COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX641 25556 RC71 .Se4 1 887 Manual of clinical d RECAP l^GTl €-4- Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/manualofclinicalOOseif MANUAL OF Clinical Diagnosis BY Dr. otto SEIFERT and Dr. FRIEDRICH MÜLLER PRIVATDOCENT IN wORZBURG ASSISTENT DER II, MED. KLINIK IN BERLIN THIRD EDITION REVISED AND CORRECTED BY Dr. FRIEDRICH MÜLLER TRANSLATED, WITH THE PERMISSION OF THE AUTHORS, BY WILLIAM BUCKINGHAM CANFIELD, A.M., M.D. (Berlin) Fellow of the American Academy of Medicine ; Member of the Medical and Chirurgical Faculty of Maryland ; Visiting Physician to the Union Protestant Infirmary of Baltimore ; Lecturer on Normal Histology, and Chief of Clinic for Throat and Chest, University of Maryland. WITH SIXTY ILLUSTRA TIONS NEW YORK & LONDON G. P. PUTNAM'S SONS %\t Knickerbocker ^rcss 1887 COPYRIGHT G. P. PUTNAM'S SONS Press of G. r. Putnam's Sons Aevv York TO HIS ESTEEMED FRIEND PROFESSOR H. KNAPP THIS WORK IS DEDICATED BY THE TRANSLATOR Ul PREFACE TO THE FIRST EDITION. The presentation of this manual to the public is due to the encouragement of our highly esteemed teacher and chef^ Geheimrath Professor Gerhardt. We have endeav- ored to supply a want by giving in an epitomized form, the different methods of examination, as well as a con- venient collection of those data and figures which should always be familiar to the physician and student. These data, on account of their number and variety, cannot be remembered with the necessary exactness, and, on the other hand, are so scattered throughout numberless text- books and monographs, that it would be troublesome and time-wasting to search for them. In selecting and ar- ranging this material, we have been led by the experience gained in holding courses, and we have also endeavored to consider the practical needs of the student and physi- cian by noting only what is reliable, and omitting every thing self-evident and of secondary importance. THE AUTHORS. Würzburg and Berlin, April, 1886, PREFACE TO THE THIRD EDITION. In preparing the third edition of this manual, I have endeavored to do justice to all the wishes expressed by the different critics, as well as to consider any wants which have become apparent since the last edition. Conse- quently, a number of improvements and additions have been made, and among them it seemed necessary to add some new illustrations, especially to the chapters on blood and urine. The illustrations of the leucocytes are from preparations of Professor Ehrlich, and those of the urinary sediment are, in part, taken from the physico- chemical atlas of Funke. The tables in the last chapter are intended to make the questions of diet and assimila- tion of practical use in the sick-room. In conclusion, I should like to thank all those gentlemen who have so kindly assisted us by their suggestions. Berlin, October, 1886. VI TRANSLATOR'S PREFACE. The favor with which this book has been received in Germany, and its eminently practical and concise man- ner of dealing with the different important points in diag- nosis, seem to justify its translation into English. It has been brought down to the latest acquisitions of science, thus representing the most advanced views. For the sake of clearness, the figures relating to weight, measure, length, etc., as well as the dose table at the end of the book, have been modified to conform to the system used in America and England. Translations from the original into French and Russian are now in press. The translator takes great pleasure in thanking in this place his friend Dr. Robert T. Wilson, for kind services and valuable suggestions rendered in the proof-reading and correction. W. B. C. loio North Charles St., Baltimore, September, 1887. vu CONTENTS. PAGE Preface to First Edition v Preface to Third Edition vi Translator's Preface vii Chap. I. — The Blood i Chap. II. — The Temperature 8 Measles . . . .10 Scarlet-Fever . . . . , . . . .10 Small-Pox . . . . . . . . ' . II Varioloid . . . . . . . " . .11 Chicken-Pox ......... 12 Typhoid Fever ........ 12 Typhus Fever ......... 13 Recurrent Fever ........ 13 Malaria .......... 14 Erysipelas . . . . . . . . .15 Pneumonia Crouposa ....... 15 Chap. III. — Organs of Respiration 16 Topography of the Chest ....... 16 Spirometry ......... 20 Percussion of the Thorax . . . . . . .21 The Normal Boundaries of the Lung .... 21 Topography of the Different Lobes of the Lung . . 22 Auscultation 27 The Breathing Sound . . . . . . .27 Rales . 28 Auscultation of the Voice . . . ... 29 Chap. IV.— The Sputum . . . . . . .32 Morphological Constituents 34 Chap. V. — Laryngoscopy 37 Voice .......... 37 The Muscles of the Larynx ...... 38 ix X CONTENTS, PAGE Nerves of the Larynx 38 Paralysis of the Vocal Cords .... 39 Chap. VI. — Circulatory System . . . 41 Inspection and Palpation .... 41 Percussion of the Heart .... 43 Auscultation of the Heart 45 The Heart Murmurs .... 46 Auscultation of the Blood-Vessels 48 Chap. VIL— The Pulse .... 50 Chap. VIII. — Digestive and Abdominal Organ S 55 The Teeth ...... 55 The Saliva ...... 56 CEsophagus . 56 Stomach ....... 57 Examination of the Stomach's Contents 58 Liver ....... 60 The Spleen ...... 61 Abdomen ...... 62 The Faeces ...... 63 Chap. IX. — The Urine-Producing System . 67 The Genito-Urinary Organs 67 The Urine 67 Normal Constituents of the Urine 70 Inorganic Constituents of the Urine . 74 Pathological Constituents of the Urine 77 Organic Sediments .... 89 Chap. X. — Transudations and Exudations 91 Chap. XI. — Parasites ..... 96 I. ANIMAL parasites : Cestodes — Tape-Worms . 96 Nematodes — Round-Worms • 98 Trematodes — Flat-Worms . 100 Arthropodes ..... . 100 . lOI II. VEGETABLE PARASITES : Hyphomycetes ..... . lOI Yeast Fungi . 102 102 CONTENTS. XI PAGE Chap. XI. — The Nervous System io8 Testing the Sensibility . 1 08 Testing the Motility III Motor Symptoms of Irritation . . . . . 112 Diagnosis by Means of Electricity .... 1 1.3 Reflexes ......... 121 The Most Important Clinical Points in the Anatomy ol the Nervous System ...... 124 Brain and Spinal Cord ...... 124 Cranial Nerves ....... 127 Spinal Nerves ...'.•. 129 Chap. XIII. — Analysis of the Pathological Concre MENTS 132 Urinary Concrements ...... 132 Concrements of the Intestine ..... 134 Salivary Calculi .....•• • 134 Gall Stones ......•• . 134 Chap. XIV. — Metabolism and Nutrition . 136 Table of the Weights of the Human Body • 143 Dose Table .....•••• . 144 Index . . . . . . 163 CLINICAL DIAGNOSIS. CHAPTER I. THE BLOOD. The whole quantity of blood in the body of an adult is equal to about -JL. of the weight of the body — that is, on an average, 5 kilograms [10 Ibs.].^ The specific gravity varies in health between 1045 and 1075- The reaction of the blood is alkaline. The amount of hceinoglobin'^ in the blood is about 14.57 grams [4 drachms] in men, and 13.27 grams [3 J drachms] in women, in 100 com. [3 ounces] of blood. On heating, the haemoglobin is resolved into brown haematin and albumen. If some blood {e. g. , that obtained from a blood stain on wood or linen), be heated to the boiling point with glacial acetic acid and a trace of common salt, and then slowly evaporated, there are formed brownish-yellow rhombic crystals of the muriate of h(zmatin, which is the same thing as h(zmin or Teichmann's crystals. The prepara- tion should then be moistened with a little glycerine, and examined with a high power under the microscope. The red blood corpuscles measure in healthy individuals ' That part enclosed in [ ] is by the translator. "^ The amount of hsemoglobin is determined by the quantitative spectral analysis or by means of a hsemochromometer. Z 2 CLINICAL DIAGNOSIS. from 6.7 yu to 9.3 /// The average size is 7.8 /f (Gram). Giant blood co7-puscles are found principally in the blood of the anaemic, and especially in those suffering from progressive pernicious anaemia. The dwarf blood cor puscles measure from 2.2 to 6 /^, and are like the normal ones, only slightly more biconcave. These are also found frequently in ansemia. By Foikilocytes are meant those red corpuscles of irregular form (pear-, club-, or biscuit-shaped) which are seen in all ansemic conditions. Microcytes are small spherical bodies, generally very rich in hemoglobin, and Fig. 1. >. ucleated red blood corpuscles. Poikilocytes. Dwarf blood corpuscles. A normal red blood corpuscle. ©*^ r^ l\ --^ ^ Giant ^ l^^~y^ - blood corpuscles. Microcytes. are found in many cases of burning and poisoning. Still we must very often consider them as artificial products. It is uncertain whether red corpuscles with crenated edges (thorn-apple-shaped corpuscles), appear in normal blood or not. When seen, they are generally considered artificial products caused by evaporation. Notwith- standing this, they are observed to form more quickly and abundantly in many cachectic conditions than in normal blood. ^ u = the one-thousandth part of a millimetre, and is known as a micro-millimetre or micron, and equals about ^-^(Jq of an inch. THE BLOOD. 3 Nucleated red blood corpuscles are seen in all severe ' cases of anaemia but they can only be recognized in stained preparations.^ Very large nucleated blood corpuscles (megalocytes) are seen m progressive per- nicious anaemia. Blood-plaques (Bizzozero ^) = Hcematoblasts (Hayem ^) are colorless flat round discs about one half the diameter of a red blood corpuscle. They change their shapes very quickly when outside of the blood-vessel. The elei}ienta7'y graiiular masses are small, often angular, colorless granules with a diameter of 1-2//. They consist in part of fat, and are probably for the most part disin- tegrated products of the blood-plaques. Fig. 2. Fig. 3. Fig. 4. Fig. 5. Fig. 6. Fig. 7. Lymphocytes. Large mononuclear Polynuclear Polynuclear Eosinophile Small size. Large size. cell. cell. cell. cell. The white blood corpuscles (Leucocytes) are divided according to Ehrlich into : (i) Lymphocytes., which are about the size of a red blood corpuscle or somewhat larger, with a large round nucleus, and a very small, often scarcely visible, protoplasm. We distinguish two forms, a smaller and a larger, which latter is only the former in a more progressive stage of development. The lymphocytes have their origin in the lymphatic glands. (2) Large mononuclear forms.^ with large round or oval nucleus and broad protoplasmic body. These are the earlier stages of development of the third. (3) The large polynuclear forni, containing a nucleus very much divided and lobulated, and which may be deeply stained 1 Fortschritte der Medicin, 1884. " Bizzozero : Virchows Archiv., Bd. xc. ■^Hayem : Archive de Physiologie, 1878-79. 4 CLIXICAL DIAGNOSIS. with aniline colors. They form by far the greatest number of the leucocytes, and are found almost exclu- sively in pus. Ehrlich designates as eosinophile cells those leucocytes in whose protoplasm a quantity of coarse, fatty, shining granules are seen, which are colored an intense red on staining a preparation of dried blood with a one-per-cent. watery solution of eosin. These cells have their origin in the marrow of bones, and are present in normal blood in small quantities only. In myeloge- netic leucaemia they are seen in large numbers. In lymphatic leucaemia it is principally the small lympho- cytes which are increased in number In order to examine the blood, it is generally sufficient to cleanse and dr)^ the finger, and, with a needle or lancet, to make a quick and deep puncture in the tip. The drop of blood should then escape without squeezing the finger, and be dropped on a clean cover-glass, which is, in turn, dropped on the slide in such a way that the blood is spread out in a thin film. In order to see the blood-plaques, a drop of a one-per-cent. osmic-acid solution is applied to the finger, and the puncture is made through this drop. Instead of the osmic acid, which is simply a consers'^ative fluid, a thin watery solution of methyl violet with 0.6 ^c of common salt may be used, which colors the blood-plaques and the nuclei of the nucleated red blood- corpuscles. In finer examinations of the blood, it is better to color a dried preparation {znd. Chap. xi. for preparation) with the follow- ing solution : 5 Haematoxylin, 2 grams [30 grains]. Alcohol, Glycerine, Distilled water, ää 100 grams [3 ounces]. Glacial acetic acid, 10 grams \2\ drachms]. Alum in excess. This mixture should stand 3 weeks in the light, and a few granules of eosin should be added to it. The dry preparations remain from 6-12 hours in the staining fluid, and then are to be washed off with water and examined. The nuclei of the nucleated red blood- corpuscles will be found to be stained intensely black. (Ehrlich.) THE BLOOD. 5 The number of red blood corpuscles is, on an average, in men, in the normal condition, 5 million ; in women, 4|- million, to a cubic millimetre [a millimetre equals -^-^ of an inch]. The number of white blood corpuscles varies between 5,000-10,000, and is temporarily increased after a hearty meal. The number of blood-plaques is about 200,000 to the cubic millimetre. The proportion between white and red blood corpuscles is, in healthy individuals, 1-500 to 1-1,000. A proportion which is more than i to 400 must be considered as a pathological increase in the number of Avhite corpuscles. Welker and Moleschott considered the proportion of white to red corpuscles to be 1:330 and 1.357. Duperie found 5.500,000, red to 5,000 white, or i:iioo ; Malassez, 1:1200 ; Hayem, Bouchut, Du- brisay found, on an average, 1:500-1,000 ; Ilalla, 1:422-811. Laache and Otto found, on an average, for men 4.97 and 4.99 million, and for women 4.43 and 4.58 million red blood corpuscles. In order to count the corpuscles, a deep puncture is made into the finger-tip, and the escaping drop is sucked up into the me'langeur until it reaches the mark T. The point of the instrument is then wiped off, and the dihitüig fluid \% sucked up to the mark loi. This mixture of blood and diluting fluid ^ is well shaken and introduced into the counting chamber, and covered by the cover-glass, which should be lightly pressed on, and then the corpuscles are counted in each square, which is etched on the cover-glass. If a thousand cor- puscles have been counted in one square, the amount of corpuscles in a cubic millimetre can be calculated, since the dilution of the blood (1:100) and the depth of the chamber are known. By using the chamber of Thoma-Zeiss (depth ^ mm., i square = ^^ cubic millimetre), the average number of corpuscles in a small square ^ This fluid may be either a 3 ,^ solution of common salt, or a 5 ^ solution of Glauber's salt, or Hayem's solution, which is corrosive sublimate, 0.5 grams [7 grains], Glauber's salt, 5.0 [i|- drachms], common salt, 2,0 [i drachm], distilled water 200.0 grams [6 ounces]. 6 CLINICAL DIAGNOSIS. is multiplied by 400,000 — that is, the whole number of corpuscles is to be divided by the number of squares which have been counted. It is more convenient to count the four small squares in one col- umn and calculate the average result of a large number of counts. This number, which is the number of blood corpuscles in any four squares, is then multiplied by 100,000. In using the chamber of Malassez or Hayem, which has a depth of i mm., the average num- ber which is in a large rectangle (=20 small squares) is to be multi- plied by 10,000. If the blood dilution is 1:200 instead of 1: 100, i, e. (up to mark 0.5 of the melangeur), the result should be multiplied by 2. Leiccocytosis, that is, an increase of the leucocytes in proportion to the red corpuscle, is observed in numerous acute diseases (typhus abdominalis, erysipelas, etc.), also in cachectic conditions (cancer). This increase of leucocytes is often very great, and may even reach as high as i to 60 red corpuscles. In Leuccemia, the amount of red corpuscles as well as of haemoglobin is generally considerably decreased, so that the number of leucocytes is very considerably increased, and almost equals that of the red corpuscles ; indeed it may equal or exceed it. In the first stages of the disease, when the increase of the white corpuscles is often less than in severe leticocytosis, the diagnosis of ieuccemia can be certain only when, in its further course, a rapid increase of leucocytes makes it very evident ; or when the proportion of white to red exceeds 1:50. In myelogenetic leucaemia, there are numerous eosinophile leucocytes, and also nucleated red blood corpuscles to be seen. Ly7Jiphatic leucaemia is characterized by an increase of lymphocytes. \vl pseudoleuc&mia there is a slight decrease in the number of red corpuscles, and in the amount of haemoglobin, and no increase of the leucocytes. In the first few days after heavy loss of blood, the amount of red corpuscles as well as of the haemoglobin sinks markedly to over 50 ^ of the normal, whereas the number of leucocytes increases. In the period of convalescence, the amount of red corpuscles increases more quickly than that of the haemoglobin. In the secondary ajiczmicz, after typhus abdominalis, tuberculosis, malaria, lead poisoning, ankylostomiasis, nephritis, cancer, etc., the number of red cor- puscles as well as the amount of haemoglobin is diminished, and the amount of white blood corpuscles increased (leucocytosis). THE BLOOD. 7 In chlorosis the amount of hemoglobin is very greatly decreased, whereas the number of red corpuscles is often very' little or not at all increased. These are therefore very pale. The amount of white corpuscles is normal. In progressive perniciotis ancemia, the number of red corpuscles is enormously reduced, often to ^ of the normal, whereas their size, and above all things, the amount of hcemoglobin is increased. An increase in the number of red corpuscles is observed in thicken- ing of the blood in cholera, as well as in many heart affections. After long-existing malaria, pigi7ient-containing letccocytes are at times seen in the blood. Micro-organisms are also observed in the blood — e. g., tubercle bacilli in miliary tuberculosis, bacilli leprce, bacilli anthracis, and the spirilla of reciirrent fever. The latter can be seen with medium power, and are best recognized from the fact that when they come in contact with the red blood corpuscles, they impart to them a jerking motion ; or they can be recognized by coloring them as a dried prep- aration, with a watery solution of gentian violet, as in the case of the bacilli anthracis. CHAPTER II. TEMPERATURE. The temperature of the body is generally taken either in the axillary space or in the rectum [and under the tongue]. In the rectum it is about 0.5°-:° higher than in the axilla. The temperature of the healthy individual measures ^ in the axilla between36.2° C. [97.1° F.] and 37.5° C. [99.5° F.]. The highest temperature is late in the afternoon, and the lowest, very early in the morning. An elevation of tem- perature can temporarily occur in consequence of bodily exertion, taking food, hot-baths, etc. A continuous ele- vation of temperature occurs /;/ fever. According to Wunderlich we have : The temperature of collapse, 36° C. [96.8° F.]. Sub-febrile temperature 37.5°-38° C. [99.5° F.-ioo.4° F.]. Slight fever 38°-38.5° C. [ioo.4°-ioi.3° F.]. Moderate fever 39° C. [102.2° F.] morning ; 39.5° [103.1° F.] evening. Considerable fever 39.5° C. [103.1° F.] morning ; 40.5° C. [104.9° F.] evening. High fever over 39.5°C. [103.1° F.] morning; over 40.5° C. [104.9° F-] evening. ' In order to convert from one scale to the other, the following formula may be used : N° C = |nO R = f n« + 32° F. TEMPERA TÜRE. 9 Hyperpyrexia, or fever over 41.5° C. [106.7°]. Also in fever there is usually a morning remission and an evening exacerbation. Exceptionally, especially in phthisis, we have the reverse — typus inversus. The difference between the highest and lowest tempera- ture decides its type of the fever, thus : Febris co7itinua =■ a daily difference of not more than 1° C. [1.8° F.]. Febris remittens = a daily difference of not more than 1.5° C. [2.7° F.]. Febris intermittens = in the course of the dav the high temperature is varied by a period of no fever. In the course of a fever we distinguish : I. Stadium incrementi = a quick rise of temperature, generally accompanied by a chill or a slowly rising temperature, II. Fastigium rz: or a stage of highest temperature. Its transition to the next stage is known as the amphibolic stage. III. Stadium decrementi. The fever fall can follow either slowly, in course of several days, in which case we have lysis ; or quickly, the crisis. At the actual crisis the temperature falls rapidly (in one day) until it goes below normal. This fall is generally accompanied by a profuse perspiration. A high rise of temperature often precedes the crisis, which is called perturbatio critica. In acute infectious diseases we distinguish the stage of incubation — that is, the time between the moment of con- tagion and the outbreak of the disease. Also in acute exanthematous diseases there is the prodromal stage, or stage of the first morbid appearances, i. e., before the outbreak of the eruption. lO CLINICAL DIAGNOSIS. Fig. 8. Temperature chart in IMorbilli. F° 1058 104. Morbilli— Measles. Incubation, ten days. Prodromal stage, three days, characterized by affections of the mucous membranes. It begins with chill and high fever ; and on the second or third day there is a slight fall of temperature. At the appearance of the eruption (on the face) the temperature ^°^'^ rises again, and reaches its 100.4 highest point when the erup- 98.6 tion is most widely dissemi- g58 nated. This is the stadium Prodromes. Eruption. Defervescence. floritionis, and laStS threC tO four days. The critical fall of temperature occurs on the sixth or seventh day of the disease, after which des- quamation begins. Scarlatina — Scarlet-Fever. Incubation, four to seven days. Prodromal stage, one to two days. It is characterized by angina. It begins with a chill and quick rise of temperature. At the end of the first or second day there is an outbreak of the c° eruption (on the breast), and 41,0 as it spreads the tempera- ^^^ ture rises. Defervescence Fig. 9. Temperature chart in Scarlatina. begins on fourth to seventh 390 day of the disease, and comes ^^■° to an end slowly, with the 37-0 paling of the eruption in 36.0 three to six days later. Desquamation then follows. TEMPERA TÜRE. II Fig. lo. Temperature chart in Variola. Variola — Small-pox. Incubation, nine days (nine to sixteen days), at the end of which time there is general disturbance of func- tions. The prodromal stage (two to five days) begins with a chill, with sudden rise of tem- ^° perature, and 41.0 often on the second or third day the first signs of the eruption are observed, s'^o laaBBOQiiBEElEDISEOBIE niiSiiliiiMSgl sasi lliiiiiiiiiiii iHiiiii IBBSBSgsS IBBBBSBB 105.8 104. 