, still more rapidly and luxuriantly in a higher temperature. The gelatin becomes liquefied. Scratch cultures are either gold- yellow (Staph, pyogen, aureus), or white (Staph, pyogen. albus), or clear yellow (cereus), or citron yellow (citreus). Upon a surface it gi-ows in round, light-brownish colonies looking like dots, which lose their sharp contour in the centre of the fluid. Mice, guinea-pigs, and rabbits die in from two to nine days after intravenous and peri- toneal injections. Mice are killed with certainty only after the sub- cutaneous injection of a large amount, but none of the other animals named are killed by subcutaneous inoculation. It can be stained by all of the aniline stains, also by Gram's method. It is the most common excitor of suppuration. It is found in abscesses, furuncles, in many cases of empysema, purulent perito- nitis ; also in ulcerative endocarditis, etc., upon the valves of the heart; in pyaemia and acute osteo-myelitis, in the suppuration which complicates typhoid fever, etc. Streptococcus pyogenes^ resembling the first named by its round cells, forms chains by progressive portions pushing out in the same direction, which sometimes twist around each other. The separate ones often vary in size. It grows slowly upon gelatin, better upon agar, in the temperature of the room, but more rapidly in an incuba- tor at a temperature of 27° C. [=98.6 F.]. It does not render gelatin fluid. The cultures upon a plate are extremely small, \ mm. diameter, yellowish to yellowish-brown in color. When inoculated by puncture it develops slowly and does not spread out upon the surface of gelatin. It is stained like the preceding. It is fatal to animals only when they have been previously weakened ; it causes redness and swelling of the rabbit's ear. There is frequently found a pus coccus which particu- larly inhabits the lymph tracts, and causes progressive phlegmon ; it is also found in pysemia, especially puerperal pyaemia, likewise fre- quently in endocarditis. Streptococcus erysipelatosus, morphologically and as regards its staining qualities, is like the preceding, but from the culture has thus far not with certainty been distinguished from it. In the rabbit's ear it causes a somewhat less active and extensive inflammation than 604 APPENDIX. the streptococcus pyogenes. The inflammation has the symptoms of erysipelas. Micrococcus gonorrhoeus (gonococcus, compare Fig. 131, p. 427) usually occurs in the form of diplococci (roll-form), which often appear as tetracocci in that the single coccus has a bright stripe, as the beginning of a new portion. It is difficult to breed, but is best done upon coagulated blood-serum, in a moist room at 32° C. [= 90° F.] (Bumm). It is stained with all of the aniline dyes, best with a con- centrated watery solution of methylene-blue, stained after the method of Grram. It seems that it is pathognomonic of gonorrhoea if found within the pus-corpuscles. Outside of the pus-corpuscles, and even in epithelial cells, there also occur other diplococci of like form and staining qualities. Bacillus anthracis (see Fig. 78, p. 280) is a rod, on an average about 5-10^ long, 1-1.25/z wide, with an abrupt end, often some- what concave, with the inclination to develop into threads, without peculiar motion. It develops upon gelatin, potatoes, in alkaline urine at the ordinary temperature of the room, better at 36° C. [= 97° F.]. Sometimes there develop spores within spores (endogenous formation of spores). Gelatin is rendered fluid ; when the amount of air is limited it develops poorly. Plate-cultures, after twenty-four hours, can be seen, when slightly magnified, as round grayish-black spots, or wavy, as if curled ; upon potatoes the cultures are gray- white, some- what elevated. It is fatal to susceptible nursing animals (mice, rabbits, guinea-pigs, certain kinds of sheep), even with the most minute inocu- lation and in a very short time. They are found in capillary blood and in all organs richly supplied with blood, particularly the spleen ; with living bodies they do not develop spores, likewise usually no long threads. They are stained by all basic aniline coloring-matters, but they are easily spoiled if the covering-glass is made too hot ; they become non-transparent if too strongly stained. They can also be stained by Gram's method. Bacilli of malignant oedema are 3— 3.5m long, 1—1. 1^ wide (Fliigge), hence thinner and shorter than the anthrax bacilli, from which they are also distinguished by the rounded ends. They form rigid threads, often of considerable length. The individual bacillus forms spores, and these are so large that they distend the bacillus. In the dependent drops they manifest peculiar motions. They only grow APPENDIX. 605 ^vhen oxygen is excluded, hence are anserobia. They develop in a reagent glass, best in gelatin to which is added a ^ per cent, solu- tion of grape sugar (Fliigge). They flourish best at the temperature of the body. But they only grow at the lower end of a deep, very fine canal formed by sticking in a needle, and this canal is to be again closed. It fluidizes the gelatin and forms an oiFensive-smelling gas. It is stained by all the aniline dyes, but poorly after the Gram method. It is found in garden soil, in muddy water, in the blood of asphyxiated animals, etc. A little of the soil taken up on the point of a penknife and put under the skin of the abdomen of a guinea-pig or rabbit generally kills it by the invasion of the bacilli in one to two days (but sometimes, during this experiment, tetanus develops). In man it causes oedema and sometimes emphysema of the skin (see p. 55). Tyjphus ahdominalis bacilli (see Fig. 121, p. 391) are short, slender rods with rounded ends, thrice as long as broad, one-third as long as the diameter of a red blood-corpuscle. They have active motions (hanging drops). They form threads in cultures and hanging drops, but not in living animal bodies. It is questionable whether they form spores. They develop, at the temperature of the room, upon gelatin, agar, potatoes, without the character of the growth being characteristic. On the other hand, the potato culture is characteristic : for some days after the inoculation it would seem as if nothing had grown — at most that the surface of the potato around the inoculating scratches has a moist shimmer ; in the whole circumference of this shimmer a very thick resisting turf of bacilli is present. But this peculiarity of be- havior is not always manifest. Upon some potatoes it is not visible. Only that culture in which it is visible is demonstrative. It is best stained with carbol-fuchsine or Loffler's alkaline methylene- blue solu- tion ;^ it is be washed only with water. It is stained after Gram's method. It regularly occurs in the intestine, spleen, liver, kidneys, also in the stools, and now and then in the blood in abdominal typhus [typhoid fever]. Tubercle bacilli (compare Fig. 40, p. 184, and Fig. 130, p. 426) are thin rods, 1.5— 3. 5/^ long (Fliigge), frequently slightly curved or somewhat broken ; they often form threads, and sometimes two or 1 30 e.em. of concentrated alcoholic solution of methylene-blue, 100 c.cm. of one per cent, solution of potassium. 506 APPENDIX. more lie close together. Very often they contain a number of egg- shaped spaces (spores), and then, when stained and slightly magnified, they sometimes look like chain micrococci. They have no inde- pendent motion. They grow best in a reagent glass upon an oblique coagulated, sterilized blood-serum and glycerin-agar, at a tempera- ture of 37.5° C. (min. 30, max. 42). At beSt they grow very slowly, and hence the strictest care is necessary that it may not de- velop excessively. (For the technique, see special works.) In four- teen days there appear small, dull-white scales and specks, which, when slightly magnified, show an arrangement that reminds one of a tangled braid of hair (compare Fig. 130, p. 426). We can have it develop upon a covering-glass and then stain it by the method described on page 185. The experiment of inoculation is best made upon guinea-pigs, by placing some sputum, for instance, in the abdom- inal cavity. Generally, there is no reaction in the peritoneum. 'After two to three weeks the glands swell, and in four to eight weeks the animal dies. Lepra hacilli, resembling small tubercle bacilli, are stained with aniline in the usual way, but also like tubercle bacilli ; hence, like the former, there may be a double staining. They are found in. leprous skin, in the glands, in the tissue-juices, in the nerves, also said to be found in the blood, etc., mostly in small and large cells resembling giant-cells. Cultures have not yet been successfully made. Anthrax hacilli are like tubercle bacilli, only somewhat broader. They are stained with Loffler's potassic methylene-blue. Stain very carefully, then wash with dilute acetic acid. They are often easier and more certainly demonstrated by culture than by animal experi- mentation. They develop rapidly upon slices of potato at 85° C. [= 97° F.], as a brownish, slimy mass. It can be inoculated upon guinea-pigs ; some maintain that puppies are better. Death follows after an indefinite time, and nodules occur in various organs (one of the first symptoms is a swelling of the testicles). The cholera bacillus (see Figs. 117, 118, p. 889, and Fig. 119, p. 390) has been very fully described upon p. 389f. It has there been pointed out that the certain proof is only made by culture. A mucous floccule from the stools or from the linen is taken, placed in a small glass with a fluid five to ten per cent, culture- gelatin, from which plate cultures are prepared. After standing APPENDIX. 607 one to two days in an ordinary temperature, small white points are seen at the bottom which gradually reach the top, and, by rendering the gelatin fluid, form deep, funnel-like depressions. At the bottom of the funnel lie the whitish cultures, not larger than a pin-head. By making an inoculation-puncture in the reagent glass there is also produced a funnel, which, from the rapid thinning of the fluidized gelatin, contains a large bubble of air. The lower part of the inoculation-puncture I'esembles a thin thread, which in some places is as clear as glass, and looks like an empty capillary tube, while in other places the culture, sunk together, consists of gray and whitish threads. In the dependent drops there is active motion, like a swarm of gnats, and the bacilli strive to reach the border. Larger plate-cultures, under a slight magnifying power, show a pecu- liar lustre and an arrangement as if they were a collection of shivered glass. The inoculation is made upon guinea-pigs, the contents of whose stomach is made alkaline by 5 c.cm. of a five per cent, solu- tion of soda (using an oesophageal catheter) ; the intestine is made quiet by injecting into the peritoneum 1 c.cm. tinct. opium for each 200 grammes weight [of the animal] ; then, by means of the oesopha- geal catheter, there is introduced 10 c.cm. of the deposit of the cholera bacilli in bouillon. After two days the animal dies (often without diarrhoea, always without vomiting) : the condition of the intestine is found to be exactly like that in cholera. In the intestines are abun- dant cholera bacilli. Bacilli of Finhler-Prior (see Fig. 120, p. 391) resemble cholera bacilli, but are thicker and plumper ; but in the colored preparations they cannot certainly be distinguished from Koch's comma bacillus. Plate-cultures develop remarkably rapidly, and render gelatin fluid in much larger quantity than cholera bacilli. This diff"erence in the rapidity of development is the best mark of distinction. When slightly magnified, the cultures seem to be very finely and uniformly granular, of a yellowish-brown color. The inoculation-puncture, likewise, shows a much more rapid fluidization, but not the clear threads beneath the upper "air-bubble," but an irregularly wide canal, which reminds one of a stocking. After a week the whole test-tube becomes fluid. Also, the inoculation of animals gives a different result — stinking intestinal contents, while in cholera they smell stale. INDEX. ABBEE, reference to, 185 ' Abdomen, distention of, from in- flammatory exudation, 314 distention of, causes of, 309 drawing-in of, causes of, 309 inspection of, 313 sound on percussing, 109 topography of, 297 tumors of, dullness over, 306 value of measuring circumfer- ences of, 316 Abdominal affections, severe hiccougli in, 540 breathing disappears in paralysis of diaphragm, 90 contents, position of, illustrated, 298 diseases, headache with, 483 distention, effect on diaphrag- matic breathing, 90 inflammation, restricting action of the diaphragm, 90 organs, irritative cough from, 165 pressure, importance of, in defeca- tion, urination, and labor, 540 reflex defined, 496 increase of, in intercostal neu- ralgia, 496 unilateral, absence of, 587 swellings, solid, feeling of resist- ance with, 116 typhus. iS'ee Typhoid Fever, wall in emphysema, 84 Abnormal constituents of urine, sec- tion on, 435-442 sounds over lungs, 125 Abscess, deep, revealed by oedema, 54 due to dentition, 286 irregular enlargement of liver from, 322 large, peptonuria with, 439 of abdominal wall, pain from, 309 case of, which simulated meteorism, 309 of chest, wall, weakened vocal fremitus with, 158 Abscess of liver, prominences on liver from, 326 tenderness with, 324 of lung, effect of, on thorax, 87 elastic threads in sputum of, 177 hsematoidin in sputum in, 172 lung tissue in sputum in, 172 purulent sputum in, 169 of spleen, unequal enlargement with, 335 of tonsil, 290 perinephritic, cause of pus in urine, 419 retro-pharyngeal, cause of cyan- osis, 43 Abscesses, staphvlococcus pyogenes found in, 603 Absolute deadness, 108 Abulia defined, 472 Accidental murmurs, 229 Accommodation in breathing, 95 of valvular deficiency, 195 paralysis of, 563, 568 Acetic acid, excess of, in stomach, 345 Acetone, a product of decomposition of albumin, 449 diaceturia with, 447 odor of breath in diabetes, 285 of urine from, 414 source of, in urine, 449 test for, 414, 449 when occurs, 414 Acetonuria, test for, 448 when occurs, 448 Acholic stools, color of, 373 odor of, 371 Achorion Sehonleinii, in vomit, 366 Achroodextrin, from starch, 353 " Acid curve " of urine in twenty-four hours, 404 intoxication in diabetic coma, 449 reaction of urine, usual, 403 urine, calculi found in, 433 Acids, fatty, needles of, in sputum, 180 39 ( 609 ) 610 INDEX. Acids, salivation caused by, 289 Acoustic amnesia, 552 ganglion, 461 nerve, 551 disease of, 572 injury of, 572 ^Acromegalia, defined, 583 Actinomyces in pleural exudation, 161 in sputum, 175 described, 189 with inflammation of mouth, 290 Acuoxylon, 140 Acute diseases not recurrent, 22 Adaptation in breathing, 95 Addison's disease described, 48 -i^gophony described, 159 jEsthesiometers, Sieveking's, use of, 474 After-sensibility, defined, 478 Age, location of heart in, 192 lung boundary differences due to, 125 old, area of heart dulness in, 205 position of apex beat in, 198 variations of percussion note by, 120 of pulse affected by, 234 Aged, venous thrombosis in marasmus of the, 268 Ageusis, with 'total hemiansesthesia, 574 Agrammatismus defined, 561 Agraphia, 552, 553 amnesia may simulate, 556 an aphasic symptom, 561 Air in peritoneal cavity, auscultation and percussion of, 318 in peritoneum, a cause of dimin- ished area of liver-dulness, 331 -passages, stenosis of inspiratory pressure diminished in, 164 sound of, on percussing over cavity containing, 109 Akataphasia defined, 561 Albumin, acetone a product of de- composition of, 449 boiling and nitric acid test, 436 -curve, 437 decomposition of, leucin and tyro- sin products of 432 ferrocyanide of potassium test, 436 Geisler's test papers, 436 in pleund fluid, 160 in serous sputum, 169 in sputum, 190 in urine, 435, 439 Albumin in urine after exertion, 437 makes the bismuth test for sugar uncertain, 444 significance of according to amount, 420 must be removed in determining nitrogen and urea, 434 physiological, small amount in urine, 405 picric acid test, 436 qualitative tests for, 435 quantitative tests for, 437 rare forms of, 489 Albuminous bodies, digestion of, 345 Albuminuria, a cause of dropsy, 53 casts scanty in physiological, 422 cyclic, 435, 437 oedema with, 54 renal casts in urine, diagnostic value of, 422 retinitis with, described, 601 when occurs, 435 Alcohol amblyopia, central scotoma in, 569 formation of, in stomach, 345 headache in poisoning with, 483 paralysis, lessened excitability in, without EaR in, 525 poisoning, odor of breath in, 285 uses of effect on disease, 21 Alcoholic amblyopia, 602 poisoning, delirium tremens from, 471 tremor, 531 Alcoholism, trembling of tongue of, _ 287 _ lipseraia in, 280 Alderton, reference to, 199 Alexia, 552 Alkalies, salivation caused by, 289 Alkaline fermentation in urine, from micrococci and bacilli, 425 odor of, 404 turbid urine from, 412 reaction of urine, sometimes in health, 403 urine, simple, distinguished from urine alkaline from fermenta- tion, 426 Allochiria defined, 478 Amaurosis after severe hemorrhages, 602 saturnina, 602 INDEX. 611 Amaurosis, temporary partial, signifi- cance of, 571 ursemic, 601 with albuminuria, 441 Amblyopia, alcohol, 569 alcoholic, and tobacco, 602 Ammoniacal fermentation of urine,402 odor of stool from urine, 372 Ammoniaco-magnesian phosphate in urine described, 431 Ammonio-magnesian phosphates in urine, 402 Amnesia, 554, 556 acoustic and visual, 552 may simulate atactic aphasia, word-deafness, word-blindness, agraphia, 556 mixed with aphasia, 555 Amnestic aphasia, 553, 554 Amoeba coli, 391 Amphoric breathing, 159 corresponds with metallic rales, 153 defined, 148 with cavities in lungs, 147 Amphoteric reaction of urine, 404 Amyloid degeneration of intestines, fats poorly absorbed in, 371 disease of spleen, 335 kidney, albuminuria with, 435 casts in urine of, 422 liver, surface of, 325 Amylolysis, disturbed in super- acidity of stomach, 356 incomplete, shown by microscopi- cal examination of vomit, 365 Amylolytic period of digestion, 342, 343 shortened, 346 Amyotrophic lateral sclerosis, 580, 586 EaR with, 524 increase of tendon reflex in, 500 lessened excitability without EaE. in, 525 partial EaR with, 525 An, an abbreviation for anode, 506 Anaemia, absence of pulse with, 243 a cause of dropsy, 53 albuminuria with, 435 alkalescence of blood diminished in, 283 caused by anchylostoma duode- nale, 382 color of blood in cases of severe, 271 Anaemia, diminished haemoglobin in, 275 dizziness with, 471 due to bothriocephalus lata, 380 to tapeworm, 377 headache with, 483 • heart-sounds often strengthened in, 217 in contrast with chlorosis as re- gards diminution of red cor- puscles, 276 leucocytosis in, 278 may be concealed by redness of face, 42 microcytes and macrocytes in, 276 microcythsemia with, 276 murmurs heard in, 229 ' oligocythaemia in, but not in chlo- rosis, 274 peculiarities of blood in, 275 pernicious, leucin and tyrosin in urine of, 432 retinal hemorrhages in, 562 uric acid increased in, 434 poikilocytosis with, 277 polyuria in, 406 progressive venous pulse with, 268 red corpuscles diminished and paler in, 275 retinal changes in, 602 splenic, enlargement of spleen in, 335 stools to be examined for parasites in, 377 subacidity of stomach in, 356 subjective sensations of vision in, 571 _ _ sensibility of hearing in, 572 tracing of pulse of, 248 urine of, very pale, 408 should be examined for ba- cillus tuberculosis, 426 venous humming in, 269 vertigo with, 472 Anaemic heart-murmurs, explanation of, 230 propagated from venous trunks in chest, 269 murmurs, 229 necrosis of pons and medulla, 462 Anaesthesia, cause of, 459 defined, 477 important distinction with refer- ence to distribution of nerve, 479 of dorsum of forearm, caution re- garding, 485 612 INDEX. Ansestliesia of mucous membrane in hysteria, 497 partial, cause of, 459 sensory, in gross hysteria, 534 total, rare, 479 Analgesia defined, 479 Anamnesis defined, 17 mode of taking, 19 scheme for, 26 unreliable regarding spasms, 533 what it comprises, 19, 20 Anarthria defined, 548 Anasarca. See CEdema. Anatomical disease, symptoms of, 587 divisions of the chest, 76 variations, cause of unequal pulse in symmetrical vessels, 257 Anatomy of heart, 191 of liver, 819 Anchylostoma duodenale, described and illustrated, 382 Anchylostomen in vomit, 364 Anchylostomiasis, 382 feces of, contains Charcot's crys- tals, 388 Aneurism, absence of pulse with, 243 aortic, pulsation in, 204 blood in sputum from rupture of 167 caution regarding, when making exploratory puncture, 162 diflicuity in distinguishing from apparent enlargement of heart, 210 effect of, upon pulse in one of two symmetrical vessels, 257 increased circumference of thorax in, 163 near oesophagus, caution regard- ing sounding oesophagus, 294 neuralgia from pressure of, 483 of abdominal aorta, 255 of aorta, and other arteries, effect on pulse, 245 crystals in sputum in hemor- rhage into lungs, 180 cyanosis from, 43 description of, 254 how distinguished from em- pyema pulsans, 102 jjressing on the larynx, 75 pressure by, upon recurrent nerve, 296, 599 of arch of aorta, affects vessels of left side, 255 Aneurism of ascending aorta, affects vessels of right side, 254 of descending aorta, 255 of innominate artery, 255 of minute arteries of brain a cause of hemorrhage, 577 of pulmonary artery, 255 phenomena of, 40 pressing heart forward, 203 pressure on nerves from, 469 pulsation of, near stomach, 302 recurrent paralysis a symptom of, _ 600 simulates enlarged heart, 209 systolic pulsations at base of heart in, 203 Angina, cause of enlargement of tongue, 286 hepatica, herpes with, 50 Ludovici, 594 cause of cyanosis, 43 necrotica, tonsils in, 290 pectoris, in organic disease of the heart, 577 pulse in, 240 Angle, epigastric, 82 in emphysematous thorax, 83 of Louis, 84 in phthisical thorax, 84 Angulus Ludovici defined, 76, 78, 81, 82 Anhidrosis, sudamina after long-con- tinued, 50 Anidrosis, 38, 581 defined, 37 Anilin, color of blood in poisoning by, 270 Animal parasites, examination of stool for, 377 exotic, 21 in sputum, 182 in urine, section on, 424 section on, 377 two found in blood, 283 Ankylostoma, 41 Ankylostoma-ansemia, 54 Anodal closure, result of, 506 Anode, at the, contraction only at the opening of the current, 506 colors blue litmus red, 505 positive pole, 504 Anomalies of breathing, 89 Anorexia, defined, 472 Anosmia, when it occurs, 573 unilateral, associated with hemi- ansesthesia, 573 INDEX. Qli AnOTe, occurrence of, important sign in tetanus, 526 AnSC, 518, 519, 520, 521,523 ^ minimal, determination of, 515 Anterior column of spinal cord, 455 cranial fossa, effect of lesion of, 457 gray columns, 492 disease of, EaR with, 524 _ horn, characteristic sign' of cere- bral and spinal paralysis above, 494 excitability of, increases skin reflex, 496 ganglia, 455, 456, 492 part in skin reflex, 496 results of disease of, 490 horns, disease of, tendon reflex diminished in, 500 effect of lesion of, 456 gray, EaR with lesions of, 524 preside over muscular tonus, 528 ofBce of, 455 pyramids, 454 roots of spinal nerves, 455 compression of, results of, 491 Anthrax bacilli, cultures, 606 described, 280, 606 illustration of, 280 Antifebrin, urine after taking, 451 Antiperistalsis of stomach, 303 Antipyrine, urine after taking, 451 Anuria from obstruction by echino- coccus, 425 in acute nephritis, 407 in hysteria, 579 Anxietv, effect of, on amount of urine, 401 pulse frequent in, 240 subjective expression of, in dys- pnoea, 99 Aorta, anatomical relations of, 254 aneurism of, pulsation in, 204 paralysis of recurrent nerve by pressure from, 538 pressure by, upon recurrent nerve, 296 relation of left carotid to, clinical importance of, 463 sclerosis of, shown by stronger aortic second sound, 217 stenosis of, commencement of, ab- sence of apex-beat in, 202 Aorta, stenosis of, from enlarged retro- peritoneal glands, 341 murmur of, where heard, 224, 225 pulse in, 252 tracing of pulse in insufficiency and stenosis of, 249 various phenomena of, 253 Aortic and tricuspid insufficiency, combined arterial and venous crural sounds with, 269 first sound, softest heart sound, 217 insufficiency, 194, 195 and stenosis, effects of, 195 opposite condition of pulse in, 252 arterial liver pulse in, 257 capillary pulse in, 256 double sound over crural artery in, 259 effect upon second sound, 258 increased arterial pulsation with, 257 murmur of, where heard, 224, 225 progressive venous pulse with, 268 nulsating splenic tumor with, 335 _ pulsation in aorta with, 254 of retinal arteries in, 602 pulse in, 251 with, 253 tracing of pulse of, 249 weakening of first sound at apex in, 219 stenosis, 194 absence of pulse Avith, 243 paleness in, 41 pulse with, 242, 244 sounds with, 258 weakening of aortic second sound in, 219 valve, insufficiency of, sounds in, 217 valves, where best heard, 213, 214 Ape-hand in paralysis, 544 Apex-beat of heart, examination of, 197 absent in pericardial adhesion, 202 and heart-beat not to be con- founded, 201, 203 causes of, 198 change in width and strength of, 200 614 INDEX. Apex-beat coincides with systole of heart, 212 displaced by retraction of lung, 209 displacement of, 199 doubling of, 202 in determining apparent enlarge- ment of heart, 210 in dislocation of heart, 211 position of, in children, 198 Avith pericardial exudation, 202 strength and breadth of, a sign of hypertrophy, 200, 201 weakening of, causes, 201 Apex, first sound at, strengthened in mitral stenosis, 218 sounds of heart heard at, 214 mitral murmurs at, 224 murmur of stenosis of left auriculo-ventricular open- ing, heard at, 224 Aphasia, with albuminuria, 441 atactic, 552, 553, 554, 559 cause of, 555 phenomena of, 558 Charcot's diagram of, 560 Lichtheim's diagram of, 557 localization of, 555 mixed with amnesia, 555 mode of procedure in testing for, 555, 556 motor, 559 sensory, phenomena of, 558 Aphasic disturbances, 549 Aphonia, 74 a result of recurrent paralysis, 599 how caused, 597 in paralysis of recurrent nerve, 538 tone of cough in, 166 Aphonic patients, 159 Aphthae, in vomit, 366 Apices of lungs, 81, 82 boundaries, 122 caution regarding slight dead- ening over, 126 cavities in, 131 diminished in phthisis, 137 disease of both, comparative percussion in, 125 dry rales with catarrh of, 150 large rales in, a sign of cavity, 152 Apices of lungs, percussion note over, 120 position of, changed by dis- eased condition in neck, 137 relatively deadened sound over, 114 shrunken, open tympanitic sound over, 110 sometimes enlarged, 136 systolic subclavian murmur at, 259 tuberculosis of, increased vesicular breathing in, 144 deadened sound with, 129 pain with, 102 prolonged expiration in, 145 tympanitic resonance over, in beginning, 127 tympanitic sound over, in be- ginning tuberculosis, 112 upper limits of, 125 Aplasia of lung, deadened sound over, 114 Apncea, 92 contracted pupils in, 93 jerking of muscles in, 93 Apoplectic attack, defined, 585 habit, 575 Apoplexy. See Cerebral hemorrhage, aphasia after an attack of, 555 decubitus after, 582 disturbance of consciousness in, 470 glocosuria with, 443 heart and vessels to be examined, 577 pulse in, 245 syncope as a precursor of, 471 tinnitus aurium sometimes a pre- cursor of, 573 transitory albuminuria with, 435 Arc de cercle, 468, 534 Area of heart dulness, enlargement of, 208 Areometer, use of, in determining specific gravity of urine, 403 Arm, motor centre for, 454 nerves of, 485 paralysis of the muscles of, 542 points of electrical irritation upon, illustrated, 509, 510 position during electrical exami- nation, 511 INDEX. 615 Arsenic, poisoning by, cause of haem- ato-jaundice, 47 -paralysis, lessened excitability in, without EaR, 525 Arterial liver-pulse, when liver en- larged, 322 pulse, propagated through the capillaries, 268 sclerosis, abnormal pulsations in arteries in, 256 condition of arteries in, 256 gallop rhythm of heart with, 221 pulse with, 244, 245 Arteries, examination of, 234 Artery, basilar, 461 middle cerebral, 462 hemorrhages and emboli most frequent in, 463 largest and most impor- tant of the brain, 462 ophthalmic, 461 posterior cerebral, portion of brain it supplies, 462 communicating, 461 vertebral, 461 A.rthritis deformans, 467, 583 pain in spine with, 483 Arthropathia in nervous diseases, 583 Articular neuralgia, 484 Arythm of pulse, 241 Arythmic breathing, 92 Ascarides in ductus choledochus, a cause of jaundice, 47 Ascaris lumbricoides described, and symptoms of, 380 eggs of, 381 illustrated, 381 Ascites, abdominal veins enlarged with, 314 associated with cirrhosis of liver, 325, 326 cause of diminished area of liver dulness, 331 caused by stasis, 314 chylous, 318 defined, and diagnosis of, 313 due to venous engorgement, 260 etfect on form of chest, 86 emplovment of deep breathing in, 323 ' may cause venous stasis, 262 press diaphragm up, 322 tympanitic sound with distention of abdomen from, 130 value of tapping for diagnosis, 318 Asiatic cholera : See Cholera Asiatica Aspergillus fumigatus (mould) in spu- tum, 175, 190 Aspermatism, 580 Asphyxia, local, in neuroses, 577 Associated movements in paralysis, defined, 535 Asthma, bronchial, expiratory dys- pnoea peculiar to, 99 rapid breathing in, 94 relation of Curschmann's spi- rals to, 180 casts in sputum of, 173 cause of cyanosis, 43 Charcot-Leyden's crvstals in, 182 in sputum of bronchial, 174 in- connection with disease of the nose, 575 oxalate of lime in sputum of, 182 simulation of, 19 spirals in sputum of, 175 uraemic, 440 Asymmetry of breathing described, 91 of pulse, 245 of skull, 465 Ataxia defined, 527 and explained, 529 diflSculty of distinguishing, from tremor, 531 of upper extremity, 561 when it occurs, 529 Ataxic aphasia, 552, 553 cause of, 555 Atelectasis in children, 98 Atelectatic ciepitation, inspiratory, defined, 154 Atheroma of aorta, systolic murmurs with, 254 of vessels a cause of hemorrhage of brain, 576 Athetosis defined, 535 Atonia in paralysis, 489 Atonic atrophic paralysis, 494 paralysis, 494 Atrophic paralysis, 490 fibrillary contractions in, 632 partial EaR in, 525 two forms of, 493 Atrophy and paralysis, parallelism between, 493 disunion of, 493 616 INDEX. Atrophy defined, 35 disturbance of vision from, 601 of inactivity, 491, 494 of muscles, 489 varieties of, 490 Atropine, effect of, on pupil, 567 poisoning, red skin in, 41 Auenbrugger, reference to, 104, 105 Aura, a prelude of epileptic convul- sion, 532 Auricle, its relation to venous pulse, 264 left, location of, 191 right, location of, 191 Auricular semi-lunar murmur, where heard, 224 Auricularis magnus nerve illustrated, 485 Auriculo-temporal nerve, illustrated, 485 Auscultation of heart, 211 points of election for, 213, 214 of intestine, 312 of lungs, 138 to be after percussion, 140 of peritoneal cavity, 318 of pulse, 257 of stomach, 307 of veins, 268 of voice, 156 when it may be omitted, 158 of whispered voice, 159 results of, in aneurism of aorta, 254 value of, when small surface of lung is involved, 126 Autocthonous clots, effect on pulse, 245 Auto-intoxication, by acetonuria, 448 by diaceturia, 448 Auxiliary muscles of inspiration and expiration, 540 named, 96 of respiration, aid in thoracic breathing, 99 Axillary lines defined, 76 nerves illustrated, 486 Azoospermia, 580 BAAS, reference to, 151 Baccilli, reference to, 159 Bacillus of anthrax, illustrated and described, 280 Bacillus described, cultures of, 604 distinguished from Koch's comma bacillus, 607 in sputum from mouth, 188, 289 in urine, 425 resembling tubercle bacillus, 400 of Finkler-Prior described, cul- tures of, 390. 