102.2 100.4 98.6 96.8 Prodromes. Eruption. Fever of suppuration. Desquamation. With the be- ginning of the pustulation there is a quick fall of tem- perature. Then comes a second and in the beginning a slight febrile movement, which reaches its climax on about the ninth day (fever of suppuration), preserves a remittent type for some time, and after a varying length ends in lysis (period of desquamation). About the six- teenth day the stadium decrustationis begins. Variolois — Varioloid. Fig. II. Temperature chart in Variolois. The incubation and prodromal stag- es are the same as in variola vera, only much lighter. The second period of fever (fever of sup- 6 puration) is want- 96.8 ing. The period of 12 CLIN IC A L DIA GXOSIS. desquamation often begins as early as the ninth or tenth day, and is generally accompanied by slight rise of temperature. Varicella — Chicken-pox, The prodromes are generally wanting. The eruption o 'S, 4 ^ d" S 2 of the vesicles begins with slight fever. The vesicles dry up after three or four days. Typhus Abdominalis — Typhoid Fever. Incubation, seven to twenty- one days. The prodromal stage lasts several days to a week, and is accompanied by general disturbances. In the first week of the disease the temperature rises by degrees, accompanied by slight chills, and reaches, on the fourth or seventh day, its highest point. This continues as a febris con- tinua until the third week in the milder forms, and until the fifth w^eek in the more severe forms. Then the morn- ing temperature begins gradu- ally to fall, while the evening temperature still remains high, until gradually lysis results, which in mild cases is in the Ü «" 5 dv od t:. >o fourth week. There is also TEMPERA TÜRE. 13 tumefaction of the spleen in the second half of the first week of the disease. Roseola occurs on the sixth to ninth day of the disease. Typhus Exanthematicus — Typhus Fever. Incubation varies from a few days to three weeks. The prodromal stage is not marked. The disease begins with a chill and rapid rise of temperature, and then it remains febris continua until the thirteenth to the seven- Fig. 13. Temperature chart in Typhus exanthematicus. C° 41.0 40.0 39,0 38.0 37-0 36.0 lüiBiigiiiiiiiii 105.8 104. 102.2 100.4 98.6 96.8 Eruption. teenth day. There are often remissions at the end of the first week. There is then a critical fall of tempera- ture, at times with transitory perturbatio critica. The eruption appears on the third to the sixth day after an inflammation of the mucous tracts. Febris Recurrens — Recurrent Fever. Incubation five to seven days. The prodromal stage is not clearly marked. The fever begins with violent chill and a (high) sudden rise of temperature, which con- tinues as in febris continua until the fifth or seventh day, and then critically falls. After a period of apyrexia, last- ing about a week, there is again an attack of fever as at 14 CLIN I CA L DIA GNO SIS. first, but not lasting so long. Often, after a period of seven days, there is a third attack, lasting one to two days. Fig. 14. Temperature chart in Febris recurrens. 41.0 40.0 39-0 38.0 37-0 36.0 piiiiSaiHEiiiRiSl PüiaiinBÜEBBläli iJÜEgiiSSSaiigHSSiBi wiSEaBaHiiaaBBiBl ISEiglSBSeSSlBBilBlSi BBSBSigSSBIBEiBBBBi F° 105.8 104. 102.2 100.4 98.6 96.8 Malaria — Febris Intermittens. Incubation seven to tv>^enty-one days. Prodromal stage is not marked. There is a chill, and the tempera- ture rises to very great height, and then sinks after a few hours to or below the normal. There is also strong per- Fig_ J, spiration. According as Temperature chart in Febris intermittens, the fe\'er OCCUrS CVerV day, or every second and c° 41.0 40.0 390 38.0 37-0 isnissaBiiissBB^ 'SSSIBBSgiBlsSSgB ä&i!gS5|iiS»S [■■■■!■■■ BsEBBimBaiai^^i ■■■■■[■■■—■■IW^— i^Bl B«WII«IMB«^Bw»BlgBB gg — I isisäSiässSsssIsSSBS 36.0 Febris quotid ; tertiana ; quartana. F° 105.8 third day, it is called quo- jQ^ tidian, tertian, and quar- 100.4 tan intermittent fever. Febris intermittens dupli- cata is that type in which ■^ two attacks occur in quick •8 succession in the course of the same day. Febris inter- mittens anteponens and post-ponens is that type in which the new attack of fever does not generally occur at the same hour of the day as the preceding attack, but sooner or later. TEMPERA TÜRE. 15 Fig. 16. Temperature chart in Erysipelas. ■I ^' • W< ^.Bi .WJB >" CLINICAL DIAGNOSIS. tened with baryta water and held over the mouth of the test tube. Carbonate of lime is present in the sediment as small spherical and biscuit-shaped [dumb-bell crystals] Fig. 27. Fig. 28. Fig- 29- Neutral Phosphates of Lime. Coffin-lid Crystals of the Am- monio-Phosphate of Magnesia. ^'1^' Spherical and Biscuit- shaped [dumb-bell] Crystals of the Carbon- ate ot Lime. bodies which dissolve with the formation of bubbles on the addition of acids. Sodiitm. The daily amount excreted is 4-6 grams [i-i|- drachms], in form of sodium oxide NagO. Potas- simn. The daily amount excreted is 2-3 grams [30-45 grains], in form of potassium oxide K^O. During fever the amount of sodium decreases, while the amount of potassium is 3 to 7 times as great. Ammonia NH3 is present in unfermented urine in small quantities only, (0.6-0.8 gram [10-12 grains]). It is much decreased in many cases of diabetes. Calciu7n. The daily amount excreted is 0.16 gram \2\ grains], in form of CaO. Mag7iesiu7n. The daily amount excreted is 0.23 gram [3} g^^i^s], in form of MgO. The sulphate of calcium (gypsum) is present in the sediment in form of fine oblique prisms and needles, which are not soluble in acetic acid. Neutral phosphate of calcium is present in form of wedge-shaped crystals which unite to form rosettes. The ammonio-magnesian phosphates^ or triple phosphates, occur as shining coffin- lid-shaped crystals. The two last of these crystals men- tioned are soluble in acetic acid. THE URINE-PRODUCING SYSTEM. "JJ Iron is present in the organism in combination and therefore appears in the ash of urine only. Pathological Constituents of the Urine. Albumen (serum albumen and serum globulin). In order to make use of the following tests, the urine should be clear, and filtered if not clear. I. Heat Test. — The urine is heated to the boiling point in a test- tube, and then one or two drops of diluted acetic acid should be added. Instead of the acetic acid, nitric acid may be used, in which case ten to twenty drops should be added. If the cloudiness caused by heating be dissolved by the acid, then it was not caused by albumen, but by the phosphates and carbonates of lime and magnesia which are freely soluble in the acids. If the cloudiness remain, or if it appear on the addition of acid, it is caused by albumen. A cloudiness often appears after adding acetic acid to the urine when it is warm, or when it has cooled off. In this case it is not due to mucin, but to albumen. If the precipitate of albumen be taken from the filter and its vol- ume approximated after three to twelve hours, an approximate result, as to the amount per cent, of albumen in the urine may be obtained. When the amount of albumen is 2 ^ to 3 ^, the whole fluid is completely coagulated. When there is i ^ of albumen pres- ent, the coagulum in the test-tube reaches half way up to the level of the urine. When o. 5 ^, \ the way up. 1 <' " 0.1 ^, Jo " 0.05 %, the curved part of the tube is barely filled with albu- men, and when there is less than o.oi % present, there is a slight cloudiness, but no precipitate. II. Heller s Test. — The test-tube containing the urine is held ob- liquely and concentrated nitric acid is poured slowly down the side of the tube so as to flow below the urine. If albumen be present, there is formed a sharply defined ring-shaped cloudiness at the point of contact between the urine and the acid. Besides albumen, a pre- cipitate in very concentrated urine may be caused by the presence of 78 CLINICAL DIAGNOSIS. urea, in which case the ring is higher and not so clear. A cloudi- ness may also be caused by nitrate of urea, and in this case the pre- cipitate is crystalline and does not appear until after standing a long time. A cloudiness may occur from the resinous substances, as after taking copaiva, styrax, turpentine, etc., but in this case the precipi- tate is dissolved, after cooling, in alcohol. The ring of albumen may be colored blue or green by indigo, or by the coloring matter of the gall. III. Test with Acetic Acid and Ferrocyanide of Potassium in the cold. — If to some urine three to five drops each of acetic acid and a lo ^ solution of ferrocyanide of potassium be added, there occurs a precipitate from the presence of albumen or hemialbtcmose. If the urine be taken in very small quantities, the precipitate appears only after a few minutes. IV. Biuret Test. — The urine is first to be made alkaline with caustic potash, and then 1-3 drops of a diluted solution of sulphate of copper are to be added, and if albumen, hemialhtanose, or peptone be present, a reddish violet solution is formed. [V. Picric Acid Test. — A delicate and convenient test used long ago in Germany and rediscovered in 1882 by George Johnson. The dry acid may be dissolved in the urine, or a saturated solution may be used, into which the urine should be slowly dropped, and if albu- men is present a cloudiness appears at once.] For the quantitative determination of albumen, see Chapter X. Heinialbuinose (Propeptone) is an intermediate state be tween albumen and peptone. This is not precipitated by heating, but by nitric acid, acetic acid, and ferro- cyanide of potassium, as well as by acetic acid and so- dium chloride. All these precipitates have the property of dissolving on heating and reprecipitating on cooling. To test for hemialbumose it is necessary, first, to remove the albu- men. For this purpose, to the urine (or to any other fluid to be ex- amined, as the contents of the stomach) 5 to 10 drops of acetic acid and \ of its volume of a concentrated salt solution are added, and the whole heated. Then the albumen will be precipitated and should be removed while hot by filtration, while the filtrate is allowed to cool off. If a cloudiness now arise on the addition of salt solution THE URINE.PRODUCING SYSTEM. 79 to the filtrate then hemialbumose is present. If too much salt solu- tion be added, the precipitate of hemialbumose cannot be redissolved by heat. Peptojies are present in the urine principally in the ab- sorption of pus and exudations (pneumonia, empyema, abscesses and puerperal fever, etc.) They are not pre- cipitated on heating, nor with nitric nor acetic acid, nor with ferro-cyanide of potassium. They a:^e tested for with the biuret test after the albumen and hemialbumose have been removed or proved absent. 10 ccm. \2.\ drachms] of a concentrated solution of sodium acetate and a few drops of a solution of iron chloride are added to 500 ccm. [i pint] of urine until there results a permanent red color ; then a caustic potash solution is dropped carefully into this mixture until it is slightly acid or neutral, and the mixture heated. After it has cooled off and been filtered, the filtrate, which ought to be entirely free from albumen, is subjected to the biuret test. Blood. — We speak of hasmaturia when the blood color- ing matter is present in the urine in combination with the blood corpuscles ; of hsemoglobinuria when the blood coloring matter is in solution without there being blood corpuscles in the sediment. The latter occurs when the blood corpuscles are dissolved by some agent (after poisoning, cold, etc.), and the haemoglobin becomes free. Urine containing blood-coloring matter is either bright red with a greenish iridescence (resembling meat juice) from the presence of oxy- haemoglobin, or it is a dark brownish-red from the presence of meta- hsemoglobin. The latter differs from oxyhasmoglobin by its being recognized in the spectroscope as a dark absorption line in the red and a paler one between the green and blue near both the oxyhsemo- globin lines. ^ ^ The spectroscopic examination may be made with the pocket spectroscope. The urine is held in a tube before the slit m the in- strument. 80 CLINICAL DIAGNOSIS. Besides, the spectroscopic test blood-coloring matter may also be recognized by the following tests : Heller s Test. — If the urine be heated with caustic potash, the earthy phosphates in precipating take the coloring matter of the blood with them, and appear reddish brown instead of white. Giiaiac Test. — About i ccm [15 drops] of a freshly made tincture of guaiac and the same amount of resinous turpentine oil are added to some urine and well shaken. If blood be present the mixture turns blue after a few minutes. Instead of turpentine oil, Hiihner- feld's mixture ^ may be used. The smallest amount of blood which can no longer be recognized by one of these methods may be looked for by examining the sedi- ment microscopically for blood corpuscles. Coloring matter of the bile. In urine there is present either the actual coloring matter of the bile (bilirubin) which is changed by Oxydation into green (biliverdin), violet, red, and yellow (choletelin), or hydro-bilirtibin (urobilin), which originates from a reduction of the col- oring matter of the gall and blood. Urine containing bilirubin is of a beer-brown color and has a yellow foam on shaking. On being shaken with chloroform the bili- rubin becomes gold-yellow and is taken up by the chlo- roform. Bilirubin is tested for by the Gmelin test. A few drops of fu- ming nitric acid are added to concentrated nitric acid until a slight yellow is observed. This mixture is then poured into a vessel con- taining urine in such a way that the acid passes down the side of the glass under the urine. Then there is formed at the point of contact of the acid and the urine, a colored ring which passes from green through violet to red and yellow. A blue ring alone may be caused ^ Glacial acetic acid, 2.0 ccm [30 drops]. Distilled water, i.o ccm [15 drops]. Oil of turpentine, Absolute alcohol. Chloroform, — of each roo.o ccm [3 ounces]. THE URINE-PRODUCING SYSTEM. 8 1 by indigo, a reddish-brown one by hydrobilirubin and other substan- ces. If a solution of iodine in iodide of potash be added to the urine containing biHrubin, it becomes a green (biliverdin). Hydrobilirubin is tested for by adding to urine 2-5 drops of a 10 % solution of the chloride of zinc, and afterwards enough ammonia to redissolve the precipitated oxide of zinc. If a green fluores- cence is observ^ed (by looking at the test-tube against a dark back- ground) in the fluid filtered from the precipitated phosphates, hydro- bilirubin is present. Instead of the chloride of zinc and ammonia, iodine-iodide of potash and caustic potash may be used. In the spectroscopic examination of urine containing hydrobilirubin (even after adding the chloride of zinc and ammonia), it may be recognized by an absorption line between the green and the blue. Gallic acids are found by Fettenkoffer s test : A grain of cane sugar is added to the fluid and the whole is evaporated with gentle heat on the cover of a porcelain crucible with a drop of concentrated sulphuric acid. If the gallic scids are present the fluid becomes purple. The same reaction may be caused by other substances (albumen, fatty acids, etc.), so that the gallic acids should first be extracted from the urine. For the procedure necessary (as evapo- rating, extracting with alcohol, precipitating with bar}'ta and ex- tracting the cholalate of barj^ta with warm water), see the text-books. Grape Sugar (Dextrose) CgH^gOg is fermented by yeast to alcohol and carbonic acid (— 2C2HgOH -j- 2CO2), shows a brown color when heated with caustic potash, is capable of reducing, and turns the plane of polarized light to the right. I. To make the fermentation test, a test-tube or eudiometer tube is first half filled with mercury, and the same amount of urine is added, only leaving enough room for a little yeast. The air bubbles are removed from the opening of the tube, which is then closed by the finger, and dipped upside down under mercury, and left there at a temperature not over 30° C [86° FJ, The presence of grape sugar soon causes a development of gas. In order to show that the gas is carbonic acid, some caustic potash is introduced through a curved pipette into the tube, and by this the carbonic acid is absorbed. 82 CLIiVICAL DIAGNOSIS. This determines the presence of grape sugar. Much more conven- ient are the ?,o-ca.\\Q^ fe7'vie}ttatio7i tubes} A piece of yeast as large as a pea is introduced into one of the tubes and urine is so added that no air enters into the vertical branch of the tube. For the sake of greater certainty a second tube with a dextrose solution and yeast, and a third tube with normal urine and yeast, may be also used. If the result of the second test is positive, this shows that the yeast is effective, and if the result of the third test is negative, it shows that the urine contains no sugar. By determining the specific gravity of urine both before and after fermentation (after 24 hours at the temperature of the room), the approximate amount of grape sugar may be obtained. The urine is made to ferment with yeast in a long-neck bottle, the opening being covered with a watch glass to prevent evaporation. After 24 hours the specific gravity of the filtered urine is taken at the same temperature. The difference in the specific gravity before and after the fermentation is read from the urinometer, each degree of which corresponds to 0.219 ^ of sugar. Thus urine which before the fermentation had a specific gravity of 1040, and after, the specific gravity of 1020, contains 4.38 % of sugar. II. Moore s Test. If urine containing sugar be heated a few minutes with one third its volume of a concentrated caustic potash solution, it turns brown. This test is reliable only when the brown color is very intense, for sugar to the amount of 0.5 % cannot thus be found. With i % of sugar the color becomes canary yellow, 2 % am- ber yellow, 5 ^ the color of Jamaica rum, and 7 ^ it becomes blackish brown and non-transparent. III. Reduction Tests. {a) Trommers Test. — To a quantity of urine, one third its volume of a caustic potash or soda solution is added, and then 1-2 drops of a diluted (5-10 ^) sulphate of copper solution. If the bright blue- colored precipitate of hydrated copper oxide remains undissolved and flocculent on shaking, no sugar is present. In the presence of sugar, glycerine, tartaric acid, ammonia, or albumen the hydrated cupric oxide dissolves, giving the urine a sky-blue color. The sulphate of copper solution should be added drop by drop until there ^ To be had of Hildenbrand in Erlangen, and Dr. R. Muenke in Berlin, N, W., Luisenstrasse, 58. THE URINE-PRODUCING SYSTEM. 83 is only a small part left undissolved on shaking the tube. If this mixture be then heated the presence of sugar will cause, before the boiling point is reached, a yellow-red precipitate of cuprous oxide (CU3O), formed by the grape sugar taking oxygen from the cupric oxide (CuO). If the fluid change color v/ithout forming a precipitate, or if the latter be not formed until the urine has cooled off, then the test is not convincing, since other reducing substances (uric acid, Creatinin, etc.) hold the cuprous oxide in solution. Exceptionally reducing substances appear in the urine from medicines taken (turpentine, chloral hydrate, chloroform, benzoic acid, salicylic acid, camphor, copaiva, and cubebs). It is generally a more certain test to let the urine stand for 24 hours, cold, after adding the substances, instead of heating it. If then a yellow precipitate of cuprous oxide appear, it can be caused by sugar alone. (3) Test with Fe kling' s solution. — Fehling's solution consists of Crystalline sulphate of copper 34.639 [520 grains]. Neutral tartrate of potash 173.0 [5^- ounces]. Ofhcinal caustic soda solution 100. o [3 ounces]. Distilled water enough to make 1000. o [30 ounces]. One ccm. [15 drops] of this is exactly reduced by 0.005 gram [y^3 grain] of grape sugar. Two ccm. [30 drops] of this fluid are put into a test tube, diluted with an equal amount of water and heated. In case the formation of the oxides takes place, which would make it unfit for use, a few ccm of urine which have been previously heated in another test-tube are added to this. If grape sugar be present, a yellowish-red precipitate is formed. In order to appro xi77iately determine quantitatively the amount of grape sugar present, the trituration method of Fehling may be car- ried out on a small scale. Two ccm. [30 drops] of Fehling's solution (corresponding to 0.0 1 gram [|- grain] of sugar) are measured off in a large test-tube and diluted with about ten times its volume of water and heated. By means of a dropper 1-3 drops of urine are then added, and the whole is heated, observing whether the fluid still shows a blue color on holding it to the light. Is this the case, then a few more drops are added, and it is again heated and again observed and then watched until the last trace of blue has just completely dis- appeared, showing that all the cuprous oxide has been reduced. We know that in the urine there is exactly o.oi gram [^ grain] of sugar, 84' CLINICAL DIAGNOSIS. and counting 20 drops to i ccm. we can calculate the percentage of sugar present. In order to save the time and trouble of making such calculation at every examination, the following table will be found convenient. It is better to dilute tne urine four or five times in a graduated glass. Drops = % Sugar. Drops = fc Sugar. Drops = % Sugar. I 20 lO 2.0 25 0.8 2 lO II 1.8 30 0.6 3 6.6 12 1.6 40 0.5 4 5 13 1.5 50 0.4 5 4 14 1.4 60 0.3 6 3-3 15 1-3 70 0.28 7 2.8 i6 1.2 80 0.25 8 2.5 i8 I.I 90 0.21 9 2.2 20 I.O 100 0.20 {c) Böttge7's Test. — The urine is made alkaline by saturating it with sodium carbonate in substance, adding a pinch of the subnitrate of bismuth (NOgBiOHg) and heating it a few minutes. Or the urine may be heated with -J-g- of its volume of Nylander's solution. This solution consists of neutral tartrate of potash 4.0 grams [l drachm], \o% solution of caustic soda 100 ccm. [3 ounces], to which are added, subnitrate of bismuth 2.0 grams [30 grains] while warm, and the whole to be filtered after cooling off. In the presence of grape sugar a broM^n or black color is formed, due to the metallic bismuth. {d) Mulde?' s Test. — The urine is first made alkaline with carbon- ate of sodium, and then a solution of indigo carmine (sulphate of indigo) is added until the urine turns blue. On heating, the indigo blue is reduced by the grape sugar present to indigo white, and on exposure to the air again, turns blue. IV. Test with Phenylhydrazin. — Two pinches of Phenylhydrazin and four pinches of the acetate of sodium are put into a test-tube, which is then half filled with water and heated. Then an equal vol- ume of urine is added, and the test-tube is heated for 20 minutes in a water bath and allowed to cool off. When the urine contains a large amount of grape sugar, a yellow crystalline precipitate of phenylglucosazone is formed, and when there is only a little grape THE URINE-PRODUCING SYSTEM. 85 suger present the sediment under the microscope shows these crys- tals of this form (v. Jaksch). V. Polariaztion Test. — The specific angle of grape sugar for yel- low sodium light {ex) D is 53°. From the degree of deviation a. in the special case, and the length / of the tube used expressed in decimeters, the percentage of grape sugar in the urine may be calcu- lated from the formula f> = — 1^ 53./ With the presence of substances turning the light to the left, as albumen or oxybutyric acid, the determination by polorization is of little value ; therefore it is best to ferment the urine and then polar- ize it a second time. Dark or cloudy urine should be made clear by the addition of -^^ its volume of sugar-of-lead solution in a measure glass, and the dilution should of course be taken into account. Sugar 0/ milk (lactose), Ci^H^^O^, is present in the urine of nursing lying-in women. It has a right rotatory- power (/-^)d = 52.5, and passes over with difficulty into alcoholic fermentation and rarely into lactic acid fer- mentation. It has the property of reduction. Inosite^ CgHj^Og, is present in polyuria. It is neither fermentable, nor does it possess the power of polariza- tion nor of reduction. For its formation see the text- books. Acetone^ CH3COCH3, is present in urine in febrile diseases, in diabetes, in certain forms of carcinoma, and in inanition and auto-intoxication. To test for the acetones a few drops of freshly-prepared nitro- ferrocyanide of sodium are added to the urine, and then a strong caustic soda solution, until it is decidedly alkaline. When the beginning purple tint turns yellow, I to 3 drops of concentrated acetic acid are added, and if the acetones be present a crimson- purple color is formed at the point of contact of the acetic acid and the mixture (Legal's test). It is better to distill the urine with some muriatic acid, and to test the distillate for acetone with Lieben's test. According to the latter a few drops of a solution of iodine in iodide of potash and caustic potash are added to a few S6 CLINICAL DIAGNOSIS. ccm. of the distillate. If the acetone be present, a yellow-white precipitate of iodoform appears at once. Diacetic add, CHgCOCH^COOH, is present in the urine in many grave cases of the contagious diseases, in grave cases of diabetes, carcinoma, and in auto-intoxication. If to some urine one or two drops of a solution of the chloride of iron be added, a gray or chocolate-colored precipitate of the phos- phate of iron appears. If more iron chloride be added, the presence of diacetic acid gives the urine a da7'k Bordeaux-red color (the iron chloride reaction of Gerhardt), which disappears at once on adding sulphuric acid. If the urine be heated first, then the reaction is very slight or not at all. If the urine already made acid with sul- phuric acid be extracted with ether, the ether takes up the diacetic acid, and may be tested for with iron chloride. Still even this re- action disappears in 24-48 hours. A brown-red color of the urine with iron chloride does not determine the presence of diacetic acid. If the urine be distilled the diacetic acid splits up into acetone and carbonic acid, and the acetone may then be determined by Lieben's test. Diazoreaction (Ehrlich). Sulphodiazobenzole unites with different kinds of unknown aromatic substances of the urine to form colored compounds. To prepare this reagent two solutions are necessary : a) Sulphanile acid 5.0 [75 drops]. Muriatic acid . 50.0 [i I- ounces]. Distilled water looo.o [30 ounces]. And V) Nitrite of sodium Oo [8 grains]. Water 100.0 [3 ounces]. When ready for use 5 ccm. [75 drops] of solution b) are to be added to 250 ccm. [8 ounces] of solution a), and this " reagent " should be prepared fresh for every test. Then to equal parts of this reagent and urine \ volume of ammonia is added, and shaken up. In cer- tam (febrile) diseases the fluid turns red (scarlet, orange, orange- THE UklNE-PliODUCWG SYSTEM. 87 red), which is especially noticeable in the foam (red reaction). This color is noticeable in typhoid fever (from the first week on), some- times in relapses, also in grave cases of phthisis pulmonum, pneu- monia, measles. The disappearance of this reaction is considered a good sign. Melanine. — In the urine of those suffering from melanotic carci- noma, melanogen is sometimes present, which forms black clouds of melanine on adding concentrated nitric acid or chromic acid to the urine. At times the urine is dark from the presence of formed mel- anine in the urine. Stilphtc?'etted hydrogen, HgS, is present principally in decomposed urine, as in cystitis. Since it is found in normal urine after long standing, only fresh urine should be taken. A few drops of muriatic acid are added to the urine in a bottle, and the opening is covered with filter-paper which has been moistened with a sugar-of-lead solution. If HgS be present the moistened paper turns dark from the formation of the sulphide of lead. Leucine ox Amidocaproic acid, and Tyrosine ox Amido-Hydroparacu- vtaric acid are present in the urine principally in acute yellow atrophy of the liver and in phosphorus poisoning. Leucine appears in yellow globules, which have a fatty gloss and are often marked with radiating lines. Ty- rosine is in the form of fine bundles of needles or globules. The urine is evaporated to syrupy consistency and left in the cold to crystallize, and then examined microscopically. Cystine is occasionally present in the sediment in the form of color- less shining hexagonal plates. Fat is occasionally present as a fine cloudiness and gives the urine a milky appearance (chyluria). This milkiness disappears on adding caustic potash and shaking up with ether. Test for Drugs. Iodine and Bromine. — Freshly made chlorine water or strong fuming nitric acid is added to the urine and then shaken with a iQ.w Fig. 30. Fig. 31. Leucine. Tyrosine. SS CLINICAL DIAGXOSIS. ccm. of chloroform, which is then colored carmine red if iodine is present, and brownish yellow if bromine is present. Nitric acid. — A brucine solution is added to the urine and the sul- phuric acid is allowed to trickle down the side of the glass and at the point of contact a red ring is formed. The same reaction may be caused by other bodies (as hydrobüirubin). Lithium. — The flame reaction or a spectroscopic examination of the ash is sufficient. Arsenic. — After remo-\-ing the organic substances -näth muriatic acid and chlorate of potash, the fluid is examined according to Marsh's test. Lead. — Fresh muriatic acid and chlorate of potash are added to destroy the organized substances, the chlorine is driven off, then the mixture is filtered off and sulphuretted hydrogen conducted through it, and if lead be present a brown color, due to the sulphide of lead, is formed. Mercury. — To the urine of one day, lo ccm. [2 drachms] of muriatic acid and a small quantity of brass or copper shavings are added, and the whole is heated. After 24 hours the urine is poured off and the metal washed several times in water made slightly alka- line with caustic potash, then washed with alcohol, then with ether, and then let dry. The metal is then brought into a long large dccy test-tube and heated red-hot. If the mercury- be present it has already amalgamated itself with the copper or brass and the heat volatilized it and caused it to be condensed on the cool parts of the tube. Now, if fumes of iodine be introduced into the tube the mer- cury is changed to the iodide of mercury which appears as a red tinge, and by careful heating may be condensed to a sharply de- fined ring. Quiniiu. — 500 cm. [15 ounces] are made alkaline with caustic potash and shaken five minutes Avith ether. The ether is then brought to the surface and evaporated off, and the remainder taken up with water and a few drops of muriatic acid. This fluid shows a blue fluorescence on adding a drop of sulphuric acid, or, if treated with strong chlorine water and concentrated ammonia, it shows a green ring. Carbolic acid (Phenol CgHjOHj — When much carbolic acid has been ingested the urine becomes greenish brown and turns dark when exposed to the air, just as t!ie urine does after taking hydro- THE URINE-PRODUCING SYSTEM. 89 quinone (C6H4(OH)2), folia uvse ursi, and tar. For the beha\äor of sulphuric acid in carbolic acid intoxication, a,nd the detection of carbolic acid, see pages 73 and 75. Salicylic acid (Oxybenzoic acid). — The urine turns violet on adding chloride of iron. Antipyrin. — The urine turns red on adding chloride of iron. Thallin. — The urine is greenish-brown and turns purple on adding iro" chloride. On shaking up the urine with ether, the unchanged thallin is also taken up by it and this turns green on adding the chlo- ride of iron. Kairin. — The urine is greenish brown, turns dark on standing, and turns brownish-red on the addition of the chloride of iron. TuTpentine . — The urine smells of violets and a precipitate is sometimes formed on adding nitric acid. Tannin. — The urine turns bluish-black on the addition of chloride of iron. Santonin. — The urine is straw -yellow and turns scarlet on the ad- dition of alkalies. Rhubarb and Senna (Chrysophanic acid). — The urine turns also red on the addition of an alkali, but the color remains permanent, while in the case of santonin it soon disappears. On the addition of baryta water the precipitate with rhubarb and senna is red, and with santonin the filtrate. Ether takes up the color of senna and rhubarb, but not of santonin. Organic Sediments. Leucocytes are present normally in a small number in the urine, and in a large amount in inflammation and suppuration in any part of the genito-urinary apparatus (nephritis, pyelitis, cystitis, gonorrhoea, fluor albus). In alkaline urine the pus is of a mucous nature. Red blood corpuscles in the urine are generally free from color, and in renal hemorrhage are often in the casts. The refial epithelium is small, round, or cuboid with a vesicular nucleus, and often very full of fat drops. They are often arranged in cylindrical form or lie on the tube casts adherent to them (epithelial casts). The appear- go CLINICAL DIAGNOSIS. ance of renal epithelium in the urine always points to a Fig. 32. morbid process in the kidney. When there ^ Ä^ ^^^ numerous fatty degenerated epithelial ^ ^'' ^^^'^ '^^ ^^ urine, it is a sign of chronic par- ^ v'» ' enchymatous nephritis. Sly u^rSerloin" Thc epithelial cells of the bladder, ureters, ^ ^tiol?"^"^^ a7id refial pelvis do not differ from each other in appearance. The cells of the superficial layers have a polygonal form, those of the deeper layer are somewhat round, often with processes (pear-shaped), and contain a vesicular nucleus. If there are many of such cells with leucocytes in the urine, it is Deep evidence of an inflammatory condition of the bladder, ure- . 1 1 • rr-n Epithelium of the bladder, terS, or renal pelvis. Ihe urethra, and renal peU-is. microscopical examination is of no assistance here, but we can generally take it for granted that the urine in pyelitis is generally acid, and in cystitis generally al- kaline. The vagina a.nd prepz^ee possess very long, flat epithelial cells like those of the mucous membrane of the mouth. The male urethra has cylindrical epithelium. These epithelial cells are often found in the suppuration of acute gonorrhoea. The gonorrhoeal pus is also charac- terized by the presence of gonococci (see Chapter XI.). Casts are effusions into the urinary tubules. They are present in all cases of albuminuria, not only in nephritis but also in all irritative conditions of the kidneys (icterus, the acute contagious diseases, heart diseases, etc). AVe distinguish (i) Hyaline casts, which consist of a homo- geneous translucent substance, and possess a very deli- THE URINE-PRODUCING SYSTEM. 9 1 cate contour, which is often scarcely visible. (2) Granu- lar casts, having a fine-grained substance, but otherwise resembling the hyaline casts. (3) Waxy casts, of a yel- low color and greater lustre, with sharply-defined contour, and are often irregularly curved and bent. They are found principally in chronic nephritis, and point to a grave disturbance. (4) Brown casts are present in frac- tures, and also in the grave cases of contagious diseases. (5) Cylindrical casts are long, irregularly broad, with long stripes on them. These are perhaps only mucous threads, and are of no diagnostic importance. Very often other substances are attached to the casts, especially to the hyaline casts, as urates, fat drops, red blood corpuscles, leucocytes, and renal epithelium. Further, there are found occasionally in the urine spermatozoa and cells of neoplasms (cancer, papilloma). Micro-organisms are present in fresh urine in several of the contagious diseases (dii^htheria, recurrent fever), in cystitis, and pyelonephritis (in a cylindrical form), also tubercle bacilli in tuberculosis of the genito-urinary tract and gonococci in gonorrhoea. Animal Parasites : (i) Echinococcus cysts and booklets. (2) Embryos of f^laria sanguinis : small snake-like worms which are exceedingly movable, and are as broad as the diameter of a red blood corpuscle, and 0.35 mm. [_|_ inch] long. (3) Distomum haematobium whose eggs have on one end or on the side a spinous process. The two last parasites may cause haematuria and chyluria {i\ Chapter XL). For the analysis of the urinary concrements see Chapter XIII. CHAPTER X. TRANSUDATIONS AND EXUDATIONS. The different serous transudations have a very different specific gravity according to their origin. They are in the order of their specific gravity ; hydrocele, hydro- thorax, ascites, anasarca, and hydrocephalus. The serous (inflammatory) exudations have a greater specific gravity than the simple transudations of conges- tion, and indeed it may generally be taken for granted that a fluid, be its origin what it may, is the product of an inflammation when its specific gravity exceeds 1018 (pleurisy, peritonitis), and that it is simply a transudation due to congestion when its specific gravity in hydrothorax is less than 1015, " ascites " " '-'■ 1012, " anasarca " " '" loio, " hydrocephalus" " " 1008.5. Now since the amount of ash, extractive matter, etc., contained in exudations and transudations varies very slightly and the amount of albumen varies very greatly, we conclude that the specific gravity is principally de- pendent upon the amount of albumen contained in these fluids. Therefore from the specific gravity the amount of albumen may be approximately determined according to the formula of Reuss, E — I (S - 1000) ~ 2,8, 93 TRANSUDATIONS AND EXUDATIONS. 93 in which E denotes the amount per cent, of albumen sought and S the specific gravity. Accordingly in a spe- cific gravity of 1018, 3.95 (fo of albumen would be calcu- lated. These rules hold good for serous exudations, but not for purulent, chylous, and very hemorrhagic exuda- tions, nor for those in diabetes, cholaemia, and uraemia. In order to determine the specific gravity, the fluid should be protected from evaporation and cooled off to the surrounding temperature, since fluid at body temper- ature has too low a specific gravity ; for every 3° Celsius [5.4° Fahrenheit] increase corresponds to about one de- gree of the araeometer less. The amount of albumen is determined by diluting a known quantity of the exudation (10 ccm. \2\ drachms] y with ten times its volume of water, heating it to the boiling point and adding dilute acetic acid drop by drop until the fluid is slightly acid. The precipitate of albu- men is then to be collected upon a filter paper which has previously been dried at a temperature of 100° C. [212° F.] and weighed, washed with water, then with alcohol and ether, the total weight to be deducted from the weight of the filter paper. The filtrate should be clear and free from albumen, which may be proved by adding a few drops of ferrocyanide of potash to the liquid. Exudations and transudations have an alkaline reac- tion, and deposit, en standing, a more or less abundant amount of fibrin. A microscopical examination reveals in the coagulum leucocytes and swollen endothelial cells, which often contain vacuoles. The contents of the echinococciis cysts are generally clear, neutral, or alkaline, and the fluid has a specific gravity ^ To determine the amount of albumen in urine 50 or 100 ccm. [i^— 3 ounces] of urine should be taken. 94 CLINICAL DIAGNOSIS. of 1008-1013, contains little or no albumen, but chloride of sodium in large quantities, as well as grape sugar and succinic acid. The latter is detected by evaporating the fluid, acidifying it with hydrochloric acid and shaking it up with ether, and after the evaporation of the ether the succinic acid remains as a crystalline mass, whose water solution with the chloride of iron forms a gelatinous, rust-colored precipitate of succinate of iron. When heated in a test-tube the irritating fumes of the succinic acid are given off, causing cough. On microscopic examination the scolices and ring of hooklets are sometimes found. In the older lifeless cysts are found crystals of Cholesterine and hsematoidine. The water of hydronephrosis is generally clear, of a specific gravity of 1010-1020, contains mucus, sometimes blood and pus, and a varying amount of albumen and of urinary constituents. But since these are also found in the fluid of the echinococcus the diagnosis of hydro- nephrosis should be made only when there is a larger amount of urea and uric acid present. Urea is detected according to the method on page 70 ; uric acid, by adding muriatic acid and examining microscopically the crystals formed, or by the murexide test. The pear-shaped epithelial cells of the renal pelvis and tube casts are also occasionally present. The contents of an ovarian cyst are generally mucous, tenacious, yellow ; but may be watery, semi-fluid, and brown. The specific gravity is between 1003 and 1055 and generally between loio and 1024. The fluid usually contains albumen and metalbumen (pseudo-albumen), which causes the mucous consistency. This is not pre- cipitated by acetic acid (differing in this respect from mucin), nor by heat, nor by nitric acid ; but falls into TRANSUDATIONS AND EXUDATIONS. 95 fibrous flakes on adding alcohol. By heating it with the mineral acids, a reducing substance is formed. To detect the metalbumen the fluid is freed from albumen by heat and acetic acid. When metalbumen is present the filtrate is opalescent and mucous. It is pre- cipitated into white flakes on adding alcohol in excess. The flakes are then pressed out and heated .with dilute muriatic acid (5 (f) until they turn brown ; after cooling off they are made alkaline with caustic soda, and a few drops of a cupric sulphate solution are added and the whole heated. If metalbumen be present there is a pre- cipitate of yellow cuprous oxide. A microscopic examination occasionally shows the presence of cylindrical and ciliated epithelium, and sometimes colloid particles. CHAPTER XI. PARASITES. Animal Parasites. Cestodes. — The tape-worms represent colonies of indi- viduals which consist of a head with hooklets and of a larger or smaller number of single individuals called proglottides or segments. The eggs which come from the matured proglottides (hermaphrodite), if they come into the stomach of the right animal, develop in its or- gans into a Cysticercus. If this Cysticercus be taken into the intestinal canal, it becomes a tapeworm. Fig. 34.1 Fig. 35. Fig. 36. Fig. 37. Fig. 38. Segment of Segment of Segments of Taenia solium. Taenia saginata. Bothriocephalus latus. Egg of Tcenia solium. Egg of Bothriocephalus latus. Tcenia Solium is 1-3 metres [yards] long. The head is as large as a pin's head, has four suckers, a rostellum or proboscis upon which there is a double row of hooks. ^ Figs. 34, 35 and 36 are from Stein's Entwickelungsgeschichte und Parasitismus der menschlichen Cestoden. 96 PARASITES. 97 The matured proglottides have the sexual openings on the side and a uterus with 7 to lo thick lateral branches, which subdivide (fig. 34). The eggs are round or oval, with a striped shell and an embryo having six hooks (fig, 37). The Cysticercus celliilosce is about as large as a pea, and is found in swine and in man (when the eggs are taken into the stomach) under the skin, in the muscles, in the brain, eye, etc. Tcenia saginata or mediocanellata is thicker and larger than the former. It has a head with four suckers, but no rostellum and no hooks. The proglottides have lateral sexual organs and a uterus which subdivides into 17 to 30 finer branches (fig. 35). The eggs are like those of the taenia solium, only somewhat larger. The Cysti- cercus is smaller, and is found in the flesh of cattle (also in deer and sheep). The BotJu'iocephalus latus is 5-9 metres [yards] long, and has a lancet-shaped head with two lateral grooves. The matured segments are broader than they are long. The uterus has a brownish tinge, and is arranged in the form of a rosette around the flat sexual openings (fig. t,6). The eggs are oval and have a cover. The cysticerci are found in fish (salmon). Taenia nana, taenia flavopunctata and taenia cucumerina (elliptica) occur sporadically in man. TcBnta echijiococcus is found in the dog. It is 2\ to 4 mm. [^j-g- of an inch] long, has -a head with booklets and suckers, and three segments, of which the last one only is matured. The cystic form of the echinococcus is found in man (in the liver, spleen, kidneys, lungs, etc.). It is observed in two forms, as a large echinococcus sac filled with daughter cysts, and as an echinococcus multi- 98 CLINICAL DIAGNOSIS. locularis, which consists of a very large number of minute cavities filled with a gelatinous substance and with concentrically arranged walls. In the echinococcus cysts, heads (scolices) with hooks are sometimes found. (For the echinococcus fluid see page 93.) Nematodes or Round Worms are bisexual. The Ascaris Itimbricoides or round worm has its habitat in the small intestine. It resembles the rain worm. The male is somewhat smaller (150-250 mm. [4-6 inches]) than the female (150-250 mm. [4-6 inches] ), and its head is rolled up. The eggs, which are evacuated in large numbers with the stools, have a thick, concentric- Fig. 40. Fig. 42. Egg' of Ascaris lumbricoides. EggofOxyuris Egg of Trichocephalus Egg of Ankylostomum vermicularis. dispar. duodenale. ally striped shell, upon which lies a projecting albuminous cover (fig. 39). The Oxyuris vermicularis or small thread-worm is found in both large and small intestines. It often passes from the intestine to the anus, causing violent itching in that region. The male is 3-5 mm. [-J-J inch] and the female 10 mm. [J- inch] long, the former having blunt ends, and the latter being pointed. The eggs, which are especially numerous around the anus of man, are oval and possess a thin shell (fig. 40). The Trichocephalus dispar or whip-worm lives in the large intestine ; it is 4-5 cm. \}\-2 inches] long, has a thread-like head extremity, and a thicker spirally rolled body in the male, and a straight slightly curved body in PARASITES. 