607 of glanders, found in blood, 282 of malignant oedema described, 604 of tuberculosis, absence of, 187 discovery of, made elastic threads in sputum less valuable, 177 found in blood (rare), 281 in sputum, 175 in urine, sign of tuberculosis of urinary passages, 426 Back, nerves of, too deep for electrical examination, 511 Bacteria, casts of, in pyaemia, 424 found in hyaline casts, 423 intestinal, in stools, value of, 388 in urine, 399 of nephritis, 427 section on their diagnostic value, 602 urine made cloudy by, 402 turbid from, 413 Balz, reference to, 174, 183 Bamber, reference to, 191 Band-box note with emphysema, 135 Barrel-shaped chest, 83 Bartels, reference to, 395 Basch, reference to, 245 Basedow's disease, blowing murmurs over lymphatic glands in, 259^ heart-beat in, 201 hemidrosis in, 38 increased strength of heart- sounds in, 216 palpitation of heart in, 577 pulse in, 240 tremor of, 531 Basilar artery, 461 Baths, cold, value of pulse in showing result of, 253 induce perspiration, 37 Baumann, reference to, 432 Berger, reference to, 190 /3-oxybuteric acid in urine of diabetic coma, 449 INDEX. 61T Biceps reflex, 499 -teudou reflex, 498 Biedert, reference to, 164, 186 Bienstock, reference to, 388 Biermer, reference to, 104, 135, 136 Bile-acids in urine, diagnostic value of, 443 small amount of, in normal urine, 405 value of, in jaundice, 46 coloring matter of, in urine, 410 deficiency of, effect on absorption of fat, 371 effect of, on color of stools, 373 not usually found in watery stools, 374 -pigment in sputum in icterus, 172 -pigments and bile acids, section on tests for, in urine, 442 vomiting of, 361 Biliary colic, vomiting in, 358 engorgement, tenderness with,324 Bilirubin, 46 Bismuth test for sugar in urine, 444 uncertain if there is albumin, 444 Bizzozero, reference to, 271 Black color of vomit, from ingestion of iron, and in acute lead-poisoning, 360 Bladder, alkaline fermentation in, cause of turbid urine, 412, 413 carcinoma villosum of, particles of tissue in urine from, 421 completely emptied by act of uri- nation, 408 crises (painful tenesmus) in tabes, 580 depot of pus in the neighborhood of, cause of hydrothionic urine, 415 distended, diagnosis of, 398 disturbance of, 587 examination of, 398 importance of emptying in exam- ing abdominal organs, 341 paralysis of, 590 position of, 398 retention of urine in, a cause of diminution of secretion, 408 tenesmus of, causes of, 400 Blindness, central, 568 result of lesion of corpora quadri- gemina, 570 Blood, abnormal additions to, 280 alkalescence of freshly drawn, 283 Blood, arterial, brighter in color than venous, 270 bacillus of typhoid fever found in, 281 -casts in urine, sign of renal hsema- turia, 424 chemical examination of, 283 color of, in cases of poisoning by various substances, 270 coloring matter of, in urine, when occurs, 410, 441 corpuscles, change in form and size of red, in anaemia, 275 counting of, 274 destruction of in intermittent fever, 434 in stools, 387 normal proportion of white to red, 278 pathological diminution of red, 275 proportion of white to red increased in anaemia, 275 red, number of, in a cubic millimetre of blood, 275 crystals in, in leukaemia, 279 diseases of, cause of paleness, 40 entire amount equals about one- thirteenth weisrht of body, 270 examination of, 270 from nose and throat, diagnosis of, 171 in sputum from rupture of aneu- rism, 167 intensity of color of, 270 in urine, form and appearance of, 412, 416 causes albuminuria, 435 -jaundice, 46 large effusions of, urobilin in urine with, 409 -making organs, development of fat in disease of, 41 microscopical examination of, 273 mode of examination of, for micro- organisms, 282 morphological constituents of, im- portance of, in diagnosis, 270 movement of, in heart, 193 murmurs, 229 normal structures of, 273 pathological conditions of, as re- vealed by the microscope, 273 -pressure, diminished amount of urine when reduced, 407 how measured, 245 618 INDEX. Blood, pure, changed by gastric juice in stomach, 362 seldom vomited, 362 spectroscopic condition of, 272 examination of, valuable in three classes of cases, 272 time it takes to coagulate after withdrawn, 283 tracing of pulse after loss of, 248 Bloody sputum described, 169 vomit (hseoiatemesis), 361 Blushing, 42 Boas's test for free muriatic acid, 351, 367 Boiling and nitric acid test for albu- min in urine, 436 Boilliau'l, reference to, 552 Bone reflexes, 500 Bones and joints in nervous diseases, section on, 583 arrest of growth of, in paralysis, 583 sound on percussion of, 109 Borborygmi, 312 Border of lungs, abnormal position of, 125 Bornhardt, reference to. 35 Bothriocephalus lata described, 379 illustrated, 379 Bottcher, reference to, 503 Boulimia defined, 472 Boundaries of lungs changed, 136 method of determining, 117, 119 parietal, of organs, 116 of liver, spleen,- and kidneys illustrated, 321 Bowels, disturbance of, from venous engorgement, 261 obstruction of, peculiar grass- green vomit with, 361 vomiting of feces in occlusion of, 364 Brachial plexus, Erb's point, 510 paralysis of, cause of anaes- thesia of the region of the median nerve, 487 Brachycardia, 238 Brachycephalus, 465 Brain, abscess of, from disease of the nose, 576 hearing in, 572 relation of, to disease of the lungs, 576 sensibility of cranium to pres- sure with, 466 Brain, absence of cough in disease of, 165 aneurism of minute arteries of, a cause of hemorrhage, 577 bloodvessels supplying, section on, 461-463 concussion of, glycosuria after, 443 cysticerci in, from taenia solium, 578 difficulty of local examination of, 463 diseases of, anomalies of breath- ing in, 91 dyspnoea in, 94 headache with, 482 inherited, 20 disturbance of vision by lesion at base of, 460 effect of local disease at base of. 457 habit which predisposes to hemor- rhage of, 575 hearing in local disease of, 572 hemorrhage and softening of, re- lation to diseases of the heart, 576 inequality of pupils in unilateral atfections of, 567 lateral view of, 452 lesion at base of, paralysis of mus- cles of one eye in, 565 local diseases of, diagnosis of, 586 hemidrosis in, 38 thrombosis of vessels of, 576 paralysis of cortex of, early spasms in, 494 postures assumed in diseases of, 33 retinitis in syphilis of, 562 slight amount of vomit in diseases of, 360 slow pulse in diseases of, 237 symptomatic epilepsy in anatom- ical diseases of, 533 symptoms, general, enumerated, 585 _ syncope in chronic diseases of, 471 syphilis of, changes in fundus oculi in, 601 tuberculous nature of diseases of, if nutrition is poor, 575 tumors of disturbance of con- sciousness with, 471 migraine with, 483 vertigo with, 472 value of pulse in showing com- plicating disease of, 253 INDEX. 619 Brain, vomiting from irritation of, 358 in rapidly developing diseases of, 578 occurs suddenly in diseases of, 359 Breath, odor of, importance of, 285 short, in deformity of chest, 88 Breathing. See also under Respiration, abdominal, 90 disappears in paralysis of diaphragm, 90 anomalies ot, 89, 91 from CO2 in blood, 92 asymmetry of, described, 91 costal type of, in women, 90 deep, during auscultation, 141 diaphragmatic, interfered with, 86 irregularity of, 92 obstructed, 74 of compression defined, 147 painful, effect of posture upon, 32 thoracic, replaced by diaphrag- matic, 90 transition, explained, 149 undefined, explained, 148 Brenner, reference to, 572 Brick-dust sediment in urine ex- plained, 402, 429, 430 Brieger, reference to, 356, 372, 432 Bright's disease, choked disc with, 601 dropsy of, explained, 440 Broca, reference to, 552, 553, 555 Bromine, urine after taking, 450 Bronchi, epithelium in sputum from, 176 Bronchial asthma, casts in sputum of, 173 Charcot-Leyden's crystals in sputum of, 174, 182 relation of Curschmann's spiral to, 180 breathing, how conducted to the ear, 143 difficult to distinguish from vesicular, 143 normal, described, 141 nottobe confounded with pathological, 141 pathological, explained, 164 difficulty of, weakened in case of filled cavity, 147 Bronchial catarrh, 94 cause of diminished vesicular breathing, 145 kind of rales with, 150 tubes, closure of, weakened vocal fremitus with, 158 pieces of, in sputum, 172 rapid breathing in diseases of. 94 sensitiveness of, a cause of cough, 165 Bronchiectasis, 131 amount of expectoration in, 168 friction sounds with. 156 odor of sputum in, 171 Bronchiectatic cavities, micrococci in sputum from, 189 ringing rales with, 153 Bronchitis, acute, mucus in first stage of, 168 a ferment in sputum of, 190 alveolar epithelium in sputum of, 177 amount of expectoration in, 168 capillary in children, 98 caused by dust, 21 Charcot Leyden's crystals in spu- tum of, 174, 182 chronic, morning cough of, 165 cyanosis in, 43 diffused, rales with, 150 fetid, crystals in sputum of, 181 micrococci in sputum in, 189 odor of sputum in, 171 relation of, to brain disease, 576 sputum in three layers in, 169, 174 fibrinous tubes iii sputum of acute and clironic croupous, 172 increased vesioular breathing in, 144 jerking, inspiration in, 145 metallic rales with, 150 non ringing rales with, when there is a broncho-pneumonic deposit, 153 prolonged expiration in, 145 purulent, coin-shaped sputa in, 169 putrid, leptothrix buccalis in spu- tum of, 184 tyrosin in sputum of fetid, 182 vital capacity of lungs in, 164 Bronchophony described. 158 Broncho-pneumonia in children, 98 620 INDEX. Bronchus, primary, when open tym- panitic sound is heard over, 111 stenosis of, 98 Bronze skin, 48 Bruit de pot fele described, 134 where it occurs, 134 Bubbling rales, 154 Buccinator nerve, illustrated, 485 Bulb, EaR with disease of the motor nerves of, 524 Bulbar paralysis, absence of bone re- flex in, 500 of reflex of pharynx in, 497 cyanosis in, 43 EaR with, 524 increased secretion of saliva in, 577, 578 lessened excitability in, with- out EaR in, 525 paralysis of diaphragm in, 90 of recurrent nerve with, 538,599 position of the soft palate in, 538 power to cough lost in, 165 quick pulse with, 577 rigid thorax in, 91 salivation in, 289 speech in, 548 pulse (bulbus jugularis), 265 Bulbus jugularis, 263, 265 murmur at, in tricuspid in- sufficiency, 268 Bumm, reference to, 604 Bursa omentalis, 299 Butyric acid, formation of, in stomach, 345 Buzzing felt near the heart, 204 G abbreviation for contraction. 'f Ca, abbreviation for cathode, 506 Cachectic conditions, chloride of so- dium in urine diminished in, 434 Cachexia, chronic, disturbance of con- sciousness in, 471 defined, 35 delirium in, 471 diminished volume of abdomen in, 309 general atrophy in, 491 indican in urine of severe, 409 leucocytosis in, 278 malarial, 41 oxaluria in, 430 Cachexia, poikilocytosis in, 277 severe, ecchymosis in, 51 state of skin in, 36 temperature in, 64 urea diminished in all kinds of, 434 Cadaveric odor of breath, 285 Caecum, to be examined in sudden obstipation, 369 Calcifications in pericardium, friction sounds from, 232 Callus, cause of pressure on nerves, 469 Camman, reference to, 140 Cancer. See also Carcinoma. cachexia of oxaluria with, 430 poikilocytosis in, 277 of head of pancreas, a cause of jaundice, 47 of rectum, pain at stool in, 370 of stomach, alkaline vomit in, 366 palpation of, 303 use of sound in, 302 navel on liver in carcinoma of liver, 325 paleness in, 41 Cancrum oris, description of, 288 Cantani, reference to, 430 Cantharides, fibrin in urine in poison- ing by, 439 Capillaries, arterial pulse propagated through, 268 Capillary pulse described, 256 Capsule, inner, lesion of, with hemi- chorea, 535 internal, 454, 461 Caput Medusge defined and explained, 262 quadratum, 464 Carbolic acid, color of urine after taking, 411, 435, 451 Carbonate of lime in urine, 431 illustrated, 431 Carbonic acid, accumulation of, a cause of cyanosis, 42 diagnostic importance of, 270 eff^ect of poisoning by, upon color of blood, 270 in blood, cause of, 43 increased exhalation of, in fever, 60 oxide poisoning, absorption bands in blood in, 272 Carcinoma. See also Cancer, acetonuria in, 448 INDEX. 621 Carcinoma, delay in absorption from stomach in case of, 355 disturbance of consciousness in, 470 effect of, on consistence of liver, 326 epithelial, in larynx, illustrated, 696 inherited, 20 irregular enlargement of liver with, 322 nutrition poor in, 575 of gall-bladder, 326 of kidney, palpation of, 395 of larynx described, 597 of liver, change in shape of, 325 difficult to distinguish from that of omentum, 340 with and without tenderness, 324 of lung, deadened sound over, 127 of oesophagus, 292, 294, 296 affecting the larynx, 75 of pancreas, diagnosis of, 340 of peritoneum, 315 of skull-wall, 465 of spleen, unequal enlargement from, 335 of stomach, absence of free muri- atic acid in, 356 hvpersecretion in cases of, '357 local increased resistance with, 302 pain of, 304 of tongue, 286 shreds of tissue in stools in, 377 ventriculi, hemorrhage from, 362 peptonuria with, 439 Carcinomatous pleuritis, cells in exu- dation of, 161 ulceration of rectum, hemorrhage from, 375 Cardia of stomach, position of, 298, 299 Cardiography of apex-beat, 202 Caries of rib, pain in, 101 cause of pleurisy, 102 of vertebrae, tenderness with, 467 Carotid artery, left, relation to aorta, clinical importance of 463 pulsation of, in health, 255 pulse in aneurism of aorta, 254 Carotids, internal, supply the brain, 461 Cartilage, sound on percussion, 109 CaSC, 518, 519, 523 determination of minimal, 515 early in tetanus, 526 Case-taking, value of, 25 CaSTe, 518 determination of, 515 early in tetanus, 526 Casts, epithelial, forms of, in urine, 424 in urine, the infallible signs of nephritis, 420 of red blood-corpuscles, ilustrated, 424 renal, kinds of, 422 preparation of, for examina- tion, 422 Catalepsy defined, 535 rarely occurs with anatomical diseases, 536 Cataract with diabetes mellitus, 562 Catarrh, acute nasal, a sign of various diseases, 74 chronic nasal, cause of neuroses, 575 nasal, 73 of intestine, meteorism with, 309 of large intestine, stool of, 373 of larynx, signs of, 593 of stomach, delay in absorption * in case of, 355 hypersecretion in cases of, 357 pain with, 303 Catheter, always to be used to draw urine in cases of unconscious- ness, 401 cystitis excited by, 425 to be used to avoid contamination of urine, 399 use of, a cause of cystitis, 579 shows residual urine, 408 Cathodal closure, result of, 506 Cathode (negative pole), 515 at the, contraction at the closing of current, 506 of galvanic current, use of, in test- ing sensibility of spinal column, 468 of the opening current of sec- ondary coil stronger than anode, 504 Caudate nucleus, blood-supply of, 462 Causes of disease, exciting, ,21 predisposing, 21 622 INDEX. Cavities, bronchiectatic, micrococci in sputum from, 189 cylindrical, effect of length upon pitch of sound, 110 experiment to illustrate, 110 in apex revealed by loud rales, 152 in lungs, amount of expectoration from, 168 bronchial breathing over, 146 coin-shaped sputa from, 169 containing air, closed-tympa- nitic sound from, 110 open or closed, tympanitic resonance over, 131 plegaphonia over, 159 large parietal, noise of spun-top over, 134 with smooth walls, 136 Cavity in lung, if filled, weaker bron- chial breathing over, 147 increased vocal fremitus with, 158 metamorphosing breathing a sure sign of, 148 purulent sputum from, 169 ringing rales with, 152 Celli, reference to, 282 Celsius' thermometer, 57 Central convolution, 459 anterior, blood-supply of, 462 left anterior, centre of acous- tic recollections, 555 posterior and anterior, illus trated, 466 blood-supply of, 462 thread of Curschmann's spirals described, 179 Cephalalgia, significance of, 482 Cercomonas (infusorium) in sputum, 183 Cerebellum ataxia in lesions of the vermiform process, 529 illustrated, 466 vermiform process of, lesion of, 534 vertigo with tumor of,472 vomiting in diseases of, 578 Cerebral abscesses, 585 affections, ataxia in, 529 artery, middle, hemorrhages and emboli most frequent in, 463 largest vessel of brain, 462 posterior, portion of brain it supplies, 462 Cerebral blowing sound in children with systole of heart, 258 congestion, with albuminuria, 441 disease, absence of cough in, 165 severe hiccough in, 540 diseases, clonic spasms in local- ized, 532 hemorrhage, Cheyne Stokes respi- ration in, 92 irritation, acetonuria with, 448 paralysis above the anterior horn, characteristic sign of, 494 EaR not present in, 525 in children, hemiathetosis in, 535 increase of tendon reflex in, 500 symptoms, significance of, 587 tumors, Cheyue-Stokes respira- tion in, 92 Cerebro-spinal meningitis, herpes with, 50 Cerebrum, 461 blood-supply of, in the region of fissure of Sylvius, 462 disease of, muscular atrophy with, 493 relation of acostic nerve to, 461 Cervical enlargement of cord, location of, 468 nerves, illustrated, 485 vertebrae, caries of, 589 Chain-coccus in urine, 426 Change of respiratory sound, Fried- reich's, defined, 113 of sound, tracheal, Williams's, 121, 130 Wintrich's, described, 111 Charcot, reference to, 279, 493, 526, 556, 557, 558, 560, 581, 582, 587 Charcot's crystals, 387 Charcot-Leyden's crystals, 179 described, 181 in asthma, 388 in sputum, 174 Cheek, nerve-supply of, 484 Cheese-spirals, 391 Chemical examination of blood, 283 Chemistry of digestion, 348 Chest, asymmetry of, 82 circumference of, in relation to weight and height, 35 dimensions of, 82 form of, in relation to disease, 81 lagging behind of, 86 pathological form of, 82 INDEX. 623 Chest, sides of, percussion note over, 120 -wall, affections of, which cause deadened sound, 130 inflammatory diseases of, weaken apex-beat, 201 thickening of, a cause of diminished vesicular breathing, 145 weakened vocal fremitus with, 158 Cheyne-8tokes respiration described, 91, 92, 93 dyspnoea in, 94 increased vesicular breathing in, 144 with uraemia, 440 Chiasm, pressure upon, atrophy of optic nerve from, 601 Children, area of heart-dulness in, 205 arrest of growth of bone in paral- ysis of, 583 at first naturally ataxic, 527 cancrutu oris in, 288 capillary bronchitis in, 152 cerebral blowing sound with sys- tole of heart in, 258 choreic motions in encenhalitis in. 535 color of stool in, 373 cracks in lips of, a sign of heredi- tary syphilis, 285 diaceturia in fever of, 447 as an independent disease in, 447 ease with which they vomit, 358 edge of liver distinct in, 323 effect of severe diarrhoea in, upon amount of blood in the body, 270 _ elasticity of thorax in, effect on rales, 153 epileptiform attacks from various causes, 533 examination of, for eruption of teeth in, 285 expansion of lungs in, after whooping-cough, 136 frequency and character of stools in, 368 gallop rhythm a sign of heart- failure in, 221 heart-sounds in, 216 hemiathetosis in cerebral paral- ysis in, 535 how to examine mouth of, 284 Children, kinds of fungus spores in stools of, 388 laryngitis in, 593 lientery stools in, 372 meat-juice stools in catarrh of large intestine in, 375 nervous disturbances from intes- tinal parasites in, 578 nursing, sour odor of stool nor- mal in, 371 percussion note in, 120 position of apex-beat in, 198 of heart in, 192 pulse in, with febrile disease, 239 rapid breathing in fever of, 94 reaction of stool in, 372 relative heart-dulness in, 207 retro-pharyngeal abscess in, 290 round worms in, 380 size of liver in, 320 sounding oesophagus of, 293 thrush in, 288 yielding thorax of, permits pro- jection in enlargement of liver, 321 Chill described, 62 with rise of temperature, signifi- cance of, 64 Chittenden, reference to, 439 Chlorate of potash, color of blood in poisoning by, 270, 271 poisoning by, causing haema- to-jaundice, 47 Chloride of calcium, poisoning by, methsemoglobin in blood in, 272 of iron reaction, test for acetone, 414 of sodium, amount of, in urine 405 in urine, 434 Chlorides usually diminished in fever, 60 Chloroform poisoning causing hsema- to-jaundice, 47 odor of breath in, 285 Chlorosis, blood-corpuscles markedly pale in, 275 color of blood in, 271 dizziness with, 471 Egyptian, 41 heart-sounds strengthened in, 217 murmurs heard in, 229 no notable diminution of red cor- puscles in, in contrast with .anaemia, 276 624 INDEX. Chlorosis, paleness in, due to loss of hsemoglobin, 41 red blood-corpuscles not dimin- ished in, 274 use of Fleischl's hsemometer in, 276 venous humming in, 269 Choked disk, b^, 587 absence of, in bulbar paral- ysis, 496 from intra- cranial pressure, 600 _ _ recognition of, 601 unilateral, 565 Cholseraia, 47 Cholera Asiatica, alkaline vomit in, 366 anuria with, 407 bacillus, cultures of, 607 described and illustrated, 389 mode of preparation of, 389 _ necessity of pure culture of, 890 color of stool in, 373 effect of discharges in, on amount of blood in the body, 270 examination of, 606 increased peristalsis in, 366 indican in urine of, 409 great quantity of stool in, 370 mucus in stools of, 374 odor of stools in, 372 peculiar vomit of, described, 361 saliva diminished in, 289 severest diarrhoea with, 369 sweat in, 38 watery stools in, 371, 374 morbus, mucus in stools of, 374 Cholesterine, crystals of, in sputum, 181 Chorda tympani, 461, 484 Chorea minor described, 534 significance of, 535 Choroid, tubercle of, 601 Choroidal tuberculosis, 562 Choroiditis syphilitica, 601 Chronic diseases, development of, in- dicated by weight of body, 35 outbreaks of, 22 Chyluria, fibrin in urine in, 439 lipeemia in, 280 Chyluria, Hpuria in, 447 produced by filaria sanguinis, 425 rare, 412 Ciliated epithelium, transfer of mucus bv, 167 Circle of Willis, 461 Circulation, disturbance of, causing paleness, 40 through lungs, 44 Circulatory aouaratus, examination of, i91 disturbances of, 576 Circulus vitiosus, in stomach, 345 Circumference of thorax increased in inspiration, 163 where measured, 162 Circumpolarization for determining presence of sugar, 447 Cirrhosis of liver, ascites with, 314 bloody vomit in, 361, 362 consistence of liver in, 326 diminished area of dulness with, 331 enlargement of spleen with, 335 made out after tapping abdo- men, 318 surface of, 325 urine of, dark, 408 venous engorgement caused by, 262 Clarke, columns of, 459 Clavicular depressions deepened, 87 Clavus hystericus, 482 Clear sound defined, 106, 109 from closed air-cavity, 110 Clinical study, value of case-taking in, 25 Clonic spasms, 530 when occur, 532 Closed tj'mpanitic sound defined, 110 heard over stomach. 111 Clothing, eiFect of, on disease, 21 CO2 in blood, effect of, on breathing, 93 Coagulation of blood slower when nutrition is disturbed, 283 Coal-dust in epithelial ceils in sputum, 177 -soot in sputum, 171, 176 Cocaine, effect of, on pupil, 567 Cocci in urine, 425 Cod-liver oil, lipuriawhen taking, 447 CofFee-grounds-stool, in gastric hem- orrhage, 375 -vomit explained, 363 Cohnheim, reference to, 53, 54, 407 INDEX. 625 Cohnheim's hypothesis regarding dropsy of kidney disease, 440 Cold baths, value of pulse in showing result of. 253 catching, disposition to headache with, 483 Colic, abdominal, from passage of gall- stones, 37() Collapse, cold sweat of, 38 described, 63 from hemorrhage in casesof ulcer of stomach, 362 shown by fall of temperature, 65 weakness of apex-beat in, 201 Colon, boundary between, and small intestine 312 distention of, for purposes of diag- nosis 311, 312 fecal masses in, increases the area of dulness near the spleen, 338 position of, illustrated, 298 relation of, to spleen, 336 transverse, scybala in, 303 tumors of transverse and descend- ing, confounded with those of spleen and kidney, 311 Color of expectoration, 168 of skin, 38 of tongue, 287 of urine, 401 -sense, testing the, 568, 571 Columns of Clarke, 459 of Goll, 459 of Tiirck, 455 Coma defined, 470 diabetic, 579 acetone odor of urine in, 414 ;S-oxybutyric acid in urine of, 449 diaceturia in, 447 odor of breath in, 285 difficulties of diagnosis in, 471 from diaceturia, 448 post-epileptic, 533 ursemic, 440 with diabetes mellitus, 579 Comma bacillus, Koch's, distinguished fromFinkler-Prior'sbacillus,390,607 Communicating artery, posterior, 461 Comparative percussion, 118, 121, 125 Compensation of heart disease, pulse in arrested, 240 of valvular deficiency, 195 Compensatory hypertrophy of one division of heart, 219 Complementary pleural sinus, 80 exudation into, 306 space, 192 Complication of disease shown by temperature, &^ Complications, value of pulse in, show- ing beginning of, 253 Concealment of disease, 19 Concentrated urine, appearance of, 402 Conception of space, how tested, 481 Concretions in urine, 433 Concussion of cranium, disturbance of consciousness in, 471 Conduction, resistance to, 512 Conductive resistance, 514 variations of, due to thickness of skin, 513 Confinement to bed, ataxia after, 529 Confluent sputa, 169 Congenital drawing in of thorax, 89 Conjugate deviation, 566 of the eye, 563 Conjunctiva, color of, 39, note. nerve supply of, 484 Consciousness, change of, in Cheyne- Stokes's breathing, 93 diseases in which disturbances of occur, 470 disturbances of, terms used for, 470 loss of, 40 sign of, 489 mydriasis with marked disturb- ance of, 566 never an entire loss of, in hys- terical convulsions, 533 obtunded, phenomena of, 471 when there is loss of, heart and vessels to be examined, 577 Consensual reaction of pupils, 567 Consistence of expectoration, 168 Consonance increases vocal fremitus, 158 Consonant rales, 152 Constipation, 368 alternating with diarrhoea, 369 and severe obstruction to be sharply distinguished, 369 habitual, in diseases of spinal cord, 578 Constrained positions and motions de- fined, 534 Constricted liver from tight lacing, 323 Constriction, feeling of, about thorax, 482 40 626 INDEX. Contagion distinguislied from infec- tion, 22 Continued fever, range of temperature of, 62 Continuous fevers, red skin in, 41 Contracted kidney, casts in urine of, 422 diminished urine vpith, 407 , polyuria with, 406 retinitis in, 601 pupil, 566 Contraction, character of, 518 laws of, 505 ■ normal, with galvanic stimu- lation, 506 minimal, 505, 515, 516 quality of, sometimes important, 515, 516 tetanic, 505 Contractions, idio-muscular, defined, 526 _ lightning-like, 507 of fibrilte, 630 paradoxical, defined, 527 quality of, depends upon relation of the nerve to the skin, 504 slowness of, in partial EaE, 523 Contracture due to over-excitability of nerves and muscles, 526 of muscles in paralysis, 495 Contractures wanting, 493 Conus aortse, 193 arteriosus, sound caused by filling of, 213 terminalis of cord, location of 468 Convalescence indicated by weight of body, 35 perspiration in commencement of, 38 pulse in, 235 temporary imbecility in. 472 Convolution, anterior central, 454 left anterior central, centre for acoustic recollection, 555 second frontal, motor centre for writing, 555 third frontal, motor speech- centre, 555 posterior central, 454 Convolutions of brain, anterior and posterior central, blood supply of, 462 posterior and 'anterior cen- tralj illustrated, 466 Convulsions. Also see Spasms clonic spasms in, 532 Convulsions, difference between hys- terical and epileptic, 533 due to eruption of teeth, 286 epileptic and hysterical, opistho- tonus with, 468 hysterical, texanic, perspiration in, 37 in children, diaceturia thought to be the cause of, 448 l^roduce cyanosis, 42 sign of nervous disease, 22 simulation of, 19 with ursemia, 440 Cooing in intestine, value of, 312 Coordinated motions in hystero-epi- lepsy, 533 spasms, 634 Coordination defined and explained, 527 disturbances of in the larynx, 597 how acquired, 527 of muscles, 488 temporary loss of, 529 Copaiva, odor of urine after taking, 414 Copper, condition of teei^h in poison- ing by, 286 Copying, power of, 550 Cord, compression of spinal, 467 spinal, effect of lesion of, 457 Corona radiata, 454 effect of lesion of, 457 Corpora quadrigemina, ataxia in le- sions of, 529 blood supply of, 462 Corpulence, 35 increases area of dulness near the spleen, 338 Corpus quadrigeminum, lesion of pos- terior, 566 Corpuscles, mucous, in sputum, 175 Cortex of brain, clonic spasms in local affections of, 532 effect of lesion of, 457 partial epilepsy a sure sign of disease of, 533 spasms from irritation of the, 530 Cortical centres, lesion of, results of, 456 where their trophic influence ceases, 466 Cortico-muscular tract, 452, 456 Corvisart, reference to, 104 Costal breathing, absence of, how met, 91 INDEX. 627 Costal breathing absent in emphy- sema, 84 defined, 83 how changed, 90 in place of diaphragmatic, 95 often wanting in women, 85 Costo - abdominal breathing, how changed, 90 Cough, diseases and conditions in which it is absent, 165 dry, defined, 166 frequency of, and time of day of, significance of, 165 moist, described; 166 nervous, 576 parts of mucous membrane from which it arises, 165 phenomena of, explained, 164 power to, when lost, 165 spontaneous, or reflex, 165 suppression of, from pain, 165 tones of, described, 166 vomiting from violent, 358 Coughing, effect on venous circula- tion, 263 produced by attempts at swallow- ing in paralysis of pharyngeal muscles, 538 removes rales, 149 Coupland quoted, 26 Covering of body, effect on vocal fre- mitus, 157 "Cracked-pot" sound, described, 134 where heard, 134, 135 Cranial fossa, anterior, middle, poste- rior effect of lesion of, 457 nerves, nuclei of, illustrated, 455 points of exit from skull, illus- trated, 458 walls, disease of, 465 Cranium, diseases of, headache with, 482 examination of, 465 local diseases of, hearing in, 572 rhachitic thickening of, 464 sensibility of, to pressure, 466 size of, at different ages, 464 Creasote, color of urine after taking, 411 Cremaster reflex, defined, 495, 495 Crepitant rales defined, 154 in capillary bronchitis. 152 Crepitation, non-uniform, 154 Crepitations in mediastinal emphy- sema, 233 Cretinism defined, 472 Cretins, skeleton of, 33 Crisis defined, 67 signs of, 63 Critical sweat in various diseases, 37 Crossed paralysis (oculomotorius) of one side and extremity of other, 566 Cross-section of chest, 163 Croup, 75, 98 casts in sputum of, 172 cause of cyanosis, 43 dyspnoea in, 93, 94 severe cough of a cause of emphy- sema of skin, 56 tone of cough in, 166 Croupous pneumonia, one-sided ex- pansion of chest in, 86 Crura cerebelli, ataxia in lesions of, 529 Crural arterial and venous sounds combined, 269 artery, double murmurs in, 259 nerve, illustrated, 487 vein, double sound over, how distinguished from that over crural artery, 268 Crus cerebri, 454, 457 injury of, 457 lesion of, crossed paralysis with, 566 median, lesion of, 534 Crutch paralysis, 488 Crystals, fat, distinguished from elas- tic threads in sputum, 177 in sputum, 174 in blood in leuksemia, 279 in feces, 387 in sputum, kinds of, 180 of cholesterine in sputum, 181 of fatty acids in sputum de- scribed, 181 Cubebs, odor of urine after taking, 414 Current-changer, 506 use of, 505 density of, in nerves and skin, 603 electric, cannot be concentrated on nerve, 503 reasons why, 504 strength of, as affected by the angle of entrance of, 604 increases, while electrodes are on the body, 503 of total, 612 of total, must be known, 513 628 INDEX. Curschmann, reference to, 179, 180 Curschmann's spirals in sputum, 178 Curvature, greater, of stomach, ana- tomical relations of, 299 boundary of, 305 in distention, 301 position of, 298 when dulness over, 306 lesser, of stomach, anatomical position of, 298 relations of, 299 Curve, Damoiseau's, 129 Cutaneous nerves of lower extremity illustrated, 487 of shoulder, arm, and hand, distribution of, illustrated, 486 veins, enlargement of, 262 Cyanosis, a result of general venous engorgement, 261 causes of, 43 described, 42 from interference with respiration • during an attack of epilepsy, 533 from poisons. See Examination of Blood, from severe coughing, 166 in paralysis, 577 in tetanus and epilepsy, 540 of newborn, 42 sometimes absent in tuberculosis pulmonum, 44 with dyspnoea, 99 Cyclic albuminuria, 435, 437 Cylindrical cavities, effect of length of, upon pitch of sound, 110 experiment to illustrate, 110 Cylindroids in urine not to be con- founded with casts, 424 Cystic hemorrhages, very free, charac- teristics of, 418 Cystin in urine, significance of, 432 -calculi, 432, 433 Cystitis, alkaline urine with, 413 caused by cystin, 432 by ptomaines, 432 from use of catheter, 579 hsematuria from, 417 hydrothionic urine with, 414 micrococci and bacilli in urine of, 425 mucus in urine of, 416 odor of urine in, 415 sediment in urine in, 419 signs of, 400 Cystitis, turbid urine with, 412 with a nervous disease, 575 Cystometer, Woillez's, 163 Cystopyelitis, 398 DAMOISEAU'S curve, 129 Dax, M., reference to, 552 Deadened resonance, 125 sound associated with feeling of strong resistance, 116 defined, 109 from thick skeletal covering, 114 relatively, where occurs, 114 where heard, 109, 113 Deadening, relative heart and liver,112 Deadness applied to sound, 106 area of, increased with extent of exudation, 128 of sound over pleural thickening, 148 relative, of sound defined, 107 Deafness, absolute and relative, 108 nervous, 572 Decomposition of intestinal contents, vegetable parasites in feces in, 388 Decubitus acutus defined, 582 described, 582 disturbance of nutrition with, 575 Deep breathing, employment of, in examining the abdomen, 323 lung sound, 108 sensibility, 473 part of, in recognizing the form of bodies, 481 section on, 479 Defecation, assisted by abdominal pressure, 540 Defervescence, stage of, 65 Deformity of chest, 81 Degeneration, character of, as deter- mined by location of lesion, 456 funnel-breast a sign of, 89 of hypertrophied heart, weak apex beat in, 201 of nerves and muscles, 520 primary and secondary, increase of tendon reflex in, 500 reaction of, complete and partial, 519 Degenerative atrophic paralysis, 492, 493, 518 atrophy. 