99 the female. The eggs are yellow in color and shaped like a lemon (fig. 41). The Angiiillula intestinalis (Rhabdonema strongyloides, Leuckart) is 2.2 mm. [i inch] long and lives in the upper part of the small intestine. The eggs, which resemble those of the ankylostomura duodenale, grow in the intes- tine to larvae 0.2 mm. [-gL- inch] long which are found in the fasces as small worms with lively movements. Out- side of the body the latter are developed to an interme- diate form, the anguillula stercoralis. This belongs to the developmental cyclus of the anguillula intestinalis. The Ankylostomum duodenale lives in the small intestine, and causes anaemia by boring into the intestinal wall {e. g., in the anaemia of the St. Gotthard tunnel work- men, brickmakers, and miners). The male is 10 mm. [^ inch] long and the female 12—18 mm. [|— i inch] long. The eggs, which are passed in large numbers with the stools, have clear, simply formed shells and an embryo which is generally undergoing fission (fig. 42). The eggs are developed a few days only, after the passage of the larvae from the intestines. The Trichina spij^alis enters the intestine through trich- inosed pork. The male is 1.5 mm. \^^ inch] long and the female 3 mm. [i- inch] long. The matured worms live in the small intestine and bring forth, after 5-7 days, young trichinae, which then bore through the intestinal walls, get into the circulation, and fix themselves in the course of the next few days in the muscular fibres, where they may become encapsuled. Their presence at first causes fever. The Filaria sanguinis is found in the tropical regions. It causes hsematuria, chyluria, and disturbances of the lymph circulation. The matured form lives in the lymphatic organs of man, and here lOO CLINICAL DIAGNOSIS. gives rise to a large number of living embryos, which are found in the urinary sediment and blood, and indeed in the latter in such large quantities that ever}^ drop of blood contains several embryos. These appear as little worms which move freely, and are surrounded by a delicate envelop. They are 0.35 mm. [yi^ inch] long and as broad as the diameter of a red blood corpuscle. The Filaria medinensis may reach 80 cm. \^o\ inches] in length and |-i^ mm. [äV^eV inch] in breadth. It occurs in the tropics, and leads to the formation of abscesses of the skin. Trematodes or Flat Worms. The Disto7num hepaticiwi is 28-32 mm. [i inch] long, of a leaf-like form, with conical-shaped forepart of the body. The eggs are very large 0.13 mm. [-gig- inch] long (see fig. 43), and with a cover. Fig. 43, Fig. 44. The Dist07num la7iceolatui?i is small- er than the former. It may reach 9 mm. ["I inch] in length. The eggs are, likewise, considerably smaller. Both are found in the gall bladder Egg of Egg of and gall ducts. The eggs are some- Distomum Distomum hepaticum. haematobium. tlmCS fOUnd in the f^CCS. The DistomujJi JicEmatobium occurs in the tropics. It lives in the abdominal veins, and causes diarrhoea, haematuria, and chyluria. The male is 12-14 nim. [|- inch] and carries in a groove in it the female, which is 16-19 nim. [-f-f inch] long. The eggs are 0.12 mm. \^-^ inch] long, are found in the urinary sediment, and have a point either at one pole or on the side (fig. 44). Arthropodes. Acarus (sarcoptes) scabiei^ or itch-insect is an oval lenticular body with eight short legs. The female is found at the end of the furrow, which is filled with the PARASITES. lOr eggs and excreta of the insect. In 8 to 14 days the young ones are hatched, and in turn bore into the skin. Acarus (demodex) folliculoriwi is longer than it is broad, and is found in comedones, especially in the face. Fediculus capitis^ or head louse ; Pediculus vestimenti, or body louse ; Pediculus pubis, or crab louse. Pulex irritans, or flea. Protozoa. In. the stools the following protozoa are sometimes found in chronic diarrhoea : Amceba coll, a round granular structure with a nucleus and a few vacuoles. Cercovionas intestinalis, pear-shaped animalculae (8-10 fx [g^y— 2^5 inch] long), with ciliated extremities. Trichomonas intesti- nalis (10—15 1^ [ä'^5~Tö irich] long), almond-shaped with ciliated ex- tremities. Balantidium or Paramceciuni coli, pear-shaped, 70-100 ß [i~3 inch] long, ciliated, with an inverted mouth. Besides these protozoa, there are found in the vaginal secretion, trichomonas vagi- nalis, and in other secretions other protozoa. Vegetable Parasites. Hyphomycetes. Achorion Schoeiileinii^ ox fames fungus, is in the shape of worm-like filaments, which are provided with septa and lateral elevations, and in their ends are round or oval, brightly shining spores (conidia). The Trychophyton tonsurans is the fungus of herpes tonsurans and circinatus, as well as of acne mentagra (sycosis parasitaria). The mycelium consists of curved and branching filaments provided with septa. The fila- ments have partly at their ends shining spores (conidia) with double contour. In the epidermis the fungus fila- ments are found, while in the hair and hair-sheath the spores (conidia) are found. The Microsporon furfur, or fungus of pityriasis ver^ I02 CLINICAL DIAGNOSIS. sicolor, is found in the yellowish epidermis scales in large numbers as a dense network of curved, more or less branched filaments, with heaps of shining spores (conidia) within. The Microsporo7i minutissii?ium is a very fine non- branching filamentous fungus without the formation of spores, and is found in erythrasma, but whether in causal relation or not is doubtful. The oidiiim albicans^ or thrush fungus, is found in the mouth cavity as well as in the oesophagus and the stomach. It consists of branching filaments, with shining, round or oval spores (conidia) at the points of bifurcation. The Aspergillus glaiictis and niger are often found in the sputum of consumptives or imbeciles, and may cause a peculiar kind of pneumonia called pneumonomycosis as- pergillina They are filaments more or less branched, with double contour and with many brown pigmented spores. In order to make the filamentous fungus visible, the preparation (from a scraped tongue, epidermis scales, hair, etc.) is allowed to stand for a few minutes in a lo ;^ caustic potash solution, which makes the albuminous substances and epidermis more translucent, and the fungus thereby all the more distinct. Yeast fungi are frequently found in fermenting condi- tions of the stomach. Schizouiycetes or Bacteria. Morphologically we distinguish {a) The Coccus (spherical or oval), and according as the cocci are single, in twos, in chains, or in a racemose conglomeration, they are called monococcus, diplococcus, streptococcus, and staphylococcus. (})) Bacillus or rod. {c) Vibrio, or cwved rod, fragments and developing form of spirilla as comma bacilli. PARASITES. 103 (^) JLepfoihrix foT^ms. filiform. {e) Spirillum. Spiral form. To the Cocci belong also the micro-organisms of erysipelas (round streptococci) and of puerperal fever, of gonorrhoea (bean-shaped dip- lococci which are found in clumps, partly in the leucocytes of the gonorrhoeal pus), of croupous- pneumonia and the pus-producing cocci, staphylococcus pyogenes aureus, the coccus of acute osteo- myelitis, and staphylococcus pyogenes albus, etc. To the Bacilli belong the micro-organisms of tuberculosis, of lepra (syphilis), of anthrax, malleus (glanders), typhoid fever, diphtheria, malignant oedema. As comma bacilli, are to be mentioned the cholera bacillus and the bacillus of Finkler-Prior. To the Spirilla belong the Spirochaeta Obermeieri, in recurrent fever, and the Spirochaeta buccalis and others. 'M .®, ^ Figs. 45-54- ^^ Fig. 4S- Fig. 46. Fig. 47. Bacillus mallei. Bacterium pneumoniae Bacillus crouposse tj^ihosus (Friedlaender). (Eberth). / ^ ^ i Fig. 50. Bacillus anthracis. Fig. 51. 'A Fig. 52. 9 Fig- 53- Fig. 49. Bacillus tuberculosis (Koch). i^ Spirillum or spirochaeta Bacillus (s. spiril- Gonococcus Obermeieri lum) cholerse Neisseri. (recurrent fever). asiaticse (Koch). Fig. 54- Streptococcus erysipelatis. Clinically, the coloring of the micro-organisms in a dried preparation is almost exclusively used. ^ * The preparation and the staining of the sections, as well as the methods of bacteria culture, are subjects too extensive to be taken up here. They may be better studied in the " Proceedings of the Royal Board of Health" (Berlin); Cornil et Babes: " Les Bac- teries " ; Friedlaender : " Microscopical Technique " ; Hueppe : " The Methods of Bacterial Investigation." I04 CLINICAL DIAGNOSIS. A small drop or particle of the substance (blood, pus, sputum, tissue juice, etc.) to be examined is spread with a platinum needle upon a clean cover-glass, or two glasses are rubbed together so that a thin film of the matter is deposited on each. The cover-glasses are then to be protected from the dust and left until dry. Then the glass, with the preparation side turned upward, is passed three times moderately quickly through the spirit flame. Dry preparations of blood should be heated a few hours at a temperature above ioo° C. (212° F.), in order to fix the haemoglobin, and the best way to accomplish this, according to Ehrlich, is to put the glass on a metal plate, to one corner of which the heat is applied. The dried preparation may then be colored. In clinical examinations aniline colors are principally used, and among them the following : {a) The acid aniline colors : Eosine, picric acid (prin- cipally in blood examination). {h) The basic aniline colors : Fuchsin (muriate of rosaniline), methyl blue, methyl violet, and gentian violet, vesuvin (Bismarck brown), and malachite green. ^ Of these colors it is well to have on hand either a concen- trated, watery filtered solution, or, what is better in the case of fuchsin, a concentrated alcoholic solution. The coloring of the dried preparations is carried out either by dropping with a glass rod some of the concen- trated watery solution on the preparation, or, if the object is to let the color work in for a longer time, by letting the cover-glass float, with the preparation down- ward, on the surface of the staining fluid in a watch-glass. In using methyl violet, gentian violet, or malachite green ^ These colors may be obtained from W, König, Berlin^ N, W, Porotheenstrasse, 35, PARASITES. 105 in a concentrated watery solution i-i minute is long enough to color ; in the case of fuchsin and methyl blue it is well to use more diluted solutions for several minutes until the proper tinge is obtained. This latter has the advantage over the other stains in not over-coloring, but in staining the nuclei and bacteria distinctly and causing no precipitate (Ehrlich). Vesuvin (Bismarck brown) should be used in a concentrated watery solution for several minutes. When the preparation is sufficiently colored it should be washed off carefully with water. Then the cover-glass is pressed between folds of filter paper and finally dried by holding it over the flame, and then examined in Canada balsam (dissolved in turpentine) or in cedar oil. The fundamental principle in examining stained bac- teria preparation is to remove the diaphragm from the microscope stage, and, if possible, then use the Abbe illuminating apparatus [condenser] without the dia- phragm, making the contour of the preparation more indistinct, and thus causing the colored objects to be more prominent. But in all other microscopical exami- nations in which the endeavor is to have the clearest possible outline in an uncolored preparation — e. g., in looking for hyaline casts, the narrowest diaphragm ad- missible should be used. Almost all micro-organisms except the tubercle bacil- lus may be colored in dry preparation according to the above methods. T/ie staining of tubercle bacilli as done according to JEhr- lich. Aniline water is prepared by shaking up one or more ccm. of aniline oil with 20 ccm. [5 drachms] of dis- stilled w^ater, and allowing it to stand a short time, and then filtering. To the clear filtrate, which may be heated Io6 CLINICAL DIAGNOSIS. to boiling in a test-tube to hasten the coloring, 5-10 drops of a concentrated alcoholic solution of diamond fuchsin are added in a watch-glass until the fluid begins to opalesce. Instead of this solution, which should be prepared fresh every time, the following of Weigert-Koch may be used, which can be kept 10-12 days. Saturated aniline water 100 ccm. [3 ounces], a con- centrated alcoholic solution of fuchsin or methyl violet 1 1 com. [2f drachms], absolute alcohol 10 ccm. [2^^ drachms]. The preparations, smeared on a cover-glass, are al- lowed to float on the solution 3-12 hours (if the solution be heated, 5—20 minutes are long enough), then taken out with the forceps, dipped for a few seconds into diluted nitric or hydrochloric acid (1:3 water), then at once thoroughly washed with Avater. If the preparations have a red color the procedure should be repeated until this color disappears. All bacteria are decolorized by the acid except the tubercle bacillus (and lepra bacillus). This preparation should then be colored by a drop of concentrated watery solution of malachite green or methyl blue, again washed thoroughly with water, dried, and examined in cedar oil or Canada balsam. The tu- bercle bacilli will then be found to be colored red, while every thing else present is green or blue. The tubercle bacilli may be recognized with a power of 350 diameters. The isolated method of staining micro-organisms accord- ing to Gra?n. The preparations are first colored for 1-3 minutes in a solution of aniline water which has been saturated with gentian violet, and then put into a solu- tion of iodine in iodide of potash,^ and then in absolute ^ Iodine i.o [15 grains] lodme 1.0 [15 grams]. Iodide of potash 2.0 [30 grains]. Distilled water 300.0 [gi ounces]. PARASITES. 107 alcohol until the preparations are decolorized. The prep- aration is then to be stained with vesuvin and examined in water, or dried and examined in cedar oil or Canada balsam. The micro-organisms are colored bluish black. In order to stain the pneumonococci of Friedländer, and their capsules, there may be made, either a solution of gentian violet in aniline water, or the solution which Ehrlich uses to stain the plasma cells. ^ The preparation should remain twenty-four hours in the solution, and then put in i^ acetic acid for a few minutes, then in alcohol, turpentine, and Canada balsam. The Lepra bacilli are colored just as well in gentian violet or methyl violet as, according to the procedure of coloring, the bacilli of tuberculosis. The micro-organisms of typhus, recu7'rent fever, glanders, anthrax, pymmia, erysipelas, etc., may be shown with any of the basic aniline colors. To color the gonococci, a drop of gonorrhoeal pus is pressed between two cover-*glasses, spread out to a thin film upon a slide, and to it are added a few drops of a concentrated watery solution of methyl blue, which is washed off in a half minute, and then dried and ex- amined in Canada balsam or cedar oil. The actinomycosis or radiating fungus, whose place among the micro-organisms is doubtful, is found in pus in the form of yellow-white granules of the size of a millet seed, which consist microscopically of a large number of fine radially arranged filaments, which end in thick, shining knobs. The masses of actinomycosis are often calcified, and should first be decalcified with diluted hydrochloric acid. Staining is superfluous. ^ Concentrated alcoholic solution of gentian violet, 50.0 [i^ ounces]. Glacial acetic acid, lo.o [2|- drachms]. Distilled water, 100. o [3 ounces]. CHAPTER XII. THE NERVOUS SYSTEM. Testing the Sensibility. We distinguish A?ic6sthesia, a loss or diminution of sensation. Hypercesthesia^ an exaltation of the same, weak stimuli causing unpleasant sensations. ParcBsthe- sice, or abnormal sensations which are not due to ex- ternal causes, as itching, crawling, formication, furry- feeling, abnormal sensation of heat and cold. NeuralgicB are attacks of pain which are confined to a certain nerve region, and they generally follow the course of the nerve. They are generally increased by pressure on the nerve on that part which is subcutaneous, and when it is pressed against a bone (pressure point). In genuine neuralgia the pain is in paroxysms. The sensibility may be equally diminished for all kinds of sensation or for some kinds only (total and partial anaesthesia). These kinds of sensations are : Touch seiise^ which may be tested by delicately touch- ing the part affected with the finger-tip or any other ob- ject. The patient, whose eyes are covered, should be very attentive to note the slightest touch. The test may be made between smooth and rough (woollen) objects. The temperature sense must then be excluded. The se7ise of locality. — The patient should be touched, 108 THE NERVOUS SYSTEM. 109 I mm. \-^-^ inch]. and then asked to show what part was touched. Healthy- individuals rarely miss, or err by 1—2 cm. [|— |- inch] only. Or, by using a pair of compasses, the smallest distance may be found in which the two points applied at the same time and in the same way can be recognized as two points. The distance in health for the following localities is as follows : Tip of the tongue Tip of the finger .... Red surface of the lips Dorsal surface of the first and sec- ond phalanx and inner sur- face of the fingers Tip of the nose . Dorsal and palmar surfaces Chin ..... End of big toe, cheek, and eyelids Bridge of the nose Heel Back of the hand Neck Forearm, leg, dorsum of the foot . 40 mm. [i inch]. Back .... 60-80 mm. [i|-2 inches]. Upper arm and thigh . . 80 mm. [2 Sense of pressure (muscular sense). — The extremity to be tested should be firmly supported and weights laid upon it, a small piece of board being put between the weight and the extremity to eliminate the sense of temperature. Under normal conditions a difference of ■^-^ of the original weight can be recognized, as well as a minimum pressure of 0.002 to i.o gram \^^ to 15 grains]. Greater disturbances of the muscular sense can be recog- nized by pressure with the finger. 12 13 22 30 35 [20 [tV v\ [} [i ft ft [f [1 ]■ no . CLINICAL DIAGNOSIS. Sense of temperature. — Test tubes, or metal vessels filled with water of different temperature, are applied to the skin. Between 25-35° C. [77-95° F.] a difference of 1° in the temperature is recognized by a healthy per- son. The test may be made by letting the patient en- deavor to' distinguish between warm breath near the skin and cold breath from a distance. Many patients will say that the irritation from the cold (ice) is hot, and vice versa (perverted temperature-sense). Electro-cutaneous sensibility. — By applying a metal brush to the skin, it may be ascertained with what strength of current (distance of the coils) the faradic stream has been felt. Sensibility to pain is tested by sticking with a needle, pinching, pulling the hair, and using strong electric cur- rent. If strong and painful irritation, as deep puncture with a needle, be felt as if the needle only touched the skin, without pain, then it is called analgesia. Analgesia occurs with unimpaired tactile sense in hysteria and tabes. Also the reverse may be noticed, /. e., simple contact may cause pain. There is often a delay experi- enced in the transmission of the sensation of pain, or an abnormal after-sensation, and, at times, the tactile and pain-producing sensations are separated and are per- ceived one after the other (a double sensation). The sejisitiveness of the deep parts — the muscles, fascia, tendons, ligaments, joints, periosteum, and bones — is classed as follows : I. The ability to judge of the weight of a body when raised up, i. e., the sense of force ; this is tested by lifting up a cloth to which weights are gradually added, and es- timating the weight. The sense of force is finer than the sense of pressure. THE NERVOUS SYSTEM. Ill 2. The ability to judge, with closed eyes, of the position of one's extremities and their passive movements ; or it may be tested by letting the patient close his eyes and attempt to touch one extremity with the other ; or, further, the power to hold the body in an upright position when the eyes are closed. If the patient stand firm with open eyes, and totter or fall when the eyes are closed (symptom of Romberg), then the sensibility of the limb is diminished. Testing the Motility. When the power of voluntary motion in a muscle is completely lost, we speak of paralysis^ and when this is only weakened, of pat-esis. According to the extent of the paralysis, we speak of a monoplegia or paralysis of single muscles or group of muscles, or of an extremity by itself ; hemiplegia, paralysis of one side ; paraplegia, paralysis of corresponding parts of both sides of the body, /. e., of both limbs, or of both arms, or of all four extremities. It should be noticed whether the state of muscular tension deviates from the normal or not. In diminished tension the paralyzed muscles are relaxed, and make no opposition to passive movements. This relaxed paralysis occurs principally in peripheral lesions in diseased con- ditions of the anterior gray horns or gray nuclei, as in infantile paralysis. In iiicreased tension the muscles are stiff, rigid, and oppose all passive movements. If the tension is in- creased, it may lead to contraction. The rigid, so-called spastic paralysis presupposes a central lesion (of the brain or spinal cord), and occurs principally in degenera- tion of the lateral pyramidal tracts of the spinal cord, 112 CLINICAL DIAGNOSIS. in spastic spinal paralysis, in amyotrophic lateral scle- rosis, in cerebral apoplexy or embolisms, etc. Spastic paralysis goes hand in hand with an exaggerated tendon reflex^ while in relaxed paralysis there is a diminution or absence of the tendon reflex. In contradistinction to the orgajiic paralyses, in which the motor tract in any part is injured, we speak of a fu?ictiona I ^dLidily SIS, where the motor tract is unimpaired, i. e., in hysterical paralysis. Ataxia means the inability, with intact power, to coor- dinate the separate muscles to a certain action — that is, a condition in which the patient makes clumsy motions, when he was previously skilful. He is asked to quickly reach for a certain object, to button a button, to write, to walk a straight line, to turn himself around, to describe a circle with the foot, etc. The patient shows ataxia when on the feet, by standing with the feet wide apart, and walking stiff-legged or stamping along. When the patient cannot control his movements with his eyes (in the dark, and with closed eyes), the ataxia is generally worse. Ataxia occurs in diseases of the spinal cord (tabes), as well as of the brain and peripheral nerves (cerebellar, alcoholic, diphtheritic ataxia). Motor Symptoms of Irritation. Spasms^ or involuntary muscular movements, are divided into clonic (interrupted quiverings of short dura- tion), and tonic (contractions of longer duration). If the tonic spasms extend to most of the muscles, it is called tetanus. Convulsions are numerous quick, powerful clonic spasms, especially if they extend over the whole body. Trernoj's occur either in muscles at rest (in paralysis THE NERVOUS ST STEM. II3 agitans), or in muscles voluntarily moved, especially in the movements which demand strength or precision (tremor of intention as in multiple sclerosis). Trembling of the eyes is called fiystagmiLS (multiple sclerosis). Choreic piove7ne?its are quick, involuntary, and incoordi- nate movements which interrupt and prevent the volun- tary motion. They occur in chorea minor, and at times, on one side after (or before) hemiplegia. Further, the following are to be mentioned : Compul- sory movements (riding motion), accompanying motions (generally central), athetosis motions (slow and rhythmic exaggerated movements of the hands), and cataleptic (waxy) muscular rigidity. Diagnosis by Means of Electricity. The test should be made both with the faradic (inter- rupted) and galvatiic (constant) current, both by direct application to the muscles, or by indirect excitation of the muscles through the nerves. The indifferent \i. e., non-active] pole (a long, flat electrode) is placed on the sternum, and the other, different [i. e., active] pole, on the nerve or muscle to be examined. A small, button- shaped electrode serves for the different pole, since it must be taken into account, for the effect of the electrical excitation, that the current reach the part to be excited, with the greatest density. The density (D) is greater in proportion as the intensity (I) of the current is greater, and the section of the conductor (S) is smaller at the spot : D = g. The electrodes, as well as the skin of the patient, should be well moistened with warm water. The situa- tion of the points in which a muscle or nerve may be 114 CLINICAL DIAGNOSIS, excited, is shown in the accompanying illustrations.^ By gradually increasing the strength of the current, we arrive at a point where the first minimum muscular con- traction takes place. The examination is begun with the faradic current and generally with the current of the secondary coil. . Fig. 55. Region of central convolutions. Region of third frontal convolu- tion and island of Reil. M. temporalis. N. f U. branch. J M.branch. facial. I Trunk. '^L. branch. N. auricular post. M. splenius capitis. M sternocleido- mastoid. N. accessor Wil- lisii. M. cucullaris. N. dors, scapulae. N. axillaris. N. thoracic, long. (M. serratus ami- cus.) N. phrenicus. Plexus brachialis. M. frontalis. M. corrug. super- cil. M. orbicular, pal- pebr. M. levator labii super. alaeque nasi. Mm. zygomatic!. M. orbicular, oris. M. masseter. M. levator menti. M. quadrat, men- ti. M.triangul. menti. N. liypoglossus. Platysma myoides. Muscles of hyoid bone. N. thoracicus an- terior (M. pecto- ral major.) Supraclavicular point of Erb (Mm. deltoideus, biceps, brachial, intern, [anticus], supinator longus etbrevis, infraspinatus et subscapularis). As a standard of measurement of the intensity of the current, the distance between the coils (R. A.) is ex- pressed in millimetres, and the current is stronger in pro- portion as the coils 2.xq further apart. ^ These are drawn from the illustrations in the text-books of Ziems- sen, Erb, Bernhardt, Rosenthal and Eichhorst. For details as to plectro-diagnosis, as well as electro-therapeutics, see these books. THE NERVOUS SYSTEM. 1 15 Also the faradic current must be graded by moving the iron rod (in the coil) ; for the current is so much the stronger in proportion as the rod is pushed further into the primary spiral. In using the galvanic current^ the cathode^ (negative zinc pole) is applied to the muscle or nerve to be examined. By gradually increasing the strength of the current, it may be determined what the least intensity is, with which, at the closing of the current, a contraction takes place (cathodal closing contraction, KaSZ^). The in- tensity is noted by giving the number of elements used, or by reading off the number on the galvanometer. Then the current is used unclosed, with the commuta- tor, (from N, the normal position, to VV, change), by which the exciting electrode becomes the anode (the positive, carbon, or copper pole), and determines the minimum of contraction on closing (anodal closing con- traction, AnSZ) and on opening (anodal opening con- traction, AnOZ). The closing and opening of the ' In filling the carbon zinc elements, the following -fluid is used : Bichromate of potash, 70.0 [17^ drachms]. Water, 900.0 [28 ounces]. Concentrated sulphuric acid, 170.0 [5| ounces.] Sulphate of mercury, 10. o [2^ drachms]. The last ingredient is to keep the zinc amalgamated. 'In order to distinguish the two poles, the ends of the wire should be immersed in a solution of iodide of potash and starch, and blue clouds, due to the free iodine and starch, are formed at the anode. Or the ends of the wires may be dipped in water, and the bubbles of hydrogen will show which is cathode, while the anode is recognized by the absence of bubbles, due to the rapid oxidation of the oxygen as fast as it is formed. •^ [For the sake of uniformity, the German abbreviations are used throughout.] Il6 CLINICAL DIAGNOSIS. current should be effected by the interrupter without changing the position of the electrodes. Under normal conditions, the results of the irritation, on gradually increasing the intensity of the current, are in the following order : — (i) Cathodal closing contraction, KaSZ. (2) Anodal opening contraction, AnOZ. (3) Anodal closing contraction, AnSZ. (4) Cathodal closing tetanus, KaOZ (lasting contrac- tion with KaS). (5) Cathodal opening contraction, KaOZ, This law holds good, however, only in indirect irrita- tion of the nerves. In direct application of the electrode to the muscle, there are generally closing contractions, and AnSZ may be equal to KSZ or even greater than it. The contractions are short, quick, and may be excited through the nerve or muscle. The intensity of the current is expressed by the num- ber of elements used, or still better, when an absolute galvanometer is at hand, in milliamperes. According to Ohm's law I z= ^ ; that is, the strength of the current or intensity (I) is in proportion to the electro- motive force (E, number of elements), and is in inverse proportion to the whole amount of the resistance pres- ent in the electric current. Now an ampere is that strength of current (I) which is generated by the electro- motive force (E) of i volt in an electric current of re- sistance (W), of I ohm. An ampere then, is equal to ^-^ . One volt is equal to ^-V of the electromotive force I ohm ^ 1 U of a Daniell element ; one ohm is equal to a column of mercury 106 cm. long, and i square millimetre in section (1.06 Siemen's unit). For medical purposes, no strength of current higher than 20 thousandth (milli-) amperes is THE NERVOUS SYSTEM. 1 17 used. With motor nerves superficially situated KaSZ occurs normally with currents of 1-3 MA strength. The strength of the current may be varied, either by inserting more or less elements, or by means of a rheo- stat, by which resistance of different degrees may be inserted into the current. The resistance in the dry epidermis is at first very great, but after using the galvanic current for some time, and thoroughly moistening the skin, the resistance is considerably diminished, so that by using a current of medium strength with the number of elements (E), re- maining the same, the strength of the current (I) increases to a certain point. A current which is not felt at the beginning of the examination, and causes no contraction, may, by keeping the current closed, and diminishing the resistance without changing the number of elements, so increase as to become painful and cause evident contraction. Quajititative changes in the electro-irritability, that is simple increase or diminution, are judged by comparing both sides of the body (in unilateral affections), and by testing analogous points which have approximately the same irritability in health, e. g., the frontal nerve, the spinal accessory in the neck, the ulnar nerve above the olecranon, and the peroneal nerve between the bend of the knee and the head of the fibula (Erb). Here it should not be forgotten that the conductive resistance of the skin is different in different parts of the body, and in different individuals. Simple increase of electric irritability occurs in tetanus, and a simple diminution of electric irritability may develop in all paralyses of long duration, which begin with simple non-degenerative muscu- lar atrophy, e. g., after apoplexy and muscular atrophy of the joint troubles. When there is a very great diminution of the electric irritability, a contraction may be caused, with the strongest currents, with > s« S) o a ;- — ,% D = Lt D r> -z " -; a O a o S Sr üt — ^ — ä SS 5.5 S = -= 5 t — s s s J3 • ii8 Nervus cruralis. Nervus tibialis. tJO Nervus obcuratorius. Nervus peroaeus. Nervus tibialis. IIQ I20 CLINICAL DIAGNOSIS, closed connection only, from the anode to the cathode (Volta's alter- native), and even this may be entirely extinguished. A qualitative change in the electric irritability, is called the rcaciio7i of degenei-ation (EaR). When a motor nerve is diseased or cut off peripherally from its trophic centre (the anterior horns of the spinal cord, or the gray matter of the cervical nerves), or if the trophic centre itself be diseased, a motor paralysis appears, the nerve becomes degenerated, and the degeneration (degenera- tive atrophy) reaches to the muscle supplied by it. The electric irritability of the nerve diminishes for the fara- dic, as well as for the galvanic current, and is destroyed after about two weeks, /. ^., the nerve ceases to conduct the electric current as well as the will. Also the direct faradic irritability of the muscle is diminished and dis- appears ; on the contrary, in the 2d or 3d week there is an increase of the dii'cct muscular irritability for the galvanic current, the contractions occur with the weak- est current, but are long drawn out a7id slow, and the formula of contraction is changed. The AnSZ occurs with the same or weaker current, as the KaSZ, and the KaOZ becomes like the AnOZ. In one or two months the galvano-muscular irritability diminishes, and disap- pears in a few months. If recovery take place the muscular tonus and voluntary motion appear, but the electric irritability returns only gradually to the normal. This " complete reaction of degeneration " only occurs in grave lesion of the nerves (transverse rupture, se- vere rheumatic facial paralysis); when the conditions of degeneration are not so grave, there is often an incom- plete, or even no "partial reaction of degeneration." In the latter case, the irritability for the nerves is retained, and also the direct faradic muscular irritability. In di- THE NERVOUS SYSTEM. 121 rect galvanic irritation of the muscles, there are neverthe- less, hyperexcitability, and change of the formula of contraction (AnSZ > KSZ), and a sloiu contraction. The latter is the actual characteristic of EaR, The reaction of degeneration is present in peripheral lesions of the motor nerves, of a traumatic, rheumatic, neurotic, or diphtheritic nature, also in disease of the gray matter of the anterior horns of the spinal cord, and of the gray nuclei of the medulla, e.g.^ in in- fantile paralysis and lead paralysis ; also sometimes in progressive muscular atrophy, bulbar paralysis, amyotrophic lateral sclerosis, myelitis, etc. The EaR is absent, however, in all cerebral paralyses (apoplexies), and in those spinal paralyses which have a central cause from the trophic centre, and also in pure myopathic paralysis (pseudo-hyper- trophy of the muscles). The trophic behavior of the paralyzed muscles is en- tirely analogous to the electric behavior. In disease of the gray matter of the anterior horns, as well as in lesions of the motor nerves peripherally from themselves, a degenerative atrophy occurs, while in paralysis whose cause lies in the motor tract central from the gray mat- ter of the anterior horns, a slight atrophy of the para- lyzed muscle takes place, but not until after a long time (atrophy of inactivity). In degenerative atrophy of the muscles, there are often fibrillary contractions observed in them. Reflexes. We distinguish skin (superficial) and tendon (deep) reflexes. It is not certain whether the latter are actually reflex or not. They do not behave alike, and may be often completely different. Among the skin reflexes which are more or less present in health, are : 122 CLINICAL DIAGNOSIS. Reflex of the sole of the foot : In exciting the sole of the foot by tickling, stroking, sticking, touching it with ice, there is dorsal flexion of the foot, and when the irri- tation is strong, the leg is drawn up against the body. Cre??iaster reflex : In exciting the inner surface of the thigh, the corresponding testicle rises up. Reflex of the abdominal walls, gluteal and scapular re- gions : In irritating the skin in these regions, the corre- sponding muscles contract. Tendon Reflexes. Patellar reflex : If the patellar tendon be percussed while the leg is crossed and co??ipletely relaxed, and the patient's attention be withdrawn, there is a contraction of the quadriceps and the leg is extended. Patellar clonus : If the patella be pushed quickly down and held there firmly, there is a rhythmic contraction of the quadriceps. Reflex of the te?ido Achillis : In percussing the tendo Achillis, there is caused a contraction of the calf muscles. Foot clonus : If the foot be seized by the ball of the great toe, and be pressed quickly upward while the knee is slightly bent, there is a rhythmic plantar-contraction of the calf muscles. In health the- patellar reflex is constant, and the reflex of the tendo Achillis frequent. The presence of the remaining tendon reflexes, also of the upper extremities (biceps, triceps, flexors of the hand etc.), is considered as a diseased reflex irritability. In order that the conditions of reflex tendon may occur, it is, above all things, necessary that the reflex circtiitho. entire. This reflex circuit is formed by the sensory nerve tracts, which go from the muscle or tendon or fas- THE NERVOUS SYSTEM. 123 cia, to the spinal cord and motor tracts which descend to the muscles, as well as to that part of the spinal cord connecting both. The reflexes are extinguished when the reflex circuit is interrupted in any part of its course, /. e.^ when the centripedal or centrifugal nerves, or their con- nection with the spinal cord (Burdach's pyramidal gray substance), are injured. The reflexes are increased \N\\Q'i\ these nerves are in an abnormally excited condition, or when the inhibitory fibres are interrupted in their course from the cerebrum through the lateral tracts to the reflex circuit. The tendon reflex is extinguished in polyomyelitis anterior (infan- tile paralysis), tabes dorsalis, peripheral nerve lesions, and diffuse myelitis. Increase of the tendon reflex is observed in sclerosis of the lateral tracts, in amyotrophic lateral sclerosis, in hemiplegia with contraction, in multiple sclerosis, division of the spinal cord above the reflex circuit, and further in dementia paralytica and hysteria, Paradox contraction (Westphal) : When the foot of the recumbent patient is quickly and firmly flexed, there is sometimes a contraction of the tibialis anticus, its ten- don is prominent, and the foot remains for a short time in this position after it has been let go. Among the reflex functions may be mentioned the passing of urine and faeces, the sexual reflex and pupil reflex. The pupil is supplied with fibres from the oculomo- torius for the sphincter pupillse as well as those from the sympathetic for the dilatator. A centre for the pupil reflex lies in the lower cervical region (cilio-spinal centre). Irritation of the sympathetic fibres coming from the centre, causes dilatation of the pupil (mydriasis spas- tica), paralysis of the same, a narrowing of the pupil (myosis paralytica). Irritation of the oculomotorius, on 124 CLINICAL DIAGNOSIS. the contrary, causes narrowing of the pupil, and paraly- sis of it, dilatation, and want of reflex for light as well as for accommodation to near objects. Reflex rigidity of the pupil for light, with retained movement for accom- modation for near objects, occurs with narrowing and inequality of the pupils, most frequently in tabes dorsalis and dementia paralytica. The Most Important Clinical Points in the Anatomy of the Nervous System. Brain and Spinal Cord. — The psychomotor region of the cerebral cortex is formed by the two central convo- lutions and their connecting part on the median surface, the lobus paracentralis. The centre for the leg probably lies in the latter and in the two upper thirds of both the central convolutions ; and in the middle third of the an- terior convolution lies the centre for the arm ; and in the lower third of the anterior convolution, the centre for the face (facialis, hypoglossus). Bordering on the latter, and in the posterior portion of the third left lower frontal con- volution, as well as in the island of Reil, lies the centre for speech. When this is injured, aphasia occurs. The cortex of the parietal lobes is brought into relation with the sensi- ble tract ; the occipital lobe is the cortical centre for the sense of sight. As there is only a partial crossing of the fibres in the chiasma of the optic nerve, an injury to the occipital lobe or to the optic tract as far as the chiasma may cause hemianopsia, /. ^., blinding on the correspond- ing side of the retina ; thus a diseased condition of the right side causes a blindness in the left half of the field of vision. A diseased condition of the central part of the chiasma causes a bitemporal hemianopsia. In an injury to the optic nerve beyond the chiasma, there THE NERVOUS SYSTEM. 12$ occurs amblyopia, or amaurosis of one entire eye. The temporal lobes are connected with the sense of hearing. The functions of the corpus striatum, nucleus lenti- formus, and thalamus opticus are not exactly known, but as they border on the inner capsules, diseased conditions of them may indirectly cause hemiplegia. The cerebel- lum is said to be the centre for coordination. When it is diseased, we have ataxia, dizziness, and vomiting. The motor fibres of the psychomotor cortical portion pass through the peduncle of the corpus callosum, and converge to the inner capsule, where they run in the middle third of the posterior crus between the opticus thalamus and the nucleus lentiformis. In its posterior third the sensory tracts ^ Anterior pyramidal tract. are found. From the ^"^^„V°' ^^ W^ *. ,. , root. /^\r%^7/^\ ^^ Antero-lateral inner capsule the motor / JIKnk '\ "^"' / ^ V_, Lateral pyramidal tracts pass through the mT, '^^ ^''^^^• . . ^^&l|if /l|-Tr Nji^^fe^:-— Cerebellar lateral pes cruris cerebri (the ^m^^^m' ^''^^^■ Posterior /~~^'^\^~"\ "^ — Tract of Burdach. sensory through the teg- -ot. ^ractofLi. mentum cruris cerebri) into the pons. The motor fibres, after their exit from the pons into the medulla, form the pyramidal bodies, and here, for the most part, cross. The crossed fibres in the lateral tract of the spinal cord pass downwards (lateral pyramidal tract. Fig, 60) ; only a small part of the motor fibres remains uncrossed, and passes down in the middle part of the anterior tract (anterior pyramidal tract). A destruction of any part of this motor tract produces, not only a paralysis of the muscle concerned, but also de- scending degeneration of the pyramidal tracts, inasmuch as their trophic centre is situated in the cerebrum. The motor fibres pass out of the pyramidal tracts into the anterior cornu of the gray matter, whose great ganglion 126 CLINICAL DIAGNOSIS. cells form the trophic centre for the peripheral motor nerves and the muscles ; and from there they pass through the anterior roots to the periphery of the body. Injuries of the motor nerves beyond the gray anterior cornua, or a morbid condition of them, produce a degen- eration of the nerves, as well as paralysis and atrophy of the muscles, with the reaction of degeneration. These paralyses are characterized as peripheral^ in distinction from central paralyses^ which are caused by a lesion of the motor tracts proximal to the gray anterior cornua. Inasmuch as in the cerebral cortex the motor centres of the single muscular regions lie far apart from each other, a lesion in that particular place generally produces monoplegia, i. e., a paralysis of one member or of one group of muscles alone, which is often connected with paroxysmal cramps in the paralyzed portion (cortical epilepsy, Jackson's epilepsy). Lesion of the inner cap- sule generally produces total hemiplegia, as well as affec- tions of the crus cerebri and the pons. (In case of dis- eased condition of the crus cerebri, there is often with it a crossed paralysis of the oculomotorius ; when the pons is diseased, there is crossed paralysis of the facialis.) All these paralyses affect the opposite side of the body, while affections of the spinal cord before the pyramidal decus- sation cause paralyses of the same side. As most lesions, however, affect the spinal cord on both sides alike, para- plegia is the principal form of spinal paralysis (myelitis, compression of the spinal cord by spondylitis or tumors). Injuries of the anterior roots, of the plexus, and of the nerves, produce paralyses of single groups of muscles. The sensory nerves, whose trophic centre is situated in the intervertebral ganglia, enter the spinal cord through the posterior roots, cross shortly after their entrance THE NERVOUS SYSTEM. 12/ (deep decussation), and ascend through the posterior columns to the brain, so that the inner columns (of Goll) contain the long, ascending bundles of fibres, while the outer columns (of Burdach) are made up of short bundles which run to the gray posterior cornua. Besides that, long bundles in the lateral column of the cerebellum pass upward. In cases of transverse section of the spinal cord, the columns of Goll and cerebellar lateral columns degenerate upward from the point of injury, and the pyramidal column downw^ard. In case of a lesion of one side of the spinal cord, there appears a motor paralysis of the same side, and anaesthesia of the other side ; besides this, a narrow anaes- thetic belt around the body at the height of the lesion (Brown-Sequard). In case of tabes dorsalis the posterior columns are diseased, and in spastic paralyses the lateral columns (tabes spastica). In amyotrophic lateral scle- rosis the anterior cornua and lateral columns are dis- eased, and in infantile paralysis and progressive muscular atrophy the gray anterior cornua are diseased. In dis- eases of the gray nuclei of the medulla oblongata (bulbar paralysis) there are disturbances of speech and degluti- tion caused by paralysis and atrophy of the lips, soft palate, muscles of deglutition, and larynx. Cranial Nerves. 1. Olfactorius. The testing of the sense of smell is accomplished by holding before the nose odoriferous and irritating substances, such as volatile oils, asafoetida, musk, etc. 2. Opticus. Test the sharpness and field of vision, and sense of color, and then examine with the ophthalmoscope. 3. Oculomotoritis supplies the levator palpebrae superioris, rectus superior, internus, and inferior, obliquus inferior, and sphinctor pu- pjllse. In paralysis, there is ptosis, diplopia, dilatation, and absence of pupillary reaction, and disturbance of accommodation, 128 CLINICAL DIAGNOSIS. 4. Trochlearis supplies the obliquus superior. 5. Trigemi7itis . The motor pert supplies the muscles of mastica- tion, the masseter, temporalis, pterygoid, mylohyoid, and the ante- rior belly of the biventer. The sensor}' part supplies the skin of the face and head as far as the ears. The first branch goes to the skin of the forehead, of the top of the head, of the upper eyelids, and of the bridge of the nose. The second branch supplies the upper half of the cheek and upper lip, and the third branch, the lower half of the cheek, the skin in the temporal region, and the chin. Besides this, the trigeminus supplies the cornea and conjunctiva and the mu- cous membrane of the mouth and nose, and the dura mater with sen- sory fibres. The lingualis from the trigeminus is the nerve of taste for the anterior two thirds of the tongue. 6. The abdiicetis supplies the abducens muscle. When it is para- lyzed, the eyeball cannot be turned outward. 7. The facialis supplies all the mimic muscles of the face, and the stylohyoideus, and the posterior part of the biventer. From the re- lation of the facialis to the petrosus superficialis major nerve, and to the chorda tympani, it is clear that in a lesion of this nerve, proximal to the ganglion geniculi, the soft palate on the same side is paralyzed and hangs lower, and that in a lesion between the ganglion geniculi and the passage of the chorda tympani, disturbances of taste occur in the anterior two thirds of the tongue, with decrease of the salivary- secretion. In central paralysis of the facialis, only the lower half of the face is usually paralyzed ; in peripheral paralysis, only the upper part. 8. Acusticus. The power of hearing should be tested, and oto- scopic examination made. g. Glossopharyngeus . The nen^e of taste for the posterior third of the tongue supplies the palate with sensory fibres. The test is to apply quinine, sugar, salt, or vinegar to the part. 10. The vagus supplies the larynx, pharynx, and oesophagus with motor and sensory fibres, and sends fibres to the contents of the chest and abdomen. Irritation of the vagus causes slowing of the pulse ; and paralysis of the nerve, a quickening of the pulse and slowing of the respiration. 