490, 493 difficulty of diagnosis in, 491 INDEX. 629 Degenerative atrophy, when wanting, 491 paralysis, 495 Deglutition -pneumonia, 600 Dehio, reference to, 143 Delayed sensibility, 478 Delirium, defined, and the diseases in which it occurs, 471 in gross hysteria, 534 -muttering in typhoid fever, 471 tremens in alcoholic poisoning described, 471 witli uraemia, 440 Dementia paralytica, atrophy of optic nerve in, 601 character of the writing of, 561 senile, mixed aphasia and amne- sia in, 555 senilis, 472 Deneke, reference to, 391 Dentition, cause of epileptiform at- tacks in children, 533 disturbances due to, 286 Deposits, pyaemic, in lungs, friction- sounds with, 156 Depression, clavicular, 81, 82, 84 ■ Morenheim's, defined, 76 states of, acetonuria in, 448 Desaga, spectroscope devised by, 272 Descendants divided by heredity, 20 Desquamation of renal epithelium in acute nephritis, 424 Detritus in stools, 887 Development, errors of, funnel-breast a sign of, 89 Deviation, conjugate, 534 primary, secondary, 563 Diabetes, acetone odor of breath in, 285 alkalescence of blood in, dimin- ished in, 283 diminished sweat in, 38 disturbance of consciousness in, 470 dyspnoea in, 576 gangrene in, 577 insipidus, 579 inosite in urine in, 447 lipaemia in, 280 mal perforant in, 582 mellitus and insipidus, polyuria with, 406 apple odor of urine in, 414 caries of teeth in, 285 cataract with, 562 Diabetes mellitus, character of urine in, 443 contradictory character of urin'^ in, diagnostic value of, 409 diaceturia in, 447 effect of, on weight of body, 36 levulose in, 447 lipuria in, 447 oxalate of lime in urine of, 430 percentage of sugar in urine of, 443 polyuria of secondary to polydipsia, 407 specific gravity of urine in, 412, 413 thirst in, 23 various nervous disturbances with, 579 neuralgia in, 483 ocular changes in, 602 oxalate of lime in sputum of, 182 saliva diminished in, 289 thrush with, 288 Diabetic coma, acetone odor of urine in, 414 /3-oxybuteric acid in urine of, 449 odor of breath of, 285 sometimes increased vesicu- lar breathing with, 144 Stadelmann's observations on. 449 Diaceturia, an independent disease in children, 447 comparison of color of urine, with test for salicylic acid, 450 in adults, when occurs, 448 in children the cause of convul- sions, 448 test for, 448 when occurs, 447 Diagnosis defined, 17 Diameter of thorax, how measured, 162 Diaphragm, action of, in stenosis of upper air-passage, 98 interfered with, 90 tested by palpation, 103 adjacent to fundus of stomach, 299 depressed by exudation, 128 in exudative pleuritis, 330 depression of, from emphysema, 199 630 INDEX. Diaphragm, effect of paralysis of, 540 of position of, on relative liver dulness, 332 of pressure upon, may inter- fere with action of heart, 40 elevation of, causes dislocation of heart, 200 fixation of, in hysteria, 576 high position of, 87, 130 due to abdominal disten- tion, 317 diminishes area of spleen dulness, 339 from paralysis, in peri- tonitis, 317 increased parietal area of heart with, 211 liver moves with, 320 in inspiration, 322 low position of renders spleen accessible, 335 paralysis of, inspiratory dyspnoea from, 99 position of, 80 aids diagnosis between pleu- ral exudation and thick- ened pleura, 130 changed with diminished volume of lungs, 137 in children, 192 of the heart changed by de- pression of 204 pressed upon by meteorism, 309 upward by enlarged liver, 322 pressure upon, a cause of paleness, 40 pushed up by subphrenic abscess, 322 rapid breathing in diseases of, 94 relation of spleen to, 332 to liver, 320 with other organs, 312 spasm of, 94, 540 trichinosis of, pain in, a cause of cyanosis, 44 upward displacement of liver in paralysis of, 323 pressure of, cyanosis from, 43 vesicular breathing increased on account of high position of, 145 Diaphragmatic breathing, 83 in place of costal, 95 friction sounds, 233 peritonitis, simulates pleuritis,161 pleurisy, tympanitic sound in lung over, 130 Diarrhoea, alternating with constipa- tion, 369 brick-dust sediment in urine of, 430 causes diminished sweat, 38 color of stool in, 373 defined, 368 due to eruption of teeth, 286 effect of severe, on the amount of blood in the body, 270 foul-smelling stool in severe, 372 infusoria found in stools of, 383 less amount of urine in, 407 quantity of stool increased in, 37C saliva diminished in, 289 watery stools in, 374 Diastole of heart, sound of, what due to and where best heard, 213, 214 sound with, 212 venous humming louder dur- ing, than in systole, 269 of ventricle, movement of blood in, 193 Diastolic collapse of cervical veins, 267 murmur at aorta, 251 murmurs, 222, 225 how distinguished from sys- tolic, 226 sound over large arteries in health, 257 Diazo-benzol-sulphuric acid test for sugar, 445 Dicrotic pulse, tracings of, 248 Dictation, writing from, 550 Diet, coating of tongue from articles of 287 effect on disease, 21 Differential diagnosis between peri- and endocardial murmurs, 232 Differentiating electrode, 501 Difficult breating, 93 Digestion, aided by mechanical action of stomach, 347 amylolytic period of, 342 bacteria in feces in anomalies of, 388 character of stools in disturbance of, 372 chemical action during, 347 duration of 347 examination of process of, 342 intestinal, shown by stools, 367 mode of procedure in examining, 350 INDEX. 631 Digestion, normal, test of, 348 particles of food found in stools in disturbed, 386 period of, prolonged, 356 shortened, 356 prolonged in dilated stomach, 346 study of process of, 341 washing out the stomach in dis- turbance of, 357 Digestive apparatus, change in weight in diseases of, 35* examination of, 284 section on disturbances of, 577 Dilatation of heart, a cause of insuf- ficiency, 194 area of dulness enlarged in, 208, 209 cause of projection of region of heart, 202 eccentric, 195 in angemia, 229 simple, 196 of stomach, 345, 348 absence of free muriatic acid in, 356 infrequency of the attacks of vomiting in, 359 with fermentation, recog- nized by seething sound, 308 Diphtheria, acute nasal catarrh in, 74 appearance of tonsils in, 290 death after examination of throat, 284 examination of mouth in cases of, 284 gallop rhythm a sign of heart- failure in 221 glands of neck enlarged in, 291 glycosuria in, 443 may cause cyanosis, 43 microscope an aid in diagnosing, from benign necrosis, 291 paleness from, 40 paralvsis of tensor of vocal cords from, 600 sequelse of, 22 sometimes uu contraction of pupil after, 568 tone of cough in, 166 Diphtheritic paralysis, position of the soft palate in, 538 Diplococci in purulent pleural exu- dation, 161 Diplococcus in urine, 399 Diplopia defined and when occurs, 472 mode of determining, 564 result of strabismus, 563 significance of, 564 Direct percussion defined, 104 Discharges, in voluntary, during attack of epilepsy, 533, 534 Disease, first appearance of, 23 location of, sometimes indicated by headache, 482 simulation of, 19 Diseases, acute, power of resistance to, 33 sometimes no contraction of pupil after, 568 ataxia after acute, 529 concealed, 19 course of, 23 directly inherited, 20 exciting causes of, 21 internal, and form of thorax, 81 names of, misused, 19 predisposing causes of 21 tracing of pulse in wasting, 248 wasting, hsemic murmurs in, 229 Displacement of apex-beat, 199 Disposition to disease inherited, 20 of lungs, 81 emphysema, with full chest, 34 tuberculosis, 34 Distention of stomach, 300, 301 artificial, methods of, 301, 302 Frerich's formula for, 301 Ziemssen's formula for, 302 Distoma haematobium, cause of hsema- turia, 283, 425 eggs of, in urine, 425 illustration of, 282 hepaticum and distoma lanceo- latum described, 383 illustrated, 384 pulmonunj, eggs of, in sputum, 183 in sputum, 174 Disturbances of speech, 548 Disturbed sensibility, local manifesta- tions of 478 Dizziness, also see Vertigo, from the eye, 563 combined with tinnitus aurium, 575 sisrnificance of, 471 Dock, reference to, 282, 391 Dolichocephalus, 465 Dorsal clonus, 499 position for inspection and palpa- tion of heart, 197 632 INDEX, Double murmur from pressure, 259 vision, mode of determining, 564 result of strabismus, 563 significance of, 564 Drawing-in, circular, of chest, 88 inspiratory, 97, 98 of abdomen, causes of, 309 of one side, 86 Drinks, certain ones which cause polyuria, 406 Dropsy, anidrosis with, 38 of kidney disease, cause of, 440 orthopncea with, 33 three causes of, 53 urea diminished in cachexia with, 434 Drunkards, lipsemia in, 280 Dry cough defined, 166 rales explained, 149 Duboisin, effect of, on pupil, 567 Dubois's induction coil, 476 Duchenne, reference to, 508 Ductus choledochus, 46 compression of, 340 Wirtungianus, 387 Dull, as a term for sound, avoided, 108 sounds, 107 Dura mater, disease of, 465 Duration of digestion, 347 of lung sound, 108 Duroziez's double murmur, 259 Dust, inhalation of, cause of bron- chitis, 21 of pneumonia, 21 Dwarf, skeleton of, 33 Dynamic sense, 479 defined, 480 Dynamometer, uselessness of, 545 Dysarthria defined, 548 Dysentery, amoeba coli in stools of, 391 blood in stools of, 373 catarrhal, mucous stool in, 374 color of stool in, 373 consistence and form of stool in, 371 feces of, contains Charcot's crys- tals, 388 meat-juice stools in, 375 odor of stools in, 372 pain and straining at stool in, 370 in left iliac fossa with, 308 shreds of mucous membrane in stool in, 377 watery stools in, 374 Dyspepsia, acute, paleness in, 40 coated tongue of, 287 Dyspepsia due to diseased teeth, 286 following healed ulcer of stomach, vomiting with, 361 foul odor of breath in, 285 gastric, headache with, 483 intestinal, fungus spores in stools, 388 nervous, 578 has marked subjective symp- toms but no physical signs, 308 subacidity of stomach in, 356 watery vomit of, 361 stools in, 372 superacidity of stomach with, 357 symptoms of, with displacement of right kidney, 396 time when vomiting occurs in, 359 Dyspnoea, 32, 74 active expiration of, 97 caused by emphysema of skin, 57 color of blood in, 270 described, 93 expiratory relation to emphysema, 85 from drawing up of diaphragm, 86 from uraemia, 440 in Cheyne- Stokes breathing, 94 in connection with nervous dis- eases, 576 in diseases of the lungs, 95 in emphysema, 84 in heart disease, 96 in paralysis of the diaphragm, 540 inspiratory, 74, 598 from paralysis of the laryn- geal muscles, 538 mixed, when exists, 100 of fever, 94 sometimes increased vesicular breathing with, 144 usually accompanied by perspira- tion, 37 Dystrophia musculorum, 493, 494, 525 EAR, affections of, in diseases of the nervous system, 672 catarrh of middle, a sign of con- genital syphilis, 286 importance of determining dis- ease of, 572 subjective sensibility of hearing in diseases of 572 suppuration of, cause of menin- gitis and abscess of brain, 467 INDEX. 633 Ear, vertigo in diseases of, 472 EaR (reaction of degeneration), 518 diseases which are excluded when it is present, 525 in myopathic muscular atrophy, 524 partial, 522, 525 relation of, to mechanical EaR, 524 significance of its absence, 525 varieties of, 523 when wanting, 525 with reference to motion, 521 Ebstein quoted, 89 reference to; 205, 208, 447 Ecchymoses, 51 Echinococcus bladders in sputum, 174, 182 change in shape of liver from, 325 in urine, 424 irregular enlargement of liver with, 322 membranous rags of, in vomit, 364 of kidney, palpation of, 395 of liver a cause of jaundice, 47 depression of liver from, 330 no tenderness with, 324 of omentum is rare, 340 prominences on liver from, 326 unequal enlargement of spleen from, 335 Ecker, reference to, 452, 466 Eclampsia gravidarum, 633 Ectasia of stomach, 345 Edelmann, reference to, 518 Edelmann's horizontal galvanometer, 503 Edinger, reference to, 453, 455, 458 Effusion in abdominal cavity, 313 into cavities a result of general venous engorgement, 261 into pleural cavity, serous, puru- lent, ichorous, complicating pneumothorax, diagnosis of, 129 percussion of, in abdominal cavity, value and method of, 316 Effusions into pleural sacs, 80 large, in abdomen, effect of, 317 Egyptian chlorosis, 382 Ehrlich, reference to, 185, 279 Eichhorst, reference to, 154, 164, 208, 247, 248, 249, 302, 424 Elastic fibres a sediment in sputum, 186 threads described, 177 Elastic threads, how distinguished from leptothrix buccalis, 184 how to obtain, for examina- tion, 178 importance of, in sputum, 177 Electric sensibility, 476 Electrical condition, diagnostic value of, 524 examination, details of method of, 507 methods of, 505 of nerves and muscles, 501 what it consists of, 505 irritation of arm, 509, 510 points of, upon the head and neck, illustrated, 503 reaction, mixed, defined, 523 what to observe in determin- ing, 516 sensibility unchanged in atrophy of inactivity, 490 Electro-diagnosis, reading the gal- vanometer in, 515 -motor points, 469 Electrode always to be applied with the same pressure, 507 Erb's fine, for faradic current, 502, 512 examining and indifferent, 512 for testing sensibility of skin illustrated, 476 indifferent, 523 and differentiating, 501 where placed and size of, 502 place of, in galvanic examination, 515 relation of size of, to intensity of current, 502 Electrotonus, 505 Elements, galvanic, number of, 514, 515 Emaciat'on cause of narrow chest, 85 how detected, 35 produced by disease of internal organs, 36 Emboli, effect of, on pulse, 245 region of brain where most fre- quent, 463 result of atheroma of vessels, 576 from thrombi in weak heart, 576 Embolism, local, low temperature in, 71 Embolus of the central artery of the retina, 562 634 INDEX. Emesis, induction of, when contra- indicated, 342 intentional, for diagnosis, 305 Emotions causes of disease, 21 Emphysema, 80, 82 a cause of hypertrophy of right ventricle, 196 action of muscles of neck in, 538 and form of thorax, 81. band box note with, 135 case of pernicious anaemia com- plicated by, 230 cause of emphysema of skin, 56 of expiratory dyspnoea, 99 of hypertrophy of right ven- tricle, 210 causes diminished parietal area of heart, 197 clavicular depression in, 84 cyanosis in, 43 diaphragmatic breathing in, 91 diminished amount of urine with, 407 expiratory pressure in, 164 disposition to, with full chest, 34 distinguished from oedema, 55 disturbs circulation through the lungs, 44 downward displacement of liver with, 322 dyspnoea in, 95 effect of, on relative liver-dulness, 332 on upper boundary of liver, 330 effects of, upon venous circulation, 263 enlargement of liver with, 322 expiratory bulging in, 98 extension of boundaries of lungs in, 136 " gallop rhythm " of heart in, 221 heart-dulness diminished in, 210 inspiratory dyspnoea with, 100 local expansion of chest in, 86 mediastinal, 57, 210, 233 muscular aid in, 84 non-ringing rales with, 153 non-tympanitic sound with, 112 of lungs, 204 a cause of displacement of heart. 199 conceals apex-beat, 201 the action of pulmonary valve, 203 Emphysema of lungs diminishes area of spleen-dulness, 339 of skin, 55 in connection with diseases of oesophagus, 296 weakens apex-beat, 201 peptonuria with, 439 prolonged expiration in, 145 rales with, 150 sequela of whooping-cough, 22 tough expectoration with, 166 value of pulse in cases of, 253 venous engorgement from, 261 vesicular breathing diminished in, 145 vicarious, 85 downward displacement of lung boundary in, 136 how developed, 87 no expiratory dyspnoea with, 100 on left side, difficulty in de- termining location of heart in, 211 vital capacity 'of lungs in, 164 , weakening of heart- sound in,, 219 with pleuritis, friction - sounds with, 156 Emphysematous thorax, 83, 85 Emprosthotonus, 539 Emptying of stomach, dangers of, 357 Empyema, amount of expectoration in, 168 crystals in sputum of, 180 hsematoidin in sputum of, 172 necessitatis, 102 pulsans, 102, 204 difficulty in distinguishing from apparent enlargement of heart, 210 pulsation in, near the heart, 204 purulent sputum in, 169 staphylococcus pyogenes found in, 603 tuberculous, 161 tyrosin in sputum of, 182 Encapsulated pleurisy defined, 129 Encephalitis in children, choreic movements with, 535 neuro-retinitis with, 601 ushered in by epileptiform spasm, 533 Encysted inflammatory exudation in abdomen, 317 Endemic diseases, 21 INDEX. 635 Endocardial murmurs, loudness of, to what due, 223 sounds felt, 204 whizzing, 227 Endocarditis a cause of insufficiency, 194 of stenosis, 194 aortse, embolus of retinal artery in, 562 embolus of central retinal artery in, 602 hajmaturia with, 417 retinal hemorrhages in, 602 sequela of scarlet fever, 22 streptococcus pyogenes with, 603 ulcerative, staphylococcus pyo- genes in, 603 valvular, relation of, to disease of the brain, 576 Engorgement, dropsy of, 440 of kidney, haematuria with, 417 of liver, surface of, 325 of spleen, 335 venous, effects of, 260 thrombosis in cedema of, 268 Enteralgia, simulation of, 19 Enteritis, amoeba coli in stools of, 391 color of stool in, 373. consistence and form of stool in, 371 forms of fat found in feces in, 386 mycotic, ptomaines in intestine in, 432 poor absorption of fat in, 371 Enteroliths, from vermiform appendix, 376 Enuresis from phimosis, 580 nocturnal, 400, 579 Eosin, staining of white corpuscles of blood with, 279 Eosinophile white corpuscles in leu- kaemia, 279 Epigastric angle, 82 in emphysematous thorax, 83 in phthisical thorax, 84 pulsation not to be confounded with simple aortic pulsation, 204 Epigastrium defined, 297 illustrated, 298 portion of liver in, 320 projection of, in enlargement of liver. 321 protrusion of, in inspiration, 90 pulsation in, 204 Epilepsy, acetonuria after attacks of, 448 Epilepsy, albuminuria with, 435, 441 clonic spasms in, 532 convulsions of, 37 cutaneous hemorrhages from at- tacks of, 582 cyanosis in, 44 differential diagnosis between genuine and symptomatic, 533 disturbance of consciousness in, 470 dyspnoea in, 95 fever with attacks of, 575 glycosuria after attack of, 443 hyperosmia and parosmia as an aura in, 574 involuntary passage of semen in, 534 of urine in, 580 Jackson's (partial or cortical), 533 described, 633 opisthotonus with convulsions of, 468 (petit mal) syncope with, 471 spasm, or convulsion, described, 432 spermatozoa in urine after at- tacks of, 421 tinnitus aurium sometimes as an aura a precursor of, 573 tonic and clonic spasm of thoracic muscles in, 540 traumatic and reflex, 530, 533 wounding of tongue during at- tacks of, 287 Epistaxis, 73 Epithelial casts, forms of, in urine, 424 illustrated, 424 Epithelium, ciliated, transfer of mucus by, 167 in sputum, 176 in urine, kinds and significance of. 420 renal, illustrated, 421 Equilibrium, an act of coordination, 527 Equinia, acute nasal catarrh in, 74 Erb, normal electrode of, 502 reference to, 461, 469, 476, 498, 501, 504, 508,509,510,511,512, 514, 516, 517.520,521,523,524, 525, 567 Erb's fine electrode, 507 point in brachial plexus, 487 supra-clavicular point, 510 Ergotism, gangrene in, 577 Eructation, odor of, 359 636 INDEX. Erysipelas, coccus of, 161 enlargement of spleen in, 335 fever in, 65 leucocytosis in, 278 recurrence of, 22 resembles inflammation of strep- tococcus erysipelatosus, 604 vomiting in, 358 Erythrodextrin from starch, 353 Esbach's albuminometer described and illustrated, 438 Escherich, reference to, 388 Eserine, elFect of, on pupil, 567 Ether poisoning, cause of hsemato- jaundice, 47 Ethmoid nerve, illustrated, 485 Etiology, value of, 20 Ewald, reference to, 349, 351, 354 Exacerbation of febrile disease shown by temperature, 65 Examination, electrical, details of, 507 general, divisions of, 31 method of, in diseases of nervous system, 463 of patients 24 of the blood, 270 special, scheme for, 27 Examining electrode, size of, 502 Exanthemata from poisons, 50 Exanthematous diseases, 49 fevers, enlargement of spleen in, 334 Excesses, venereal, cause of disease, 21 Excitability, bilateral variations of, 518 increased in tetanus, 526 lessened, when it occurs, 525 mechanical, of muscles and nerves, 526 of nerve (muscle), degree of, 505 quantitative and qualitative, of nerves and muscles, 516 Excitement, eftect of, on amount of urine, 401 on heart-sounds, 216 on pulse in fever, 240 upon pulse, 235 headache after, 483 induces perspiration, 37 mental, effect of, on heart, 198 heart not to be examined after, 201 syncope from, 471 Exciting causes, effects of, on chronic diseases, 21 of disease, 21, 22 Exclusion, determining limits of liver by, 328 Exertion, albumin in urine after, 437 effects of, in auscultation of heart, 211 on action of heart, 198 on pulse in fever, 240 upon pulse, 235 headache after, 483 heart not to be examined after, 201 mental, glycosuria after, 443 muscular, a cause of idiopathic hypertrophy, 196 over-, weakness of heart-sounds from, 218 severe, a cause of emphysema of skin, 56 Exhaustion which accompanies vomit- ing, 359 Exophthalmia, 565 Exophthalraus paralyticus, 563 Exotic diseases, 21 Expectoration absent when there is no cough, 167 defined, 167 examination of, 167 general characteristics of, 168 kinds of, 168 Experiment to illustrate effect of length of cylindrical cavities upon pitch of sound, 110 Experimental meal, Ewald's, 349 Jaworski's, 349 Leube's, 347 relative merits of each, 349 Expiration, bronchial breathing usu- ally most distinct with, 147 effect of, on circulation in jugular vein, 262 in emphysema, 84 muscles of, 97 position of liver during, 320 pressure of respiratory air in, 164 prolonged, in commencing tuber- culosis of apices an im- portant sign, 150 when occurs, 145 role of the abdominal muscles in, 540 sound of, bronchial in character, 142 Expiratory bulging, 98 dyspnoea in emphysema, 84 relation of, to emphysema, 85 to inspiratory, 100 INDEX. 687 Expiratory dyspnoea, when exists, 99 pressure greater than inspiratory, 164 valvular sound in the crural vein in health, 269 Exploratory puncture, directions re- garding, 162 of abdomen, value of, 318 of pleura, how performed, 160 of the heart, 234 use of, 130 Exposure a cause of disease, 21 Extra-pericardial friction sounds, 233 Extremities, nerves of, motor tracts of, illustrated, 453 Extremity, lower, muscles of, 545 muscles of the upper, 540 Exudation depressing the diaphragm, 128 diagnosis of, from transudation, 160 extent of, shown by area of dead- ness, 128 in abdomen, value of measuring circumference of, 316 increase of chloride of sodium in urine with, 434 inflammatory, in abdomen, 317 kinds of, in pleural cavity, 161 plegaphonia over, 159 pleural, encapsulated, 128 measurement of thorax in, 163 pleuritic, effect of, on vocal fre- mitus, 157 or pericardial, conceals apex- beat, 201 purulent, in sputum, 167 Eye, affections of, in diseases of the nervous system, 561 cystercerci in, from taenia solium, 578 determining paralysis of muscles of, 564 I function of individual muscles of, 564 inflammation and ulceration of, from paralysis of nerve, 484 movements of, paralpsis of mus- cles, 562 muscles of, 536 significance of paralysis of, : 564 Eyelids, dropsy of, in kidney disease, 440 I Eyes, how closed, 536 I Eyes, relation of, to vision, illustrated, 570 unequal refraction of two, 567 FACE, motor centre for lowe. por- tion, 454 muscles of, 536 three most distinct points upon, i _ 510 Facial nerve, chorda tympani nerve joins the, 461 effects of paralysis of, 536 increased mechanical excita- bility of, in tetanus, 526 lesion of, from caries of pet- rous portion of temporal bone, 469 motor tracts of, illustrated, 453 paralysis of, 548 paralysis, diminished secretion of saliva in, 578 effect upon taste in, 574 hearing in, 572 reflex, 497, 499 rheumatic, partial EaE, in, 525 rheumatic paralysis, 520 sense of taste in anterior portion of tongue affected in paralysis of, 461 tract, paralysis of, bone reflex present in, 500 Faradic battery, secondary or induced current, for examining nerves and muscles, 501 current causes tetanic contraction, 506 comparative unimportance of the poles, 504 Erb's fine electrode for, 507 relation of total strength to galvanic current, 514 strength of, how measured, 502 examination of nerve-muscle, de- scribed, 512 to be followed by galvanic, 514 excitability of the two sides of the body, 516 Farado-culaneous sensibility, 476, 477 Fasting stomach, gastric secretion in, 346 638 INDEX. Fat, absence of, 34 development of, in diseases of blood-making organs, 41 drops of, in urine, significance of, 420 effect of, on extent of abdomen, 309 in conjunctiva not to be con- founded with jaundice, 45 in urine after fatty food, 405 lumps, needle-shaped crystals in stools, significance of, 386 people, veins of, 260 striae produced by accumulations of, 52 variations in amount of, 34 Fatigue a cause of disease, 21 Fatty acids, crystals of, in sputum, 184 in sputum of gangrene, 190 degeneration of heart, paleness in, 41 of kidney, epithelium found in urine of, 421 heart, Cheyne-Stokes respiration, 92 Fauces, vomiting from tickling of, 358 Favus in vomit, 366 Fear produces perspiration, 36, 37 Febrile diseases cause change in weight, 36 exacerbation shown by tem- perature in, 65 haemic murmurs in, 229 perspiration in, 37 pulse in, 239 subnormal temperature in, 63 value of pulse in, 253 weakness of heart-sounds in, 218 Febris hepatica, herpes with, 50 recurrens, 37 Fecal accumulation in stenosis of in- testine, 369 odor of stool masked by other sub- stances in, 372 vomiting not always fatal, 364 when occurs, 364 Feces, balls of, in intestine, diagnosis of, 310 Charcot-Leyden's crystals in, 181 in urine, 315 involuntary discharge of, in at- tacks of epilepsy, 534 microscopical constituents of, il- lustrated, 385 examination of, method of, 385 Feces mixed with blood, significance of, 375 physical and chemical peculiari- ties of, 370 section on, 367 Feculent exudation in pleural exuda- tion, 161 odor of urine, 414 Fehleisen, reference to, 427 Fehling's solution, estimating amount of sugar by, 446 test for sugar, compared with polarizing method 447 Female sexual organs, headache with diseases of, 483 Ferment, in gangrene of lungs and bronchitis, 190 Fermentation, alkaline, in urine, from micrococci, 425 ammoniacal, of urine, effect of, 402 increased formation of lactic acids in subacidity of stomach, with, 356 in dilated stomach, 346 in intestinal canal, acid reaction of stool in, 372 alkaline reaction of stool in, 372 microorganisms that excite, in stomach, 343 of contents of stomach with dila- tation of stomach, 308 of urine in bladder, cause of turbid urine, 412, 415 test for sugar, 445 Ferrocyanide of potassium test for albumin in urine, 436 Fetor of breath, 285 Fever. Also see Temperature, acetonuria in, 448 albuminuria with, 435 alkalescence of blood diminished in, 283 anidrosis of, resists therapeutic measures, 38 brick- dust sediment in urine of, 430 casts in, 422 cause of increased dyspnoea, 96 chill of, phenomena of, 40 chloride of sodium in urine dimin- ished in, 434 chlorides diminished in, 60 coating of tongue in, 287 continued, sweat diminished in, 38 INDEX. 639 Fever, continued, urine in, 426 continuous, significance of, 587 critical purturbation in, 68 curve, effect of antipyretics on, 67 dark color of urine of, 408 defervescence of, 67 defined, 60 delay in absorption from stomach in cases of, 355 diaceturia in, 447 diminished amount of urine in, 407 disturbed nutrition in, 575 effect of, upon heart's action, 201 exacerbation of, 62 frequent pulse with, 238 heart sounds strengthened in, 217 hectic, 68 hyaline casts in urine of, 423 in connection with nervous dis- eases, 575 increase of urea in, 433 urobilin in urine in, 48 increased frequency of respiration in, 94 formation of CO2 in, 93 intermittent destruction of red corpuscles in, 434 herpes with, 50. malarial, defined, 70 irregular in various diseases, 71 lips in, 285 mucus in urine of, 416 of pus formation in, 68 pulse in, 240 recurrence of, 66 recurrent, microorganisms of, found in blood, 281 red skin in, 41 tongue in, 287 relapsing, leucocytosis in, 278 section on, 57 slow pluse in critical decline of, 237 sound heard over crural artery in high, 259 subacidity of stomach in, 356 subnormal temperature in crisis, 63 three types of, 62 thrush in, 288 tracing of pulse of, 247 trembling of tongue in, 287 tremor with rapidly-rising, 531 typical course of, 64 uric acid increased in, 434 Fever, urinary products increased in, 60 urobilin in urine in, 409 variations of temperature in, 63 with albuminuria, 441 Fibres-elastic in sputum, 175 Fibrillary contractions, 530 defined, 532 Fibrin, floccules of, in the fluid from puncture of pleura, 160 in urine in hjematuria, 439 Fibrinous tubes in sputum, 172 Fibroma of larynx def^cribed, 597 pedu^iculated, in larynx, illus- trated, 596 Fifth nerve illustrated, 485 Filaria sanguinis hominis, cause of hsematochyluria, 283 effects upon theurineand urinary passages, 425 illustration of, 282 Filehne, reference to, 190, 198 Finger-percussion, 105 advantages over hammer per- cussion, 116 how done, 118 -pleximeter percussion, 105 Fingers, characteristic positions of the hand and, in paralysis, 544 distribution of nerves to, 485 paralysis of the muscles of, 543 Finkler and Prior's spirals, 390, 607 how distinguished from cholera bacillus, 391 illustrated, 391 Fischer, reference to, 478 Fischl, reference to, 177 Fissure of anus, pain at stool in, 370 of Rolando illustrated, 466 of Sylvius, artery of, 462 effect of occlusion of, 462 Flechsig, reference to, 452, 535, 586 Fleischl's hsemometer recommended, 271, 276 Flexibilitas cerea defined, 535 Fluctuation in abscess of liver and echinococcus, 326 sign of fluid, 315 Fliigge, reference to, 184,289, 604, 605 Fluid, nature of, in plural cavity, by puncture, 160 Fluids, effect of drinking, on color of urine, 402 Folic musculaire, 534 Fontanelle, cerebral blowing sound heard while still open, 258 640 INDEX. Food, albuminous, source of uric acid in urine, 405 certain ones which cause polyuria, 406 character and amount of stool af- fected by, 370 color of the vomit from kinds of, 360 effect of, upon color of stool, 372 oxalate of lime in urine after cer- tain foods named, 430 particles of, in stools, 386 tests of rapidity of passage of, from the stomach, 354 when in sputum, 167 Foot clonus, 499 quaking with, 531 paralysis of muscles of, 547 phenomenon, defined, tested, sig- nificance of, 499 objection to ordinary method of examination, 501 sole of, reflex, 495 Foramen ovale, open, systolic venous pulse with, 267 Forearm, paralysis of muscles of, 543 Forehead, liow wrinkled, 536 Form, knowledge of, section on, 481 of expectoration, 168 of spinal column, 467 Fossa infra-spinata, 77 deadened sound over, 114 of Sylvius, illustrated, 466 supra-spinata, 77 Fossae on front of thorax, 76, 81 Fourth ventricle, 455 Frankel, A., pneumonia coccus of, 188 reference to, 161 Frankel, B., reference to, 297 Fredericq, reference to, 2S6 Fremissement cataire, 227 Fremitus, laryngeal, 75 vocal, palpation of, described, 156 Frequency of breathing, anomalies of, 91 Frerichs, reference to, 301, 443 Frey, reference to, 246 Friction, sensible, how recognized, 155 -sounds, extra-pericardial, 233 felt near heart, 204 not heard if fluid is present, 156 not to be confounded with moist rales, 155 over peritoneum, 318 pericardial, 230 Friction-sounds, pleuritic, described, 155 sometimes a favorable sign, indicating absorption of fluid, 156 when occur, 156 Friedlander, pneumonic coccus of, 188 Friedreich, reference to, 180, 191, 267, 268, 269 Friedreich's change of sound de- scribed, 113, 133 Frontal convolution, left third, motor speech-centre, 555 third, blood supply of, 462 lobe illustrated, 466 Frothy sputum, 169 Fruity odor of urine, 414 - when occurs, 414 Fuliginous deposit on lips in fevers, 285 Fulness of veins increased, 260 Functional disease of nervous system, sudden return to normal con- dition, a certain sign of, 587 neurosis, analgesia in, 479 Fundus oculi, changes in, in diseases other than nervous, 601 changes of, in nervous dis- eases, 600 of stomach, anatomical relations of, 299 position of, 298 Fungi found in urine, 425 in sputum, 174, 183 pathogenic, section on, 389 spores of, in feces, when found, 388 Funke, reference to, 429 Funnel-breast, cause of, 89 described, 88 Fiirbringer, reference to, 182 Furuncles, staphylococcus pyogenes found in, 603 GABETT, reference to, 187 Galacturia, 412 produced by filaria sanguinis, 425 Gall-bladder, distended, when felt, 322 emptying of, by pressure, 326 enlargement of, 331 normal and pathological con- dition of, 326 obstruction of, a cause of en- larged liver, 322 position of, 320 INDEX. 641 Gall-bladder, suppuration of, gall- stones in stools from, 376 -stones a cause of jaundice, 47 accompanied by chill and fever, 64 appearance of, described, 376 in feces, how to find, 376 sometimes can be felt, 326 Gallop rhythm of heart described, 220, 221 Galvanic battery, constant current of, for examining nerves and mus- cles, 501 current, a strong, should never be used upon head, 511 effect of, only at closing and opening of current, 506 how to distinguish the poles of, 504 measure for strength of, 502 must not have too small an electrode, 502 normal electrode for, 507 quality of reaction with, 506 relation of, to total strength of faradic current, 514 used in determining the con- ductive resistance, 512 examination, how conducted, 515 methods, and explanation of terms used, 506 should always follow the fa- radic, 514 muscular i-eaction, normal, dia grammatic representation of, 519 resistance, 476 stimulation, qualitative irrita- bility of muscles, 518 tetanus, 505 Galvanometer, absolute, 503 damping of vibrations of, 515 Edelraann's, 518 limits of exactness of results from, 504 time when to be read, 512, 515 Ganglia of anterior horn, 456 Ganglion, acoustic, 461 geniculate, 461 spheno-palatine, 461 Gangrene, infusoria in sputum of, . 183 odorless, 171 of lung, crystals in sputum of, 180, 181 effect on thorax, 87 Gangrene of lung, elastic threads in sputum of. 177, 179 fatty acids in sputum of, 190 ferment in, 190 fetid sputum in, described, 174 micrococci in sputum of, 189 mucus in three layers in, 169 odor of sputum in, 171 relation of, to brain disease, 576 rupture into oesophagus, 296 spontaneous, in neuroses, 577 starch corpuscles in sputum of, 180 Gartner, reference to, 389 Gas in stomach and intestines some- times gives a lung-sound, 113 intestinal, effect on movements of diaphragm, 90 sound on percussing over cavity containing, 109 Gastric crises defined, 578 juice, coagulating effect of, 353 secretions, accumulation of, 346 Gastritis, vomiting of pus in phleg- monous, 364 Gastro-duodenal catarrh, 46 Gastroxia, 361 Gastroxynsis, 361 Geigel, reference to, 267 Geisler, reference to, 436 Geniculate ganglion, 461 Genital apparatus, disturbance of, sec- tion on, 580 Gerhardt, reference to, 125, 132, 191, 259, 414 Gerhardt's change of sound described, 133 Gestures an acquired faculty, 549 Glanders, bacilli of, found in blood, 282 Glands, enlarged, compression of bron- chi by, 43 Gleet, diplococcus in urine, 427 may be due to tuberculosis, 426 Glioma, usually single, 585 Glossitis cause of enlargement of tongue, 286 Glosso-pharyngeus nerve, 461 Glossy skin, 581 Glottis, dilators of, paralysis of, 99 spasm of, cause of cyanosis, 43 due to eruption of teeth, 286 muscles of, 597 vibrations of, in phonation, 157 41 642 INDEX. Glycosuria, after poisoning with va- rious substances named, 443 in disease of oblongata, 579 when occurs, 443 Glyksemia, polyuria due to, 407 Gmellin's test for bile in urine, 442 Goll, columns of, 459 Gonococci illustrated, 427 in pus of gonorrhoea, 427 stains of, 427 Gonorrhoea, coccus of, 604 haematuria from, 417 Goose's throat, a condition of arteries, 256 Gorges, reference to, 404 Gottstein, reference to, 595 Gout, neuralgia in, 483 uric acid found in blood in, 283 often diminished during attack of, 434 Gouty diathesis, increase of uric acid in, 434 Gram, reference to method of staining, 188, 189, 190, 282, 603, 604, 605 Granular casts, generally are hyaline, 424 illustrated, 424 Grape sugar in urine, when it occurs, 443 Graphic communication, disturbances of, 549 Gray substance of spinal cord, destruc- tion of, results of, 491 Greater circulation, perspiration in engorged condition of, 37 slowing of, a cause of cya- nosis, 44 Griesinger, reference to, 382 Guaiac, tincture of, test for bile pig- ment, 441 Gummata, change in shape of liver from, 325 of larynx, 595 syphilitica, in larynx, 596 Gums and teeth, examination of, 285 Giinzburg, reference to, 352 Gutbrod, reference to, 199 TJABITATION, a cause of disease, Habits, a cause of disease, 21 Habitual headache, hereditary, 483 Hseraatemesis described, 361 diseases with which it occurs, 362 Htematin, absorption bands of, 272 Hsematin in solution, test for, 441 Hsematoidin, 46 casts mixed with, in urine, 424 crystals of, in sputum, 180 in urine, 432 in lungs of patients who have died from heart disease, 177 in sputum, 172, 176 Hsemato-jaundice, 47 Hsematoma of dura mater, inequality of pupils in, 567 Haematuria, 410, 416 albumin with, 441 due to strangulus gigas, 425 fibrin in urine in, 439 from distoraa haematobium, 425 produced by filaria sanguinis, 425 use of microscope in, 418 when occurs, 417 Hsemic murmurs, 229 Hsemin, crystals of, illustrated, 363 test for, 363, 364, 375, 442 Haemochromometer, instrument for estimating number of red corpuscles in blood, 271 Haemoglobin, absorption band of, 273 amount of, diminished in anaemia and chlorosis, 275 diagnostic importance of, 270 appearance of, as a sediment in urine, 419 approximative determination of amount of, 271 casts of lumps of, 424 diminished in blood in oligo- cythsemia, 275 poikilocytosis with, 277 exact quantity of, only deter- mined by quantitative spectrum analysis, 272 in separate corpuscles may be in- creased, 277 loss of, cause of paleness, 40 scale for estimating percentage of, in blood, 272 tests for, 441 urine to be examined for, when no corpuscles are found, 418 Haemoglobinaemia, 46,410 color of blood in, 271 examination of blood in, 271 value of spectroscopic examina- tion of blood in, 272 Haemoglobinuria, 410, 419 albumin with, 441 INDEX. 643 Hsemometer, Fleischrs,recommended, 271, 276 Hsemophile, haematuria in, 417 Haemoptysis, caution against speaking in, 159 Haeser, reference to, 412 Hair, growth of, 583 Half-moon-sliaped space (Traube) de- defined, 127, 128, 137, 299, 300, 306, 329, 333 diminished by enlarged spleen, 339 by exudation, 307 encroached upon by en- larged liver, 331 in examining the spleen, 337 outer boundary of, found by spleen, 333 Hallervorden, reference to, 449 Hallucinations of sight in delirium tremens, 471 Hammer-pleximeter percussion, 105 Hammond, W. A., reference to, 535 Hand and fingers, characteristic posi- tions of, in paralysis, 544 distribution of nerves to, 485 importance of knowledge of mus- cles of, and their innervation, 545 mode of examination in paralysis, 544 nerves of, 485 paralysis of muscles of, 543 Hartnack, reference to, 175, 181, 185, 281 Hauser, reference to, 184 Hawking described, 166 Hayem's counting chamber described, 274 Head and neck, points of electrical irritation upon, illustrated, 508 a strong galvanic current should never be used upon, 511 distribution of cutaneous sensitive nerves upon, illustrated, 485 nerves of, 484 nervous pain in, 466 Headache, circumscribed, when dis- ease causing it is so, 482 from uraemia, 440 significance of, 482 unilateral (migraine), 483 Health, patellar tendon reflex always present in, 499 Hearing, centre of, 460 Heart, action of, increases perspira- tion, 37 interfered with by pressure on diaphragm, 40 rapidity and strength of, 212 anatomy of, 191 apparent enlargement of, 209 auscultation of, 211 -beat not to be confounded with apex beat, 201, 203 boundary between, and lung illus- trated, 304 caution regarding, when making exploratory puncture, 162 change in form of, 196 in systole, 198 chronic diseases of, paleness in, 41 subnormal temperature with, 64 -deadness, boundaries of, 124 diminished with extension of lung boundaries, 136 small when lungs are ex- panded, 136 degeneratian of, weakens apex- beat, 201 diminished work of, weakens apex-beat, 201 disease, Cheyne-Stokes breathing in, 92 development of fat in, 41 dyspnoea in, 96 effects of, on circulation through lungs, 44 hsematoidin in the lungs of patients who have died from, 177 importance of second pul- monary sound in, 218 infarction of spleen from, 335 inherited, 20 pulse in, 239 with effusion, 33 with slight compensation, gallop rhythm with, 221 dislocation of, 199 displaced by exudation, 128 displacement of, by tumors, 255 disturbed in chronic jaundice, 47 -dulness, absolute, 205 area of, enlarged, 208 diminished, 210 displacement of, 210 parietal area of heart, 204 relative, defined, 205, 207, 208 644 INDEX. Heart-dulness, size and diagnostic value of, 207 enlarged, 1 arger parietal area with, 197 enlargement of, cause of expan- sion of chest, 86 diagnosis of, 200 effect on apex, 199 left, makes the half-moon- shaped space smaller, 806 pulsations at base of, in, 203 simulated, 197 examination of, 191 excited action of, in Basedow's case, 201, 259 in nicotine poisoning, 201 exploratory puncture of, 234 failure. Also see Heart, weak. Cheyne-Stokes breathing in, 92 confused sounds in, 212 diagnostic value of heart- sounds in, 217 due to disease of its muscle, 40 dyspnoea in, 96 gallop rhythm a sign of, 221 pulse in, 240 lowering of temperature in, 71 first sound a mixed one, 214 doubled, 216 hsematoidin in sputum in disease of, 172 hypertrophy and dilatation, area of dulness enlarged in, 208 of, pulse in, 244 or dilatation of, not to be mistaken in retraction of lung, 137 other than valvular, 196 increased labor of, measured by specific gravity of urine, 413 inspection and palpation of, 197 -liver boundary of, 329 location of, in side position of patient, 193 mechanical displacement of, 87 method of percussing, 208 movement of blood in, 193 murmurs, localization of 223 organic distinguished from inorganic, 230 endocardial, defined, 221 relation of, to time of action of the heart, 224 transmission of, 228 when heard, 222 Heart muscle, diminished amount of urine in diseases of, 407 weakness of sounds in paral- ysis of, 218 nervous affections of, in connec- tion with disease of the nose, 575 neuroses, 577 normal percussion figure of, 205 organic disease of, palpitation and pain with, 577 murmur of, 219 paleness a symptom of disease of, 40 _ palpitation of, in mitral defects, 240 nervous, 201 parietal area of, changed by dis- location of, 211 percussion of, 204 physical phenomena of, 193 place of, makes asymmetry of sound on right or left side of chest, 121 points of election for auscultating, 213, 214 position of, 191 in children, 192 powerful action of, a cause of thoracic pulsation, 102 pressed upon by meteorism, 309 projection of neighborhood of, 202 pulsations at base of, 203 of, palpation of, 102 pulse in valvular disease of, 240 relation between size and energy of action of, 201 of, and area of dul- ness, 205 of, and parietal por- tion, 196 of, to diseases of the brain, 576 of, to lungs, 79 relative deadness of sound over, 124 representation of action of, 215 resistance of, 205, 208 simple dilatation of, 196 slow pulse in certain conditions of, 237 ■sound, metallic, in pneumo-peri- cardium, 210 -sounds doubled, 219 metallic, explained, 221 normal, described, 212 variations of, 216 origin of, 212 INDEX. 645 Heart-sounds, pathological changes in, 216 strengthened, heard over larger area, 217 tone of, variations of, 216 weakening of individual, 219 when weakened, 218 strength of, estimated by pulse, 240 value of absolute dulness, 207 of pulse in displacement of, 253 in showing complicating disease of, 253 valvular disease of, enlargement of liver with, 324 sequela of rheumatism, 22 venous engorgement from defect of right, 261 weak. Also see Heart failure, area of dulness enlarged in, 209 murmurs indistinct in, 223 thrombi in, a cause of em- boli. 576 with dilatation, a cause of insufficiency, 194 weakness, character of pulse in, 243, 244 Hearing, importance of, determining disease of, 572 morbidly acute, 672 place of, in speech, 550 subjective sensibility of, when oc- curs, 572 testing of, 571 Heat induces jjerspiration, 37 sensations of, 577 Heaving, strong apex-beat, 200, 201 Hebetude, tongue often left protruding when there is, 287 Hectic fever, 68 in tuberculosis, 42 Hegar, reference to, 311, 398 Height, relation of, to weight, 35 Heitzmann, reference to, 590 Heller, reference to, 378, 379, 383, 384 Heller's test for blood pigment, 441 for hsemin, 364 Heraatemesis with pulmonary hemor- rhage, 167 Hemialbuminose in urine, 435. 439 Hemialbumose, a rare constituent of urine, 439 Hemiansesthesia, 460, 461 associated with unilateral anos- mia, 573 Hemiansesthesia defined, and when occurs, 479 in gross hysteria, 534 Hemianopsia, 460 cortical, 568 homonymous, defined, 569 illustrated, 570 phenomena of, 571 Hemiathetosis occurs in same loca- tions as hemichorea, 535 Hemichorea, 535 Hemicrania, one-sided redness of face in, 42 unilateral redness of head in, 577 Hemidrosis defined, 37 in Basedow's disease, 38 Hemiopia, 460 Hemiplegia, 457, 494 arthropathia in old, 583 ataxia in some cases of, 529 cruciata, 456, 489 decubitus in, 582 defined, 489 dorsal flexion of foot with, 535 hemichorea a forerunner or result of, 535 right, illustrated, 453 -sided, aphasia with, 555 Hemisphere, right, has nothing to do with speech, 555 Hemisystole, double positive venous pulse in, 267 explained, 202 Hemoptysis defined, 170 Hemorrhage, bloody color of sputum from, 170 cause of urobilin-icterus, 48 cerebral, effect on breathing, 91 most frequent in the region supplied by the middle cerebral artery, 463 slow pulse in, 237 cutaneous, contrasted with hyper- emia, 42 effect of, on amount of blood in the body, 270 internal, shovm by temperature, 65 sudden fall of temperature with, 63 long-continued, a cause of dropsy, 53 microcythsemia after, 276 of lungs caused by distoma pul- monale, 183 646 INDEX. Hemorrhage of lungs, diagnosis from hemorrhage of stomach, 170 starch corpuscles in sputum, 180 of pons or oblongata, effect of, 457 of stomach, 40 microscope useless in, 365 rectal, stools of, described, 374 retinal, in hemorrhagic diathesis, 562 slow pulse with, 237 source of, in haimaturia, diag- nosis of, 417 subnormal temperature with, 63 sudden amaurosis after severe, 602 symptoms of, 40 Hemorrhages, cutaneous, 51 distinguished from inflam- mations, 51 in jaundice, 47 when occur, 582 Hemorrhagic diathesis, hemorrhage of stomach in, 362 in chronic jaundice, 47 retinal hemorrhage in, 562 exudation with tubercle and car- cinoma of pleura, 161 infarction of kidney, hsematuria with, 417, 418 Hemorrhoids, hemorrhage from, 375 pain at stool with, 370 Henle, reference to, 421, 486, 487, 641 Hepatitis cause of enlarged liver, 322 interstitial, surface of liver in, 325 Hepatization of lung, deadened re- sonance over, 126 Hereditary disposition to headache, 483 taint shown by funnel-breast, 89 Heredity, 20 Hering, spectroscope devised by, 272 Hernia, examination of seats of, 308 Hernia cause of pressure on nerves, 469 Hernial orifices to be examined in sudden obstipation, 369 Herpes facialis, 50 labialis and nasalis, 50 zoster, relation to nerves, 581 Herringham, reference to, 437 Heubner, reference to, 112, 135, 317 Hiccough defined, 540 severe in abdominal and cerebral affections, 540 High lung sound, 108 Hildebrand, reference to, 356 Hippocrates, reference to, 138, 156 Hippocratic succussion confounded with splashing from" stom- ach or colon, 156 described, 156 Hirschmann, reference to, 503 History, clinical, defined, 17 previous, what comprises, 20 Hoarseness, how caused, 598 Hoffmann, reference to, 481, 482 Homonymous parts to be tested to- gether, 507 Hooke, reference to, 138 Hoppe, reference to, 190 Horseshoe kidney, 393 Hour-glass stomach, 302 Huber, reference to, 428 Hiifner, reference to, 434 Hutchinson's spirometer, 164 teeth, sign of congenital syphilis, 286 triad, signs of syphilis, 286 Hyaline casts described, and when oc- cur, 422 granular forms, 424 illustrated, 423 various additions to, 423 Hydatid vibration with echinococcus of kidney, 396 of liver, 326 Hydrsemia, albuminuria with, 435 cause of oedema, 53, 54 color of blood in, 271 leucocytosis in, 278 peculiarities of blood in, 275 polyuria in, 406 Hydrocephalus, anosmia with, 573 choked disc with, 600 head unevenly balanced in, 539 how distinguished from rhachitis, 464 pressing upon third ventricle, 601 slow pulse with, 237 with macrocephalus, 464 Hydrocyanic acid, color of blood in poisoning by, 270 Hydronephrosis, palpation of, 396 tenderness in inflammatory, 396 Hydropericardium, cause of weakened heart-sounds, 219 increases area of heart-dulness, 209 Hydroperitoneum. See Ascites. Hydro-pneumothorax, splashing in, 233 Hydrops vesicae fellese, 326 Hydrothionic urine, 415 INDEX. 647 Hydrothorax, diagnosis by explora- tory puncture, 129, 160 Hyjosesthesia defined, 477 Hypacidity of gastric juice, effect of, 344 Hyperacidityof gastric juice shown by microscopical examination of vomit, 365 Hyperfesthesia defined, 478 Hyperidrosis defined, 37 Hypermetropia, 567 Hyperosmia in hysteria and insanity, 574 Hyperpyrexia, 61 Hypersecretion of gastric juice with vomiting in nervous dyspepsia, 361 of stomach juices, diagnosisof, 355 with hyperacidity of stomach, 361 Hypertrophic liver, surface of, 325 Hypertrophy combined with atrophy, 493 compensatory of one division of heart, 218 idiopathic, of heart, 196 of a ventricle shown by strength- ening of the sound of corre- sponding valve, 217 of heart, area of dulness enlarged in, 208 cause of projection of region of heart, 202 compensatory, 195 degeneration of, weak apex- beat in, 201 not to be mistaken in retrac- tion of lung, 137 other than valvular, 196 right and left, 251 (with dilatation), diagnosis from simple dilatation, 196 of left ventricle, 252 aortic second sound felfc in, 218 pulsation with, 258, 254 apex-beat, when absent in, 202 capillary pulse in, 256 heart - sounds strength- ened in, 217 polyuria with, 406 pulsations in arteries in, 256 pulse with, 242 slow pulse with, 237 Hypertrophy of muscles, 490, 493 how recognized, 494 of right heart, venous engorge- ment with, 261 ventricle caused by emphy- sema of lungs, 210 pulmonary second sound felt in, 218 with emphysema of lungs, 204 Hyphidrosis defined, 37 Hypnosis, catalepsy with, 536 over-excitability of nerves and muscles in, 526 Hypochondria, oxalate of lime in urine of, 430 phosphaturia in, 432 Hypochondriuni defined, 297 illustrated, 298 left, projection of, by enlarged spleen, 334 spleen lies in, 332 projection of right, in enlarge- ment of liver, 321 right, portions of liver in, 319 Hypodermic syringe used in explora- tory puncture of pleura, 160 Hypogastrium defined, 297 illustrated, 298 Hypoglossal paralysis, unilateral, de- scribed, 537 Hypoglossus, paralysis of the, 548 Hysteria, absence of pharyngeal reflex in, 497 allochiria in, 478 anaesthesia of larynx in, 576 of pliarynx in, 577 aphonia in, 598 catalepsy with, 536 disturbance of breathing in, 576 dumbness after an attack of, 548 epithelium in bloody sputum of, 176 gross, described, 534 headache with, 482 hemianseatliesia with, 479 hemidrosis in, 38 hyperosmia and parosmia in, 574 hypersecretion of stomach in, 357 increased tendon reflex in, 500 laryngeal spasm in, 576 loss of voice in, 538 narrowing of field of vision in, 569 nervous cough in, 165 opisthotonus with convulsions of, 468 648 INDEX. Hysteria, palpitation of heart with, 577 paralysis in, 75 of diaphragm in, 90 peculiar bloody sputum with, 171 polydipsia and polyuria with, 406 relations of, to sexual organs in women, 581 sensibility of cranium to pressure in, 466 spasms in, 37, 494, 581 tenderness of vertebrae in, 467 tonic spasms in, 532 total ageusis points to, 574 tremor with, 531 unilateral elevation of tempera- ture in, 71 vomiting in, 358, 361, 578 Hysterical and epileptic spasms, dif- ference between, 633 convulsions, likeness of, to epi- leptic, 533 hemiansesthesia, 587 paralysis, EaR not present in, 525 persons, over-excitability of, 626 signs, 534 Hystero-epilepsy, 538 cyanosis in, 43 distinguished from epilepsy, 580 stages of, 634 tongue never'bitten in attacks of, 287 -traumatic neurosis, analgesia in, 479 paralysis, 493 Hysterogenous zones, 581, 687 in gross hysteria, 534 ICTERUS. Also see Jaundice, bile pigment in sputum in, 172 catarrhal, oxalate of lime in urine of, 430 hepatogenic, color of stool in, 373 slow pulse in, 237 neonatorum, 47 urobilin with, 411 with puerperal pyaemia, a case of, 602 Idiocy defined, 472 Idio muscular contractions defined, 526 Idiopathic migraine, 483 neuralgia, 483 Idiotism, increased secretion of saliva in, 577 Idiots, incontinentia alvi in, 578 Idiots, involuntary discharge of urine by, 579 skeleton of, 33 Ileo-csecal region, cooing in, in ty- phoid fever, 312 illustrated, 298 -inguinal nerve illustrated, 487 Ileus, when occurs, 364 Iliac fossa, left, pain in, with dysen- tery, 308 right, pain in, with typhoid fever, typhlitis, disease of vermiform appendix, 308 regions, pain in, due to. inflam- mation, 309 vein, oedema of legs from com- pression of, 314 pressure upon, by enlarged retro-peritoneal glands, 341 Imbecility defined, 472 Immediate percussion defined, 104 Inacidity of gastric juice, 345, 346, 356 Inactivity, atrophy of, defined, a re- rult of paralysis, 490 Inanition, acetonuria in, 448 slow pulse in, 237 Incisura cardiaca, 192 and parietal relation of heart, 197 illustrated, 304, 327 in deep inspiration, 125 the lung- heart boundary, 122 Incompensation, difficulties in making diagnosis when present, 253 of heart defined, 219 Incontinence of urine, 400, 579 Incontinentia alvi, when occurs, 370, 578 Incubation, period of, defined, 22 Incubator, testing digestive power of gastric juice in, 362 Indican, coloringpigmentin urine, 402 in urine, 435 described, and tests of, 409, 435 when occurs, 409 Indifferent electrode, 601 where placed, 602 Indirect percussion defined, 104 Inebriety concealed, 20 Infantile paralysis, 493 Infarction, hemorrhagic, of kidney, hsematuria with, 417, 418 of lung, deadened sound over, 127 mucous, mucus in feces in, 387 INDEX. 649 Infarction of lun^s, bronchial frothing in, 146 dyspnoea in, 95 friction sounds with, 156 weak percussion over, 115 pulmonary, bloody sputum in, 170 Infection distinguished from conta- gion, 22 Infectious diseases, 20 acute, delirium in, 471 headache with, 483 leucocytosis in, 278 ataxia after acute, 529 disturbance of consciousness in, 470 EaR with paralysis in, 524 enlarged liver with, 322 enlargement of spleen in, 334 epileptiform attacks in the beginning of acute, 533 gallop rhythm a sign of heart failure in, 221 glycosuria in, 443 hsemato-jaundice in, 47 haemoglobin in urine with, 411 indicated by high morning temperature, 64 local gangrene in acute, 577 position of patient in, 32 respiration in, 91 slight amount of vomit in , 360 ulceration of larynx with acute, 595 value of pulse in beginning of, 253 venous thrombosis in severe acute, 268 vomiting in beginning of cer- tain, 358 influence, neuralgia from, 483 Inflammation, leucocytosis in all kinds of, 278 oedema in the neighborhood of, 54 of chest, pain with, 101 Infra -clavicular spaces, percussion note over, 119, 120 Infra-scapular space, 77 Infra-trochlear nerve illustrated, 485 Infusoria found in stools of diarrhoea, 383 in sputum, 183 Inguinal region defined, 297 illustrated, 298 pain in, from psoas abscess, 309 Inhalation of dust a cause of disease, 21 Inherited diseases, 20 tendency, 20 Injuries, scars from, important in nervous diseases, 52 Inner capsule, disturbance of vision by lesion of, 460 Inorganic murmurs, 229 sediments in urine, section on, 428-433 most frequent fornds in urine, 428 Inosite in urine in diabetes insipidus, 447 Insane, incontinentia alvi in the, 578 involuntary discharge of urine by the, 579 Insanitv, hyperosmia and parosmia in, 57.4 superacidity of stomach in, 357 Inspection of abdomen, 313 of intestine, method of, 308 of kidneys, 394 of stomach, 299 of thorax, 81 of veins, 260 position of patient during, 81 Inspiration, atelectatic crepitation in, 154 auxiliary muscles of, 96 causes rapid emptying of veins, 262 deep, effect on area of heart- dul- ness, 206 forced, cause of, 100 increased circumference of thorax in, 163 in emphysema, 84 jerking, when and where occurs, 145 pressure of respiratory air in, 164 relation to pulsus paradoxus, 263 systolic subclavian murmurs heard at close of, 259 tonic and clonic spasm of thoracic muscles of, in tetanus, 540 variation of pressure during, in pleural and subphrenic cavity, 317 vesicular breathing only heard in, 142 Inspiratory dyspnoea, relation to ex- piratory, 100 when exists, 99 with emphysema, 100 650 INDEX. Inspiratory pressure, in what diseases diminished, 164 Insufficiency due to endocarditis, 194 mitral, systolic venous pulse with, 267 of aorta, cause of pulsation, 254 255, 256 of crural vein valve, mur^nur with, 268 of tricuspid valve, positive venous pulse pathognomonic of, 264 pulmonarv second sound in, 218" of valve, effect of, 194 valvular, effects of, 193 Intelligence, cloudiness of, in ursemia, 440 development of, 549 Intensity of lung sound, 108, 112 of sound of organs containing air explained, 106 Intercostal muscles, atrophied with lung cavities, 98 pain in trichinosis of, 44 paresis of, pulsation with, 102 nerves, neuralgia of, in tabes, 484 neuralgia, 101 increase of abdominal reflex in, 496 space, second, heart-sounds heard at, 214 spaces, 82, 84 in phthisical thorax, 84 Intermittent fever, 69 destruction of red corpuscles in, 434 herpes with, 50 increase of ch loride of sodium in urine in, 434 malarial, defined, 70 range of temperature of, 63 sweat in, 37 Internal capsule, 454, 461 blood-supply of, 462 effect of lesion of, 457 of local disease of, 459 hemiansesthesia with deposits in, 479 jugular veins, positive venous pulse in, 265 organs, disease of, effect on weight of body, 36 diseases of, effect on skin, 39 effect of engorgement of veins on, 260 Interscapular space, 77 percussion note over, 120 Intestinal bacteria in stools, value of, 388 canal, portion of, in stool, from sloughing, 376 catarrh, acid or alkaline stool in, 372 bilious stool in, 373 diffuse dull pain with, 308 due to tape-worm, 377 infusoria found in stools in, 383 mucus in feces in, 387 mucous stools in, 374 particles of food in feces in, 386 contents, decomposition of veget- able parasites from, 388 crises defined, 578 digestion shown by stools, 366 discharges, frequency and char- acter described, 367, 368 diseases with diminished sweat, 38 gas hinders action of diaphragm, 90 hemorrhage, 65 phenomena of, 40 infarction defined, 374 irritation from worms, a cause of epileptiform attacks in chil- dren, 533 peristalsis sometimes can be seen, 309 Intestine, amyloid degeneration of, forms of fat found in feces in, 386 auscultation of, 312 invagination of, character of pain with, 308 percussion of, 311 perforation of, cause of pneumo- thorax, 210 resistance of fluid in, in compari- son with air, 315 small, mistaken for colon, 310 Intestines, closed tympanitic sound heard over, 111 disturbance of, from venous en- gorgement, 261 examination of, 308 points in, 370 hemorrhage from, appearances of blood in, 375 importance of emptying, in ex- amining abdominal organs, 341 INDEX. 651 Intestines, inflating:, for purposes of diagnosis, 312 lung-sound, wlien heard over, 113 metallic sounds over, 112 Invagination of intestine, character of pain with, 308 Invalidism, venous thrombosis as a result of, 268 Involuntary discharges during an at- tack of epilepsy, 533, 534 of stool, 579 Iodide of potassium found in saliva, 289 in urine after taking, 450 Iron colors the vomit black, 360 -dust, detection of, 177 in epithelial cells in sputum, 177 in sputum, 171 solution of chloride of, a test for salicylic acid in urine, 354 in the presence of alco- hol, sugar, and acid salts, 351 Irrigation of rectum, 311 Irritability, electrical and mechanical, of muscles, 488 of nerves and muscles, faradic and galvanic, representation of, 521 Irritation, direct, 505 indirect, 505 of nerves from pressure, 482 peripheral, sensitiveness to, 472 Ischiatic nerve, electrical examination of, 511 Ischuria paradoxa, 580 Itching in jaundice, 47 JACKSON'S epilepsy, 533 described, 533 Jaffe, reference to, 190 Jaksch, reference to, 180, 272, 279, 282. 283, 381, 382, 384, 385, 388, 423, 424, 439, 444, 447, 448 Jaundice, 45. Also see Icterus, gall-stones in stools with, 376 itching in, 47 sometimes caused by ascaris in ductus choledochus, 381 sweat in, 38 with engorgement from displace- ment of right kidney, 396 with puerperal pysemia, a case of, 602 Jaworski's experimental meal, 349 Jendrassik, reference to, 501 Jerking breathing, where noticed, 143 inspiration distinguished from in- terrupted inspiration, 146 when and where occurs, 145 Johnson, reference to, 436 Joint neuroses, 583 Joints, chronic disease of, atrophy with, 493 muscular atrophy from diseased, lessened excitability without EaE, 625 ■ Jugular vein, right, shape of opening and its relation to venous hum- ming, 269 veins, phenomena of circulation in, 262 Jurasz, reference to, 258 KAHLER, reference to, 439 Kaltenbach, reference to, 398 Kan n en berg, reference to, 183, 427 KaSC, 520 Kast, reference to, 434, 519, 520 Keratin, coating for pills, in testing rapidity of passage of food from the stomach, 354 Keratitis, parenchymatous, a sign of syphilis, 286 Kidnev, amyloid, casts in urine of, 422, 423 contracted, casts in urine of, 422 diminished sweat in, 38 gallop rhythm of heart in, 221 cedema from, is fugitive, 440 polyuria with, 406 relation to heart disease, 576 disease, alkaline vomiting in, 366 dropsy of, disease of, 440 engorgement of, casts in urine of, 422 hyaline casts in urine of, 423 lateritious sediment in urine, 430 epithelium from in case of dis- ease, 421 fatty, fatty casts in urine of, 423 hemorrhage of the pelvis of, diag- nosis of, 418 hemorrhagic infarction of, haema- turia with, 417, 418 horseshoe, 393 large white, adipose white cor- puscles in urine of, 420 652 INDEX. Kidney, large white, paleness in, 41 left, adjacent to fundus of stom- ach, 299 new formations of, when can be felt, 395 position and relation of right and left, 392 pulse in contracted, 244 tenderness in tumor of, 395 of region of, when occurs, 395 tracing of pulse of contracted, 247 tumors of, diagnosis of, 397 value of percussion in, 397 urine from only one, 400 vicarious- action of one, 408 wandering, 395 Kidneys,anatomical situation of,411us- trated, 393 anatomy and topography of, 392 engorgement of, albuminuria with, 435 examination of, section on, 392- 451 injury to, hsematuria with, 417 local examination of, 394 location of, illustrated, 321 pathological condition of, 394 position of, 79 value of pulse in showing compli- cating disease of, 253 Klemperer, reference to, 354, 437 Knee-phenomenon, synonym for pa- tellar reflex, 498 Koch, reference to, 185, 390, 391 Koch's cholera bacillus, described and illustrated, 389 comma bacillus distinguished from Finkler-Prior's bacillus, 607 Kosselt, reference to, 190 Kreatinin hinders examination for sugar in urine, 405 Krehl, reference to, 246 Kronecker, reference to, 297 Kiihne, K., reference to, 439 Kiilz, reference to, 447 Kuspmaul, reference to, 263, 301, 303, 551, 552, 555, 556, 558 Kypho-scoliosis, 467 a cause of hypertrophy of right ventricle, 196 cases in which spleen can be felt, 334 deadened sound over, 114 described, 88 Kypho-scoliosis, dyspnoea from, 95 Kyphosis, 467 described, 88 from paralysis of erector trunci, 539 LAACHE, reference to, 275, 429, 430, 431, 432 Lachrymal nerve illustrated, 485 Lacing, tight, constriction of liver from, 323 Lactic acid, excess of, in stomach, 345, 346 fermentation, effect of, 343 tests for, in contents of stom- ach, 351 Lactose in urine, when occurs, and when demonstrable, 447 Laennec, reference to, 104, 138, 142, 191 Laennec's pectoriloquy described, 159 Lagging behind in paralysis of sen- sation, 485 detected by palpation, 103 in breathing described, 87, 91 in stenosis of a bronchus, 98 Lagophthalmus, 536 Lalopathy, 548 Lameness, simulation of, 19 Landerer, reference to, 54 Landois, reference to, 246 Landois & Sterling's Physiology, re- ferred to, 505 Lardosis from paralysis of erector trunci, 539 Laryngeal mirror, 591 muscles, action of, and effects of paralysis of, 538 spasm defined, 576 Laryngitis, acute, 598 circumscribed phlegmonosa, re- sults in abscess, 594 hypoglottica illustrated, 593 serious nature of, 594 in children, 593 Laryngoscopic examination of the larynx, section on, 589 image, reversal of parts in, 591 Larynx, abnormal redness of mucous membrane of, 592 casts of, in croup, 172 color of mucous membrane of, 591 evidence in, of pressure by tumors, 255 examination of, 74 for recurrent paralysis, 296 INDEX. 