11. The accessorius supplies the stern o-cleido-mastoid and the trapezius. J2, The hypGglosstis, the motor nerve of the tongue, supplies th^ THE NERVOUS SYSTEM. I29 genio-glossus, hyo-glossus, stylo-glossus, the innermost muscles of the tongue, the genio-hyoideus, omo-hyoideus, sterno-hyoideus, hyo- thyroideus, and stemo-thyroideus. In paralysis of the hypoglossus, the tongue turns toward the paralyzed side. Spinal Nerves. 1. Plextis cervicalis (ist-4th cervdcal nerve) supplies the post-occi- pital region behind the ear, neck, and shoulders with sensorv' nerves ; the deep cervical muscles and the scaleni, with motor nerves. From the fourth cer\'ical ner\'e the phrenic branches, and forms the motor nerve of the diaphragm. 2. Plexus brachialis (5th-Sth cervical nerve, ist and 2d dorsal nerve). In lesion of a certain pail of this plexus, there is a motor paralysis of the deltoid, biceps, brachialis internus [anticus], supin- ator longus, infraspinatus (paralysis of Erb). The nervi thoracici anterioj'es supply the musculus pectoralis major and minor. The nervtis iJioracicns longus supplies the musculus serratus anticus major [serratus magnus]. The nervus dorsalis scapuhe supplies the musculi rhomboidei, levator [anguli] scapulae, and serratus posticus superior. The nervus siiprascapularis supplies the musculus supraspinatus and infraspinatus. The nervus subscapularis supplies the musculus subscapularis, teres major, and latissimus dorsi. The nervus axz7/ar/j- supplies the musculus deltoideus, teres minor, and sensory fibres go to the skin of the outer side of the upper arm. The nervus cutaneus mediiis and medialis supply the skin of the median (inner surface) side of the forearm. The 7iervus niusctilocutaneus supplies the musculus biceps, coraco- brachialis, brachialis internus [anticus], and the skin on the radial side of the forearm. The nervus inedianus supplies the musculus flexor carpi radialis, pronator [radii] teres and pronator quadratus, flexor digitorum com- munis superficialis and profundus (in part), palmaris longus, flexor pol- licis longus and brevis, abductor and opponens pollicis ; the skin of the palmar surface of the hand from the thumb to the middle of the third [ring] finger ; and the dorsal side of the ungual phalanx of the first and second finger. 130 CLINICAL DIAGNOSIS. In paralysis of this nerve, pronation and flexion of the hand is al- most entirely impossible, and flexion and opposition of the thumb and flexion of the finger in the last two phalanges, is impossible ; on the contrary, the first phalanges can be flexed by the interossei. With the last three fingers, whose flexor profundus is partly supplied by the nervus ulnaris, the power of grasping is still retained. The neriJits ulnaris supplies the musculus flexor carpi ulnaris, flexor digiiorum profundus for the last three fingers, the muscles of the ul- nar side of the hand, the interossei, lumbricales, adductor pollicis ; the skin of the ulnar side of the hand on the palmar side as far as the middle of the third [ring] finger, and on the dorsal side to the middle of ihe second finger. In paralysis of this nerve there is diminished power of lateral move- ment towards ihe ulnar side as well as loss of power to flex the last three fingers : further, also, there is loss of motion of the little fin- ger in flexion of the first phalanges and extension of the last pha- langes of the four last fingers, and loss of power to spread the fingers out and draw them together. In paralyses Avhichhave existed a long time we have the claw-like position of the hand, in which case the first phalanges are flexed towards the dorsal surface and the end phalanges towards the palmar surface. This is caused by atrophy of the interossei. The nervtis radialis supplies the extensors of the arm, hand, and fingers, the musculus triceps, supinator longus and brevis, all the muscles on the posterior surface of the forearm, namely, the extensor carpi radialis longus and brevis, extensor carpi ulnaris, extensor digi- torum communis, extensor indicis and digiti minimi, extensor pol- licis longus and brevis, abductor pollicis longus. The cutaneous branches go to the posterior surface of the upper arm and forearm, to the dorsal surface of the thumb, and the skin as far as the middle of the second finger. In paralysis of this nerve there is inability to extend the relaxed muscles of the hand and fingers, as well as to extend and abduct the thumb. The outstretched arm cannot be supinated (but on flexion of the arm the forearm can be supinated by the biceps). Such a paraly- sis is observed in lead paralysis, except that the supinator longus is generally exempt. The sensory disturbances in paralysis of the nerves of the arm may be inferred from the above description of the distribution of the sensory branches, but the symptoms are generally less distinctly marked. THE NERVOUS SYSTEM. I3I 3. The dorsal nerves supply the skin and muscles of the thorax and abdomen. 4. The plexus lumbalis (12th cervical to ist-4th dorsal nerve) goes to the skin of the lower abdominal region, of the anterior surface of the thigh, and of the inner surface of the leg. The motor branches sup- ply the internal pelvic muscles. The nervus cruralis supplies the musculus quadriceps femoris, sartorius, pectineus ; the nervus obtur- atorius supplies the musculus obturator, adductor magnus, longus, and brevis, and gracilis. 5. The plextis sacralis (5th lumbar to lst-5th sacral nerve) supplies the bladder, rectum, sexual organs, perineum, and nates with motor and sensory branches. The ner\Tis ischiadicus [sciatic nerve], which supplies the skin on the posterior surface of the thigh, on the outer side of the leg, and on the foot as well as the musculus biceps, semitendinosus and semi- membranosus, divides half way down the thigh into the nervus tibialis and peroneus, the former of which supplies the muscles on the pos- terior surface of the leg (calf muscles) and of the under surface of the foot, the latter going to the muscles on the anterior surface of the leg and foot (see Figs. 58 and 59). CHAPTER XIII. ANALYSIS OF THE PATHOLOGICAL CON- CREMENTS. Urinary Concrements. — The concrement should be rubbed to a fine powder, and a part of it heated red hot on a platinum spatula or on a porcelain crucible top. If the concrement be completely destroyed, or if only a small amount of ash remain behind, then it con- sists of organic substance, /. Hens' eggs (after taking off the shell) 26.1 14.1 2. 19 10.9 1 I egg weighs, without the shell, on an average, 45 grams [i| ounce]. Cow's milk (good quality) . 12.92 4.13 0.64 3.90 4.20 1 Cow's milk (inferior quality) II. 7 3-5 0.5 2.7 4-5 5 Butter 88.3 0.5 87.0 0.5 ■J Cheese 66.8 32.2 4-75 26.6 2.97-' A Bacon ..... 95-6 b Wheat flour (fine) 85.14 8.91 1.42^ I. II 74.28 -' White bread .... 72.0 9.6 1.5' 1.0 60.0 3 Black bread .... 63.29 8.5 I.O 52.5 1 Pastry food (the average of seven varieties) .... 44.2 8.7 15.0 28.9 3 Raw potatoes (without skin) 26.62 2.31 0.37 23-3 4 Cooked potatoes (without skin) . 25-4 2.18 0.35 23.0 4 Uncooked peas .... 86.59 21.25 3-40 1. 17 61.8 4 Rice 86.5 8.31 1.33 89.2 4 Vegetables (average) . 27-7 2.2 0.35 3-9 18. 1 6 Bouillon ..... 0.09 0.057^ 0.8 ■^ Soup (the average of ten varieties) 8.4 I.I 1-5 5-7 2 White wine .... 14.0 0.033 2.0 Red wine (French) II. 7 0.0182^ 2.34 Sherry ..... 20.5 0.20 3-27 •-' Bavarian beer .... 9-7 0.44 5-78 ^ Analysis of C. v. Voit ; - of König ; ^ of Renk ; ^ of Rubner 5 of F. Midler ; ^ of Hoffmann. 142 CLINICAL DIAGNOSIS. carbo-hydrates (starch, sugar) are generally very com- pletely used up, while a very large part of the fats is passed out unused with the fasces. In many pathological conditions the absorption of the nutritious substances is badly carried out, as in diarrhoea. In absence of gall in the intestine (icterus), the fats are not easily absorbed. The absorption ir. health of some of the most im- portant articles c: :::d is shown in the following table (Rubner) : Food- - ;^ » C ^ Ol X.)l Fat (^. Carbo- hydrates Fat of (lOO grams [3 otmcesl bacon) 9.1 4-4 150 4-9 4-1 9-4 14.9 11.8 8.5 2 •" ; 19.2 9 - 50 S.9 Z • 1 20.7 32.0 j 20.5 20.4 32.2 18.5 6.1 j 22-6 12. 1 17.4 o I.I 10.9 1.6 0.9 7-6 15-4 5.3 1.6 Finally, may be added a list of important factors neces- :a.ry for calculation in the experiment of metabolism : Nitrogen : Urea. = i . 2.143. Nitrore- : A^^--.:tr. = i ; ^..i^. N::r:rer. : Vji-r::^.iz r:.: ^:3.::^ce = i ; 29.4. Urea : Alburr.er: ■=. i : 2.9. Urea: Muscular substance = i ; 13.71. Muscular substance : Nitroier. = i : c.034. Albumen : Nitrogen = i : c.i6. Table of the Weights of the Human Body MALE. Age, 'Height in ft. and inches. Weisht. At birth. I year. 2 3 4 5 6 7 8 9 lO 12 14 i6 i8 20 25 30 40 50 60 ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. 7 m. 3 in. 8 in. 9 in. 3 in. 5 in. 8 in. 9 in. 2 in. 6 in. 10 in. 3 in. 6 in. 8 in. 9 in. 9 in. 8 in. 6 in. 5 in. 0.496 m. 0.696 m. o. 797 m. 0.860 m. 0.932 m. 0.990 m. 1.046 m. 1. 112 m. 1. 170 ra. 1.227 m. 1.282 m. '1.359 m. 1.4S7 m. 1. 610 m. 1.700 m. "1.711 m. 1.722 m. 1.722 m. 1. 713 m. 1.674 ni. ^1.664 m. 7 lbs. ; 3-20 kg.] 22 " 10.00 ' 26 " 12.00 ' 29 " 13.21 ' 33 " 15-07 * 36 " 16.70 ' 39 " 18.04 ' 44 " 20.16 ' 49 " 22.26 ' 53 " [24.09 * 57 " 26.12 ' 68 " 31.00 ' 89 " .40.50 ' 117 " 53-39 ' 135 " 61.26 ' 143 " L65.00 ' 150 " 68.29 ' 152 " 68.90 ' 151 " [68.81 ' 148 " "67.45 ' 144 " '65-50 ' FEMALE. Age. Height in ft. and inches. Weight. At birth. I ft. 6 in. '0.483 m." 6 lbs. " 2.91 kg." I year. 2 ft. 3 in- 0.690 m. 20 ' . 9-30 ' 2 " 2 ft. 6 in. 0.7S0 m. 25 ' 11.40 ' 3 " 2 ft. 9 in. ^0.850 m. 27 ' 12.45 ' 4 " 3 ft. 0.910 m. 31 ' 14.18 ' 5 " 3 ft. 2 in. 0.974 m. 34 ' 15.50 ' 6 " 3 ft. 4 m. 1.032 m. 37 ' 16.74 ' 7 " 3 ft. 7 m. 1.096 m. 40 ' .1S.45 ' 8 " 3 ft, 9 m. 1. 139 m. 43 ' 19.82 ' 9 " 3 it. II in. 1.200 m. 50 ' 22.44 ' 10 " 4tt. I in. 1.24S m. 53 ' 24.24 ' 12 " 4 It. 4 m. 1.327 m. 67 ' .30-54 ' 14 " 4 It. 9 m. [1.447 m. 84 ' [38.10 ' 16 " 4 ft. II in. 1.500 m. 98 ' 44-44 ' 18 ■' 5 ft. I in. 1.562 m. 117 ' .53- 10 ' 20 " 5 ft. 2 in. 1.570 m. 120 ' 54-46 ' 25 " 5 ft. 2 in. 1.577 ni. 121 ' '55-08 ' 30 " 5 It. 2 in. ,1.579 m._ 121 ' ^55-14 ' 40 " 5 tt. I m. .1-555 ni. 129 ' 5S.45 ' 60 " 5 ft. 1.516 m. 125 ' [56.73 ' - 144 CLIN IC A L DIA GNO SIS. DOSE TABLE. [The döses given are for adults. For hypodermic use the dose should be one half, and for use by the rectum, twice that by the mouth. The dose for children is calcu- lated by adding 1 2 to the age of the' child, and divid- ing by the age, thus : for a child 4 years old the dose would be ^^^ = 4 or ^ of the dose for adults. The doses are given in terms, both of the Apothecaries' and of the Decimal metric system. Dose expressed in terms of Dose Remedies. apothecaries' expressed in weights '' metric terms. and measures. Acet. colchici ..... f 3 ss to 3 i 2 to 4 ccm. " lobelise . Tq^ XV to Ix I to 4 ccm. ' ' opii ■q V to X 0.30 to 0.60 ccm. " sanguinar. TU XV to XX I to 2 ccm. " Scillae . TU X to XXX 0.60 to 2 ccm. Acid. acet. dil. TFl. Ix to XC 4 to 6 ccm. " arsenios. gr- Ä to 3!^ o.ooi to 0.005 gni- " benzoic. gr. V to XV 0.30 to I gm. " boracic. . gr. V to X 0.30 to 0.60 gm. " carbolic. gr. j to iii 0.05 to 0.20 gm. " gallic. gr. iij to XV 0.20 to I gm. " gall, in albuminuria gr. X to Ix 0.60 to 4 gm. " hydrobrom. (34 %) . gr. X to XV 0.60 to T gm. " hydrobrom. dil. TTi XV to xl I to 4 ccm. " hydrochlor. dil. Til X to XXX 0.60 to 2 ccm. " hydrocyan. du. ■ni ij to vj 0. 10 to 0.40 ccm. " lactic. gr. XV to Ix I to 4 gm. " nitr. dil. Til X to XXX 0.30 to 2 ccm. " nitro-hydrochlor. dL .. Til V to XX 0.30 to 1.20 ccm. " phosphoric. (50 ^ gr. iij to V 0.20 to 0.30 gm. " phosphoric, dil. Til X to Ix 0.60 to 4 ccm " saHcyl. . gr. V to XV 0.30 to I gm. " sulphuric, dil. Til V to XXX 0.30 to 2 ccm. " sulphuric, atom. m V to XXX 0.30 to 2 ccm. " sulphuros. TU XXX to Ix 2 to 4 ccm. " tannic. , gr. ij to X o.io to 0.60 gro. DOSE TABLE. 145 Dose expressed in terms of Dose Remedies. apothecaries' expressed in weights metric terms. and measures. Aconitina (white crystals) gr- ¥70 to lio 0.00015 to 0.0005 gm. Adonidine gr. TO to \ 0.06 to 0.02 gm. Aloe gr. ii to V 0. 10 to 0.30 gm. Aloe et canella gr. V to xxx 0.30 to 2.0 gm. Aloinum gr. j to iij 0.06 to 0.20 gm. Alumen (expectorant ) gr. iij to x 0.20 to 0.60 gm. " exsiccat. gr. V to XXX 0.30 to 2 gm. Ammonii benzoas gr. X to XX 0.60 to 1.2 gm. " bromid. gr. V to XXX 0.30 to 2 gm. ' ' carb. gr. iij to X 0.20 to 0.60 gm. " chlorid. gr. XV to XXX I to 20 gm. " iodid. gr. iij to XV 0.20 to i.o gm. " phosph. gr. V to XX 0.30 to 1.2 gm. ' ' picras gr. i to ^ 0.15 to 0.03 gm. " sulph. gr. iij to XV 0.20 to 1.0 gm. ' ' valer. gr. iij to XV 0.20 to 1.0 gm. Amyl nitris TH, ij to V 0. 10 to 0.30 gm. Anthemis 3 ss to 3 j 2.0 to 4.0 gm. Antimonii et pot. tartr. (diaph.) gr. tV to \ 0.004 to o.oi gm. " et pot. tartr. (emetic) gr. j to ij 0.05 to 0,10 gm. oxid. gr. j to ij Q.05 to o.io gm. ' ' oxysulphuret. gr. \ to 11 0.03 to 0.10 gm. " sulphid. . gr. \ to ij 0.03 to o.oi gm. ' ' sulphuret. gr. i to 11 0.03 to o.io gm. Antipyrine gr. V to XV 0.30 to 1.0 gm. Apomorph. hydrochlor. gr. h to TO 0.002 to 0.005 gm. Aqua ammonige TT]^ VJ to XXX 0.40 to 2 ccm. " amygd. amar. f 3 ij to XV 8.0 to 16.0 ccm. ' ' camphorae f § ss to ij 15 to 60 ccm. " chlori f 3 j to iv 4 to 15 ccm. " creasoti . f 3 j to iv 4 to 15 ccm. " laurocerasi IHvj to XXX 0.40 to 2 ccm. Argenti iodidum gr. i to ij 0.03 to O.IO gm. " nitras . gr. ^ to i O.OI to 0.02 gm. " oxid. . gr. I- to ij 0.03 to O.IO gm. Arnica gr. V to XX 0.30 to 1,20 gm. Arsenici iodidum gr. eV to tV o.ooi to 0.005 gm. Asafcetida gr. V to XX 0.30 to 1.20 gm. Atropina gr. T¥8 to 3V 0.005 to 0.002 gm. Atropinse sulph. gr. T^8 to ^ 0.005 to 0.002 gm. 146 CLINICAL DIAGATOSIS. Dose expressed in terms of Dose Remedies. apothecaries' expressed in weights metric terms. and measures. Auri et sodii chlorid. gr. 3V to iV 0.002 to 0.004 gni- Belladonnas folium . g^"- J 0.05 gm. Bismuthi citras gr. iij to XV 0.20 to i.o gm. " et ammon. citr. gr. j to XV 0.05 to 1.0 gm. " sub-carb. . gr. vj to XXX 0.40 to 2 gm. sub-nitr. . gr. vj to XXX 0.40 to 2 gm. ' ' tannas gr. vj to XXX 0.40 to 2 gm. " valer. gr. j to iij 0.05 to 0.20 gm. Brucina . gr. -h to tV o.ooi to 0.004 gm. Buchu gr. XX to XXX 1.20 to 2.0 gm. Caffeina . gr. j to V 0.05 to 0.30 gm. Caffeinse citras gr. j to V 0.05 to 0.30 gm. Calcii bromidum gr, V to XXX 0.30 to 2.0 gm. " carb. gr. XV to Ix I to 4 gm. " hypophosphis gr. iij to XV 0.20 to I gm. " iodidum gr. j to iij 0.05 to 0.20 gm. " phosphas gr. XV to XXX I to 2 gm. Calumba gr. X to XXX 0.60 to 2.0 gm. Calx sulphurata gl-- i to j 0.02 to 0.05 gm. Cambogium gr. I to iv 05 to 0.25 gm. Camphora gr. iij to X 0.20 to 0.60 gm. Camph. monobrom. gr. ij to V o.io to 0.30 gm. Cantharis gr. 1 to ij 0.03 to 0.10 gm. Cardamonum . gr. V to XXX 0. 30 to 2 gm. Castoreum gr. vj to XV 0.40 to I gm. Catechu . gr. XV to XXX I to 2 gm. Cerii nitras gr. j to iij 0.05 to 0.20 gm. " oxalas gr. j to iij 0.05 to 0.20 gm. Chinoidinum . gr. iij to XXX 0.20 to 2 gm. Chloral hydrat. gr. iij to XV 0.20 to I gm. Chloroformum TTlj to V 0.05 to 0.30 ccm. Cinchona gr. XV to Ix I to 4 gm. Cinchonidina and its salts gr. j to XXX 0.05. to 2 gm. Cinchonina and its salts gr. j to XXX 0.05 to 2 gm. Cinnamonum . gr. vj to XXX 0.40 to 2 gm. Codeina .... gr. \ to ij 0.03 to O.IO gm. Colchici radix . gr. ij to vj 0.03 to 0.40 gm. " semen gr. ij to vj 0.03 to 0.40 gm. Colocynthis gr. V to XV 0.30 to 1.0 gm. Confectio opii . gr. X to XX 0.60 to 1.20 gm. DOSE TABLE. H7 Dose expressed Remedies. in terms of apothecaries' weights and Dose expressed in metric terms. measures. Confectio sennse .... gr. j to ij 0.5 to o.io gm. Conii fol. ..... gr. iij 0.20 gm. Coniina and its salts gr. -g\ to gV o.ooi to 0.002 gm. Copaiba ...... VI XV to Ix I to 4 ccm. Creasotum ..... TTi j to iij 0.05 to 0.20 ccm. Creta prsepar. .... gr. XV to Ixxv I to 5 gm. Croton chloral .... gr. j to x 0.05 to 0.60 gm. Cubeba ...... gr. XV. to Ix I to 4 gm. Cupri acetas ..... gr. 1 to vj 0.03 to 0.40 gm. " sulphas ..... gr. i to X 0.03 to 0.60 gm. Cuprum ammon. .... gr. i to j o.oi to 0.05 gm. Curare ...... gr. T5 to i 0.002 to O.OI gm. Decoct, aloes comp. f § ss to ij 15 to 60 ccm. " chimaphilae flij 60 ccm. " citronae .... f!ij 60 ccm. ' ' sarsap comp. f I ij to vj 50 to 200 ccm. Digitalinum ..... gr. eV to 3V O.OOI to 0.002 gm. Digitalis ...... gr. i to ij 0.03 to 0.10 gm. Duboisina and its salts gr. tIj to ^V 0.0005 to O.OOI gm. Elaterinum, U. S. P., 1880 gr. ^V to I'e O.OOI to 0.004 g'll- Elaterium " 1870 gr. tV to i 0.004 to 0.03 gm. Emetina and salts, (emetic) gr. i to i 0.008 to 0.016 gm. " and salts, (diaph.) gr. 3-i^ to 3V 0.0005 to 0.002 gm. Ergota ...... gr. XV to Ix I to 4 gm. Ergotinum ..... gr. ij to viij 0.10 to 0.50 gm. Eserinae and its salts gr. 6¥ to -^ O.OOI to 0.004 gm. Extr. absinthii fl. ... VI XV to XXX I to 2 ccm. ' aconiti fol. (Engl.) . gr. i to j 0.02 to 0.05 gm. ' aconiti fol., U. S. P., 1870 . gr. i to ij 0.03 to O.IO gm. ' aconiti fol. fluid. -ni i to V 0.05 to 0.30 ccm. ' aconiti rad., U. S. P., 1880 . gr. A to i 0.005 to 0.015 gm. ' aconiti rad. fluid . . . TTl, ^ to ijss 0.03 to 0.13 ccm. ' agaric fl. .... TTt V to XX 0.30 to 1.20 ccm. ' aloes aquos. .... gr. i to iij 0.03 to 0.20 gm. ' anthemidis .... gr. ij to X 0.10 to 0.60 gm. * anthemidis fl. ... VI XXX to Ix 2 to 4 ccm. ' arnicse flor. .... gr. iij to viij 0.20 to 0.50 gm. ' arnicae fl. .... TU V to XV 0.30 to I ccm. ' arnicse rad. .... gr. ij to V 0.10 to 0.30 gm. ' arnicse rad. fl. ... TTl V to XV 0.30 to I ccm. 148 CLINICAL DIAGNOSIS. Remedies. Extr. aiomat. fl. auranlii. cort. fl. bellad. fol. (Engl.) bellad. alcohol bellad. fol. fl. bellad. rad. bellad. rad, fl, berber. aquifol. fl. berber. vulg. fl. brayerse fl. bryoniae fl. buchu fl. . calami, fl, calend. fl. calumbse calumbae fl. cannab. Amer. fl. cannab. ind. . cannab. ind. fl. cantharidis fl. capsici fl. cardam. comp. fl. carnis cascarillas fl. . castanese fl. catechu liquid, caulophylli fl. Cimicifugae fl. . cinchonae cinchonse fl. cinchonge arom. fl, cinchonae comp. fl. colch. rad. colch. rad, fl. . colch. sem. fl, colocynth colocynth comp, condurango fl. conii fol, (Engl.) conii fol, ale, U. 1 Dose expressed in terms of apothecaries' weights and measures. TTL XXX to Ix f 3 1^ to ijss gr- i to I gr. i to i TTl iij to vj gr- i to i m j to iij TT|, XV to XXX TT!, XV to XXX f 3 ij to iv TTj^ XV to Ix f 3 ss to ijss ■n[ XV to Ix "fTj, XV to Ix gr. iij to X TU XV to Ix TT[ iij to XV gr. I to i TTi iij to vj ■ni j to iij TTi j to iij TTi XV to xlv gr. XV to Ix f 3 f to ijss f 3 I to ijss TIL viij to XXX Til XV to XXX TI], viij to XXX gr. XV to XXX TTI XXX to Ix TT[ XXX to Ix f 3 ss to jss gr. i_ to li TTI iij to XV TTI 1-1 to X gr. \\ to V gr. i^ to V TTI viij to XXX gr. j to iv P., 1870, gr. I to li Dose expressed in metric terms. 2 to 4 ccm. I to 10 ccm. o.oi to 0.04 gm. o.oi to 0.03 gm. 0.20 to 0.40 ccm. 0.008 to 0.016 gm. 0.05 to 0.20 ccm. I to 2 ccm, I to 2 ccm, 8 to 16 ccm. 1 to 4 ccm. 2 to 10 ccm, I to 4 ccm. I to 4 ccm. 0.20 to 1.20 gm. I to 4 ccm. 0.20 to I ccm. O.OI to 0.03 gm. 0,20 to 0.40 ccm. 0.05 to 0.20 ccm. 0.05 to 0.20 ccm. I to 3 ccm. I to 4 gm. 3 to 10 ccm. 3 to 10 ccm. o, 50 to 2 ccm. I to 2 ccm. 0.50 to 2 ccm. 1 to 2 gm. 2 to 4 ccm. 2 to 4 ccm. 2 to 6 ccm. 0.02 to 0.08 gm. 0.20 to I ccm. 0.08 to 1.20 ccm. 0.08 to 0.30 gm. 0.08 to 0.30 gm. 0.50 to 2 ccm. 0.05 to 0.25 gm. 0.05 to 0.08 gm. DOSE TABLE. 149 Dose expressed in terms of Dose Remedies. apothecaries' weights and measures. expressed in metric terms. Extr . con. (fr.)alc., U. S. P., 1880 . gr. fto j 0.02 to 0.05 gm. conii fol. fl. . Til, iij to XV 0.20 to I ccm. con. (fr.) fl. U. S. P., 1880 TU l| to V 03 to 0.30 ccm. convallariae rad. fl. . HI, XV to XXX I to 2 ccm. cubebse fl. TT|, XV to XXX I to 2 ccm. damianse fl. f 3 ss to ijss 2 to 10 ccm. delphinii fl. TTL j to iij 0.05 to 0.20 ccm. digitalis . gr. i to i o.oi to 0.03 gm. digitalis fl. ■ni I to vj 0.05 to 0.40 ccm. duboisiae gr. i to i 0.015 to 0.03 gm. duboisise fl. TT[ V to X 0.30 to 1.20 ccm. dulcamarae gr. V. to XV 0.30 to I gm. dulcamarse fl. f 3 j to ij 4 to 8 ccm. ergotse . gr. iss to viij 0.08 to 0.5 gm. ergotae fl. TTl, XV to Ix I to 4 ccm. erythroxyli fl. f 3 ss to ij 2 to 8 ccm. eucalypti fl. euonymi fl. eupatorii fl. euphorb. ipec. ferri. pom. fl. TTl, XV to Ix TTj, XV to Ix TTl, XXX to Ix TTj, V to XXX gr. iij to XV I to 4 ccm. 1 to 4 ccm. 2 to 4 ccm. 0.30 to 2 ccm. 0.20 to I gm. frangulce fl. fuci vesiculos. gallse fl. f 3 ss to ijss TTl, XV to XXX f 3 ss to ij 2 to 10 ccm. 1 to 2 ccm. 2 to 8 ccm. gelsemii . gelsemii fl. TTj, ij to viij TTj, j to viij o.io to 0.50 ccm. 0.05 to 0.50 ccm. gent. fl. . . gent. comp. fl. geranii fl. TTj, XXX to ix TTl, XXX to Ix Til XV too XXX 2 to 4 ccm. 2 to 4 ccm. I to 2 ccm. gossypii fl. TT], XV to xlv I to 3 ccm. granali. rad. cort. fl f 3 ss to ij 2 to 8 ccm. grind, rob. fl. TTi XXX to Ix 2 to 4 ccm. guaiaci ligni fl. TIj, XXX to Ix 2 to 4 ccm. guaranae fl. Tit XV to XXX I to 2 ccm. hgematoxyli gr. V to XXX 0.30 to 2 gm. hsematoxyli fl. hamamelid fl. . TTj, XXX to Ix TT], XXX to XC 2 to 4 ccm. 2 to 6 ccm. helleb. nigris . gr. \ to iij 0.03 to 0.20 gm. helleb nigris fl. TU, V to XV 0.30 to I ccm. humuli . f » gr. iij to XV 0.20 to I gm, l^^O CLINICAL DIAGNOSIS. Dose expressed in terms of Dose Remedies. apothecaries' expressed in weights metric terms. and measures. Extr. humuli fl TTl, iij to XV 0.20 to 1 ccm. ' hydrangese fl. TTl, XXX to Ix 2 to 4 ccm. ' hydrastis gr. iij to X 0.20 to 1.20 gm. ' hydrastis fl. . ni, V to xxx 0.30 to 2.0 ccm. ' hyoscyami (Engl.) . gr. j to iv 0.05 to 0.25 gm. ' hyoscyami ale. gl-. J to ij 0.05 to 0. 10 gm. ' hyoscyami fol. fl. . TT]^ iij to XV 0.20 to I ccm. ' hyoscyami sem. fl. . TU ij to viij 0. 10 to 0.50 ccm. ' ignatiae . gr. 1 to li 0.02 to 0.65 gm. ' ignatiffi fl. TTl j to vj 0.05 to 0.40 ccm. ' ipecac fl. TTi iij to Ix 0.20 to 4 ccm. ' iridis versicol. gr. iij to vj 0.20 to 0.40 gm. ' iridis versicol fl. TTi XV too XXX I to 2 ccm. ' jalapas, U. S. P., 1S70 gr. V tox 0.30 to 0.60 gm. ' jalapae ale. gr, iij to vj 0.20 to 0.40 gm. ' jalapse fl. TTl XV to Ix I to 4 ccm. ' junip. fl. TTl xxx to Ix 2 to 4 ccm. ' kamala fl. TTl xxx to Ix 2 to 4 ccm. ' kino liquid TTl XV to xxx I to 2 ccm. ' kramari^ gr. V to XV 0.30 to I gm. ' lactucae fl. TTl XV to Ix I to 4 ccm. ' lactucarii fl. TTl V to XXX 0.30 to 2.0 ccm. ' leptandrae gr. iij to X 0.20 to 0.60 gm. ' leptrandrae fl. TTl XXX to Ix 2 to 4 ccm. ' lobelia fl. TTl j to V 0.05 to 0.30 ccm. ' lupulini fl. TTl V to XV 0.30 to I ccm. ' matico fl. TTl XXX to Ix 2 to 4 ccm. ' myricas fl. TTl XXX to Ix 2 to 4 ccm. ' nectandrcC fl. f 3 j to iv 4 to 16 ccm. ' nuc. vom. gr. \ to \\ 0,02 to 0.08 gm. ' nuc. vom. fl. Til I to iv 0.05 to 0.30 ccm. ' opii gr. \ to \ o.oi to 0.03 gm. ' papaveris gr. \ to ij 0.03 to o.io gm. ' papaveris fl. Til XV to xlv I to 3 ccm. ' pareirce fl. TTl XXX to Ix 2 to 4 ccm. ' petroselini fl. f 3 j to ij 4 to 8 ccm. ' physostigmce gr. tV to \ 0.004 to 0.01 gm. ' physostigmse fl. TTl j to iij 0.05 to 0.20 ccm. ' phytolaccae baccar. ii. TTlv to XXX 0.30 to 2 ccm. " * Phytolacca rac I. gr. j to iij 0.05 to 0.20 gm. DOSE TABLE. 