653 Larynx, inflammations near, cause of cyanosis, 43 laryngoscopic examination of, sec- tion on, 539 view of, 590 local examination of, 75 nervous diseases in which it is affected, 576 normal sound over, 119 open tympanitic sound, when it is percussed, 110 paralysis of various muscles of, and results, 598 pathological condition of, 592 position and movements of por- tions of, 592 sensitiveness of, a cause of cough, 165 spasm of muscles of, 597 stenosis of, 97 tone of cough in ulceration and stenosis of, 166 tympanitic sound over, 121 ulceration of, a cause of emphy- sema of skin, 56 what to observe in examining, 591 Lateral column of spinal cord, 455 Lateritious sediment in urine, 402, 429, 430. Laveran, reference to, 282 Law of contraction, 518 Lead colic, drawing in of abdominal wall in, 309 pulse with, 244 tracing of pulse of, 247 headache in poisoning with, 483 neuralgia from poisoning by, 483 paralysis, 543 EaR in, 525 poisoning, 21 black vomit in acute, 360 cause of paleness, 41 condition of teeth in, 286' double sound heard over cru- ral artery in, 259 Leanness, significance of, 34 Leg, motor centre for, 454 muscles of, and their paralysis, 546 points of electrical irritation upon, 514 Legal, reference to, 448 Length of Thorax, 163 Lenticular nucleus, 454 blood-supply of, 462 disease of both internal seg- ments, with chorea, 535 Leo, reference to, 344 . Lepra, 21 bacillus described, staining of cultures of, 606 Leptothrix buccalis illustrated, 289 in urine, 428 in sputum, 175, 184 pharvngomycosis leptothricia, 29 f Lesion, location of, in cortico-muscu- lar tract, effect of, 456 Lethargy, defined, 470 Letzerich, reference to, 190 Leube, reference to, 302, 347. 355, 426, 434, 445, 474 Leube's experimental meal, 347, 348 Leucin, form of, in urine, 431, 432 when occurs, 432 Leuckart, reference to, 379 Leucocytes with large nuclei, 279 Leucocythseraia, relative, 275 Leucocytosis a physiological condi- tion during digestion, 278 defined, 278 Leukaemia, 41 albuminuria with, 435 color of blood in, 271 crystals in blood in, 181 defined, 278 greatest enlargement of spleen in, 335 hsematuria in, 417 red corpuscles diminished and paler in, 275 retinal changes in, 602 uric acid increased in, 434 use of microscope in, 279 various forms of, 279 Levulose, in urine, when occurs, 447 Lewis, reference to, 391 Levden, reference to, 174, 179, 182, i90, 202, 267, 388 Lichtheim, reference to, 53, 552, 553, 555, 556, 558, 560 Lieben, reference to, 448 Liebermeister, reference to, 68, 238, 356 Liebig, reference to, 434 Lientery stools, 372 Life, mode of, cause of disease, 21 Light, source of, for laryngoscopic ex- aminations, 589 Lime, oxalate of, in sputum, 182 Linea costo-articularis, 332, 338 Lines drawn on thorax, 76 Lingual nerve, chorda tympani in, 461 Lintels, 185 654 INDEX. Lintels of tubercular sputum, 177 Lipsemia defined and when occurs, 280 Lipomatosis cordis, weak apex-beat in, 201 Lips, color of, 285 Lipuria, 412 occurs in chyluria, 447 Literal agraphia an aphasic symp- tom, 561 aphasia, 553, 556 paragraphia, 561 Litten, reference to, 427 Liver, acute yellow atrophy of, ecchy- mosis in, 51 anatomy of, 319 average boundary lines of, 329 cancer-navel upon, in carcinoma, 825 cirrhosis of, tender at first, 324 venous engorgement caused by, 262 consistence of, in various diseases, 326 constricted, sometimes tender, 324 deadness, absolute, 124 illustrated, 304 in right mammillary line, 108 relative, small when lungs expanded, 136 downward displacement of, 128, 321, 322, 324 movement of, in inspiration, 322 enlargement of, causes and signs of, 322 displacement from, 330 due to venous engorgement, 260, 261 effect on form of chest, 86 makes half- moon - shaped space smaller, 306 projection of right hypochon- drium in, 321 examination of, 319 granulated, surface of, 325 inspection of, 320 -kidney angle, 393 location of, illustrated, 321 lower border of, rarely felt, 321 mobility of boundaries of, 329 mode of palpating described, 266 motions during breathing, 323 organs that border it, 320 palpation and percussion of, 323 value of, 332 Liver, pathological conditions of, 324 relations of its boundaries, 329 percussion limits of, illustrated, 326, 327, 328 , position of, 78, 79 and boundaries of, illustrated, 319 as affected by pleurisy or pneumothorax on right or left side, 331 pressure upon, from meteorism, 309 proportion of, that is parietal, 320 -pulse, 302 arterial, 257 venous, 266 relative, deadness of sound over, 124 size and form of, 324 in children, 320 slight projection of, in children, 320 square position of, 330 -stomach boundary, 329 surface of, in various diseases, 325 that is displaced downward not to be confounded with enlarged, 331 tilting of, in pleurisy, 199 tumor of, 306 unequal enlargement of, 331 wandering, position of, 322 not in contact with dia- phragm, 322 Lobes of the brain, upper and lower parietal, temporal, and frontal, 466 of the lungs, boundaries of, 80 Lobulated liver, from deep syphilitic scars, 325 Loljus paracentral is, 454, 459 Local sense, how tested, 474 Location of thoracic contents illus- trated, 319 sense of, 473 Lofiier, reference to, 605, 606 Logwood, color of urine after taking, 411 Lordosis, 467 from weakness or paralysis of muscles of spine, 467 Louis, angle of, defined, 76, 78, 81, 82, 84 in phthisical thorax, 84 Lowenfeld, reference to, 523 INDEX. 655 Lower extremity, illustration of cuta- neous nerves of, 487 nerves of, 488 points of electrical irritation upon the back of, illus- trated, 513 Ludovici, angulus, 76, 78, 81, 82 Ludwig, reference to, 198, 246 Lumbar enlargement of cord, loca- tion of, 468 Lumbo inguinal nerve illustrated, 487 Lung-cavities, atrophy of intercostal muscles in, 98 bronchial breathing over, 146 metallic sounds over, 112 tympanitic sound with, when communicating with air, 131 compression of, against thoracic wall increases vocal fre- mitus, 158 by large exudation, 128 from high position of dia- phragm, 317 contraction of ,diiFerentiated from primary deformity of chest, 88 diminishes area of spleen- dulness, 339 left, eflfect on heart, 203 emphysema of cellular tissue from perforation of, 56 fistula, sound of, defined, 153 gangrene of, mucus in three layers in, 169 -heart boundary, 122, 125 -kidney boundary, 123 left, lower border of, boundary of, 125 -liver boundary, 122, 124, 125, 328, 329 overlaps the spleen and dimin- ishes area of dulness over, 339 retracted, tympanitic sound with, 111 sequestra, 172 shrinking of 197 -sound defined, 108 -spleen boundary, 122, 124 -stomach boundary, 122, 124 thickening of, ringing rales with, 152 tissue, decreased tension of, 135 in sputum in abscess of lung, 172 no irritative cough from, 165 Lung tissue, relaxation of tympanitic sound with, 130 retracted, noise of spun-top over, 135 thickening of, bronchial breathing in, 146 Lungs, abnormal sounds over, 125 abscess and gangrene of elastic threads in sputum, 177 hsematoidin in sputum, 172 active mobility of, 125, 210 amount of expectoration from cavities in, 168, 169, 175 anatomical boundaries of, 78, 79 auscultation of, 138 borders of, 80 boundaries of, changed, 136, 304, 319 rules to be observed in deter- mining, 124 brown induration of, dyspnoea in, 96 catarrh of larynx in disease of, 593 chronic diseases of subnormal temperature with, 64 consolidation of cyanosis in, 43 contraction of, a cause of hyper- trophy of right ventricle, 196 difficulties in determining their boundaries, 123 diminished volume of, how recog- nized, 137 diseases of, form of thorax in, 81 which cause dyspnoea, 95 disposition to disease of 81 disturbances of the circulation through, 44 dust diseases of, 21 elasticity of, lost in emphysema, 84 emphysema of, a cause of dis- placement of heart, 199 weakens apex-beat, 201 examination of, 76 gangrene of Also see Gangrene, odor of sputum in, 171 hemorrhage of, in tuberculosis, 170 large cavity in, metallic heart- sounds with, 221 lobes of boundaries of, 80 location of illustrated, 321 lower border of, in children. 192 relatively deadened sound over, 114 boundary of, 122 656 INDEX. Lungs, normal percussion of, bounda- ries of, 121 sound over, 119 cedema of, bloody sputum with, 170 dyspnoea in, 95 serous sputum a peculiarity of, 169 percussion of, described, 118 posterior boundaries of, illus- trated, 123 pressure upon, by meteorism, 309 rapid breathing in inflammation of, 94 relation of disease of, to certain brain diseases, 576 to diaphragm, 80 retraction of, measure of thorax in, 163 near the heart, 137 upward displacement of liver with, 323 shrinking of, a cause of displace- ment of heart, 199, 200, 211 both pulmonary sounds strengthened in, 218 pulsations at base of heart in, 203 starch corpuscles in the sputum in hemorrhage of, 180 symptoms of hsematemesis in hemorrhage of, 167 thickening of, deadened sound from, 114 feeling of resistance with, 116 metallic rales with, 150 simulates enlarged heart, 209 thoracic boundaries of, 77 topographical anatomy of, 76 tuberculosis of, see Tuberculosis tumor of, peculiar sputum in, 171 tumors of, deadened sound over, 127 value of pulse in showing compli- cating disease of, 253 vital capacity of, relation to size of body, 164 wounds of, a cause of emphysema of skin, 56 Lupus, may be the cause of catarrh of larynx, 593 Luschka, reference to, 78, 79, 192, 319, 321 Lustgarten, reference to, 399, 427 Lymphatic glands, blowing murmurs over, 259 leucocytosis in swelling of, 278 Lymphatic glands swollen in syphilis and diphtheria, 290 Lymphosarcoma of spinal cord, he- mialbumose in, 439 Lysis defined, 67 Lyssa, increased tendon reflex in, 500 M-A (milliamperes) strength of cur- rent measured in, 512, 515 Macrocephalus with hydrocephalus, 464 Macrocytes, defined, occur in anaemia and in pernicious anaemia, 276 Maixner, reference to, 439 Malaise, from uraemia, 440 Malaria, bacillus of, 282 diagnostic value of temperature in, 64 haemoglobin in urine of, 411 melanaemia in, 280 neuralgia from, 483 spleen much enlarged in, 335 Malarial cachexia, 41 intermittent fever, 70 Malignant growths cause of paleness, 41 pustule, 21 examining blood for micro- organism of, 282 Mai perforant, defined, 582 Mammillary line corresponds with border of liver, 327 edge of liver at, 323 variations of, 77 lines, 297 defined, 76 Manegegang, 534 Mania, with uraemia, 440 Manneberg, reference to, 399, 427 Manometer, use of, in puncture of cavity, 318 Marasmus defined, 35 Marchiafava, reference to, 282 Marching a cause of disease, 21 Marey, reference to, 246 Marie, reference to, 560, 583 Martins, reference to, 199 Masseter spasm in trismus, 532 Mastication, difiiculty of, in paralysis, 537 muscles of, 536 Matterstock, reference to, 259 Maxilla, superior, nerve supply of mucous membrane of, 484 Meals, effect upon pulse, 235 INDEX. 657 Measles, 49 acute nasal catarrh in, 74 coin shaped sputa in bronchitis of, 169 epileptiform convulsions in the beginning of, 533 inflammation of larynx in, 75 petechise in, may be overlooked, 51 recurrence of, 22 Measurement of thorax in' aneurism of aorta, 254 Measuring circumference of abdomen, value of 316 the thorax, 162 Meat-juice stools in dysentery, 375 Mechanical EaR, 526 irritation, neuralgia from, 483 Median nerve, anaesthesia in the re- gion of, from paralysis of brachial plexus, 487 distribution to hand, 545 illustrated, 486 paralysis of, 544 Mediate percussion deiined, 104 Mediastinal emphysema, crepitations of, 233 pericarditis, 204 tumor, measurement of thorax in, 163 producing pressure-paralysis of recurrent nerve, 538 swelling of cutaneous veins over sternum sign of, 262 venous engorgement from, 261 tumors affecting larynx, 75 displacement of the heart by, 199 effect on heart, 201 Mediastinitis, callous, diastolic col- lapse of cervical veins in, 267 effect upon venous circulation, 263 Mediastinum displaced by exudation, 128 displacement of, how recognized, 137 thickening of, simulates enlarged heart, 209 tumors of, cyanosis an effect of, 44 Medicines, exanthem from use of, 50 urine as affected by, 450 Medulla, anaemic necrosis of, 462 blood-supply of 462 softening of, 599 Melaena neonatorum, hemorrhage of stomach with, 362 Melanaemia defined, and connection with malaria, 280 Melancholia attonita, 536 Melanotic tumors, color of urine with, 411 Meltzer, reference to, 297 Meniere's disease, tinnitus aurium with, 573 Meninges, disease of, feeling of con- striction about thorax in, 482 tumors of, disturbances of con- sciousness from, 471 Meningitis, anosmia from, 573 basilar, rigidity of neck in, 468 slow pulse in, 237 breathing in, 91 cerebro-spinal, herpes with, 50 irregular temperature with, 71 Cheyne-Stokes respiration in, 92 choked disc with, 600 consciousness may be retained in. 471 disturbance of consciousness in, 470 drawing-in of abdominal wall in, 309 from disease of the nose, 576 headache with, 482 irregular temperature in, 71 neuro-retinitis with, 601 pain in spine in, 483 posture in, 33 pulse in, 245 purulent, affections of hearing with, 572 relation of, to disease of the lungs, 576 sensibility of cranium to pressure in, 466 slow pulse with, 239 spinalis, herpes zoster in, 581 spinal, rigidity of spinal column in, 468 tenderness of vertebrae in, 467 tubercular, suspected when nu- trition is poor, 575 value of pulse in showing devel- opment of, 253 vomiting in, 358 Memory, loss of, 556 testing of, 469 Mental condition, during spasm, 530 disease, first traces of, 470 42 658 INDEX. Mental diseases, hemidrosis in, 38 disturbance due to fever, 60 impressions produce perspira- tion, 36 nerve illustrated, 485 Mercurial poisoning, 21 cause of paleness, 41 Mercury, cocci in mouth in poisoning by. 289 condition of teeth in poisoning by, 286 headache in poisoning with, 483 neuralgia from poisoning with, 483 salivation caused by, 289 Mesenteric glands, disease of, forms of fat found in feces, in, 386 Mesocardia, 211 Mesogustrium defined, 297 Metallic aiter-sounds defined, 112 associated sound accompanies bronchial breathing, 148 heart-sound, 210 murmurs, 227 pericardial splashing, 233 poisons from inhalation, 21 rales, ir)0 sound defined, 112 with pneumothorax, 135 with various conditions, 136 tone over large cavities with smooth walls, 131 Metamorphosing breathing defined, 148 Meteorism cause of diminished area of liver-dulness, 331 effect on extent of abdomen, 309 on form of chest, 86 employment of deep breathing in, 323 intestinal, 313 or peritoneal, metallic heart- sounds with, 221 pressure by, upon liver, dia- phragm, lungs, heart, 309 with and without pain, value of, in diagnosis, 314 Meteorismus peritonei defined, 313 value of percussion in, 317 Methsemoglobin, absorption band of, 273 in the blood in poisoning by chloride of calcium, 272 spectroscopic examination for, 442 Methods of auscultation, direct and indirect, 138 Methods of percussion of thorax, 118 Methyl-violet test for free muriatic acid, 451 Miasm, 21 Microcephalus, 465 Micrococci, casts of, in septic pro- cesses, 427 in mouth, 289 in purulent plural exudation, 161 in sputum from mouth, 188 Micrococcus gonorrhoeus described, 604 tetragenus, 184 ureae, 426 Micro-millimetre, value of, 185, note. Micron, a measure, value of, 185, note. Microorganisms, examining blood for, 273 in mouth, 289 in sputum, 167 in stomach, destroyed by anti- septic action of gastric juice, 343 excess of, 345 in the blood, 280 in urine, staining of, 415 mode of examining blood for, 282 that excite fermentation, 342 Microcytes, 276 in anaemia, 276 in pernicious ansemia, 276 Microcythaemia, 274 after hemorrhages in anaemia, 276 Microscope, diagnosis of thrush by aid of, 288 examination of contents of mouth by, 289 generally useless in determining hemorrhage of stomach, 365 magnifying power, use in exam- ining the blood, 273 use of, in diagnosis of diseases of palate and pharynx, 291 in examining for cocci and bacilli in urine, 426 urinary sediments, 415, 419 in haematuria, value of, 418 Microscopic appearance of uric acid, 428 examination of blood, mode of procedure, 273 value of, 271 of urate of soda and lime, 429 Micturition, difficult, a cause of dimi- nution in amount of urine, 407 INDEX. 659 Middle cranial fossa, effect of lesion of, 457 Migraine defined, symptoms of, and when occurs, 483 hemidrosis in, 38 inequality of the pupils in, 567 sometimes preceded by tinnitus aurium, 573 temporary partial amaurosis in, 571 unilateral redness of head in. 577 vomiting with attacks of, 578 Miliaria. 50 Miliary tuberculosis affecting the cho- roid, 562 Milk, color of stool wlien the diet con- sists of, 373 particles of, in sputum, 175 Miller, reference to, 391 Milliampere-meter, 503 Mind, condition of, mode of examin- ing, 469 Minimal contraction, 512, 514 Minkowsky, reference to, 449 Miserere, when occurs, 364 Mitral disease, enlargement of liver with, 322 of heart, paleness in, 41 venous engorgement in, 261 first sound, the loudest heart- sound, 217 insufficiency, 194, 195, 196 and stenosis, effects of, 195 color of skin in, 41 dyspnoea in, 96 murmur of, 224, 225 pulse with, 242 systolic venous pulse with, 267 murmur heard at apex, 224 stenosis, 194 absence of pulse with, 243 arhythm of pulse in, 241 character of pulse with, 243 division of second sound at apex in, 220 double sound over crural ar- tery in, 259 first sound strengthened at apex in, 218 pulse in, 251, 253 weakening of aortic second sound in, 219 valve causes a systolic sound, 213, 214 where best heard, 213, 214 Mobility of spinal column dimin- ished, 467 of spleen, 335 Mode of life, effect on complexion, 39 Moist cough described, 166 rales, 149 explained ; when occur, 151 Monoplegia, 457 facialis, brachialis, cruralis, de- fined, 489 with partial epilepsy, 533 Monos (infusorium) in sputum, 183 Moore's test for sugar, 445 Morbus Addisonii, 48 Basedowii, apex-beat with, 201, 216 blowing mnrmur with, 259* tremor of, 531 Werlhofii, hfematuria in, 417 Morenheim's depression defined, 76 Morgagni, sinus, 591 Moritz, reference to, 132 Morphia, effect of, on pupil, 567 induces perspiration, 37 poisoning by, Cheyne - Stokes breathing in, 92 tremor from, 531 Mosso, reference to, 93, note. Motility, disturbances of, 488 of lungs, when diminished, 137 Motion, loss of, from paralysis and stiffness not to be confounded, 488 Motor aphasia, 553 cortical regions, location of, 466 of occipital and temporal lobes, relation to cra- nium, 465 cranial nerves, 455 memory, 549 points, 508 stimuli, 456 Mould in sputum, 190 Mouth, effect of opening and closing of, upon the pitch of sound. 111 examination of, 284 microscopical examination of con- tents of, 289 odor from, importance of, 285 open, tympanitic sound when it is percussed, 110 Movements, associated, defined, 535 sensation of, defined, 474 Mucin in urine, test for, 441 Muco-purulent sputum described, 168 Mucor (mould) in sputum, 190 Mucous colic, 374 660 INDEX. Mucous corpuscles in vomit, 365 deposits upon larynx, 692 infarction, mucus in feces in, 387 membrane of larynx, color of, 591 reflexes of, 496 sputum described, 168 stool described, and sisrnificance of, 373 threads in urine not to be con- founded with casts, 416 Mucus, cloud of, in normal urine, 402 in feces, 387 in three layers described, 169 in urine, 416 causes it to be jelly-like, 419 chemical proof of, 416 threads of, in sputum, 175 Muguet in sputum, 175 Mulberry tongue a sign of scarlet fever, 287 Miiller, reference to, 386, 387 Miiller, F., reference to, 371 Multiple neuritis, diagnosis from tabes, 580 EaR with, 524 neuralgic pain in, 484 sclerosis, allochiria in, 478 atrophy of the optic nerve in, 562, 661 narrowing of field of vision in, 569 scanning speech in, 548 tremor with, 531 Mumps (inflammation of parotid gland), 288 Muriatic acid, excess of, in stomach, 345 free, testing for, with phloro- glucin- vanillin, 350 with tropaolin paper, 350 when wanting, 356 in stomach, 344 quantitative examination, 351 relation to pepsin, 352 Murmurs, anaemic, 229 blowing over lymphatic glands,259 characters of, 227 combination of several, diflFeren- tiation of, 228 diastolic and systolic, 228 diflFerential diagnosis between peri- and endocardial, 232 double, described, 259 endocardial, loudness of, to what due, 223 Murmurs heard over veins, 268 heart, when heard, 222 metallic, 227 pericardial, 230 presistolic, 228, 251 explained, 226 normal venous pulse with, 263 systolic and diastolic, 226 subclavian, 259 that can be felt, 227 Muscles and nerves, electrical exami- nation of, 501 mechanical excitability of, 526 auxiliary, of inspiration, 96 of respiration, 83, 541 behavior of, when irritated, 507 diagram of their innervation, 454 disturbance of nutrition and tone of, 489 EaR with degenerative atrophy of, 524 increased tonus of voluntary, 535 motor points of, 508 nutrition of, nervous influence, 456 of arm and hand, importance of a knowledge of, and their in- nervation, 645 of the eye, action of, and paralysis of, 562 function of individual, 564 paralysis of, 562 of the lower extremity, 646 of the thorax, diaphragm and abdomen, 640 effects of paralysis of, 640 of the trunk, action of, and effect of paralysis of, 539 of the upper extremity, 540 spinal, pain in, 483 tonus of, 528 voluntary, innervation, function, and the diseases that disturb them, 536 Muscular atrophy from diseased joints, lessened excitability with- out EaR, 525 spinal progressive, fibrillary contractions in, 532 dystrophia, 493 irritation, direct, on the back, 512 rheumatism, pain in spinal mus- cles, 483 sense, 474, 480 defined, 480 test for, 481 INDEX. 661 Muscular sense, tract of, 459 Musculo-spiral nerve, examination of, 512 muscles supplied by, ex- amination of, 515 paralysis of, from com- pression, 487 Music an acquired faculty, 549 power to firoduce, 550 Mydriasis, 566, 567 Myelitis, 580 allochiria in, 478 diminished tendon reflex in, 500 transversa, 492, 493 clonic spasms in, 532 cystitis in, 579 increase of tendon reflex in, 500 involuntary passage of urine in, 580 Myocarditis, arhythm of pulse in, 241 flbrinous, slow pulse in, 237 pulse in, 252 pulsus intercedens in, 241 weak apex-beat in, 201 Myopathic muscular atrophy, EaR in, 524 lessened excitability in, without EaR, 525 paralysis, EaR not present in, 525 skin reflex lost in, 496 progressive muscular atrophy, 525 spasm, 493 Myopia, 567 Myosis. 566, 567 Myositis ossificans, a cause of rigid thorax, 91 cyanosis with, 44 Myotonia congenita, 532 increased mechanical excita- bility in, 526 Myotonic reaction, described, 524 in Thomsen's disease, 518 NAILS, in peripheral paralysis, 583 Names of diseases, misuse of, 19 Naphthalin, color of urine after taking, 411,451 Narcotics, disturbance of conscious- ness in poisoning by, 470 Nasal polypi, cause of neuroses, 575 Naunyn, reference to, 449, 478, 575 Neck and head, points of electrical irritation upon, illustrated, 508 Neck, nerves of, 485 Neelsen, reference to, 187 Negative venous pulse, 263 Neisser, reference to, 427 Nelaton's oesophageal catheter, use of, to wash out stomach, 347 sound, use of, 302, 355 Nephritis a cause of cardiac hyper- trophy, 196 of dropsy, 53 acute and chronic, albuminuria with, 435 casts of albumin in urine of, 424 hemorrhagic, desquamation of renal epithelium in, 424 slow pulse with, 237 amount of diminution of urine indicates severity of, 407 bacteria in urine of, 427 casts the infallible sign of, 420 chloride of sodium in urine di- minished, 434 chronic, cause of paleness, 41 haemorrhagica, blood-corpuscles in casts in urine of, 423 mucus threads in urine of, beside casts, 416 oedema with, 54 parenchymatous, pus-corpuscles in urine of, 420 renal casts in urine of, 422 epithelium in urine of, 421 retinitis with, 601 saliva contains urea in, 289 sequela of scarlet fever, 22 sometimes phosphates in urine are diminished in, 435 sweat in, 38 tenderness in acute, not chronic, 395 tracing of pulse of, 247 turbid urine in, 412 urea diminished in, 434 Nephrolithiasis, 433 hsematuria with, 417 Nerve centres, vasomotor influences from, on pulse in symmetrical vessels, 257 faradic examination of, described, 512 lesion of, degeneraiive atrophy from, 491 points, 508 sensibility to pressure in neuritis, 468 662 INDEX. Nerve trunk, exiimination of, its course must be known, 468 Nerves and muscles, electrical exam- ination of, 601 cutaneous, of the lower extremity illustrated, 487 distribution of sensory cutaneous, 484 individual peculiarities of in re- lation to the skin, 504 irritation and pain from pressure, section on, 482 mechanical excitability of, 526 neuralgia as sequela of inflamma- tion of, 483 of head, 484, 485 of lower extremity, 488 peripheral, and their surround- ings, 468 points of tenderness in, 484 of stimulation, 508 shoulder, arm, and hand, 485 Nervous cough, a dry cough, 166 during menstruation, 165 disease of heart, increases strength of heart-sounds, 216 diseases, diagnostic value of symp- toms in, 583 disturbances of the vegetative system in, 575 importance of scars from in- juries, 52 local sweating in, 38 patients, rapid breathing in fever, 94 system, anatomical diseases of, 586 anatomy of, 452 central, injuries to, glyco- suria after, 443 chapter on examination of, 452-587 convulsions in disease of 22 differential diagnosis of func- tional aud anatomical dis- eases of, 587 diseases of, diagnosis of, 586 Nervousness, dizziness with, 471 subjective sensibility of hearing in, 572 Neubauer, reference to, 412 Neukirch, reference to, 121 Neuralgia, defined, cause of, 483 glycosuria with, 443 in head, 483 intercostal, 101 Neuralgia, sensitive points in nerves, 468 simulation of, 19 tenderness of nerves during, 484 with diabetes mellitus, 579 Neuralgic pain in connection with feeling of constriction, 482 in herpes zoster, 581 Neurasthenia, cerebral, with vertigo, 472 headache of, 482 pain in spine in, 483 phosphaturia in, 432 spinalis, 580 Neuritis, acute degenerative, 493 acoustic, subjective sensibility of hearing with, 573 ataxia in diffuse peripheral, 529 condition of nerve in, 468 degenerative, 491 EaR with, 524 herpes zoster from, 581 multiple, lessened excitability v/ithout EaR in, 525 partial ¥jaR in, 525 nerve sensitive to pressure in, 484 of phrenic nerve, effect on dia- phragm, 90 optica, 652 from intracranial pressure 600 peripheral, cyanosis in, 43 degenerative atrophy with, 491 gangrene in, 577 with diabetes mellitus, 579 Neuro-fibroma, condition of nerve in, 468 Neuroma, condition of nerve in, 468 Neuro-retinitis Brightii, choked disk with, 601 diabetic, 602 when occurs, 601 Neuroses, hypersecretion of stomach in, 357 increased tendon reflex in, 500 joint, 583 local sweating in, 38 narrowing of field of vision in, 569 phenomena of pulse in, 577 pulse in certain, 240 sometimes inherited, 20 vomiting in, 358 Neurosis, slow pulse as a, 238 INDEX. 663 Neurotic bronchial spasm, cause of dyspnoea, 94 causes for glycosuria, 443 Newly-born, urate casts in urine of, 424 urine of, frequently contains albumin, 405 weight of, 35 Nicotine, headache in poisoning with, 483 neuralgia from poisoning with, 483 poisoning, effect on heart, 201 palpitation of heart in, 577 Niemeyer, P., reference to, 140 Night-sweats in phthisis, 38 Nitrate of silver, deposit of, 49 Nitric acid test for albumin, 436 Nitro-benzole, color of blood in poi- soning by, 271 poisoning by, odor of bitter almonds in vomit, 366 Nocturnal enuresis, 400 Noise of spun-top described, 134, 135 where it occurs, 134 Noma, description of, 288 Non-tympanitic sound caused by ten- sion, 111 defined, 108 from closed air-cavity, 110 over sternum, 121 transition to tympanitic, explained, 112 where occurs. 111, 112 Noorden, reference to, 404 Normal boundaries of lungs, 119 electrode, 502, 503, 506, 507, 512, 516 percussion boundaries of lungs, 121 Nose, blood from, appears as hsemate- mesis, 361 disease of, migraine with, 483 examination of, 73 fluids escape by, in paralysis of soft.palate, 537 nerve-supply of mucous mem- brane of, 484 relation of diseases of, to nervous diseases, 575 suppuration of, cause of menin- gitis and abscess of brain, 467 Nostrils, how dilated, 536 Nothnagel, reference to, 373, 374, 387, 388 Nourishment, insuffidient, a cause of drawing-in of abdomen, 309 Nuclear paralysis, synonym for bulbar paralysis, 497 Nursling. Also see Children. Nurslings, stomach-digestion in, 344 Nutrition, disturbance of, cause of ophthalmia neuro-para- lytica, 484 disturbed, blood coagulates slower in, 283 how to judge of, 34 of muscles, 488, 489 signs of, 489 variously affected in diseases of the nervous system, 575 Nylander's reagent, 444 Nymphomania, 472 Nystagmus, horizontal and rotatory, defined, 565 abbreviation for opening of cur- , rent, 506 Obermeier, reference to, 281 Obersteiner, reference to, 478 Oblongata, 455, 461 diseases of, glycosuria in, 443 effect of lesion of, 457 glycosuria in disease of, 579 Obstipation (constipation), 369 increase of indican in urine in obstinate, 409 large stools after prolonged, 370 Obturator nerve, illustrated, 487 Occipital lobe, blood supply of, 462 centre for conception of writ- ing in optic portion of cor- tex of the, 555 illustrated, 466 lobes, effect on vision of lesion of, 460 nerves illustrated, 485 Occupation a cause of disease, 21 Oculomotorius, absence of pupillary reaction of light in paralysis of, 568 inequality of pupils in unilateral paralysis of, 567 muscle, dilatation of pupil in paralysis of, 566 total paralysis of, 565 Odor from mouth, importance of, 285 of expectoration, 168 of sputum described, 171 664 INDEX. Odor of urine, pathological, 414 Odors of urine, normal and adven- titious, 404 CEdema.. 52 a result of general venous engorge- ment, 261 cause of, explained, 54 collateral, 54 deceptive increase of weight, 35 distinguished from emphysema of skin, 55 due to ankylostomo-anaemia, 5i from kidney disease, 440 nephritis, 54 in paralysis, 577 may conceal venous stasis, 262 near heart, weakens apex-beat, 201 of chest- wall, cause of deadened sound, 130 weakened vocal fremitus with, 158 of engorgement, venous throm- bosis with, 268 of glottis, cause of cyanosis, 43 of larynx, 594 of legs, from compression of iliac veins, 314 of lungs, albumin in sputum in, 190 bloody sputum with, 170 crepitant rales with, 154 dyspnoea in, 95 serous sputum a peculiarity of, 169 tympanitic sound with. 111, 130 showing deep abscess, 54 slight, disappears between even- ing and morning, 54 striae from, 52 (Edematous skin in empyema, 86 Q5sophagoscopy, 297 CEsophagus, anatomy of, 291, 292 auscultation of, 297 carcinoma of, producing pressure- paralysis of recurrent nerve, 638 compression of, 296 congenital stenosis of, 292, 296 danger of inducing emesis when it is eroded, 342 dilatation of, 296 disease of, a cause of drawing-in of abdomen, 309 examination of neighborhood of, 291, 296 QEsophagus, expectoration from, in hysteria, 171 location of stricture of, 295 obstruction of, 296 percussion of, 296 perforation of, cause of pneumo- thorax, 210 pressure upon recurrent nerve from carcinoma of, 255, 599 recurrent paralysis a symptom of carcinoma of, 600 rupture of, a cause of emphysema of skin, 56 sounding of, dangers of, 294 difficulties of, 294 method of, 293 stenosis of, obstipation with, 369- Oidium albicans, description of, 287 Old age, anosmia in, 573 nutrition of skin in, 36 reaction of pupils to light, slow in, 567 slow pulse in, 237 Olfactory nerve, 461 anosmia with compression of,. 573 Oligocythsemia, diminution of red cor- puscles, 273 haemoglobin diminished in, 275 occurs in ansemia, 274 Oliguria in hysteria, 579 Omentum, dulness over, from fat, 30& examination of, 340 shrinking of, in tuberculosis, 340- Onanism concealed, 20 One-sided action of diaphragm, 90 Open pneumothorax, tympanitic sound, 110, 111, 113 Ophthalmia, neuro-paralytic, 484 Ophthalmic artery, 461 Ophthalmoplegia externa, 566 Ophthalmoscope, examination with^ 600 Opisthotonus, 496, 532, 534, 539 defined, 468 with meningitis and tetanus, 467 Opium poisoning, Cheyne- Stokes breathing in, 92 Optic nerve, 551 absence of pupillary reaction in atrophy of, 568 atrophy of, after severe hem- orrhages, 602 in diabetes, 602 in tabes, 562 course of, 460 INDEX. 665 Optic nerve, dilatation of pupil in atrophy of, 566 illustrated, 460 inequality of pupils in paral- ysis of the, 567 lesion of, 565 narrowing of field of vision from atrophy of, 569 primary atrophy of, when occurs, 601 thalamus, 454 blood supply of, 4&2 hemichorea with lesion of, 535 Organic heart murmurs explained, 221 Orthopnoea, 97 diseases in which it occurs, 32 effects of, 33 in heart disease, 197 Oscillation of the eyeball, 565 Osier, reference to, 282, 391 Osmic parsesthesia in hysteria and insanity, 574 Osteomyelitis, staphylococus pyogenes in, 603 Ostium venosum, 218 Ovarian hypersesthesia, 581 tumor, differential diagnosis from tumor of kidney, 396 made out after tapping abdo- men, 318 Oxalate of lime, concretions of, 433 in sputum, 182 in urine, forms of, described, 429, 430 microscopic appearance of, 430 wheu it occurs, 430 Oxaluria defined, 430 Oxybutyric acid interferes with cir- cumpolarization for sugar, 447 Oxygen, deficiency of, a cause of cy- anosis, 43 diagnostic importance of, 270 effect of deficiency of, on color of blood, 270 Oxyhsemoglobin, absorption band of, 271, 272, 273 effect of, upon color of blood, 270 Oxyuris in vomit, 364 vermicularis, described, 382 found in urine, 425 illustrated, 381 P A IN, a cause of rapid breathing, 94 a cause of suppression of cough, 165 Pain accompanies diseases of the ab- dominal cavity, 314 after use of sound in oesophagus, significance of, 294 cold- and heat-, test of, 475 dilatation of pupil with severe, 566 effect of, on reaction of pupils, 567 frequent pulse with severe, 240 from pressure on nerves, 482 in respiration, a cause of dimin- ished vesicular breathing, 145 in spine, various causes of, 483 in swallowing, significance of, in diseases of oesophagus, 292 produced bv pressure on stomach, 299, 300, 303 produces perspiration, 37 restricting action of diaphragm, 90 sensibility to, how tested, 476 spontaneous, section on, 482 syncope from, 471 tenderness of spleen, when occurs, 335 thoracic, produced bv pressure, 101 with movements of bowels, when occurs, 370 Palate, examination of, 284 sense of taste in, 461 soft, electrical irritation of, 510 examination of, 290 innervation of, 637 muscles of, 536 Pale skin. 39 Paleness due to diminished hasmoglo- bin, 40 unilateral, in hysterical hemi- ansesthesia, 577 various causes of, 40 Palpation above and below zygoma, what it shows, 537 in disease of peritoneum, 314 in examining throat, 285 of arteries, 256 of intestine, 308 of kidney, importance of, 895 of liver described, 266 how performed, 323 value of, 332 of mouth, 288 of oesophagus, 292, 293 of peritoneum through vagina, 316 of pharynx, 290 666 INDEX. Palpation of pulse, how performed, 234 of rectum described, 311 of spleen, 334 of stomach, 302 of thorax, 100 of veins, 260 of vocal fremitus described, 156 respiratory, how performed, 103 use of, in heart-murmurs, 227 Palpatory percussion of heart's resist- ance, 205, 208 Palpitation in organic disease of heart, 677 nervous, causes stronger heart- beat, 201 of heart in mitral defects, 240 Pancreas, anatomical relation of, 299 cancer of, a cause of jaundice, 47 examination of, 340 Pancreatic juice, deficiency of, 371 Panizza, reference to, 177 Papilloma of larynx described, 596 Para-ansesthesia defined, 479 Paradoxical contractions defined, 527 Parsesthesia defined, and when occurs, 482 osmic, 574 Paragraphia, 559 an aphasic symptom, 561 Parallelism between atrophy and paralysis, 493 Paralvses, kinds of, in which there is EaR, 524 Paralysis aifecting the larynx, 75 agitans, 530, 531 and atrophy, parallelism be- tween, 493 the writing often good, 561 associated movements in cerebral, spinal, and peripheral, 535 atonic, characteristic of, 494 atrophic, 490 atrophy of inactivity, a result of, 490 of muscles with, 491 cerebral, EaR not present in, 525 or spinal, above the anterior horn, characteristic sign of, 494 contracture of muscles after, 495 crossed, illustrated, 453 degenerative atrophic, 492, 518 determined by extent and location of lesion, 457 extent of, 489 Paralysis from pressure, partial EaR in, 525 heart and vessels to be examined when there is, 577 how produced, 456 incontinentia alvi with, 370 increased excitability in cerebral, spinal, and neuritic, 526 intermitting, general, 525 of arm, or one side of body, with albuminuria, 441 of brachial plexus, cause of anaes- thesia of the region of mediari nerve, 487 of crico -arytenoid muscles, dys- pnoea from, 75 of diaphragm cause of inspiratory dyspnoea, 99 cyanosis from, 43 dislocation of heart in, 200 of dilators of glottis, cause of in- spiratory dyspnoea, 99 of extensors of the trunk, effect of, 539 of extremities, cause of, 457 illustrated, 453 of facial nerve, effects of, 536 tract, bone reflex present in, 500 of heart, pulse in, 240 of intestine in peritonitis, 369 of laryngeal muscles, dyspnoea from, 93 of muscles concerned in cough, 165 of arm, 542 of eye, significance of, 564 of head and neck, 539 of inspiration, effects of, on thorax, 91 of mastication, tongue, soft palate, and pharynx, 537 of shoulders, 541 of speech, 548 of the lower extremity, 545 of pharyngeal muscles, effect of, 538 of phrenic nerve shown by pal- pation, 103 of respiratory muscles, cyanosis from, 43 dyspnoea from, 95 of soft palate described, 537 of various muscles of larynx, causes and results of, 598 of voluntary muscle defined, 488 INDEX. 667 Paralysiri, peripheral, disturbance of sensation lags behind that of motion in, 485 nails in, 583 permanent, illustrated, 522 phenomena, method of examina- tion, 488 progressive, imbecility with delu- sions in, 472 signs of, 23 syncope in, 471 radial, ansesthetic zone with, 479 rheumatic facial, 491, 520 section on, 488 tremors of, distinguished from spasm, 531 varieties of, determined by loca- tion of lesion, 456 with partial EaR, illustrated, 522 return of motility, illustrated, 521 Paralytic dementia, character of the writing of, 561 thorax described, 84 Paraphasia, 553, 559 testing for, 556 Paraplegia, inferior superior, 457, 489 Parasites, animal, 21 in sputum, 182 in urine, 424 intestinal, nervous disturbances in children from, 578 vegetable, 425 in feces, significance of, 388 Parasternal lines, defined, 76 Paresis defined, 488 of detrusor urinse, in tabes, 408 of muscle of eye, 562 of muscles of speech, 548 of quadriceps muscle, 546 symptoms of, 489 with ataxia in cerebral disease, 529 with partial epilepsy, 533 Parietal area of heart changed by dis- location of, 211 boundaries of organs, 116 lobes of brain, superior and infe- rior, blood-supply of, 462 upper and lower, illus- trated, 466 organs defined, 113 tumors of chest, feeling of resist- ance with, 116 Parosmia in hysteria and insanity, 574 Parotid gland, inflammation of, 288 Parturient patients, perspiration of, 38 Passive mobility of lungs, 125 Patellar reflex, absence of, name for, 499 always present in health, 499 synonyms defined, how tested, 498 Pathogenic fungi, found in urine, varieties of, 427 section on, 389 Pathological odor of urine, 414 respiratory sounds, 144 urine, section on, 406-450 Pathognomonic sign of tricuspid in- sufficiency, 264 Patient, position of, during percussion of thorax, 118 Pectoralis reflex, 499 Pectoriloquy, Laennec's, described, 159 Pediculi, marks of, 51 Pel, reference to, 180 Peliosis rheumatica defined, 51 Pelvis, muscles attached to, 545 Pemphigus, 581 Penzoldt, reference to, 143, 198, 306, 354, 436, 445, 450 Penzoldt's test for bile in urine, 442 Pepsin, relation between, and muriatic acid in the stomach, 344, 345 Peptone in sputum after crises in pneumonia, 190 in urine, confounded with albu- min, 437 when occurs, 439 test for, 353 Peptones, 343 Peptonizing of milk in stomach, 344 Peptonuria distinguished from albu- minuria, 435 when occurs, 439 Percussion, comparative, 118, 121 for relative heart -dulness, 207 depth to which it reaches, 113 difference between weak and strong, 107 different results of strong and weak over spleen, 338 effect of feeble, 114 foundation of, 106 general remarks upon, 103 668 INDEX. Percussion, gentle and strong, illus- trated, il5 hammer, 104, 105, 120 _ used in ])legaphouia, 159 use of, 116 in testing mechanical excitability of muscles and nerves, 526 history and methods of, 104 light, in pleuritic exudation, 127 metallic sound with, 112 note, diiference by volume of tis- t^ue, 107 variations of, in individuals, by age, region, and sex, 120 of abdoininal cavity, 316 of heart, 204 methods of, 205 of intestine, 311 of kidnev, 394 of liver, 326 mode of. 328 value of, 332 of lungs, boundaries upon the back illustrated, 123 in front illustrated, 122 of oesophagus, 296 of spleen, 336 of thorax described, 118 over thick covering, representa- tion of, 113 results of, in aneurism of aorta, 254 rod-pleximeter described, 135 strong, of supra-clavicular fossa, 130 when not to be used, 117 value of, in locating deeply seated deposits, 116 three methods of, 105 topographical, defined, and uses of, 116 value of, in tumors of kidney, 397 Pericardial exudation, cause of weak- ening of heart sound, 219 conceals apex-beat in dorsal position, 201, 202 cyanosis from, 43, 44 exudations, deadened sound over lung compressed by, 127 friction sound, disappearance of, explained, 231, 232. 233 murmurs, 230 changes in, in contrast with endocardial, 232 sounds, felt, 204 Pericardial splashing, metallic. 233 Pericarditis adhesiva, a cause of sys- tolic drawing-in, 204 diastolic collapse of cervical veins in, 267 divided second sound in, 220 pulse with, 243 diagnostic importance of pulse in, 253 differential diagnosis from pleu- risy and peritonitis, 233 downward displacement of liver in, 322 escape of fluid into oesophagus, 296 externa, cause of diminished mo- tility of lungs, 137 friction sounds with, 156 exudativa, causes projection of chest-wall, 203 decreased tension of lung near, 135 effects on position of liver, 331 increased area of heart-dul- ness in, 209 pulse in, 252 tympanitic sound near, 130 weak apex-beat in, 201 friction sounds with, 231 position of apex-beat in, 209 pulse in, 253 value of pulse in diagnosis of, 253 of radial pulse in, 202 venous engorgement from, 261 Pericardium, diseases of, paleness of symptoms of, 40 distention of, cause of expansion of chest, 86 effusion into, 33 fluid in, increases area of heart- dulness, 209 tuberculosis of, friction sounds with, 232 Perichondritis, 594 laryngea, from deep ulcerations, 596 of trachea and bronchi, 172 Perinephritic abscess, cause of pus in urine, 419 Perinephritis, palpation of, 395 purulent, diagnosis of, 395 tenderness with, 395 Perineuritis, condition of nerve in, 468 nerve sensitive to pressure in, 484 INDEX. G69 Periosteal and fascial reflexes, 499 reflex, 497 Periostitis, neuralgia from, 483 of ribs, pain with, 101 Peripheral irritation, sensitiveness to, 472 mixed nerves, origin of, 455 nerves, disease of, diminished tendon reflex in, 500 EaR with lesion of, 524 examination of, 468. nutrition of, 456 neuritis, ataxia with, 529 sight, testing, 569 Peripleuritis, cause of deadened sound, 130 effect of, on boundary of liver, 329 Perisplenitis, cause of apparent en- largement of spleen, 335 due to stenosis of intestine, 310 Peristalsis, action of, in digestion, 343 increased, character of stools with, 372 effect on character of stools, 368 of stomach, diminished, 348 Peristaltic motions of stomach, in hy- pertrophy and dilatation, 302 Peritoneal deposits, cause of apparent enlargement of spleen, 335 eff'usion, a cause of cyanosis, 45 alkaline urine with, 413 exudation, diminished amount of urine with, 407 fluid, encysted, 315 friction sound, 233, 318 sounds over spleen, 339 Peritoneum, air in, a cause of dimin- ished area of liver dulness, 331 bands in, found after tapping ab- domen, 318 distention of abdomen in diseases of, 313 _ examination of, 312 fluid in, gives deadened sound, 114 pain in disease of, interfere with circulation, 44 rapid breathing in diseases of, 94 sarcoma and carcinoma of, 315 tenderness of liver, if involved in carcinoma of liver, 324 value of percussion over perito- neal cavity, 316 vomiting in inflammation of, 358 Peritonitis, acute, pain of severe, 314 cause of cyanosis, 43 caution against talking in, 159 Cheyne-Stokes breathing' witb, 92 chronic, diagnostic points of, 315 little or no pain with, 314 diaphragmatic, interferes with action of diaphragm, 90 simulates pleuritis, 161 dislocation of heart with. 200 effect on form of thorax, 86 fecal vomiting in severe, 364 general, cause of tympanitic sound with, 130 grass-green bilious vomit in, 361 indicau in urine of. 409 local, shown by palpation, 103 meteorisra with, 313 obstipation an early sign of, 369 pain and tenderness with, 308 paralysis of diaphragm in, 90 pulse in, 244, 253 shrinking of omentum in simple, 340 staphylococcus pyogenes found in purulent, 603 subphrenic, defined, 317 friction sound with, 233 tenderness of liver with, 324 time when vomiting occurs in, 359 tuberculous, surface of liver in, 325 tympanites with, 309 Perityphlitis, paljjation of abdomen with, 310, 315 Pernicious anaemia, 41 case of, with heart complica- tions, 230 microcytes and macrocytes in, 276 poikilocytosis not pathogno- monic of, 277 red corpuscles diminished and paler in, 275 retinal changes in, 602 size and form of red corpus- cles in, 276 Peroneus nerve, electrical examina- tion of, 511 illustrated, 487 -paralysis defined, 546 Perspiration, 36. Also see Sweat, a cause of subnormal temperature, 63 670 INDEX. Perspiration alternates with amount of urine, 37 contains bile in jaundice, 46 insensible, 37 greater at night, 37 local, 581 office of, 37 relation of, to amount of urine, 401 sudamina after profuse, 50 varieties of, 37 Perverse sensibility to changes of temperature, 478 Petechiae, 49, 51 Petrosal nerve, superficial, 461 Pettenkofer's test for bile in urine, 442 Petters, reference to, 414 Pfluger, reference to, 189, 505, 506 Pharyngomycosis leptothricia, de- scription, of, 291 Pharyngeal muscles, action of, and effect of paralysis of, 638 syphilis, usually with ulceration of larynx, 595 Pharynx, anaesthesia of, 577 diseased condition of, 290 examination of, 284 expectoration from, in hysteria, 171 inflammation near, cause of cy- anosis, 43 irritability of, how overcome, 590 muscles of, 536 reflex of, absence in hysteria and bulbar paralysis, 496 sound from, confusing to begin- ners, 142 Phase des grand mouvements, 534 Phenyl-hydracin test for sugar, 444 Phimosis, results of, 580 Phlegmon of larynx, 594 progressive, streptococcus pyo- genes in, 603 Phlegmonous laryngitis, illustrated, 594 Phi oroglucin- vanillin test for free mu- riatic acid, 350 Phonation described, 157 in paralysis of soft palate, 537 position of vocal cords during, 592 Phosphate crystals in urine of cyst- itis, 419 of lime illustrated, 430 in urine, 402 Phosphates, deposit of, in urine, 402 in urine, diminished in rhachitis, 435 Phosphatic calculi, 433 Phosphaturia defined, 431 when occurs, 432 Phosphoric acid, salt of, in urine, 431 Phosphorus, acute poisoning by, leu- cin and tyrosin in urine of, 432 lipuria in poisoning by, 447 odor of garlic in vomit in poison- ing by, 366 poisoning, a causeof jaundice, 47 ecchymosis in, 51 odor of breath in, 285 peptonuria with, 439 Phrenic nerve, paralysis of one, shown by palpation, 103 Phthisical thorax described, 84 ulcer of larynx, illustrated, 594 Phthisis, absence of cough in, a bad sign, 165 accommodation in, 96 and form of thorax, 81 asymmetry of breathing in, 91 chronic, extension of area of heart-sounds in, 217 cyanosis from severe cough of, 166 diminished apex of lungs in, 137 dry cough in beginning of, 166 friction sound with, 156 fungi in cavities of, 175 importance and value of the ex- amination of stomach digestion in, 356 inspiratory pressure diminished in, 164 lagging in, 103 morning cough in, 165 muco-purulent sputum in, 169 neuralgia in, 483 night-sweats of, 37 orthopnoea in, 32 systolic subclavian murmurs with, 259 tenderness with, 101 undefined breathing in beginning of, 149 vital capacity of lungs in, 164 vomiting in, 358 Pick, E., reference to, 357 Picric acid, color of urine after taking, 411 effects of, not to be con- founded with jaundice, 45 INDEX. 671 Picric acid test for albumin, 436 Pigeon-chest described, 88 Pilocarpin, effect of, on pupil, 567 Pio Foa, pneumonia diplococcus of, 188 Piorry, reference to, 104, 191 Pitch, as affected by tension of walls, 110 change of, in pneumothorax with fluid, 136 over lung cavity, 13] differences of^ 107 of closed air containing cavities, how determined, 110 of lung-sound depends on tension, 112 of open tympanitic sound, 111 of vesicular breathing, 142 Plantar nerve illustrated, 487 Plasmodium malarise, 282 Plegaphonia defined, 159 Plethora distinguished from abnormal redness of skin, 41 Pleura, diseases of, form of thorax in, 81 rapid breathing in, 94 with effusion, 33 exploratory puncture of, 160 exudation in left, diminishes the half-moon-shaped space, 307 inflamed, a cause of cough, 165 serous exudations of, whispered voice with, 159 shrinking of, cause of displace- ment of heart, 211 thick, feeling of resistance with, 116 thickened, and pleural exudation, how distinguished, 129 thickening of, deadened resonance with, 129 diagnosis of, by puncture, 160 simulates enlarged heart, 209 tumors of, distinguished from pleuritic exudate, 160 one-sided expansion of chest in, 86 weakened vocal fremitus with, 158 Pleural cough, a dry cough, 166 effusions, 80 deadened sound over, 114 endothelium in exudation, 161 exudation, effect on boundary of liver, 329 Pleural exudation, effect of, on circula- tion through lungs, 44 encapsulated, 128 measurement of thorax in, 163 exudations, a cause of diminished vesicular breathing, 145 inflammations restricting the ac- tion of diaphragm, 90 sacs, boundaries of, 80 surface, growths on, conductors of vocal fremitus, 158 Pleurisy, also see Pleuritis, asymmetry of breathing in, 91 caused by caries of rib, 102 differential diagnosis from peri- carditis and i)eritonitis, 233 downward displacement of liver in. 322 due to fracture of rib, 102 effect on position of liver whether on right or left side, 331 effects of, on the chest, 87 encapsulated, defined, 129 exploratory puncture in, 162 exudative, complicating pneumo- nia, character of bronchial breathing with, 147 non-tympanitic sound with, 112 first symptom of, 137 lagging in, 103 paleness a symptom of, 40 position in bed in, 32 shrinking after, diminishes area of spleen dulness, 339 tubercular, 161 with exudation, dyspnoea in, 95 with oedema of chest-wall, 54 Pleuritic eflfusion, alkaline urine with, 413 exudation a cause of displacement of heart, 211 conceals apex-beat, 201 cyanosis from, 43 deadened sound over lung compressed by, 127 deadness and feeling of re- sistance with, 126 diminished amount of urine with, 407 displacement of liver by, 324 expansion of chest with, 85 pulse with, 245 vocal fremitus increased above, 158 672 INDEX. Pleuritic exudation, with compression of lungs, bronchial breathing from, 147 exudations, segophony with, 159 encapsulated, 86 feeling of resistance with, 116 with tumors of thorax, 129 friction-sound, an extra-pericar- dial, 233 ■ sometimes heard when there is no inflamma- tion, 155 -sounds described, 155 not to be confounded with liumming rales, 150 where most distinctly heard, 155 Pleuritis, also see Pleurisy, adhesive, vital capacity of lungs in, 164 carcinomatous, 161 diagnosis by exploratory punc- ture, 160 diaphrngmatica shown by palpa- tion, 103 differeiitial diagnosis from pneu- monia, puncture in, 160 exudative, displacement of apex- beat in, 199 effect on liver-dulness, 330 fixation of heart in, 200 inspiratory pressure dimin- ished in, 164 tympanitic sound with, 111 weak bronchial breathing with, 147 pulse in, 253 purulent, 102 rupture of fluid into oesophagus, 296 septic, 161 sicca, 155 friction-sound with, 156 tenderness due to, 101 with emphysema, friction-sounds with, 156 Pleximeter defined, 104 double, of Seitz, 105 finger used as, in percussing in- testine, 312 hand as, how to be held, 119 -rod, described, 135 use in diagnosing venous pulse, 266 used in plegaphonia, 159 Pneumatometer, Waldenburg's, 164 Pneumatometry described, 164 Pneumonia, absence of cough a bad sign, 165 acute and chronic, alveolar epi- thelium in sputum of, 177 and pleurisy, differential diag- nosis when in left chest, 307 asymmetry of breathing in, 91 bloody sputum of, 169 bronchial breathing in, 146 caused by dust, 21 chlorides in urine in, 434 coccus of, 188 staining of, 188 course of temperature in, 67 critical sweat of, 37 croupous, bloody sputum in, 170 crepitant rales in, 1-54 deadened resonance with, 126 fever in, 65 fibrinous tubes in sputum of, 172 loud bronchial breathing with, 147 tenderness with, 101 tough expectoration with, 166 tympanitic sound in stage of engorgement and resolution, 130 with, 111 Curschmann's sj)irals sometimes in sputum of, 180 decided increase of urea after crisis of, 434 deglutition, 600 differential diagnosis from pleu- risy, puncture in, 160 dyspnoea in, 95 effect on boundary of liver, 329 extension of area of heart-sounds in. 217 ■fibrinous tubes in sputum of croupous, 172 friction-sounds with, 155 hsemato-jaundice in, 47 herpes facialis with, 50 increase of urea in, 433 increased vocal fremitus with, 158 lobar, extent of deadening corre- sponds with lobe of lung in, 126 lobular, thickening and deaden- ing with, 127 lagging ill, 103 massive, deadness and feeling of resistance with, 116, 126 non-tympanitic sound from sur- rounding tissues, 112 INDEX. 673 Pneumonia of left lower lobe, dimin- ished half-moon- shaped space, 307 extension of dead- ness in, 127 peptone in sputum of, after crisis, 190 peptonuria with, 439 position in bed in, 32 pulse in, 239 rapid breathing with, 94' reactive friction sounds with, 156 recurrence of, 22 ringing rales with, 151 sometimes non-ringing rales with, 153 spirals in sputum of, 173, 175 undefined breathing in, 149 unilateral elevation of tempera- ture in, 71 ushered in by epileptiform spasm, 533 vomit in, 358 with jaundice, bile-pigment in sputum of, 172 Pneumonic deposits, catarrhal, tym- panitic sound over, 130 noise of spun-top over, 135 thickening, weak percussion over, 115 Pneumono-koniosis [disease from in- halation of dust], 155 Pneumo-pericardium, closed tympa- nitic sound heard over, 111 diminished area of heart-dul- ness with, 210 metallic heart-sounds in, 221 sounds over, 112 Pneumo thoracic cavity, rod-plexi- raeter percussion over, 136 Pneumothorax, circumscribed, 86 complicated by effusion in pleu- ral cavity, 129 cyanosis from, 43 diminished vocal fremitus with, explained, 158 displacement of the apex-beat in, 199 downward displacement of liver with, 322, 331 dyspnoea in, 95 effect of, on relative liver-dulness, 332 effect on position of liver, whether on right or left side, 331 Pneumothorax, effect of, on upper boundary of liver, 330 expansion of chest in, 85 hydro-, diagnosis by exploratory puncture, 160 lung-sound over, 113 metallic heart-sounds in, 221 rales with, 153 sounds over, 112, 135 non tympanitic sound with, 135 of right side displaces mediasti- num, 137 one-sided expansion of lung with, 136 open and closed amphoric breath- ing with, 148 bronchial breathing over, 147 tympanitic sound with. 111, 135 water-whistling sound with, 153 plegaphouia over, 159 position in bed in, 32 pulse with, 245 sero- and pyo-, succussion with, 156 tympanitic sound with, 134 with fluid, change of pitch in, 136 with op en fistula, noise of spun-top over, 134 Poikilocytes defined, 277 Poikilocythaemia, 274 Poikilocytosis defined, 277 in leukaemia, 279 not pathognomonic of pernicious anaemia, 277 Poikilo-microcythsemia, 275 Points douloureux, 484 Points of electrical irritation upon the upper part of the ihigh illus- trated, 511 Poisoning a cause of collapse, 40 acute, disturbance of conscious- ness in, 470 albuminuria in acute, 435 animal, petechise, in, 50 by atropine, red skin in, 41 by carbonic acid gas, absence of cough in, 165 weakn ess of heart-sounds in, 218 oxide, absorption -bands in blood in, 272 by copper, 286 by inhalation, 21 by lead, 286 43 674 INDEX. Poisoning, by mercury and lead, cause of paleness, 41 cocci in mouth in, 289 condition of teeth in, 286 by nicotine, effect on heart, 201 by opium or morphine, Cheyne- Stokes breathing in, 92 color of skin in cases of, by va- rious substances, 271 condition of mucous membrane of mouth from, 288 lead, double sound heard over crural artery in, 259 odor of breath in, value of, 285 with carbonic acid, effect on color of blood, 270 Poisons causing haemato jaundice, 47 corrosive, hemorrhage of stomach from action of, 362 effect of, upon the pupil, 567 exanthemata from, 50 Polarizing method for quantitative determination of albumin, 438 Poles of battery, how to distinguish quickly, 504 Polioencephalitis, choreic motions in paralyzed limbs, 535 Poliomyelitis, 491, 493, 580 acuta, chronica, EaR with, 524 ushered in by epileptiform spasm, 533 anterior, chronic, 520 arrest of growth of bone in, 583 diminished tendon reflex in, 500 Pollution from phimosis, 580 Polysesthesia defined, 478 Polydipsia, polyuria with, 406 to make up loss of water, 407 Polyuria (diabetes insipidus), 579 in hysteria, 579 when occurs, 406 Pons, 454 anaemic necrosis of, cause of, 462 ataxia in lesions of, 529 blood supply of, 462 effect of lesion of, 457 lesion in, effect of, 456 motor cranial nerves separate in, 455 Portal engorgement, hemorrhage of stomach in, 362 vein, enlargement of spleen in occlusion of 335 obstruction of, a cause of ascites, 314 Portal vein, scars of, effect on consist- ence of liver, 326 Position, dorsal, atalectatic crepitation in, 154 effect of change of, on pericardial friction sounds, 232 of body, effect on pulse in, 235 in examining kidney, 395 of patient, 31 during inspection, 81 percussion of thorax, 118 effect on heart-sounds, 220 upon area of dulness in hydropericardium, 209 in auscultation of heart, 211 in examining heart, 206 variations of lung border with change of, 125 Positive venous pulse, systolic, 264 tracing of, 265 Posner, reference to, 405 Posterior cranial fossa, effect of lesion of, 457 cutaneous nerve illustrated, 487 roots of spinal nerves, 455 Posture, change of, effect of, on apex- beat, 198 effect of, on area of dulness in exudation, 128 in examining spleen, 336 Potassium, iodide of urine after taking, 450 use of in testing rapidity of passage of food from the stomach, 354 Poupart's ligament, 297 Predisposing causes, effects of, on chronic diseases, 21 of disease, 21 Pregnancy, double sound heard ever crural artery in, 259 scars of, 52 Pressure, intra-abdominal, upon liver, 319 intra-cranial, polyuria and gly- cosuria with, 579 on head and vertebra, pain from, 484 partial EaR in paralysis from, 525 sensation of, 474 sensibility of cranium to, 466 -sound over large arteries, 258 -tone over large arteries, 258 Presystolic murmur, 228, 251 murmurs, explained. 226 normal venous pulse in, 263 INDEX. 675 Previous history, what it comprises, 20 Primary myopathic atrophy, a disease of muscle, 493 Prior, reference to, 390, 607 Profession, a cause of disease, 21 Progressive muscular atrophy, 491, 493 cyanosis in, 44 spinal, EaR with, 524 partial EaR in, 525 nuclear paralysis, 566 paralysis, contracted pupil with, 566 diminution of temperature with, 575 fever with, 575 mal perforant, 582 mydriasis in, 566 reflex rigidity of pupil not fre- quent in, 567 Propeptone, rare in urine, 439 test for, 353 Prussia acid poisoning, odor of breath in, 285 Pseudo-bulbar paralysis, 548 -crisis of fever, 67 -hypertrophy, 493 of muscles, 490 how recognized, 494 -leukaemia, 41 Psoas abscess, pain in inguinal region from, 309 Psychical condition of patient, 31 disturbances, 585 of respiration, 83 Psycho-motor tract, 452 Psychoses, acetonuria in, 448 catalepsy with certain, 536 increased secretion of saliva in, 577 Ptomaines, connection between, and cystin, 432 Ptosis, 563 Ptyalism, 288 Puerile breathing described, 142 Puerperal fever, peptonuria with, 439 patients, lactose in urine of, 447 period, a cause of disease, 22 pyaemia, retinal hemorrhage in, 602 streptococcus pyogenes in, 603 Pulmonary artery, aneurism of, 255 heart-sounds, both strengthened from shrinking of lungs, 218 hemorrhage described, 170 Pulaxonary insufficiency, 194, 195 phthisis. See Tuberculosis semilunar murmur, where heard, 224 stenosis, 194 murmur of, where heard, 225 weakening of pulmonary second sound in, 219 Pulsating affections, difficult to dis- tinguish from apparent enlarge- ment of heart, 210 splenic tumor, with aortic insuf- ficiency, 335 Pulsation, epigastric, 302 near heart in empyema, 204 Pulsations at base of heart, 203 Pulse, absence of, 243 affected by external temperature, 235 by position of body. 235 a measure of the work of left ven- tricle, 218 arterial, at the spleen, rare, 257 auscultation of, 257 bulbar, jugular sound with, in tricuspid insufficiency, 268 capillary, 256 diagnostic value of, 251 dicrotic, tracing of, 247 different forms of, 242 double murmur with large and quick, 259 effect of sleep upon, 235 of meals upon, 235 equal, 236 felt later than heart systole, 204 filiform trembling, 243 frequent, when occurs, 238 hard, not to be confounded with arterial sclerosis, 244 importance of, in pericarditis, 209 increased frequency of, in fever, 60 in crises, 63 in pyaemia, 69 intermittent, 236, 241 irregularity of volume of, 241 its value in febrile diseases, 253 method of observing, 235 negative venous, 267 of no value in distinguishing sys- tolic and diastolic murmurs, 226 pathological frequency of, 237 phenomena of, in neuroses, 577 quality of, 236, 241 quickening of, in vomiting, 359 676 INDEX. Pulse, radial examination of, 234 felt between the time of first and second sounds of heart, 212 in aneurism of aorta, 254 value of, in pericarditis, 202 in showing work of heart, 202 relation of, to temperature not constant, 61 rhythm of, 236 size of, not shown by sphygmo- graph, 250 slow, in jaundice, 47 then faster, with albuminuria, 441 when occurs, 237 sphygmographic tracing of, ex- plained, 246 symmetry of radial, 245 tracing of, with temperature, 236 unequal in symmetrical vessels, significance of, 257 value of, in showing beginning complications, 253 variation of its frequency with age, 234 variations of, affected by sex, 235 venous, described, 263 differential diagnosis of, 266 want of rhythm of, 241 wire, 244 Pulsus alternans, 202, 243 bigeminus, 241, 243, 252 tracing of, 250 celer, 253 tracing of, 248 deficiens, 241 dicrotus, 243, 244 durus, 244 incidens, 252 inequalis, tracing of, 250 intercidens, 243, 244 intermittens, 241 magnus, 244 mollis, 244 paradoxus, 243, 263 tardus, 244 tracing of, 249, 250 vacuus, 244 Pulvinar of optic thalamus, effect of lesion of, on vision, 460 Puncture, explorative, use of, 130 exploratorv, of heart, 234 of liver, 326 Puncture, variations of pressure dur- ing, in subphrenic and pleural cavities, 317 Pupillary reflex, 496 Pupils always dilated in dyspnoea, 99 as affected by poisons, 567 changes of, bQ'o contraction of, 568 during accommodation, diag- nostic significance of, 568 dilatation and contraction of, with migraine, 483, 563, 566 hemianopsic rigidity of, 571 inequality of, and conditions in which it occurs, 567 reaction of, in hysterical spasms, 534 reflex changes in size of, 567 rigidity of, 567, 587 size of, affected by degree of illu- mination, 566 Purpura hemorrhagica, 51 Purulent exudation, examination of, 161 in sputum, 167 sputum described, 169 odor of, 171 peptone in. 190 white blood-corpuscles in, 176 stools, when occur, 376 Pus in urine gives a small amount of albumin, 435 makes it turbid, 412 when occurs, 419 vomiting of, 364 Pustule, malignant, 21 Pyjemia, cutaneous hemorrhage in, 51 enlargement of spleen in, 335 haemato-jaundice in, 47 herpes with, 50 intermittent fever in, 69 pulse in, 239 rash resembling scarlet fever in> 50 retinal hemorrhages in, 602 staphylococcus pyogenes in, 603 streptococcus pyogenes in, 603 sweat in, 37 Pyelitis calculosa, 398, 433 stoppage of one ureter by, 400 Pyelonephritis, hyaline casts, peculiar form with, 423 Pyloric stenosis, 348 a cause of diminished volume of abdomen, 309 diagnosis of, 303 INDEX. 