151 Dose expressed in terms of Dose Remedies. apothecaries' expressed in weights and metric terms. measures. Extr. phytolaccse rad. fl. . TTlV to XXX 0.30 to 2 ccm. ' pilocarpi fl. TTixV to Ix I to 4 ccm. ' pimentae fl. ■ni,xv to xlv I to 3 ccm. ' piper nigr. fl. . TT^xv to xlv I to 3 ccm. ' podophylli gr. \ to \\ 0.03 to 0.08 gm. ' podophylli fl. . Tr[v to XXX 0.30 to 2.0 ccm. ' polygoni fl. TT^XV to XXX I to 2 ccm. * polygonati fl. . TTlv to XV 0.30 to I ccm. ' prun. virg. fl. . TTLxxx to Ix 2 to 4 ccm. ' quassise . gr. j to V 0.05 to 0.30 gm. ' quassiae fl. TlXxxx to Ix 2 to 4 ccm. ' quebracho fl. . TTix to Ix 0.60 to 4 ccm. ' quercus fl. TUxxx to Ix 2 to 4 ccm. ' rhamni cath. ft. fl. TT|,xxx to Ix 2 to 4 ccm. ' rhamni pursh. cort. fl. TTj,xxx to cxx 2 to 8 ccm. * rhei gr. V to XV 0.30 to I gm. ' rhei fl. . TTLxv to xlv I to 3 ccm. ' ricini fol. fl. . f 3 ss to ij 2 to 8 ccm. ' rutae fl. . TTLxv to XXX I to 2 ccm. ' sabinae fl. TUv to XV 0.30 to I ccm. ' sanguin. fl. TTiv to XV 0.30 to I ccm. ' santali citr. fl. f 3 j to ij 4 to 8 ccm. ' santonicae fl. . TUxv to Ix I to 4 ccm. ' sarsap. fl. f 3 ss to ij 2 to 8 ccm. ' sarsap. comp. fl. f 3 ss to ij 2 to 8 ccm. ' sassafras fl. f 3 ss to ij 2 to 8 ccm. ' Scillae fl. . TTiv to XXX 0.30 to 2 ccm. ' Scillae comp. fl. TTl^V to XXX 0.30 to 2 ccm. ' scoparii fl. f 3 ss to j 2 to 4 ccm. ' senegae fl. TTLv to XV 0.30 to I ccm. * sennae fl. f 3 j to iv 4 to 16 ccm. ' serpent, fl. TTLxxx to Ix 2 to 4 ccm. ' siraarubae fl. . fH^XV to XXX I to 2 ccm. * spigeliae fl. TTIXV to Ix I to 4 ccm. ' spigeliae et sennce fl f 3 ss to ij 2 to 8 ccm. ' stillingiae fl. f 3 ss to ij 2 to 8 ccm. ' stillingiae comp. f 3 ss to ij 2 to 8 ccm. * stramonii (Engl.) gr. \ to j 0.03 to 0.05 gm. ' stramonii fol. ale. gr. i to 1 0.02 to 0.04 gm. ' stramonii seiri. gr. i to 1 o.oi to 0.03 gm. 15^ CLIN I CA L DIA GNOSIS. Dose expressed in terms of Dose Remedies. apothecaries' expressed in weights metric terms. and measures. Extr stramonii fl. . TTlj to vi 0.05 to 0.40 ccm. " sumbul fl. TT|,xv to Ix I to 4 ccm. t ( taraxaci . gr. V to XV 0.30 to I gm. " taraxaci fl. f 3 S3 to ij 2 to 8 ccm. t ( toxicodendri fl. mj to V 0.05 to 0.30 ccm. < 1 trifol. prat. fl. f 3 j to ij 4 to 8 ccm. (< urticae rad. fl. . TTl^V to XV 0.30 to I ccm. < ( ustilag. maid. fl. TT[XV to Ix I to 4 ccm. " uvae ursi fl. TT^XXX to Ix 2 to 4 ccm. " valer. gr. V to XV 0.30 to I gm. ( < valer. fl. Tf|,xxx to Ix 2 to 4 ccm. " veratr. vir. fl. TT[ij to viij 0. 10 to 0.50 ccm. < 1 verbense fl. TTl^XV to Ix I to 4 ccm. " viburni opuli fl. f 3 j to ij 4 to 8 ccm. " viburni [prunifol] fl f 3 j to ij 4 to 8 ccm. " yerbse santae fl. f 3 i to 3 j I to 4 ccm. " zingiberis fl. TIlv to XXX 0.30 to 2 ccm. Ferr (( (< < I < 1 < 1 ( 1 arsen. benzoas . bromid. . carb. sacch. chlorid. . citr. et ammon. citr. et ammon. sulph. et ammon. tartr. et cinchonid. citr. et pot. tartr. . et quin. citr. . et strychnin, citr. ferrocyanid. hypophosphis . iodidum . iodidum sacch. lactas oxalas oxid. hydrat. . oxid. magnet. phosphas gr. -gV to \ gr. j to V gr. j to V gr. iv to XV gr. j to iij gr. V to X gr. V to X gr. V to X gr. V to XV gr. V to X gr. XV to Ix gr. V to X gr. j to XV gr. iij to V gr. V to X gr. j to V gr. ij to X gr. j to iij gr. j to iij § ss to ij gr. V to X gr. i to V 0.003 to 0.03 gm. 0.05 to 0.30 gm. 0.05 to 0.30 gm. 0.25 to I gm. 0.05 to 0.20 gm. 0.30 to 60 gm. 0.30 to 0.60 gm. 0.30 to 0.60 gm. 0.30 to I gm. 0.30 to 0.60 gm. I to 4 gm. 0.30 to 0.60 gm. 0.05 to I gm. 0.20 to 30 gm. 0.30 to 60 gm. 0.05 to 0.30 gm. 0. 10 to 0.60 gm. 0.05 to 0.20 gm. 0.05 to 0.20 gm. 15 to 60 ccm. 0.30 to 0.60 gm. 0.05 to 0.30 gm. (< hypophosphas f r gr. j to V 0.05 lo 0.30 gm, DOSE TABLE. DJ Dose expressed in terms of Dose Remedies. apothecaries' expressed in weights metric terms. and measures. Ferri sub-carb. .... gr. V to XXX 0.30 to 2 gm. " sulphas . gr. j to iij 0.05 to 0.20 gm. " sulphas exsiccat. gr. i to li 0.03 to 0.08 gm. " valer. gr. j to iij 0.05 to 0.20 gm. Ferrum ammoniat. , gr. V to X 0.30 to 0.60 gm. dialys. TT[j to XV 0.05 to I ccm. '• redact. gr. j to V 0.05 to 0.30 gm. Filix mas 3 j to ij 4 to 8 gm. Fuchsine . gr. j to iij 0.05 to 0.20 gm. Galla gr. X to XX 0.60 to 1.20 gm. Gambogia gr. ij to iij 0. 10 to 0.20 gm. Gentiana gr. X to XXX 0.60 to 2 gm. Guarana . gr. V to XXX 0.30 to 2 gm. Hydrarg. c. creta gr. V to X 0.30 to 0.60 gm. " chlor, cor res. gr. ^ to iV O.ooi to 0.005 gn^. " chlorid. mite gr. 1 to viij O.OI to 0.50 gm. " Cyanid. gr. iV to i 0.004 to 0.03 gm. " iodid. flav. gr. i to j O.OI to 0.05 gm. " iodid. rubr. gr. A to i 0.004 to 0.03 gm. " iodid. vir. gr. i to j O.OI to 0.05 gm. " oxid. flav. gr. j\ to i 0.004 to 0.03 gm. " oxid. nigr. gr. iV to j 0.005 to 0.05 gm. " oxid. rubr. gr. iV to i 0.004 to 0.03 gm. " subsulphas flav. gr. i to j 0.015 to 0.05 gm. " sulphureL. nigr. gr. V to X 0.30 to 0.60 gm. " sulphuret. rub. gr. V to X 0.30 to 60 gm. " c. magn. . gr. V to X 0.30 to 0.60 gm. Infusum brayerae 1 ! ij to viij 60 to 250 ccm. " buchu f!ij 60 ccm. " digitalis f 3 ij to iv 8 to 16 ccm. " eupatorii f!ij 60 ccm. " sennse comp. f ! j toij 30 to 60 ccm. ulmi . Aä libitum. Ad libitum. lodinum . . , . gr. I to j 0.015 to 0.05 gm. lodoformum gr. j to iij 0.05 to 0.20 gm. Ipecacuanha expect. gr. i to j O.OI to 0.05 gm. " emet. . gr. XV to XXX I to 2 gm. Jalapa gr. XV to XXX I to 2 gm. Juniperi baccae 3 j to ij 4 to 8 gm. Kairine .... gr. ij to X 0. 10 to 0.60 gm. 154 CLINICAL DIAGNOSIS. Dose expressed in terms of Dose Remedies. apothecaries' expressed in weights metric terms. and measures. Kino gr. X to XXX o.6o to 2 gm. Krameria . gr. X to XXX o.6o to 2 gm. Lacto-pepline . . gr. X o.6o gm. Lactucaiium . gr. iij to X 0.20 to o.6o gm. Liq. ammon. acet. . . f S ij to viij 8 to 25 ccm. " acidi arseniosi . iq^ij to vij 0. 10 to 0.50 ccm. " arsen. ethydr. iod. (Donovan's sol.) TTlij to vij o.io to 0.50 ccm. " ferri chloridi TTlij to X o.io to 0.60 ccm. " ferri dialys. ■rT[j to XV 0.05 to I ccm. " ferri nitrat. . TTlv to XV 0.30 to I ccm. " pepsini f 3 ij to iv 8 to 16 ccm. " potassse . TT^V to XXX 0.30 to 2 ccm. " potassii arsenit. (F owler's solution) TT[iij to vij 0.20 to 0.50 ccm. " potassii citrat. f 3 ij to iv 8 to 16 ccm. " sodse Tr[v to XXX 0.30 to 2 ccm. ' ' sodii arseniatis (Pearson's solution) TT^iij to vij 0.20 to 0.50 ccm. Lithii benzoas . gr. ij to v O.IO to 0.30 gm. " bromid. . gr. i to iij 0.05 to 0.20 gm. " carb. gr. ij to vi O.IO to 0.40 gm. " citr. gr. ij to V O.IO to 0.30 gm. " salicylas gr. ij to viij O.IO to 0.50 gm. Lobelia . gr. V to X 0.30 to 0.60 gm. Lupulinum gr. V to X 0.30 to 0.60 gm. Magnesia gr. XV to Ix I to 4 gm. Magnesii carb. gr. XV to Ix I to 4 gm. " citr. gran. 3 j to viij 4 to 32 gm. " sulphas 3 j to viij 4 to 32 gm. " sulphis gr. v to XXX 0.30 to 2 gm. Manganesii oxid. nig r. (binoxid.) gr. ij to X O.IO to 0.60 gm. sulphas . gr. ij to X O.IO to 0.60 gm. Manna f i to ij 30 to 60 gm. Massa copaibae gr. V to XXX 0.30 to 2 gm. *' ferri carb. gr. v to XV 0.30 to I gm. " hydrarg. gr. i to XV 0.05 to I gm. Mist ammoniaci f 3 iv to viij 15 to 30 ccm. " asafoetidse f 3 iv to viij 15 to 30 ccm. " chloroformi f 3 iv to viij 15 to 30 ccm. " cretae f!Jtoij 30 to 60 ccm. " ferri comp. f 3 ss to ij 15 to 60 ccm. " ferxi at ammon acet. f 1 ss to j 15 to 30 ccm. DOSE TABLE. 155 Dose expressed in terms of ' Dose Remedies. apothecaries' expressed in weights metric terms. and measures. Mist glycyrrh. comp. f 3 j to iv 4 to 16 ccm. " magnes. et asafoet. . f 3 j to iv 4 to 16 ccm. " potassii citn f 1 ss to ij 15 to 60 ccm. ' ' rhei et sodse f § ss to j 15 to 30 ccm. Morphiae murat. gr. i to i o.oi to 0.03 gm. sulph. gl-- i to 1 0.008 to 0.03 gm. " acetat. gr. i to i 0.01 to 0.03 gm. " sulph. liq. . f 3 j to iv 4 to 16 ccm. " sulph. liq. (Magendie TTl,ij to XV O.IO to I ccm. Moschus .... gr. V to X 0.30 to 0.60 gm. Myrrha .... gr. X to XX 0.60 to 1.20 gm. xNapthalin gr. j to ij 0.05 to O.IO gm. Xarceina .... gr. \ to ij O.OI to O.IO gm. Nicotia .... gr. eV to jV o.ooi to 0.025 gm. N itro-glycerinum gr. in to A 0.00 1 to 0.004 g'^^. Nux vomica gr. j to V 0.05 to 0.30 gm. Oleoresina asphidii . gr XV to Ix I to 4 gm. " capsici . gr. i to i 0.01 to 0.03 gm. " cubebae . ' gr. V to XXX 0.30 to 2 gm. " lupulini . gr. ij to V O.IO to 0.30 gm. " piperis . gr. i to iij 0.05 to 0.20 gm. " zingiberis gr. j to iij 0.05 to 0.20 gm. Oleum amygdal amar. Tflitoi 0.008 to 0.015 ccm. " anisi TTiij to V O.IO to 0.30 ccm. " cajuput TTiij to V O.IO to 0.30 ccm. " chenopodii ■nivto X 0.30 to 0.60 ccm. " copaibse TUviij to XV 0. 50 to I ccm. " cubebae TT[XV to XXX I to 2 ccm. " eriger . TT1,V to XV 0.30 to I ccm. " eucalypti TF\,x to XXX 0.60 to 2 ccm. limon. . TTLij to iv O.IO to 0.20 ccm. " morrhuse f 3 j to iv 4 to 16 ccm. *' olivae . . . f 3 j to iv 4 to 16 ccm. ' ' phosphoratum gr. j to iij 0.05 to 0.20 gm. " ricini f § j to iv 4 to 32 ccm. " sabinse . TTlj to iij 0.05 to 0.20 ccm. " terebinth. TT|, V to XXX 0.30 to 2 ccm. " tiglii . Tn,itoi 0.01 to 0.08 ccm. Opium, 14 % morphine gr. \ to 4 O.OI to 0.08 gm. Pareira . . , , 3 ss to j 2 to 4 gm. 156 CLnXICAL DIAGXOSIS. Dose expressed' in terms of i Dose Remedies. apothecaries' ■ expres>ed in weights ! and measures. metric terms. Paraldehyd. Tllxx to xl I.20 to 2.40 ccm. Pelletierine gr. V to XV 0.30 to I gm. Pepsinum purum gr. XV to 1 ss I to 15 gm. " saccharatum gr. XXX to 3 j 2 to 30 gm. Petroleum 3 ss to j 2 lo 4 gra. Phosphorus gr. T-k to ^V 0.0005 to 0.003 gm. Physostigminse salicyl gr. ^l^ to Jj, 0.0005 to 0.003 gm. ' ' sulphas gr. 3-k lo -h 0.0005 to 0.003 gm. Picrotoxinum . C- eV to I o.ooi to 0.02 gm. Pilocarpina and salts gl-- -^4 to i- o.ooi to 0.03 gm. Pil. aloes pil. j to iij pil. j to iv ' aloes et asafoet. " ij to V " ij to v ' aloes et ferri " j to iij " j to iij • aloes et mast. " j to iij " j to iij 1 aloes et myrrhs " ij to V " ij to V • antim, comp. " j to iij " j to iij ( asafoetidse . " j to vj " j to vj < cathart. comp. . " j to iv " j to iv • ferri comp. * " ij to v " ij to v • ferri iodidi " j to iv " j to iv • galbani comp. " j to V " j to V • hydrarg. gr. S3 to XV 0.025 to I gm. • opii . pil. j to ij pil. j to ij i phosphor! . " j to iv " j to iv ( rhei . " ij to V " ij to v " rhei comp. ' ' ij to V " ij to V Piperinum " gr. j to viij 0.05 to 0.50 g[n. Plumbi acetas . gr. i to iij 0.03 to 0.20 gm. ' ' iodidum gr. \ to iij 0.03 to 0.20 gm. Potassii acetas . gr. XV to Ix I to 4 gm. " bicarb. gr. v to Ix 0.30 to 4 gm. '' bichromat. . gr. i to i o.oi to 0.25 gm. ' * bitartr. gr. j to ij. 0.05 to 0.40 gm. " bromid. gr. v to Ix 0.30 to 4 gm. " carb. . gr. V to XXX 0.30 to 2 gm. " chloras gr. V to XXX 0.30 to 2 gm. " citras . . , gr. XV to Ix I to 4 gm. " Cyanid, gr- tV to 1 0.004 to o.ooS gm " et sodii tartr. 3 i- to j 15 to 30 gm. " ferrocyanid. . gr. X to XV 0.60 to I gm. DOSE TABLE. 157 Dose expressed in terms of Dose Remedies. apothecaries' expressed in weights metric terms. and measures. Potassii hypophosphis gr. V to XV 0.30 to I gm. " iodid. . gr. ij to XV 0. 10 to I gm. " nitras . gr. V to XV 0.30 to I gm. " permanganat. gr. ss to j 0.03 to 0.06 gm. " sulphas 3 j to iv 4 to 16 gm. " sulphidum . gr. j to X 0.05 to 0.60 gm. " sulphis gr. XV to XXX I to 2 gm. " sulphuret gr. ij to _vj 0. 10 to 0.40 gm. tartras 3 j to viij 4 to 30 gm. Prunus Virginia 3 ss to j 2 to 4 gm. Pulv. antimonialis . gr. iij to X 0.20 to 0,60 gm. " aromat. . gr. V to XXX 0.30 to 2 gm. " cretae comp. gr. V to XXX 0.30 to 2 gm. " glycyrrrh. comp. gr. XXX to Ix 2 to 4 gm. " ipecac, et opii (Dover) gr. V to XV 0.30 to I gm. " jalapa comp. . gr. xxx to Ix 2 to 4 gm. " morphinse comp. gr. V to XV 0.30 to I gm. " rhei comp. gr. XXX to Ix 2 to 4 gm. Quinidina (and salts) gr, j to xxx 0.05 to 2 gm. Quinina (and salts) . gr. j to xxx 0.05 to 2 gm. Quininae arsenias gr- \ to j o.oi to 0.05 gm. Resina copaibae gr. ij to x o.io to 0.60 gm. " jalapae gr. ij to V o.io to 0.30 gm. " podophylli . gr- \ to \ 0.008 to 0.03 gm. " scammonii . gr. ij to x O.IO to 0.60 gm. Resorcin ..... gr. V to xxx 0.30 to 2 gm. Rheum . gr. ij to XXX O.IO to 2 gm. Sabina gr. V to X 0.30 to 0.60 Salicinum gr. V to XXX 0.30 to 2 gm. Santoninum gr. j to V 0.05 to 0.30 gm. Sapo gr. V to XXX 0.30 to 2 gm. Scammonium gr. iij to XV 0.20 to I gm. Scilla gr. i to ij 0.05 to O.IO gm. Senega gr. X to XX 0.60 to 1.20 gm. Senna gr. V to Ix 0,30 to 4 gm. Serpentaria 3 j to ij 4 to 8 gm. Sinapis 3ij 8 gm. Sodii acetas gr. XV to Ix I to 4 gm. ' ' arsenias gr. Jj to iV o.ooi to 0.005 gm. " benzoas gr. V to XV 0.30 to I gm. 158 CLINICAL DIAGNOSIS. Remedies. Sodii bicarb. . •' bi sal phis ' ' boras bromid . carb. " carb. exsicc. ' ' chloras ' ' hypophosphis ' ' hj^osulpbis " iodidum . ' ' phosphas " salicylas . ' ' santonin as ' ' sulpbas *' sulphis Sparteinse sulph. Spigelia . Spir. sether. comp. " aether, nitrosi ' ' ammoniae " am^moniae arom ' ' camphors ' ' chlorof ormi " lavend. comp. " menth. pip. Stramonii folium Sirychnina and salts Siyrax Sulphur Syr. acidii hydriodidi allii *' calcii lactophos ' ' calcis " ferri bromidi " ferri iodidi " ferri oxidi " ferri hypophosph " fer. quin, et str. phos " hypophosphit. " hypophosph. c. fer. " ipecac. Dose expressed in terms of apothecaries' weights and measures V to XXX V to XXX V to XXX V to XXX V to XXX V to XV V to XXX V to XV V to XXX V to XV ij to y:^ V to XXX gr. ij to X gr. j to ij V. to XXX gr. gr. gr. gr. gr- gr- gr. gr. gr. gr. gr- 1 to i 4 "^^ 2 gr. gr. gr. X to I j TTl, XXX to Ix f 3 ss to ij TTl, V to XXX TTl, XV to XXX Tli V to XXX TTl XV to Ix TTl, XXX to Ix TTL XXX to Ix gr. j to ij gr. :^ to ^a^ gr. X to XX 3 ss to iv f 3 j to iv f 3 j to ij ni XV to XXX TTl XV to Ix m XV to Ix f 3j f3j f3j f3j f2j f 3 ss to iv Dose expressed in metric terms. 1 0.30 to 2 gm. 0.30 to 2 gm 0.30 to 2 gm 0.30 to 2 gm 0.30 to 2 gm 0.30 to I gm 0.30 to 2 gm 0.30 to I gm 0.30 to 2 gm 0.30 to I gm 0. 10 to I gm 0.30 to 2 gm o.io to 0.60 gm. 0.05 to 0.10 gm. 0.30 to 2 gm. o.oi to 0.03 gm. 0.60 to 30 gm. 2 to 4 ccm. 2 to 8 ccm. 0.30 to 2 ccm. I to 2 ccm. 0.30 to 2 ccm. I to 4 ccm. 2 to 4 ccm. 2 to 4 ccm. 0.05 to O.IO gm. o.ooi to 0.005 gin. 0.60 to 1.20 gm. 2 to 16 gm. 4 to 16 ccm. 4 to 8 ccm. I to 2 ccm. I to 4 ccm. I to 4 ccm. 4 ccm. 4 ccm. 1 '4 ccm. 4 ccm. 4 ccm. 2 to 16 ccm. DOSE TABLE. 159 Dose expressed in terms of Dose Remedies. apothecaries' expressed in weights metric terms. and measures. :>yr. krameri^e .... f 3 SS to iv 2 to 16 ccm. lactucarii f3j to iij 4 to 12 ccm. pruni virginianse f3j to ij 4 to 8 ccm. rhei f3j to iv 4 to 16 ccm. rhei arom. f3j to iv 4 to 16 ccm. rosae f3j to ij 4 to 8 ccm. rubi f3j to ij 4 to 8 ccm. sarsap. comp. . f 3 j to iv 4 to 16 ccm. Scillae f 3 ss to j 2 to 4 ccm. Scillae comp, (hive-sirup) Tr|, XV to Ix I to 4 ccm. senegse f 3 j to ij 4 to 8 ccm. " sennse f 3 j to iv 4 to 16 ccm. Testa prasparata gr. V to XX 0.30 to 1.20 gm. Thallin .... gr. iv to viij 0.25 to 0.50 gm. Tiiict. aconiti fol. TTLviij to xvj 0.50 to I ccm. ' aconiti rad. . TTljtO V 0.05 to 30 ccm. ' Jicon. rad. (Flemings) TT[| to ijSS 0.04 to 0.15 ccm. ' aloes (18S0) . f 3 ss to ij 2 to 8 ccm. ' aloes et myrrhae f 3 i to ij 4 to 8 ccm. ' arnicce flor. . Tllv to XXX 0.30 to 2 ccm. ' arnicoe rad. . TTI,XV to XXX I to 2 ccm. ' asafcetidse TT|,xxx to Ix 2 to 4 ccm. ' belladonnce . Tr[v to XV 0.30 to I ccm. calumbee f 3 i to iv 4 to 16 ccm. ' cannabis ind. TT[XV to XXX I to 2 ccm. ' cantharid. TTlv to XV 0.30 to I ccm. ' capsici . TTl,V to XV 0.30 to I ccm. cardamomi f3i 4 ccm. ' cardamomi comp. . f3i 4 ccm. * catechu comp. f 3 ss to ij 2 to 8 ccm. ' Cimicifugae TTlxxX to Ix 2 to 4 ccm. ' cinchonae f 3 ss to ij 2 to 8 ccm. ' cinchonae comp. f 3 ss to ij 2 to 8 ccm. ' colchici rad. . TTLv to XV 0.30 to I ccm. ' colchici sem. Tn^v to XV 0.30 to I ccm. ' conii TTlv to XXX 0.30 to 2 ccm. ' cubebce . f 3 j to ij 4 to 8 ccm. ' digitalis TiXv to XV 9.30 to r ccm. ' ferri acet. Tri,xv to XXX I to 2 ccm. * ferri chloridi TTlx to Ix 0.60 to 4 ccm. i6o CLINICAL DIAGNOSIS. Dose expressed in terms of Dose Remedies. apothecaries* expressc'l in weights metric term,. and measures. Tinct. ferii chloricli aether. ITixV to XXX I to 2 ccm. ' ferri pomati . TTLxv to Ix I to 4 ccm. gallse f 3 ss to ij 2 to 8 ccm. ' gelsemii Tllv to XV 0.30 to I ccm. ' gentian comp. f 3 ss to 3 ij 2 to 8 ccm. ' guaiaci . TTixxx to Ix 2 to 4 ccm. ' guaiaci ammon. TUxxx to Ix 2 to 4 ccm. ' hellebori TTix to XV 0.30 to I ccm. ' humuli . f 3 j to ij 4 to 8 ccm. ' hydrastis TTLxxx to xc 2 to 6 ccm. * hyoscyami fol. TTLxv to Ix I to 4 ccm. ' hyoscyami sem. TTl,xv to XXX I to 2 ccm. ' ignati^ . TT[V to XV 0.30 to I ccm. ' iodini . TTlv to X 0.30 to 0.60 ccm. ' iodini comp. . TTiij to X 0.12 to 0.60 ccm. ' ipecac, et opii TT[v to XV 0.30 to I ccm. ' jalapse . f 3 ss to ij 2 to 8 ccm. ' kino f 3 ss to ij 2 to 8 ccm. ' kramericC f 3 ss to ij 2 to 8 ccm. ' lavend. comp. f 3 ss to ij 2 to 8 ccm. ' lobelias . "n[xv to xlv I to 3 ccm. ' lupulini . f 3 ss to ij 2 to 8 ccm. ' matico . f 3 ss to ij 2 to 8 ccm. ' moschi . TT[xv to Ix T to 4 ccm. ' myrrhae f 3 ss to j 2 to 4 ccm. ' nuc. vomicae . TFi,v to xlv 0.30 to 3 ccm. ' opii TT^v to XV 0.30 to I ccm. ' opii camph. . niv to Ixxv 0.30 to 5 ccm. * phytolaccce TUv to Ix 0.30 to 4 ccm. ' physostigmatis Tri,v to XV 0.30 to I ccm. ' quassiae f 3 ss to ij 2 to 8 ccm. " ' rhei f 3 j to viij 4 to 30 ccm. ' rhei arom. TT|,xxx to Ixxv 2 to 5 ccm. ' rhei dulc. f 3 j to iv 4 to 16 ccm. ' sanguinarias . Tr|,xv to Ix I to 4 ccm. * Scillae TTLv to Ix 0.30 to 4 ccm. * serpentariae . f 3 ss to ij 2 to 8 ccm. ' stramon. fol. TT^v to XV 0.30 to I ccm. ' stramon. sem. TTlv to XV 0.30 to I ccm. ' strophanthi . Tltij to vj o.io to 0.40 ccm. DOSE TABLE. I6l Dose expressed in terms of Dose Remedies. apothecaries' expressed in weights metric terms. and measures. Tinct. sumbul. .... TT1,V to XXX 0.30 to 2 ccm. ' ' valer. f 3 ss to ij 2 to 8 ccm. '■ valer. ammon f 3 ss to ij 2 to 8 ccm. " veratr. vir. Tiliij to X 0.20 to 0.60 ccm. ' ' zingiberis Tr|,xv to Ix I to 4 ccm. Trinitrine (nitroglyce jrine) TTlj to iij 0.05 to 0.20 ccm. Ureihan . gr. XV to Ix I to 4 gm. Uva ursi . 3 ss to j 2 to 4 gm. Verat. alb. gr. j to iij 0.05 to 20 gm. Veratria . gr- iV to i 0.005 to 0.02 gm. Zinci acet. gr. j to ij 0.05 to o.io gm. " bromid. gr. \ to ij 0.03 to o.io gm. ' ' Cyanid. gr- iV to i 0.055 to 0.015 gm. ' ' iodid. gr. \ to iij 0.03 to 0.20 gm. ' ' oxid. gr. I to X 0.05 to 0.60 gm. ' ' phosphid gr- iV to i 0.005 to o.oi gm. " sulphas (emetic) gr. XV to XXX I to 2 gm. " valerianas gr. j to v 0.05 to 0.30 gm.] INDEX. Abbe's condenser, 105 Abdomen, 62 Acarus folliculorum, loi " scabiei, 100 Acetone, 85 " test for, 85 Achorion Schoenleinii, loi Acid, amido-caproic, 87 *' a m i d o-hydroparacumaric, aromatic oxi-, 73 carbolic, 73 carbonic, 75 chrysophanic, 89 diacetic, 86 hippuric, 73 hydrochloric, 74 muriatic, 74 oxalic, 73 phosphoric, 75 sulphuric, 75 " test for, 75 uric, 71 " test for, 73 Actinomycosis, examination of, 107 " in sputum, 36 ^gophony, 30 Air, complemental, 21 " ordinary breathing, 21 " reserve, 21 " residual, 21 Albumen, 77 ** acetic acid and ferro- cyanide of potassium, test for, 78 " amount used, 136 " " set free, 136 Albumen, biuret test for, 78 " heat test for, 77 " Heller's test for, 77 " picric acid test for, 78 Ammonia, 76 " test for, 132 Amoeba coli, loi Anaemia, progressive perni- cious, 7 " secondary, 6 Anaesthesia, 108 Analgesia, no Anasarca, 92 Anguillula intestinalis, gg Angulus Ludovici, 16 Aniline colors, 104 Ankylostomum duodenale, gg Anode, 115 Apnoea, 20 Arthropodes, 100 Ascaris lumbricoides, g8 Ascites, 92 Aspergillus glaucus, 102 " niger, 102 " threads in sputum, 36 Ataxia, II2 Auscultation, 27 Balantidium or paramaecium coli, lOI Bacillus anthracis in sputum, 36 Bacillus or rod, 102 Bacteria, 102 Biermer, 26 Bile, 80 " coloring matter of, 80 Bilirubin, 80 " Gmelin's test for, 80 163 164 CLINICAL DIAGNOSIS. Biliverdin, 80 Biuret reaction, 70 Bizzozero, 3 Bladder, 67 Blood, amount of haemoglobin in, I " bacilli anthracis in, 7 *' " leprae in, 7 " examination of the, 4 " micro-organisms in, 7 " quantity of, i " reaction of, I " specific gravity of, I " spirilla of recurrent fever in, 7 " tubercle bacilli in, 7 " in urine, 79 Blood corpuscles, dwarf, 2 " " enumeration of, 5 " giant, 2 " " proportion between red and white, 5 Blood-plaques, 3 Blood-vessels, auscultation of, 48 Bothriocephalus latus, 97 Bouchut, 5 Brain and spinal cord, 124 Breast, chicken, 16 " cobbler's, 16 " funnel, 16 Breathing sound, 27 " amphoric, 27, 28 " bronchial, 27, 28 " changes in the fre- quency of, 20 " increase in the fre- quency of, 20 " undetermined, 27, 28 " vesicular, 27 Bronchophony, 29 Bruit de pot fele, 21 Burdach, 123 Calcium, 76 " sulphate of, 76 Calculi, faecal, 134 " salivary, 134 Casts in urine, 90 Centre for arm, 124 Centre for face, 124 leg, 124 " sense of sight, 124 " speech, 124 Cercomonas intestinalis, loi Cestodes, 96 Charcot, 36, 65 Chest, circumference of, 18 " enlargement of, 18 " topography of, 16 Cheyne, 20 Cheyne-Stokes respiration, 20 Chicken-pox, 12 Chlorosis, 7 Choletelin, 80 Choreic movements, 113 Clavicle, 16 Clonus, foot, 122 " patellar, 122 Coccus, 102 Coefiicient of Häser, 68 Concrements, analysis of the pathological, 132 " urinary, 132 Condenser, Abbe's, 105 Convulsions, 112 Creatinine, 73 Cressol, 73 Crisis, 9 Crystals, Charcot-Leyden, in sputum, 36 *' Cholesterine, in spu- tum, 36 ' ' fatty acid, in sputum, 35 " leucine, in sputum, 36 " tyrosine, in sputum, 36 Current, constant, 113 " density of, 113 " faradic, 113 " galvanic, 113 " intensity of, 113 " interrupted, 113 " strength of, 113 Curschmann, 35 Cypho-scoliosis, 16 Cyphosis, 16 Cysticercus cellulosae, 97 Cystin, 133 •' test for, 133 INDEX. 165 Dextrose, 81 " bismuth test for, 84 " Böttger's test for, 84 " Fehling's test for, 83 " fermentation test for, 81 " Moore's test for, 82 Mulder's test for, 84 " Phenylhydrazin test for, 84 " polarization test for, 8 5 " quantitative test for, 83 " reduction tests for, 82 " Trommer'stest for, 82 Diacetic acid, 86 " test for, 86 Diagnosis, by means of electrici- ty, 113 Diazoreaction, 86 Diet of sustenance, 136 Distomum haematobium, 100 " hepaticum, 100 " lanceolatum, 100 Dose table, 144 Dubrisay, 5 Ductus arteriosus Botalli, 44 Dulness, cardiac, 43 Duperie, 5 Dyspnoea, 19 " expiratory, 19 " inspiratory, 19 " mixed form of, 20 Ehrlich, 3, 4, 105 Electrodes, 113 Elementary granular masses, 3 Eosinophile cells, 4 Epithelium, alveolar, in sputum, 34 " cylindrical, in spu- tum, 34 " pavement, in spu- tum, 34 " in sputum, 89-90 Erysipelas, 15 Ewald, 57 Exner, 39 Fastigium, g Fat 87 Favus fungus, loi Faeces, 63 " in cholera, 65 " color of, 64 " consistence of, 63 " crystals in, 65 "of Charcot-Neu- mann in, 65 " digestive juices in, 63 " in dysentery, 65 " epithelium in, 66 fat in, 65 " leucocytes in, 65 " micro-organisms. 66 " mucus in, 64 " products of excretion in, 63 " red-blood corpuscles in, " remains of food in, 63, 65 " in typhoid fever, 65 Febris continua, 9 " intermittens 9, 14 " recurrens, 13 " remittens, 9 Fermentation tubes, 82 Fever, considerable, 8 " high, 8 " intermittent, 14 " malarial, 14 • " moderate, 8 *' recurrent, 13 " scarlet, 10 " slight, 8 " typhoid, 12 " _ typhus, 13 Filaria medinensis, 100 " sanguinis, 99 Fluid, battery, 115 diluting, 5 Flea, loi Food, absorption of, 142 " composition of, 142 Formula of Reuss, 92 Fremitus, pectoral, 31 " vocal, 31 " pericardial, 42 " pleuritic, 30 " Friedländer, 107 1 66 CLINICAL DIAGNOSIS. Gallic acid, Pettenkoffer's test for, 8i Gall-stones, 134 Gastric juice, amount of acid in, " " digesting strength of, 59 Gerhardt, 26 Gibbus, 16 Gmelin, 64 Gonococci, staining of, 107 Gram, 2, 106 Grape sugar, 81 bismuth test for, 84 Böttger's test for, 84 Fehling's test for, fermentation test for, 81 Moore's test for, 82 Mulder's test for, 84 Phenylhydrazin test for, 84 polarization test for, 85 quantitative test for, 83 reduction tests for, 82 Trommer's test for, 82 Gypsum, 76 Haematin, I Hsematoblasts, 3 Hsematoidin in sputum, 35 Haematuria, 79 Haemin, i Haemoglobin, i Hemoglobinuria, 79 Haser, coefficient of, 68 Halla, 5 Harrison, 17 Harrison furrow, 17 Hay em, 3, 5 Heart, apex beat of the, 41 Heart, auscultation of the, 45 " inspection and palpation of, 41 Heart, movements of the, 42 " percussion of the, 43 " sounds of the, 45 Heart murmurs, 46 " " diastolic, 46 ** " endocardial, 47 " " pericardial, 47 " friction, . 47 ** " presystolic, 46 " " strength of, 46 " " systolic, 47 Heart sounds, metallic 46 " " reduplication of the, 46 " " reduplication of the first, 46 Hemialbumose, 78 " test for, 78 Hemianopsia, 124 Hemiplegia, iii Herpes circinatus, loi " tonsurans, loi Hippocrates, 30 Hoffmann, 141 Human body, table of the weight and height of, 143 Hydrobilirubin, 80 " test for, 81 Hydrocele, 92 Hydrocephalus, 92 Hydronephrosis, 94 Hydro-quinone, 73 Hydrothorax, 92 Hypersesthesia, 108 Hyperpyrexia, 9 Hyphomycetes, loi Hypochrondrium, 17 Hypoxanthine, 73 Indican, 73 " test for, 74 Inspiration, duration of expira- tion and, 19 Iron, 77 Itch-insect, 100 INDEX. 167 Kidneys, 67 Koch, 106 König, 141 Kronecker, 57 Laache, 5 Lactose, 85 Laryngoscopy, 37 Larynx, 37 " auscultation of the, 37 " muscles of the, 38 " nerves of the, 38 " percussion of the, 37 Law, Ohm's, 116 Leptothrix forms, 103 " threads in sputum, 36 Leube, 58 Leucaemia, 6 " lymphatic, 6 Leucine, 87 Leuckart 99 Leucocytes, 3 " pigment containing, 7 " in sputum, 34 " in urine, 89 Leucocytosis, 6 Leyden, 36 Line, anterior axillary, 17 " costo-articular, 17 " mammary, 17 *' median, 17 " middle axillary, 17 " parasternal, 17 *' posterior axillary, 17 " scapula, 17 Liver, 60 " position of, 60 Lordosis, 16 Louse, body, loi " crab, loi " head, loi Lung, apex of the, 21 " dulness over the, 23 " lower border of, 22 " movement of the, 22 " normal boundaries of, 21 " topography of the lobes of the, 22 Lung, total capacity of, 20 " upper boundary of, 21 Lymphocytes, 3 Lysis, 9 Magnesium, 76 Malaria, 14 Malassez, 5 Measles, 10 Meinert, 137 Melanine, 87 test for, 87 Meltzer, 57 Metabolism and nutrition, 136 Microcytes, 2 Micro-organisms, 7 " coloring of, 104 '* Gram's method of staining, 106 " in sputum, 36 *' " urine, 91 Microsporon furfur, loi " minutissimum, 102 Mohrenheim, 16 Mohrenheim's groove, 16 Moleschott, 5 Monoplegia, 11 1 Morbilli, 10 Motility, testing the, iii Motor symptoms of irritation, 112 Müller, F., 141 Narrowing, expiratory, ig Nematodes, 98 Nerves, cranial, 127 " dorsal, 131 " spinal, 129 Nervi thoracici anteriores, 129 Nervous system, most important clinical points in the anatomy of the, 124 Nervus abducens, 128 " accessorius, 128 " acusticus, 128 " axillary, 129 " cutaneus medialis, 129 " " medius, 129 1 68 CLINICAL DIAGNOSIS. Nervus dorsalis scapulae, 129 " facialis, 128 " glossopharj'ngeus, 128 " h}^oglossus, 128 I " ischiadicus, 131 *' medianus, 129 " musculocutaneus, I2g " oculomotorius, 127 " olfactorius, 127 " opticus, 127 " radialis, 130 " subscapulariS, 1 29 " suprascapularis, 129 " thoracicus longus, 129 " trigeminus, 128 " trochlearis, 128 " ulnaris, 130 " vagus, 128 Neumann, 65 Neuralgia, 108 Nothnagel, 64 Nystagmus, 113 CEsophagus, 56 " auscultation of, 56 " length of, 56 Ohm's law, 116 Organs, digestive and abdominal, 55 " genito-urinary, 67 Oidium albicans, 102 Otto, 5 Ovarian cyst, 94 Oxyuris vermicularis, 98 Parsesthesia, 108 Paradox contraction, 123 Paralysis, in " central, 126 " functional, 112 " peripheral, 126 Paraplegia, in, 126 Parasites, 96 " animal, 96 " " in sputum, 36 " vegetable, loi Paresis, in Pectoriloquy, 30 Pediculus capitis, loi Pediculus pubis, loi " vestimenti, loi Peptones, 79 " test for, 79 Percussion note, Biermer's change of, 26 height and depth of, 25 Percussion tone, Gerhardt 's change of, 26 " " respiratory change of, 26 Phenols, 73 Playfair, 137 Plexus brachialis, 129 " cervicalis, 129 " lumbalis, 131 " sacralis, 131 Pneumonia crouposa, 15 Pneumonococcus in sputum, 36 *' staining of, 107 Poikilocytes, 2 Pole, active, 113 " different, 113 " indifferent, 113 " non-active, 113 Potassium, 76 '* sulpho-cyanide of, 73 Propeptone, 78 Protozoa, loi Pseudoleucasmia, 6 Pulex irritans, loi Pulse, 50 capillary, 43 " dicrotic, 53 " frequency of, 50 " fulness of, 51 " hardness of, 52 " hyperdicrotic, 53 " monocrotic, 53 " quickness, 51 " rhythm of, 50 " size of, 51 " subdicrotic, 53 venous, 43, 53, 54 Rales, 28 " crepitant, 29 INDEX. 169 Rales, dry, 29 " metallic, 29 " metallic tinkling, 29 " moist, 29 " mucous, 29 " non-metallic, 29 " sub-crepitant, 29 Reaction of degeneration, 120 " " " complete, 120 " " " partial, 120 Recurrent fever, 13 Red blood corpuscles, increase in number of, 7 nucleated, 3 number of, 5 size of, I in sputum, 35 " urine, 89 Reflex of the abdominal, gluteal, and scapular regions, 122 Reflex, cremaster, 122 " exaggerated tendon, 112 " extinguished, 123 " increased, 123 " patellar, 122 " pupil, 123 " sexual, 123 " skin, 121 " ot the sole of the foot, 1 22 " of the tendo Achillis, 122 Reflexes, tendon, 122 Renk, 141 Respiration, Cheyne-Stokes, 20 " jerking, 27 ** metamorphosing, 27, 28 ** normal relation be- tween the fre- quency of pulse and, 18 " number of, 18 " organs of, 16 '* puerile, 27 *' retarding of, 20 " systolic vesicular, 27 Reuss, 92 Rhabdonema strongyloides, 99 Romberg, iii Romberg, symptom of, in Round worms, 98 Rubner, 139, 141 Saliva, 56 " constituents of, 56 " diastatic ferment of, 56 " reaction of, 56 " specific gravity of, 56 Sarcina in sputum, 36 Scapula, 16 Scarlatina, 10 Scarlet-fever, 10 Schizomycetes, 102 Sense, of force, no " of locality, 108, 109 " muscular, 109 " of position, in " of pressure, 109 " of temperature, no Sensibility, 108 " electro-cutaneous, no " to pain, no Sensitiveness of the deep parts, no Small-pox, II Space, interscapular, 17 Spasm, 112 " clonic, 112 " tonic, 112 Sodium, 76 Sound, clear, 21 " cracked-pot, 21, 23 " deep, 21 •' dull, 21 " empty, 21 " full, 21 " high, 21 " metallic, 21, 25 " non-tympanitic, 21 " tympanitic, 21, 24 Spirillum, 103 Spirometry, 20 Spleen, 61 " position of, 61 Sputum, 32 " actinomycosis in, 36 " alveolar epithelium in, 34 I/o CLINICAL DIAGNOSIS. Sputum, amount of, 34 " animal parasites in, 36 " aspergillus threads in, 36 " , bacilli anthracis in, 36 " black, 34 " bloody, 32 " blue-colored, 33 " bronchial casts in, 35 " Cholesterine crystals in, 36 " Charcot-Leyden crys- tals in, 36 " color of, 33 " consistency of, 33 " Curschmann's spirals in 35 " cylindrical epithelium in, 34 " elastic fibres in, 35 " fatty acid crystals in, 35 " green, 33 " haematoidin in, 35 ' ' leptothrix threads in, 36 " leucine crystals in, 36 " leucocytes in, 34 " lung parenchyma, 35 " micro-organisms in, 36 " morphological constitu- ents of, 34 " muco-purulent, 32 " mucous, 32 ' ' pavement epithelium in, 34 " pneumonococcus in, 36 " purulent, 32 " " constituents of, 32 " purulo-mucous, 32 " reaction of, 34 red, 34 " red-blood corpuscles in, 35 " sanguineo-mucous, 32 " sanguineo-serous, 32 " sarcinse in, 36 " serous, 32 " smell of, 33 '* tubercle bacilli in, 36 Sputum, tyrosine crystals in, 36 " yellow ochre, 33, 34 Stadium decrementi, 9 " incrementi, 9 Stage of incubation, 9 " prodromal, 9 Sternum, 16 Stokes, 20 Stomach, 57 " digesting strength of, " examination of the contents of, 58 " percussion of, 57 " position of, 57 " size of, 57 " tumors of, 58 Substances, non-nitrogenous, 138 Succussio Hippocratis, 30 Sugar of milk, 85 Sulphuretted hydrogen, 87 " test for, 87 System, circulatory, 41 " nervous, 108 " urine-producing, 67 Table, dose, 144 Tsenia cucumerina, 97 " echinococcus, 97 " flavopunctata, 97 " nana, 97 " saginata s. mediocanel- lata, 97 " solium, 96 Tape-worm, 96 Teeth, 55 milk, 55 " permanent, 55 Teichmann's crystals, I Temperature, 8 " of collapse, 8 sub-febrile, 8 Tension, diminished, iii " increased, iii Test for acetone, 85 *' " albumen, acetic acid, and ferrocya- nide of potas- sium test, 7§ INDEX. 171 Test for albumen, biuret test, 78 " " " heat test, 77 " " " Heller's test, < ' ♦ * " p i c r i c-a cid test, 78 " " ammonia, 132 " '* antipyrin, 89 " " arsenic, 88 " " bile, Gmelin's test, 80 " " " Pettenkoffer's test, 81 " " blood, guaiac test, 80 " " " Heller's test, 80 " " bromine, 87 " " carbolic acid, 88 " " cystine, 133 " " diacetic acid, " " drugs, 87 " " grape sugar, test, 84 " " grape sugar, test, 84 " " grape sugar, test, 83 " *' grape sugar, tiontest, 81 " " grape sugar, Moore's test, 82 " " grape sugar, Mulder's test, 84 *' " grape sugar, Phenylhy- drazin test for, 84 " " grape sugar, polariza- tion test for, 85 " " grape sugar, reduction tests for, 82 " " grape sugar, Trommer's test, 82 " " iodine, 87 " " kairin, 89 " " lead, 88 " " lithium, 88 " " melanine, 87 " " murexide, 132 " " nitric acid, 88 " " quinine, 88 " " rhubarb, 89 •* " salicylic acid, 89 86 bismuth Böttger's Fehling's fermenta- Test for santonine, 89 " " senna, 89 " " sulphuretted hydrogen, 87 " " tannin, 89 " " thallin, 89 " '* turpentine, 89 " " uric acid, 132 " " xanthine, 133 Testing the sensibility, 112 Tetanus, 112 Thoma, 5 Thorax, breadth of, 17 " height of, 17 " narrow, 18 " percussion of, 21 " size of, 17 Thrush fungus, 102 Touch sense, 108 Transudations and exudations, 92 Transudations and exudations, albumen in, 92 Transudations and exudations, contents of, 93 Transudations and exudations, specific gravity of, 92 Traube, half-moon shaped space of, 57 Trematodes, 100 Tremors, 112 Trichina spiralis, 99 Tricocephalus dispar, 98 Trichomonas intestinalis, loi " vaginalis, loi Triple phosphates, 76 Trychophyton tonsurans, loi Typhus abdominalis, 12 " exanthematicus, 13 Typhoid fever, 12 Typhus fever, 13 Tyrosine, 87 Tuberclebacilli, Ehrlich'smethod of staining, 105 " " in sputum, 36 " " in Weigert- Koch's fluid for staining, 106 Urea, 70 " test for, 70 1/2 CLINICAL DIAGNOSIS. Uric acid, test for, 132 Urine, 67 acetone in, 85 albumen in, 77 amido-caproic acid in, 87 amido - hydroparacumaric acid in, 87 ammonia in, 76 amount of, 68 animal parasites in, gi antipyrin in, 89 arsenic in, 88 bile in, 80, 81 blood in, 79 " " guaiac test for, 80 blood in. Heller's test for, 80 blood in, microscopical test for, 80 bromine in, 87 calcium in, 76 carbolic acid in, 88 carbonic acid in, 75 casts in, 90 chrysophanic acid in, 89 cystine in, 87 dextrose in, 81 diacetic acid in, 86 drugs in, 87 epithelium in, 89, 90 fat in, 87 grape sugar in, 81 g^'psum in, 76 heniialbumose in, 78 hydrochloric acid in, 74 inorganic constituents of, 74 inosite in, 85 iodine in, 87 iron in, 77 kairin in, 89 lactose in, 85 lead in, 88 leucocytes in, 89 lithium in, 88 magnesium in, 76 melanine in, 87 mercur)' in, 88 Urine, micro-organisms in, 91 ** nitric acid in, 88 " normal constituents of , 70 " organic sediment in, 89 " pathological constituents of, 77 . " peptones in, 79 " phosphoric acid in, 75 " potassium in, 76 " propeptone in, 78 " quinine in, 88 " reaction of, 68 " red blood corpuscles in, 83 " rhubarb in, 89 " salicylic acid in, 8g " santonin in, 89 *' senna in, 89 " sodium in, 76 " specific gravity of, 68 " sugar of milk in, 85 ' ' sulphuretted hydrogen in, ^7 . . . " sulphuric acid in, 75 " tannin in, 89 " thallin in, 89 " turpentine in, 89 " tyrosine in, 87 Urobilin, 80 Valves, aortic, 45 " mitral, 45 " pulmonar)% 45 " tricuspid, 45 Varicella, 12 Variola, 11 Varioloid, ii Variolois, II Vertebral column, 16 Vibrio, or curved rod, 102 Vocal cords, closure of the, 38 " " paralysis of the, 39 " " tension of the, 38 " " -widening of the, 38 Voice, 37 " auscultation of, 29 " bass, 37 " closed nasal, 37 " diphthonic, 37 " falsetto, 37 INDEX. 173 Voice, hoarse, 37 " metallic, 30 " open nasal, 37 " tripartite, 37 " want of, 37 " weak, 37 V. Voit, 137, 140, 141 Vomitus, blood in, 59 ' ' carbonate of ammonia in, 60 epithelium in, 60 gall in, 60 leucocytes in, 60 mucus in, 59 oidium albicans, 60 remains of food in, 60 sarcinae in, 60 schizomycetes in, 60 swallowed saliva in, 59. urea in, 60 yeast cells in, 60 Voussure, 42 Weigert, 106 Welker, 5 Westphal, 123 White blood corpuscles, 3 " " " large mono- nuclear, 3 " large poly- nuclear, 3 " " " number of, 5 Wintrich, 26 Worms, flat, 100 " round, 98 '* small thread, 98 " tape, 96 " whip, 98 Wunderlich, 8 Xanthine, 73 " test for, 133 Yeast fungi, 102 Zeiss, 5 JPUSLICATJONS OF G. P. PUTNAM'S SONS. Students' Manuals. MANN. A Manual of Prescription Writing. By Matthew D. Mann, M. D., Late Examiner in Materia Medica and Therapeutics in the College of Physicians and Surgeons, New York. Fourth edition. Revised, enlarged, and corrected according to the U. S. Pharmacopoeia of 1880. i6mo, cloth ........ $1 00 This book is meant to supply a want which, has been greatly felt by American medical students and junior practitioners, viz, : a text-book which should contain clear and concise directions for correctly composing and writing prescriptions. " It should be in the hands of every physician and student in the countrj'." — Medical Record, January, 1879. PRUDDEN. A Manual of Practical Normal Histology. By T. Mitchell Prudden, M. D., Director of the Physiological and Patho- logical Laboratory of the Alumni Association of the College of Physi- cians and Surgeons, N. Y., etc., etc. i6mo, cloth . . . $1.25 " It seems to be thoroughly up with the present state of histology, is clearly written, and convenient in shape, and I have no doubt will be highly useful to the working student. I shall take great pleasure in recommending it to those enquiring for a guide of this kind." — Prof. Jas. Tyson, M. D., University of Pennsylvania. AMIDON. The Student's Manual of Rational Electro-Therapeu- tics. By R. W. Amidon, A. M., M. D., Lecturer on Therapeutics at the Woman's Medical College of the New York Infirmary, etc. , etc. , With diagrammatic illustrations. i6mo, cloth . • . . $1 00 " Undoubtedly, a most valuable little book for the student and busy pactitioner." — Western Medical Reporter. BULKLEY. The Student's Manual of Diseases of the Skin. By L. D. BuLKLEY, M. D. $1 25 " Comprehensive and practical." — American Practitioner, LEFFERTS. Pharmacopoeia for the Treatment of Diseases of the Larynx, Pharynx, and Nasal Passages. With remarks on the selection of remedies, choice of instruments, and methods of making local applications. By Geo. M. Lefferts, M. D. i6mo, cloth $1 00 " A convenient book for the general practitioner . . . and has the stamp of originality in that it embodies the fruits of Dr, Leffert's ripe experi- ence, " — American Practitioner, PUBLICATIONS OF G. P. PUTNAM'S SONS. STURGIS. The Student's Manual of Venereal Diseases, being the University Lectures delivered at Charity Hospital, B. I., during the Winter Session of 1S79-80. By F. S. Sturgis, M. D., Clinical Lect- urer on Venereal Diseases in the Medical Department of the University of the City of New York, etc., etc. Fourth edition. i6mo, cloth, $i 25 " Students and Physicians, buy this book ! Do not merely take it from library. It is cheap, it is complete, it is correct. It will be long before another book of this kind need appear to enter into competition with this one, which entirely supplies a long-felt need." — Boston Aled. and Surg. your. FRIEDLAENDER. Manual of Microscopical Technology, for use in the Investigations of Medicine and Pathological Anatomy. By Carl FRIEDLAENDER, M. D. Translated, with American Additions, by S. Y. Howell, M. D. Illustrated. i6mo, cloth . . . . $1 00 KITCHEN. The Student's Manual of Diseases of the Nose and Throat. By J. M. W. Kitchen, M. D. Illustrated. i6mo, cloth $1 00 Prof. Wm. A. Hammond writes : "It appears to be just what is needed by the general practitioner, and will doubtless have a wide circulation," " A well-arranged and valuable manual on this important specialty. The author has a correct view of the matter." — Med. Herald, St. Joseph, Mo. CUTLER. Manual of Differential Medical Diagnosis. By Condict W. Cutler, M. D. i6mo, cloth $1 25 " This manual has decided merit, and will commend itself to everyone engaged in the study of Medicine. . . . The author displays rare skill and judgment in contrasting disease. His differentiation is clear, but not too sharply drawn, and displays extensive labor and research as well as practical knowledge." — N. Y. Medical Journal, Oct., 30, 1886. CUTLER. Differential Diagnosis of Diseases of the Skin. By Condict W. Cutler, M. S. M. D., Attending Physician to the New York Dispensary, Assistant Surgeon to the Skin Department, N. Y. Hospital. Author of " Manual of Differential Medical Diagnosis," etc. MORRIS. How We Treat Wounds To-Day. A Treatise on the subject of Antiseptic Surgery which can be Understood by Beginners. By Robert T. Morris, M. D. 4th edition. i6mo, cloth . $1 00 " The author has done his task well." — N. Y. Medical Record. UPSHUR. Disorders of Menstruation (Student' Manual of). A Practical Treatise. By John N. Upshur, M. D., Professor Medical College of Virginia. i6mo, cloth $1 25 " Contains many valuable hints." — Medical Record. " Will prove a most useful little volume." — Nashville Jour, of Medicine and Surgery. G. P. PUTNAM'S SONS, Publishers. NEW YORK: LONDON ; 27 and 29 Wßst 23cj Street, 27 King William Street, Strand, PUBLICATIONS OF G. P. PUTNAM'S SONS. THE STUDENTS' AIDS SERIES. PREPARED FOR STUDENTS OF MEDICINE AND PHARMACY. HANDSOMELY PRINTED IN i6M0 FORM, CONVENIENT FOR THE POCKET. PAPER, 25 CENTS ; CLOTH, 50 CENTS. Aids to Anatomy. A multum-in-parvo guide for Students going up for Examination. By George Brown, M.R.C.S. , L.S.A., Late Demon- strator of Anatomy at Westminster Hospital Medical School. Fourth thousand. " This little book is well done." — The Lancet. " With this little work students need have no dread of College Examiners." — Medical Press. Aids to Chemistry. Specially designed for Students preparing for Exam- ination. Part I. — Inorganic : Oxygen to the Metalloids inclusive. By C. E. Armand Semple. Third edition. " Students will find it simply invaluable." — Medical Press. Aids to Chemistry. By the same author. Part II. — Inorganic : The Metals. Aids to Chemistry. By the same author. Part III. — Organic. Aids to Forensic Medicine and Toxicology. By W. Douglass Hem- ming, M.R.C.S. "A great boon to those who are studying for the Examination." — Stu- dents' yournal. Aids to Therapeutics and Materia Medica. Part. I. — The Non- Metallic and Metallic Elements ; Alcoholic and Ethereal Preparations, etc. By C. E. Armand Semple. PUBLICATIONS OF G. P. PUTNAM'S SONS. Aids to Therapeutics and Materia Medica. Part II. (Double Part). The Vegetable and Animal Substances. By C. E. Armand Semple. Aids to Physiology. By B. Thompson Lowne, F.R.C.S. Aids to Diagnosis. Parti. — Semeiological. By J. Milker Fothergill, M.D., M.R.C.P. Aids to Diagnosis. Part II. — Physical. By J. C. Thorowgood, M.D., M.R.C.P. Aids to Diagnosis. Part III. — AMiat to Ask. By J. Milner Fother- gill, M.D., M.R.C.P. Aids to Rational Therapeutics. By J. Milxer Fothergill. Aids to Medicine. Part I. (Double Part). The General Diseases : Diseases of the Lung, Heart, Blood-vessels, and Liver. By C. E. Armand Semple, B.A., M.B. Aids to Medicine. Part II. (Double Part). The Pathology of the Kidney, Pancreas, Spleen, Mouth, QEsophagus, Stomach, Intestines, Peritoneum, and Throat. By C. E. Armand Semple. Aids to Medicine. Part III. (Double Part). Diseases of the Brain and its Membranes, of the Nervous System, of the Spinal Cord, and of the Ear. By C. E. Armaxd Semple. Aids to Medicine. Part IV. — Treating of Fevers, Skin Diseases, Worms, etc. By C. E. Armand Semple. I7i preparation. Aids to Surgery. By George Brown, M.R.C.S. Aids to Gynecology. By Alfred S. Gubb, L.R.C. P., M.R.C.S. Aids to Obstetrics. (Double Part). By Samuel Nall, B.A., M.R.C.P., London. G. P. PUTNAM'S SONS, PubUshers. NEW YORK; LONDON; 27 and 29 West 23d Street. 27 King William Street, Strand, HOW WE TREAT WOUNDS TO-DAY. By ROBERT T. MORRIS, M.D. G. P. PUTNAM'S SONS, Publishers, New York and London. THIRD EDITION REVISED. l6 MO., CLOTH. Price ^i.oo. BRIEF EXTRACTS FROM PRESS NOTICES. The saucy little book has made a hit. — Am. Pract. and Ne-ws^ Oct. 30, 1886. This book is rich in bombast, but destitute of any practical value. — Medical Bulletin., Nov., 1886. The book is so thoroughly practical that it must be commended to those who wish to acquire an exact knowledge of the details of antiseptic treatment. — Boston Med. and Surg. Jour.., 1886. The quaint and sarcastic remarks strike the reader at once and cannot fail to enable him to remember the directions given. Any one who carries out the details given in this work will secure aseptic results. — British Med. Jour.., Dec. 4, 1886. Mais ce rapide aper9u ne pent donner qu'une idee fort insuffisante de ce prßcleux petit traite, et nous ne saurions trop en recommander la lecture. — Revue de Chirurgie., Dec. ID, 1886. We wish we might see this book in the hands of every practitioner of medicine in the world to-day. We are satisfied that the world would be better off. — Neiv England Med. Monthly., Feb., 18S6. This beyond doubt is as contemptible a book as was ever written for medical men The style to be expected from an ardent partisan with little knowledge and bad taste. — Med. Herald^ Nov., 1886. This book should be in the hands of every practitioner. — Med. Press., May, 1886. A most admirable treatise for study by hospital stewards and others connected with the medical administration of the armv and navy. — Army and Navy Jotir.., July, 1886. We wish that every physician in the land could be supplied with this book. — Ala. M. and S. Jour.., Oct., 1886. If the principles proclaimed in this little book were rigidly carried out by all surgeons now WE TREAT WOUNDS TO-DAY. there would be fewer deaths in hospital and private practice. — Chicago M. and S. Jour, and Exam.., Nov., 1886. A book which we cannot too highly praise If read and studied by surgeons in general would save much suffering and many lives. — Pacißc M. and S. Jour, and West- ern Lancet., April, 1886. A prominent example of superlatively bad stj-le and sophistical reasoning. — Sozithern Practitioner., Dec, 1886. A spicy little book written in the characteristic stj'le of the true-born American citizen. — Canada M. a7id S. Jour. y July, 1886. The author is evidently a bright and interesting man, judging from the way in which he handles the pen. His style is racy and singularly attractive. — Cincinnati L. and C.^ March 8, 1886. The laconic style of the author and the sledge-hammer way in which he deals with the follies of those who persist in the treatment of wounds by the old methods has a fascination about it that charms and Interests the reader to the end. — Indiana Med. /our.. May, 1886. The author shoots his facts like bullets' against the mark. Without waste of time or space. — The Med. Library , 1886. The author has done his work well Language terse and aphorisms pungent. — N. Y. Med. Record. March 20, 1886. The plan of the volume is capital. Everj^ page abounds in practical hints from an evi- dently practical surgeon. — London Med. Press and Circ, June 30, 1886. The quaint and often sarcastic style of the book makes the sound principles it advocates only the more impressive. — North-western Lancet., Feb., 1886. Dr. Morris has a style all his own in medical literature, and impresses what he says. — Med. and Surg. Rep., Nov. 6, 1886. There is so much superficial, so-called antiseptic work being done, that such a clean-cut, positive, detailed setting forth of what constitutes real antiseptic work as this is, is called for. — Annals of Surgery , Feb., 1887. A valuable book which commends itself to ^x&ry intelligent reader, and which no student of the ars chirurgica can afford to be without. — Progress Nov., 1886. " The deep-laid scheme "" of the author to make a disturbance with this little work has proved effective. We prophesy- numerous editions and a correspondingly thankful pro- fession. — Med. Register^ Feb. 12, 1887. The author is well acquainted with his subject. — London Med. Record, Aug. 16, 1886. ''-^