677 Pyloric stenosis, effects of, 345, 346 obstipation with, 361) Pylorus, demonstration that it does not close, 302 in distention of stomach, 301 position of, 298, 299 scars and hypertrophy of, 303 separation of fluid and solids at, o-tu Pyonephrosis, lipuria in, 447 palpation of, 395 Pyo-pneumocardium, metallic splash- ing with, 233 Pyramidal tract, 452, 454, 455, 456, 492, 500 above the oblongata, affec- tion of, 548 injury of, 457 in the spinal cord, EaR not present in lesion of, 525 lateral, how found, 455 lessened excitabilityin, with- out EaR, 525 part in skin reflex, 496 spasms from irritation of, 530 tonic spasms in lesion of, 532 Pyrosis hydrochlorica, 357 Pyuria, due to strangulus gigas, 425 QUALITATIVE excitability of nerves and muscles, 516, 518 Quality of contractions, depends upon the relation of the nerve to the skin, 504 of pulse, 236 of sound, terms for, 108 Quantity of expectoration, 168 Quineke. reference to, 161, 267, 271, 277, 575 Quinsy (abscess of tonsil), 290 RACHITIS, diminution of phos- phates in urine in, 435 Radial artery, abnormal course of, 242 nerve, electrical examination pf, 511 faradic examination of, 512 illustrated, 486 muscles supplied by, exami- nation of, 515 paralysis of, from compres- sion, 487 in axilla, 488 Radial nerve, small cutaneous fila- ments to dorsum of fore- arm, 485 pulse, asymmetry of, 245 diagnostic value of, 251 simultaneous on two sides, 236 sphygmographic tracing of, explained, 246 Railroad neuroses, narrowing of field of vision in, 669 Rales acquire a metallic tone, 148 bubbling, 154 crepitant, defined, 154 sign of capillary bronchitis, 152 dry, explained, 149 elasticity of thorax in children cause ringing, 153 humming, hissing, whistling, so- norous, sibilant, 149 loudness of, explained, 152 metallic, 150 moist, explained and when occur, 151 not to be confounded with friction sounds, 155 palpation of, 100 removed by coughing, 149 ringing, in thickening of lungs, 152 sounds are rarely to be felt, .155 the substances which cause, 165 toneless, 146 various sizes, 152 Reaction of degeneration (EaR), 490, 491, 492, 493, 518 complete and partial, 519 course of, 520 diagrammatic representation of, 520 diseases which are excluded when it is present, 525 distinct symptoms of, 587 mixed, 525 partial, 525 significance of its absence, 525 varieties of, 523 when occurs, 524 wanting, 525 variations of, 403 of expectoration, 168 of urine, generally acid, 403 quality of, with galvanic current, 505 678 INDEX. Reaumur, thermometric scale, 57 Records of cases, keeping of, 24 Recti muscles, intestinal peristal- sis seen when they are separated, 310 Rectum, odor of stool in ulceration of, 372 pain at stool, in various diseases of, 370 palpation of, 311 tumors of, examination for, 311 Rectus abdominis muscle, dulness over, 328 Recurrent fever, defined, 70 enlargement of fever in, 324 microorganism of, found in blood, 281 nerve, compression of, 296 effects of paralysis of, 538 paralysis of, from pressure, 599 pressure upon, 255 paralysis, results of, 698 what a symptom of, 600 spirals, 281 Red blood-corpuscles, alterations in size and form of, 276 changes in the number and character of, 273 decomposition of a cause of jaundice, 46 increase of chloride of sodium in urine from destruction of, 434 in sputum, 176 nucleated, 279 number of in a cubic millimetre of blood, 275 seldom found in vomit, _ 365 size of, 276 variation in number of, 271 Redness, local, when physiological, 42 Reflector, Tiirck's, for examining the larynx, 589 Reflex, abdominal, increase of, in in- tercostal neuralgia, 496 unilateral absence of, 587 arc, constituents of, 500 biceps, 499 -tendon, 498 bone, absence of, in bulbar paral- ysis, 500 Reflex bone present in paralysis of facial tract, 500 changes in size of pupils, 567 choking, absence of, in bulbar paralysis, 496 cough 165 cremaster, defined, 495, 496 fascial, 497, 499 increased, 496 manifestations of muscles, 488 may be absent, 496 patellar, increased tonus of quad- riceps disturbs the, 498 name for absence of, 499 synonyms, defined, how tested, 498 tendon, always present in health, 499 pectoralis, 499 periosteal, 497 pharyngeal, absence of, in hys- teria, 497 and bulbar paral- ysis, 496 pupillary, 496 rigidity of pupils, 567, 587 skin, defined, how tested, 495 increased by excitability of anterior horn, 496 mechanism of, 496 sole of foot, 495 spinal centres, 455 suppression of urine, 408 from echinococcus, 425 tendo-Achillis, and foot-phenom- enon defined, how tested, sig- nificance of, 499 tendon, 493 an attendant phenomenon of spasm, 494 diminished in spinal progres- sive muscular atrophv, 500 in tabes dorsalis (very important), 500 illustration of mechanism of explained, 500 increase and diminution of, goes parallel with tonus, 500 of, in cerebral paralysis, 500 in primary degeneration, 600 in secondary degenera- tion, 500 INDEX. 679 Reflex tendon, increase of, in spastic spinal paralysis, 500 in spinal paralysis from disease of pyramidal tract, 500 increased in hysteria, 500 in strychnia poisoning, 500 in tetanus, 500 in the phenomenon of paradoxical contrac- tions, 527 mixture of, and direct mus- cular irritation, 501 of upper extremities, 499 when diminished or lost, 500 when increased, 500 Reflexes, bone, 500 cutaneous and tendon, diagram of, 497 predominant ones in arm and lesc, 500 seat of skin and tendon, 528 skin, not so important an aid in diagnosis as tendon reflexes, 498 tendon, aid in diagnosis, 498 and skin, seat of, 528 importance of, 497 section on, 495, 497 Regional difference of thoracic sounds, 125 Relapsing fever, critical sweat in, 37 hectic with, 69 leucocytosis in, 278 Relative deadness of sound, 108 heart-, liver-, spleen-deadness,327 liver dulness, 327 variation in location of, 332 Relaxed lung tissue, tympanitic sound with, 112, 130 Remission of temperature, 62 Remittent fever, 62, 65, 70 in other febrile diseases, 68 range of temperature of, 62 vomiting, an early symptom of, 358 Remittent typhus fever, hectic with, 69 Renal calculi, 398 accompanied by chill and fever, 64 colic, vomiting in, 358 engorgement, hsematuria in, 418 epithelium in urine, forms of, and diagnostic value of, 421 sand, 433 Rennet ferment, 343 Rennet-zymogen test for, 353 Residence, place of, cause of disease, 21 Residual urine, causes of, 408 not normal, 408 Resistance, electrical, as affected by the angle of entrance of the current, 504 inversely proportional to cross section of electrode, 502 of skin, important point re- garding its increase, 503 feeling of, 109 over hepatized lung, 126 power of, 33 sensation of, described, 116 Resonance, deadened, when devel- oped, 126 Resorcin, test for muriatic acid in stomach, 351 urine after taking, 451 Respiration. Also see Breathing, anomalies of, 89 change of sound in, 113 effect of. on apex-beat, 198 forced, 97 in dyspnoea, 96 how palpated, 103 increased, a cause of dyspnoea, 93 frequency of, in fever, 60, 94 in crisis, 63 in relation to form of thorax, 81 interference with during an at- tack of epilepsy, 533 irregular, 83 larynx during quiet, 592 motions of, 81 normal, 81 described, 82, 141 quiet, heart dulness in, 206 relation of, to amount of urine, 401 sighing, 92 symmetrical, 83 tumors of kidney do not move with, 395 types of, 83 Respirations, number of, 82 Respiratory apparatus, disturbances of, in nervous diseases, 575 centre, 457 disturbance of, in Cheyne- Stokes breathing, 93 irritation of, in fever, 94 displacement of stomach, 303 motions, effect upon circulation in jugular veins, 262 680 INDEX. Respiratory movements of thorax, pal- pation ofj 100 palpation of, 102 muscles, dyspncea from paralysis of, 576 organs, cough as a sign of disease of, 165 disease of, perspiration in, 37 sound, metallic, 136 sounds, pathological, 144 Restlessness from uraemia, 440 JEietentio alvi, 370 from paralysis of abdominal muscles, 578 Retention of urine, 400, 408, 579 Retina, electrical reaction of, 571 embolus of the central artery of, 562 Retinal apoplexy, a forerunner of cere- bral hemorrhage, 601 arteries, pulsation of, when occur, 602 artery, emboli of the central, a forerunner of cerebral embolism, 601 Retinitis in syphilis of the brain, 562 syphilitica, 601 Retraction of apex of lung in tuber- culosis of, 127 of lung, increases area of heart dulness, 209 of lungs, measurement of thorax in, 163 tympanitic sound with, 112 Retro-peritoneal glands, enlargement of, 340 confounded with aortic aneurism, 341 -pharyngeal abscess, 290 a cause of cyanosis, 43 Reynolds, reference to, 448 Rhachitis, 464 forms of, 88 how distinguished from hydro- cephalus, 464 Rheumatic facial paralysis, 491 disturbance of hearing with, 572 partial EaR with, 525 paralysis, EaR with, 524 Rheumatism, articular, recurrence of, 22 chronic articular, phosphaturia in, 432 pain in spine with, 483 inherited, 20 Rheumatism, intercostal neuralgia not to be confounded with, 484 occasionally slow pulse in, 237 of chest-muscles, pain in, 101 of thoracic muscles, rapid breath- ing in, 94 peptonuria with acute, 439 perspiration of, 38 sequelae of, 22 simulation of, 19 Rhonchi, metallic sound with, 136 sibilant, M9 sonorous^ol, 153 Rhubarb, color of urine after taking, 411, 450 Rhythm of breathing, anomalies of, 91 of heart-sounds described, 212, 213. 220 of pulse, 236 tracing of, 250 Ribs, character of in phthisical thorax, 84 deformity of, 82 form of, 81, 82 fracture of, diagnosis of, 102 how counted, 77 in emphysematous thorax, 83 markedly bowed, deadened sound over, 114 pain in disease of, 101 rapid breathing in fracture of, 94 sharply bowed, causes deadening of sound over, 126 Rice-water stools defined, 374 vomit, in Asiatic cholera, de- scribed, 361 Richardson, reference to, 246 Riegel, reference to, 153, 173, 182, 246, 250, 264, 265 Riess, reference to, 208 Rigidity of paralysed muscles, 494 Rigors, in abscess of liver, 326 Risus sardonicus, tonic spasm of face, 532 Rod-pleximeter percussion, 317 described, 135 metallic sound with, 112 use of, 306 Rolando, fissure of, illustrated, 466 Romberg's symptom, 480 Rosenbach's test for bile in urine, 442 Roseola, 49 Round worms, described and symp- toms of, 380 in vomit, 364 INDEX. 681 S abbreviation for Schliesuny, closure 5 of current, 506 Saccharomyces in diabetic urine, 428 Sahli, reference to, 230, 269 Salicylic acid, urine after taking, 450 Saliva, acidity of stomach, stimulates secretion of 346 coloring matter of bile in, 46 diminished in facial paralysis, _ 578 ■ increased secretion of, when oc- curs, 577 nerve presiding over secretion of, 484 various conditions of, 287 when diminished, 289 Salivary glands, examination of, 288 Salivation, description of, 288 Salkowski, reference to, 172, 181, 434, 445 Salol, broken up in the intestine, made use of to determine rapidity of passage of food from stomach, 354 urine after taking, 451 Salzer, reference to, 125 Sanger, reference to, 398 Santonin, color of urine after taking, 411 effects of not to be confounded with jaundice, 45 Santorini, cartilage of, 591, 592 Sarcina in urine of alkaline fermenta- tion, 428 pulmonalis, in sputum, 184 ventriculi described, 366 in vomit, 365 Sarcoma of kidney, palpation of, 395 of larynx, 597 of lung, deadened sound over, 127 of peritoneum, 315 of skull-wall, 465 Satyriasis, 472 Scale of Fleischl's hsemometer, 272 Scanning speech, 548 Scapula, paralysis of the muscles at- tached to, 541 percussion note over, 120 position of 82 Scapular line, 77, 333 Scarlet fever, 49 ecchymosis in, 51 enlargement of spleen in, 334 epileptiform convulsions in the beginning of, 533 Scarlet fever, glycosuria in, 443 haemoglobin in urine, 411 mulberry tongue in, 287 recurrence of, 22 red skin of, 41 sequelte of 22 slow pulse in nephritis of, 237 value of pulse in showing complications of, 253 vomiting in, 358 Scars, 52 in larynx, causes of, 596 on tongue due to syphilis, 288 Scherwald, reference to, 159, 434 Schizomycetes in mouth, 289 in vomit, 365 pathogenic, section on, 389 the only microorganism found in blood, 280 Schleroderma, on thorax, effects of, 91 Schreiber, reference to, 346, 357 Schulte, reference to, 524, 525, 582 Scintillations with migraine, 483 Sclerosis, multiple, allochiria in, 478 vertigo in, 472 of arteries, cause of hypertrophy of heart, 196 Scoliosis, 467 described, 88 from paralysis of erector trunci, 539 Scorbutus, cocci in mouth in, 289 condition of teeth in, 286 cutaneous hemorrhages in, 51 hsematuria in, 417 peptonuria with, 439 Scotoma, central, in alcohol and to- bacco amblyopia, 569 Scrofula, caries of petrous bone in, 572 chronic catarrh a sign of 74 nutrition poor in, 575 Scrofulosis indication of tuberculosis, 22 scars of, 52 Scybala, diagnosis of, 310 Sebacic acid, odor of, in vomit, 366 of stool in infantile diar- rhoea, 371 ■ Secretion of gastric juice, threefold importance of knowledge of, 342 Sediment, kinds of, in urine, and sig- nificance of 402 Sediments in urine, in inflammation of urinary tract, 419 urinary, of organic bodies, 416 682 INDEX. Seelegmiiller, reference to, 485, 496 Seitz, reference to, 105, 148 Self-consciousness during attack of spasm, 530 Semen, involuntary discharge of, in attacks of epilepsy, 534 Semilunar valves cause diastolic sound, 218 Senator, reference to, 177, 405 Senile dementia, mixed aphasia and amnesia in, 555 Senna, color of urine after taking, 411, 450 Sensation of movements defined, 474 Sense of heat and cold, how tested, 475 of pressure, 474 of space defined, how tested, 474 of touch, how tested, 473 Senses, organs of, 561 special, centres and tracts of, 460 Sensibility, deep, 459, 473 part in coordination, 528 part taken by, in recognizing the form of bodies, 481 section on, 479 disturbances of, section on, 472 local manifestations of disturbed, 478 of skin, 473 use of, in recognizing form of bodies, 481 superficial, part of, in coordina- tion, 528 to changes of temperature pre- vented, 478 to pain, how tested, 576 increase of, 478 tract of, 459 Sensitiveness of vertebral column to pressure, 467 Sensory aphasia, 552 condition of the hearing must be determined in, 578 cutaneous nerves, distribution of, 484 tract, blood-supply of. 462 section on, 459 Sepsis, enlargement of spleen in, 335 rash resembling scarlet fever in, 50 retinal hemorrhage in, 562 Septic hemorrhage of kidney, hsema- turia with, 417 Sequelae, 22 Serous sputum, a peculiarity of oedema of the lungs, 169 Serous sputum described, 169 Sex, variations of pulse from, 235 Sexual diseases concealed, 19 Seyler, reference to, 190 Shaking spasm, 531 Shattuck, reference to, 282 Shoemaker's breast, cause of, 89 Shoulder, nerves of, 485 Shrinking of one side, 86 Sibilant rales, 149 Sibson's furrow defined, 76 Sieveking's aesthesiometer, use of, 474 Sighing respiration, 92 Sight, place of, in faculty of writing, 550 tract of, 460 Silver, nitrate of, deposit of, 49 Simon, reference to, 398 Simulation of disease, 19 Singultus, defined, 540 Sinus of peritoneal cavity, position of, 299 phrenico-costalis, 80 Situs inversus viscerum, 193 position of liver, 331 Size of body, relation to lung capacitv, 164 of communicating opening, effect upon pitch of sound, 109 Skeleton, deformity of, effect on chest, 88 Skin, appearance of, over the abdo- men when latter is distended, 313 bronze, 48 color of, 38 as affected by state of blood, 271 characteristic in some dis- eases, 41 cutaneous hemorrhages in, in jaundice, 57 deep disturbance of nutrition of, iti diabetes mellitus, 579 diagnostic value of its appearance, 49 disturbance of, section on nervous relation of, 581 effect of thickness of, on conduc- tive resistance of, 512 emphysema of, 55 weakens apex-beat, 201 examination of, 39 glassy, 581 hemorrhages of, 51 in cases of poisoning, 271 INDEX. 683 Skin inspection of, with reference to condition of blood, 270 nutrition of, 36 oedema of, in perinephritis, 395 cedeinatous, in empyema, 86 of face, dropsy of kidney disease first in, 440 pale, 39 redness of, 41 reflex, defined, how tested, 495 increased by excitability of anterior horn, 496 mechanism of, 496 seat of, 528 reflexes, not so important aid in diiignosis as tendon reflexes, 498 sensibility in, part in coordina- tion, 459, 527 use of, in recognizing the form of bodies, 481 state of, during a chill, 62 various conditions of, 36 Skoda, fundamental sentences from, 109 reference to, 104, 138, 152, 191, 199 Skull, asymmetry of, form of, 455 examination of, 463 Sleep, effect of, on pulse, 235 paralysis, 543 Smallpox, 49. Also see Variola, cutaneous hemorrhage in, 51 enlargement of spleen in, 335 infectious in utero, 20 larynx in, 75 leucin and tyrosin in urine of, 432 scars of, 52 vomiting in, 358 Smegma bacillus, 400 Smell, section on sense of, 461 testing the sense of, 573 Smothered sound, 108 Snellen's plates for testing vision, 568 Sodium, chloride of, in urine, 434 Softening of pons or oblongata, effect of, 457 Sole of the foot, reflex of, how elicited, 495 Sommerbrodt, reference to, 246 Somnolence defined, 470 from uraemia, 440 Sopor defined, 470 Sound, abnormally loud and deep per- cussion, where occurs, 135 Biermer's change of, described, 136 Sound, conditions that^etermine the quality of, 109 * dissimilarity of, on right and left sides of chest, 121 Friedreich's change of respira- tory, defined, 113 described, 133 individual differences of, 120 metallic, defined, 112 moist cracked-pot, 135 normal, over lungs, trachea, and larynx, 119 of falling drops, 153 qualities of, terms for, 108 rectal, use of, 311 regional differences of, 120 Williams's tracheal change of, 121 Wintrich's change of described, 111 explained, and when oc- curs, 138 Sounds, centre for conception of, 557 intellectual perception of, 552 qualities of, explained, 106 Space, conception of, test for, 481 complementary, 192 Spasm, active, of paralyzed muscles, 494 of muscles of speech, 548 of thoracic muscles, dyspnoea from, 95 sensation of, of muscles, 479 defined, 480 Spasms. Also see Convulsions, defined, 530 from intestinal parasites, 578 hysterical, 587 voluntary muscles, 530 Spastic paralysis, 492 contracture after, 495 pseudo-paralysis, 494 spinal paralysis, flexion of foot with, 535 increase of tendon reflex in, 500 Special senses, centres and tracts of, 460 Specific gravity of urine, diagnostic value of, 413 how measured, 403 if high, sugar probably present, 443 in disease, 412 relation of color to, 408 Spectroscopic examination of blood, 270 684 INDEX. Spectroscopic examination, value of, 271 urine, for methgemoglobin, 442 Spectrum analysis, quantitative for determining amount of haemoglobin in blood, 272 Speech, an acquired faculty, 549 -centre, motor, interruption of, 558 location of, 555 difficulty of in bilateral paralysis of the soft palate, 538 disturbances of, 548, 549 how acquired, 549 in paralysis of soft palate, 537 place of hearing in, 550 right hemisphere has nothing to do with, 555 Spheno palatine ganglion, 461 supplies the soft palate, 537 Spermatic nerves, illustrated, 487 Spermatorrhoea, 421 Spermatozoa, in urine, diagnostic value of, 421 Sphincter vesicae, spasm of, due to echinococcus, 425 Sphygmograph, pathological forms of pulse shown by, 247 tracing of radial pulse explained, 246 Sphygmomanometer, use of, 245 Spinal column, curvature of, effects of, 87 diminished mobility of, 467 section on, 467 sensitiveness to pressure, 467 cord, cervical, diminution of tem- perature in injuries of, 575 injury to, fever with, 575 difficulty of local examina- of, 463 disease of, feeling of constric- tion about thorax in, 482 diseases of, diagnosis of, 586 EaR not present in paralysis from lesion of pyramidal tract in, 525 incontinentia alvi in disease of, 370 increased irritability of, in- creased tendon reflex with, 500 Spinal cord, lessened excitability in, without EaR, 525 lumbar, residual urine in dis- eases of, 408 lympho- sarcoma of, hemial- bumose in, 439 relation of, to spinal column described, 468 spasm from irritation of the anterior horns of, 530 curvature, 82 irritation, pain in spine with, 483 tenderness of vertebrae with, 467 paralysis, above the anterior horn, characteristic sign of, 494 from disease of pyramidal tract, increase of tendon reflex in, 500 spastic, dorsal flexion of foot with, 535 progressive muscular atrophy, di- minished tendon reflex in, 500 fibrillary contrac- tions with, 532 Spine, pain in, various causes of, 483 Spinning-top, noise of, 128 Spirals, Charcot-Leyden's crystals 'upon and in, 182 Curschmann's, illustrated, 178 described, 179 Finkler-Prior's, 390, 607 in sputum of croupous pneumonia, 173 of pneumonia, 175 Spirillum recurrens in hemorrhage of kidney, 427 Spirochaeta in mouth, 188, 289 Spirometer, Hutchinson's, 164 Spirometry described, 163 Splashings in intestine, 312 Spleen, adjacent to fundus of stomach, 299 anatomy of, 332 arterial pulse at, rare, 257 auscultation of, 339 boundaries of, 336 consistence of, 335 -deadness illustrated, 304, 337 diseases in which it is enlarged, 334 -dulness, enlargement of, difficul- ties in determining, 339 enlarged, causes projection of left hypochondrium, 334 enlargement of, diagnosis of, 339 INDEX. 685 Spleen, enlargement of, due to venous engorgement, 260 effect of, on form of chest, 86 from venous engorgement, 261 makes the half-moon-shaped space smaller, 306 examination of, 332 form aad surface of, 335 infarction of, cause of enlarge- ment, 335 inspection of, 334 -kidney angle, 393 leucocytosis in inflammation of, 270 location of illustrated, 321 -lung angle, 338 defined, 333 measuring the, 337 mobility of, 335 palpation of, 334 pathological relations of, 338 percussion of, 336 portion that is parietal, 333 position of, 79 illustrated, 333 relation to colon, 336 to diaphragm, 332 to lung, 333 size of, in various diseases, 335 tenderness of, diseases in which it occurs, 335 topography of, 332 tumor of, 306 not diagnosticated from per- cussion alone, 338 wandering, described, 336 differential diagnosis of, 397 when it can be felt, 334 Splenic ansemia, enlargement of spleen in, 335 Sponge, hot, use of, in testing sensi- bility of spinal column, 468 Sputum, character of, with refer- ence to certain brain diseases, 576. chemical examination of, 190 crystals in, 174 defined, 167 fibrinous tubes in, 172 importance of examiningby naked eye, 171 note in three layers, fetid, described, 174 microscopical examination of, 175 Sputum, muco-purulent, crystals in. 181 odor of, described, 171 spirals in, 174 substances visible in, by naked eye, 171 Stadelmann, reference to, 443, 449 Staphylococcus pyogenes, 602 cultures of, 603 Starch corpuscles in sputum, 180 grains, in vomit, 365 Starches, changed into erythro- and achroo-dextrin, 353 interference with digestion of, 344 Stenosis, auscultatory sounds of, 297 of air-passage, inspiratory pres- sure diminished in, 164 labored respiration in, 93 of aorta, murmur of, when heard, 224 pulse in, 240, 252, 255 slow pulse with, 237 of intestine, indicated by band- like, flat scybala, 371 obstipation in, 369 peristalsis to beseen with, 310 tympanites with, 309 of larynx, described, 75 voice in, 74 of left auriculo-ventricular open- ing, dyspnoea in, 96 of oesophagus, 292 of trachea, 97, 98 of upper air-passages, cause of di- diminished vesic- ular breathing,145 diminished frequency of respiration in, 91 of valves and effects of, 194 weaken the sounds of, 219 Stereognosis, defined, and test for, 481 Sterility, 21 due to syphilis, 21 Sternal lines defined, 76 Sternum, acts as a thick pleximeter, 121 and ribs in emphysema, 83 character of percussion - sound over, 123, 124 heart-sounds heard over, 214 non-tympanitic sound over, 121 Stethography defined, 164 of thorax, 162 Stethoscope, double murmur from pressure with, 259 in examining heart, 220 686 INDEX. Stethoscope, mode, use, and kinds of, 139 use of, in auscultation of heart, 211 of pulse, 257 of veins, 268 in cardiac murmurs, 232 with venous humming, 269 value of, in auscultating over spleen, 340 when to be used, 140 Stiff-neck, 539 Stigmates hysteriques, 534, 587 Stimulation, points of, 608 Stintzing, normal electrode by, 502 reference to. 354, 502, 503, 512, 616, 517, 518, 523 Stohrer, reference to, 476, 503 Stokes, reference to, 92, 142 Stolnikow, reference to, 190 Stomach, abscess of circumscribed pain with, 314 acute catarrh of, paleness in, 40 alkaline urine with dilatation of, 413 _ amyloid degeneration of mucous membrane of, 356 anatomy of, 297 atrophy of mucous membrane of, 356 passage of oil into intestine in, 354 auscultation of, 307 blood from, in expectoration, 167 boundary illustrated, 304 cancer of, peptonuria with, 439 catarrh of, absorption from, 364 superacidity with, 357 vomit in, 360, 361 closed tympanitic sound heard over, 111 coating of tongue in diseases of, 287 decomposition of contents of, 356 digestion described at length, 342 duration of, 344 how studied, 341 mode of examining, 347 pathological disturbance of, 344 prolonged, 346 value of results of examina- tion of, 366 dilatation of, 348 absorptive power in, 355 causes of 345 Stomach dilatation, indicated by sar- cina and torulse in vomit, 365 infrequency of the attacks of vomiting in, 359 symptoms of with displace- ment of right kidney, 396 with fermentation of contents, seething sound over, 208 diseases of, in which there is di- minished or absence of free muriatic acid, 356 distensibility of, 300 disturbance of, with migraine, 483 examination of, 297 extent to which it is parietal, 299 fasting, value of examination of, 355 great amount of vomit in dilata- tion of 360 -heart space, 306 hemorrhage of, 40, 170 acid reaction of blood in, 170 distinguished from that from lungs, 362 hour-glass, 302 hypersecretion in ulcer of, 357 hypertrophy of muscular coat of, 346 inflated, metallic heart-sounds with, 221 inflation for diagnosis, 300 inspection and palpation of, 299 mode of 299 -liver space, circular, 306 -lung sound, when heard over, 113 space, circular, tympanitic sound over, 306 metallic sound over, 112 method of examining fasting, 355 movements of, part in digestion, 353 normal cannot be defined through abdominal wall, 300 percussion of, 304 perforating ulcer of, stool of 372 cause of pneumothorax, 210 position of, 78 if dilated, 305 illustrated, 319 of lower border of, illus- trated, 327 of, when moderately full, 305 INDEX. 687 Stomach-pump, use of, in washing out the stomach, 348 purposes for which it is to be emptied, 357 rapidity of passage of food from, tests for, o54 resonance in region of heart dul ness, 206 rinsing out, in studying contents of, 341 section of, examination of con- tents of, 341 significance of acid secretion of, 357 sudden amaurosis after severe hemoiThage of, 602 superacidity with ulcer of, 357 symptomatology of dilatation of, 346 tests of absorptive power of, 354 ulcer of, hemorrhage from, 362 vertigo in diseases of, 472 vomiting in diseases of, 358 washing out of, 347, 357 Stomatitis, cause of enlargement of tongue, 286 Stone in pelvis of kidney, tenderness with, 395 Stool, acholic, color of, 373 odor of, 371 bilious, described, 373 bloody, described, 374 color, constituents, and admix- ture of, 372 fatty, described, 374 Stools, consistence and form of, 371 involuntary discharge of, 579 in attacks of epilepsy, 534 odor of, 371 purulent, when occur, 376 reaction of, 372 watery, when occur, 374 Strabismus, defined, 562 lateral, divergent, convergent, de- fined, 563 Strangling, from irritability of larynx, 590 Strangury, causes of, 400 Strength, rapid decline of, 587 Streptococci, in purulent pleural exu- dation, 161 Streptococcus erysipelatous, described, 603 in urine, 399 pyogenes, 161 description of, 603 Striae, 52 from ascites, 313 on abdomen, cause of, 314 Stricture of CBsophagus, location of, 295 Stridor laryngeus vel trachealis, 97 Strongylus gigas, cause of pyuria and hsematuria, 425 Structure of body, 33 Struma, blowing murmurs over lym- phatic glands in, 259 Striimpell, reierence to, 67, 178, 249, 250, 440, 466, 478, 535, 554 Strychnia poisoning, increased tendon reflex in, 500 Stupor defined, 470 Subacidity in dilated stomach, 346 of stomach, efiect of, 344, 348, 356 Subjective sensibility, 472 Subphrenic abscess, downward dis- placement of liver from, 322, 330 peritonitis, diagnosis of, 317 Succussion, Hippocratic, described, 156 pathognomonic of hydro-pneumo- thorax, 156 Sudamina, 50 Sugar, determination of, by circum- polarization, 447 in urine, 443 qualitative test for, 444 quantitative test for, 445 often in urine of health, 405 uric acid in urine hinders exami- nation for, 405 Sulphuric acid in urine, 435 Superacidity. Also see Hyperacidity, of stomach, 348 contents, when it occurs, 351 diseases in wnich it occurs, 357 effect of, 344 free muriatic acid with, 346 signs of, 356 Supersecretion. Also see Hypersecre- tion, of gastric juice, what diseases it occurs with. 357 Suppression of urine, due to venous engorgement, 260 reflex, of urine, 408 Suppuration, cause of paleness, 41 of ear and nose, cause of menin- gitis and abscess of brain, 467 688 INDEX. Supraclavicular depression deepened from contraction of apex of lung, 87 percussion of, 118, 130 Supraorbital nerve, illustrated, 485 Suprascapular nerve, illustrated, 486 Supratrochlear nerve, illustrated, 485 Swallowing, difficulty of, in bilateral paralysis of soft palate, 538 difficulty of, in paralysis, 537 pain in, 75 Sweat. Also see Perspiration. accompanies remission of fever, 62 alterations of, 38 cold, with dyspnoea, 99 critical, in recurrent typhus, 70 diminished, 38 Sweating, accompanies vomiting, 359 cause of diminution of urine, 407 effect of, on color and amount of urine, 402 local, 38 Syllable- stumbling, 553 Sylvius, embolus of the fossa of, 562 fissure of, artery of, 462 fossa of, illustrated, 466 Sympathetic paralysis, inequality of pupils in, 567 Sympathetica spastica, unilateral vaso- motor disturbances in, 577 Symphysis pubis, significance of dul- ness above, 316 Symptom, Romberg's, 480 Symptomatic, migraine may be, 483 neuralgia, 483 Symptomatology of diseases of ner- vous system, section on, 463 value of, 20 Symptoms, concealment of, 19 direct and indirect, in nervous diseases, 585 Syncope defined, significance of, 471 Syphilis, affecting larynx, 75 liver, 324 change in shape of liver from scars of, 325 changes in fundus oculi with, 601 chronic catarrh, a sign of, 74 cicatrices of, dyspnoea from, 93 concealed, 19 congenital, Hutchinson's teeth a sign of, 286 constitutional, paleness in, 41 cracks in lips of children, a sign of hereditary, 285 deformed nose from, 73 Syphilis, diagnosis of, when brain and spinal cord are affected, 586 glands of neck enlarged in, 291 haemoglobin in urine of, 411 hereditary, early signs of, 22 infectious in utero, 20 inherited, 29 irregular enlargement of liver with, 322 may be a cause of catarrh of larynx, 693 middle ear catarrh in, 572 mucous patches in mouth in, 288 nervous diseases from, 581 neuralgia from poison of, 483 nocturnal headache with, 482 nose affected in, 576 primary and secondary outbreaks of, 22 scars of, 52 on tongue from, 288 sterility caused by, 21 subcordal laryngitis from, 593 tonsils in, 290 ulceration of larynx with, 595 Syphilitic formations of tongue, 286 gummata on liver, 326 on skull, 465 infiltration and ulceration of larynx, 592 difficulty of diagnosis of, 595 iritis, 562 scars in larynx, 596 Syringo-myelitis of cervical cord, 582 trophic disturbance of bone in, 583 Systole of heart, collapse of veins with, 264 movement of blood in, 193 sound with, 212 Systolic drawing-in, 267 near apex of heart, 202, 204, 220 heart-sound, what due to and where heard best, 213, 214 murmur, 252 at apex, 251 heard with aortic stenosis, 258 over pulmonary artery, when, 255 ^ with atheroma of aorta, 254 murmurs, 222, 225 how distinguished from dias- tolic, 226 I AD EX. 689 Systolic, positive venous pulse is, 264 [ Taenia mediocanellata described, 378 sound in health over large arte ries, 257 subclavian murmur described and explained, 259 trembling and pulsation in epi- gastrium, 204 true venous pulse, rare in facial veins, 267 venous pulse, 266 with mitral insufficiency, 267 vesicular breathing, 143 T abbreviation for tetanic contrac- , tion. Tabes, allochiria in, 478 arthropathia in, 583 atrophy of optic nerve in, 601 bladder crises (painful tenesmus) in, 580 disturbance in, 580 brittleness of bones in, 583 cystitis with, 579 decline of genital function in, 580 dorsalis, ataxia the most impor- tant symptom of, 529 atrophy of optic nerve in, 562 contracted pupil with, 566 diminished tendon reflex (very important), 500 mydriasis in, 566 feeling of constriction about tho- rax in, 482 gastric crises with, 578 herpes zoster with, 581 hypersecretion of stomach in, 357 inequality of the pupils in, 567 intestinal crises with, 578 laryngeal spasm with, 576 laxness of muscles in, 494 location of, 484 mal perforanc in, 582 migraine in, 483 neuralgia in initial stage of, 483 pain in spine with, 483 polyuria and glucosuria in, 579 residual urine with, 408 tenderness of vertebrae in, 467 vomiting in, 361 illustrated, 379 solium, cysticerci in brain from, 578 described, 377 eggs of, described, 378 parts of, illustrated, 378 poikilocytosis in, 277 Talma, reference to, 151 Taste, mode of testing the sense of, 574 sense of, location of, 461 Teale, reference to, 62 Teeth and gums, examination of, 285 caries of, in diabetes mellitus, 285 condition of, in poisoning by mer- cury, lead, copper, 286 in scorbutus, 286 diseased, a cause of dyspepsia, 286 disturbances which accompany eruption of, 286 Hutchinson's sign of congenital syphilis, 286 Temperament, effect upon pulse, 235 Temperature. Also see Fever an index of severity of disease, 61 chart, value of pulse record on, 253 course of 62 daily variations of 60 dangerous to life, 61 diagnostic value of, section on, 64 diminution of, when occurs, 575 efi'ect of, on perspiration, 36 exacerbation of, 62 complication shown by, 65, 67 fall of, collapse with, 70 sign of collapse, 67 frequency of taking, 59 highest observed, 62 local, 71 lowering of, 71 normal, variations of, 59 relation to pulse not constant, 61 remission of, 62 section on, 57 subnormal, section on, 63 table of, 61 taking of, methods, 58 tracing of, with pulse, 236 unilateral elevation of in hysteria, 71 variations of pulse due to external, 235 Tables of comparison of the two sides of the body, with faradic and gal- Temporal artery, pulsation in, 256 vanic current, 517 ' convolutions, second and third, Tseuiacucumerina, described and illus- \ blood supply of, 462 trated, 380 [ lobe, 461 44 690 INDEX. Temporal lobe, illustrated, 466 Tenderness of intestine, kinds of, and diseases with, 308 of liver, when manifest, 324 of nerve during neuralgia, 484 of region of kidney, when occurs, 395 Tendo-Achillis reflex and foot phe- nomenon defined, how tested, sig- nificance of, 499 Tendon reflex, 493 an attendant phenomenon of spasms, 494 increase and diminution of, goes parallel with tonus, 500 increased in the phenomenon of paradoxical contrac- tions, 527 in partial epilepsy, 533 mechanism of, illustration explained, 500 mixture of, and direct mus- cular irritation, 501 of upper extremities, 499 seat of, 528 when increased, 500 reflexes, aid in diagnosis, 498 importance of, 497 section on, 497 when diminished or lost, 500 Tenesmus at stool, 370 of bladder, cause of, 400 Tension diminished, gives deep nou- tympanitic sound, 112 of lung tissue diminished, 135 effect on pitch, 112 of wall of closed air cavity, effect on pitch of sound, 110 of walls, effect upon change of pitch of sound, 111 Terminal arteries, defined, 462 Test papers, Geisler's albumin, 436 Testing the sensibility to irritation, 473 Tetanus, cyanosis in, 44 dyspnoea in, 95 fever with, 575 galvanic, 505 increased excitability in, 526 tendon reflex in, 500 opisthotonus with, 468 tonic and clonic spasm of tho- racic muscles in, 540 spasms in, 532 Thallin, urine after taking, 451 Thermsesthesiometer, use of, 475 Nothnagel's, described, 475 Thermometer, selection of, 58 Thermometers, scales of, 57 Thermometric scales, comparison of,61 Thigh, points of electrical irritation of, illustrated, 511 -sound, 109 associated with feeling of strong resistance, 116 defined, 106 term used for dull, 108 when heard, 113 Third nerve, paralysis ot, 566 Thirst, in febrile diseases, 287 Thoma-Zeiss's apparatus for counting blood corpuscles, 274 Thompson, reference to, 286 Thomsen's disease, 493 myotonic reaction in, 518 Thoracic breathing aided by auxiliary muscles, 99 conditions that abolish it, 91 replaced by diaphragmatic, 90 diseases, position in bed in, 32 duct, compression of, a cause of chylous ascites, 318 organs and deformities of chest, 81 pain produced by pressure, 101 viscera, position of, 78, 79 Thorax, anatomical prominences of, 76 circumference of, increased in in- spiration, 163 where measured, 162 covering of, effect of, on heart- sounds, 216 cross-section of, 163 deformity of, a cause of disloca- tion of heart, 199 larger parietal area of heart, 200 effect of elasticity of, on heart- sounds, 216 emphysematous, 85 examination of, in connection with disease of oesophagus, 296 flexibility of, 83 flexible projection of, in diseases of the heart, 203 form of, 81 important, 33 frequent measurements of, value of, 163 inspection of, 81 inspiratory enlargement of, 83 length of, 163 INDEX. 691 Thorax, local expansions of, 86 measurement of, 162 one-sided extension of, 85 palpation of, 100 paralytic, described, 84, 85 pathological forms of, 83 percussion of, described, 118 phthisical, often absent in phthi- sis, 85 right side measures more than left, 168 rigid, causes of, 91 diaphragmatic breathing with, 91 prevents projection in en- largement of liver, 321 short, position of apex-beat in, 198 _ tympanitic resonance in re- gion of heart-dulness in, 206 sound on percussing, 109 tumors of, measurement of thorax in, 163 value of pulse in deformity of, 253 repeated measurement of, in aneurism of aorta, 254 wall of, dulling effect on heart- sounds, 217 yielding, in children, 98 Throat and neck, muscles of, 538 Thrombosis, effect upon pulse in one of two symmetrical vessels, 257 local low temperature in, 71 of large veins of lower extremities, 268 of veins a cause of cyanosis, 45 renders deep veins accessible, 260 venous, effects of, 262 when and where it occurs, 268 Thrombus, closure of venous trunk by, 261 Thrush, description of, 287 in children, spores in feces, 388 microscopic appearances of, 290 stenosis of oesophagus from, 296 Tinnitus aurium, sometimes a pre- cursor of migraine, apo- plexy, or epilepsy, 573 with migraine, 483 Tobacco amblyopia, 602 central scotoma in, 569 use of, effect on disease, 21 Toes, paralysis of muscles of, 547 Toluylendiamin, poisoning by, caus- ing hsemato-jaundice, 47 Tone, as applied to heart-sounds, 212 of heart-sounds, variations of, 216 pitch of, how effected, 109 Tongue and soft palate, electrical irri- tation of, 510 coating of, 287 color of, 287 dryness of, 287 enlargement of, 286 examination and conditions of,286 in typhoid fever, 287 motor centre for, 454 muscles of, 536 that move it, and effect of their paralysis, 537 nerve-supply of anterior two- thirds of, 484 normal mobility of, in hysterical dumbness, 548 not bitten in hysterical spasms, 534 often bitten during attack of epi- lepsy, 533 sense of taste in, 461 anterior two-thirds from the chorda, and poste- rior one - third from glosso-pharyngeus,574 taste in the anterior portion of, affected in paralysis of facial nerve, 461 trembling of, in alcoholism, fevers, and typhus, 287 wounds of, 287 Tonic spasms, 530 when occur, 532 Tonus of muscles, 488, 496, 528 disturbance of, 489 method of testing when only slightly increased, 501 of paralyzed muscles increased, 494 of quadriceps, increased, disturbs patellar reflex, 498 Tonsils, condition of, in tonsillitis, syphilis, diphtheria, etc., 290 crvstals in sputum from inflamed, ■l81_ offensive plugs from lacunae of, 171, 174 Tooth-mucus bacillus, like comma ba- cillus, 391 Topographical percussion defined, and uses of, 116 relation between surface of brain and skull, illustrated, 466 Topography of abdomen, 297 692 INDEX. Torula cerevisiae, in fever, 388 in vomit, 365 with normal digestion,366 Touch, sense of, how tested, 473 Toxic headache, causes of, 483 influences, neuralgia from, 483 paralyses, EaR with, 524 Trachea, casts of, in sputum of croup, 172 change of sound in, 130 distance of bifurcation of, from incisor teeth, 291 epithelium in sputum from, 176 mucous rales in, 165 normal sound over, 119 open tympanitic sound, when it is percussed, 110 sensitiveness of, a cause of cough, 165 stenosis of, 97 inspiratory drawing -in of chest wall in, 98 tympanitic sound over, 121, 130 ulceration of, a cause of emphy- sema of skin, 56 Tracheal change of sound explained, 132 sequestra of, in sputum, 172 tone, Williams's, described. 111, 131 Transfusion of blood, haemoglobin in urine after, 411 Transition breathing, 148, 149 corresponds to hinted rales, 153 Transparency of expectoration, 168 Transudation, diagnosis of, from exu- dation, 160 Transudations, effect of absorption of, on reaction of urine, 413 increase of chloride of sodium in urine with, 434 Trapezius muscle, paralysis of, eflFect of, 541 Traube, reference to, 104, 151, 179, 259, 306, 440 Traumatic hemorrhages, 51 hysteria, narrowing of field of vision in, 569 paralysis, EaR in, 525 Traumatism, exposure of nerves to, 468 Treatment, vaHie of pulse in, showing result of, 253 Trembling (tremor), 530 Tremor, graphic representation of, 531 Tremor, mercurialis, 531 saturninus, 531 senilis, 531 with hysteria, 531 Trichina spiralis described, 383 importance of, 383 illustrated, 384 Trichinae in stools, 383 in vomit, 364 Trichinosis, 383 cyanosis with, 44 Trichomonas vaginalis, found in urine, 425 Tricocephalus dispar, described and illustrated, 383 Tricuspid insufficiency, 194, 195 case of relative, referred to, 266 double sound with, over crural vein, 268 murmur of, where heard, 225 positive venous pulse pathog- nomonic of, 264 relative, pulmonary second sound in, 218 venous murmur with, 268 murmur, where heard, 224 stenosis, 194 venous engorgement from, 261 valve, causes a systolic sound, 213, 214 Trigeminus nerve, 461 anosmia due to paralysis of, 574 sense of taste in anterior portion of tongue affected in disease of, 461 Triple-phosphates, deposit of, in urine, 402 illustrated, 430 in sputum, 182 in urine described, 431 Trismus, masseter spasm in, 532 Trommer's test for sugar, 444 used in estimating amount of sugar, 446 Tropaolin-paper, use of, in testing for free muriatic acid, 350 Trophic influences of the cortical cen- tres, 456 Trunk, muscles of, and efiect of their paralysis, 539 nerves of, 485 Tubercle bacilli, illustration of, 184 in sputum in tuberculosis of larynx, 595 INDEX. 693 Tubercle bacilli, mode of examina- tion, 185 only present with disintegra- tion, 161 staining of, 186, 187 bacillus, cultures of, described, 605 in blood, rare, 281 in feces, presence explained, 391 in pleural exudation, 161 in sputum, 175 in urine, illustrated, 426 sign of tuberculosis of urinary passages, 426 Tubercular cachexia, 41 deposits, small tympanitic sound over, 130 peritonitis, 315 enlargement of spleen in, 335 surface of liver in, 325 tenderness of the liver with, 324 ulceration, result of infiltration in larynx, 595 Tuberculosis, 82. Also see Phthisis acute miliary, of lung and pleura, friction sounds with, 155 pulse in, 239 affections of ear with, 572 cachexia of oxaluria with, 430 catarrh of larynx in tuberculosis of lungs, 593 Charcot-Leyden's crystals in spu- tum of, 182 choroidal, 562, 601 chronic, Curschmann's spirals in sputum of, 180 remittent fever of, 68 color of face in, 42 crystals of cholesterin in sputum of, 181 deepening of clavicular depression in, 87 diagnosis of, by aid of microscope, 291 disposition to, with narrow chest, 34 , dyspnoea in, 95 effect on weight, 36 elastic threads in the sputum of, 177 fever in. 65 fibrin in urine in, 439 forms of fat found in feces in, 386 Tuberculosis in apices of lungs, with cavities, 131 indicated by scrofulosis, 22 infections in utero, 21 inherited, 20 intestinal, feces contain Charcot's crystals, 388 infusoria found in stools of, 384 tenderness with, 308 miliary, petechise in, 50 of apex of lung, increased vascu- lar breathing in, 144 prolonged expiration in, 145 of apices, pain with, 102 of larynx, 75 of lungs, 22 disturbance of the circulation through them, 44 night-sweats of, 38 shown by tubercle bacillus, 187 of lymphatic glands, effect on ab- sorption of fats, 371 of pericardium, friction sounds- with, 232 of peritoneum, little or no pain with, 314 of pleura, a cause of tenderness, 101 of tonsil, 290 of urinary apparatus, 398, 426 shreds of tissue in urine of, 421 passages, 400 pulmonary hemorrhage in, 170 red border upon gum in, 286 shrinking of omentum in, 340 thrush with, 288 tracing of pulse of, 248 tympanitic sound over apices of lungs in beginning of, 112 ulceration of larynx with, 595 weight of body in, 35 with paralytic thorax, 85 Tuberculous and syphilitic laryngitis, differential diagnosis of, 593 infiltration and ulceration of lar- ynx, 592 Tumor of kidney, tenderness with, 395 of liver or spleen, 306 of lungs, peculiar sputum of, 171 Tumors, abdominal, effect on form of thorax, 86 tympanitic sound near, 130 cause of venous stasis, 262 694 INDEX. Tumors, cause of inspiratory dyspnoea, 99 cerebral, slow pulse with, 237 conceal apex-beat, 201 glandular, cause of pressure on nerves, 469 in chest cavity, dyspnoea from, 95 in lungs, weak percussion over, 115 intestinal, percussion of, 312 intra- tracheal, dyspnoea with, 93 neuralgia from pressure of, 483 of brain, disturbance of conscious- ness with, 471 sensibility of cranium to pressure with, 466 of chest cavity, bronchial breath- ing from, 146 diagnosis of, by punct- ure, 160 wall, cause of deadened sound, 130 pulse in, 253 of intestine, diagnosis of, 310 kinds of, 310 of kidney, described, 394 diagnosis of, 397 value of percussion with, 397 of pleura, one-sided expansion of chest in, 86 of stomach, dullness over, 306 and spleen, respiratory mo- tion of, 322 pulsation with, 302 of thorax, irregular boundary of, 129 measurement of thorax in, 163 of tongue, a cause of enlargement, 286 of transverse and descending colon easily confounded with those of spleen or kidney, 311 of vertebrae, tenderness of, 467 of wall of stomach, 300 near stomach not felt, 303 pressure of, a cause of jaundice, 46 Turbinated bones, enlargement of, a cause of neuroses, 575 Tiirck, reference to, 594 Tiirck's reflector, 589 Turpentine, odor of urine after taking, 414 Tympanites, effect of, upon extent of abdomen, 309 Tympanitic deadened sound, 131 resonance in region of heart-dul- ness, 206 near an infiltrated lung, 126 near heart, when, 210 open or closed, over lung cavities, 131 over lung containing scat- tered deposits, 127 with high tension of lung- tissue, 135 sound further defined, 109 intensity of, 109 just above large exudation, 128 musical pitch of, 109 occurs with lack of tension of lung-tissue, 110 on right side of chest over stomach or colon, 121 over apices in beginning tuberculosis, 112 diseased lungs, causes of, 130 larynx and trachea, 121 where heard, 109 with pneumothorax, 154 with retracted lung, 111, 112 sounds, 107 Typhlitis described, 315 recurrence of, 22 tenderness in iliac fossa with, 308 Typhoid fever, ve^ Typhus abdominalis abscess of abdominal muscle in, 309 of muscles in, 54 bacillus of, cultures of, 605 described and illustrated, 391 , 605 found in blood in, 281 staining of, 605 consciousness, disturbance of, in, 470 cough, absence of, 165 feces of, contain Charcot's crystals, 388 glucosuria in, 443 haemoglobin in urine of, 411 headache in, 483 hemorrhage in, shown by temperature, 65 subcutaneous in, 51 ileo-csecal cooing in, 312 infusoria in stools of, 384 INDEX. 695 Typhoid fever, intestinal hemorrhage in, 375 tenderness in, 308 leucin and tyrosin in urine of, 432 leucocytosis in, 278 mental condition in, 32 paralytic chest from, 85 peptonuria in, 439 posture in, 32 pulse in, 238, 239 tracing of, 247 rash of, resembling scarlet i'ever, 50 recurrence of, 50 roseola in, 49 spleen, enlargement of, in, 334 spermatozoa in urine in, 421 staphylococcus pyogenes in the suppuration which ac- companies, 603 stools thin in, 371 sweat in remittent stage of, 38 temperature, course of, 65 variation of, in, 66 tongue, state of, in, 287 tympanitis in, 309 ulceration of the larynx in, 595 Typhus abdominalis. See Typhoid Fever fever, cutaneous hemorrhages with, 51 eruption of, 49 typical course of fever in, 65 Tyrosin, form of, in urine, 432 in sputum, 182 in urine, illustrated, 431 when occurs, 432 UFFELMANN'S test for lactic acid, 351 Ulcer of stomach, blood in stool from, 375 hemorrhage from, 362 pain in, 303 superacidity with, 357 supersecretion of stomach with, 357 Ulceration of larynx, seldom with catarrh, 595 Ulceration of larynx, voice in, 74 of trachea and bronchi, 172 Ulcerations, deep, of skull wall, 465 internal, a cause of emphysema of skin, 56 Ulnar nerve illustrated, 486 distribution to hand, 545 electrical examination of, 511 position of the hand in par- alysis of, 544 neuritis from fracture of internal condyle of humerus, case of, 469 Ultzmann, reference to, 429 Umbilical region, illustrated, 298 Unconsciousness, catheter always to be used to draw the urine, 401 faradic test of, 476 involuntary discharge of urine during, 579 Undefined breathing explained, 148 Unequal pulse in symmetrical vessels, significance of, 257 respiration, 92 Ungar, reference to, 182 Unilateral convulsions in partial epi- lepsy, 533 skin reflex, 495 Unverricht, reference to, 153, 154 Upper extremities, tendon reflex of, 499 _ Uraemia, ammoniacal odor of vomit in, 366 Cheyne Stokes breathing in, 92 coma from, 440, 470 defined, 440 dyspnoea in, 576 epileptiform spasms in, 533 headache with, 483 slight amount of vomit with, 360 symptoms of, 440 urea diminished in, 434 vomiting in, 358 Ursemic amaurosis, 601 Urate of ammonia, form of, in urine, 432 illustrated, 430 in urine, 402 of soda and lime, described, 429 Urates, precipitation of, by albumin test-papers, 437 Urea, amount of, in twenty-four hours, 405 cannot be determined from spe- cific gravity of urine, 412 increase of, 433 696 INDEX. Urea in saliva in nephritis, 289 method of determining amount of, 434 quantitative determination of, value of, 413, 434 Ureter, obstruction in, a cause of diminished secretion of urine, 407 one, stopped up in tuberculosis,400 Ureters, examination of, 398 Urethra, diminished amount of urine from stricture of, 408 Uric acid as a urinary sediment de- scribed, 428 concretions of, 433 crystals of, illustrated, 429 diathesis, increase of uric acid in, 434 found in blood in gout, 283 hinders examination for sugar, 405 salts, separation of, from cooled urine, 402 source of, in urine, 405 when increased, 434 Uridrosis defined, 38 Urinary apparatus, chapter on exami- nation of, 392 disturbances of, section on, 579 examination of, what it com- prises, 392 "calculi, cause of, 429 casts, most important element in pathological urine, 421, 422 constituents in solution, 433 anomalies in amount of, 433 diseases, sweat in, 38 passages, deep-seated inflamma- tion of, fibrin in urine of, 439 products in fever, 408, 416, 422, 423 sediments, 404 examination of, 415 of organic bodies, 416 Urination, assisted by abdominal pressure, 540 frequent causes of, 400 Urine, acidity of, how determined, 414 affected by medicines, 450 always to be drawn with catheter when there is unconsciousness, 401 amphoteric reaction of, 404 anomalies in amount of, 406 causes of diminution of (anuria), 407 Urine, clear, to be tested for sugar if specific gravity is high, 443 color and transparency of, in disease, 401, 408 complete diminution of (anuria), 407 concentrated, appearance of, 402 effects of, 400 concretions in, 433 contains bile in jaundice, 46 contamination of, how to avoid, 399 daily average amount of, 401 determining amount of nitrogen- ous material in, value of, 434 diminution of, in fever, 60, 407 discoloration of, causes of, 410 examination of section on, 399 fermentation of, effect of, on its appearance and character, 402 increase in pigments of, 409 in uro-genital tuberculosis, 426 involuntarily discharged in at- tacks of epilepsy, 534 involuntary discharge of, when occurs, 579, 580 mode of procedure in examining, 400 normal, section on, 401 odor of, 404 due to medicines, 414 pathological odor of, 415 section on, 406-450 reaction of, generally acid, 403 in disease, 413 retention and incontinence of, 400 rule for approximation of solid constituents from specific grav- ity, 412 secretion of, less at night, 401 soluble constituents of, named and described, 404 specific gravity of, how measured, 403 when diminished, 413 staining of, from medicines, 411 suppression of, causes of, 407 due to venous engorgement, 260, 261 table of colors of, useless, 408 turbidness of, when passed is pa- thological, and when occurs, 411 Urobilin, coloring pigment in urine, 402, 409 • -icterus, 48, 409 INDEX. 697 Urobilin, tests for, 410 origin of, 48 Urobilinuria, 46 Urometer, requisites of, 403 Uterus, diseases in utero, 20, 21 Uvse ursi, color of urine after taking, 411 Uvula, position of, in paralysis of soft palate, 537 VAGI, compression of; 599 Vagina, taking temperature in, 68 Vaginal mucus in urine, 416 Vagus centre, 457 slow pulse in irritation of, 237 irritation of, by bronchial tumors, 576 nerve, weakness of heart-sounds in paralysis of, 218 paralysis of, pulse in, 240 quick pulse in, 577 Valleix's points of tenderness, 101, 484 Valve, insufficiency of, eflPect of, 194 stenosis of, effect of, 194 Valves of heart, part taken by, in the heart-sounds, 213 where best auscultated, 213, 214 Valvular defects revealed by mur- murs, explanation of, 221 deficiency a cause of cyanosis, 44 compensation for, 195 disease of heart, haematuria with, 417, 418 enlargement of liver with, 324 incompensation in, a cause of diminished amount of urine, 407 value of pulse in, 252 insufficiency and its effects, 193 relative, murmurs with, 230 sound in jugular vein, 265 Varicella, 49 Variola. Also see Smallpox. ulceration of larynx with, 595 Vasomotor centre, pulse in irritation of, 245 disturbances, when occur, 577 influences upon pulse in symmet- rical vessels, 257 Vegetable parasites in urine, 425 Vegetative system, disturbance of, in nervous diseases, section on, 575 Vein, portal, enlargement of spleen in occlusion of, 335 Veins, auscultation of, 268 examination of, 260 of abdomen, enlarged with as- cites, 314 of skin enlarged in aneurism of aorta, 254 phenomena of circulation in, 267 Vena cava inferior, pressure upon by enlarged retro-peritoneal glands, 341 Venereal excesses, cause of disease, 21 Venous engorgement, effect on color of the blood, 270 effects of, 260 enlargement of spleen with, 335 of tongue, 286 humming explained, 269 louder on right side, 269 synonyms for, 269 when occurs, 269 -liver pulse, 266 with enlarged liver, 322 pulse described, 263 double positive, in hemisys- tole, 267 positive, tracing of, 265 progressive, in aortic insuf- ficiency, 267 in veins of hand and back of foot, 268 tracing of, 264 stasis a cause of jaundice, 47 a cause of oedema, 64 ecchymosis from, 51 thrombosis, when and where oc- curs, 268 Ventricle, contraction of, causes a sys- tolic heart-sound, 213 hypertrophy of, shown by streng- thened sound of corresponding valve, 217 left, hypertrophy and dilatation of, shown by displacement of apex, 200 Vermiform appendix, 317 inflammation of, Cheyne- Stokes breathing in, 92 tenderness in disease of, 308 usually no tumors with in- flammation of, 316 698 INDEX. Vertebrae, spines of, sensitive to pres- sure, 467 Vertebral artery, 461 column, section on, 467 Vertigo, also see Dizziness defined, and when occurs, 472 from the eye, 663 Vesicular breathing described, 142 diminished, causes of, 145 origin of, 142 pathological changes of, 144 special peculiarities of, 143 Vicarious action of centripetal influ- ences in coordination, 528 of diaphragm in defective thoracic breathing, 540 of kidney, 408 participation of neighboring nerves, 485 of nerve, 479 Vidian nerve, 461 Vierordt, C, reference to, 275 Vierordt, H., reference to, 35, 217, 283 Vierordt, K.. reference to, 246, 272 Vierordt, O., reference to, 154, 180 Virchow, reference to, 177 Vision, concentric limitation of, 587 of the field of in gross hysteria, 534 narrowing of field of, 569 disturbance of, from choked disc, amount of, 600, 601 disturbances of, in diseases of the nervous system, 562 in ursemia, 440 subjective sensations of, 571 testing field of, 568, 569 for central sharpness of, 568 Visual amnesia, 552, ' Vocal cords, position of, during pho- nation, 592 in paralysis, 599 fremitus, aid in determining appa- rent enlargement of heart, 210 aids in diagnosis between pneumonia and pleuritic exudation, 158 increased, when, 158 palpation for, 100 described, 156 technique of. 157 variations of, 157 weakness or suppression of, when occurs, 157 Vogel, reference to, 408 Voice, character of, in paralysis of muscles of speech, 548 effect upon, from paralysis of laryngeal muscles, 538 in disease, 74 Voit, C, reference to, 434 Volume of air cavity, effect upon pitch of sound, 109 of an extremity, measurement of, 490 of cavity, effect upon change of pitch of sound. 111 if closed, effect on pitch, 110 of muscles, diminution of, 491 Voluntary motion, 455 muscle, spasms of, 530 Vomicae, 131. Also see Cavities in Lungs. Vomit, chemical examination of, 359 coffee-ground, test for heemin in, 363 color of, 360 comma bacilli in, in cases of cholera Asiatica, 390 microscopical appearance of, 360 examination of, 364 odor of, value of, 366 quantity of, 360 reaction of, in various conditions, 366 section on, 359 watery, watery-mucous, and mu- cous, significance of, 360 Vomited material illnstrated, 365 Vomiting, act of, described, 358 central, diseases in which it oc- curs, 358 due to round-worms, 380 frequency of, 359 from irritability of larynx, 590 from severe coughing, 166 from uraemia, 440 in diseases of abdominal organs other than the stomach, 358 induction of, when contra-indi- cated, 342 kinds of, clinically distinguished, 358 of use in obtaining contents of stomach, 341 phenomena associated with, 359 reflex, 358 section on, 358 time when it begins, 359 ways in which it occurs, 358 INDEX. 699 Vomiting, when it occurs in nervous diseases, 578 Vomitus matutinus potatorum, 359, 361 amount of vomit in, 360 WAGNEE, E , reference to. 171 Waldenburg, reference to, 164 Wandering kidney, 395 diagnosis of, 396 differential diagnosis of, 397 liver, 331 signs of, 324 spleen, 335 described, 336 differential diagnosis of, 397 "Wasting diseases, haemic murmurs heard in, 229 significance of, 34 Water-brash of drunkards, 361 -whistling defined, 153 Waxv casts, a form of hyaline, 423 illustrated, 423 Weichselbaum, rei'erence to, 427 Weigert, reference to, 185 Weight, loss of, a sign of disease, 23 of bodv, increase and diminution, 34, 35 relation to height, 35 Weil, Handbook of Topographical Percussion, quoted, 112 -Luschka, quoted, 78, 79 quoted, 113, 122, 123, 125 reference to, 116, 121, 130, 132, 133, 192, 206, 207, 259, 304, 306, 312, 319, 321, 327, 332 (note), 333, 336, 338, 393 Wernicke, reference to, 552, 553, 555, 556, 558, 601 Westphal, reference to, 498, 499, 525, 527 Westphal's view of tendon reflexes, 500 Whispered voice, auscultation of, 159 Whiteblood-corpuscles in sputum, 176 increased proportion of, to red, in anaemia, 275 in urine of cystitis, 419 normal proportion of, to red, 278 with hsematoidin needles, 432 corpuscles, increase of, in leukae- mia shown by microscope, 279 White kidney, large, fatty casts in urine of, 423 dropsy with, 440 form of epithelium in urine of, 421 lipuria in, 447 Whooping-cough, effect of, on venous circulation, 263 expansion of lungs after, 136 expiratory bulging in, 98 microbe of, 190 phenomena of, described, 166 relation to emphysema, 22 severe cough of, a cause of emphysema of skin, 56 vomiting in, 358 Will, conscious, participation in co- ordination, 528 Williams's tracheal tone described, 111, 121, 131, 132 Willis, circle of, 461 Wintrich, reference to, 104 Wintrich's change of sound described, 111, 132, 159 Woillez's cystometer, 163 Wolff, reference to, 246 Women apt to conceal disease, 20 Word-blindness, testing for, 556 -deafness, 55, 461 defined, 552 testing for, 556 the condition of the hearing must be determined in, 573 Worms, a cause of epileptiform attacks in children, 533 Wrisberg, cartilages of, 591 Writer's cramp, 532, 561 Writing, an acquired faculty, 549 centre for, 557 diagnostic value of the character of, 561 disturbances of power of, 549 how acquired, 549 Wunderlich, quoted, 65, 68, 69, 70 Wunderlich's table of temperatures, 61 VANTHIN crystals, 433 YEAST cells in sputum, 190 fungus in urine, important when there is sugar, 428 Yellow atrophy of liver, acute, dimi- nution of phosphates in urine with, 435 700 INDEX. Yellow atrophy of liver, acute, leucin and tyrosin in urine of, 432 acute, urea diminislied in, 434 diminished area of dul- ness with, 331 fever, hsemato -jaundice in, 47 hemorrhage of stomach in, 362 ZEISS' apparatus for polarization, 447 reference to, 175, 274, 281, 447 Zenker, reference to, 179 Ziehl, reference to, 187 Ziemssen, reference to, 164, 302, 508, 593, 594, 596, 598, 599 Zimmerlin, reference to, 524, 525 Zygoma, what palpation above and below shows, 537 Zygomatic nerve illustrated, 485 COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE :||| pI ■ W'i.'VJ' 41 ^ "" fl ,1 i C28(l 140) Ml 00